Public health as culture. The social construction of the childhood lead poisoning epidemic in France

Bibliographic Data

ID23147237
AuthorsD Fassin (0000-0002-7684-2410, Inserm, corresponding author)
Year2004
Volume69
Issue1
Pages167-177
Publication date2004-12-01
Peer ReviewedYes
Open AccessNo
TypeARTICLE
VenueBritish Medical Bulletin (JOURNAL)
Journal identifiersISSN: 0007-1420 • E-ISSN: 1471-8391
PublisherOxford University Press (OUP) (PUBLISHER)
DOI10.1093/bmb/ldh017
PMID15226205
OpenAlexW2155920435
LanguageEN
Citations received17
References cited13

What is public health? Since 1928, when the question was first asked to the participants of a symposium held by the American Public Health Association, it has received many answers. The purpose of this paper is not to propose an additional definition, but to analyse how public health is socially constructed and produced. Instead of prescribing what it should be, I will describe it as it is. More precisely, I want to show that it is a human activity which transforms natural phenomena into cultural facts. In order to defend and illustrate this point, I will present a case study on the history of lead poisoning in France. In 1981, a team of paediatricians at the Edouard Herriot University hospital in Lyon, with toxicologists from the Alexis Carrel Faculty of Medicine, published an article entitled ‘Lead poisoning revealed by severe encephalopathy: pica does exist in France’ in the journal Archives françaises de pédiatrie1. The article examined the case of a 5-year-old boy called Mammar, hospitalized for consciousness disorders and digestive symptoms. While the diagnostic investigations dragged on without conclusive results, the child’s neurological condition worsened. After several convulsions, a neurosurgical operation was carried out on the assumption that he may be suffering from hydrocephalus. A few days after the surgery a blood test eventually revealed lead poisoning, confirmed shortly afterwards by an interview with his parents who said that their child ‘ate the paint flaking off the walls of their dilapidated house’. Lead poisoning had nevertheless been difficult to identify because in France at the time it was thought to be ‘rare in general pathology, especially in paediatrics’. The child was treated by chelation and his clinical condition improved. Six months later, we are told, he had fully recovered and had no after-effects. Yet no social investigation was carried out: there was no visit to his home, his siblings were not given blood tests, and the family was not offered alternative housing. The little boy simply went home and most probably carried on poisoning himself, if not by eating flakes of paint, assuming that his parents kept him away from that source of contamination, then at least by inhaling lead particles, which would have been unavoidable. At the time, doctors saw lead poisoning as a clinical problem the treatment of which was entirely the responsibility of the hospital. Mammar’s sickness was thus destined to remain a ‘success story’, especially since he was not one of the dramatic cases of encephalopathy ‘resulting in death (in 30% of cases) or in mental backwardness or convulsions (in 80% of cases)’, as the authors commented. Between 1956 and 1981, only 10 cases of infantile lead poisoning had been reported in France. Less than two decades later, in 1999, an inquiry by Inserm, the French National Institute for Health and Medical Research, estimates the number of child victims of lead poisoning at around 85,000, corresponding to a contamination rate of 1.94% if the international threshold of 10 μg/dl is applied2. The report proposes two types of protocols for large-scale screening and intervention. The first one, a population approach, implies a screening of children from low-income families and, once they are diagnosed as contaminated, investigates the housing in which they live. For the 50,000 homes thus identified, the ‘cost of palliative work is estimated at 2.5 billion francs, and 5 billion francs if the lead is to be eradicated’. The second one, an environmental approach, focuses on old and dilapidated housing supposed to expose its occupants to high risk of lead intoxication. For the 150,000 homes selected through this procedure, ‘the cost of the strategy is estimated between 11.5 and close to 20 billion francs’, the authors assert. Between the 1981 article and the 1999 report, the isolated case has thus become an epidemic. In addition to clinical identification, the goal is now also mass diagnosis. The treatment of children by chelation is being backed-up by treatment of their homes by renovation. A disease that was said to be exceptional has finally become a political priority inscribed in a law passed in 1998. Lead poisoning has entered the public health domain. Meanwhile, however, there has been no spectacular increase in the prevalence of infantile lead poisoning. It is the way in which the disease is viewed that has changed3. It is now an issue of population, risk, thresholds, collective measures instead of individuals, symptoms, biology and medicines. The fact that the child is called Mammar, i.e. is of African origin, that he comes from an underprivileged home and lives in a dilapidated building, is now important, whereas in the past, these were simply anecdotal elements in a clinical