Good morning, Mr. Chairman and Members of the Subcommittee.
I am Dr. Leonardo Trasande. I am a pediatrician and Assistant Professor of Community & Preventive Medicine and Pediatrics at the Mount Sinai School of Medicine. I am also the Assistant Director of the Center for Children’s Health and the Environment, the nation’s first academic policy center devoted to the protection of children against environmental threats to health.
Approximately three to 4 million children and adolescents in the United States live within 1 mile of a federally designated Superfund hazardous waste disposal site. These children are at especially high risk of exposure to chemical toxicants released from these sites into air, groundwater, surface water, and surrounding communities. In the face of a growing body of scientific knowledge about the preventable, environmental causes of learning and behavioral problems in our children, we must take prudent action, and today I urge the members of this Subcommittee to take three important steps to prevent chronic disease in American children:
* Expeditious identification and cleanup of Superfund sites,
* Full funding for the NIEHS/EPA Superfund Basic Research Program, and
* Full funding for the National Children’s Study.
The Need for Identification and Cleanup of Superfund Sites
The EPA Superfund program is especially critical to the health of these children. Rapid identification and cleanup of these sites is so important because children are especially vulnerable to many chemicals that exist at many of the Superfund sites in our nation. There are several reasons why children are so sensitive to chemical toxins, and the research that we have undertaken in our Superfund Basic Research Program at Mount Sinai has contributed greatly to the understanding of these factors:
* One important reason why children are so vulnerable to environmental chemicals is that they have disproportionately heavy exposures. Pound per pound of body weight, children drink more water, eat more food, and breathe more air than adults, and so they take proportionately more of the toxins in water, food and air into their little bodies. Small children’s exposure is magnified further by their normal behaviors – their play close to the floor, and their hand-to-mouth activity, which we pediatricians call “normal oral exploratory behavior.”
* A second reason for their great susceptibility to chemical toxins is that children do not metabolize, detoxify, and excrete many toxins in the same way as adults; thus the chemicals can reside much longer in children’s bloodstreams and cause more damage.
* A third reason is that children are undergoing rapid growth and development, and those very complex developmental processes are easily disrupted.
* Finally, children have more future years of life than most adults and thus have more time to develop chronic diseases that may be triggered by early environmental exposures.
Over the past thirty years, chronic diseases of environmental origin have become epidemic in American children, and are the diseases of greatest current concern. These include:
* Asthma, which has more than doubled in frequency since 1980 and become the leading cause of pediatric hospitalization and school absenteeism;
* Birth defects, which are now the leading cause of infant death. Certain birth defects, such as hypospadias, have doubled in frequency;
* Neurodevelopmental disorders - autism, dyslexia, mental retardation, and attention deficit/ hyperactivity disorder (ADHD). These conditions affect 5-10% of the 4 million babies born each year in the United States. Reported rates of autism are increasing especially sharply - more than 20% per year.
* Leukemia and brain cancer in children and testicular cancer in adolescents. Incidence rates of these malignancies have increased since the 1970s, despite declining rates of mortality.
* Testicular cancer has risen by 55%, and primary brain cancer by 40%. Cancer is now the second leading cause of death in American children, surpassed only by traumatic injuries; and
* Preterm birth, which has increased in incidence by 27% since 1981.
These rapidly rising rates of chronic disease threaten the health of our children and the future security of our nation. Indeed, concern is strong among the pediatric community that these rapidly rising rates of disease may create a situation unprecedented in the 200 years of our nation’s history, in which our current generation of children may be the first American children ever not to enjoy a longer life span than the generation before them.
Evidence is increasing that many environmental chemicals found at Superfund sites contribute to the causation of disease in children. Lead, mercury, polychlorinated biphenyls (PCBs) and certain pesticides have been shown to cause brain damage and to contribute to learning disabilities and to disruption of children’s behavior. Benzene, 1,3-butadiene, and pesticides have been etiologically associated with childhood malignancies. Ambient pollutants - airborne fine particulates, ozone, oxides of nitrogen, and diesel exhaust also have been shown to increase incidence of asthma and to trigger asthmatic attacks. Although many of the causes of developmental problems in children are still not known, a recent National Academy of Sciences study suggests that at least twenty-eight percent of developmental disabilities in children -- dyslexia, attention deficit disorder and mental retardation -- are due to environmental causes.
