A CALL FOR ACTION FOR THE PREVENTION AND TREATMENT OF LEAD POISONING IN DEVELOPING COUNTRIES

Recommendations on National Policy and Implementation

This document was prepared by the Executive Committee of the International Conference on Lead Poisoning held in Bangalore, India, on February 8-10, 1999, based on the discussions and recommendations of the participants. It is submitted as a "call for action" by governments, industry, health and environmental institutions, and other concerned organizations in developing countries. The views expressed herein do not necessarily reflect the official positions of the institutions represented by the committee members.

These recommendations are offered as guidelines for policy and implementation. The priorities, time-line, organizational structure, and resources to be allocated will vary by country, depending on the extent of the problem currently faced, and the existing institutional infrastructure and the actions already undertaken to deal with lead poisoning.

Preamble

Lead poisoning is a major environmental disease presently affecting hundreds of millions of people, especially children, pregnant women and occupational workers. According to several studies conducted in India, over 50% of the children living in many of its major cities already have elevated blood lead levels of over 10 mg/dL, raising serious concerns about their health, well-being, and future potential to be productive members of society.

Lead, a highly toxic substance, can significantly affect the health of people exposed, even at low levels. While the effects at varying levels of exposure will differ, there is no established "safe" level of exposure. Significantly elevated levels of blood lead can cause damage to systems and organs such as the heart, kidneys, liver, circulatory system, and central nervous system (including brain), leading ultimately to death in extreme cases.

Several studies have clearly established the adverse neurological effects of lead as reflected in a decrease in IQ and learning ability in young adulthood; for every 10 mg/dL increase in blood lead, IQ may decline by as much as 2-4 points. There is also a strong link between even low doses of lead exposure and intellectual deficit in children. Long term exposure to this metal results not only in poor school performance but also reduces success later in life.

Cost-benefit studies have shown that the benefits outweigh the cost of prevention by a great margin; a detailed analysis in practically every situation will demonstrate to decision-makers that they "cannot afford not to" implement an effective program. While the factors involved will vary from country to country, the primary model and methods used for prevention and treatment are the same the world over. There is ample scientific knowledge about the problem, and the numerous successful experiences in dealing with it in several countries can be readily adapted to situations in developing countries for their policy formulation and implementation.

The international conference held in Bangalore, India presented an important opportunity for scientists, public policy experts, and industry leaders from over 20 countries to share their experiences and to identify cost-effective strategies to deal with lead poisoning. The outcome of this endeavor is a detailed set of recommendations made by over 100 of the world's leading experts on the subject, which are contained in the published proceedings of the conference (copy enclosed). This document summarizes those recommendations as they apply to makers of public policy.

Critical Steps in Establishing and Implementing a National Plan

1. Political Will and Participation of Various Constituencies

In countries worldwide, lead poisoning is often a national problem, the solutions for which demand the active participation of different stakeholders - ministries, government agencies at central, state and local levels, industries, public health institutions, NGOs and other concerned organizations. The government must take the leadership for concerted action, recognizing the seriousness of this environmental crisis that affects a large segment of its population, particularly children who are the country's future workforce. The government must begin to force changes in long standing practices in industry and public services -- such as eliminating leaded gasoline, testing for lead in water supply, food and other consumer products, and regulating lead in industrial emissions. Strong political will is required to cut across the various interest groups and constituencies to work toward a unified national goal of substantially reducing lead poisoning.

2.      National Goals and Targets

Applying the lessons learned from successful programs in industrialized countries, it is possible to implement source control measures and other required preventive actions to bring down environmental lead within "acceptable limits" within a 15-year timeframe. The primary goal should be to ensure blood lead levels below 10 mg/dL for children. Other goals include identification and reduction of lead exposures among populations at highest risk, such as those working in or living near lead-related industries, and treating those who have highly elevated levels of blood lead with medications capable of removing lead from the body safely.

