TOOLKIT LIBRARY

As part of ISCHE’s commitment to bridging the gap between science and policy, we are pleased to share the first in what we hope will become an essential reading list of documents that have shaped children’s environmental health. We call this the ISCHE Toolkit Library. The annotations in these documents will reflect conversations between senior and early-stage colleagues about the document’s historical context, strengths, and other teachable moments for CEH professionals across all career stages. The ISCHE toolkit library is an evolving project that intends to bring ISCHE members together in informal discussions of research translation, promote mentorship, and cultivate dynamic reading of milestone scientific policy documents in CEH. This first installment of the ISCHE toolkit library focuses on the landmark. Appendix of the 2005 CDC Statement on Preventing Lead Poisoning in Young Children [1].


Those of us who do research in Children’s Environmental Health (CEH) believe that our work will make a difference in children’s lives. This was certainly true of Herb Needleman, a pediatrician and psychiatrist who did the first persuasive study of cognitive effects from lead exposures so low that they did not produce symptoms. However, ISCHE past-president and club co-founder David Bellinger tells a story about Herb, who was David’s post-doctoral mentor. Herb’s 1979 paper reported that school children with no evidence of lead poisoning but relatively high levels of lead in their teeth had lower scores on IQ and other neuro-cognitive tests. The day after it appeared, in the influential New England Journal of Medicine [2], Herb said “I’m so disappointed. I thought the world would change.” Research may be an important first step, but advocacy, policy, regulation, and other, often many other, steps have to be taken before the science prevents harm to children.

Setting the Context

This 2005 CDC statement documents the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP, pronounced A-Clip) accepting the report of their Work Group on the effects of lead at low exposures on children. In 2005, lead was the most-studied pediatric environmental toxicant, and arguably still is. While many studies showed that children with higher blood leads had lower IQ, there remained controversy about whether these studies showed that lead, and not some other factor, caused the lower IQ. What level of evidence should be required to eliminate such a well-studied exposure? The answer must not only be good enough scientifically, but also must meet the needs of policy makers. The ACCLPP Work Group responded to this challenge with something close to a formal review article, but designed to answer a specific question – does the research support a causal relationship between lead exposure and deficits in IQ when blood lead has not exceeded 10 ug/dl? If so, how can the arguments of those who do not accept that causal relationship be refuted?

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Food for Thought

During our conversations about this document, we visited and re-visited the role of scientific research in policy and regulation. That discussion yielded new information for both of us, but also lots of questions about where we go from here. In addition, when we had a few members  look at the material, they noticed things we missed.  Some of these questions might lead to other influential papers for the ISCHE toolkit, or to sessions at future meetings.


  1. Is lead exposure actually controlled today? Children’s blood lead levels have fallen substantially since the mid-1970s. The fall is due to banning leaded gasoline and eliminating lead from new residential paint. However, at the turn of the 21st century (around the time of this 2005 document), about 16% of children 6 years and under lived in housing with lead hazard, mainly from lead paint [3]. Why was lead poisoning from deteriorating paint in homes not eliminated? What actions could have been taken, or should be taken now? Much of the housing around in 2005 is gone now, but much of it remains.

  2. 2. Widespread lead exposure in Flint MI in 2014 [4] and Newark via water distribution systems with old lead pipes have more recently demonstrated that lead continues to be an environmental justice issue. What role does science play now, as decisions are made about replacing lead pipe? Are current surveillance systems adequate to detect ongoing lead exposures? If not, should they be?


    3. What does lead policy in the US tell us about lead policy in other countries? When Dorota Jarosinska, now at WHO Euro, was a Fulbright fellow with Walter, they compared Polish and US lead policy, and found little overlap [5]. WHO has an Initiative in Children's Environmental Health, once directed by ISCHE member Ruth Etzel. It provides materials, convenes workshops, etc. But much more could be done to collaborate and build capacity for lead policy internationally.


    4. Some have recommended precaution in the face of uncertainty: “Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation.”[6] This approach is more popular in Europe than in the US. Would precaution have been a better strategy?

References

  1. Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children. Atlanta: CDC; 2005. https://www.cdc.gov/nceh/lead/publications/prevleadpoisoning_508.pdf
  2. Needleman HL et al Deficits in Psychologic and Classroom Performance of Children with Elevated Dentine Lead Levels N Engl J Med 1979; 300:689-695
    DOI: 10.1056/NEJM197903293001301
  3. Rio Declaration on Environment and Development, Principle 15, U.N. Doc. A/CONF. 151/26 (Aug. 12, 1992)
  4. Jacobs DE, Clickner RP, Zhou JY, Viet SM, Marker DA, Rogers JW, Zeldin DC, Broene P, and Friedman W. The prevalence of lead-based paint hazards in U.S. housing.Environmental Health Perspectives 2002110:10 CID: https://doi.org/10.1289/ehp.021100599
  5. Ruckart PZ, Ettinger AS, Hanna-Attisha M. The Flint Water Crisis: A Coordinated Public Health Emergency Response and Recovery Initiative. J Public Health Management Practice 2019: 25; S84-S90
  6. Jarosinska D, Rogan WJ. Preventing lead poisoning in children: can the US experience inform other countries? The case of Poland. Cent Eur J Public Health. 2003;11(4):192-197)

Prepared by Drs. Walter Rogan (Senior Investigator for Epidemiology Branch, NIEHS, retired) and Jennifer Ames (Postdoctoral Research Fellow at the Division of Research, Kaiser Permanente Northern California)

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