Environmental and Disaster Displacement Policy Organisational Cooperation Between The Un High Commissioner For Refugees and The International Organisation For Migration Silvana Lakeman Full Chapter
Environmental and Disaster Displacement Policy Organisational Cooperation Between The Un High Commissioner For Refugees and The International Organisation For Migration Silvana Lakeman Full Chapter
Environmental and Disaster Displacement Policy Organisational Cooperation Between The Un High Commissioner For Refugees and The International Organisation For Migration Silvana Lakeman Full Chapter
Environmental and
Disaster Displacement
Policy
Organisational Cooperation between the UN High
Commissioner for Refugees and the International
Organisation for Migration
Silvana Lakeman
Bremen International Graduate School of Social Sciences
University of Bremen
Bremen, Germany
© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
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Acknowledgements
I would like to thank all who provided feedback throughout the process of
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vii
Contents
ix
x Contents
Index249
Abbreviations
xi
xii Abbreviations
xiii
CHAPTER 1
International Organisations
and the Climate-Migration Nexus
During my time working on this book, the world has been gripped by a
global pandemic. Political and media attention are naturally fixated on
scientific, social and economic developments in response to Covid-19, and
momentum regarding climate change—arguably the largest threat to
humanity in the twenty-first century—has been placed on the backburner.
Despite this, few issues have received as much debate on the global stage
as migration and climate change in recent decades, and it is my belief that
in the coming years, these issues will dominate once more. Oftentimes,
climate change and migration overlap in complex and messy ways. Recent
reporting supports the argument that climate change is contributing to an
increase in both the frequency and the intensity of slow and sudden-onset
climatic events, which are major drivers of human displacement (UNDRR/
CRED, 2020). Natural hazards, such as tropical cyclones, flooding,
desertification, drought and bushfires, are increasingly unsettling tens of
millions of people worldwide, leading to natural disasters. Further, those
in the poorest, most underdeveloped parts of the world are disproportion-
ately affected by these phenomena. In fact, according to the Internal
Displacement Monitoring Centre (IDMC), 2018 saw almost 17.2 million
individuals newly displaced internally due to climate-related disasters,
mostly in developing countries (IDMC, 2019a). Now more than ever,
inter-governmental and international organisations (IGOs and IOs) with
an agenda to protect displaced populations have an important role to play
have the potential to equate to greater competition in the long run at the
international organisational level.
In many ways, the proliferating threat of climate change (and its ability
to worsen or exacerbate conflict and hazards which may result in natural
disasters and displacement) is the epitome of the modern crisis. This is
especially true in the sense that climate change does not respect borders or
confine itself to one policy area (Boin & Lagadec, 2000, p. 185). Given
the position of international organisations at the frontline for cross-
boundary issues, it is perhaps unsurprising that climate change threatens
to undermine the work of a vast variety of IOs across a range of policy
spheres. Those studying crisis management would suggest it is not climate
change or ensuing challenges that cause issues, but rather the systems—
including organisations—we have in place, and their inability to adapt and
uphold their legitimacy in the face of adversity (Dayton et al., 2004,
p. 168). Despite this challenge, crises can also be powerful instigators for
positive organisational change and learning opportunities for organisa-
tions to grow and adapt to new realities (Wang, 2008, p. 427).
while minimalists (such as Black, 2001, and Massey et al., 2010) have
emphasised ‘the complexity of the interaction between environmental and
social systems’, noting that environmental change is just one of many
complex factors that may drive human movement (Morrisey, 2012, p. 38).
When it comes to definitions, maximalists have employed the term ‘envi-
ronmental refugee’, with the relatively few supporters of the creation of
such a definition arguing that the term was first used by a UN body (the
UN Environmental Programme) in a 1985 report, and that its previous
use at the UN provides a strong basis for its future use at the UNHCR in
particular (El-Hinnawi, 1985).
In more recent years, there has been a notable softening of rhetoric
between these two camps of thought. Bettini (2014, p. 185) has high-
lighted that nowadays, ‘nobody objects to the idea that climate change
will have a large influence on mobility’. An increasingly popular way to
approach the issue is somewhere in the middle; Cantor (2021, pp. 270–271)
has pointed to a consensus that even as one of potentially many overlap-
ping factors, environmental change ‘may produce distinct forms of mobil-
ity, as in circumstances of sudden or extreme environmental change’.
Minimalists have even softened on the use of the term ‘environmental
refugee’ (Morrisey, 2012, p. 38), with François Gemenne admitting that
despite associated legal issues, there may be benefits to using it—forgoing
the term ‘is also, in a way, forgoing the idea that climate change is a form
of persecution against the most vulnerable and that climate-induced
migration is a very political matter, rather than an environmental one’
(Gemenne, 2015, p. 71).
Perspectives on the issue continue to shift and, as environmental change
becomes an increasingly important factor in human mobility, often beyond
the desks of scholars. In 2006, the Maldives petitioned for an extension of
the 1951 Geneva Convention Relating to the Status of Refugees to include
the term ‘environmental refugees’, which was rejected (McAdam, 2011a,
p. 103). Since then, further solutions at the international level have been
discussed and proposed, such as legal concepts including ‘deterritorialised’
states or ‘nations ex-situ’ for those left without territory due to rising sea
levels (Burkett, 2013; Rayfuse, 2010). However, such proposals lack a
comprehensive analysis of previous international organisational responses
to specific cases of displacement, both short and long term. Some have
highlighted existing bilateral agreements between states that may prevent
more permanent migration as a solution, such as the Recognised Seasonal
Employer scheme in New Zealand (Shawn & Gemenne, 2011); however,
1 INTERNATIONAL ORGANISATIONS AND THE CLIMATE-MIGRATION NEXUS 9
a consideration of how directly relevant IOs may play a future role in such
schemes remains largely underdeveloped. Regarding actual attempts to
claim asylum or refugee status, a lack of definitional expansion has defini-
tively inhibited individuals seeking safety from environmental threat, as in
the popularised case of a Kiribati national seeking refuge in New Zealand
due to the effects of climate change (Library of Congress, 2016). The case
of Ioane Teitiota, who made the claim in 2013, was more recently rejected
by the United Nations, which found that Teitiota was not in immediate
danger. However, the case has set a precedent for the future of legal
debates in this area (BBC News, 2020). Although it remains to be seen
what effect this landmark ruling will have for the future management of
environmental displacement, future discussions should at least consider
the role of UNHCR and IOM, given their positioning as prominent refu-
gee and migration IOs. Indeed, UNHCR and legal scholars have more
recently further clarified available legal frameworks for cross-border pro-
tection in the context of climate change and disasters—at least in part
motivated by precedent set by the Teitiota case (UN High Commissioner
for Refugees, 2020a). While there have been international attempts involv-
ing IOM and UNHCR to address cross-border displacement due to cli-
mate change, such as the Nansen Initiative and Platform on Disaster
Displacement (McAdam, 2016), gaps remain regarding a critical analysis
of IO involvement and influence in such projects.
