Tuzla: a pollutant thermal power plant in the heart of the Balkans

The city of Tuzla, in the heart of the Balkans, was once famous for its salt mines. But it is coal that shaped the city during the 20th century, and it is to coal that we now owe a complex situation of environmental contamination and health concerns.

With 110,979 inhabitants at the last census (2013), Tuzla is the third largest city in Bosnia and Herzegovina and one of its main industrial centres. The modern industrial development was based upon the nearby coal mines exploited since the early 1900s: mostly open-pit mines that have uncovered mountains, changed the morphology of the land, heated the nearby villages and towns, and powered factories. In particular, since the early 1960s, the Banovici (brown coal) and Kreka (lignite) mines have supplied a large thermoelectric plant, the Tuzla Thermal Power Plant (TPP) presently owned by the state-owned Elektroprivreda Bosne i Hercegovine (EBiH). Today the plant consists of six units, the two oldest of which are inactive but not yet decommissioned, while the last one started operations in the 1980s. TPP Tuzla produces around 3.1 TWh per year according to company figures, or about 40% of the electricity produced in Bosnia and Herzegovina. EBiH is planning to build a new coal-fired thermoelectric unit with a capacity of 450 megawatts, called Tuzla 7, to replace the currently operating but obsolete units 3, 4 and 5. However, the project is surrounded by controversy and uncertainty. Meanwhile the installation of a desulphuriser at Unit 6, which has been pending for years, has yet to take place.
In this context, TPP Tuzla is a source of environmental and public health concerns. The plant is located at the edge of town, next to a residential area. Six artificial reservoirs collect the plants spent ashes within a few kilometres in the surrounding hills. The neighbourhood of Bukinje vividly illustrates the situation: the plant is just across the road, its cooling towers overlooking the elementary school; on the other side, the neighbourhood is squeezed between two ashes dumps. Bukinje accounted for 663 inhabitants at the last census, but it is said to have shrunk to some 150 in recent years. The suburban village of Ši´cki Brod (1.367 inhabitants in 2013), Divkovi´ci and Plane (a few dozen inhabitants each) are similarly close to either the plant or its slag landfills. In these communities, cases of chronic bronchitis, asthma, and cancer are a common experience. Respiratory disorders are frequent even among children as young as two years old. Yet, systematic studies on the health of the population exposed to the plant effluents are scarce. When questioned, the Public Health Office of the Federation of Bosnia and Herzegovina replied that it has no means of monitoring the impact of industrial pollution. Similarly, the Health Institute of the Tuzla Canton stated that it lacks the facilities for systematic monitoring. 
In fact, the only specific research carried out so far has been promoted by an NGO of Bosnia and Herzegovina, the “Centar za ekologiju i energiju” (Centre for Ecology and Energy, CEE). 
The author, Nurka Pranjic (M.D, Ph.D.) is a professor at the Department of Occupational and Environmental Health of the Faculty of Medicine of the University of Tuzla. In 2016, she conducted a cross-sectional study screening long-term effects of exposure to air pollution and heavy metals in areas close to ​​the slag landfill and the Tuzla Thermal Power Plant, comprising the suburban communities of Bukinje, Divkovi´ci, Plane and Ši´cki Brod. Previously, in 2015, three NGOs (Centre for Ecology and Energy – CEE, Bosnia and Herzegovina; CEKOR, Serbia; and Green Home, Montenegro) had performed a monitoring of soil and water in the areas surrounding the plant and the landfills. Samples of human hair, soil, water, sediment, fish, and chicken eggs were collected and tested for the presence of heavy metals: mercury (and methylmercury in living tissue: hair, eggs, fish), lead, arsenic, nickel, cadmium, and chromium. This monitoring revealed an extensive contamination by heavy metals in water, land, as well as in plants and fish. 

Interview to Nurka Pranjic

M.D, Ph.D., Department of Occupational and Environmental Health, Medical Faculty University Tuzla, Bosnia and Herzegovina

Professor Pranjic, can you explain how you carried on your research and how would you describe the state of public health related to coal activities in the area exposed to the Tuzla thermal power plant?
The study included 502 respondents, 237 men (47.2%) and 265 women (52.8%). The mean age of the subjects was 52.40±13.988 years. The survey was conducted by surveying citizens, and participation in the survey was voluntary. We used a modified Janice Potter questionnaire on the signs and symptoms of environmental exposure to heavy metals to conduct a household-to-household screening survey in the selected area; this was the fieldwork of an educated interviewer.
The respondents are residents of Divkovici, Plane, Bukinje, and Šicki Brod, a total of 402 respondents. The control group consisted of 100 inhabitants of Solina, a local community situated away from both the Thermal Power Plant and the dumps (>12 km road distance and >4 km air distance from the Thermal Power Plant and the slag landfill). The respondents of the control group represent the general population of the municipality of Tuzla. The target and the first research group (group I) consisted of citizens living in peripheral settlements near the slag dump and near the Thermal Power Plant: 51 residents of Divkovi´ci and 121 residents of Plane. The second research group consisted of residents living close to the Thermal Power Plant and the slag landfill: 85 inhabitants of Bukinje and 145 of Šicki Brod.