case. This new set of words and things, signs and facts, that replaces or shifts the medical set can be viewed as the expression of a public health culture4. It is a social construct that generates meaning through which the world is represented, here in terms of an epidemic that calls for strong political mobilization, rather than in terms of isolated cases left in professionals’ hands. In other words, it can be defined as ‘an historically transmitted pattern of meanings embodied in symbols’5. But childhood lead poisoning is not only the result of a translation from clinical language into epidemiological facts, it is also a disease produced by insalubrious housing; public health significations are not only incorporated into cultural symbols, they are also embodied in physical organs. Beyond social operations and closely linked to them, lead poisoning imposes its materiality inscribed in bodies6. The first perspective which focuses on the role played by social agents to establish the evidence of the epidemic is classically considered as constructionist. The second perspective which emphasizes the way in which the social structures produce inequality in the distribution of lead poisoning can be called realistic. In order to analyse this culture of public health and to understand how it relates to the nature of the problem, two hypotheses will be proposed on the naturalization of its objects and the culturalization of its subjects. The first proposition is that public health naturalizes its objects. This operation, which consists of inscribing evidence in the nature of things, generally eludes analysis, since it seems so obvious—and, precisely, so natural. Yet it is an essential feature of any medical culture, although possibly the most hidden one or, more precisely, the least questioned7. Today, for the journalist or government minister, for the organization volunteer or municipal doctor, the 85,000 child victims of lead poisoning exist as such an obvious fact that they all forget to question the previous evidence of a rare disease. Health problems are not only biological realities that specialists elucidate, they are also epidemiological facts that they construct8. Public health is not content simply to discover—it invents. To revert to our original children poisoned by lead. In 1981 in Lyon, the little boy had been sent back to his parents and the doctors had considered it enough to see him for consultations, as was standard practice in French paediatric units. In 1985 in Paris, a little girl who was less severely poisoned however aroused more concern among the doctors treating her. They went beyond the usual prerogatives of their profession and organized a visit to her home9. There the welfare worker noted that the child’s family, of Malian origin, was living in a dilapidated flat with flaky paint and floors that were caving in. Dismayed by what she saw, she alerted the municipal maternal and child health services, but had difficulty convincing them of the gravity of the situation. Nobody at the time thought that lead poisoning could be a public health problem10. The social paediatrician who was in charge of the area later admitted that she had only ever heard of the disease in connection with occupational medicine and was totally unaware that it existed in children. But, from that moment, lead poisoning had left the confines of the hospital. Children were still diagnosed and treated in paediatric wards, but as more and more clinicians tended to recognize this reputedly silent and polymorphous disease, other agents—e.g. public health doctors, toxicology specialists and social workers—increasingly took an interest in it as well. Recognition of the problem gathered momentum. A retrospective study identified 20 cases in Paris between 1984 and 1986, and two small-scale epidemiological studies were undertaken in 1986 and 1987 by a doctor and a biologist, both with little experience in biostatistical research11. One study was descriptive: it covered the 52 residents of two buildings in which the first cases had been diagnosed. It demonstrated that only children under the age of six showed signs of poisoning, in a proportion of four to seven. The findings excluded contamination through water, which had initially been incriminated, and even the researchers were surprised to discover that the paint on the walls contained extremely high levels of lead. The second study took an aetiological approach. It compared 82 children at risk because they lived in dilapidated homes, with 40 children living in newer buildings, both located in a similar social environment. The causal role of the housing conditions was established, as seven cases of poisoning were found in the first group and none in the second, whereas in the apartments of the contaminated children high levels of lead were found on the walls and woodwork. From then on the movement spread: the maternal and child health services set up targeted screening; the public health department of the Bichat medical faculty proposed a monitoring system; and two humanitarian organizations arranged a mission to the USA to investigate the screening and prevention measures implemented in American cities. In 1990, 5 years after the first case that had stirred people into action, 1500 cases of lead poisoning in children had been recorded in Paris