1. Differential Morbidity and Mortality in Israel
and its Relation to Particulate Air Pollution
James KRIKUN
Environmental Advisor – Municipality of Qiryat Motzkin, Israel
ABSTRACT
The deleterious effects of particulate matter air pollution on human health are
now well recognized. In 2001, 18,760 tons of PM 10 were released into the air
in Israel.. Less than 1,500 tons of this came from mobile sources, the
remainder from stationary ones. Besides the above, a total of over 670,000
tons of SOx and NOx were also released. Recently statistics regarding
malignancy morbidity and mortality due to all causes and based on Israel's 14
geographical districts have become available. Analysis of data for the periods
of 1983-1994 and 1996-97 indicates that the regions with the longest and
greatest degrees of industrial air pollution had elevated rates of mortality due
to heart disease, stroke, lung cancer, respiratory diseases and hypertension.
These regions also led in non-Hodgkin's lymphoma morbidity.
1. Introduction
The possible effects of airborne pollutants on public health have been studied
for ca. 25 years, based on large scale epidemiological studies (Hoover and
Fraumeni 1975) (Blot et al. 1977) (Gottlieb et al. 1982) (Kaldor et al. 1984)
(Wesolowski et al. 1980) and continuing to the studies of 2002 by (Pope et
al.2002).
Correlations between pollutant sources and/or pollutants and morbidity/mortality due to
malignancies, respiratory and cardiovascular diseases have been established. Possible
mechanisms between pollutant actions and their effects have been suggested by Seaton (1995)
and reviewed (Brunekreef and Holgate 2002) . Perhaps the most meaningful studies regarding
particulate matter effects have been conducted by Pope et al. (1995) and Schwartz (1999) that
have shown that what may at one time have been considered relatively low pollution status
may in fact lead to meaningful increases in total, cardiopulmonary and lung cancer mortality
rates.
A possible approach in considering air pollution effects on impacted populations could be
retrospective analyses of morbidity and mortality, according to causes, over meaningful time
periods on a regional/district basis. When compared to other districts, given similar
population characteristics and differences in air pollution status, conclusions as to air pollutant
impacts might reasonably be made.
Israel is a small country with a relatively small but highly concentrated populations whose
health status is closely monitored. Within the country, large differences, both historically and
quantitatively existed in air pollution status. This was mainly due to geographic, topographic
and climatic conditions. Israel's 14 geographic districts are presented in Fig 1. The Haifa
district, due to availability of excellent port facilities became, starting in the 1930's, Israel's
major industrial district. It became the locale of its first and still largest petroleum refinery,
and one of Israel's first three oil fired electricity generating plants. Besides these, numerous
industries such as ancillary petrochemical, chemical, biochemical, fertilizer, cement, metal,
automotive battery, paper and textile industries, among others, were established. Most of
these are operating to this day. In the adjoining Akko district a chlor-alkali, paint, and large

2. metal working facilities were established. One of these was a very large capacity scrap iron
recycling facility.
Fig. 1–A Map of Israel's 14 Geographic Districts
In contrast the Tel Aviv districts became the center for economic,
administrative and trade activity, with only negligible industrial activity. An oil
fired power plant is located there. The Jerusalem district, situated inland,
became the center of government activity, university and other learning
institutions with no industry whatsoever. A third oil fired power facility was
established in the Ashqelon district. In the early 1980's a large coal fired power
plant was established in the Hadera district. In the latter a large paper mill and
tire factory have also been operational for 50 years. It should be mentioned
here that for several decades most of the facilities mentioned above, including
the fuel oil electricity generating facilities operated, and still are operating
without any flue gas cleaning equipment. This had led to large emissions of
SOx, NOx, PM10. Refinery volatile organic compounds (VOC) emissions are
very high, perhaps due in part to outdated equipment (HME 2002).
The only means adopted to reduce SOx emissions was the gradual utilization of fuel oil with
lower S content. Thus up to 1986 all fuel oil used had an S content of 3.5%, which was
gradually reduced to 1.0 and 0.5% S used at present. However, due to the increased demand
for power and other needs, total SOx emissions, have since 1980 remained constant, being ca.
308,000 tons/yr to 311,000 tons/yr in 2001, with two-thirds from power generation. In 1985
ca. 17% of all SOx in the country was emitted in the Haifa district. By 1990 this value was
15%. In contrast, NOx emissions, increased from ca.80,000 to 367,00 tons/yr during the same

3. period due to increased mobile sources (CBS 2002). Particulate matter < 10 microns PM 10
decreased from ca. 27,000 to 19,000 tons/yr, although the earlier figures may be a
misrepresentation due to incorrect estimations from mobile sources (Ginsberg et al. 1998).
