CHAPTER 1

Executive Summary: Action Plan to Reduce Lead in the Americas



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LEAD IN THE AMERICAS: A call for action CHAPTER 1 Executive Summary: Action Plan to Reduce Lead in the Americas

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LEAD IN THE AMERICAS: A call for action EXECUTIVE SUMMARY: ACTION PLAN TO REDUCE LEAD IN THE AMERICAS The consensus of the conference participants can be summarized clearly and directly: for many populations in the Americas, human exposure to lead is excessive, produces disease, and must be reduced. The magnitude of this exposure, and the pathways through which it occurs, vary from country to country and are not always well-characterized. Leaded gasoline remains a major source of exposure in Argentina, Suriname, Ecuador, Peru, and probably in other countries as yet undocumented, but it has been largely eliminated in Brazil, Canada, and the United States. Lead-glazed ceramic (LGC) is commonly used to cook or store food in Mexico, Ecuador, and probably in many other countries of the Americas. All countries have many point sources of lead emissions, such as smelters, battery plants, and scrap metal recovery facilities. These range from large factories to microenterprises (in many countries of the region, these are family-run businesses that are usually unregistered by governmental agencies and are difficult to access and regulate). Some countries recognize problems with lead paint, but in patterns that appear to vary considerably. Although quantitative information about levels of lead in air, water, and food is available for relatively few countries, the data that are available suggest the presence of levels that pose significant hazards to health. Systematic population surveys of blood lead levels have only been undertaken in the United States. Less systematic data compiled elsewhere point to some serious problems. Average blood lead levels in children in some of these surveys are as high as 39 µg/dl, and the proportion of children with blood lead levels above 10 µg/dl in some studies is 100 percent. Clearly, lead exposure is widespread, albeit heterogeneous. Hence, conference participants recognized that the optimal approach to prevention will vary from country to country, as will the political and economic strategies needed to achieve success. These are issues to be decided by communities, workers, industries, public health professionals, clinicians, political leaders, and other stakeholders in each country. More-

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LEAD IN THE AMERICAS: A call for action over, conference participants were mindful that many countries of the Americas were not represented at the conference. Accordingly, those present did not attempt to reach consensus on specific recommended actions. Nevertheless, the major sources of lead exposure are known, primary prevention is imperative and attainable, and those present agreed that an Action Plan is necessary to achieve prevention. They hoped that this general approach would be of use in the Americas and in other regions. Critical steps of the Action Plan include: Assemble and share the necessary information; Build capacity and train the necessary personnel; Build political will; Involve the target community; Make the needed technical changes; Determine and communicate the benefits, and costs, of eliminating lead from industrial processes and uses; Identify cases, prevent further exposures, and provide clinical care; Evaluate the results; Follow-up. There was universal agreement that primary prevention through technical change is necessary and appropriate, and consistent with proven principles of public health. Specifically, conference participants agreed on a wide-ranging set of recommendations: Move toward the elimination of lead in gasoline, ceramic glazes, paints, and solder on food cans; Strictly limit workplace exposures to lead and releases from macro-and microindustrial sources; Implement surveillance of high-risk populations and environmental monitoring; Focus on interventions that have been shown to be cost-effective and sustainable in countries of the Americas and elsewhere in the world; Conduct evaluation research, so that the success and cost-effectiveness of prevention and control strategies can be assessed on a regular basis; Ensure the involvement of all parties having a direct interest in reducing lead exposure, including government agencies, large and small industries, organized labor, health care providers, and community groups.