Despite reporting in recent years that a majority of human displace-
ment due to environmental and disaster-related causes have been (and will
continue to be) internal (IDMC, 2019b), internal displacement as a result
of environmental stressors has not received the same academic and policy
attention as cross-border displacement. Nor has the involvement of
UNHCR and IOM—despite definitive proof regarding their involvement
in disaster scenarios. This could be because many perceive the existence of
the 1998 UN Guiding Principles on Internal Displacement to be a suffi-
cient legal and normative protection framework (Koser, 2011). While the
Guiding Principles state that national authorities are primarily responsible
for protection and humanitarian assistance in cases of internal displace-
ment, IOs do ‘have the right to offer their services in support of the inter-
nally displaced’, and states should not see this offer as an interference or
an unfriendly act (UN High Commissioner for Refugees, 1998). Further,
when national authorities are simply ill-equipped (or potentially politically
unwilling) to handle the enormity of a disaster or environmental degrada-
tion that may result in displacement, international organisations may play
10 S. LAKEMAN
Central African Republic (Darcy, 2016; Hanley et al., 2014; Steets et al.,
2010; Telford et al., 2006). Although these evaluations indicate willing-
ness to learn, that most are self-conducted or published by IOs, or out-
sourced to consultants with a potential interest in future employment
opportunities with organisations, leaves a gap that this book may begin to
fill as an independent study.
Although work has been done over the years on the complementariness
of (Sampson, 2004) and consultative relationships between (Gunter,
1977) IOs, much academic criticism of international organisational
response has stemmed from topical concerns, such as the expansive work
done on IO engagement in the health sector in post-disaster contexts.
Here, work has been done in relation to psychosocial interventions when
national capacities are overwhelmed (Ganesan, 2009), in relation to the
bureaucratic structures limiting collaboration in humanitarian contexts
(Parmar et al., 2007) as well as information sharing and coordination
(Burkle & Hayden, 2001), to name a few examples. Some work has also
been carried out from the perspective of UN member states regarding
their interest in managing IOs (De Koster & Holvoet, 2012), and on the
use of UN collaboration to exert influence at the World Bank (Das, 2009).
However, as yet, little work has been done in any significant detail to con-
textualise and consider how or why organisations have become involved in
the way that they have, based on previous experiences and their own lim-
ited capacities at any given point in time. Indeed, little work has been done
beyond evaluations of specific disasters to consider organisational involve-
ment in the overall topic of environmental and disaster response at all.
Granted, the EACH-FOR (Environmental Change and Forced Scenarios)
project (CORDIS, European Commission, 2012) investigated patterns of
environmental migration relevant to questions of politics. However, dis-
cussion of international governance was largely limited to regional adapta-
tion and did not make specific demands of international organisations
such as UNHCR or IOM. Likewise, comprehensive work on climate
change and migration by Piguet et al. (2011) has placed little emphasis on
questioning whether international organisations have adapted or devel-
oped in response to, and in relation to one another on, this issue.
There has also been a rejection of the idea to create a new agency to
lead in this issue area—or at least few developments as such (McAdam,
2011b; McNamara & Gibson, 2009), despite limited suggestions to cre-
ate one in earlier years (Biermann & Boas, 2010; Docherty & Giannini,
2009; Okeowo, 2013). The rationale behind this rejection is that we
1 INTERNATIONAL ORGANISATIONS AND THE CLIMATE-MIGRATION NEXUS 15
already have a variety of IOs (primarily bodies within the UN) which have
decades upon decades of experience in specific fields which inadvertently
overlap with the issue area—namely, UNHCR and IOM. So long as these
IOs are active and involve themselves on matters of environmental and
disaster displacement (and we expect them to) insufficient consideration
of these IOs is to the detriment of academics, policymakers and IOs them-
selves. Moreover, unbiased research on the involvement of IOs in this
issue area is a worthwhile venture in and of itself, particularly as experts
have recognised the unique (and very real) influence of research on poli-
cymaking when it comes to all matters environmental migration. Gemenne
and Rosenow-Williams (2016, p. 238) have pointed to the fact that this
particular research area is rather unique, in that it brings policymakers and
researchers together in a plethora of settings—thus increasing the poten-
tial for developments between research and policy.
What does all of this mean for organisations working to respond to
disasters and with those displaced by such events? Convergence, as intro-
duced earlier, is witnessed at the humanitarian response level as well. While
for decades, IOs have traditionally taken a purely response-driven and
emergency aid-based approach to disaster scenarios, an increase in the
number and severity of disasters due to global factors such as climate
change has rendered this approach increasingly unsustainable for both
affected populations and IOs alike (Hilhorst, 2018). Instead, there has
been a shift towards humanitarian action focused on improving the ongo-
ing situation of vulnerable and affected populations, so as to reduce the
effects or likelihood of disaster from occurring in the first place (Marin &
Naess, 2017). IOs are therefore shifting from traditional conceptions of
humanitarian response to what has been dubbed ‘new’ humanitarianism;
focused on broader resilience, disaster risk reduction and sustainable
development measures. The 2005 Humanitarian Reform Process at the
UN, resulting in the IASC Cluster Approach for emergency response, is
representative of a clear shift from response driven to preventative human-
itarian response (Marin & Naess, 2017). However, given that internal dis-
placement due to disaster is often protracted, such efforts have invariably
meant that IOs are increasingly engaged over longer periods of time on
longer-term solutions to problems not originally intended as theirs to
solve. In response to this shift, Hilhorst (2018, p. 6) has raised a valid
question to keep in mind: ‘What does the new paradigm mean for the
identity and legitimacy of humanitarian agencies?’
