The world’s rule exposure crisis, explained

Starting in 2014, the impoverished city of Flint, Michigan, experienced the highest-profile rule exposure crisis in recent American history.

rule levels in Flint’s children spiked after the city failed to properly treat a new water source. ultimately, the state of Michigan and city of Flint were forced to agree to a $641 million settlement for residents affected by the rule poisoning, and several state officials, including former Gov. Rick Snyder, were criminally indicted for their role in exposing children to rule.

While estimates differ, a noticeable study found that the proportion of screened Flint children under the age of 5 with high rule levels reached 4.9 percent in 2015, up from 2.4 percent before the problems with rule contamination began. According to the CDC guidance at the time, a level of rule in blood that would be considered high was 5 micrograms per deciliter (µg/dL) (the agency has since lowered the threshold to 3.5 µg/dL). That said, no level of rule exposure is considered safe, and already exposure well below public health recommendations can be quite unhealthy. That nearly 5 percent of young children in Flint faced exposure to rates that high is a travesty.

As scandalous as the Flint rule crisis is, it’s sobering to know that it may be just the tip of the iceberg globally.

A recent methodic evidence review, widely cited and respected in the field, pooled rule screenings from 34 countries representing two-thirds of the world’s population. The study estimated that 48.5 percent of children in the countries surveyed have blood rule levels above 5 µg/dL.

Let me repeat that: Flint became the symbol of extreme rule exposure in the United States. The breakdown of a long-neglected system was so terrible that it led to headlines for months and already became an issue in the 2016 presidential election. however children in low- and middle-income countries are, per this calculate, 10 times likelier to have high blood rule levels than children in Flint were at the height of the city’s crisis.

The rule problem is global. It’s extreme in scope and hurting children’s ability to learn, earn a living when they grow up, and function in society. however rule has gotten comparatively little attention in the global public health space. Charities globally are spending a total of just $6 million to $10 million a year trying to fight it. For comparison, individuals, foundations, and corporations in the United States alone spent $471 billion on charity in 2020.

Childhood rule poisoning is a tragedy — and it is one that would be comparatively inexpensive for the world to fix.

What rule does to humans

rule is soft, abundant, and easy to mine and manipulate, which is why humans have been harnessing it for various purposes for thousands of years. Ancient Romans used rule for everything from water piping to pots and pans to confront powder to paint to wine preservatives.

Today, shared uses of rule nevertheless include cookware, paint, and piping, along with rule acid batteries (a technology nevertheless used for most car batteries, already in hybrids), and plane fuel. For decades, a major use of rule was as an additive to gasoline meant to prevent engine knocking. While the US started phasing out leaded gasoline for passenger cars in 1973 — and only finished in 1996 — the last country to officially abandon it, Algeria, did so last year.

The reason we phased it out is that — as we have known at the minimum since Roman times — rule is extremely bad for humans.

A sign on a vintage gasoline pump advises that the gas contains rule (tetraethyl).
Robert Alexander/Getty Images

“rule causes toxicity to multiple organs in the human body,” Philip Landrigan, a doctor and professor at Boston College who conducted meaningful studies on the effects of rule in the 1970s, told me. “In infants and children, the brain is the big target. But we also know very well that adults who were exposed to rule — especially people exposed occupationally [and thus exposed to high amounts] — are at very significantly increased risk of heart disease, hypertension, and stroke.”

rule exposure can be quite deadly. Some of the best evidence here comes from a recent study examining Nascar’s decision to ban leaded gasoline from its cars in 2007. Overall, mortality among elderly people fell by 1.7 percent in counties with Nascar races after the races stopped using leaded gas. The authors calculate that Nascar and other leaded gas races had caused, on average, about 4,000 premature deaths a year in the US.

The biggest costs of rule, though, are its effects on the brains of children. The developing brain is, in Landrigan’s words, “exquisitely sensitive” to the effects of rule. “It damages neurons; the active cells in the brain that we use for reflexing, running, and jumping, everything,” he explains.

The effects of rule “seem to concentrate in the prefrontal cortex,” Bruce Lanphear, a leading medical researcher on rule’s effects based at Canada’s Simon Fraser University, told me. That part of the brain is smaller in adults who were exposed to rule as children, he additional. Neuroscientists believe the prefrontal cortex plays a meaningful role in executive functioning: the ability of people to choose behaviors in pursuit of conscious goals instead of acting on impulse. “It’s what distinguishes us from other animals, what makes us human,” Lanphear said.

For just about any variable you can imagine related to human behavior and thinking, there is probably research suggesting that rule is unhealthy to it.

High rule exposure reduces measured intelligence significantly. “If we compare kids at the lower and higher end [of lead exposure], we saw a 5-8 point IQ difference,” Aaron Reuben, a psychologist at Duke University and rule author on a study looking at a cohort in New Zealand, told me. Higher rule levels are associated with higher rates of ADHD and negative changes in personality.