Emissions of VOC's from transportation was ca. 70,000 tons and from the Haifa refinery and
ancillary petrochemical plant, ca. 8,600 tons in 2001 (CBS 2002, HME 2002).
1. Particulate Matter Emissions
Measurement of suspended particulate matter equal to or less than 10 microns
has only begun within the last decade on any appreciable basis. Three
authorities conduct these measurements: the government, local municipalities
and the Israel Electric Corp. Recently PM 2.5 measurements have been
undertaken. Most of the equipment measures PM on a continuous basis.
Equipment is either beta attenuation or T.E.O.M. The T.E.O.M readings are not
adjusted. There is some confounding effect with regard to PM 10 values within
Israel due to the large south to north decrease in desert derived crustal material.
Thus in the Beersheva and Jerusalem regions, districts with no major PM10 emissions, high
readings are obtained. Nevertheless, when PM 2.5 measurements are considered it can be seen
that the Haifa, Tel Aviv and Ashqelon values are very high, ranging from 23-32 µg/m3 on an
annual basis. A recent report indicates that measurements in the city of Tel Aviv of PM 2.5
readings are 50% of that of PM10. In the Haifa district, average annual values of ca.50% PM
2.5 of PM10 have also been published (HME 2002) . When we consider that SO4 is usually
the major component of PM 2.5 it may be useful to briefly consider the SOx status in the
Haifa district from a temporal view. In their book, Guldmann and Shefer (1980) analyzed the
air pollution status in the Haifa district. They calculated that 155 tons/day of SOx was
released in 1969. Data regarding SOx emissions show that by 1985 a decrease to ca. 140
tons/day was achieved, which dropped to ca. 85 tons/day in 1990. Thus, today's PM 2.5
values and SOx to SO4 conversions in the past suggest that ca. 35-45 µg/m3 of PM 2.5 on an
annual basis may have been extant in the years 1975-85. Data regarding PM10 emissions in
the Haifa district are available on an annual basis only from 1996. That year, from combustion
sources alone 2,444 tons were emitted from stationary sources, ca.13% of PM10 from
stationary sources of all of Israel. By 2001 this value was reduced to 1,816 tons/yr, due in part
to the closure of the cement facility. (CBS 2001, HME 2002). The paper by Ganor et.al.
(1988) provides excellent data as to particle size, quantity and deposition from the three oil
fired power facilities. However, it should be emphasized that besides combustion sources, the
population of the Haifa and three adjoining districts were also impacted by PM 2.5 from large
ferrous and non-ferrous metal, P.V.C, and other major polluting industries.These facilities are
in the main located in the Akko district and have been operating for four decades.
Besides the data for the Haifa district some analysis for the Tel Aviv district is available from
a study analyzing PM 10 derivations (Ginsberg et.al. 1998). During 1996 PM 10 was
57 µg/m3, the largest sources being the power facility which contributed 48% of the total,
36% from vehicles and 14% from crustal matter. It may be mentioned here that mobile
sources in Israel increased from 539,000 to 1,831,000 between 1980 and 2000. As the Tel
Aviv district is by far the most congested with regard to population, mobile source pollution is
extremely high there at present.
2. Public Health Impacts
In 1994 the results of a four- year study regarding xenobiotics in wild and
domestic animals collected in th Acre (Akko) Valley were published (Fishelson
et al. 1994). Collections of 16 species including mammals were made in the
middle 1980's, and various organs analyzed for metals and PCB's.Other
analyses included various enzyme activities. Extremely high levels, far above

4. those previously reported were found for such metals as Fe, Ni, Mg and Pb.
For Pb and Ni values were greater than one order of magnitude. PCB's levels
were also very high. The stage was thus perhaps set for the results provided in
studies which were published and as yet unpublished regarding morbidity and
mortality causes on a regional basis , that is in Israel's 14 districts (Ginsberg
1983, 1992, Ginsberg & Tulchinsky, 1992, Ginsberg et al., unpublished
report). Other studies regarding mortality are also considered (Shemesh and
Elkana, unpublished report). It should be emphasized here that due to Israel's
small size the concentration of populations are extremely high, ranging from
1000-6000 inhabitants/km2 in the urbanized districts. As distances to major
medical centers are small, high care facilities are available to the vast majority
of the population. Record keeping, including addresses is maintained via
individual identity numbers. There is an active cancer registry.
a. Malignancy Statistics
In their report published in 1992 (Ginsberg and Tulchinsky 1992) pointed out
that as early as 1980-81 the Haifa district was the only one out of 14 that led in
more than one cancer site incidence.The sites were colorectal, breast,
lymphomas and all sites.The adjoining Akko district led in lung cancer.
