Lead and Health

Author: Charlene A. Fenster

School/Organization:

Randolph Career Academy

Year: 2019

Seminar: Lead & Health

Grade Level: 9-12

Keywords: dental assistants, Health, lead, paint

School Subject(s): Health

Many contaminants, be they heavy metals or pathogenic microorganisms, can be transmitted via a variety of routes, ingestion, inhalation and absorption manifesting in a plethora of adverse outcomes, short-term or long-term, with individual and societal costs. Prevention and/or remediation are possible within a coalescence of factors, including due diligence, compliance, education, civic participation, and political will. Specifically, lead poisoning derived from soil, water, and air, originating from sources long ago outlawed, continues to poison the population, more so those living in urban, underserved, minority, and poor areas, and at times, without a vote and democratic representation.

This progressive literature-based curriculum will focus on the development of an environmental health literacy (EHL)/health literacy (HL) program leading to understanding the mechanisms of health risks, methods of exposure reduction, and the empowerment of individuals to effect changes that reduce/eliminate health disparities and promote environmental justice in their lives and their communities.1,2

Focused on lead, the design, however, is flexible and can be adapted to any addressing the etiology, transmission, manifestations, prevention, management/treatment, and costs of any agent toxic to the human ecosystem and/or the environment. The units of learning encompass: Cultural Competency; Lead Poisoning; Lead Tests; Environmental Justice; Heroes, Education and Advocacy.

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Full Unit Text
Content Objectives

Problem Statement

Lead poisoning stemming from lead in paint and paint dust, soil, and corrosive water traveling through leaded and lead soldered pipes contributes to adverse effects ranging from skin rashes to cognitive detriments contributing to reduced productivity, loss of personal lifetime earnings, dependence upon governmental support, and a loss of tax revenue to support communal needs. Many residential homes in Philadelphia were built prior to 1978 when leaded paint was banned, are served by leaded water service lines, and are built in proximity to former lead smelters that generated lead residuals, resulting in lead residue in the soil.

Rationale

This curriculum is designed for dental assistants but would be relevant to others with healthcare interest. Content from the TIP Program intersects with the foundational elements and content of the Dental Assisting Program outlined by the Pennsylvania Department of Education Bureau of Career and Technical Education’s established curriculum and the American Dental Association Commission on Accreditation Dental Assisting and Dental Hygiene Standards, the PDE Dental Assisting Task List, along with many facets of the Civics and Government; Science; Reading, Writing, Speaking and Listening; Reading in Science and Technology;

Writing in Science and Technology; Science, Technology, and Engineering Education; Health, Safety and Physical Education; Family and Consumer Sciences; Environment and Technology; Career Education and Work; and 21st Century Readiness Skills Common Core Standards.

In healthcare, students learn about the modes of disease transmission and how to apply that knowledge to prevent cross-contamination and development of disease sequela. The translation of this skill to understanding lead routes of entry and the consequences of such is a natural application of critical thinking. The prevention of cross-contamination while conducting lead tests is essential to self-protection and accurate results.

In dental assisting, students collect data from patients through medical/dental/social histories. An extension of such includes collecting data using student-generated questionnaires and surveys regarding environmental factors such housing, soil, water, paint and paint dust, along with blood lead levels, and physical and behavioral conditions.

The CDC recommends spore testing to verify sterilization techniques. Students must interpret the results in positive/negative terms and determine the course of action. Similarly, students will verify that the lead swab tests for paint and dust are valid and determine the next course of action.

Health care education includes a knowledge base that studies methods of disease prevention, treatment, and possible cure. The same intellectual infrastructure applies to studying methods of preventing lead poisoning, through an understanding of how it got there in the first place, mitigating and possibly eliminating exposure, and how to manage the adverse effects, all through an environmental health literacy framework.

To develop, deepen, and broaden a schema of disease, a healthcare professional must continually query, analyze and organize the data, and present the research. So to must a student investigating lead and its health implications.

In dentistry, practitioners must develop an understanding of the properties of materials, and the appropriate manipulation of such in compliance with OSHA and EPA regulations, as well as CDC recommendations. The same is true when investigating lead and its ramifications.

