WHO/SDE/PHE/02.06

World Health Organization Healthy Environment for Children WHO/SDE/PHE/02.06

Initiating an Alliance for Action

World Health Organization Initiating an Alliance for Action

© World Health Organization 2002

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SUMMARY

hildren are exposed to serious health risks international level, and by alliances at the national from environmental hazards. Over 40% and local level. Cof the global burden of disease attributed to environmental risk factors fall on children below This initiative is seen as an umbrella, 5 years of age, who account for only about 10% encompassing all efforts that support action based of the world’s population. Environmental risk on scientific evidence. This should ensure that factors often act in concert, and their effects are investments are made to address real priorities exacerbated by adverse social and economic through the most cost-effective measures. Key conditions, particularly poverty. Children are elements for implementation include taking stock particularly vulnerable, and action needs to be of ongoing efforts; creating a popular movement taken to allow them to grow up and develop in by mobilizing all potential players that can make good health, and to contribute to economic and a difference; consolidating and disseminating social development. The aims for action are set scientific knowledge on risk factors and cost- by the Millennium Development Goals, whose effective interventions; initiating and promoting targets are reduced child mortality and research to complement existing knowledge and environmentally sustainable development. support efficient action, and efforts to make healthy environments for children a major The Healthy Environments for Children initiative component of policy-making; promoting the is designed to protect children from the physical healthy settings approach; and fostering hazards in their environment, within the context intersectoral, integrated collaboration. of social, economic and behavioural determinants. This initiative should build upon the active and Priorities will be set at the local, national or committed involvement of various stakeholders, regional level by the initiative, and a number of such as decision-makers, community leaders, priority risk factors have been identified as major teachers, health professionals, nongovernmental global issues, requiring concerted international organizations (NGOs), the private sector, and the action. These are: household water security, families. The outcome is expected to be the hygiene and sanitation, air pollution, disease creation of a concerted, popular, participatory and vectors, chemical hazards, and injuries and inclusive movement, supported by a global alliance accidents. Approaches to scale up actions are of key institutions and organizations at the proposed for each risk factor.

The present document has been prepared by the WHO Secretariat in support of discussions to be held during the World Summit on Sustainable Development (WSSD) in Johannesburg, South Africa, in August/September 2002. Information is presented to stimulate the creation of an alliance for action, as broad-based as possible, for the initiation of a worldwide movement on Healthy Environments for Children during the months immediately following the WSSD.

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TABLE OF CONTENTS

1. THE NEED FOR ACTION ...... 1

2. ENVIRONMENTAL RISK FACTORS FOR CHILD HEALTH...... 3

3. PRIORITY ENVIRONMENTAL HEALTH ISSUES...... 7 3.1 Household water security ...... 7 3.2 Hygiene and sanitation...... 9 3.3 Air pollution ...... 11 3.4 Disease vectors ...... 13 3.5 Chemical hazards ...... 15 3.6. Injuries and accidents ...... 17

4. CREATING HEALTHY SETTINGS ...... 18

5. MECHANISMS FOR IMPLEMENTATION ...... 21

6. MONITORING CHILDREN’S ENVIRONMENTAL HEALTH...... 23

7. BUILDING A GLOBAL ALLIANCE ...... 24

ANNEX – THE BANGKOK STATEMENT ...... 27

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1. THE NEED FOR ACTION

hildren today live in an environment Poor children: that is vastly different from that of a ■ are more likely to die in the first month Cfew generations ago. New challenges of life, in the first year of life, or before include increasing industrialization and they reach the age of five; globalization, rapid urban population growth, non-sustainable consumption of natural ■ are sick more often and more seriously; resources, and increases in the trade and use ■ are less well-nourished and are more likely of chemicals. While economic development to lag behind in growth and psychosocial and improved hygiene and health care have development; led to a significant decrease of childhood ■ are more likely to have difficulties at morbidity and mortality in many parts of the school and on the job world, new “modern” risks to children’s health must now be added to the “basic” … than better-off children. environmental risks such as unsafe drinking- water, lack of adequate sanitation, and indoor Social, economic and behavioural factors air pollution, which are closely linked with largely impact on the health outcomes due to and aggravated by persistent poverty and unhealthy environments. Malnutrition social inequity. Exposure to environmental associated with poverty often results in an risk factors during childhood may not only increased susceptibility to infections and to impact on a child’s health, but ill-health the effect of chemical pollutants, and so do outcomes may persist through into adult life unhealthy behaviours, such as inadequate or may appear during adulthood. Unsafe and personal hygiene, and the lack of a care-giving unhealthy environments are thus violating social environment. This requires a children’s rights to health, and represent a comprehensive approach addressing not only serious threat to the potential for sustainable the physical environment, but also the development. psychosocial and economic determinants that impact on health outcomes. While the environmental burden of ill health affects all children, it is greatest among the poor, whether in the poor regions of the Healthy Environments for Children – The world, in poor countries, in poor foundation of sustainable development communities or in poor households within Sustainable development has three main cities. Inequities in child health constitute components: economic development, social systematic and relevant differences between justice, and environmental protection. Healthy population groups that are both avoidable and environments for children are at the same time unfair. These inequities not only relate to a a condition depending on all of these elements. socioeconomic gradient (e.g. income, education), but often exist in relation to Poverty is the single biggest threat to children’s gender, family structure (e.g. orphans, single- health and affects children often through parent households), geographic differences environmental factors such as sanitation and (e.g. rural versus urban), ethnicity and other clean air. Economic development and social justice are prerequisites to overcome poverty. factors.

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■ to help countries and communities create The bare survival of millions of children is at stake and needs to be addressed now. In and maintain healthier environments, addition, many environmental exposures of enabling children to grow and develop children cannot be corrected during their adult to their full potential as citizens in their life. Healthy environments are a condition to own right and contribute to sustainable safeguard children’s intellectual, social and development; and economic potential, and the future of our societies. ■ to promote safe and healthy homes and communities for children, as well as While the environmental burden of disease is by far highest among poor children, the healthy behaviours. environment also impacts on those children living in medium and high income societies. For action to be successful, credible and concrete targets will have to be set at the local level, taking into consideration the priority environmental threats to be addressed, the Goal and objectives appropriate settings in which children are exposed to given risk factors, and the needs Children are more susceptible than adults to of the different age groups involved. Action the effects of environmental health hazards, will centre on environments where children, and therefore require special protection. The boys and girls of all age groups from aim of the current initiative is to launch a conception to adolescence, spend their time movement to ensure appropriate action to in their homes and surroundings, schools and promote healthy environments for children. recreation areas, and community places in This movement will be supported by an both urban and rural areas, especially (but not alliance and involve partners from various exclusively) in the developing countries. sectors, and at various levels of responsibility. The overall goal of the movement is to prevent One major aim of the movement will be: “the disease and disability in children associated home as a safe place” for every family, with biological, chemical and physical irrespective of the level of their income. There environmental hazards, with due recognition is a need for basic protection of each child of the importance of behavioural, social and given a space with access to clean drinking- economic factors. This goal is in line with the water and food, adequate sanitation, a space free from risk of injury, such as unprotected Millennium Development Goals i.e. to fires, or unprotected machinery and tools, a reduce child mortality (Goal 4), and to ensure space protected from as much indoor environmental sustainability (Goal 7). Thus, pollution as possible, and with as much the movement should be instrumental in daylight as possible. The child needs a achieving the target to “reduce by two-thirds stimulating environment, including toys, colours and enough space for play, tailored between 1990 and 2015 the under-five to the different needs of infants, children and mortality rate”. adolescents.

The main objectives of the movement will be: It should be recalled that malnutrition is ■ to provide the knowledge base to enable responsible for by far the largest global burden informed policy action; of disease through its effects on the immune system. The achievement of food security is a ■ to raise the awareness of decision-makers key prerequisite to achieve health and and ensure their political commitment environment objectives. Therefore, the to take action; movement could not achieve its goals and

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targets without concurrent progress being ■ Declaration of the Environment Leaders made in combating malnutrition of children of the Eight (G8) on Children’s at all age levels. Environmental Health (1997), as confirmed by the Banff Ministerial Statement on the World Summit on Growing international concern calls for Sustainable Development (2002). action ■ The United Nations General Assembly Special Session on Children (UNGASS) The Convention on the Rights of the Child (2002). (1989) lays down the fundamental right of ■ The Bangkok Statement – A Pledge to every child to “the enjoyment of the highest Promote the Protection of Children’s attainable standard of health”. Several recent Environmental Health (2002): see international declarations and policy Annex. statements demonstrate a growing commitment to a healthier and safer Several other recent recommendations address environment for children. Three of these are specific issues related to healthy environments of particular relevance: for children, such as the ILO Convention 182 on the Worst Forms of Child Labour (1999).

