"Lead exposure is responsible for income loss equivalent to like six to 8% of GDP every single year. There's a massive burden of disease, that's what we're trying to address." - Lucia Coulter

In this episode of the Giving What We Can podcast, we are joined by Lucia Colter, a doctor turned charity founder.

Lucia recently co-founded the Lead Exposure Elimination Project (LEEP).

LEEP works to eliminate lead poisoning worldwide by advocating for the regulation of lead paint. Lucia is also a member of the Giving What We Can community, where she used to be the co-president of our Cambridge chapter.

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Transcript

Lead Exposure Elimination Project

00:49 - What problem is the Lead Exposure Elimination Project working on?

We are trying to reduce childhood lead poisoning in low and middle-income countries. Childhood lead poisoning is this really neglected, but huge scale problem, that affects around one in three kids.

It affects children's developing brains and is a neurotoxin.

It causes neuro developmental problems like reduced intelligence, behavioral problems, reduced educational attainment, and reduced future income later in life as well. Then it also has these physical health problems: it causes cardiovascular disease, it causes kidney disease, anemia, growth, stunting -- all of these impacts which are spread across this really huge number of children (around over 800 million children worldwide).

In some countries it's even thought that lead exposure is responsible for income loss equivalent to like 6-8% of GDP every single year. That's a massive burden of disease, I think it's 1% of the burden of disease (at least).
That's what we're trying to address.

01:54 - How does LEEP reduce lead exposure?

At the moment we're focusing on lead exposure from paint. We think it's a really important source of lead exposure, and we also think it has the strongest evidence-based for being tractable to address. Lead in paint has been banned in high-income countries (like UK, Australia, US) for 50 years or so but in a lot of low-income countries it's still being used in really huge amounts.

In many countries, populations are growing quickly. Urbanization is going quickly. and so paint markets are growing and more and more lead is being added into the environment as being put on homes, being put in schools and over time.

There is lead in paint, the lead in paint on walls forms dust and flakes, and then children get it in their mouths -- and that's what causes lead poisoning in childhood.

Firstly, we identify countries where we think that there's a lot of lead in paint. and then we go to these countries or we work with partners in these countries to carry out paint sampling studies where we:

Go and buy a load of paint
Do a bit of market analysis; and
Analyze it for lead content.

It's pretty crazy because this data just doesn't exist already: people really don't know if there is lead in paint in a lot of countries. So we find out. Then we share the information with the health ministries, the regulatory authorities, and other important stakeholders -- and we say: this is a big problem.

We raise awareness about the impact of childhood lead poisoning. We show them that there's a lot of lead in the paint. and then we explain the solution, which is basically effective regulation of that lead paint, basically banning it for household use at least hopefully more broadly.

Then we support them in introducing or enforcing regulation. Sometimes they might already have regulations that are just not being enforced, or they might not have any.

So, we can bring together stakeholders, we can provide technical advice and that sort of thing.

And then the other part of it is that we also work with the paint manufacturers themselves so we offer them technical advice to help them switch to lead-free and access non-lead ingredients.

We hope that with better enforcement of lead paint regulation, plus the support in things like reformulation there'll be less lead paint on the market. Less lead paint use, less childhood lead exposure that will have an impact on children's health and wellbeing and future potential.

Luke: Yeah, that's great. I guess this is another example of problems that we don't recognize because they don't exist anymore in high-income countries. You kind of assume that this is the case everywhere.

04:28 - Why lead exposure is neglected

Lucia: Yeah, exactly. I think another reason why it's neglected is obviously partly that it doesn't exist in wealthy and powerful countries so much anymore -- or if it does it's just legacy problems (like old lead paint on walls or old lead lead in pipes). So it's not affecting the most wealthy and powerful people in the world.

I also think there's just the fact that it's such an invisible problem, even compared to traditionally neglected tropical diseases, like infectious diseases (e.g. malaria).

I think lead is again different because although it's affecting one in three kids, you wouldn't know it because the effects that it has are neuro-neurodevelopmental problems. These health problems later in life, they're not things that you'll see someone suffering from and know that it's a result of lead exposure.

Whereas, with malaria you'll have cyclical fevers, and with tuberculosis you'll be having cough and weight loss, but with lead exposure it's not obvious. So it doesn't seem like a priority problem to address, or to even to research.