Diseases of environmental origin in American children are also extremely costly to our nation. Four of the leading diseases of environmental origin in American children – lead poisoning, childhood asthma, neurodevelopmental disabilities and childhood cancer – have been found to cost our nation $54.9 billion annually. Mercury pollution has been found to cost our nation $8.7 billion annually as a result of lost economic productivity, and an additional 1566 cases of mental retardation have been associated with mercury pollution. Each of these cases is associated with additional special education and health care costs that are disproportionately borne by the American taxpayer. By cleaning up toxic waste sites, we reduce toxic exposures and prevent chronic disease, and thus reduction of unnecessary toxic exposure to Superfund chemicals can be an effective and cost-effective approach to improving child health in America. This Subcommittee should therefore continue to ensure that EPA is fully executing its duties under the Superfund program to identify and clean up hazardous waste sites in the safest and most expeditious manner possible.
The Need for Continued Full Funding of the Superfund Basic Research Program
The Superfund Basic Research Program (SBRP) is equally critical if we are to understand and prevent the environmental causes of chronic childhood conditions that have now reached epidemic proportions in our nation. The National Institute of Environmental Health Sciences' (NIEHS) Superfund Basic Research Program is a unique program of basic research and training grants directed towards understanding, assessing, and reducing the adverse effects on human health that result from exposure to hazardous substances. Grants made under this program are for coordinated, multicomponent, interdisciplinary programs. The technology within this program is on the cutting edge of assessing and evaluating human exposure, effects of hazardous substances and transport of chemicals through various media from waste sites. This program is researching and developing many innovative technologies for detecting, assessing, and reducing toxic materials in the environment.
The NIEHS/EPA SBRP had previously focused on understanding the impact of toxic environmental exposures on the health of adults. However, it has become apparent that this database of information is not necessarily applicable to children. The program recognized this deficit early and, accordingly, has directed an increasing percentage of its diverse research efforts toward understanding the effects of environmental exposures on children's health. These studies in universities across the United States include fetal, infant, childhood, and adolescent research. Research in exposure assessment is of particular interest.
The below Table provides a snapshot of some of the previous projects that have been supported in the past by the SBRP in the area of children's health.
While it seems that studies of adult exposures might most efficiently investigate gene-environment interactions related to the disorders that produce the greatest disability, hospitalization, and death, which occur in adults rather than children, this focus ignores the growing evidence of important and even crucial environmental contributions to adult disorders that start early in development. Because early environmental exposures are so important, a longitudinal assessment of the environment from the preconceptual period through infancy is essential to unravel the underlying susceptibility to diseases of adulthood. It is now clear that vulnerability to a particular risk factor is often determined not only by the genome acquired at conception, but also by dynamic modifications to the genome, and therefore to assess gene-environment interactions adequately, not only will the stable DNA sequence be essential but also epigenetic modifications to nuclear and mitochondrial DNA will have to be identified. Thus continued emphasis on child health studies within the Superfund Program is especially critical going forward.
