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UPDATE no.12 October 2001 INCHES
October 22, 2001-The International Network on Children's Health, Environment and Safety
In this update :
News items
INCHES funding
Topics
Declaration
With the last update you received the Declaration on Children and their health and their environment as it was discussed at the INCHES Coordination Committee Meeting in Washington. Did anyone forward it to your members or contactpersons? We would like to hear if there were any reactions.
Message from Wondy Asnaken from UNEP, Geneva
I am writing to you to introduce a magazine entitled Teen Planet that deals with a specific environmental topic. Teen Planet is an outreach magazine published by the Regional Office for Europe of the United Nations Environment Programme (UNEP/ROE) intended to provide an attractive and easy to read information product on international environmental agreements, facilitate discussions on related issues and disseminate tailor-made information targeted at both young audiences and to any one who is with an interest in youth development.
In addition, it is an information and communication channel intended to show that environmental degradation is a challenge and a concern for young people. We believe the magazine should guide and empower young people with the necessary knowledge on how to protect, preserve and improve the state of the environment, and help drive the changes necessary to ensure a future that they can enjoy.
So far we have we published three issues this year:
1. environment as human rights issue
2. how to protect biological diversity
3. Children of Rio - what is sustainable development
I am now working on Issue 4 that is focusing on "Children's Environmental Health and the Rights to a Safe and Healthy Environment". This issue will also focus on the work of INCHES which you are part of it.
More nations are thinking about their priorities for the 2002 Earth Summit. It seems that children's health is getting more attention. As example one can look at the website of the Government of Canada on the Earth Summit. Health and Environment has become proposed theme. There are more governments to follow. See website: www.canada2002earthsummit.gc.ca/en/health_environment_e.cfm
More news from Canada:
The next 4th International Children's Conference on the Environment will be held in Victoria, Canada, May 21-25. This conference will be organised by UNEP. The conference will provide children with the opportunity to explore environmental issues, express views and deepen their understanding of solutions to environmental problems. This conference is for children in the age group of 10- 12 years, nominated by, or representing a school or community group; interested in environmental issues and actively involved in an environmental project.
Any donations (or suggestions of possible donors) are welcome at bank account nr.: 526292490 ABN AMRO (swiftcode ABNANL 2A), Dieren, the Netherlands.
In this paragraph we would like to place some items that are important for their contents. If anyone wishes to send in an abstract on any topic related to children's environmental health and safety, mail it to the email address of the update.
The topic of today is related to dealing with clusters of diseases. It is taken from a report of the Health Council of the Netherlands. Below first there is a short introduction of this council, then will follow a summary of the report.
The Health Council of the Netherlands (Gezondheidsraad) has a long history. It has existed in one form or another since 1902, with the Health Council in its present form established by the 1956 Health Act. The Health Council is a statutory advisory body to the government. The Health Act of 1956, amended in 1997, defines the Council's duties as follows:
"… to advise the government and Parliament on the current level of knowledge with respect to public health issues ..."
Mission
The Health Council of the Netherlands informs the government on the current level of knowledge in the field of public health. This includes identifying developments, which are relevant to government policy. The Council's recommendations encompass subjects, which affect the health of the population, such as medicine, health care, environmental protection, nutrition, occupational hygiene and living conditions. These recommendations are drawn up by independent committees of leading experts, who are nominated in a personal capacity.
The Domain of the Health Council
The Health Council's domain is wide and varied. The Council endeavours to answer questions relating to health and disease by considering the many influences and interrelationships involved: how do the environment, socio-economic conditions, human behaviour and lifestyle, genetic predisposition and acquired characteristics combine to influence the health of the individual? Assessing population screening programmes, making recommendations for adequate nutrition and analysing risk factors for both human health and the environment: all of these activities are included in the Health Council's remit.
Medical technology assessment, the evaluation of the efficacy and efficiency of applied medical technologies, forms an important subcategory within the activities of the Council. Ethical, legal and societal aspects are considered where applicable.
All Health Council publications are available through the World Wibe Web (www.gr.nl).