05:24 - Other effects of lead exposure

Luke: Correct me if I'm wrong, but I seem to recall that a lot of crime reduction in some high-income countries was ~15 years following the removal of a lead that was causing childhood development problems.

Lucia: Yeah, there are these absolutely fascinating correlations between reductions in environmental lead and reductions in crime and it's a trend that's seen in different countries and like in different periods of time. So it seems that it could actually be having this societal impact as well of crime reduction when you reduce lead exposure.

The evidence for that is weaker than the evidence for the other impacts of exposure. But it still seems to be quite fairly compelling and super interesting as well.

Luke: Yeah, and there are these long run effects that you're interacting with if it affects development.

Lucia: Yeah, exactly. Recently there was a study that came out showing the impact of lead on personality traits as well, over a lifetime.

There's some evidence that it reduces conscientiousness and agreeableness, increases neuroticism and that sort of thing. Which obviously at a population level, when so many people are exposed, you can imagine that having a really significant societal impact.

06:43 - Progress since LEEP launched

So far we have carried out a paint sampling study that showed that paint in Malawi so base paint in Malawi contains really high levels of lead. And we shared those findings with the Malawi Ministry of Health and the Malawi Bureau of Standards, and raised awareness with them about the impact of childhood lead exposure.

As a result of our meetings with them and sharing that data, they started actually implementing lead paint regulation. They've started monitoring paint for lead content and they're updating their paint standard to be in line with the who recommended limit for lead content.

We're also working with manufacturers there to help them overcome any barriers to switching to lead-free.

So that's pretty cool, because we've been going just for a few months. We haven't even been around for a year yet and we've already had this progress in Malawi getting the paint regulation implemented.

We've also run a paint study now in Botswana and we actually found that the paint on the market in Botswana is almost all imported from South Africa -- and South Africa does have lead paint regulations. So we didn't find high levels of lead there.

We're now also in the process of running these paints studies in Zimbabwe and Madagascar as well.

07:58 - Monitoring and evaluation

[Monitoring and evaluation is] definitely a priority for us because we need to know if it's actually reducing the amount of lead paint on the market, which is what we care about.

Well, a good indicator for what we care about, which is actually childhood lead poisoning.

We'll be carrying out regular followup studies in all the countries where we run this intervention. This will tell us if that enforcement's working and it also keeps the pressure on keeping momentum going for enforcement and compliance as well. That'll be quite helpful because the sampling they do, the monitoring they do is they go to manufacturers and they do sampling audits, whereas we do market sampling.

So it's kind of complimentary as well to their monitoring. and then if the compliance isn't increasing as quickly as we expect, we can, we can do other things as well. So we could, for example, increase the pressure a bit through things like public and media involvement and that sort of thing.

09:01 - Plans to scale up

The plan for year two is to expand operations. So we would ideally like to carry out these paint sampling studies in eight more countries and then get started with that kind of advocacy and industry outreach in those where we do find high levels of lead in paint, which will probably be the majority of those countries.

We will also be expanding our team. There are still over 76 countries with no lead paint regulation and even more which have regulation that's probably not being enforced. and so the more quickly we can work in as many countries as possible, the more quickly the amount of lead paint being used can be reduced.

And as I mentioned before this, the use of lead paint is increasing quickly because of this population growth and urbanization. And all of that paint going into the environment it's going to be there for years and years to come. so if we can replace that with safer paint as soon as possible, then our impact can be a lot, a lot bigger.

10:17 - Why lead regulation hasn't been a priority earlier

In Malawi it just wasn't known to be a problem, there was no data to show that there was lead in paint. The relevant stakeholders didn't know that lead in paint was a problem. I think there was kind of probably some impression that lead in paint was an outdated technology that had kind of naturally been phased out over time. It just wasn't known to be a problem to address, which is pretty pretty wild.

11:01 - Other sources of lead poisoning

Luke: Yeah, I think it's pretty fascinating. In Flint, Michigan there was a lot of awareness around the problems that they were having there again, that was pipes in their water supply. But you think that that would have been a trigger for a lot of places to start to think about: "what is our environmental lead?"

Lucia: Yeah. Another interesting thing is that there are even more sources that could be as important as paint and could also be tractable to address, that are problems in low-income countries, that we don't know about because they just haven't been studied yet. One that we'd like to investigate a bit more is lead in spices.

