Search

A life-course approach to health encompasses strategies across individuals' lives that optimize their functional ability (taking into account the interdependence of individual, social, environmental, temporal and intergenerational factors), thereby enabling well-being and the realization of rights. The approach is a perfect fit with efforts to achieve universal health coverage and meet the sustainable development goals (SDGs). Properly applied, a life-course approach can increase the effectiveness of the former and help realize the vision of the latter, especially in ensuring health and well-being for all at all ages. Its implementation requires a shared understanding by individuals and societies of how health is shaped by multiple factors throughout life and across generations. Most studies have focused on noncommunicable disease and ageing populations in high-income countries and on epidemiological, theoretical and clinical issues. The aim of this article is to show how the life-course approach to health can be extended to all age groups, health topics and countries by building on a synthesis of existing scientific evidence, experience in different countries and advances in health strategies and programmes. A conceptual framework for the approach is presented along with implications for implementation in the areas of: (i) policy and investment; (ii) health services and systems; (iii) local, multisectoral and multistakeholder action; and (iv) measurement, monitoring and research. The SDGs provide a unique context for applying a holistic, multisectoral approach to achieving transformative outcomes for people, prosperity and the environment. A life-course approach can reinforce these efforts, particularly given its emphasis on rights and equity.Une approche sanitaire fondée sur le parcours de vie englobe des stratégies tout au long de la vie des individus qui optimisent leur capacité fonctionnelle (en prenant en compte l'interdépendance de facteurs individuels, sociaux, environnementaux, temporels et intergénérationnels), assurant ainsi le bien-être et l'exercice des droits. Cette approche s'inscrit parfaitement dans les efforts déployés pour parvenir à une couverture sanitaire universelle et atteindre les objectifs de développement durable (ODD). Lorsqu'elle est correctement appliquée, une approche fondée sur le parcours de vie peut accroître l'efficacité de la première et aider à concrétiser l'ambition des seconds, en assurant notamment la santé et le bien-être pour tous à tous les âges. Sa mise en œuvre exige une compréhension commune par les individus et les sociétés de la manière dont la santé est façonnée par de multiples facteurs tout au long de la vie et d'une génération à l'autre. La plupart des études réalisées ont porté sur des maladies non transmissibles et le vieillissement des populations dans les pays à revenu élevé, ainsi que sur des aspects épidémiologiques, théoriques et cliniques. L'objectif de cet article est de montrer que l'approche sanitaire fondée sur le parcours de vie peut être élargie à toutes les tranches d'âge, toutes les questions de santé et tous les pays en s'appuyant sur une synthèse des données scientifiques existantes, les expériences de différents pays et l'avancement des stratégies et programmes en matière de santé. Un cadre conceptuel de l'approche est présenté ainsi que les conséquences de sa mise en œuvre sur: (i) la politique et l'investissement; (ii) les services et systèmes de santé; (iii) les actions locales, multisectorielles et multipartites; et (iv) les mesures, la surveillance et la recherche. Les ODD fournissent un contexte unique pour l'application d'une approche globale et multisectorielle en vue d'obtenir des résultats porteurs de transformation pour les individus, la prospérité et l'environnement. Une approche fondée sur le parcours de vie peut renforcer ces efforts, notamment parce qu'elle met l'accent sur les droits et l'équité.Un enfoque basado en la salud para toda la vida engloba estrategias durante la vida de las personas, que optimizan su capacidad funcional (teniendo en cuenta la interdependencia de los factores individuales, sociales, ambientales, temporales e intergeneracionales), permitiendo así el bienestar y la realización de los derechos. El enfoque encaja perfectamente con los esfuerzos por lograr una cobertura sanitaria universal y cumplir los objetivos de desarrollo sostenible (ODS). Si se aplica correctamente, un enfoque para toda la vida puede aumentar la eficacia del primero y ayudar a alcanzar la visión de este último, especialmente para garantizar la salud y el bienestar en todas las edades. Su aplicación requiere una comprensión compartida entre individuos y sociedades sobre cómo la salud depende de múltiples factores presentes a lo largo de la vida y entre generaciones. La mayoría de los estudios se han centrado en las enfermedades no contagiosas, en el envejecimiento de la población en los países con ingresos altos y en cuestiones epidemiológicas, teóricas y clínicas. El objetivo de este artículo es