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LEAD IN THE AMERICAS: A call for action More broadly, conference participants recognized the need for continued economic development of the region as a means of providing alternatives for those who currently earn their living in cottage industries that contribute to lead exposure and for generating the capital necessary to invest in clean technologies and abatement. The following paragraphs describe the generic components of the Action Plan to control lead exposure with which the majority of participants concurred. The first discussed is technical change, the centerpiece of efforts to control lead exposure. MAKE THE TECHNICAL CHANGES Conference participants agreed that specific technical changes to reduce lead exposure are necessary throughout the Americas. Attendees were cognizant of the financial, cultural, and political barriers that exist, and of the important competing priorities in development generally and in health specifically. Nevertheless, the following changes were recommended. The conference participants call on the countries of the Americas to move toward the elimination of lead in gasoline. This recommendation is supported by several facts. First, there is clear evidence that human exposure to lead from gasoline is widespread, and that eliminating lead from gasoline lowers population blood lead levels by reducing lead in air, foods, and dusts and soils. Second, there is a readily available alternative: unleaded gasoline. Third, that many countries in the Americas have already eliminated or reduced the use of tetraethyl lead in gasoline indicates that this change is feasible. Fourth, all major constituencies, including many of the representatives from manufacturers of tetraethyl lead attending the conference, agreed that lead in gasoline needs to be phased out. The conference participants call on the countries of the Americas to move toward the elimination of lead in manufactured food containers. This recommendation is also supported by several facts. First, there is good evidence that the use of lead-containing solder in food cans results in contamination of food. (This view was initially countered by some members of industry, who noted correctly that the soldered surface does not necessarily contact the food in the cans. Research has demonstrated, however, that contamination of the interior surface of the cans generally occurs during the production process and is in many cases unavoidable.) Second, technical

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LEAD IN THE AMERICAS: A call for action and economically affordable alternatives are readily available. Third, the success of several countries in eliminating lead-containing solder from cans demonstrates that this change is feasible. Fourth, the substitution of welded joints for lead-containing solder has been shown to derive the following commercial benefits: a 3-5 percent reduction in raw materials, resulting from the smaller welded joint; no net additional costs from retooling because material costs most often offset equipment costs; and a smaller welded joint provides a larger surface area for advertising, and a potential for increased market share. Conference members recommended that each country, through collaboration among its public health authorities, canning industry, and other interested parties, move rapidly toward eliminating the use of lead-containing solder in food cans. The conference participants call on the countries of the Americas to move toward the elimination of lead in ceramic glazes. Members of the working group on ceramic glazes noted that there is inadequate information about the extent of LGC use in most countries of the Americas, or on the relative contribution of LGC as a source of human exposure. Mexican data demonstrate, however, that LGC pottery and cookware are widely used and can be an important source of lead exposure among women of reproductive age. Moreover, it is not only the users of LGC products who are exposed to lead; the artisans and manufacturing workers who make these products—and their families—also sustain lead exposure, sometimes at levels much higher than those found in users. Technical alternatives are readily available, although further research is necessary to optimize and verify their performance in some situations. (For example, some alternative glazes require very high firing temperatures that cannot be attained in the simple kilns of small-scale producers.) The phaseout of LGCs in the Americas will be a complex challenge because the manufacturing of ceramics is extremely heterogeneous, ranging from large industries to family enterprises, and practices are in some cases based on entrenched cultural traditions. The conference participants emphasized that participation of all players, and special sensitivity to the needs of small producers, will be required to achieve a phaseout of LGCs. The conference participants call on the countries of the Americas to move toward the strict control of lead in paint. Members of the working group on leaded paint noted that, as with LGC, important data are missing on the use of lead in paint in the Americas. The extent of its use and its relative