16 S. LAKEMAN
A Multi-dimensional Approach
to Agency Involvement
and its Cluster Approach for humanitarian response, may prescribe what
appropriate action should be for UNHCR and IOM. However, this is not
akin to presuming rules always dictate agency behaviour or decision-
making, nor is following a logic of appropriateness a panacea for morality
or efficiency—those carrying out ethnic cleansing, for example, have fol-
lowed rules seen as ‘natural, rightful, expected and legitimate’ (March &
Olsen, 2011, pp. 2–3).
March and Olsen also hypothesise that it should be easier to follow a
logic of consequences to justify decisions, as self-interpreting conduct as
‘appropriate’ (or not) seems a more complicated exercise than simply
rationalising behaviour and decisions in terms of one interest over another
(March & Olsen, 2011, p. 17). When it comes to switching logics of
behaviour entirely, a logic of consequences may replace a logic of appro-
priateness if following the rules no longer seems satisfactory—especially
regarding new targets and goals that do not easily fit within the status quo
of expected responsibility or familiar activities. Inversely, a logic of appro-
priateness should dominate when the actor or organisation’s environment
is fairly stable, patterns of action and the actors themselves are well estab-
lished, and memories of behaviour are well institutionalised (March &
Olsen, 2011, p. 17). This understanding could mean multiple things for
IOM and UNHCR. For one, UNHCR and IOM have a relatively shared
history, and via institutions such as the Inter-Agency Standing Committee
and the Cluster Approach (under the auspices of the UN more generally)
they should also have frequent interaction and shared experiences on some
level. However, environmental disasters are hardly a picture of stability,
and despite efforts to stabilise organisational involvement, there will always
remain an element of uncertainty—particularly regarding resource avail-
ability and individual country situations. It is therefore not clear from an
analysis of March and Olsen’s picture of logics where the IOM and
UNHCR would fall.
Classifying IOs in one way or another to understand why they may
behave as they do is not a new concept; multiple scholars have directly or
indirectly addressed the topic in a variety of ways. For example, Cox et al.
(1973) systematise agencies based upon their histories, institutional frame-
work, and stated functions, whilst Scott and Davis (2006) have under-
taken a treatment of IOs as either rational, natural or open systems. Ness
and Brechin (1988) have identified that aspects of structure, technology,
goals and environment are determinants for organisational performance,
considering the study of, and sociology of, organisations together. Lastly,
1 INTERNATIONAL ORGANISATIONS AND THE CLIMATE-MIGRATION NEXUS 23
entities with their own detailed historical paths of involvement that war-
rant analysis—individual historical paths can both be considered as valu-
able findings in their own right, as well as reflected upon as to whether
they are illustrative of theorised mechanisms for normative and func-
tional IOs.
work together in this capacity (e.g. alongside each other in the Cluster
Approach in their respective leadership roles). We may also hypothesise
that either they themselves or external forces (such as member states)
expect and trust them to continue working in this way. Historically inher-
ited roles as specialists and partners on refugees and migration also indi-
cate why IOM and UNHCR choose to differentiate themselves when it
comes to an association with landmark documents such as the GCR and
GCM; with emerging issue areas such as environmental and disaster dis-
placement challenging existing positions, it may be comforting to relegate
tasks and define positions in an attempt to reaffirm a status quo.
As stated earlier, a third question in this book is in relation to the poten-
tial impact of local agency presence. Path dependency from a purely his-
torical institutionalist perspective might tell us that when an issue arises or
disaster strikes, field offices at UNHCR and IOM are likely to consider
how they have responded to similar situations in the past, and as a result,
engage according to what ‘worked’ before—placing them on a path
dependent trajectory. However, path dependency in the strictest sense
does not fully account for organisational behaviour ‘in the moment’ (e.g.
in disaster response scenarios). The concept of policy inheritances—
whereby ‘policies today are not made in a vacuum; they are built on previ-
ous policy decisions, which exert a heavy hand on future
commitments’—strengthens the path dependence argument, as it accom-
modates ‘on-the-ground’ decision-making and action (Jones &
Baumgartner, 2007, p. 49). This concept born from larger theories of
behavioural change is highly synonymous with path dependence and is a
particularly useful explanation for the assumption that agencies will rely on
a combination of past experiences and existing local capacities to respond
to disasters. The underlying idea of this claim is that organisations have a
limited capacity to tackle multi-dimensional issues as they emerge, and so
decision-making is often reliant on the status quo’—or how a similar issue
was tackled in the past. Priorities are set based on perceived urgency, which
is context sensitive. This project assumes that as the ‘first responder’ to a
disaster on behalf of the wider IO, field offices for UNHCR and IOM will
likely consider a natural disaster in their locality ‘urgent’, and shift atten-
tion to that disaster. On a very empirical level, this means that local offices
potentially have to make decisions on: how they will divert funding from
ongoing projects elsewhere in the country; if they will request increased
funding and support staff from head offices, and if they will reach out to
partner organisations for help on tackling certain aspects of their work?
1 INTERNATIONAL ORGANISATIONS AND THE CLIMATE-MIGRATION NEXUS 29
of Southeast Asia. Several months later, bodies were still being found, and
the Philippines faced a humanitarian crisis, with almost two million left
homeless and more than six million internally displaced (Mercy Corps,
2013). The event prompted the United Nations to activate the Cluster
System, in which groups of both UN and non-UN agencies and organisa-
tions worked to address a variety of issues such as nutrition, health and
shelter. The event also prompted a large variety of celebrities, companies
and NGOs to raise emergency funding for those affected (Dy & Stephens,
2016), and the 2013 United Nations Climate Change Conference was
coincidentally underway when Haiyan struck, where the UN representa-
tive for the Philippines declared a hunger strike in solidarity with his kins-
men back home (Abano, 2013).
