protecting the fetus and the child
from environmental hazards

a healthy environment
for all children

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Advocacy for Pediatric Environmental Health

Carol Stroebel, Isabella Clemente, RN, MSN, CPNP, Barbara Sattler, RN, DrPH, Ben Gitterman, MD

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advocate\advckt, n, 1: one who pleads another's cause 2: one who argues or pleads for a cause or proposal ó advocacy \ ad-vc-kc-s'

This module outlines the importance of advocacy efforts by practitioners in the field of pediatric environmental health and describes key steps to becoming an effective advocate. The material will equip faculty to train students to identify appropriate areas for advocacy, plan and execute advocacy efforts, and identify resources to support those efforts.

Learning Objectives

Note to Instructor: This module includes suggested assignments designed to teach students key steps in the process of advocating for an issue. A case study included at the end of the module outlines steps health care professionals can take in advocating to decrease childhood lead poisoning.

After completing this module, faculty will be equipped to teach students and residents to:

• Define and provide examples of advocacy
• Understand the power and responsibility that health providers have to influence beliefs, behaviors and policy
• Identify the seven critical steps to effective advocacy

The Voice Of The Health Care Provider

"Politics is a crucial part of pediatrics. How else are we going to get better schools, health care for our children, and housing for their families, if not by political activity?"
ó Dr. Benjamin Spock

Health care providers often advocate for change ó for example: by attending a hospital meeting to propose expansion of a busy clinic, or encouraging their patients to stop smoking. One-on-one advocacy skills are valuable when communicating with patients and their families.

Sometimes, however, making change one person at a time is not sufficient because many aspects of public health are not controlled by the individual patient or consumer.

In these instances, improvements in health conditions can only be achieved through changing the policies and institutions affecting a community and its members.

For example, when children's health is at risk from a toxicant in their community, one response could be to educate caregivers on minimizing their children's exposure to the toxicant. An alternate response might be to seek changes that would reduce or ban the presence of the toxicant in the community. Restating this example in terms of a public health model: removing the source of exposure would be a mode of primary prevention, while minimizing a child's exposure would be a method of secondary prevention.

In today's world, all health care professionals have the responsibility to advocate for policies that improve health and prevent health problems. Doctors and nurses are often welcome members of advocacy campaigns because their expertise and professional judgement gives them unparalleled credibility regarding health issues in the community. They are often sought for interviews and cited by the media when a health issue arises.

It is important to understand the power of this credibility and use it wisely. Silence from the medical or nursing community also makes a statement.

Suggested Assignment: Question for Students: 1. Identify examples of some of the unique expertise that the health care profession brings to the environmental health arena. Examples of health care professionals' unique expertise: Some general examples include scientific training, high credibility, and perspectives on health, prevention, long-term impacts of environmental exposures, and non-monetary impacts. The progress that has been made in decreasing human exposure to lead, thus lowering the average blood lead levels of children, was made in large part by research findings followed by the advocacy efforts of health professionals. Researchers, health care providers and public health experts communicated their knowledge of the hazards of lead exposure to the public and to policy makers, resulting in stronger public health protections.

Environmental Advocacy

Environmental advocacy fits perfectly in the health practitioner's job description.

Nurses and physicians are trained not only to treat illness, but to prevent it. Therefore, it should be as natural to ensure that a child's environment is free of potentially Advocacy for Pediatric Environmental Health harmful contaminants as it is to confirm that your young patients are immunized against infectious diseases.

We can advocate for an improved environment for children's health in many ways, working as individuals or in groups. Environmental advocacy can be as simple as writing a letter to the local school board, or as complex as lobbying for national legislative change. Understanding which approach to use will help you to be more effective in serving your patients and community.

Individual Advocacy Efforts

Simple acts of advocacy can be integrated into individual practices and medical or nursing school training.

• Students and residents may work at local health fairs. This provides a good opportunity to present information on environmental health issues, such as lead poisoning or sun protection.
• Students at some universities have taken this process a step further, and learned to use the local cable access equipment to produce public service announcements (PSAs) on environmental health issues.
• Community newsletters and newspapers are often receptive to articles authored by local health care providers. Hospitals and clinics also have newsletters or other regular mailings in which students or clinicians can add short messages.
• Some hospitals and universities sponsor health messages on local radio and TV spots; we can make sure that these include information on environmental health.
• Waiting rooms provide a great opportunity to educate patients and their families.
• Clinicians, in their presentations to parent groups, can also include a discussion of children's environmental health.