2. ENVIRONMENTAL RISK FACTORS FOR CHILD HEALTH

hroughout the world, children face environmental risk is associated with many significant threats to health from a different health outcomes, and a range of Twide range of environmental hazards. environmental exposures may influence a Preliminary estimates suggest that up to one particular disease condition. This is based on third of the global burden of disease can be the contribution of environmental risk factors attributed to environmental risk factors. Over to global child mortality and morbidity, 40% of this burden fall on children under 5 thereby highlighting the biggest years of age who make up only about 10% of environmental threats to children’s health, and the world’s population. Inadequate drinking- illustrates the potential for disease prevention water and sanitation, indoor air pollution, through the association of specific risk factors injuries and other risk factors are the root with distinct settings. In addition, there are cause for more than 4.7 million deaths non-environmental risk factors which tend to suffered annually by children under five from aggravate the health impacts emanating from illnesses aggravated by unhealthy the child’s environment. Nutrition is one such environments. key factor, either in the form of malnutrition or the lack of micronutrients or in the form The health and environment linkages of obesity due to sedentary lifestyle or affecting children are numerous and complex. unhealthy eating habits. In most cases, exposure to a particular

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Health-and-hygiene-environment linkages for children

Community Setting School Home

Risks factor

Disease

outcomes ransportation

Housing conditions

Emergency situations

T

Lead

Food safety and supply

Recreational activities Occupational Environments

UV radiation

Outdoor air

Pesticides and other chemicals

Disease vectors

Indoor air

Water, sanitation and

Diarrhoeal diseases

Acute respiratory Infections

Tuberculosis

Perinatal effects

Nutritional diseases

Malaria & other vector diseases

Child cluster diseases

Chronic respiratory diseases

Cancer

Injuries & accidents

Drowning

Poisonings

Cognitive effects

While a global analysis of the burden of associated with persistent poverty and social disease in children associated with inequity. The two major problems are: environmental risk factors helps identify communicable diseases due to lack of safe priorities for global action, additional risk water and sanitation, and acute respiratory factors may result in a high disease burden at infections due to high levels of indoor air the regional or local level. Developing a cause- pollution in combination with unhealthy effect matrix for a particular geographical housing. The virtual disappearance of these region based on a differentiated analysis of two leading causes of child mortality, with the burden of disease will help identify the transition towards an industrialized priorities for regional initiatives or society, demonstrates the dominant influence programmes to create healthy environments of socioeconomic factors on the nature and for children. magnitude of children’s health problems.

However, communicable diseases do not An unequal disease burden: the risk occur exclusively in developing countries and transition toxic chemicals are not exclusively associated with industrialized countries. There are A differentiated analysis of the global burden pockets of poverty in rich countries where of disease (GBD) reveals that most certain population groups experience environmental threats to children’s health are deprivations with their associated health

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problems, which are similar to those in radiation, endocrine disruptors, autoimmune developing countries. Also, toxic chemicals effects, and other diseases not directly related are increasingly being used in developing to the quality of the child’s environment. Any countries, often with fewer controls and potential health-and-environment linkages regulations than in industrialized countries. require further research and a search for other causative factors or combinations of factors. There is a clear shift in the pattern of leading environmental health problems in children. Environmental risks to children tend to be This differential is not only measurable greater among rural populations compared between rich and poor countries but also with urban populations, and an unequal between population groups within a given disease burden on the rural poor may be country and within any urban agglomeration, further aggravated by lack of access to health ranging from periurban slums with sub- care. However, the health status of children standard housing to affluent modern suburbs. living in urban poverty is equally Typical “modern” risks include chronic preoccupying. Consequently, population- respiratory illnesses, asthma, immunological based risk assessment is the prerequisite of a disorders, neurological, neurodevelopmental cost-effective strategy, with tailored and behavioural effects, as well as childhood interventions to reduce the environmental cancers. In addition, there are emerging risks disease burden in children. such as environmental allergens, UV

Transition of children’s environmental health risks with economic status

Basic risks : Unhealthy housing Basic risks Unsafe water supply Lack of sanitation Indoor air pollution Lead in gasoline Modern Importance of risks Modern risks : environmental Respiratory factors (asthma) risks Transport accidents (injuries) Recreational activities Toxic chemicals

Emerging issues : UV radiation Emerging Environmental allergies risks Endocrine disruptors

Low Middle High Income Populations Populations Industrialized Socio-economic in poverty in transition societies development

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Focus on action Specific issues may be of relevance to geographically defined areas of the world. For The above overview of health and example, Australia has the highest rate of skin environment linkages demonstrates that the cancer in the world, which is attributable to design and implementation of programmes people’s exposure to high levels of UV to promote healthy environments for children radiation. Frequent sun exposure and sunburn must, in addition to addressing global risks, in childhood set the stage for high rates of tackle problems at the regional and local level. skin cancer later in life, and may cause or Only the selection of key risk factors locally accelerate cataract development and limit the can guarantee that one sees the prevailing effectiveness of the immune system. Similarly, health risks in combination, and can detect arsenic contamination of drinking-water their synergistic or aggravating effects drawn from groundwater is a priority issue detected. in some countries of South-east Asia.

For example, the Strategy for Children’s Identifying priorities and building a Environmental Health in Latin America and programme should take into account and seek the Caribbean has identified the following as synergies with existing activities such as single- priorities for action: (i) water resources, water issue campaigns for water or food security; quality and basic sanitation, (ii) indoor and risk-focused programmes to eradicate the outdoor air quality, (iii) heavy metals, (iv) worst forms of child labour, to prevent injuries pesticides, and (v) climate variability and and accidents, or to create a tobacco-free change. environment; and disease-specific programmes such as Roll Back Malaria. The Third European Ministerial Conference Activities to create healthy environments for on Environment and Health, held in London children should complement these efforts in 1999, recognized (i) injuries, (ii) smoking rather than re-create existing programmes. and environmental tobacco smoke, and (iii) asthma and other related respiratory diseases As a first step, and to make the best use of as the main environmental threats to scarce resources, global action should focus children’s health in Europe. In addition, the on improving the health and wellbeing of apparent increase in childhood cancers and those children who are most at risk, as neurodevelopmental disorders, and the risk described in detail in the following section. of water and food-related diseases are also subjects of major concern.

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3. PRIORITY ENVIRONMENTAL HEALTH ISSUES

hroughout the developing world, of reducing by two thirds the under-five traditional environmental health mortality rate. Thazards remain the primary source of ill-health today e.g. biologically contaminated water, poor sanitation, indoor smoke, 3.1 Household water security rampant disease vectors such as mosquitoes, an inadequate food supply, and unsafe waste A child’s wellbeing is highly dependent on disposal which are all usually associated with both the quality and the availability of water, poverty and social exclusion. In addition, the and on how well this precious resource is very same populations are often also exposed managed. Around the world, both biological to toxic chemicals with little or no protection. disease agents and chemical pollutants are Children’s health problems resulting from compromising drinking-water quality. these hazards rank among the highest Contaminated water causes a range of diseases environmental burden of disease worldwide. which are often life-threatening. Of the water- borne diseases affecting children, the most Significant progress in reducing the deadly are diarrhoeal infections. Diarrhoea is environmental burden of disease on a global estimated to cause 1.3 million child deaths scale can only be achieved through focusing per year, constituting about 15% of total child on the key risk factors. Comprehensive deaths under five in developing countries. The comparative risk assessment suggests most dramatic event in recent history has been concentration on a cluster of six the cholera epidemic in South America, which environmental issues, as follows: started in Peru in 1991 and then swept across ■ Household water security the continent. ■ Hygiene and sanitation The public health importance of diarrhoea ■ Air pollution among children lies partly in the high ■ Disease vectors mortality rates as well as in the interactions between malnutrition, recurrent diarrhoea ■ Chemical hazards and impaired child development. Contrary ■ Injuries and accidents. to breastfed infants, bottle-fed infants are highly exposed to the effects of unsafe The combined effects of these environmental drinking-water. It cannot be overemphasized risks are, in one way or another, “diseases of that the transmission routes for infectious poverty” and constitute the bulk of child agents are complex and thus contribute to the mortality and morbidity on a global scale. The complexity of prevention. Interventions in proposed action programme for healthy water supply, sanitation and hygiene are environments for children is designed to focus estimated to reduce diarrhoeal incidence, on on interventions to prevent or reduce child average, by a quarter (25%) and child exposure to these risk factors, and to support mortality by 65%. However, selected health services at all levels in managing related interventions have been shown to be much disease outcomes. Thus it should make a more efficient in certain settings. crucial, if not decisive, contribution towards achieving the Millennium Development Goal