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LEAD IN THE AMERICAS: A call for action contribution as a source of human lead exposure are not well characterized in most countries. Data from the United States indicate, however, that lead-based paint is a prominent source of lead exposure among U.S. children. In addition, the use of lead-based paint exposes workers who manufacture, remove, apply, and work near it, and their family members, and results in lead-containing dust in households and the general environment, potentially affecting many more people. Comprehensive control of this source of exposure is extremely complex, for several reasons. First, in some countries lead-containing paint is already in place in millions of homes, commercial facilities, and structures such as bridges; removing lead from newly manufactured paint would not reduce exposure from these sources. Second, lead-containing paint is used in a wide range of applications—from toys to artists' supplies, from homes to bridges. Third, efforts to control lead at the point of use is difficult, since paints are applied by millions of individual painters and homeowners. In contrast, it is feasible to control lead in paint at the point of manufacture, because paint formulaters tend to mix feedstock pigments —many containing lead—from a limited number of manufacturers. Also, alternatives are currently available, including paints with very low lead content and paints without lead, although the costs of these paints tend to be considerably higher than those of lead-based paints in most countries of the Americas. In summary, the conference participants recognized the need for more data on the nature and extent of the use of lead-based paint in the Americas, and on the magnitude of associated human lead exposure. They also agreed, however, that countries of the Americas should immediately begin to take steps to eliminate lead from paint, especially in residential applications, but also in commercial applications. The conference participants call on the countries of the Americas strictly to limit workplace exposures to lead. The hazards of occupational lead exposure have been well recognized for centuries, and international guidelines on limiting exposure have been available for decades. Members of the working group on occupational and industrial health endorsed the need for enforceable limits on lead levels in workplace air and for medical removal with full pay and job security for workers whose blood lead levels exceed a threshold, and they recommended that the acceptable threshold levels used as a basis for enforcement be standardized to the extent possible across the countries of the region. Working group members endorsed several additional general components of occupational lead exposure con-

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LEAD IN THE AMERICAS: A call for action trol: (1) primary prevention through adoption of lead-free technologies wherever possible, and through strict control technologies otherwise; (2) enforceable hygiene practices in workplaces such as washing facilities, lockers for clothes changing, smoking restrictions, and personal protective equipment where appropriate; (3) regular medical surveillance of exposed workers, including monitoring of blood lead levels; and (4) worker training regarding lead hazards. Relatively complete programs are in place in Colombia, the United States, Canada, and several other countries of the Americas. All countries should strive to implement such programs, with the active involvement of labor organizations, industries, government agencies, and health care providers. The conference participants call on the countries of the Americas to implement appropriate public health initiatives such as surveillance of high-risk populations, environmental monitoring, and education of the public and workers. The preceding recommendations are directed to primary prevention, and are centered on technical interventions that will directly reduce lead exposure. The final recommendation addresses a variety of public health initiatives, many of which are also discussed in the context of specific sources of lead exposure. Surveillance programs are necessary to identify cases of lead toxicity for early intervention and treatment, monitor population trends, identify and quantify principal sources of lead exposure, evaluate the efficacy of interventions, and support education efforts. Successful surveillance programs should be simple and inexpensive, and to the extent possible should take advantage of existing programs and facilities. Surveillance should include both biological sampling of high-risk populations and environmental sampling of known or suspected sources of exposure. As noted above, exposure assessment is especially important with regard to ceramics and paints, sources for which the magnitude of exposure in many countries remains largely undefined. It is essential that such programs include provisions for control and follow-up of excessive blood lead and environmental lead levels, and that medical confidentiality in the workplace be safeguarded. A separate but linked public health effort is education. It is essential that vigorous educational efforts be directed at policymakers, health care providers, workers, industrialists and managers, and members of the public. Of special importance, health care providers need to be trained to recognize and respond to lead toxicity, and workers need practical training in the recognition and prevention of lead toxicity. Training and surveillance can often be effec-

