Community priorities in a landscape of environmental lead contamination: Intersectionality of poverty, well-being, and environmental contamination

Kabwe, Zambia, is known in the global health world for its high concentrations of environmental lead and associated high blood lead levels (BLLs) in children, and thus it is a key region for exploring the intersections of human health and well-being (United Nations Sustainable Development Goal, SGD #3) and environmental health (SGD #12 and #15). Despite multiple efforts to remediate lead from the landscape, lead contamination remains pervasive in some neighborhoods in Kabwe. This article explores why even great global health intervention strategies to mitigate a toxic environment might not be as transformative or locally welcomed as anticipated. We argue that complex global health problems bleed across multiple sustainable development goals, and that interventions that ignore poverty (SGD #1) might be particularly prone to poor outcomes.

Kabwe, Zambia, is the provincial capital of Central Province located about 110 km north of the national capital of Lusaka (Figure 1). From the early 1900s through 1994, the Broken Hill Mine in Kabwe was Zambia’s principal producer of lead (Pb) and zinc (Zn). During 88 years of underground mining, the Broken Hill Mine produced 1.8 metric tons (Mt) of Zn, 0.8 Mt of Pb, and minor amounts of silver, vanadium oxide, and cadmium (Cd) [1]. The mine was relatively unregulated and the activities of mining and smelting of Pb, Zn, and Cd and the production of sulfuric acid led to widespread pollution [2, 3]. In 1994, the Broken Hill lead and zinc mine closed official operation, yet high levels of heavy metal contamination in the surrounding neighborhoods have not yet been successfully remediated. The areas around the mine in Kabwe remain one of the most environmentally contaminated areas in the world [4] with lead, a toxic heavy metal, evident in the dust, soil [2, 5, 6, 7], water [8], and in children’s blood [6, 9, 10]. Objectively, lead contamination is a significant threat to the health of people living in the communities surrounding the old mine.

Kabwe’s lead contamination has marshalled international attention. Both Time Magazine and The Guardian listed Kabwe as one of the most polluted places in the world [11, 12]. Larry Price, Pulitzer Prize winning photographer, illustrated Kabwe’s environmental health hazards and the economic plight of people living in the areas surrounding the Broken Hill Mine through his Pulitzer Center series “The Black Death of Kabwe” [13]. For over a decade, Pure Earth (formerly named Blacksmith, an international nonprofit organization dedicated to environmental problem-solving in low- and middle-income countries) had worked, household by household, to remediate the contamination. They partnered with Environment Africa and the Kabwe Municipal Council to cover yards and gardens in the Chowa neighborhood of Kabwe with a geofabric, covered in turn with uncontaminated dirt and soil [14]. However, there is evidence that dust, carried by wind, recontaminates remediated areas [15]. The World Bank [16] allocated $65.6 million to remediate Kabwe’s contamination among other areas, in December 2016 with plans for completion by 2022; the project includes food supplementation of children found with BLLs higher than 20 µm/dL and the chelation therapy for those with BLLs above 45 µm/dL [17], which has begun to alleviate some of the worst consequences of environmental lead contamination. However, there are ongoing concerns voiced in an open letter from the United Nations that environmental remediation efforts continue to be inadequate and even that Zambian officials have “continued to allow small-scale and artisanal mining to take place in the lead-contaminated areas” [18]. Given the significant negative health consequences of lead contamination, and the numerous international efforts as well as funding devoted to remediating Kabwe’s toxic areas, it is curious that mining activities and lead contamination remain pervasive in the communities downwind from the Broken Hill Mine site.

To explore why this might be the case, and in line with community-based or partnership models for research [19, 20, 21], we designed an open-ended household oral survey to better understand the concerns of people in the communities surrounding the mine, including concerns about the mine and lead contamination. Our data suggested that lead contamination is indeed a concern, but it is only one of the prevalent concerns in the community, and indeed, for many, it is not the most pressing concern. These findings are important to bear in mind, not only for those currently working to remediate lead contamination in Kabwe, but for all agencies embarking on externally designed global health or “development” projects.

