- Email: [email protected]
Environmental Health Policy & Children’s Health
Department
www.jpedhc.org
Legislation and Health Policy
Section Editor Karen G. Duderstadt, PhD, RN, CPNP University of California— San Francisco School of Nursing, Family Health Care San Francisco, California
Environmental Health Policy & Children’s Health Karen G. Duderstadt, PhD, RN, CPNP
Reprint requests: Karen G. Duderstadt, PhD, RN, CPNP, University of California San Francisco, School of Nursing, 2 Kirkham St., Box 0606 N411Y, San Francisco, CA. 94143-0606. J Pediatr Health Care. (2006). 20, 411413. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.08.012
Journal of Pediatric Health Care
Each year, environmental toxins contribute significantly to the burden of total health care costs for children in the United States. Children are at higher risk for toxins in the environment because they absorb toxic substances at a rate 1 to 5 times that of an adult (Gitterman and Bearer, 2001). Children also live and play closer to environmental hazards on the ground, which increases their concentrations of inhaled toxic substances as compared to adults (American Academy of Pediatrics Committee on Environmental Health, 2003). The increased exposure and absorption of toxins occurs during periods of rapid growth and development in the young child and impacts health outcomes in later childhood and in adulthood. There are a number of environmental conditions that impact on children’s health, including indoor and outdoor air quality, exposure to chemical pollutants and biological toxins, overcrowding, ambient noise level, work environment of parents and caretakers, and exposure to environmental hazards in the home, school, and neighborhoods. Surveillance of potential environmental hazards and their impact on children’s health has become more challenging in recent years. Determining safe levels of exposure to chemical and biological hazards and levels of exposure that cause ad-
verse health effects has proven difficult as the number of chemicals and biological substances in the environment increases. ENVIRONMENTAL HEALTH POLICY Local, state, and federal regulatory policies have succeeded in limiting exposures to some environmental pollutants and eliminating some environmental hazards known to be harmful to children’s health. Lead abatement programs in the United States are a primary example of community efforts to limit exposures to toxins (Box 1). Decline in Blood Lead Levels New data from the Third National Report on Human Exposure to Environmental Chemicals shows continued progress in the reduction of blood lead levels in children. Estimates from the National Health and Nutrition Examination Survey (NHANES) found the number of children with elevated lead levels (levels ⱖ10 g/ dL) has declined. Between 1999
BOX 1. Definition Toxicants refer to an environmental hazard from chemical pollutants, and toxins are hazards from biological sources.
November/December 2006
411
and 2002, 1.6% of children 1 to 5 years of age had elevated blood levels. This percentage has decreased from 4.4% in the early 1990s (Centers for Disease Control and Prevention [CDC], 2005). Lead abatement programs have been effective in reducing the level of lead toxicity in the environment. Many states and local governments have implemented effective surveillance programs to enforce stricter regulations on lead abatement. This improved surveillance of blood lead concentration levels and lead abatement has been costly. The estimate of the proportion of health care costs attributable to lead poisoning is $43.4 billion annually (Landrigan, Schechter, Lipton, Fahs, and Schwartz, 2002).* Monitoring Safe Levels of Exposure Lead at any level adversely affects children. The greatest amount of neurological damage in young children from substances like lead occurs at the lowest levels of exposure over time. The CDC’s level of concern for children’s blood lead concentrations remains at 10 g/dL. However, recent evidence increases concern for children’s neurobehavioral functioning at lead concentrations below this level (Lidsky and Schneider, 2006). Blood lead concentrations have been shown to be adversely associated with IQ. At levels below 10 g/dL, IQ declined in children 3 to 5 years of age by an average of 7.4 points as lifetime blood lead concentrations increased from 1 to 10 g/dL (Canfield et al., 2003). These findings indicate children’s sustained exposure to environ-
*The total annual cost of lead poisoning to U.S. Society includes the estimated annual costs of lead screening, evaluation and treatment of elevated lead levels, environmental lead abatement, and the lost productivity of children and adults multiplied by the ‘cost per case’ of lifetime lead toxicity.