Group Advocacy Efforts

Although much can be accomplished as an individual, sometimes an issue is best addressed by collective efforts.

• An effective first step in approaching a community-wide concern can be to create an environmental health committee. For example, a school district's environmental health committee can review the use of pesticides in schools, asthma-related and air quality concerns, and building renovation issues. Committee members can reflect a wide range of interest and expertise by including school nurses, community health professionals, school employees, parents, and other community representatives.
• The passage of local, state, or federal legislation and the shifting of policies is best accomplished through organized group action. Rarely will one person, working alone, make the progress that a variety of individuals and organizations, working together, can make. For example, a health care professional may be concerned about the presence of a toxicant in a state's drinking water. Joining forces with state medical and nursing organizations, environmental groups, and other concerned citizens is likely to be the best way to generate governmental action.

Suggested Assignment: Questions for Students: Identify examples of other individual or group advocacy efforts in which health care professionals can participate. Brainstorm examples of advocacy in a wide range of issues (international health, managed care, reproductive health, etc.) How can these individual and group advocacy strategies from other fields can be adapted for efforts to protect children from environmental health hazards?

Seven Steps To Effective Advocacy

What most people commonly think of as advocacy ó actions such as testifying before a committee or holding a news conference ó are components of what is usually a multi-stage process. Environmental policies are made in many arenas, and in most of these, the health care professional's voice must be heard.

To be effective, advocates need to take the time to study what and who they hope to change, and to understand the processes by which change occurs.

The following sections outline the key steps to effective advocacy, framed in terms of the following questions:

1. What is my goal?
2. What scientific information do I need?
3. What other groups or individuals are involved in this policy issue?
4. Who are the relevant decision-makers?
5. Who are my potential partners?
6. How do I develop and implement a strategy?
7. How do I evaluate my effectiveness and plan future efforts?

A. What is My Goal?

Though goal-setting may seem obvious, identifying the desired ultimate outcome is a necessary and basic step. Advocates should begin by honing and understanding a goal. Goals may be short-term, medium range, and long-term. They may be educational, primary or secondary prevention, or a treatment modality.

They may be vague (to make our community safer for children) or specific (to screen all area children who are at risk of lead poisoning or to halt House Bill 1234, which will weaken our state's environmental regulations). Progressing through the following steps, you will learn more about your goal and its possible refinements and ramifications.

Addressing health impacts from environmental exposures often means addressing existing governmental regulations and policies. Basic civics (and psychological and economic) concepts are helpful in understanding how our policy-makers work ó both elected officials and those staffing our agencies. It is important to understand the mechanisms by which policies are made, changed and enforced.

Suggested Assignment for "What Is My Goal": Question for Students: 1. Consider the needs of your community or practice population. Select one general and one specific advocacy goal for your community or practice. These goals will be used for future assignments in this module. Sample Responses: Examples of general and specific goals can be found in the case study at the end of this module, and in the following table:
General goal:	Specific goal:
Decrease childhood lead poisoning in community	Test blood lead levels of all children
Stem increase in asthma among youth	Asthma education program for parents
Decrease pesticide exposure in schools	Parental notification in advance of pesticide use in schools
Decrease childhood lead poisoning in community	Lead paint mitigation in low income neighborhoods
Decrease pesticide exposure in schools	Schools adopt integrated pest management
Decrease presence of pesticide X in tap water	State requires water systems to report on levels of pesticide X in water
Decrease exposure to pesticide X in tap water	EPA halts/severely limits use of pesticide X

B. What Scientific Information Do I Need?

Sound information is the foundation of successful arguments for change. Health care professionals have a critical responsibility to assure that the information they present is accurate. A key element to participating in an advocacy campaign is doing the homework.

• Seek out supporting information from credible sources. Become familiar with the material. Be able to communicate the information effectively.
• Brief summaries of key scientific studies, written in lay terms and explaining the connection to the issue of concern, are usually more effective than providing the studies themselves.
• Summaries should focus on what is known about health impacts and the scope of the problem. They should not use medical terms not commonly used by the public. Where appropriate, such material should include information specific to the jurisdiction of a community- or state-based effort.