I don't know if you've heard about this, but there was a study in Bangladesh recently that showed that a lot of turmeric has really high concentrations of lead and that's because the producers add yellow lead pigment to the turmeric root to make it a more appetizing color (because I think it can turn out a bit pale depending on the conditions that it's produced in). So they add this lead pigment which leads to really high levels of lead in food, which you're directly putting into your mouth. So that's a problem in some places in Bangladesh -- it's been shown to be a problem in Georgia as well (the country) and probably is relatively widespread.

So we could start doing some sampling on spices as well and then see if we can apply a similar intervention to what we're doing with paint.

There are probably more sources and huge amounts of research yet to be done.

12:45 - Biggest risks to LEEP

There are a couple of things that we've been thinking about a lot recently.

One is that progress could slow down in Malawi, it could take longer than we hope to actually reach the point of having less lead paint on the market. For example, if government or industry stopped engaging or stopped prioritizing it

So far engagement's been really good and momentum has been really good, but that could slow down for a number of reasons, like COVID or just other stuff happening (there are huge numbers of priorities for these people). There are things we can do if that happens, like we can start increasing the pressure through the public, and media, and that sort of thing.

Another risk and uncertainty is the extent to which our progress in Malawi is Replicable in other countries. We'll be able to get a better sense of that over the next year as we continue working in Zimbabwe and Madagascar and as we expand to other target countries as well. But it's hard to say at the moment.

13:44 - How can people support LEEP?

If you're interested in what we're up to, you could sign up to our newsletter on our website, leadelimination.org, and we can keep you updated with study results that we're doing and everything else that's going on.

We are fundraising at the moment as well. So, if you're interested in donating to a project like LEEP working on lead exposure, then again on our website (leadelimination.org) you can donate.

Also if you are interested in seeing if there volunteering or internship opportunities, we sometimes have some of those things that come up as projects. So you can email me at lucia@leadelimination.org.

If anyone has any kind of expertise or advice, we're always looking for feedback, we're always looking for advice. So yeah, let us know.

Charity Entrepreneurship

14:48 - Overall experience with Charity Entrepreneurship

Luke: I'd love to hear a little bit about your experience with going through Charity Entrepreneurship?

Lucia: Yeah. It was a great experience. It was really, really brilliant. I went through the program last summer. I think without that, I wouldn't have had the confidence or support to start a charity at this point in my career, and if I did, it probably would have also just had a lower chance of making quick progress or being high impact cost-effective. So it was really brilliant, yeah.

15:44 - Support provided by Charity Entrepreneurship

Luke: What did Charity Entrepreneurship do to help you get started and to support you throughout the process?

Lucia: The first thing is this kind of two-month incubation program (and that happened last summer). It was actually remote because of COVID but it was still pretty great, and that was where I decided to work on this intervention.

They had done research during the previous year looking at what charity ideas to recommend, and one of them was advocating for lead paint regulations. That was why we chose this intervention.

It's also where I paired up with my co-founder, who was also on the program, Jeff Rafferty. It's also where we got our initial seed grant.

What they do during the program, as well as setting you up with all of this stuff, is they teach you just a huge amount of really practical and relevant content about how to start a charity:

How to make a cost-effectiveness analysis
How to plan monitoring and evaluation strategy
How to hire
How to make a six month plan

All of that kind of stuff.

I would highly recommend it for anyone remotely interested. I think a lot more people should consider it because I never really considered it until I saw someone else do a similar thing -- and then I was like "Oh! That's a career option? That's a high impact thing I could actually probably do!".

The other thing they do is they give ongoing support. So it's been almost a year and we still have weekly mentoring with the Charity Entrepreneurship team.

Then there's this whole community of their previous incubatees who've also started charities that we get support from.

It's really fun and satisfying to be learning a lot really quickly and it's also just really fulfilling to actually be doing something that has a high chance of being impactful or relatively high chance of being impactful and making a difference -- so that's really great!

There are things about it that are a lot more stressful than even working as a junior doctor during a pandemic:

Like the kind of uncertainty, you never really know if you're doing the right thing;
A lot of it's very high stakes;
That you really want to get it right; and
It's all on you and your co-founder.

But I think that's just part of doing something with high expected value: it's risky, but potentially really good.

