Basic strategies to protect from environmental hazards - Inches

Basic strategies to protect
from environmental hazards
Tee L. Guidotti
Mid-Atlantic Center for
Children’s Health and the
Environment
Washington, DC
IV International Conference on
Children’s Health and the
Environment

What are we preventing
Spectrum of
outcomes:
short-term efffects
(“poisoning”)
subclinical effects
contribution of hazard
as risk factor for
multifactoral disease
In the case of
neurodevelopmental
effects, later and
adult behaviors that
place person at risk
Schema of the Adverse Childhood
Experiences Study:
www.acestudy.org/aboutacestudy.php

Modes of Prevention
Primary prevention
Of disease state
Elimination of exposure, modification of host
susceptibility, interruption of transmission
Secondary prevention
Of disease progression
Early detection and intervention while disorder can be
corrected
Tertiary
Of disability
Medical or rehabilitation intervention to improve
outcome

Strategies to achieve prevention
Operationalizing prevention
Three basic strategies:
Individual child protection
Preventive medicine model
Public health model

Individual child protection
Social strategy is parent education
Monitor their activities
Create a safe environment
Educate parents
Mobilize social institutions
Medical monitoring
Instill sense of responsibility
Surrounding the child with a
“cocoon” of safety
Primary prevention strategy
State intervenes only when failure
Etobicoke
(Canada) Brighter
Futures Coalition

Rose’s paradigms for collective action
The public health and
preventive medicine
models were first defined
by the late Geoffrey A.
Rose, of the London
School of Hygiene and
Tropical Medicine. They
have been articulated in his
many books and papers.
See: Rose G. The Strategy of
Preventive Medicine.
Oxford, 1992.

Preventive medicine (high risk) paradigm
Applies when there is a known, defined group at
high risk for an adverse outcome
Screen for markers of risk (e.g. blood lead)
Intervene only in those individuals who are at
high risk
If marker is early in process of causation and risk is
reversible, primary prevention is possible
If not, secondary prevention is practical objective
Useful only when there is a practical intervention
State intervention for compliance
Requires intact clinical healthcare system

Example: Lead
Blood lead screening
Identifies children at risk
Targeted intervention
Subclinical damage has already
occurred!
Secondary prevention
Medical intervention for high
elevated BLL is tertiary prevention
Housing should be screened!
Lead paint driving factor
Obstacle is private property rights
Movement growing to change this
http://leadconnections.org/images/LeadScree
ningInfo.jpg

CDC Level of Concern
This is theory behind “Level of
Concern”
Concept now questionable
because demonstrated effects
at lower levels
Controversy over change to
recommendation
No obvious intervention at this or
lower levels
Would revising level drive
reduction in exposure levels

Public health strategy
Applies when risk is present to some degree
among all members or population
Reduce risk for all members of the population,
regardless of risk status
Biggest gains in reduced risk will be seen in higher risk
groups, of course
Gains across all risk groups
Cross-sectoral, many different sources
Requires concerted effort, programming, often
state intervention
Competing health priorities
Attributable risks may be unknown
Program priorities among different outcomes, needs

Example: Lead
Better fits “no threshold”
concept of toxicity
Monitor by mean BLL
All-source reduction
Track by geometric mean
in population
Prevents subclinical
damage and contribution
to multifactoral outcomes
How to do so
Regulation, manufacturing
standards, education, etc.
How to allocate
resources

Limitations of the strategies
The different prevention strategies achieve
different goals for lead
All require screening, monitoring
Individual child
protection
Preventive
medicine
Public health
All risks
(individual)
Frequency of
“poisonings”
(individual)
Prevention of toxicity
(population)
Often unreliable
Secondary
prevention
Sustainability

Summary
Three ways to protect children are not
equally effective applied to lead hazard
Individual protection by parents can fall short
Preventive medicine (“high risk”) paradigm
works best to prevent clinical/subclinical
poisoning and otherwise serves children poorly
Public health paradigm is primary prevention
Screening remains important to monitor
progress