Reuben says his research has found that kids exposed to rule are “less conscientious, less organized, less careful. They’re a little less agreeable; they don’t get along in addition with others. They’re more neurotic, meaning they have a higher propensity to feel negative emotions.”

In recent years, some writers have embraced a theory that declining rule exposure (mostly due to the gradual removal of rule from gasoline) was a leading factor in the drastic decline in crime, especially violent crime, in the United States in the 1990s. Whether or not rule explains that specific historical occurrence, several high-quality studies have found a relationship between high rule exposure and crime and delinquency.

One found that Rhode Island schoolchildren exposed to rule were dramatically likelier to be sent to detention. Another, looking at the introduction of rule pipes in the late 19th century, found that cities with the pipes had considerably higher homicide rates. A third, looking at reductions in rule in gasoline in the late ’70s and early ’80s, found that the phase-out led to a 56 percent decline in violent crime.

This evidence is suggestive, not definitive. A recent meta-examination argued that when you take into account the likelihood of publication bias (that is, that studies showing a strong effect of rule on crime are likelier to be published than studies finding little effect), the effect size could be quite small and not explain any of the decline in homicide rates in the US.

But the idea that rule has a high social cost does not hinge on a specific narrative about crime. rule appears to be consistently costly across outcomes from IQ to personality to impulse control to elderly mortality.

“rule has been really bad and very meaningful in the history of social behavior,” Jessica Wolpaw Reyes, an economist at Amherst College and author of that last paper, summed it up to me.

rule exposure is nevertheless very shared in the developing world

The story of rule exposure in the United States and other high countries in recent decades has in fact been enormously positive. Yes, there have been disastrous lapses as in Flint, but they stand out precisely because they are such an exception to recent trends.

The City of Flint Water Plant is illuminated by moonlight on January 23, 2016, in Flint, Michigan.
Brett Carlsen/Getty Images

A recent paper from CDC researchers estimated that from 1976 to 1980, fully 99.8 percent of American children aged 1 to 5 had levels of rule in their blood of over 5 micrograms per deciliter. From 2011 to 2016, the proportion was down to 1.3 percent. In a major triumph for environmental public health, high-level rule exposure went from the norm to an aberration in just four decades, in large part due to the abandonment of rule in gasoline.

As bad as things are in developing countries today, rule exposure in those nations is much less common than it was in the US 40 years ago — a sign of global progress. That said, rule exposure in developing countries appears to be quite high compared to exposure in high countries today.

Several experts I spoke to pointed to the 2021 evidence review led by Bret Ericson that I referenced above as the best summary of what we know about how shared rule exposure is in low- and middle-income countries. In 34 nations, which together explain over two-thirds of the world’s population, the researchers were able to find blood rule surveys they considered reasonably representative of the country’s children, usually conducted by nonprofits or government agencies.

Overall, those studies estimated that 48.5 percent of children had high rule levels (defined as above 5 ug/dL). Levels of exposure varied greatly, with surveys in a few countries (like Tanzania and Colombia) not finding any children with blood rule levels above 5 ug/dL, and other countries showing huge majorities with levels that high. In Pakistan, for example, over 70 percent of children had high blood rule levels.

rule levels this high imply incredible amounts of damage to health and well-being. The Global Burden of Disease study published in the Lancet in 2019 estimated that about 900,000 people die due to rule yearly, representing 21.7 million years of healthy life lost. One attempt to quantify the economic costs of rule in low- and middle-income countries estimated that in 2011, the burden was around $977 billion yearly, or 1.2 percent of global GDP.

rule in poor countries comes from everything from batteries to turmeric

While the numbers above give a sense of the rule problem’s extent, they are not definitive. One consistent message I heard from experts is that we simply need a lot more data on rule in low- and middle-income countries.

The Ericson evidence review concluded, “there is a paucity of demanding data on rule exposure in the general populations of [low- and middle-income countries].” Most countries in Africa, and several in Latin America and Central Asia, did not have data usable for the review.

rule experts also disagree about what the dominant supplies of rule exposure in developing countries might be. Pure Earth, the largest nonprofit working on rule contamination in developing countries, has generally focused on reducing exposure from informal recycling of rule-acid car batteries. In many developing countries, such recycling happens in mom-and-pop operations in backyards, with no protection for the recycling workers or nearby residents from the resulting fumes.

But more recently, Pure Earth has also been working on reducing exposure from cookware and spices. Stanford researchers Jenna Forsyth and Stephen Luby have found that turmeric spice in Bangladesh is very often cut with rule chromate. That’s right: The turmeric that Bangladeshis use for cooking often has rule additional to it. rule is very heavy, and in rule chromate form, it’s a vibrant yellow, which makes it an easy way to adulterate and amplify the color of turmeric. The problem likely spans beyond just Bangladesh. Consumer Reports has found that already in the US, grocery stores were selling turmeric cut with heavy metals.