Suggested Assignment, "What Scientific Information Do I Need?": Questions for Students: 1. Identify sources of scientific information relevant to your specific goals. 2. Summarize this information in a manner that would be effective in educating and persuading a non-scientist about your position. An excellent example of identifying and summarizing scientific information, developed by the Alliance to End Childhood Lead Poisoning, is included in the case study at the end of the module. Another example of the importance of using appropriate, clearly summarized scientific information can be found in a recent debate within the Clinton Administration on a controversial air quality standard. In the midst of discussions, a study looking at infant mortality and particulate air pollution (PM10) was released. The national health organizations that alerted the Administration to the importance of the study could have quoted from its abstract: "Overall postneo-natal mortality rates were 3.1 among infants with low PM10 exposures, 3.5 among infants with medium PM10 exposures, and 3.7 among highly exposed infants." The groups found it more convincing to summarize the findings in terms that non-scientists would understand ó "the study suggests that particulate air pollution has a significant adverse impact on infants older than one month" and related the study to the existing "wide variety of valid studies which underscore the connection between air pollutants and harm to children's health."

C. What other groups or individuals are involved in this policy issue?

In addition to knowing the scientific evidence that supports a position, the advocate should also investigate the policy landscape, specificially the current relevant debates and the actors in environmental health policy related to your issue.

It is important for the advocate to become familiar with non-governmental organizations that provide outreach and education and/or advocate about the environment and environmental health issues. Examples of such organizations include:

• National environmental organizations, including the Environmental Defense Fund, the Sierra Club, and the Natural Resources Defense Council
• Professional associations such as the American Public Health Association and the American Academy of Pediatrics have an active environmental health section or committee. Both the American Medical Association and the American Nurses Association have begun addressing environmental health issues.
• Educational organizations such as the North American Environmental Education Association
• Targeted organizations such as the American Lung Association and the National Asthma and Allergy Foundation also have a substantial environmental component to their work.
• Most national organizations have state and local chapters, like the state affiliates of the American Public Health Association, state medical societies and state nurses' associations, as well as state and local chapters of such organizations as the Sierra Club. The state- and local-level organizations typically adopt (and/or shape) the national policies, but may also work on issues that are state-or area- specific.
• Many community-based organizations are active in environmental issues. Some of these groups are rooted in communities of color which may be facing special environmental health issues. In addition, grassroots groups emerge in response to specific environmental threats, and can be vital resources in connecting to community concerns.

The Resource Guide on Children's Environmental Health, published by the Children's Environmental Health Network, provides information about these and other governmental and non-governmental organizations and agencies active in advocating for children's environmental health. The Guide can be accessed at http://www.cehn.org.

Suggested Assignment, "What other groups or individuals are involved in this policy issue?": Questions for Students: 1. Using the Resource Guide on Children's Environmental Health, identify governmental and non-governmental organizations you might contact regarding the general and specific advocacy goals you have selected. 2. Develop questions you might ask these organizations about their involvement and position on the issue you have selected. Additional examples of organizations involved in lead poisoning prevention are provided in the case study at the end of the module, along with sample questions to ask these organizations.

D. Who are the relevant decision-makers?

Identifying the relevant decision-makers and their decision-making processes is a critical step in creating/designing an effective and efficient advocacy effort. Many forces may facilitate the changes you seek to accomplish - individuals, community members, organizations, policy makers/regulators ñ it is essential to identify all relevant parties and focus your efforts accordingly.

The advocate should investigate what has been done in other communities, state legislatures, public health offices, etc. Seeking lessons from what has worked and what hasn't can save much time and effort.

Government Institutions

The prime regulatory federal agency responsible for protecting our environmental quality is the U.S. Environmental Protection Agency (EPA). In the last several years, the EPA has been slowly shifting its focus to more health-related issues and community outreach and education. In addition to the EPA, federal agencies that address environmental health concerns include the following:

• The National Center for Environmental Health, housed in the Centers for Disease Control, focuses on understanding environmental health trends, surveillance, and prevention interventions.
• The Agency for Toxic Substances and Disease Registry addresses environmental health issues around hazardous waste sites, specifically Superfund sites.
• The U.S. Department of Housing and Urban Development has increased staff in its environmental office and has established a substantial lead paint program to address the environmental threat of lead poisoning.
• The U.S. Department of Agriculture has authority over farming practices and shares pesticide regulatory issues with the EPA.
• The U.S. Department of Energy and the Department of Defense have several major environmental health initiatives associated with contaminated sites.

