Letters to the Editor - August 15, 2001 - American Family Physician

Letters to the Editor

Physicians' Desk Reference: 50 Years Later

TO THE EDITOR: Your highlights of 50 years of family medicine prompted me to compare the 4th edition of Physicians' Desk Reference of 1950 with the 54th edition of 2000.

The 1950 edition has 428 pages of drug descriptions and weighs 1 3/4 lb. The 54th edition has 3,252 pages and weighs 8 1/4 lb.

We have, as they say, come a long way.

JAMES PARKER, M.D.
725 Bookcliff Avenue
Grand Junction, CO 81501

Primary Prevention of Lead Poisoning in Children

TO THE EDITOR: I have dealt with the problem of lead-poisoned children for more than 40 years now--in family practice, later as a local health director and, finally, as a State Health Commissioner before returning to academia. I appreciated the "Practical Therapeutics" article titled "Lightening the Lead Load in Children"¹ for its timely and necessary information.

Inspections in Portsmouth, Va. for Lead Paint

Inspection stage

1971

1974

Initial inspections 1,022 3,237

Re-inspections 2,600 4,856

Total Initial violations 1,022 1,241

Remaining in violation at year's end * 198

*--Information unavailable

Information from Annual reports of the Portsmouth city health department for 1973-74:19.

Your readers should also know about a very successful program of primary prevention that began in Portsmouth, Va., in 1971 and has continued successfully to the present. The Portsmouth program was patterned after one started a decade earlier in Ypsilanti, Mich. In all core cities, the main housing units most likely to be a source of lead poisoning are rental units frequently owned by persons who live out of town.

The Portsmouth program was initiated to protect children from lead poisoning and to avoid treatment. The treatment outlined in the article¹ focuses on secondary intervention and occurs because lead-poisoned children in cities are like the canaries that had been used in mines to detect poison gasses. When lead poisoning is detected in a child, then action is taken. Unfortunately, by this time, the child is usually permanently affected.

In Portsmouth, an ordinance was enacted that required all rental units be checked by health department environmentalists to ensure that, prior to occupancy, the rental units were habitable and without danger to children. The Building Code of America (BOCA) Housing standards used included testing for lead paint. To be sure the units were not rented without inspection, the utility companies were required to shut off all service to the unit until it was approved for occupancy by the staff of the health department.

Owners of rental units in Portsmouth are required to reimburse the health department the cost of inspections, so that cost to the general taxpayer is not incurred. Computer connections between the health department and utility companies ensure fast turnaround of habitable units.

During the three subsequent years following 1971, housing compliance (compliance with the entire code, including removal of or protection from lead hazards, based on 1970 standards) went from 45 percent to 90 percent and has improved each year since.²The accompanying table shows the increase in inspections; a significant increase in the number of rental housing unit inspections occurred after the rental code went into effect.

In some states, such as Texas, this approach cannot be used because the state's constitution shelters housing owners.

All physicians should consider urging members of their city and county councils to adopt similar primary prevention programs.³

C.M.G. BUTTERY, M.D., M.P.H.
HCR 67, Box 3535
Urbanna, VA 23175-9305

REFERENCES

1. Ellis MR, Kane KY. Lightening the lead load in children. Am Fam Physician 2000;62:545-54.

2. Annual report of the Portsmouth city health department 1973-74.

3. Buttery CM. Handbook for health directors. New York: Oxford University Press, 1991:119-20.

IN REPLY: We appreciate Dr. Buttery's insights concerning the importance of primary prevention of lead poisoning. Although the main focus of our article¹ was secondary prevention and treatment of children with lead poisoning, we agree with Dr. Buttery that additional focus on primary prevention is needed. It is encouraging to read about the success of the Portsmouth program. Unfortunately, the history of lead poisoning intervention is replete with stories of frustrations and failures, as well. For example, Berney² relates the failure of a 1957 effort in Baltimore to detect and remove lead paint from dwellings before occupation. Among the reasons cited for this failure were opposition of local landlords and health department concerns about the time and effort needed to enforce lead paint removal. These and other factors, such as opposition from the lead, real estate and insurance industries, continue to serve as obstacles to the prevention of lead poisoning. Due, in part, to the pressures from these interest groups, success measures of primary prevention at the federal level have been limited.³ This highlights the importance of physicians' active support of local and state efforts toward primary prevention of lead poisoning.

MARK R. ELLIS, M.D., M.S.P.H.
KEVIN Y. KANE, M.D., M.S.P.H.
Family Practice Residency
Cox Health Systems
1423 N. Jefferson, Ste. A100
Springfield, MO 65802

REFERENCES

1. Ellis MR, Kane KY. Lightening the lead load in children. Am Fam Physician 2000;62:545-54.

2. Berney B. Round and round it goes: the epidemiology of childhood lead poisoning, 1950-1999. Milbank Q 1993;71:3-39.

3. Needleman HL. Childhood lead poisoning: the promise and abandonment of primary prevention. Am J Public Health 1998;88:1871-7.

Corrections

The legend for Figure 1 of the article "Medical Management of Obesity" (July 15, 2000, page 419) contains an error. The white area of the figure indicates normal weight; the blue (center) area indicates overweight; the pink (top right) area indicates obese.

Two photographs in the article "Treatment of Plantar Fasciitis" (February 1, 2001, page 467) were incorrectly labeled. Figure 1, on page 469, shows the gastrocnemius and soleus stretches in reverse order.

Clarification

In the article "Evaluating the Febrile Patient with a Rash" (August 15, 2000, page 804), the prodrome of erythema infectiosum is described on page 808 as possibly consisting of fever, anorexia, sore throat and abdominal pain, with the classic facial rash appearing once the fever resolves. Sore throat and abdominal pain should not be included in Table 2 (pages 806 and 807) in the column for diagnostic clues to erythema infectiosum, because these symptoms are not characteristic of that illness, although they may appear.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors reserve the right to edit correspondence to meet style and space requirements.

Copyright © 2001 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

August 15, 2001 Contents | AFP Home Page | AAFP Home | Search