A WORLD WITHOUT LEAD Paving the Path to a Healthy, Productive Future A WORLD WITHOUT LEAD Paving the Path to a Healthy, Productive Future © 2025 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Design: Creative Services, Global Corporate Solutions, World Bank. A WORLD WITHOUT LEAD Paving the Path to a Healthy, Productive Future ACKNOWLEDGEMENTS This report was prepared by a team led by Ernesto Sánchez-Triana. The core team included Bjorn Larsen, Santiago Enriquez, Mary-Jean Brown, and Claudia Serrano. The extended team included Tayo Adedeji (Task Team Leader), Elena Strukova, Johannes Heister, Michael Brody (American University), Stephan Bose-O’Reilly (University of Munich), Richard Fuller (Pure Earth). The Task Team is grateful for the strategic guidance and support provided by Juergen Voegele (Planet Vice President), Richard Damania (Chief Economist, Planet Vice Presidency), Valerie Hickey (Global Director for the Climate Change Department), Genevieve Connors (Acting Global Director for the Environment Department), and Jiang Ru (Practice Manager of the Global Platform Unit of the Environment Department). This report was improved by the comments and suggestions of the peer reviewers of previous versions: Richard Damania, Susmita Dasgupta, Kseniya Lvovsky, Johannes Heister, Claire Chase, Harinath Sesha Appalarajugari, Frank Van Woerden, Marc-Francois Smitz, and Katherine von Stackelberg. Stan Wanat provided editorial support. This report is supported by the Korea Green Growth Trust Fund (KGGTF), a partnership between the World Bank Group (WBG) and the Republic of Korea. As a technology-driven and implementation-focused trust fund, the partnership supports countries in their innovative and sustainable growth strategies and investments. This partnership reflects a shared commitment to the World Bank’s mission of creating a world free of poverty on a livable planet. Find out more: www.wbgkggtf.org. The generous financial support of the donors to Global Program on Sustainability (GPS) is also gratefully acknowledged, including the UK’s Department for Environment Food & Rural Affairs (DEFRA); Germany’s Federal Ministry for Economic Cooperation and Development (BMZ); and Switzerland’s State Secretariat for Economic Affairs (SECO). ii CONTENTS ACKNOWLEDGEMENTS ii ACRONYMS ix EXECUTIVE SUMMARY xi 1 INTRODUCTION 1 2 IMPACTS OF LEAD ON HUMAN CAPITAL AND THE ENVIRONMENT 5 2.1. Introduction 6 2.2. Blood lead measurement 7 2.3. Lead impacts on human health and children’s development 9 2.4. Impacts of lead exposure on brain and neurological development 10 2.5. Lead exposure and cardiovascular health 20 2.6. Chronic lead exposure 22 2.7. Surveillance and identification of hotspots 22 2.8. Appraisal of environmental health impacts from recycling of used lead-acid batteries 26 2.9. Ecological effects of lead exposure 31 2.10. Conclusions 32 3 LEAD POLLUTION: EXTENT, SOURCES, AND PATHWAYS OF LEAD IN THE ENVIRONMENT 47 3.1. Introduction 48 3.2. Sources of lead 51 3.3. Source apportionment 71 3.4. Conclusions 72 iii 4 LEAD POLLUTION ROBS CHILDREN OF THEIR FUTURE AND KILLS MILLIONS OF ADULTS – ESTIMATING GLOBAL IMPACTS ON HEALTH 91 4.1. Introduction 92 4.2. Global lead exposure 93 4.3. Health effects of lead exposure 95 4.4. IQ loss in children 96 4.5. Cardiovascular disease mortality in adults 100 4.6. Conclusions 105 5 GLOBAL HEALTH COST OF LEAD POLLUTION: A CALL FOR ACTION 111 5.1. Introduction 112 5.2. Global cost of IQ losses 112 5.3. Global cost of adult mortality 116 5.4. Alternative methods to quantify the cost of lead exposure 118 5.5. Conclusions 121 6 SCOPE AND ECONOMIC EFFICIENCY OF SOLUTIONS TO PREVENT AND CONTROL LEAD POLLUTION IN THE ENVIRONMENT 125 6.1. Introduction 126 6.2. Rehabilitation of ULABs contaminated sites 126 6.3. Remediation of soils contaminated by mining and smelting 128 6.4. Lead in drinking water 133 6.5. Standards on the concentrations of lead in air, water, soil, and consumer products 135 6.6. Eliminating lead-paint hazards 136 6.7. Converting lead-glazed pottery production: Mexico 141 6.8. Eliminating lead in spice: Bangladesh and Georgia 142 6.9. Iron Supplementation 143 6.10. Conclusions 144 iv A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 7 TOWARDS A LEAD-FREE PLANET 153 7.1. Introduction 154 7.2. Investments 156 7.3. Policy reforms 158 7.4. Institutional capacities to prevent and remediate lead contamination and exposure 163 7.5. Outlook 167 Annex 1: Blood Lead Levels and Health Effects by Country/Economy 183 Annex 2: Cost of Lead Exposure by Country/Economy 190 Annex 3: Model Law and Guidance for Regulating Lead Paint 197 Annex 4: Conceptual Site Model of Potential Exposures at Artisanal and Small-Scale Gold Mining (ASGM) Sites 212 Annex 5: Lead in Paint Regulations and Standards 214 Annex 6: Lead in Consumer Products 222 Annex 7: Permissible Limits for Lead (Pb) in Water, Air, And Soil 229 Annex 8: Key References and Resource Guides for Environmental Sampling 236 Annex 9A: Biomonitoring Resources 244 Annex 9B: Modeling Tools 248 Annex 10: Tools for Measuring Human Lead Exposure 251 Contents v BOXES Box 2.1. Georgia’s Environmental Health (lead) Surveillance System 24 Box 2.2. Health Surveillance in Bhutan 25 Box 7.1. Priority Investments to Prevent and Remediate Lead Contamination and Exposure 156 Box 7.2. Priority Policy Reforms to Prevent and Remediate Lead Contamination and Exposure 159 Box 7.3. Institutional Capacities Needed to Prevent and Remediate Lead Contamination and Exposure 164 FIGURES Figure 2.1. Brain Volume Loss (Red to Orange) in Young Men with Lead Poisoning in Early Childhood Compared to a Standard Brain Template (Gray) 11 Figure 2.2. Population-Level IQ Losses and Blood Lead Levels 15 Figure 2.3. Blood Lead Levels and Robbery Rates 19 Figure 2.4. General Conceptual Site Model of Sources for Health Outcomes at ULAB Sites 27 Figure 2.5. Potential Exposure Pathways by Exposure Route and Environmental Media at ULAB-Recycling Sites 28 Figure 3.1. Global Mine Production, 2000–21 (thousand metric tons) 48 Figure 3.2. Lead Usage 49 Figure 3.3. Comparison of Lead Uses in the United States, 1975–2003 49 Figure 3.4. Cumulative Number of Countries Banning Leaded Gasoline, 1986–2021 51 Figure 3.5. Persistent Threats: Diverse Sources of Global Lead Pollution 68 Figure 4.1. Country BLLs from Ericson et al. and the GBD 2019 93 Figure 4.2. Population-Weighted Mean Blood Lead levels (BLLs) in 2019 94 Figure 4.3. Loss of IQ Points from Lead Exposure in Early Childhood 97 Figure 4.4. IQ Point Losses per Child from Pb Exposure by Country Income and Region 98 Figure 4.5. IQ Loss from Lead Exposure 99 Figure 4.6. Relative Risk of CVD Mortality from BLL of 1–20 μg/dL 101 Figure 4.7. CVD Deaths (‘000) from Pb Exposure by Country-Income Classification in 2019 102 Figure 4.8. CVD Deaths (‘000) from Pb Exposure in LMICs by Region in 2019 103 vi A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Figure 5.1. Cost of IQ Losses in Children by Country Income Classification in 2019 113 Figure 5.2. Cost of IQ Losses in Children by Country Income Classification in 2019 114 Figure 5.3. Cost of IQ Losses in Children in LMICs by Region in 2019 114 Figure 5.4. Cost of IQ Losses in Children in LMICs by Region in 2019 114 Figure 5.5. Welfare Cost of Adult Mortality from Lead Exposure by Country Income Classification in 2019 (central estimate) 117 Figure 5.6. Welfare Cost of Adult Mortality from Lead Exposure by Country Income Classification in 2019 (central estimate) 117 Figure 5.7. Welfare Cost of Adult Mortality from Lead Exposure in LMICs by Region in 2019 (central estimate) 118 Figure 5.8. Welfare Cost of Adult Mortality from Lead Exposure in LMICs by Region in 2019 (central estimate) 118 Figure 5.9. Estimated Health and Economic Cost of Global Lead Pollution 120 Figure 6.1. Countries with Lead Paint Laws, December 2022 137 Figure 6.2. Massive Returns: Economic Efficiency of Interventions to Prevent and Reduce Lead Pollution 145 TABLES Table 2.1. Lead Impacts on Human Health, Cognitive Development, and Behavior 9 Table 2.2. IQ Losses and Risk Factors – Estimated Full Scale IQ (FSQ) Point Losses Associated with Different Risk Factors in a Population of 25.5 Million US Children 16 Table 2.3. Overview of Biomarkers of Exposure for Lead 29 Table 2.4. Test Methods for Lead: Strengths and Challenges 30 Table 3.1. Lead (Pb) Concentrations in Various Products 61 Table 3.2. Distribution of Lead Concentrations and the Distribution of Highly Lead-Tainted Samples above the Reference Level across 11 Product Types, Aggregated for 25 Countries 63 Table 5.1. Key Parameters and Values Used for Estimating the Cost of Lead Exposure in Children in LMICs 115 Table 5.2. Global Welfare Cost of Adult Lead Exposure in 2019 116 Table 6.1. Benefits and Costs of Remediating the Mining Dumpsite and Soil Removal in Highly Polluted Residential Areas, Kabwe, Zambia 133 Table 6.2. Permissible Lead Limits and Standards 135 Contents vii Table 6.3. Key Assumptions for Estimation of Benefits of Lead-Free Paint 140 Table 6.4. Benefits and Costs of Banning Leaded Paint in Malawi 141 Table 6.5. Benefits and Costs of Converting to Lead-Free Ceramic Pottery Production in Mexico 141 Table 6.6. Benefits and Costs of Eliminating Lead from Turmeric in Bangladesh and Georgia 143 Table A7.1. Permissible Limits for Lead (Pb) in Water Used for Irrigation and Agricultural Purposes in Various Countries 229 Table A7.2. Permissible Limits for Lead (Pb) in Drinking Water in Various Countries 230 Table A7.3. Permissible Limits for Lead (Pb) in Ambient Air in Various Countries 231 Table A7.4. Permissible Limits for Lead (Pb) In Soil Across Various Countries 232 Table A8.1. Site-Characterization Resources 236 Table A8.2. Criteria for Analytical-Method Selection 237 Table A8.3. Sources of Analytical Guidelines for Contaminated-Site Assessments 238 Table A8.4. US EPA Laboratory Methods 240 Table A9.1. Overview of Biomonitoring Studies 241 viii A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE ACRONYMS Acronym Description ACCLPP Advisory Committee on Childhood Lead Poisoning Prevention ADHD Attention deficit hyperactivity disorder BCR Benefit-cost ratio BLL Blood lead levels CAC Command-and-control CDC US Center for Disease Control and Prevention CKD Chronic kidney disease COED Cost of environmental degradation CSM Conceptual Site Model CVD Cardiovascular disease DALYs Disability-adjusted life years EAP East Asia and Pacific ECA Europe and Central Asia ENSANUT National Health and Nutrition Survey EPA US Environmental Protection Agency EPR Extended product responsibility fMRI Functional magnetic resonance imagery GBD Global Burden of Disease GDP Gross domestic product GRADE Grading of Recommendations, Assessment, Development and Evaluation HICs High-income countries ICCM International Conference on Chemicals Management IOMC Inter-organization Programme for the Sound Management of Chemicals IQ Intelligence quotient IRL Reference level LAB Lead-acid batteries LAC Latin America and Caribbean LICs Low-income countries LMICs Low- and middle-income countries Acronyms ix Acronym Description MDI Mental Development Index MICS Multiple Indicator Cluster Survey MNA Middle East and North Africa NHANES National Health and Nutrition Examination Survey NTP US National Toxicology Program OSHA Occupational Health and Safety Administration PAPM Philippine Association of Paint Manufacturers PCFV Partnership for Clean Fuels and Vehicles Ph Hydrogen potential PM2.5 Fine particulate matter RR Relative risk SA South Asia SAICM Strategic Approach to International Chemicals Management SD Standard deviation SDI Sociodemographic index SDWA Safe Drinking Water Act SSA Sub-Saharan Africa TMREL Theoretical minimum-risk exposure level ULABs Used-lead acid batteries UMI Upper-middle income UNEP United Nations Environment Program USAID United States Agency for International Development USEPA United States Environmental Protection Agency WHO World Health Organization YLL Years of life lost ZMERIP Zambia Mining and Environmental Remediation and Improvement Project x A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE EXECUTIVE SUMMARY There is no known safe blood lead concentration in children and adults. Lead exposure leads to cognitive impairment, learning difficulties, and neurological and behavioral problems in children. It is also associated with conduct disorder and criminal behavior. Lead’s effects on human health include cardiovascular disease (CVD) mortality and morbidity, a higher risk of chronic kidney failure, hypertension, anemia, liver damage, and adverse reproductive outcomes. Exposure to lead during pregnancy, particularly in its late stages, is a risk factor for preterm birth and low birth weight and has significant impacts on infant growth and neuropsychological development. Prenatal lead exposure is associated with increased systolic blood pressure and anemia. Lead pollution also causes significant environmental harm. Its effects include the disruption of ecosystem functions, species decline, and alterations in population dynamics. Lead also impacts the development and reproduction of wildlife and agricultural animals. Once in the biosphere, lead does not break down and can accumulate in the food chain, posing risks to predators, scavengers, and humans consuming contaminated food. Despite the elimination of leaded gasoline in the 1990s and 2000s, which reduced average blood lead levels (BLLs) worldwide, the threat of lead exposure persists. Other sources of lead continue to expose people to this chemical, as studies consistently report elevated BLLs in adults and children. Key sources of lead include recycling of used lead-acid batteries, formal and informal mining and smelting, drinking water contaminated by lead pipes and plumbing materials, paints, cookstuffs and cookware, spices and cosmetics, medicines, toys, e-waste. ammunition and military operations, and automotive and small aircraft emissions. Source apportionment is key to identifying the sources and pathways of lead pollution in areas where the population is exposed to multiple sources. The main global health effects of lead exposure include the loss in children’s intelligence quotient (IQ) and cardiovascular disease (CVD) mortality among adults. The magnitude of these two health effects was estimated for low- and middle-income countries (LMICs) and high-income countries (HICs). Based on estimated global blood lead level (BLL) distributions, as many as 46 and 28 percent of children under five years of age in LMICs had BLLs above 5 and 10 micrograms per deciliter (μg/dL), respectively. Estimated global IQ losses in young children from these BLLs were 765 million in 2019, of which 729 million were in LMICs. This is, on average in LMICs, nearly 5.9 IQ points per child over the child’s first five years of life. Losses are highest in low-income countries (LICs) at 6.7 IQ points per child and xi lowest in high-income countries (HICs) at 2.9 per child. The IQ losses per child are substantial because IQ averages about 100 and a large share of children experience even larger losses from lead exposure. The estimated global CVD adult mortality from lead exposure was 5.5 million in 2019. The number of deaths is over six times as high as previously estimated by the Global Burden of Disease (GBD) 2019. The new estimate is based on a methodology that estimates CVD mortality directly from BLLs, while the GBD 2019 estimated only the indirect effect of lead on CVD mediated through high blood pressure. Lead inflicts significant costs on both children and adults worldwide. Global IQ losses were estimated to cost $1.4 trillion (I$2.4 trillion international dollars). This cost is the present value of lifetime income losses from the IQ loss in 2019. The cost is equivalent to 1.6 percent of global GDP in 2019. This is 1.8 percent of Purchasing Power Parity-adjusted (PPP-adjusted) Gross Domestic Product (GDP). The cost reached 2.2 percent of GDP in LMICs (2.4 percent of PPP-adjusted GDP) and as high as 8.3 percent in Low-income Countries (LICs) (8.5 percent of PPP-adjusted GDP) (Larsen and Sánchez-Triana 2023). The global welfare cost of adult lead exposure, or the cost of cardiovascular disease (CVD) mortality, is estimated at $1.9–6.0 trillion in 2019 (I$ 3.3–10.3 trillion) based on the estimated range of 2.4–7.1 million CVD deaths. The cost is equivalent in size to 2.2–6.9 percent of global GDP in 2019 (2.5–7.7 percent of PPP- adjusted GDP). The central estimate of cost is $4.6 trillion (I$7.9 trillion), equivalent in size to 5.3 percent of global GDP (5.9 percent of GDP (PPP). Various interventions are available to address lead pollution. These include investments and policy reforms. In a wide variety of contexts and cases, the benefits of investments and policy reforms to reduce lead exposure are higher than their costs. Several interventions have the potential to benefit many children and adults while requiring relatively minor investments. Other interventions may have more localized benefits or entail significant costs. However, even in these cases, the benefits outweigh the costs because they result in reduced BBLs and have long- term benefits such as reduced cardiovascular mortality and increased lifetime earnings from intervention beneficiaries. The interventions to tackle lead pollution are worthwhile in diverse locations and at various scales. The economic contributions of lead-related industries are vastly overshadowed by the immense societal costs of lead exposure. To effectively address this crisis, a coordinated approach is required, combining strategic investments and policy reforms to protect people at risk while also focusing on eliminating lead from the global economy. xii A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Investments are required to remediate lead-contaminated soils, replace lead pipes and water solder in plumbing systems, and remove lead-containing paints from buildings. Policy reforms should include updating lead standards in air, soil and water pollution control regulations, phasing out lead-acid batteries, and banning lead-containing paints and lead glazes in foodware, lead-containing consumer products, recycled aluminum cookware, lead-containing military weapons and ammunition. Regular monitoring and data collection are critical for informed decision- making. Establishing comprehensive air, soil, and water monitoring programs and routine health surveillance programs improves the detection of contamination, enabling timely interventions to safeguard communities from exposure. Executive Summary xiii imv / iStock xiv A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 1 INTRODUCTION Exposure to lead (Pb) is arguably one of the most significant challenges faced by countries across all income levels, particularly low- and middle-income countries (LMICs). Several factors contribute to lead’s severe and widespread negative impacts, which negatively affect millions of people globally. There are no safe levels of lead for humans, which means that people experience negative health effects even after being exposed to what could be considered low levels of lead. Many of these health effects are irreversible and have life- long consequences; for instance, children exposed to lead can suffer from impaired intelligence and learning disabilities that will affect their opportunities to learn at school and develop professionally, which will reduce their lifetime earnings. Adults are also vulnerable to lead exposure, which results in increased cardiovascular diseases and, eventually, in premature deaths. Furthermore, there are multiple sources of lead, including many that people associate with healthy habits and traditional practices, such as spices, teas, cosmetics, jewelry, toys, and glazed pottery. Other sources of lead include mining and smelting, recycling of batteries, lead pipes used in water supply systems, paint, electronic and electric appliances, and e-waste, among others. Executive Summary 1 Controlling lead exposure is a priority The health effects of lead include cardiovascular development challenge. Robust evidence shows disease mortality and morbidity, children’s cognitive that lead exposure has significant consequences impairment, learning difficulties, and neurological for individuals, but also for societies at large. It can and behavioral problems. Exposure to lead during reduce the number of children who are considered pregnancy, particularly in its late stages, has gifted and who might become leaders in their significant impacts on infant growth. The chapter society, while increasing the number of children also discusses available tools for screening and who have mild intellectual disabilities and will diagnosing lead poisoning. need help to complete everyday tasks. Impairment of neurological development and behavioral Chapter 3 discusses the extent, sources, problems caused by lead exposure stymie the and pathways of lead exposure. Despite the development of human capital that countries elimination of leaded gasoline in the 1990s need to develop. Furthermore, the poor are more and 2000s, which led to a reduction in average likely than affluent populations to be exposed blood lead levels worldwide, the threat of lead to highly lead-contaminated environments, and pollution persists. Studies reviewed in the chapter consequently, exposure can be an obstacle both to consistently find elevated blood lead levels in poverty reduction and to a more equal distribution children caused by the significant amounts of of the benefits of development. Responding to the lead released by everyday products and industrial widespread and significant effects of lead exposure processes into the environment, underscoring the is not the responsibility of environmental or health ongoing nature of this environmental and public authorities only; it calls for whole-of-government health toxic. The chapter presents an overview of approaches that address all potential sources of trends in lead-mining production and describes lead, adopt policies and regulations to prevent how lead is introduced into different products. It lead exposure, and invest the resources needed to also delves into the risks posed by highly polluting identify and remediate contaminated sites. activities, such as formal and informal mining and smelting, which are responsible for brownfields Despite robust evidence documenting the and lead discharges into the air, water, and soil that tragic and widespread consequences of lead affect both workers and adjacent communities. The exposure, the issue has received little attention chapter also discusses different types of studies from policy makers around the world. Recent that can be developed to craft effective regulations calls to action by the G-7 have increased the and develop data-driven strategies to combat visibility of this issue. This publication aims to pollution and improve public health. contribute to creating a lead-free world by raising awareness about the widespread and significant Chapter 4 quantifies the health effects of health impacts caused by lead exposure, while also lead exposure. It focuses on loss in children’s highlighting best practices and lessons learned intelligence quotient (IQ) and cardiovascular from interventions and policy reforms implemented disease mortality among adults. The chapter to address it. It comprises the following six presents estimates of these two health effects chapters, in addition to the introduction. globally and for countries of different income levels and geographic areas. It shows that IQ losses are Chapter 2 summarizes the scientific evidence on highest in Low-Income Countries, and regionally, in the health effects of lead exposure, which shows South Asia. The analysis presented in this chapter that there are no safe lead levels for humans. also finds that 5.5 million people died from lead 2 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE exposure in 2019, a figure that is over six times as The diversity of examples presented in this chapter high as estimated by the Global Burden of Disease suggests that interventions to tackle lead pollution 2019 report. are worthwhile in diverse locations and at various scales. Chapter 5 presents estimates of the global health cost of lead pollution. It summarizes the findings Chapter 7 presents the conclusions and of research conducted at the World Bank and recommendations. It advocates for a coordinated published in Lancet Planetary Health that calculated approach to address the lead crisis that combines the magnitude of these costs for LMICs and High- strategic investments and policy reforms to income Countries (HICs) (Larsen and Sánchez-Triana protect people at risk while also focusing on 2023). The chapter presents further findings at the eliminating lead from the global economy. regional level and by country-income classification. It emphasizes that investments are required to The chapter finds that global IQ losses were remediate lead-contaminated soils, replace lead estimated to cost $1.4 trillion, which is equivalent to pipes and water solder in plumbing systems, and 1.6 percent of global GDP in 2019. The global welfare remove lead-containing paints from buildings. cost of adult lead exposure is estimated to be Policy reforms should include updating lead $4.6 trillion, which is equivalent in size to 5.3 percent standards in air, soil and water pollution control of global GDP. The significant costs of lead pollution regulations, phasing out lead-acid batteries, and are similar in scale to those of other high visibility banning lead-containing paints and lead glazes pollution challenges, including air pollution or in foodware, lead-containing consumer products, inadequate water supply, sanitation, and hygiene. recycled aluminum cookware, lead-containing military weapons and ammunition. It also Chapter 6 discusses various interventions highlights the importance of regular monitoring available to address the different sources of lead and data collection for informed decision- pollution. These include investments in cleanup making. Establishing comprehensive air, soil, and and remediation programs that address lead water monitoring programs and routine health pollution from recycling of used lead-acid batteries surveillance programs improves the detection of (ULABs) and from mining and smelting operations, contamination, enabling timely interventions to infrastructure works to remove lead pipes in water safeguard communities from exposure. supplies, converting processes and substituting products to eliminate lead exposure from ceramic In sum, this report emphasizes that to improve pots and aluminum cookware, and the purchase overall health and well-being, we must make and administration of iron supplements to protect environments “lead safe,” particularly for children from the negative effects of lead exposure. children. This is no small task; it will require They also include policy instruments such as legal dedication, ingenuity, skill, and concerted effort bans or restrictions on the use of lead in paint and by many people in many sectors. Ensuring that in spices. The analyses presented in the chapter children and adults are not exposed to lead will show that, in a wide variety of contexts and cases, have a direct, immediate, and measurable effect on the benefits of policy reforms and investments to their health. Many of the strategies described here reduce lead exposure are higher than their costs are well documented, and mechanisms to target because they result in reduced blood lead levels and these strategies to at-risk populations are mature. have long-term benefits such as increased lifetime Strengthening and widening these efforts is an earnings by beneficiaries of these interventions. urgent matter. INTRODUCTION 3 umesh negi / iStock 4 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE IMPACTS OF LEAD ON HUMAN CAPITAL AND THE ENVIRONMENT 2 Chapter Overview There is no known safe blood lead concentration in children and adults. Lead exposure leads to cognitive impairment, learning difficulties, and neurological and behavioral problems in children. It is also associated with conduct disorder and criminal behavior. Lead’s effects on human health include cardiovascular disease (CVD) mortality and morbidity, a higher risk of chronic kidney failure, hypertension, anemia, liver damage, and adverse reproductive outcomes. Exposure to lead during pregnancy, particularly in its late stages, is a risk factor for preterm birth and low birth weight and has significant impacts on infant growth and neuropsychological development. Prenatal lead exposure is associated with increased systolic blood pressure and anemia. Lead pollution also causes significant environmental harm. Its effects include the disruption of ecosystem functions, species decline, and alterations in population dynamics lead also affects the development and reproduction of wildlife and agricultural animals. Once in the biosphere, lead does not break down and can accumulate in the food chain, posing risks to predators, scavengers, and humans consuming contaminated food. Health departments and ministries of health, along with environmental agencies, use blood-lead testing surveillance data to monitor BLLs and to identify geographic areas, subpopulations, and ethnic groups. Surveillance data serve as a benchmark against which the impact of interventions to control or eliminate sources of lead can be measured. Executive Summary 5 exhibit challenges completing tasks that require focus, coordination, rapid response times, and decision-making. All these challenges reduce the quality of the labor force and affect societies at large. Lead’s effects on human health include cardiovascular disease (CVD) mortality and morbidity, a higher risk of hypertension, anemia, and chronic kidney failure. Additionally, lead affects the reproductive systems of both males and females. Studies reveal that pregnant women tend to have greater complications due to lead accumulation. Exposure to lead during pregnancy, particularly in its late stages, is a risk factor for preterm birth and low birth weight and has significant impacts on infant growth and neuropsychological development. Prenatal lead exposure is associated with increased systolic LIGHTFIELD STUDIOS / Adobe Stock blood pressure and anemia. Other effects of lead exposure include infertility, miscarriage, neural defects in early childhood, and maternal 2.1. Introduction hypertension. Elevated BLLs in men lead to reduced sperm mobility, fertility, sperm count, and There is no known safe blood lead concentration abnormal sperm morphology (Collin et al. 2022a). in children and adults. Robust evidence shows that lead causes a wide range of long-term Lead does not degrade in the environment negative effects. In children, lead exposure causes and negatively affects species ranging from neurological damage, reduced IQ, behavioral microorganisms and insects to wildlife and problems, stunting, and diverse developmental and agricultural animals. Because it accumulates health issues. Lead exposure can also cause long- in the food chain, lead poses risks to predators, term negative health effects, including increased scavengers, and humans that consume cardiovascular disease. contaminated plants and animals. These impacts can have ecosystem-wide implications, including Affected children often perform poorly in biodiversity loss, changes in population dynamics, school and complete fewer years of education, and reduced ecosystem resilience. which generally leads to diminished skills and job prospects when they become adults. This chapter discusses the effects of lead Behavioral problems, including impulsivity and exposure on humans and on the environment. aggression can limit the employability of exposed It has nine sections. The second section children, while health problems lead to higher examines the measurement of lead in the absenteeism and early retirement. Workers who human body and identifies blood lead levels were exposed to lead during their childhood can (BLL) as the most valuable tool for screening and 6 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE diagnosing lead poisoning. Section 2.3 explains 2.2.  Blood lead measurement the various health and developmental effects that are observed at different BLLs. The fourth Biological samples, such as blood, provide section focuses on the impacts of lead exposure accurate evidence of combined exposure on children’s development, learning, and behavior. to contaminants of concern and exposure The fifth section discusses the linkages between pathways or routes. Such samples also allow lead exposure and cardiovascular health. The for the analysis of possible indicators of health sixth section provides an overview of the health outcomes or nutritional and health status (von effects of chronic lead exposure. Section 2.7 Stackelberg et al. 2022). In the case of lead discusses the importance of surveillance programs. exposure, BLLs are used to diagnose individuals Section 2.8 summarizes guidelines for designing with lead poisoning because symptoms are most representative studies and sampling guidelines often vague or nonexistent at the time of exposure. to estimate the health impacts from exposure to Several other human tissues and fluids, such land-based contaminants from small-scale ULAB as hair, teeth, bone, and urine, also reflect lead recycling activities, including lead. Section 2.9 exposure. However, the concentration of lead in provides an overview of the ecological effects whole blood has gained wide acceptance as the of lead exposure, including negative impacts on most useful tool for screening and diagnostic specific species and at the ecosystem level. The testing. WHO has developed detailed guidelines ninth and final section summarizes the conclusions for blood-lead sampling and laboratory methods of this review of the health impacts of lead (WHO 2011), as well as a guideline for the clinical exposure. management of exposure to lead (WHO 2021). Ольга Симонова / Adobe Stock Impacts of Lead on Human Capital and the Environment 7 To understand BLLs, it is helpful to clarify how As environmental sources of lead are controlled lead levels in blood occur and change over time. or eliminated, there is a steady decline in blood An individual’s BLL reflects an equilibrium between lead in individuals born after the decrease in current environmental lead exposure and the ambient lead levels. This decline has provided an preexisting amount of lead in the body because of opportunity to study the impact of lead exposure earlier lead exposure. This lead is predominantly in children and adults with lower blood lead stored in mineralizing tissues, especially bones concentrations. These studies have been unable and teeth (ATSDR 2023; Latif Wani, Ara, and Ahmad to identify a “safe” BLL—one where there are no Usmani 2015). In young children, approximately adverse effects at the individual or population 70 percent of their total body lead is stored in level and with a margin of safety. In response bones, while in adults, this figure increases to to these findings, the Advisory Committee on about 94 percent (Barry, Todd, and Steenland Childhood Lead Poisoning Prevention (ACCLPP) 2019; Latif Wani, Ara, and Ahmad Usmani 2015). suggested the use of a reference value based on In the case of children, this means that soft tissues the 97.5th percentile of the blood lead distribution like the kidneys, liver, and brain absorb a larger in US children to identify those who require further proportion of lead, potentially leading to significant investigation (ACCLPP 2012). Consequently, using health implications (Latif Wani et al. 2015; Samuel data from the US National Health and Nutrition Collin et al. 2022). The half-life of lead in blood is Examination Survey (NHANES) conducted between about 30 days, but the half-life of lead stored in 2007 and 2010, the blood lead reference value bones can range from years to decades, depending (BLRV) was established at 5 µg/dL. This BLRV on the type of bone and the life stage of the was revised in 2021 and lowered to 3.5 µg/dL individual (CDC 2017; Samuel Collin et al. 2022). (CDC 2021). WHO has recommended a practical The half-life of lead in the tibia can be 7 to 26 years threshold level of 5 µg/dL at which for an individual (McNeill et al. 2018). While BLLs reflect only short- “the source(s) of lead exposure should be identified term exposure to lead, bone lead levels reflect and appropriate action taken to reduce and cumulative exposure. terminate exposure” (WHO 2021). Bone lead levels are a time-integrated measure The link between BLLs and adverse effects of both current and past lead exposure as bone on children’s IQ, academic performance, and is remodeled or metabolized to meet calcium lifetime achievement has been the subject needs during periods of rapid growth and of thousands of studies. In most of the early particular life stages, such as during pregnancy prospective studies, many children had prenatal or and advanced age (ATSDR 2023; Hu et al. 2007; early childhood exposures exceeding 10 µg/dL. In Radulescu and Lundgren 2019). In young children, modern longitudinal studies, BLLs are considered continuous growth results in constant bone high if they exceed either 10 µg/dL or 5 µg/dL, remodeling, and bone lead is exchanged with blood while some studies use both values. Studies, lead much more frequently than in adults (Hu et al. especially those conducted after 2021, are likely 2007). As a result, even after the removal of lead to bring about even lower BLL benchmarks. The sources, children’s BLLs decrease slowly for months findings of selected studies are summarized below. to years due to previous exposures (Gwiazda, Campbell, and Smith 2005). 8 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 2.3.  Lead impacts on human health and children’s development Multiple studies have analyzed the association between BLLs and adverse health impacts and have found that as the concentration of lead in blood rises, so does the severity of the adverse Rawpixel / iStock effects (table 2.1). TABLE 2.1. Lead Impacts on Human Health, Cognitive Development, and Behavior Blood lead Health effects References concentration < 10 µg/dL • Decreased IQ, cognitive performance, academic Hemmativaghef (2022); achievement in children, attention-related behavioral Hong et al. (2014); problems. Kim et al. (2013); • Delayed puberty and reduced postnatal growth and mental development in children. Spontaneous abortion National Toxicology Program (2012); and preterm birth. World Health Organization (2017) • Impaired renal and kidney function, some hearing loss, and hypertension. > 25 µg/dL • Anemia, kidney and liver damage, and short-term Schwartz et al. (2011); memory loss. World Health Organization (2017) • Adverse reproductive outcomes. > 50 µg/dL • Decreased hemoglobin synthesis and damage to the Schwartz et al. (2011); nerves (peripheral neuropathy and reduced nerve World Health Organization (2017) velocity). • Severe neurological features in children. > 100 µg/dL • Abdominal pain/colic, constipation, and vomiting. Agency for Toxic Substances and • Features of acute poisoning and severe neurological Disease Registry (2020); features. Kosnett et al. (2006); • Cerebral edema and damage to brain functions and World Health Organization (2017) structures (encephalopathy). Impacts of Lead on Human Capital and the Environment 9 Adverse effects associated with BLLs as low as of life can compound these risks (Marcus, Fulton, 3.5 µg/dL are consistent across a wide range of and Clarke 2010). Nonetheless, lead poisoning health outcomes, across major physiological can affect the cognitive skills and behaviors of systems from reproductive to renal, among individuals of all ages, with impacts manifesting multiple groups, and from studies using in both childhood and adulthood. A compelling substantially different methods and techniques. body of evidence has demonstrated that lead The US National Toxicology Program (NTP) found causes a continuum of long-term adverse effects sufficient evidence to confirm that, in children, BLLs ranging from subtle decreases in IQ to increased of less than 5 µg/dL are associated with increased likelihood of behavioral problems such as attention diagnosis of attention-related behavioral problems, deficit hyperactivity disorder (ADHD) and stunting greater incidence of problem behaviors, and (Mufune 2024; Ramirez-Ortega et al. 2021). decreased cognitive performance. These problems were indicated by lower academic achievement, Prenatal lead exposure is associated with an decreased IQ, and reductions in specific cognitive increased risk of low birth weight, an important measures. NTP also found (a) limited evidence that predictor of many lifelong adverse health blood lead < 5 µg/dL is associated with delayed effects. Given the wide variations in the effects puberty and decreased kidney function in children ≥ that lead exposure can have on individuals and that 12 years of age and (b) sufficient evidence that BLLs multiple factors affect IQ, it is difficult to predict < 10 µg/dL in children are associated with delayed lead exposure’s long-term impact on an individual puberty and reduced postnatal growth (NTP 2012). child. Nonetheless, even at these low levels, lead A study of 1,150 mothers and their subsequent has significant adverse effects at the population newborns revealed similar findings, suggesting that level. The adult impacts include loss of earnings, exposure to lead during pregnancy, particularly an economic cost borne by society at large during its late stages, has significant impacts on (Bellinger 2017). infant growth (Hong et al. 2014). Mechanisms underlying the adverse 2.4.  Impacts of lead exposure effects of lead poisoning on brain on brain and neurological development development The biological mechanisms underlying the impact of high BLLs in childhood include lead- For decades, lead has been known to cause caused interference with neurotransmission neurological damage in children, which is often and disruption of cell migration during critical reflected in reduced intelligence quotient times of brain development. This is mainly due (IQ) scores (Lanphear et al. 2005). Children to the underdeveloped blood-brain barrier and the are known to be at greater harm from lead than increase in cellular growth during this life stage adults due to children’s higher absorption, intake (Ramirez-Ortega et al. 2021). In a study of young levels, and certain behavioral characteristics such adults whose blood tests showed an average as hand-to-mouth tendencies that make them BLL of 15 µg/dL as young children, there was a more susceptible. Additionally, the development significant inverse association of mean childhood of the blood-brain barrier during the early stages BLL with brain activation in the left frontal gyrus 10 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE and left middle temporal gyrus, as measured by These brain areas and structures are associated functional magnetic resonance imagery (fMRI) with language acquisition, reading, cognition, (Cecil et al. 2008). Further studies on this cohort and executive function. The diminished activation have linked earlier exposure to lead with altered in these regions in subjects with higher childhood myelination and axonal integrity (Brubaker BLLs suggests that lead exposure during early et al. 2009). Similarly, research conducted in lab childhood disrupts the development of the settings has demonstrated that lead can disrupt normative neural substrates of language and has a both the NMDA receptor, a critical component long-term impact on the functional neuroanatomy in brain development, and the calcium-related of language. The Cecil et al. (2008) study (figure 2.1) processes within the brain. This interference, also found evidence of some compensation in that where lead functions as a blocker or mimics there was increased brain activation in the right calcium under certain circumstances, affects the temporal lobe in areas thought to correspond brain´s capacity to establish robust connections closely with the damaged regions in the left between nerve cells and its ability to learn and hemisphere. However, the researchers cautioned adapt. Consequently, this disruption can lead to that a compensatory alternative pathway does not challenges in performing tasks like spatial learning necessarily yield equivalent performance to that and memory (Ramirez-Ortega et al. 2021). achieved using the normal pathway for the same function (Cecil et al. 2022; Yuan et al. 2006). FIGURE 2.1. Brain Volume Loss (Red to Orange) in Young Men with Lead Poisoning in Early Childhood Compared to a Standard Brain Template (Gray) Source: Cecil et al. 2008. Note: Cecil et al (2008) conclude that childhood lead exposure is associated with region-specific reductions in adult gray matter volume. The figure shows the affected regions, which include the portions of the prefrontal cortex and anterior cingulate cortex responsible for executive functions, mood regulation, and decision-making. Cecil et al. (2008) provide the following information to explain the figure above: “A composite representation of regions with significant volume loss for male and female CLS participants (n = 157) associated with mean childhood blood lead concentrations is shown with red and yellow clusters overlaid upon a standard brain template (seen at multiple angles; the first row presents views from the midline of the left and right hemispheres, respectively; the second row demonstrates views from the back and front of the cerebrum, respectively; the third row shows the lateral right and left hemispheres; and the fourth row shows views from below and above the cerebrum).” Impacts of Lead on Human Capital and the Environment 11 GDM photo and video / Adobe Stock Impacts of prenatal and early the risk to deliver preterm, low-birth-weight childhood lead exposure infants compared to those with lower levels (Zhang et al. 2016). Similarly, in Peru, an increase Prenatal exposure to lead is a significant in maternal blood lead resulted in a 76.5-gram predictor of developmental status in early reduction in birth weight at a lead level of 5 µg/dL childhood (Ramirez-Ortega et al. 2021). Lead (Berky et al. 2023, 1). Further research shows that freely diffuses across the placenta and has been a twofold increase in maternal blood lead levels is detected in the brains of fetuses in the first associated with a 47-gram reduction in birth weight trimester. This is evidence that exposure to lead (Issah et al. 2024, 16). A study from Japan suggests occurs prior to the adverse outcomes (Ettinger and that reducing both maternal lead and tobacco Wengrovitz 2010). In a meta‐analysis of 20 studies exposure could decrease low birth weight rates by involving 11,474 newborns exposed to prenatal 27 percent (Nishihama et al. 2022, 6). lead, a significant negative association was found between lead exposure and birth weight, with Lead exposure is believed to be linked to an estimated decline of 79.6 g in birth weight the “South Asia Enigma,” a phenomenon in per 1 μg/dL maternal blood lead (Wang et al. which 25 percent of infants in South Asia 2020). Consistently, studies demonstrate that are born with low birth weight. Globally, low higher maternal lead levels are linked to lower birth weight—often exacerbated by prenatal birth weights and an increased risk of premature lead exposure—is a leading contributor to births, elevating health risks for newborns neonatal illness, mortality, and long-term health (Wang et al. 2020). issues, now recognized as the primary cause of malnutrition-related deaths in children (Aboagye For instance, in China, mothers with elevated et al. 2022; Jana, Dey, and Ghosh 2023; Jeena et al. lead levels in their urine had almost three times 2020; Rahman et al. 2016). 12 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Beyond birth weight, prenatal lead exposure gating process (Kponee-Shovein et al. 2020). This affects other physical growth markers and suggests that maternal BLLs during pregnancy can cognitive development. Lead exposure during predict teenage cognitive functions. pregnancy has been linked to smaller head circumference and shorter body length at birth, In addition to cognitive impacts, lead exposure both of which are important indicators of newborn during pregnancy impairs a child’s ability to health. Significant inverse associations have also manage stress, increasing their risk of future been found between prenatal BLLs and later health issues, including cardiovascular disease. neurobehavior, with studies highlighting how lead Prenatal lead exposure can disrupt the body’s exposure in the womb disrupts brain development, stress management system, passing this burden contributing to cognitive and behavioral challenges on to the child. For instance, children exposed (Kim et al. 2013; Kponee-Shovein et al. 2020; to higher lead levels in the womb—measured by Ramirez-Ortega et al. 2021). Prenatal lead exposure maternal tibia lead levels—experienced a 1 percent weakens connectivity in the fetal brain, particularly increase in allostatic load1 for every 1 µg/g increase between hemispheres responsible for learning in maternal lead (Halabicky et al. 2023, 1). This and coordination, leading to difficulties with allostatic load reflects the body’s inability to cope focus, attention, and self-regulation later in life with stress over time. Additionally, prenatal lead (Thomason et al. 2019, 7). Notably, even moderate exposure disrupts cortisol production, a hormone late exposure in late pregnancy significantly affects critical for stress regulation. Infants whose neurodevelopment in infants, underscoring the mothers had BLLSs of 10 µg/dL or higher during serious cognitive risks associated with prenatal lead pregnancy had 40 percent lower cortisol levels at exposure (Shah-Kulkarni et al. 2020, 5). 12 months compared to those with lower exposure (Gundacker et al. 2021, 6). Reduced cortisol levels In a Republic of Korea study of mothers and can lead to premature maturation of the stress- infants, even relatively low maternal lead response system, resulting in long-term stress- levels in late pregnancy (maternal geometric management difficulties and increasing the risk of mean 1.27 µg/dL (range: 0.12–4.28 µg/dL)) were cardiovascular diseases later in life. Studies of lead- associated with decreased scores on the mental exposed children have also shown reduced cortisol development index (MDI) when infants were levels, linked to sensory-integration problems, six months old. MDI scores decreased by -1.95 such as difficulties with touch, balance, and body for each µg/dL increase in maternal BLL in late awareness (Gundacker et al. 2021, 11). pregnancy (Kim et al. 2013). Similarly, prenatal lead exposure has been associated with cognitive Elevated lead levels during pregnancy may also developmental delays by age two; children of increase the risk of elevated blood pressure in mothers with the highest blood lead concentrations children, setting the stage for cardiovascular were 1.55 times more likely to experience delays complications. Studies have associated higher compared to those whose mothers had the lowest maternal lead levels with increased systolic blood levels (Jia et al. 2023). Research in Mexico City pressure (SBP) in children by the age of five (Farzan further found that prenatal exposure to lead causes et al. 2018; 1,293). Additionally, lead exposure prepulse inhibition (PPI) deficits in children and can cause severe anemia by competing with iron, adolescents. PPI is an indicator of the sensorimotor with an estimated 60%–70% of pregnant women 1 Allostatic load = an index of an individual’s body burden of stress in multiple biological systems. Impacts of Lead on Human Capital and the Environment 13 in LMICs experiencing anemia during pregnancy. levels rise from 20 to 30 µg/dL (Lanphear et al. Exposure to lead is also associated with stillbirths 2005). Similar IQ effects were seen in a study and miscarriages. of 172 New Zealander adults tested for lead at age 11 years (Reuben et al. 2017). Each 5 µg/dL increase in BLL (range 4–31 µg/dL) resulted in a Lead exposure and children’s 1.79-point decrease in IQ. In a study conducted in cognitive abilities Egypt, a 1 µg/dL increase in BLLs was associated with a two-point decline in IQ as measured by Lead exposure also has significant effects the WISC-III full-scale IQ instrument (P < 0.001; on IQ, with several analyses suggesting an 95 percent confidence interval (CI) 1.5–2.9 decline). association between lead exposure and a The best cutoff value of BLLs above which most decrease in IQ. Children with BLL > 5 µg/dL or of the study children had cognitive dysfunction equal can score between three to five points lower was 9 µg/dL (sensitivity 94.6 percent and in intelligence tests compared to children with specificity 87.3 percent) (Mostafa, El-Shahawi, and lower lead concentrations (Lanphear et al. 2018). Mokhtar 2009). Lead exposure is thought to be responsible for 10 percent of intellectual disability cases where the Lead poisoning will also have important effects cause is unknown (Rees and Fuller 2020). at the population level. Although the effects of lead can be devastating for an individual In a 2020 study encompassing 3,316 children child, many children have BLLs that cause subtle across eight case-control studies, a compelling decreases in IQ or academic performance. link emerged between lead exposure and These changes may go unnoticed by health-care a reduction in IQ. The case group comprised providers or educators. However, typical ways children exposed to lead levels surpassing of measuring the burden of disease for lead in 10 µg/dL, while the control group encompassed a population include quantifying the number those with lower exposure levels. Given the of children who will meet the definition of mild variation in lead-exposure durations within the cognitive disability (IQ < 70) or fail to meet the studies, researchers conducted a subgroup definition of gifted (IQ ≥ 130). These methods analysis. Within the subgroup exposed to lead for demonstrate some of the adverse effects of lead less than 4.5 years, a gap of 3.53 IQ points was on children’s health. For example, reducing the observed, with the control group displaying higher population mean IQ from 100 to 95, as can be scores. Similarly, in the subgroup exposed to lead expected to occur as BLLs move from 2 to 8 µg/dL, for more than 4.5 years, a 22.63 IQ point difference will increase the number of children defined as was reported between the control and case groups having mild intellectual disability by an estimated (Heidari et al. 2022). 9.4 million (57 percent). In addition, the number of children who are considered gifted will decline A pooled analysis of seven longitudinal cohort from 6 million to 2.4 million (World Bank based studies also suggested that the rate of decline on Lanphear et al. 2018). As a result, there will in IQ loss per µg/dL of lead in blood is greater be a 57 percent increase in children needing at BLLs < 10 µg/dL. The analysis showed a loss some help with activities of daily living while of 6.2 IQ points as BLLs move from 1 to 9 µg/dL, there is a comparable decrease in high-achieving compared to two IQ points as levels move from children expected to be leaders in their societies 10 to 19 µg/dL. A further 1.1 IQ points are lost as (figure 2.2). 14 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE FIGURE 2.2. Population-Level IQ Losses and Blood Lead Levels Mean IQ 100 Mean IQ 95 57% increase 6 million mild mental retardation 6 million gifted 9.4 million mild mild mental retardation 2.4 million gifted 20 40 60 80 100 120 140 160 180 20 40 60 80 100 120 140 160 180 Source: World Bank based on Lanphear et al. 2018. As strong as this picture is, it may result of lead exposure in US children; and second, underestimate the population implication comparing this to the estimate of IQ points lost of BLLs in childhood by failing to account for to common congenital anomalies, cancers, and those IQ points lost by children in the middle other chemical exposure in children (table 2.2). This of the IQ distribution. Based on an international estimate may not be generalizable to low-income pooled analysis of longitudinal studies of blood countries where communicable diseases also affect lead and IQ and the US National Health and children’s development. However, the estimate Nutrition Examination Survey (NHANES) survey, does suggest that unless the adverse effects of lead Bellinger (2012a,b) has proposed the following: on the population are measured as a whole, there First, quantifying the total number of IQ points lost, is a risk of seriously underestimating lead’s impacts measured using the Full Scale IQ (FSIQ) test, as a on public health (Bellinger 2012a). CineLens/peopleimages.com / Adobe Stock Impacts of Lead on Human Capital and the Environment 15 TABLE 2.2. IQ Losses and Risk Factors – Estimated Full Scale IQ (FSQ) Point Losses Associated with Different Risk Factors in a Population of 25.5 Million US Children Risk factor Total no. of FSIQ points lost Medical conditions Congenital heart disease 104,805 Preterm birth 34,031,025 Type 1 diabetes 185,640 Acute lymphocytic leukemia 135,788 Brain tumors 37,288 Duchenne muscular dystrophy 68,850 Neurodevelopmental disorders Autism spectrum disorder (ASD) 7,109,899 Pediatric bipolar disorder 8,164,080 Attention deficit/hyperactivity disorder (ADHD) 16,799,400 Postnatal traumatic brain injury 5,827,300 Socioeconomic, nutritional, and psychosocial factors Nonorganic failure to thrive 5,355,000 Iron deficiency 9,409,500 Environmental chemical exposures Methylmercury 284,580 Organophosphate pesticides 16,899,499 Lead 22,947,450 Source: Bellinger 2012a. Reproduced with permission from David Bellinger; further permission required for reuse. Beyond its effects on IQ, lead exposure also For instance, in Korea, children with BLLs above disrupts other areas of cognitive development, 2.3 µg/dL faced a 2.5-fold greater risk of ADHD including attention and behavioral regulation, (Park et al. 2016, 5), while in India, children increasing the risk of attention deficit/ diagnosed with ADHD had median hair lead levels hyperactivity disorder (ADHD). Exposure to of 3.12 µg/dL, compared to 1.1 µg/dL in controls lead has been linked to various ADHD subtypes, (Nayak et al. 2023, 156). In Guiyu, China, children with even low BLLs increasing the risk. Studies with BLLs above 10 µg/dL had 2.4 times higher risk show that BLLs below 3 µg/dL are associated of developing ADHD compared to those with lower with ADHD symptoms, reinforcing that no level levels (Zhang et al. 2015, 4). Similar associations of lead exposure is safe (Donzelli et al. 2019; have emerged globally: Children with moderate Farmani et al. 2024). BLLs between 5 and 10 µg/dL in Massachusetts, US, showed a 66 percent higher likelihood of ADHD Even minimal lead exposure can impair diagnosis (Ji et al. 2018), and in Canada, each unit neurodevelopment and contribute to ADHD. increase in BLL raised ADHD risk by 2.08 times 16 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE (Arbuckle et al. 2016, 93). Research in Chile showed functioning. Such outcomes lead to increased a 2.33-fold increased risk of ADHD for children with aggressive behavior, impulsivity, attention deficit BLLs at 5 µg/dL or higher (Muñoz et al. 2020), while hyperactivity disorder (ADHD), and lower IQ, all of a study in Egypt revealed significantly higher lead which are characteristics known to be associated levels in children with ADHD compared to control with violent behavior (WHO 2017). groups, particularly noting an elevated risk among female patients with inattentive-type ADHD (El- Early childhood exposure to lead—including Morsi et al. 2019). prenatal and postnatal exposure, such as through breast milk—has been found to Lead exposure is particularly associated with influence behavior (Ramirez-Ortega et al. hyperactivity and impulsivity. A German study 2021). Prospective data from the Cincinnati Lead reported that for each doubling of BLLs, impulsivity Study measured blood lead quarterly across the increased by 20 percent, and the overall ADHD first 78 months of life and the number of times a scale increased by 9 percent (Donzelli et al. 2019, person was arrested across the life course (from 6). In Mongolia, children exhibiting all three ADHD ages 18 to 33) and in later adulthood (ages 27 subtypes—inattentive, hyperactive/impulsive, to 33) (Wright et al. 2021). Childhood blood lead and combined—had significantly higher hair lead concentration prospectively predicted variation levels (Amgalan et al. 2020). A study in Belgium in adult arrests and arrests over the life course, also found that prenatal lead exposure significantly indicating that lead absorption is associated with increased hyperactivity at ages 7–8, with a doubling crime. Winter and Sampson (2017) also found that of lead exposure linked to a 3.43-fold increase a 1 µg/dL increase in childhood BLL significantly in ADHD risk (Sioen et al. 2013, 229). Similar predicts a 0.37-point increase in adolescent associations have been found in Mexico, where low impulsivity, anxiety, and depression. levels of lead exposure were positively linked to hyperactive and impulsive behavior (Huang et al. The association between preschool lead 2016, 868). exposure and later delinquent behavior has been studied in some detail over the last several decades. The first study to report that Childhood lead exposure and lead poisoning was the strongest predictor of behavioral problems criminal behavior in males was a 1,000-child longitudinal study in Philadelphia (Denno 1990). The correlation between lead exposure and In a later longitudinal-cohort study, an association crime has been documented in case-control between low-level prenatal lead exposure and studies that compare criminal behavior in behavioral problems in adolescents was found, children with high BLLs versus children from supporting findings in previous case reports and similar socioeconomic backgrounds with low cross-sectional studies (Dietrich et al. 2001). There BLLs (Doleac 2017). Lead exposure has also been were consistent findings in a subsequent case- found to be associated with aggressiveness and control study of 194 adolescents ages 12–18 who other conduct problems, including antisocial were convicted of delinquency compared to 146 behaviors (Higney et al. 2022; Marcus, Fulton, nondelinquent controls from nearby high schools. and Clarke 2010; Winter and Sampson 2017). In The cases had significantly higher mean bone lead addition, exposure to lead in childhood can affect levels compared to controls (11 ppm vs. 1.5 ppm) neuropsychological development and cognitive and were four times more likely than controls to Impacts of Lead on Human Capital and the Environment 17 have bone lead levels > 25 ppm after adjusting later in life found a very strong association between for the usual confounding factors (Needleman high BLLs and subsequent crime rates over time et al. 2002). This study suggests that reduced in Australia, Britain, Canada, Finland, France, Italy, brain volumes in regions responsible for cognition New Zealand, and West Germany (figure 2.3) and emotional regulation are linked to childhood (Nevin 2007). lead exposure and subsequent criminal arrests (Beckwith et al. 2021). In one ecological study, researchers found that cities using lead water pipes had homicide In a longitudinal-prospective study of 376 rates that were 24 percent higher 20 years infants, those individuals with higher lead levels later than cities that did not use lead water in childhood had a higher rate of arrest and a pipes (Fiegenbaum and Muller 2016). Another decrease in brain volume as young adults. For ecological study of census tract BLLs and assault every 5 µg/dl increase in BLLs at age 6, the risk of rates 21 years later was conducted in St. Louis, being arrested for a violent crime as a young adult Missouri. The study found that, controlling for increased by almost 50 percent (Wright et al. 2008). concentrated disadvantage, the census tracts Several studies have also highlighted an association with the highest percentage of children with between lead exposure and children’s behavior BLLs ≥ 5 µg/dL had > 7 times violent crimes rates (Rees and Fuller 2020). A 1 unit increase in BLL than census tracts with the fewest children with increases the probability of suspension from school BLL ≥ 5 µg/dL (Boutwell et al. 2016). by 6.5 to 9.3 percent, as reported (Aizer and Currie 2019). Aizer and Currie (2019) found a statistically Talayero et al. (2023) conducted a systematic significant effect between BLL and incarceration review of the association between lead exposure rates for boys. While estimates are not precise, they and crime. The review included a total of 17 peer do suggest that a 1 increase in BLL can increase reviewed studies. The review identified a wide the probability of incarceration between 27 and range of diverse outcomes between exposure to 74 percent. Emer et al. (2020) also found that as lead at multiple windows of development and later the concentration of lead in blood increases, so delinquent, criminal, and antisocial behavior. The does the risk of firearm-violence perpetration. The outcomes that were significantly associated with authors suggest that individuals with BLL between lead exposure were primarily those related to an 5 to 10 µg/dL and 10 to 20 µg/dL have a risk ratio of arrest, incarceration, or conviction of some type. 2.5 and 3.1, respectively (Emer et al. 2020; Talayero The review also found that these effects increased et al. 2023). when the magnitude of lead exposure increased. Even studies that did not find links between lead Extending this logic to national and exposure and criminal behavior found that lead international crime statistics, Nevin showed exposure was linked with antisocial behavioral that lead-exposure trends explained much of traits. The authors concluded that their review, in the variation in US violent crime rates from 1960 conjunction with the available biological evidence, to 1998 (Nevin 2000). A 2001 study found that in demonstrates that an excess risk for criminal US counties, air lead levels significantly predicted behavior in adulthood exists when an individual murder rates (Stretesky and Lynch 2001). Similar is exposed to lead in utero or during childhood associations between preschool BLLs and crime (Talayero et al. 2023). 