The economic case for protecting children from chemical hazards Leonardo Trasande, MD, MPP Associate Professor of Pediatrics, Environmental Medicine and Health Policy New York University

Why are children are uniquely vulnerable? Pound for pound, drink more water, eat more food and breathe in more air Less well able to detoxify or eliminate chemicals from their bodies Developing organ systems are more susceptible Greater years of life in which chronic conditions can occur as a result of early life exposures National Academy of Sciences 1993

Evidence confirming child vulnerability Epidemic increases in chronic disease in US and other industrialized nations (asthma, childhood cancers, certain birth defects, learning/developmental disabilities) – Contemporaneous with widespread increase in use of chemicals Trasande et al Dec 2011 Health Affairs

Population studies quantify strong and consistent associations with chemical exposures – US National Academy of Sciences: 28% of developmental disabilities at least in part due to environment – Benzene and 1,3-butadiene associated with childhood cancer – Outdoor air pollutants are well documented to worsen and may increase risk of development of asthma Evidence confirming child vulnerability Trasande et al Dec 2011 Health Affairs

Why have we been slow to protect children? Toxic Substances Control Act of 1976 does not require premarket testing of chemicals – Fewer than ½ of most produced chemicals in US have any toxicity testing data; fewer than 1/5 have data with respect to impacts on development Epidemiologic studies post hoc take years Outcomes have many potential confounders Criteria of reproducibility, consistency Uncertainty about dose-response relationships (also linear pedagogy), thresholds

Why have we been slow to protect children? Strong vested (economic) interests with powerful political forces Subclinical effects are not as powerful as the Minamata or Bhopal disasters Cost-benefit analyses are complicated by one group enduring costs (industry) with another group enduring benefits (children) – How do you estimate the cost to industry of environmental intervention? (Incentive to inflate)

Case study 1: Lead in gasoline

The Success and Near-Failure of Lead in Gasoline Lead phased-out from gasoline (catalytic converters or kids?) beginning 1975 Fix discovered for catalytic converters: does lead get back in? Only when data on lock-step decrease of blood lead levels and lead use presented is effort to phase back in blocked

Retrospectively, a Wise Economic Decision Grosse et al Environ Health Perspect 110: (2002)

Global Benefits of Phasing Out Lead From Gasoline Range from $1-$6 trillion/year, with a best estimate of $2.45 trillion/year. These benefits may also be expressed as 4% of global GDP. Tsai and Hatfield 2011 J Environ Health

Case study 2: Mercury emissions from coal-fired power plants

How can economic analyses drive policy? Bush EPA proposes relaxation on mercury emissions requirements for coal-fired power plants – Technical analyses in support of "Clear Skies" failed to incorporate or quantify consideration of the health impacts resulting from increased mercury emissions

What are the Economic Consequences of Mercury Pollution? Trasande et al Environ Health Perspect 113: (2005) Also identified 1566 additional cases of mental retardation associated with IQ loss from methylmercury toxicity, at a cost of $2.0 billion. (Trasande et al Am. J. Ind. Med. 49:153–158, 2006)

What happened? Arguably influenced US Senate debate Administration bill fails EPA enacts Clean Air Mercury Rule (CAMR; essentially = Clear Skies) Multiple states enact more aggressive regulations (PA, GA, MI and others) Multi-state lawsuit overturns CAMR

The global case for reducing mercury emissions 15 Global health costs from loss of productivity due to mercury pollution could amount to as much as $29.4 billion in Pacyna et al 2008 Reductions in emissions could contribute $1.8–2.2 billion in global economic benefits in 2020, with similar benefits for subsequent cohorts of children born with lower levels of exposure from their mothers who ingest less contaminated fish. Sundseth et al 2010

Case study 3: Policy failures from in the US to protect children

In addition to mercury… US policy action to limit childrens exposure to known chemical hazards has also been extremely limited. Funding for lead-hazard control programs did not meet levels projected to be necessary for eliminating childhood lead poisoning by US National Ambient Air Quality Standards still do not adequately protect children from the respiratory effects of outdoor air pollutants.

Economic costs, 2008 Trasande and Liu May 2011 Health Affairs

How does this compare? Trasande and Liu May 2011 Health Affairs

Case study 4: Regulating Bisphenol A in food uses

Bisphenol A (BPA) Used to manufacture polycarbonate resin Recently banned from baby bottles and sippy cups by US Food and Drug Administration Breakdown product of coatings intended to prevent metal corrosion in food and beverage containers Comprehensive, cross-sectional study of dust, indoor and outdoor air, and solid and liquid food in preschool age children suggested that dietary sources constitute 99% of BPA exposure Dietary interventions have reduced geometric BPA 66% in children and adults Crossover trial of canned food consumption increased BPA 1221% (suggesting 92% reduction if BPA was removed from aluminum cans) Schecter et al. Environ Sci Technol. 2010;44(24): Wilson et al.Environ Res. Jan 2007;103(1):9-20. Tavernise S. New York Times, 17 July 2012 edition.