So it's been a really good experience overall.

17:46 - Transition from being a doctor

Luke: I'd be interested in hearing how you found the transition from kind of your medical work to being in a charity and doing something quite different.

Lucia: Yeah, it was a big shift.

One of the main differences is going from playing a role in a system and knowing exactly what you're supposed to do to working out from more first principles. Like: "Actually, what should I be doing? How do I prioritize things?" -- that's quite a transition. But it's also just a really fun one because it's part of being able to create something and then see things different from how they would be if you weren't doing the thing.

Whereas when you're part of a health system and you're working as a doctor the most you can do is make sure things go how they're supposed to go.

Whereas when you're starting something new, they're going in a way where they wouldn't have otherwise gone (the counterfactual impact I suppose). I think the Charity Entrepreneurship support has been huge. It made a huge difference in making that transition easier as well.

Because we have these mentors and people who've been through like the early stages of a charity startup themselves and we can get that guidance and an understanding of what it's all like, and the support as well.

So that's been good.

I do miss clinical medicine a bit, but I can still do some: I did a shift last week in the emergency department just for fun.

So that's nice.

Luke: I play music for fun, you do a medical shift in an emergency room.

19:32 - Shifting identity from a doctor to charity entrepreneur

Lucia: [laughs] but yeah, I think that makes the shift easier.

Cause the other part of the shift is an identity shift. Right?

Being a doctor is like a super well-defined identity. Everyone understands and it's well-respected -- and then all of a sudden you're just doing something quite weird that a lot of people don't really get.

And that can be hard. There's just something difficult about that. That's a bit of an adjustment as well, but it's all good.

I'm still a doctor, I can still practice medicine a bit and that kind of thing, which makes it easier.

Luke: Yeah. Are you glad that you spent the not-an-insignificant amount of time in medicine to have that training as both foundational work, as well as your fall back and various other benefits?

Lucia: Yeah, I think so. I don't know whether if I could go back again, I would have chosen to study medicine and practice as a doctor, but I definitely do feel that there are benefits from it.

So, like you say, the fullback option is really nice. It's a nice piece of security when I'm taking that quite a risky career decision. It's nice to know that I can always always do that.

The other thing is I think studying medicine and practicing as a doctor gave me more confidence in myself and my own abilities. I know I can do stuff and that's quite empowering -- and makes me feel again more confident to do something a bit more risky.

The other thing that I'm grateful for from medicine is the credibility that it gives you being a doctor when you're working with health ministries or partners in other countries who are also doctors.

It does help, so that's pretty cool.

As a doctor you learn relevant stuff about health systems and healthcare, and people. You learn a lot about communication and decision-making and all of these things that are pretty cross-applicable as well.

So I feel glad that I did it, but I'm not saying that it wouldn't have been better not to do something else, like maybe a more direct route into something impactful.

Luke: Yeah, that being said, it's hard to have a direct route into what you're doing right?

Lucia: Yeah. [laughs] That's true. Yeah.

Luke: And I'm sure it helps in evaluating the work that you're doing as well. That your foundational literacy in the medical side of things?

Lucia: Yeah, and the research literacy as well. Part of my degree included a lot of research and that sort of thing -- and that's pretty helpful.

Effective altruism and Giving What We Can

22:33 - Personal experience of loss

Luke: That's great. I'd like to wind back the clock a little bit and tell us a little bit more about how you first encountered these ideas and kind of this spark of what inspired you to try and use your time and money and resources to do good in the world.

Lucia: I was probably around eight years old and one of my school friends actually died of leukemia. I just remember thinking a lot about how that's a really bad thing. This is really sad for his family and his friends. I thought a lot about the impact that has on his mom and his little brother.

I remember just being in my bedroom and looking around at my stuff and thinking: "I would literally give away all of my toys, all of my clothes, everything to change that outcome". And of course, you can't do that, but it got me thinking that there are actually things you can do to prevent people from dying.

And I was aware of people in other contexts where kids are dying for preventable reasons. I started kind of feeling very uncomfortable with this idea that we would do so much for the people who are close to us, the people who we see and care about, and yet we don't really apply that to people farther away and people who other people care about just as much as other people's friends.

So I think that's when I first started reflecting on that not being quite right.

I don't know if I really formulated exactly what that meant for how I wanted to live my life, but definitely kind of had this growing unease with the norm of just focusing on the people around you and not thinking about the impact you can have on others as well.