18 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE FIGURE 2.3. Blood Lead Levels and Robbery Rates Average preschool Crime rate per Average preschool Crime rate per blood lead 100,000 blood lead 100,000 30 300 30 300 25 250 25 250 20 200 20 200 15 150 15 150 10 100 10 100 5 50 5 50 0 0 0 0 3 8 3 8 3 8 3 8 3 8 40 58 45 63 50 68 55 73 60 78 65 83 70 88 75 93 80 98 85 03 90 08 95 13 8 97 97 98 98 99 99 00 00 01 01 01 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 20 19 : 20 19 : 20 :1 :1 :1 :1 :1 :1 :2 :2 :2 :2 :2 50 55 60 65 70 75 80 85 90 95 35 19 19 19 19 19 19 19 19 19 19 19 Lead year: Crime year (23 year lag) Lead year: Crime year (23 year lag) Australia average preschool blood lead Canada average preschool blood lead Australia robbery through 2002 (Nevin 2007 analysis) Canada robbery through 2002 (Nevin 2007 analysis) Australia robbery trend in 2002–18 Canada robbery trend in 2002–18 Average preschool Crime rate per Average preschool Crime rate per blood lead 100,000 blood lead 100,000 30 300 30 300 25 250 25 250 20 200 20 200 15 150 15 150 10 100 10 100 5 50 5 50 0 0 0 0 40 58 45 63 50 68 55 73 60 78 65 83 70 88 75 93 80 98 85 03 90 08 95 13 8 40 8 45 63 50 68 55 73 60 78 65 83 70 88 75 93 80 98 85 03 90 08 95 13 8 01 95 01 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 20 19 : 20 19 : 20 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 19 19 : 20 19 : 20 19 : 20 :2 :1 :2 35 35 19 19 19 Lead year: Crime year (23 year lag) Lead year: Crime year (23 year lag) Britain average preschool blood lead USA average preschool blood lead Britain robbery through 2002 (Nevin 2007 analysis) USA robbery through 2002 (Nevin 2007 analysis) Britain robbery trend in 2002–18 USA robbery trend in 2002–18 Source: Nevin 2020. © R. Nevin. Reproduced with permission from Rick Nevin; further permission required for reuse. Impacts of Lead on Human Capital and the Environment 19 Juan / Adobe Stock 2.5.  Lead exposure and ischemic heart disease (Lanphear et al. 2018, e181; Lanphear et al. 2024). Lead exposure is cardiovascular health associated with a 151% higher risk of stroke (Lamas et al, 2021). Several studies have tracked Lead exposure poses a significant threat to the age-standardized death rates from stroke cardiovascular health, increasing the risk of attributable to lead exposure, confirming lead’s serious conditions. Individuals exposed to lead contribution to cerebrovascular disease (Dang are 85 percent more likely to develop coronary et al., 2024). Growing evidence suggests that heart disease compared to those with lower lead exposure promotes atherosclerosis, the exposure levels. Additionally, they face a 4 percent major mediator of cardiovascular disease. Lead higher risk of overall cardiovascular disease and has been shown to promote atherosclerosis in a 63 percent higher risk of stroke (Chowdhury experimental models, and associations have et al. 2018). Even low levels of lead exposure are been found between low-level lead exposure linked to increased risks of various cardiovascular and atherosclerosis in human carotid arteries diseases, including ischemic heart disease, (Rosengren et al., 2025). This underscores the fact hypertension (high blood pressure), and strokes that even small increases in lead levels can have (Lanphear et al. 2018; Lanphear et al. 2024). a significant impact on heart health. Individuals For example, increasing BLLs from 1.0 µg/dL already at risk for cardiovascular disease due to to 6.7 µg/dL is associated with a 70 percent other factors are even more vulnerable to the higher risk of death from cardiovascular disease effects of lead, experiencing more than double the and a 108 percent higher risk of death from risk when lead levels rise (Park and Han 2021, 6). 20 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Lead exposure is a serious threat to the heart and blood vessels. This disruption can cardiovascular health that can have lasting lead to conditions such as high blood pressure, effects. Once in the body, lead can be stored a well-known risk factor for heart disease and in bones or bind to red blood cells for decades. stroke (Lamas et al. 2023; Lamas, Ujueta, and This prolonged storage means that even after Navas-Acien 2021). Furthermore, lead competes exposure has ended, lead can gradually leach back with zinc and copper, which play key roles in into the bloodstream. Over time, the continuous regulating cellular functions and protecting against presence of lead in the body can harm critical damage. Over time, this replacement can lead to systems, including the cardiovascular system, atherosclerosis, a condition characterized by the brain, and kidneys, creating a long-term risk for buildup of plaque in the arteries, making them heart and blood vessel health (Lamas et al. 2016; narrower and stiffer, thereby restricting blood flow. Lamas, Ujueta, and Navas-Acien 2021; Zachariah Research indicates that even small increases in et al. 2024). blood lead levels are associated with a 3 percent higher risk of developing atherosclerotic plaque Previous estimates primarily focused on blood for every 10 µg/L rise in blood lead (Guldbrand pressure and hypertension as the key factors et al. 2024, 4). linking lead exposure to CVD. However, emerging estimates have uncovered a more intricate picture, Lead also contributes to harmful processes that indicating that lead exposure affects not only can further damage the cardiovascular system. cardiovascular health through blood pressure but One of these effects is oxidative stress, which also exerts direct effects. A comprehensive meta- occurs when harmful molecules accumulate and analysis, pooling data from more than 30 original damage cells, including those in the arteries. This studies and 60,000 participants, examined the cellular damage weakens the walls of blood vessels, relationship between BLLs and blood pressure or making it easier for plaque to build up and further hypertension (Navas-Acien et al. 2007). The meta- compromise arterial health (Chowdhury et al. 2018; analysis concluded that the estimated increase in Guldbrand et al. 2024). Additionally, lead reduces systolic blood pressure associated with a 2-fold the production of nitric oxide, a crucial molecule increase in blood lead levels (for example, from that helps blood vessels relax and maintain healthy 5 to 10 µg/dL) ranged across reviews from 0.6 to blood flow. When nitric oxide levels drop, blood 1.25 mmHg. The evidence in that systematic review vessels become stiffer and narrower, making it is sufficient to infer a causal relationship between more challenging for the body to regulate blood lead exposure and elevated blood pressure pressure effectively. This can lead to elevated (Navas-Acien et al. 2007). blood pressure, significantly increasing the risk of cardiovascular problems, including heart attacks Lead has detrimental effects on cardiovascular and strokes (Lamas, Ujueta, and Navas-Acien 2021; health due to its ability to disrupt essential Zachariah et al. 2024). bodily functions. One significant mechanism is its replacement of vital minerals such as calcium, Lead exposure has far-reaching consequences zinc, and copper, which are crucial for maintaining for cardiovascular health. Research has found proper heart and blood-vessel function. When a significant correlation between higher lead lead replaces calcium in tissues, it interferes with levels and elevated systolic blood pressure, along essential processes like muscle contractions in with decreased levels of “good” HDL cholesterol, Impacts of Lead on Human Capital and the Environment 21 which further contributes to heart disease risk liver damage, anemia, stunting, peripheral (Park and Han 2021, 6). Moreover, lead exposure neuropathy, short-term memory loss, and can lead to changes in gene function, affecting adverse reproductive outcomes. Acute high- how heart and blood vessel cells work. This occurs level lead exposure (BLLs ≥ 70 µg/dL) is less well by altering how genes are expressed without studied. However, case reports describe symptoms changing the actual DNA (Lamas et al. 2016; of abdominal pain/colic, vomiting, constipation, Lamas et al. 2023). peripheral neuropathy, cerebral edema, and encephalopathy, which can lead to seizures, coma, Experimental studies conducted to estimate and death (ATSDR 2020; Kosnett et al. 2007). the health effects of lead found that chronic exposure to this substance caused A growing body of evidence implicates low-level hypertension and enhanced the development chronic lead exposure (BLLs as low as 5 µg/dL) as of atherosclerosis by inactivating nitric oxide, an important risk factor for all-cause mortality, increasing the formation of hydrogen peroxide, cardiovascular disease mortality, and ischemic inhibiting endothelial repair, impairing heart disease mortality. Co-existing risks or angiogenesis, and promoting thrombosis. conditions such as diabetes, hypertension, and In addition, higher concentrations of lead in smoking cigarettes in concert with chronic low- human beings’ blood have been associated with level lead exposure increase the risk of mortality hypertension, electrocardiographic abnormalities, (Lanphear et al. 2018; Lanphear et al. 2024; Larsen peripheral arterial disease, and left-ventricular and Sánchez-Triana 2023). hypertrophy (Aoki et al. 2016; Khalil et al. 2009; Lustberg and Silbergeld 2002; Menke et al. 2006; Navas-Acien et al. 2006; NTP 2012; Pirkle et al. 2.7.  Surveillance and 1985; Schrober et al. 2006; Weisskopf et al. 2009; identification of hotspots USEPA 2006). The cardiovascular effects of lead extend The existing studies provide a compelling beyond increased blood pressure and argument that supports taking a closer look hypertension. Lead exposure is associated with at blood and environmental lead levels in an increased incidence of coronary heart disease, most countries, particularly LMICs. Public stroke, and peripheral arterial disease (Navas-Acien health surveillance is critical for the identification et al. 2007). In a study of more than 6,000 people, and prevention of emerging and reemerging even after adjusting for other factors that predict diseases that account for the greatest burden of the risk of cardiovascular disease, higher BLLs were diseases. Such surveillance should provide health independently related to a higher risk of subclinical information in a timely manner so that countries myocardial infarction (Wang et al. 2022). can make informed decisions on proactive measures to safeguard public health. 2.6.  Chronic lead exposure Health departments and ministries of health, along with environmental agencies, The adverse health effects of chronic high- use blood-lead testing surveillance data to level lead exposure (BLLs ≥ 25 µg/dL) have monitor BLLs and to identify geographic been well studied and include kidney and areas, subpopulations, and ethnic groups. 22 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Surveillance data serve as a benchmark Nearly all national surveillance data come from against which the impact of interventions to studies in high-income countries, with a few control or eliminate sources of lead can be exceptions. Nonetheless, an increasing number measured. of organizations are providing technical and/or financial support for improved public health In some countries, population-based surveillance, including lead poisoning. For example, biomonitoring is also conducted to provide in 2018, UNICEF, in partnership with the National robust, population-based estimates of Statistics Office of Georgia, carried out a Multiple the nature and extent of lead poisoning Indicator Cluster Survey (MICS) in Georgia (UNICEF and generate statistics that describe the 2019) (box 2.1). Bhutan has similarly taken steps to distribution of BLLs in the population. For establish a national surveillance system to monitor example, in the US, NHANES conducts surveys children’s lead levels (box 2.2). The Government of the concentrations of many chemicals in of Bangladesh announced the launch of the MICS two-year waves. These surveys provide data for Round 7 (2024–25), which will include a model for a nationally representative sample of the US collecting data on BLLs and other toxic metals population. With the removal of lead in gasoline for the first time in the country. This decision and the systematic control or elimination of was influenced by research conducted in 2022 by other sources of lead, the NHANES, as well as UNICEF and other partners that analyzed BLLs population-based surveys of Germany, Korea, in children in Dhaka and four districts. Lead was and Poland have documented a significant and detected in all samples, with 40 percent of children sustained decrease in average BLLs in these in four districts and 80 percent in Dhaka exceeding countries. the 5 µg/dL threshold (UNICEF Bangladesh 2024). Additionally, Pure Earth conducted a market Because programs are often charged with screening that found lead contamination in identifying the populations at the highest 24 percent of tested consumer products, with risk for elevated BLLs, the data may have higher levels in metallic foodware (59 percent), a positive bias. Reporting criteria vary by paints (54 percent), and ceramic foodware jurisdiction. Facilities and laboratory methods (44 percent) (Sargsyan et al. 2024). A 2020 study also vary considerably by jurisdiction (WHO 2011). reported the results of BLLs taken of 31,373 For these reasons, surveillance data should not children in China between 2013 and 2015 (Li et al. be compared across jurisdictions. Nonetheless, 2019). In Mexico, BLLs of 1,457 children taken as a jurisdiction can reasonably use surveillance part of the National Health and Nutrition Survey data to compare progress within that same (ENSANUT) were reported in a 2018 study (Téllez- jurisdiction over time under the assumption that Rojo et al. 2019). Countries expected to report the underlying mechanisms for screening and national findings beyond 2024 include Bangladesh, reporting do not vary substantially. Ghana, Peru, and the Philippines, among others. Impacts of Lead on Human Capital and the Environment 23 BOX 2.1. Georgia’s Environmental Health (lead) Surveillance System Since 2018, the Government of Georgia (GoG) with elevated BLLs and adopt a more systematic has made significant strides in addressing lead approach to tackle lead exposure. pollution, including the launch of the Environmental Health (lead) Surveillance System in 2023. Key In 2019, the Prime Minister established an efforts began when the GoG, in partnership with interministerial working group on combatting lead UNICEF, decided to include a blood sampling exposure, leading to the approval of the State Health component in the 2018 National Multiple Indicator Programme on lead. In 2020–21, the GoG adopted Cluster Survey (MICS-2018) to measure children’s regulations on toxicants in toys and varnishes and BLLs. The MICS is a multipurpose household survey, began monitoring toys sold in Georgia. designed to collect internationally comparable and representative data on a wide range of indicators The establishment of NCDC’s Chemical Risk-Factor about women and children. Research Laboratory marked another milestone in the development of Georgia’s lead surveillance The survey, conducted by UNICEF in collaboration system. With support from UNICEF and other with Georgia’s National Center for Disease Control development partners, the laboratory was fully and Public Health (NCDC), the National Statistics equipped and its staff trained in 2021. Partner Office of Georgia, and the Italian National Institute support included the following: of Health (Istituto Superiore di Sanitá–ISS), collected blood samples of 1,578 children age 2–7. • Acquisition of equipment. Four X-ray Integrating a BLL module into the MICS allowed for fluorescence analyzers, portable handheld data collection at a lower cost and more efficiently devices to test toxic metal content in different than through a separate BLL survey. It also kinds of specimens; an atomic absorption enabled analyses of the relationship between lead spectrometer for determining concentrations prevalence and other standard MICS indicators, of chemicals such as lead, mercury, cadmium such as water quality and wealth index. or arsenic in blood, water or food; and a triple quadrupole inductively coupled plasma mass The blood samples collected by the MICS were spectrometer for isotope ratio analysis to analyzed at the ISS’s laboratory using inductively identify sources of lead exposure, along with a coupled plasma mass spectrometry, the “gold gas chromatograph and a liquid chromatograph. standard” for lead testing. ISS also conducted stable isotope ratio analysis to help trace sources of • Quality assurance through collaboration with contamination. international reference laboratories. Findings revealed that with 41 percent of children The Environmental Health (Lead) Surveillance had a BLL ≥ 5 µg/dL, with regional disparities System was designed to systematically monitor ranging from 18 percent in the eastern province of lead levels in children, products, and the Kvemo-Kartli to 85 percent in the western region of environment. It enables scientific data collection Adjara. These results prompted the GoG to launch and analysis, source identification, and follow-up a clinical follow-up program targeting children for affected children. Source: UNICEF 2023. 24 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE BOX 2.2. Health Surveillance in Bhutan Bhutan conducted the National Blood Lead of anemia was 32.0% among children with BLLs Level Survey 2024, the country’s first nationally of less than 3.5 µg/dL and increased to 50.1% representative household survey on BLLs in among children with BLLs between 10.0 µg/ dL and children. Bhutan’s experience illustrates the 19.9 µg/ dL. Similarly, as BLLs increased, a higher importance of surveillance to establish a robust percentage of children had developmental delays baseline of BLLs in the population, understand the in problem solving/cognition, personal-social, and distribution of lead poisoning across geographic overall developmental domains. 17.2% of children areas, and identify socio-economic factors with a BLL of 10-19.9 µg/dL had a developmental associated with higher blood levels. delay, compared with 32.7% of children with a BLL ≥20 µg/dL. The survey was a subset of the National Health Survey (NHS) and included a sample of 2,959 Compared with children living in a home with children aged 1-6. The survey considered the blood cement/ tile/marble floors, those living in a home lead reference value of 3.5 µg/dL established with other materials were significantly more by the US Centers for Disease Control and likely to have a BLL ≥3.5 µg/dL. The likelihood was Prevention (CDC) to identify children who may highest for children living in a home with wood/ need intervention. The survey found that 75.9% of bamboo flooring (2.42 times more likely), followed children had a BLL ≥3.5 µg/dL, with children one by those living in a home with exterior mud-based/ and two years old showing the highest rates at rammed walls (1.62 times higher) and those living 78.8% and 78.56%, respectively. The percentage of in homes with interior mud-based/rammed walls children 1-6 years old with a BLL ≥3.5 µg/dL was (1.42 times higher). A possible explanation of slightly higher in urban areas (77%) than in rural this finding is that cleaning wooden floors might areas (75.2%). be more difficult than cleaning other types of flooring if dust is contaminated with lead. However, The analysis found significant variations in additional testing of the flooring and dust is children’s BLLs across various dzongkhags needed to confirm this finding. (administrative sub-divisions) and regions in Bhutan. In seven out of the 20 dzongkhags, more The type of religion practiced in the household than 90% of children had BLLs ≥3.5 µg/dL, with showed a highly statistically significant association the highest percentage found in Paro (98.7%). In with higher BLLs. Children living in households contrast, 13.3% of children had a level ≥3.5 µg/dL practicing Hinduism and Buddhism were 1.26 in Phuentsholing Thromde (an urban area under and 2.85 times, respectively, more likely to have Chukha Dzongkhag). Nationally, the mean BLL a BLL ≥3.5 µg/ dL than children in a household of children aged 1-6 was 5.3 µg/ dL, with higher practicing Christianity. These results seem to be BLL values concentrated in western and central linked to results showing that 44.2% of Jinlab pills dzongkhags, including Paro (6.8 µg/dL), Dagana containing sacred medicinal substances had lead. (6.7 µg/dL), and Mongar (6.6 µg/dL). While children from households practicing the three religions had been given a Jinlab religious pill The survey also found an association between BLLs, at least once in their life and in the six months prior anemia, and developmental delays. The prevalence to the survey, the percentages were significantly Impacts of Lead on Human Capital and the Environment 25 BOX 2.2. Health Surveillance in Bhutan (continued) higher for household practicing Buddhism BLL ≥3.5 µg/dL than in urban areas (56.0%). 61.3% (71.6% of children had been given a pill at least of women with less than a class 12 education had once and 56.1% in the past six months), compared a BLL ≥3.5 µg/dL, compared with 56.5% of those with households practicing Hinduism (32% and with a class 12 education or higher. In the case of 19.9%, respectively) and households practicing children in monastic institutions, the survey found Christianity (6.9% and 6%, respectively). that 86% had a BLL ≥3.5 µg/dL and that children in monastic institutions had a higher mean BLL The survey also tested 124 pregnant women and (5.9 µg/dL) than the sampled children aged 1-6 breastfeeding women who had delivered within the (5.3 µg/dL). previous six months, and 207 children ages 4-12 from 17 monastic institutions. These results were The survey also identified sources of lead not nationally representative but provided the first exposure. The tested items that had lead levels data ever in Bhutan on BLLs in these demographic above the reference threshold included 75.2% groups. of religious items; 60.7% of latches, bolts, locks, and doorknobs; 50% of brass and metal utensils; The results showed that 58.9% of pregnant or 44.2% of Jinlab pills; 36% of drinking cups and breastfeeding women had a BLL ≥3.5 µg/dL. glasses; 25% of aluminum utensils; and 20% Slightly more women in rural areas (60.8%) had a of spices. Source: Ministry of Health, Royal Government of Bhutan. 2024. 2.8.  Appraisal of contaminants (including lead) originating environmental health from ULAB activities for particularly vulnerable populations, such as children, and the general impacts from recycling of population within a single household in the used lead-acid batteries2 vicinity of ULAB sites in LMICs. To achieve this objective, biomonitoring and health-outcome Von Stackelberg et al. (2022) developed general data are linked to household survey data and guidelines for designing representative studies environmental data (for example, soil, dust, and developing uniform sampling guidelines water, agricultural products, and fish) at the to estimate the health impact from exposure individual level from an exposed population to land-based contaminants from small-scale compared to individuals from an unexposed ULAB recycling activities, including lead. (reference) population. The guidelines provide The guidelines’ recommendations aim to guide sample-size recommendations for lead and other research to assess the relationship between contaminants, as well as environmental media, environmental contamination, exposures, biological sampling data, household survey data, and health outcomes related to a subset of and health outcome data. 2 This section draws from von Stackelberg et al. 2022. 26 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE The guidelines are based on a Conceptual the pathways and routes by which individuals in Site Model (CSM), which provides a qualitative, the population can be exposed to lead and other graphical overview of the relationship contaminants. between sources of contaminants, migration of contaminants through the An exposure pathway refers to the physical environment, exposure pathways, and movement of an agent from a source or point of health outcomes (figure 2.4). The CSM release through the environment to a receptor demonstrates how contaminants that are released, (for example, air, groundwater, surface water, emitted, or discharged from ULAB sources can soil, sediment, dust, or food chain). Exposure migrate through the environment, depending on routes describe the different ways by which agents local conditions (for a CSM for artisanal and small may enter the body following external contact (for mining, see annex 4). The CSM also demonstrates example, inhalation, ingestion, dermal) (figure 2.5). FIGURE 2.4. General Conceptual Site Model of Sources for Health Outcomes at ULAB Sites Source/ Release/ Transport Exposure Exposure Health pathway Contaminant Process Discharge mechansim route outcomes Particulate Hyperkeratosis; Skin, Extraction Fugitive dust bladder, lung (deposition) cancers; Neurodevel- Surface soil opmental and Surface water cognitive outcomes (runoff) in children; chronic Groundwater obstructive Particulate (leaching) Outdoor/ pulmonary disease Processing Surface soil indoor dust (COPD) and Soils (yards, etc.) Inhalation concentrating As Drinking water Dermal Surface water Irrigated crops Ingestion Neurodevelopmental Ambient air Aquatic food and cognitive Vapor and (dispersion) chain outcomes in children; Pb COPD; cardiovascular particulate Fugitive dust disease (CVD); (deposition) Chronic kidney Amalgamation Surface water disease Surface soil (runoff) Groundwater (leaching) MeHg Surface water Neurodevelopmental and cognitive Smelting Vapor and outcomes in children; particulate Bioaccumulation Drinking water CVD Irrigated crops Hg Groundwater Ingestion (leaching) Aquatic food chain Surface soil Wastewater Surface water Source: von Stackelberg et al. 2022. Impacts of Lead on Human Capital and the Environment 27 FIGURE 2.5. Potential Exposure Pathways by Exposure Route and Environmental Media at ULAB-Recycling Sites AIR SOIL/DUST WATER Vapors and Dust settling Vapors and dust released particles due to outdoors due to into tap, surface or releases from dismantling groundwater due to solid smelting batteries or waste or wastewater INHALATION discharges to water smelting Contamination due Soil or dust released to Contaminated tap, to transfer of ground; contaminated surface or groundwater; contaminants from soil transfers to animal agricultural products air to animals or from or plants to animals contaminated due to plants to animals contaminated irrigation (meat, milk, eggs) INDIGESTION Skin contact Skin contact with Skin contact wit with settled contaminated tap, surface or particles or dust soil or dust groundwater DERMAL Migration of contamination Exposure pathways Wind Animal ingestion from blowing Eating plants in contaminated soil in vapors contaminated and dust Inhaling food outdoor vapors Drinking contaminated Rising water vapors or dust Inhaling indoor into air vapors and dust Skin contact and Contaminated vegetables Tracking dust/soil ingestion of dust from soil and water into home Source: World Bank compilation. Note: As = arsenic; Cd = cadmium; Pb = lead. 28 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Biomarkers of exposure are measurements to an accredited laboratory are considered in biological matrices that reflect the total the gold standard for Pb analysis. Laboratory- absorbed or internal dose of a contaminant based devices employing atomic absorption from all sources and exposure routes and spectrometry (AAS) or inductively coupled plasma pathways. In some cases, metabolites, as opposed mass spectrometry (ICP-MS) technology are gold to parent compounds, may provide the most standards for evaluating lead levels in human reliable measures of exposure. Biological sampling blood and tissues, have lower detection limits, matrices can include urine, blood, toenails, teeth, higher maximum detection thresholds, and and hair. Breast milk and cord blood are additional operate free from environmental constraints. matrices but are not generally recommended due Table 2.3 provides an overview of the advantages to the invasiveness of data collection and limited and limitations of different biological matrices for utility in relating exposure to health outcomes for sampling Pb. The final column is used to identify an infant population. whether the matrix is useful for additionally capturing a biomarker of effect (for example, Whole blood (not serum blood) is the most obviating the need for additional sample reliable biological matrix for evaluating Pb collection). Table 2.4. provides an overview of exposures. Venous blood samples collected by the strengths and challenges of various methods a trained medical professional and submitted for testing for lead. TABLE 2.3. Overview of Biomarkers of Exposure for Lead Biological Can matrix be used to matrix and Advantages Limitations evaluate health outcome? contaminant Lead Venous blood Well-vetted, standardized Requires medical professional; Can do complete blood count routine analysis with highest requirements for processing, and metabolic panel; additional precision and reliability storage, handling markers related to anemia Capillary blood LeadCare in-field analyzer, Pb only; shows higher HemoCue in-field for (including dried immediate results. Alternatively, variability compared to hemoglobin (anemia) blood spot) can use dried blood spot and venous blood sample sent to as marker of potential send to laboratory. Dried blood laboratory. Field conditions intermediate effect. Can spot shows high variability may compromise ability to measure calcium compared to venous blood measure accurately Urine No advantages other than Can be used but not preferred Standard renal panel being less invasive (for example, albumin, proteinuria) as marker for renal damage-can use spot sample Impacts of Lead on Human Capital and the Environment 29 TABLE 2.3. Overview of Biomarkers of Exposure for Lead (continued) Biological Can matrix be used to matrix and Advantages Limitations evaluate health outcome? contaminant Hair No advantages other than Can be used but not No relevant outcome being less invasive preferred; reflects direct measurement contact of hair with dust rather than absorbed exposure Toenail/fingernail Least invasive; lowest cost High detection levels. Needs No relevant outcome and immediate results in-field to be correlated with blood measurement using XRF. No specific storage levels. LeadCare in-field or transport requirements. always preferred Provides information on short- term and long-term exposures Source: World Bank compilation. TABLE 2.4. Test Methods for Lead: Strengths and Challenges Method Strengths Potential challenges Capillary Easier to obtain consent, less invasive Sensitive to environmental contaminants; and painful for children, shorter collect only a small amount of blood. Low levels procedure and time, no need for skilled unreliable or below detection limit. nurses or phlebotomists. Immediate results shared with caregivers, reducing burden on study team for follow-up. Venous Easier to obtain a larger blood sample. Requires trained medical professional, more Less likely to be contaminated. invasive, harder to obtain consent, may fail if child has small or deep vein or is dehydrated. Delay in the reporting of the results. Uncertain national laboratory capacity to analyze in a timely manner. Dried blood spot Minimum pain; stable and easily stored Both filter and sampling process are susceptible (capillary) and carried; no local laboratory required. to contamination, no immediate result, heterogeneous distribution may bias results. Likely need to be sent to a specialized lab. Other micro-sampling Minimum pain; stable and easily stored No immediate result. Likely need to be sent to a methods such as and carried; no local laboratory required. specialized lab. VAMS (capillary) Defined and very small sample volume. 30 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 2.9.  Ecological effects of lead them (Jarup 2003). Lead contamination reduces exposure plant growth and reproductive success, such as fewer flowers being produced at higher lead concentrations (Collin et al. 2022b). Lead contamination significantly disrupts ecosystem functions by adversely affecting Lead exposure, which can result from soil sensitive microorganisms, particularly at contamination or water pollution, is toxic to high concentrations. These disruptions slow many insects, birds, fish, amphibians, and decomposition rates and hinder nutrient cycling, mammals. Exposure to lead affects the growth, leading to broader ecological imbalances. development, reproductive outcomes, and survival Additionally, lead toxicity contributes to species of these species. Birds may suffer from anemia, decline, altering food-web dynamics, and emaciation, brain damage, and mobility issues, destabilizing ecological interactions. Persistent including difficulties flying, landing, and walking. contamination favors the survival of only the Mammals that are exposed to lead suffer a wide most tolerant species, reducing biodiversity and range of health and behavioral effects, including reshaping both terrestrial and aquatic ecosystems. impaired movement, learning difficulties, increased Lead contamination can lead to habitat aggression, decreased birthweight, and higher degradation, creating conditions that may not mortality rates. The negative effects caused by lead support diverse species, potentially affecting the have been observed in both wild and domesticated entire ecosystems (Luby et al. 2024). agricultural mammals, such as cattle, sheep, pigs, and goats (Luby et al. 2024). Lead does not degrade in the environment and can remain in the soil for decades, affecting Aquatic species, particularly fish, can plants and soil microorganisms. Higher accumulate lead through direct exposure lead concentrations are associated with lower to contaminated water or by consuming concentrations of soil organisms, including bacteria, smaller organisms that have bioaccumulated fungi, and nematodes, which play an essential role lead. Lead toxicity in fish populations can lead in nutrient cycling and soil fertility (Luby et al. 2024). to decreased reproduction, slower growth, and increased mortality. Contaminated Lead is also toxic to plants. While most plants aquatic ecosystems experience reductions in do not absorb significant lead quantities, it can biodiversity and alterations in the food web still interfere with root growth, photosynthesis, (Ansar et al. 2024). and nutrient uptake. Research has indicated that an increase in soil lead concentration from Lead bioaccumulates in the food chain, posing 0 ppm to 1,000 ppm significantly affects wheat risks to predators, scavengers, and humans seed germination, reducing it from 98 percent consuming contaminated food, including to 50 percent, and diminishes the biomass plants and animals. Lead bioaccumulation produced by 44 percent (Lamhamdi et al. 2011). leads to higher concentrations in predators and Leafy vegetables and root crops are particularly potentially causes tremors, behavioral changes, susceptible to absorbing these metals. As a and even death in sensitive species. The use of result, root vegetables like carrots and sweet lead-containing bullets is a significant source of potatoes may contain the highest levels of lead, lead exposure for wildlife and humans. When posing health risks to humans who consume these bullets are used to shoot wildlife, they can Impacts of Lead on Human Capital and the Environment 31 fragment into hundreds of small pieces, many socioeconomic status and levels of education. of which are small enough to be easily ingested Lead’s effects on human health include by scavenging animals or to be retained in meat cardiovascular disease (CVD) mortality and prepared for human consumption. Wildlife, morbidity, a higher risk of chronic kidney failure, especially waterfowl, can suffer fatal poisoning hypertension, anemia, liver damage, and adverse from ingesting lead shot or weights, with effects reproductive outcomes. Exposure to lead during seen within days (Bellinger et al. 2013). pregnancy, particularly in its late stages, is a risk factor for preterm birth and low birth weight and has significant impacts on infant growth and 2.10. Conclusions neuropsychological development. Prenatal lead exposure is associated with increased systolic The evidence overwhelmingly underscores that blood pressure, can cause anemia, and impairs there are no safe BLLs. Lead exposure consistently children’s ability to manage stress. leads to cognitive impairments, IQ losses, learning disabilities, and behavioral problems in children. Blood lead level (BLL) has emerged as the Prenatal exposure can have lasting impacts primary tool for screening and diagnosing lead on childhood developmental outcomes, with poisoning, offering a comprehensive measure repercussions extending into adulthood. Lead of both current and cumulative exposure. exposure affects children’s ability to succeed in Additionally, population-based monitoring holds school and contribute productively to society. These the potential to offer a comprehensive view long-term consequences translate into significant of BLL distribution in a population, facilitating productivity losses. the identification of at-risk groups and at-risk geographic locations. Surveillance efforts are The effects of lead are even more extensive crucial to monitor BLLs and further pinpoint high- than previously believed. Lead exposure risk areas, enhancing comprehensive responses to affects adults, particularly those with lower lead exposure. 32 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE References Aboagye, Richard G., Bright Opoku Ahinkorah, Abdul-Aziz Aoki, Yutaka, Debra J. Brody, Katherine M. Flegal, Tala Seidu, James Boadu Frimpong, Anita Gracious H. I. Fakhouri, Daniel A. Axelrad, and Jennifer Archer, Collins Adu, John Elvis Hagan, Hubert D. 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Key sources of lead include recycling of used lead-acid batteries, formal and informal mining and smelting, drinking water contaminated by lead pipes and plumbing materials, paints, cookstuffs and cookware, spices and cosmetics, medicines, toys, e-waste, ammunition and military operations, and automotive and small-aircraft emissions. Source apportionment is key to identifying the sources and pathways of lead pollution in areas where the population is exposed to multiple sources. Executive Summary 47 3.1. Introduction production has seen a boost, surging beyond four million tons in 2010 and maintaining that level ever For many decades, the use of leaded gasoline since (figure 3.1). A large increase in production was the main cause of widespread exposure to took place in Asia, with the region moving from hazardous lead levels. The global phaseout of producing less than 1 million tons in the late 1990s leaded gasoline is an environmental and public and early 2000s to more than 2.5 million tons in health success story, but it might have contributed 2022 (ILZSG 2023). to creating a false perception that lead production was reduced and that lead exposure is no longer a Lead‘s high recyclability, combined with the major environmental and health challenge. fact that its quality remains intact during the recycling process, makes lead particularly Lead’s usage is widespread, with every single valuable to numerous industries. In 2022, country in the world using it either directly secondary lead production accounted for or indirectly. It is refined or smelted into a wide 65 percent of global output, and in Europe and range of products, including batteries, ammunition, the Americas, this figure represented 83 percent and pigments for food and cosmetics. Supply and 92 percent, respectively, of total production and demand for lead remain high at the global (ILZSG 2023). The use of recycled lead grew from level, with key sources such as batteries expected about 3.5 million tons in 2000 to about 8 million to grow. In the past 30 years, global lead-mine tons in 2022 (Luby et al. 2024). FIGURE 3.1. Global Mine Production, 2000–21 (thousand metric tons) 6,000 4,500 3,000 1,500 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 Source: World Bank using statistics from the US Geological Survey, Mineral Commodity Summaries 2022. Notably, 86 percent of the world’s lead is used in lead-acid batteries (LABs), which have experienced batteries, followed by rolled extruded products a sustained and significant increase in demand, (figure 3.2). Since the 1980s, there has been a driven by growing demand from the automobile global trend of decreasing or stabilizing lead usage industry and renewable energy sector (figure 3.3). in applications such as cable sheathing, rolled and Lead usage in other sectors has been declining extruded products, ammunition, alloys, pigments, over the last three decades, primarily due to and gasoline additives. The notable exception is environmental concerns (ILZSG 2023). 48 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE FIGURE 3.2. Lead Usage 1% Roled and extruded products Lead compounds including 1% lead oxides and salts Shot and ammunition 5% 86% Lead acid batteries Other (allows and solder) 7% Source: World Bank based on ILZSG 2023. FIGURE 3.3. Comparison of Lead Uses in the United States, 1975–2003 Metric tons Camparison of Lead Uses (1975–2003) 1.6 1.4 1.2 Storage batteries Other 1.0 Ammunition Paint and glass 0.8 pigments Gasoline additives Solder 0.6 Storage batteries Brass and bronze 0.4 0.2 0 19 5 76 19 7 19 8 19 9 80 19 1 19 2 19 3 19 4 19 5 19 6 19 7 19 8 19 9 19 0 19 1 19 2 19 3 19 4 19 5 19 6 19 7 19 8 20 9 20 0 20 1 20 2 03 7 7 7 7 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 0 0 0 19 19 19 Year Source: World Bank based on data from the US Geological Survey, Lead End-Use Statistics, 2005. Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 49 SoumenNath / iStock LABs have become the dominant force behind Moreover, the global push toward greener, lead consumption in recent decades, with more sustainable energy ironically adds to this demand continuing to grow. Since 1960, the use demand. As renewable energy systems grow, so of lead in LAB production has skyrocketed from does the need for efficient energy storage, which is 0.6 million tons to 10 million tons by 2012. By directly proportional to the rising demand for LABs 2022, an estimated 10.3 million tons of lead were (UNEP 2020). consumed annually in LAB production alone, with about 6.5 million tons obtained from LAB recycling This chapter examines trends in the production (UNEP 2023a). The lead industry often relies on of lead and the main sources of lead exposure. informal recycling practices in LMICs with weak This chapter has three additional main sections. environmental regulations, leading to widespread Section 3.2 discusses the main sources of lead: lead contamination and exposure. mining and primary and secondary smelting, including recycling of lead acid batteries; lead-paint LABs serve a variety of essential functions and hazards; lead in consumer products, medicines, are deeply integrated into everyday life. Their and foodstuffs; e-waste; water; and photovoltaic demand continues to rise, driven by their critical appliances. Section 3.3 discusses available roles in renewable energy storage and automotive approaches for source apportionment that can applications. The automobile industry already be used to identify and prioritize sources of lead accounts for 65 percent of global LAB demand pollution in Low- and Middle-Income Countries (European Parliament 2023), and as the global (LMICs). The chapter’s conclusions are presented in vehicle fleet expands, with projections of 2 billion section 3.4. cars and 790 million trucks by 2040 (WEF 2016), LAB usage is expected to increase even further. 50 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 3.2.  Sources of lead Gradually, other nations began to follow (figure 3.4). A significant breakthrough occurred in 2006 Leaded gasoline, once a primary application when Sub-Saharan Africa became lead-free, and of lead, has now been eliminated, marking by 2021, the global phaseout was completed with a shift in lead usage. In the 1970s, leaded fuel Algeria implementing its ban (UNEP 2021). While was used worldwide, despite its harmful effects the elimination of leaded gas marks a significant on human health. Growing awareness led to achievement, it also highlights that the use of lead regulatory actions, with Japan becoming the has not been eradicated, but has shifted to other first country to ban leaded gasoline in 1986. applications, remaining a health concern. FIGURE 3.4. Cumulative Number of Countries Banning Leaded Gasoline, 1986–2021 Cumulative number of countries banning leaded petrol (1986–2021) Number of countries 140 120 100 80 60 40 20 0 86 19 7 19 8 19 9 19 0 19 1 19 2 19 3 19 4 19 5 96 19 7 19 8 20 9 20 0 20 1 20 2 20 3 20 4 20 5 06 20 7 20 8 20 9 20 0 20 1 20 2 20 3 20 4 20 5 16 20 7 20 8 20 9 20 0 21 8 8 8 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 2 19 19 19 20 20 Year Source: Ritchie 2022. An estimated 86 percent of lead is currently used to line tanks that hold corrosive liquids such used in lead-acid storage batteries such as those as sulfuric acid. Because of these characteristics, found in vehicles and for solar-energy and wind- in the past, lead was widely used in a variety of energy storage (ILZSG 2023). Certain properties products, including cosmetics, residential and other of lead, namely its ductility and resistance to types of paint, solder, pipes, and gasoline. It is corrosion and tiny cracks that result in leaks, make still used in some paints for color and to enhance it a particularly good material for constructing anticorrosive and drying properties. Because of its water pipes. In addition, its noncorrosive properties density and ability to absorb radiation, lead makes make it very useful in products that hold or touch an excellent shield against harmful radiation. highly acidic substances. For example, lead is Lead is also still used in military weapons and for Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 51 recreational shooters. Lead can easily be recycled Recycling of used lead-acid (Global Battery Alliance and World Economic batteries Forum 2020, 8). Lead can be melted down for reuse using readily The relative contributions of different lead- available equipment because of its low melting exposure sources to blood lead levels (BLLs) point (327.5°C). Recycling lead from used batteries remain insufficiently characterized. A recent is known to result in high lead exposures that can meta-analysis by Kinally et al. (2025) identified cause severe health effects and contaminate the several key sources of lead exposure and their environment. average associations with elevated BLLs: The increased use of electric three-wheeled • Industrial Lead Pollution Hotspots (proximity vehicles has been a key driver in the growing to sources, such as informal used lead-battery demand for LABs and used lead-acid batteries recycling, mining, and smelting): +42.3 µg/L (ULABs). These vehicles have become popular in many countries, such as China, India, and other • Occupational and Take-Home Exposure: Asian countries because these vehicles offer +31.4 µg/L several advantages, including their capacity to • Deteriorated Lead-Based Paint: +28.0 µg/L navigate congested urban streets, provide last- mile connectivity, and reduce tailpipe-pollutant • Lead-Contaminated Foodware (for example., emissions by up to 90%–95% compared to vehicles glazed ceramics, melamine): +19.3 µg/L fueled with diesel (SMEP 2023). The global market • Lead in Food Products: +15.4 µg/L for LABS for three-wheelers is expected to continue its accelerated expansion, with its value projected • Traditional Medicines and Cosmetics: +19.8 µg/L to grow from US$1.3 billion in 2021 to US$5.6 billion • Smoking (active and secondhand): +17.3 µg/L by 2030 (Custom Market Insights 2022). • Geophagy (ingestion of soil): +12.9 µg/L Batteries for electric three-wheelers have These sources often disproportionately affect become a major source of lead pollution. An low-income and minority neighborhoods in electric three-wheeler needs between four and six cities, where older infrastructure and proximity dry LABs with a voltage of at least 12 volts. Lead to industrial sites are more common. The constitutes at least 70 percent of the materials prevalence and severity of these exposure sources used to make these LABs, with a weight of vary widely by region. For instance, lead-glazed between 14 and 21 kg of lead per battery. In many ceramics are a significant concern in Mexico, LMICs, these batteries are primarily supplied by traditional Ayurvedic medicines in India, and informal recyclers working in small workshops industrial emissions in parts of China and Sub- or in “backyard smelters” that carry out lead- Saharan Africa. Kinally et al. (2025) emphasize battery recycling (von Stackelberg et al. 2022). An the urgent need for quantitative assessments of estimated half of all used lead-acid batteries in additional exposure pathways, including leaded LMICs are recycled in the informal sector (Global drinking-water infrastructure; recycled metal Battery Alliance and World Economic Forum 2020, cookware (notably aluminum); firearms; plastics 13). In these settings, there are few or no facilities (for example, toys and food containers); and for neutralization and safe disposal of battery electronic waste. electrolytes. Thus, the battery acid is dumped onto 52 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE soil or into nearby streams or lakes, contaminating Because of the primitive nature of these the water table, rivers, and sanitary systems. operations and their number, with the number of informal ULAB sites estimated to range Occupational hygiene is virtually nonexistent, between 10,000 and 30,000 globally, the control and few operators wear more than a scarf or of lead poisoning from their emissions is a mask to protect themselves from lead fumes. major challenge (Global Battery Alliance and Systems to control furnace exhausts are also World Economic Forum 2020, 13). In 2008, at least nonexistent, and residues are unstable, leachable, 18 children died, and many more were poisoned and have a high lead content. Residues are from lead in Dakar, Senegal, after exposure to dumped indiscriminately around the premises contaminated dust and soil from the recycling of of the informal smelter or sent to a local waste ULABs (Haefliger et al. 2009). Between 1987 and dump. Many of the informal operations are 2012, 32 mass lead poisonings of children, workers, carried out in the backyard of houses, resulting in or both were reported in the popular or scientific widespread exposure of residents (Poudel et al. press (OK International 2012). These accounted 2023). The informal secondary lead sector often for the poisoning of thousands of individuals sells its recycled lead to a licensed recycler to sell and several deaths. Since then, there have been it in the international metal market or to battery numerous other reports documenting the adverse manufacturers. impact of informal-sector recycling on children’s epitavi / Adobe Stock Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 53 and adults’ health, including extremely elevated stored in outdoor piles; lead waste such as mine blood lead levels (Ansari et al. 2020; Chowdhury tailings or “chat”; and dust caused by wind erosion et al. 2021). and plant vehicular traffic (EPA 2020; Singh and Li 2013). Lead mining and smelting operations release The case of Bangladesh is illustrative of the lead into the air, soil, and water. Emissions can significant challenges posed by the rapidly cause widespread lead contamination downwind growing demand for ULABs for electric from the facility, with measurements of soil and three-wheelers. These vehicles generate about dust lead levels greater than the 100,000-ppm 77 percent of total ULABs in the country. High upper-concentration value of most field X-ray import tariffs of more than 30 percent on lead fluorescence spectrometry (XRF) instruments used and more than 80 percent on lead-acid batteries to measure lead contamination. make domestically recycled lead a significantly cheaper option. Informal and illegal ULAB recycling Serious outbreaks of childhood lead poisoning operations supply an estimated 50 percent of have been documented in Australia, Canada, the batteries used for electric three-wheelers in China, Nigeria, Poland, Senegal, the US, Zambia, the country. Lead is recycled in unlicensed open and many other countries because of the pit smelting sites, or “bhattis“, where safety and contamination of communities adjacent to environmental regulations are not observed active primary lead or other minerals mines or weakly enforced. The number of these sites and smelters, or recycling plants (Bose-O’Reilly increased from about 50 in 2010 to 800 in 2023 et al. 2018; Dooyema et al. 2012; Haefliger et al. (SMEP 2023). As of 2020, more than 100,000 2009; Jarosinska et al. 2003). Even relatively people were employed in informal and illegal ULAB efficient mining operations can result in enormous recycling operations (Pure Earth 2020). waste, emissions to air, soil, and water, and a legacy of environmental contamination in nearby communities. Around the world, unsafe mining Mining and smelting and smelting practices have been responsible for a continuing series of environmental and human Formal sector: mining and smelting health disasters. Such disasters have caused and continue to cause great human tragedy and Lead is found naturally as a sulfide ore undermine social stability, economic development, containing small amounts of copper, iron, zinc, and sustainability goals (OK International 2011). precious metals, and other trace elements. The Preventing child and adult exposure to primary lead in this ore, typically after being concentrated lead mining and smelting involves controlling or at or near the mine, is transported and processed eliminating fugitive emissions as well as preventing into metallurgical lead at a smelter or refinery. “take-home” exposures when parents or other Emissions of lead and particulate matter occur adults working at the facilities bring toxic lead dust in varying amounts from nearly every process into vehicles or homes (Rivera García et al. 2012). component within primary lead smelters and refineries, and are also emitted by the mining Good plant design, with a reduction of the of other products, including zinc and gold. potential for the emission of contaminating The lead-particulate emissions include fugitive substances, is of paramount importance, and emissions from blast furnaces and sinter machines; the newer smelting processes are inherently unloading, storage, and transfer of dust; materials much cleaner than traditional blast furnaces. 