Moderator:
Mr. Alan B. Fast; Panel: Dr. J. Mitra, Dr. N.S. Kumar, Dr. S.J.S.
Flora, Dr. M. Hernandez-Avila, Dr. S. Akbar, Ms. Ann Carroll
Mr. Alan Fast
Mr. Alan Fast
presented the following ideas from his experience with the New York
City Lead prevention program:
- Educating the
community serves as an inroad to the community.
- Before one
tries to educate the community, the educator has to do research;
know where the source of lead is, where the people congregate and
what type of media they use.
- You need not
educate everyone; you can save resources by concentrating on target
populations.
- Make use of
sports figures, movie and television stars, and politicians to help
spread the message.
- Identify who
is affected by lead poisoning and tailor the message directly to
them
- In addition
to telling the target audience about the problem, always remember
to tell them what to do about the problem
- The families
who visit the doctor on a regular basis are easy for the doctor
to reach. Those families who do not visit the doctor regularly are
tougher, so the method must be creative.
- Use temples,
churches and other groups who already reach out to the community.
- The message
should always be simple. If possible more graphics and color than
text, or even better might be the use of graphics alone by itself.
Dr. S. Narayani
Shivkumar
The lead problem
is a universal problem. Prevention is needed at three levels :
First Level -
Tackle lack of knowledge
Second Level -
Suggest how an individual can help oneself.
Third Level -
Implement community related programs
- There is not
much awareness of the lead problem (in India) even amongst the educated
people. So first and foremost is the creation of public awareness.
Children are the most affected. The pediatrician should convey to
the parents on how lead affects their children.
- Just as we
had immunization card we could have a lead screening card. Maintain
a record of the child’s lead level, and if the blood lead level
is found to increase, then the source should be identified. There
should be more active involvement of school and educational media.
- Schools could
convey messages to parents and initiate lead screening programs
in co-ordination with hospitals. The public should also be made
aware of the lead problem by television, radio, newspaper etc.
- Community
based programs where children are screened for anemia and calcium
deficiency are very necessary.
- Create more
medical facilities for periodic screening. Involve more organizations
like The George Foundation.
Ms. Ann Carroll
She spoke from
her experience as the Manager of the Lead Reference Center (LRC) in
the New South Wales Environment Protection Authority, based in Sydney,
Australia. A summary of the important ideas she presented are as follows:
- In New South
Wales before educational programs are developed, social research
on the skills, knowledge, attitudes and behavior of the general
public, health care providers and industry are conducted.
- The research
indicated the general public was aware of the hazards of lead and
were capable of naming specific health impacts of lead.
- The public,
health care providers, and industry had limited knowledge about
what they could do to prevent exposure or minimize risks.
- In planning
statewide community education or communication strategies to educate
the general public about steps they could take to minimize exposure
or reduce risks from lead, it was important to educate doctors and
health care providers first, as patients would ask them questions.
- Building and
construction industries were also important target audiences as
they frequently create lead hazards by unsafe work, endangering
themselves, their clients and their families.
- For all target
audiences, both literate and illiterate, graphics and colors are
an important part of educational efforts.
- New South Wales
research has also found that there are no materials or courses currently
available that discuss ways to safely use lead for a wide range
of industries. The LRC has developed a training module and course
materials on safe lead management for members of the building and
construction industry as well as transport and manufacturing.
- It is particularly
important that workers get information about safe work practices
and the hazards of ‘take-home’ lead or lead work in family living
areas. Recent US NIOSH research found children of workers in the
construction industry were 6 times more likely to have elevated
blood lead levels than other children. Australian research also
found children of workers employed in the lead mining or automotive
or smash repair or whose parents had hobbies involving ceramics,
painting glass, car repair or making fishing sinkers were at greater
risk of elevated blood lead level than other children.
Dr. M. H. Avila
He made the following
observations:
- Designing and
developing an education program requires educational expertise.
In deciding on the kind of educational program to be implemented,
we should contact the people who specialize in making these kind
of programs. The community should always be involved in the development
of these programs.
- Use graphics
for educating the people.
- He showed a
graph depicting high lead levels in the Mexican population in 1995,
prior to the educational effort, and the decline in blood lead level
in the same population in 1997 after the people were educated about
lead.
Dr. S. J. S.
Flora
In modern society
many preparations consumed by man are found highly contaminated by
lead. Lead salts are being used in traditional cosmetic and medicines.
Ignorance about material hazards such as lead plates and foil used
by the unskilled and uneducated persons operating technical repairing
of day-to-day household utensils can lead to the tragedies. Lead awareness
programs are being carried out in different countries, but those techniques
may not fully apply to developing countries. Developed countries are
employing strategies and tactics that are unique to their countries.
In India, because of high illiteracy, the challenge is much greater.