Laboratory and clinical procedures require methodical, meticulous, and accurate preparation, execution, and documentation. The implementation of a variety of lead tests, water, soil, paint and dust, and artifacts and scrupulous documentation and analysis requires the same skills set.

Intrinsic to caring for patients is the natural inclination to educate not just the patient population, but also those with the power to influence the health care options for patients. This evolution from treatment to advocacy for access to quality health care is paralleled through a pursuit for environmental justice when it comes to the subject of lead poisoning.

Given that much research exists about the impacts of environmental factors, cultural traditions and preconceptions, socioeconomic status (SES), level of education, degree of health literacy, type of employment, and level of insurance on the oral and systemic health of individuals and their communities, this progressive literacy grounded curriculum introduces students to the research, reading comprehension, writing processes, along with data collection, organization, and interpretation of the knowledge base and laboratory test skills, and the creation of educational materials for advocacy purposes requisite to achieving the goal of environmental health/health literacy advocate, change agent, activist.

Learning units vary in length from days to more than a week given the interdisciplinary approach to each unit. The entire curriculum could span a semester or even longer in that it is integrated into an existing one.

Background

Cultural Competency

There exists no possibility of advancing change in behaviors, laws, perspectives without the ability to see through someone else’s lens. Cultural competency undergirds both curricula in facilitating both environmental health literacy (EHL) and health literacy (HL) throughout the student population and beyond to the communities that surround us, our patient base, school group, families, neighborhoods, and city.

As the instructor in the Dental Assisting High School Program in the School District of Philadelphia, it is incumbent upon me to develop a curriculum that cultivates citizen-scientists (such as Rachel Carson-Silent Spring-1962) with a high degree of health and environmental health literacy. Given that much research exists about the impacts of environmental factors, cultural traditions and preconceptions, socioeconomic status (SES), level of education, degree of health literacy, type of employment, and level of insurance on the oral and systemic health of individuals and their communities, this curriculum will focus on the development of an EHL/HL program leading to understanding the mechanisms of health risks, methods of exposure reduction, and the empowerment of individuals to implement some control over and effect changes that reduce/eliminate health disparities and promote environmental justice in their lives and their communities.1,2 This progressive literature-based program introduces students to the research, reading comprehension, analysis, synthesis, data gathering, information organization and evaluation strategies and skills requisite to navigating the assigned texts and identification of key points of information that will be utilized for creating educational materials, PSAs, social media communications, surveys, generation of advocacy items, such as petitions, letters to politicians, and oral presentations to stakeholders (health care and public health professionals, policy makers, politicians, teachers, students, and the general public). It encompasses units of learning in the following topics: Lead, Health and Cultural Competency; Lead Poisoning; Lead Tests; Lead, Health and Environmental Justice; Heroes, Education and Advocacy.
The practice of dentistry encompasses the use of substances, such as lead, mercury, silver, acrylates, fluoride, ionizing radiation, among others to achieve and/or maintain benchmarks of health. The profession also addresses the etiology, prevention and management of the primary dental diseases, caries and periodontal disease, along with the oral implications of systemic diseases. Therefore, the design of this curriculum is intended to be flexible enough to address any oral, systemic, or environmental health concerns through the generation of a cadre of students who apply the evidence-based knowledge, skills and competencies distilled from the curriculum and forge a community-academic partnership to effect positive health outcomes in their own lives and those of their communities. However, lead and health is a primary focus of this unit. As health care providers, we and the public, expect us to practice ethically, in compliance with the American Dental Hygienist’s Association’s (ADHA) Code of Ethics Core Values, encompassing the following:2

Autonomy: Treat patients with respect; patients have the right to informed consent
Confidentiality: Respect confidentiality of patient information
Societal trust: Value patient trust and understand that public trust in the profession is based on clinician actions and behaviors
Nonmaleficence: Protect patients and minimize harm
Beneficence: Promote the well-being of individuals and the public                                                                                                                                                                                                                                                                                                                                                             Justice and fairness: Support the fair and equitable distribution of health care resources                                                                                                                                                                                                                                                                                                                Veracity: Tell the truth

It is expected, then, that practitioners speak out about patient care or the lack thereof, even when such action could potentially affect their employment.2 Such actions are analogous to the Flint water crisis that will be addressed in this unit.