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Water quality Health outcomes - - Contamination by pathogenic contamination pathogens Diarrhoeal diseases, Typhoid, - Chemical pollution Hepatitis A,E,F (e.g. arsenic, fluoride)

Poverty Lack of access to safe water resources Health outcomes - chemical contamination Arsenicosis Water quantity Fluorosis Insufficient quantities of safe water available for drinking, cooking and personal and domestic hygiene

Hygiene-related diseases Trachoma Scabies

Some dangerous chemicals also occur purposes is considered as important as its naturally in groundwater, notably fluoride quality. Already, one third of the world’s and arsenic. The consumption of fluoride-rich population lives in countries facing moderate drinking-water results in serious health effects, to high water stress, if not water scarcity, and ranging from dental fluorosis to crippling water tables are falling in every continent. If skeletal fluorosis, both effects being present trends continue unchecked, it is irreversible. Children whose teeth and bones estimated that two out of three people on are still developing are most susceptible to earth will live in water-stressed conditions by high fluoride concentrations. This is further the year 2025. Globally, 1.1 billion people aggravated by poor nutritional status. are today without access to a clean and Symptoms start to develop during childhood, adequate water supply. And too little water and preventing exposure represents the only for basic needs makes it virtually impossible effective intervention. At least 25 countries to maintain the necessary minimum of across the globe are affected. In Bangladesh personal hygiene and sanitary conditions in and India (West Bengal), high concentrations the home. of arsenic have been found in tubewells and arsenicosis has become widespread. Arsenic Traditionally, improvements in water supply can cause severe and irreversible health effects, and sanitation have been promoted as even at chronic and low levels of exposure, essential public health measures to improve with onset in early childhood and symptoms the population’s health status. If universal emerging gradually. There are at least twelve piped and regulated water supplies were to other countries suffering from naturally high be achieved, about 7.6 billion episodes of arsenic levels in water. diarrhoea could be prevented annually, a 70% reduction. These are critical interventions for The availability of at least minimal amounts the health of populations and of children in of water for drinking and other personal particular.

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Scaling-up of actions service coverage are to be found in Asia and Africa where more than half of the rural Further strengthening of the evidence base, populations are excluded from any with better geographical coverage and measurable progress in this area. Globally, 2.4 specificity for children in different age groups billion people, most of them in developing is required in the area of water accessibility countries, do not have access to improved and safety, and this should underpin policy- sanitation facilities. Data collected over ten making and advocacy for cost-effective years show that little progress has been made interventions. in reducing this number.

Improved water supply and sanitation has Unhygienic conditions and practices at the long been targeted as a priority for health and household level create a dangerous development. It was central to the environment with immediate health risks to International Drinking Water Supply and children. Also, lack of sanitation facilities in Sanitation Decade, and more recently is schools helps transmit diseases. Waste dumps reflected in the Millennium Development sited on the outskirts of almost all major cities Goals set by world leaders at the UN provide hazardous environmental conditions Millennium Summit in September 2000. The to those living nearby, and even more so to target is to “halve, by 2015, the proportion those living as scavengers on such wastes. of people without sustainable access to safe Sanitation interventions, technical and drinking water” through the promotion of managerial, are badly needed in all areas in affordable and environmentally sound houses, schools, and within the community technologies. at large. These must be accompanied by the necessary behavioural changes in the child and Action has also to be accelerated to fulfil the adult populations, which pose a formidable commitment made at the UN Millennium hygiene education challenge to the health Summit to halt the unsustainable exploitation sector. of water resources by developing water management strategies at the regional, Tr achoma is one of the infectious diseases national and local levels, which will secure which are linked to environmental conditions, both equitable access and adequate water and is thus amenable to effective supplies. environmental interventions. Worldwide there are around 6 million people irreversibly Capacity-building efforts should be geared blinded by trachoma and about 500 million towards strengthening the enforcement of people are at risk of the disease. Improved existing environmental regulations on water sanitation and hygiene behaviour contribute quality and resource protection. This requires significantly to the control of trachoma. also close monitoring of drinking-water Through the provision of adequate quantities quality at the local service level through of water alone, about one quarter of the practical and cost-effective methods. burden of this disease could be prevented or reduced.

3.2 Hygiene and sanitation Intestinal worms severely affect about 10% of the population of the developing world. Children, due to their direct exposure to soil Lack of adequate sanitary facilities and poor and other helminth-carrying material are hygienic practices are common throughout especially at risk, and they are generally more the developing countries; the lowest levels of worm-infested than adults. Intestinal parasitic

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Poverty Lack of access to basic sanitation infrastructure

Pathogenic contamination of the environment and of drinking water resources

Health outcomes Diarrhoeal diseases Trachoma Scabies Helminthic infections Education - Ascariasis Lack on information on -Trichuriasis health consequences of poor - Hookworm hygiene Poor hygiene in a contaminated environment leads to person-to-person transmission of disease and contamination of food

infections in children can lead to household sanitation facilities through malnutrition, anaemia and retarded growth, affordable interventions, including the depending upon the severity of the infection, development of a sense of responsible in addition to their adverse effects on the ownership and use following the common immune system. Exposure to helminths and rules of hygiene. All potential pathways of hookworms can be effectively controlled disease transmission have to be addressed, through improved sanitation, hygiene and including drinking-water, safe handling of water supply. food, excreta disposal, and personal hygiene.

Improved hygiene practices, including both Scaling-up of actions hand and face washing, and safe handling and disposal of children’s faeces should be Further work on the evidence base, specifically promoted through educational campaigns in targeting children, is required across the the community and in kindergartens and spectrum of sanitation, hygiene and schools. behavioural interventions to reduce infectious diseases with an environmental etiology. This Several UN and other organizations in 2000 entails child-specific research efforts on the launched FRESH (Focusing Resources for impact of alternative sanitation methods on Effective School Health) to achieve more child disease outcome, supported by pilot- child-friendly schools. This includes a simple scale and expanded implementation of high- set of core interventions, health-related school yield health interventions, using feedback policies, provision of safe water and sanitation from experience to guide future activities. in all schools, skills-based health and hygiene education, and school-based health and The setting of most significance in the child’s nutrition services. environment is the home and this should be given prime attention. This implies improved