mostrar cómo el enfoque basado en la salud para toda la vida se puede extender a todos los grupos de edades, temas de salud y países, mediante la creación de una síntesis de las pruebas científicas existentes, la experiencia en diferentes países y los avances en estrategias y programas de salud. Se presenta un marco conceptual del enfoque junto con las implicaciones para la aplicación en los siguientes campos: (i) política e inversión; (ii) servicios y sistemas de salud; (iii) acción local, multisectorial y de varias partes interesadas; y (iv) medición, supervisión e investigación. Los ODS proporcionan un contexto único para aplicar un enfoque holístico y multisectorial a fin de alcanzar unos resultados transformadores para las personas, la prosperidad y el medio ambiente. Un enfoque para toda la vida puede intensificar estos esfuerzos, sobre todo por su énfasis en los derechos y la equidad.يتضمن نهج مسار الحياة للتمتع بالصحة مجموعة من الاستراتيجيات على مدار حياة الأفراد وهي تعمل على تحسين قدرتهم الوظيفية (مع مراعاة الترابط بين العوامل الفردية، والاجتماعية، والبيئية، والزمانية، وبين الأجيال المختلفة)، وهو الأمر الذي يتيح التمتع بالصحة والعافية وإعمال الحقوق. ويعد هذا النهج مناسبًا تمامًا للجهود الرامية إلى تحقيق تغطية صحية شاملة وتلبية أهداف التنمية المستدامة (SDG). يمكن أن ينتج عن تطبيق نهج مسار الحياة بشكلٍ صحيح، زيادة فعالية الخدمة الأولى والمساعدة على تحقيق رؤية الأهداف الأخيرة المذكورة، وخصوصًا في ضمان التمتع بالصحة والعافية لجميع الأشخاص بكافة الأعمار. ويتطلب تنفيذه وجود تفاهم مشترك بين الأفراد والمجتمعات حول كيفية تكوين مبادئ الصحة من خلال العديد من العوامل على مدار الحياة وعبر مختلف الأجيال. لقد ركزت معظم الدراسات على الأمراض غير المعدية، وعلى السكان المسنين في البلدان مرتفعة الدخل، وعلى المشكلات الوبائية والنظرية والسريرية. إن الهدف من هذه المقالة هو توضيح كيف يمكن تمديد نطاق نهج مسار الحياة للتمتع بالصحة ليشمل جميع الفئات العمرية، والموضوعات الصحية، والبلدان من خلال البناء على توليفة من الأدلة العلمية المثبتة بالفعل، والخبرة في مختلف البلدان، وأوجه التقدم المحرز في الاستراتيجيات والبرامج الصحية. يتم تقديم إطارًا مفاهيميًا لهذا النهج إلى جانب ذكر الآثار المترتبة على تنفيذه في المجالات التالية: (1) السياسة والاستثمار؛ (2) والخدمات والنظم الصحية؛ (3) والإجراءات التي يتم اتخاذها على المستوى المحلي والقطاعات المتعددة والجهات المعنية المتعددة؛ (4) والقياس والرصد والبحث. توفر أهداف التنمية المستدامة سياقًا فريدًا من نوعه لتطبيق نهج شامل عبر العديد من القطاعات لتحقيق النتائج التحويلية للأشخاص والرخاء والبيئة. ويمكن لنهج مسار الحياة أن يعزز هذه الجهود، لا سيما بالنظر إلى تركيزه على الحقوق والمساواة.种健康的生活方式，包括优化机能水平的个人生活策略（考虑到个人、社会、环境、时间和代际因素之间的相互依赖性），从而实现福祉和权利。该方式完全符合实现全民健康保障和可持续发展目标。适当采用这种生活方式可以提高前者的有效性，并有助于实现后者的愿景，特别是在确保所有年龄段人民的健康和幸福方面。它的实施需要个人和社会共同理解：在整个生命和几代人中，健康是如何受到多种因素影响的。大多数研究都集中在高收入国家的非传染性疾病和老龄化人群以及流行病学、理论和临床问题上。本文旨在展示如何通过综合现有的科学实证、不同国家的经验以及卫生策略和方案的进展，将该健康的生活方式推广到所有年龄段、健康主题和国家。展示该方式的概念框架以及实施对下列领域产生的影响：(i) 政策和投资；(ii) 卫生服务和系统；(iii) 地方、多部门和多方利益相关者的行动；(iv) 测量、监测和研究。可持续发展目标为采用全面、多部门的方法实现人民、繁荣和环境的变革成果提供了独特的环境。一种生活方式可以加强这些努力，特别是考虑到对权利和公平的重视。.Подход к здоровью, рассчитанный на всю продолжительность жизни человека, включает в себя применяемые на протяжении всей жизни людей стратегии, которые оптимизируют их функциональные способности (с учетом взаимозависимости индивидуальных, социальных, экологических, временных и межпоколенческих факторов), тем самым обеспечивая благополучие и реализацию прав. Этот подход идеально сочетается с усилиями по достижению всеобщего охвата медико-санитарным обслуживанием и целей в области устойчивого развития (ЦУР). Правильно применяемый подход на протяжении всей жизни может повысить эффективность первого и помочь реализовать концепцию последних, особенно в обеспечении здоровья и благополучия для всех людей любого возраста. Его реализация требует общего понимания отдельными людьми и обществом того, как под воздействием нескольких факторов формируется здоровье в течение всей жизни и из поколения в поколение. В большинстве исследований основное внимание уделялось неинфекционным болезням и пожилой группе населения в странах с высоким уровнем доходов, а также эпидемиологическим, теоретическим и клиническим вопросам. Цель этой статьи — показать, как подход к здоровью, рассчитанный на всю продолжительность жизни, может быть распространен на все возрастные группы, вопросы относительно здравоохранения и страны, опираясь на обобщение существующих научных данных, опыта в разных странах и достижений в стратегиях и программах здравоохранения. Представлены концептуальные схемы подхода, а также последствия для реализации в следующих областях: (i) политика и инвестиции; (ii) медико-санитарное обслуживание и система здравоохранения; (iii) местная, многосекторальная деятельность с участием многих заинтересованных сторон и (iv) измерения, мониторинг и исследования. ЦУР представляют собой уникальный фон для применения целостного многосекторального подхода к достижению таких результатов, которые оказывают преобразующее воздействие на людей, их благосостояние и окружающую среду. Данный подход может подкреплять эти усилия, особенно с учетом его акцента на правах и справедливости.