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LEAD IN THE AMERICAS: A call for action tively linked. Such efforts can help to build the political will to control lead exposure, and can enable exposed persons to take steps to protect themselves. ASSEMBLE AND SHARE THE NECESSARY INFORMATION Any major public health program must be based on solid data. But lead is a unique hazard: a great deal is known about lead toxicology, and the benefits of decreasing exposure have been established beyond doubt. There was widespread agreement among conference participants that steps to control lead exposures need not, and indeed should not, await further physiologic or toxicologic data. Further information for decisionmaking is needed, but only in limited and specific ways. Two kinds of information, now only partially available, are particularly important: patterns of lead exposure, and methods of control. The extent of lead use, its distribution in the environment, and the extent of human absorption, are only incompletely characterized in much of the hemisphere, particularly at the local level. For example, participants in the workshop on lead in ceramics noted the paucity of quantitative data on the use of LGCs in Ecuador, Bolivia, Peru, and many other countries of the Americas. In general, conference participants agreed that the populations at highest risk of lead exposure, and the settings in which lead exposure is most likely, must be identified, and their exposures quantified. This highlights the fundamental role of surveillance and monitoring, including both biological testing and environmental sampling. Such research does not extend the frontiers of science, but it serves time-honored and essential functions: it documents the existence and magnitude of problems, translating the theoretical and distant to the immediate and local. Similarly, conference participants agreed that there is a need for further information on methods of control. In some cases this involves narrowly technical information. For example, participants in the workshop on food, water, and waste disposal noted that a Japanese technology—lining existing lead pipes with plastic to minimize leaching of lead into drinking water—may have promise, but that information on the cost and efficacy of this technology is not readily available. In other cases the needed information could extend beyond the technical to the social and political. For example, what are the practical, affordable alternatives to backyard battery-recycling operations in countries with few resources, and how can they be successfully introduced? The research methods applicable

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LEAD IN THE AMERICAS: A call for action here range from historical case studies to environmental engineering investigations to cost-benefit analyses. There was a clear consensus that more research is necessary to achieve control of lead toxicity in the Americas, but it must be research that is targeted, action-oriented, and directly relevant to prevention within the country or region in which it is conducted. One example of this type of analysis endorsed by conference participants would be an extension of the 1994 Pan American Health Organization survey conducted by Drs. Isabelle Romieu and Marina Lacasana, whose initial results appear in this volume. Unfortunately, requests for information yielded responses from only 16 of 28 nations surveyed, leaving considerable uncertainty, especially for the Caribbean countries, and the authors were unable to ascertain whether a nonresponse from a given country indicated just that or a true lack of data. Moreover, research results must reach those who need to know. There are many important audiences, including government policymakers, decisionmakers and technical staff in large industries, representatives of the microindustries that form much of the economy in Latin America and the Caribbean, organizations that represent labor and communities, health care providers in public health agencies and on the clinical front lines, and the media. To be effective, research results must be translated into terminology and formats that can be readily understood by these important and diverse audiences. Education and dissemination are therefore essential components of research. Existing knowledge about the health effects of lead must be shared in a culturally appropriate manner with members of the public; in particular, parents must be taught the hazards lead poses for their children. Public health workers also need to be aware of lead as a hazard. Similarly, workers in industries where lead exposure can occur must be informed about lead hazards, recognition of early signs and symptoms of toxicity, and means of prevention. Approaches such as chemical information sheets, which detail chemical health hazards and are currently being used with success in the United States, Canada, Mexico, and a limited number of other countries in the Americas; product labeling; mandatory worker training sessions; and school-based training should be considered. Public health workers have a special responsibility to communicate with policymakers, informing them of lead hazards and advocating control measures. Through such channels of communication, necessary information once assembled can be translated into preventive action.