The postcolonial landscape of sub-Saharan Africa is littered with the environmental consequences of mineral extraction, including the Zambian Copperbelt [22, 23]. These negative consequences are often borne by people living in the low income, often unplanned communities that emerge on the borders of industrial extraction sites, like those neighborhoods surrounding the Broken Hill Mine of Kabwe.

In substantial areas closest to the abandoned mine, soils are heavily contaminated with toxic metals [2, 5, 7, 24, 25, 26]. Large piles of mine wastes were left on the surface and illegal artisanal activities include smelting some of these tailings for more Pb extraction or use of contaminated soil to make bricks for buildings [27].

The profound environmental contamination has associated health consequences. The most dramatic and widely studied are the BLLs. Especially in young children, lead contamination negatively affects cognitive and behavioral development. BLLs higher than 3.5 μg/dL are considered elevated by the Center for Disease Control (CDC) [28]. The CDC recommends initiating chelation therapy for children with BLLs over 45 μg/dL [29]. A 2006 Zambian study concluded that there were 650 cases in the neighborhoods surrounding the mine with BLL > 65 µg/dL; levels that could induce subacute toxicological effects [5, 9]. In another study of 246 children under age 7 living in the area around the Kabwe Mine, 37% had BLL exceeding 65 µg/dL with one sample as high as 427.8 μg/dL [10, 30]. These data demonstrate extensive lead poisoning of children in the Kabwe Community.

The vast majority of the research in Kabwe has focused on Pb contamination of soil and BLLs of small children and some animals with single time point studies, with recent research on the ways in which high BLLs in small children are negatively associated with health-related quality of life of their mothers [27]. Most importantly, while communities have been involved as study subjects or local employees, the interventions that have been undertaken by both private and public institutions have not actively engaged the community in the research or the decision-making process.

The history of global health interventions, even those with the very best of intentions and with measurable human benefit, has a spotty record. During the cholera outbreak in Brazil in the 1990s, sick and impoverished community members would not seek health care or follow the preventative recommendations of public health workers at least partially because of a public health campaign that inadvertently was interpreted by poor people as equating people with cholera with dogs who needed to be exterminated [31]. The polio eradication campaign has been stalled in Pakistan because community health workers delivering oral polio vaccines in Pakistan must now go door-to-door with armed escort to avoid assassination by community members [32]. Even smallpox eradication, perhaps the single greatest global public health achievement of the 20th century, was marred by the violence and brutality with which some people were forced to be vaccinated against their will [33]. In each of these cases, the intervention goal was laudable and the strategy obvious from a global or public health perspective; however, the outcome of not incorporating local perspectives had negative, unintended consequences.

This critique is not new. Classic global health interventions, like those above, tend to be grounded in assumptions that legitimize outsider perspectives, rapid assessment techniques, judgments, and values above those of local community members. Criticisms of paternalism are prevalent in global health publications [34]; however, implementing non-paternalistic interventions when funding organizations are typically external and have external (rather than local) motivations is difficult at best. Anthropologists and others have long emphasized the importance of “slow research” prior to implementing global health interventions [35, 36, 37]. Slow research using ethnographic methods results in a rich understanding of local assumptions, practices and concerns that can facilitate local buy-in and/or adaptation of interventions to meet local needs, and are associated with better project outcomes [38]. Indeed, two research strategy movements—community-based participatory research and partnership action research—have emerged as explicit ways of incorporating local community members in research and intervention initiatives [39]; however, with more people at the table, it can be increasingly difficult to align the requirements of external funders with the interests of scientists and the diverse needs of local community members.

Our project was designed to be a first step toward a more ethnographic study exploring how community members in Kabwe perceived their local context and needs, including the extent to which the well-documented lead contamination and related health consequences were of concern within the affected communities.

To explore the local sense of well-being and the concerns of households about their family members and their community, including their concern priorities, an open-ended oral household survey was conducted in 3 neighborhoods surrounding the Broken Hill Mine. The project was reviewed by the Miami University Institutional Review Board (IRB) and permission obtained locally from the Kabwe Municipal Council Department of Public Health.