Safeguarding the continued existence of humanity requires building societies that cause minimal disruptions of the essential planetary systems that support life. While major successes have been achieved in improving health in recent decades, threats from the environment may undermine these gains, particularly among vulnerable populations and communities. In this article, we review the rationale for governments to invest in environmental Common Goods for Health (CGH) and identify functions that qualify as such, including interventions to improve air quality, develop sustainable food systems, preserve biodiversity, reduce greenhouse gas emissions, and encourage carbon sinks. Exploratory empirical analyses reveal that public spending on environmental goods does not crowd out public spending on health. Additionally, we find that improved governance is associated with better performance in environmental health outcomes, while the degrees of people's participation in the political system together with voice and accountability are positively associated with performance in ambient air quality and biodiversity/habitat. We provide a list of functions that should be prioritized by governments across different sectors, and present preliminary costing of environmental CGH. As shown by the costing estimates presented here, these actions need not be especially expensive. Indeed, they are potentially cost-saving. The paper concludes with case examples of national governments that have successfully prioritized and financed environmental CGH. Because societal preferences may vary across time, government leaders seeking to protect the health of future generations must look beyond electoral cycles to enact policies that protect the environment and finance environmental CGH.

Background The update of the global burden of disease attributable to the environment is presented. The study focuses on modifiable risks to show the potential health impact from environmental interventions. Methods Systematic literature reviews on 133 diseases and injuries were performed. Comparative risk assessments were complemented by more limited epidemiological estimates, expert opinion and information on disease transmission pathways. Population attributable fractions were used to calculate global deaths and global disease burden from environmental risks. Results Twenty-three percent (95% CI: 13–34%) of global deaths and 22% (95% CI: 13–32%) of global disability adjusted life years (DALYs) were attributable to environmental risks in 2012. Sixty-eight percent of deaths and 56% of DALYs could be estimated with comparative risk assessment methods. The global disease burden attributable to the environment is now dominated by noncommunicable diseases. Susceptible ages are children under five and adults between 50 and 75 years. Country level data are presented. Conclusions Nearly a quarter of global disease burden could be prevented by reducing environmental risks. This analysis confirms that eliminating hazards and reducing environmental risks will greatly benefit our health, will contribute to attaining the recently agreed Sustainable Development Goals and will systematically require intersectoral collaboration to be successful.

Environmental health risks especially affect women and children, because they are more vulnerable socially and because exposures to environmental contaminants create greater risks for children's developing bodies and cognitive functions. According to the 2016 World Health Organization (WHO) estimates, modifiable environmental risk factors cause about 1.7 million deaths in children younger than five years and 12.6 million total deaths every year. (1) Although the Global strategy for women's, children's and adolescents' health (2016-2030) (2) was launched during the United Nations Sustainable Development Summit 2015, governments rarely recognize the sustainable development agenda as a transformative factor for health. The sustainable development goals (SDGs) offer opportunities for countries to create healthier environments for women, children and adolescents. This paper explores how the SDGs can be used to reduce environmental health risks and enhance the health of women, children and adolescents. In particular, we focus on drivers for urbanization and sustainable development (e.g. transport, housing, urban design and energy provision) that can advance the global strategy, but have not traditionally been a focus of health policy-making. We frame the discussion around the three pillars of the global strategy: survive, thrive and transform, while recognizing the inevitable overlap between these objectives. Survive Since women and children are especially affected by the environment, intersectoral interventions that reduce environmental risks will improve early childhood survival as well as reducing risks of premature death throughout the life-course. For instance, household air pollution from dirty fuels and inefficient cookstove technologies was estimated to have caused around 4 million premature deaths in 2012 and was responsible for more than half of deaths due to childhood pneumonia. (3) Among women, indoor exposures to household cookstove smoke were estimated to cause 34% (452 548/1336601) of chronic obstructive pulmonary disease deaths, 21% (732 937/3 476 815) of stroke deaths, 19% (93 537/489 390) of lung cancer deaths and 14% (479478/3425 835) of ischaemic heart disease deaths in 2012. (4,5) Improving access to reliable electricity and clean water in health-care facilities can also help reduce maternal and newborn mortality, as such infrastructure is a critical determinant of quality of care. (6) A review of health-care facilities in 11 sub-Saharan African countries showed that an average of 26% of facilities had no electricity whatsoever. (7) Another review of 54 low- and middle-income countries found that 38% (25 118/66 101) of health facilities lack a clean drinking water source. (8) Ensuring that health-care facilities have access to power and water is a minimum requirement for attracting women to facilities and guaranteeing quality services for safe childbirth. Thrive Housing and energy sector interventions that promote the transition to cleaner fuels and technologies for domestic cooking, heating and lighting can not only reduce deaths but improve the health of the 3 billion people worldwide who are reliant upon inefficient and polluting cookstoves. For this reason, the monitoring framework of the Global strategy for women's, children's and adolescents' health (2016-2030) explicitly tracks an indicator for "primary reliance on clean fuels and technologies" in households as part of its thrive pillar. (9) Examples of cleaner fuels and technologies include liquefied petroleum gas, biogas, ethanol and electricity including photovoltaic solar-power for lighting. Improving access to clean fuels and technologies can also reduce the burden of childhood burns and poisonings due to the use of kerosene for cooking and lighting. While most of the estimated 3 million deaths annually from outdoor ambient air pollution are among adult populations, reducing such pollution exposures are also critical to improving children's health and development across the life-course. …