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3.3 Air pollution particles, carbon monoxide, and carcinogenic compounds. Air pollution is a major environment-related health threat to children and a risk factor for Infants are most at risk due to the immaturity both acute and chronic respiratory disease. of their respiratory organ systems and their Outdoor air pollution, primarily a high exposure when carried on their mother’s consequence of traffic and industrial back or placed near the cooking stove. The processes, remains a serious problem in cities assessment of the burden of disease throughout the world, particularly in the attributable to indoor air pollution, which is megacities of developing countries. It is currently under way, will further strengthen estimated that a quarter of the world the evidence that indoor air pollution presents population is exposed to unhealthy a substantial risk to children’s health and concentrations of air pollutants. In recent demands concerted global action. years, indoor air pollution has received more and more attention: a pollutant released While second-hand tobacco smoke and indoors is a thousand times more likely to certain outdoor air pollutants are known risk reach the lungs than a pollutant released factors for acute respiratory infections, indoor outdoors. Indoor air pollution is strikingly air pollution from biomass fuel smoke is by different in industrialized and developing far the biggest single contributor to the global countries, and also varies between urban and burden of disease. In principle, several rural settings. While the main concern in different types of interventions are capable of developing countries is the exposure to producing a reduction in exposure to indoor combustion products from biomass fuel and air pollution. These include (i) interventions coal, poor indoor environments in the relating to the source of pollution, e.g. industrialized world are characterized by changing to cleaner fuels or improved stoves, reduced ventilation, the presence of biological (ii) interventions in the living environment, agents such as moulds, and a myriad of e.g. better ventilation, and (iii) changes in user chemicals in furnishing and construction behaviour, e.g. keeping children away from materials. the smoke or eliminating tobacco smoking in the home. Beyond their effectiveness in reducing the level of indoor air pollution, Acute respiratory infections these interventions should also meet several other criteria such as local participation, in More than half of the 2.1 million annual particular of women, to ensure a culturally deaths in children under five caused by acute appropriate and sustainable approach. lower respiratory infections may be associated with indoor air pollution, lack of adequate Initial work on assessing the economic costs heating, or other precarious living conditions. and benefits of interventions in household Indoor air pollution from the combustion of energy is encouraging. For example, the cost- biomass and coal is a serious and widespread effectiveness of an improved stove appears to problem in developing countries. Some 3 compare favourably with other important billion people worldwide rely on biomass fuels health interventions. However, as and coal for cooking and heating needs. Of interventions to reduce indoor air pollution these, approximately 800 million depend on have a wide range of implications for health agricultural residues and animal dung as and quality of life, an appropriate assessment sources of fuel because of severe fuel wood of their cost-effectiveness may require novel shortage. Traditional low-efficiency cooking approaches. stoves produce heavy smoke with fine

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Health effects of indoor pollution Quality of housing Fair evidence : - Inadequate ventilation - Acute lower respiratory infections - Crowded, unsanitary - Chronic obstructive pulmonary disease conditions - Lung cancer (coal) Poverty Tentative evidence : Lack of resources restricts -Tuberculosis options to obtain - Low birth weight and use cleaner fuels and - Cataract improved housing - Asthma - Other cancers

Simple fuels Reliance on simple fuels and polluting, inefficient stoves restricts opportunities for education and economic activity to escape poverty

Secondary effects - Risk of burns - Injuries during fuel collection - Opportunity cost for time collecting fuel - Quality of life (smoky, sooty home, inadequate lighting)

Scaling-up of actions Asthma and chronic respiratory disease There is an urgent need to consolidate experience of interventions to date, and to Asthma, allergies and chronic respiratory undertake a comparative evaluation of disease are among the leading causes of experiences in different settings. Based on chronic disease in children. In recent decades, such a review, concepts for effective asthma incidence rates saw a threefold increase interventions and supporting policies should in some industrialized countries, and be developed and made available approximately 25 000 annual childhood internationally and locally for capacity- deaths are due to asthma. The International building. This will require multi-sector Study of Asthma and Allergies in Childhood collaboration at the international, national (ISAAC) demonstrated enormous differences and local level to combine the expertise in in the prevalence of asthma symptoms, areas as diverse as health, energy, environment ranging from less than 10% in Asia, Northern and financing. Africa, Eastern Europe and the Eastern Mediterranean region to more than 30% in Strong advocacy will be needed to raise most English-speaking countries. awareness about the magnitude of the problem among stakeholders, and to generate The child who is “always sick” or “missing support for basic and applied research into school” is a common problem in many the effects of indoor air pollution on child communities, creating concern for parents, health, and, in particular, to develop and teachers and doctors. implement interventions and supportive policies. Maternal smoking during pregnancy and second-hand tobacco smoke are two of the main risk factors associated with chronic respiratory disease and the development of

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asthma, particularly if the exposure to smoke Scaling-up of actions occurs during periods of lung growth and development. While the lack of Stronger advocacy is required to raise the immunological challenge by infections in awareness of decision-makers and the general early life appears to favour the development public about the burden that chronic of allergies later in life, the relationship respiratory disease in children imposes on the between early infections and asthma is less family, the community, and the health system clear. Early-life exposure to allergens may about the associated economic costs and sensitize children, thereby increasing the risk preventive and curative solutions available. of the so-called atopic diseases such as hay Policy-makers, healthcare workers, and fever, eczema, dermatitis and asthma. It is yet communities – in particular families and unclear whether air pollution contributes to schools - have specific roles to play in the the development of asthma. However, prevention and treatment of chronic exposure to biomass fuels is strongly associated respiratory diseases that start in childhood. with chronic obstructive pulmonary disease Healthcare workers are in a position to (COPD), and exposure to coal smoke with identify children at particular risk of chronic lung cancer. respiratory disease, and to suggest appropriate actions that families and communities can Indoor and outdoor air pollutants can take to protect them. enhance the severity of chronic respiratory disease, and increase both the frequency and Policy measures to eliminate smoking are to severity of asthma attacks. Important indoor be strengthened in all countries, especially in air triggers include smoke (from cooking, those settings where children spend most of smoking and heating), moulds, dust mites, their time. Furthermore, measures to control cockroach allergens and other biological outdoor air pollution are key elements in the agents, while known outdoor air triggers prevention of chronic respiratory disease in include ozone and particulate matter. children. Research into the causes of asthma, Additional non-environmental triggers of and the effectiveness and cost-effectiveness of asthma include pharmaceuticals, rigorous preventive measures should be strengthened. exercise, temperature changes and emotional factors. 3.4 Disease vectors Asthma and allergic disorders particularly affect urban children. Poor households and Major global demographic, environmental schools are more likely to be reservoirs for dust and societal changes occurring in the last mites, cockroach allergens, moulds and other decade contribute to the re-emergence of indoor triggers of asthma. Poor children are vector-borne and other diseases, many of more likely to be hospitalized for asthma, and which have an important impact on children’s more likely to suffer chronic health effects and health and development. A considerable social dysfunction. Poor children are also least proportion of the disease burden for four key likely to benefit from the best care practices: vector-borne diseases malaria, they tend to receive treatment in emergency schistosomiasis, Japanese encephalitis and rooms without follow-up by chronic care dengue haemorrhagic fever falls on children providers, are less likely to receive the under five years of age. maintenance medication required, and have no access to environmental and social Malaria is rampant in Sub-Saharan Africa and counselling. many countries in Asia and Latin America,

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where children under five suffer high For the control of schistosomiasis, case mortality and morbidity. In older children, detection and drug treatment proved to be malaria remains an important cause of most cost-effective in the short term, but as mortality and morbidity and significantly prevalence levels drop it becomes increasingly contributes to low educational achievement. expensive to keep them low. Enhanced Malaria exists in 100 countries and accounts environmental management, provision of for more than 800 000 deaths annually, basic sanitation and community health mostly in children under five. About 90% of education should be put into place to make the disease burden resides in Africa. the achievement of drug treatment Schistosomiasis is a water-borne disease that sustainable. affects children and adolescents mainly because of their specific behaviours: lack of Scaling-up of actions hygiene and swimming in contaminated water. It is endemic in 74 developing Sound and sustainable approaches to countries, with more than 80% of infected controlling disease vectors, and integrated people living in Sub-Saharan Africa. High prevention strategies should be put in place. infection rates and individual worm loads set This requires increased research into the the scene for a debilitating infection which development of safe alternative pesticides, and may cause severe damage to the liver or on alternative approaches such as biological bladder over many years, and can result in control and integrated vector management. premature death. The use of such approaches should be Japanese encephalitis occurs only in South promoted at community level. Decision- and South-east Asia, where it is linked with making criteria and procedures for irrigated rice production ecosystems. community-based interventions should be Outbreaks occur in cycles. The annual developed, with the aim of reducing the number of clinical cases is estimated at about transmission risk in specific agricultural 40 000. Some 90% of these cases are children ecosystems. in rural areas, with a 20% case-fatality rate. Efforts should build on existing programmes Dengue affects mainly urban populations (the for vector-borne disease control. In the case Aedes species that transmit dengue are adapted of malaria, collaboration with the Roll Back to the man-made environment), and in Malaria (RBM) programme on rapid children the infection can develop into assessment of the malaria situation, on dengue haemorrhagic fever or dengue shock promoting the use of bednets and syndrome with high levels of mortality. chemoprophylaxis, and on developing Annually, mortality due to dengue fever is zooprophylaxis for malaria control in rice estimated at around 13 000; more than 80% irrigation schemes offers opportunities in this of these deaths occur in children. respect. A combination of five interventions in different settings is proposed for the Given the importance of personal behaviours mosquito-borne diseases: use of insecticide- for prevention of vector-borne diseases, impregnated mosquito nets; the fitting of education on hygiene practices and screens to windows, doors and eaves of houses; behaviours among parents, child care-givers the application of zooprophylaxis in places and children should be provided. Safe where mosquitoes are distinctly zoophilic; the domestic water management should be use of insect repellents; and improved water promoted with the aim of reducing dengue management. risk.

