Sheryl Magzamen: Engaging School Districts in the Fight Against Lead Poisoning

Sheryl Magzamen is an Assistant Professor of Epidemiology at Colorado State University. In her knowledge exchange project at UW-Madison, she worked to raise local school districts’ awareness of the effects of lead poisoning on educational outcomes.

Why did you decide to participate in this project?

Sometimes data are already there and they need to tell a better story.

Sometimes data are already there and they need to tell a better story. With this particular project, there wasn’t a whole lot of excitement about lead and cognitive outcomes anymore—we’ve known for so long about the detrimental effects of lead. However, the opportunity to try and engage new stakeholders was my excitement about the project. We enlisted the help of the Wisconsin Department of Public Instruction to reengage in this project, thinking that if we could make lead exposure more than a public health and environmental concern, if the agency realized kids are entering elementary school unprepared to learn because of what they’re exposed to in the environment, then the school system could be an important stakeholder in trying to remediate the environment from heavy metals as well. When the project got funded, in 2008, there was a lot of talk about No Child Left Behind and school performance and evaluation of teachers. We thought, “Well, can you really put this all on the school and the teachers if the kids are coming to school with problems as well?” So that was the whole impetus for the project: broadening the group of concerned organizations regarding lead exposure.

Did you have any worries getting started with the project?

I am drawn to epidemiology because it’s the science of public health. However, I feel that as the science has developed, we tend to focus a lot more on “shiny tools”: fast computers to do complex computation or a lot of lab equipment to get more refined exposures. The actual connection to public health has been getting more and more tenuous. So I feel like there was definite negativity surrounding this type of activity. Of course, John and Steph and Dave [the site directors] are always amazingly supportive, but it was hard.

If putting out more and more science isn’t working well, what do we do?

I was an intern at the State Health Department working with these lead data, and I really liked that, because the connection to policy and progress is so much easier to see if you’re at a state agency than it is if you’re in the academy. I liked having a foot in both worlds, and I was really excited about trying to figure out the system. Again, we’ve been arguing about lead since 1920 basically, and nothing has been done about it. So what’s our next step? If putting out more and more science isn’t working well, what do we do?

How did you initiate the project?

I was talking to folks on campus, and Marty Kanarek [Professor of Population Health Sciences at UW-Madison] said, “You have to talk to people at the state about lead, there’s this great database.” I ended up talking to the chief medical officer for the public health program at the state, Henry Anderson, about some asthma research I wanted to do. He didn’t think the type of data I wanted would be available, but he encouraged me to pursue the lead research.

My background was in asthma epidemiology, but working in lead research is the same paradigm that’s been driving my research in general. There are social factors linked to race, poverty, poor built environment, lack of access to health care, and the environment, including lead or air pollution or chemical stressors, leading to negative health outcomes. These relationships proliferate in mostly urban areas, urban non-white areas. The exposure’s different and we’re looking at cognitive outcomes instead of respiratory outcomes, but it’s really the same problem.

One of Marty’s doctoral students worked at the state department on the lead project, and Jeff [Havlena] and I got along fabulously, so it was really easy to find a great team to work with. And then this grant came through the university. Blue Cross Blue Shield privatized in Wisconsin, and the two medical schools got money as a result of that privatization to do population health research. So we applied for a grant and we got it, which was great.

How did the research go?

Like HIPPA, there’s FERPA, which is the privatization of school records. Initially when we approached the State Department of Public Instruction to do the project, it was going to be a statewide project. We were trying to make the argument that in Wisconsin, a state with such old housing stock and since it’s pretty cold there in the winter, lead paint is ubiquitous. We were trying to say, “This isn’t just a black inner city problem. This is a statewide problem.” We had all the data for the Department of Health Services and the education data from the State Department of Public Instruction, but we came up against FERPA. After the superintendent signed off on it, their lawyers got hold of it and said “You can’t do this project the way it’s written—or at all.”

Did you end up getting the test scores eventually?

We did, but we had to really limit the scope of the project. What we ended up doing was focused on Milwaukee and Racine because we had agreements with those districts. Racine was great. We could advertise and ask parents for their consent to release the test scores. In Milwaukee we got a database from the state health department and then had to ask parents to release their test scores by doing address database matching. That school district was a lot less receptive to active recruiting. We actually had to use the state lead database to try and find parents 10 years after their kid’s blood lead was tested to do the project. We thought we’d get about 7,000 people, and we ended up getting 1,100.

How did the knowledge exchange go?

The knowledge went out, and I’m not sure if it actually hit anyone. The partnership with the state pretty much ended when we got the data. So I don’t think we made any headway in terms of putting lead on the map as a place of concern for the Department of Public Instruction.

It was really having community-based partners that helped us with knowledge exchange.

We did a good job in Racine. The Racine County Health Department is incredibly proactive and knew that lead exposure was a problem. They did press releases and talks about our work and were incredibly cooperative in terms of getting the word out. So it was really having community-based partners that helped us with knowledge exchange.

The initial inroads that we tried to make were really with people who understood the problem well and were champions of the cause. The tougher thing has been trying to convince the school districts that this is important. There’s our work and there has been a lot of other work, especially recently, trying to link exposure and outcome databases. I would hope that the school district would start paying attention and lending some voice to it, but it’s largely stayed within the environmental health community. That’s another frustration with this knowledge transfer project. We just have hit some pretty strong institutional barriers, and we haven’t been able to change the conversation.

