Landrigan Lancet 1975

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Budget Allocation

From figures available in other countries, it can be

postulated that a free comprehensive health service for

everyone would require expenditure of at least U.S.$100-300 per person per year. This figure excludesthe cost of training doctors, nurses, and others. It

also excludes capital expenditure, which may require$100m.-200m. for a modern teaching hospital of 500beds and$2m.-20m. for district hospitals of 50-100beds. It is possible therefore to contemplate exenditure,far in excess of present estimates and appropriations,which would still leave about 80% of the populationwithout an effective health service.

The only alternative is to build fewer large hospitals,but more health centres and small district hospitalsproviding free or partly-free service for the populationsubdivided into units of 5000-20,000. people. These

units, staffed by"

nuclear " health teams of doctor,

nurse-practitioner, sanitarian, and medical auxiliary,can be linked to district hospitals providing 1 bedper 2000-5000 of population. District hospitals shouldbe linked for special services, training, and additionalresource to existing teaching centres. A plan of thiskind would offer considerable economy in expendi-ture, would provide a much wider and more realisticbase for training and health education, and, above all,would reach a much higher proportion of the popula-tion. The nuclear health teams can be increased as

recruitment and training proceed. The district unitswould provide bases for epidemiologically planned

surveillance and in-progress evaluation of activity.

Conclusion

To anyone who has witnessed in a developingcountry the work of field units and small district

hospitals, it is clear beyond doubt that national adop-tion of a first-things-first community-based plan mustbring visible benefit to the community because itidentifies common disorders which can be controlled-

notably malnutrition, intestinal, respiratory, urinary,and skin infections, simple surgical, ocular, orthopaedic,and obstetric defects, anaemia, and debilitating diseases.

Control of such conditions, by improving well-being,family health, earning power, and morale, opens doorsfor family-planning, health education, and self-helpthrough family, extended-family, and locality networks,thereby concentrating more of the resource of medicinein the front-line of human suffering where it belongs.This approach is a necessary intermediate between

the successful but austere " barefoot " doctor planof China and the extravagant hospital-doctor plans ofmost other countries. It is already clear that somestringency is required to reconcile health needs with

geography, available manpower, and economy even in

highly developed countries. In developing countries,it is difficult to see any alternative, if standards oflife and health are to be raised; but it is easy to seehow suffering and possibly disaster might occur inthe short term if first things continue to take secondplace in policy.

REFERENCES

1. See, for instance, E. W. Hope, Health at the Gateway. London, 1931.2. Illich, I. Lancet, 1974, i, 918.

NEUROPSYCHOLOGICAL DYSFUNCTION IN

CHILDREN WITH CHRONIC LOW-LEVEL

LEAD ABSORPTION*

PHILIP J. LANDRIGANROBERT W. BALOH

WILLIAM F. BARTHEL

RANDOLPH H. WHITWORTH

NORMAN W. STAEHLING

BERNARD F. ROSENBLUMBureau of Epidemiology, U.S. Public Health Service,

Center for Disease Control, Atlanta, Georgia;Department of Psychology, University of Texas

at El Paso, Texas; Reed Neurological Research Center,Center for Health Sciences, University of California at

Los Angeles; and El Paso City-County HealthDepartment

SummaryTo investigate the relation betweenlow-level lead absorption and neuro-

psychological function, blind evaluations were under-taken in forty-six symptom-free children aged 3-15

years with blood-lead concentrations of 40-68 g.per 100 ml. (mean 48 g. per 100 ml.) and in seventy-eight ethnically and socioeconomically similar controlswith levels


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fine motor, perceptual-motor, behavioural, and cog-nitive function. Subtle but statistically significantdifferences were found between the groups in perform-ance i.Q. and in fine motor function, but not in verbal

i.Q. or in tests of behaviour.

Methods

Survey PopulationAll children included in this study were aged 3 years

9 months to 15 years 11 months and had lived within

6-6 km. of the El Paso smelter for at least 12 of the 24

months preceding the study. All except three had taken

part in a survey of blood-lead levels in August, 1972 11; thethree exceptions were sibs of survey participants. Ex-cluded were any children with a history of symptoms com-

patible with acute lead poisoning or acute lead encepha-lopathy and children who had at any time received edeticacid (E.D.TIA. chelation therapy. Included were fourchildren who had received oral penicillamine therapy, butwhose blood-lead levels had not fallen below 40 g. per100 ml. on repeated determinations.