14 ◆ Healthy Environment for Children

3.5 Chemical hazards particularly heavy metals, pesticides and persistent organic pollutants, is a prerequisite The use of chemicals has increased for the protection of children’s health. Due dramatically due to the economic to the magnitude of their health impact on development in various sectors including children, the initial focus for action will be industry, agriculture and transport. As a on lead and pesticides, but this by no means consequence, children are exposed to a large implies that other chemicals should be number of chemicals of both natural and ignored. man-made origin. Exposure occurs through the air they breathe, the water they drink or Lead bathe in, the food they eat, and the soil they Children are particularly vulnerable to the touch (or ingest as toddlers). They are exposed neurotoxic effects of lead: relatively low levels virtually wherever they are: at home, in the of exposure can reduce IQ scores, and cause school, on the playground, and during learning disabilities, poor school performance, transport. or violent behaviour, and result in reduced lifetime earnings. This has economic and Chemicals may have immediate, acute effects, social consequences for society as a whole. In as well as chronic effects, often resulting from certain developing regions of the world, more long-term exposures. About 47 000 persons than one third of all children are still affected die every year as a result of such poisoning. by high levels of lead. In developed countries, Many of these occur in children and only a small minority of children are affected adolescents, are unintentional (“accidental”), by high lead exposures, mainly the urban and can be prevented if chemicals were poor. Focused action aimed at prevention of appropriately stored and handled. Chronic exposure is essential. The main sources of exposures to various chemicals may result in exposure may vary according to local context, a number of adverse outcomes, including and lead-health interactions can be complex, damage to the nervous and immune systems, as shown in the diagram. impairment of reproductive function and development, cancer, and organ-specific Sources of exposure vary according to local damage. Sound management of chemicals, context e.g. lead in gasoline and paint, in

Distal causes Proximal causes Physical and Outcome pathophysical Leaded pipes for water Lead concentration in Neurological effects supplies water causes IQ effects

Body burden of lead, Learning disabilities Lead concentration in e.g. Blood lead Leaded paints air and dust Anaemia Violent behavior

Other effects Leaded gasoline; traffic density; industrial activity Lead in food

Leaded cans for food and drinks Occupational lead exposure

Lead in cosmetics and folk remedies

◆ 15 Initiating an Alliance for Action

glazed ceramics, in emissions from smelters, Chronic, low-level exposure to pesticides is in battery recycling industries, use of lead linked with neurological, developmental, pipes for water supply, or a contaminant in reproductive and other effects in children. food or an ingredient in traditional medicines. Persistent pesticides that are present in the diets of small children (including breast milk) A number of activities are being undertaken, raise particular concern. They accumulate in including awareness-raising, preparation of fatty tissue, and remain stored in the fatty study protocols and documents on lead tissue of the body over long periods. exposure, estimation of the global burden of disease (GBD), and provision of technical Scaling-up of actions advice to countries on a case-by-case basis. Focused action aimed at prevention of More child-specific research, as well as exposure is essential and efforts to reduce lead activities to strengthen surveillance exposure have to be intensified in the light of mechanisms and promote regulatory the large percentage of children in the world measures and risk-reduction interventions, are who are affected. required in addition to the ongoing provision of information and technical advice to Pesticides countries, collection of case data on children’s exposure and poisoning, classification of Pesticides are used in agriculture and in public pesticides by hazard, and recommendations health programmes as important elements in on the public health use of pesticides. an integrated approach to vector control. However, they may pose a serious health Policy actions and regulatory measures should problem to the whole population. The risks be put in place to reduce or eliminate exposure are higher for infants, children and to priority chemical pollutants affecting child adolescents, as they may be exposed during health and development, such as persistent periods of special vulnerability. organic pollutants and heavy metals. As a first step in reducing children’s exposure to lead, Unsafe use, storage and disposal of pesticides governments should be urged to phase out are the main causes of acute poisoning. the use of leaded gasoline. Mechanisms should Pesticides such as insecticides, herbicides and be put in place to provide logistical, financial rodenticides are accessible to children in rural and technical support for such efforts. areas, but may also be found by toddlers Regulatory measures should be encouraged exploring their home, garden sheds or garages. to promote safe use of chemicals and A study in Canada showed that almost 60% substitution by safer alternatives. Integrated of poisoning cases registered at a paediatric agricultural practices should be promoted to hospital were due to pesticides and that the reduce reliance on the use of toxic pesticides. effects of most pesticides were acute and severe. In developing countries, the real At the local level, action should be taken to incidence of pesticide poisoning is difficult promote the safe use of chemicals through to assess, but is assumed to be high. A large the provision of evidence-based information number of child and adolescent workers are on health risks from exposure to chemicals exposed to pesticides through agricultural and on cost-effective interventions to work, as they are commonly involved decision-makers. Aspects of chemical safety informally in the preparation and application and health should be incorporated into school of pesticides. Children are also exposed as curricula, and health personnel should be bystanders during spraying for agricultural trained to recognize and prevent toxic pest control. exposures. The commitment and active

16 ◆ Healthy Environment for Children

involvement of communities in such efforts mainly to farming activities, pesticide should be solicited. poisoning, and drowning. In the urban areas, most injuries are traffic related, or linked to gadgets and electrical appliances, falls or 3.6 Injuries and accidents poisonings resulting from household chemicals and pharmaceuticals ingested by Each year unintentional injuries account for small children. The environmental factors more than 400 000 deaths globally, the leading to injury may also be associated with majority in children and adolescents. Most social factors, such as family stress and critical of these occur in low- and middle-income life events (e.g. hospitalization or chronic countries. Many of those who survive these disease of a parent, or change of residence). injuries suffer life-long disabling health consequences. In the European region, 3 to 4 The environmental factors leading to injuries deaths out of 10 that occur in children are often associated with other environmental between the ages of 0 and 4 years are a health risks. For example, home and school consequence of injury. construction and furnishing materials can lead to unintentional injuries, and poisoning may Injuries are commonly classified based on result from exposure to chemicals unsafely “intentionality”. Most road traffic injuries, used or stored. Intentional injuries resulting poisoning, falls, fire and burn injuries, and from child maltreatment are associated with drowning are unintentional. Intentional physical and cognitive deficits in the abused injuries include interpersonal violence infants, poor parenting skills, marital conflict, (homicide, sexual assault, neglect and and lack of social support systems for families. abandonment, and other maltreatment), Urban transport, land use patterns, and suicide, and collective violence (war). recreation areas are linked to road traffic Evidence suggests that some children and injuries, as well as to exposure to air pollution adolescents are more vulnerable to certain and noise. Workplaces pose specific physical types of injuries. For example, poisoning, and chemical risks to adolescent workers, drowning, burns, and maltreatment by whose vulnerability is increased by unsafe caregivers affect primarily small children, behaviours. while road traffic accidents, interpersonal violence and sports injuries tend to affect older There is a need to identify how these multiple children and adolescents. In addition, injuries environmental health risks cluster in certain tend to be more prevalent in boys. settings in order to plan preventive strategies that can lead to cost-effective health gains Unfortunately, poor children commonly live among children and adolescents. The key in unsafe environments and are, therefore, settings to consider include, for example, the exposed to risks that increase their likelihood home, the school and the route to the school, of being injured. These children are playgrounds, leisure and sports areas, the particularly vulnerable as they have less chance rural-agricultural environment, and urban of overcoming these risks, and have fewer transport. advantages such as access to educational opportunities and health services. Community-based interventions using relevant information on local patterns of The injury rates and patterns differ from injury and their causes have reduced the rates country to country, even within the same of injuries in many countries (especially the region, and from urban to rural areas. For industrialized ones). The prevention of example, in the rural areas injuries are related injuries is achieved through environmental