The aforementioned Core Values assume the participation of the patient/public in the partnership for establishing and maintaining quality of health care. Cultivating community-engaged research (CEnR) and acceptance of education through its resident citizen-scientists are predicated upon a culturally competent process that facilitates the acquisition of data and the dissemination of messaging compatible with existing beliefs and attitudes that is culturally and linguistically effective in achieving the desired outcomes-behavior changes that improve health by preventing, reducing or abating causative factors and in addressing misinformation and embedded misperceptions.1 Methods of communication that avoid microaggression and establish a rapport and develop trust undergird the partnerships necessary to recognize and then act upon health disparities; partnerships between academia and the public, government and academia, government and the public, and policy-makers-academia-the public.

Two communication approaches that lend themselves to elevating the EHL/HL of those afflicted are the “teach-back method” and the LEARN (listen, explain, acknowledge, recommend, negotiate) model.3 A mnemonic tool identified in the literature-D-I-V-E-R-S-E-establishes a framework for students/clinicians seeking to broaden their perspectives of the populations with whom they work/treat. It enables them to sensitively query their patients or community members about their cultural demographics, ideas of health and illness, views of health care modalities, expectations from those in charge, the influence of religious beliefs or traditions, environmental factors influencing a person’s daily functioning and assess levels of health and colloquial language literacy.4

These communication methods and the mnemonic align with those of Dr. Mona Hanna-Attisha, Director of the Pediatric Residency Program at Hurley Medical Center, a public teaching hospital affiliated with Michigan State University. As a medical educator, she insists that her pediatric residents treating patients in the underserved community of Flint, MI, most of whom are on Medicaid, begin their Community Pediatrics rotation with a tour of the city in which their patients live. It is critical that they “open their eyes” to the health and environmental disparities in which their patients exist and the intrinsic resilience they display. Drawing upon her high school days as an environmental science major and activist, she instills in her residents the ethical mantra of beneficence and justice: to promote the well-being of individuals and the public and to support the fair and equitable distribution of health care resources. Her book, What the Eyes Don’t See, personalizes the lead poisoning crisis of the Flint, MI water supply and provides a culturally sensitive framework for all persons to operate in maintaining a balance between health care and operations.5

Let’s start at the beginning. What is lead poisoning? What are the sources of lead? What are the routes of transmission?

Lead is a naturally occurring heavy metal that is used in many industries, such as paint, and was used in the gasoline that fuels automobiles; it is inexpensive to mine and process.

The by-products of smelting lead or burning leaded gasoline become airborne and due to the weight of lead, promptly descend to the ground and incorporate into the soil and waterways. As a heavy metal, lead does not biodegrade. Contact with the lead contaminated soil can be tracked into the home on clothes and shed. Items on the floor are then put into a toddlers’ mouth, chronically exposing the child. Food grown in the lead contaminated soil and ingested raises Blood Lead Levels (BLL).5,6

The lead in paint chips or dust can be inhaled and sometimes ingested.6 Given that in the US, leaded gasoline was outlawed in 1990 and lead emissions from smokestacks have been reduced due to regulations passed in 1970 and that lead was prohibited in interior paint products in 1978, BLL have generally declined except in areas near the smelters and in housing built before 1978 that has not been abated. Both instances are generally in poor, urban, underserved communities unable to afford property remediation, frequently unaware of tenant rights and owner responsibilities, with irregular health care evaluating the BLL, physical and cognitive development of young children.

Other sources of lead exposure through airborne routes come from fumes or respirable dust emanating from remediation or abatement procedures including sanding or heating old lead paint or from melting or burning automobile batteries or ammunition or toys, such as lead soldiers or cars.6

A study by Graziano et al reported that infants demonstrate BLL like their mothers because lead crosses the placental barrier.6 A calcium demand during gestation causes bone resorption releasing the lead stored in the mother’s bone into the blood stream. A randomized placebo-controlled trial by Hernandez-Avilla et al found that calcium supplementation in some Mexican women resulted in lower BLL possibly by decreasing bone resorption.6 Some baby formula contains lead. Little lead in human milk is transferred because it is less concentrated than that in the blood. Breastfed babies are exposed to slightly less lead than bottle fed as reported by Gulson et al.6

