EHJ July 2004, pages 208-211
As European politicians gathered to discuss the future for children's health and the environment in Budapest last month, Nick Warburton asks if today's adults are failing in their responsibilities to protect children

Elizabeth Salter-Green was so concerned by the presence of man-made chemicals in her body that she had samples of her blood, breast milk and fat taken for analysis. When she got the results back, she was deeply disturbed to find that her levels of contamination were well above those considered to be "normal".

Among the substances tested for were polychlorinated biphenyls (PCBs), a group of chemicals used to insulate electrical devices and known to disrupt hormones and harm immune systems, and the insecticide DDT, which is acknowledged to disrupt endocrine glands. Banned in the UK during the 1980s, both have long half-lives. These banned chemicals, along with many that are in current use, such as brominated flame retardant chemicals are persistent, as in once they enter the body, they don't disappear, and are bio-accumulative - they like to stick to human body fat.

As head of the World Wildlife Fund's toxics programme, Ms Salter-Green had very good reason to be concerned. But the grim discovery was particularly worrying as she was planning to have a family in the near future and some of the contaminants found in high levels were known to be harmful to developing foetuses. "A lot of neurological wiring occurs in day zero to day 60 odd," she says. "But obviously you only need a very minute amount of hormone mimicking or disrupting substances of which PCBs and dioxins are classic examples that would lead to neurological impairment."

Her concerns are understandable. Last month, the WWF published a damning report Compromising our children, which showed that chemical levels found in some members of the general public are sufficient to harm children's brain development and co-ordination. And concerns are not limited only to neurological impairment. Chemical exposure has also been linked to behavioural problems and fertility.

"It's a very broad brush thing to say, but you as a man will probably have half the sperm count that your grandfather had. If your grandson has half the sperm count that you've got, his grandson will probably be technically infertile," she says. "I am not saying that chemicals are totally responsible for that because men don't take enough exercise, they can smoke too much and drink too much, but chemicals are definitely, definitely a contributory factor."

The persistent and bio-accumulative effect of banned chemicals such as PCBs and DDT are a major concern, but so too are chemicals with similar chemical structures that are currently used on the market. Figures published by the WWF show that only 14 per cent of chemicals used in the largest volumes have the minimum amount of data publicly available to make even an initial basic safety assessment. Ms Salter-Green says manufacturers need to make sure chemical products for the home environment are safe.

Stricter regulation is needed, she continues, including a requirement for chemical companies to test their chemicals retrospectively. Her concerns are echoed by Dr Vyvyan Howard, senior lecturer in the department of human anatomy and cell biology at Liverpool University. "If compounds persist and bio-accumulate then I think that is enough reason to want to regulate them," he says. "Whether they have an observable adverse effect or not, the fact that they bio-accumulate and persist means that we can't metabolise them properly."

As an experienced toxico-pathologist, Dr Howard knows all too well the difficulties inherent in assessing the effects of chemicals on foetal development. "One of the problems is that we are challenged with a very complex mixture of literally tens of thousands of compounds which weren't around 60 or 70 years ago," he says. "We simply don't have the tools to sort out a soup of that complexity and yet we know that in there are some compounds which are deeply disturbing."

Providing children with adequate protection from chemical exposure is just one of a gamut of environmental health challenges that face society. Children are often one of the silent victims of this generation's quest for wealth-gain and yet they are also among the most vulnerable as Genon Jensen, policy director of the European Public Health Association (EPHA) explains. "Children, because they're growing, eat more in relation to their body weight and they breathe more air to their body weight, so have the potential to be more contaminated as well," she says.

Disturbing figures, published by the EPHA, emphasise the disparity in burden carried by children, showing that while adults absorb 10 per cent of any lead in food, children absorb 40 per cent. The EPHA reports that up to 30 per cent of children are still living in urban areas that have too high levels of lead.

A study published in the Lancet last week, looking at the environmental burden on children's health in Europe, offers a sobering insight into the damage inflicted on children. Researchers from the Institute of Hygiene and Epidemiology at the University of Udine and the Institute of Child Health in Trieste, Italy, reported that 40 per cent of the global disease burden associated with the environment affects children aged five years or younger.

Indeed, at foetal, neonatal, school-age and pubertal phases, children are vulnerable and exposed to a whole raft of different agents. When you take into account their life expectancy, children are also the most likeliest to endure exposure for the longest time.

Children are almost entirely dependent on their parents to create and maintain safe and healthy environments. Even before they are born, children are vulnerable to parental exposure to pollution and toxic consumption. A classic example is environmental tobacco smoke (ETS).

As Peter Helms, professor of child health at Aberdeen University, explains, intensity of exposure is only part of the problem. As young children are more dependent on their parents, so they are more likely to be around them and face exposure. Maternal smoking is the strongest influence because the foetus is exposed. The other factor, he continues, is increased vulnerability. Children's lungs are still growing and don't really stop developing until two and half or three years of age.

Prof Helms is a member of one of the European Commission's nine technical working groups, set up last year to advise the EC on what environmental hazards were relevant for its environment and health action plan for 2004-2010, since adopted by the EC on 9 June. The plan was officially launched as the EC's main contribution to the World Health Organisation's fourth ministerial conference on environment and health, held in Budapest on 23-25 June.

Meeting between November 2003 and March 2004, the groups focused on four diseases or clinical problems: respiratory health and allergies, neurodevelopment, endocrine disruptors and childhood cancers. The group's findings have been outlined in an eight-page summary document, published by the EC last month.

