Water Quality, Environmental Contaminants and Disease Burden in Europe: An Ecological Analysis of Associations with Disability-Adjusted Life Years

Rivers and groundwater supply 88% of Europe’s freshwater and are critical for public health. We examined whether cross-country differences in arsenic, lead, mercury, and nickel concentrations in groundwater and rivers are associated with disease burden. In an ecological cross-sectional study of 24 European countries, nationally aggregated concentrations from the European Environment Agency’s Waterbase Water Quality (2016–2019) were linked to cause-specific disability-adjusted life years (DALYs) from the Global Burden of Disease 2021 for six disease groups. Variables were z-standardized. Associations were assessed using Pearson correlations and linear regression with Benjamini–Hochberg correction. Missing concentrations were addressed via multiple imputation by chained equations using 1980–2025 monitoring records, and models were sequentially adjusted for health system, demographic, and economic indices. In groundwater, lead was positively associated with diabetes and kidney disease DALYs and remained significant after imputation and adjustment (β = 0.60, p = 0.011). In rivers, arsenic was positively associated with all-cause, cardiovascular, and neoplasm DALYs in unadjusted analyses but attenuated after adjustment and/or imputation. No consistent associations were observed for mercury or nickel. These continent-wide, non-causal findings can help prioritize monitoring and risk management and support progress toward Sustainable Development Goal 6.