Many federal agencies have equivalent organizations at the state, city, and county level. For instance, each state has a designated agency responsible for addressing federal environmental regulations. States may also pass their own, more stringent environmental regulations.

Regardless of the level or branch of government, processes are usually formally established, are frequently open, are often influenced by public opinion (including media, petitions, etc.), and should offer opportunities for public comment. Individuals are usually provided with recourse to reverse or modify a legislative, regulatory, or judicial decision.

Private Entities

Private entities ó a local business, a medical center, the corporation operating a facility in your community ñ may not have strict legal requirements to listen to individuals or community entities. They are not required to make decisions or share information as openly as governmental entities. Some public information resources may exist such as corporate annual reports or government-mandated reports on toxic emissions from a facility. Though it may take more effort to uncover this information than in the public sector, understanding the organization's structure and key decision-makers is an important first step to effective advocacy.

Though private entities may not be legally required to open their decision-making process to the public, most perceive a responsibility to maintain good public relations in the communities in which they operate, and respond to pressures that can range from gentle reminders of their civic responsibilities to boycotts and protests. As taxpayers, the people in a community affected by an entity's decisions have the right to publicly raise concerns about tax burdens these entities create.

Changing the actions of a private institution requires a well-conceived strategic plan with incremental steps for increasing pressure. For example, the plan might include an initial request to meet with an institution's decision-makers, followed by a community forum to which representatives of the institution are invited.

Then, if the institution does not modify its position, a broader community campaign that includes media attention might be initiated.

Community Organizations

Most community organizations are non-profit, low-budget groups with full agendas, few or no staff, few resources, and great reliance on volunteers. They also often have great potential to influence policy-makers as well as members of the neighborhood or community.

It is helpful to get an idea of the mission and structure of such groups. Do they have a board? Who is on it? Is their membership open? What is the role of their staff? Do they provide services? Do they advocate or lobby? Do they have a specific geographic focus (i.e., are they interested only in local issues, or also state and federal issues)?

Suggested Assignment, "Who are the relevant decision-makers?": Questions for Students: 1. Identify relevant decision-making parties with jurisdiction over your selected advocacy goal. Include all governmental, non-governmental, and community parties. Report on how you identified these decision-makers. 2. Outline the decision-making process used by these parties. 3. Report on the decision-makers' most recent actions and anticipated next steps on the topic. Additional examples of lead-poisoning decision makers and decision processes are included in the case study at the end of the module.

E. Who are my potential partners?

In many advocacy efforts, building a broad-based coalition is the single most effective step that you can take. Allies can be found among elected officials, other professional organizations, groups with an interest in children (such as Parent Teacher Associations and scouting groups), groups of concerned and vocal parents (those in the community and those outside of the community who may have children with a common health problem), business leaders, churches, unions, and many others.

In seeking to educate the residents of a community, it is helpful to work with others who have a stake in the community. Strategies include: asking the local grocer to print your message on their shopping bags, working with the local newspaper and cable access channels; and asking local faith-based organizations to include appropriate material in their bulletins.

Identifying individuals and groups that may join in advocacy efforts involves hard work, creativity, and persuasion. Obviously, the most likely allies are those who would benefit if the advocacy goal is successful. However, thorough background investigations of decision-makers and other groups involved in the issue (steps C&D) may uncover a variety of partners who have expertise and shared concern about this topic. One coalition of health professionals promoting a helmet law found a persuasive and unlikely ally in a local funeral director, who spoke movingly about the young people he'd buried "just because they didn't use a helmet." When working with partners, it is important to remember that advocates are judged by the company they keep. Before signing onto a coalition letter, advocates should assess and confirm their comfort level with the sponsoring organization's reputation, credibility, and the statements made in the letter.

Suggested Assignment, "Who are my potential partners?" Questions for Students: 1. Identify potential allies for the specific advocacy goals you have selected. Additional examples of lead-poisoning potential partners are included in the case study at the end of the module.

F. How do I develop and implement a strategy?

After defining a goal, becoming familiar with the policy landscape and the people and process leading to change, the next step is to design a strategy that utilizes resources, partners, and tools that are most suitable to the goal. Examples of resources and tools include:

Informational materials

• relevant research findings
• anecdotes and personal experiences
• examples from other communities, states, and/or nations

Endorsements

• from organizations
• from individuals, including petitions
• in the form of coalition letters, coalition advertisements, etc.