To analyse agency involvement across policy, operational and individual
levels, this book draws from a wide range of both primary and second-
hand sources. A significant bulk of primary sources are from UNHCR and
IOM themselves, in the form of first-hand publications available from
agency archives online. I analysed all publicly available, relevant docu-
ments from both agencies on the topic of environmental and disaster dis-
placement between 2008 and 2017, as well as on Typhoon Haiyan. These
documents included speeches, press releases, policy papers, reports and
official statements. Publications were systematically collected with docu-
ments filtered for key terms, including ‘natural disaster displacement’,
‘environmental displacement’, ‘disaster’, ‘migration and climate change’,
and ‘migration and environment’. Although I largely abstain from use of
the word ‘natural’ in relation to disasters, it is not uncommon for interna-
tional organisations to employ the term to differentiate between environ-
mental and ‘man-made’ disasters (usually associated with violent conflict),
and thus its inclusion in initial searches was warranted. For the second part
of this book, documents specifically mentioning ‘Typhoon Haiyan’ were
of interest, with special preference given to those referring to the cyclone’s
presence in the Philippines. All publications were manually checked for
their relevance and arranged by date prior to analysis.
In addition to first-hand publications, 13 in-depth, semi-structured
interviews with staff members of UNHCR and IOM from both headquar-
ters in Geneva and field offices in the Philippines and other countries, as
well as former employees and high-level experts from within the UN, were
conducted. Seven in-person interviews were conducted in Geneva,
Switzerland, during and surrounding the sixth Session of the Global
Platform for Disaster Risk Reduction (2019) and at UNHCR and IOM
32 S. LAKEMAN
In the lung, stomach, kidney, and heart, only traces were found.
Dixon Mann[7] describes some experiments in which potassium
iodide was given in cases of chronic poisoning, and during the whole
of the experiments the fæces and urine were analyzed three times a
week. He found by this means that a considerable amount of lead
was being eliminated by the intestine. He therefore administered 2
grammes of lead acetate three times a day for five days to a patient,
and he found that the fæces contained 0·1762 gramme the first day,
0·17411 gramme the second day; the fourth day it had fallen to
0·0053 gramme, and on the sixth day to 0·0006 gramme. The
largest amount at any one time in a day obtained from the urine was
only just over 0·001 gramme; the average amount found in the case
of chronic poisoning was about 3 milligrammes, whereas the
greatest amount at any one time in the urine was only 0·9
milligramme.
The quantity of lead present in the brain necessary to determine
acute poisoning is not known, and it is probable that an extremely
minute quantity will produce very serious effects; and in support of
this may be quoted a number of observations in which search has
been made for the metal in persons who have died of diseases
affecting the brain associated with other symptoms of poisoning, and
yet post-mortem examination of the brain by chemical methods has
not revealed the presence of any lead whatever. In the case reported
by Mott (see p. 71), no lead at all was recognized in the brain.
There are no reasons, therefore, for supposing that the immunity
to lead poisoning depends on the fixation and storing up of the
poisonous metal in a non-poisonous form in some special situation in
the body, and, further, the particular situation in the body richest in
lead in any given case of poisoning will depend rather on (1) the type
of compound causing the poisoning, and (2) the portal through which
such poisoning occurs.
The question of the detection of lead in the body is referred to in
the chapter dealing with Chemical Examination. It is as well to point
out in this connection that chemical investigation of the amount of
lead present in the organs of persons dying from lead poisoning
should, if possible, always be made where there is any doubt as to
the diagnosis.
Certain observers—amongst them Gautier[8]—are of opinion that
traces of lead may be found in normal persons. Thus, in a rat (Mus
decumanus) Gautier found 2 milligrammes of lead in 60 grammes of
liver. He considers that in many persons at least 0·5 milligramme of
lead may be swallowed daily incorporated with the food, as a
number of foods are liable to contamination by lead. Tinned foods,
particularly those which are soldered up after the materials have
been placed in the tin, certain tinned fruits with acid juices, often
contain small masses of solder loose in the tins; in the case
particularly of fruits the natural acid may slowly dissolve the lead
from the solder. The amount of so-called “normal” lead, if it is to be
found at all, must be very small, and would certainly be much smaller
in the case of a normal person than in one who had been subject to
definite lead poisoning. Such experimental evidence as is
forthcoming supports the clinical observations that persons exposed
to small doses of lead eventually develop tolerance of the metal, so
that they may ultimately withstand many times the dose sufficient in
the first instance to produce poisoning.
Such circumstances are the natural factors in the prevention of
poisoning, and if due care be given to their significance, the surgeon
in charge of any lead works may by judicious treatment and
alternation of employment so assist and strengthen the natural
defensive forces that susceptibility may be diminished, and the
degree of tolerance increased to a very considerable extent. We do
not imply that efficiency in the exhaust ventilation can be in any way
relaxed; all we desire to emphasize is that certain natural defensive
forces of the body do undoubtedly exist by which susceptible
persons ultimately become less susceptible, and that by appropriate
means these defensive forces may be augmented.
Susceptibility and immunity to poisoning by lead may be
considered, according to the type of lead compound absorbed,
further in its relation to age and sex. All compounds of lead are not
poisonous in the same degree; the more easily soluble compounds
are more poisonous than the less soluble. On the other hand,
compounds which appear at first sight unlikely to produce poisoning
may do so; for instance, fritted lead or lead silicate, a substance
largely used in the potteries as a glaze, and manufactured by fusing
together litharge and a silicate, would appear at first sight to be quite
an innocuous substance. Owing to its method of preparation,
however, it is not a pure compound of lead and silica, but contains
lead oxide, metallic lead, etc., entangled in its meshes, and
experimentally one of us (K. W. G.) has demonstrated that such a
compound may be acted on by the tissues of the body, both when
injected subcutaneously and even when inhaled, and so gradually
produce definite symptoms of lead poisoning, but at a much slower
rate than the more poisonous lead compounds. The fineness of
division in which the compound of lead exists is another factor
affecting its poisonous nature; the more finely divided particles find
their way into the lung more easily than the coarser particles. Various
subsidiary matters may also determine the susceptibility in a given
individual, and of these a certain number require mention, as they
probably act as definite predisposing factors. Age and sex may be
regarded as predisposing factors to lead poisoning, and certain
diseases also.
