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Journal Issue: Children with Disabilities Volume 22 Number 1 Spring 2012

Prevention of Disability in Children: Elevating the Role of Environment
Stephen A. Rauch Bruce P. Lanphear

Healthy Communities: Challenges and Successes

We have a remarkable opportunity to protect the health of children and prevent the development of disability. While it is not yet definitive, a growing body of evidence shows that prenatal or early-life exposure to chemicals or malnutrition can have severe effects on physical and mental development that persist over the life span and that effects are found at increasingly lower levels of exposure. Children are routinely exposed to thousands of man-made chemicals, most of which have not been tested for safety, from an early age, and often even before they are born. From a very young age, children are inundated with marketing for fast-food restaurants, sugary cereals, tobacco, and alcohol; these exposures can shape their developing behaviors, food preferences, and decisions to smoke or drink alcohol. While the task may seem daunting, these exposures are all modifiable if we have the will to do so, and taking action would produce considerable benefits.

Reducing toxic exposures is not impossible. C. Arden Pope and his colleagues estimated that as much as 15 percent of the increase in life expectancy from 1980 to 2000 in many U.S. cities was attributable to environmental regulations that reduced air pollution.97 Further reductions in allowable levels of airborne pollutants are likely to result in even greater benefits.98 Another promising finding is a reduction in asthma rates brought about by smoking bans. In Scotland and Kentucky, recent bans on smoking in public places have each led to an 18 percent reduction in child asthma hospitalizations and emergency-room visits in the areas affected by the bans.99 Through coordinated public health campaigns, social attitudes about smoking are changing, and tobacco use has declined.100 Regulations lowering the allowable levels of lead in gasoline, paints, and other consumer products led to an 84 percent reduction in children with elevated blood lead (more than 10 micrograms per deciliter) in the United States between 1988–91 and 1998–2004.101 And while efforts to curb childhood obesity have, thus far, been unsuccessful at the societal level, a few school-based programs have had some success in lowering the body mass index for some children or increasing their physical activity.102

These success stories demonstrate the potential benefits that could result from wide-scale prevention of disability in children. But it is not enough to address this chemical or that risk factor when thousands more have not been tested and new ones are introduced every day. Many of the best-known environmental risk factors have been decreasing in recent decades, yet the prevalence of childhood disability is rising. If the established pollutants are not responsible for the increase in disability, those other exposures that are responsible must be identified. If we want to make meaningful progress in preventing disability and promoting health, we must be willing to make fundamental changes to our environment. We must ask ourselves: What kind of world do we want to live in? What would a healthy city or community really look like?

Many interventions aimed at mothers with small children have been shown to be effective in giving children a healthy base for development. Breast feeding is known to lower risks of such wide-ranging conditions as asthma, obesity, and diabetes, and it is associated with greater mental development in preterm infants.103 Increasing rates of breast feeding will require not only educational campaigns but the removal of structural and institutional barriers for breast-feeding mothers; new federal legislation requiring employers to provide space and break time for mothers provides some support in states without previous legislation, although barriers to acceptance still remain.104

Another intervention that has gained support is the practice of nurses' visits to low-income first-time mothers in their home to promote care of healthy infants and injury prevention. Evidence for the effectiveness of this intervention is mixed, but randomized trials have shown that one program, the Nurse Family Partnership, which has been tested around the country and now operates in thirty-two states, reduces maltreatment and behavioral problems and increases cognitive performance in children.105 These successes provide ideas for changes that would work at a larger level, but investments in these interventions must be long term to be effective; it takes years for the benefits to accrue. Such programs are thus often deemphasized in favor of medical treatments that produce more immediate results for the individual but few long-lasting benefits for society.

