Measuring The Effects of Mining on Peru's Public Health: Is The Apurimac Region Prepared To Assess Heavy Metal Exposure?

Peru’s Ministry of Health has approached Duke University because it seeks help with evaluating whether heavy metals exposure (in mining regions) is associated with adverse health outcomes. To aid in this effort, I have proposed a new framework for health monitoring that incorporates new clinical assessment tools and diagnostic tests to begin evaluating whether heavy metals exposure (in mining regions) is associated with human health outcomes. This framework is proposed as a pilot program to be tested in Apurimac by Peru’s Ministry of Health (MOH), following the completion of their current presidential election.
Tools developed will evaluate exposure to five heavy metals: lead, arsenic, cadmium, selenium, and mercury. The information generated is anticipated to provide the MOH the ability to identify exposures to environmental hazards and health risks in Apurimac and the possibility of introducing a national surveillance program that identifies environmental health risk factors in other mining regions of Peru. Addition, we expect improved ability to identify public health needs, evaluate program costs, diagnose and treat patients suffering from heavy metal exposure, and increased transparency and awareness of environmental risk factors. The first section of this report provides an overview of the economic contributions that mining makes to the Peruvian economy, the environmental hazards that stem from mining metals, the potential health risk due to heavy metal exposure, and the inability of the Peruvian healthcare infrastructure for linking public health to environmental exposure. It also emphasizes the need to adapt new population health management practices to regions with unique needs based on industry presence, i.e. mining, and likely environmental hazards. The second section provides background and context. It explains how humans can be exposed to heavy metals and what the toxic effects are for each respective exposure pathway and heavy metal. It also explains how copper, gold, and silver mining is a source of exposure to lead, arsenic, cadmium, selenium and mercury. It also reviews historical case studies of heavy metal exposure near mining sites in Peru. This section also provides an overview of the Apurimac Region’s formal and informal mining industry, its demographic and social characteristics, its daunting epidemiology, and its inability to meet public health needs with its current healthcare infrastructure. The third section explains the goals of the pilot program proposed by this paper. It lists explicit objectives for enabling Peru’s MOH and Apurimac’s health agency the ability to link population health to environmental exposure. Secondary objectives are defined to help evaluate program efficiency, effectiveness, and scalability. The S.M.A.R.T. Goals framework is recommended for refining pilot program objectives. Several challenges are acknowledged and listed for consideration during goal formulation.
The fourth section is an overview of methods and materials used to illustrate the various aspects involved in implementing the proposed population health surveillance program. It describes four phases for project rollout, a new clinical procedure, a unique patient and health provider survey tool for environmental exposure data collection, laboratory analysis protocols, and data storage and reporting instructions. This section also discusses limitations regarding data collection and analysis specifically related to literacy, language barriers, and biases. The fifth section of the report describes the anticipated outcomes from the pilot study, referencing the ability to integrate clinical protocols at the National and Regional levels, with newly gained clinical capacity to link public health to environmental risk factors. For example, this section proposes new clinical diagnosis codes, i.e. ICD-10--“Lead”, for associating morbidity and mortality with an environmental exposure to a heavy metal. This section also expands on the benefits of meeting the pilot’s secondary goals. The sixth section dives into the uncertainty of success associated with the execution of such a novel approach to integrate both population health management and environmental health. It cautions against implementing the recommendation brought forth in this report without proper examination from the national and regional health agencies and other pertinent stakeholders. Peru’s mining economy is, and will remain, a going concern and threat to human health because it’s expected to continue for several years into the future. However, by providing political support for the health surveillance pilot program proposed in this report, regional health agencies should be able to identify environmental health hazards and protect the communities they are responsible for. Eventually, the outcomes from the pilot program should be used to identify how the environments in regions with a large mining footprint are impacting human health. Creating a near real-time population health surveillance platform for Peru’s MOH would be an accomplishment not seen even in the most developed economies or health systems. For the sake of Peru’s reported 5.86 million people who are said to be dependents of mining sector employees, I strongly encourage Peru’s Ministry of Health to carefully consider my recommendations and move forward with them.