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LEAD IN THE AMERICAS: A call for action BUILD CAPACITY AND TRAIN THE NECESSARY PERSONNEL Many countries of the Americas lack the necessary human and technical infrastructure to control lead exposure. For example, participants in the surveillance workshop noted that many countries have no adequately equipped laboratories for blood lead testing, no technicians trained to manage such laboratories, and no sanitarians or engineers trained and equipped to carry out field measurements of environmental lead. Addressing these deficits should, therefore, be an important part of any hemispheric plan to reduce lead exposure. Workshop participants urged North-South and South-South collaboration to offer assistance in technical training and equipping in countries that lack the infrastructure to develop lead surveillance programs. The example of Europe was cited on occasion; there, as part of the process of economic integration, cross-training of industrial hygienists from various countries has been highly successful. One promising initiative was discussed by Dr. Henry Falk and Dr. Robert Jones of the U.S. Centers for Disease Control and Prevention (CDC). They described the CDC's lead testing proficiency program, which includes careful provisions for quality control and is free to participating laboratories. Dr. Falk indicated that this program is available to laboratories throughout the hemisphere, and that CDC might assist in training laboratory personnel in each country or region, with the recognition that testing equipment would have to be purchased with funds from other sources. A second promising initiative was introduced by Dr. Rob McConnell of the Pan American Center for Human Ecology and Health (ECO), who discussed plans for regional capacity building in environmental epidemiology. A skilled complement of professionals, with expertise in laboratory methods, epidemiology, industrial hygiene, environmental engineering, and clinical medicine, is essential for the successful control of lead exposure in the Americas. BUILD POLITICAL WILL Even if information is readily available, and even if trained personnel are in place, lead exposure will not be easily controlled. Entrenched traditions govern such practices as ceramics manufacturing and use. Powerful financial interests stand in the way of some changes. Limited resources preclude such interventions as the wholescale upgrading of refinery processes to allow for reformulation of gasoline with large amounts of high-octane components as a replacement for leaded fuel.

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LEAD IN THE AMERICAS: A call for action For these reasons, each country must build the political will to implement changes. How to do so will, of course, vary from country to country. Veterans of public health campaigns, especially in the United States, spoke of the success of strict government regulation and offered persuasive historical examples—for example, elimination of leaded gasoline. Workshop participants generally agreed, however, that cooperative approaches including industry, government, the health sector, labor, and others, were preferable. An underlying theme of the conference, and of the recommendations that emerged, was the necessity of multisectoral cooperation and “buy-in” in achieving prevention. Some of the representatives of the lead industry who were present admirably exemplified this approach, acknowledging that leaded gasoline is a product with a limited commercial life, and joining in dialogue about its phaseout in coming years. Conference participants also agreed on the importance of presenting data, where available, on the cost-effectiveness of reducing lead in the environment. Communicating the economic advantages of strategies to reduce lead exposure can be an important instrument for building political will. Dr. Tania Tavares, in the working group on food, water, and waste disposal, introduced an analytical framework relevant to building political will. For any proposed change, the following questions are addressed: What is the necessary change? How is it to be accomplished? Who must act to do it? What incentives exist, or can be created, to encourage the change? What supporters might promote the change? For example, in considering the elimination of lead solder in food cans, the working group noted that action must be taken by the canning industry, and identified important incentives that have been realized by companies that have made the change: savings in raw materials, cost neutrality of the change, decreased liability, and increased market share. Through such an analysis, and through active advocacy directed toward decisionmakers in government, industry, the health sector, and elsewhere, the political will to control lead exposure must be built. INVOLVE THE TARGET COMMUNITY The improvement of health is a multidisciplinary process. While conference participants acknowledged that environmental change (for example,

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LEAD IN THE AMERICAS: A call for action removal of lead from gasoline, implementation of occupational lead exposure controls) must be central to any effective national or regional strategy to reduce lead exposure, they also agreed that sustained action requires that the affected (target) population be aware of the health problem and understand and accept the available means of preventing or controlling that problem. This can be accomplished only through the exchange of health information, appropriately geared to the needs and understanding of the community, and through engaging community members in the identification of problems and strategies to solve them. Accordingly, there was broad consensus among conference participants that active community involvement is a necessary prerequisite for effective prevention and control of lead poisoning across the hemisphere. Participants agreed that the growing movement to involve community members and other local “stakeholders” in health promotion and disease prevention and control programs has demonstrated clearly that such individuals can be vital to the development of innovative and sustainable solutions at the local level. The poster and plenary presentations of successful community-based programs—such as the Alameda County Lead Poisoning Prevention Program (U.S.A.), Trail Community Lead Task Force (Canada), Johnson and Johnson Corporation/New Jersey Head Start Association (U.S.A.), United Parents Against Lead (U.S.A.), and Tijuana Lead Program of El Colegio de la Frontera Norte (Mexico)—support this approach as an important vehicle for lead poisoning prevention and control. Conference participants agreed that involving a broad range of affected and interested parties—which could include parents and other family members, workers, local public health professionals and health providers, community-based nongovernmental organization (NGO) personnel, other appropriate public agency representatives (for example, on behalf of housing, labor, and insurance commissions), and individuals representing industry—in program development and implementation is central to any effective and sustainable strategy. DETERMINE AND COMMUNICATE THE BENEFITS, AND COSTS, OF ELIMINATING LEAD FROM INDUSTRIAL PROCESSES Reducing or eliminating lead exposure can be profitable in the long run, as shown in the case studies and workshops of U.S. gasoline lead reduction and removal of leaded solder by the Mexican canning industry. Some measures to reduce or eliminate lead, however, require initial costs. A