In 2001 the Ministry of Health published a report which provided cancer incidence statistics
from 1984-1999 on a regional basis (Barchana 2001). Examination of the report demonstrates
that from 1984-1999 Haifa and Akko led the rest of the 12 districts in total site incidence and
such malignancies as non Hodgkin's lymphoma (NHL). Whereas in 1984-86 male and female
ASR for total cancer sites for the 12 districts was ca. 233/100,000 and rose to 285/100,000 in
1996-98; for the average of the Haifa+Akko districts the rates were 272 and 322 respectively
for males and 285 and 342 respectively for females for the same time periods. Individual
municipalities in the Haifa district had nearly twice the national rates in NHL. The adjoining
districts also had comparatively higher rates of NHL than the rest of the country. The Haifa
and Tel Aviv districts led the other 12 with regard to mortality due to lung cancer for
extended time periods. (Ginsberg et al. unpublished report).
b. Cardiovascular and Other Disease Mortality
In common with Western countries mortality due to cardiovascular disease
(CVD) is the leading cause of death in Israel. In the previously mentioned
studies of Ginsberg (1992) and Ginsberg et al., (unpublished report) all causes
of mortality were categorized and ratios established for the Israel standard
population adjusting for: age, sex and continent of birth. Between the years
1983-1994 over 327,000 deaths were categorized, based on Israel's 14 districts.
The data was presented as either under or over, as a percentage of the country
average=100.
The results for the Haifa ,Tel Aviv and Jerusalem districts for the years
1969-1994 with regard to mortality due to CVD are presented in TABLE 1.
TABLE 1- Cardiovascular Mortality During 3 Time Periods in 3 Districts in
Israel.
DISTRICT 1969–1978 1983–1986 1987–1994
JERUSALEM **93 **81 ***91
TEL AVIV **97 99 101
HAIFA 101 **112 ***117
The Values Represent Percent Over or Under The Country Average of 100.
** Denotes P<0.001,
*** Denotes P<0.0001

5. As the populations considered were large, highly significantly differences
were observed for the 1983-86 and 1987-1994 periods relating to elevated
mortality in the Haifa district when contrasted to the Tel Aviv and Jerusalem
districts. All three adjacent districts to Haifa also showed highly significant
elevated mortality due to CVD for both time periods, generally increasing with
time. In contrast the Tel Aviv and Jerusalem districts remained the same as the
country average.
It should be emphasized here that comparable populations were examined, and in this case
only Jewish populations were analyzed. When comparisons were made which included non-
Jewish inhabitants the same results were obtained. For the Haifa district in 1987-1994 total
CVD mortality was 17% over the national average, sig. at P<0.0001. The adjoining Yizre'el
and Hadera rates were 11 and 17% respectively, also sig. at P<0.0001. The specific heart
diseases for Haifa were: 13, 29 and 16% greater for acute myocardial infarctions, other
ischemic and other heart diseases respectively, all significantly above the country average at
P<0.0001. In contrast, for the same time periods Jerusalem had a 9% lower rate, sig.at
P<0.0001 and Tel Aviv 1% greater, not significant. Haifa and two adjoining districts had
elevated mortality due to hypertension, Jerusalem sig. 28% less, Tel Aviv 3% greater , not
significant. Mortality due to stroke was 9,18,11 and 30% greater in the Haifa, Yizre'el ,Akko
and Hadera districts respectively, all significant. Jerusalem had 16% and Tel Aviv 3% less
than the country average for stroke, both significant. The Hadera district also had highly
elevated respiratory diseases mortality, 172%, sig.at P<0.0001. The Ramle district, with a
relatively small population but industrialized, also had during 1983-1994 elevated mortality
rates due to CVD, cancer and respiratory diseases.
A rough analysis of mortality causes for the whole population according to the districts for
1996-97 also shows the same trends outlined above. In brief the Haifa and 3 adjoining
districts had relative CVD mortality of 12 and 19% respectively greater than average.
Jerusalem was 16-14% lower, and Tel Aviv similar to the country average. The 4 northern
districts and Jerusalem have a total population of over 2 million and comparable ethnic
composition.