Objective: To assess the impact of inadequate water and sanitation on diarrhoeal disease in low- and middle-income settings. Methods: The search strategy used Cochrane Library, MEDLINE & PubMed, Global Health, Embase and BIOSIS supplemented by screening of reference lists from previously published systematic reviews, to identify studies reporting on interventions examining the effect of drinking water and sanitation improvements in low- and middle-income settings published between 1970 and May 2013. Studies including randomised controlled trials, quasi-randomised trials with control group, observational studies using matching techniques and observational studies with a control group where the intervention was well defined were eligible. Risk of bias was assessed using a modified Ottawa-Newcastle scale. Study results were combined using meta-analysis and meta-regression to derive overall and intervention-specific risk estimates. Results: Of 6819 records identified for drinking water, 61 studies met the inclusion criteria, and of 12 515 records identified for sanitation, 11 studies were included. Overall, improvements in drinking water and sanitation were associated with decreased risks of diarrhoea. Specific improvements, such as the use of water filters, provision of high-quality piped water and sewer connections, were associated with greater reductions in diarrhoea compared with other interventions. Conclusions: The results show that inadequate water and sanitation are associated with considerable risks of diarrhoeal disease and that there are notable differences in illness reduction according to the type of improved water and sanitation implemented.

Objective: To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases. Methods: For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks. Results: In 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group. Conclusions: This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene. © 2014 The Authors. Tropical Medicine and International Health published by John Wiley & Sons Ltd..

Background: Nearly 13 million new cancer cases and 7.6 million cancer deaths occur worldwide each year; 63% of cancer deaths occur in low- and middle-income countries. A substantial proportion of all cancers are attributable to carcinogenic exposures in the environment and the workplace. Objective: We aimed to develop an evidence-based global vision and strategy for the primary prevention of environmental and occupational cancer. Methods: We identified relevant studies through PubMed by using combinations of the search terms “environmental,” “occupational,” “exposure,” “cancer,” “primary prevention,” and “interventions.” To supplement the literature review, we convened an international conference titled “Environmental and Occupational Determinants of Cancer: Interventions for Primary Prevention” under the auspices of the World Health Organization, in Asturias, Spain, on 17–18 March 2011. Discussion: Many cancers of environmental and occupational origin could be prevented. Prevention is most effectively achieved through primary prevention policies that reduce or eliminate involuntary exposures to proven and probable carcinogens. Such strategies can be implemented in a straightforward and cost-effective way based on current knowledge, and they have the added benefit of synergistically reducing risks for other noncommunicable diseases by reducing exposures to shared risk factors. Conclusions: Opportunities exist to revitalize comprehensive global cancer control policies by incorporating primary interventions against environmental and occupational carcinogens.

Neglected tropical diseases (NTDs) affect over 1 billion people. Safe water, sanitation and hygiene (WASH) contribute to prevention and management of most NTDs. Linking WASH and NTD interventions has potential to impact on multiple NTDs and can help secure sustainable and equitable progress towards universal access to WASH. The need to address the determinants of NTDs has been acknowledged. In response, WHO has published a new Global Strategy: 'Water, Sanitation and Hygiene for accelerating and sustaining progress on Neglected Tropical Diseases'. The Strategy focuses on cross-cutting actions that benefit disease control and care efforts, and strengthen health systems. Implementation of the strategy and the accompanying action plan can help ensure that the health and development agenda leaves no one behind.

This warming has been linked to more extreme weather conditions such as intense floods and droughts, heavier and more frequent storms, and a possible increase in frequency and intensity of the El Nino Southern Oscillation. These changes are largely caused by human activities, mainly the burning of fossil fuels releasing carbon dioxide (CO