As chair of the respiratory health group, Prof Helms says there was a unanimous view among its members that one of the biggest impacts on children's health improvement was the need to reduce exposure to ETS. "Smoking doesn't cause asthma, but it certainly does cause significant respiratory morbidity in the under fives and it also interferes with lung growth and development," he says.

While governments cannot stop people smoking in their homes, he says they should lead by example, by introducing a ban on smoking in public places. Governments, Prof Helms continues, have a responsibility to protect the health of the population and vulnerable groups that can't remove themselves. "It's all right for an adult to say, 'I don't want to go in a bar', but if you are a foetus inside a pregnant mum working in one of these environments..."

The problem is that adults cannot always control the environments in which they live. Even those fortunate enough to live in affluent areas or work in safe environments do not have much control over issues such as exposure levels of contaminants.

As Ms Jensen explains, a lot of policies have been set at risk levels, which are based on adult exposure and not at children's risk levels. Also, few studies have looked at whether the contaminants we have are affecting children much more than adults. The EPHA believes that current policies need to be reviewed to better protect children and other vulnerable groups. "Some of the exposures that they may have very early in life may not come out until they are 30 or 50 with a huge cost to society," she says.

Nor are we completely safe indoors, where we spend about 85 per cent of our time. According to Prof Helms, indoor air quality is an emerging area of research with issues such as new chemicals in the home, treatment on carpets and fabrics and toiletries. "They've been tested on animals and they are supposed to be safe but we don't know anything about long-term low-dose exposure in human subjects," he says.

Everywhere you look it seems children are paying a heavy price for our neglect of the environment. Whether it's basic risks such as poor air quality and bad housing, modern risks like high-levels of man-made toxins and inadequate toxic waste disposal or emerging risks such as endocrine disruptors and skin damage through climatic change, time and again children are left clutching the short straw.

All too often adults forget that children are not as fully developed. But that still doesn't stop us from treating them like adults when it suits us. "We shouldn't simply treat children as young consumers," says Jane Landon, associate director at the UK's National Heart Forum, on the issue of food choices and dietary patterns. "We have a duty of care, particularly around the provision of healthy food and making sure benefit levels are set at appropriate levels so that low-income families can afford the necessary requisites for a healthy diet."

Concerned about the seeming neglect of this duty, the National Heart Forum is campaigning for a national plan for children and young people's health and wellbeing. The Young at Heart initiative which gave rise to the proposals for such a plan in 2001, was based on the reality that coronary heart disease, stroke and diabetes all track from early life into adulthood.

As Ms Landon explains, traditionally, most prevention strategies have looked at what action could be taken in an adult population. She argues that it is much more important to look at the determinants of health at the earliest point, which is why the initiative looks at pre-conceptual nutrition in mothers right through to infancy and exposure to risk factors, and setting a healthy start.

"Very often we have double standards around children," she says. "With school meals in this country, the Soil Association's report produced last year pointed out that the quality of meals that we are serving up in schools, if you actually look at what is spent on them, is inferior to the food served up in prisons." She is quick to stress that this does not mean prisons should be served inferior foods. "But what it does flag up is a curious lack of concern or due respect for the needs of children and what we provide for them."

Perhaps it's easy to forget that adults make a lot, if not most, of the decisions that affect children. Ms Landon wonders if many of these decisions are the right ones. She believes children should be involved a lot more in how decisions are made, not just in terms of food in schools but also physical activity. "It's about how we as a responsible generation don't always apply the same sort of considerations to children's needs as perhaps adult needs," she says.

Promoting more physical activity is obviously something to be encouraged but it's not quite as straightforward as that, Prof Helms explains: "It's all very well saying to people walk to school and do more exercise, but if you have a playing field, which is just next to a motorway or if your walking route has to cross major roads, it's dangerous first of all, and for those with respiratory problems it's worse."

In some areas, Ms Landon believes adults are blatantly neglecting children's needs, and points to the recent obesity report to emphasise the point. "If you look at the child obesity figures, I think it's frankly scandalous. It's scandalous neglect that we've allowed children, through becoming more sedentary and at the same time eating an energy dense diet, to put on weight. There are serious immediate-term consequences both in terms of their health and also their mental wellbeing," she states emphatically.

Media headlines have got considerable mileage out of fears of a potential obesity epidemic and quite rightly so. Obesity not only has direct health impacts such as heart disease, it can exacerbate other conditions as well, for example respiratory health. "It is very clear that if you are overweight as well as having asthma, for example, your asthma is more severe and is more persistent," says Prof Helms.

Action is clearly and urgently needed to safeguard "the future of our children", the theme of last month's conference. The EC's environment and health action plan offers perhaps one of the best opportunities to tackle some of the issues but is it a case of promising more than it can deliver?

According to Prof Helms, the EC's summary document does mention tobacco smoke, but rather than call for a ban on smoking in public places, one of the working group's recommendations, it says that member states should continue with tobacco control. The document also says nothing about exercising in clean air and the impact on obesity and its relation to respiratory health. It looks suspiciously like the EC has picked up on the easy targets where it doesn't have to negotiate with politicians and industry.

Things are unlikely to get better at the national level, where there is an ominous lack of joined up thinking and commitment in government circles. As Ms Landon points out: "It took a long time to squeeze a walking strategy out of the government and it's guidance-based. This is the difficulty. A lot of the efforts and initiatives with a public health goal are based on guidance. They are not backed up by any statutory requirements or regulations and are consequently difficult to implement and impossible to enforce."

Children deserve better than this. We may not often think about their needs but they certainly have a voice, even if it's struggling to be heard by the adults around them.