Report
Health Council of the Netherlands. Local environmental health concerns; risk communication, exposure assessment and cluster investigation. The Hague: Health Council of the Netherlands, 2001; publication no. 2001/10
Concerned citizens are increasingly contacting local authorities to ask whether seemingly unusually large numbers of similar health complaints or disorders in their neighbourhood (a 'disease cluster') may be related to exposure to local environmental factors. Below an advisory report on epidemiological research methods in response to public concerns about local environmental health issues and aspects of risk perception and risk communication.
The Committee detailed its task as follows:
- Compile and evaluate the possibilities and limitations of risk communication in situations of local environmental health concerns, with attention to the differences in risk perceptions of the parties involved.
- Compile and evaluate the possibilities and limitations of a risk assessment in situations of suspected exposure to local environmental factors.
- Compile and evaluate the possibilities and limitations of research into possible relations between local environmental factors and disease clusters, as observed by the public.
According to an estimate of the National Institute of Public Health and the Environment (RIVM), two to five percent of the total number of disability adjusted life years in the Dutch population is attributable to environmental pollution. Besides air and noise pollution caused by traffic, factors in the indoor environment make the largest contribution, especially in the form of dampness, radon and passive smoking. The relatively large impact of general risk factors, including demographic and socio-economic characteristics, as well as life style, makes it difficult to determine the direct effect of physical or chemical environmental factors on local differences in the occurrence of diseases or health complaints. The health status of a neighbourhood or district may for instance depend significantly on the local age distribution. In view of the natural variation in place and time, a concentration of certain disorders in a particular area may also be based on coincidence. However, it is understandable that people note such a disease cluster and report it, especially if they are concerned about the quality of the local environment.
Concern about health effects of exposure to local environmental factors may lead people to experience, notice and report health problems, particularly non-specific health complaints, such as headaches, dizziness and tiredness. This is apparent from various studies on the prevalence of such health complaints attributed to environmental pollution, such as waste dumps, air pollution and electromagnetic fields. Sensory observations, such as odour and noise nuisance may play a role in this. It is striking that many complaint patterns display similarities, regardless of the differences in exposure to hazardous agents. If a somatic cause cannot be found, the complaints are categorised as 'medically unexplained'. Such physical complaints do not arise directly from the exposure but indirectly through uncertainty and concern. They occur often if residents experience a lack of control of the situation or if they have no trust in the authorities concerned. This process of chronic stress, symptom perception and attribution may be reinforced by authorities or health care workers playing down health problems or by the media magnifying them. The Committee believes that insight into and the recognition and acceptance of the effect of stress factors on health could prevent a (further) increase in medically unexplained complaints in stressful situations.
Risk perception and risk communication
When assessing the risks, experts place the emphasis on quantitative data, whereas citizens are much more likely to base their opinions on qualitative aspects, such as the nature and origin of the contamination to which they consider to be exposed, usually involuntarily. For example, when evaluating risks, members of the public take into account considerations such as the lack of familiarity with or lack of control over the pollution or its source. They also take into consideration the uncertainty about the possible health risks, the credibility of the source of the information and the level of trust in the executive or supervisory bodies. The discrepancies between the public's opinion about the risk and that of the risk assessors or the authorities can create a great deal of tension. The government cannot therefore do with scientific explanations of the risks but must also pay particular attention to the risk perception of all parties involved.
In the case of local environmental health problems, the Committee believes early risk communication is extremely important, in the sense of an exchange of information and opinions between the authorities, the public and the other parties involved about the nature and extent of the risk.
Proper risk communication can help ensure that those involved are able to form a considered opinion about any risks posed by local environmental factors and can help create greater understanding and trust between the parties. In this respect, the Committee believes the involvement of local residents is a precondition for an effective policy to address a local environmental health problem. If notified in good time about research results, for example, the media can play a positive role in this area too.
The Committee believes that guidelines for risk communication and citizen participation may be useful in the approach to local environmental health problems, although hardly any research has been conducted into the efficacy of such guidelines. Risk communication and public participation are not only important in making a hazardous situation controllable. There must also be sufficient opportunity for an anticipatory policy on environmental health. This could lay the foundations for a better relationship based on trust between the authorities and the public, which could possibly prevent unjustified concerns arising.