Given the direct link between the many sources of lead (in air, soil, water and food) and the levels of blood lead, it is necessary to set standards for controlling lead in the environment. Based on the relative importance of various lead sources, priorities must be established and the required resources should be made available for prevention. Industries should be required to meet the standards established for lead control within set dates. Implementation of source control must be time-bound: top priority items need to be accomplished within the initial 5 years, and longer-term issues should be addressed within 10-15 years.

3.      Example of Priorities within a National Program

National priorities for reducing lead poisoning must be based on recognition of the following realities:

• Young children and workers in lead-based industries are at highest risk. Damage caused to human organs, particularly the brain and the nervous system, from persistent exposure to lead is often irreversible.
• Prevention through control of sources and pathways of exposure, and proper nutrition are the most cost-effective solutions.
• Treatment with chelation drugs is recommended for those with highly elevated levels of blood lead (for treatment protocols, see Conference Proceedings), but it does not offer a "complete cure." Moreover, the high cost of treatment is prohibitive for most individuals.

Consequently, a national strategy to deal with lead poisoning should have the following priorities:

• Eliminate/reduce lead from all major known sources, such as leaded gasoline in automobiles, lead-based paint, pollution by industries that use lead, etc.;
• Eliminate/reduce major pathways that contaminate air, soil, water and food, particularly within homes and schools where young children spend most of their time;
• Clean up major lead contaminated areas, especially potential life-threatening environments;
• Identify high-risk areas through selective screening of blood lead levels, and make affordable chelation therapy available to those in need.
• Educate industry leaders on the hazards of lead and the need to eliminate lead contamination/pollution;
• Disseminate information to health care providers and families on recognition and prevention of lead toxicity;
• Focus research toward identifying and monitoring lead poisoning sources that are not yet clearly understood;
• Organize public awareness programs to educate the population about the dangers of lead and protection measures.

It is important to note that the above steps to control lead exposures need not, and indeed should not, await further data on the ill effects of lead. There is ample evidence on which to act without delay.

The following table lists specific priority items relating to prevention and treatment, which need immediate implementation; if instituted without delay, the realistic estimated time to accomplish each item is given below. Table 1: Priority Items for Prevention and Treatment

4.      Implementation

To carry out the above activities on a national scale, the necessary human and technical infrastructure and organization are required. Institutional framework must be established to implement the many inter-related tasks: environmental and product standards are set, appropriate laws are formulated and passed, compliance is monitored and enforced, education and dissemination of information are continually carried out, and laboratories are set up for measuring lead levels in blood, consumer products and environment. These and other tasks call for coordinated prevention measures to be implemented by the various agencies of the government, the private sector and NGOs.

Given the different dimensions of this issue, a number of government ministries need to be involved in the many activities of a lead control program: energy and transportation ministries for unleaded fuel in automobiles, environment and labor ministries for environment, workplace and product safety, health ministry for prevention and treatment measures, law and justice ministry for enforcement, and so on. Under this scenario and considering the major significance of this problem for any nation, it is recommended that a national commission be set up, for example, within the office of the chief executive (prime minister/president) of the country. This commission could be responsible for setting national goals, making legislative recommendations, coordinating and monitoring the progress of implementation by the various agencies of the government.

Example of Organizational Structure for Policy Formulation and Implementation

The success of the program will depend on the commitment and cooperation of the many constituencies that have major roles to play in its execution. As such, the various stakeholders must be represented in the national commission on lead poisoning -- government officials from transportation, energy, health, environment, and law enforcement, and representatives from the private sector including industries, medical and environmental research institutions, consumer groups, and NGOs. The commission should oversee the progress of the national lead prevention and treatment program in the following areas:

• Resource Allocation

Funding for a national program to deal with lead poisoning must compete with the demands of other important priorities. Given the limited financial resources available to a developing country, the lead program has to be very cost effective. Resources have to be allocated to areas where benefits are likely to be the greatest. Undoubtedly, prevention is the one area that will yield maximum results both in the short and long run. Hence, we recommend that a significant majority of the available funds be allocated to source control and elimination/reduction of pathways. One of the most important components within prevention is the transition to unleaded fuel by all vehicles as quickly as is feasible.