Participating children were divided into two groups:in the lead-absorption group were all those who in August,1972, had had a blood-lead of 40-80 /tg. per 100 ml., andthe three sibs not tested in 1972 but whose blood-leadlevels in 1973 exceeded 40 Ag. per 100 ml. The control

group comprised children whose blood-lead levels hadbeen 05 by chi-square). The fol-lowing subtests were used in the w.i.s.c.: information,arithmetic, comprehension, and digit span in the verbal


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scale, and picture completion, block design, object assem-bly, and coding in the performance scale. Subtests in thew.P.P.s.i. were information, arithmetic, comprehension,and sentence completion in the verbal scale, and picturecompletion, block design, animal house, and geometricdesign in the performance scale. The vocabulary subtestwas omitted from the verbal scale of both w.i.s.c. and

W.P.P.S.I. because of the poor standardisation whichresults on translation of this subtest into Spanish. AllWechsler scores were age standardised. As a further

measure of perceptual-motor function, all children wereadministered the Bender motor gestalt test," which meas-ures accuracy in copying simple geometric designs; accu-racy was scored using an age-standardised scale 18 Thebehaviour of each child in the psychological testingsituation was evaluated by the psychometrist using astandardised 5-point rating-scale.

Blood-lead

A venous blood-sample for lead analysis was obtainedfrom every child in 1973 at the time of the neuropsycho-

TABLE III-MEDICAL HISTORY DATA

All results non-significant by t test.

logical testing. Analysis was performed in duplicate bymodified Delves cup atomic-absorption spectrophoto-metry,20 and results are expressed as the mean of the twodeterininations.

Results

Mean age in the lead absorption group was83 (3-4) years and in the control group 9.3

(3-6) years (table i). This difference was not

statistically significant (p>0.10). 65 % of the leadgroup and 58 % of the controls were male. The

groups matched closely in ethnic background, primary

language, socioeconomic index,13 and duration ofresidence near the smelter.

Blood-lead Data

Blood-lead data which had been below 40 jug. per100 ml. in 1972 tended to remain stable (table I); of

eighty blood-lead levels below 40 g. per 100 ml. in

1972, all except two remained below that mark in1973. The two children whose blood-lead rose above

40 p,g. per 100 ml. were excluded from further analysis,and the remaining seventy-eight were considered to

comprise the control group.Blood-lead levels which had been 40 jug. per

100 ml. in 1972 tended to be lower in 1973, probablybecause many children had moved from the imme-

diate vicinity of the smelter, smelter emissions had

decreased, and the population had aged. The meanin this group fell from 48.3 to 40ug. per 100 ml.

(table i), and in twenty-two of the forty-six childrenin the lead-absorption group the 1973 blood-level hadfallen below 40 p,g. per 100 ml. Accordingly, childrenin the lead-absorption group were divided into two

TABLE IV-RESULTS OF QUANTITATIVE NEUROLOGICAL TESTING = MEAN :I:: S.D.

* 0-001 < p < 0-01 by one-tailed t test.

subgroups on the basis of whether the blood-lead

level did or did not remain 40 ,ug. per 100 ml., and

various characteristics of the two subgroups wereexamined. They did not differ significantly in meanage (8-3 v. 8-4 years), language spoken (100% u. 95%Spanish-speaking), mean length of residence in the

study area (6-9 v. 6-4 years), or socioeconomic index(64 v. 71, both in the lower-middle socioeconomic

range). Children whose lead levels were 40 jug. per100 ml. in both examinations did tend, however, tohave lived closer to the smelter. in 1972 (71 % v.

23 % within 1-6 km.), and they were more likely tohave spent the first 2 years of their lives within 1-6 km.of the smelter (58% v. 14%). No significant differ-ences were found between children in the two sub-

Regression of finger-wrist tapping speed (dominant hand), byage and study group.

For lead-absorption group y (taps/10 sec.)=0-22x (age in yr.)+21-42 (r=0-55).

For control group y=0-22x+26-22 (r=0-67).


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groups in the results of any medical, neurological, or

psychological testing, and data from the subgroupsare, therefore, combined.

Medical Data

Pica, colic, clumsiness, irritability, and convulsionswere all reported by parents to have been more highly

prevalent among children in the lead-absorption groupthan among controls (table ill). None of the observeddifferences were, however, statistically significant.Neither hyperactivity nor other behavioural abnor-

mality was significantly more common in either groupas measured by parental questionnaire

14or by the

physicians examination.

Finger-wrist tapping was significantly slower in thedominant hand of children in the lead-absorptiongroup (46-4 taps in 10 seconds v. 54-1, p


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the low prevalence of pica in El Paso indicates thatit is less necessary there than elsewhere as a mechanism

of lead intake given the almost ubiquitous avail-ability to particulate lead near the smelter; Sayre et al.22suggest that the normal hand-to-mouth activity of

young children is sufficient to account for considerable

absorption of lead in a high-lead environment. A fur-ther argument against a central role for pica in explain-ing these data is that performance l.Q. and finger-wristtapping scores changed but little when children with-out a history of pica were examined separately (tableVIII).Two previous studies 8,10 of neuropsychological

function in children living near smelters, one fromEl Paso," have produced negative results. Thisvariation reflects the difficulty inherent in this sortof evaluation, but may also stem in part from differ-ences in study design. In each of the previous investi-

gations, the high-lead group was defined geographic-

ally in terms of proximity to the smelter, rather thanby blood-lead level. Thus, in each case the exposedgroup contained numerous children with blood-leadlevels

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Landrigan Lancet 1975