Exposure assessment
The most suitable instrument for evaluating possible health effects of exposure to environmental factors is a risk assessment. An important feature of risk assessment is the comparison between the degree of exposure and health-based recommended exposure limits.In the case of local environmental health problems, estimating external exposure by determining the concentrations in water, air, soil or crops will generally suffice. The Committee believes that a determination of internal exposure (body burden) will only be necessary in exceptional cases and only if certain conditions are met. The possible advantages of this, such as reducing the uncertainty or concern about any effects on health have to be weighed against the disadvantages, such as difficulties with interpreting individual measurement results.
On the basis of an exposure and risk assessment it can be determined whether the exposure exceeds relevant health-based limits and whether measures or advice on behaviour are necessary to reduce the health risks. The transparency of the entire process is important, as an exposure and risk assessment can be fairly complex. As far as possible, the perspective and knowledge of those concerned must be taken into account.
Cluster investigation
Questions from the public about disease clusters that are attributed to environmental exposures by those reporting them are often addressed to the Municipal Health Service, which is assigned a task in this area by the Public Health Act. The Committee is in favour of the stepwise approach the Municipal Health Services take to disease clusters. This approach is now widely supported and distinguishes between 3 phases (orientation, verification and quantification) and 3 tracks (the health, environmental and relationship track). In a survey among Municipal Health Services of how they dealt with suspected disease clusters in the years 1993 to 1997, it emerged that already in the verification phase the number of health problems in the potentially exposed population was found not to differ from what would be expected on the basis of global population characteristics. If the verification phase of a cluster study does support the suspicion that a disease cluster exists, it is advisable to use the data from existing health registries to investigate the degree to which the number of disease cases has increased.
The Committee's preferred practice for adoption by the Municipal Health Service is the calculation of standardised morbidity ratios for the area concerned, rather than the use of advanced cluster analysis methods, the most of which are too complex for decentralised use. Little significance can be attached to the results of statistical testing, performed after the cluster has been noticed. The reason for this is that testing afterwards does not meet the fundamental condition for the validity of a statistical test, as no real random sample has been taken. Moreover, the delineation in terms of place and time is only made afterwards.
If more health problems are found than were expected, it is worthwhile considering a study of the occurrence of the disorder in earlier periods or in other areas with a comparable level of exposure. The delineation in terms of place and time can then be chosen in advance, on the basis of the exposure, in order to avoid bias of the results. The Committee believes that any such supra-regional study, which may also use advanced techniques, should be conducted by or in co-operation with organisations with expertise in spatial statistics and cluster analysis.
Further epidemiological research
If a disease cluster has been shown to exist ánd if a proper exposure assessment makes it plausible that the local environmental exposure is or has been sufficiently high to cause health effects, further etiological epidemiological research may be considered. Research of this kind, in which health data and exposure data are collected at the individual level, is intended to determine a possible link between personal exposure to environmental pollution and particular health effects. As a rule, this is only worthwhile if the study will be conducted under strict conditions; especially the number of cases has to be sufficiently high. If the conditions are not met, the disadvantages may outweigh the benefits, especially if the research is combined with blood and urine analysis. It is therefore essential to discuss beforehand with those concerned about the possibilities and limitations of the investigation, in order to avoid creating expectations that cannot be met.
Recommendations
The Committee has defined the following aspects as important elements in any pragmatic approach of local environmental health problems by public bodies:
- take worries about exposure to local environmental factors seriously
- pay attention at an early stage to risk communication and public participation
- perform a systematic and transparent exposure assessment
- consider exposure reducing measures in the case of any nuisance or undesirable exposure
- pay attention to any possible somatic consequences of stress
- follow a stepwise approach to environment-related disease clusters
- take into account coincidence as an explanation of detected disease clusters
- be critical when conducting descriptive epidemiological studies
- explain under which conditions a further epidemiological study would be advisable
- involve communication specialists in epidemiological studies.
- Any reactions or additions are welcome -
The Coordination committee expects from each organization that endorses INCHES to send at least one item of interest of their work that could be relevant for the other participants in the network. Please send material, ideas, reports or suggestions for distribution to Peter van den Hazel or Marie Louise Bistrup. We will distribute information af general interest through e-mails, electronic networks or place it at the INCHES web-site.
Last updated 13 February 2002
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