1. Vulnerability of Children to Environmental Assaults Philip J. Landrigan, MD, MSc Mount Sinai School of Medicine New York, USA Workshop on Environmental Threats to the Health of Children in the Americas Lima, Peru April, 2003

2. Children Today are Surrounded by an Ever Increasing Number of Chemicals

3. Synthetic Organic Chemical Production

4. Most of the chemicals to which children are exposed have not been properly tested for toxicity 80,000 + chemicals in commerce 2,863 produced or imported in quantities of 1 million p80,000 + chemicals in commerce 2,863 produced or imported in quantities of 1 million pounds or more per year (high production volume [HPV] chemicals) No basic toxicity information is publicly available for 43% of HPV chemicals Full information on toxicity is publicly available for only 7% of HPV chemicals --EPA: Chemical Hazard Data Availability Study, 1998

5. Children are Especially Vulnerable to Environmental Toxins “Children are not Little Adults” Greater exposure pound-for-pound Diminished ability to detoxify and excrete many chemical toxins Heightened biological vulnerability, e.g., thalidomide, DES More years of future life US National Academy of Sciences, 1993

6. Patterns of Disease in Children Change as Nations Undergo Transition to Industrialization Infectious diseases exert a less powerful influence over patterns of disease and death Chronic diseases become increasingly important This phenomenon is termed the epidemiological transition

7. The Epidemiolgical Transition in the United States

8. The predominant causes of illness, hospitalization and death among children in the developed nations today are chronic diseases of multifactorial and incompletely understood etiology “The New Pediatric Morbidity” Evidence is accumulating that environmental factors contribute to the causation of these diseases

9. Examples of the New Pediatric Morbidity Asthma Pediatric Cancer Birth defects Neurodevelopmental disabilities

12. Childhood Cancer (Age 0-19), Age-Adjusted Incidence and Death Rates, 1975-1996 Source: Pediatric Monograph 1999, Surveillance, Epidemiology, and End Results Program Division of Cancer Control and Population Sciences, National Cancer Institute. American Cancer Society, Surveillance Research

14. U.S. Incidence of Testicular Cancer The overall incidence of testicular cancer rose substantially in the United States from 1973 to 1996. Specifically rates in white males increased 51.2% over that period, while rates for black males rose only 17.3% (the latter increase was not statistically significant). While undescended testes, inguinal hernia, and prenatal factors have been implicated as possible risk factors, the cause of the trend in unknown.

16. Case Study in Developmental Disabilities - Lead Poisoning  A report from Queensland, Australia in 1904 described an epidemic of lead poisoning in young children.  Clinical and epidemiologic investigation traced the source of the outbreak to the ingestion of lead- based paint by children playing on verandahs.  This report led to the banning of lead-based paint in many nations, although not in the United States until 1978.

17. Clinical Lead Poisoning Coma and convulsions Peripheral neuropathy Kidney failure Anemia

18. Subclinical Lead Poisoning Decreased IQ Altered behavior Slowed nerve conduction Elevated uric acid Elevated FEP

19. Subclinical Toxicity … the concept that relatively low dose exposure to certain chemicals … may cause harmful effects to health that are not evident with a standard clinical examination. The underlying premise is that there exists a continuum of toxicity, in which clinically apparent effects have their asymptomatic, subclinical counterparts.

20. Population Impact of Subclinical Toxicity

22. Subclinical toxicity has become a widely recognized phenomenon in Children’s Environmental health Lead Methyl Mercury Polychlorinated biphenyls (PCBs) Certain pesticides (probably))

23. Children’s Environmental Health - The International Dimension The export of toxic chemicals and hazardous processes from the industrially developed to the developing nations of the world has the potential to profoundly change patterns of morbidity and mortality, especially in children

24. Examples of the International Spread of Toxic Chemicals Bhopal Asbestos export Export of “banned” pesticides Arsenic in Bangladesh Pesticides in central Asia Export of hazardous waste

25. Bhopal, India: A Sentinel Event

26. Bhopal, India

27. Outside Carbide Factory. Bhopal, India

28. Bhopal, India

29. The International Spread of Lead in Gasoline Lead was first added to gasoline in 1922 By the 1970s, almost all gasoline produced worldwide contained lead In the USA, peak annual consumption was almost 200,000 tons (mid-1970s) A disaster for public health Recognition of toxicity to children led to removal of lead from gasoline led to removal of lead from petrol

30. Lead used in gasoline declined from 1976 through 1980 Year 1975197619771978197919801981 30 40 50 60 70 80 90 100 110 Gasoline lead Lead used In gasoline (1000 tons) Source: Annest, Pirkle, Makuc, et al., Chronological trend in blood lead levels between 1976 and 1980. NEJM 1983; 308;1373-7.

