Welcome At Maastricht University “Health in all Policies”.... or better Child and Youth Health in all Policies? Tobias Schulte in den Bäumen Institute for Public Health Genomics (IPHG)

The guiding principles and concepts of EU health policies : Health in All Policies approach Focus on health promotion and prevention Bridge health inequities Tackle global health issues Address ageing, technology, cross-border issues Develop comparable data EU, MS and stakeholders work together to make strategy work

Health in all Policies (HiAP): A …not so…. new doctrine „The purpose of the doctrine is to highlight ways in which population health can be improved through coherent action in sectors other than health sector. In practice this means that health arguments are taken into account in decision making with relevance to the determinants of health”.

The situation Prevention: Acceptable risk levels are developed by looking at the Dutch / European Standard (Caucasian?) citizen Therapy: The safety and efficacy of health technologies is assessed by looking at available evidence; the evidence often does not cover children. Policies are often not developed specifically for children. Pharmaceuticals for children were often not developed due to ethical, legal and economic constrains. The situation changes slowly as the EU / EMA introduced a new paediatric regulation in 2006 (Regulation 1901/2006).

The legal situation Citizens are enforcing their interests through fundamental rights Children have the same fundamental rights as adults Many policy documents include specific rights of children such as the Charter of Fundamental Rights of the EU or the UN Convention on the Rights of the Child from In practice children have a clear advocacy problem. Parents are entitled to enforce the rights of their children; but we also see that parents are often a big risk factor for children (nutrition, passive smoking, abuse).

The legal situation II Art 24 of the Charter of Fundamental Rights 1.Children shall have the right to such protection and care as is necessary for their well-being. They may express their views freely. Such views shall be taken into consideration on matters which concern them in accordance with their age and maturity. 2. In all actions relating to children, whether taken by public authorities or private institutions, the child's best interests must be a primary consideration. 3.Every child shall have the right to maintain on a regular basis a personal relationship and direct contact with both his or her parents, unless that is contrary to his or her interests.

The legal situation III Convention on the Right of the Child (ratified and enacted in the Netherlands 1995) Art 24 Explanatory Note: Health and health services The child has a right to the highest standard of health and medical care attainable. States shall place special emphasis on the provision of primary and preventive healthcare, public health education and the reduction of infant mortality. They shall encourage international cooperation in this regard and strive to see that no child is deprived of access to effective health services.

The challenge: Translating Knowledge into Child and Youth Policies The success of the Health in all Policies approach depends on the ability of institutions to translate emerging knowledge into policies So far there is no constant up- and downstream of knowledge between life sciences and policy making in emerging areas like genomics and Public Health In order to have an impact, scientists have to deliver messages which can be translated into actions. It is useless to report an increased relative risk of 1.09, it may make a substantial difference to report a clearly defined attributable risk (AR) which can be tackled by a product or process regulation.

The Future of Health in all Policies

The health of individuals and populations depends on various factors which interact with each other. From a legal perspective it is not possible to address all issues in one legal act. Law has to construct a web of regulations which interact. A further problem follows from the idea of law: law strives to set up rules which are applicable for all member of a society. Law is not prepared for personalized healthcare. If we want to assess and reduce health risks for each individual child, we would have to regulate rather both, the process and the expositions. Law also has to ensure that rules are not in conflict with each other. With the amount of regulations in both the Member States and the Commission, this is almost undoable.

Determinants of Health Income and Social Status Education, Culture and Literacy Employment/Working / Learning Conditions  Law Social Environments  Law Physical Environments  Law Personal Health Practices and Coping Skills Healthy Child Development  Law Biology and Genetic Endowment  Law Health Services  Law Gender

Genetic Modulation of Exposure Risk Exposure No Exposure 4-Fold Risk 2-Fold Risk Background Risk Level (low) Sensitive Genotype Sensitive Genotype Resistant Genotype Resistant Genotype

What are the legal and political consequences? Policies need to address the individual risk assessment. A one size fits all policy does not fit anymore when we look at gene- environment and gene-gene interactions. Citizens (Patients) must be empowered to reduce their individual risks. How do we make sure we reach the children? Policies must be “open” to address individual needs. This implies also consequences for social and medical services. If producers market “risky” products for children, they should be forced to monitor the child specific risks associated to their products. Health goals can only be achieved when all policies including non- health regulations fit together in a coherent legal system.

The case study: Fine Particles / Ambient Air Polution

The case study: the consequences According to the EU: “Air pollution reduces life expectancy and causes serious health problems, including chronic bronchitis, respiratory problems and asthma. The enormous cost to the European economy in terms of human health is estimated to be somewhere between €427 and €790 billion a year. This new air quality legislation will reduce exposure to fine particulates which, together with ground-level ozone, are responsible for the premature death of around 370,000 persons across the EU every year”.

The EC Answer: Directive 2008/50/EC of 21 May 2008 on ambient air quality and cleaner air for Europe Article 23 Air quality plans 1. Where, in given zones or agglomerations, the levels of pollutants in ambient air exceed any limit value or target value, plus any relevant margin of tolerance in each case, Member States shall ensure that air quality plans are established for those zones and agglomerations in order to achieve the related limit value or target value specified in Annexes XI and XIV. In the event of exceedances of those limit values for which the attainment deadline is already expired, the air quality plans shall set out appropriate measures, so that the exceedance period can be kept as short as possible. The air quality plans may additionally include specific measures aiming at the protection of sensitive population groups, including children. Where air quality plans must be prepared or implemented in respect of several pollutants, Member States shall, where appropriate, prepare and implement integrated air quality plans covering all pollutants concerned.

Conclusions

Health in all Policies is a multi- and interdisciplinary approach which requires input from life sciences, Public Health, ethics, political sciences and law. Health in all Policies allows a holistic approach towards health policies as policies are not artificially fragmented but seen as an interacting net of policies. The success of the concept depends on the clear definition of health needs and the assessment of health impacts of policies. Legal rules are needed to enforce the achievement of health goals. They also need to be flexible enough to reflect new and emerging knowledge. Health in all Policies should enable us to protect individuals; none of us is average, we are all unique.