How did you measure the results?

We were hoping for just having roundtable conversations with school districts, just starting a conversation. What can we do about this, where can we help, what does this result in?

Our project graduate student, Mike Amato, analyzed lead exposure and school suspensions and expulsions, and we found that lead exposure made a difference. We thought schools would really pay attention, particularly because Mike had found lead partially explained racial gaps in problem behaviors in school.

But it just didn’t seem to impact anyone. I think academics, administrators, and educators read different literature, and we have different mandates. I have a large focus on school health research, both prior to and after my time in Wisconsin, and I’ve found it’s really the willingness of a partner to engage in the conversation not only for the sake of the research but also for how it is going to impact the students. That is so critical. We didn’t have that. That was a huge lesson learned for me in doing this kind of work. It’s really doing it at the community level, so the people that you’re working with have a stake in the results.

Did you invite people from the schools to come to roundtables? Did they say no?

Basically the state said, “We will give you the data, but we’re not going to be the conduit. You have to approach individual school districts to do this.” We went to Milwaukee because it’s the biggest school district in the state and it has the biggest lead problem. And Racine was approached because our on-ground partners in the health department were able to leverage their relationship with the schools.

In Milwaukee, we went and presented to their research committee because you have to apply to do your research project there. They just told us “No, it’s not our concern.” To actually do the project we had to work around the school district. We just didn’t find a willing partner, and that could be because in a big urban school district that’s under pressure for meeting testing scores and having poverty issues, it’s just one more problem, and again it’s a problem they can’t do anything about. They could potentially, if they hire more Special Ed teachers or have different policies related to delinquency, but at what cost? We backed away from them because we weren’t getting any traction with this project.

What were your best and worst experiences during this project?

My best experience was working with people who were really committed to this issue. People who are smart, dedicated, and have both the analytic skills and the political savvy and the people skills to actually get this off the ground.

My worst experience was the bureaucratic nightmares. Sometimes, it makes you not want to do this kind of research. Everyone is throwing up barriers your way, and you kind of think, “All I want to do is help! All I want to do is try to make things better.” I think a lot of that comes from risk aversion. Just by nature, there are organizations that are more conservative than others.

If you could do it over again, what do you wish that you knew?

With any type of work like this, you can’t build a relationship in a year. It takes time and trust and a willingness to mutually find a solution.

I wish I knew a lot more about how to effectively build relationships. That’s not anything that I was trained to do. Epidemiologists look at 1s and 0s—we have to be reminded that they’re actually people. I wish I had the background to anticipate barriers. With any type of work like this, you can’t build a relationship in a year. It takes time and trust and a willingness to mutually find a solution.

What is the most important thing you learned about communicating with nonacademics?

To be cognizant of the big picture. For example, even though lead is important, lead is responsible for about a 7-point decrease in test scores. If we measure the effect of race and poverty, 30 points can be attributed to socioeconomic status and 25 points can be attributed to race. Sometimes I struggle in explaining to people why this is important when there are clearly so many other things going on in kids’ lives that are really driving the results.

What I try to focus on is the idea that lead exposure is preventable and avoidable, whereas we don’t really know what to do about poverty at this point. For lead exposure and air pollution, we actually have remediation techniques. They’re incredibly costly to society, but this is something we can fix. I try to make that a primary message: prevention. We understand the mechanisms for this, it’s really well established through a lot of literature, but the question is what do we do about it? I try to keep that perspective as part of the conversation—it’s not about what is more important, but that we can actually prevent this from happening.

Has your thinking about knowledge exchange changed since you started this project?

When do you say, “This is beyond my expertise, and I’ve done what I can, and to implement data or to implement this knowledge is really the responsibility of another organization or entity?”

Yes. Sometimes I think “Oh, it’s this organic process,” and it’s not. It has to be very structured and deliberate. How do you have those conversations? How do you effectively communicate whom you need to have around the table? And for me, when do you let go? When do you say, “This is beyond my expertise, and I’ve done what I can, and to implement data or to implement this knowledge is really the responsibility of another organization or entity?” Just having to be OK with that can be hard. And it has a lot to do, again, with competing interests and what other people and other organizations have on their plate at the time.

How do knowledge exchanges figure into your career now?

Here in Colorado, I’m working with the Healthy Schools grant, working with school districts to understand the indoor air quality and health and performance of school occupants. I’m also working on a project looking at respiratory health in dairy workers, and the principal investigator has really been building up relationships with dairy producers and making the convincing argument that when you have a sick workforce, that’s a cost to production. Making health part of that argument makes business sense to them. Likewise, making health part of the argument for schools makes sense for them in terms of attendance, the health of their teachers, the effectiveness of their teaching methods, and their ultimate outcomes: test scores and grades.

What type of scholars should participate in knowledge exchange projects?

I’m a big picture person. I like to see how the whole thing fits together, and not everyone does. You have to like being in the field, and you have to have a long-range vision and be comfortable with long-term outcomes. If you want to understand the process and how the big picture fits together, then I think this is a good, really interesting path. For me, understanding the context in which your data occur is a critical part in potentially understanding how to prevent disease. If that’s attractive to you, then I think that this is a good process to engage.