Why are we still not lead free? Community based system dynamics modeling to address lead exposure in Cleveland, Ohio

Background: Exposure to lead causes negative neurological, cardiovascular, and respiratory health effects, as well as increased criminal involvement. Children are at particular risk, and the impacts of lead last through the lifespan. Lead exposure is not random. Due to structural racism and historical housing law discrimination, lead poisoning is concentrated in predominantly Black cities and neighborhoods, such as Cleveland, Ohio. Cleveland is at the center of the lead epidemic, with rates of lead poisoning 4 times the national average. Objective: Our goal was to engage with community stakeholders to (1) develop a shared understanding of lead in Cleveland and (2) illustrate mechanisms to decrease lead exposure. Methods: We piloted a half-day community based system dynamics workshop in collaboration with community organizations focused on lead exposure using structured group model building scripts (“Hopes and Fears”, “Graphs over Time”, “Connection Circles”, and “Action Ideas”). These were used to create an exploratory simulation model highlighting health inequities of lead poisoning and potential leverage points to advance regional health equity. Results: Causal feedback relationships were found between environmental justice, remediation, testing, and efforts for change. Five action idea themes were identified: financial resources; programs; policy; education and outreach; and, changing the narrative. Broadly, the approach demonstrated the feasibility of engaging with community organizations in support of city public health department efforts to address racism as a public health crisis. Conclusion: Group model building provides a method to engage with community stakeholders and illustrate the structures and mechanisms of lead exposure. Future work will continue to engage communities and local governments to accelerate community based implementation strategies for scaling and sustaining testing, mitigation, and abatement efforts to advance environmental justice.