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LEAD IN THE AMERICAS: A call for action leading example is the removal of lead from gasoline, owing to the costs of reformulating unleaded gasoline to achieve equivalent octane. Another example is the removal of lead-containing paint from existing housing. Other public health efforts, such as establishing lead testing laboratories and providing population surveillance and product testing, also entail costs. Offsetting these costs, in some instances, may require funding from external sources. The preliminary list of federal and private organizations involved in lead poisoning prevention provided in Appendix D of this report provides a means of obtaining preliminary information toward this end. But there also are costs associated with not reducing or eliminating lead exposure. These include the direct medical costs of such lead-related conditions as hypertension (and resulting strokes and myocardial infarctions) and renal failure, the direct costs of remedial education for children with learning impairments, and the opportunity costs incurred when potentially creative, productive people cannot fully contribute to their communities and nations. There are also the enormous, but unquantifiable, “costs” in human suffering of those with lead poisoning and their families. Whereas the costs of reducing lead exposure are generally short-term costs, the costs of not reducing lead exposure continue to accrue over many years. The conference participants noted and lamented the relative paucity of careful cost-benefit analyses of reducing lead exposure. Although cost-benefit analyses often have important limitations, such as neglect of equity issues and inability to quantify some costs, they have the virtue of making certain benefits explicit. In the past, industries required to limit emissions or to change processes have sometimes argued that such changes are financially prohibitive. These costs, however, can be greatly overstated–as noted by the removal of lead solder from Mexican cans described by Alfonso de León. In other instances, a requirement to limit emissions can lead to innovative technologies and increased efficiency, actually saving money. Several examples of this kind were cited at the conference. For the benefit side of the equation, a thorough analysis would consider the diseases and disability avoided by reducing exposure, with the potentially large associated savings to society. Such thorough analyses might well demonstrate that reducing lead exposure not only improves public health, but is also eminently affordable.

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LEAD IN THE AMERICAS: A call for action IDENTIFY CASES, PREVENT FURTHER EXPOSURES, AND PROVIDE CLINICAL CARE The major focus of the conference was on reducing lead exposure through primary prevention, and on detecting lead toxicity promptly to permit early intervention (secondary prevention). Reducing morbidity among victims of lead toxicity (tertiary prevention) was also addressed. The principal intervention in cases of lead toxicity is removal from exposure. Nevertheless, two other approaches currently not used in most countries of the Americas deserve attention: medical treatment of lead toxicity and rehabilitation. Medical treatment of lead toxicity rests primarily on chelation therapy, using calcium disodium edetate (EDTA), British antilewisite (BAL), penicillamine, succimer (DMSA), or a combination of these (Frumkin, in press). Chelation therapy is widely accepted in the treatment of lead encephalopathy, with extreme elevations of blood lead (in the range of 80–100 µg/dl or higher), since it promotes rapid reduction in circulating lead and accelerated excretions of lead. The efficacy and safety of chelation in treating low to moderate elevations of blood lead, however, are not well established. Data from well-conducted clinical trials (one is under way in the United States) are badly needed. Another problem is that these medications are very costly, especially for poorer nations, and some require intensive medical oversight. To the extent that efficacy is established, mechanisms to make chelating agents available at affordable prices will need to be developed. Lead toxicity can have irreversible effects on the nervous system. Little information is available on the optimal management of affected persons, or on the efficacy of rehabilitation treatment. However, as more lead-exposed individuals reach older ages, where the effects of aging and cumulative lead toxicity combine to cause cognitive and affective dysfunction, this issue will take on increasing importance. Again, further research will be necessary to clarify any effective clinical approach. EVALUATE THE RESULTS The countries of the Americas all face competing demands for social investment and for the attention of public health workers. Accordingly, it is essential to evaluate the results of interventions that aim to reduce lead exposure. Careful outcome studies, from individual workplaces to countrywide studies, should be initiated when interventions are launched. In this volume, for example, Dr. Robert Scala has described the association