There exists no protocol to measure BLL in blood used for transfusions. Extremely low birth weight babies receive transfusions of up to 90% donor blood. Although Bearer et al recommended using units with BLL < 0.09umol/L, they found elevated concentrations in one third of the transfusions.6

Although the water itself in municipal water supplies is generally not a problem, elevated BLL can be caused from drinking tap water due to a lack of anti-corrosive treatments to the water causing leaching of lead from the lining of old pipes and/or the solder in the pipes. Municipal water is treated, generally with some type of chlorine chemical. However, when water disinfection chemical formulas are changed, i.e.: from chlorine to chloramine, the more corrosive nature of the water can cause lead to leach from the inside of the service lines that connect the service mains to the interior pipes in the home, causing increased BLL in children, according to Lanphear et al.6

There are two recent major events demonstrating where this has occurred, in Washington, DC in 2003-2004 and again in Flint, MI in 2014. Due to dire economic circumstances leading Flint, MI into bankruptcy, it was decided in April, 2014 to switch the water source from Lake Huron to the Flint River. Although the Flint River water was deemed safe by the Michigan DEQ, the decision was made to switch from chlorine to a more highly corrosive chloramine disinfectant, but no anti-corrosive treatment was added. This lead to the release of solubilized lead from the interior of the lead and lead soldered service lines, in direct violation of the EPA’s Safe Water Drinking Act (1974) Lead and Copper Rule (1991) mandating that action needs to be taken when tap water is deemed too corrosive.5,

Originally, SDWA focused primarily on treatment as the means of providing safe drinking water at the tap. The 1996 amendments greatly enhanced the existing law by recognizing source water protection, operator training, funding for water system improvements, and public information as important components of safe drinking water. This approach ensures the quality of drinking water by protecting it from source to tap.7 www.epa.gov/safewater. The water in the house can be tested and compared to the EPA’s safe water thresholds: www.epa.gov/safewater/lead/index.html6

The problem is when lead gets into human bodies causing deleterious effects:

Multiple studies in several countries reveal that current low lead levels manifest as cognitive impairment as measured on IQ tests. Although BLL peak at 2 years of age, a systematic review of the epidemiological evidence demonstrates that IQ test results are not reliable until 5 years of age.6 In studies conducted in 2003 by Canfield et al and Bellinger and Needleman, similar results revealed that a loss of 7 or more IQ points occurred after the first 10ug/dL of lifetime average blood lead concentration.6

Evidence of lead in the bone implies that exposure is cumulative. Needleman et al report that bone lead levels are higher in adjudicated delinquents and are associated with aggression and attention disorders, inferring that the effects of lead exposure are permanent.6 Pocock et al demonstrated that lead interferes with heme biosynthesis, inhibiting the action of two enzymes required to complete the heme ring, aminolevulinate dehydratase and ferrochelatase resulting in microcytic anemia. However, because lead interference with heme synthesis is not manifested below a BLL of 25ug/dL, the erythrocyte protoporphyrin (EP) screening test is viable only in populations of children suspected of higher levels of lead exposure.6 Chisolm et al reported that high concentrations of BLL, i.e.: > 60ug/dL, may exhibit CNS premonitory symptoms, including headaches, abdominal pains, anorexia, reduced dexterity or coordination, constipation, hyperactivity or drowsiness, which can rapidly lead to vomiting, stupor, and convulsions.6 Adults with high BLL due to chronic occupational (handling automobile batteries, painting bridges, working at a shooting range and handling, ingesting, or inhaling lead residuals, lead abatement worker, or avocational lead exposure (handling/melting lead ammunition or toy soldier/car hobbyist) may manifest clinical symptoms including colic, peripheral neuropathy, and chronic renal disease.6

Do I have it-how will I know? Signs and Symptoms:

Research conducted by Mahaffey et al, Pirkle et al, and the CDC reveal statistics showing that children ages 1-5 demonstrated decreasing median BLL as follows: 1976 to 1980: 15ug/dl; 1988-1991: 3.6ug/dL; 1991: 1/11 (9%) of all US children: > 10ug/dL; 1999: 1.9ug/dL. Due to suburbanization and those living in newer housing with no lead paint, BLL dropped except in poor, urban areas with older housing painted with lead and no discretionary funds to remediate. Therefore HUD required, as of 1989, and CDC recommended, targeted screening of only children eligible for Medicaid, of whom 80% showed elevated BLL. As of 2005, the Advisory Committee on Childhood Lead Poisoning Prevention mandated that all Medicaid-eligible children must be screened and Medicaid will reimburse for the two screenings at ages one and two. However, most are not.6

