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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
- 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.
- 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.
- 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
| No. |
Item |
Target Duration |
| 1 |
Eliminate the use of leaded gasoline by all vehicles,
both old and new, including two- and three-wheelers |
5 Yrs. |
| 2 |
Establish laws that require industries to comply with
set safe standards/levels for lead as they pertain to consumer
products, work environments, and waste |
5 Yrs. |
| 3 |
Monitor and ensure that lead in drinking water and milk
supplies is within safe levels |
5 Yrs |
| 4 |
Discontinue the use of lead solder in pipes for public
water supply, and replace them with safe materials where
feasible |
5 Yrs. |
| 5 |
Except in certain industrial uses, ban paint containing
lead |
5 Yrs. |
| 6 |
Prohibit the sale of food processing appliances, cooking
utensils and food storage containers/pots that may leak
lead |
5 Yrs. |
| 7 |
Require day-care, pre-school, kindergarten and primary
school classrooms to be as dust-free as possible before
children arrive each day |
5 Yrs. |
| 8 |
Train health care providers to diagnose lead poisoned
cases, provide treatment where needed, and offer preventive
steps to patients and families |
On-going |
| 9 |
Increase awareness among the general population about
lead poisoning, and provide information about day-to-day
preventive measures |
On-going |
| 10 |
Monitor lead levels in the environment, consumer products,
and workplaces, including cottage industries, and ensure
compliance of laws relating to lead |
On-going |
| 11 |
Clean up highly lead-contaminated areas, including removal
of topsoil for safe disposal |
15 Yrs. |
| 12 |
Carry out periodic and selective screening for blood lead
of individuals living or working in high-risk areas, and
make available safe and effective orally administered chelating
agents at affordable prices for cases where treatment is
required |
On-going |
| Note: Target Duration reflects the
time period within which the related item needs to be accomplished.
However, continued monitoring and compliance must be assured
beyond target duration. |
- 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
# 210, 5th 'A' Cross, HRBR Extn.
3rd Block, Kalyananagar Post
Bangalore, 560043. India
Tel: 91-80-5440164, 5444170
Fax: 91-80-5440210
georgef@vsnl.com
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