Perspectives | Editorial The Impact of Endocrine Disruption: A Consensus Statement on the State of the Science doi:10.1289/ehp.1205448 Ake Bergman, 1 Jerrold J. Heindel, 2,a Tim Kasten, 3,b Karen A. Kidd, 4 Susan Jobling, 5 Maria Neira, 6,c R. Thomas Zoeller, 7 Georg Becher, 8 Poul Bjerregaard, 9 Riana Bornman, 10 Ingvar Brandt, 11 Andreas Kortenkamp, 5 Derek Muir, 12 Marie-Noel Brune Drisse, 6,c Roseline Ochieng, 13 Niels E. Skakkebaek, 14 Agneta Sunden Bylehn, 3,b Taisen Iguchi, 15 Jorma Toppari, 16 and Tracey J. Woodruff 17 1 Department of Materials and Environmental Chemistry, Stockholm University, Stockholm, Sweden; 2 National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA; 3 United Nations Environment Programme (UNEP), Geneva, Switzerland; 4 Department of Biology & Canadian Rivers Institute, University of New Brunswick, Saint John, New Brunswick, Canada; 5 Institute for the Environment, Brunel University, Uxbridge, Middlesex, United Kingdom; 6 Department of Public Health and Environment, World Health Organization, Geneva, Switzerland; 7 Biology Department, Morrill Science Center, University of Massachusetts, Amherst, Massachusetts, USA; 8 Division of Environmental Medicine, Norwegian Institute of Public Health, Oslo, Norway; 9 Institute of Biology, University of Southern Denmark, Odense, Denmark; 10 Department of Urology, School of Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa; 11 Department of Environmental Toxicology, Uppsala University, Uppsala, Sweden; 12 Aquatic Ecosystems Protection Research Division, Water Science & Technology Directorate, Environment Canada, Burlington, Ontario, Canada; 13 Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya; 14 University Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark; 15 Department of Bioenvironmental Science, Okazaki Institute for Integrative Bioscience, National Institute for Basic Biology, National Institutes of Natural Sciences, Okazaki Aichi, Japan; 16 Departments of Physiology and Paediatrics, University of Turku, Turku, Finland; 17 Department of Obstetrics, Gynecology and Reproductive Sciences, Institute for Health Policy Studies, University of California San Francisco, Oakland, California, USA In 2002, the joint International Programme on Chemical Safety (IPCS) of the World Health Organization (WHO), the United Nations Environment Programme (UNEP), and the International Labour Organisation (ILO) published a report titled Global Assessment of the State-of-the-Science of Endocrine Disruptors (http://www.who.int/ ipcs/publications/new_issues/endocrine_disruptors/en/). Since 2002, intense scientific work has improved our understanding of the impacts of endocrine-disrupting chemicals (EDCs) on human and wildlife health, such that in 2012, the UNEP and WHO, in collaboration with international experts, have produced an updated document on EDCs, State of the Science of Endocrine Disrupting Chemicals - 2012 (http:// www.who.int/ceh/publications/endocrine/en/index.html) that includes scientific information on human and wildlife impacts and lists key concerns for decision makers and others concerned about the future of human and wildlife health. The basis for these key concerns is described in the State of the Science of Endocrine Disrupting Chemicals - 2012 (http://www.who. int/ceh/publications/endocrine/en/index.html) and includes extensive references to the science behind the concerns. A shorter summary, primarily for decision makers, elabo­rates on the key concerns listed below and and also on suggested considerations related to EDCs (State of the Science of Endocrine Disrupting Chemicals - 2012: Summary for Decision-Makers; http://www.who.int/ceh/publications/endocrine/en/ index.html). The key concerns noted in the State of the Science of Endocrine Disrupting Chemicals - 2012 (http://www.who.int/ceh/publications/ endocrine/en/index.html) are as follows: • Human and wildlife health depends on the ability to reproduce and develop normally. This is not possible without a healthy endocrine system. • Three strands of evidence fuel concerns over endocrine disruptors: ǹ ǹ The high incidence and the increasing trends of many endocrine- related disorders in humans; ǹ ǹ Observations of endocrine-related effects in wildlife populations; ǹ ǹ The identification of chemicals with endocrine disrupting proper- ties linked to disease outcomes in laboratory studies. • Many endocrine-related diseases and disorders are on the rise. ǹ ǹ Large proportions (up to 40%) of young men in some countries have low semen quality, which reduces their ability to father children. ǹ ǹ The incidence of genital malformations, such as non-descending testes (cryptorchidisms) and penile malformations (hypospadias), in baby boys has increased over time or levelled off at unfavour- ably high rates. ǹ ǹ The incidence of adverse pregnancy outcomes, such as preterm birth and low birth weight, has increased in many countries. ǹ ǹ Neurobehavioural disorders associated with thyroid disruption affect a high proportion of children in some countries and have increased over past decades. ǹ ǹ Global rates of endocrine-related cancers (breast, endometrial, ovarian, prostate, testicular and thyroid) have been increasing over the past 40–50 years. ǹ ǹ There is a trend towards earlier onset of breast development in young girls in all countries where this has been studied. This is a risk factor for breast cancer. ǹ ǹ The prevalence of obesity and type 2 diabetes has dramatically increased worldwide over the last 40 years. WHO estimates that 1.5 billion adults worldwide are overweight or obese and that the number with type 2 diabetes increased from 153 million to 347 million between 1980 and 2008. • Close to 800 chemicals are known or suspected to be capable of inter- fering with hormone receptors, hormone synthesis or hormone con- version. However, only a small fraction of these chemicals have been investigated in tests capable of identifying overt endocrine effects in intact organisms. ǹ ǹ The vast majority of chemicals in current commercial use have not been tested at all. ǹ ǹ This lack of data introduces significant uncertainties about the true extent of risks from chemicals that potentially could disrupt the endocrine system. • Human and wildlife populations all over the world are exposed to EDCs. ǹ ǹ There is global transport of many known and potential EDCs through natural processes as well as through commerce, leading to worldwide exposure. ǹ ǹ Unlike 10 years ago, we now know that humans and wildlife are exposed to far more EDCs than just those that are POPs [persis- tent organic pollutants]. ǹ ǹ Levels of some newer POPs in humans and wildlife are still increasing, and there is also exposure to less persistent and less bioaccumulative, but ubiquitous, chemicals. Address correspondence to A. Bergman, Department of Materials and Environmental Chemistry, Stockholm University, SE-10691 Stockholm, Sweden. E-mail: ake.bergman@mmk.su.se United Nations Environment Programme (UNEP) address: 13 chemin des Anemones, CH-1219 Chatelaine, Geneva, Switzerland. a The author is an employee of the National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health (NIH); any statements, opinions, or conclusions contained herein do not necessar- ily represent the statements, opinions, or conclusions of the NIEHS, NIH, or the U.S. government. b The authors are staff members of the United Nations Environment Programme (A.S.B. is now retired). The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the decisions or policies of the United Nations Environment Programme. c The authors are staff mem- bers of the World Health Organization (WHO). The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the views, decisions, or policies of the WHO. This article should not be reproduced for use in association with the promotion of commercial products, services, or any legal entity. The WHO does not endorse any specific organization or products. Any reproduction of this article cannot include the use of the WHO logo. The authors declare they have no actual or potential competing ­financial interests. A 104 Environmental Health Perspectives volume 121 | number 4 | April 2013 •