Media efforts (including community and ethnic newspapers)

• Letters to the editor
• Op-ed columns
• News stories
• Editorials resulting from visits with editorial writers
• Public Service Announcements
• Appearances on TV, radio, news, and public affairs shows
• News conferences
• News releases

Direct contact with those whose knowledge, attitudes, and behavior you seek to change

• Materials in waiting rooms
• Participation in health fairs
• Articles in patient newsletters
• Speeches to parents and other community groups
• Rallies and other events to increase public awareness
• Letters and phone calls
• Office visits with an official or staff
• Asking questions at a town meeting
• Attending a hearing
• Testifying at a hearing

Again, the critical challenge will be to determine which tools will be most effective in the effort at hand.

Successful strategies account for opponents as well as allies. Advocacy strategies should take into account the answers to the following questions:

• "Who will oppose you, and why?"
• "Who benefits from the status quo?"
• "What are the possible barriers to success?"

Timing and proactivity are key. It is important to know how to use the right resources when they can be most effective. For example, calling committee members to express dissatisfaction after a vote is usually not as effective as contacting them with opinions before the vote. Meeting with local editorial writers about a regulation that was just finalized will not impact the regulation; it is better to meet with them before or during the rule's development.

The public arena of policy debate can change rapidly and unpredictably, so strategies must be flexible. For example, a favorable editorial in a large newspaper may convert a moribund issue into a hot topic. A completely unrelated issue may subsequently emerge, however, and capture the priority attention of the relevant county board committee.

Lastly, not every act of advocacy involves a full-blown effort. Individuals who write a single letter to the editor, who bring their professional knowledge to an advisory panel, or who are active in their professional associations, also serve a vital advocacy role. It is extremely important to encourage students to play such roles in their professional lives.

One outline for a successful strategy might include the following components:
Goal: Convince caregivers to have their children tested for lead poisoning
Audience: Parents and other caregivers of young children
Message: "Test your child. It's easy, it's free, it's important"
Messenger: Materials in waiting rooms, HMO newsletters, direct contact with health care providers, mailings to day care centers, door-to-door distribution of information in targeted neighborhoods
Temporal Context: On-going educational program targeted at specific subpopulation of the general public

Suggested Assignment, "How do I develop and implement a strategy?": Question for Students: 1. Building on the information you have gathered in earlier sections, outline a suggested strategy for your advocacy goals. You may want to use the frame-work outlined above and provide the goal, audience, message, messenger, and temporal context. Additional examples of lead-poisoning strategies are included in the case study at the end of the module.

G. How do I evaluate my effectiveness and plan future efforts?

Follow-up activities to a successful campaign include:

• Thanking partners and allies, especially those policy-makers in leadership roles;
• Following up on the implementation of an ordinance, policy, or law;
• Assuring that the victory isn't reversed in the future; and
• Exploring whether the momentum and foundation of the campaign coalition should be maintained and applied to another issue.

Follow-up activities to an unsuccessful campaign include:

• Again, thanking partners and allies, especially those policy-makers in leadership roles;
• Identifying how the effort could have been improved;
• Rethinking arguments, allies, timing and targets; and
• Deciding if and how to make another attempt.

Change is often slow and incremental. Rarely do major policy advances happen quickly. Compromises are the nature of our political process. Legislatures adjourn only to reconvene.

In brief, advocacy efforts take time to bear fruit and may produce less-than-ideal improvements. In our system, however, advocacy may be the only means to achieve these needed changes. It is important to remember that changing a behavior or a policy contributes to changing how people think about our environment and its effect on our children's health and future.

Advocates must not be discouraged by the fact that knowledge and science do not immediately win the day. It is helpful to bear in mind the eventual successes of other campaigns. In 1925 a U.S. Public Health conference urged the suspension of the sale of leaded gasoline until the dangers of leaded gasoline were determined. It was not until 1979 that leaded gasoline was prohibited. However, the 1979 step would not have occurred without the involvement of public health advocates.

Fortunately, since the elimination of leaded gasoline, the blood lead levels of U.S. children have declined substantially.

Suggested Assignment, "How do I evaluate my effectiveness and plan future efforts?": Question for Students: 1. Imagine that your advocacy goals have been met. Outline the steps that you will take to follow up on your successful campaign. 2. Imagine that your advocacy goals have not been met. Outline the steps that you will take to follow up on your (perhaps temporarily) unsuccessful campaign.