412 Volume 20 • Number 6
mental lead at low levels adversely affects their health. Further evidence on the adverse effects of low levels of lead toxicity would require the CDC to reexamine the level of concern of blood lead concentration in children. Diligence in lead abatement remains a priority for children’s health. ENVIRONMENTAL INEQUALITY Special populations of children remain at higher risk for lead toxicity and exposure to other environmental hazards. Public health researchers have begun to explore the role of disparate exposures to environmental pollutants and the contribution to health inequities and health disparities (Evans and Kantrowitz, 2002). Children living in low-income families and children of color tend to live near environmentally hazardous facilities and bear a larger share of the health burden from exposure to toxins (Brulle and Pellow, 2006). Protection of these populations of children remains a major public health concern. Sound environmental health policy is critical for the protection of these special populations of children to limit their exposure to toxins. The Environmental Protection Agency (EPA) defines environmental justice and fair treatment in relation to environmental laws, regulations, and policies: “Fair treatment means no population, due to policy or economic disempowerment, is forced to bear a disproportionate share of the negative human health or environmental impacts of pollution or environmental consequences resulting from industrial, municipal, and commercial operations. . .” (Institute of Medicine Committee on Environmental Justice, 1999). The environmental justice movement continues to assess the effectiveness of public health efforts to reduce exposures to specific chemicals. Currently, only
43% of high-volume chemicals have been tested for their potential toxicity on humans, and only 7% of the chemicals tested have been studied for possible effects on young children and the developing fetus (Landrigan, 2005). Researchers, policy analysts, and environmental justice groups are advocating for adoption of the Precautionary Principle, a paradigm shift in how society addresses environmental risks (Bruelle and Pelloa, 2006). Rather than presuming that specific chemicals or production processes are safe until proven hazardous to human health, the Precautionary Principle shifts the burden of proof to the producers to show an absence of harm (Bruelle and Pellow, 2006). Under this principle, communities with populations living in areas with exposures to chemicals pollutants suspected to cause harm can argue for temporary suspension of use or elimination of production of chemical substances until absolute proof that the chemical is not associated with adverse health effects. Recent legislation in Germany, Sweden, Australia, Scotland, and Norway resulted in adoption of the Precautionary Principle. ENVIRONMENTAL HEALTH ADVOCACY Nurses and Nurse Practitioners caring for children have a long history of effectively advocating for environmental health at the local, state, and federal levels. These efforts have contributed to environmental health policies that have improved the health outcomes of children. Numerous state and federal laws enacted in the 1990s addressed issues of lead exposure, environmental tobacco smoke, and chemical pollutants hazardous to children’s health. In October 2002, the CDC solicited nominations from health care providers and the public for categories of chemicals for possible inclusion in further studies on potential chemJournal of Pediatric Health Care
ical toxicants. They received nominations for hundreds of chemicals (CDC, 2002). Pediatric health care providers need to develop an increased awareness of exposures to toxins and sources of chemical toxicants in children’s surroundings and observe for potential effects on children’s health (Box 2). It is important to be aware of potential chemical and biological hazards in the communities where children under their care live and play. Advocacy for increased surveillance of potential biological toxins and chemical pollutants and for community testing of potentially harmful substances remains a priority. State and federal legislation is needed to increase funding for research on chemical and biological substances and to establish safe levels of exposure to pollutants for adults and children, particularly during critical periods of development. CONCLUSION The lifelong impact of exposure to lead and the burden of public health care costs related to lead toxicity remain critical examples of the importance of ongoing surveillance of potential chemical and biological hazards in children’s surroundings. Legislators and health policy analysts should study the benefits of adoption of the Precautionary Principle as an adjunct to
Journal of Pediatric Health Care
BOX 2. Environmental health resources for pediatric health care providers Centers for Disease Control and Prevention (CDC) www.cdc.gov Agency for Toxic Substances and Disease Registry www.atsdr.cdc.gov Environmental Protection Agency www.epa.gov Children’s Environmental Health www.cehn.org/index.html National Environmental Educational and Training Foundation www.neetf.org/Health/PEHI
public health surveillance of chemical and biological substances. Developing prudent environmental health policies and limiting exposure to chemical and biological toxins protects the health of our children now and in the future. REFERENCES Bruelle, R. J., & Pellow, D. N. (2006). Environmental justice: Human health and environmental inequalities. Annual Review of Public Health, 27, 103-124. Canfield, R. L., Henderson, C. R., CorySlechta, D. A., Cox, C., Jusko, T. A., & Lanphear, B. P. (2003). Intellectual impairment in children with blood lead concentrations below 10 micrograms per deciliter. New England Journal of Medicine, 348, 1517-1526.