The research was conducted during June and July of 2016 and 2017 using a convenience sampling method. If no male or female household head of the household was available or willing to participate, the next household was approached. Verbal informed consent was obtained in the local language of Bemba or the national language of English when participants’ primary language was other than Bemba. The oral survey was administered following consent. Generally, the survey was conducted in Bemba, but English was used when the participants spoke a language other than Bemba. When conducted in Bemba, the interviewer wrote down phrases, which were directly translated to English. When conducted in English, full sentences were recorded verbatim.

The oral survey opened with a standard question response style demographic survey inquiring of the household head about the number of people living in the household and the educational, occupational, and general health status of each person living in the household. Particular attention was paid to the physical and mental health, and cognitive development of the children in the household given that children tend to have the most marked ill effects of lead contamination. After these demographic and health-related questions, the oral survey transitioned to open-ended questions, including: What are your most pressing concerns about your family? What are your most pressing concerns about your community? What are your most pressing concerns about your environment? What are your thoughts about the closing of the mine? What do you think is the most important problem in your community? What do you consider the worst things about living in Kabwe? What is the one thing you would like to see fixed in Kabwe?

The responses to these open-ended questions are reported here. Oral surveys typically lasted 15–30 min. Each household was sampled for environmental lead concentrations in the soil, dust, drinking water, and plants being grown for consumption; these data are currently being analyzed and will be published separately. Detailed observational notes were also taken describing nonverbal behaviors of the participants during the oral survey, and the house and its environment. The observed conditions of the house were used as a proxy for relative household economic status. While house amenities may not accurately reflect the up-to-date economic resources of current residents (because features of houses at the time of building may have been supplemented by gifts from family or public subsidies) as a proxy measure for relative economic status in terms of access to resources, it is a useful tool. Four economic well-being groups were estimated using detailed field notes, with Group 1 as the lowest economic well-being and Group 4 as the highest. Categorization into Group 1 was indicated by factors such as a mud or woven house, a lack of glass windows, and a straw roof. Group 2 was indicated by a brick home, metal roof, and undefined property lines. Group 3 was indicated by a brick home, shingled roof, and defined property lines. Group 4 was indicated by the same factors as Group 3 but with extra amenities such as unbroken glass windows, walls and gates surrounding the home, or car ports for vehicles. These categorizations allowed for exploration of any associations between relative economic status and open-ended responses.

Data were analyzed using Dedoose [40], a mixed methods data analysis software program. Every concern brought up by participants in response to any question was inductively coded, with resulting coded categories of concern including health, lead, economic well-being, education, access to water, sewage and sanitation, roads and transportation, or miscellaneous concerns. Using analytical tools in Dedoose, we examined the frequency of mentioned concerns and overlaps of types of concerns (e.g., health and lead) in responses. The responses, grouped by economic well-being, were normalized to account for varying numbers of respondents in each group. Categorized concerns were analyzed in total, as well as in response to specific questions asked during the survey.

Forty-nine households, representing a total of 285 people, participated in the study. Most respondents, 67.3% (N = 33), came from a neighborhood known as Mines, 22.4% (N = 11) of respondents were from the Makanda Nyama neighborhood, and 10.2% (N = 5) were in the Makululu neighborhood (see Figure 2).

In our open-ended survey conversations with household heads, multiple concerns related to living in Kabwe were often voiced. Community concerns included health issues related to lead, but lead contamination was not necessarily people’s primary concern. Of all the 243 concerns recorded throughout the open-ended survey conversations, 6.25% (N = 16) were health concerns. Of those health concerns, 43.8% (N = 7) were related to concerns about the environmental lead pollution. Thus, overall, 2.88% of the total concerns voiced by participants dealt with lead impacts on health.