Furthermore, even among the literate, particularly the medical doctors,
there is not much information available to them in medical textbooks
about lead toxicity. Thus, it invariably leads to the situation where
doctors recommend symptomatic treatment rather than specific. Because
of this, lead poisoning which is certainly far more prevalent than
is recognized, citizens do not receive proper treatment and guidance.
Some of the preventive
measures by which we can reduce the incidence and severity of lead
poisoning among the Indian population are listed below:
- Inclusion of
chapters describing metal toxicology in general and lead poisoning
in particular in the medical textbooks. Doctors can also play a
major role in educating the illiterate population, as they are generally
the persons who are being approached by almost all classes of general
population. They can educate them by telling them about the common
hygienic measures.
- Small chapters
in textbooks of children about metal poisoning and how to prevent
them can also be very useful.
- Install or
improve corrosion control to minimize lead level at water taps.
- Install treatment
processes to reduce lead in source water entering the distribution
system.
- Replace lead
service lines when more than 10% of targeted drinking water samples
exceed the permissible lead.
- In the lead
acid battery industry, make the lead production safe by installing
automatic and machine controlled devices, by providing protective
gear like mask, replaceable filters, gloves, boots and working clothes.
- Scrupulous
observance of personal hygiene during and immediately after working
hours like cleaning of hands, and taking bath before leaving the
hazardous factory.
- Constant monitoring
of the workers' health regarding the lead levels in blood and urine
and allotting them alternate work in "safe" areas.
- Where dust/fumes
are generated, they should be isolated from other areas and preferably
be enclosed with proper ventilation arrangement.
- Need to have
a special monitoring agency in the department of mines to control
lead pollution. The entire unit, whether organized or unorganized,
should register with this agency. This agency should monitor the
manufacturing units for safety, and pollution control equipment
should be installed where required.
- The State Pollution
Control Boards could verify and monitor dust emissions.
- It should be
made obligatory for all the units in lead recovery to submit material
balance statement to the Ministry of Mines.
Mr. Jon Forster
Mr. Forster served
as Policy Analyst for the NYC Department of Health. A summary of the
important ideas he presented are as follows:
- The Lead Prevention
Program started in New York City in 1970. The program now focuses
on children and treatment.
- In New York,
80% children under 2 years and 60% children under 6 years have been
screened for lead.
- He emphasized
that physicians should be involved. Physicians should be asked to
help formulate programs for physicians.
- ‘Train the
trainers’ programs for training people already working in the community
should be encouraged.
- Create awareness
and provide screening in the community by using loudspeakers to
invite the target audience to be screened on the spot.
Mr. Michael
Van Alphen
Dr. Alphen is
director of Lead Research at Port Perie Environmental Health Center,
Australia. He made the following points:
Educate the Nations
Leaders. Few leaders of India and its States fully appreciate the
day-to-day hazards of Pb poisoning to children and the general population.
The leaders of India’s businesses, the manufacturing industries and
individual factory owners also appreciate little of child Pb poisoning.
There is ineffective regulation of Pb and other toxic components in
consumer goods, and many products manufactured in India contain levels
of Pb that can potentially Pb poison children. In light of this, educating
the political and business leaders is probably the bigger priority.
Its not just the message of the human health problems of Pb that are
relevant, but the message should be that there are options for dealing
with it and the benefits.
There is much
more advantage in educating those with power and influence as they
could have immediate, positive and powerful ramifications through
the whole community. Continued lobbying/education of the health, industry
and environment ministries is required.
Roles of the health
professionals:
1) Educate the
public health workers
2) Educate and
provide tools to the medical profession.
3) Targeted education
and intervention
In regard to the
third point, educate the media. Give the media stories, give them
material and be accessible to them.
In order to reduce
Pb in drinking water, select municipal and drinking water control
authorities and give them with education regarding Pb. The same goes
for the manufacturers of eating utensils, paints and many other industrial
concerns. There are many groups of people who will require tailor-made
education, as for example construction workers, house painters, etc.
There is also some crossover in India at least between child Pb exposure
and occupational exposure issues of cottage industries.
Lead poisoning
in India is frequently referred to by some in the medical profession
as being either symptomatic or non-symptomatic to the degree that
you may suspect two things. There is a high incidence of Pb poisoning
in India, but due to the non-availability of blood lead (PbB) analysis
facilities, many medical practitioners fail to diagnose Pb poisoning
in India.
This comment perhaps
underlies the role of the medical profession in Pb poisoning and therefore
the level of medical education required in this field. The key roles
of the medical profession are making medical diagnoses and conducting
medical management of patients. So here are two clear areas where
specific education is required. In the case of the diagnosis of Pb
poisoning, we should be sure that all general practitioners are aware
of the clinical signs of Pb poisoning and know where to go to get
an accurate/reliable blood Pb analysis.