et al., 1992). After gradual intensification of efforts over the ensuing 10 years, the WHO and its member states and partners are implementing a combined strategy for the control of schistosomiasis and soil-transmitted helminths, integrated into ongoing health and education initiatives (WHO, in nrenaration, a). This strategy is summarized-in the World Health Assemblv (WHA) resolution of Mav 2001 KVHA. 200 1). ~l?re resolution urges member .states to ‘ensure access to essential drugs against schistosomiasis and soil-transmitted helminthiasis in all health services in endemic areas for the treatment of clinical cases and groups at high risk of morbidity such as women and children, with the goal of attaining a minimum target of regular administration of chemotherapy to at least 75% and up to 100% of all school-age children at risk of morbidity by 20 10. This policy is based on the evidence that morbidity can be controlled by periodical treatment of high-risk groups with anthelminthics. The burden of disease

Background and objectives Between November 2007 and March 2008, 18 children died from a rapidly progressive central nervous system disease of unexplained origin in a community involved in the recycling of used lead-acid batteries (ULAB) in the suburbs of Dakar, Senegal. We investigated the cause of these deaths. Methods Because autopsies were not possible, the investigation centered on clinical and laboratory assessments performed on 32 siblings of deceased children and 23 mothers and on 18 children and 8 adults living in the same area, complemented by environmental health investigations. Results All 81 individuals investigated were poisoned with lead, some of them severely. The blood lead level of the 50 children tested ranged from 39.8 to 613.9 μg/dL with a mean of 129.5 μg/dL. Seventeen children showed severe neurologic features of toxicity. Homes and soil in surrounding areas were heavily contaminated with lead (indoors, up to 14,000 mg/kg; outdoors, up to 302,000 mg/kg) as a result of informal ULAB recycling. Conclusions Our investigations revealed a mass lead intoxication that occurred through inhalation and ingestion of soil and dust heavily contaminated with lead as a result of informal and unsafe ULAB recycling. Circumstantial evidence suggested that most or all of the 18 deaths were due to encephalopathy resulting from severe lead intoxication. Findings also suggest that most habitants of the contaminated area, estimated at 950, are also likely to be poisoned. This highlights the severe health risks posed by informal ULAB recycling, in particular in developing countries, and emphasizes the need to strengthen national and international efforts to address this global public health problem.

The United Nations Commission for Sustainable Development may not appear, at first sight, to be a major playing field for public health. Nevertheless, when environment, energy and development ministers from around the world assembled in New York on 1-12 May 2006 for the Commission's 14th session, health concerns in relation to energy production and consumption emerged as a prominent argument in discussions on energy for sustainable development. In his opening speech, Secretary General Kofi Annan called attention to the fact that indoor air pollution from solid fuel use is one of the world's ten major causes of mortality and morbidity. (1) More than half the world's population--3.2 billion people--still burn coal and biomass fuels such as wood, dung and crop residues to meet their basic energy needs. (2) Indoor air pollution from burning these solid fuels on open fires or traditional stoves comprises a variety of health-damaging pollutants including particles, carbon monoxide and different carcinogens (3) and is the cause of a public health tragedy. Every year, 1.5 million people die from inhaling indoor pollutants that often exceed accepted guideline limits for outdoor air: in the case of fine particles, the limit is exceeded by 100 times or more. (4, 5) Children and women are disproportionately affected, with nearly 800 000 deaths attributable to indoor air pollution occurring among children under five years of age and more than 500 000 such deaths occurring among women. (5) Preventing deaths caused by polluted indoor air must no longer be delayed. In the short term, stoves that burn more cleanly and use fuel more efficiently, ventilation that is improved through smoke hoods or enlarged spaces in the eaves, and changes in housing design can substantially reduce pollutant levels. In the longer term, the use of cleaner fuels, such as liquefied petroleum gas, biogas or other modern biofuels, can eliminate the current indoor air pollution epidemic. Improving access to modern energy services--including electricity and modern cooking fuels and appliances--is essential if the world is to achieve its Millennium Development Goals (MDGs). The United Nations Millennium Project recommends an additional MDG target "to halve, by 2015, the number of people without effective access to modern cooking fuels, and to make improved cooking stoves widely available". (6) The challenge in working towards this target is enormous: every day for the next 10 years, 485 000 people will need to gain access to cleaner fuels or improved stoves. Even if the target is realized, 1.5 billion people will still be left on the sidelines of development in 2015. (5) "Effective solutions exist and the economic case for taking practical solutions to scale is just as strong as the humanitarian case", emphasized the late Dr LEE Jong-wook, Director-General of WHO. …