Lead emerged as a concern most strongly in response to our direct question asking specifically about thoughts on the closing of the Broken Hill Mine. The most common response, at 33% (N = 16), was that they had no thoughts or comments on the closing of the mine whatsoever. The next most common response to the specific question about the closing of the mine was voiced by 31% (N = 15) of respondents who named concerns about lead contamination and the associated health risks. For example, one mother responded, “lead poisoning is too much; our health and that of our children are at risk.” Another person said that the government must focus on “lead remediation, as that is the basis of all the problems.” When asked, the most common health consequence attributed to lead exposure was memory deficiency or decreased learning capacity. One respondent complained that “the lead confuses the children.” Lead was also attributed to other health problems. When asked about her opinion of the mine, one woman responded that the mine is a “source of lead illness and flu.”

Notably, in response to the question on the closing of the mine, 27% (N = 13) expressed economic concerns. One respondent, included in these percentages, expressed both economic and lead concerns in her answer. Examples of these economic concerns included “too bad [the mine] closed, it was a source of income” and “[the mine] increased the standard of living when it was open.” One person summarized the situation thus: “The mine closing caused poverty and suffering; it should be reopened.” A former employee of Pure Earth, an NGO working on lead remediation in Kabwe, stated, “There’s nothing good here. There’s a lot of poverty here. Again, it goes back to the government. Mitigation of lead is one of my biggest concerns. Water supply is very inconsistent, so we resorted to digging wells.” However, the backyard neighbor of that employee stated, “Biggest concern about the mine? [It’s] too bad there’s no more employment.”

Additional responses to the question about the closing of the mine were more difficult to categorize, with 4% (N = 2) associating the closing of the mine with blowing dust, and one person commented “Good that it is no longer in operation” but did not explain why it was good. Another person stated that “kids play in the mine dump,” without evaluating the benefits or harms of such play. Lead contamination was thus a prominent but not dominant concern for community members when they listed their concerns specifically about the mine.

The concern about lead diminished significantly when asked questions with a broader scope. When asked the general question “What do you consider the worst things about living in Kabwe?” respondents sometimes offered more than one response. Economic hardships were voiced by 27 household heads, in particular the lack of employment opportunities. The next most commonly listed “worst things” were water, sewage and sanitation, and roads. Lead was the fifth most prominent concern, listed as the “worst thing” by only 8 households. Four household heads mentioned violence and crime as the worst thing about living in Kabwe, with one saying that her biggest concern was that “people kill each other at night.”

We also tried to encourage household heads to prioritize their greatest need by asking, “What is the one thing you would like to see fixed in Kabwe?” Even with this specific question, household heads sometimes responded with more than one greatest need. Job creation and access to financial resources was deemed as the concern or the thing that most needed fixing by 36.7% of household heads (18 of 60 total responses for the question). For example, one respondent said that they hoped for more companies. Another household stated, “it’s hard to stay in Kabwe if not employed by the government.” One family hoped for new companies “so that young people don’t engage in crimes like stealing,” a response that again hints at the intersectionality of local concerns. Many other households simply stated “jobs” or “money” in response to this question. Strikingly, of the 18 responses mentioning the economy, 2 household heads said that the problem they most wanted fixed was the reopening of the mine because it would provide local employment.

The quality of the roads was the second most frequently voiced need with 22.4% of household heads (11 of 60 responses) prioritizing road improvements to increase access to transportation or to decrease the dust from the dirt roads. “Cover the roads because they bring dust into the home,” said a head of a household in which tuberculosis is a concern. Another person responded that there are too many potholes, especially during the rainy season. Indeed, one household head said that the roads should be the top priority, saying “fix the roads, then water problems.”

Access to a clean and consistent source of water was an item of concern for 18.4% of household respondents (9 of 60 responses: 15% of all responses or 18.4% of households). Several household heads said that hand-pumped water would be an important improvement. One said that her house “only has water for 30 minutes every day.”

Lead remediation was the next most commonly mentioned need to be fixed raised by 16.3% of household heads (8 of 60 responses). One person voiced it thus, “Find a lasting solution to the lead because people can’t relocate.” In this, we see hints of frustration that previous solutions have not been lasting as well as a sense that people feel economically trapped making relocation not an option. Household heads also prioritized improving school quality and recreational activities for youth (10.2% or 5 of 60 responses) as well as improving sewage and sanitation (8.2% or 4 of 60 responses).