3. Discussion And Conclusions
As pointed out earlier, a number of epidemiological studies have established
correlations between certain industrial activities and morbidity/mortality.
Perhaps the most relevant to the present analysis are the reports by Kaldor et al.
(1984) and Weslowski et al. (1980). In these studies, conducted in Contra
Costa County, California, U.S.A., mortality causes were evaluated in
populations residing at various distances from conglomerates of refinery,
power generating and chemical industries. Rates were adjusted to age, sex and
socioeconomic status. A five-year study period was used. Data for emissions of
SOx, NOx and hydrocarbons were collected and their concentration measured
at various distances from point emissions. Five PAH’s were also measured in
the ambient air, and mutagenicity of particles evaluated. The epidemiological
study demonstrated that the populations closest to point emissions had greater
total, heart disease and stroke mortality, as well as all site cancer morbidity.
When California and Haifa pollution status are compared, it cn be seen that
although daily SOx emissions in Contra Costa and Haifa were similar in
magnitude, with ca. 140 t/d there were very large differences in SO2 readings
at the respective monitoring stations. Thus, in Contra Costa, residents in the
impacted areas were exposed to 1-3.5 µg/m3 whereas during the same periods
residents in Haifa were impacted to levels of 104-41 µg/m3 at the worst locale
during 1985-1990 to as little as 15-4 during 1991-1998 at others, with the
average for the city and surrounding suburbs being in the range of 15 to 6

6. µg/m3 during 1991-1998. However, when we extrapolate results obtained at the
various stations, it can be calculated that during 1985-1990 most of the
residents were exposed to levels of 30-12 µg/m3 during the years 1985-1990.
The difference in the values found is due to the special topographic and
prevailing wind directions, which in the Haifa region mitigate rapid dispersion
of air pollutants (Guldmann and Shefer, 1980). Using SO2 as a surrogate it
may be expected that hydrocarbon levels were also very high, perhaps in the
order of 2-3 x greater than that found in Contra Costa (1.4-5.8 µg/m3). It should
be mentioned here that extremely high ozone levels are found as far as 10 kms.
from the point sources of relevant pollutants.
The similarities in disease mortality according to causes between California and Haifa are
striking. However, the California comparisons are between various locales. The Israeli
statistics have the disadvantage that all 14 districts are analyzed together to provide a basis,
and then the districts evaluated in comparison to the country average. Thus, when the Haifa
district is evaluated at +17% above the country average for CVD, it means that another
district may -17% for the same cause. It should be pointed out that all-cause mortality was
significantly greater also in the Haifa and two major adjoining districts, being 9, 7 and 11%
over the country average during the 1987-1994 period. The Tel Aviv, Ramle and Beersheba
districts were 2, 8 and 3% greater. The Jerusalem district was 8% lower.
In common with California, the Haifa district has elevated rates of cancer morbidity, mortality
due to heart disease, stroke and all-causes. Elevated morbidity/mortality due to sentinel
diseases such as leukemia, lung cancer, hypertension and NHL are also applicable to this
and/or adjacent districts. We know today that some of the industries emitted large amounts of
Pb, Cr, Cd, Ni, Zn, Fe and Mn. The Haifa/Akko districts have at least eight major sources of
dioxin/furan emissions, besides that emitted from fuel combustion. That dioxin may be having
major impacts can be seen from the study by Shecter et al (1997) which showed that a number
of years ago dioxin levels were relatively high in blood samples of Israeli women and Israeli-
produced basic foodstuffs, all this without municipal waste incineration.
Mortality due to heart disease and stroke was 42.9% of total non-trauma deaths during the
period of 1987-1994 for the country and 50.2 for the Haifa district. A study not yet published
which analyzed age and sex adjusted mortality in all of Israel's municipalities of over 10,000
inhabitants, 83 in number, showed there was very little correlation between the
socioeconomic status and mortality rates. This finding was unexpected, as in most such
studies there is a strong correlation between the two. This study showed that adjusted
mortality in four major urban population centers for the years 1990-1997 indicated large
variations between them. Thus the Jerusalem rate was 567/100,000 and Beersheba, a city
which for over 40 years was Israel's center of the chemical plant protection production
industry and for over 20 years the locale of its toxic waste storage and incineration,
680/100,000. The Tel Aviv and Haifa values were between the two. Thus it may be that
geographic-determined environmental factors, as suggested by Ginsberg (1992 ) may be a
major factor in determining mortality due to major causes in Israel in some districts. The
conclusions reported here are preliminary. Studies are under way to pinpoint
pollutant/morbidity-mortality relationships. If, however, the results of Pope et al (2002) and
others which suggest that long-term exposure to relatively low particle levels lead to increased
rates of all-cause, cardiopulmonary and lung cancer mortality apply to the Israeli experience,
then excess morbidity and mortality due to environmental pollution may be exacting a toll not
previously considered, both from the human and economic viewpoints. If so, all reasonable
means should be applied to reduce this pollution.