This is a major embarrassment for the health sector: health facilities serve as foci for infection and patients seeking treatment fall ill and may die, for the lack of the most basic requirements for good hygiene – safe, reliable water supplies and adequate sanitation. Preg -nant mothers rely on a birthing environment that, at a minimum, does not place them or their baby at risk. Infections cause nearly half of late neonatal deaths (430 000)

Cancer has become the second leading cause of death worldwide (Ferlay et al. 2008). Almost 13 million persons are diagnosed each year with cancer, and 7.6 million die (Ferlay et al. 2010). Today more than half of all cancers and 63% of cancer deaths occur in low- and middle-income countries (LMICs), a burden that is expected to grow in future years as the “Western lifestyle” spreads and the number of persons in LMICs who live to old age continues to increase (Ferlay et al. 2010). Toxic exposures in the environment, including workplace exposures, are responsible for a substantial percentage of all cancers (Danaei et al. 2005 Christiani 2011). Precise apportionment is not possible because of gaps in the exposure data, interactions between environmental and lifestyle carcinogens, and differences from country to country in exposure patterns (Pruss-Ustun and Corvalan 2006). However, credible estimates from the World Health Organization (WHO 2009) and the Internation Agency for Research on Cancer (IARC; Straif 2008) suggest that the fraction of global cancer currently attributable to toxic environmental exposures is between 7% and 19%. Asbestos, silica, arsenic, and radon are among the most common environmental carcinogens. All are considered proven causes of human cancer by IARC (El Ghissassi et al. 2009; Straif et al. 2009). Exposures to all remain widespread and are especially intense and uncontrolled in LMICs. Asbestos, for example, continues to be produced and used in quantities of nearly 2 million tons per year (U.S. Geological Survey 2011). While its use in Western Europe, the United States, and Canada has virtually ceased, export to the developing world is aggressively marketed and steadily increasing (Allen and Kazan-Allen 2008). For example, between 2000 and 2007, India’s consumption of asbestos is reported to have doubled (Burki 2010). Many cancers caused by environmental and occupational exposures can be prevented (Christiani 2011). Primary prevention—environmental interventions that halt the exposures that cause cancer—is the single most effective strategy. Primary prevention reduces cancer incidence, and it saves lives and billions of dollars. Successful examples include reductions in lung cancer and mesothelioma following bans on asbestos, reductions in bladder cancer after elimination of aniline dyes, reductions in leukemia following imposition of controls on benzene, and termination of hepatic angiosarcoma in chemical workers following introduction of closed-circuit technology for vinyl chloride polymerization (Christiani 2011). Despite their proven feasibility and cost-effectiveness, efforts to prevent environmental cancers have lagged. In contrast to vigorous and well-coordinated global efforts to prevent cancers caused by tobacco (WHO 2003), much more needs to be done in environmental cancer control and to further develop strategies for prevention of environmental causes of cancer (WHO 2008). To address these gaps and to develop a new global policy framework for environmental cancer, the WHO convened an international conference on “Environmental and Occupational Determinants of Cancer: Interventions for Primary Prevention” in Asturias, Spain, on 17–18 March 2011. The conference produced the “Asturias Declaration” (WHO International Conference on Environmental and Occupational Determinants of Cancer: Interventions for Primary Prevention 2011), which recommends that primary prevention of environmental and occupational cancers be an integral component of global cancer control. Specific recommendations of the declaration include the following: The WHO should develop a global framework for control of environmental and occupational carcinogens that concentrates on the exposures identified by IARC as proven or probable causes of human cancer (IARC 2011). The WHO should develop measurable indicators of carcinogen exposure and cancer burden to guide cancer surveillance worldwide. All countries need to adopt and enforce legislation and regulations to protect their populations, especially the most vulnerable (pregnant women, fetuses, infants, children, and workers) against environmental and occupational cancers. All countries need to develop communication campaigns tailored to local needs to educate their populations about environmental causes of cancer and prevention strategies. Corporations should comply with all rules and regulations for prevention of environmental and occupational cancers and adhere to the same standards in all countries—developed and developing—in which they and their subsidiaries operate. Conference participants agreed that successful prevention of environmental cancer will require partnerships among countries and collaborations of public health authorities with ministries of environment, labor, finance, and trade. In addition, independent, publicly funded research on environmental and occupational causes of cancer is an essential prerequisite to prevention (Tomatis 1995). The recommendations made by the participants in the “Asturias Declaration” complement and reinforce cancer control strategies focused on individual behaviors and medical practice. They will contribute to prevention of diseases beyond cancer and therefore synergize with the United Nations (UN) global agenda for control of noncommunicable diseases that is to be discussed at the UN General Assembly in September 2011 (UN General Assembly 2010). These recommendations will also prevent recurrence of such tragedies as the global asbestos epidemic, which now claims > 100,000 lives each year.