54 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Pollution abatement technologies, including the A variety of tools are available to reduce worker treatment of exhaust gases and liquid effluents exposure and control emissions in secondary to remove a proportion of the metal content, smelting facilities. These include engineering have also significantly reduced emissions. Other controls to remove lead particulate and transport general measures to improve the cleanliness of it off-site for storage, recycling, or both. Personal sites have been implemented to varying degrees. respiratory protection equipment helps protect These measures, taken together, have considerably workers during most phases of the smelting reduced emissions. There are legal limits and operations. Automated process-control systems can recommended guidelines for concentrations alert personnel to system failures. Regulations and of lead in ambient air outside plants. The WHO enforcement strategies, coupled with monitoring guideline value of 0.5 µg/m33 has not been achieved of air and worker BLLs, contribute to enhancing by most sites. occupational health and industrial safety. Formal sector: secondary smelting Demand for energy storage is expected to grow rapidly in the coming years as the world turns increasingly to renewable energy sources. Most of the lead produced today and for the foreseeable future will come from secondary sources through the recycling of lead scrap. Lead scrap includes used lead-acid batteries (ULABs), cable coverings, pipes, sheets, various electronics, and lead-coated metals. Solder, product waste, and dross may also be recovered for their small lead content. Most secondary lead is used to produce batteries for vehicles, photovoltaic panels, and solar and wind-power storage. Formal-sector secondary smelters are much smaller versions of primary lead smelters, and the issues and requirements for protection of human health and the environment are similar. Secondary smelting has gone from being responsible for 50 percent of total refined lead production in 1990 to over 75 percent in 2020 (Roberts 2020). 3 https://environment.ec.europa.eu/topics/air/air-quality/eu​ Kai Beercrafter / Adobe Stock -air-quality-standards_en Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 55 Artisanal and small-scale mining concentration of lead in these media ranges as high as 140,000 mg/kg in soil (Gottesfeld et al. 2018). Artisanal and small-scale mining has become Even after mines or smelters are closed, heavily common in areas where mines no longer lead-contaminated dust is blown from tailings or produce enough ore to make them viable “chat” piles onto nearby properties and bodies of for large-scale operations. On a global scale, water. Formal-sector secondary smelters in Brazil, there has been a significant increase in artisanal China, and Kenya; abandoned mining sites in and small-scale mining, with an estimated 40.5 Australia, Canada, China, and the US; and informal million individuals engaged in this sector in 2017, ULAB facilities in Africa, Eastern Europe, and the in contrast to earlier estimates of 30 million in Pacific Rim have all been identified as sources of 2014 and 12 million in 1999. This has not only elevated BLLs in surrounding communities. Some transformed itself into a vital source of metals of these sites have come under scrutiny only after and minerals but also plays a pivotal role in the the facilities’ plants have ceased operations. production of approximately 20 percent of the world’s gold supply (IISD 2017). Lead pollution Investigations have demonstrated a link can originate from artisanal and small-scale gold, between BLLs and lead contamination that copper, and other mineral mining. A large lead persists in topsoil (Mielke et al. 2019; Tarrago poisoning episode in artisanal and small-scale and Brown 2017). Soil lead concentrations are gold mining happened in Zamfara, Nigeria, when highest within a 2.7–kilometer radius of the artisanal miners were mining ore that contained facility (Fritsch et al. 2010; Garcia-Vargas et al. over 10 percent lead. Accidentally, over 400 2014; Stafilov et al. 2010). In some areas, the use children died in Zamfara due to ingesting lead of mine tailings or “chat” as gravel has spread dust, an unknown and unwanted side product the lead contamination over an even wider area, generated by ore processing (Dooyema et al. 2012, such as through truck or rail transport of lead Plumlee et al. 2013). Artisanal gold mining has ores from mines to smelters. For example, in received far more attention, and some strategies Northeastern Oklahoma, a study revealed that used to improve conditions in small-scale gold abandoned mine waste contained particles with mines might be modified and used for lead mining high lead concentrations that were susceptible (Gottesfeld et al. 2019; Landrigan et al. 2022; von to wind transport and that airborne lead may be Stackelberg et al. 2022). responsible for up to 10 percent of the annual lead mass flux to a lake situated 18 km away from the chat piles (Li and McDonald-Gillespie 2020). Legacy sites: abandoned or closed mines, smelters, and recycling sites Remediation of lead contamination is site- specific. Every site, regardless of size, should The fumes and dust from lead mining, smelting, have comprehensive testing of environmental recycling, and other industrial uses of lead media using validated sampling and analytic create extremely high levels of lead in soil that techniques. For large sites, understanding the persist for decades or more. Some sites can underlying geology, groundwater and surface- encompass hundreds of square miles, while others water data, weather patterns, and wind direction may be much more limited. In sites around the is a key element to remediation design. These sites world where the ambient lead levels have been require oversight from trained risk assessors and measured in soil, interior house dust, and air, the remediation experts. 56 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE fotoVoyager / iStock Capping of mine tailings and chat piles, soil Interventions in addition to remediation removal and replacement, or covering the soil include community education on cleaning with landscaping cloth and clean soil have all strategies, improved nutrition to reduce lead been found effective in the short term. However, absorption, and hygiene strategies such as none of these interventions is permanent. They frequent handwashing. However, none of these must be monitored and maintained to ensure strategies has been demonstrated to be effective that protective coverings remain in place. unless coupled with control or elimination of Recontamination can also readily occur even environmental lead hazards (Nussbaumer-Streit with areal and zonal remediations, and this is et al. 2016). certainly a risk with spot remediations in the presence of adjacent or nearby non-remediated tracts, as leaded dust falls from farther away Water contaminated with lead and is deposited on remediated sites. Therefore, remediation must be a long-term, macro-scale Ingestion of contaminated water can be a (not a micro-scale) effort (Harvey et al. 2016; significant source of lead exposure. Higher Mushak 2003). Several low-cost, low-technique levels of lead in water have been associated remediation strategies are under study. These with a decrease in the cognitive development of include phytoremediation using native grasses or children and a higher incidence of miscarriages other plants to accumulate lead, phosphate, or and fetal death (Edwards 2014; Lu, Levin, and other chemical applications to immobilize the lead Schwartz 2022). and increase organic soil amendments (Kafle et al. 2022; Nedjimi 2021). Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 57 For many decades, lead has long been used in infrastructure continue to pose a lingering risk of plumbing materials and solder in drinking water lead exposure. systems, including pipe components, solder joints, taps and fittings in plumbing systems, Lead pollution in water may also originate from pumps or well parts. These materials can be other sources previously described, including made of lead, lead-containing metal alloys, and industrial discharges, mining activities, polyvinyl chloride (PVC) or unplasticized polyvinyl and runoff from contaminated soil. Using chloride (uPVC) with lead stabilizers. Lead leaches contaminated water for drinking or cooking can into tap water with changes in water hydrogen result in lead exposure. In addition, using water potential (pH) and through the corrosion of contaminated with lead for irrigation can also plumbing materials that contain lead. The WHO’s lead to food contamination and exposure through Guidelines for Water Quality indicate that lead is ingestion of such food (WHO 2021b). different from other chemical hazards in that most lead in drinking water results from lead service In the US, lead contamination of tap water connections and plumbing in buildings. Thus, the was once a major cause of lead exposure. main solution to reduce lead exposure from water In 1986, the Safe Drinking Water Act (SDWA) sources consists of removing plumbing and fittings was passed, requiring the use of lead-free containing lead, while also implementing other plumbing components in the installation or measures such as corrosion control and ensuring repair of public water supply systems used for that no new sources of lead are introduced during human consumption by 1988 (EPA 2023). The US the repair of existing systems or the construction of regulations revised the definition of lead-free in new ones (WHO 2022). 2011 by lowering the maximum lead content and establishing a method for calculating lead content While the practice of using lead in plumbing has (EPA 2023). Nonetheless, by 2015, a study of 2,146 been discontinued due to growing recognition private water supply systems in Virginia found of its hazards and regulatory restrictions in that 80 percent of samples had detectable lead many countries, its legacy remains an issue. In concentrations, with at least 19 percent reporting high-income countries, such as the US, the use of elevated lead concentrations above the standard of lead in new plumbing systems was banned under 15 µg/L (Pieper et al. 2015). the Safe Drinking Water Act of 1986, and efforts to replace older lead pipes are ongoing (US EPA, n.d.). Water and other beverages can also be In contrast, in many LMICs, lead plumbing remains contaminated when they are prepared or more prevalent. For example, in Madagascar, stored in lead-containing utensils or vessels, research has identified the continued installation including lead-ceramic-glazed pottery and other of water pumps with locally manufactured lead glassware. The greater the concentration and components. Similarly, a study across three West duration of lead in drinking water, the greater the African countries found that 80 percent of tested exposure to lead. In children, lead in drinking water water systems contained at least one component has been associated with BLLs ≥10 μg/dL, with exceeding lead reference values (Bonefield and formula-fed infants the most at risk for high blood Todd 2024; Fisher et al. 2021). Furthermore, lead levels. Relatively small fluctuations in factors even in countries like the UK, lead is still used such as temperature, pH, alkalinity, and dissolved in certain components, such as closed central solids affect the solubility of lead (Frank et al. heating systems (DWI, n.d.), and older homes and 2019; Schock 1990). For large and medium-sized 58 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE water providers, corrosion-control measures that standards for groundwater and drinking water prevent lead from leaching into water from pipes quality in Pakistan (Kumar et al. 2023). and fixtures have been demonstrated to be a cost- effective way to reduce water lead levels (Levin 1986). Changes in water treatment and disinfection Lead-paint hazards practices can substantially undermine lead- corrosion control (Tiemann 2004). In the 1970s and 1980s, many high-income nations enacted laws to control the lead in Lead in water is also likely to be a significant paints. These efforts, along with the Global risk in LMIC. A study concluded that Addis Ababa’s Alliance to Eliminate Lead Paint, have set the stage drinking water is likely to be a source of lead for a decline in the use of lead for paints. Major exposure (Endale et al. 2021). In Madagascar, lead industry players, such as PPG—the world’s largest contents in locally manufactured water hand pumps, paint producer—and AkzoNobel, the third largest, which accounted for about three-quarters of water have announced the removal of lead from all systems in the country, were found to be a source their products. Additionally, organizations like the of aqueous lead exposure. Dissolved aqueous lead Malaysian Paint Manufacturers Association and the measurements from these pump systems were Philippine Association of Paint Manufacturers have found to frequently exceed the WHO guideline of committed to similar initiatives (IPEN 2020). 10 μg/l. Removing the leaded components from the water supply system led to a reduction in the However, by 2022, more than 57 percent of the percentage of children who had a BLL above 5 μg/dL countries lacked legally binding controls to from 96 percent to 65 percent, and the median BLL limit the production, import, and sale of lead for the population fell from 8.6 μg/dL to 6.3 μg/dL. paints (UNEP 2022). Countries that have enacted By removing the source of lead exposure, it is such laws have generally either banned lead expected that the intervention will lead to continued additives or established a lead-paint standard on decreases in BLLs (Buerck et al. 2023). total lead concentration, ranging from 90 ppm, which is the lowest currently technically feasible Research conducted in rural areas of Ghana, level, to 600 ppm (UNEP 2022). Unfortunately, Mali and Niger found that 9 percent of samples paint continues to be an important source of lead from 260 community water systems tested pollution at the global level, both in countries with positive for lead levels greater than the WHO and without regulatory limits. Paint that is sold standard. However, approximately 80 percent of in LMICs often exceeds that standard with levels the water systems contained parts that exceeded of 10,000 ppm, 20,000 ppm, or more, although levels considered safe for use in drinking water paint without added lead is available in those systems (0.25 percent by mass, according to countries at comparable prices (IPEN 2017; UNEP current international guidance) (Fisher et al. 2021). 2022). Likewise, with bans and regulations mostly In Bangladesh, concentrations of lead in surface targeting decorative and residential paints, lead water were found to be as high as 0.98 mg/L. is still present in other types of paints, such as Also in Bangladesh, concentrations of lead in industrial paints (UNEP 2018). drinking water measured in Rajshahi City exceeded standards (Parvin, Haque, and Tareq 2022). Lead Though lead paint was banned in High-income concentrations were also found to exceed the Countries decades ago, paint on walls predating limits recommended by the WHO and the national the ban is an ongoing source of lead exposure, Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 59 especially for children, since they crawl on the often misleading when used to indicate whether a floor and, due to their hand-to-mouth activities, paint contained lead. In one study, paints labeled ingest lead chips and dust from the floors. Even “100 percent lead-free” had levels ranging from the removal of old lead paint constitutes a possible 6,000 to 100,000 ppm (IPEN 2018). source of exposure to children and adults, since lead-containing dust is generated (UNEP 2022). Anecdotal reports of industrial lead paints Unless lead paint is eliminated in all countries, lead applied to household, playground, or toy paint is likely to be exported across national borders. surfaces are common, but there have been few attempts to quantify the problem. For example, Since 2009, more than 100 studies have shown a study of 19 anticorrosive and automotive paints that paints with high levels of lead are available from 13 brands used for decorative purposes for sale in LMICs (UNEP 2022). A 2021–23 market in Cameroon found that 47 percent had a lead survey revealed that 41 percent of paints for large content greater than 90 ppm, and 11 percent had a surfaces and 11 percent of paints for crafts exceed lead content greater than 10,000 ppm (IPEN 2017). the reference level of 90 ppm (Fuller 2024). The widespread use of decorative paints in LMICs has become more common as increasing disposable Lead in cookware and income enables families to paint their homes cookstuffs, spices and cosmetics, with more colorful and durable options instead of medicines, toys, and other whitewashing. A 2013 UNEP report presented results consumer products for lead testing of 234 cans of decorative paints from nine countries: Argentina, Azerbaijan, Chile, Despite growing evidence of adverse health Côte d’Ivoire, Ethiopia, Ghana, Kyrgyzstan, Tunisia, effects related to lead, it is still widely used and Uruguay. The report found that all tested paint in consumer products such as toys, costume brands contained samples with more than 10,000 jewelry, cosmetics, medicines, and traditional ppm of lead. Extremely high lead levels in paints remedies; food and beverages including tea, (more than 99,000 ppm) were found in paints from spices, and ceremonial powders; cookware and Argentina, Côte d’Ivoire, Ethiopia, and Tunisia. (UNEP pottery; and tobacco smoking (Rooney et al. 2013). The rapid market screening project found 2022). Lead can be introduced into these products that 41 percent of the 437 paint samples intended by adulteration, deliberate addition of lead because for large surfaces, analyzed from 25 countries, of its perceived usefulness to add weight to the exhibited lead levels exceeding the reference level product, inadvertent contamination by contact of 90 ppm. Even in countries with a legal ban on with lead on grinding or processing equipment or lead paint, levels above 90 ppm were common, dyes and wrappings, and through ambient lead in including in Colombia, India, Kenya, Kyrgyz Republic, areas with widespread contamination. Table 3.1 Mexico, Pakistan and Vietnam (Sargsyan et al. 2024) illustrates the concentrations of lead in different (see annex 6). Studies also showed that labels were consumer products. 60 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE 3.1. Lead (Pb) Concentrations in Various Products Maximum Product Country Unit Guideline Reference concentration Cosmetics Lipstick France 0.37 Türkiye 9.05 Iran 18.67 China 33.48 Nail polish Türkiye 8.36 Iran 12.36 ppm FDA 2016; Eyeliner Türkiye 6.45 Note: 10 ppm FDA 2022; Iran 8.57 values have been Navarro-Tapia et al. 2021; Eye pencil Türkiye 6.64 converted Wang et al. 2020; China 10.08 from ug/g Zafarzadeh et al. 2018 Eyeshadow Türkiye 3.78 to ppm Iran 6.16 Mascara Türkiye 6.22 Iran 7.09 Kohl Germany/Spain 61,654.78 10–20 ppm Face paints China 16.2 Food Vegetables Italy 0.0422 0.10 mg/kg Crustaceans Italy 0.0390 0.5–1.5 mg/kg European Commission and mollusks 2021; Cereal (Gofio) Spain 0.153 Ferreira de Oliveira et al. Cereal (Barley Spain 0.520 mg/kg 0.20 mg/kg 2021; Gofio) Malavolti et al. 2020; Corn Spain 0.050 0.05 mg/kg Rubio-Armendariz 2021 Chocolate Ecuador 1.515 (beans) 0.1 mg/kg Peru 2.065 Paints Paint samples China 116,200 90 ppm Cameroon 500,000 Tanzania 120,862 Njati and Maguta 2019; ppm 100 ppm Thailand 505,716 WHO 2021 South Africa 189,000 600 ppm Brazil 170,258 Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 61 TABLE 3.1. Lead (Pb) Concentrations in Various Products (continued) Maximum Product Country Unit Guideline Reference concentration Toys PVC toys China 860,000 South Africa 145,000 Consumer Product Safety United States 22,550 ppm 100 ppm Commission n.d.; Thailand 4,486 Njati and Maguta 2019 West Bank and Gaza 6,036 India 2,104 Pottery Ceramic ware South Africa 64,668 Thailand 31 FDA 2010; Portugal 19,635 ppm 0.5–3 ppm Mathee, Renton, and Indonesia 653 Street 2023 China 963 Water Drinking water Addis Ababa 62.6 Barn et al. 2014; US 9.7 Cradock et al. 2022; ug/L 10–15ug/l Canada 71.1 EPA 2024; Jarvis and Fawell 2021 Electronics Average battery Global <10 kilograms California Department of Car battery Global 7.26–9.52 Resources, Recycling and Cell phones US 0.224 Recovery 2019; (models 2008+) Intrakamhaeng, Clavier, Computers/PCs US 0.06 mg/L and Townsend 2019; (models 2008+) UNEP 2023b Smoke detectors US 12.2 Note: Cells in red reflect values above the relevant guideline. Cells in green reflect a value under the level set by the relevant guideline. Lead is widely available in many common analyzed their lead content. Threshold values products from markets in LMICs. Research (TV) were surpassed in 51 percent for metal conducted in 25 LMICs collected 5007 products, foodware (TV 100 ppm), 45 percent for ceramics including metal foodware, ceramics, cosmetics, (TV 100 ppm), and 41 percent for paints (TV 90 paints, toys, spices, and other foods, and ppm) (Sargsyan et al. 2024) (table 3.2) (see annex 6). 62 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE 3.2. Distribution of Lead Concentrations and the Distribution of Highly Lead-Tainted Samples above the Reference Level across 11 Product Types, Aggregated for 25 Countries 25th 75th  > Reference Product type Total # Minimum Median Maximum percentile percentile level [%] Metal foodware 520 ND ND 118 754 119,500 51 Ceramic foodware 308 ND ND 73 3,665 397,100 45 Plastic foodware 364 ND ND ND ND 3,289 12 Toys 781 ND ND ND 13 97,300 13 Cosmetics 812 ND ND ND ND 1,000,000 12 Paints – large surface 437 ND ND 1 1,518 807,309 41 Paint craft/art 70 ND ND ND ND 93,500 11 Paint—unclassified 102 ND ND 10 3,400 79,000 47 Herbal/traditional 54 ND ND ND ND 31 4 medicines Sweets 111 ND ND ND ND 5 3 Spices 1,084 ND ND ND ND 622 2 Staple dry food 364 ND ND ND ND 17 1 Total N 5,007           Source: Sargsyan et al. 2024. Note: ND = “non-detect.” The effective limit of detection was in general 2 ppm lead. The study included the following countries: Armenia; Azerbaijan; Bangladesh; Bolivia; Colombia; Egypt; Georgia; Ghana; the Indian states of Maharashtra, Tamil Nadu, and Uttar Pradesh; Indonesia; Kazakhstan; Kenya; Kyrgyzstan; Mexico; Nepal; Nigeria; Pakistan; Peru; the Philippines; Tajikistan; Tanzania; Tunisia; Türkiye; Uganda; and Vietnam.. Cookstuffs and cookware were prevalent in ceramic foodware across all regions, with 45 percent of the 308 samples Food can be contaminated in many ways. exceeding the reference level of 100 ppm. In Historically, low-fired earthenware and traditional 11 locations, the median sample value was above stone mills reinforced with lead joints were the reference level, indicating that contaminated recognized as common potential sources of lead items are a common occurrence (Sargsyan contamination in food. Research has revealed lead et al. 2024). The use of lead-glazed ceramics is a concentrations as high as 2,000 ppm in flour from common practice in Mexico. A study found that traditional stone mills (Azcona-Cruz et al. 2000; the prevalence of high BLLs (≥5μg/dL) in children El-Sharif et al. 2000; Rojas-Lopez et al. 1994). ages 1–4 was 30.7 percent among lead-glazed ceramics users and 11.8 percent in non-users Ceramic and glass cookware, along with (Tellez-Rojo et al. 2020). enameled drinking vessels, can also introduce lead contamination into food. The rapid market Lead exposure from cookware is a significant screening analysis revealed that high lead levels concern in LMICs, where artisanal aluminum Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 63 DedMityay / Adobe Stock products have largely replaced cast iron pots. guidelines for maximum permissible levels of These aluminum cookware items, often made lead in foodstuff, which remains for fruits below from recycled materials like car parts and e-waste, 0.1 mg/kg fresh weight (EC 2021). Frank et al. lack proper anodization, leading to the migration (2019) also suggest that other foods, including of lead into food (Weidenhamer, Chasant, and fish, poultry, and produce, may have elevated Gottesfeld 2022). A 2023 survey covering 25 LMICs lead levels. found that 51 percent of metal cookware samples contained unsafe lead levels, and 57 percent of Chocolate products, including dark chocolate, cookware exceeding reference lead levels were often perceived as a healthier snack, have aluminum-based (Sargsyan et al. 2024), with been found to contain elevated levels of lead particularly high contamination in pots, pans, and and cadmium, both of which pose health risks. cooking utensils. Despite research on aluminum A test of 48 cocoa-containing products revealed leaching, the health risks from lead and other that at least one-third of these items exhibited heavy metals in aluminum cookware remain levels of concern for either lead or cadmium. largely unexamined (Weidenhamer et al. 2014). California’s standard maximum allowable dose Testing has shown lead concentrations exceeding level for lead stands at 0.5 micrograms per 100 ppm across multiple regions, potentially day. Notably, 82 percent of dark chocolate bars contributing to elevated blood lead levels tested had lead levels surpassing the threshold (Sargsyan et al. 2024). for a single serving size. For instance, a well- known brand of chocolates recorded lead levels Furthermore, food crops, particularly fruit, at 539 percent above the 100 percent threshold can also have large lead concentrations (Consumer Reports 2023). because of soil contamination. For example, a literature review found that the average lead Monitoring of the food supply and content in certain fruits ranged from 11 mg/kg to enforcement of laws and regulations are 26 mg/kg (Kumar et al. 2020). This concentration effective at identifying lead concentrations is much higher than the European Commission’s in products and foodstuffs. For example, the 64 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Mexican government has enacted laws regarding mean lead level of 134.5 ppm, had an average BLL the production and evaluation of ceramics, as well of 13.1 µg/dL, and 91 percent had BLLs ≥ 5 µg/dL as a program to encourage ceramic producers (Brown et al. 2022). to look for alternatives to lead glazing, which could serve as a model (Diaz-Ruiz et al. 2017). In Georgia exceptionally elevated lead Efforts are currently underway to genetically concentrations were found in various spices. modify imported staple crops to breed crops The median lead concentration in six spices with lower lead accumulation rates (Clemens with elevated levels of the metal ranged from 2019). Furthermore, lead remediation efforts 4 to 2,418 times the acceptable level (Ericson to effectively clean up contaminated sites and et al. 2020). Policy interventions resulted in a reduce lead accumulation in the food chain decrease of lead levels in spices in Georgia. are needed. Several sustainable and innovative The concentration of lead in spices exhibited a approaches have been suggested, including decline over time, reaching a maximum of 14,233 electrokinetic remediation and chemical μg/g in 2020 and subsequently decreasing to stabilization (Kumar et al. 2020). 36 μg/g in the final sampling round of 2022 (Forsyth et al. 2024). Spices and cosmetics In Bangladesh, lead chromate contamination of turmeric decreased significantly across the In New York City, health workers collected country following a multi-faceted intervention spices for a 10–year period and found that spices (Forsyth et al. 2023). The successful intervention purchased abroad were more than three times included providing credible information on the as likely to exceed the 2-ppm reference value dangers of lead, onsite XRF testing of the product compared with the spices purchased in the at mills, and good enforcement of laws banning US. The lead concentration in the spices varied by adding lead to turmeric. This intervention could country of origin, with those purchased in Georgia serve as a model and be easily adapted to other being the most likely to exceed the reference countries where lead-adulterated spices have been value (70 percent of samples ≥ 2 ppm), followed identified (Ericson et al. 2020; Forsyth et al. 2019; by Bangladesh (54 percent), Morocco (48 percent), Forsyth et al. 2024). Nepal (30 percent), and Pakistan (25 percent). Samples purchased in India, Jamaica, and Mexico Investigators in North Carolina found that, were less likely to exceed the reference level of in addition to spices, lead was common in 2 ppm, although some extreme concentrations ceremonial powders, teas, and cosmetics were found in samples obtained in Belarus and imported from Asia, India, Mexico, and India (Hore et al. 2019). the Middle East. These included herbal teas and remedies: ash powder, Azarcon, Balguti Between 2012 and 2020, several studies found Kesaria, Bali Gali, Ghasard, Greta, Kandu, Mojhat turmeric adulterated with lead chromate (a ceremonial drink), and Pay-loo-ah; ceremonial pigments in Bangladesh and India (Brown et al. powders: Kum Kum, incense, Pooja powder, 2022; Forsyth et al. 2019; Forsyth et al. 2023). Rangoli, and Vibuti (ash powder); and cosmetics: In India, children living in households with lead- Kohl, Kajal, Kum Kum, Sindoor, and Surma contaminated spices, including turmeric, with a (Angelon-Gaetz et al. 2018). Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 65 Complementary or alternative Thailand exposed that 13 percent of toy samples medicines exhibited lead levels exceeding 600 ppm, with an average lead content of 283.98 ppm (Decharat, Because complementary or alternative Maneelo, and Chuchay 2013). This is considerably medicines are ‘‘natural”, they are generally higher than the lead content limit set for children’s believed to be free of toxic effects and health products in the US in 2011 by the Consumer risks. However, ethnic remedies may contain lead, Product Safety Commission of 100 ppm (Consumer other heavy metals, and toxic substances. For Product Safety Commission 2011). In 2007, upon example, certain branches of Ayurvedic medicine release of information about lead-based paint contain heavy metals because these are thought to coatings on children’s toys exported from Asia to have therapeutic benefits for particular ailments. Europe, the US, and other developed countries, Traditional remedies that contain lead have been took serious action where millions of toys were reported to the US Centers for Disease Control and recalled, and stringent regulations for controlling Prevention (CDC) for decades (Meyer, Brown, and the lead content in imported toys were formulated Falk 2008). Kratom, a tropical tree from Southeast (Ridlington, Van Heeke, and Mierzwinski 2014). Asia, has often been used as a traditional medicine Njati and Maguta (2019) reported that PVC toys to treat different health conditions, including pain, in India and the US showed lead content ranging depression, and opioid use disorder. In the US, from 2,104 to 22,500 ppm, while in China and South for example, it is used as an herbal supplement. Africa, it ranged from 860,000 to 1,450,000 ppm, Nonetheless, research has found evidence of respectively. toxic metals in kratom products, including lead, in levels ranging from 0.2 µg/g to 1.4 µg/g of raw leaf material. While kratom products are often E-waste and waste disposal consumed in lower quantities, there are individuals consuming 10–60 grams per day (Prozialeck, Of the estimated 62 million tons of e-waste Fowler, and Edwards 2022). For these people, that were produced globally in 2022, only 22.3 kratom products alone can represent an important percent was documented as formally collected source of lead, reaching the suggested maximum and recycled (Baldé et al. 2024). The handling level intake of lead, also known as the Interim of e-waste in many LMICs is generally limited to Reference Level. The FDA has calculated these inadequate processing in backyards (for example, levels at 2.2 micrograms per day for children and smashing or breaking open casings), manual 8.8 micrograms per day for adults, with recent stripping to remove electronic boards for resale, adjustments lowering the previous levels of 3 and and burning to liberate and recover selected 12.5 micrograms per day, respectively (FDA 2023; materials. Other bulk components, including Frank et al. 2019). cathode ray tubes (CRTs), are disposed of in open dumpsites. When e-waste is improperly handled, it can release as many as 1,000 different chemical Toys substances into the environment. Lead is one of the common substances released into the environment Some plastic toys have also been identified if e-waste is recycled, stored, or dumped using as potential sources of concern due to their inferior activities, such as open burning (Widmer elevated lead concentrations, posing an et al. 2005). Inhaling lead particles generated by increased risk to children. A study conducted in burning of e-waste or ingestion of contaminated 66 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE foods and water contributes to lead poisoning in For many years, traditional lead-based solder people living in near e-waste recycling and disposal alloys were favored for their high quality and sites. In Montevideo, Uruguay, recovering metals low cost. However, this preference has started from e-waste, particularly burning cables to obtain to shift. The European Union’s Waste Electrical copper, is estimated to have caused one in four and Electronic Equipment (WEEE) and Restriction cases of lead exposure treated at the pediatric of Hazardous Substances (RoHS) directives, which environmental unit (Poudel et al. 2023). ban the use of lead in electronics, along with similar regulations, have led to a transition toward Results from a meta-analysis on lead exposure lead-free solders in many regions, particularly in from e-waste showed that among e-waste- consumer electronics (EPA 2001; Padmanaban exposed children, the total geometric mean BLL and Sunderraj 2024). Despite this progress, lead- was 7.54 μg/dL (95% CI: 6.77, 8.31). Children’s based solders have not been fully phased out. BLLs displayed a decreasing temporal trend, from Some specialized sectors still rely on them due 11.77 μg/dL in 2004–06 to 4.63 μg/dL in 2016–18. to their unique properties, such as resistance to The difference in children’s BLLs between the corrosive environments and a lower melting point exposure group and the reference group was from (Padmanaban and Sunderraj 2024). This shift 6.60 μg/dL (95% CI: 6.14, 7.05) in 2004 to 1.99 μg/dL mirrors the broader trend of lead usage: while (95% CI: 1.61, 2.36) in 2018 (Huang et al. 2023). it is decreasing in more common applications, lead continues to play a role in industries where Many LMICs have committed to increasing the alternatives are not yet as suitable. rate of electricity generated from renewable energies, including solar technologies that Ammunition and military use photovoltaic systems (PVs). However, PV operations technology utilizes lead. Lead can then be released into the environment from PV waste Ammunition remains a persistent source of or from possible leakages from damaged PV contamination. Regulations governing the use of devices (Ren et al. 2022). A study in China and lead in ammunition remain limited (Arnemo et al. India calculated that the expansion of PV solar 2016). In Europe, the European Chemicals Agency power in both countries will result in significant (ECHA) proposed in 2021 an EU-wide restriction on environmental lead emissions, with estimated the use of lead in ammunition for hunting, sports lead emissions generated during the production, shooting, and fishing (ECHA n.d.). Despite growing fabrication and manufacturing, and recycling awareness of its environmental and health risks, processes (Gottesfeld et al. 2011). Lead-free comprehensive regulations on lead ammunition PVs substitutes are the subject of research and are still lacking. Europe alone uses an estimated development efforts (Schileo and Grancini 2020). 18,000 to 21,000 tons of lead annually for hunting, Less toxic alternatives, such as tin, have also been contributing to contamination in both wetland considered to replace lead. and non-wetland environments (Treu, Drost, and Stock 2020). Additionally, other uses of leaded The use of lead in solder has also seen a decline, ammunition, such as indoor shooting ranges or though it has not been fully eliminated, as military applications, fall outside the scope of most its application persists in certain industries. regulations (ECHA 2020). Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 67 FIGURE 3.5. Persistent Threats: Diverse Sources of Global Lead Pollution 7 6 2 4 5 3 1 4 68 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 1 ULAB RECYCLING Informal recycling of Used Lead-Acid Batteries (ULABs), especially in LMICs, is a major source, contaminating environmental media and people. Lead-acid batteries account for an estimated 86% of lead currently mined or recycled annually. MINING AND SMELTING 2 Formal and informal mining and smelting release lead to air, water and soil. Abandoned sites continue to leach lead into the environment for decades. 3 WATER CONTAMINATION Lead pipes, solder, and other plumbing materials in locally manufactured water pumps contaminate drinking water, particularly risky for children. 4 CONSUMER PRODUCTS Lead is still found in paints, artisanal cookware/ ceramics, spices, cosmetics, medicines, and toys due to adulteration or contamination. 5 E-WASTE Improper handling and disposal of electronic waste releases lead into soil and water near recycling sites and dumps. 6 AMMUNITION AND MILITARY OPERATIONS Lead in ammunition contaminates soil, water, and game meat. Military operations and unexploded ordnance are long-term sources. 7 AUTOMOTIVE AND SMALL-AIRCRAFT EMISSIONS Residual dust from past leaded gasoline persists. Tires, brakes, and leaded aviation gasoline (for small piston- engine planes) continue to release lead. Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 69 All heavy weapons ordnance and some maintenance shop workers, including those propellants contain lead and other metals. working in the airports where these airplanes Exposure to lead largely results from the firing operate, and repair/ overhaul facilities. of weapons and explosions and can also affect Communities living near airports where piston- the individuals firing the weapons. Fragments engine aircraft operate also face significant risks and debris from munitions and propellants can potentially including exposure through inhalation contaminate soil and water, particularly in acidic of airborne emissions or ingestion of food, water, environments that may mobilize metals and wet or other materials, including dust and soil, that environments that can facilitate the transport of have been contaminated through a pathway metals to groundwater. Even intact unexploded involving lead deposition from ambient air. ordnance is a potential long-term point source of contamination, including through leaks that pollute Several studies have found higher BLLs in soil and water. High concentrations of lead have children living near airports where piston- also been observed on sites where small arms engine aircraft operate (National Academies ammunition is destroyed (Waseim et al. 2019). of Sciences, Engineering, and Medicine 2021). Lead exposure from these sources can persist for Miranda, Anthopolos, and Hastings (2011) decades, representing a significant risk for civilian examined the associations between BLLs and populations even after conflicts end. Lead is also proximity of the residence to an airport for children still used in ammunition for recreational shooters ages 9 months to 7 years in North Carolina. They and can result in lead ingestion from contamination found that lead from aviation gasoline may have of game meat (WHO 2021b). a small (2.1%–4.4%) but significant impact on blood lead levels in children who live in proximity to airports where such gasoline is used. The Automotive and small-aircraft magnitude of the estimated effect of living near emissions airports was larger for those children living within 500 m of the airport. Historically, leaded gasoline was a major source of lead emissions. Although leaded gasoline has Wolfe et al. (2016) estimated that IQ losses been phased out in most countries, residual lead from exposure to lead from aviation gasoline in dust from past use can persist in soil and dust. in the US result in about $1 billion in damages Even in countries where leaded gasoline has been from lifetime earnings reductions, with an banned, lead from tires and brakes contributes to additional $0.5 billion in economy-wide losses air pollution (Taylor and Kruger 2020). due to decreases in labor productivity. Zahran et al. (2017) studied the relationship between Aviation gasoline is another source of lead BLL data from more than 1 million children and pollution. While commercial aircraft use jet fuel their proximity to 448 airports in Michigan. They that does not contain lead, small piston-engine found consistent evidence that aviation gasoline planes still use lead aviation gasoline. In the US, in use is significantly linked to elevated BLLs in 2017, they emitted approximately 470 tons of lead, children living near airports. They estimate which contributed to lead emissions in the air. the social damages (IQ point loss and IQ point loss to future earnings) attributable to leaded The groups most at risk of lead exposure from aviation gasoline consumption to be at least piston-engine airplanes include flight line and $10 per gallon. 70 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 3.3.  Source apportionment Laycock et al. (2022) identified potential environmental sources of lead contributing Source apportionment involves identifying to high blood lead concentrations in children the sources of pollution and determining their across 36 households, reflecting nationwide respective contributions to pollution levels. This concerns. Through lead isotope analysis, the process employs various tools, including emission authors discerned distinct lead compositions inventories, source-oriented models, and receptor in paint and soil compared to dust and blood, models, to gather information about pollution indicating a minimal contribution of soil and paint sources and assess their impact on the environment. to BLLs. Conversely, isotopically similar lead profiles Source apportionment is key to identifying the between dust, spices, and blood suggested a sources and pathways of lead pollution in areas significant contribution of dust and spices to blood where the population is exposed to multiple sources. lead levels, consistent with prior research linking household dust to elevated BLLs. Lead isotopes are a potential tool for identifying specific sources of lead in both blood and Similar studies have been conducted in an environmental samples, thus allowing attempt to apportion the contribution of the identification of major environmental individual sources of lead in the BLLs of children contributors to BLLs. Lead has four stable exposed to multiple contaminated media. In the isotopes: 204Pb, 206Pb, 207Pb, and 208Pb. These Republic of Georgia, a 2018 survey indicated that isotopes will act as a signature or “footprint” that over 40 percent of children ages 2–7 had elevated will help pinpoint the sources of lead contamination blood lead concentrations exceeding 5 µg/dL. This in the environment, including human activities (Lead study aimed to evaluate the feasibility of using ores display an origin-specific isotopic composition lead isotope ratios (LIRs) to identify and rank (signature) ratio of 206Pb/207Pb and 208Pb/206Pb). the primary sources of lead exposure for these These ratios do not change during the physical children. By analyzing blood and environmental or physicochemical processes associated with samples from 36 children with high BLCs, the smelting, refining, and manufacturing. Thus, stable research revealed that spices, tea, and paint Pb isotope ratios can then be used to trace the were the most closely associated with elevated origin of the pollution, such as coal or gasoline lead levels, while other sources like sand and soil combustion and ore smelting/recycling (Longman showed less direct connection, thereby guiding et al. 2018; Tuccillo et al. 2023). targeted intervention efforts (Leonardi et al. 2023). For example, in Mexico, matching the isotope Zeng et al. (2022) employed both lead isotopes ratios of the BLLs of Mexican women with soil and the positive matrix factorization (PFM) model and dust lead levels in and around their homes to discern sources of heavy metals in soils from successfully identified that the primary ore of an tourist areas around Syram Lake, China. The adjacent mine was a major source of lead for the PMF model accounts for data matrix uncertainty women. The analysis found a strong association and provides contributions of pollutant sources between the women’s BLLs and isotope ratios of to heavy metals under nonnegative constraints, locally available glazed pottery, which were also yielding positive results in source apportionment very similar. The investigators concluded that these research across various environmental mediums. two sources were the most important contributors Combining these models with isotopes has proven to the women’s BLLs (Vázquez Bahéna et al. 2017). to be an effective approach for identifying pollution Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 71 sources, particularly in scenarios where multiple targeted solutions to address the most significant sources coexist. contributions, leading to more efficient regulations. Furthermore, source apportionment data enhances Forsyth et al. (2019) conducted an isotopic pollution models, facilitating more accurate analysis to determine the primary source of prediction of pollution levels and the effectiveness lead exposure in rural Bangladesh. By examining of control measures. It can also guide resource the lead isotopic composition of 45 blood samples allocation by directing efforts toward the most alongside potential lead sources, they evaluated impactful pollution sources (Coelho et al. 2022; contributions from three key pathways: food stored Thunis et al. 2020). in Pb-soldered cans, contaminated turmeric, and geophagous materials such as clay and soil. The analyses of lead isotopic composition, combined 3.4. Conclusions with a case-control and sampling approach, provided evidence that turmeric adulterated with Unfortunately, because lead has been used, and the yellow lead-bearing pigment was the main continues to be used, in so many products, it is source of lead exposure in targeted districts. widely available, causes extensive contamination of the environment - including air, water, soil, Advances in laboratory instruments may offer and food - and therefore poses significant a significant improvement in the analytical health risks to millions of people, particularly precision and accuracy of lead isotope in LMICs. Major sources of lead, such as batteries, measurements. This allows for much more precise are expected to grow in the coming years, driven identification of lead sources contributing to BLLs. by trends such as increased penetration of electric Therefore, significant advancements in linking vehicles and deployment of renewable energy lead from exposure sources and more effective generation and storage, which could potentially identification and targeted removal of prevalent result in increased exposure to lead. lead sources contribute to BLLs in exposed individuals (Swaringen et al. 2022). Removing one Today, an estimated 86 percent of lead is used dominant source of lead may not prevent exposure in lead-acid storage batteries, such as those to other sources. Given that there is no known safe found in vehicles and for solar and wind energy BLL, it seems more prudent to control or eliminate storage. An estimated 65 percent of lead for all identified lead sources to prevent further LABs is obtained from recycling LABs, primarily in exposure. This is especially true for children with LMICs. Because of the primitive nature of these BLLs higher than the reference value. operations and their number, with informal ULAB sites estimated to be between 10,000 and 30,000 Source apportionment is a tool for crafting globally, the control of lead poisoning from their effective regulations and developing data- emissions is a major challenge. driven strategies to combat pollution and improve public health. By pinpointing the Mining and smelting are key sources of lead precise contributors to pollution - whether they pollution, including formal, informal, artisanal, are natural sources or anthropogenic sources - and small-scale operations, legacy sites, and source apportionment provides insights into e-waste recycling sites. Each of these types of the sources of pollution. Understanding specific operations has its set of challenges and potential sources of pollution allows policymakers to design solutions. For formal operations, good plant 72 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE design, with a reduction of the potential for the There are several pathways for lead ingestion, emission of contaminating substances, is of including the use of lead-containing cookware. paramount importance, and the newer smelting Historically, low-fired earthenware and traditional processes are inherently much cleaner than stone mills reinforced with lead joints were traditional blast furnaces. recognized as common potential sources of lead contamination in food. High levels of lead The informal sector of lead mining and smelting are common in ceramic foodware in all regions, often lacks facilities for neutralization or safe and it can leach into food. Additionally, artisanal disposal. Artisanal and small-scale mining has aluminum cookware, which has replaced cast iron, become common in areas where mines no longer has also been associated with lead contamination produce enough ore to make them viable for large- during the cooking process. In low and middle- scale operations. On a global scale, there has been income countries, this cookware is made from a significant increase in artisanal and small-scale materials including recycled engines, electronics, mining. and cans. The use of such materials has led to the leaching of metals, including lead and chromium. Lead is found in drinking water. For many Beyond the impact on end users, the manufacture decades, lead has long been used in plumbing of lead-containing ceramic and aluminum materials and solder in drinking water systems, cookware is a source of substantial occupational including pipe components, solder joints, taps exposure, especially if workers are unaware of the and fittings in plumbing systems, pumps or well potential for lead exposure. parts. Lead leaches into tap water with changes in water hydrogen potential (Ph) and through Contaminated foods and adulterated spices are the corrosion of plumbing materials that contain other significant sources of lead exposure. Soil lead. Some countries have adopted legislation and contamination can result in high Pb concentrations regulations requiring the use of lead-free plumbing in food crops, with available evidence pointing components. Leaded pipes and materials are to high lead content in fruits, fish, poultry, and also found in irrigation systems, resulting in the produce in countries from different regions and contamination of food and soils. income levels. Additionally, lead is added to spices such as turmeric for brightness and color (lead Lead is used in paints for color and to enhance compounds have diverse, bright hues of yellow anticorrosive and drying properties. Many and red) in some countries in South Asia, Eastern countries have yet to adopt legally binding controls Europe, the Middle East, and North Africa. to limit the production, import, and sale of lead paints despite evidence of the risks of lead paint Complementary or alternative medicines and toys are and the availability of paint without added lead among the consumer products that have been found at comparable prices. The widespread use of in many instances to have lead levels that significantly decorative paints in LMICs has become more exceed the limits set by national regulations. common as increasing disposable income enables families to paint their homes with more colorful In many LMICs, e-waste is processed and durable options instead of whitewashing. informally, often through manual stripping, Unless lead paint is eliminated in all countries, lead open burning, and dumping, which releases paints are likely to be exported across national hazardous substances, including lead, into the borders, highlighting the need to deepen efforts to environment. Exposure to lead from e-waste phase out lead paint globally. recycling contributes to poisoning. A meta-analysis Lead Pollution: Extent, Sources, and Pathways of Lead in the Environment 73 found that children exposed to e-waste had a emitting approximately 470 tons of lead in 2017. geometric mean BLL of 7.54 μg/dL. Those most at risk of exposure include airport workers, maintenance personnel, and nearby Lead ammunition remains a significant communities, who may inhale airborne lead or source of environmental contamination, ingest contaminated dust and soil. with limited regulations governing its use. Recreational shooting contributes to exposure, Identifying environmental lead sources including ingestion of lead from contaminated requires context-specific evaluations and game meat Beyond hunting, lead exposure thorough assessments of potential origins. occurs in military applications, indoor shooting Various source apportionment tools exist to assist ranges, and ordnance use, where lead-containing in this process, including isotopic analysis. These munitions release contaminants into soil and water. tools help pinpoint the primary sources of lead Unexploded ordnance and sites where ammunition contamination in different contexts, thereby aiding is destroyed can also serve as long-term sources of in prioritizing those sources most responsible contamination. Lead exposure persists long after for pollution. However, challenges persist in the conflicts end, posing risks to civilians. source apportionment. These challenges include the complexity of environmental systems, the Although leaded gasoline has been phased need for accurate and comprehensive data, and out in most countries, residual lead persists the difficulty in distinguishing between different in soil and dust, and vehicle tires and brakes pollution sources. Moreover, the effectiveness of continue to contribute to air pollution. 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The magnitude of these two health effects was estimated for low- and middle-income countries (LMICs) and high-income countries (HICs). Based on estimated global blood lead level (BLL) distributions, as many as 46 percent and 28 percent of children under age 5 in LMICs had BLLs above 5 and 10 micrograms per deciliter (μg/dL), respectively. Estimated global IQ losses in young children from these BLLs were 765 million in 2019, of which 729 million were in LMICs. This is, on average in LMICs, nearly 5.9 IQ points per child over the child’s first five years of life (Larsen and Sánchez-Triana 2023). Losses are highest in low-income countries (LICs) at 6.7 IQ points per child and lowest in high-income countries (HICs) at 2.9 per child. The IQ losses per child are substantial because IQ averages about 100, and a large share of children experience even larger losses from lead exposure. The estimated global CVD adult mortality from lead exposure was 5.5 million in 2019. The number of deaths is over six times as high as estimated by the GBD 2019 (Larsen and Sánchez- Triana 2023). The new estimate is based on a methodology that estimates CVD mortality directly from BLLs, while the GBD 2019 estimated only the indirect effect of lead on CVD mediated through high blood pressure. Executive Summary 91 Богдан Стеблянко / Adobe Stock 4.1. Introduction The impact of lead exposure in LMICs is confirmed by the World Bank’s cost of environmental Lead is toxic to the human body, and exposure degradation (COED) studies in Bangladesh (2024), to lead continues to cause substantial health Colombia (2006), the Lao People’s Democratic effects among both children and adults Republic (2021), Mexico (2020), Peru (2007), Sindh- globally.4 The most commonly used indicator of Pakistan (2015), Vietnam (2022), and Yucatan lead exposure is lead concentration in venous Mexico (2021) (Sánchez-Triana et al. 2007; 2015; blood, or blood lead level (BLL) (von Stackelberg et 2020; 2021; World Bank 2007; 2021; 2022; 2024 ). al. 2021; von Stackelberg et al. 2022). BLLs globally have fallen substantially after the phaseout of This chapter presents estimates of the global lead in gasoline. However, an increasing body health effects of lead exposure based on of research has confirmed that severe health estimates of mean BLLs from the Global effects occur even at low BLLs with no safe lower Burden of Disease (GBD) 2019 in 183 countries threshold. BLLs are a particular concern in Low- and in 2019. Estimated health effects of lead exposure Middle-income Countries (LMICs), where estimated include the loss in children’s intelligence quotient average BLLs are as much as 3.5 times as high as (IQ) and cardiovascular disease (CVD) mortality in High-income Countries (HICs) and at levels with among adults. The estimated health effects are substantial impairment of neuropsychological only partial because they do not include many development in young children and cardiovascular other health and behavioral effects, including disease (CVD) in adults. acute lead poisoning. 4 This chapter draws on Larsen, B., and E. Sánchez-Triana. 2023. “Global Health Burden and Cost of Lead Exposure in Children and Adults: A Health Impact and Economic Modelling Analysis.” Lancet Planet Health 7 (10): E831–40. 92 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 4.2.  Global lead exposure countries using urban population share, number of road vehicles per capita; year of phaseout of Estimating the global health effects of lead leaded gasoline; and a sociodemographic index exposure requires global lead exposure (SDI) (reflecting total fertility, education level of the estimates such as BLLs. Two recent sets of global population 15 years of age or older, and income BLL estimates are reviewed here: Ericson et al. per capita). The 183 countries accounted for (2021) and GBD 2019. 99.9 percent of the global population in 2019. Ericson et al. report estimates of mean BLLs in The differences in estimated BLLs in Ericson children and adults in 34 and 37 LMIC countries, et al. and the GBD 2019 are summarized in respectively, from their systematic review of Larsen and Sánchez-Triana (2023). For the entire BLL measurement studies published from 2010 group of countries in Ericson et al., the population to 2019. The total population in the countries was weighted mean BLL in Ericson et al. is 13 percent 5.2 billion (80 percent of the population in LMICs in higher than the population-weighted mean BLL of 2019, but only 38 percent of the population in LICs). the same countries from the GBD 2019 for children and 2 percent higher for adults. There are, however, GBD 2019 reports estimates of mean BLLs in large differences in BLL estimates between Ericson children and adults in 183 LMIC and HIC for et al. and the GBD 2019 for individual countries the year 2019 based on 554 BLL measurement as indicated by the wide distribution around the studies in 84 countries. Based on these studies, red line in figure 4.1 for both children (left) and GBD 2019 modeled BLLs for an additional 99 adults (right). FIGURE 4.1. Country BLLs from Ericson et al. and the GBD 2019 Country BLL (µg/dL) from Ericson et al. Country BLL (µg/dL) from Ericson et al. 10 12 8 10 8 6 6 4 4 2 2 0 0 0 2 4 6 8 10 0 2 4 6 8 10 12 Country BLL (µg/dL) from GBD 2019 Country BLL (µg/dL) from GBD 2019 Source: World Bank produced from Ericson et al. 2021 and GBD 2019. Note: Left: Children’s BLL. Right: Adults’ BLL. Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 93 One reason for these differences may be that Triana (2023) to estimate health effects of lead only one to three BLL measurement studies exposure, as these data are most complete on were available for half of the countries in a global basis. Mean estimated BLLs in children Ericson et al. The similarity in BLLs is much and adults were 4.6 µg/dL in LMICs and 1.3 µg/dL greater for the ten countries with six or more in HICs. BLLs are highest in LICs and decline with BLL measurement studies. These countries alone income per capita. Regionally, in LMICs, BLLs are account for 60 percent of the population in LMICs. lowest in Europe and Central Asia (ECA) and highest in South Asia (SA) and Sub-Saharan Africa (SSA) The BLL estimates for 183 countries from the (figure 4.2). GBD 2019 were used by Larsen and Sánchez- FIGURE 4.2. Population-Weighted Mean Blood Lead levels (BLLs) in 2019 BLL (µg/dL) BLL (µg/dL) 7.0 6.6 7.0 6.2 6.0 5.4 6.0 5.2 5.1 5.0 5.0 4.6 4.1 4.0 4.0 3.4 3.6 3.3 3.0 3.0 2.3 2.0 2.0 1.3 1.0 1.0 0 0 LI LMI UMI HI World EAP ECA LAC MENA SA SSA LMICs Source: Larsen and Sánchez-Triana 2023 based on country BLLs from the Global Burden of Disease 2019 reported at https://lead.pollution.org/ Note: LI=low-income; LMI=lower-middle-income; UMI=upper-middle-income; HI=high-income countries; LMICs=low- and middle-income countries. World Bank regions: EAP=East Asia and Pacific; ECA=Europe and Central Asia; LAC=Latin America and Caribbean; MNA= Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. Only LMICs are included. The mean BLLs “hide” the extent of elevated to estimates reported by Ericson et al. of 49 and BLLs in the population in, for instance, “hot 32 percent of children with BLLs above 5 and spots”. Based on estimated BLL distributions (see 10 µg/dL, respectively. In contrast, an estimated Larsen and Sánchez-Triana 2023 Supplement), 5 and 1 percent of children under five in HICs an estimated 46 and 28 percent of children had BLLs above 5 and 10 μg/dL, respectively. The under five in LMICs had BLLs above 5 and situation is similar for adults (Larsen and Sánchez- 10 μg/dL, respectively, in 2019. This is comparable Triana 2023). 