What are the main results of your research? 
Collectively, the impact of lifelong exposure to heavy metals on the morbidity and mortality of citizens living directly next to the power plant and the slag landfill is very high: Bukinje 69%, Ši´cki Brod 39%, Plane 27%, Divkovi´ci 47% compared to the control area of ​​Solina 3% (probably professional exposure), according to Score of Janice Potter test.
The main health risk is heavy metals dispersed as air pollutants. A large number of heavy metals are known to be carcinogenic, and high concentration of air pollution was detected near the Thermal Power Plant, the site of coal combustion. Compared to the control group in Solina, the risk of disease due to exposure to heavy metals is 27 times higher for residents in Bukinje and 10 times higher in Šicki Brod (p<0.000).
Particularly alarming is the mortality from cancer in the population living near the thermal power plant and the slag: Bukinje 53%, Divkovi´ci 53%, Ši´cki Brod 38%, and Plane 21%; Solina 15% (p<0.000).  
The prevalence of cancer is significantly higher in areas close to TPP and slag dumps. The most common cancers among local respondents are lung cancer (56), colon cancer (19), breast cancer (17), and uterine cancer (12). The situation is different in Solina, with 5 cases of prostate cancer, 4 of malignant blood diseases, 3 cases each of breast and lung cancers. 
We found 6 cases of paediatric cancer, five in Bukinje and one in Plane.
In addition to cancer, the prevalence of cardiovascular disorders was significantly higher than in the control area: Solina 7% vs Bukinje 44%, Ši´cki Brod 29% (Group I), Plane 28%, 20% Divkovi´ci (Group II) (p<0.000), that is about 3 to 6 times more often than in the control area. However, compared to the prevalence in the general population of Bosnia and Herzegovina (9.9%), the prevalence of cardiovascular diseases in our respondents is 2 to 4 times higher.
Also, the prevalence of pulmonary emphysema was significantly higher in settlements close to the TPP and the slag dumps than in the control area, as well as anaemia and thyroid hypofunction, osteoporosis, muscle stiffness and tremor, and a number of other health disorders.

When I visited residents in Bukinje in October 2021, I was told that almost every family experiences poor health, cancer, and respiratory diseases; yet, many complained that the authorities do not listen to them. Can you comment on this? After your research was published in 2018 by the Centre for Ecology and Energy, was there any monitoring by the institutions of public health or the academic institutions? 
People are dying from the effects of environmental pollution, but a healthy environment is not a priority! Unfortunately, medical schools do not have relevant subjects and postgraduate studies do not include health risk assessment and prevention measures.

Conflict of interest: none declared.

Research material

• Pranjic N. Oboljemanje i umiranje ljudi izloženih teškim metalima u neposrednoj Blizini odlagališta šljake i pepela termoelektrane Tuzla (“Illness and death of people exposed to heavy metals in the vicinity of the Tuzla power station and its ash dumps”). CEE 2018. Available from: https://bit.ly/3tA5E10 (in Bosnian).
• Forti M. La centrale a carbone che avvelena Tuzla e frena la transizione energetica. Internazionale.it 2021. Available from: https://www.internazionale.it/reportage/marina-forti/2021/10/25/tuzla-centrale-carbone (in Italian)