Age.—Young persons are regarded as more liable to lead
poisoning than adults, although it is difficult to obtain definite figures
on the point, the duration of employment acting as a disturbing factor
in estimating the susceptibility of young persons. They may have
worked in a lead works for a year or more without showing any signs
of poisoning, but develop them later in adult life, although it is very
likely that absorption had taken place during the earlier period. In the
Report of the Departmental Committee on the Use of Lead in the
Potteries (Appendix XII.), the attack rate for the period 1899 to 1909
for young persons is 19·3 per 1,000, and for adults 18·8 for the same
period, but the figures upon which these attack rates are based are
too small to build any conclusion. The general clinical conclusions of
appointed surgeons and certifying surgeons in the various lead
factories would be, we believe, that the susceptibility of young
persons is at least twice that of adults, and there is some ground for
supposing that the tissues of an adult when growth has ceased more
readily adapt themselves to deal with the absorption and elimination
of poisonous doses of lead than do the tissues of a young person.
Sex.—Women are more susceptible to poisoning by lead than
men, and in lead poisoning from drinking water the proportion of
women (especially pregnant women) and children attacked is stated
to be higher than in men, and one such epidemic is quoted by Oliver
where the rise in the number of miscarriages and premature births
led to the discovery of the fact that the water-supply was
contaminated with lead. The close relationship of lead poisoning to
miscarriage has been repeatedly made out, especially by Oliver, in
the white lead industry as carried on twenty years ago. Oliver also
quotes the effect upon rabbits[9], Glibert upon guinea-pigs[10], and in
the experiments of one of us (K. W. G.), referred to on p. 99, all the
animals to which lead was given during pregnancy aborted; and,
further, with one exception out of eight animals, all died of lead
poisoning, not as the result of the abortion, but some time later,
although no further administration of lead was made. This confirms
the well-known abortifacient effect of diachylon, and there is no
doubt that the lead circulating in the maternal blood determines the
abortion. Further, observers who have examined the fœtus in such
cases have demonstrated the presence of lead in the fœtus itself.
Oliver[11] found that eggs painted with lead nitrate did not hatch out,
and on opening the eggs the embryos were found to have reached
only a limited stage of development, and to have then died, whereas
control eggs painted with lime produced live chicks. From what is
stated later with regard to the curious action of lead upon the blood,
the mechanism of abortion is easily understood; it is probable that
placental hæmorrhages are produced, as in other organs of the
body. But the effect of lead on the female is not only apparent during
pregnancy. A considerable number of women working in lead
processes suffer from amenorrhœa, and often from periods of
menorrhagia and dysmenorrhœa, which as a rule is the more striking
symptom. The effect of lead on the uterine functions, however, only
exists so long as the constant intake of the poison is taking place,
and many cases are recorded where women, after having had
successive abortions while working in lead factories, have ultimately
gone through a normal pregnancy and given birth to a living child.
This circumstance bears a strong analogy to the similar train of
events in syphilis.
In the Report of the Committee on the Use of Lead in the
Potteries, some inquiry was made with regard to the possible
association of lead absorption on the male side as a predisposing
cause of infant mortality and premature birth. The tables given are
not very conclusive, and from our own observations there seems to
be very little evidence for supposing that a male lead worker is less
likely to beget children, or that his children are more likely to be
unhealthy than those of men working in any other industrial process.
We are here speaking of the effect of lead under the conditions of its
general use in this country now. In the absence of any precautions
whatever as to daily absorption of dangerous dust, the effect on the
offspring, even in the case of male lead workers, may well be
evident, as has been shown by Chyzer[12] in the manufacture of
pottery as a home industry in Hungary. One greatly disturbing factor
in estimating the greater susceptibility of the female than the male in
many lead industries is that the more dangerous work is performed
by the women, such, for instance, in the Potteries, as the process of
colour-blowing and ware-cleaning.
Predisposing Causes of Lead Poisoning.—In lead poisoning,
as in many other diseases, a number of predisposing and
contributory causes may be cited which tend to lower the
susceptibility of the individual to the poisonous effect of the metal
and its compounds, or to so modify the functions of the body that a
smaller dose of poison may produce more profound changes than
would otherwise be the case.
Certain diseases may be regarded as predisposing causes by
lowering the general resistance of the body tissues to the influence
of lead, and a consideration of the chapter on Pathology will at once
demonstrate how seriously certain diseases may contribute in this
way.
The peculiar effect of lead is upon the blood and the walls of the
bloodvessels, and it will therefore follow that any disease which may
affect the intima of the bloodvessels may predispose to lead
poisoning; and, further, as the elimination of lead takes place to a
certain extent through the kidney, any disease which affects either
the renal epithelium or the general maintenance of the excretory
function of the kidney may predispose that organ to the irritative
effects of the lead circulating in the blood. In the same way, the
condition of lead absorption in which the balance of absorption and
elimination of lead remains in such a ratio that no definite symptoms
of lead poisoning appear may have that delicate balance easily
upset by the introduction of some secondary cause, which, when
operating in association with lead absorption, may precipitate
symptoms attributable to poisoning by that metal. Chronic alcoholism
especially, producing as it does definite changes in the kidney of
itself—changes which it is impossible to distinguish by the naked eye
from the effects of lead poisoning—must clearly act as a
predisposing, if not even an exciting, cause of lead kidney infection.