alone12. An epidemic was born. For this translation of clinical observations into epidemiological data to be possible, a change had to occur in the worldview of medical professionals—or at least of some of them13. First, new intellectual objects had to be mobilized. There was a gradual shift away from the language of symptoms, doses, X-rays and chelation, towards groups, screening, risks and health measures. Individual reasoning based on clinical observation made way for a population-oriented approach to public health. Second, new practical tools were applied: in addition to treating contaminated children, surveys were undertaken on the residents of dangerous buildings; professionals started to calculate poisoning rates rather than simply relating the cases of contaminated children; and evidence was gathered through comparative studies rather than by simply questioning parents regarding their children’s habits. With these objects and tools it became possible to establish the frequency of the health problem, its target and its cause, all of which had formerly been impossible to infer simply by reading the North American medical literature on the subject, despite its availability. This change of perspective was of the same nature, although on the scale of the small Parisian medical world and a much shorter time-span, as the one that had spawned ‘the rise of statistical thinking’ a century earlier14. The main difference was that knowledge through figures was now socially and scientifically accepted. It was no longer a question of imposing it against the supporters of the individual approach, as the promoters of the ‘numeric method’ had done15. But it had become necessary to apply an interpretative framework that French doctors were ill-equipped to use. Their training included public health based on programmes inherited from the great treatises of the late 19th century, but no initiation into statistics16. In the early 1980s in French medical faculties, epidemiology was still a description of epidemics, not a science of numbers. It was only under the two-fold influence of an academic current of mathematics applied to health, and an activist movement demanding a community approach to medicine, that the ‘new epidemiology’ made its way into universities, districts and ministries. But until this point it was still a matter of scholarly culture. In fact, the social construction of the lead poisoning epidemic must be set in a vaster context of cultural change through which the governance of human beings affects not only individuals but populations, not only care for the ill and, more generally, to but also risk prevention and, more of In the case of lead poisoning in children, to this new approach was The Paris municipal housing dragged their when it to and at in on old National health were to recognize prevention of lead poisoning in children as a health the agents towards and for of the and gravity of the were and as a result of their (in the case of public health their (in the case of of humanitarian or, their profession (in the case of social these agents of the of their Yet this is not to history of the disease, as the North American it of interest of a political or nature, it to the of the through which a public health culture is But in order to understand fully the of construction of childhood lead poisoning, one must into a as it is the fact by cases into an the social agents to describe a disease. this is time medical describe their in a The lead poisoning reported by paediatricians only 10 in a of a century is not the same disease as the one for which public health specialists 1500 cases in 5 The was generally in severe a proportion of which we can was as The to through towards housing To be in both it was a matter of an of in the but even this fact has In the previous levels of lead in the blood whereas in the new six out of seven cases of contamination were under the threshold at that time, was set at The social agents noted that since screening had no more of encephalopathy had been In other words, as the epidemic the number of clinical cases of the health problem is most in the of the paediatricians their observations in the early they set lead levels at to medical literature of the the two epidemiological studies were carried out later in the the had been to under 1990, the 1500 Parisian cases were identified on the of the for of North American surveys that a between lead levels considered to be and and disorders in children and the became 10 it is in to this that the number of contaminated children is estimated at 85,000 by the as the threshold the epidemic in statistical The to the was not an one since it was based on knowledge of the of lead. Yet it up a new encephalopathy as a result of lead poisoning that a to be to has been by a that only of can that social are and that is in a risk of backwardness at and of (in statistical It is way of of the thus defined by public health. While to a natural it transforms it into a new but The is no longer to some children but to the public health culture is not only in its way of the disease but also in its way of The second proposition is that public health its subjects. In other words, it and on the culture of for it is and and it is to change so that they may have a or longer It thus a of with its it has the the other has