PoPulationand Public HealtH etHics

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wHose role is it to Deal witH societal DeterMinants oF HealtH? The case of the Nigerian lead-poisoning epidemic John D. Pringle, Ph.D. (c) Dalla Lana School of Public Health & Joint Centre for Bioethics, University of Toronto, Toronto ON joHn.PRIngle@utoRonto.Ca Introduction In February 2010, dozens of infants and children in a remote rural village in northern Nigeria arrived at the local health clinic with symptoms such as lethargy, fever, vomiting, weight loss, bulging fontanels, neck stiffness, partial paralysis and seizures. Despite treatment, many died. A team from an international non-governmental organization (Ingo) arrived to provide assistance. Around this time, the price of gold had surged as a result of the global financial crisis. Gold extraction activities had increased and rock grinding machines proliferated in and around household compounds. Although illegal, artisanal gold mining offered poor subsistence farmers a way to supplement their meagre incomes and alleviate their poverty. The Ingo diagnosed the epidemic among children as lead poisoning, based on high levels of lead in their blood. The ore their parents had been mining contained lead as well as gold, leading to a fine lead dust blanketing homes and village compounds. Young children were highly exposed as they 176 Donald C. Cole, Ph.D. Dalla Lana School of Public Health Divisions of Epidemiology and Global Health, University of Toronto, Toronto ON
inadvertently inhaled and ingested the dust. In a period of months, hundreds of children died; thousands more remain at risk for the chronic effects of lead poisoning. Who should respond, nationally and globally, to such crises? Case In recent years, the public health surveillance system in northern Nigeria has proven inadequate, with epidemics of measles, meningitis and cholera going undetected through official channels. Aware of this situation, the Ingo was conducting active measles and meningitis surveillance in the area when it heard of many children dying in a remote village. Once the Ingo arrived onsite, it was told by the local community health worker that he had informed his superiors of the mysterious outbreak, but simply received more of the same antimalarial drugs that were proving ineffective. A calculation of the death rate qualified the situation as a humanitarian emergency. The Ingo assembled a team to provide 24-hour medical care onsite and sought special government permission to send blood samples to a lab in Europe for analysis. It was these efforts that led to the diagnosis of a lead-poisoning epidemic. At the village clinic, the Ingo took over management. Then, as a first for the organization, it worked with two local field hospitals to establish a lead-poisoning treatment program, providing free chelation treatment for the worst affected: children five years of age and under and breast-feeding mothers. In both the first village and another that was similarly affected, the Ingo provided health education and organized transportation to hospital. Other international organizations arrived to conduct community health surveys and implement environmental remediation (cleaning and soil removal and replacement). To date, more than 400 children have died, amounting to more than 40 per cent of the children in one village alone, and there is an entire generation of young village residents at risk of death or serious short- and long-term irreversible health effects. It has been described as unprecedented and the worst such lead-poisoning outbreak in modern human history. Yet, despite the well-established role of lead contamination as the source of the epidemic, illicit artisanal mining continues. Ingos may inadvertently contribute to the continuation of this mining. By providing free environmental remediation (and in many cases, paying the Whose role is it to deal with societal determinants of health? 177
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PoPulationand Public HealtH etHics
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contents Acknowledgements - page 5
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acknowleDgeMents The Partners would
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» Create a tool to support instruc
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Each of the discussants took on thi
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Twenty years on, things have change
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intervention (say reduction in mort
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ethics understands dilemmas not onl
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priority setting. 17 Once more, usi
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6 See for example the WHO Commissio
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obesity surveillance in scHool cHil
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esearch 2 Inevitably children will
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esearch Case discussion in response
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It would be ideal to get active inf
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esearch participation, leading to a
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to sHare or not to sHare? Secondary
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esearch Scenario shift » What if t
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esearch Many different parties have
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esearch of his concern for people w
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esearcH etHics anD conFlicts oF int
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esearch and non-public information
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esearch reFerences 1 Public Health
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esearch Key ethical dimensions Perh
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esearch such support, seen across t
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esearch Proposed resolution Enablin
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a tool For etHical analysis oF Publ
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esearch are explicit. In Quebec, su
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esearch reFerences 1 Bayer, R. and
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Part two Policy
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policy being increasingly introduce
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policy behaviour. Therefore, the et
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policy 18 Chapman, S. and Freeman,
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policy through outdoor smoking, any
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policy that this is an injustice. W
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DeFerring blooD Donation FroM Men w
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policy 26 per cent of new infection
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policy 6 NHS Blood and Transplant.
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policy public trust might also incl
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policy lived in certain regions in
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policy 4 Zou, S., Musavi, F., Notar
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policy Case description For nearly
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policy 3 Economic conditions could
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policy essential to examine the his
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policy lMICs. Evidence-based introd
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policy governments, regional develo
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First nations Drinking water Polici
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policy federal government was aware
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policy reFerences 1 Health Canada.
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policy Core issue Case study author
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policy Additional issues It may be
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policy Arguably, an exception might
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policy Case Following the pharmaceu
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policy 3 What potential harms may b
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policy in the “anti-cancer vaccin
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policy adults may choose for themse
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policy Men also suffer some HPV-cau
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ManDatory iMMunization oF local Pub
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policy for exemptions and declinati
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policy Case discussion in response
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policy the degree of infringement o
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Part tHree Practice
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practice Case The Inquiry found tha
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Page 142 and 143: practice Getting Clear on What’s
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Page 146 and 147: practice Cervical cancer is relativ
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Page 182 and 183: practice The ethical principle of b
Page 184 and 185: practice Identify the options avail
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