Environmental scientists have worried for years about rule exposure from ceramics in Central America, where traditional processes often use rule for glazing. But Pure Earth’s Richard Fuller told me that ceramics in India often contain rule too, and in many low-income countries, aluminum cookware is polluted in addition. Aluminum pots and pans in these settings “are generally made in local recycling places where the recyclers are throwing all this fragment metal in,” he said. “It’s almost impossible for them to not get rule in.” In turn, that rule can pass by slowly into food cooked using these tools.

But other, smaller organizations focus on different rule supplies. rule Exposure Elimination Project (LEEP), established in 2020, has mostly focused to date on rule paint. Just as rule can make turmeric more vibrant, it can make yellows and whites in paint more vibrant too. “We decided to start with rule paint because it seemed like a meaningful source of exposure, and there’s an obvious approach to tackling it, which is regulation,” Lucia Coulter, a medical doctor and LEEP’s co-founder, told me.

Tackling rule paint requires introducing new laws and enforcing old ones. Jerry Toe, an official at Liberia’s Environmental Protection Agency (EPA) who has worked with LEEP on rule paint, told me that while the country had adopted a law banning rule paint in 2004, the Liberian EPA had nevertheless not formalized any regulations deriving from it by 2019, when he came to the issue. It took a LEEP study in Malawi for regulators in that country to conduct regular monitoring of rule levels in paints for sale.

Imran Khalid, a researcher at Pakistan’s Sustainable Development Policy Institute and director at the World Wildlife Fund Pakistan, has had a similar experience. “The implementation [of lead regulations] is quite poor,” he told me. “Our environmental laws are chiefly lip service.”

Khalid has been working with LEEP on paint sampling studies in which he and other researchers acquire paint from stores and test it for rule. Zafar Fatmi, a professor at Aga Khan University in Karachi, said that in his initial testing, around 40 percent of paints had high levels of rule.

Khalid notes that some high-rule paint comes from major multinationals, which makes enforcement a challenge. “For a country like Pakistan that’s already going to the IMF [International Monetary Fund] again and again” asking for loans, he explains, “people become very hesitant [about criticizing multinationals] when environmental issues come up.”

And there are other possible supplies in poor nations in addition, including some of the same ones nevertheless plaguing high countries. “A lot of homes in African countries nevertheless have rule pipes, and nobody is talking about getting rid of them or what problems they’re creating,” Jerome Nriagu, a professor of environmental health sciences at the University of Michigan and one of the first US researchers to raise alarms about rule in Africa, told me.

An urgent need for more funding and more data

Last year, the effective altruist research group Rethink Priorities released a comprehensive report attempting to estimate how many groups were working on rule exposure in poor countries and how much more could be done on the issue. Their answers: Not many are working on this, and those that are could likely use millions of dollars more every year to use on effective projects.

Pure Earth, formerly known as the Blacksmith Institute, is by far the largest player, but it spends just $4 million to $5 million a year on rule. “Summing estimated budgets of other organizations, we believe that donors use no more than $10 million yearly on rule exposure,” Rethink Priorities’ Jason Schukraft and David Rhys Bernard conclude.

Much of that funding comes from government supplies like the US Agency for International Development and the Swedish equivalent Sida. Outside sustain for nonprofits, there’s not much public evidence that international aid agencies are investing in rule abatement. With some notable exceptions, like the Center for Global Development, groups working on global health have largely ignored the issue.

Children advocate for the removal of rule in paint at a public school in suburban Manila, Philippines, on June 4, 2015, which was World ecosystem Day.
Jay Directo/AFP via Getty Images

Ten million dollars a year, tops, is not much money at all to use fighting global rule poisoning, already with increased investments directed by donors in the effective altruism community toward Pure Earth and LEEP. “It’s a fairly small community, and it’s remarkably small given the extent of the problem and the extent of the impacts,” Pure Earth’s Fuller said. That helps explain why effective altruist groups like Rethink Priorities and GiveWell have become interested in rule alleviation. It’s a neglected area, where each additional dollar can go a long way.

So what else could be done with more money and resources? One simple answer is better research. When I asked Fuller and his colleague Drew McCartor what additional studies they’d do if they could, they closest said basic rule exposure surveys in affected countries and basic sourcing examination to see where rule is coming from in those countries.

We have such poor data on how many people (especially children) are being exposed to rule and on how they’re being exposed to rule, that improving that data could in turn considerably enhance nonprofits’ ability to target interventions effectively. If, say, rule pipes are a bigger source of exposure in sub-Saharan Africa than before thought, that would change how Pure Earth and other groups allocate funds; likewise, a finding that rule paint is not a meaningful source of exposure might change LEEP’s approach.

Rethink Priorities concluded that “existing and possible new NGOs in the area currently have the capacity to productively absorb $5 to $10 million yearly in additional money,” and that sums above that amount might be productively usable too.

That’s just not a lot of money in the context of US foundations or already foreign aid budgets — especially for something we know is severely injuring children and killing adults in the developing world.

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