Centers for Disease Control and Prevention National Center for Environmental Health. (2005). Third Annual Report on Human Exposure to Environmental Chemicals. Atlanta, GA: Centers for Disease Control and Prevention. Etzel, R. A., & Balk, S. J. (Eds) (2003). Pediatric Environmental Health. Elk Grove Village, IL: American Academy of Pediatrics. Evans, G. W., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 303331. Centers for Disease Control and Prevention. (2002). Federal Register, Vol. 67, No. 194. Retrieved October 7, 2002 from http://www.cdc.gov/exposurereport/ pdf/fr_100702.pdf. Gitterman, B. A., & Bearer, C. F. (2001). A developmental approach to pediatric environmental health. Pediatric Clinics of North America, 48, 1071-1083. Institute of Medicine Committee on Environmental Justice. (1999). Toward environmental justice: Research, education, and health policy needs. Washington, DC; National Academy of Press. Landrigan P. J., Schechter, C. B. Lipton, J. M., Fahs, M. C., & Schwartz, J. (2002). Environmental pollutants an disease in American children: Estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer and developmental disabilities. Environmental Health Perspectives, 110, 721-728. Landrigan, P. J. (2005). Children as a vulnerable population. Human and Ecological Risk Assessment, 11, 235-238. Lidsky, T., & Schneider J. (2006). Adverse effects of childhood lead poisoning: The clinical neuropsychological perspective. Environmental Research, 100, 284-293.
November/December 2006 413
www.jpedhc.org
Legislation and Health Policy
Section Editor Karen G. Duderstadt, PhD, RN, CPNP University of California— San Francisco School of Nursing, Family Health Care San Francisco, California
Environmental Health Policy & Children’s Health Karen G. Duderstadt, PhD, RN, CPNP
Reprint requests: Karen G. Duderstadt, PhD, RN, CPNP, University of California San Francisco, School of Nursing, 2 Kirkham St., Box 0606 N411Y, San Francisco, CA. 94143-0606. J Pediatr Health Care. (2006). 20, 411413. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.08.012
Journal of Pediatric Health Care
Each year, environmental toxins contribute significantly to the burden of total health care costs for children in the United States. Children are at higher risk for toxins in the environment because they absorb toxic substances at a rate 1 to 5 times that of an adult (Gitterman and Bearer, 2001). Children also live and play closer to environmental hazards on the ground, which increases their concentrations of inhaled toxic substances as compared to adults (American Academy of Pediatrics Committee on Environmental Health, 2003). The increased exposure and absorption of toxins occurs during periods of rapid growth and development in the young child and impacts health outcomes in later childhood and in adulthood. There are a number of environmental conditions that impact on children’s health, including indoor and outdoor air quality, exposure to chemical pollutants and biological toxins, overcrowding, ambient noise level, work environment of parents and caretakers, and exposure to environmental hazards in the home, school, and neighborhoods. Surveillance of potential environmental hazards and their impact on children’s health has become more challenging in recent years. Determining safe levels of exposure to chemical and biological hazards and levels of exposure that cause ad-
verse health effects has proven difficult as the number of chemicals and biological substances in the environment increases. ENVIRONMENTAL HEALTH POLICY Local, state, and federal regulatory policies have succeeded in limiting exposures to some environmental pollutants and eliminating some environmental hazards known to be harmful to children’s health. Lead abatement programs in the United States are a primary example of community efforts to limit exposures to toxins (Box 1). Decline in Blood Lead Levels New data from the Third National Report on Human Exposure to Environmental Chemicals shows continued progress in the reduction of blood lead levels in children. Estimates from the National Health and Nutrition Examination Survey (NHANES) found the number of children with elevated lead levels (levels ⱖ10 g/ dL) has declined. Between 1999
BOX 1. Definition Toxicants refer to an environmental hazard from chemical pollutants, and toxins are hazards from biological sources.