care of public health the to them to the operation even more when the other is and in other words, when it in its cultural The the the the or African are all despite to be This to any public action, but because it a strong of for the of public health is probably more than other history of lead poisoning. In 1981 in Lyon, had been said the little years later in Paris, we are that the little girl is African and that she lives in a dilapidated the other cases diagnosed in the same hospital the few and the children diagnosed all were from North and from Paris and its most lead poisoned children are of African and noted the team of Yet their is with living pica are more in families is a cultural is a of the for that people to and, for a time, it was the most for lead poisoning in children contaminated by eating paint flakes off walls and It was here with a practice of eating to be of African and to a for children’s Lead poisoning was thus considered to be the of a cultural In from the the children’s African had public health could one for this of from on their many had that they were i.e. activity that to the of professionals they were with disease of and for a possible source of contamination in the of More African and objects were closely examined in with parents and compared with of dangerous being to for and by with the as to the of the epidemic and its it was they to all possible this of cultural is if we that in North for more than a century, paint had been considered as the main source of poisoning of children, and that on paint the first Parisian inquiry had high lead it was not the role of old paint became difficult to This was when pica the dilapidated housing conditions are a are all the victims the are not they must be we were The first were the children and they were and their time on the or in of a left to the were and they to their children or to their This was for in the in the this against in of not for their children its cultural to its these academic in France with the of a of who on a for and the main risk to the of dilapidated and specialists of the of this in of a of the of a child of In terms of a from pica was from whereas the was as and this the to be a that the as While it not the responsibility of paint and the of this many noted with the towards a collective culture, and an individual one, It finally health for was more and more proposed instead of i.e. to their children’s and to their floors Yet history would have had a to these in In the in showed that more children of lead poisoning than children, even there were four as many children, and that of how their programmes were in who were of the of lead but were to away from The to the question of there is a high of infantile lead poisoning among African children in Paris and its the same high among children in years to be not in culture. The also as a political In the early French its to was only for a few more At the same time the with in social and a few from and from the French who the of were off from the and from to social housing. with and even they had to for the most dilapidated housing in which they were or that was at high rates that they were not in a to In some this was by the of several and people for a proportion of the of most underprivileged or of cities. The fact that under these conditions childhood lead poisoning affects them more than is the result of a history by the political of more than the of cultural Yet it is that in and as as in in or in public health has so been to investigate the rather than questioning the This of similar to the of a of practical that culture and it a of these To be not all cultural to public health can be in this but practical is a Public health is generally as at the of The into this knowledge and are considered to be facts of nature that simply have to be made in and in the language of and risk The supposed of and are to to a culture that has to be for their This between two and natural and in the of public health, of of and it into as it would for that we the between the facts of and the social operations of the of the for and the of Lead poisoning affects children, from African families living in insalubrious on the threshold it can be in terms of neurological problems or of a in the on it is a disease with cultural or the of and housing will on the way in which the health problem is For the the the the estimated number of cases will be, so that a of will the disease is as the result of the health approach will whereas if it is as the of social measures will be Public health is thus the cultural activity through which a biological fact, here lead poisoning in children, is constructed as a social fact, an infantile epidemic with its figures and its and its aetiological and its practical answers. social construction of one may we the of the or its or its public health as a culture does not a is as as biological One could even that the is the that can be to the simply to be of that if we are to be for This is based on a study which was by the French of and in with It has been by

Biology · Environmental health · Lead (geology) · Lead poisoning · Psychiatry · Public health · Aging, Elder Care, and Social Issues · French Urban and Social Studies · Historical and Scientific Studies · Medicine · Nursing

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