Studies by Needleman et al and Sciarillo et al, on teeth with elevated tooth lead concentrations reported those students were more inattentive, hyperactive, disorganized, and less able to follow directions, with subsequent higher rates of failure to graduate high school, reading disabilities, and absenteeism in senior year of high school.6

Regarding a psychological assessment, data from epidemiological studies report a diminishment in attention, executive function, social-behavioral modulation, visual-spatial skills, balance, and fine-motor coordination at later stages in development when they can be reliably measured in children who registered BLL > 20ug/dL at two years of age. Therefore, the Advisory Committee on childhood Lead Poisoning Prevention suggests that in anticipation of the manifestation of developmental delays and abnormal behavior as the child ages, the record should be left open despite a decrease in BLL after two years of age.6

What about treatment? Can it be cured? Can you get the lead out? Can the effects be reversed?

Both Ruff et al and Tong et al, published follow-up data of two separate studies evaluating the outcomes of chelation therapy with ethylenediaminetetraacetic acid (EDTA) and therapeutic iron, when indicated, with children measuring BLL between 25 and 55 ug/dL and found those children whose BLL decreased the most

showed some or little, respectively, improvement in IQ scores.6

The Treatment of Lead Exposed Children Trial (TLC) randomly administered succimer to 780 two-year old children with BLL of 20-44 ug/dL with follow-up at five and seven years of age. Despite a transitory decrease in the treated children’s BLLs, no improvement in cognitive, neuropsychologic and behavioral tests occurred. Furthermore, subsequent data mining of the TLC study by Liu et al revealed improved test scores at the five-year follow-up, but only in the placebo group, not the succimer treated group. Thus, evidence shows that chelation therapy does not reverse cognitive impairment. BLL decreased in both groups as the children aged most likely due to an increase in body mass and blood volume and a diminishment of mouthing activities. Thus, low or lower BLL after two years of age do not mean that lead poisoning and the consequential adverse effects did not occur.6

Children older than two years, with elevated BLL, > 20ug/dL, are most likely experiencing continued exposure to lead dust or chips either within their own homes or locations regularly visited, such as school, relatives, daycare centers, etc., with deteriorating lead paint surfaces on walls or window sashes or tracked in from surrounding soil around homes near bridges with exterior lead paint, or smokestacks, operating or not. Soil can be tested for lead following EPA guidelines:6 www.epa.gov/lead/leadtest.pdf

Recognizing that treatment is ineffective, primary prevention is the best strategy to protect children from lead poisoning effects. When blood lead levels are 5mcg/dl or higher, an environmental approach should be initiated including an environmental history, along with an inspection of the child’s primary residence and any regularly visited sites, a measurement of lead in paint, soil, and water, control of immediate lead hazards, and remediation of the house as indicated.6 Depending upon the results, interventions should be initiated, such as extensive professional cleaning, always wet, never dry and vacuum only with a HEPA filter, paint stabilization (repaint), and removal and replacement of window sashes that can interrupt exposure. However, temporary relocation is suggested to avoid exposure to the inhalation, ingestion, and/or skin absorption of the lead dust created in the remediation process.6

Medical management for children where the exposure has been controlled, but continues to exhibit BLL > 45ug/dL includes succimer. Pediatricians experienced in the protocol can be located through state health departments, and pediatric environmental health specialty units at www.aoec.org/pehsu.htm, calling the local poison control center, or the AAP Committee on Environmental Health. The treatment’s side effects include abdominal distress, transient rash, elevated hepatocellular enzyme concentrations, and neutropenia. There is no evidence that the treatment will improve cognitive function.6

Children with BLL > 70ug/dL that are unable to tolerate succimer can be treated with parenteral EDTA or a third

line oral chelator, D-penicillamine, as recommended by the AAP Committee on Drugs.6

In addition to environmental and medicinal approaches to reducing BLL, dietary interventions with iron, calcium, and vitamin C have been shown in laboratory and clinical data to interfere with lead absorption through iron and calcium and to enhance renal excretion due to Vitamin C administration.6