◆ 17 Initiating an Alliance for Action

modifications, changing the designs or (home, school, playground, other), based structures (engineering), applying and/or upon the priority issues identified and the reinforcing regulatory measures, and, overall, experience with preventive interventions and changing unsafe behaviours through their effectiveness. Pilot projects to address education. childhood environmental and injury risks through integrated preventive strategies and Scaling-up of actions their evaluation especially in developing countries will stimulate the policy process Further work is required on reviews of the and ensure that interventions are based on existing evidence on the links between evidence. environmental factors and injuries occurring in specific settings. The preparation and Regulatory measures, environmental changes, dissemination of reports on the magnitude and education play a crucial role in the of those risks, their common determinants, prevention of injuries and accidents in and on the most susceptible groups would children’s environments. However, the most help communities to plan interventions. successful interventions are those where these three approaches are combined. Strategies for action should be defined and proposed for each of the settings considered

4. CREATING HEALTHY SETTINGS

hildren are often exposed not just to community. Health hazards and their one physical risk factor at a time, but determinants in children’s everyday Cto several of them simultaneously. environment have to be identified and Their effects are mostly modulated by protective measures that can be adopted by behavioural, social and economic conditions, parents, families, neighbours, teachers, health resulting in an exacerbation of ill-health and community workers, the local outcomes. Sound approaches to create healthy population, and the children themselves have environments for children, therefore, need to to be devised, promoted and facilitated. address a whole plethora of factors acting in concert. Bearing this in mind, it is evident Many of the determinants of risk in children’s that the child itself should be placed in the microenvironments lie beyond the control of centre of action, and not individual risk the local community. Policies and strategies factors. This necessitates taking a holistic will be advocated and promoted to address approach, with a view to improving the the larger socioeconomic and political factors settings or places where children spend their contributing to contamination and lives. deterioration of the environment and impeding progress towards a resolution of The focus is on places where children live and these problems. grow: the home, the school and the

18 ◆ Healthy Environment for Children

Health hazards in the home and the physical (e.g. noise) and chemical risks that community can threaten children’s health. Hazards including infectious diseases transmitted Indoor air pollution from cooking and through water, and physical risks associated heating (notably using wood, coal and with poor construction and maintenance charcoal) and inadequate ventilation are the practices are examples of risks children face major hazards in the family home in rural at school throughout the world. areas of developing countries. Tobacco smoke is a significant indoor contaminant in many The safety of outdoor air in the community places. Lack of clean water is another major depends on proximity to the polluting hazard and the further the source of water industry, power plants, and areas of high from the home, the greater the risk to health. traffic load. Inside cars and buses, and in the Contamination of food and poisoning from street, especially in urban areas, children are household products is difficult to avoid in exposed to high levels of the classic cramped and ill-equipped homes or shelters. contaminants associated with motor vehicle Overcrowding exacerbates sources of exhaust. Millions of street children in the infection. Houses may provide inadequate world live, work, sleep and breathe in the shelter; they may be too cold, too hot, street 24 hours a day, and are particularly inadequately lit and damp. Dangerous vulnerable to multiple potentially fatal hazards substances in building materials, such as lead including abuse, unintentional injury and or asbestos, pose additional problems, as do violence. various building standards, for example unsafe electrical wiring. In the workplace, children’s exposure may not be very different from adults but children are Settings in the community include the school, less experienced, less aware and less able to the street, the playground, the workplace ask for or comply with safety regulations. (farming, commerce, industry, the informal They are also more vulnerable to adverse sector, “cottage industries”), industrial sites, health effects, such as musculo-skeletal trauma waste dumps, and the interior of vehicles and stress, as well as to exposures to toxic during transport and in rural areas, the home chemicals. In rural areas, children work in the and the surrounding fields. fields without any protection even when pesticide spraying is going on all around and The school environment shares some of the above them. same problems as the home. The physical school environment includes the school Children often play near dumps, landfills, and building and all its contents (including illegal discharges and may be exposed to physical structures, infrastructure, furniture, dangerous levels of toxic substances. The and the use and presence of chemicals and ground itself (including the floor of houses) biological agents), the site on which a school is also a source of chemical and biological is located, and the surrounding environment contaminants such as pesticide residues and including air, water, nearby land uses, lead if near heavy traffic. roadways and other hazards, as well as materials that children may come into contact with. Provision of safe water, sanitation and shelter are basic necessities for a healthy physical learning environment. Equally important is protection from biological,

◆ 19 Initiating an Alliance for Action

Components of healthy environments for children

Provision of basic necessities ■ Shelter ■ Warmth ■ Water ■ Food ■ Light ■ Ventilation ■ Sanitary facilities ■ Emergency medical care

Protection from biological threats ■ Moulds ■ Water-borne pathogens ■ Food-borne pathogens ■ Vector-borne diseases ■ Venomous animals ■ Rodents & hazardous insects

Protection from physical threats ■ Traffic and noise ■ Violence and crime ■ Injuries and accidents ■ Radiation ■ Heat and dust

Protection from chemical threats ■ Air pollution ■ Water pollution ■ Pesticides and other chemicals ■ Hazardous waste ■ Hazardous materials and finishes ■ Cleaning agents ■ Second-hand tobacco smoke

Who can do what in the community? in some cases, older children can all contribute to an initial assessment which is the Many health hazards are common to all community’s first task. settings and appropriate interventions will take this into account. However, problems in Core messages, key targets, and priority action each setting may best be tackled by a specific can then be decided by local committees of set of actors. There is a need to identify and teachers, health workers and local community support solutions, which build on the capacity leaders (such as religious leaders, village of community members, local resources and councils, and civilian groups). Simple vested interests. measures requiring materials and equipment, which can be made locally, can be undertaken Typical patterns of risk and the most frequent, through collective community effort, with by resulting health hazards, can be identified financial and technical support from local so that efforts can be devoted most efficiently municipal or national authorities when to priority problems. Teachers, parents, health required. Such an initiative could be the and social workers, local organizations and, creation of smoke-free public spaces and

20 ◆ Healthy Environment for Children

schools. Next comes the identification and Teachers play a major role in education on adaptation of appropriate technologies and prevention and protection; older children and facilitatory mechanisms to support action young people who are particularly effective (financially and technically), which is locally in conveying essential messages and providing controlled and implemented. examples to young children can assist them in this task. Community groups, coordinated A key protective factor in the home is parental by local health workers, can also provide (usually maternal) presence. Given their information and simple training to groups of multiple responsibilities, poor women are adults. This requires finding or designing unlikely to be able to devote much time to clear, simple educational materials and basic watching their children. Fuel and water protection messages to be integrated into sources close to the home to reduce the hours school curricula. Targeted mass media spent in these survival activities are essential. programmes, such as radio and TV Basic education in simple and cheap hygiene campaigns, could effectively support this and nutrition (handwashing, breastfeeding) process. and prevention of unintentional injuries can significantly reduce risks. Simple appropriate technologies such as fuel-efficient, closed stoves are urgently needed.

5. MECHANISMS FOR IMPLEMENTATION

he key to implementing a programme considered. It needs to be driven by a strong on Healthy Environments for commitment to act primarily at the local and TChildren will be the creation of a national level. concerted, popular, participatory and inclusive “movement”, which addresses the While working towards achieving the issue in an integrated manner, centring on the Millennium Development Goals and their children rather than on individual specific targets, the movement needs to go environmental hazards. The basic principle further than only reducing child mortality by on which the movement builds is that the aiming at combating morbidity and stakeholders at every level can make a improving the quality of life of children. In difference e.g. decision-makers at developing strategies for action, the principle international, regional, national and of subsidiarity should prevail i.e. actions community levels, community leaders, should be taken at the lowest appropriate teachers, NGOs, the private sector and level, and as near as possible to the respective families. Besides the health sector, the target group. Decisions and actions that can movement must involve various other sectors, most effectively be taken at the local level including environment, energy, transport, should not be taken at the national level or housing, agriculture and education. Action higher. As a first step, specific, ambitious but needs to be based on scientific evidence to achievable targets for action with clearly ensure that the major environmental identified responsibilities, and traceable determinants of adverse health outcomes in milestones must be established at the local, children are adequately addressed, and that national, and international level. Mechanisms the most appropriate interventions are need to be put in place to ensure the provision