In experiments upon animals, it was found that the addition of
alcohol to the diet of an animal which was the subject of chronic lead
absorption precipitated the attack of definite poisoning; in other
words, the latent period of lead poisoning—that is to say, the
resistance exhibited by the tissues to the toxic influence of lead—
was considerably diminished by this addition of a second irritant,
alcohol. In several experiments, also, where the form of lead
experimented with was one of the least toxic of the lead compounds,
the animals subjected to such a compound alone did not become
poisoned, but succumbed if alcohol were added to their diet. This
experimental work is amply borne out by the clinical evidence of all
persons who have had experience of industrial lead poisoning, as
cases of colic and wrist-drop are frequently observed in lead workers
shortly after alcoholic excesses. Individuals, therefore, who are
suspected of the alcoholic habit should not be employed in any
process where they are likely to run risk of absorption of lead dust.
Such diseases as syphilis and gout, by causing a heightened
arterial tension or definite disease of the intima of the bloodvessels
themselves, tend to weaken the arteries in much the same manner
as does lead circulating in the blood, and must on that account act
as predisposing causes.
In persons employed in lead trades some species of tolerance is
generally developed, and if the functions of the body progress in the
normal way the balance of elimination and absorption are equal,
and, as will be seen later, the chief channel for the elimination of lead
from the body is through the bowel. It follows, therefore, that any
disease which tends to produce constipation or chronic inactivity of
the normal intestinal functions will also tend to lower the resistance
of the individual to lead poisoning.
Of the various types of intestinal disease of a chronic nature—
such, for instance, as chronic dysentery, colitis, and the like—little
need be said; but the predisposing effect of diseased conditions of
the upper portion of the alimentary canal must not be overlooked,
more particularly affections of the oral cavity itself. This special type
of infection, often included under the term of “oral sepsis,” besides
producing anæmia, is also a constant cause of intestinal
disturbance, and as such operates as a particular predisposing
cause of lead poisoning.
With regard to gout the evidence is not so clear. It was pointed out
by Garrod[13] that gout was common among house-painters, and it
has been generally stated that lead poisoning predisposes to this
complaint. In the opinion of a considerable number of observers,
however, gout is by no means common among persons working in
white lead factories or lead-smelting works, but there seems to be
some reason to suppose that it is somewhat common among those
persons employed in the painting trades, but not among those
employed in the manufacture of paints and colours. From the
experiments carried out by one of us [K. W. G.[13]]. it seems probable
that the occurrence of gout among painters may be associated with
the use of turpentine, largely employed in the ordinary processes of
painting, as this substance in particular is not one that is used by
workers in other lead trades, and, from experiments performed on
animals, the inhalation of turpentine vapour was found to produce
very definite changes both in the kidney and the general metabolism
of the body.
Malnutrition.—Malnutrition is recognized as a predisposing
cause of practically all forms of disease, and with a chronic
intoxication, such as lead poisoning, malnutrition and starvation, with
its attendant depression of all the vital forces of the body, is
essentially a predisposing cause of poisoning, so much so that even
the fact of commencing work without previously partaking of food
may operate directly as a cause of poisoning. It has been found,
moreover, experimentally by one of us [K. W. G.[14]] that an animal
fed with milk containing lead nitrate did not develop poisoning,
though the control animal developed well-marked symptoms of
poisoning with a much smaller dose given in water.
Anæmia.—Anæmia has already been referred to as occurring
with great frequency in persons who are absorbing lead, and it
usually forms one of the chief factors in the symptom-complex of
lead cachexia. As the action of lead is particularly upon the blood
and the hæmopoietic organs, diminishing the number of red cells
and the amount of hæmoglobin, and impairing the organs from which
fresh blood-cells are produced, a disease or state associated with
anæmia other than of lead origin acts as a definite predisposing
cause in the development of toxic symptoms in a worker in an
industrial lead process.
Among the anæmias, two particular types may be referred to as of
chief importance. In the first place, chlorosis, the anæmia occurring
particularly in young women, is often associated with intestinal
stasis. Lead anæmia occurring in a chlorotic person is always more
severe than simple lead anæmia. Young persons suffering from
chlorosis, therefore, should not be employed in a dangerous lead
process until the anæmia has been treated. The second type of
anæmia, which, from its frequency, may be also regarded as a
predisposing cause of lead poisoning, is chronic secondary septic
anæmia. Anæmias of this type, as was pointed out by William
Hunter[15], resemble in many points the original idiopathic or
Addisonian anæmia, often termed “pernicious anæmia,” and one of
us has had occasion to inquire into the curious type of secondary
anæmia associated with septic affections of the upper respiratory
tract, particularly those related to chronic suppurative affections of
the accessory sinuses of the nose, of the gums, of the mucous
membrane of the mouth and the throat. The commonest forms of this
secondary anæmia are those due to chronic post-nasal discharge,
and to chronic infections of the gums and alveolus of the jaws, the
latter often classed together under the term “pyorrhœa alveolaris.”