Environmental Injustice/Justice:

The concept of environmental justice originated in the US in the 1980s in Warren County, NC, a predominantly impoverished African-American community and “refers to the uneven distribution of environmental quality between different social groups and relates decreasing socioeconomic status to an increasing burden of exposure to environmental hazards.”7 Both Northridge and Frumkin concur that poverty-stricken, frequently minority, areas are “socio-structurally weak neighborhoods” characterized by deteriorating housing, high population density, exposure to emissions from industrial plants and heavy traffic without the counterbalance of “environmental commodities,” such as safe playgrounds, open green spaces, readily accessible health care and healthy food sources. These economically, socially, and politically weak communities manifest significant adverse health effects from such environmental exposures.7 On October 24-27 1991, the first National People of Color Environmental Leadership Summit was held in Washington, DC. The seventeen Principals of Environmental Justice were developed to advance the rights and voice of all peoples, regardless of race, culture, language, religion, and SES, to a toxic-free and sustainable environment and for compensation for transgressions against the aforementioned.8 President Clinton issued an executive order (12898) on February 11, 1994 ordering all federal agencies to review all programs and policies involving minority and low-income populations to identify and address “disproportionately high and adverse human health or environmental effects.”9

It is curious that poor housing conditions continue to exist when awareness of the link between dilapidated housing and infectious diseases was publicized in the 19th century during the urban sanitary reform movement.7

An example of compounding environmental injustice is the Flint water crisis. First and foremost, the economic crisis in Flint lead to cost cutting measures that lead to a series of non-elected Emergency Managers (EMs) appointed by the governor and meant the loss of the public voice in the governance of their city; a loss of the checks and balances intrinsic to a democracy intended to provide equal protection and justice for all. Without oversight and accountability, dismissal of evidence by the EPA, the governor’s office, the Michigan Department of Health and Human Services (MDHHS), the Michigan Department of Environmental Quality (MDEQ), the Genesee County Health Department, from a diversified strata of credible professionals, including a researcher-pediatrician (Dr. Mona Hanna-Attisha), a professor of civil and environmental engineering from Virginia Tech University,

along with other environmental engineers (Elin Warn Betanzo) and internal EPA researchers (Miguel Del Toral), lead to water that poisoned citizens in Flint for twenty months, with long-term adverse effects.5,10 Even GM knew. Recognizing that rust on newly machined parts was caused by the water, the plant switched its water supply to the neighboring Flint Township. The company received a waiver from the government, meaning the government knew. The state provided employees of Flint’s municipal government with bottled water.5 The town knew it was in violation of the EPA Lead and Copper Rule that requires action when water supplies are found to be corrosive.11 Local citizens presented signs and symptoms of the adverse effects, such as clumps of hair falling out, rashes appearing after bathing, and abdominal pain, to the city council. Although water testing results of 400 ppb, the EPA action level is 15 ppb, the blame was ascribed to the plumbing, despite the recent replacement of metal piping with plastic material, polyvinyl chloride (PVC). Despite media coverage of the problem on Michigan Radio, The Flint Journal, MLive.com, the ACLU blog and Deadline Detroit, government officials continued to “blame the victim,” discredit the data from experts, and blatantly violate the Copper and Lead rule of the Safe Drinking Water Act.

The media, often termed the fourth branch of government, was one vehicle providing a voice for the citizens of the town. Another is a nascent public-private partnership between the Michigan chapter of the ACLU and the Ford Foundation. The ACLU’s concern was that the voting public no longer had a voice in a governmental operation run by an appointed, not elected official (many as it turns out). The philanthropy of the Ford Foundation funded the investigative reporting that was out of reach for traditional media providing scientific evidence from an EPA employee’s report of the high levels of lead found in the tap water of Flint residents.10

The costs associated with lead poisoning involve lead abatement, treatment of the long-term effects, many of which are neurologic, resulting in cognitive deficiencies, loss of work income and tax revenue, health care costs, and the ramifications of crime and have been estimated by Attina and Trasande at $50.9 billion dollars in the US. Conversely, the savings, as reported by Grosse, Schwartz, and Jackson report that lowering of BLL in 3.8 million two-year-old children annually result in $110-$319 billion per year due to increased IQ points rendering greater worker productivity. Rosner estimates the cost of primary prevention of lead poisoning, national lead abatement, at $1 trillion dollars.10