As discussed elsewhere in this issue of the Bulletin of the World Health Organization, human health and climate change are inextricably linked.1–3 This month, the World Health Organization (WHO) will, for the first time, bring together high-level government representatives, development partners and technical experts in a global conference on climate and health. What does the conference plan to achieve, how can it empower countries to protect health from climate risks and gain the health benefits of addressing climate change, and why is it needed now? The first aim is to provide the evidence for health actors to engage on this issue. The Intergovernmental Panel on Climate Change’s March 2014 report4 updated the evidence on the health risks of climate change. It concluded that climate change acts mainly by exacerbating existing health problems but also affects water, food and nutrition security, and that the most vulnerable populations are those that are already most affected by climate-related diseases. It highlighted the possibility of high-end climate scenarios – including warming by 4–7 °C over much of the globe by 2100 – that would lead to some critical thresholds being crossed. Such warming might make outdoor physical activity in the hottest parts of the year dangerous in many locations. Some human habitats may be lost altogether as low-lying countries are submerged by rising seas. Climate change is a threat to a bottom line of sustainable development – human health. New studies and practical experience can help guide an appropriate response. There is evidence that poverty alleviation and preventive health programmes can decrease vulnerability and override some of the risks presented by climate change. Evidence also shows that actions to reduce greenhouse gas emissions and air pollution can result in large health gains. Air pollution is estimated to cause one in every eight deaths,5 so reduction of emissions of black carbon and other short-lived pollutants may not only slow warming but also avert almost 2.5 million deaths annually.6 The deaths and disease thus prevented could offset much of the cost of greenhouse-gas mitigation.7 In developing more socially beneficial, cost–effective and widely supported policies for the mitigation of climate change, the arguments, evidence and voices of the health community are critical. This WHO conference will explore ways of building health resilience to climate risks, for example through improving health, water and sanitation services. Participants will also deliberate how best to ensure that more sustainable and low-carbon development choices result in improved urban environments and health-care provision. It will showcase programmes implemented around the world and the international initiatives supported by the United Nations (UN) system – such as the Global Framework for Climate Services. The conference is intended to be one important step in addressing what may be the defining issue for public health during this century.8 The core international processes for health need to be closely connected with those for climate change. The conference will therefore build on the link between climate and health that was selected as the theme of the general discussion at the World Health Assembly (WHA) in May 2014. The outcomes will inform future WHA discussions on the renewal of WHO’s work on air pollution, climate change and health. While health actors can do much within their own ministries or facilities, a truly effective public health response will depend on actions taken across government and by other partners. The conference is therefore timed and designed to ensure that the health sector contributes fully to any international agreements on climate change that might arise from deliberations at the Climate Summit – organized by UN Secretary-General Ban Ki-Moon – to be held in September 2014 in New York and the UN Framework Convention on Climate Change’s Conference of the Parties to be held in Paris in December 2015. In recent years, many countries have made important progress in protecting the health of their populations from climate change. It is hoped that this conference will encourage and support more countries to do the same.

imately 60,000 in weather-related natural disasters. 4–6 A warmer and more variable climate threatens to lead to higher levels of some air pollutants; increase transmission of diseases from poor water, sanitation, and hygiene; and increase the hazards of extreme weather. Taken together, climate change threatens to slow, halt, or reverse the progress that the global health community is now making against many of these hazards. In the long run, however, the health impacts from the gradual build-up of pressure on the natural, economic, and social systems that sustain health, and which are already under stress in much of the developing world, may contribute as much, if not more, as acute shocks such as natural disasters or disease epidemics. These slow stresses include reductions and seasonal changes in the availability of fresh water, regional drops in food production, and rising sea levels. Each of these changes has the potential to force population displacement and to increase the risks of civil conflict. 7 Health effects are expected to be more severe for elderly people and people with infirmities or preexisting medical conditions. Two additional groups are also likely to bear resulting health burdens: children and the poor. The major diseases that are most sensitive to climate, and therefore to climate change— diarrhea, malaria, and infections associated with undernutrition— are childhood diseases of poverty. The gaps in health outcomes we are now trying so hard to address may grow even greater, and the populations that are most vulnerable may paradoxically be those that have made the least contribution to the greenhouse gases that are causing climate change. 8 The global public health community has a common interest in facing up to health risks wherever they occur in the world. Ongoing climate change, coupled with globalization, will make it more difficult to control infectious diseases within their current ranges. Health challenges arising from population displacement and conflict are unlikely to stay confined within national borders. Improved health conditions for all populations, alongside faster and more effective international disease surveillance, constitute a vital contribution to global health security. In order to respond to this challenge, WHO has identified five strategic objectives in the support that it gives to Member States.