94 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 4.3.  Health effects of lead only 4–5 weeks in blood. Thus, bone lead level exposure is more of an indication of lead exposure in the past, while blood lead levels better reflect current exposure to lead.6 As this chapter seeks to present Lead is toxic to the human body. Lead in the estimates of the major health effects of current human body can originate from exposure to lead lead exposure, BLL is the exposure indicator used in for instance air, drinking water, food, dust, soil, in this chapter. paint, cosmetics, utensils, some herbal medicines, children’s toys, ornaments and jewelry, and other materials and articles containing lead. Human exposure to lead has many known health effects. Known effects include neuropsychological impacts (for example, impaired intelligence and increased incidence of mild intellectual disabilities5), and attention- related and behavioral impacts in children. Rocha and Trujillo (2019) provide a review of cognitive and behavioral effects of lead exposure in both children and adults. There is some evidence of adverse birth outcomes from lead exposure, such as lower birth weight. Adverse effects in adults include increased blood pressure and cardiovascular disease, chronic kidney disease (CKD), anemia and gastrointestinal symptoms (WHO 2003). Neuropsychological impacts in children are typically assessed based on lead exposure during their first 5–6 years of life. There is no known lower BLL threshold below which there are no neuropsychological impacts in children, impacts on blood pressure and cardiovascular disease among adults, and impacts on renal functioning (that is, kidney disease). Health effects of lead have been evidenced by their association with BLL and lead in bone. Javier / Adobe Stock The half-life of lead in bone is 20–30 years, while 5 Increased incidence of mild intellectual disabilities from lead is a result of IQ losses that bring a child’s IQ below 70 points (WHO 2003). 6 Blood lead levels are also influenced by release of lead from bones which can take place under several circumstances. Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 95 4.4.  IQ loss in children Rothenberg (2005) confirmed this relationship by using the same pooled data as in Lanphear et al. Effects of lead exposure in children include A subsequent study, also using the same pooled cognitive impairment, increased risk of data, took the analysis further (Crump et al. 2013) attention deficit or hyperactivity disorder, and reconfirmed the log-linear relationship. IQ and increased risk of antisocial and criminal losses increase sharply from low BLLs and flatten behaviors (Landrigan et al. 2018). One such out at higher BLLs. Since no safe BLL has been well-established and quantifiable effect of lead established, a theoretical minimum-risk exposure exposure in children is neuropsychological level (TMREL) of 0 μg/dL was applied by Larsen impairment measured as IQ loss.7 The effect is and Sánchez-Triana (2023) based on Crump et al. found to occur even at very low BLLs (Crump et al. (2013) (figure 4.3). Sensitivity analysis with TMREL 2013; Jusko et al. 2008; Lanphear et al. 2005; Surkan of 1–2 μg/dL was undertaken. et al. 2007). In fact, no BLL threshold below which there are no impacts on children’s IQ has been Other studies have also confirmed a loss in IQ identified in the international research literature. from BLLs below 10 μg/dL (Jusko et al. 2008; Gilbert and Weiss (2006) argued for a BLL action Surkan et al. 2007), and more recently a prospective level of 2 µg/dL nearly two decades ago, Carlisle cohort study of a population-representative birth et al. (2009) for a benchmark of 1.0 µg/dL, and the cohort in New Zealand found that each 5µg/dL European Food Safety Authority for a benchmark higher BLL at the age of 11 years was associated dose level of 1.2 µg/dL for neurotoxicity in children with 1.6 points lower IQ score in adulthood a decade ago (EFSA 2013). The US Environmental (Reuben et al. 2017). This is the same loss in IQ as Protection Agency (USEPA), in a recent economic found by Crump et al. for an increase in BLL from analysis of lead abatement, employed three 7 to 12 µg/dL. alternative IQ loss models, two of which applied a zero BLL threshold (USEPA 2020). IQ losses due to lead exposure among children under five years were estimated for each country A seminal study by Lanphear et al. (2005), based from the log-linear relationship between children’s on a pooling of seven international longitudinal BLL and IQ discussed above, mean BLLs by country cohort studies, specified a log-linear function from the GBD 2019, and the distribution of the that best describes the relationship between children’s BLLs around the mean BLL value of each children’s BLL and their IQ. Rothenberg and country.8 7 Intelligence quotient (IQ) is a score on standardized tests designed to assess intelligence. 8 The distribution is characterized by a log-normal distribution function (see Larsen and Sanchez-Triana 2023 Supplement). 96 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE FIGURE 4.3. Loss of IQ Points from Lead Globally, an estimated 765 million IQ points Exposure in Early Childhood were lost due to lead exposure in 2019. As IQ loss (points) much as 95 percent of these losses, or 729 million 12 IQ points, were in LMICs. The largest losses in LMICs were in SSA (235 million), SA (230 million), 10 and EAP (137 million) (Larsen and Sánchez-Triana 8 2023). The losses over the children’s first five years of life are 5.7 IQ points per child globally if 6 the children’s BLLs remain at the 2019 level over 4 their first five years. The loss ranges from 2.9 IQ points in HICs to 6.7 points in LICs and, regionally 2 in LMICs, from 4.2 points in ECA to 6.6 points in 0 SA (figure 4.4). 0 2 4 6 8 10 12 14 16 18 20 BLL (µg/dL) Source: Produced from the log-linear function for IQ loss (points) = β[ln (BLL+1)] with β=3.246 for childhood lifetime BLLs up to the time of IQ testing reported in Crump et al. (2013). nadezhda1906 / Adobe Stock Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 97 FIGURE 4.4. IQ Point Losses per Child from Pb Exposure by Country Income and Region BLL (µg/dL) BLL (µg/dL) 7.0 6.7 7.0 6.6 6.2 6.2 6.1 5.9 5.7 6.0 6.0 5.2 5.3 5.0 5.0 5.0 4.2 4.0 4.0 2.9 3.0 3.0 2.0 2.0 1.0 1.0 0 0 LI LMI UMI LMIC HI World EAP ECA LAC MENA SA SSA Source: World Bank estimates. Note: IQ point losses per child = cumulative losses in early childhood. LI=low-income; LMI=lower-middle-income; UMI=upper-middle-income; HI=high-income countries; LMIC=low- and middle-income countries. World Bank regions EAP=East Asia and Pacific; ECA=Europe and Central Asia; LAC=Latin America and Caribbean; MNA=Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. Only LMICs are included. Sensitivity analysis respectively. For HICs, however, estimated IQ losses decrease by as much as 20 and 54 percent, Estimates of IQ losses are influenced by the choice respectively (Larsen and Sánchez-Triana 2023). of TMREL and the distribution of BLLs around the Globally, the effect is a decrease of 4 and mean BLL. 13 percent. Theoretical minimum-risk exposure Blood lead level distribution level (TMREL) The BLL distribution around the mean TMREL establishes the BLL below which BLL value is characterized by a log-normal it is assumed that there are no IQ losses. distribution function specified by the mean BLL The TMREL is, however, uncertain but highly and the standard deviation (SD) (WHO 2003). unlikely to be higher than 2 μg/dL in light of A low standard deviation implies that BLLs are available research (Carlisle et al. 2009; Lanphear clustered close to the mean BLL. A high standard et al. 2005). For countries with high mean BLLs deviation implies that BLLs are spread over a larger in children, the choice of TMREL has minor effect range of values. on total estimated IQ losses, while the opposite is the case in countries with low mean BLLs. For the For LMICs with a mean BLL of 4.6 μg/dL, the group of LMICs, increasing the TMREL from 0 to difference in estimated IQ losses is less than 1.0 μg/dL and from 0 to 2 μg/dL only decreased 2 percent for the group of all LMICs for an SD of estimated IQ losses by 3 and 10 percent, +/- 1.4 around the mean SD of 3.84. For HICs with 98 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE a mean BLL 1.3 μg/dL, the difference in estimated FIGURE 4.5. IQ Loss from Lead Exposure IQ losses is less than 4 percent for an SD of +/- IQ loss (points) 0.4 around the mean SD of 2.12 (see Larsen and 12 Sánchez-Triana 2023 Supplement). The reason for 10 the somewhat larger effect on estimated IQ losses in HICs, even for a smaller percentage difference 8 in SD, is the greater curvature or nonlinearity of 6 the BLL-IQ function at lower BLLs. With a TMREL of 2 μg/dL, the effect of the variation in the SD 4 on estimated IQ losses is minimal for LMICs 2 but increases substantially to 20–30 percent for 0 HICs as the majority of children have BLLs below 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 2 μg/dL. BLL (µg/dL) Crump et al. (2013) Attina and Trasande (2013) Sources: Produced from Attina and Trasande (2013) and Comparison with previous Crump et al. (2013). global study One previous study has estimated the IQ Lead exposure and learning loss of lead exposure in children in LMICs outcomes as a group (Attina and Trasande 2013). It is therefore worthwhile comparing the estimate The IQ reduction associated with lead exposure from that study to the estimate presented in this translates into measurable learning losses, as chapter. Attina and Trasande estimated a loss of diminished cognitive abilities limit children’s 406 million IQ points in LMICs in 2008 while the academic potential. Lead exposure accounts for estimate presented in this chapter is 729 million as much as 20 percent of the gap in educational in 2019 despite substantially higher BLLs in Attina outcomes between high- and low-income countries and Trasande. The reasons for the lower IQ loss (Crawfurd et al. 2024). in Attina and Trasande are that they used a 0.513 IQ point loss per 1 μg/dL for BLLs 2–10 μg/dL; Each natural log unit increase in BLL 0.19 point loss for BLL 10–20 μg/dL; and 0.11 corresponds to a 0.12 standard deviation point loss for BLL ≥ 20 μg/dL. This substantially reduction in learning outcomes. This means that lowers the BLL–IQ loss curve as seen in figure for every increase in BLL, children’s learning scores 4.5 compared to Crump et al. (2013), which was are likely to decrease by a small but noticeable used to develop the estimates presented in this amount. This reduction is consistent across reading chapter. As explained in section 4.4 above, the and mathematics scores, indicating that lead relationship between IQ loss and lead exposure exposure uniformly impairs cognitive abilities established by Crump et al is based on pooled essential for academic success. Reducing average date from seven international longitudinal BLLs from 5.3 µg/dL to 0.5 µg/dL could boost cohort studies. national learning outcomes by 4 to 31 points on Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 99 the World Bank harmonized scale (HLO)9, with an means they ranked 0.90 to 1.2 places lower average improvement of 23 points. For example, compared to their peers. This gap in performance the Democratic Republic of Congo, currently the continued as these children moved through school lowest-ranked country in the study with a score (Shadbegian et al. 2019; 1). of 248 points in the HLO —far below the global mean of 500—stands to improve by 29 points if Building on evidence of potential gains from BLLs are reduced to 0.5 µg/dL. African nations lowering BLLs, targeted interventions have such as Nigeria and Cameroon would experience demonstrated substantial impacts on learning gains of 28 and 31 points, respectively. In Asia, outcomes. Interventions to reduce acute lead significant improvements are projected in Nepal, exposure lead to increases in learning outcomes Bangladesh, and Thailand, with increases of 29, 27, for children. For instance, in Nigeria and the and 25 points, respectively. European countries like Dominican Republic, remediation efforts reduced Kosovo and Romania would benefit from increases BLLs—from 149 µg/dL to 15 µg/dL in Zamfara and of 14 and 17 points, while Latin American nations from 20.6 µg/dL to 5.34 µg/dL in Haina—resulted such as Colombia, Ecuador, and Brazil could see in improvements of 0.28 standard deviations in their scores rise by 20, 18, and 14 points (Crawfurd learning outcomes and 0.16 standard deviations et al. 2024; 20). These improvements would close in test scores, respectively (Crawfurd et al. 2024, 21 percent of the 110-point learning gap between 22–23). These findings underscore the potential developing and developed nations, highlighting the benefits of reducing lead exposure to enhance crucial role that reducing lead exposure plays in global educational outcomes. narrowing global educational disparities. A one-unit decrease in average BLLs among 4.5.  Cardiovascular disease children in Rhode Island reduced the probability mortality in adults of being substantially below proficient in reading by 0.96 percentage points, from a baseline of 12 percent. This means that if Lead exposure has been found to increase 12 percent of children were below proficient mortality risk in adults. The GBD estimated in reading, this reduction would lower that global deaths from lead exposure at about 902,000 percentage to approximately 11 percent. A similar in 2019, of which 849,000 were cardiovascular improvement was observed in math scores, with disease (CVD) deaths and 53,000 were chronic decreased by 0.79 percentage points (Aizer et al. kidney disease (CKD) deaths (GBD 2019 Risk Factors 2018; 3). In North Carolina, children with BLLs of Collaborators 2020). The focus in this chapter is 5 µg/dL performed worse in math and reading on CVD deaths, given that CVD deaths constitute compared to children with BLLs below 1 µg/dL. 94 percent of total deaths from lead exposure in Specifically, these children scored lower, which GBD 2019. 9 The World Bank’s Harmonized Learning Outcomes (HLO) database is a large-scale effort to compile and standardize student assessment data from around the world. It includes data from seven different testing programs, including international and regional assessments, across 164 countries, representing 98 percent of the global population. The database provides comparable metrics for student learning outcomes by converting regional test scores to an international scale. It covers data from 2000 to 2017, disaggregated by schooling level (primary and secondary); subject (reading, mathematics, and science); and gender. This harmonization allows for meaningful global comparisons of educational performance, particularly in developing countries. In 2021, the HLO reported an average learning score of 500 points, with a standard deviation of 100 points, indicating a range of scores from a high of 622 to a low of 226. 100 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Douglas Rissing / iStock The GBD 2019 report estimated CVD mortality FIGURE 4.6. Relative Risk of CVD Mortality from lead exposure based on bone-lead levels from BLL of 1–20 μg/dL modeled from BLLs, and relations between bone Relative risk (RR) lead and blood pressure, and blood pressure 3.00 and CVD mortality. Lead exposure has, however, 2.75 cardiovascular effects beyond effects mediated 2.50 through blood pressure, as evidenced in a Scientific 2.25 Statement by the American Heart Association in 2.00 2023 (Lamas et al. 2023). 1.75 1.50 Brown et al. (2020) developed a health impact model that used the concentration-response 1.25 relationship between BLLs and CVD mortality 1.00 0 2 4 6 8 10 12 14 16 18 20 risk from four studies, thus directly estimating BLL (µg/dL) CVD mortality (Aoki et al. 2016; Lanphear et al. Menke et al. (2006) Lanphear et al. (2018) 2018; Menke et al. 2006; Ruiz-Hernandez et al. Ruiz-Hernandez et al. (2017) Aoki et al. (2016) 2017). All four studies analyzed BLLs of the adult population in the United States from one or more Source: Larsen and Sánchez-Triana (2023) Supplement. of the nationally representative National Health Derived from Brown et al. (2020) and the four individual studies. The risk function derived from Aoki et al. (2016) and Nutrition Examination Surveys (NHANES) from is for whole blood BLL for comparability with the other 1988 to 2010. The studies found a wide range in three studies. relative risk (RR) of CVD mortality (figure 4.6). Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 101 The relative risk functions imply a TMREL BLL CVD deaths due to lead exposure among of 1 μg/dL. However, elevated CVD mortality risk adults was estimated from the relationship (RR > 1) from lead exposure may occur at BLLs between BLL and CVD mortality risk discussed below 1 μg/dL as no safe level of lead exposure above, mean adult BLLs by country from the has been established. The relative risk functions GBD 2019, and the distribution of adult BLLs were therefore adjusted by Larsen and Sánchez- around the mean BLL value of each country.10 Triana (2023) with a linear BLL–CVD mortality risk Accordingly, estimated global CVD deaths due to relationship for BLLs in the range of 0–2 μg/dL. lead exposure were 2.4–7.1 million in 2019. About The unadjusted relative risk function was used for 2.15–6.4 million of the deaths, or 90 percent, were sensitivity analysis. in LMICs while 0.22–0.72 million were in HICs. More than half of the deaths in LMICs were in UMI At the average BLL of 4.6 μg/dL in LMICs the countries, 42 percent were in LMI countries, and increased risk of CVD mortality is 19–71 percent. 7 percent were in LI countries (figure 4.7). The At the average BLL of 1.3 μg/dL in HICs the increased deaths constituted 15–44 percent of all CVD deaths risk is 3–10 percent by the unadjusted risk functions in LMICs. and 5–18 percent by the adjusted risk functions. FIGURE 4.7. CVD Deaths (‘000) from Pb Exposure by Country-Income Classification in 2019 XXXX XXXX 8,000 3,500 3,333 7,000 3,000 2,727 718 2,640 6,000 2,435 576 2,500 2,194 5,000 510 1,973 2,000 4,000 6,406 1,500 3,000 1,088 4,735 5,283 909 2,000 220 1,000 433 1,000 2,151 500 327 363 154 0 0 Aoki et al. Ruiz- Lanphear Menke et al. LI LMI UMI (2016) Hernandez et al. (2006) Aoki et al. (2016) Ruiz-Hernandez et al. (2017) et al. (2017) (2018) Lanphear et al. (2018) Menke et al. (2006) LMIC HIC Source: World Bank estimates. Note: LI=low-income countries; LMI=lower-middle-income countries; UMI=upper-middle-income countries; HI=high-income countries; LMIC=low- and middle-income countries. 10 The distribution is characterized by a log-normal distribution function (see Larsen and Sánchez-Triana 2023 Supplement). 102 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Regionally, CVD deaths from lead exposure appropriate ones for estimating global CVD in LMICs are highest in EAP and SA. These two mortality from lead exposure. In this case, regions account for 68 percent of deaths in LMICs, the range of CVD deaths is 5.2–5.8 million, with or 1.5–4.3 million deaths (figure 4.8). a central estimate of 5.5 million in 2019. This implies a 30 percent attributable fraction from lead Estimated CVD deaths from lead exposure exposure of all global CVD deaths, as in Larsen represent a very wide range. The study by Aoki and Sánchez-Triana (2023). Compared to other et al. is based on more recent NHANES surveys environmental risk factors, the GBD estimated than the other studies, with a very low mean mortality from PM2.5 ambient and household air BLL and only 6 percent of participants with BLL pollution was 4.1 and 2.3 million, respectively, in over 5 µg/dL. The study by Menke et al. (2006) 2019 (World Bank 2022). limited the sample to participants with BLLs below 10 µg/dL, while as many as 26 percent of adults in One-quarter of the individuals estimated to die LMICs are estimated to have BLL above this level from CVD due to lead exposure are of productive as previously noted. The risk functions by Aoki age below 65 years. These individuals lose on et al. and Menke et al. may therefore not reflect average 34 years of life, including ten years of labor the situation in most LMICs. force participation, according to years-of-life-lost (YLL) calculations by the GBD 2019. The years of life This leaves the risk functions from Lanphear lost among these individuals is 44 percent of total et al. and Ruiz-Hernandez et al. as the most YLLs lost from CVD mortality due to lead exposure. FIGURE 4.8. CVD Deaths (‘000) from Pb Exposure in LMICs by Region in 2019 XXXX 3,000 2,585 2,500 2,119 2,000 1,894 1,754 1,466 1,500 1,322 1,000 850 708 615 511 574 507 430 500 309 346 421 321 357 378 421 224 148 174 139 0 EAP ECA LAC MENA SA SSA Aoki et al. (2016) Ruiz-Hernandez et al. (2017) Lanphear et al. (2018) Menke et al. (2006) Source: World Bank estimates. Note: World Bank regions: EAP=East Asia and Pacific; ECA=Europe and Central Asia; LAC=Latin America and Caribbean; MNA= Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. Only LMICs are included. Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 103 Sensitivity analysis lower or higher (that is, 1.7 or 2.3), estimated deaths would be 9 percent lower or 8 percent Estimated CVD deaths from lead exposure are higher in the HICs. Thus, estimated CVD deaths influenced by three factors: from lead exposure are somewhat sensitive to variation in SD in HICs but much less so at the i. The TMREL below which potential mortality risk global level. is not accounted for. ii. The standard deviation or distribution of BLLs around the mean BLL in each country. Shape of the E-R function iii. The shape of the BLL–CVD mortality exposure- response (E-R) function. Very few participants in the studies from the United States had BLLs above 20 µg/dL or even 10 µg/dL. The shape of the exposure-response TMREL function above these BLLs is, therefore, uncertain. Truncating the function so that the relative risk A TMREL BLL of 0 μg/dL was applied by Larsen does not increase for BLL above 20 µg/dL only and Sánchez-Triana (2023) as a base case for reduces the global CVD mortality estimate by estimating CVD mortality from lead exposure. 4 percent. Even truncating the function at 10 µg/dL Applying instead a TMREL of 1 μg/dL, as suggested reduces the mortality estimate by only 11 percent by the unadjusted relative risk functions derived (see Larsen and Sánchez-Triana 2023 Supplement). from Brown et al. (2020) in figure 4.6, reduces This shows that even for most LMICs and LMICs as estimated global CVD deaths by less than 4 percent. a group with substantially higher BLLs than in HICs, The largest effect is for HICs in which estimated it is the shape of the E-R function for BLLs up to CVD deaths are reduced by 16 percent because a 10 µg/dL that matters the most. large share of the population in these countries has BLLs below 1 μg/dL. Comparison with previous estimates Standard deviation The Institute for Health Metrics and Evaluation The distribution of BLLs around the mean BLL (IHME) has included lead exposure as a risk is characterized by a log-normal distribution factor in its Global Burden of Disease (GBD) function specified by the mean BLL and the reports. Until recently, IHME assessed the link standard deviation (SD) (WHO 2003). For the between lead exposure and cardiovascular mean BLL of 4.6 μg/dL in LMICs, the estimated disease only through its effects on systolic blood SD is 3.88 (see Larsen and Sánchez-Triana 2023 pressure. Based on this approach, IHME estimated Supplement). If the SD were 35 percent lower that hypertension due to lead exposure caused or higher (that is, 2.5 or 5.3), estimated deaths approximately 1.5 million deaths globally and would be 6 percent lower or 4 percent higher in approximately 34 million DALYs globally in 2021 the LMICs. (GBD 2019 Risk Factors Collaborators 2020). However, according to Brauer (2024), the GBD 2023 For the mean BLL of 1.3 μg/dL in HICs, the report will update its methodology to also include estimated SD is 2.02. If the SD were 15 percent the direct effects of lead on CVD mortality, based 104 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE on the evidence discussed previously that lead of children under five years of age in LMICs had increases the risk of cardiovascular disease through BLLs above 5 and 10 μg/dL in 2019, respectively. pathways that are independent of the direct effect In contrast, 5 and 1 percent of children in HICs have on hypertension. these BLLs. The situation is similar for adults. As discussed in chapter 2, lead is not only The estimated global IQ losses in young children a risk factor for hypertension but also for from lead exposure were 765 million in 2019 atherosclerosis, stroke, and ischemic heart (Larsen and Sánchez-Triana, 2023). This is, on disease (Dang et al. 2024; Lamas et al. 2021; average, nearly 5.7 IQ points per child over the Lanphear et al. 2024). Since lead is a risk factor child’s first five years of life. Losses are highest in for atherosclerosis, it has implications for all LICs at 6.7 per child and lowest in HICs at 2.9 per cardiovascular disease mortality, including strokes child. Regionally, among LMICs, IQ losses are and coronary heart disease (Lanphear et al. 2024, highest in SA at 6.6 per child and lowest in ECA at 1626). These results make lead exposure one of 4.2 per child. The IQ losses per child are substantial, the highest risk factors in worldwide mortality. The considering that IQ averages about 100 and that a new estimates of CVD mortality from lead exposure large share of the children experience even larger discussed in this publication, together with those losses from lead exposure. caused by fine particulate matter (PM2.5) air pollution and nitrogen dioxide (NO2) air pollution, The estimated global CVD adult mortality from add substantially to the global burden of disease lead exposure was 2.4–7.1 million in 2019 with from environmental risk factors (World Bank 2025). a central estimate of 5.5 million. The number of deaths is over six times as high as estimated by the GBD 2019 (Larsen and Sánchez-Triana 2023). 4.6. Conclusions The new estimate is based on a methodology that estimates CVD mortality directly from BLLs Exposure to lead continues to be a worldwide while the GBD 2019 estimated only the indirect environmental health risk with substantial effect of lead on cardiovascular disease mediated health effects among both children and adults. through high blood pressure. The approach used Estimated population-weighted BLL in LMICs is as for the new estimates is supported by evidence much as 3.5 times as high as in HICs and at levels showing that lead exposure has cardiovascular with substantial impairment of neuropsychological effects beyond effects mediated through blood development in young children and cardiovascular pressure, as stated in a Scientific Statement effects in adults. Estimates indicate that BLLs are by the American Heart Association in 2023 highest in LICs and lowest in HICs. Regionally BLLs (Lamas et al. 2023). are highest in SA followed by SSA and MNA, and lowest in HI regions. While global BLLs have declined substantially since the phaseout of leaded gasoline, there The mean BLLs “hide” the extent of elevated remain multiple sources of lead exposure. BLLs in the populations. Based on estimated Annex 1 presents the BLLs and health effects by BLL distributions, as many as 46 and 28 percent country/economy. Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 105 References Aizer, Anna, Janet Currie, Peter Simon, and Patrick Vivier. Crump, K. S., C. Van Landingham, T. S. Bowers, D. 2018. “Do Low Levels of Blood Lead Reduce Cahoy, and J. K. 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Fewtrell, and More Productive Societies. Washington, DC: R. Kaufmann, and A. Prüss-Üstün. 2003. World Bank. Lead: Assessing the Environmental Burden of Diseases at National and Local Levels. https:// Zax, Jeffrey S., and Daniel I. Reese. 2002. “IQ, Academic apps​.who​.int/iris/handle/10665/42715 Performance, Environment, and Earnings.” (accessed May 30, 2025). Review of Economics and Statistics 84 (4): 600–16. Lead Pollution Robs Children of their Future and Kills Millions of Adults – Estimating Global Impacts on Health 109 umesh negi / iStock 110 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE GLOBAL HEALTH COST OF LEAD POLLUTION: A CALL FOR ACTION 5 Chapter Overview Lead inflicts significant costs on both children and adults worldwide. The magnitude of these costs was estimated for low- and middle-income countries (LMICs) and high-income countries (HICs) in research at the World Bank published in The Lancet Planetary Health (Larsen and Sánchez-Triana 2023). This chapter summarizes the findings by Larsen and Sánchez- Triana and presents further findings at the regional level and by country-income classification. Global IQ losses were estimated to cost $1.4 trillion (I$2.4 trillion international dollars). This cost is the present value of lifetime income losses from the IQ loss in 2019. The cost is equivalent to 1.6 percent of global GDP in 2019. This is 1.8 percent of purchasing power parity–adjusted (PPP-adjusted) gross domestic product (GDP). The cost reached 2.2 percent of GDP in LMICs (2.4 percent of PPP-adjusted GDP) and as high as 8.3 percent in low-income countries (LICs) (8.5 percent of PPP-adjusted GDP) (Larsen and Sánchez-Triana 2023). The global welfare cost of adult lead exposure, or the cost of cardiovascular disease (CVD) mortality, is estimated at $1.9–6.0 trillion in 2019 (I$3.3–10.3 trillion) based on the estimated range of 2.4–7.1 million CVD deaths. The cost is equivalent in size to 2.2–6.9 percent of global GDP in 2019 (2.5–7.7 percent of PPP-adjusted GDP). The central estimate of cost is $4.6 trillion (I$7.9 trillion), equivalent in size to 5.3 percent of global GDP, which is 5.9 percent of GDP (PPP) (Larsen and Sánchez-Triana 2023). Executive Summary 111 5.1. Introduction This chapter presents the updated cost of children’s lead exposure. The cost of IQ losses in Lead, a toxic substance, continues to inflict children is an economic productivity loss because significant costs on both children and adults IQ loss is associated with a loss in lifetime earnings. globally. This chapter presents the global cost IQ losses therefore have long-term economic of IQ losses in children and CVD mortality in impacts. adults in 2019. The methodologies, data, and parameters that influence the cost estimates for The cost of CVD mortality is a welfare cost each demographic group are discussed in the based on how individuals value changes in sections below. The methodological approach the risk of mortality that may result from lead used to develop such estimates is described in the exposure. The cost of CVD mortality does not supplementary appendix of Larsen and Sánchez- translate into a GDP loss. The report presents the Triana (2023). cost of CVD mortality as a percentage of GDP to illustrate the magnitude of the cost and is not an Importantly, the estimates presented here do indication of the impact of adult lead exposure not account for a wide range of other health on GDP. and behavioral effects, including acute lead poisoning. From that perspective, the estimated cost is only a partial representation since it is 5.2.  Global cost of IQ losses difficult to isolate the effects of lead on different health and economic endpoints, from other The cost of IQ losses is estimated by the effect confounding effects, such as socioeconomic factors of IQ on lifetime income. The existence of a that may also influence individuals’ health and relationship between IQ and lifetime income has productivity. The sections below discuss ranges long been established (Grosse and Zhou 2021; for each cost estimate and a sensitivity analysis Johnson and Neal 1998; Lin, Lutter, and Ruhm that contributes to assessing the robustness of the 2018; Lundborg, Nystedt, and Rooth 2014; Salkever presented results. Cost estimates are presented 1995; Salkever 2014a,b; Schwartz 1994; US EPA for 2019. It is likely that as economies grow, and 2020; Zax and Reese 2002). Multiple studies have actions are taken to reduce lead exposure, cost used this relationship for estimating the cost of IQ estimates will evolve. losses from lead exposure in, for instance, France, the US, and in LMICs (Attina and Trasande 2013; A 2013 study of lead exposure among children Gould 2009; Grosse et al. 2002; Muennig 2009; in LMICs estimated that the economic cost from Pichery et al. 2011). the loss in children’s intelligence due to lead was 4 percent of gross domestic product (GDP) in A lifetime income effect of 2.0 percent per Africa, 1.9 percent of GDP in Asia, and 2 percent IQ point was applied by Larsen and Sánchez- of GDP in Latin America and the Caribbean Triana (see Larsen and Sánchez-Triana 2023 (LAC) in 2011 (Attina and Trasande 2013). Attina Supplement). This is the same effect size as and Trasande assembled blood lead level (BLL) applied by Attina and Trasande (2013). The measurement studies from the period 2000 to 2010 income effect was applied to the share of children and developed a regression model to predict BLLs expected to enter the labor force in the future in 2008 in countries without BLL measurement using current labor force participation rates. studies and in countries with older studies. Annual future income growth was assumed to 112 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Imgorthand / iStock be 2.5 percent in LMICs and 1.5 percent in HICs. FIGURE 5.1. Cost of IQ Losses in Children by The discount rate of future income was set at twice Country Income Classification in 2019 the per capita income growth rate as proposed I$, billions by the World Bank for project economic analysis 3,000 (World Bank 2016). 2,446 2,500 Based on these rates, the global IQ losses 2,000 1,702 are estimated to cost $1.4 trillion (I$2.4 trillion 1,500 international dollars).11 This cost is the present value of lifetime income losses from the IQ loss in 1,000 854 736 743 2019. The cost of IQ losses in LMICs was $719 billion 500 (I$1,702 billion) (figure 5.1). The cost is equivalent 112 in size to 1.6 percent of global GDP in 2019 0 LI LMI UMI LMIC HI World (1.8 percent of PPP-adjusted GDP). The cost reached an equivalent of 2.2 percent of GDP in LMICs Source: Estimates based on Larsen and Sánchez-Triana (2023). (2.4 percent of PPP-adjusted GDP) and as high as 8.3 percent in LICs (8.5 percent of PPP-adjusted Note: LI=low-income countries; LMI=lower-middle- income countries; UMI=upper-middle-income countries; GDP). This cost as a share of GDP is seven times as LMIC=low- and middle-income countries; HI=high-income high as the cost of GDP in high-income countries countries. (HICs) (figure 5.2) (Larsen and Sánchez-Triana 2023). 11 International dollars (I$) are US dollars adjusted for purchasing-power parity. Global Health Cost of Lead Pollution: A Call for Action 113 FIGURE 5.2. Cost of IQ Losses in Children by FIGURE 5.3. Cost of IQ Losses in Children in Country Income Classification in 2019 LMICs by Region in 2019 % of GDP (PPP) I$, billions 10 600 556 8.5 500 8 418 400 6 300 280 4 3.7 198 200 2.4 123 128 1.7 1.8 2 1.2 100 0 0 LI LMI UMI LMIC HI World EAP ECA LAC MENA SA SSA Source: Estimates based on Larsen and Sánchez-Triana Source: World Bank estimates based on Larsen and (2023). Sánchez-Triana (2023). Note: LI=low-income countries; LMI=lower-middle- Note: Regions EAP=East Asia and Pacific; ECA=Europe income countries; UMI=upper-middle-income countries; and Central Asia; LAC=Latin America and Caribbean; LMIC=low- and middle-income countries; HI=high-income MNA= Middle East and North Africa; SA=South Asia; countries. SSA=Sub-Saharan Africa. Only LMICs are included. By region, the cost of IQ losses in LMICs is FIGURE 5.4. Cost of IQ Losses in Children in highest in absolute terms in East Asia and LMICs by Region in 2019 Pacific (EAP), followed by South Asia (SA) and % of GDP (PPP) Sub-Saharan Africa (SSA) (figure 5.3). As a 7.0 6.5 percentage of GDP, the cost is by far highest in 6.0 SSA and lowest in EAP and ECA. While the cost is 5.0 highest in absolute terms in EAP, it is second to lowest in percentage of GDP (figure 5.4). 4.0 3.5 3.0 3.0 2.1 2.0 1.8 1.4 1.0 0 EAP ECA LAC MENA SA SSA Source: World Bank estimates based on Larsen and Sánchez-Triana (2023). Note: Regions: EAP=East Asia and Pacific; ECA=Europe and Central Asia; LAC=Latin America and Caribbean; MNA= Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. Only LMICs are included. 114 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Comparison with previous chapter, reduces the cost from 2.08 to 1.35 percent global study of GDP (PPP adjusted) in LMICs.12 Attina and Trasande (2013) estimated the cost of lead exposure in children in LMICs as a group at Sensitivity analysis I$977 billion, equivalent to 2.08 percent of GDP (PPP) (table 5.1). This estimate, as a percentage There are several parameters that influence of GDP, is only slightly lower than the estimate of the estimate of cost of IQ losses. This includes 2.41 percent presented in this chapter, despite the effect of IQ losses on lifetime income, future the fact that the estimated IQ loss in this study is income growth, and the discount rate of future 80 percent higher than the estimate by Attina and income, which are discussed below in the following Trasande (see previous chapter). sections. The main reason for the relatively high estimate The estimated cost of lead exposure is of cost by Attina and Trasande is that they applied proportional to the effect of IQ losses on the estimated income effect of IQ losses to all lifetime income. Applying a lifetime income children “regardless of whether they eventually effect of 1.5 or 2.5 percent per IQ point gives an will join the labor force” or not (Larsen and estimated global cost of 1.4 and 2.3 percent of Sánchez-Triana 2023). Applying income losses only global GDP (PPP adjusted), respectively, (Larsen to the share of the child population that is projected and Sánchez-Triana 2023). to eventually participate in the labor force, as in this TABLE 5.1. Key Parameters and Values Used for Estimating the Cost of Lead Exposure in Children in LMICs This study Attina and Trasande (2013) (for year 2019) (for year 2011) Mean BLL (μg/dL) 4.6 8.1a TMREL (μg/dL) 0 2 IQ losses in LMICs (million) 729 406 IQ loss per child (first 5 years of life) 5.94 3.45 Lifetime income effect per IQ point 2.0% 2.0% Annual income growth 2.5 % 1% Discount rate 5% 3% Income effect applied to labor force only Yes No Cost of IQ losses (I$, billions) I$1,702 I$977 Cost of IQ losses (% of GDP (PPP) in LMICs) 2.41% 2.08% b Note: a Mean BLL is from the year 2008. b Calculated here; not presented in Attina and Trasande (2013). 12 The rate of labor-force participation among those ages 15–64 in LMICs was 65 percent in 2019 (World Bank 2023). Global Health Cost of Lead Pollution: A Call for Action 115 Future growth of income and the discount rate of World Bank (2022). The cost of premature mortality future income affect today’s value or the present estimated by the VSL is a welfare cost and not an value of the cost of IQ losses. Larsen and Sánchez- economic productivity cost. A comparison of the Triana (2023) applied an annual income growth of cost with GDP (percent of GDP) simply illustrates 2.5 percent in LMICs and 1.5 percent in HICs. The the magnitude of the cost and is not an indication discount rate is twice the income growth rate as of the impact of adult lead exposure on GDP. proposed by the World Bank (World Bank 2016). The cost of CVD morbidity is not estimated here. Changing these rates to 1 percent annual income The cost of CVD morbidity relative to the cost of growth and 3 percent discount rate, as in Attina and mortality is found to be quite minor in the case Trasande, increases the estimated global cost slightly of adult lead exposure, or at 5 percent in a recent from 1.8 to 2.0 percent of global GDP (PPP adjusted) study in Mexico (World Bank 2020). and the cost in LMICs from 2.4 to 2.8 percent of GDP The global cost of adult lead exposure, or the (PPP adjusted), and reduces the cost in HICs from welfare cost of CVD mortality, is estimated at 1.2 to 1 percent of GDP (PPP adjusted). $1.9–6.0 trillion in 2019 (I$3.3–10.3 trillion) based on the estimated range of 2.4–7.1 million CVD deaths. These ranges were estimated based on 5.3.  Global cost of adult the concentration-response relationship between mortality BLLs and CVD mortality risk from four studies, as explained in chapter 4. The cost is equivalent in size The cost of premature mortality is estimated by to 2.2–6.9 percent of global GDP in 2019 (2.5–7.7 using a value of statistical life (VSL). The VSL is percent of PPP-adjusted GDP). The central estimate calculated based on individuals’ “willingness to pay of cost is $4.6 trillion (I$7.9 trillion), equivalent to (WTP)” for a reduction in the risk of death.13 The VSL 5.3 percent of global GDP (5.9 percent of GDP (PPP)) for each country is estimated using the method in (table 5.2) (Larsen and Sánchez-Triana 2023). TABLE 5.2. Global Welfare Cost of Adult Lead Exposure in 2019 Ruiz- Central Lanphear Menke Aoki et al. Hernandez estimate et al. et al. et al. $, trillions 1.9 4.3 4.6 4.9 6.0 % of GDP equivalent 2.2% 5.0% 5.3% 5.6% 6.9% I$, trillions (PPP) 3.3 7.5 7.9 8.4 10.3 % of GDP (PPP) equivalent 2.5% 5.6% 5.9% 6.3% 7.7% Source: Central estimate is from Larsen and Sánchez-Triana (2023). Estimates based on the four studies are World Bank estimates. 13 The Value of a Statistical Life (VSL) is an economic concept used to quantify the benefit of reducing the risk of death. It represents the amount of money that a large group of people would collectively be willing to pay to reduce the risk of one statistical death within that group. This is not the value of an individual life, but rather a measure of the value placed on small reductions in mortality risk across a population. For example, if 100,000 people are each willing to pay $100 to reduce their individual risk of dying by 1 in 100,000, the VSL would be $10 million (100,000 people × $100 each) (US EPA 2024). This concept is often used in policy making to evaluate the cost-effectiveness of regulations and interventions aimed at improving public health and safety (Knieser and Viscusi 2019). 116 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE The central estimate of the welfare cost in LICs (figures 5.5 and 5.6). The cost reaches of CVD mortality is highest in absolute an equivalent of 7.8 percent of GDP in LMICs terms and as a percentage of GDP in upper- (7.6 percent of PPP-adjusted GDP), or twice as high middle-income (UMI) countries and lowest as in HICs. FIGURE 5.5. Welfare Cost of Adult Mortality from Lead Exposure by Country Income Classification in 2019 (central estimate) $, billions I$, billions 7,910 5,000 4,591 8,000 4,500 4,000 6,000 5,346 3,500 3,000 4,150 2,520 2,500 2,152 2,072 4,000 2,000 2,564 1,500 2,000 1,000 1,154 500 355 13 42 0 0 LI LMI UMI LMIC HI World LI LMI UMI LMIC HI World Source: World Bank estimates based on Larsen and Sánchez-Triana (2023). Note: Regions: EAP=East Asia and Pacific; ECA=Europe and Central Asia; LAC=Latin America and Caribbean; MNA= Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. FIGURE 5.6. Welfare Cost of Adult Mortality from Lead Exposure by Country Income Classification in 2019 (central estimate) % of GDP (PPP) 10 8.4 8 7.6 5.8 5.9 6 4.1 4 3.2 2 0 LI LMI UMI LMIC HI World Source: World Bank estimates based on Larsen and Sánchez-Triana (2023). Note: LI=low-income countries; LMI=lower-middle-income countries; UMI=upper-middle-income countries; LMIC=low- and middle-income countries; HI=high-income countries. Global Health Cost of Lead Pollution: A Call for Action 117 By region, the welfare cost of mortality from FIGURE 5.8. Welfare Cost of Adult Mortality lead exposure in LMICs is by far the highest from Lead Exposure in LMICs by Region in in absolute terms in EAP and lowest in SSA 2019 (central estimate) (figure 5.7). As a percentage of GDP, the cost % of GDP (PPP) is highest in the LMICs of Europe and Central 14.0 13.2 Asia (ECA) at 13.8 percent, followed by EAP at 12.0 8.7 percent, and lowest in SSA at 2.6 percent 10.0 (figure 5.8). The main reason for the high cost 8.4 in the LMICs of ECA is the high susceptibility 8.0 7.1 to cardiovascular disease and mortality in the 6.0 5.6 4.6 aging population in these countries, while the 4.0 2.6 main reason for the cost being lowest in SSA is 2.0 a much younger population and a lower rate of cardiovascular disease than in the LMICs in ECA 0 EAP ECA LAC MENA SA SSA (Larsen and Sánchez-Triana 2023). Source: World Bank estimates based on Larsen and Sánchez-Triana (2023). Note: Regions: EAP=East Asia and Pacific; ECA=Europe and Central Asia; LAC=Latin America and Caribbean; MNA= Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. Only LMICs are included. FIGURE 5.7. Welfare Cost of Adult Mortality from Lead Exposure in LMICs by Region in 2019 (central estimate) 5.4.  Alternative methods I$, billions 3,000 to quantify the cost of lead 2,635 2,500 exposure 2,000 The estimates presented in this chapter were 1,500 1,181 developed using the “cost of environmental 1,000 degradation,“ which has been used by the 669 444 World Bank since the publication of the 1992 500 304 112 World Development Report and has been 0 refined over time (Sánchez-Triana et al. 2007; EAP ECA LAC MENA SA SSA Croitoru and Sarraf 2017; Sánchez-Triana Source: World Bank estimates based on Larsen and et al. 2021; World Bank 2007; 2021; 2022). The Sánchez-Triana (2023). methods are comparable to those employed in Note: Regions: EAP=East Asia and Pacific; ECA=Europe public health literature. This approach is effective and Central Asia; LAC=Latin America and Caribbean; in translating public health concerns into widely MNA= Middle East and North Africa; SA=South Asia; SSA=Sub-Saharan Africa. Only LMICs are included. used and well-understood economic indicators. 118 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Additionally, the approach provides robust These complexities hinder the application estimates that are useful for identifying priorities of causal study designs, such as randomized and ranking environmental health problems even controlled trials (RCTs), which rely on well- in data-scarce contexts, such as worldwide lead defined interventions and the assumption of exposure. exchangeability between exposure groups (Pearce et al. 2019). In response, researchers have Alternative methods that could quantify the employed alternative strategies, such as natural economic costs of lead exposure include causal experiments, where pollution levels change due to statistical analysis. Causal statistical methods external events or policy shifts affecting one region aim to identify and estimate cause-and-effect but not another. While such designs can enhance relationships from data, distinguishing them from causal inference compared to correlational studies, mere statistical associations or correlations between they are limited by the rarity of quasi-random risk factors and outcomes (Stafoggia et al. 2023). variation and the opportunistic nature of such These methods typically involve study designs that events (Bind 2023). control for confounding variables, thereby improving the accuracy of causal effect estimates. For instance, Causal inference studies also require large, this would directly entail inferring the effects of IQ high-quality datasets. In the US, for example, losses on labor productivity. integrating data from disparate sources—each with different geographic resolutions and classification However, applying causal methods in schemes—poses significant challenges (Dominici environmental health assessments presents 2023). These studies are computationally intensive, unique challenges. This field often deals with especially when addressing continuous or time- exposures in dynamic, evolving populations, varying exposures. In LMICs, data limitations— where randomizing individuals to potentially such as the lack of information on children’s BLLs harmful environmental conditions is both and environmental lead concentrations—further unethical and impractical (Pearce et al. 2019). constrain causal research. Environmental risk factors frequently affect entire communities, complicating efforts to The approach selected for the estimates presented isolate causal effects (Bind 2019). Measurements in this report recognizes the methodological of lead pollution are also nonrandom. Data are challenges associated with statistical methods and often collected in high-risk or heavily polluted the need for data that are currently unavailable in areas using diverse methods, not all of which are most LMICs, as well as the proven usefulness of the standardized or approved by regulatory authorities. cost of environmental degradation in quantifying This introduces potential biases in both sampling and communicating the impacts of environmental and measurement. degradation. Global Health Cost of Lead Pollution: A Call for Action 119 FIGURE 5.9. Estimated Health and Economic Cost of Global Lead Pollution HEALTH IMPACTS ECONOMIC IMPACTS Average IQ Loss per Cost of IQ Losses child in Low- and Middle- Income Countries US$1.4 trillion 5.9 points income loss IQ Lost Globally in Children 765 million IQ points Cost of IQ Losses as % of Global GDP Cardiovascular Disease 1.6% (CVD) Mortality in Adults (2019) Cost of IQ Losses as % of GDP in Low Income Countries 5.5 million adult CVD deaths 8.3% from lead exposure Welfare Cost of Adult Mortality (Global) Proportion of CVD deaths from US$4.6 trillion lead exposure in LMICs Welfare Cost as % of Global GDP 15%-44% 5.3% NOTE: All data from 2019 120 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 5.5. Conclusions of cost is $4.6 trillion (I$7.9 trillion), equivalent to 5.3 percent of global GDP (5.9 percent of GDP (PPP)) Exposure to lead continues to be a worldwide (Larsen and Sánchez-Triana 2023). The cost of CVD environmental health risk with substantial mortality is a welfare cost based on how individuals costs among both children and adults. The value the risk of mortality. Comparison to GDP is, high BLLs in LMICs originate from a variety of therefore, only an illustration of the magnitude sources of lead exposure with measurements of cost and not an impact on GDP. However, CVD of lead concentrations in consumer products deaths from lead exposure that occur during and foods. working life also have a productivity cost. The global IQ losses are estimated to cost The central estimate of global cost places lead $1.4 trillion (I$2.4 trillion international dollars).14 pollution at par with the global cost of PM2·5 This cost is the present value of lifetime income ambient and household air pollution combined, losses from the IQ loss in 2019. The cost is as estimated by the World Bank (World Bank equivalent to 1.6 percent of global GDP in 2019 2022). Moreover, the estimated cost is only partial (1.8 percent of PPP-adjusted GDP). The cost and, therefore, conservative because it does not reached 2.2 percent of GDP in LMICs (2.4 percent include many other health and behavioral effects of PPP-adjusted GDP) and as high as 8.3 percent in of lead exposure, including acute lead poisoning. LICs (8.5 percent of PPP-adjusted GDP) (Larsen and Annex 2 presents the costs of lead exposure by Sánchez-Triana 2023). country/economy. The cost of IQ losses in children is an economic These costs are robust estimates based on productivity cost because IQ loss is associated available data, with the limitations and caveats with a loss in lifetime earnings. The cost is discussed in the previous sections. Alternative estimated as the present value of future income methods that could be used to quantify the losses from the loss of IQ in 2019. The large share economic costs of lead exposure include causal of the cost of IQ losses in the total cost in LICs statistical analysis. However, applying causal and the SSA region is due to high birth rates, a methods in environmental health assessments high share of the population being children, and presents unique challenges, including the feasibility a relatively small elderly population susceptible to and ethical challenges of randomizing people’s cardiovascular disease. exposure to lead, nonrandom measurements of lead pollution that can introduce potential The global cost of adult lead exposure, or the biases in both sampling and measurement, and welfare cost of CVD mortality, is estimated the requirement of large, high-quality datasets at $1.9–6.0 trillion in 2019 (I$3.3–10.3 trillion) that are nonexistent in most LMICs (Bind 2023; based on the estimated range of 2.4–7.1 million Dominici et al. 2022; Pearce et al. 2019). The cost CVD deaths. The cost is equivalent in size to of environmental degradation has been used for 2.2–6.9 percent of global GDP in 2019 (2.5–7.7 decades to quantify and communicate the impacts percent of PPP-adjusted GDP). The central estimate of environmental degradation. 14 International dollars (I$) are US dollars adjusted for purchasing-power parity. Global Health Cost of Lead Pollution: A Call for Action 121 References Attina, Teresa M., and Leonardo Trasande. 2013. Kniesner, Thomas J., and W. Kip Viscusi. 2019. “Economic Costs of Childhood Lead Exposure “The Value of a Statistical Life.” Economics in Low- and Middle-Income Countries.” Environ and Finance. https://doi.org/10.1093​ Health Perspect 121 (9): 1097–102. doi:10.1289/ /acrefore/9780190625979.013.138 ehp.1206424 Larsen, Bjorn, and Ernesto Sánchez-Triana. 2023. “Global Bind, M. 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Global Health Cost of Lead Pollution: A Call for Action 123 SOPHIE-CARON / iStock 124 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE SCOPE AND ECONOMIC EFFICIENCY OF SOLUTIONS TO PREVENT AND CONTROL LEAD 6 POLLUTION IN THE ENVIRONMENT Chapter Overview Various interventions are available to address lead pollution. These include investments and policy reforms. The investments include the cleanup and remediation programs that address lead pollution from mining and smelting operations and from recycling of used lead-acid batteries (ULABs), infrastructure works to remove lead pipes in water supplies, removing lead in paint at the household level, converting processes and substituting products to eliminate lead exposure from ceramic pots and aluminum cookware, and the administration of iron supplements to protect children from the negative effects of lead exposure. Policy reforms include air, water, and soil quality standards, regulations to ban lead in paint, lead in biological species, lead in cosmetics, and in general in consumer products. In a wide variety of contexts and cases, the benefits of investments and policy reforms to reduce lead exposure are higher than their costs. Several interventions have the potential to benefit many children and adults while requiring relatively minor investments. Other interventions may have more localized benefits or entail significant costs. However, even in these cases, the benefits outweigh the costs because they result in reduced BBLs and have long-term benefits such as reduced cardiovascular mortality and increased lifetime earnings by the beneficiaries of such interventions. The interventions to tackle lead pollution are worthwhile in diverse locations and at various scales. Executive Summary 125 6.1. Introduction However, the diversity of examples presented in this chapter underscores that the benefits of As discussed in previous chapters, blood lead reducing lead exposure far outweigh the costs levels (BLLs) reflect a multitude of lead-exposure of implementing these interventions, often sources. These include recycling of used lead- by several orders of magnitude. The examples acid batteries, primary and secondary mining and highlight that interventions to tackle lead pollution smelting operations, drinking water contaminated are favorable in diverse locations, at various by lead pipes and plumbing materials, paints, scales, and across sources of lead exposure. While cookstuffs and cookware, e-waste, ammunition, attention to optimal remediation in each context and automotive and small crafts, among others. is critical to increase benefits relative to costs, the Furthermore, many consumer products contain technical feasibility and economic rationale for lead, such as cosmetics, alternative medicines, toys, addressing most sources of lead exposure are clear and plastic footwear. Lead concentrations vary and compelling. significantly by country. This chapter examines the scope and economic 6.2.  Rehabilitation of ULABs efficiency of interventions to reduce, phase contaminated sites out, and prevent lead pollution. The chapter reviews investments and policy options to prevent and reduce lead exposure. Key investments Global lead consumption exceeded 12 million discussed include cleanup and remediation tons in 2022. About 4 million tons were from mines of lead-contaminated sites, particularly those and 8 million tons were recycled lead. 86 percent of affected by recycling of ULABs; mining and lead consumption is for battery production (ILZSG smelting; infrastructure upgrades to replace lead- 2023). Lead is one of the most recycled metals containing water pipes and plumbing materials; in the world, most of which are from ULABs (von and elimination of lead exposure from ceramic and Stackelberg et al. 2022). All the lead contained in aluminum cookware. these batteries can be recovered and recycled. Recycling of lead in LMICs is often undertaken by The chapter also analyzes the economic informal recyclers with rudimentary production efficiency of selected interventions. The technologies pointing to the scale of the pervasive factors that influence the economic efficiency of lead pollution in LMICs (Gottesfeld et al. 2018). interventions include the costs of the interventions, which range from multi-million-dollar investments There are tens of thousands of ULAB recyclers required to remediate contaminated sites and and abandoned ULAB-recycling sites in replace lead components in water-supply systems LMICs and a smaller number of ongoing to several hundred thousand dollars for the and abandoned mining sites. Abandoned implementation of policies to eliminate lead in sites continue to expose children especially to paint and spices, and reconversion of pottery- contaminated soil, dust, and sometimes drinking production systems. Similarly, multiple factors water (Caravanos et al. 2013; Chatham-Stephens influence the interventions’ benefits, such as et al. 2014; Dowling et al. 2016). The health effects the number of beneficiaries, baseline BLLs and of exposure to lead in the population surrounding reductions expected from the intervention, and these abandoned sites can be severe (Caravanos assumptions regarding the complexity or scope of et al. 2016; Chatham-Stephens et al. 2014; the intervention. Ericson et al. 2016). 126 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Zoonar GmbH / alamy Two studies assessed the health benefits and activities and other physical contact. Rehabilitation costs of remediation interventions at two of the sites allows future generations of children to abandoned sites contaminated with lead. The grow up in a cleaner environment. first study is a cost-effectiveness analysis of the remediation of an abandoned secondary lead smelter site in Haina, Dominican Republic. The Small-scale lead-acid battery intervention involved on- and off-site removal recycling: Dong Mai, Vietnam and encapsulation of waste and contaminated soil. Health benefits were estimated based on In Vietnam, informal industry, including measurements of pre- and post-intervention BLLs ULAB recycling, is often conducted in small to of the affected population and included both medium-sized areas. These areas produce a range averted cases of cardiovascular disease in adults of consumer and industrial goods and typically and intellectual disability in children. Averted cases have inadequate waste-management practices. were converted to disability-adjusted life years The activities are also characteristically household- (DALYs). The study estimated that the intervention based, with individual homeowners often working cost per DALY averted was in the range of $392 to in concert to complete sequential tasks in the $3,328 depending on the lifespan of the project, production of a single product. In one such village, discount rate, and IQ decrement from lead Dong Mai Village, Chi Dao Commune, Hung Yen exposure. The benefits to children accounted for Province, where ULABs had been recycled since over 95 percent of total health benefits (Ericson 1978, a multifaceted intervention to reduce lead et al. 2018a). The remediation projects are likely to exposures was implemented (Ericson et al. 2018). benefit children more than adults since children are Legacy waste from previous recycling was identified more exposed to lead in soil and dust through play as a primary source of lead contamination. Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 127 Due to the scale of the recycling, lead hazards 6.3.  Remediation of soils were widespread in the village. Ongoing contaminated by mining and waste sources and ongoing recycling activities were also identified as sources of contemporary smelting contamination. The current recyclers were engaged in manually removing wastes from the furnace, Soils in many communities have been battery breaking, and smelter operations. Lead contaminated by lead from point-source dust deposited on the clothing of all workers emissions from lead smelters, active or was also an important source of exposure to abandoned mines, deterioration of exterior the workers and their families. In addition, lead paint, the past use of leaded gasoline, and hazards were also created when the lead materials other sources. Exposure to lead in soil and were transported around the village on motorbikes related house dust is widespread in many and small trucks to a formal industrial operation for communities worldwide. Given the extent of processing. soil lead contamination and the need to ensure that lead hazards are eliminated, an evidence- A detailed assessment of the extent of soil based approach is required to prevent access or contamination was conducted in May 2013. remediate the soils and prevent children’s and Average soil concentrations in Dong Mai before the adults’ ongoing exposure. For communities with intervention were 3,940 milligrams per kilogram point sources of lead whether large-sector or (95 percent confidence interval (CI): 1,567–6,312 small-sector industries, so-called “cap-and-cover” milligrams per kilogram; median = 648 milligrams techniques have been most successful. This chapter per kilogram). The 3,940 level was well beyond describes two small-scale cases and two large-scale the US threshold at that time of 400 milligrams case from countries with different income levels. per kilogram for bare soil where children play (Ericson et al. 2018, 184). At the close of the project, Despite the differences in the scale of these average lead concentrations in surface soil in all projects and other site-specific differences, they 96 targeted yards were confirmed to be below were all informed by the same principles: the cleanup threshold value of 100 milligrams per • Widespread dissemination of information about kilogram. This is well below the comparable US the hazards of lead exposure to the exposed threshold. The BLLs of 204 Dong Mai children ages community 0–6 years were obtained at the beginning of the intervention in December 2013, six months after its • Reliance on community political and completion in September 2014, and again a year cultural leaders to work with project staff later in May 2015. Following the elimination of the and community members in designing and lead hazards, median blood lead concentrations conducting the remediation decreased by 67 percent, from 40.35 μg/dL • Deep respect for cultural norms and practices (Interquartile range (IQR) = 30–59.2) to 13.3 μg/ • Use of residents to conduct the work whenever dL (IQR = 7.1–19.8) during the 18-month study possible period. However, the levels continued to be higher than 5 micrograms per deciliter (ACCLPP 2012; • Training of local officials in all aspects of the Ericson et al. 2018, 185). work. 128 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE In all cases, continued monitoring and technology, and equipment (NRC 2003, 344). maintenance will be required to ensure that the For example, traditional farming tools were used treatments remain secure and that new efforts to to excavate contaminated soils from residential access the metals still available at the site do not compounds that heavy equipment could not access. cause recontamination. The Zamfara Ministry of Environment and local government area staff were trained to supervise Soil remediation in a low-resource labor, administer payrolls, and procure materials, context: Zamfara, Nigeria supplies, and equipment. International NGOs and UN bodies—Médecins Sans Frontières, Terra Zamfara State, located in the northwestern part Graphics, Blacksmith Institute, United Nations of Nigeria, has a population of approximately Children’s Fund, and United Nations Emergency 3.7 million, of which 20 percent are estimated Relief Fund—provided funding, equipment, and to be children ≤ 5 years old. Farming is the technical assistance for cleanup, quality assurance, major livelihood, with more than 80 percent of and quality control. These organizations were the people participating in agricultural activities. responsible for database management to verify The community’s resource constraints are illustrated complete contaminant identification and removal. by several indicators captured by the 2008 Nigeria The project was carried out over three years (2010– Demographic and Health Survey, including access to 2013) in eight villages with a combined population of electricity in only 18.8 percent of households, access 15,874. It was implemented during the dry season to to an improved source of water in 27.6 percent of households, and improved sanitation facilities in 27.5 percent of households (National Population Commission of Nigeria and ICF Macro 2009). In March 2010, an outbreak of acute lead poisoning began in two villages in Zamfara that resulted in severe neurological morbidity and death in children. The source of the outbreak was found to be lead-contaminated gold ore, processed dry with low technology methods in remote villages. Lack of environmental and/or occupational health controls during ore-processing operations has caused extensive contamination of villages and fatal amounts of lead being inhaled and ingested by the population, particularly children. The mean blood lead concentration for children in one village was 153.3 μg/dL (range 55.9–331.0 μg/dL) and 107.5 μg/dL (range 36.5–445.0 μg/dL) for children in the other village (Dooyema et al. 2012, 604). The Bunker Hill Superfund Site remediation protocols were adapted for rural Zamfara using existing institutions; employing local track5 / iStock labor; and using familiar labor practices, Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 129 avoid interference with agricultural activities, and as measures families can employ. The capacity, funding became available. Given that the population authority, funding, and responsibility for the is predominantly Muslim, and the traditional cleanup were transferred to the Nigerian federal, religious leadership system, chaired by local Emirs, state, and local governments. Zamfara State and has strong political and social influence in Zamfara local government staff were trained to manage and State, the project was also implemented in a way supervise remediation and undertake sustainable that did not coincide with Ramadan and other local programs to prevent future epidemics (Tirima holidays (Tirima et al. 2016). et al. 2016). Several of these staff were later able to quickly respond to a similar event in neighboring Remediation within each village was carried out Niger State, thus preventing the loss of life seen in four steps: (1) characterization, (2) excavation in Zamfara. Nevertheless, small-scale mining of contaminated media, (3) replacement with provides much-needed income to families. The clean soils or concrete, and (4) waste disposal. high price of gold poses a continuing threat that The social and technical context of the cleanup ore processing will resume, and the village will be required adaptability, and remedial protocols were re-contaminated. Sustainable, transferrable, safer reevaluated and modified based on experience mining practices are of critical importance, given during the project. Examples include developing the economic importance and rootedness of small- separate health messaging for males and females scale mining in countless rural economies across as well as community engagement efforts; the developing world. employing village tailors in the production, repair, and laundering of work uniforms; and having local blacksmiths manufacture excavation hoes from Addressing lead exposure from scrap metal. mining activities: Zambia Overall, project remediation achieved 77%–98% In 1904, lead zinc-mining operations began in reductions in mean residential soil-lead what is now Kabwe, Zambia. Shortly thereafter, concentrations in the village with maximum reports of lead poisoning among miners began levels less than 400 milligrams per kilogram, to surface. These illnesses were attributed to the the US criterion for lead in bare soil where failure to control toxic lead fumes from mining and children play. Testing of all 944 residential ore-processing activities. Over the next century, the compounds in the eight villages showed pre- ore-processing activities not only affected workers remediation lead concentrations for individual but also contaminated the surrounding community compounds ranged from 19 milligrams per and affected residents. In 1975, a British kilogram to 35,380 milligrams per kilogram versus investigator, A. R. L. Clark, described the extent post-remediation concentrations ranging from of lead contamination of soil, air, and plants and 13 milligrams per kilogram to 400 milligrams found a direct correlation between environmental per kilogram. About 43 percent of the residential lead contamination and the BLLs of postpartum compounds were decontaminated by July 2013 women and their newborns (Human Rights (Tirima et al. 2016, 1472). Watch 2019). The response relied heavily on local leaders Three environmental lead assessments and workers. The engagement of villagers and conducted between 2003 and 2014 confirmed community leaders developed awareness of the that children in Kabwe were exposed to lead dangers of artisanal mining and the protective in their environment and that, as a result, 130 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE they had persistently and extremely high BLLs in collaboration with the Ministries of (Caravanos, Fuller, and Robinson 2014). The Education and Health. The project included three assessments found that nearly all children had BLLs components in addition to project management ≥ 20 micrograms per deciliter, which is four times (World Bank 2016): the BLL considered warranting environmental • Remediating contaminated hotspots and remediation. About 50 percent of the children had improveming environmental infrastructure, BLLs at which the WHO recommend chelation including the identification, characterization, therapy to reduce BLLs. Dozens of children had and remediation of known hot spots of BLLs above the level at which untreated children contamination in Kabwe and other locations. will die or be left severely disabled by seizure This component also included a voluntary in disorders and major intellectual disabilities situ remediation program for households and (Bose-O’Reilly 2018). hot spots, and development of environmental infrastructure to improve the environment These studies also indicated that the lead surrounding targeted communities. This contamination of soils in Kabwe is serious, with component would also help the government to townships close to the mining area being the close old tailings dams. most highly contaminated. Townships close to the mining area are polluted with lead levels in soil well • Strengthening the environmental governance above the 400 milligrams per kilogram recommended of the mining sector and environmental level for bare soil in areas where children play. Surface agency through a variety of interventions, soil Pb concentrations ranged from 139 milligrams including policy support and capacity building. per kilogram to 62,142 milligrams per kilogram, with These interventions to be in areas such as the a geometric mean concentration of 1,470 milligrams assessment of environmental health risks, per kilogram. Of the 339 soil tests, 25.4 percent were inspection of mine-safety risks to communities, higher than 400 milligrams per kilogram. providing guidance to mining companies on mine closure, progressive maintenance of Additional data collected in 2015 found that tailings dams, and identification and mapping of children’s BLLs ranged from an average of health risks in critically polluted areas. 15 micrograms per deciliter to 85 micrograms • Strengthening municipal councils’ capacity to per deciliter in Kabwe. Airborne dispersion of lead provide environmental services, such as waste and direct ingestion of soil and dust were found management, clean drinking water, medical to be the main pathways for lead exposure for the interventions for children and women exposed local population. Groundwater or surface water to lead contamination, and agricultural soil and irrigated crops also represented important productivity due to acidic exposure from SO2 pathways. The risks of lead exposure faced by emission from past copper-smelting operations. youth and women also increased because of high levels of unemployment and unfettered access to The development of ZMERIP was informed by a idle mining sites. cost-benefit analysis. Costs included investment costs of $10 million per year over five years and In 2016, the World Bank’s Board approved maintenance costs of $2.8 million per year over funding for the government of Zambia’s 20 years. Project benefits included a reduction in ZMERIP project, administered by the Zambian the loss of 1,800–9,000 IQ points in children with Ministry of Mines and Mineral Development the following associated benefits: Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 131 • Increases in lifetime earnings Yamada et al. (2023) assessed potential • Reduced adult cardiovascular mortality interventions in Kabwe, including remediation of the mining dumpsite at a cost of $35 million and • IQ improvements from the provision of medical soil removal in highly polluted residential areas at treatment through nutritional supplements to a cost of up to $50 million. Health benefits were people with elevated BLLs estimated based on pre- and post-intervention • Improved welfare of the local population BLLs for future birth cohorts in the town over their lifetime. Benefits included a reduction in IQ loss • Reduced lead exposure because of restored in early childhood and an associated increase in ecosystems lifetime income and averted premature mortality • Increased employment and regional in adulthood. The study considered the benefits development, including potential for project and costs of remediating only the dumpsite replication and scaling up. versus the benefits and costs of remediating the dumpsite and residential areas. This comparison The analysis assumed a five-year was conducted assuming that the percentage implementation period, a lifetime period of of the soil that could be removed represented fifteen years following project completion, either 75 percent or 95 percent of the soil in that and a 6 percent discount rate. The results of the area, depending on technical difficulties (for economic analysis indicated an economic rate of example, the soil near existing structures) and return within the range of 16–34 percent, with the opposition from the owners of land and buildings. net present value at $18–59 million and the BCR The study reports a BCR of 1.4–2.3 (table 6.1) above 1.0 (World Bank 2016). (Yamada et al. 2023). Виталий Сова / Adobe Stock 132 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE 6.1. Benefits and Costs of Remediating the Mining Dumpsite and Soil Removal in Highly Polluted Residential Areas, Kabwe, Zambia Cost of remediation ($, millions) Benefit of remediation ($, millions) Benefit- Intervention Residential Total IQ Mortality cost ratio Total Dumpsite area benefit improvement reduction Dumpsite 35.1 35.1 n.a. 80.2 73.7 6.5 2.3 remediation only 75% of residential 74.2 35.1 39.1 105 96.5 8.8 1.4 soil is removable 95% of residential 84.7 35.1 49.6 134 122 11.6 1.6 soil is removable Source: World Bank based on Yamada et al. (2023). Note: n.a. = Not applicable. 6.4.  Lead in drinking water et al. 2001; Brown and Margolis 2012; Kennedy et al. 2014). As the result of reports in Washington DC; Flint, Michigan; and several other communities, Lead is unlikely to be present in sources of child development advocates, pediatric health water unless a specific source of contamination care providers, and the public health community exists. In areas with widespread lead organized efforts to replace the lead pipes. contamination, the primary and secondary water sources (well, borehole, or groundwater) should be tested. However, lead has long been used in Flint, Michigan plumbing materials and solder that are in contact with drinking water as it is transported from its In April 2014, Flint, Michigan, under state- source into homes. Lead leaches into tap water appointed emergency management, changed its through the corrosion of plumbing materials that water supply from Detroit-supplied Lake Huron contain lead. The greater the concentration and water to the Flint River, intending to reduce the duration of lead in drinking water, the greater the city’s costs for water. Shortly after the switch to exposure to lead. Lead pipes and fixtures have Flint River water, residents reported concerns about been used to transport water for millennia. water color, taste, and odor. They also reported skin rashes and bacteria, including E. coli were Pipes are the plumbing component most likely to detected in the distribution system (Hanna-Attisha leach significant amounts of lead into drinking et al. 2016). Lead pipes were common in the city’s water (Levin et al. 2008). The US EPA’s Integrated water system, which was more than a century. The Exposure Uptake and Biokinetic (IEUBK) model presence of this lead, coupled with highly corrosive estimates a 0.042 microgram per deciliter change in water from the industrial Flint River, dissolved blood lead per 1 ppb difference of lead in water (US the scale on the pipes’ inner surface and resulted EPA 2007; 2017). There are multiple cases of increased in lead leaching from the pipes into the water. percentages of children with BLLs ≥ 5 micrograms A local pediatrician found a two-fold increase in the per deciliter in communities with lead pipes (Brown percentage of children with BLLs ≥ 5 micrograms Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 133 per deciliter (2.1 percent to 4 percent), and alerted • Improving testing to better locate elevated lead state and local public health officials (Hanna-Attisha levels in drinking water et al. 2016, 283). • Establishing a new lead level that would jumpstart mitigation measures sooner and in The county health department subsequently more communities than the existing threshold declared a public health emergency (Hanna- • Requiring more and complete replacement Atisha et al. 2016, 283). Shortly after, the State of lead service lines (instead of partial of Michigan released an action plan with short- replacements), requiring testing in elementary and long-term solutions focusing on additional schools and childcare facilities sampling, filter distribution, and corrosion control (Hanna-Attisha et al. 2016, 287). Large-scale efforts • Requiring water systems to identify and to test all Flint residents less than 18 years old; make public the location of lead service lines development and deployment of a holistic plan (US EPA 2020). to reduce children’s exposure; institute academic, nutritional, and other supports to help mitigate the The US EPA’s economic analysis estimated impact of the exposure; and replacement of lead that the implementation of the updated rule water pipes and a change in the water distribution would result in benefits that exceed its costs system are all currently underway. All these efforts by a 2:1 ratio (US EPA 2019). However, the US EPA no doubt had, and will continue to have, a positive only quantified benefits resulting from averted impact on the lives of Flint children. However, IQ losses among children. In comparison, an unfortunately, once lead exposure has affected a independent analysis conducted by researchers child adversely, there is no known intervention that from the Harvard T. H. Chan School of Public Health will reverse the damage (Jacobs 2023). estimated that the annual health benefits and other benefits resulting from the implementation As a result of the Flint disaster, as well as the of the rule would exceed costs by at least 35-fold recognition of the prevalence of lead water pipes (Levin and Schwartz 2023). The analysis considered and the problems of aging water infrastructure, the a broader range of benefits, including reduced US EPA, state and local officials, water utilities, labor health harms such as the following: unions, and other nongovernmental organizations have committed to advance and accelerate lead- • Short-term damage to children’s cognitive pipe replacement. functioning, estimated at $645 million annually • Attention deficit and hyperactivity disorder (ADHD) Removing leaded pipe and water solder in children, estimated at $211 million annually in plumbing systems: United States • Impaired hearing in children, estimated at In the US, the federal government banned the $47 million annually use of leaded pipe and solder in water-plumbing systems in 1986. However, by 2016, around 7 percent • Depression and ADHD in adults, estimated at of households served by community water systems $64 million annually still had lead service lines. In addition, about 400,000 • Hypertension in adults, estimated at $94 million schools were estimated to be at risk from lead in annually water (The White House 2021). To address this risk, the US EPA updated its Lead and Copper Rule with • Deaths related to cardiovascular disease, provisions aimed at the following objectives: estimated at $8,142 million ($8.1 billion) annually. 134 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE In addition, the rule’s requirement to better control 6.5.  Standards on the water corrosion of water infrastructure and some concentrations of lead in air, household appliances would result in benefits of between $2.4 and $7.8 billion annually. water, soil, and consumer products The US Government estimated that it would cost, on average, $4,700 to fully replace a lead Policy instruments have been adopted in service line. Considering that there are between different countries to reduce lead-exposure 6 and 10 million lead service lines across the US, from key sources. By enacting regulatory the cost of replacing all lines would range between measures, authorities worldwide have responded $28 and $47 billion (Campbell and Wessel 2021). to concern about the health and other risks posed The US Congress approved a bill Infrastructure by lead exposure. These measures encompass Investment and Jobs Act, Public Law No: 117-58, limits and standards dictating permissible lead signed by President Joseph Biden on 15 November levels in diverse media such as water, air, and 2021. This law provides $15 billion over five soil. Furthermore, specific guidelines have been years for lead water pipe replacement. The data established for products like food and paints. underscore the significant investments needed to These regulatory efforts aim not only to mitigate reduce lead exposure, but also that such supported environmental contamination but also safeguard interventions would result in benefits that public health by reducing exposure to harmful lead significantly outweigh their costs. levels. While table 6.2 provides only a few examples TABLE 6.2. Permissible Lead Limits and Standards Source Standard/limit Agency Drinking water 10 ug/l World Health Organization Bottled water 5 ppb Food and Drug Administration Food Various but ranging mostly 0.0–0.5 mg/kg European Commission Food Various but ranging mostly 10–20 ppb US Food and Drug Administration Air (ambient) 0.15 µg/m3 US Environmental Protection Agency Air (workplace; 8-hour time- 50 µg/m3 Occupational Safety and Health weighted average) Administration Soil (residential; play areas) 200ppm US Environmental Protection Agency Soil (residential; non-play areas) 1,200 ppm US Environmental Protection Agency Paints 90 ppm. Some countries have higher Global Alliance to Eliminate Lead in Paint limits of 100 or 600 ppm Face paints 10–20 ppm US Food and Drug Administration Cosmetics 10 ppm US Food and Drug Administration Toys 100 ppm US Consumer Product Safety Commission Ceramic ware 0.5–3 ppm US Food and Drug Administration Source: World Bank. Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 135 of limits and standards—such as those for food, (WHO) Global Health Observatory, in 2022, a total ceramics, paints, water, and toys in select regions of 93 countries had laws limiting the content of like Europe and the US—annex 7 offers a more lead in paint, and 19 countries were in the final comprehensive overview, detailing permissible stages of drafting lead-paint laws (figure 6.1) limits across multiple countries for irrigation and (WHO 2023). drinking water, ambient air, and soil. The Global Alliance to Eliminate Lead Paint (Lead Paint Alliance) is working with countries to Regulatory standards for lead have evolved over prevent lead paint at the source by establishing time and will continue to do so. Countries have lead-paint laws to prohibit the manufacture, progressively adopted more stringent limits on lead sale, and distribution of lead paint. The alliance concentrations and contents, driven by growing is a partnership that has UNEP and the WHO as its scientific evidence demonstrating lead’s adverse secretariat, is chaired by the US EPA, and includes effects, even at levels once considered low or safe. governments, industry, environment and health Given the robust body of research showing that groups, and the American Bar Association. no level of lead exposure is without risk, existing standards should be reassessed and strengthened The Lead Paint Alliance has developed tools to reflect this reality. to help countries design and establish laws, including the UNEP Model Law and Guidance for Regulating Lead Paint (UNEP 2018). This 6.6.  Eliminating lead-paint model provides a template for lead-paint laws that hazards can be customized to address country-specific legal frameworks. The UNEP Model Law promotes Eliminating lead-paint hazards in homes is a establishing a lead-concentration limit of 90 ppm necessary step to terminate children’s exposure in all paints as the most effective way to eliminate to lead. However, unless hazards are carefully lead paint (see annex 3). This is the lowest and addressed using personal protective equipment most protective maximum regulatory limits on lead (PPE) for workers, removal of families during the in residential and decorative paints. However, limits work, and meticulous cleanup as demonstrated range from 90 to 1,000 ppm. Annex 5 lists countries by post-remediation testing of dust-lead levels, with lead paint hazard regulations, specifying their remediation can and often has resulted in established limits. significant increases in BLLs of workers and families. The most hazardous methods include Other tools available to support efforts to uncontrolled scraping, sanding, and burning of the eliminate the hazard of lead in paint include paint (Amitai et al. 1987). statutory and regulatory strategies, guidance on compliance and enforcement of lead-paint laws, Lead-paint hazards can be prevented before technical guidelines for lead-paint reformulation, children are exposed and without the expense examples of voluntary efforts to assist small paint of remediation and cleanup if the use of lead manufacturers with paint reformulation, and paint is legally banned. Levels of lead in paint are market-based decisions by multinational paint lowest in countries that have lead-paint laws (IPEN manufacturers to stop using lead additives in their 2017). According to the World Health Organization products (UNEP 2017; WHO 2023). 136 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE FIGURE 6.1. Countries with Lead Paint Laws, December 2022 Lead-paint regulation Yes No No data Not applicable IBRD 49239 | NOVEMBER 2025 Source: WHO 2023. There are also technically feasible alternatives Eliminating existing lead-paint to lead paint available in developing countries hazards in housing: United States at costs comparable to paint with lead, and the production of paint without added lead In the US, house dust contaminated by is possible (UNEP 2013). An extensive review crumbling old paint and ingested during of available substitute ingredients found that normal hand-to-mouth activity is a reformulation of lead paint can provide well-proven dominant lead pathway for most children. substitute pigments and drying agents. For one of Prevention strategies focus on reducing lead two companies that reported a price differential, the contamination in-house dust, and children’s cost of lead paint was €0.35 ($0.38) per cubic meter access to residential lead hazards. Usually, these versus €0.71 ($0.77) per square meter for the lead- strategies are brought to bear only after the free paint. For the second company, lead paint cost identification of a lead-poisoned child, although €0.31 ($0.34) per square meter versus €0.20 ($0.22) studies of efforts to reduce elevated BLLs in per square meter for lead free (Safinah Group 2015). children indicate that the benefit of intervening Paint companies have seldom, if ever, increased the when children are already poisoned is small. In retail price of reformulated paints (IPEN 2017). many areas, even when a child with a very high BLL has been identified, the lead hazards that As a result of the work of the Lead Paint Alliance, caused the poisoning often go unattended. Thus, there is support from industry, NGOs, and children who are born or move into buildings governments that lead-paint laws are necessary, where a child had lead poisoning in the past are and an increasing number of countries are also at risk for lead exposure. (Brown et al. 2001) enacting them. Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 137 Евгений Панов / Adobe Stock Investigators conducted a case study to one birth cohort in the US range from $1.9 billion to determine whether state-mandated measures $12.1 billion (Pew 2017, 45). to control lead hazards decrease the number of children with high BLLs in homes where a child had previously been identified. They Preventing lead-paint hazards by compared two states with, and one state without, banning the manufacture and sale of laws requiring lead-hazard controls to determine lead paint: The Philippines whether the laws were effective. In the two states with lead laws, children were 20 percent The elimination of lead paint in the Philippines less likely than the ones without legislation to is an example of a successful lead-paint law have subsequent high BLLs (adjusted OR = 0.21, to reduce and prevent childhood exposure (95 percent CI 0.082, 0.537)) (Kennedy et al. 2014). to lead from paint. The Philippines was one of the first low- or middle-income countries Although the initial costs of making this housing (LMICs) to regulate lead in paint and establish lead-safe may seem prohibitive, remediating a lead concentration in paint as ≤ 90 ppm total lead-paint hazards in US housing built before lead. The development of the Philippines’ lead- 1978 was recently estimated at $1.9 billion paint law involved a government-initiated multi- (Pew 2017, 45). The costs of not intervening are stakeholder process and is a good example of staggering. One comparative analysis found how to identify key stakeholders and how to that lead-safe housing yielded $80,910 savings elicit stakeholder input for policy development. per child from decreased medical and education The process of developing the Philippines’ lead- costs and increased productivity for protected paint law began in response to the International children expected to live in the lead safe unit over Conference on Chemicals Management (ICCM) a 10-year period (Brown 2002). Overall estimates decision to adopt lead in paint as an emerging of preventing BLLs ≥ 2 micrograms per deciliter in policy issue. After the first Global Forum of the 138 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Lead Paint Alliance in 2009, the government of Industry groups, particularly the Philippine the Philippines’ Department of Environment and Association of Paint Manufacturers (PAPM) Natural Resources (DENR) became interested in and the Samahan sa Pilipinas ng Industriyang joining the Lead Paint Alliance and working on Kimika (SPIK, or the Chemical Industries national and international legislation to ban lead Association of the Philippines), were a critical paint (Mayuga 2023). part of the process of developing the Chemical Control Order. The PAPM, in partnership At the local level, civil society groups, principally with civil society groups, organized capacity- the EcoWaste Coalition in partnership with building workshops on lead-paint elimination IPEN, a global organization committed to a and abatement and worked with member paint toxics-free future, played a key role in raising companies in promoting compliance with the order. awareness about the issue of lead paint In a unique collaboration, the PAPM, EcoWaste under the EU-funded IPEN Asia Lead Paint Coalition, and IPEN developed the standard for the Elimination Project. Specifically, they used the Lead Safe Paint® certification program (IPEN 2015, results of lead-paint analyses conducted in 2010, 15). At present, three paint manufacturers in the 2013, and 2015 for awareness-raising and outreach Philippines are participating in the world’s first to government, industry, and the public. They also independent third-party certification process to increased awareness of the problem of lead in toys verify the lead content in paint. Only paints that are and other consumer products (IPEN 2015, 14). certified are allowed to carry the lead-safe label on their paint cans (IPEN 2015, 14). The Philippines Chemical Control Order (DAO 2013–24), issued in 2013, set an upper limit of 90 ppm total lead for paint used for all Abolishing lead in paint: Malawi purposes whether architectural, decorative, household, or industrial applications. The Paint standards in Malawi came into force at order contained phased effective dates, with the the end of 2020 with a 0-ppm lead limit. These law going into effect in 2016 for architectural, standards are being revised to a maximum limit decorative, and household paints, and in 2019 of 90 milligrams per kilogram consistent with the for industrial applications. To promote the recommended limit for lead-free paint (UNEP 2023). mandatory use of lead-safe paints, national and Analysis conducted for this publication estimated local authorities, including the Department of the benefits and costs of this policy measure. Interior and Local Government and the Department of Education, have promulgated policies in The cost of lead-free paint is assumed to be the support of the order. These include a certification same as the cost of leaded paint based on a review program to reward companies with recognition for by IPEN of retail prices in six Asian countries, which reformulating paint products without added lead found both lower and higher prices of lead-free and working with small paint manufacturers to than of leaded paint.15 resolve technical issues posed by lead elimination (IPEN 2015, 15). 15 https://wedocs.unep.org/bitstream/handle/20.500.11822/22855/Module%20E%20Lead%20alternatives_FINAL.pdf?sequence​ =1&isAllowed=y (retrieved November 19, 2023). Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 139 TABLE 6.3. Key Assumptions for Estimation of Benefits of Lead-Free Paint Assumption Parameter values Rationale Painted homes in 2021 18% of all homes Equivalent to the urban population share, assuming rural homes generally have not been painted New homes painted per 5% of total painted homes Somewhat higher rate than the growth rate of the urban year population to account for some penetration of painting of homes in rural areas over the next 20 years Homes repainted per year 4% of painted homes Assuming homes are repainted every 25 years Source: World Bank. The benefits of lead-free paint materialize exposure to paint chips and dust. Many studies gradually. Benefits accrue in proportion to new have identified lead paint in the home environment homes being painted each year with lead-free as a significant contributor to BLLs in LMICs paint instead of leaded paint and in proportion (AbuShady et al. 2017; Ahangar et al. 2021; da to homes already painted with leaded paint that Rocha Silva et al. 2018; Dhimal et al. 2017; Kalra et are repainted with lead-free paint (table 6.3). al. 2013; Patel et al. 2001). However, few studies Without the banning of leaded paint, homes provide quantified magnitudes of the effect on painted with leaded paint are projected to BLLs. One such study in Benin quantified the effect increase from 18 percent of all homes in 2021 to on BLL from the presence of paint chips in the 31 percent in 2041. With the banning of leaded living environment (Bodeau-Livinec et al. 2016).16 paint, homes painted with leaded paint will Applying the effect to Malawi suggests that the decline from 18 percent of all homes in 2021 presence of paint chips is associated with a 3.0 to 6 percent in 2041 as homes are increasingly micrograms per deciliter (95 percent CI: 0.65–6.4 painted and repainted with lead-free paint. micrograms per deciliter) increase in children’s This difference between the two scenarios forms BLL. Therefore, benefits in Malawi are estimated the basis for estimating the benefits of banning for a decline in BLL of this magnitude when a lead paint. child lives in a home painted with lead-free paint instead of leaded paint. The effect of lead paint on The size of the effect of leaded paint in homes children’s BLL is modeled with a five-year lag since on children’s BLL depends on multiple factors. it takes time before painted surfaces deteriorate These include the concentrations of lead in paint, and exposure to the lead in paint increases. The the degree of deterioration of painted surfaces, estimated benefit-cost ratio (BCR) ranges from 101 the presence of paint chips and dust in the to 705 (table 6.4 ). home environment, and the degree of children’s 16 Bodeau-Livinec et al. (2016) reported the following effect size on BLL from the presence of paint chips in the home: ln(BLL + X) – ln(BLL) = 0.49 (95% CI: 0.13, 0.86) where BLL is mean BLL in children in homes without the presence of paint chips, and X is the effect on BLL from paint chips in the home. Thus X = BLL (e0.49 – 1). 140 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE 6.4. Benefits and Costs of Banning Leaded Paint in Malawi Low Central High Mean BLL in children in homes with lead-free or no paint a 4.70 4.70 4.70 Mean BLL in children in homes with leaded paint 5.4 7.7 11.1 IQ points gained per child 0.35 1.36 2.45 Benefit ($) 76,076,820 294,547,026 528,773,330 Cost ($) 750,000 750,000 750,000 BCR 101 393 705 Source: World Bank estimates based on intervention cost data from the Lead Exposure Elimination Project (LEEP). Note: a GBD (2019) reports an estimated BLL of 4.7 micrograms per deciliter in children in Malawi. the families would otherwise use lead-glazed pots: 6.7.  Converting lead-glazed 0.50 IQ points for children in families that would pottery production: Mexico use them 1–2 times per month to 1.30 IQ points for children in families that would use them daily. The In Mexico, the use of lead-glazed ceramic estimated BCRs range from 142 for the infrequent pots for food preparation, storage, and eating users to 361 for the daily users (table 6.5). is associated with elevated BLLs in children (Tellez-Rojo et al. 2017; 2019). Analysis of data from ENSANUT 2018–201917 revealed that children’s TABLE 6.5. Benefits and Costs of Converting mean BLL was 3.7 micrograms per deciliter in to Lead-Free Ceramic Pottery Production in households that never used lead-glazed ceramic Mexico pots versus 4.95 micrograms per deciliter in households that used lead-glazed ceramic pots Frequency of 1–2 times 2–3 times with a frequency of use ranging from less than using lead- Daily per month per week once per month to daily.18 glazed pots Mean BLL using 4.50 5.50 6.00 The cost of converting to lead-free pottery lead-glazed pots making has been estimated at $450,000 for Mean BLL using 3.7 3.7 3.7 50 pottery makers that can produce pots lead-free pots for 15,000 families per year. For each year of IQ points gained 0.50 1.05 1.30 production, the 15,000 families purchasing the per child lead-free pots will, on average, give birth to 900 children annually over the period of the useful BCR 142 294 361 life of the pots, which is assumed to be five years. Source: World Bank estimates based on intervention These children’s estimated gain in IQ points from cost data from Pure Earth (2015) and BLL data from using lead-free pots depends on the frequency that Téllez-Rojo (2017). 17 Encuesta Nacional de Salud y Nutrición. 18 Data provided by Martha María Téllez-Rojo, Centro de Investigación en Nutrición y Salud, Instituto Nacional de Salud Pública, Mexico, March 1, 2023. Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 141 6.8.  Eliminating lead in spice: Georgia took swift action to curtail this practice Bangladesh and Georgia and within two years lead was almost eliminated from spices in Georgia.19 A study of nine major turmeric-producing The benefits and costs of eliminating lead districts in Bangladesh found evidence of a lead from turmeric in Bangladesh and Georgia are additive in turmeric in seven of the districts presented in (table 6.6). The cost of government (Forsyth et al. 2019a). The practice of adding lead to action is estimated at $400,000 in Bangladesh turmeric to enhance its color was widespread, and and $625,000 in Georgia. Benefits are estimated extremely high concentrations of lead were often for three scenarios with elimination of lead found (Forsyth et al. 2019a,b; Gleason et al. 2014). in turmeric causing a BLL decline of 0.5 to The Government of Bangladesh, in collaboration 1.5 micrograms per deciliter. This effect on with researchers, acted in 2019 to stop the practice BLL corresponds to a consumption of 1 gram of adding lead to turmeric. The percentage of of turmeric per day with lead concentrations turmeric sampled from markets with detectable lead of 5–15 µg per gram of turmeric.20 The decreased from 47 percent before the intervention concentrations of 5–15 micrograms per deciliter to 0 percent in 2021 (Forsyth et al. 2023). are well within the bounds found by Forsyth et al. (2019a,b) and Gleason et al. (2014). In Georgia. the Multiple Indicator Cluster Survey (MICS) 2018 undertook BLL measurements in Benefits are estimated for 15 percent of a nationally representative sample of children annual birth cohorts in Bangladesh and 40 ages 2–7 years. The measurements showed a percent in Georgia for twenty years following mean national BLL of 6 micrograms per deciliter the elimination of lead in turmeric. Baseline with mean BLLs of 8.4–12.8 micrograms per BLL with lead in turmeric is the national average deciliter in four regions and 3.9–5.2 micrograms BLL of 6.8 micrograms per deciliter in children per deciliter in the remaining six regions of the under five in Bangladesh in 2019 according to the country (NSO 2019). An assessment of sources of GBD 2019, and the average BLL of 9 micrograms lead exposure was subsequently undertaken in a per deciliter in the regions with high lead sample of homes and markets. concentrations in turmeric in Georgia in 2018. Children are, on average, expected to gain from The assessment found high concentrations 0.2 to 0.7 IQ points from the reduction in BLL in of lead in multiple spices, with lead in spices the three scenarios. particularly widespread in the two western regions where BLLs were found to be among The BCRs range from 2,600 to 8,382 in the highest (Ericson et al. 2020). Further Bangladesh and 100–316 in Georgia indicating investigation revealed that most of the lead huge returns on the government intervention was added to spices by large importers and (table 6.6). This stems from the larger number wholesalers for the purpose of yellow color of children immediately benefiting from the enhancement of the spices. The Government of intervention at a modest cost. 19 https://www.pureearth.org/solving-the-mystery-of-widespread-lead-poisoning-in-georgian-children/ (accessed August 30, 2023). 20 Modelled effect of dietary intake of lead by a two-year-old child using the EIUBK model version 2 from US EPA. 142 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE 6.6. Benefits and Costs of Eliminating Lead from Turmeric in Bangladesh and Georgia Annual Mean child BLL (µg/dL) IQ points Benefit- Country birth With Pb in Without Pb gained Benefit ($) Cost ($) cost ratio cohort turmeric in turmeric per child BCR Bangladesh 445,525 6.80 6.30 0.22 1,040,047,475 400,000 2,600 Bangladesh 445,525 6.80 5.80 0.45 2,153,917,034 400,000 5,385 Bangladesh 445,525 6.80 5.30 0.69 3,352,894,550 400,000 8,382 Georgia 20,118 9.00 8.50 0.17 62,356,462 625,000 100 Georgia 20,118 9.00 8.00 0.34 128,085,144 625,000 205 Georgia 20,118 9.00 7.50 0.53 197,571,742 625,000 316 Source: World Bank estimates based on intervention cost data from Pure Earth (2915) and BLL predictions in relation to lead concentrations in turmeric using the US EPA’s IEUBK Model, developed by US EPA to support assessments of health risks from exposures of children to lead. The model is publicly available at https://www.epa.gov/superfund/lead​ -superfund-sites-software-and-users-manuals The reductions in BLLs and gains in children’s Analytical work estimated the benefits and IQ points from the interventions assessed in costs of iron supplementation in Bangladesh this section may not seem very large. This is, (World Bank, 2024). The costs of the intervention however, an improvement from just addressing included the cost of a syrup with a dose of single sources of exposure among numerous 12.5 milligrams of iron per child daily for a three- sources to which populations in LMICs are month period, and the cost of promoting and exposed. delivering the iron supplement to the targeted children. For iron-deficient Bangladeshi children, iron supplementation may reduce BLLs by 0.8 to 6.9.  Iron Supplementation 1.2 micrograms per deciliter. Studies have found some evidence that iron The benefit of this reduction in mean BLL is supplementation to iron-deficient children under an estimated gain of 0.4–0.6 IQ points. This age five years is associated with a moderate gain is valued at 2 percent of lifetime income per reduction in BLLs. The WHO recommends a IQ point for the percent of children expected to supplemental daily dose of 10–12.5 milligrams of iron be in the labor force who could have a higher for children ages 6–23 months and of 30 milligrams lifetime income. Iron supplementation also for children ages 24–59 months for three consecutive provides a reduction in the prevalence of anemia months a year (WHO 2016). Iron supplementation is (Pasricha et al. 2020). That analysis calculated a likely to be more effective if it is administered from BCR of 6.6 to 9.1 for the intervention, with around age six months and is repeated multiple times until 75–85 percent of the benefits resulting from the the child reaches at least age five years, because prevention of IQ losses from lead exposure and the children are most susceptible to impairment of remaining 15–25 percent from anemia reduction their neuropsychological development from lead (World Bank, 2024). exposure during the early years of life. Scope and Economic Efficiency of Solutions to Prevent and Control Lead Pollution in the Environment 143 6.10. Conclusions such rehabilitation. In addition, such remediation projects will enable future generations of children Robust evidence shows that lead exposure to grow up in a cleaner environment, highlighting results in significant adverse effects, including the valuable contributions of tackling lead pollution increased CVD mortality among adults and to countries’ and communities’ human capital and IQ losses among children, among many other sustainable development. adverse effects. Complementary evidence indicates that various interventions are available The varied examples presented in this chapter to address the different sources of lead pollution illustrate that interventions to address lead and that these are economically efficient, resulting pollution are effective in different regions, at in benefits that outweigh their costs. In some multiple levels, and for a diversity of sources. cases, the benefits can be orders of magnitude Focusing on the most suitable interventions higher than the associated costs, as in the case for each specific context can help maximize of the elimination of lead additives in turmeric in the benefits relative to the costs. A portfolio of Bangladesh and Georgia, banning lead paint in interventions can help reduce the adverse effects Malawi, and converting lead pottery in Mexico. of lead exposure on children’s neuropsychological These interventions have particularly high BCRs development, increased mortality and morbidity because of their potential to benefit many children in adults, and on the environment. The technical while also requiring relatively minor investments. feasibility and economic justification for tackling Other interventions may have comparatively lower most sources of lead exposure are well-established. BCRs because they may be site-specific, such as remediating a particular contaminated site where Preventing lead contamination and exposure a relatively smaller number of children are at remains the most effective and efficient risk. However, even in these cases, the benefits approach for mitigating its health impacts. outweigh the costs because they result in reduced The cases presented in this chapter underscore BBLs and, therefore, have long-term benefits, such the need for investments in remediation efforts to as increased lifetime earnings by the beneficiaries protect individuals who would otherwise continue of such interventions. (See figure 6.2.) to be affected by existing sources of lead exposure. However, neither remediation projects nor existing Remediating lead pollution generally requires medical treatments can reverse the damage caused significant investments, as illustrated by the by lead poisoning. Lead chelation remains the multi-million-dollar investments required to primary intervention for individuals with elevated remediate soil pollution and remove lead pipes BLLs. However, studies have yielded inconsistent and plumbing materials in water systems. findings regarding its effectiveness in reducing Remediation projects are likely to benefit the risk of CVD events or improving cognitive primarily children who are more exposed to scores and behavioral profiles. These discrepancies lead in soil and dust through play activities and highlight the critical importance of primary other physical contact and who are also more prevention in addressing lead-related health risks vulnerable to lead exposure. Children currently (Lanphear et al. 2024). exposed to contaminated sites can benefit from 144 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE FIGURE 6.2. Massive Returns: Economic Efficiency of Interventions to Prevent and Reduce Lead Pollution Benefit-Cost Ratio (BCR) BANGLADESH The economic return (benefit) generated Eliminating lead additives in turmeric for every $1 invested (cost) on the intervention. $ , –$ , MEXICO Source: World Bank 2023 ZAMBIA Converting lead- Remediation of glazed pottery mining dumpsite production Iron supplementation and soil removal in $ –$ residential areas $ . –$ . Source: World Bank 2020 $ . –$ . World Bank 2024 Source: Yamada et al. 2023 GEORGIA Replacing MALAWI Eliminating lead lead-contaminated Abolishing lead additives in turmeric aluminum cookware in paint $ –$ $ –$ $ . –$ . Source: World Bank Source: World Bank World Bank 2024 Interventions to prevent lead pollution are not just public health measures— they are among the most economically efficient development investments globally, yield- ing hundreds, and even thousands, of dollars in benefits for every dollar spent. 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Despite its historical use in various industries, lead is not essential for the global economy. The negligible economic contributions of lead-related industries are vastly overshadowed by the immense societal costs of lead exposure. To effectively address this crisis, a coordinated approach is required, combining strategic investments and policy reforms to protect people at risk while also focusing on eliminating lead from the global economy. Investments are required to remediate lead-contaminated soils, replace lead pipes and water solder in plumbing systems, and remove lead-containing paints from buildings. Policy reforms should include updating lead standards in regulations bearing on the control of air, soil, and water pollution, phasing out lead-acid batteries, and banning lead-containing paints and lead glazes in foodware, lead-containing consumer products, recycled aluminum cookware, and lead-containing military weapons and ammunition. Regular monitoring and data collection are critical for informed decision-making. Establishing comprehensive programs to monitor the air, soil, and water, and routine health-surveillance programs improves the detection of contamination, enabling timely interventions to safeguard communities from exposure. Executive Summary 153 7.1. Introduction diminishing their job prospects in adulthood. Additional behavioral issues, like impulsivity and Lead exposure is a global crisis. In 2019, lead aggression, limit employability, while chronic caused an estimated 5.5 million premature health conditions result in higher absenteeism deaths globally, resulting in a global welfare and early retirement. Workers exposed to lead loss of $4.6 trillion (I$7.9 trillion international in childhood may face difficulties with focus, dollars)21, equivalent in size to 5.3 percent of coordination, rapid response tasks, and decision- global GDP (5.9 percent of GDP (PPP)). Lead making, ultimately reducing labor quality, exposure also caused an estimated loss of productivity, and the development of human 765 million IQ points among children globally, capital. Several risk factors for lead poisoning resulting in a loss of income estimated at include poverty, poor nutrition, living in industrial $1.4 trillion (I$2.4 trillion). This is equivalent zones, and the use of cookware. to 1.6 percent of global GDP in 2019 (1.8 percent of PPP-adjusted GDP) (Larsen and Lead also wreaks havoc on ecosystems. It Sánchez-Triana 2023). leads to increased mortality and developmental issues in microorganisms, plants, insects, birds, Beyond these effects, lead exposure amphibians, fish, and mammals. These disruptions inflicts extensive harm on public health, contribute to biodiversity loss, altered population the environment, and the economy. dynamics, and weakened ecosystem resilience. Evidence suggests there are no safe blood lead In turn, human populations suffer from reduced levels in children. In addition to IQ loss, lead agricultural productivity, exposure to contaminated exposure causes adverse effects, including, food sources, and from the degradation of natural learning disabilities, behavioral problems, criminal ecosystems that economies and overall wellbeing activity, and attention deficits. At higher levels, depend on. lead can also result in death. In addition, exposure to lead has been associated with an increase Despite the elimination of leaded gasoline in in children with mild mental retardation and a the 1990s and 2000s, which led to a reduction in decrease in those considered gifted. Prenatal average blood lead levels worldwide, the threat exposure to lead can also predict development of lead pollution persists. Multiple sources of status in early childhood and is associated lead, including legacy pollution from the use of with reduced fetal growth, lower birth weight, leaded gasoline and abandoned mines, continue to hypertension and, potentially, preeclampsia, expose people to this toxic chemical. Key sources preterm birth and spontaneous abortion of lead include mining and smelting—including (WHO 2021). formal operations; artisanal and small-scale mining; and informal recycling of ULABs—water The behavioral consequences of lead pipes and plumbing fixtures; e-waste recycling exposure place a heavy social and and disposal; consumer products (for example, economic burden on communities. Children metal and ceramic foodware, cosmetics, toys, exposed to lead often struggle academically, and traditional medicines); automotive and small- complete fewer years of education, and aircraft emissions; and ammunition and military experience reduced skill development, operations. 21 International dollars (I$) are US dollars adjusted for purchasing-power parity. 154 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Lead is not essential for the global economy yet lead in these products continues to harm and the industry’s contribution to the global millions of people every year. Even if the use of lead economy is minuscule compared with its in most sectors is declining, it will take decades for impacts. In 2020, the global value of lead-based the elimination of lead if left to market forces and products was estimated at around $100 billion the continuation of existing strategies (Luby et al. (Luby et al. 2024). Most markets for lead-based 2024). products have been in decline since at least 2006, as companies increasingly substitute lead with less Countries facing greater lead exposure are also toxic, readily available alternatives. One notable those that tend to have the lowest capacity to exception is lead-acid batteries (LABs), which develop and enforce environmental regulations account for an estimated 86 percent of the lead and the least resources to invest in remediation. currently mined or recycled annually. The demand Low- and middle-income countries (LMICs) for LABs is projected to grow in the coming years, suffer the highest burden of lead exposure, with driven by increased energy generation from most affected adults and children living in these renewable sources and the use of electric vehicles. countries. The mean estimated BLLs in children and adults were 4.6 µg/dL in LMICs, compared with Responding to the lead crisis calls for 1.3 µg/dL in high-income countries (HICs). These investments and policy reforms to protect mean estimated BLLs are highest in low-income people at risk while also focusing on eliminating countries (LICs), at 6.6 µg/dL and decline as per lead from the global economy. Efforts to capita income rises (Larsen and Sánchez-Triana eliminate lead from products such as gasoline, 2023). Financial and economic instruments will paint, cosmetics, and spices started decades ago, play an essential role in mobilizing the resources Quality Stock Arts / Adobe Stock Towards a Lead-Free Planet 155 BOX 7.1. Priority Investments to Prevent children and adults until the pollution sources are and Remediate Lead Contamination and prevented and controlled. Investments should be Exposure prioritized to target the most significant sources of lead exposure, including contaminated soils and water, and buildings with lead-containing paints • Remediate lead-contaminated soils (box 7.1). • Remove leaded pipe and water solder in plumbing systems Investments to remediate contaminated soils • Remove lead-containing paints from buildings are a top priority. In many communities, soils have been contaminated by lead from point- source emissions from lead smelters and battery recycling, active or abandoned mines, other required to strengthen the capacities to develop, industries, the past use of leaded gasoline, and implement, and enforce environmental regulations deterioration of paints in households. Given the in these countries. Ultimately, tackling lead extent of soil-lead contamination and the need exposure will depend on governments’ unwavering to ensure that lead hazards are eliminated, an commitment to enforce regulations limiting and evidence-based approach is required to prevent banning the use of lead, even if it means standing access to or remediate soils and prevent children’s against vested interests and powerful groups. and adults’ ongoing exposure. For communities with point sources of lead, whether large-sector or This chapter discusses several interventions small-sector industries, so-called “cap-and-cover” available to address the various sources of techniques have been widely used. lead pollution. Section 2 identifies investments to clean up contaminated soils, replace water Remediation projects generally require pipes, or remove lead paint in households. substantial funding. Resources are needed to Section 3 discusses policy instruments such cover expenses ranging from contaminant removal as legal bans or restrictions on the use of lead and clean soil replacement, to implementing in consumer products and standards limiting extensive health surveys and advocacy to reduce lead levels in environmental media. Section 4 children’s lead intake and investments to support focuses on the implementation of these actions, the livelihoods of affected communities. Examples building the required institutional capacities, of brownfield-remediation projects include the including the establishment of monitoring Bunker Hill Superfund Site in the US, which networks and laboratories, as well as equipping invested $220 million between 1985 and 2000, health professionals with the tools to identify and the World Bank–funded $65.6 million Zambia the populations at risk and develop appropriate Mining and Environmental Remediation and management strategies. Improvement Project (ZMERIP). Remediating pollution from ULAB-recycling 7.2.  