By their physical design, cities and towns can lend themselves either to a healthy population or to one with high levels of disability and disease. One aspect of cities that has received much attention is the built environment. As noted, the built environment is linked with obesity, but just as environments can be "obesogenic," they can also promote physical activity and healthful eating. By designing cities with efficient public transportation, greater urban density, mixed land use, and easy access to fresh produce, more healthful choices would become easier to make. As with any engineering solution, however, these large-scale changes will require great effort, leadership, expense, and collective will.

Increased public transportation, in particular, would make cities more healthful on several fronts. Fewer cars on the road, particularly if a greater share of them emitted fewer pollutants, would reduce air pollution levels, which would lead to lower rates of asthma and cardiovascular disease and to longer life expectancy.106 Greater use of public transportation could also lower levels of obesity; one study found that users of public transit in Atlanta were more than twice as likely to meet the recommended levels of physical activity.107 Another study after the addition of light rail transit in Charlotte, North Carolina, found that transit users lost weight compared with those who did not use it.108

Environments are social, as well as physical. It is virtually impossible to shield a child from the marketing that surrounds her at every stage of her life, and research is making it increasingly clear that the repetitive exposures leave a mark. One way to improve children's health would be to restrict certain types of advertising. Tobacco ads are already banned from television, but depictions of smoking in movies still influence children's decisions about whether (or when) to begin smoking. Similar arguments can be made for alcohol and fast food: one study estimated that a ban on fast-food advertising aimed at children and adolescents would reduce rates of overweight children by 18 percent for children aged three to eleven, and 14 percent for those aged twelve to eighteen.109 Increasing children's media literacy might also give children some "resistance" against marketing and a healthy suspicion of advertisers' claims. While such media savvy may help counter the most harmful effects of the consumer culture, the only widely effective solution is likely to be regulation of marketing to children. The British government has banned junk food advertisements in programs aimed at children under sixteen; it remains to be seen whether other countries will follow with similar regulations.110

Finally, virtually every health measure available is connected with socioeconomic status. Efforts to reduce poverty will require a high level of coordination and political determination and may require realigning a nation's collective priorities. Some programs, such as instituting a living wage, have sought to address specific aspects of poverty. Limited evidence is available about the feasibility and effectiveness of a living wage, but few would argue that a family's basic needs, such as housing, food, clothing, and health care, should go unmet.

What would a healthy community look like? In many ways, Vancouver, on the west coast of Canada's British Columbia, fits this description. The city has low levels of air pollution and relatively low rates of smoking (15.1 percent of people over age fifteen, lower than the rest of Canada or the United States).111 The city is built to encourage walking, bicycling, and use of public transit; the number of major highways that cut through the heart of the city is minimal. And its inhabitants seem to live longer, healthier lives. In 2005–09, Vancouver's life expectancy at birth was 82.6 years, which—if it were a country—would rank second only to Japan.112 In addition, Vancouver has begun an initiative to become the world's greenest city by 2020, an effort that includes sustainable industries, low levels of air pollution, and a citywide goal of walking, cycling, or using public transportation for at least half of all trips taken.113 This vision is in stark contrast with cities of the past that aspired to attract industry, only to end up with high levels of air pollution and widespread sprawl centered around cars and highways. One might imagine policies influencing other aspects of life that affect children's health: low-density billboards and restrictions on marketing unhealthful products would create a more healthful media environment. Cities could institute a living wage for workers, following the example of more than 100 U.S. cities, or commit to providing health care for its uninsured residents, as San Francisco has done.114

A nation that committed itself could take actions that would prevent childhood disabilities by greatly reducing exposures to environmental hazards, at a great savings in human capital and health care costs. A strategy for the prevention of disability must prioritize and target prevalent environmental exposures across populations, rather than continue to focus primarily on the treatment of high-risk or susceptible children. Preventing disabilities will require us to change the way we live—how we build our communities, travel, regulate pollutants, and invest our resources. We now have the evidence and tools to profoundly improve the health and functioning of children, but implementing a preventive strategy will take a concerted effort involving parents, pediatricians, public health officials, policy makers, and society at large.