November/December 2006
411
and 2002, 1.6% of children 1 to 5 years of age had elevated blood levels. This percentage has decreased from 4.4% in the early 1990s (Centers for Disease Control and Prevention [CDC], 2005). Lead abatement programs have been effective in reducing the level of lead toxicity in the environment. Many states and local governments have implemented effective surveillance programs to enforce stricter regulations on lead abatement. This improved surveillance of blood lead concentration levels and lead abatement has been costly. The estimate of the proportion of health care costs attributable to lead poisoning is $43.4 billion annually (Landrigan, Schechter, Lipton, Fahs, and Schwartz, 2002).* Monitoring Safe Levels of Exposure Lead at any level adversely affects children. The greatest amount of neurological damage in young children from substances like lead occurs at the lowest levels of exposure over time. The CDC’s level of concern for children’s blood lead concentrations remains at 10 g/dL. However, recent evidence increases concern for children’s neurobehavioral functioning at lead concentrations below this level (Lidsky and Schneider, 2006). Blood lead concentrations have been shown to be adversely associated with IQ. At levels below 10 g/dL, IQ declined in children 3 to 5 years of age by an average of 7.4 points as lifetime blood lead concentrations increased from 1 to 10 g/dL (Canfield et al., 2003). These findings indicate children’s sustained exposure to environ-
*The total annual cost of lead poisoning to U.S. Society includes the estimated annual costs of lead screening, evaluation and treatment of elevated lead levels, environmental lead abatement, and the lost productivity of children and adults multiplied by the ‘cost per case’ of lifetime lead toxicity.
412 Volume 20 • Number 6
mental lead at low levels adversely affects their health. Further evidence on the adverse effects of low levels of lead toxicity would require the CDC to reexamine the level of concern of blood lead concentration in children. Diligence in lead abatement remains a priority for children’s health. ENVIRONMENTAL INEQUALITY Special populations of children remain at higher risk for lead toxicity and exposure to other environmental hazards. Public health researchers have begun to explore the role of disparate exposures to environmental pollutants and the contribution to health inequities and health disparities (Evans and Kantrowitz, 2002). Children living in low-income families and children of color tend to live near environmentally hazardous facilities and bear a larger share of the health burden from exposure to toxins (Brulle and Pellow, 2006). Protection of these populations of children remains a major public health concern. Sound environmental health policy is critical for the protection of these special populations of children to limit their exposure to toxins. The Environmental Protection Agency (EPA) defines environmental justice and fair treatment in relation to environmental laws, regulations, and policies: “Fair treatment means no population, due to policy or economic disempowerment, is forced to bear a disproportionate share of the negative human health or environmental impacts of pollution or environmental consequences resulting from industrial, municipal, and commercial operations. . .” (Institute of Medicine Committee on Environmental Justice, 1999). The environmental justice movement continues to assess the effectiveness of public health efforts to reduce exposures to specific chemicals. Currently, only
43% of high-volume chemicals have been tested for their potential toxicity on humans, and only 7% of the chemicals tested have been studied for possible effects on young children and the developing fetus (Landrigan, 2005). Researchers, policy analysts, and environmental justice groups are advocating for adoption of the Precautionary Principle, a paradigm shift in how society addresses environmental risks (Bruelle and Pelloa, 2006). Rather than presuming that specific chemicals or production processes are safe until proven hazardous to human health, the Precautionary Principle shifts the burden of proof to the producers to show an absence of harm (Bruelle and Pellow, 2006). Under this principle, communities with populations living in areas with exposures to chemicals pollutants suspected to cause harm can argue for temporary suspension of use or elimination of production of chemical substances until absolute proof that the chemical is not associated with adverse health effects. Recent legislation in