Learning Methods

The learning tasks presented in this module can be assigned individually, assigned for small group discussion, or presented in class to trigger general discussion.

Evaluation Methods

Students should be encouraged to identify opportunities for advocacy and to undertake at least one advocacy effort (individually or jointly) during their training. At the end of the program, faculty may hold a seminar to allow students to share their experience with their colleagues, learning from and evaluating each other's efforts.

References

Lozano P, Biggs V, Sibley B, et al. Advocacy training during pediatric residency. Pediatrics 94,4:532-536 (1994).

Nelms B. Child advocacy: the need is great. Jrnl of Ped Health Care 3,1:1-2 (1989).

O'Brien S, Parker S, Greenberg J, Zuckerman B. Putting children first: the pediatrician as advocate. Contemp Ped 103-118 (1997).

American Academy of Pediatrics. Government Affairs Handbook. Washington DC: AAP 1998.

Johnson C. How Our Laws Are Made. Washington DC: U.S. Government Printing Office, 1998.

Legislative Advocacy Handbook: A Guide To Influencing Legislators and Policymakers. Albany NY, 1992.

Landrigan P, Carlson J. Environmental Policy and Children's Health. The Future of Children 5,2:34-53 (1995).

Case Study: Lead Poisoning In Centerville

This case study illustrates a hypothetical advocacy effort in the town of Centerville, state of Columbia, USA. The case study addresses the seven steps to effective advocacy, outlined in detail earlier in the module:

• What is my goal?
• What scientific information do I need?
• What other groups or individuals are involved in this policy issue?
• Who are the relevant decision-makers?
• Who are my potential partners?
• How do I develop and implement a strategy?

  A: What is my Goal?

  Centerville advocates determine that their general goal will be to decrease childhood lead poisoning. With lead, as with other environmental toxicants, specific advocacy activities can take two main approaches:

  • primary prevention strategies to remove the hazard from the environment (such as eliminating lead from gasoline), and
  • secondary prevention strategies to mitigate the effects of the hazard (such as dealing with existing lead-based paint in residences or screening children to identify and treat lead-poisoned children).

  For the goal of decreasing childhood lead poisoning, specific goals may take primary and/or secondary prevention approaches. Examples include:

  • Local:
    Testing of children
    Residential mitigation requirements for lead-based paint in housing
    Soil mitigation

  • State:
    Testing of children
    Prohibiting use of leaded paint in schools
    Licensing lead abatement contractors, risk assessors and inspectors

  • Federal:
    Prohibiting lead in paint
    Prohibiting lead in gasoline
    Prohibiting lead in children's toys
    Prohibiting lead in consumer products (such as mini-blinds)
    Requirements for disclosing leaded paint in residences upon sale
    Requiring reporting of lead emissions from industrial facilities and mines

  • International:
    Prohibiting lead in gasoline
    Prohibiting lead in paint

  Centerville advocates decided that their specific goal would be to "test blood lead levels of all children under age 6" (a secondary prevention effort).

  B. What scientific information do I need?

  Sources of scientific information about lead include the Centers for Disease Control and Prevention's National Center for Environmental Health, the National Institute of Environmental Health Sciences, the National Lead Information Center Clearinghouse, National Lead Information Center Hotline, the Hispanic Health and Nutrition Examination Survey, and many others.

  The Centerville and Columbia public health departments should be contacted to find out how many children in the community have been found to have elevated blood lead levels and the percentage of children under age 6 who have been screened.

  The following text, developed by the Alliance to End Childhood Lead Poisoning, is an example of an effective educational summary of scientific information. What is Lead Poisoning? Lead is a heavy metal used in many materials and products. When absorbed into the body, it is highly toxic to many organs and systems. Even very limited exposures to lead are hazardous to children. Lead is a natural element and does not break down in the environment. Once lead has been dispersed and redeposited in the environment, it will remain to poison generations of children unless it is controlled or removed. The Problem of Childhood Lead Poisoning Over the past 20 years, childhood lead poisoning has declined dramatically in the United States due to limits on lead in gasoline, paint, food cans, and other consumer products. However, lead poisoning is still an important health problem, affecting an estimated 890,000 preschoolers. While lead poisoning crosses all socioeconomic, geographic, and racial boundaries, the burden of this disease falls disproportionately on low-income families and families of color. In the United States, children from poor families are eight times more likely to be poisoned than those from higher income families. African-American children are five times more likely to be poisoned than white children. Nationwide, about 22% of African-American children living in older housing are lead poisoned ó a staggering statistic. In some communities, the poisoning rate is much higher.