There is a need
for better access to PbB analysis facilities in India before much
additional education of the medical profession can pay-off. The medical
profession is trained to act on medical facts; blood Pb analyses are
the foundation of a general practitioner’s role. The two appear to
go hand in hand. Without the PbB analysis, the medical profession
is largely blind to the Pb problem. Medical practitioners need the
diagnostic tools. Some parts of the profession in pediatrics, occupational
health and toxicology have a more focussed / professional interest
in Pb poisoning. My view is that Pb poisoning will only influence
the medical profession more widely when the diagnostic tools are more
widespread. There is no argument however that the medical profession
needs more information. The family doctor will most frequently deal
with sick people who, among other things, may have Pb poisoning. The
general practitioner will not generally be a front line person in
the detection of Pb poisoning as they will do little Pb-specific case-finding
work. The general practitioner will not often be doing home visits
to try and determine sources of Pb poisoning. The ‘family doctor’
or ‘local doctor’ will invariably be an intermediary between the parent
and the public health worker and the hospital or pediatrician.
Who says you need
PbB testing to find Pb poisoned children? I could take you to a car
battery assembly workshop where there are 8-12 year old boys working,
and would say there is a very high chance that they are Pb poisoned.
Similarly go to a silversmiths and see a 6 month baby being cradled
in the lap of the owner father while he polishes brassware and crucibles
are being fired nearby.
You can readily
conduct case-finding exercises and identify children at risk using
public health field workers and public health programs without substantial
PbB diagnostic analysis support. At this time in India, there are
many tens of thousands of small factories where children are being
Pb poisoned. All that is needed is understanding the pattern of Pb
poisoning associated with a particular industry and then go and target
those industries and locate the associated Pb poisoned children. Clearly
diagnostic support is required but the PbB testing would not be the
central crutch upon which such programs are based. Information is
crucial and education of the public health worker is critical.
Educational messages
need to get to pregnant women and to families with very young children.
The message has to get out before children are Pb poisoned. Pb poisoning
should be prevented before a child is born. Pb poisoning prevention
is a goal which is not about passively studying the age at which children
attain their peak PbB level, but directed towards all possible reductions
in Pb exposure at every stage.
In order to educate
the illiterate, we need to get answers to some basic questions.
What percentages
by demographics are illiterate?
What languages?
What proportion
listen to radio?
What proportion
watch TV?
What proportion
go to the movies?
What proportion
read newspapers?
How does the above
break-down from poor to rich states? Are there mass media education
options? Or, is there a need for targeted media and mass media? The
petrol station where you now get your unleaded petrol could distribute
information about Pb poisoning. If 50% of the population of India
is illiterate, how are you going to make a difference to the 50% or
more of Indian children having a PbB > 10 ug/dl? How are you going
to put it across? If you focus on text based public information, you
will not achieve much!!
How can you even
consider issues such as communicating to the parent of a Pb poisoned
child with a view to discovering sources of Pb exposure if that person
does not know what Pb is? What is Pb? What items often found in the
home contain Pb? In these situations graphical means are required.
Sketches of all Pb items are required so as to communicate to people
about Pb. You have to find something familiar to the illiterate.
This is the key
issue for children also. The sort of literature that is pitched to
children so as to educate them about the risks of Pb should also be
highly graphical. In a community where 70% are illiterate, then substantial
effort has to be placed in graphical resources.
In the case of
children, they are the most easily educated in the community and can
readily pick up and accept messages about Pb poisoning. These children
can then look out for their brothers and sisters and readily pass
on the material learned to their parents. Children can be your teaching
network.
Children readily
take home colouring books and learn about messages while they colour
things in, and they show these things to their parents. Children will
also readily take home storybook format ‘picture-books’ with interesting
detail-filled colour pictures. It is easy to get children on your
side with colorful brochures, perhaps badges, hankies or face-washers.
These may all seem like bribes but kids are pretty loyal.
One important
issue when it comes to having children jabbed in the arm with a needle
or pricked on the finger when they visit your clinic is that you have
to try send them away happy or otherwise they may not come back!
How do you get
across the message to children to wash their hands before eating?
Cartoons showing happy figures washing their hands is one method.
Other networks
include maternity hospitals/ schools /child care facilities/community
groups.
Lapel badge
used in Australia education campaign for children
TIPS FOR A
FAMILY TO AVOID OR LESSEN LEAD EXPOSURE:
1. DON’T USE HOT
WATER FROM THE TAP FOR COOKING OR DRINKING,
BECAUSE HOT WATER
IS MORE LIKELY TO CONTAIN LEAD THAN COLD.
2. NEVER MIX HOT
TAP WATER WITH INFANTS FORMULA OR JUICE.