Investments sites is also essential to protect children from lead. There are tens of thousands of ULAB recyclers Investments in remediation and cleanup of and abandoned ULAB-recycling sites in LMICs sources of lead pollution are necessary to and a smaller number of ongoing and abandoned solve the lead crisis. Lead will continue to poison mining sites. Abandoned sites continue to expose 156 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE children, especially to contaminated soil, dust, the action levels of the World Health Organization and sometimes drinking water (Caravanos et al. (WHO) (5 μg/dL) and CDC (3.5 μg/dL), underscoring 2013; Chatham-Stephens et al. 2014; Dowling the importance of preventing lead exposure as the et al. 2016). The health effects of exposure to lead only effective strategy to protect children (ACCLPP in the population surrounding these abandoned 2012; Ericson et al. 2018, 185). sites can be severe (Caravanos et al. 2016; Chatham-Stephens et al. 2014; Ericson et al. 2016). Cleaning up sites from lead pollution from Interventions such as on- and off-site removal ammunition storage from military and police and encapsulation of waste and contaminated operations is also crucial. These include sites soil have effectively reduced health risks, polluted by armed conflict and by activities such particularly for children who are more exposed as storage and training involving ammunition to lead in soil and dust through play activities and explosives. Decomposition of metal-military and other physical contact. This is illustrated by waste and especially ammunition (due to its lead the multifaceted interventions implemented to sulfide coating) can take up to 70 years. In areas remediate ULAB pollution in Dong Mai Village, of high combat activity, including in Croatia, Vietnam, where average soil concentrations fell agricultural soil samples have mean values of lead from 3,940 milligrams per kilogram to less than 100 that are higher than the values in areas of low milligrams per kilogram, and median BLLs fell from combat activity, even long after combat has ended 40.35 μg/dL to 13.3 μg/dL. BLLs remained above (UNEP 2022). Mayur Kakade / iStock Towards a Lead-Free Planet 157 Replacing lead pipes and other lead-containing that lead-safe housing generates $80,910 in elements in water-supply systems is another savings per child over a 10-year period due to urgent priority. In the US alone, the estimated reduced medical expenses, lower education costs, investment to replace lead pipes ranges between and increased productivity (Brown 2002). Broad $4,700 and $5,000 per pipe (Elmer 2024; economic assessments suggest that preventing Environmental Policy Innovation Center 2025). BLLs ≥ 2 micrograms per deciliter in a single birth While the amount of these investments is high, cohort in the US could yield savings between their benefit-cost ratios are estimated at 2.35, $1.9 billion and $12.1 billion (Pew 2017, 45). To with the resulting benefits clearly outweighing ensure lasting progress, investments to eliminate their costs. lead-paint hazards must be accompanied by policy reforms banning lead-based paint to prevent future Removing lead-paint hazards in homes is contamination. essential to prevent children’s exposure to lead. However, without strict safety measures— such as personal protective equipment (PPE) for 7.3.  Policy reforms workers, temporary relocation of families during remediation, and thorough post-remediation The implementation of targeted policies and testing of dust-lead levels—interventions can regulations to reduce and eliminate lead inadvertently lead to significant increases in exposure has already saved millions of lives BLLs among workers and residents. The most and has the potential to save millions more. hazardous removal methods include uncontrolled The global phase-out of lead in gasoline, for scraping, sanding, and burning of the paint instance, has been instrumental in saving tens of (Amitai et al. 1987). millions of lives. In the US, the prohibition of lead additives in gasoline and house paint, along with Professional removal of lead-based paint the replacement of lead water pipes, has led to a typically involves removal, encapsulation, remarkable reduction in blood lead levels—over enclosure, or replacement of the lead paint. In 65 percent in 15 years and 95 percent in 25 years, the US, encapsulation (sealing in lead paint) is the respectively (Lanphear et al. 2024). These examples most affordable method with an average cost of underscore the critical role that policy reforms $1 to $4 per square foot. Enclosure (covering with and robust legal frameworks play in mitigating new surfaces) costs from $7 to $13 per square the harmful effects of lead exposure. Priority foot and is more durable than encapsulation. reforms that countries should adopt to address Complete removal (stripping, sanding, or chemical lead contamination and exposure include updating removal) is the only option that offers a permanent pollution-control regulations; phasing out lead-acid solution. It costs from $8 to $17 per square foot batteries; and banning lead-containing paints and (Houselogic 2024). lead glazes in foodware, lead-containing consumer products, recycled aluminum cookware, and lead- The cost of remediating lead-paint hazards in containing military weapons and ammunition US housing built before 1978 was estimated (box 7.2). at $1.9 billion (Pew 2017, 45). While the costs of eliminating lead paint from existing buildings Phasing out lead-acid batteries in LMICs is may seem prohibitive, the costs of inaction are a top priority. Lead-acid batteries account for staggering. One comparative analysis estimated approximately 86 percent of global lead usage, 158 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE BOX 7.2. Priority Policy Reforms to Prevent photovoltaic systems, and electric mobility. and Remediate Lead Contamination and Currently, lithium batteries are an available Exposure option, made of a less toxic material, and offering increasingly attractive performance and prices for various energy-storage applications, including in • Phase out lead-acid batteries motorcycles, cars, and microgrids. In the coming • Ban lead-containing paints and lead glazes in decades, alternative battery technologies such foodware, lead-containing consumer products, as sodium-ion, magnesium-ion, and aluminum- recycled aluminum cookware, and lead-containing ion are expected to diversify options and reduce military weapons and ammunition dependence on lithium (Luby et al. 2024). Current • Update lead standards in regulations to control air, subsidies to photovoltaic systems containing lead soil, and water pollution and lead-acid batteries should be repurposed to safer alternatives while also incentivizing investments in the infrastructure required to safely manage such alternatives. and their demand is expected to grow due to Buy-back programs should be established to increased power generation from solar and wind decommission existing lead-acid batteries energy, as well as the rising use of electric vehicles. safely. These programs can be developed Recycling used lead-acid batteries is a major source incorporating effective practices from “take-back” of lead pollution, primarily because at least half programs implemented in countries such as Brazil of these batteries are recycled in informal sites, and the UK, which establish a legal obligation for such as small workshops or backyard smelters, battery manufacturers to collect used batteries which lack proper safety measures and facilities safely and ensure they are treated by a certified for neutralizing and safely disposing of battery battery operator. This centralized oversight electrolytes. This leads to severe environmental simplifies regulatory enforcement, allowing the contamination and significant lead exposure for government to focus on monitoring manufacturers workers, who typically have minimal protection, rather than overseeing thousands of individual and for nearby communities. Promoting formal shops, distributors, and recycling facilities recycling of lead-acid batteries in LMICs has (Hirst et al. 2023). The decommissioning programs been unsuccessful. Informal recyclers tend to be should establish responsibilities for every stage of cheaper and therefore capture a major share of the supply chain—including retailers, distributors, the market. Additionally, even formal operations transporters, manufacturers, and disposal lack the technology used by original equipment facilities—to guarantee proper battery collection manufacturers, resulting in significant risks of lead and disposal. To prevent improper handling, contamination. regulations should mandate that battery acid remain sealed within the batteries until they reach Fiscal policies should be strengthened to certified disposal facilities. Strict standards should incentivize the use of alternatives using safer also govern the transportation of ULABs, ensuring materials and technologies in place of lead-acid that trucks and drivers adhere to safety protocols. batteries. A key step is to repurpose subsidies Additionally, decommissioning programs should designed to encourage the increased generation define the requirements to become a certified of energy from renewable sources, particularly battery-treatment operator, and the compliance Towards a Lead-Free Planet 159 records, reports, and audit trails of proper recovery and more environmentally responsible battery and disposal processes that manufacturers and technologies. battery operators must provide to authorities. The establishment of oversight mechanisms, including Lead-paint hazards can be prevented before site inspections and penalties and legal sanctions children are exposed and without the expense for noncompliance, are essential to compel battery of remediation and cleanup if the use of lead manufacturers and operators to comply with paint is legally banned. Levels of lead in paint established regulations (Hirst et al. 2023). are lowest in countries that have lead-paint laws (IPEN 2017). The United Nations Environment To accelerate the adoption of non-lead battery Programme (UNEP) recommends establishing a technologies, countries should develop robust concentration limit that is as low as technically procurement policies as a strategic tool. feasible (UNEP 2018). The lowest and most Public procurement is widely acknowledged as protective maximum regulatory limits on lead in a powerful tool for incentivizing industries to residential and decorative paints have been set develop environmentally sustainable works, at 90 ppm total lead content. Close collaboration products, and services. By leveraging purchasing among government, industry, and civil society power, governments can drive innovation, has been essential for the adoption of legal bans particularly in sectors where public buyers on lead paint in many countries. According to the constitute a significant share of the market, WHO Global Health Observatory, in 2022, a total of such as infrastructure, health care, and public 93 countries had laws limiting the content of lead transportation (OECD 2024). These policies should in paint, and 19 countries were in the final stages be designed to evaluate and compare various of drafting lead-paint laws. However, a significant non-lead battery alternatives—including lithium- number of countries have yet to adopt similar laws, ion, sodium-ion, and solid-state batteries— and limited available information suggests the based on key factors such as performance, need to strengthen enforcement in countries where cost, lifespan, and recyclability. In particular, such laws have been adopted. procurement policies should prioritize efficiency, performance, toxicity, and environmental impact, Eliminating lead in spices is another pressing with a strong emphasis on minimizing harm to priority. Several countries, including LMICs, have human health and ecosystems. Complementary successfully eliminated lead contamination in regulations must ensure that suppliers meet spices within a relatively brief time frame through stringent environmental certifications, reinforcing strict enforcement of regulations. For instance, sustainability commitments throughout the the Government of Bangladesh implemented supply chain. Furthermore, governments multifaceted interventions between 2017 and should mandate the establishment of take- 2021 to reduce lead-tainted turmeric. These back programs for used batteries alongside interventions included disseminating through news strict standards for responsible disposal and media scientific findings that identified turmeric as recycling. To remain effective, procurement a source of lead poisoning, educating consumers policies must be periodically reviewed and and business owners and operators about the updated to reflect technological advancements, risks of lead chromate in turmeric through public evolving market trends, and regulatory changes. notices and direct engagement, and utilizing a By continuously refining procurement criteria, rapid lead detection technology (x-ray fluorescence countries can sustain progress in adopting safer analyzer—XRF) to enforce policies prohibiting 160 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE turmeric adulteration. Fines were imposed on implementing mandatory labeling and certification shops found to be selling adulterated turmeric. The of lead-free kitchenware and other products. proportion of market turmeric samples containing detectable lead dropped from 47 percent in Banning the use of lead in ammunition is a 2019 to 0 percent in 2021, while mills with direct critical measure to mitigate environmental evidence of lead-chromate adulteration fell from harm and protect individuals who consume 30 percent to 0 percent over the same period. game meat regularly. According to European Wholesale traders reported that the government Chemicals Agency (ECHA) estimates, prohibiting crackdown, along with penalties for violating food the sale and use of lead gunshot, bullets, and standards, provided strong incentives to cease other projectiles—along with lead-based fishing the sale of brightly-colored roots adulterated with weights—could prevent an estimated 1.7 million lead chromate. The deployment of XRF analyzers tonnes of lead emissions over 20 years. Phasing played a pivotal role in improved monitoring out the use of lead in large-caliber bullets and and enforcement. With a capital cost of US$30– gunshot could avoid an annual IQ loss in up to US$40,000, these devices are approximately one- 7,000 children who eat game meat frequently. tenth the cost of laboratory mass spectrometers. These figures highlight that ammunition is a major Additionally, XRF analyzers require no consumables, source of lead contamination, positing risks to reagents, or extensive training, making them a human health and ecosystems. Implementing cost-effective and accessible tool for detecting comprehensive regulations to eliminate lead-based contamination (Forsyth et al. 2023). ammunition will not only safeguard vulnerable populations but also contribute to long-term Regulations should be adopted to ban lead in environmental sustainability. all kinds of consumer products, lead glazes in foodware, and recycled aluminum cookware. Efforts to reduce lead exposure from e-waste Organizations, such as WHO, the UN Food and should begin by enforcing burning bans and Agriculture Organization, and well-resourced closing loopholes for the shipping of e-waste regulatory agencies from different countries have from HICs to LMICs. In 2023, only 22.3 percent of adopted standards, public health guidance, a e-waste was formally collected and recycled in an level of concern, or a regulatory limit for lead in environmentally sound manner worldwide. Open key products. These instruments are based on burning of e-waste is a widespread practice in available information about the levels of lead in countries with low formal collection and recycling these products that would result in an increase in rates. It is mainly carried out to remove plastics blood lead level if such products were regularly and isolate metals—for example, burning of wires, consumed. Examples include limits on lead in plastic metal assemblies, PCBs, and so forth—or cosmetics, toys, spices, food, sweets, herbal and to reduce the volume of unwanted materials traditional medicines, pottery, and electronics, (Baldé et al. 2024). Open burning exposes workers among others. However, similar instruments are and nearby communities to lead and other toxic missing for products such as ceramic, metal, and chemicals via inhalation, ingestion, and dermal foodware, which have been found to include lead exposure, and pollutes soil, air, and water in and in many LMICs. Priority actions should include around the informal working areas (Vaccari et al. designing and implementing regulations to 2019). While 81 countries have adopted e-waste prohibit the use of lead glazes in foodware and legislation, enforcement remains a genuine the use of scrap metal in cookware along with challenge globally. Key obstacles to improved Towards a Lead-Free Planet 161 e-waste management include low collection as the type of water body (for example, rates, limited recycling infrastructure, and illegal freshwater or saltwater); key water uses (for shipments of e-waste in many parts of the world example, recreation); and a goal (for example, (Baldé et al. 2024). Enforcing bans of e-waste in protection of human health or aquatic life). US informal recycling sites and dumpsites, as well as Water Quality Criteria establish a maximum closing loopholes in e-waste regulations that allow concentration of lead to protect aquatic life illegal e-waste flows from HICs to LMICs under from acute toxicity of 65 µg/l in freshwater and the guise of “donation” or “refurbishing” purposes 210 µg/l in saltwater. For chronic toxicity, the (Vaccari et al. 2019). standard sets a continuous concentration of 2.5 µg/l in freshwater and 8.1 µg/l in chronic Updating lead standards in regulations to saltwater. control air, soil, and water pollution is required to comprehensively tackle lead pollution. • Agriculture. The “Code of Practice for Standards should recognize that there is no safe the Prevention and Reduction of Lead limit on lead and that standards, therefore, must Contamination in Foods” published jointly by limit the amount of lead emitted or discharged by the FAO and WHO (2022) identifies agricultural pollution sources and the ambient concentrations and manufacturing practices that can minimize of lead. Specific instruments include the following: lead contamination of foods. These include protecting water for irrigation, livestock • Air-quality standards can limit the farming, and aquaculture from sources of lead concentration of lead in ambient air. The air contamination. Lead levels should be monitored quality guideline (AQG) for lead set by the WHO to prevent or reduce lead contamination of is 0.5 µg/m³ for a calendar year. (See annex 7 for crops, livestock, and aquaculture products. The more information about the permissible limits guidelines include a maximum concentration of for lead in ambient air set by various countries.) lead of 5.0 mg/L (Qadir et al. 2023), but several LMICs have adopted standards for water for • Soil-quality standards. Countries have irrigation including Argentina (0.2 mg/L) and adopted various standards, frequently focusing China (0.2 mg/L). (See annex 7.) on specific land uses, such as agricultural, residential, or conservation areas. LMICs such • Drinking-water standards to protect the as Peru, Poland, and Vietnam have established population from the risk of leachable lead permissible limits for lead in diverse types of from pipes, plumbing materials, and fixtures soil. In Peru, the maximum limit is 70 mg/kg in used in water-supply systems should recognize agricultural areas and 140 mg/kg in residential that there is no safe limit on lead. The WHO areas and parks. Poland set a limit of 100–200 emphasizes that every effort should be made mg/kg in agricultural areas. Vietnam has set to maintain lead levels in drinking water as a limit of 70 mg/kg in both agricultural and low as reasonably practical and below the residential areas (see annex 7). guideline value when resources are available (WHO 2022a). Annex 7 lists the permissible • Ambient water-quality standards are limits for lead in drinking water set by various often established based on criteria such countries. 162 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 7.4.  Institutional capacities strategies to collect data to identify primary to prevent and remediate sources of pollution and establish the pathways through which individuals and communities lead contamination and are exposed to lead. Such data, as well as exposure information about the characteristics of lead, its behavior in the environment, and factors that influence uptake rates in the exposed population, The adage that it is impossible to manage enable the development of data-based multi- what is not measured is particularly relevant stakeholder approaches to diagnose, treat, and for confronting the lead crisis. However, most prevent lead poisoning. Effective implementation countries do not have environmental monitoring of these actions will also require building the systems in place or conduct regular blood level required institutional capacities, including testing to measure reliably and systematically the establishment of monitoring networks people’s exposure to lead. In the absence of and laboratories, as well as equipping health- such systematic monitoring of lead exposure, care organizations with the tools to identify environmental and health agencies in many populations at risk and diagnose individuals with LMICs are unaware of how widespread lead lead poisoning (box 7.3). Having these systems poisoning is in their own countries. Filling this in place is key because symptoms are most often knowledge gap will require a combination of vague or nonexistent at the time of exposure. kamiphotos / Adobe Stock Towards a Lead-Free Planet 163 BOX 7.3. Institutional Capacities Needed to of attainment for regulatory standards. These Prevent and Remediate Lead Contamination networks should include monitoring stations and Exposure equipped with automatic analyzers to measure key pollutants, including lead, as well as other pollutants such as chemical species in fine • Implement monitoring networks of air, soil, and water particulate matter (PM2.5). To support regulatory • Establish routine surveillance programs of blood lead compliance, monitors should be grade-level and levels, with public reporting have strict operating standards for parameters • Strengthen institutions for chemical-management such as accuracy, precision, measurement range, governance and drift, among other aspects. Networks for monitoring air quality should also be equipped with • Conduct public-awareness campaigns about the devices for capturing air samples and measuring risks of lead-acid batteries, lead paint, lead glazes pollutant concentrations, including continuous in footwear, lead-free spices, recycled aluminum analyzers and integrated/manual samplers, as well cookware, lead-free cosmetics, and other consumer as modules to collect meteorological data, such as products wind speed and direction, temperature, humidity, • Implement consumer-education initiatives to increase pressure, solar radiation, and precipitation. demand for lead-free paint, foodware, cookware, and Telemetric systems or wireless networks are ceramics required to transmit data in real-time or near real-time to central databases for analysis and reporting, while data storage, processing, and quality-assurance systems are essential to ensure accuracy and reliability. Stations for monitoring air Implement monitoring networks of air, soil, quality should be properly located, with enclosures and water. Investments and technical support that ensure the thermal and acoustic isolation are required to equip authorities in LMICs required to maintain analyzer performance, as with the resources and capacity to monitor well as with a reliable power supply and physical lead concentrations in the air, water, and soil. security measures. Resources are required to Comprehensive strategies to monitor lead pollution regularly calibrate and maintain the equipment to call for the establishment of environmental uphold data quality and sensor accuracy. monitoring networks that enable routine measurement of lead exposure. Such strategies Well-functioning of environmental monitoring include air-quality monitors that measure lead systems require strong political commitment to concentrations in outdoor air and regular collection ensure a continuous allocation of the necessary of drinking-water samples in priority areas. Also to human, material, and financial resources. be included in such strategies is the taking of soil Common challenges faced by environmental samples from various locations and depths, as well monitoring organizations in LMICs include lack as including soil-lead monitoring in environmental of qualified staff, consumables, and supplies; health programs and site-remediation projects. insufficient budgets for regular maintenance and difficulties finding qualified technicians and spare Networks for monitoring air quality should parts to repair equipment; absence of, or weak provide high-quality data to inform air quality implementation of, quality systems; and in many decision-making, policy making, and evaluation cases, basic operational issues, such as irregular 164 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE power supply (Pinder et al. 2019). Monitoring as lead in paint or certain spices, to overall lead networks must be coupled with laboratories exposure within a community. Conversely, “bottom- that can analyze the collected samples using up source assessments” are vital for pinpointing standardized, approved methods to quantify lead. the sources affecting specific populations and Having a national or regional reference laboratory assessing the relative significance of various that can validate the accuracy of the results sources in areas with BLLs. This information is provided by other laboratories is an essential, but critical for prioritizing interventions. Additionally, frequently missing, element of the environmental bottom-up assessments can investigate the monitoring networks required in LMICs. root causes of contamination in specific media and identify sources responsible for severe lead Effective lead monitoring in drinking water poisoning, enabling targeted actions at local, requires consistent and systematic testing by regional, and national levels (Bonnifield and Todd water suppliers and regulatory agencies. Given 2024a). that lead concentrations can fluctuate over time, monitoring efforts should incorporate a probability- Similarly, strengthening capacities to conduct based adaptive sampling plan to accurately chemical speciation analyses would lead to an assess exposure levels. Where prior knowledge improved understanding of how lead behaves in indicates potential sources of lead contamination, the environment, help prioritize interventions sampling strategies should be targeted to focus to tackle sources of lead exposure, and inform on these areas, ensuring a proactive approach to the design of effective responses. This should identifying risks. Any detection of elevated lead include lead-speciation analysis to help identify the levels must prompt a comprehensive investigation specific chemical composition of lead emitted from to determine the extent of exposure, identify various sources. These include the historical use of contamination sources, and guide remedial actions. leaded gasoline, vehicles (including non-exhaust In cases where lead levels exceed safety thresholds, emissions such as those from brakes and tires), and mitigation measures should be implemented to primary and secondary smelting, as well as lead- progressively reduce concentrations to as low as speciation analysis to better understand the levels reasonably achievable. Ideally, lead levels should of toxicity and environmental effects of different be reduced to below the WHO guideline value, lead species. Speciation data would enable safeguarding public health and minimizing long- authorities to create comprehensive emissions term risks (WHO 2022b). inventories, better model lead behavior in the environment and lead’s associated health impacts To address lead exposure effectively in LMICs, and formulate effective regulations and strategies it is essential to invest in enhancing analytical to safeguard public health and the environment capabilities for identifying lead sources, (Simon et al. 2010). including conducting source-apportionment studies. Understanding the origins of lead Speciation in water should be conducted pollution and the specific pathways through which to assess lead bioavailability and solubility populations are exposed is crucial for developing in water. In turn, this information can inform targeted, evidence-based interventions. Given strategies to minimize and prevent exposure the multiple sources of lead, “top-down source- (especially in vulnerable populations like children) apportionment” methods can help determine the and develop targeted remediation techniques. contribution of specific potential sources, such In the case of drinking water, lead speciation can Towards a Lead-Free Planet 165 help identify the most harmful forms of lead, guide that can be implemented by medical, nursing, and effective corrosion-control strategies and the use of public health schools. Such studies should be done water-treatment chemicals, and inform regulatory in concert with community-based organizations to practices to ensure safe drinking water. estimate the characteristics and extent of exposure. Because these small-area surveys use a randomly Monitoring BLLs, particularly in children, should selected sample of residents or households, they be complementary to environmental monitoring can be compared to both the national surveys and and will be key to ensure that countries are similarly conducted studies in other areas. Coupled advancing towards a lead-free future. Monitoring with comprehensive environmental sampling and lead exposure in LMICs is challenging because of questionnaires on participants’ demographic and the significant costs and technical requirements of behavioral characteristics, small-area analyses have existing measurement tools. If the existing capacity been used to (a) identify lead sources in children’s of laboratories to test BLLs is low or nonexistent, environments, (b) determine the contribution of then significant investments will be required to various lead sources to the BLLs of children living in develop such capacity, including procurement of the area. and (c) implement source-remediation and equipment, consumables and supplies, and trained health-education campaigns that prevent further staff. (See annex 10 for a summary of existing lead poisoning. Findings from these analyses tools to measure lead exposure.) LMICs might should be used to improve primary and secondary focus initial efforts to monitor lead poisoning by prevention efforts, including case management and conducting active surveillance through national educational services by trained staff. and/or subnational representative BLLs surveys. These surveys can be conducted at reasonable Strengthening institutions is essential for costs because only a relatively small subset of sound chemical management governance. the population must be sampled and tested to Management of lead and chemicals in general obtain representative results (Bonnifield and Todd requires clear institutional mandates that assign 2024). LMICs such as Bhutan and Georgia have responsibilities for policy design, implementation, successfully completed their first national BLL and enforcement to specialized technical units with survey with support from development partners. qualified staff. A first step would be for LMICs to The surveys helped establish a robust baseline conduct a detailed analysis of the organizational of BLLs in the population, providing information structure under their environmental and health about trends and distribution of lead poisoning ministries, and other relevant agencies, to assess across geographic areas and socioeconomic whether such elements are in place. Based on such factors. Ideally, government-led active surveillance information, LMICs should consider measures such should be conducted routinely (every few years) as the establishment of a cadre of environmental using a representative sample at the national or specialists with clear professional paths that will regional level. attract and retain talented individuals. These conditions will foster decision-making and policy Governments should complement national making by people with adequate backgrounds and and subnational population-based surveys experience. with small-population, small-area analyses. National governments can collect data to assess the Given the diverse sources of lead pollution, severity of lead exposure by supporting relatively fostering interagency coordination is essential. inexpensive small-population, small-area analyses This can be achieved through initiatives that 166 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE promote data sharing, joint monitoring, and Multiple channels may be needed to reach a critical collaborative enforcement actions. Agencies should mass of people, including social media, mass be encouraged to set specific, measurable goals and traditional media, and community-focused within their action plans and to systematically spaces (for example, places of worship, schools, track their progress. An effective performance- workplaces, health fairs, and community meetings evaluation system should focus on direct impacts or cultural events) (UNICEF 2025). on environmental quality, such as reductions in lead levels in air, water, soil, and children’s blood. Publicly disseminating these data can create strong 7.5. Outlook incentives for compliance and improve institutional performance. There is no safe lead level, and because pollution originates from diverse sources, Raising awareness and educating people exposure is ubiquitous. The health and social about the dangers of lead is necessary because effects of lead poisoning are significant, widely people cannot see, smell, or taste lead in their ranging, and often irreversible. Thus, the only real environment or in the products they use or solution to protecting people from lead poisoning consume. Additionally, there are frequently no is to identify and phase out environmental sources symptoms of lead exposure, and lead is found of lead (Lanphear, Navas-Acien, and Bellinger 2024; in many products that have deep traditional Luby et al. 2024). and cultural roots. Countries should develop a communications strategy including a clear, Living in a lead-free world is an ambitious, measurable objective; well-defined audiences; a yet feasible and just goal. Previous efforts to strategy to influence the target audience to reach phase out lead paint and leaded gasoline, and the the objective; a detailed activity plan to guide banning of lead in spices, among other relevant implementation; and monitoring and evaluation to examples, offer relevant lessons and inspiration assess the effectiveness of communication efforts to achieve this goal. Leaders must recognize lead (UNICEF 2025). not only as an environmental or health priority challenge, but rather as a priority development Priority education and awareness-raising efforts challenge given its significant impacts on health, should focus on key sources of lead exposure. human capital, productivity, and the environment. These should include lead-acid batteries, lead pipes, lead paint, lead glazes in footwear, lead-free The priority next steps to address lead pollution spices, recycled aluminum cookware, cosmetics, should include investments to remediate and traditional medicines, and other consumer clean up sources of pollution, policy reforms to products. Efforts should also include consumer- eliminate lead from the global economy, and education initiatives to increase demand for lead- strengthening institutional capacities to design free paint, foodware, cookware, and ceramics. and implement evidence-based strategies. Messages in the communications strategy should Resources dedicated to preventing lead exposure include scientific information about health effects are resources invested in human capital. These and realistic actions that the audience can take, actions will primarily benefit children, who are including minor changes and examples of activities disproportionately exposed to lead through play already being implemented by community activities and physical contact and are particularly members, which allow them to feel empowered. vulnerable to its toxic effects. Reducing lead Towards a Lead-Free Planet 167 exposure leads to measurable decreases in BLLs, next steps. Ensuring that children and adults are yielding long-term benefits such as improved not exposed to lead will have a direct, immediate, health outcomes and increased lifetime earnings. and measurable effect on their health. Many of the By tackling lead contamination, countries can strategies described here are well documented, protect their most at-risk populations while and mechanisms to target these strategies to securing lasting economic and public health at-risk populations are mature. Strengthening benefits. and widening these efforts is an urgent matter. As already stated in 1969 by Rene Dubois: “The To improve overall health and well-being, problem (of childhood lead poisoning) is so well environments must be “lead safe.” This is no defined, so neatly packaged with both causes and small task; it will require dedication, ingenuity, cures known, that if we don’t eliminate this social skill, and concerted effort by many people in many crime, our society deserves all the disasters that sectors. The actions outlined in this report are the have been forecast for it” (Oberle 1969). 168 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE References Amitai, Y., J. W. Graef, M. J. Brown, R. S. Gerstle, N. Kahn, Brown, Mary Jean, Jane Gardner, James D. Sargent, and P. 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Towards a Lead-Free Planet 171 182 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE ANNEX 1: BLOOD LEAD LEVELS AND HEALTH EFFECTS BY COUNTRY/ECONOMY BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population Afghanistan 14.3 11,825,548 8.9 30,884 81 Albania 4.1 166,465 5.7 4,601 161 Algeria 3.6 5,255,494 5.3 32,757 76 Angola 4.2 7,085,735 5.7 9,059 28 Argentina 2.3 2,797,131 4.2 25,811 57 Armenia 2.6 163,884 4.5 3,757 127 Australia 1.3 888,395 2.9 7,475 29 Austria 1.1 217,483 2.6 3,845 43 Azerbaijan 2.4 606,408 4.3 11,044 110 Bahamas, The 2.0 17,872 3.9 196 50 Bahrain 2.4 85,180 4.3 332 20 Bangladesh 6.8 20,596,306 6.9 138,054 85 Barbados 2.0 11,787 3.9 205 72 Belarus 2.6 396,486 4.5 20,963 221 Belgium 2.4 506,892 4.3 8,840 77 Belize 2.5 32,394 4.4 124 32 Benin 5.4 2,804,310 6.3 4,373 37 Bhutan 2.5 43,188 4.4 324 42 Bolivia 6.5 1,758,945 6.8 6,630 58 Bosnia and Herzegovina 3.1 146,915 5.0 5,849 177 Botswana 3.9 336,909 5.5 1,217 53 Annex 1: Blood Lead Levels and Health Effects by Country/Economy 183 BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population Brazil 2.6 12,990,097 4.5 110,049 52 Brunei Darussalam 1.4 19,464 3.1 80 18 Bulgaria 2.0 237,971 3.9 17,981 258 Burkina Faso 8.2 5,391,254 7.3 9,526 47 Burundi 5.6 2,692,315 6.4 4,210 37 Cabo Verde 2.4 43,353 4.3 280 51 Cambodia 5.3 2,040,461 6.3 11,907 72 Cameroon 5.8 5,838,334 6.5 10,464 40 Canada 1.2 1,014,967 2.7 10,812 29 Central African Republic 7.0 1,438,039 7.0 3,024 64 Chad 9.4 5,161,908 7.7 6,079 38 Chile 1.5 723,721 3.2 5,150 27 China 3.4 75,934,770 5.2 1,497,112 107 Colombia 2.2 3,015,720 4.1 17,767 35 Comoros 2.9 111,873 4.8 337 40 Congo, Dem. Rep. 5.9 24,061,756 6.5 36,208 42 Congo, Rep. 2.8 810,581 4.7 2,050 38 Costa Rica 3.3 333,575 5.1 2,136 42 Cote d’Ivoire 5.1 5,375,624 6.2 8,446 33 Croatia 1.7 126,496 3.5 4,832 119 Cuba 4.7 660,524 6.0 15,062 133 Cyprus 1.3 38,449 2.9 451 38 Czech Republic 1.6 376,414 3.4 9,423 88 Denmark 1.4 186,715 3.1 2,428 42 Djibouti 2.8 111,922 4.7 355 36 Dominica 2.4 6,225 4.3 63 88 184 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population Dominican Republic 4.5 1,216,144 5.9 10,027 93 Ecuador 2.9 1,435,230 4.8 6,318 36 Egypt, Arab Rep. 6.6 16,795,863 6.8 108,625 108 El Salvador 4.4 598,053 5.8 3,555 55 Equatorial Guinea 1.9 178,872 3.8 204 15 Eritrea 3.1 493,201 5.0 2,015 58 Estonia 1.7 49,232 3.5 1,603 121 Eswatini 5.1 177,737 6.2 584 51 Ethiopia 4.4 21,513,504 5.8 27,599 25 Fiji 1.4 55,420 3.1 412 46 Finland 0.8 90,282 2.0 1,838 33 France 1.4 2,307,559 3.1 26,363 39 Gabon 2.0 242,016 3.9 572 26 Gambia, The 5.6 538,339 6.4 1,029 44 Georgia 2.3 210,649 4.2 7,560 203 Germany 1.3 2,263,093 2.9 52,781 63 Ghana 2.9 4,227,266 4.8 11,634 38 Greece 1.7 292,442 3.5 10,929 102 Guatemala 5.8 2,439,666 6.5 6,339 38 Guinea 7.3 3,062,114 7.1 6,108 48 Guinea-Bissau 6.3 407,136 6.7 898 47 Guyana 4.0 91,888 5.6 853 109 Haiti 8.1 1,920,043 7.3 11,511 102 Honduras 5.4 1,353,342 6.3 5,940 61 Hungary 2.0 360,299 3.9 14,053 144 Iceland 0.9 9,633 2.2 63 17 Annex 1: Blood Lead Levels and Health Effects by Country/Economy 185 BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population India 6.2 154,507,700 6.7 1,064,213 78 Indonesia 3.2 22,751,294 5.1 205,000 76 Iran, Islamic Rep. 5.1 8,057,808 6.2 67,421 81 Iraq 4.4 6,726,165 5.8 29,148 74 Ireland 1.3 171,605 2.9 1,499 30 Israel 1.5 584,510 3.2 2,121 23 Italy 1.1 1,066,987 2.6 27,555 46 Jamaica 3.5 176,782 5.3 2,135 72 Japan 1.1 2,262,710 2.6 43,389 34 Jordan 2.7 1,110,051 4.6 3,349 33 Kazakhstan 1.9 1,507,608 3.8 14,174 77 Kenya 2.8 6,693,597 4.7 11,624 22 Korea, Dem. People’s Rep. 6.6 2,347,131 6.8 43,417 169 Korea, Rep. 1.5 981,184 3.2 13,267 26 Kuwait 1.6 185,003 3.4 751 18 Kyrgyz Republic 3.5 907,627 5.3 5,792 90 Lao PDR 3.8 879,744 5.5 4,608 64 Latvia 2.0 72,798 3.9 3,587 188 Lebanon 1.2 249,167 2.7 2,128 31 Lesotho 7.5 406,028 7.1 1,752 82 Liberia 7.2 1,081,444 7.0 1,822 37 Libya 2.1 490,284 4.0 2,959 44 Lithuania 1.7 95,784 3.5 4,164 149 Luxembourg 1.0 14,669 2.4 136 22 Madagascar 4.8 5,145,162 6.1 13,042 48 Malawi 4.7 3,726,656 6.0 5,745 31 186 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population Malaysia 1.4 1,559,228 3.1 9,265 29 Mali 9.1 6,304,523 7.6 8,498 43 Malta Marshall Islands Mauritania 3.9 789,524 5.5 1,362 30 Mauritius 1.9 48,237 3.8 717 57 Mexico 4.5 11,501,994 5.9 61,945 49 Moldova 4.0 191,137 5.6 8,302 312 Mongolia 2.8 352,337 4.7 2,851 88 Montenegro 1.9 27,142 3.8 856 138 Morocco 3.1 3,277,411 5.0 36,174 99 Mozambique 4.7 6,539,451 6.0 11,730 39 Myanmar 4.0 5,132,750 5.6 48,296 89 Namibia 4.6 405,128 5.9 1,396 56 Nepal 6.3 3,975,210 6.7 19,311 68 Netherlands 1.1 433,544 2.6 4,959 29 New Zealand 1.8 216,130 3.6 2,467 50 Nicaragua 2.8 664,205 4.7 2,379 36 Niger 12.1 8,620,941 8.4 7,916 34 Nigeria 4.9 44,208,061 6.1 60,865 30 Norway 1.3 158,161 2.9 1,844 34 Oman 1.9 332,697 3.8 1,065 21 Pakistan 4.9 37,229,799 6.1 127,674 59 Panama 2.9 367,970 4.8 1,578 37 Papua New Guinea 2.2 1,013,427 4.1 3,657 42 Paraguay 3.5 725,808 5.3 3,274 46 Annex 1: Blood Lead Levels and Health Effects by Country/Economy 187 BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population Peru 6.0 3,876,102 6.6 11,896 37 Philippines 5.0 14,904,320 6.2 78,178 72 Poland 1.6 1,261,697 3.4 32,097 85 Portugal 2.0 335,493 3.9 8,491 83 Puerto Rico 1.1 52,240 2.6 1,027 32 Qatar 1.9 113,243 3.8 240 8 Romania 2.6 901,235 4.5 41,853 216 Russian Federation 2.5 6,450,538 4.4 271,938 188 Rwanda 3.7 2,093,189 5.4 3,949 31 Samoa 2.1 23,482 4.0 126 64 São Tomé and Príncipe 3.7 33,302 5.4 91 42 Saudi Arabia 1.8 2,396,272 3.6 9,409 27 Senegal 3.9 2,909,544 5.5 5,468 34 Serbia 2.4 279,175 4.3 16,767 241 Sierra Leone 6.3 1,657,884 6.7 3,590 46 Singapore 1.9 188,818 3.8 1,477 26 Slovak Republic 1.6 192,107 3.4 4,922 90 Slovenia 1.2 53,030 2.7 1,021 49 Somalia 7.9 4,854,905 7.2 7,875 51 South Africa 3.9 6,737,209 5.5 28,802 49 South Sudan 5.4 1,829,471 6.3 2,730 25 Spain 1.6 1,203,167 3.4 24,148 51 Sri Lanka 2.4 1,368,616 4.3 12,188 56 St. Lucia 2.6 9,465 4.5 124 68 St. Vincent and the 3.3 7,128 5.1 114 103 Grenadines Sudan 6.8 10,065,373 6.9 30,951 72 Suriname 2.8 51,661 4.7 413 71 Sweden 0.9 247,748 2.2 3,151 31 188 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE BLL CVD deaths in 2019 IQ losses in 2019 in 2019 (central estimate) Per 100,000 ug/dL Number Per childa Number population Switzerland 1.6 287,916 3.4 4,403 51 Syrian Arab Republic 4.6 2,232,432 5.9 16,914 99 Tajikistan 5.2 1,620,943 6.2 8,578 92 Tanzania 3.9 12,005,537 5.5 18,455 32 Thailand 1.6 2,239,386 3.4 21,175 30 Timor-Leste 4.9 194,965 6.1 934 72 Togo 5.0 1,605,559 6.2 3,167 39 Trinidad and Tobago 1.5 59,924 3.2 686 49 Tunisia 3.1 1,022,546 5.0 10,848 93 Türkiye 1.5 4,167,608 3.2 30,176 36 Turkmenistan 2.1 556,913 4.0 4,306 72 Uganda 3.8 8,662,297 5.5 9,368 21 Ukraine 1.5 1,151,973 3.2 76,962 173 United Arab Emirates 1.5 288,005 3.2 1,471 15 United Kingdom 1.1 1,823,848 2.6 21,906 33 United States 1.1 9,535,648 2.6 111,397 34 Uruguay 3.5 195,036 5.3 3,317 96 Uzbekistan 2.9 3,891,929 4.8 31,909 95 Vanuatu 3.0 44,670 4.9 259 86 Venezuela, RB 4.4 2,822,663 5.8 22,630 79 Vietnam 3.3 7,611,186 5.1 77,081 80 West Bank and Gaza 2.1 548,547 4.0 1,578 34 Yemen, Rep. 11.1 7,879,164 8.1 26,315 90 Zambia 2.9 3,031,562 4.8 5,281 30 Zimbabwe 9.2 3,587,011 7.6 7,934 54 Sources: BLLs are from https://lead.pollution.org. IQ losses and deaths are World Bank estimates. Note: a. IQ losses per child are losses over the first five years of life. BLLs and health effects are not reported or estimated for some countries/economies due to lack of data. Annex 1: Blood Lead Levels and Health Effects by Country/Economy 189 ANNEX 2: COST OF LEAD EXPOSURE BY COUNTRY/ECONOMY Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Afghanistan 2,226 10,167 11.65 920 4,204 4.82 Albania 268 726 1.75 2,114 5,723 13.83 Algeria 6,698 20,051 3.94 10,656 31,901 6.27 Angola 5,029 11,719 5.31 1,995 4,648 2.11 Argentina 8,740 20,044 1.94 24,298 55,723 5.40 Armenia 222 683 1.62 1,485 4,567 10.86 Australia 20,309 19,722 1.46 39,490 38,349 2.84 Austria 4,633 5,447 1.04 18,220 21,421 4.08 Azerbaijan 400 1,252 0.83 4,575 14,315 9.52 Bahamas, The 161 182 1.25 669 757 5.21 Bahrain 367 733 0.95 769 1,535 1.99 Bangladesh 10,897 29,072 3.60 17,736 47,316 5.86 Barbados 113 102 2.17 455 408 8.73 Belarus 879 2,630 1.39 12,778 38,244 20.26 Belgium 10,605 12,544 2.00 39,046 46,182 7.37 Belize 55 83 2.90 45 68 2.38 Benin 1,346 3,779 9.35 343 963 2.38 Bhutan 70 248 2.71 91 322 3.51 Bolivia 1,642 4,199 4.01 1,841 4,709 4.50 Bosnia and Herzegovina 334 869 1.67 3,101 8,064 15.47 Botswana 444 1,032 2.42 873 2,030 4.76 190 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Brazil 35,195 61,606 1.91 83,181 145,603 4.52 Brunei Darussalam 211 440 1.57 229 477 1.70 Bulgaria 727 1,833 1.07 16,699 42,119 24.58 Burkina Faso 1,426 4,198 9.06 438 1,288 2.78 Burundi 317 950 10.52 53 158 1.75 Cabo Verde 55 115 2.79 76 157 3.83 Cambodia 998 2,777 3.69 1,333 3,708 4.92 Cameroon 2,955 7,503 7.62 1,029 2,614 2.66 Canada 21,745 24,168 1.25 48,420 53,815 2.79 Central African Republic 80 168 3.59 71 149 3.19 Chad 1,363 3,160 12.05 240 555 2.12 Chile 3,177 5,365 1.13 8,578 14,485 3.04 China 237,301 388,144 1.65 1,357,725 2,220,782 9.47 Colombia 5,032 12,237 1.55 9,959 24,220 3.08 Comoros 55 127 4.63 30 69 2.52 Congo, Dem. Rep. 5,122 10,742 10.82 1,019 2,138 2.15 Congo, Rep. 562 959 5.19 265 453 2.45 Costa Rica 1,315 2,195 2.13 2,403 4,012 3.89 Cote d’Ivoire 2,582 6,161 4.39 1,363 3,252 2.32 Croatia 834 1,683 1.38 7,749 15,638 12.83 Cuba 1,690 2,817 1.66 11,714 19,523 11.48 Cyprus 414 613 1.24 1,272 1,883 3.81 Czech Republic 3,529 6,504 1.43 21,911 40,381 8.89 Denmark 5,165 5,165 1.48 13,660 13,662 3.92 Djibouti 138 233 4.16 86 145 2.60 Dominican Republic 2,513 5,821 2.83 7,538 17,459 8.48 Annex 2: Cost of Lead Exposure by Country/Economy 191 Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Ecuador 3,267 6,259 3.04 3,221 6,170 3.00 Egypt, Arab Rep. 10,951 44,424 3.61 27,223 110,429 8.98 El Salvador 728 1,589 2.69 1,165 2,543 4.31 Equatorial Guinea 360 856 3.27 151 359 1.37 Eritrea 103 327 5.20 65 205 3.26 Estonia 500 820 1.59 3,889 6,379 12.39 Eswatini 268 631 6.08 175 412 3.97 Ethiopia 6,602 17,799 6.87 1,407 3,793 1.46 Fiji 95 221 1.72 220 510 3.97 Finland 1,940 2,046 0.72 8,675 9,145 3.23 France 45,355 55,369 1.67 104,282 127,307 3.84 Gabon 321 649 1.93 382 771 2.29 Gambia, The 154 471 8.73 46 140 2.60 Georgia 218 714 1.23 3,142 10,301 17.71 Germany 49,741 60,272 1.29 232,589 281,831 6.05 Ghana 3,018 7,726 4.51 1,820 4,659 2.72 Guatemala 3,338 6,498 4.35 2,285 4,448 2.98 Guinea 993 2,493 7.31 398 998 2.93 Guinea-Bissau 104 308 7.75 36 108 2.72 Guyana 145 267 3.38 373 688 8.70 Haiti 462 1,103 5.44 491 1,172 5.78 Honduras 1,127 2,612 4.49 1,099 2,546 4.38 Hungary 2,430 5,011 1.51 24,379 50,278 15.15 Iceland 292 262 1.21 397 356 1.64 India 93,530 312,672 3.25 166,305 555,961 5.78 Indonesia 23,530 69,992 2.10 70,411 209,446 6.29 192 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Iran, Islamic Rep. 8,917 23,467 1.89 33,208 87,390 7.03 Iraq 7,611 14,483 3.25 14,182 26,986 6.06 Ireland 3,152 3,536 0.81 10,257 11,506 2.64 Israel 10,817 10,458 2.74 9,331 9,022 2.36 Italy 13,883 18,488 0.69 91,362 121,662 4.57 Jamaica 317 578 1.93 953 1,735 5.79 Japan 37,251 40,017 0.73 175,219 188,231 3.45 Jordan 1,442 3,436 3.30 1,163 2,770 2.66 Kazakhstan 3,347 9,439 1.86 13,450 37,930 7.47 Kenya 5,209 12,932 5.45 1,435 3,562 1.50 Korea, Dem. People’s Rep. 531 1,365 2.96 1,719 4,419 9.57 Korea, Rep. 9,948 13,477 0.61 42,321 57,334 2.58 Kuwait 944 1,529 0.70 2,327 3,771 1.73 Kyrgyz Republic 337 1,407 3.98 536 2,238 6.34 Lao PDR 520 1,672 2.86 893 2,873 4.92 Latvia 551 994 1.61 6,809 12,295 19.96 Lebanon 482 949 0.90 1,437 2,830 2.69 Lesotho 181 451 7.36 126 314 5.12 Liberia 239 572 7.80 62 147 2.01 Libya 852 1,752 1.64 1,985 4,083 3.81 Lithuania 733 1,439 1.35 8,332 16,365 15.37 Luxembourg 666 704 0.94 1,271 1,344 1.79 Madagascar 952 3,126 6.76 381 1,252 2.71 Malawi 571 1,531 7.45 121 325 1.58 Malaysia 3,773 9,758 1.03 10,464 27,066 2.87 Mali 2,242 6,100 12.80 454 1,236 2.59 Annex 2: Cost of Lead Exposure by Country/Economy 193 Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Mauritania 346 1,115 4.55 161 520 2.12 Mauritius 155 331 1.09 762 1,629 5.37 Mexico 22,777 47,135 1.81 56,150 116,197 4.46 Moldova 227 686 1.90 3,163 9,546 26.46 Mongolia 375 1,118 2.70 1,026 3,061 7.40 Montenegro 71 185 1.29 712 1,852 12.95 Morocco 2,872 7,015 2.46 8,794 21,479 7.53 Mozambique 966 2,619 6.47 307 833 2.06 Myanmar 2,030 7,721 2.67 4,782 18,189 6.28 Namibia 633 1,282 5.12 552 1,118 4.46 Nepal 1,229 4,084 4.01 1,340 4,453 4.37 Netherlands 10,055 11,443 1.11 24,466 27,843 2.69 New Zealand 3,547 3,704 1.71 10,385 10,846 5.02 Nicaragua 401 1,179 3.20 323 952 2.58 Niger 1,755 4,017 13.57 232 530 1.79 Nigeria 33,367 80,031 7.45 9,542 22,887 2.13 Norway 4,589 4,066 1.14 12,787 11,331 3.17 Oman 972 1,824 1.26 1,790 3,361 2.33 Pakistan 15,187 57,748 5.46 11,325 43,061 4.07 Panama 1,288 2,682 1.93 2,632 5,483 3.94 Papua New Guinea 912 1,465 3.65 709 1,139 2.84 Paraguay 1,008 2,459 2.64 1,493 3,643 3.92 Peru 6,462 12,392 2.85 7,010 13,443 3.09 Philippines 14,843 39,513 3.94 21,387 56,932 5.68 Poland 8,245 18,091 1.39 52,631 115,478 8.89 Portugal 3,317 5,228 1.40 20,403 32,150 8.58 194 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Puerto Rico 671 733 0.64 3,515 3,844 3.35 Qatar 741 1,104 0.40 1,331 1,982 0.73 Romania 4,294 10,735 1.72 57,515 143,780 23.00 Russian Federation 22,540 56,776 1.35 310,988 783,345 18.59 Rwanda 833 2,410 8.23 188 545 1.86 Samoa 34 54 4.05 40 63 4.72 São Tomé and Príncipe 34 70 7.84 12 25 2.84 Saudi Arabia 10,548 22,293 1.33 21,314 45,049 2.69 Senegal 1,413 3,454 5.99 512 1,251 2.17 Serbia 695 1,783 1.35 11,243 28,841 21.87 Sierra Leone 315 1,118 7.99 102 363 2.60 Singapore 3,325 5,167 0.89 8,154 12,672 2.19 Slovak Republic 1,511 2,673 1.43 10,005 17,690 9.49 Slovenia 647 1,021 1.20 2,669 4,216 4.97 Somalia 207 493 12.77 32 75 1.94 South Africa 13,345 28,905 3.80 14,515 31,440 4.13 South Sudan 299 667 6.03 61 137 1.24 Spain 14,665 20,904 1.05 72,097 102,774 5.17 Sri Lanka 1,165 4,117 1.39 3,981 14,071 4.74 St. Lucia 32 44 1.49 126 174 5.93 St. Vincent and the 15 27 1.86 71 124 8.65 Grenadines Sudan 1,944 18,156 10.29 912 8,516 4.82 Suriname 93 231 2.34 251 623 6.30 Sweden 5,459 5,904 1.03 15,506 16,769 2.92 Switzerland 11,494 9,951 1.63 32,807 28,404 4.67 Syrian Arab Republic 857 1,436 4.21 1,166 1,954 5.72 Annex 2: Cost of Lead Exposure by Country/Economy 195 Cost of CVD deaths in 2019 Cost of IQ losses in 2019 (central estimate) $, millions I$, millions % of GDPa $, millions I$, millions % of GDPa Tajikistan 395 1,596 4.87 483 1,952 5.95 Tanzania 5,428 13,402 8.34 1,277 3,152 1.96 Thailand 5,646 13,903 1.04 15,015 36,976 2.76 Timor-Leste 80 202 4.79 77 193 4.60 Togo 449 1,104 8.22 119 293 2.18 Trinidad and Tobago 246 389 1.02 1,305 2,059 5.41 Tunisia 960 3,241 2.47 2,933 9,904 7.56 Türkiye 9,147 28,197 1.21 26,690 82,276 3.54 Turkmenistan 1,063 2,399 2.56 2,632 5,940 6.33 Uganda 2,649 7,747 7.70 431 1,261 1.25 Ukraine 1,318 4,807 0.81 23,770 86,669 14.64 United Arab Emirates 2,520 4,086 0.60 5,778 9,370 1.37 United Kingdom 33,701 38,808 1.19 90,788 104,544 3.21 United States 263,813 263,813 1.23 671,952 671,952 3.14 Uruguay 1,086 1,506 1.94 6,144 8,521 10.96 Uzbekistan 1,545 6,531 2.67 4,117 17,396 7.11 Vanuatu 45 48 4.88 51 54 5.51 Venezuela, RB 3,158 6,672 2.34 8,534 18,032 6.32 Vietnam 5,744 17,716 2.19 16,096 49,642 6.15 West Bank and Gaza 602 1,128 4.01 363 681 2.42 Yemen, Rep. 2,666 6,454 9.62 1,485 3,594 5.36 Zambia 1,060 2,974 4.59 444 1,245 1.92 Zimbabwe 1,872 3,777 8.73 725 1,463 3.38 Source: World Bank estimates. Note: Cost of lead exposure is not estimated for some countries/economies due to lack of data. a. Cost as a percent of GDP and as a percent of GDP (PPP) is the same at the country level. 196 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE ANNEX 3: MODEL LAW AND GUIDANCE FOR REGULATING LEAD PAINT This annex was reproduced by the World Bank from UNEP 2018. 3A.1 Introduction To achieve this global goal, all countries must eliminate the use of lead additives in new paints This document provides guidance to countries by establishing and enforcing lead paint laws. An drafting new laws to establish legal limits on lead important strategic goal of the Lead Paint Alliance content in paints, as a measure to protect human is for all countries to have lead paint laws in place health and the environment. It can also be a by 2020.23 As of September 2017, only one-third of useful tool for countries interested in modifying countries around the world had confirmed to the their existing laws. It was developed by the United Lead Paint Alliance that they have legally binding Nations Environment Programme (UNEP) in controls on lead paint.24 There are still many support of the Global Alliance to Eliminate Lead countries where using lead paint in homes and Paint (Lead Paint Alliance).22 schools, and on toys and other children’s products is not prohibited. This creates a significant risk ‘Lead paint’ is paint or a similar coating material to children. Countries that have not yet done so to which one or more lead compounds have are urged to enact and enforce effective national been added. The primary goal of the Lead Paint legislation, regulations and/or standards to stop Alliance is to prevent the exposure of children to the manufacture, sale and import of lead paints. lead from paints containing lead, and to minimize occupational exposure to lead paint. The Lead Paint Countries that have enacted laws to limit the lead Alliance is working to phase out the manufacture content in paint have generally used one of two and sale of lead paint, and eventually to eliminate approaches: (a) establish a set of chemical-specific the risks that such paints pose. regulatory limits based on the risks of individual 22 This model law and guidance supplements the online Toolkit for Establishing Laws to Control the Use of Lead in Paint developed by partners of the Lead Paint Alliance. This toolkit, which was “designed to provide information to government officials who are interested in establishing legal limits for lead in paints in their countries,” contains useful background information (but not model legal text, which is included in this Model Law and Guidance) and is available at https://www.unenvironment.org/toolkit-establishing​ -laws-eliminate-lead-paint 23 The Lead Paint Alliance was formed under the auspices of the Strategic Approach to International Chemicals Management (SAICM), pursuant to SAICM Resolution II/4 B. SAICM provides a policy framework to achieve the goal that, by 2020, chemicals will be produced and used in ways that minimize significant adverse impacts on the environment and human health. The strategic goals for the Lead Paint Alliance are included in its 2012 Business Plan, available at https://www.unenvironment.org/resources/publication​ /global-alliance-eliminate-lead-paint-business-plan 24 WHO (World Health Organization). Regulations and Controls on Lead Paint, Global Health Observatory, WHO http://www.who.int​ /gho/phe/chemical_safety/lead_paint_regulations/en Annex 3: Model Law and Guidance for Regulating Lead Paint 197 lead compounds that are used as additives in paint a regulation or legal order under a chemicals (currently used in the European Union REACH management law (for example the Philippines) or regulation25); or (b) establish a single regulatory as part of an environmental protection law (for limit on the total concentration of lead in paint example Nepal). Some countries have established from all sources (currently used in 31 countries) lead limits through a national standards bureau (UNEP 2017). Both approaches have been (for example Kenya). The model law can be adapted successful in limiting the lead content in paint, to fit within a country’s legal framework but should but the chemical-specific approach requires risk retain the key aspects described in this guidance. assessments of individual lead compounds that may be beyond the capacity of many developing For the sake of brevity, this guidance uses the countries. In contrast, a single regulatory limit on term ‘agency’ to refer to the relevant government total lead content does not require extensive risk entity that will be responsible for implementing assessments and is much simpler for governments the lead paint law. In different countries, the to implement and enforce. Manufacturers can relevant government entity may be, for example, achieve a low legal limit on total lead content the environment ministry/ agency, the health in paint by developing formulations that do not ministry/agency, or the standards-setting bureau. intentionally use any lead additives and that take Where different entities will be responsible for into account potential residual lead content in raw implementing different parts of a lead paint law, it material ingredients. will be important for them to collaborate from the outset of the drafting process, and to agree on and establish clear lines of responsibility. 