The National Children’s Study -- Safeguarding the Health of Our Children
Finally, in this testimony I wish to point out the critical need for funding the National Children’s Study, which will unearth so much important information of the health effects of chemicals found at Superfund sites. The National Children’s Study is a prospective multi-year epidemiological study that will follow 100,000 American children, a nationally representative sample of all children born in the United States, from conception to age 21. The study will assess and evaluate the environmental exposures these children experience in the womb, in their homes, in their schools and in their communities. It will seek associations between environmental exposures and disease in children. The diseases of interest include all those listed above. The principal goal of the Study is to identify the preventable environmental causes of pediatric disease and to translate those findings into preventive action and improved health care. The National Children’s Study was mandated by Congress through the Children’s Health Act of 2000. The lead federal agency principally responsible for the Study is the National Institute of Child Health and Human Development. Other participating agencies include the National Institute of Environmental Health Sciences, the Environmental Protection Agency, and the Centers for Disease Control and Prevention. By working with pregnant women and couples, the Study will gather an unprecedented volume of high-quality data on how environmental factors acting either alone, or in combination with genetic factors, affect the health of infants and children. Examining a wide range of environmental factors – from air, water, and dust to what children eat and how often they see a doctor – the Study will help develop prevention strategies and cures for a wide range of childhood diseases. By collecting data nationwide the study can test theories and generate hypotheses that will inform biomedical research and he care of young patients for years to come. Simply put, this seminal effort will provide the foundation for children’s healthcare in the 21st Century.
Six aspects of the architecture of the National Children’s Study make it a uniquely powerful tool for protecting the health of America’s children:
1. The National Children’s Study is prospective in its design. The great strength of the prospective study design is that it permits unbiased assessment of children’s exposures in real time as they actually occur, months or years before the onset of disease or dysfunction. Most previous studies have been forced to rely on inherently inaccurate retrospective reconstructions of past exposures in children who were already affected with disease. The prospective design obviates the need for recall. It is especially crucial for studies that require assessments of fetal and infant exposures, because these early exposures are typically very transitory and will be missed unless they are captured as they occur.
2. The National Children’s Study will employ the very latest tools of molecular epidemiology. Molecular epidemiology is a cutting-edge approach to population studies that incorporates highly specific biological markers of exposure, of individual susceptibility and of the precursor states of disease. Especially when it is embedded in a prospective study, molecular epidemiology is an extremely powerful instrument for assessing interactions between exposures and disease at the level of the individual child.
3. The National Children’s Study will incorporate state-of-the-art analyses of gene-environment interactions. Recognition is now widespread that gene-environment interactions are powerful determinants of disease in children. These interactions between the human genome and the environment start early in life, affect the health of our children, and set the stage for adult disorders. The heroic work of decoding the human genome has shown that only about 10-20% of disease in children is purely the result of genetic inheritance. The rest is the consequence of interplay between environmental exposures and genetically determined variations in individual susceptibility. Moreover, genetic inheritance by itself cannot account for the sharp recent increases that we have seen in incidence of pediatric disease.
4. The National Children’s Study will examine a nationally representative sample of American children. Because the 100,000 children to be enrolled in the Study will be statistically representative of all babies born in the United States during the five years of recruitment, findings from the Study can be directly extrapolated to the entire American population. We will not need to contend with enrollment that is skewed by geography, by socioeconomic status, by the occurrence of disease or by other factors that could blunt our ability to assess the links between environment and disease.
5. Environmental analyses in the National Children’s Study will be conducted at the Centers for Disease Control and Prevention. The CDC laboratories in Atlanta are the premier laboratories in this nation and the world for environmental analysis. Because the testing will be done at CDC it will be the best available, and the results will be unimpeachable.
6. Samples collected in the National Children’s Study will be stored securely and will be available for analysis in the future. New tests and new hypotheses will undoubtedly arise in the years ahead. Previously unsuspected connections will be discovered between the environment, the human genome and disease in children. The stored specimens so painstakingly collected in the National Children’s Study will be available for these future analyses.
Congress has already laid a firm foundation for the National Children’s Study. Between 2000 and 2005, the Congress invested more than $55 million to design the study and begin building the nationwide network necessary for its implementation. Seven Vanguard Centers and a Coordinating Center were designated in 2005 at sites across the nation – in Pennsylvania, New York, North Carolina, Wisconsin, Minnesota, South Dakota, Utah and California – to test the necessary research guidelines – with plans to expand the program to 38 states and 105 communities nationwide. The tough job of designing and organizing is nearly complete. Funding for the Study this year will permit researchers to begin achieving the results that will make fundamental improvements in the health of America’s children. To abandon the Study at this point would mean forgoing all of that dedication, all of that incredible effort, and all of the logistical preparation.