3. RUN THE WATER
FOR A MINUTE WHEN IT HASN’T BEEN RUN FOR MORE
THAN 6 HOURS.
4. WASH CHILDREN’S
HANDS FREQUENTLY, ESPECIALLY THOSE OF YOUNG
CHILDREN WHO
OFTEN PUT HANDS IN MOUTHS. HANDS SHOULD
ALWAYS BE WASHED
AFTER PLAYING OUTDOORS AND BEFORE THEY
EAT.
5. FEED CHILDREN
A DIET WITH ADEQUATE AMOUNTS OF IRON AND
CALCIUM, WHICH
HELP PREVENT THE ABSORPTION OF LEAD.
6. DAMP-MOP OR
DAMP-DUST YOUR HOME FREQUENTLY, CONCENTRATE
ON PLACES WHERE
PAINTED SURFACES RUB TOGETHER SUCH AS
WINDOW AND DOOR
FRAMES AND FLOORS. AVOID DRY SWEEPING OF
DUST BECAUSE
IT WILL STIR UP AND SPREAD LEAD DUST. VACUUMING
WITH A CONVENTIONAL
VACUUM CLEANER MIGHT SPREAD DUST, THE
USE OF A HEPA
VAC IS PREFERRED.
7. AVOID ALL AREAS
WHERE RENOVATIONS OR DEMOLITION ARE TAKING
PLACE. DO NOT
SAND OR SCRAP LEAD -PAINTED WALLS WITHOUT
PROPER PREPERATION
AND CONTAINMENT AND TRY TO HAVE
CHILDREN OUT
OF THE HOUSE.
8. WASH BABY TOYS
AND PACIFIERS FREQUENTLY.
9. DON’T ALLOW
CHILDREN TO PLAY UNDER ELEVATED HIGHWAYS OR
BRIDGES.
10. DON’T ALLOW
CHILDREN TO PLAY WITHIN 100 FEET OF HIGHWAY AND
BUSY DUSTY STREETS.
11. IF HOUSEHOLD
MEMBERS WORK IN JOBS THAT EXPOSE THEM TO LEAD,
HAVE THEM CLEAN
UP OUTSIDE OF THE HOME BEFORE ENTERING. TAKE
SHOWERS AT WORK
AND HAVE TWO SETS OF CLOTHES TO WEAR.
CLEAN OFF SHOES
CAREFULLY AND WASH HAIR DAILY BEFORE
ENTERING THE
HOUSE.
12. PLANT SHRUBS
AND GRASS AROUND OUTSIDE OF HOUSE AND
CLOSELY MONITOR
FOR PAINT CHIPS AND PEELING PAINT AND REMOVE
THEM QUICKLY.
13. BEWARE OF
HOBBIES THAT EXPOSE CHILDREN TO LEAD, LIKE THE
MAKING OF FISHING
SINKERS AND LEAD SHOT BULLETS, MAKING
POTTERY, AND
WORKING WITH PAINT OR MOLTEN LEAD.
14. BE AWARE OF
THE ENVIRONMENTS YOUR CHILD PLAYS IN AND VISITS.
15. NEVER OPEN
CANS THAT HAVE DENTED SEAMS.
16. REMOVE ACID
FOODS FROM CANS: TOMATOES, PINEAPPLES, AND
APPLE JUICE,
ETC. NEVER STORE FOOD IN OPEN CANS!
17. CHECK THE
WALLS OF SCHOOLS FOR PEELING PAINT AND DUST.
18. IF YOU HAVE
TO RENOVATE OR BUILD IN THE HOUSE, KEEP THE
CHILDREN AWAY
UNTIL COMPLETELY FINISHED AND PROPERLY
CLEANED UP.
19. WASH HANDS
CAREFULLY BEFORE PREPARING FOOD.
20. AVOID EATING
FOODS THAT WERE COOKED IN OIL THAT WAS NOT
COVERED AND LOCATED
OUTSIDE ALONG BUSY ROADS.
21. BE WARY OF
ALL PAINTED TOYS AND CHECK THEM FOR LEAD.
22. LAUNDER WORK
CLOTHES SEPARATE FROM FAMILY CLOTHES.
23. AVOID CERTAIN
COSMETICS AND FOLK REMEDIES THAT MAY STILL
CONTAIN LEAD.
24. AVOID ALL
MEDICAL REMEDIES THAT USE LEAD. ASK YOUR LOCAL
HEALTH DEPT.
TO MAKE SURE!
25. ALL MOTHERS
WHO ARE BREAST-FEEDING SHOULD BE CAREFUL AND
TO AVOID ANY
LEAD: NO SANDING OF PAINTED SURFACES, AVOID LEAD
FUMES, ETC.
Example of
an education guide from NYC Dept. of Health :