3A.2  Purpose and Scope As countries draft new laws to limit lead content in The purpose of this guidance is to assist countries paint, it is recommended that they provide access to to enact new laws (or to modify their existing laws) information about the new laws and opportunities to establish a single regulatory limit on the total for public consultation and engagement. The paint lead content in paints. The guidance describes and coatings industry and other stakeholders can key elements of effective and enforceable legal often provide valuable input and suggestions for requirements. It also provides a model law that effective laws. Many countries that have been incorporates the key elements and reflects the successful in enacting lead paint laws have actively best approaches currently found in lead paint laws engaged stakeholders (such as paint manufacturers around the world. and civil society organizations) by establishing working groups or similar mechanisms for input Countries may use the model law to help develop and discussion throughout the process. their own laws, in accordance with existing legal frameworks and other national circumstances. For Finally, while this model law and guidance focuses example, some countries use consumer protection. on establishing a regulatory limit on the total lead content in new paint and similar coating Laws that establish a limit on lead content in materials, consumer exposure to lead from paint consumer paints (for example the US), while already applied to products may need stricter others establish limits on lead in paints through control. Accordingly, countries may wish to review 25 See website of European Chemicals Agency at https://echa.europa.eu/regulations/reach/understanding-reach 198 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE their existing consumer product safety laws and glazes and primers. Lead additives are most consider prohibiting the import and manufacture commonly used in solvent-based paint due to of consumer products coated with lead paint, their specific chemical properties; such solvent- especially products intended for use by children. based lead paints and coatings are still widely available and used in many countries. Water-based latex paint, on the other hand, rarely contains 3A.3  Method of Development intentionally added lead compounds (IPEN 2016) A proposed draft of this guidance document was Paints may also include ingredients contaminated developed by a working group of representatives with lead. For example, paints may include natural from UN Environment, the World Health clays and other raw materials that may contain Organization and the US Environmental Protection residual lead content. Therefore, it is not technically Agency. The working group looked at examples feasible to set a “zero” limit for lead content of existing laws and regulations pertaining to in paint. However, if a manufacturer does not lead paint from several countries and reviewed intentionally add lead compounds to its paints and information compiled in the Global Report on the takes into account the residual lead content in raw Status of Legal Limits on Lead in Paint, published by materials, then the total lead content in the paint UN Environment in 2016. The group also consulted will be low (IPEN 2016). with government bodies responsible for consumer protection and standard setting. In countries without legal limits, paint with high levels of lead can still be used for decoration The proposed draft was reviewed by the Lead Paint of interior and exterior surfaces in homes and Alliance Advisory Council. The Advisory Council is public buildings; on roads, bridges and industrial comprised of representatives from governments, equipment; and on toys, furniture and playground industry, environmental and health NGOs, and equipment. However, nonleaded pigments, driers international organizations. A revised draft was and anticorrosive ingredients are widely available then provided for review by partners of the Alliance for use in solvent-based paints and are used by and the general public via the Lead Paint Alliance manufacturers to produce high-quality paints in all website. Comments from this secondary review were regions of the world. Increasingly, paint producers considered during the finalization of the guidance. around the world are publicly acknowledging the feasibility of eliminating the use of intentionally added lead compounds in all paints. 3A.4  Background on Lead in Paint 3A.5  Case for Legal Limits Paint is typically a mixture of resins, pigments, The weathering, peeling or chipping of old lead fillers, solvents and other additives. Historically, paint releases lead into dust and soil, in and lead compounds have been intentionally added around homes, schools and other locations. Dust to paint to give it certain properties such as contaminated with lead can also be brought into colour, reduced corrosion on metal surfaces or the home on the clothes of those who work in faster drying time. For the same reasons, lead industries where such dust is generated, including compounds may be present in other types of paint factories where lead continues to be used. coatings, including varnishes, lacquers, enamels, Lead-contaminated soil and dust are easily Annex 3: Model Law and Guidance for Regulating Lead Paint 199 ingested and absorbed, particularly by young Trasande 2013). In addition, the cost of removing children when they play on the floor or outdoors existing lead paint from surfaces in homes, and put their hands or objects in their mouths. schools and other buildings can be substantial.26 Children also ingest lead if they mouth and chew It therefore makes economic sense for countries toys painted with lead paint. Both children and to enact laws that prevent future removal costs by adults can be exposed to lead in paint chips establishing a legal limit on lead content in new and dust generated during the removal of old paint. lead paint. By contrast, the financial cost of eliminating the The negative health effects from exposure to lead use of lead compounds in many paints is low; have been known for many years, and include many manufacturers have already successfully effects on multiple body systems. Lead can cause reformulated paint products to avoid the permanent damage to the brain and nervous intentional addition of lead. According to a paint system, resulting in decreased IQ and behavioural industry spokesperson, “the reformulation of problems. It can also cause anaemia, increase residential and decorative paints to eliminate lead the risk of kidney damage and hypertension, and additives is feasible, and the technical and cost impair reproductive function. impacts are manageable” (IPPIC 2016). Young children are especially vulnerable to the Lead released into the environment from any adverse effects of lead. Even relatively low levels source, including lead paint, is also toxic to plants, of exposure can cause serious and, in some cases, animals and micro-organisms. In all studied animals, irreversible neurological damage. There is no known lead has been shown to cause adverse effects in level of lead exposure that is considered safe. several organs and organ systems, including blood, central nervous, kidney, reproductive and immune The negative impacts on children’s developing systems. It bioaccumulates in most organisms, brains from exposure to lead have staggering with environmental exposures occurring through economic costs. These costs are borne by the multiple sources and pathways. affected children, their families, and societies at large. They include health care costs, losses in Eliminating the source of lead exposure is the productivity and intellectual disability. The Institute single most effective way of protecting people from for Health Metrics and Evaluation has estimated the harmful effects of lead. The removal of lead that, based on 2015 data, lead exposures from from gasoline has produced dramatic reductions all sources account for 12.4 percent of cases of in airborne emissions and associated exposures, idiopathic intellectual disability (that is, intellectual and public health impacts around the globe. disability without another known cause) (IHME Similarly, most industrialized countries adopted 2016). The largest financial burden is borne by low laws or regulations to control the lead content of and middle-income countries. Estimated annual residential and decorative paints in the 1970s and costs (in international dollars) of lead exposure by 1980s, based on clear findings that paint containing global region, based on loss of IQ include: Africa lead is a major source of lead exposure for children. – $134.7 billion; Latin America and the Caribbean – The continued use of lead in paint in many parts $142.3 billion; and Asia – $699.9 billion (Attina and of the world, however, remains an unaddressed 26 For example, the cost of removing lead paint from homes most in need of remediation in the United States has been estimated at between $1.2 billion and $11.0 billion (Gould 2009, 1162). 200 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE source of human exposure. Laws, regulations or institutional responsibilities and arrangements enforceable standards are needed in every country for the management and enforcement of the lead to stop the manufacture, sale and import of lead- paint law. containing paints. In accordance with these objectives, the key The global paint and coatings industry is rapidly elements of a lead paint law include the following: expanding as a result of the economic development D. Defining key terms and ensuring that the scope of countries around the world. Therefore, unless the of the law is clear: practice of manufacturing and selling paints with added lead is eliminated, the risks of lead exposure a. persons and activities that are regulated will also increase. The growing demand for paints, (e.g. manufacture, sale and import) especially for residential and decorative use in b. types of paint applications that are developing countries, should be met with paints that regulated (e.g. all paint applications or are not formulated with added lead compounds. certain applications such as residential, decorative, etc.) Establishing lead paint laws will help countries ensure that the level of lead in domestic production B. Establishing a clear legal limit on total lead and imported paint (and similar coating materials) content in paint does not exceed the national legal limit. C. Setting the effective dates of the new requirements By producing or using paints without added lead compounds, paint manufacturers and commercial D. Providing methods for ensuring compliance paint users (such as toy manufacturers) can ensure and enforcement their continued access to markets where lead E. Specifying consequences of non-compliance content in paint is already restricted. It can also reduce potential commercial risks (including health F. Providing any necessary general provisions risks to workers and customers, and compliance and liability claims) and protect the reputation of This section provides explanations and drafting the industry. notes for the key elements of a lead paint law. A model law reflecting these key elements is provided in Appendix I. Objectives and Key Elements of Effective Lead Paint Laws Key Element A: Define key terms and ensure that the scope of the law The objectives of legal limits on lead in paint, is clear established through lead paint legislation and/or regulation (hereafter described as ‘lead paint law’), Lead paint laws should clearly define key include: (1) the prevention of the manufacture, terms used throughout the law. Key terms may sale and import of paint that contains lead above include, for example, ‘manufacturer’, ‘paint’, and an established legal limit; (2) the development ‘total lead content’. The model law in Appendix I of a system with methods for compliance and provides definitions of key terms. enforcement; and (3) the establishment of Annex 3: Model Law and Guidance for Regulating Lead Paint 201 stating: “DANGER: CONTAINS LEAD. DO NOT APPLY TO To be successful, a law should specify the activities SURFACES ACCESSIBLE TO CHILDREN OR PREGNANT and persons that are regulated. The model law WOMEN.” Failure to include such a label shall subject in Appendix I prohibits the sale, offer for sale, the manufacturer or importer to penalties as set forth manufacture for sale, distribution into commerce in [insert penalties section]. and import of paint that exceeds the established legal limit (see Appendix I, sections B and F). The model law places specific requirements (e.g. testing Key Element B: Establish a clear and declarations of conformity) on manufacturers legal limit on the total lead content in and importers of paint (see Appendix I, section D). new paint The law should also specify the types of paint that As discussed in the Introduction, the purpose of are regulated. Countries should decide whether this document is to assist countries interested in to apply the legal limit to all paints or to allow establishing a single regulatory limit on the total exemptions for certain paints for specific purposes. concentration of lead in paint from all sources. It is entirely possible to restrict the use of lead Setting a specific legal limit on total lead content in all paints, and the Philippines and Kenya have helps the regulated community understand the done so27. This has the benefit of protecting the rules and ensures that the law is more easily whole population from lead exposure from paint, enforceable. This requires specifying a quantitative especially in countries where both household paint limit and a valid method to measure the quantity and industrial paint are frequently sold side by side for lead in paint. in retail outlets. The lowest and most protective regulatory limit The model law provided in Appendix I applies the that has been set in countries for lead in residential total lead limit to all paints (household, industrial, and decorative paints is 90 parts per million (ppm) agricultural, etc.) (see Appendix I, section B). total lead content, based on the weight of the total However, if a country chooses to exempt certain non-volatile content of the paint or the weight of types or uses of paints from the total lead limit, it the dried paint film. (This specific limit can also be should require such paints to bear a legible, visible measured and expressed in a law or standard as warning label so that consumers are aware of 0.009 percent or 90 mg/kg of total lead, based on the potential health hazards involved with using the dry weight of the paint film.) The 90 ppm limit exempted paint. is technically feasible for manufacturers to achieve by avoiding the addition of lead compounds and If exemptions are allowed then the following taking into account residual (unintentional) lead language is recommended for a labelling content in certain paint ingredients. requirement - as well as for the label itself: Paint testing conducted by environmental groups Manufacturers and importers of paint and similar in numerous developing countries shows that, coating materials that are not subject to the ban while high levels of lead are not uncommon, levels set forth in [insert section] shall include on the label below 90 ppm are achievable (IPEN 2016). Canada, of each paint or similar coating product a warning India, Kenya, Nepal, the Philippines, Tanzania and 27 WHO (World Health Organization). Regulations and Controls on Lead Paint. Global Health Observatory, WHO. http://www.who.int​ /gho/phe/chemical_safety/lead_paint_regulations/en 202 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE the United States of America have all set a legal While there is no safe level of lead exposure, a limit of 90 ppm total lead content. Several other regulatory limit based on total lead will be more countries are also considering adopting the 90 ppm protective of health than a limit based only on regulatory standard. Switzerland and Thailand have soluble lead. The model law in Appendix I therefore limits of 100 ppm total lead, while some countries uses a regulatory approach based on limiting have adopted a limit of 600 ppm: Argentina, the total lead content in paint. (See Appendix I, Brazil, Chile, Costa Rica, Dominica, Guyana, Jordan, section B). Mexico, Oman, Panama, South Africa, Sri Lanka and Uruguay (UNEP 2017). The model law in Appendix I uses 90 ppm as the total lead limit because it is Key Element C: Set effective dates for the lowest existing legal limit and thus provides the the new requirements best available health protection, and is technically feasible. (See appendix I, section B.) Lead paint laws should specify dates when the requirements set out in the law will come into It is important to specify that the legal limit in effect. In establishing such dates, countries paint should be defined as ‘total lead’ content may wish to work with industry to determine a rather than ‘soluble lead’ content.28 Currently, a few reasonable amount of time needed to source and countries regulate paint on toys using a limit on procure alternative materials, to alter product soluble lead, which is the amount of lead that can formulations and processes, and to sell or dispose be extracted using a standard acid treatment test. of existing stocks of paint containing lead above Measuring soluble lead is intended to simulate the the total limit. amount of lead that is bioavailable for absorption by children, such as when a child chews on a toy One way to allow time for industry to change coated with lead paint. Recent research suggests, its practices and come into compliance with the however, that soluble lead is not the predominant total lead limit is to provide a reasonably delayed form of exposure for children, and that particulate effective date for the 90 ppm total lead limit, (insoluble) lead found in dust, soil and paint chips is applicable to all paints covered by the law. Most a more significant contributor to chronic and acute lead paint laws that limit lead to 90 ppm or 100 exposure (Deshommes et al. 2012). Unmaintained ppm have required compliance within one year of painted surfaces, as well as weathering and ageing, passage of the law.29 (For sample language for a generate paint chips and dust that contaminate delayed effective date, see Appendix I, section C, soil and house dust, thus increasing the potential option 1). for exposure to lead All lead in paint, whether soluble or insoluble in a lab test, has the potential As an alternative to a broadly applicable delayed to be available for exposure through inhalation effective date for the 90 ppm limit, countries or ingestion, especially by young children who may wish to provide phased effective dates, crawl and play on the floor and outside on soil. depending on the type of paint. This approach is 28 For an overview of measurement methods, see WHO (2011), Brief guide to analytical methods for measuring lead in paint. http://www.who.int/ipcs/assessment/public_health/lead_paint.pdf 29 Countries limiting lead in paint to 90 ppm that required compliance immediately or within one year include: Canada, India, Kenya, Nepal, Tanzania, and the US. Thailand limits lead to 100 ppm and required compliance within one year. Switzerland limits lead to 100 ppm and required compliance within 15 months. The Philippines is unique in allowing three years for compliance for architectural, decorative and household applications, and six years for industrial applications. Annex 3: Model Law and Guidance for Regulating Lead Paint 203 designed to take into account the different uses government inspections to ensure compliance and performance requirements of paints, and the with the total lead limit. In addition to these relative harms posed by such uses. For example, mechanisms built into the law itself, governments a law could allow more time for industrial paints can also promote compliance by educating industry to come into compliance with the total lead limit about the requirements of the law and how to but less time for decorative paints intended for meet them. household use or other applications likely to contribute to childhood lead exposure. (For sample language for a phased effective date, see i)  Third-Party Testing Appendix I, section C, option 2). To promote compliance, a lead paint law should Countries should encourage laboratories to require manufacturers and importers to submit acquire the necessary equipment, expertise and sufficient samples of paint or similar coating accreditation to perform the required testing of materials to a third-party laboratory accredited lead paint. Current lack of in-country laboratory under international standards for testing for capacity need not be an impediment to a lead compliance with the 90 ppm total lead limit. paint law going into effect, as industry can still Manufacturers and importers will rely on this third- comply with the law by sending paint samples to party testing to issue declarations of conformity, laboratories in other countries that are qualified certifying that their paint product or similar coating to perform the required testing. Additionally, for material complies with the 90 ppm total lead limit imported paints, manufacturers and importers can (see section ii. below). ‘Sufficient samples’ is defined rely on test results from qualified laboratories in as the number of samples the ‘agency’ determines the country of origin under the model law under necessary to provide a high degree of assurance certain circumstances (See Appendix I, section D). that the tests conducted accurately demonstrate compliance with the 90 ppm total lead limit. Key Element D: Establish mechanisms Manufacturers and importers should be required to promote compliance with, and to submit sufficient samples of a paint product’s enforcement of, the total lead limit first production batch or lot for third-party testing. Testing the first production batch or lot will be Effective lead paint laws promote compliance sufficient to meet the testing requirement unless a and provide mechanisms for enforcing the legal material change occurs in the production process limit. They also assign clear responsibilities for for that paint product – such as a change in the various actions required by the new law or ingredients or a change in an ingredient supplier. regulation. In the event of a material change in the production process, the law should require new third-party Mechanisms for promoting compliance with, and testing to be conducted and new declarations of enforcement of, the legal limit should include: conformity to be issued. In order to ensure that (1) required testing of paint and similar coating testing is not unduly burdensome and duplicative, materials by a third-party laboratory; (2) required importers may be allowed to rely on a foreign ‘declarations of conformity’ with the total lead limit manufacturer’s test results to issue a declaration by manufacturers and importers based on the of conformity, as long as the importer exercises third-party laboratory testing; and (3) authorized due care to ensure that the manufacturer’s test 204 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE results meet the requirements of the law, and the a foreign manufacturer’s testing under specified importer maintains appropriate records of the circumstances, but the importer must issue its own test methodology and results. (See Appendix I, declaration of conformity (see Appendix I, section section D.) D). Declarations of conformity and certifications are both types of ‘conformity assessment’ An essential part of setting a regulatory limit is procedures – an internationally recognized term specifying the analytical testing methods that will that covers activities used to provide confidence in be used to determine whether a product complies a product supplier’s compliance with safety, health, with the limit; the model law, therefore, requires environmental and fair commerce requirements.31 manufacturers, importers and laboratories to use Conformity assessment systems come in many internationally recognized sampling and testing types, which have varying degrees of complexity methods. A number of existing methods for the and resource investment. ‘Certification’ (as the preparation of samples and the analysis of lead in term is used internationally) generally has two paint are available and are summarized in the WHO essential characteristics: (1) it is conducted by ‘Brief guide to analytical methods for measuring a third party and (2) it includes some form of lead in paint’. The WHO guide is available in surveillance activity by the third party to ensure English, Chinese, French, and Spanish at http:// ongoing compliance once initial compliance with www.who.int/ ipcs/assessment/publichealth​ a requirement has been determined. Many third- /lead/en/. In addition, internationally recognized party certification bodies use an on-product mark sampling and testing methods for lead in paint or symbol to attest to the conformity of certified are referenced in the model law (see Appendix I, products. Similar to a certification approach, the section D) and are listed in Appendix II. declaration of conformity approach used in the model law requires testing by an independent, third-party laboratory accredited under rigorous, ii)  Declarations of Conformity internationally approved standards. Unlike a certification approach, however, the model law The second key mechanism for compliance is the does not rely on the creation and involvement requirement that manufacturers and importers of a separate certifying body to ensure ongoing issue a ‘declaration of conformity’, stating that their compliance with the lead limit. paint product or similar coating material complies with the law’s 90 ppm total lead limit. These The declaration of conformity approach is declarations are based on the third-party testing recommended and used in the model law described above and are sometimes referred to because it places the obligation for compliance on as ‘certifications’ in countries with existing laws manufacturers and importers. Manufacturers and and regulations.30 The law should specify who importers must ensure testing by an accredited must provide the declaration of conformity and laboratory and must sign a sworn affidavit stating to whom it must be provided, and describe the that their paints comply with the 90 ppm total lead required content of the declaration. As indicated limit. Failure to do so subjects these parties to civil in the previous section, an importer may rely on (and possibly criminal) penalties. 30 For example, the United States’ Consumer Protection Safety Act, 15 U.S.C. § 2051 et. seq., refers to ‘certifications’ by manufacturers and importers. These certifications are based on third-party testing by government-approved laboratories. 31 ISO/IEC Guide 2 provides definitions for various types of conformity assessment. Annex 3: Model Law and Guidance for Regulating Lead Paint 205 iii)  Government Inspections law defines ‘person’ to include an individual, partnership, corporation, association or non-profit Inspections by the relevant agency are critical to organization. (See Appendix I, section A.) ensuring that paints are manufactured and imported in conformity with the country’s total lead limit. The Key Element F: General Provisions model law authorizes government agents to enter a location at ‘reasonable times’ to inspect and test In drafting lead paint laws, countries may find they paint or similar coating materials, as long as they need to reference provisions from other existing first present appropriate credentials to the owners laws that relate to the manufacture and import or operators or agents in charge of the location. The of paints, to help ensure that lead paint is being model law also authorizes the government to test handled appropriately. For example, countries may paints in a ‘reasonable manner’ in order to assess wish to refer to applicable waste management laws compliance with the law. (See Appendix I, Section E). to address the transport, treatment, storage and disposal of lead paint. (See Appendix I, section K). Key Element E: Specify clear, transparent consequences for non-compliance 3A.6  Appendix 1 Model Lead- Effective lead paint laws clearly articulate prohibited acts. (See Appendix I, section F). They Paint Law also dictate the consequences of non-compliance, The text below is intended solely as a guide for including providing for specific and meaningful governments to develop a new national law or penalties. Where a country already has general modify an existing law to limit the total lead legal provisions relating to civil penalties and content in paints. It does not constitute a legal criminal sanctions for offences, it may wish to interpretation or binding obligation in relation to refer to the provisions of the parent legislation any international convention. The model law can in its lead paint law. (See Appendix I, section G, be adapted so that it fits appropriately within a option 1). If a country does not already have parent country’s legal framework but should retain the legislation relating to penalties or sanctions, or key elements of effective and enforceable legal wishes to incorporate independent, specific civil requirements, as described in this guidance. and criminal penalty provisions within its lead paint law, the model law provides sample language. (See Appendix I, section G, option 2). The lead A  Definitions (examples) paint law may also provide for criminal fines and ‘Coating material’ means a product, in liquid, paste imprisonment for knowing and willful violations of or powder form, that, when applied to a substrate, the law. (See Appendix I, section H). forms a layer possessing protective, decorative and/or other specific properties. In addition to specifying meaningful penalties for non-compliance, effective lead paint laws identify ‘Disposal’ means the treatment, temporary storage remedies such as injunctive relief and seizure or and systematic destruction of lead and lead recall of paints that do not comply with the total compound waste in accordance with the applicable lead limit (See Appendix I, section I). The lead paint provisions of the law regulating hazardous wastes.’ law may also include provisions to enable citizens and other ‘persons’ to bring actions to enforce ‘Importer’ means any person that undertakes the the law. (See Appendix I, section J.) The model entry of a product into a country. 206 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE ‘Manufacturer’ means any person who undertakes date of promulgation of this law for industrial the physical or chemical transformation of applications. substances into a new product, performed either by power-driven machines or by hand and markets D  Declaration of Conformity Based on it under his/her name or trademark or private label. Testing by Third-Party Laboratory ‘Paint’ means a pigmented coating material which, Declaration of Conformity when applied to a substrate, forms an opaque dried film having protective, decorative or specific • Before distributing in commerce or importing technical properties. for consumption any paint or similar coating materials, a manufacturer or importer shall: ‘Person’ means an individual, partnership, corporation, association or nonprofit organization. – submit sufficient samples of the first production batch paint to a third-party ‘Substrate’ means a surface to which a coating laboratory accredited under [see below] to material is applied or is to be applied. be tested for compliance with the 90 ppm total lead limit in [cite to section], and ‘Total lead content’’ is defined as a weight percentage of the total nonvolatile portion of the paint or as a – based on such testing, issue a declaration of percentage of the weight of the dried paint film. conformity that certifies that such products comply with the 90 ppm total lead limit in [cite to section]. B  Legal Limits on Total Lead Content • Manufacturers and importers shall maintain Paint and similar coating materials must not contain records of declarations of conformity and lead (calculated as lead metal) in excess of 90 ppm laboratory test results and attestations, which of the weight of the total nonvolatile content of the support such declarations of conformity, for a paint or the weight of the dried paint film. period of at least [5 years]. • An importer of paint may rely on a foreign C  Effective Dates manufacturer’s test results to issue its own declaration of conformity provided that the Option 1: Delayed Effective Date importer exercises due care to ensure the manufacturer’s test results meet the requirements Paint and similar coating materials may contain of this law, and that the importer has records lead above the 90 ppm total lead limit in [section] of the laboratory test results and attestations until, but not after, one (1) year from the date of regarding how the testing was conducted. promulgation of this law [or insert date]. ‘Sufficient Samples’ as used in [section above] Option 2: Phased Effective Dates means the number of samples of paint or similar coating materials that [Agency] determines is Paints and similar coating materials may contain sufficient to provide a high degree of assurance lead above the 90 ppm total lead limit in [section] that the tests conducted for declaration of for one (1) year from the date of promulgation of conformity purposes accurately demonstrate the this law for architectural, decorative and household ability of such products to meet the 90 ppm total applications, and for three (3) years from the lead limit in [cite to section]. Annex 3: Model Law and Guidance for Regulating Lead Paint 207 New Declaration of Conformity after • provide the declaration of conformity to distributors and retailers, and Material Change • provide the declaration of conformity to • ‘Material Change’ means a change that the [Agency] upon request. manufacturer or importer makes to the design, manufacturing process or the source of component parts, for the paint or similar Content of declaration of conformity. coating material, which a manufacturer or Each declaration of conformity shall include: importer, exercising due care, knows or should • identification of the paint or similar coating know, could affect compliance with the 90 ppm material covered by the declaration, total lead limit in [section]. • identification (name, contact address) of the • In the event of a ‘material change’, manufacturer or importer certifying compliance a manufacturer or importer must: with the 90 ppm total lead limit, – submit sufficient samples of the paint or • identification of the object of the declaration of similar coating material to a third-party conformity (e.g. name, type, date of production laboratory accredited under [see below] to or model number of a product, description be tested for compliance with the 90 ppm of a process, management system, person or total lead limit in [cite to section], and body, and/or other relevant supplementary – based on such testing, issue a new information), declaration of conformity that certifies • a sworn affidavit signed by the manufacturer or that such paint or similar coating material importer stating that the paint or similar coating complies with the 90 ppm total lead limit in material is in compliance with the 90 ppm total [cite to section]. lead limit, and • contact information for the testing laboratory Who must issue the declaration of and the individual maintaining records of test conformity results. • In the case of paint or similar coating material manufactured in [X country], the manufacturer Accreditation of third-party laboratory must issue the declaration of conformity pursuant to [section]. • ‘Third-party laboratory’ means an independent laboratory that has no interest in the • In the case of paint or similar coating material transaction between the manufacturer or manufactured outside [X country], the importer importer and the distributor or retailer, and must issue the declaration of conformity that has been accredited under ISO/IEC 17025 pursuant to [section]. by a signatory to the International Laboratory Accreditation Cooperation (ILAC) Mutual To whom must the declaration of Recognition Arrangement (MRA), or one of its recognized regional bodies, such as the Inter- conformity be given American Accreditation Cooperation (IAAC), • Manufacturers and importers of paint or similar the European cooperation for Accreditation coating materials must: (EA), or the Asia Pacific Laboratory 208 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Accreditation Cooperation Incorporated • fail to furnish a declaration of conformity (APLAC). required by [cite section] or issue a false declaration of conformity if such person in the • For its accreditation to be accepted to test for exercise of due care has reason to know that the the 90 ppm total lead limit for declaration of declaration of conformity is false or misleading conformity purposes, a third-party laboratory in any material respect, or shall be accredited for and use [specify sampling and testing methods here – e.g. ASTM, ISO • exercise, or attempt to exercise, undue influence standards and provide for updating, perhaps on a third-party laboratory with respect to the via Agency website, to account for test methods testing or reporting of the results of testing of changing/improving over time. See Appendix II any product. for recommended methods.] G Penalties E  Government Inspections Option 1 For purposes of implementing this law, officers or employees of [Agency], upon presenting • Any person who violates the requirements appropriate credentials to the owner, operator or specified in this [Act/Regulation/ Order] shall be agent in charge, are authorized: liable thereof to the applicable administrative and criminal sanctions as provided for under • to enter, at reasonable times, any factory, Sections ………. of [insert the general penalty warehouse, or establishment in which paint or provision of the parent legislation]. similar coating materials are manufactured or held, and Option 2 • to inspect and test, at reasonable times and in a • Any person who violates section [Prohibited reasonable manner, such paint and similar, Acts] shall be subject to a civil penalty not to • coating materials to assess compliance with exceed [amount] for each such violation. this law. • A violation of section [Prohibited Acts] shall constitute a separate offence with respect to F  Prohibited Acts each paint or similar coating material product involved, except that the maximum civil penalty It shall be unlawful for any person to: shall not exceed [amount]. • sell, offer for sale, manufacture for sale, • The maximum penalty amounts authorized distribute in commerce, import into [X country], in [cite section above] shall be adjusted for any paint or similar coating material that inflation [as reflected in applicable regulations contains lead or lead compounds and in which or tied to specified index]. the lead (calculated as lead metal) is in excess • The [Relevant factors in determining the of 90 ppm of the weight of the total non-volatile amount of the penalty: content of the paint or the weight of the dried paint film, • Agency or applicable court] shall consider the nature, circumstances, extent and gravity • fail or refuse to permit entry or inspection and of the violation, including the severity of the testing pursuant to Section E, Annex 3: Model Law and Guidance for Regulating Lead Paint 209 risk of injury, the number of paints or similar J  Citizen Suits coating materials which were distributed, the appropriateness of the penalty in relation to Any person may bring an action in any [applicable the size of the business of the person charged, court of X country] to enforce [section], to obtain including how to mitigate undue adverse appropriate injunctive relief, and to apply any economic impacts on small business, and other appropriate civil penalties under [section], payable such factors as appropriate. to [government of country X]. H  Criminal Penalties A court with jurisdiction over a citizen suit under this provision may order the defendant to pay the A violation of section [Prohibited Acts] is attorney’s fees and reasonable litigation costs of punishable by: the plaintiff bringing a good faith citizen suit under this provision. • A violation of section [Prohibited Acts] is punishable by: K  General Provisions • imprisonment for not more than [X years] for a knowing and willful violation of that Transport, Treatment, Storage and Disposal section, or Requirements • a penalty of [X amount], or • Manufacturers and importers of paints and similar coating materials must comply with applicable • both. provisions of the [applicable waste management law] and those to be prescribed by the [relevant Any individual director, officer or agent of a Agency or competent authority] for the transport corporation who knowingly and willfully authorizes, and treatment, storage and disposal of lead orders or performs a violation of section wastes and contaminated equipment off-site. [Prohibited Acts] shall be subject to penalties under this section without regard to any penalties to which that corporation may be subject under [above section]. 3A.7  Appendix II Recommended International Standards In addition to the penalties provided by [above section], the penalty for a criminal violation of this Recommended International law may include the forfeiture of assets associated Standards for Sample Preparation: with the violation. ISO 1513, Paints and varnishes – Examination and I  Injunctive Relief and Seizure preparation of test samples The [applicable courts of X country] shall have ISO 1514, Paints and varnishes – Standard panels jurisdiction to restrain any violation of section for testing [Prohibited Acts] and to authorize seizure or order the recall of the paint or similar coating material ASTM E1645-16, Standard Practice for Preparation that does not comply with the 90 ppm total lead of Dried Paint Samples by Hotplate or Microwave limit, and/or other appropriate relief. Digestion for Subsequent Lead Analysis 210 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Bioavailability and Bioaccessibility of Lead ASTM E1979-17, Standard Practice for Ultrasonic Particles.” Chemistry Central Journal 6: 138. Extraction of Paint, Dust, Soil, and Air Samples for Subsequent Determination of Lead Gould, E. 2009. “Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits Recommended International of Lead Hazard Control.” Environmental Health Perspectives 117. https://ehp.niehs.nih.gov/doi​ Standards for Test Methods: /10.1289/ehp.0800408 ISO 6503, Paints and varnishes - Determination of IHME (Institute for Health Metrics and Evaluation). 2016. total lead - Flame atomic absorption spectrometric GBD Compare Data Visualization. Seattle, WA: method IHME, University of Washington. http://vizhub​ .healthdata​.org/gbd-compare ASTM E1645-16, Standard Practice for Preparation of Dried Paint Samples by Hotplate or Microwave IPEN (International Pollutants Elimination Network). Digestion for Subsequent Lead Analysis 2016. Global Lead Paint Elimination Report. http://ipen.org/documents/global-lead-paint​ ASTM D3335-85a(2014), Standard Test Method for -report-2016. Low Concentrations of Lead, Cadmium, and Cobalt in Paint by Atomic Absorption Spectroscopy UNEP (United Nations Environment Programme). 2018. Model Law and Guidance for Regulating Lead ASTM E1613-12, Standard Test Method for Paint. https://wedocs.unep.org/bitstream​ Determination of Lead by Inductively Coupled /handle/20.500​.11822/22417/Model_Law​ _Guidance_%20Lead​_Paint.pdf?sequence=7 Plasma Atomic Emission Spectrometry (ICP-AES), Flame Atomic Absorption Spectrometry (FAAS), or UNEP (United Nations Environment Programme). 2017. Graphite Furnace Atomic Absorption Spectrometry Update on the Global Status of Legal Limits on (GFAAS) Techniques Lead in Paint. UNEP. https://www.unenvironment​ .org/resources/publication/2017-update-global​ -status-legal-limits-lead-paint References WHO (World Health Organization). n.d. Regulations Attina, Teresa M., and Leonardo Trasande. 2013. “Economic and Controls on Lead Paint. Global Health Costs of Childhood Lead Exposure in Low- and Observatory. http://www.who.int/gho/phe​ Middle-Income Countries.” Environ Health /chemical_safety/lead_paint_regulations/en Perspective 121 (9). Report and map available at http://www.med.nyu.edu/pediatrics/research​ WHO (World Health Organization). 2011. Brief Guide to /environmentalpediatrics/leadexposure Analytical Methods for Measuring Lead in Paint. http://www.who.int/ipcs/assessment/public​ Deshommes Elise, Robert Tardif, Marc Edwards, _health/lead_paint.pdf Sebastien Sauve, and Michele Prevost. 2012. “Experimental Determination of the Oral Annex 3: Model Law and Guidance for Regulating Lead Paint 211 ANNEX 4: CONCEPTUAL SITE MODEL OF POTENTIAL EXPOSURES AT ARTISANAL AND SMALL-SCALE GOLD MINING (ASGM) SITES This annex was reproduced by the World Bank based on von Stackelberg, Williams, and Sánchez-Triana (2022). Sources: von Stackelberg, Williams, and Sánchez-Triana 2021; von Stackelberg, Williams, and Sánchez-Triana 2022. Note: As=arsenic; Hg=mercury; MeHg=methylmercury; and Pb=lead. 212 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE References von Stackelberg, K., P. R D. Williams, and E. Sánchez- von Stackelberg, Katherine, Pamela R. D. Williams, Triana. 2021. “A Systematic Framework for and Ernesto Sánchez-Triana. 2022. Artisanal Collecting Site-Specific Sampling and Survey Scale Gold Mining: A Framework for Collecting Data to Support Analyses of Health Impacts Site-Specific Sampling and Survey Data to from Land-Based Pollution in Low- and Middle- Support Health-Impact Analyses. International Income Countries.” International Journal of Development in Focus. Washington, DC: Environmental Research and Public Health 18 (9): World Bank Group. 4676. doi:10.3390/ ijerph18094676. Annex 4: Conceptual Site Model of Potential Exposures at Artisanal and Small-Scale Gold Mining 213 ANNEX 5: LEAD IN PAINT REGULATIONS AND STANDARDS The table below provides information on countries’ status with respect to legally binding controls on lead paint. Legally binding controls (regulations or Year Country Limits standards established on lead paint) Afghanistan No Albania Yes 2019 0* Algeria Yes 1997 5,000 ppm Andorra No Angola No Antigua and Barbuda No Argentina Yes 2009 600 ppm Armenia Yes 2014 5,000–150,000 ppm Australia Yes 2008 1,000 ppm Austria Yes 2008 0* Azerbaijan No Bahamas No data Bahrain No Bangladesh Yes 2018 90 ppm Barbados No Belarus Yes 2010 5,000–150,000 ppm Belgium Yes 2008 0* Belize No Benin No Bhutan No Bolivia No data 214 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Legally binding controls (regulations or Year Country Limits standards established on lead paint) Bosnia and Herzegovina No Botswana No data Brazil Yes 2008 600 ppm Brunei Darussalam No data Bulgaria Yes 2008 0* Burkina Faso No Burundi No Cote d’Ivoire No Cabo Verde No data Cambodia No Cameroon Yes 2017 90 ppm Canada Yes 2016 90 ppm Central African Republic No Chad No Chile Yes 1997 600 ppm China Yes 2020 90–1,000 ppm Colombia Yes 2020 90 ppm Comoros No Congo No Cook Islands No data Costa Rica Yes 1995 600 ppm Croatia Yes 2008 0* Cuba Yes 1984 20,000 ppm Cyprus Yes 2008 0* Czechia Yes 2008 0* Korea, Dem. People’s Rep., No data Annex 5: Lead in Paint Regulations and Standards 215 Legally binding controls (regulations or Year Country Limits standards established on lead paint) Congo, Dem. Rep. No Denmark Yes 2008 0* Djibouti No Dominica Yes 2007 600 ppm Dominican Republic No data Ecuador Yes 2013 100–600 ppm Egypt Yes 2022 100–5,000 ppm El Salvador No Equatorial Guinea No data Eritrea No data Estonia Yes 2008 0* Eswatini No Ethiopia Yes 2018 90 ppm Fiji No Finland Yes 2008 0* France Yes 2008 0* Gabon No Gambia No Georgia Yes 2021 90 ppm Germany Yes 2008 0* Ghana No Greece Yes 2008 0* Grenada No data Guatemala No Guinea No Guinea-Bissau No 216 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Legally binding controls (regulations or Year Country Limits standards established on lead paint) Guyana Yes 2004 600 ppm Haiti No Honduras No Hungary Yes 2008 0* Iceland Yes 2008 0* India Yes 2016 90 ppm Indonesia No data Iran, Islamic Rep., No data Iraq Yes 2011 90 ppm Ireland Yes 2008 0* Israel Yes 2019 90 ppm Italy Yes 2008 0* Jamaica Yes 2023 90 ppm Japan No Jordan Yes 2018 90 ppm Kazakhstan Yes 2007 Limit not specified Kenya Yes 2017 90 ppm Kiribati No data Kuwait Yes 2018 600 ppm Kyrgyz Republic Yes 2013 Limit not specified Lao PDR Yes 2021 90 ppm Latvia Yes 2008 0* Lebanon Yes 2019 Limit not specified Lesotho No Liberia No Libya No data Annex 5: Lead in Paint Regulations and Standards 217 Legally binding controls (regulations or Year Country Limits standards established on lead paint) Liechtenstein Yes 2008 0* Lithuania Yes 2008 0* Luxembourg Yes 2008 0* Madagascar No Malawi Yes 2020 Limit not specified Malaysia No Maldives No Mali No Malta Yes 2008 0* Marshall Islands No data Mauritania No data Mauritius No Mexico Yes 2013 600 ppm Micronesia, Fed. Sts., No data Monaco Yes 2008 0* Mongolia No Montenegro Yes 2012 Limit not specified Morocco Yes 2021 90 ppm Mozambique No Myanmar No Namibia No data Nauru No data Nepal Yes 1997 90 ppm Netherlands Yes 2008 0* New Zealand Yes 2010 1,000 ppm Nicaragua No 218 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Legally binding controls (regulations or Year Country Limits standards established on lead paint) Niger No Nigeria No Niue No data North Macedonia Yes 2014 Limit not specified Norway Yes 2008 0* Oman Yes 2008 600 ppm Pakistan Yes 2017 100 ppm Palau No Panama Yes 1996 600 ppm Papua New Guinea No data Paraguay Yes 2022 90 ppm Peru Yes 2021 90 ppm Philippines Yes 2013 90 ppm Poland Yes 2008 0* Portugal Yes 2008 0* Qatar Yes 2005 600 ppm Republic of Korea Yes 2022 90 ppm Republic of Moldova No Romania Yes 2008 0* Russian Federation Yes 2010 600 ppm Rwanda No St. Kitts and Nevis No St. Lucia No St. Vincent and the Grenadines No data Samoa No San Marino No data Annex 5: Lead in Paint Regulations and Standards 219 Legally binding controls (regulations or Year Country Limits standards established on lead paint) São Tomé and Príncipe No Saudi Arabia Yes 2020 90 ppm Senegal No Serbia Yes 2015 600–50,000 ppm Seychelles No data Sierra Leone No Singapore No Slovakia Yes 2008 0* Slovenia Yes 2008 0* Solomon Islands No Somalia No data South Africa Yes 2009 600 ppm South Sudan No data Spain Yes 2008 0* Sri Lanka Yes 2003 90–600 ppm Sudan No Suriname No Sweden Yes 2008 0* Switzerland Yes 2006 100 ppm Syrian Arab Republic No Tanzania Yes 2016 90–100 ppm Türkiye Yes 2024 1,000–3,000 ppm Tajikistan No Thailand Yes 2016 100 ppm Timor-Leste No Togo No 220 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Legally binding controls (regulations or Year Country Limits standards established on lead paint) Tonga No data Trinidad and Tobago Yes 2012 600 ppm Tunisia No Turkmenistan No data Türkiye Yes 2024 1,000–3,000 ppm Tuvalu No Uganda No Ukraine Yes 2021 90 ppm United Arab Emirates Yes 2014 Limit not specified United Kingdom Yes 2008 0* United States Yes 1977 90 ppm Uruguay Yes 2011 600 ppm Uzbekistan No data Vanuatu No Venezuela, RB No data Vietnam Yes 2020 90–600 ppm Yemen No Zambia No Zimbabwe No Source: WHO 2024. *Note: Lead concentration limit: European Commission Regulations No 1907/2006 on the Registration, Evaluation, Authorization and Restriction of Chemicals, and 1272/2008 on classification, labelling and packaging of substances and mixtures. Restricts the addition of certain specific lead compounds to paint intended for use by the general public. Reference WHO (World Health Organization). 2024. Legally-Binding Controls on Lead Paint. Global Health Observatory. https://www​ .who.int/data/gho/data/themes/topics/indicator-groups/legally-binding-controls-on-lead-paint Annex 5: Lead in Paint Regulations and Standards 221 ANNEX 6: LEAD IN CONSUMER PRODUCTS32 Rapid Market Screening Program: Screening Products for Lead in 25 Countries Introduction • Within each global region, balancing a mix of countries with and without evidence of In 2022 and 2023, Pure Earth conducted a Rapid lead-tainted products (or countries that are Market Screening (RMS) program aimed at hypothesized to sell these products based on enhancing our collective understanding of lead- cultural similarities). contaminated consumer products and foods that contribute to lead poisoning in LMICs and The RMS was conducted in 25 countries: Armenia; advancing the ability of all actors to implement Azerbaijan; Bangladesh; Bolivia; Colombia; Egypt; solutions. The program’s methodological aspects, Georgia; Ghana; the Indian states of Maharashtra, findings, and key information were published in a Tamil Nadu, and Uttar Pradesh; Indonesia; report (Pure Earth 2023) and an article in a peer- Kazakhstan; Kenya; Kyrgyz Republic; Mexico; Nepal; reviewed journal (Sargsyan et al. 2024). This annex Nigeria; Pakistan; Peru; the Philippines; Tajikistan; summarizes the information presented in both Tanzania; Tunisia; Türkiye; Uganda; and Vietnam. sources. Recognizing the vast size and diversity of India, the sampling strategy focused on three geographically distinct states within the country (Maharashtra, Methods Tamil Nadu, and Uttar Pradesh). As such, the study covered 27 locations. The general types of products The overall goal was to select 25 geographically sampled in each country were selected following diverse LMICs for the RMS, including at least one a series of global desk assessments that reviewed country from each of the six World Bank-classified literature on lead concentrations in a variety of regions that represent the majority of LMICs: Africa, products in LMICs. An initial list of product types Middle East and North Africa, East Asia and the and a sample desk assessment were then provided Pacific, South Asia, Europe and Central Asia, and to the researchers in the countries. The initial list Latin America and the Caribbean. Within each of was designed to examine common items across these regions, candidate countries were listed and geographies but also allowed for flexibility based weighted for inclusion based on several factors: on local contexts. The researchers chose any relevant items for their countries, supporting • Prioritizing countries with evidence of a high their choices with references (both published prevalence and/or severity of childhood lead and unpublished), and carried out initial product poisoning. For this purpose, an extensive screening. Based on this formative research, eleven literature review was performed. product types were selected for analysis: ceramic 32 This Annex has been contributed by Richard Fuller of Pure Earth. 222 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE foodware, metal foodware, plastic foodware, the United States (US), prioritized in that order. cosmetics, toys, paints intended for large surfaces, We could not identify existing reference levels paints for art and crafts, spices, sweets, staple dry for total lead in foodware (items used to cook, foods, and traditional and herbal medicines. serve, consume, and store food). We engaged in a substantial effort to test the degree to which lead Sample collectors in each country selected at least leaches from metal foodware (mostly aluminum) three or four geographically diverse cities, and with a variety of lead concentrations under various selected, when possible, at least one wholesale cooking scenarios, with the results of this leachate bazaar and one retail market in each city to testing being prepared for publication. For the purchase items. Samples were collected between RMS assessment, a reference level of 100 ppm of September 2022 and May 2023. total lead for all types of foodware was applied. This reference level for total lead is not based on The collected samples were initially screened for an existing regulatory standard, and lead dose lead content using portable X-ray fluorescence per use is likely also affected by the type of food analyzers (XRF) following a standard protocol. All prepared, the method and duration of cooking, data collected by the investigators were entered and other contextual factors. The use of 100 ppm into a central database using the Survey CTO total lead as a conservative threshold is supported platform. Subsets of samples from each country by leaching tests, which indicated that pots with were sent to Pure Earth’s headquarters in New York total lead below 100 ppm leached less than the for quality control, which consisted of confirmatory WHO drinking-water standard of 10 ppb (19 out testing of 354 representative samples by a certified of 20 pots tested). Notably, the 100 ppb threshold laboratory and spot checking of field XRF results. could result in a blood lead level of around Local versus New York XRF measurements generally 0.5 ug/dL based on the US EPA’s IEUBK model, compared well. New York XRF and laboratory data assuming a daily intake of 250 g of food at this lead indicated issues with the field XRF readings from concentration. Kazakhstan and Tajikistan, which limited the data from these countries to samples that were sent to New York. Results Lead content in the sampled product was The RMS analyzed a wide variety of consumer compared to a “reference level” pertinent to that products and materials. Sampling took place in 382 product. These reference levels serve as thresholds shopping venues (markets, shopping areas, malls, indicating where United Nations (UN) agencies and stores). A total of 5,007 samples were taken. including the World Health Organization (WHO) or particularly well-resourced regulatory authorities For metal foodware, total lead levels in 51 percent have established public health guidance, a level of the 520 samples collected were above the of concern, or a regulatory limit for lead in each reference level of 100 ppm. In nine locations, the product class. The assumption being made here maximum level exceeded 10,000 ppm. was that these levels would result in an increase in blood lead level when regularly consumed or For ceramic foodware, high lead levels were otherwise exposed. We selected existing regulatory common across all regions, with 45 percent of 308 standards and guidance values promulgated samples above the reference level of 100 ppm. by UN agencies, the European Union (EU), and In 11 locations, the median sample exceeded the Annex 6: Lead in Consumer Products 223 reference level, suggesting that contaminated kohl. These samples had concentrations of 637,600 items are common, and in 25 of the study locations ppm (equivalent to 64 percent lead) and one (all but Pakistan and Uttar Pradesh State, India), the million ppm (equivalent to 100 percent lead) lead maximum lead level was more than 10 times the as assessed by XRF, with lower but still extremely reference level. high concentrations (equivalent to 29 percent and 32 percent, respectively) reported by confirmatory Out of 364 plastic foodware samples, 12 percent laboratory testing. In some cultures, kajal/kohl is showed lead levels exceeding the reference level of applied to infants and children. The item with the 100 ppm. Unlike ceramic and metal foodware, for third-highest lead concentration of lead (128,400 which many countries had samples with maximum ppm) was face paint intended specifically for concentrations above 10,000 ppm, all samples of children. plastic foodware were below 3,300 ppm. For spices, 2 percent of 1,084 samples were For paints, high lead concentrations were prevalent above reference level of 2 ppm. The highest in new paints even among countries that have concentrations were found in turmeric and certain already adopted a 90 ppm limit. The paint samples spice mixes such as garam masala, curry powder, were divided into two product types: paints and mole, as well as cardamom, achiote (annatto), intended for use on large surfaces, such as interior coriander, caraway, ginger, salt, chili, paprika, and exterior walls, and paints intended for crafts, cinnamon, and pepper. Only six countries showed art, and other specialty uses. In total, 41 percent significant amounts of lead in spices. of the 437 samples of paint for large surfaces were above the reference level of 90 ppm. Out of 70 Less than 5 percent of herbal/traditional medicine samples of paint for crafts, art, and other specialty (4 percent), sweets (3 percent), and staple dry food uses, 11 percent showed lead levels exceeding 90 (1 percent) were above reference levels. ppm. More than half of the study locations had maximum lead concentrations exceeding 10,000 In summary, out of a total of 5,007 product samples ppm, while 10 locations had samples exceeding from 25 countries, 913 samples had concentrations 20,000 ppm. of lead exceeding the relevant reference level based on XRF readings, representing 18 percent For toys, high lead levels above the reference of all samples. Metal foodware, ceramic foodware, level of 100 ppm were found in 13 percent of 781 and paints most frequently exceeded the relevant samples tested. This product type encompasses reference levels. In all 25 countries where this a variety of hard toys, composed primarily of assessment was conducted, consumer products plastic items, but also including metal, wood, or were identified that exceeded at least some other materials. Some of these toys were also reference levels. found to have paint or coatings on them, with lead concentrations either in the paint or the underlying Sargsyan et al. (2024) do not purport that these substrate. findings can be considered definitive for a country or region or globally, but they provide indications of For cosmetics, 12 percent of the 812 samples were potential sources of concern and hot spots where above the reference level of 2 ppm, across many supply chains do not effectively regulate for lead subcategories. The items with the highest lead contamination. concentration were eyeliners, known as kajal or 224 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Annex 6: Lead in Consumer Products Paint— Paints— Staple/ Herbal/ Ceramic Metallic Plastic Cosmetics Toys large crafts/ Spices Sweets dry traditional Region Country foodware foodware foodware % % surfaces art % % foods medicine % % % % % % % Caucasus Armenia 36 11 6 7 3 0 0a 4 NA 11 NA Caucasus Azerbaijan 100 63 60a 10 69 100 NA 0a NA NA NA Caucasus Georgia 48 16 0a 0 3 50a 7 0 NA 0a NA C. Asia Kazakhstan NA NA NA 0a 33a NA NA 0 NA 0a NA C. Asia Kyrgyzstan 44 19 13 15 6 33 NA 0 NA 0 NA C. Asia Tajikistan 100a NA NA 0a 0a NA NA 60a NA 0a NA S.S. Africa Ghana 18 55 0 7 14 0a 0a 0 NA 0 NA S.S. Africa Kenya 62 53 25 6 3 36 NA 0 NA 0 NA S.S. Africa Nigeria 29 66 4 18 16 76 NA 0 NA 0 NA S.S. Africa Tanzania 67a 35 4 3 10 7 NA 2 3 0 NA S.S. Africa Uganda 8 73 20 2 0 16 NA 0 NA 6 100a L. America Bolivia 60 54 14 46 6 0a NA 0 0a 0 NA L. America Colombia 50 40 24 10 12 31 11 2 0 0 0 L. America Mexico 67 25 8 7 22 93 NA 3 4 0 0a L. America Peru 42 69 17 9 2 10 0 2 NA 0 0a MENA Egypt 50 55 13 42 4 0a NA 2 NA 0a 0 MENA Tunisia 56 12 4 11 4 50 NA 0 NA 0 17 MENA Turkey 53 67 19 100a 29 70 NA 25a NA NA NA S. Asia Bangladesh 44 59 9 6 13 0a 50a 7 NA 17 NA 225 226 Paint— Paints— Staple/ Herbal/ Ceramic Metallic Plastic Cosmetics Toys large crafts/ Spices Sweets dry traditional Region Country foodware foodware foodware % % surfaces art % % foods medicine % % % % % % % Maharashtra, S. Asia 71 63 19 3 21 19 17 0 NA 0 0a lndia Tamil Nadu, S. Asia 50 70 14 9 23 57 NA 0 NA 0 NA India Uttar Pradesh, S. Asia 0 65 0 2 24 42 NA 12 NA 0a 0a India S. Asia Nepal 9 100 12 0 0 0 NA 0 NA 0 0 S. Asia Pakistan 20a 75 8 30 13 35 NA 9 0 0 NA A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE SE Asia Indonesia NA 60 NA 33 10 97 NA 0 NA 0 NA SE Asia Philippines 13 24 0 13 6 16 0a 0 NA 2 0 SE Asia Vietnam 29 56 0 23 7 59 50 3 NA 0 0a Table 3: Percentage of samples exceeding reference level per product type and by country. * Results from five or fewer sources. Discussion all forms of foodware, a high lead concentration on exterior surfaces does not tell us how much Previous studies have highlighted elevated levels lead is leaching into food. The type of glaze, the of total and leachable lead in metal foodware temperature in which it is fired, types of food made in LMICs, particularly in inexpensive prepared or served in it, and ways in which the item aluminum foodware. These pots are generally is used can all affect leachability and thus exposure. light, inexpensive, and have good conductivity, Ceramics with high concentrations of lead were which helps conserve fuel usage. Such foodware not limited to handmade, artisanal, or traditional has previously been found to be made from pieces, but included mass-produced pieces that mixed scrap metal from engine parts, radiators, may have been imported to the country where electronic appliances, and aluminum cans. Some they were purchased. The leachability of lead from aluminum pots are sourced from material smelted various ceramic glazes produced and used under in large formal smelters, but a proliferation of small different conditions is an area that requires further informal smelters can be found in all countries. research that was beyond the scope of the study. The leachable lead from these pots represents an As of January 2024, 48 percent of countries in exposure source through ingested food cooked in the world had legally binding controls on lead these pots. Pure Earth has conducted leachability concentrations in new paints. Many of these testing of more than 100 aluminum foodware have adopted regulations based on a model law samples to improve our understanding of the establishing a maximum lead concentration of allocation of leachable lead in LMICs and potential 90 ppm. However, many of the paint samples doses of lead per use. The results of the leachate analyzed through the RMS study that exceeded investigations in aluminum foodware are being 90 ppm were collected from countries that have a prepared for publication. Of the 102 pots tested, 90 ppm regulatory limit. In eight of the countries 45 percent had lead concentrations in the leachate (Colombia, Georgia, Kenya, Kyrgyz Republic, exceeding 10 µg/L, which could result in a blood Mexico, Pakistan, the Philippines, and Vietnam), lead level in children above 0.47 μg/dL based on and the Indian states (Maharashtra and Tamil modeling conducted using IEUBK. The highest Nadu Uttar Pradesh) where such regulations apply, leachate concentration found was 2,900 μg/L in more than 10 percent of paint samples had lead a pot from Indonesia, a concentration that could concentrations above 90 ppm (details see Sargsyan result in a BLL of about 45 μg/dL if used daily. The et al. (2024); Supplement C). This suggests a pots with the highest leachate concentrations were considerable enforcement gap in these locations. from South and Southeast Asia. In cosmetics, in addition to high lead levels in Sargsyan et al. (2024) found a high frequency (45 kajal/kohl, elevated lead levels were found in percent) and relatively wide geographic distribution other traditional products, including henna of lead in ceramic foodware. Challenges regarding and kumkum (a red powder made of turmeric the use of lead-based glazes have been well- and other ingredients and used for social and documented in Mexico and have been identified religious purposes in India). Lead levels above elsewhere, but the RMS study shows a fairly the reference level were also found in a variety of uniform geographic distribution of contaminated conventional cosmetics, such as nail polish, lipstick, items. This does not necessarily mean that these and eyeshadow as previously described, as well as pieces all contribute to exposure equally. As with Annex 6: Lead in Consumer Products 227 face powder, mascara, eyeliner, liquid foundation/ clear global public health impact since lead from concealer, and hair products. these products exposes pregnant women, infants, children, adolescents, and adults. Few LMICs Previous studies have identified elevated lead conduct large surveys or ongoing monitoring levels in certain spices from countries around the of children’s blood lead levels. The result is that Mediterranean, the Caucasus, and South Asia, there is little visibility into the prevalence, severity, among other locations. In several countries, prior and geographic distribution of lead poisoning programs have confirmed that elevated lead for many countries. This study highlights the concentrations were the result of producers adding allocation of potential lead exposure sources and lead-based pigments to spices to make their the importance of blood lead level surveillance and colors brighter. The RMS study was not designed related source apportionment to prioritize product- to focus specifically on countries known to have and non-product lead exposure sources and their contaminated spices, nor to focus solely on the elimination in LMICs. types of spices that have been identified as more often contaminated. Rather, the RMS study includes The RMS was implemented between 2021 and 2023 a broad range of spice types from countries that and was supported by generous grants from Open were selected based on product-agnostic criteria. Philanthropy, GiveWell, and the Effective Altruism As a result, the findings generally show low levels of Global Health and Development Fund. lead in spices, except in a handful of countries. References Conclusion Pure Earth. 