Blood lead screening and treatment require some initial investment in setting up laboratories, purchasing equipment and drugs, and training health care providers. Blood lead levels need to be periodically monitored in different populations so as to initiate appropriate responses in the early stages of a particular problem. The monitoring should be done using standard protocols approved by experts in the area, and analytical quality assurance must be assured.

Chelation treatment is considered only in highly elevated blood lead cases that are caused mostly by industries and harmful consumer products. In such instances, employers may be required to cover the cost of treating their employees and others affected by contamination, and product liability must be effectively enforced. Public health services must also try to make local treatment affordable.

The remaining financial resources may be used to fund research projects in the areas of alternate prevention and treatment methods, such as nutritional supplements and new technologies. It should be noted that industrialized countries are carrying out considerable on-going research in these areas, and private funding sources may also be sought for such activities.

·         Monitoring of Progress, Evaluation and Follow-ups

It is important to monitor the progress of prevention measures and to evaluate the results of interventions that aim to reduce lead exposure. Careful outcome studies, from individual workplaces to nationwide conditions, should be initiated to understand the effectiveness of the program. Data from such studies will help to assess the efficacy and cost-effectiveness of specific interventions, guide future strategies, and provide a valuable resource for both environmental agencies and public health planners. Data and results from such studies should be made available to all the constituencies involved in the issue so that innovative solutions and positive adjustments to the program may be achieved.

Concluding Remarks

Human exposure to lead is a major environmental health hazard, and failure to adequately address this problem with urgency would cause serious health and economic consequences to the nation. However, significant reduction in exposures to lead can be achieved cost-effectively through preventive measures. In many industrialized countries, a decrease of over 70% in the average blood lead level of the population was achieved in less than 20 years. The successful experiences of developed countries in this area can be employed in developing countries with minor adjustments at a much lower cost, yielding great benefits. Governments are urged to take immediate and decisive measures to address this serious public health issue.

List of Participants in the Preparation of this Report

The members of the special committee who participated in the preparation of this paper represent the conference sponsors as well as several leading institutions that are dedicated to addressing the lead poisoning problem worldwide. The paper is submitted on behalf of the participants of the conference who gave valuable suggestions. The members of this group are listed below:

Mr. Richard Ackermann, Sector Director, Environment, South Asia, World Bank
Dr. Karim Ahmed, President, Global Children's Health & Environment Fund, and former Deputy Director, Health, Environment & Development, World Resources Institute, USA
Dr. Henry Falk, Assistant Administrator, Agency for Toxic Substances & Disease Registry, USA
Mr. Herbert H. Fockler, Senior Advisor and Board Member, Global Children's Health & Environment Fund, USA
Dr. N. K. Ganguly, Director General, Indian Council of Medical Research. Dr. Abraham M. George, Managing Trustee, The George Foundation
Dr. Rachel Kaufmann, Chief, Epidemiology Section, Lead Poisoning Prevention Branch, Centers for Disease Control and Prevention, USA
Dr. Kamala Krishnaswamy, Director, National Institute of Nutrition, India
Dr. M. Markowitz, Professor of Pediatrics, Albert Einstein College of Medicine, USA
Dr. P.P. Nair, Adj. Professor of Public Health, The Johns Hopkins University, USA
Mr. William Nitze, Assistant Administrator, US Environmental Protection Agency
Mr. Steve Null, Director, Friends of Lead-Free Children, USA
Dr. H.N. Saiyed, Director, National Institute of Occupational Health, India
Dr. P.K. Seth, Director, Industrial Toxicology Research Center, India
Dr. Yasmine von Schirnding, former Director, Office of Global and Integrated Environmental Health, World Health Organization
Dr. Babasaheb Sonawane, Acting Director, National Center for Environmental Assessment-Washington Office, US Environmental Protection Agency

Submitted on behalf of the above individuals.

Abraham M. George
Chairman
Executive Committee of the International Conference
on Lead Poisoning Prevention & Treatment

November 3, 1999

The George Foundation
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