Tourism, inequality and health. Rethinking sustainability

the regional burden of disease. Although tourism is a strategic driver of economic growth, its implications for public health remain poorly investigated. The objective is to study whether and under what conditions tourist flows generate health benefits or risks. Design/methodology/approach – Health is measured using Disability-Adjusted Life Years (DALYs) provided by the Global Burden of Disease project. Using panel data for 20 Italian regions from 2008 to 2021, we analyze tourism intensity, average length of stay and spatial concentration of arrivals. The application of a hybrid withinbetween model allows us to distinguish between short-term and long-term structural differences. Findings – The results show a dual impact. In the short term, longer stays and concentrated arrivals are associated with an increase in DALYs, signaling pressure on health services and the local environment, while a greater number of arrivals is associated with a reduction in DALYs. In the long term, regions with structurally high tourism intensity tend to be associated with worse health outcomes; however, higher per capita income seems to mitigate these negative effects. Policies should focus on redistributing flows, reducing concentration and strengthening the resilience of local health systems. Redistributive policies and sustainable management approaches can transform tourism into a lever for creating both economic and health value. Originality/value – The contribution lies in the use of DALYs, a measure never applied in tourism studies, and in the adoption of a model that separates temporal dynamics from structural differences.