2023. Rapid Market Screening Program. The sources of lead that contribute to lead https://www.pureearth.org/rapid-market​ poisoning vary by location, not only between -screening-program/ countries, but also between provinces, cities, and even households. Prior studies of lead- Rees, Nicholas, and Richard Fuller. 2020. The Toxic Truth: contaminated goods have typically focused on a Children’s Exposure to Lead Pollution Undermines single product type in a single geographical region. a Generation of Future Potential. UNICEF and The RMS provides a broader analysis of various Pure Earth. goods from a geographically diverse set of 25 LMICs. By analyzing lead concentrations in over Sargsyan, Aelita, Emily Nash, Gordon Binkhorst, Jenna E. 5,000 consumer products and food samples from Forsyth, Barbara Jones, Gabriel Sanchez Ibarra, markets around the world, the RMS highlights lead sources that potentially affect large populations, Sarah Berg, Andrew McCartor, Richard Fuller, and exposing children and adults alike, often in their Stephan Bose-O’Reilly. 2024. “Rapid Market own kitchens. Screening to Assess Lead Concentrations in Consumer Products across 25 Low- and Middle- With so many consumer products in 25 countries Income Countries.” Scientific Reports 14: 9713. containing significant amounts of lead, there is a https://doi.org/10.1038/s41598-024-59519-0 228 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE ANNEX 7: PERMISSIBLE LIMITS FOR LEAD (Pb) IN WATER, AIR, AND SOIL This annex provides an overview of permissible The following table presents examples of countries lead limits in water (for agriculture and drinking that have established permissible limits for lead in purposes), ambient air, and soil across a selection water used for irrigation and agricultural purposes, of countries. While not exhaustive, the lists in along with the corresponding values. this annex highlight varying regulatory standards aimed at protecting human health and the environment. TABLE A7.1. Permissible Limits for Lead (Pb) in Water Used for Irrigation and Agricultural Purposes in Various Countries Maximum Acceptable Level / Country Agency Reference Standard (mg/l) 0.2 Australia Department of Climate Change, Energy and the Commonwealth of Environment and Water Australia 2024 0.2 Argentina Ministry of Environment and Sustainable Ecofield, n.d. Development 5.0 Chile National Institute of Standardization Norma Chile Oficial 1987 0.2 China General Administration of Quality Supervision, Zhao et al. 2022 Inspection and Quarantine 5.0 Ecuador Ministry of Environment FAO 2015 0.1 Israel Government of Israel Zhao et al. 2022 0.1 Italy Government of Italy Zhao et al. 2022 0.2 Jordan Jordan Standards and Metrology Organization Zhao et al. 2022 5.0 Kenya Minister of Environment and Natural Resources Kenya Gazette 2006 0.15 Tanzania Tanzania Bureau of Standards TBS, n.d. 5.0 United States US Environmental Protection Agency Zhao et al. 2022 0.1 Saudi Arabia Ministry of Environment, Water and Agriculture Zhao et al. 2022 2.0 South Africa Department of Water Affairs and Forestry DWAF 1996 ANNEX 7: PERMISSIBLE LIMITS FOR LEAD (Pb) IN WATER, AIR, AND SOIL 229 The following table presents examples of countries that have established permissible limits for lead in drinking water, along with their respective values. The guideline value for Pb in drinking water set by the World Health Organization (WHO) is 0.01 mg/L. TABLE A7.2. Permissible Limits for Lead (Pb) in Drinking Water in Various Countries Maximum Contaminant Country Agency Reference Level (MCL) (mg/l) 0.01 Australia National Health and Medical Research Australian Government (n.d.) Council 0.05 Bangladesh Department of Public Health Engineering DPHE 2019 0.01 Brazil Ministry of Health Normas Brasil 2017 0.005 Canada Health Canada Government of Canada 2021 0.05 Chile National Institute for Standardization Norma Chilena Oficial 2005 0.01 China National Standardization Committee USDA and GAIN 2023 0.01 Colombia Ministry of Environment and Sustainable MMADS 2007 Development 0.005* European Union European Chemicals Agency ECHA, n.d. 0.01 Ghana Ghana Standards Authority GSA 2021 0.01 India Bureau of Indian Standards BIS 2012 0.01 Japan Ministry of Health, Labor and Welfare MHLW 2015 0.01 Mexico Secretary of Health SEGOB 2021 0.01 Nigeria Standards Organization of Nigeria NIS 2015 0.05 Pakistan Ministry of Environment Pakistan Environmental Protection Agency 2008 0.01 South Africa South African Bureau of Standards Integral Laboratories 2015 0.015a United States US Environmental Protection Agency US EPA, n.d. 0b Note: *MCL by 2036; **Maximum Contaminant Level Goal (MCLG) = The level of a contaminant in drinking water below which there is no known or expected risk to health. MCLGs allow for a margin of safety and are unenforceable public health goals. 230 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE The following table presents examples of countries that have established permissible limits for lead in ambient air, along with their respective values. The air quality guideline (AQG) for Pb set by the World Health Organization (WHO) is 0.5 µg/m³ for a calendar year. TABLE A7.3. Permissible Limits for Lead (Pb) in Ambient Air in Various Countries Standard Averaging Country/ value Agency Reference Time Region (µg/m3) 0.5 1 year Australia Department of Climate Change, Energy, the Australian Government Environment and Water 2021 0.5 1 year Bangladesh Department of Environment DOE 2014 0.5 1 year Brazil Ministry of Environment CONAMA 2018 0.5 1 year Chile Ministry of Environment MMA 2000 0.5 1 year China Ministry of Ecology and Environment MEE 2016 0.5 1 year Colombia Ministry of Environment and Sustainable MADS 2017 Development 1.0 1 year Egypt Environmental Affairs Agency FAO 1994 0.5 1 year Ethiopia Environmental Protection Authority US EPA 2003 0.5 1 year European Union European Commission European Commission, n.d. 0.5 1 year India Central Pollution Control Board CPCB 2006 1.0 1 year Indonesia Government of Indonesia FAO 1999 0.5 1 year Mexico Federal Commission for the Protection against Government of Mexico Health Risks (COFEPRIS) 2017 1.0 1 year Nigeria National Environmental Standards and Federal Republic of Regulations Enforcement Agency Nigeria Official Gazette 2014 1.0 1 year Pakistan Pakistan Environmental Protection Agency Government of Pakistan 2012 1.5 3 months Philippines Department of Environment and Natural DENR 2000 Resources 0.5 1 year South Africa South African Bureau of Standards SABS 2011 1.0 1 year United Arab Federal Environment Agency FAO 2006 Emirates 0.5 1 year United Kingdom Department for Environment Food & Rural UK Government 2020 Affairs 0.15 3 months United States US Environmental Protection Agency US EPA, n.d. 1.5 24 hours Vietnam Ministry of Natural Resources and Environment Government Portal 2023 Source: World Bank. ANNEX 7: PERMISSIBLE LIMITS FOR LEAD (Pb) IN WATER, AIR, AND SOIL 231 The following table presents examples of countries that have established permissible limits for lead in different types of soil. TABLE A7.4. Permissible Limits for Lead (Pb) In Soil Across Various Countries Maximum Permissible Type of soil Country Agency Reference Values (mg/kg) 375a Agricultural Ministry of Environment and Ecofield, n.d. Sustainable Development Argentina 500a Residential Ministry of Environment and Sustainable Development 700 Residential Brussels Capital Government Carlon 2007 200 Special area (parks, green Belgium areas, agricultural areas) 140 Residential Canadian Council of Ministers Newfoundland of the Environment Labrador (n.d.) Canada 70 Agricultural Canadian Council of Ministers CCME 1999 of the Environment 250–350 Farmlands, pastures, State Environment Protection FAO 1995 China vegetable fields Bureau 300 Residential Ministry of Environment Carlon 2007 Czech Republic 500 Recreational 300 Residential Estonia Minister of Environment FAO 2004 50–300 General European Union European Council Eury-Lex 2022 210–500 Residential Ministry for the Environment New Zealand New Zealand 800 Recreational Government 2012 70 Agricultural Ministry of Environment El Peruano 2017 Peru 140 Residential; parks 100–200 Agricultural Poland Ministry of Environment Carlon 2007 200 Habitat and agricultural National Environmental NEMC 2007 Tanzania Standards Committee 400b Residential; play areas US Environmental Protection US EPA 2001 United States 1,200 b Residential; non-play areas Agency 70 Residential Ministry of Natural Resources Kenji 2015 Vietnam 70 Agricultural and Environment Source: World Bank. Note: a. Reported as ug/g; converted to mg/kg; b. Reported as ppm; converted to mg/kg. According to the Department of Ecology of the State of Washington, 1ug/g = 1 mg/kg & 1ppm = 1 mg/kg. https://apps​ .ecology.wa.gov/eim/help/ValidValues/UOMConversions?FailsCheck=False¤tPg=3 232 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Lead is naturally present in soil. Nonetheless, especially in high-risk areas such as urban centers human activities have contributed to increased or industrial sites, where contamination is more levels of lead in soil, which may present likely (Oorts et al. 2021). serious health risks, particularly for children and vulnerable populations, since it can be Despite the universal goal of reducing lead ingested through dust or absorbed by plants exposure, soil-lead standards vary significantly in contaminated areas. Lead in soil can also from one country to another and even between contribute to overall environmental lead states, as shown in table A7.4 above. These exposure (EPA 2020). To mitigate these risks, differences are due to variability in local many countries have set specific standards to environmental conditions, land use, and exposure regulate the amount of lead permissible in soil. scenarios. For instance, countries with industrial These standards aim to reduce lead exposure and legacies may have higher permissible thresholds prevent health complications like lead poisoning, due to a higher background level of lead in the often reflecting permissible levels at which there environment. Conversely, countries that adopt is reasonable certainty that adverse health effects more conservative approaches may establish will be minimized (Madhavan et al. 1989). The lower limits, setting thresholds close to natural standards, often expressed as concentration background levels of lead in soil (Tapia-Gatica et al. thresholds (mg/kg) of contaminants in soil, 2022). Furthermore, legal frameworks surrounding above which certain actions are recommended these standards differ with respect to enforcement, or enforced, are referred to by various names with some countries requiring strict adherence, across countries, such as “screening values,” while the legal frameworks of other countries act “reference values,” “maximum permissible limits,” as generic guidance or screening levels to identify or “quality standards” depending on the regulatory areas that may need further evaluation and framework (Carlon 2007). Exceeding these limits possibly corrective action such as cleanups (Carlon frequently prompts actions like soil remediation, 2007; EPA 2024). restricted access to the area, or crop-management measures to prevent the transfer of lead through The traditional approach to pollution management food sources (Srivastava et al. 2022; UMass 2017). typically relies on local assessments based on concentration standards, where a contaminated The process of establishing these standards site is considered risky if its pollutant levels typically involves a risk assessment that considers exceed predefined quality standards. While this the toxicity of lead and exposure levels for method helps identify contamination risks at a humans or ecosystems. Various factors are local level, it has limitations. Studies have shown taken into account, including dose-response that remediation efforts based on concentration relationships between soil-lead levels and blood standards are often not technically or economically lead concentrations (Madhavan et al. 1989). feasible (Verreydt et al. 2012). Additionally, the Bioavailability is another key factor, as lead in use of concentration standards does not provide soil can behave differently depending on the a complete picture of how pollution spreads or soil’s composition, pH levels, and organic matter the risks posed to downstream areas, such as content. As a result, regulatory bodies set drinking-water supplies or ecosystems. This lack thresholds that are protective of human health, of comprehensive data also makes it difficult to ANNEX 7: PERMISSIBLE LIMITS FOR LEAD (Pb) IN WATER, AIR, AND SOIL 233 compare and prioritize which contaminated sites References will be addressed through interventions. Australian Government. n.d. 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By understanding this movement, the Values in Europe. A Review and Evaluation of flux-based approach provides a clearer picture National Procedures towards Harmonizations. European of how pollutants are spreading and where they Commission, Joint Research Centre, Ispra. might cause harm. It also involves continuous https://esdac.jrc.ec.europa.eu/ESDB_Archive​ monitoring and evaluation of the effectiveness of /eusoils_docs/other/EUR22805.pdf the management strategy, allowing for real-time adjustments to ensure more sustainable, long- CCME (Canadian Council of Ministers of the term management. 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CPCB (Central Pollution Control Board). 2006. “National 2003. “Guidelines Ambient Environment Ambient Air Quality Standards.” https://clip.cpcb​ Standards for Ethiopia.” https://plasticsdb.surrey​ .gov.in/index.php/notification/national-ambient​ .ac.uk/documents/Ethiopia/Republic%20of%20 -air-quality-standards/ Ethiopia%20EPA%20(2003)%20Ambient%20 Environment%20Standards%20for%20Ethiopia​ DENR (Department of Environment and Natural .pdf Resources ). 2000. “Implementing Rules and Regulations for RA8749.” https://pab.emb.gov​ European Commission. n.d. “EU Air Quality Standards.” .ph/wp-content/uploads/2017/07/RA-8749-IRR​ https://environment.ec.europa.eu/topics/air/air​ -DAO-2000-81.pdf -quality/eu-air-quality-standards_en DOE (Department of Environment). 2014. Monthly US EPA (US Environmental Protection Agency). n.d. Air Quality Monitoring Report. https://doe​ “National Primary Drinking Water Regulation.” .portal.gov.bd/sites/default/files/files/doe​ https://www.epa.gov/ground-water-and​ .portal.gov.bd/page/cdbe516f_1756_426f​ -drinking-water/national-primary-drinking​ _af6b_3ae9f35a78a4/2020-06-13-16-12​ -water-regulations#two -ad80d5df0ae65d04f8a85031d05c733d.pdf US EPA (US Environmental Protection Agency). n.d. DPHE (Department of Public Health Engineering). “NAAQS Table.” https://www.epa.gov/criteria-air​ 2019. “Water Quality Parameters Bangladesh -pollutants/naaqs-table#1 Standards.” https://dphe.gov.bd/site/page​ /15fa0d7b-11f1-45c0-a684-10a543376873/water​ US EPA (US Environmental Protection Agency). 2020. -quality-parameters- “Lead in Soil.” US EPA. https://www.epa.gov​ /sites/default/files/2020-10/documents/lead-in​ DWAF (Department of Water Affairs and Forestry). -soil-aug2020.pdf#:~:text=There%20is%20no%20 1996. South African Water Quality Guidelines – single%20threshold%20that%20defines%20 Volume 4 Agricultural Use: Irrigation. https:// acceptable,are%20mostly%20focused%20on%20 www.dws.gov.za/iwqs/wq_guide/edited/Pol​ cleaning%20up%20industrial%20properties. _saWQguideFRESHIrrigationvol4.pdf US EPA (US Environmental Protection Agency). 2024. Ecofield. n.d. Argentina, Residuos Peligrosos – Decreto “Updated Residential Soil Lead Guidance for 831/93. Anexos II Tablas. https://www​ CERCLA Sites and RCRC Corrective Action .ecofield​.net/Legales/Residuos_pel/ley24051​ Facilities.” https://semspub.epa.gov/work/HQ​ -dec831-93/dec831-93_anexo%20II%20Tablas​ /100003435.pdf .htm#TABLA%209 World Bank. 2024. People’s Republic Of China, Sustainable El Peruano. 2017. “Aprueban Estándares de Calidad Soil Pollution Management Project (P181487), Ambiental (ECA) para Suelo – Decreto Project Appraisal Document. Washington, DC: Supremo N. World Bank. ANNEX 7: PERMISSIBLE LIMITS FOR LEAD (Pb) IN WATER, AIR, AND SOIL 235 ANNEX 8: KEY REFERENCES AND RESOURCE GUIDES FOR ENVIRONMENTAL SAMPLING This annex is from von Stackelberg et al. 2022. Guidelines for Site Characterization and Developing Sampling Plans When developing a site-specific characterization and sampling plan, multiple resources are available for consultation, as listed and described in table A8.1 below. TABLE A8.1. Site-Characterization Resources Source Description Canadian Council of Ministers of the Environment. Guidance for site characterization, risk assessment, and Guidance Manual for Environmental Site general contaminated-site assessment. Characterization in Support of Environmental and Human Health Risk Assessment. https://ccme.ca/en/res/guidancemanual-environmentalsi techaracterization_vol_1e.pdf Demetriades, A., and M. Birke. 2015. Urban Geochemical Guidelines provided by EuroGeoSurveys of Brussels; Mapping Manual: Sampling, Sample Preparation, provide detailed information on mapping and site Laboratory Analysis, Quality Control Check, Statistical characterization from a European perspective. Processing and Map Plotting. Brussels: EuroGeoSurveys. ESDAC (European Soil Data Centre) website: https://esdac​ The European Soil Data Centre (ESDAC) of the European .jrc.ec.europa.eu/. Commission’s Joint Research Centre is the thematic center for soil-related data in Europe. Its goal is to be the single reference point for and to host all relevant soil data and information at the European level. It contains a number of resources: datasets, services or applications, maps, documents, events, projects, and external links. US EPA (US Environmental Protection Agency). 1989. Provides guidance on site characterization and sampling “Interim Final RCRA Facility Investigation (RFI) Guidance, strategies. Volume II of IV: Soil, Ground Water and Subsurface Gas Releases.” EPA 530/SW-89-031. Washington, DC: EPA. 236 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE A8.1. Site-Characterization Resources (continued) Source Description US EPA (US Environmental Protection Agency). 2014. This Sampling and Analysis Plan (SAP) guidance “Sampling and Analysis Plan—Guidance and Template: and template is designed to assist organizations in Version 4, General Projects.” R9QA/009.1. Washington, documenting procedural and analytical requirements for DC: EPA. projects involving the collection of water, soil, sediment, or other samples taken to characterize areas of potential environmental contamination. ISO (International Organization for Standardization). Establishes general principles for packing, preservation, 2017. ISO 18400-105:2017, Soil Quality—Sampling— transport, and delivery of soil samples and related Part 105: Packaging, Transport, Storage and materials; requirements for chemical analysis of samples. Preservation Of Samples. Olusola, O. I., and O. K. Aisha. 2007. “Towards “…Proposes…procedure…for comparable, representative Standardization of Sampling Methodology for Evaluation and cost effective, soil sampling; …explores…policy issues of Soil Pollution in Nigeria.” Journal of Applied Sciences regarding standardization of sampling activities and and Environmental Management 11 (3): 81–85. analytical process as it relates to soil pollution in Nigeria” (Olusola and Aisha 2007, 81). Source: von Stackelberg et al. 2022. TABLE A8.2. Criteria for Analytical-Method Selection Criteriona Rationale Gold standard Method demonstrates contaminant and matrix specificity; widely used in epidemiological studies Broadly applicable Applies to more than just one contaminant Used in LMIC studies Documented use in the literature Feasibility In field versus send to lab and correlation between field and laboratory results Cost To be determined Detection level Detection level relative to expected concentrations Capability Laboratory likely to have calibrated method Local capability In consultation with local expertise Source: World Bank. Note: a. Criteria given in order of importance. LMIC= Low- and Middle-Income Countries. Annex 8: Key References and Resource Guides for Environmental Sampling 237 Laboratory methods for and solid waste—will depend on many factors, environmental sampling some of which can be determined a priori and some of which will require additional collaboration by the accredited laboratory performing the The US-based ASTM International (https://www​ analyses and the in-field research team. The .astm.org/) (formerly known as the American Society general criteria for method evaluation are given in for Testing and Materials) and the International table A8.2. Standards Organization (ISO, https://www.iso. org/) are the preeminent organizations providing Table A8.3 provides a non-exhaustive list of guidelines and standards for collecting and resources most often used internationally in analyzing environmental samples across different selecting analytical methods for contaminated- matrices. The specific methods chosen to analyze site assessments. Relevant US EPA laboratory metals in water, soil, dust, agricultural products, methods for environmental sampling are shown in fish, and other matrices—such as sludge, fertilizer, table A8.4. TABLE A8.3. Sources of Analytical Guidelines for Contaminated-Site Assessments Source Description ASTM International website: https://www.astm.org/. Internationally recognized as the authority on guidance and guidelines for laboratory testing, collecting samples, metals analysis, and many other standards. Available for purchase individually or by subscription by topic. EA (Environment Agency). 2006. The Determination of Guidance from the UK Environment Agency on laboratory Metals in Solid Environmental Samples: Methods for methods for metals in solid matrices. the Examination of Waters and Associated Materials. Booklet. Bristol, UK: EA. US EPA (US Environmental Protection Agency). n.d. US EPA offices and laboratories, and outside “Collection of Methods.” Environment Measurements organizations, have developed approved methods and Modeling. EPA https://www.epa.gov/measurements​ for measuring contaminant concentrations. Contains -modeling/collection-methods. extensive links to many laboratory resources and a complete listing of approved methods. US EPA (US Environmental Protection Agency). n.d. US EPA’s SW-846 Compendium provides a complete “The SW-486 Compendium.” https://www.epa.gov/hw​ listing and guidance of all US EPA-approved laboratory -sw846/sw-846-compendium methods. Most methods are intended as guidance. European Union Reference Laboratory for Heavy Metals Determination of As, Cd, Hg, and Pb in food and feed in Feed and Food (EURL-HM), European Commission. products including pet food; validated a method for the https://www.feedsafety.org/activities/eurl/eurl-heavy​ determination of MeHg in seafood; determination of iAs -metals/ in food of vegetable origin. 238 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE TABLE A8.3. Sources of Analytical Guidelines for Contaminated-Site Assessments (continued) Source Description Hageman, P. L. 2007. “Determination of Mercury in Discussion of updated CVAFS methods for determining Aqueous and Geologic Materials by Continuous Flow– total Hg in geologic materials and dissolved Hg in Cold Vapor–Atomic Fluorescence Spectrometry (CVAFS).” aqueous samples; replaces the methods in use prior In US Geological Survey Techniques and Methods, Book to 2006. 5, Chapter 2. Reston, VA: US Geological Survey. ISO (International Organization for Standardization). Microwave digestion of sludge, treated biowaste, and soil 2013. ISO 16729:2013, Soil Quality—Digestion of Nitric using nitric acid suitable for all metals. Acid Soluble Fractions of Elements. ISO (International Organization for Standardization). Specifies a method for determining metals in aqua regia 2013. ISO/TS 16965:2013, Soil Quality—Determination of or nitric acid digests or other extraction solutions of Trace Elements Using Inductively Coupled Plasma Mass sludge, treated biowaste, and soil. Spectrometry (ICP-MS). Source: von Stackelberg et al. 2022. Annex 8: Key References and Resource Guides for Environmental Sampling 239 240 TABLE A8.4. US EPA Laboratory Methods Method Title Type Analyte Technique Media/Matrix Date # 3005A Acid Digestion of Waters for Total Recoverable Sample Multi-metal Acid digestion Surface water, July 1992 or Dissolved Metals for Analysis by FLAA or preparation screen; As, groundwater ICP Spectroscopy. https://www.epa.gov/sites​ Pb /default/files/2015-12/documents/3005a.pdf 3010A Acid Digestion of Aqueous Samples and Sample Multi-metal Acid digestion Aqueous samples, July 1992 Extracts for Total Metals for Analysis by FLAA or preparation screen; As, extracts, wastes with ICP Spectroscopy. https://www.epa.gov/sites​ Pb suspended solids /default/files/2015-12/documents/3010a.pdf 3015A Microwave Assisted Acid Digestion of Aqueous Sample Multi-metal Microwave-assisted acid Aqueous samples, Feb. 2007 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Samples and Extracts. https://www.epa.gov​ preparation screen; As, digestion drinking water, extracts, /sites/default/files/2015-12/documents/3015a​ Pb wastes with suspended .pdf solids 3020A Acid Digestion of Aqueous Samples and Sample Pb Acid digestion Aqueous samples, July 1992 Extracts for Total Metals for Analysis by GFAA preparation extracts, wastes with Spectroscopy. https://www.epa.gov/hw-sw846​ suspended solids /sw-846-test-method-3020a-acid-digestion​ -aqueous-samples-and-extracts-total-metals​ -analysis 3031 Acid Digestion of Oils for Metals Analysis Sample Multi-metal Acid digestion Oils, oil sludges, tars, Dec. 1996 by Atomic Absorption or ICP Spectrometry. preparation screen; As, waxes, paints, paint https://19january2017snapshot.epa.gov/sites​ Pb sludges, other viscous /production/files/2015-07/documents/epa​ petroleum products, -3031.pdf 3040A Dissolution Procedure for Oils, Greases, or Sample Multi-metal Solvent dissolution Oils, greases, waxes Dec. 1996 Waxes. https://www.epa.gov/sites/default​ preparation screen; As, /files/2015-12/documents/3040a. Pb 3050B Acid Digestion of Sediments, Sludges, and Sample Multi-metal Acid digestion Sediments, sludges, Dec. 1996 Soils. https://www.epa.gov/sites/default​ preparation screen; As, soils, and oils /files/2015-06/documents/epa-3050b Pb TABLE A8.4. US EPA Laboratory Methods (continued) Annex 8: Key References and Resource Guides for Environmental Sampling Method Title Type Analyte Technique Media/Matrix Date # 3051A Microwave Assisted Acid Digestion of Sample Multi-metal Microwave-assisted acid Sediments, sludges, Feb. 2007 Sediments, Sludges, Soils, and Oils. https:// preparation screen; As, digestion soils, and oils www.epa.gov/sites/default/files/2015-06​ Pb /documents/epa-3050b.pdf 7010 Graphite Furnace Atomic Absorption Determinative Multi-metal Graphite furnace Groundwater, domestic Feb. 2007 Spectrophotometry. https://www.epa.gov/sites​ screen; As, atomic absorption wastes, industrials /default/files/2015-07/documents/epa-7010​ Pb spectrophotometry (GFAA wastes, extracts, soils, .pdf or GFAAS) sludges, sediments 7000B Flame Atomic Absorption Spectrophotometry. Determinative Pb Flame atomic absorption Groundwater, aqueous Feb. 2007 /2015​ https://www.epa.gov/sites/default/files​ spectrophotometry (FLAA samples, extracts, -12/documents/7000b.pdf or FAAS) industrial waste, soils, sludges, sediments 6800 Elemental and Molecular Speciated Isotope Determinative Pb Isotope dilution mass Water samples, solid July 2014 Dilution Mass Spectrometry. https:// spectrometry (IDMS), samples, extracts, www​ .epa.gov/sites/default/files/2015-12​ molecular speciated digests, blood, foods /documents/6800.pdf isotope dilution mass spectrometry (SIDMS) 6200 Field Portable X-Ray Fluorescence Spectrometry Determinative Multi-metal X0ray fluorescence Soils, sediments Feb. 2007 for the Determination of Elemental screen; As, Concentrations in Soil and Sediment. https:// Pb www.epa.gov/hw-sw846/sw-846-test-method​ -6200-field-portable-x-ray-fluorescence​ -spectrometry-determination 6020B Inductively Coupled Plasma Mass Spectrometry. Determinative Multi-metal Inductively coupled Water samples, waste July 2014 /2015​ https://www.epa.gov/sites/default/files​ screen; As, plasma-mass extracts, digests -12/documents/6020b.pdf Pb spectrometry (ICP-MS) 241 242 TABLE A8.4. US EPA Laboratory Methods (continued) Method Title Type Analyte Technique Media/Matrix Date # 6010D Inductively Coupled Plasma Optical Determinative Multi-metal Inductively coupled Groundwater, digested July 2014 Emissions Spectrometry. https://www.epa​ screen; As, plasma-atomic (or optical) aqueous and solid .gov/hw-sw846​ /sw-846-test-method-6010d​ Pb emission spectrometry matrices -coupled-plasma-optical-emission​ -inductively​ (ICP-AES or ICP-OES) -spectrometry-icp-oes 3052 Microwave Assisted Acid Digestion of Sample Multi-metal Microwave-assisted acid Siliceous matrices, Dec. 1996 Siliceous and Organically Based Matrices. preparation screen; As, digestion organic matrices, and https://19january2017snapshot.epa.gov/hw​ Pb other complex matrices -sw846/sw-846-test-method-3052-microwave​ A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE -assisted-acid-digestion-siliceous-and​ -organically-based_.html 7472 Mercury in Aqueous Samples and Extracts by Determinative Hg Anodic stripping Drinking water, natural Dec. 1996 Anodic Stripping Voltammetry (ASV). https:// voltammetry (ASV) surface water, seawater, www.epa.gov/sites/default/files/2015-12​ domestic or industrial /documents/7472.pdf wastewater, soil extracts 7473 Mercury in Solids and Solutions by Thermal Determinative Hg Thermal decomposition Solids, aqueous samples, Feb. 2007 Decomposition, Amalgamation, and Atomic and atomic absorption digested solutions Absorption Spectrophotometry. https://www​ spectrophotometry (AAS) .epa.gov/hw-sw846/sw-846-test-method​ -7473-mercury-solids-and-solutions-thermal​ -decomposition-amalgamation-and 7474 Mercury in Sediment and Tissue Samples by Determinative Hg Atomic fluorescence Sediment, tissue Feb. 2007 Atomic Fluorescence Spectrometry. https:// spectrometry (AFS) www.epa.gov/hw-sw846/sw-846-test-method​ -7474-mercury-sediment-and-tissue-samples​ -atomic-fluoresce Source: von Stackelberg et al. 2022. Bioaccessibility and ASTM International. 2020. “ASTM e1728—20, standard Bioavailability of Lead and Practice for Collection of Settled Dust Samples Using Wipe Sampling Methods for Subsequent Arsenic: US EPA Guidance Lead Determination.” West Conshohocken, PA: ASTM international. https://www.astm.org​ US EPA (US Environmental Protection Agency). 2007. /standards/e1728.htm. “Guidance for Evaluating the Oral Bioavailability of Metals in Soils for Use in Human Health Risk Friederich, N.J., M. Karin, K. M. Bauer, B. D. Schultz, Assessment.” OSWERR 9285.7-80. Washington, and T. S. Holderman. 1999. “The Use of DC: EPA. Composite Dust Wipe Samples as a Means of Assessing Lead Exposure.” American Industrial US EPA (US Environmental Protection Agency). 2015. Hygiene Association Journal 60 (3): 326–33. “Guidance for Sample Collection for In Vitro doi:10.1080/00028899908984449. Bioaccessibility Assay for Lead (Pb) in Soil.” OSWER 9200.3-100. Washington, DC: EPA. HUD (US Department of Housing and Urban Development). 2012. “Wipe Sampling of Settled US EPA (US Environmental Protection Agency). 2017. Dust for Lead Determination.” in Guidelines for “Method 1340: In Vitro Bioaccessibility Assay for the Evaluation and Control of Lead-Based Paint Lead in Soil.” SW-846 Update Vi. Washington, Hazards in Housing, 2nd ed., appendix 13.1. DC: EPA. Washington, DC: HUD. https://www.hud.gov​ /sites/documents/lBPH-40.Pdf US EPA (US Environmental Protection Agency). 2017. “Release of Standard Operating Procedure for US EPA (US Environmental Protection Agency). 1966. an in Vitro Bioaccessibility Assay for Lead and “Analysis of Composite Wipe Samples for Lead Arsenic in Soil and ‘Validation Assessment of in Content.” EPA 747-R-96-003. Washington, Vitro Arsenic Bioaccessibility assay for Predicting DC: EPA. Relative Bioavailability of Arsenic in Soils and Soil-Like Materials at Superfund Sites.’” OLEM 9355.4-29, April 20. Washington, DC: EPA. References https://clu-in.org/download/contaminantfocus​ /arsenic/arsenic-oleM-9355.4-29.pdf. von Stackelberg, Katherine, Pamela Williams, Ernesto Sánchez-Triana, Santiago Enriquez, and Claudia Dust-Sample Collection Serrano Cordova. 2022. Recycling of Used Lead-Acid Batteries: Guidelines for Appraisal of Environmental ASTM International. 2018. “ASTM D6966—18, Standard Health Impacts. International Development in Practice for Collection of Settled Dust Samples Focus. Washington, DC: World Bank.  Using Wipe Sampling Methods for subsequent determination of Metals.” West Conshohocken, PA: ASTM International. https://www.astm.org​ /standards/d6966.htm. Annex 8: Key References and Resource Guides for Environmental Sampling 243 ANNEX 9A: 244 BIOMONITORING RESOURCES This annex is from von Stackelberg et al. 2022. Table A9.1 at the end of this section provides an overview of biomonitoring studies conducted in LMICs related to ULAB or smelting activities. TABLE A9.1. Overview of Biomonitoring Studies Biological A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Reference Location Industry Pollutant Analytical Method Analytical Lab Notes Matrix LEAD Baghurst Port Pirie, Lead Lead Capillary Electro-thermal Dept. of Chemical Cited prior study showing close et al. (1992) South smelter blood atomization Pathology at correlation (r=0.97) b/w capillary and Australia atomic absorption Adelaide Centre venous sampling (Calder et al. 1986) spectrometry for Women’s and Children’s Health Malcoe et al. North- Lead Lead Venous Graphite furnace Samples shipped to Oklahoma State Dept. of Health lab (2002) eastern and zinc blood atomic absorption Oklahoma mining spectrometry Jones et al. Senegal Lead acid Lead (1) Venous (1) Graphite furnace (1) Samples shipped “HI” LeadCare readings sent to lab (2011) (Thiaroye battery blood atomic absorption to Pasteur Cerba- Sur Mer) disposal (2) spectrumetry certified lab (France) Capillary (2) LeadCare (2) In field blood portable test kits Lo et al. Zamfara Gold ore Lead Venous LeadCare II portable Samples were Product lots of all blood collection supplies (2012) State, processing blood analyzer analyzed at the Blood were prescreened for lead contamination Nigeria Lead and Inorganic by CDC labs, and supplies were stored in Metals Lab (Gusau, plastic bags before collection to prevent Zamfara) in-field contamination Annex 9A: Biomonitoring Resources Biological Reference Location Industry Pollutant Analytical Method Analytical Lab Notes Matrix Caravanos Kabwe, Lead Lead Capillary LeadCare II portable In field et al. (2014) Zambia mining blood analyzer and smelting Gao et al. Wuxi City, N/A Lead Capillary Graphite furnace Shipped to School of Public Health, Beijing Medical University (2001) China blood atomic absorption spectrometry Boselia et al. Giza, Egypt N/A Lead Blood Flameless atomic Air and Industrial Hygiene Lab at CA State Dept. of Health Services (2004) absorption (Berkeley, CA) Riddell et al. Central N/A Lead Venous LeadCare analyzer; Samples were Cited previous field work demonstrating (2007); Philippines blood subset analyzed analyzed at a central good correlation (r=0.829) between Solon et al. using atomic laboratory in Manila LeadCare device and AAS (Counter (2008) absorption et al. 1998); study also measured spectroscopy hemoglobin (HemoCue Blood Hemoglobin Photometer) and red blood cell folate (Architect system) Xie et al. China (16 N/A Lead Capillary BH2100 Tungsten NR QA/QC program for blood lead levels (2013) cities) blood atomizer absorption higher than 10 ug/dL (used double test spectrophotometer method) Daniell et al. Hung Yen Battery Lead Capillary LeadCare II portable In field Children only; confirmatory venous (2015) Province, recycling blood analyzer sampling for high field levels; extensive northern soil, survey, medical data also collected Vietnam Grigoryan Northern Metal Lead Capillary LeadCare II portable In field Blood samples collected following CDC et al. (2016) Armenia mining blood analyzer recommended finger stick method; cites and results of CLIA waiver clinical field trials smelting that found good correlation (r=0.979) b/w this device and GFAAS Source: von Stackelberg et al. 2022. 245 Biomonitoring and biological sample collection COPHES (Consortium to Perform Human Biomonitoring should be conducted under the supervision of a on a European Scale). http://www.eu-hbm.info​ trained medical professional, and most Institutional /cophes Review Boards and ethics-review organizations will make that a prerequisite prior to data collection. Cornelis, R., B. Heinzow, R. F. Herber, J. M. Christensen, This annex provides links to accepted methods for O. M. Poulsen, E. Sabbioni, D. M. Templeton, sample collection across biological matrices, as well Y. Thomassen, M. Vahter, and O. Vesterberg. as information on efforts worldwide to coordinate 1995. “Sample Collection Guidelines for Trace biomonitoring programs: Elements in Blood and Urine (Technical Report).” Pure and Applied Chemistry 67 (8–9): 1575–608. Association of Public Health Laboratories in the United https://publications.iupac.org/pac-2007/1995​ States, The National Biomonitoring Network /pdf/6708x1575.pdf (NBN) is a collaboration of federal, regional, state, and local laboratories that conduct Cornelis, R, B. Heinzow, R. F. Herber, J. M. Christensen, biomonitoring for use in public health practice. O. M. Poulsen, E. Sabbioni, D. M. Templeton, https://www.aphl.org/programs/environmental​ Y. Thomassen, M. Vahter, and O. Vesterberg. _health/nbn/Pages/default.aspx 1996. “Sample Collection Guidelines for Trace Elements in Blood and Urine.” Journal of CDC (US Centers for Disease Control and Prevention). Trace Elements in Medicine and Biology 10 (2): 2006. CDC Specimen-Collection Protocol for 103–27. https://pdfs.semanticscholar.org/7ac0​ a Chemical-Exposure Event. https://www​ /eafc14016bd9104fd7fecb22cc4cc2976867.pdf .health.ny.gov/guidance/oph/wadsworth​ /chemspecimencollection.pdf Discussion of Measuring in Lead in Biological Matrices from the ATSDR Toxicological Profile. 2020. CDC (US Centers for Disease Control and Prevention). https://www.ncbi.nlm.nih.gov/books/NBK589538/ Guidelines for Measuring Lead in Blood Using Point of Care Instruments. 2013. https:// EFSA (European Food Safety Administration). www.cdc.gov/nceh/lead/acclpp/20131024​ “Biomarkers in Risk Assessment: Application _pocguidelines_final.pdf for Chemical Contaminants.” http://ec​ .europa.eu/environment/life/project​ CDC (US Centers for Disease Control and Prevention). /Projects​/index.cfm?fuseaction=home​ The Lead Laboratory. 2013. “Measurement .showFile&rep=file&fil=DEMOCOPHESII_2011_4​ Procedures for the Determination of Lead _Biomarkers-in-risk-assessment.pdf Concentrations in Blood and Urine; Approved Guidelines – 2nd edition.” h CLSI. https://www​ FDA (US Food and Drug Administration), “BEST .cdc.gov/nceh/lead/lab/default.htm (Biomarkers, Endpoints, and other Tools) Resource.” https://www.ncbi.nlm.nih.gov/books​ CLSI (Clinical and Laboratory Standards Institute). 2024. /NBK326791/pdf/Bookshelf_NBK326791.pdf Document C40-A2. Wayne, PA: CLSI. https://clsi​ .org/standards/products/clinical-chemistry-and​ IPCS (International Programme on Chemical -toxicology/documents/c40/ Safety). “Environmental Health Criteria 246 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 155 Biomarkers and Risk Assessment: Concepts World Health Organization (WHO). and Principles.” http://apps.who.int/iris​ /bitstream/handle/10665/39037/9241571551​ WHO (World Health Organization). 2010. “WHO -eng.pdf;jsessionid=77D78AFFF865ABE58A​ Guidelines on Drawing Blood: Best Practices in 666BB4941A9330?sequence=1 Phlebotomy.” Geneva: WHO, accessed January 3, 2018, WHO | WHO guidelines on drawing blood: US EPA (US Environmental Protection Agency). best practices in phlebotomy Guidelines for Human Exposure Assessment Risk Assessment Forum. https://www.epa.gov​ WHO (World Health Organization). 2011. “Brief Guide /production/files/2016-02/documents​ /sites​ to Analytical Methods for Measuring Lead in /guidelines_for_human_exposure_assessment​ Blood.” http://www.who.int/ipcs/assessment​ _peer_review_draftv2.pdf /public_health/lead_blood.pdf Annex 9A: Biomonitoring Resources 247 ANNEX 9B: MODELING TOOLS A variety of modeling approaches are available biomonitoring data. This may allow for less data for quantifying and predicting contaminant fate, collection in the future or achieve other goals. transport, external and internal exposures from source to outcome as presented in the Conceptual Depending on the model’s complexity, some Site Model (CSM). Fate and transport models are degree of experience working with specific models used to quantify the movement of contaminants is generally required (that is, typically it is not through environmental media to the point of possible to simply start using a model without any exposure. For example, groundwater models prior experience). Models generally require site- predict expected concentrations in groundwater specific calibration and verification to effectively from leaching in soils or other mechanisms. These support decision-making. models could be used together with measured soil concentrations and site-specific parameters to predict groundwater concentrations, which could Integrated Exposure Uptake then be verified using measured groundwater measurements. Biokinetic Model for Lead in Children (IEUBK), US EPA There are many different models that could be applied along the continuum from contaminant source to health outcome, and they vary in The Integrated Exposure Uptake Biokinetic (IEUBK) complexity and required inputs. This annex Model for Lead in Children is a stand-alone, provides links to resources to consult in deciding Windows-based software developed by the US EPA. which models to use and identifies a limited set The model predicts the distribution of expected of specific models relevant to assessing exposure blood lead concentrations for a hypothetical child to metals in LMICs. For example, the Integrated or population of children based on measured or Exposure Uptake Biokinetic Model for Lead in assumed concentrations of lead in the environment, Children (IEUBK) is a model developed by the US particularly soil and drinking water. From this EPA to predict expected blood lead levels in children distribution, the model calculates the probability from measured concentrations in soil. This model, that predicted blood lead concentrations will exceed together with LMIC-specific exposure factors a user-defined level of concern (default 10 µg/dL). could be combined to predict the biomonitoring The user can then explore an array of possible data. Similarly, a number of physiologically changes in exposure media that would reduce the based pharmacokinetic (PBPK) models exist to probability that blood lead concentrations would be link external exposure concentrations to internal above this level of concern. Beginning in 1990, the concentrations in target organs, tissues, and model has undergone many iterations and review blood, which can then be verified in a limited way cycles and has been well vetted in the literature and (for example, blood, urine, and hair) using the elsewhere. 248 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE The model is optimized for children less than age often rodents, are exposed to known quantities 7 who are exposed to environmental lead from of contaminants via specific exposure routes. many sources. The model can also be used to The animals are sacrificed at various time points predict cleanup levels for various media assuming and organ-specific contaminant concentrations residential land use. Studies show the model is assessed. The animal data relate to humans most sensitive to the amount of soil and dust through a comparison of physiological rate ingested per day. In decreasing order of sensitivity, constants (for example, breathing rate, blood predicted lead uptake is moderately sensitive to volume, and so on). the assumed absorption fraction for soil/dust and diet, the soil-lead concentration, the indoor dust- lead concentration, dietary lead concentration, References contribution of soil lead to indoor dust lead, and the half-saturation absorbable intake (based on the Kenyon, E. M., and H. J. Clewell, III. 2015. “Toxicokinetics output-input ratio). Finally, the predicted probability and Pharmacokinetic Modeling of Arsenic.” of exceeding a specified level of concern is highly In Arsenic: Exposure Sources, Health Risks, sensitive to changes in the geometric standard and Mechanisms of Toxicity, edited by deviation (GSD). The GSD is a measure of the J. Christopher States, chapter 22. https://doi.org​ variability among individuals who have contact with /10.1002/9781118876992.ch22 a fixed lead concentration and is based on analyses of data from neighborhoods having paired sets of This book illustrates the chemistry, toxicology, and environmental concentration and blood lead data health effects of As using novel modeling techniques, from HICs. This value likely differs for LMICs. case studies, experimental data, and future perspectives. Chapter 22 in particular focuses on PBPK modeling for As. Adult Lead Model (ALM), US EPA Liao, C. M., T. L. Lin, and S. C. Chen. 2008. “A Weibull-PBPK While the IEUBK model is designed for children, Model for Assessing Risk of Arsenic-Induced the ALM focuses on adults. The required inputs Skin Lesions in Children.” Science of the Total are similar, but the model is designed for adult Environment 392 (2–3): 203–17. populations. Mumtaz, M., J. Fisher, B. Blount, and P. Ruiz. 2012. “Application of Physiologically Based Physiologically Based Pharmacokinetic Models in Chemical Risk Assessment.” Journal of Toxicology. https://www​ Pharmacokinetic (PBPK) Models .ncbi.nlm.nih.gov/pmc/articles/PMC3317240/ for Metals Ruiz, P., B. A. Fowler, J. D. Osterloh, J. Fisher, and PBPK models are contaminant-specific and typically M. Mumtaz. 2010. “Physiologically Based used to evaluate contaminant disposition in the Pharmacokinetic (PBPK) Tool Kit for human body following exposure. The models Environmental Pollutants–Metals.” SAR and QSAR are generally based on studies in which animals, in Environmental Research 21 (7–8): 603–18. Annex 9B: Modeling Tools 249 Ruiz, P., M. Ray, J. Fisher, and M. Mumtaz. 2011. von Stackelberg, Katherine, Pamela Williams,, and “Development of a Human Physiologically Ernesto Sánchez-Triana. 2022. Artisanal Based Pharmacokinetic (PBPK) Toolkit for Scale Gold Mining: A Framework for Collecting Environmental Pollutants.” International Journal Site-Specific Sampling and Survey Data to of Molecular Sciences 12 (11): 7469–80. Support Health-Impact Analyses. International Development in Focus. Washington, DC: World von Stackelberg, K., P. R. D. Williams, and E. Sánchez- Bank. https://hdl.handle.net/10986/36592 Triana. 2021. “A Systematic Framework for Collecting Site-Specific Sampling and Survey von Stackelberg, Katherine, Pamela Williams, Ernesto Data to Support Analyses of Health Impacts Sánchez-Triana, Santiago Enriquez, and Claudia from Land-Based Pollution in Low- and Middle- Serrano Cordova. 2022. Recycling of Used Lead-Acid Income Countries.” International Journal of Batteries: Guidelines for Appraisal of Environmental Environmental Research and Public Health 18 (9): Health Impacts. International Development in 4676. doi:10.3390/ ijerph18094676. Focus. Washington, DC: World Bank. 250 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE ANNEX 10: Annex 10: Tools for Measuring Human Lead Exposure TOOLS FOR MEASURING HUMAN LEAD EXPOSURE Personnel Equipment Logistical Precision and Risk of Timeliness of Ethics and Methods Marginal Cost Requirements Requirements Requirements Limit of Detection Contamination Results Acceptability Methods to measure lead levels in blood Graphite Highly Requires Instruments Must be Limit of detection Low 2 to 3 minutes, Relatively Furnace (or variable and significant cost $30,000 to transported to between 0.2 and but only after invasive venous electrothermal) challenging training; $50,000. Tests a laboratory for 1 μg/dL samples blood draw Atomic to quantify laboratories require reliable analysis proficiency have been Absorption must energy and testing varies transported to a Spectrometry participate water sources, depending on laboratory (GFAAS) (capillary as well as each laboratory’s or venous, but supplies that can quality standards information for be difficult to venous) source in LMICs Inductively Highly Requires Instruments Must be Lower limit of Low 0.5 to 3 minutes Relatively Coupled variable and highly skilled cost $150,000 to transported to detection of after samples invasive venous Plasma Mass challenging laboratory $300,000. a laboratory for 0.049 μg/dL have been blood draw Spectrometry to quantify technicians. Tests require analysis (lowest of any transported to a (ICP-MS) Laboratories reliable energy, technology). Lab- laboratory (capillary or must water sources, to-lab variability venous, but participate in and supplies is lowest in information for proficiency that can be proficiency venous) testing difficult to testing source in LMICs 251 252 Personnel Equipment Logistical Precision and Risk of Timeliness of Ethics and Methods Marginal Cost Requirements Requirements Requirements Limit of Detection Contamination Results Acceptability LeadCare II A single test Users can A LeadCare Samples can Limit of detection Significant Three minutes Capillary blood (capillary) kit costs conduct tests II analyzer is be taken and is fixed at 3.3 μg/ and available at samples are ~$10, but currently priced analyzed at the dL.lix Proficiency point-of-care. generally more can vary around $3,000 point of care. testing data Process cannot acceptable. significantly Test kits have Patients can show site-to- be automated Information by location a relatively receive results site variability can be shared and provider short shelf-life immediately of +/–1.8 μg/ immediately and limits on dL for sample with patients temperature and concentrations and/or their elevation between 3 and parents 4.1 μg/dL LeadCare Plus A single test Requires some LeadCare Plus Blood must be Limit of detection Significant After a sample Capillary blood and LeadCare costs ~$15, lab training device cost is stored from is fixed at 1.9 is transported samples are in A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE Ultra (capillary) but can vary ~$3,500 and 1°C–25°C from μg/dL for both to the general far more by location LeadCare Ultra collection until technologies laboratory, acceptable. and provider costs ~$25,000. analysis results can be Since samples The laboratory obtained within must be must provide its 3 minutes transported to own pipette a laboratory, there must be a system for communicating results to patients and parents X-Ray Small cost Some level Machines If analysis occurs For Total-XRF, Moderate to Requires blood Capillary blood Fluorescence associated of laboratory cost $75,000 in a laboratory, there is a limit high spot to dry, and draw is more (XRF) with Dried with the expertise may to $110,000 samples must of detection for most precise likely to be Blood Spots dried be required for energy- be transported. between 0.59 measurements, acceptable (DBS) (capillary) blood spot dispersive XRF, Analysis can be and 2.23 μg/ an analysis time card, and and $120,000 conducted at dL. For energy- of ~30 minutes. materials to $140,000 for point of care dispersive XRF, More powerful used Total XRF. XRF if portable the current limit devices have analyzers have technology is is 1.7 μg/dL reduced time to limited lifespans used nine minutes Annex 10: Tools for Measuring Human Lead Exposure Personnel Equipment Logistical Precision and Risk of Timeliness of Ethics and Methods Marginal Cost Requirements Requirements Requirements Limit of Detection Contamination Results Acceptability Methods to measure lead levels in bone K-XRF Negligible Requires Machine costs Sampling must Limit of detection Negligible 30–40 minutes There is some significant $60,000 to be conducted of 2–10 μg/g concern about training to $100,000. at a central Precision radiation from deploy Russia is the location deteriorates as XRF devices, only supplier of the radioactive although it the radioactive source decays seems to cause isotope used for minimal risk this technology L-XRF Negligible Can be trained Machine costs Portable Previous limits of Negligible 3–5 minutes Radiation is within a few $30,000 to instrument detection were higher than hours $45,000 allows for point- 7–10 μg/g. that for K-XRF, of-care testing Recent but dose is still unpublished relatively low research suggests lower limits of 0.6 to 2.75 μg/g.l Methods to measure lead levels in teeth Surface dental Material Requires Significant Not reported Limit of detection Teeth cleaning Biopsy time Requires enamel acid etch costs are significant dentistry and of 12 μg/g. preparation is less than consent to carry microbiopsy very low expertise in scanning Precision can reduces the a minute. out sampling dentistry to equipment be affected by likelihood of Scanning takes conduct safely required the requirement exogenous approximately of normalizing contamination, 30 minutes levels to calcium but some risk remains Laser Ablation- Not reported Significant Significant As analysis is Not reported Significantly Not reported Teeth must be Inductively expertise equipment carried out on lower risk than extracted or fall Coupled required for needed teeth which have for Surface out naturally. Plasma-Mass analysis for sample fallen out. These Dental Enamel Extraction solely Spectrometry preparation and may be sent to a Acid Etch for measurement analysis central location Microbiopsy is not ethically for analysis viable 253 Source: Based on Bonnifield and Todd (2024). References and Practice.” CGD Policy Paper 329. Washington, DC: Center for Global Development. https://www​ Bonnifield, Rachel, and Rory Todd. 2024. “Tools for .cgdev.org/sites/default/files/tools-measuring​ Measuring Human Lead Exposure: A Review of -human-lead-exposure​-review-methods-and​ Methods and Implications for Future Research -implications-future-research-and.pdf 254 A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE A WORLD WITHOUT LEAD: PAVING THE PATH TO A HEALTHY, PRODUCTIVE FUTURE 256 256 Annex 10: Tools for Measuring Human Lead Exposure