BPA, obesity and cardiovascular risk Experimental studies suggest that BPA disrupts multiple metabolic mechanisms, at levels commonly seen in US population – Increases fat cell size – Disrupt adiponectin function – Low-grade synthetic estrogen Estrogen-testosterone balance may have sex-specific differences in influence on body mass Masuno et al. J Lipid Res. 2002;43(5): ; Sakurai K et al. Br J Pharmacol. 2004;141(2): ;

Urinary BPA concentration has been associated with: – Adult and childhood obesity – Adult diabetes, cardiovascular diagnoses and abnormalities in liver function – Increased frequency of later coronary artery disease in later life – Poorer executive function and behavior in children Carwile JL, Michels KB. Environ Res. 2011;111(6): ; Lang al. JAMA. 2008;300(11): ;Melzer et al. PLoS One. 2010;5(1):e8673; Melzer et al. Circulation. 2012;125(12): ; Braun JM et al. Pediatrics. 2011;128(5): ; Trasande et al JAMA 2012;11: BPA, obesity and cardiovascular risk

Childhood obesity costs

Adult cardiovascular cost

Benefits and costs of replacing BPA Alternatives to BPA include polyester coatings and oleoresin linings in cans as well as polyethylene plastic, glass and aluminum containers. If oleoresin linings cost 2.2 cents more than those derived using BPA, and 100 billion aluminum cans are produced annually, then the incremental cost of replacing BPA would be $2.2 billion.

BPS replacing BPA? Emerging evidence suggests replacement of BPA and BPS Similar, weak estrogen like BPA Disrupts signaling of estrogen in animal studies Does not degrade as easily in seawater Bisphenol A Bisphenol S Liao et al Environ Sci Technol Jun 19;46(12): Liao et al Environ Sci Technol Jun 19;46(12): Grignard et al Toxicol In Vitro Aug;26(5): Vinas and Watson EHP doi: /ehp Danzl et al Int J Environ Res Public Health Apr;6(4):

What do we learn from these case studies?

Take away messages 1-3 While not always decisive, economic cost estimates can be influential and document the consequences of failures US/global experience with economic benefits of removal of lead from gasoline should be applied to continuing efforts to remove it from paint globally Economic estimates of mercury pollution costs and potential benefits of abatement should be prominent part of global mercury treaty negotiations

The increasingly global chemical picture OECD estimates in 2020: industrializing nations will account for 33% of global chemical demand and 31% of production – compared with 23 percent and 21 percent, respectively, in 1995 – industrializing nations are expected to lead in the manufacture of high production volume chemicals – occurs against a backdrop of insufficient infrastructure to protect public health and the environment

Take away message 4 Sound chemicals management must be implemented in industrializing nations to avoid repeating the experience with chronic disease epidemics in the industrialized nations – Need not interfere with economic development

Context to take away message 4 Early warning signs of similarly disturbing trends in industrializing countries have recently emerged – Sustained increase between 1982 and 2002 in the incidence of acute lymphocytic leukemia in children in Mexico. – Increases over the past five to ten years in childhood asthma prevalence in many developing countries. – WHO estimates that 5.8% of life-years lost because of disabilities in children living in low- and middle- income countries are attributable to lead exposure and air pollution Cites in Trasande et al Dec 2011 Health Affairs

Costs are being felt globally World Bank 2010: direct and indirect costs of childhood disease associated with air and water pollution were 9.3 percent in Ghana and 8.8 percent in Pakistan, respectively, of these two countries' gross domestic products cost in China of pediatric and adult health costs associated with air and water pollution: 4.3% of China's GDP Cites in Trasande et al Dec 2011 Health Affairs

Principles of sound chemicals management Precaution, or the use of cost-effective measures to prevent potentially hazardous exposures before scientific understanding is complete; Right to know, or informing the publicespecially vulnerable groupsin a timely fashion about the safe use of chemicals and any releases of chemicals into the environment; Focus on preventing the use of hazardous chemicals and the production of pollutants, rather than focusing on managing wastes; Internalization of environmental and health costs, or ensuring that the consequences of exposures are reflected in the price of chemicals through such approaches as polluter pays; and Use of best available scientific information, in making decisions such as what chemicals to allow into the market. Trasande et al Dec 2011 Health Affairs

Context for the costs of sound chemicals management The global chemical industry has annual revenues of more than $3 trillion dollars per year. If mechanisms were created so that the industry itself effectively financed chemicals management, at a cost of just 0.1 percent of the industrys annual revenues, more than $3 billion would be available for that purpose. Trasande et al Dec 2011 Health Affairs