The National Children’s Study will yield benefits that far outweigh its cost. It will be an extraordinarily worthwhile investment for our nation, and it can be justified even in a time of fiscal stress such as we face today. Six of the diseases that are the focus of the Study (obesity, injury, asthma, diabetes, autism and schizophrenia) cost America $642 billion each year. If the Study were to produce even a 1% reduction in the cost of these diseases, it would save $6.4 billion annually, 50 times the average yearly costs of the Study itself. But in actuality, the benefits of the National Children’s study will likely be far greater than a mere 1% reduction in the incidence of disease in children. The Framingham Heart Study, upon which the National Children’s Study is modeled, is the prototype for longitudinal medical studies and the benefits that it has yielded have been enormous. The Framingham Study was launched in 1948, at a time when rates of heart disease and stroke in American men were skyrocketing, and the causes of those increases were poorly understood. The Framingham Study used path-breaking methods to identify risk factors for heart disease. It identified cigarette smoking, hypertension, diabetes, elevated cholesterol and elevated triglyceride levels as powerful risk factors for cardiovascular disease. These findings contributed powerfully to the 42% reduction in mortality rates from cardiovascular disease that we have achieved in this country over the past 5 decades.
The data from Framingham have saved millions of lives – and billions of dollars in health care costs. The National Children’s Study, which will focus on multiple childhood disorders, could be even more valuable. We do not need to wait 21 years for benefits to materialize from the national Children’s Study. Valuable information will become available in a few years’ time, as soon as the first babies in the Study are born.
Consider, for example, data on premature births. The rate of U.S. premature births in 2003 was 12.3%, far higher than the 7% rate in most western European countries. Hospital costs associated with a premature birth average $79,000, over 50 times more than the average $1,500 cost for a term birth. Just a 5% reduction in rates of prematurity would cut hospital costs by $1.6 billion annually. Within just two years, that savings would match the full cost of the Study.
The Study enjoys a broad group of supporters, including The American Academy of Pediatrics; Easter Seals; the March of Dimes; the National Hispanic Medical Association; the National Association of County and City Health Officials; the National Rural Health Association; the Association of Women’s Health, Obstetric and Neonatal Nurses; United Cerebral Palsy; the Spina Bifida Association of America; and the United States Conference of Catholic Bishops, just to name a few. This broad and diverse group recognizes the overwhelming benefits this Study will produce for America’s children.
Congress first authorized the National Children’s Study in 2000, and has appropriated $55 million since then to design the Study, complete preparatory research, and designate the seven Vanguard sites that will conduct preliminary testing.
This has been a wise investment that should not be abandoned just as the Study is about to bear fruit. Unfortunately, the Administration has not provided continued funding in the FY ’07 budget, a decision which threatens to squander the investment already made and to throw away the multi-generational benefits the Study will yield. Funding for the Study this year requires a commitment of $69 million. These funds will be used to begin enrolling children in the study. They will enable the NIH to continue establishing the 105 study sites around the country. We urge Congress to fully fund the National Children’s Study. It is an investment in our children – and in America’s future. The National Children’s Study will give our nation the ability to understand the causes of chronic disease that cause so much suffering and death in our children. It will give us the information that we need on the environmental risk factors and the gene-environment interactions that are responsible for rising rates of morbidity and mortality. It will provide a blueprint for the prevention of disease and for the enhancement of the health in America’s children today and in the future. It will be our legacy to the generations yet unborn.
In summary, Congress is poised to take three critical steps to improve the health and economic security of our nation. Through continued expeditious cleanup of Superfund sites and prevention of toxic chemical exposures from these hazardous waste sites, we can prevent disease before it occurs in children. We need to continue to support the Superfund Basic Research Program which provides desperately needed information about the environmental fate and toxic effects of Superfund compounds, and we need full funding for the National Children’s Study if we are to develop effective methods of preventing diseases of environmental exposure among American children.
Thank you. I shall be pleased to answer your questions.