  C. What other groups or individuals are involved in this policy issue?

  Some of the national organizations involved in childhood lead poisoning issues are the Alliance to End Childhood Lead Poisoning, the American Academy of Pediatrics, the National Safety Council, and the National Center for Lead-Safe Housing. Most states and many communities have agencies and non-profit organizations dedicated to fighting lead poisoning; in our hypothetical example of Centerville, they include a state agency, the Columbia Bureau for Public Health, and a non-profit organization, Lead-Free Centerville.

  Sample questions to consider for the organizations serving the mythical city of Centerville:

  • What are the primary and secondary lead poisoning prevention programs in our area?
  • Does your organization place an emphasis on prevention, screening, or treatment?
  • What are the resources available for screening?
  • How many children under the age of 6 have been screened?
  • What are your organization's current priorities and activities?
  • What efforts have you undertaken in the past and how well have they worked?

  D. Who are the relevant decision-makers?

  At the national level, the U.S. Department of Housing and Urban Development (HUD) provides the most resources to communities and states for lead poisoning prevention programs. HUD also allocates funds to support lead abatement in residences. The Maternal and Child Health Bureau of the U.S. Department of Health and Human Services administers block grant funds to the states and funds research and community grants relevant to environmental health issues. The National Center for Environmental Health of the Centers for Disease Control monitors blood lead levels of the nation's population. All of these agencies are subject to Congressional oversight and rely on Congress for funds.

  In many states, the public health department is the key player in identifying and treating children with elevated blood lead levels. State programs are subject to legislation passed by state legislators and signed by the governor. In Columbia, the "Columbia Bureau for Public Health" is under the jurisdiction of the State Assembly's Committee on Public Health and Safety and the State Senate's Committee on Corrections and Health and Human Services. Two members of the Assembly committee represent Centerville districts.

  The city or county health department usually implements lead programs in local communities, at the direction of the county board of supervisors, city council, or other governing or advisory bodies. Low-income housing programs are often administered by government-controlled agencies or non-profit, community-run housing authorities. In our example, a non-profit organization, Lead-Free Centerville, receives some city funds and is run by an executive director supervised by a board of directors.

  E. Who are my potential partners?

  For a lead-screening program in our hypothetical example of Centerville, potential allies include Lead-Free Centerville, parents groups, other health professionals, teachers and learning disabilities specialists, employers, the Centerville Community Hospital and Assembly members on the relevant committee.

  Potential opponents may include owners of rental properties and others concerned about the cost of lead paint abatement in homes, or decreases in housing values. The Centerville Housing Authority, which administers low income housing programs, was identified as a particularly important factor. The Authority's support is difficult to predict. It may support a lead-screening program, or may oppose a program because of concern about its legal responsibility to mitigate lead paint in its units. More research will need to be done.

  F. How do I develop and implement a strategy?

  Depending upon the status of the situation in our example of Centerville, a range of strategies could be appropriate. For example:

  Goal: Provide funding for testing Centerville children under age 6 for lead poisoning
  Message: Budget and approve funds for testing our children
  Messenger: Letters from and visits by Centerville constituents and institutions; editorial column by head of local learning disabilities association
  Audience: State legislators (especially those on relevant committees, especially those representing Centerville), governor
  Context: In advance of the annual budgeting and appropriations process

  OR

  Goal: With adequate funding available, inform and engage health care providers in testing program
  Message: Children under 6 should be tested ó and can be tested free of charge through the SafeCenterville program of Lead-Free Centerville. Urge parents to take advantage of this test.
  Messenger: Newsletters of Centerville chapters of health professional associations, Centerville Hospital employee newsletter and employee bulletin boards, paycheck inserts for hospital and HMO employees, grand rounds
  Audience: Health care providers; emphasis on pediatric and family practice providers
  Context: On-going peer-to-peer educational process for the program's duration

  OR

  Goal: Convince care-givers to have their children tested for lead poisoning
  Message: Test your child. It's easy, it's free, it's important
  Messenger: Materials in waiting rooms, HMO newsletters, direct contact with health care providers, mailings to day care centers, door-to-door distribution of information in targeted neighborhoods Audience: Parents and other caregivers of young children
  Context: Educational program targeted at specific subpopulation of the general public