This term is an exceedingly clumsy one, indicating a discharge of
pus from the gum edges and sockets of the teeth, which are often
loose. The disease commences as an infective gingivitis along the
edges of the gum, and progresses to rarefying osteitis of the alveolar
process, and often of the body of the bone. The affection rarely gives
rise to pain, and as a rule the individual is entirely unaware that any
chronic suppuration is present, and little or no notice is therefore
taken of the disease. Progressive anæmia may thus be set up
without any knowledge of its cause, partly by absorption of the actual
bacteria and their products through the alveolar bloodvessels, and
partly by the fact of the constant swallowing of pus and bacterial
products, which set up various forms of chronic gastro-intestinal
incompetence. From the discharges of the mouth, and issuing from
the gum edges, numerous bacteria have been isolated, and in more
recent work one of us [K. W. G.[16]] has succeeded in isolating and
identifying certain bacteria as a direct cause of arthritis deformans, a
malady occasionally, but without sufficient grounds, ascribed to lead
poisoning. Arthritis of various types may occur in persons engaged in
lead trades, but in all such cases we have had the opportunity of
examining there has been some obvious source of septic infection,
and no evidence that the arthritis was due to the action of lead. It is
most important to draw the attention of those engaged in the
protection of lead workers from the dangers of their occupation to
these chronic septic conditions of the mouth, and it may be taken as
a general rule that, wherever the blue line makes its appearance
along the gums, such gums are in a state of chronic infection, and
the appearance of the blue line is merely a secondary effect. It is
exceedingly rare to find the blue line in persons with intact gums and
clean teeth; and although attention is frequently drawn to the fact
that a lead line exists in a person whose teeth are normal, little or no
notice is taken of the presence or absence of a suppurative condition
of the gum margins. Moreover, such a suppurative condition does
not always result in obvious inflammation of the gum edges, and
very considerable destruction of the alveolus and the interdental
bone may exist without any obvious signs of its presence, unless the
case be examined carefully with a fine probe. This particular point
has been the subject of experiment by one of us. Animals exposed
to the influence of air laden with lead dust never develop a blue line,
although all the usual symptoms of lead poisoning make their
appearance. When, however, some slight suppurative lesion of the
gums was produced by an inoculation into the gum tissue of
organisms isolated from a case of infective gingivitis in a human
being, the site of inoculation and any suppurative lesion that resulted
locally at once allowed the development of a blue line, and it was
only in animals so treated that it was possible to produce
experimentally the Burtonian line.
There is no doubt that any chronic septic infection may predispose
to lead poisoning through the production of a secondary anæmia,
and it is therefore inadvisable to pass for work in a lead process of a
dangerous nature any persons suffering from an infected condition of
the mouth. It follows also that the care of the mouth and gums
should be rigorously enforced upon all persons employed in lead
trades, as the mere mechanical facilities for the accumulation of
débris around the individual teeth tends to increase the quantity of
lead dust that may be retained in the mouth. This is gradually
rendered soluble and absorbed, through the action of the bacterial
acids which are always produced along the gum margins when any
entangled food is retained in the interdental spaces.
One further point of importance attaches to the infections of the
upper respiratory tract—namely, the constant ingestion of bacteria of
a fermentative type. By this means the contents of the stomach may
be maintained in a state of hyperacidity, and any small quantities of
lead which become swallowed are thereby at once rendered soluble
in the intermeal periods.
Of the other types of anæmia which may act as predisposing
causes of lead poisoning, little need be said, as they are either
associated with other grave symptoms or are rare in this country. But
as all forms of anæmia, particularly septic anæmia, malarial fever,
etc., are associated with destruction of the blood-cells, the presence
of basophile staining granules in the red corpuscles of such persons
is a constant feature, and must not be confounded with the basophile
staining owing its origin to the effect of lead.
In addition to the diseases mentioned which may be said to
predispose to lead poisoning, certain other diseases have been
stated to be predisposed to by the action of lead. It is no doubt a fact
that where chronic anæmia, wasting, loss of subcutaneous fat,
decreased muscular power, and general lowering of the metabolic
activity of the body, are produced, an individual so affected may be
supposed to be more susceptible to certain infectious diseases, and
among these stress has been laid on the alleged association of
phthisis with lead absorption. This point is discussed in the next
chapter.
In summing up the difficult question of predisposition to lead
poisoning, together with the correlated questions of susceptibility and
immunity, certain facts may at any rate be clearly stated:
1. Undoubted individual susceptibility and immunity exist with
regard to lead poisoning in exactly the same way as individual
susceptibility and immunity may be shown to exist towards poisoning
by many other metals and drugs. Therefore, given the same
opportunities for infection, a person showing early signs of lead
absorption may be regarded as susceptible.
2. Females are at least twice, and probably three times, as
susceptible to lead poisoning as are males. Much of this
susceptibility is determined by the extra stress thrown upon the
female generative organs.
3. Certain diseases predispose to lead poisoning mainly by nature
of the alterations in metabolism produced—chiefly anæmia.
4. Many persons engaged in lead industries become gradually
tolerant of the absorption of lead, and in time resist much larger
doses than would have been possible at the commencement of
exposure, but in such persons the balance between absorption and
excretion upon which that tolerance depends may become easily
disturbed by intercurrent disease or sudden increase in absorption.
REFERENCES.
[1] Cloetta: Dixon Mann’s Forensic Medicine and Toxicology, p. 463.
[2] Oliver, Sir T.: Diseases of Occupation, p. 142.
[3] Goadby, K. W.: Departmental Committee on Lead Poisoning, etc., in
China and Earthenware Manufacture, Appendix No. XXV.
[4] Meillère and Richer: Meillère’s Le Saturnisme. Paris, 1903.
[5] Blyth: Abstract of Proc. Chem. Soc., 1887-88.
[6] Hougounencq: Meillère’s Le Saturnisme, p. 73.
[7] Dixon Mann: British Medical Journal, 1893.
[8] Gautier: Société de Biologie, April, 1903.
[9] Oliver, Sir T.: British Medical Journal, May 13, 1911, p. 1096.
[10] Glibert, D. J.: Le Saturnisme Expérimental. Extrait des Rapports
Annuels de l’Inspection du Travail. Bruxelles, 1906.
[11] Oliver, Sir T.: Diseases of Occupation, p. 139.
[12] Chyzer, A.: Des Intoxications par le Plomb se présentant dans la
Céramique en Hongrie. Budapest, 1908.
[13] Garrod: The Lancet, 1870.
[14] Goadby, K. W.: Departmental Committee on Lead Poisoning, etc., in
China and Earthenware Manufacture, Appendix XXV.
[15] Hunter, William: Severest Anæmias.
[16] Goadby, K. W.: The Lancet, March 11, 1911.
CHAPTER IV
STATISTICS OF PLUMBISM[A]
[A] Based mainly on reports received from certifying factory surgeons during the ten years 1900-1909.
Classification of notified cases of lead poisoning was carried out on practically the same
lines between the years 1900 and 1909, and comparison of the data so collected has
interest, in view of their large number—nearly 7,000—in respect of (1) increase or decrease
in recorded amount in each one of eighteen classes of industries; (2) severity and number
of attack—i.e., whether first, second, third, or chronic; and (3) main symptoms.