Germany, Sweden, Australia, Scotland, and Norway resulted in adoption of the Precautionary Principle. ENVIRONMENTAL HEALTH ADVOCACY Nurses and Nurse Practitioners caring for children have a long history of effectively advocating for environmental health at the local, state, and federal levels. These efforts have contributed to environmental health policies that have improved the health outcomes of children. Numerous state and federal laws enacted in the 1990s addressed issues of lead exposure, environmental tobacco smoke, and chemical pollutants hazardous to children’s health. In October 2002, the CDC solicited nominations from health care providers and the public for categories of chemicals for possible inclusion in further studies on potential chemJournal of Pediatric Health Care
ical toxicants. They received nominations for hundreds of chemicals (CDC, 2002). Pediatric health care providers need to develop an increased awareness of exposures to toxins and sources of chemical toxicants in children’s surroundings and observe for potential effects on children’s health (Box 2). It is important to be aware of potential chemical and biological hazards in the communities where children under their care live and play. Advocacy for increased surveillance of potential biological toxins and chemical pollutants and for community testing of potentially harmful substances remains a priority. State and federal legislation is needed to increase funding for research on chemical and biological substances and to establish safe levels of exposure to pollutants for adults and children, particularly during critical periods of development. CONCLUSION The lifelong impact of exposure to lead and the burden of public health care costs related to lead toxicity remain critical examples of the importance of ongoing surveillance of potential chemical and biological hazards in children’s surroundings. Legislators and health policy analysts should study the benefits of adoption of the Precautionary Principle as an adjunct to
Journal of Pediatric Health Care
BOX 2. Environmental health resources for pediatric health care providers Centers for Disease Control and Prevention (CDC) www.cdc.gov Agency for Toxic Substances and Disease Registry www.atsdr.cdc.gov Environmental Protection Agency www.epa.gov Children’s Environmental Health www.cehn.org/index.html National Environmental Educational and Training Foundation www.neetf.org/Health/PEHI
public health surveillance of chemical and biological substances. Developing prudent environmental health policies and limiting exposure to chemical and biological toxins protects the health of our children now and in the future. REFERENCES Bruelle, R. J., & Pellow, D. N. (2006). Environmental justice: Human health and environmental inequalities. Annual Review of Public Health, 27, 103-124. Canfield, R. L., Henderson, C. R., CorySlechta, D. A., Cox, C., Jusko, T. A., & Lanphear, B. P. (2003). Intellectual impairment in children with blood lead concentrations below 10 micrograms per deciliter. New England Journal of Medicine, 348, 1517-1526.
Centers for Disease Control and Prevention National Center for Environmental Health. (2005). Third Annual Report on Human Exposure to Environmental Chemicals. Atlanta, GA: Centers for Disease Control and Prevention. Etzel, R. A., & Balk, S. J. (Eds) (2003). Pediatric Environmental Health. Elk Grove Village, IL: American Academy of Pediatrics. Evans, G. W., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 303331. Centers for Disease Control and Prevention. (2002). Federal Register, Vol. 67, No. 194. Retrieved October 7, 2002 from http://www.cdc.gov/exposurereport/ pdf/fr_100702.pdf. Gitterman, B. A., & Bearer, C. F. (2001). A developmental approach to pediatric environmental health. Pediatric Clinics of North America, 48, 1071-1083. Institute of Medicine Committee on Environmental Justice. (1999). Toward environmental justice: Research, education, and health policy needs. Washington, DC; National Academy of Press. Landrigan P. J., Schechter, C. B. Lipton, J. M., Fahs, M. C., & Schwartz, J. (2002). Environmental pollutants an disease in American children: Estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer and developmental disabilities. Environmental Health Perspectives, 110, 721-728. Landrigan, P. J. (2005). Children as a vulnerable population. Human and Ecological Risk Assessment, 11, 235-238. Lidsky, T., & Schneider J. (2006). Adverse effects of childhood lead poisoning: The clinical neuropsychological perspective. Environmental Research, 100, 284-293.
November/December 2006 413