Finally, one mother prioritized the need for solutions to address local violence, specifically asking for “more police stations, and patrolling at night.” Solutions to address violence were embedded in the different priorities of increasing employment options, school quality, and youth recreation activities which multiple household heads suggested would help prevent local violence.

Local concerns varied greatly from household to household. Consider, for example, one household that was unique because the household head had worked for Pure Earth and thus may have had more knowledge about the lead pollution than others. He described one of his sons as a “slow learner” attributing it to the lead contamination. When asked specifically about his opinion on the mine, this former Pure Earth employee responded with concerns about pollution and the lack of government action to resolve the issue. Still, when asked about his overall concerns about Kabwe, lead was just one of several concerns. He listed “poverty” first, as the worst thing about living in Kabwe. He had a brick home, shingled roof, and defined property boundary, and fell in Group 3 category for relative local economic well-being. By comparison, one of his neighbors saw the closing of the mine primarily as an economic burden while another neighbor had no knowledge of any lead contamination, stating job creation should be the highest priority in the area. The diversity of opinions and needs of families on just one street provides insight to the complex nature of local concerns that link multiple SGDs, while also foregrounding the central importance of the economy and SGD #1, even for relatively well-off community residents.

It is also worth highlighting that all participants voiced multiple concerns. For example, one mother commented in relation to the closing of the mine that “lead is the source of illness and flu” but when asked about the most important thing that needed fixing, she responded that access to water was the most important issue. Another woman’s thoughts about the mine focused on concerns about lead, saying “lead affected the children, giving [them] learning disabilities and colds and makes the kids crazy.” She went on to say that while her children are tested for BLL about once a month and told to drink milk to help bones resist absorbing lead, she had only been given 1 “packet” of milk for 5 people living in her household, and she complained that milk was insufficient. She also complained that she had been told to plant grass on her compound, but she was unable to because she hadn’t been given any money to do so. However, when later in the conversation, the same woman was asked about “the worst thing” about life in Kabwe, she didn’t talk about lead. Instead, she said that the worst thing was that there were “no jobs for young people and graduates” and that creating jobs should be top priority. In short, the concerns of people in Kabwe are more complicated than the international focus on lead remediation would suggest.

A broad look at all the 243 concerns raised by the household heads at any point during the conversations prompted by our open-ended oral survey found that the most commonly mentioned concerns were, in order, economic well-being (N = 66), environmental lead contamination (N = 38), access to water (N = 29), road (N = 26), education (N = 22), sewage sanitation (N = 21), health (N = 16), and other/misc (N = 25; Figure 3). When those concerns were mapped onto the relative economic status of the respondent, concerns were unevenly distributed (Figure 4). Higher-income households were more concerned about lead contamination than lower-income households, and none of the respondents in Group 2, the second lowest level of economic well-being, mentioned lead contamination at all and instead more frequently mentioned economic and water concerns. In contrast, those in the next highest economic category, Group 3, were those that voiced the most concerns about lead contamination. Economic concerns were a significant priority for all household heads.

Given the known high rates of lead contamination, our findings did not align with our expectation that environmental contamination would be community members’ most pressing concern. Overall, when asked specifically about the mine, one-third of respondents expressly mentioned lead concerns, so lead is a significant concern, but in response to the entire oral survey, the importance of lead contamination wanes considering other pressing concerns.

These findings suggest that efforts to solve the lead contamination problem may find a lack of local buy-in due to the conflicting ideas of the most pressing needs of the community. Kabwe’s lead contamination captures global attention for its toxicity [11, 12], but our study suggests that economic daily needs of community members are of equal or greater concern [13]. Community members may be unlikely to participate in projects that they feel are not aligned with their pressing concerns, and for most of the people in Kabwe, the most pressing concern was economic well-being including opportunities for youth.