Commentary by Pietro Comba

The interview given by Prof. Nurka Pranjic of the University of Tuzla (Bosnia and Herzegovina) to Marina Forti, independent journalist with long-lasting experience in the study of communities residing in contaminated sites, is of the utmost interest for all those concerned with the health impact of industrial sites in Europe. 
This interview is published in the present issue of E&P, with links to some original documents.^1,2 As it is discussed here below, the town of Tuzla is characterized by the presence, in its neighbourhoods, of coal mines and of a major thermoelectric power plant, fuelled with local coal. 
In Western European countries, we are currently engaged in the process of decommissioning from coal to less hazardous processes (thus pursuing both environmental integrity and human health), while in Tuzla the situation seems to remain unchanged, at least in the medium term. In considering this finding, we should emphasize the role of epidemiological studies conducted in Italy with respect to major coal power plants such as those of Civitavecchia^3-5 and Brindisi.⁶
In Italy, the alerts on the possible health impact of coal power plants for the populations resident in their surroundings started, orientatively, in the Eighties, and were immediately countered by criticism expressed by scientific experts collaborating with the coal power plants management. These criticisms turned out to be somehow beneficial, though, because they compelled epidemiologists to strongly improve their protocols in order to produce figures relevant in terms of causation. This implied, among else, to thoroughly refine the estimation of environmental exposures and to integrate geographic and analytic epidemiological study designs. The core issue often was to search for correlations between estimated exposure to spatial patterns of coal plant emissions and distribution at (micro)geographic level of occurrence of adverse health outcomes, taking into account potential confounding variables.
This appears to be the setting in which a collaborative effort between Tuzla University and the network of Italian environmental epidemiologists associated with E&P might be most valuable.
Three aspects, in this frame, should be considered.
First of all, the most valuable contribution provided by Prof. Pranjic to the detection and reporting of a dramatic environmental contamination episode allows to explore possibilities of realizing a new investigation supported by the methodological approaches developed in Italy in the last four decades. Prof. Pranjic has pursued both environmental characterization and mapping of the occurrence of environmental related diseases in this context.
In light of the unavoidable problems of low statistical power due to sample size constraints, it could be appropriate to rely on interval estimation, rather than significance testing, to express the study findings.
Secondly, there exists now an institutional frame for promoting the study and intervention for contrasting the health impact associated with residence in contaminated sites in the 53 Countries of the European Region of the World Health Organization (WHO): this strategy was adopted at the Fifth Ministerial Conference held in Ostrava (Czech Republic) June 13-15 2017.⁷ Thirdly, at an operational level, the European COST Action “Industrial Contaminated Sites and Health Network”, coordinated by the Italian National Institute of Public Health (ISS), has produced an excellent set of initiatives and documents that may turn out quite suitable in the Tuzla setting. In this frame, the WHO Collaborating Centre for Environmental Health in Contaminated Sites, located at ISS, might play a pivotal role in defining the road to be taken in order to design and implement a comprehensive study on the health impact of Tuzla coal power plant on the resident population. Without discussing here the many relevant technicalities of such a project, I would stress two points, namely training and capacity building for young investigators, and setting up a participatory process with the affected community, together with its institutional and social actors.⁸
Hoping that this approach might turn out to be feasible, I would like to close this brief comment by expressing my gratitude to Prof. Pranjic for bravely approaching this major environmental health problem in her country, which is so close to ours, to Dr. Marina Forti for her sound and precise narrative, to Dr. Borko Bajic from the Ministry of Health of Montenegro for his valuable advice in approaching the issue of Environmental Health in the Balkans, and to Dr Giada Minelli, Head of the Statistical Office of ISS, for helpful discussion on methodological aspects.

Conflicts of interest: none declared.

References

1. Pranjic N. Oboljemanje i umiranje ljudi izloženih teškim metalima u neposrednoj Blizini odlagališta šljake i pepela termoelektrane Tuzla (“Illness and death of people exposed to heavy metals in the vicinity of the Tuzla power station and its ash dumps”). CEE 2018. Available from: https://bit.ly/3tA5E10 (in Bosnian).
2. Forti M. La centrale a carbone che avvelena Tuzla e frena la transizione energetica. Internazionale.it 2021. Disponibile all’indirizzo: https://www.internazionale.it/reportage/marina-forti/2021/10/25/tuzla-centrale-carbone (in Italian)
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6. Galise I, Serinelli M, Morabito A et al. L’impatto ambientale e sanitario delle emissioni dell’impianto siderurgico di Taranto e della centrale termoelettrica di Brindisi. Epidemiol Prev 2019;43(5-6):329-37.
7. World Health Organization. Declaration of the Sixth Ministerial Conference on Environemnt and Health. Disponibile all’indirizzo: https://www.euro.who.int/__data/assets/pdf_file/0007/341944/OstravaDeclaration_SIGNED.pdf
8. Marsili D, Pasetto R, Iavarone I, Fazzo L, Zona A, Comba P. Fostering Environmental Health Literacy in Contaminated Sites: National and Local Experience in Italy From a Public Health and Equity Perspective. Front Commun 2021;6:697547.