Many have weighed in on recommendations going forward. Landrigan and Bellinger recommend mapping the sources of lead and removing it. Jacobs and colleagues have initiated a campaign for locating and removing lead at the National Center for Healthy Housing. In Flint, the governor’s task force made forty-four recommendations following the water crisis including, following up on the exposed citizens through establishment of a Flint Toxic

Exposure Registry, routine lead screening of children in their primary physician’s office coupled with follow-up for all children in the state with elevated BLL.10

Dr. Hanna-Attisha’s Flint Child Health and Development Fund was established more broadly to enable access to pediatric health care, early childhood and parenting education, nutritional and social services. The aforementioned will be provided through the MSU/Hurley Pediatric Public Health Initiative whose mission is to “increase children’s readiness to succeed in school.” The Flint Water Task Force also recommended setting aside monies within the Michigan Health Endowment Fund to address the healthcare needs of the exposed Flint children.10

The AAP has proposed governmental recommendations as follows: “The US EPA and HUD should review their protocols for identifying and mitigating residential lead hazards (e.g., lead-based paint, dust, and soil) and lead-contaminated water from lead service lines or lead solder and revise downward the allowable levels of lead in house dust, soil, paint, and water to conform with the recognition that there are no safe levels of lead.”10

The environmental injustice perpetrated upon the citizens of Flint is wholly preventable if all parties demonstrate respect for one another and the rule of law. The government must be representative of the people through a democratic electoral process, those in power in government must listen to and consider all sides, including the scientific evidence presented, the media must continue as the “outsider” to question until answers are satisfactory, the citizenry must own its right to a voice and proceed proactively to secure the protections the government is designed to render.

Advocacy: What can I do to prevent, reduce or abate it? I am not a hero, I am just one person.

By the end of the curriculum, students should have developed sufficient knowledge, skills, resources and confidence to transition into the role of a change agent, environmental activist, advocate, whatever term feels comfortable. In this unit, they will take the last run at changing their perspective from learner to educator and someone who can go out beyond the bounds of their comfort zone and make a difference. The unit focuses on reading about and identifying the characteristics of a “hero,” and through self-assessment determine what they can do and how their learning style strengthens the strategies they choose to employ, such as, but not limited to: conduct lead testing in their school, home, and community; conduct surveys, questionnaires, interviews with the aforementioned; create educational materials such as PSAs, brochures, flyers, posters, social media blasts, blogs; generate advocacy items, such as petitions, letters to stakeholders (health care and public health professionals, policy makers, politicians, teachers, students, and the general public), and deliver oral presentations utilizing any of the aforementioned.

 

Teaching Strategies

The core of the curriculum is literacy development on all levels, reading (comprehension), writing (composing original pieces), listening, speaking, and viewing.

Therefore, all units contain varying degrees of reading difficulty and will begin with reading comprehension strategies modeled and employed by the instructor to include, but not limited to: close reading; sustained silent reading (SSR); round robin reading aloud; circling unknown vocabulary; chorally reciting challenging

The core of the curriculum is literacy development on all levels, reading (comprehension), writing (composing original pieces), listening, speaking, and viewing.

Therefore, all units contain varying degrees of reading difficulty and will begin with reading comprehension strategies modeled and employed by the instructor to include, but not limited to: close reading; sustained silent reading (SSR); round robin reading aloud; circling unknown vocabulary; chorally reciting challenging

Objectives

Although each teaching unit plan presents its own objectives aligned with the unit topic, overall objectives for this curriculum include:

  1. Development and demonstration of cultural competency. (Unit 1)
  2. Understand the etiology (including government failures), transmission, adverse effects, prevention, and remediation of lead poisoning. (Unit 2)
  3. Conduct controlled laboratory tests within quality assurance protocols, collect and analyze data, and determine corrective actions if necessary. (Unit 3)
  4. Understand environmental injustice and the democratic infrastructure, including the media, to bring about environmental justice. (Unit 4)
  5. Develop a knowledge base sufficient to advocate for reforms to improve the environment and overall health of the community. (Unit 5)