31. Blood lead Year 1975197619771978197919801981 30 40 50 60 70 80 90 100 110 9 10 11 12 13 14 15 16 17 Gasoline lead Lead in gasoline and lead in blood NHANES II, 1976-1980 Blood lead levels (  g/dL) Lead used In gasoline (1000 tons) Source: Annest, Pirkle, Makuc, et al., Chronological trend in blood lead levels between 1976 and 1980. NEJM 1983; 308;1373-7.

32. 1974197619781980198219841986198819901992 2 4 6 8 10 12 14 16 18 Blood lead levels (  g/dL) 0 1994199619982000 Blood lead levels in the U.S. population 1976 -1999 NHANES II, III, 99+ Year Source: CDC. National Report on Human Exposure to Environmental Chemicals, March 2001

33. Phase Out of Lead Worldwide The beneficial effects of the removal of lead from petrol were seen in the following countries: USA Western Europe Australia Canada New Zealand South Africa China El Salvador India Mexico Thailand

34. The International Export of Asbestos

35. Trends in World Production of Asbestos YearProduction (tons) 1963 1973 1978 1983 1988 1993 1994 1995 1996 2,922,000 4,614,000 5,159,000 4,276,000 4,323,000 2,650,000 2,410,000 2,308,300 (a) 2,140,000 (a) (a) Chrysotile only.

36. World Production of Asbestos by Country (tons), 1995 Russia Canada China Brazil Zimbabwe South Africa Greece Swaziland India United States Colombia Romania Yugoslavia 1,000,000 510,800 250,000 180,000 145,000 100,000 50,000 30,000 25,000 9,000 5,000 3,000 1,000

37. Principal Chrysotile Consuming Countries in 1994 NationAnnual usage (tons) Russia China Japan Brazil Thailand India South Korea Iran France Indonesia Mexico Columbia Spain USA Turkey Malaysia South Africa TOTAL 700,000 220,000 195,000 190,000 164,000 123,000 85,000 65,000 44,000 43,000 38,000 30,000 29,000 25,000 21,000 20,000 2,021,000

38. Asbestos is Known to Cause the Following Diseases: Lung Cancer Malignant Mesothelioma Asbestosis Other Malignancies

39. On the basis of these facts the Collegium Ramazzini has called for an international ban on all uses of asbestos. ICOH has joined the Collegium Ramazzini in calling for this ban

40. Domestically Forbidden Pesticide Exports from USA, 1997-2000 Products unregistered in the U.S. were exported at an average rate of 16 tons per day 57% of products were shipped to developing nations Over 21% of products were shipped to Belgium and the Netherlands The rest (22%) of products were shipped to unknown destinations, probably also developing nations Largest-volume chemicals exported –Butachlor (nearly 14 million pounds) –Carbosulfan (10.2 million pounds)

41. The WHO Program in Children’s Environmental Health An extremely positive development The theme this year of World Health Day is “Healthy Children in Healthy Environments”

42. The Bangkok Declaration We will have to continue to join together as we do today, to continue sharing our knowledge, experience, and support. This conference is a call to governments, civil society, the private sector, and the whole international scientist community to renew our commitment to children’s health by advancing a new vision for the 21 st century – a vision in which every child has a healthy life and a clean environment. Professor Le Hung Lam Hanoi School of Public Health, 2002

43. Actions Needed for Prevention Child-Protective Risk Assessment Child-Protective Regulation Right-to-Know Legislation Children’s Environmental Health research Training programs Increased emphasis on the Precautionary Principle – Presume that children are more vulnerable in the absence of evidence to the contrary International Program in Children’s Environmental Health

44. A New Direction in Research National Children’s Study A multi-year prospective epidemiological study to examine the influence of children’s early life exposures to environmental toxins As many as 100,000 children followed from before birth to at least 18 years of age Explore simultaneous impact of many risk factors on the long term health of children

45. Critical Research Questions to be addressed through the National Children’s Study Contribution of indoor and ambient air pollution to the origins of asthma Environmental causes of developmental disabilities in children Effects of endocrine disruption Causes of the rising incidence of certain pediatric cancers

46. Summary What are Children? Our children are the current inhabitants of a developmental stage through which all humans must pass The protection of children is essential for the sustainability of the human species They are our future