7. 4. References
Barchana, M. 2001. Geographical Mapping of Malignant Diseases in Israel.
State of Israel. Min. Of Health. Israel Nat'l. Cancer Registry. 55 pp. (in
Hebrew).
Blot, W.J., Brinton, L.A. et al. 1977. Cancer mortality in U.S. counties with
petrochemical industries. Science 198:51-53
Brunekreef, B. and Holgate, S.T. 2002. Air pollution and health. The Lancet
360:1233-1242.
Central Bureau of Statistics (CBS). 2002. Report for the year 2001. (in
Hebrew).
Fishelson, L., Yawetz, A. et al. 1994. The environmental health profile (EHP)
for the Acre Valley (Israel): Xenobiotics in animals and physiological
evidence of stress. Science of the Total Environ. 144:35-45.
Ganor,E., Altshuller, H. et al. 1988. Vanadium and nickel as indicators of
power plant pollution. Water, Air & Soil Pollution 42:241-252.
Ginsberg, G.M. & Tulchinsky,T.H. 1992. Regional differences in cancer
incidence and mortality in Israel: possible leads to occupational causes.
1992. Isr. Jl. Med. Sci. 28:534-543. Ginsberg, G.M. 1983. Standardized
mortality ratios for Israel, 1969-78. Isr. Jl. Med. Sci. 19:638-643.
Ginsberg, G.M. 1992. Standardized mortality ratios for Israel, 1983-86. Isr. Jl.
Med. Sci. 28:868-877.
Ginsberg, G.M., Salahov, E. et al. Standardized mortality ratios by region of
residence. Israel 1987-1994: a tool for evidence based policy making?
Unpublished report.
Ginsberg, G.M., Serri, A. et al.1998. Mortality from vehicular particulate
emissions in Tel-Aviv-Jaffo. World Transport Policy and Practice 4:27-31.
Gottlieb, M.S., Shear et al. 1982. Lung cancer mortality and residential
proximity to industry. Environ. Health Perspectives 45:157-164.
Guldmann, J.M. & Shefer, D. 1980. Industrial Location and Air Quality
Control. A Planning Approach. John Wiley & Sons. 237 pp.
Haifa District Ass. of Municipalities for the Environment (HME) 2002. Report
for year 2001. (in Hebrew)
Hoover, R., & Fraumeni Jr., J.F. 1975. Cancer mortality in U.S. counties with
chemical industries. Environm.Research 9:196-207.
Kaldor, J., Harris, J.A. et al. 1984. Statistical association between cancer
incidence and major-cause mortality, and estimated residential exposure to
air emissions from petroleum and chemical plants. Environ. Health
Perspectives 54:319-332.
Pope III, A.C., Burnett, R.T. et al. 2002. Lung cancer, cardiopulmonary
mortality and long-term exposure to fine particulate air pollution. Jl. Am.
Med. Ass. 287:1132-1141
Pope III, A.C., Thun, M.J. et al. 1995. Particulate air pollution as a predictor of
mortality in a prospective study of U.S. adults. Am.J. Respir. Crit. Care
Med.151:669-674.
Schecter, A., Papke, O. et al. 1997. Dioxins, dibenzofurans, and PCB's in
human blood, human milk, and food from Israel, the West Bank, and Gaza.
Organohalogen Cmps. 33:457-461.
Schwartz, J. 1999. Air pollution and hospital admissions for heart disease in
eight U.S. counties. Epidemiology 10:17-22.
Seaton,A. 1995. Particulate air pollution and acute health effects. The Lancet
345:176-178.
Shemesh, E. & Elkana, Y. Adjusted mortality rates in Israeli municipalities and
social factors. Unpublished report (in Hebrew).

8. Wesolowski, J.J., Flessel, P.C. et al. 1980. The chemical and biological characterization of
particulate matter as part of an epidemiological cancer study. Proceedings of the 1980
Conference on Aerosols in Science, Medicine and Technology – Physical and Chemical
Properties of Aerosols. Gesellshaft fur Aerosolforschung, Schmallenberg, West Germany.