I think that was probably the first thing.

23:59 - Moral awakening from Peter Singer

And then when I was around 12 years old, I went on a camping holiday with my grandpa and decided to bring a couple of books. I've never really been a big reader, but I was like, "You know what, I'll read -- I think that's what people do on holiday!". And I took Twilight -- highly recommend it -- and I also took this collection of essays by Peter Singer that I just found on the bookshelf at home. It's called Writings On An Ethical Life (I don't think it's still in print).

One night I was reading Famine, Affluence and Morality, and, I I know you're familiar with this, but in the conclusion Singer argues that: if it's within our power to prevent something bad from happening without sacrificing something of equal moral significance, then we ought to morally do it. It doesn't matter if that person is like a neighbor's child or if it's someone 10,000 miles away.

That essay had just a huge impact on me. I remember just having these very strong and overwhelming mixes of emotions.

One of the emotions was validation and relief, like "Okay, I've been thinking this is a problem for a while. I've been thinking this seems like the correct conclusion, but like here is a legitimate philosopher in a book saying what I thought was probably true, but I would always doubt it because that's not how other people in my life seem to live their life or seem to agree with" -- so that was pretty cool.

And then I guess the other emotion with that was like "Oh no, if this is really true, then this has huge implications for how we should prioritize things in our lives and has massive implications for how I should live my life going forward" -- so that was big.

And I think that kind of made it all a lot more concrete for me.

Like, "Yeah, this makes sense. Other people think so too. Let's do something about it."

Luke: Yeah. And at this stage in your life, did you know anyone else who thought similarly?

Lucia: No, just Peter Singer. I became his biggest fan.

I didn't really know anyone else. I started talking about it with more people after this. And I started to find people who agreed. So that was cool.

And then when I was in high school, I heard about Giving What We Can and that was really awesome.

And I was like "Yes, this is clearly a good idea. The Giving What We Can Pledge, I'm definitely going to take that when I'm old enough". And that was nice to know that there's this community out there of other people thinking the same way.

26:35 - Discovering the effective altruism community

And then when I got to university, I went to Cambridge where there was already an effective altruism chapter, so I got involved there and that was brilliant.

And then in my third year, I co-ran Giving What We Can at Cambridge. And again, just upwards from there.

I spent a whole six years at university doing medicine. And I think even at all of that, it was the best part. You get to meet other people who are already really engaged in these ideas and other people who've thought about the same things as you and you get to discuss with them and learn from them, and that's pretty awesome.

And I'm still friends with a load of people from the chapter back then. Still having those people to learn from, discuss things with, to just generally be inspired by is really, really helpful. It's just great.

I think it also made me personally feel more motivated. when you're doing something with other people, it's just more motivating.

It helps you help you take more concrete actions as well. So, you know:

Taking a Giving What We Can Pledge;
Becoming vegan;
Making career decisions

All of those actually important steps are just way, way easier when you have other people around you doing the same thing, or kind of validating that it's a reasonable decision.

Then the other thing, I guess, is that it opens up a lot of opportunities as well. You meet other people going in the same direction as you, with the same values. And then you can work with them later, you can volunteer with them, you can get involved in other projects and organizations -- and that's really cool.

So yeah, highly recommend getting involved in the community -- it's really good.

28:14 - Talking about effective altruism

Lucia: In terms of talking to other people about effective altruism and The Pledge and that sort of thing: I think the kind of the way it usually seems to go is that people already kind of have these ideas and kind of agree -- they just haven't found that this is "a thing". So it's really awesome to be there when people find out that this is "a thing that really matters to them" and that there are other people. And you can be part of that journey of moving forward with taking those core values and beliefs that people have and actually helping them fulfill those and make it part of their life.

So that's really nice, yeah.

Closing

28:54 What's next for Lucia & LEEP?

Lucia: I'm very excited about expanding LEEP. I'm excited to try and multiply our impact in new countries and look at how many children we can impact: "how many DALYs we can avert?". [laughs] Sounds lame, but that's very exciting for me. And I'm excited about expanding our team - that will be really cool.

And also it's exciting to just be able to be more engaged in the community and talk to more people about these kinds of options and even about lead exposure and other neglected things and have that kind of influence on other people.

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