Notification was first enjoined by Section 29 of the Factory and Workshop Act, 1895,
which subsequently, on consolidation of the Factory Acts, became Section 73 of the Act of
1901. This enactment requires every medical practitioner, attending on, or called in to visit,
a patient whom he believes to be suffering from lead poisoning contracted in a factory or
workshop, to notify the case forthwith to the Chief Inspector of Factories at the Home Office;
and a similar obligation is imposed on the occupier of a factory or workshop to send written
notice of every such case to the certifying surgeon and inspector of factories for the district.
In form there is close similarity between this section and that requiring notification under the
Infectious Diseases (Notification) Act; but whereas the symptoms of these diseases are,
within well-recognized limits, precise, in lead poisoning the differential diagnosis has not
infrequently to be made from a variety of common ailments—headache, anæmia,
rheumatism, abdominal pain; and there is no precise standard of what constitutes lead
poisoning.
The notification of the practitioner as a rule gives no information beyond the belief that the
case is one of lead poisoning. As a matter of routine the notification is followed up by an
inquiry by the certifying surgeon and inspector to see whether regulations already in force
have been infringed in the particular work-place or not, and as to how far there may have
been contributory negligence on the part of the sufferer. The data supplied on the surgeon’s
report form the basis of the tabulation[1]. Brief explanation is wanted of the method adopted
in classification. Cases represent all attacks reported within a year, and not previously
reported within the preceding twelve months, so as to make the number of persons and
cases in a year the same. Where the interval between two reports on the same person was
more than twelve months, the fresh attack was again included. The number of such second
reports on persons already included in a return numbered 284 (4·2 per cent.), and a portion
of these certainly, probably not more than 100, have been included twice or thrice in the
total 6,638 cases. Cases in which there was obvious error in diagnosis, or in which the
opinion of the certifying surgeon was very strongly against the diagnosis (especially when
the report had been made in the first instance by the occupier alone, and not by a medical
practitioner), were excluded from the return. These numbered 458 (6·8 per cent.). Others,
again, where there was a strong element of doubt, but not to be regarded as more than a
difference of opinion between two medical men, were marked doubtful and included. Of
these there were 424 (6·3 per cent.).
The classification of industries was designed to represent the way in which the poisoning
may be supposed to originate from (a) lead fumes (1 to 4), (b) handling metallic lead (5 and
6), (c) dust from lead compounds (7 to 14), and (d) lead paint (15 to 17). We attach now
only slight importance to this attempt to define causation, as it will appear from our survey
that we regard almost all cases as the result of inhalation either of fumes or dust.
The reports describe not only the particular attack, but also the general condition of the
patient at the time of the attack. Very frequently a combination of symptoms—colic,
anæmia, and varying degree of paralysis—are described as present, and when this is the
case each one of them has been entered under the appropriate heading. The total number
of symptoms, therefore, greatly exceeds the number of cases, but this does not affect the
correctness of the estimate of each one as a proportion on the total number reported. The
reports do not give detailed information such as can be gained from hospital records.
Especially is this the case with the symptoms of paralysis and encephalopathy.
Table III. shows the number of reported cases included in returns for each of the years
1900 to 1909. On the total figures there has been a reduction of 47·7 per cent. In the
several industries the salient feature is that the considerable diminution achieved is limited
to industries—notably white lead, earthenware and china, litho-transfers, and paints and
colours—in which, under regulations or special rules, locally applied exhaust ventilation for
the removal of dust, and periodical medical examination of the workers, have been required.
Where, owing to the nature of the processes carried on, it has been found impracticable, in
the present state of knowledge, to apply local exhaust ventilation, and where periodical
examination of the workers is lacking, as in smelting of metals[A] and industries using paint,
there has been tendency to increase in the number of cases. In coach-building the increase
is in part due to activity in the motor-car industry.
[A] This is now required by the regulations dated August 12, 1911.
1. Smelting of
metals 41218 665 702 282 381 241 331 372 28 543 341
2. Brass works 754 5 6 91 11 51 101 15 5 61 3
3. Sheet lead and
lead piping 1093 92 14 6 7 9 7 11 12 17 171
4. Plumbing and
soldering 21712 28 27 202 164 242 213 26 231 23 9
5. Printing 20017 211 302 263 162 194 15 132 19 231 182
6. File-cutting 21119 8 92 10 15 12 204 242 271 467 403
7. Tinning and
enamelling 1382 21 10 25 181 141 10 14 11 10 5
8. White lead 1,29531 322 793 71 1087 901 1162 1092 1431 1897 3586
9. Red lead 108 10 12 7 6 10 11 6 13 14 19
10. China and
earthenware 1,06557 585 11712 1038 1074 843 1064 973 874 1065 2008
10a. Litho-transfers 48 1 2 10 5 5 3 3 2 7 10
11. Glass cutting
and polishing 489 42 31 4 41 3 — 4 82 113 7
12. Enamelling iron
plates 521 3 7 6 4 2 3 4 31 9 11
13. Electric 2856 272 251 21 26 271 33 28 161 491 33
accumulators
14. Paints and
colours 4227 392 25 351 37 571 321 391 46 56 561
15. Coach-building 69741 956 703 703 857 563 494 745 631 654 705
16. Ship-building 26910 271 15 221 261 322 48 241 151 281 322
17. Paint used in
other
industries 45218 42 471 492 373 492 273 461 441 61 505
18. Other
industries 65920 572 785 562 662 701 533 40 64 891 864
The principal figures are those of the cases, fatal and non-fatal; the small figures relate to fatal cases only.
For the sake of completeness the figures for the years 1910 and 1911 are given below. The grand totals are
comparable with those for each of the years 1900 to 1909, but not the total for all of the several groups of
industries. Thus, the name of heading No. 7 is altered to “Tinning of metals,” and No. 12 to “Vitreous
enamelling,” because of regulations widening their scope, and now including cases which previously figured in
No. 18, “Other industries.”