◆ 21 Initiating an Alliance for Action

of technical, financial and other support ■ Research and development. Evidence- required in countries to implement national based actions require an investment in initiatives through integrated, intersectoral research to supplement existing mechanisms and building national knowledge, in particular leading to an partnerships for action. improved knowledge base on children’s environmental health risk factors and The major elements of the implementation their linkages, and to the development strategy are envisaged to be: and evaluation of operational ■ Taking stock of ongoing efforts. A major interventions and their cost-effectiveness. preliminary step is to evaluate work However, this investment into research currently underway. This requires the should not delay immediate action on collection of information on ongoing issues where adequate knowledge is efforts that are targeting children in the already available. field of health and environment at all ■ Influencing policies. Healthy levels, with an emphasis on international environments for children should be and major national efforts, and the placed high on the public health agenda, preparation of an inventory highlighting and should be an integral part of the need for action and the potential for development policies. Children’s health cooperation and synergies. and the environment should be a driving ■ Creating a popular movement. Healthy force for multisectoral policies. One environments for children will only success story is that of lead removal of become a reality if all the potential players lead from gasoline, a transport policy feel that they can make a difference from measure, was based on evidence of the their respective angle. Taking adverse cognitive effects in exposed responsibility for action with the children, and resulted in improved knowledge that everyone can make a environmental conditions and child difference will ensure the success of the health. Efforts should be made to increase initiative. The movement needs to awareness among high-level decision- encompass all children, rich and poor, makers of the importance of providing living in rural and urban communities, safe and clean environments for children, both in developing and in industrialized and of promoting healthy behaviours in countries. order to ensure children’s growth, development and good health. ■ Consolidating and disseminating ■ scientific knowledge. Action to be taken The healthy settings approach. Integrated must be evidence-based. The collection, approaches are the key to creating healthy evaluation and dissemination of environments for children. The concept information on children’s health, of healthy schools, healthy homes, and environmental determinants, and their healthy communities provides an linkages, as well as on cost-effective appropriate mechanism to implement interventions and their efficacy constitute such approaches. It covers the a first line of action. Use of generally dissemination of information about, and agreed, scientifically validated indicators the promotion of, cost-effective, is essential to measure progress. Finally, economically sustainable and culturally simple and easily accessible systems to appropriate interventions for improving disseminate this information need to be the quality of the children’s homes and established. schools, and community environments. This includes education and awareness-

22 ◆ Healthy Environment for Children

building, provision of basic necessities in allow the detection and management of the respective setting, and ensuring paediatric disease outbreaks of protection from biological, physical and environmental etiology. Specific health chemical risk factors. In the case of sector interventions need to be developed communities, the healthy settings and evaluated, building on existing approach allows the mobilization of services and networks, and making better community leaders to champion the use of available interventions and tools. necessary actions, and the creation of ■ Intersectoral cooperation. Multi-sectoral, mechanisms for participatory action by integrated approaches are required. various community groups. Interventions through appropriate ■ Support to the health sector. Raising the sectors, other than the health sector, can awareness of health professionals about in many instances better ensure that environmental risk factors in children and preventive actions are taken through cost- their linkage to adverse health outcomes, effective interventions. Sectors to be whether they occur during childhood or involved include environment, transport, later in life, is key. It requires the agriculture, housing, energy, and others. development of appropriate training and Sound agricultural policies, for example, guidance materials for physicians, nurses, could result in a reduction of children’s midwives, and other health professionals, exposure to pesticides. The education and the inclusion of such material in sector is key here, since knowledge is one curricula. Expanding monitoring, of the most effective tools to avoid surveillance and response systems should unhealthy environments and behaviours.

6. MONITORING CHILDREN’S ENVIRONMENTAL HEALTH

hildren’s health and wellbeing are These indicators will not only guide policies strongly affected by environmental and action, and help governments to assess Cproblems, but too little is known the success of their programmes, but will also about how much of the burden of disease speak more forcefully for children than words caused by environmental problems falls on alone. A project to launch an international, children. A programme of independent collaborative effort to develop, pilot-test and auditing and monitoring of progress in monitor indicators will be initiated at the improving the health status of children in World Summit on Sustainable Development relation to their environment has to be by the US Environmental Protection Agency, established at the national and international in cooperation with a variety of national and level. Several recent international declarations, international partners. The initiative builds including the G8 Ministerial Statement on on ongoing efforts, such as the framework for the World Summit on Sustainable children’s environmental health indicators Development (2002), highlighted the need developed by WHO and the activities of for more information and called for action to regional institutions in Europe and the develop children’s environmental health Americas. indicators.

◆ 23 Initiating an Alliance for Action

Exposure-side indicators Health-side indicators

Home Morbidity Asimplemodel of environmental Community health indicators

Ambient This recognizes three sets of environment Mortality environment health indicators : those that represent exposures to environmental hazards (`exposure-side´indicators), those that represent health effects arising from these exposures (`health-side´ indicators),and those that represent the responses to Preventive Remedial these risks (`action´indicators). actions actions

Action indicators

The Joint Monitoring Programme for Water The estimation of the environmental burden Supply and Sanitation (JMP), which of disease at the national and local level will combines WHO’s and UNICEF’s experience also contribute directly to the monitoring of and resources, may serve as a model system children’s environmental health. Guidance for for monitoring children’s environmental this assessment is currently being prepared for health. Since 1991, the JMP has regularly ten environmental risk factors. Future reported on the status of the water supply and assessments will directly reflect the disease sanitation sector, and supports countries in burden borne by children and thereby their monitoring efforts. monitor progress in reducing different environmental health problems over time.

7. BUILDING A GLOBAL ALLIANCE

Why a Global Alliance? countries to develop and implement effective programmes and policies. Moreover, by The diversity of challenges and players working together they will be able to involved in addressing children’s accomplish the tasks and objectives that environmental health indicates that no single would otherwise be unattainable or delayed. entity – be it a government or WHO – can tackle the problems alone. Rather, a broad- An alliance can draw upon new and based alliance is needed that draws on the compelling evidence of the effectiveness of unique and complementary strengths of interventions to tackle the various dimensions several government departments and sectors of children’s environmental health, link that (at local and national level), consumer groups knowledge to community action, and and NGOs, the private sector, the UN family mobilize additional resources for as well as Foundations, and research and implementation. Further, a strong and multi- academic groups. By working together, they institutional alliance could advocate globally will more effectively address the gaps in for increased resources to promote healthy capacity and the needs that exist in many environments for children, as well as for the

24 ◆ Healthy Environment for Children

use of effective tools. Acting together, the governments and the close involvement of alliance members could provide a communities and civil society, but also the clearinghouse for information and research, support and guidance of an international which will be a basis for community and alliance. national action. Global direction, advocacy and resource The structure of the alliance will be critical mobilization are essential. However, national for providing the political links, direction and movements are vital for creating and ensuring form which will facilitate intersectoral action safe and healthy environments for children and community participation. Experience in and promoting hygienic behaviours. National many other areas of public health suggests that movements will catalyse the efforts of different for the goals and objectives of the initiative stakeholders, coordinate actions, and to be optimally met, a flexible structure will strengthen networks. They will help identify work best. It needs to reflect global diversity, the main environmental risks and prepare be able to endorse a selected number of local strategies for informing their strategic directions and actions, and remain communities, and for promoting education open to future partners who may wish to join and research on environmental health issues. over the months and years to come. They will ensure that global ideas are translated into local reality. In each area of environmental risks described above, many players are already active. It is crucial to acknowledge past and ongoing Developing the Global Alliance work, and to highlight the potential value that will be added as alliance members are drawn The first activities for developing the alliance into scaled-up, and more globally oriented are adequate planning and agreements on how actions. The alliance’s success, however, will to operate. The Alliance should aim at not be limited to its ability to address each of becoming fully functional by early 2003. The the issues separately, but rather by the way in tasks to be accomplished are likely to include: which, through acting together, better ■ An event to mark the founding of the solutions will be found for addressing alliance, and to give an indication of children’s health issues and environmental risk priority areas for future action. factors in a more effective and synergistic way. ■ Initial alliance members at the global and The sharing of information, expertise and national levels will be identified through efforts will result in the following important widely published “calls to action”. benefits: firstly, increasing the effectiveness of Identification of appropriate alliance interventions; secondly, expanding the reach members is a critical step as it determines of limited resources; and thirdly, stimulating the legitimacy of the initiative and the governments and others to act in a collective, ability to develop new insights, ideas and coherent approach. The alliance is expected approaches, and to establish consensus. to make a measurable difference to the Alliance members should be attainment of its objectives within a 3 to 5 interdependent in reaching solutions to year framework. identified problems and issues. ■ A small interim stakeholder group will Local, community-based approaches are be set up (to be broadened with time), essential to support the sustainability of whose first task will be to convene a series interventions. Local movements will require not only political backing from national