Our conclusions are limited by the methodological constraints of this preliminary study. These constraints include the lack of fluency of the head researcher in the local language; the project was reliant on 2 local graduate students and a local community health worker in 2016 and a local graduate student in 2017. There was also potential bias in the survey design, which asked about thoughts related to the closing of the mine prior to asking about general community concerns. Asking about the mine could have biased respondents to voice concerns about lead, however given that only 31% responded with concerns about the lead, if question order biased people to respond with concerns about lead, thoughts or concerns unrelated to lead might have emerged as even more important than our data suggest. Our results point to a need for a large collaborative effort which would include in-depth ethnographic interviews coupled with environmental sampling to completely survey the communities surrounding the mine and identify, in partnership with local community members, innovative approaches that would simultaneously meet the needs of external bodies concerned about lead contamination as well as the economic needs or other emergent concerns of the community. Overwhelmingly, the community needs these concerns to be addressed in some way to allow for adequate buy-in toward remediation efforts. Our findings suggest that community members experience a daily struggle to attain an education, find a job and reliable transportation, access potable water, and feed their families. These difficulties may pose a more imminent threat to security and contentedness and therefore precede the need to remediate lead contamination.

In Kabwe, strategies to solve the environmental lead contamination have achieved some success at decreasing environmental exposure and negative health consequences; however, they have done little to address the primary concerns of the community in Kabwe. Implementing measures to improve other aspects of life in Kabwe, especially economic concerns, is vital to community cooperation and satisfaction with interventions.

The broader relevance of our study is the strong reminder that locally relevant global health interventions may improve long-term outcomes. The importance of community engagement for global health research has long been recognized [41]. Our findings contribute to the evidence that communities directly affected by interventions can and need to be involved in the planning so that their most pressing needs are also part of the intervention design and engaging local stakeholders and their feedback is likely to improve intervention outcomes [42, 43].

Our conclusions can be summarized by the responses of one mother in the summer of 2017. She was employed as a medical professional, and in response to a discussion on lead remediation, she expressed that she was concerned about her children’s BLL and asked where she might go to have them tested. However, when asked her opinion about the closure of the mine, she thought it was “too bad [that there was] no more employment.” Moreover, when asked about her main concerns living in Kabwe, lead was not mentioned, but instead she mentioned local violent crime and talked at length about poor drainage, listing poor drainage as the single most important problem to fix. Her responses illustrated the complicated concerns of community members that spill across multiple SGDs and only partially overlap with the dominant concerns of external organizations implementing interventions focused on the toxic lead environment in Kabwe.

We thank the community members of Kabwe for voluntarily participating in our project and sharing their thoughts and concerns with us. In addition, we thank Jessy Zgambo Akatumwa, Charity Mundia, Gabriel Filippelli, and Given Moonga for their contributions to this project.

Support for the research upon which this article is based was provided in part by the Global Health Research Innovation Center at Miami University and by Fulbright-Hays.

Nosiku Munyinda is currently Co-Principal Investigator under the Health Component of the World Bank project and the Japanese funded Kabwe Mine Pollution Amelioration Initiative. The authors have no other conflict of interest to report.

The views expressed in this article are the authors’ own and not an official position of the institutions with which the authors are affiliated.

Data curation, investigation, supervision, formal analysis, visualization, writing (original, reviewing, editing): RS.

Conceptualization, funding acquisition, investigation, methodology, supervision, formal analysis, writing (original, reviewing, editing): MCH.

Investigation, writing (review and editing): INg.

Data curation, investigation, methodology, supervision, resources, writing (review and editing): SM.

Resources, methodology, writing (review and editing): NM.

Resources, reviewing and editing: INy.

Project administration, conceptualization, funding acquisition, resources, Visualization, writing (review and editing): JL.

How to cite this article: Serafin R, Cameron Hay M, Ngoma I, Mutiti S, Munyinda N, Nyambe I, Levy J. Community priorities in a landscape of environmental lead contamination: Intersectionality of poverty, well-being, and environmental contamination. Adv Glob Health. 2024;3(1). https://doi.org/10.1525/agh.2024.2133157

Editor-in-Chief: Craig R. Cohen, University of California San Francisco, CA, USA

Senior Editor: Fernando O. Mardones, Pontifical Catholic University of Chile, Santiago, Chile

Section: Advancing Planetary Health