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LEAD IN THE AMERICAS: A call for action between removing lead from gasoline in the United States and declining blood lead levels in the population, based on the work of Pirkle and colleagues (Pirkle et al., 1994). Data from such studies will help to assess both the efficacy and cost-efficiency of specific interventions, guide future strategies, and provide a valuable resource for public health planners throughout the region and the world. FOLLOW-UP Even the best-designed public health prevention and control programs will yield little benefit if their implementation and maintenance are given insufficient care and attention. Acknowledging this point, conference participants concurred strongly on the need for continued, active follow-up of programs deriving from the Action Plan described in this summary. Followup should include identification of broadly accepted milestones amenable to ongoing evaluation, as well as mechanisms to ensure program sustainability. Milestones amenable to evaluation can include, for example, targeted reductions in blood lead levels in the general population or in populations at special risk, such as the occupationally exposed. The successful achievement of these and other milestones will depend on the acceptance and implementation of the components of the Action Plan described above. Sustainable solutions can only be guaranteed when there is effective communication and coordination of activities to reduce lead exposures, both within and across local, country, and regional levels. At the country level, effective linkages should include responsible parties in government, national and local NGOs, and community coalitions. Because the responsibilities for health actions in the Americas—as elsewhere in the world—are being progressively transferred from central to local governments, and ultimately to the individual, public education and other mechanisms that promote long-term changes in the health actions of communities and the health behaviors of individuals are becoming an increasingiy important basis for sustainability. At the regional level, linkages between bilateral and multilateral organizations such as the Pan American Health Organization (PAHO), the U.S. Agency for International Development (USAID), the Inter-American Development Bank, and the World Bank and country and local governments can be particularly productive. Examples of such linkages include PAHO's Regional Plan for Investment in Health and the Environment, which seeks to engage countries and donors in a common agenda for improvement, and

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LEAD IN THE AMERICAS: A call for action USAID's Regional Housing and Urban Development Office (RHUDO) for Latin America, which sponsors initiatives to improve urban health. Both programs produce data that can be used to better characterize the dimension of the lead hazard in the Americas and promote interventions to address specific problems. These kinds of programs should be encouraged in advancing a regional agenda for lead poisoning prevention and control. In summary, the conference participants came to two general conclusions. The first conclusion was definite and specific: lead exposure, in its various forms, should be reduced or eliminated throughout the countries of the Americas. The second conclusion was flexible and general: the preferred approaches to preventing lead poisoning will vary from country to country, depending on the kinds of exposure that exist and the social, political, and economic circumstances of the local environment. The Action Plan described in this summary provides generic guidelines for national efforts to prevent lead poisoning that allow for adaptation in each country. Finally, the conference participants emphasized the importance of collaboration among constituencies such as industry, labor, environmentalists, communities, and government, as well as among countries facing comparable challenges. Note: The Committee to Reduce Lead in the Americas is indebted to one of its members, Dr. Howard Frumkin, for having provided the substantive first draft of this chapter based on his plenary summation in Cuernavaca.

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