◆ 25 Initiating an Alliance for Action

of consultative and “brainstorming” and sanitation, indoor air pollution, meetings to help further define the key chemical hazards, injuries, and disease objectives, functions and outcomes of the vectors. This will help to focus the alliance, and to steer the alliance in the interests and energies of the diverse agreed direction. groups. ■ A communication and advocacy strategy ■ Continuous review of ongoing or will be developed which will focus on planned activities of the different alliance mobilizing additional financial resources members will help determine emerging and encouraging key decision-makers to opportunities for future collaboration. support the planned actions. ■ As this work progresses, the alliance ■ In this process, the specific contribution founders will announce sets of time- of each alliance member in the initiative bound objectives attainable within the will be identified and agreed upon. newly created resource and political base ■ Task Forces to tackle specific issues and for the Healthy Environments for develop draft plans of action will be set Children initiative, and action plans for up. They will, for example, identify implementation will rapidly be put in operational research priorities, or select place. specific issues and work areas like water

26 ◆ Healthy Environment for Children

ANNEX

THE BANGKOK STATEMENT A pledge to promote the protection of Children’s Environmental Health

e, the undersigned scientists, doctors and public health professionals, educators, Wenvironmental health engineers, community workers and representatives from a number of international organizations, from governmental and nongovernmental organizations in South- East Asian and Western Pacific countries, have come together with colleagues from different parts of the world from 3 to 7 March 2002 in Bangkok, Thailand, to commit ourselves to work jointly towards the promotion and protection of children’s health against environmental threats.

Worldwide, it is estimated that more than one-quarter of the global burden of disease (GBD) can be attributed to environmental risk factors. Over 40% of the environmental disease burden falls on children under 5 years of age, yet these constitute only 10% of the world population. The environmental burden of paediatric disease in Asia and the Pacific countries is not well recognized and needs to be quantified and addressed.

We recognize: That a growing number of diseases in children have been linked to environmental exposures. These range from the traditional waterborne, foodborne and vector-borne diseases and acute respiratory infections to asthma, cancer, injuries, arsenicosis, fluorosis, certain birth defects and developmental disabilities.

That environmental exposures are increasing in many countries in the region; that new emerging risks are being identified; and that more and more children are being exposed to unsafe environments where they are conceived and born, where they live, learn, play, work and grow. Unique and permanent adverse health effects can occur when the embryo, fetus, newborn, child and adolescent (collectively referred to as “children” from here onwards) are exposed to environmental threats during early periods of special vulnerability.

That in developing countries the main environmental health problems affecting children are exacerbated by poverty, illiteracy and malnutrition, and include: indoor and outdoor air pollution, lack of access to safe water and sanitation, exposure to hazardous chemicals, accidents and injuries. Furthermore, as countries industrialize, children become exposed to toxicants commonly associated with the developed world, creating an additional environmental burden of disease. This deserves special attention from the industrialized and developing countries alike.

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That environmental hazards arise both from anthropogenic and natural sources (e.g. plant toxins, fluoride, arsenic, radiations), which separately and in combination can cause serious harm to children.

That restoring and protecting the integrity of the life-sustaining systems of the earth are integral to ensuring children’s environmental health now and in the future. Therefore, addressing global changes such as human population growth, land and energy use patterns, habitat destruction, biodiversity loss and climate change must be part of efforts to promote children’s environmental health.

That despite the rising concern of the scientific community and the education and social sectors about environmental threats to children’s health and development, progress has been slow and serious challenges still remain.

That the health, environment and education sectors must take concerted action at all levels (local, national, global), together with other sectors, in serious efforts to enable our countries to assess the nature and magnitude of the problem, identify the main environmental risks to children’s health and establish culturally appropriate monitoring, mitigation and prevention strategies.

We affirm:

That the principle “children are not little adults” requires full recognition and a preventive approach. Children are uniquely vulnerable to the effects of many chemical, biological and physical agents. All children should be protected from injury, poisoning and hazards in the different environments where they are born, live, learn, play, develop and grow to become the adults of tomorrow and citizens in their own right.

That all children should have the right to safe, clean and supportive environments that ensure their survival, growth, development, healthy life and well-being. The recognition of this right is especially important as the world moves towards the adoption of sustainable development practices.

That it is the responsibility of community workers, local and national authorities and policy- makers, national and international organizations, and all professionals dealing with health, environment and education issues to ensure that actions are initiated, developed and sustained in all countries to promote the recognition, assessment and mitigation of physical, chemical and biological hazards, and also of social hazards that threaten children’s health and quality of life.

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We commit ourselves:

To developing active and innovative national and international networks with colleagues, in partnership with governmental, nongovernmental and international organizations for the promotion and protection of children’s environmental health, and urge WHO to support our efforts in all areas, especially in the following four:

PROTECTION AND PREVENTION – To strengthen existing programmes and initiate new mechanisms to provide all children with access to clean water and air, adequate sanitation, safe food and appropriate shelter: ■ Reduce or eliminate environmental causes and triggers of respiratory diseases and asthma , including exposure to indoor air pollution from the use of biomass fuels and environmental tobacco smoke. ■ Reduce or eliminate exposure to toxic metals such as lead, mercury and arsenic, to fluoride, and to anthropogenic hazards such as toxic wastes, pesticides and persistent organic pollutants. ■ Reduce or eliminate exposure to known and suspected anthropogenic carcinogens, neurotoxicants, developmental and reproductive toxicants, immunotoxicants and naturally occurring toxins. ■ Reduce the incidence of diarrhoeal disease through increased access to safe water and sanitation and promotion of initiatives to improve food safety. ■ Reduce the incidence of accidents, injuries and poisonings, as well as exposure to noise, radiation, microbiological and other factors by improving all environments where children spend time, in particular at home and at school. ■ Commit to international efforts to avert or slow global environmental changes, and also take action to lessen the vulnerability of populations to the impact of such changes.

HEALTH CARE AND RESEARCH – To promote the recognition, assessment and study of environmental factors that have an impact on the health and development of children:

■ Establish centres to address issues related to children’s environmental health. ■ Develop and implement cooperative multidisciplinary research studies in association with centres of excellence, and promote the collection of harmonized data and their dissemination. ■ Incorporate children’s environmental health into the training for health care providers and other professionals, and promote the use of the environmental history. ■ Seek financial and institutional support for research, data collection, education, intervention and prevention programmes. ■ Develop risk assessment methods that take account of children as a special risk group.

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EMPOWERMENT AND EDUCATION – To promote the education of children and parents about the importance of their physical environment and their participation in decisions that affect their lives, and to inform parents, teachers and caregivers and the community in general on the need and means to provide a safe, healthy and supportive environment to all children:

■ Provide environmental health education through healthy schools and adult education initiatives. ■ Incorporate lessons on health and the environment into all school curricula ■ Empower children to identify potential risks and solutions. ■ Impart environmental health expertise to educators, curriculum designers and school administrators. ■ Create and disseminate to families and communities culturally relevant information about the special vulnerability of children to environmental threats and practical steps to protect children. ■ Teach families and the community to identify environmental threats to their children, to adopt practices that will reduce risks of exposure and to work with local authorities and the private sector in developing prevention and intervention programmes.

ADVOCACY – To advocate and take action on the protection and promotion of children’s environmental health at all levels, including political, administrative and community levels:

■ Use lessons learned to prevent environmental illness in children, for example by promoting legislation for the removal of lead from all gasoline, paints, water pipes and ceramics, and for the provision of smoke-free environments in all public buildings. ■ Sensitize decision-makers to the results of research studies and observations of community workers and primary health care providers that need to be accorded high priority to safeguard children’s health. ■ Promote environmental health policies that protect children. ■ Raise the awareness of decision-makers and potential donors about known environmental threats to children’s health and work with them and other stakeholders to allocate necessary resources to implement interventions. ■ Work with the media to disseminate information on core children’s environmental health issues and locally relevant environmental health problems and potential solutions.

For all those concerned about the environmental health of children, the time to translate knowledge into action is now.

Bangkok, 7 March 2002

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