Dooyema et al. individual compounds, contributing to wide- spread contamination. The increase in lead contamination and continued use of mer- cury also warrant investigation into the health effects from multiple metals in children and adults. Further research on multiple metal exposures in this population is needed. During and after this investigation, accounts of similar ore-processing activi- ties and increased rates of child mortal- ity were reported in other nearby villages. Characterizing the full extent of the outbreak remains an urgent and ongoing matter. As more affected villages are identified, medical treatment and environmental remediation will require trained personnel and increased funding. Initiating medical treatment in the absence of environmental remediation is not only ineffective in reducing children’s lead exposure and body burden, but also may cause more harm than good (Chisholm 1992). CDC recommendations for follow-up and rehabilitation of lead-poisoned children in the United States prioritize control or elim- ination of sources of exposure as the most essential intervention, and great progress has been made to reduce lead exposure (CDC 2002). In these villages in Nigeria, contami- nation of water systems, crops, and animals, as well as the risk of recurrent contamina- tion from villages who temporarily cease and then resume ore processing, remain enormous issues to be addressed. Community-based education campaigns are ongoing. Messages include the need for blood lead testing and environmental remediation and the dangers of ore processing, particularly within the con- fines of the village. Beginning in June 2010, chelation ther- apy was provided free of charge in hospitals supported by MSF and Nigerian staff for all children < 5 years of age in the surveyed vil- lages. Hundreds of children have undergone chelation therapy, and unpublished data from MSF clinics in these villages indicate that child mortality has been reduced from ~ 43% immediately before the investigation to < 1% postinvestigation. Each compound in the vil- lages has been remediated to decrease the risk for lead poisoning. Environmental remedia- tion efforts spearheaded by TerraGraphics (Moscow, ID, USA) and the Blacksmith Institute (New York, NY, USA), with the support of Nigerian state and local officials, began in early June 2010. TerraGraphics/ Blacksmith Institute provided technical assis- tance and training for the remediation, and the manual labor was largely performed by Nigerian state, local, and village members. Remediation included removing contami- nated surface soil and replacing it with clean uncontaminated soil and disposing of con- taminated soil in secure landfills. Remediation drastically brought down soil lead levels 606 inside compounds and reduced exposure of the children to lead. Remediation efforts also included education messages emphasizing the importance of prohibiting ore-processing activities and ore-processing materials inside the compound. However, postremediation follow-up is necessary to determine the long- term efficacy of the remediation. Unfortunately, the type of artisanal and small-scale mining (ASM) demonstrated in this article is occurring on a global scale. According to the Global Mercury Project, an initiative of the United Nations, ASM occurs in > 55 countries, and 10–15 million miners work globally, primarily in Africa, Asia, and South America. An estimated 100 million people globally rely directly or indirectly on ASM for their livelihood (Spiegal and Veiga 2007). For many individuals, participation in mining is driven by poverty and a lack of economic opportunities, especially in rural communities, as seen in this outbreak. ASM is the source of 20–30% of the world’s gold (Spiegal and Veiga 2007). The price of gold continues to rise on the global market, and during the last decade gold has increased 360% (Swenson et al. 2011). ASM has long been recognized as having negative health and environmental impacts. Mercury exposure in mining communities has been well established in the literature in places such as Brazil, Indonesia, Zimbabwe, and Ghana (Global Mercury Project 2006; Kwaansa-Ansah et al. 2010), but much less is known about other toxic chemicals, such as lead. Findings from this investigation should be included into existing global initiatives to address other heavy metals in addition to mercury. Conclusion In this article we describe an outbreak of childhood lead poisoning related to artisa- nal mining that resulted in child mortality rates unprecedented in modern times. To our knowledge, this is the first documentation of an outbreak of childhood lead poisoning asso- ciated with artisanal gold mining. Twenty-five percent of children < 5 years of age in the two villages died from May 2009 to May 2010, and 97% of surviving children had BLLs that required chelation therapy. Extensive envi- ronmental contamination was found in both of the villages and inside individual family compounds. The response to this outbreak required extensive coordination with federal and state ministries, international nongovern- mental organizations, international organiza- tions, and U.S. government agencies. The need for technological assistance and transfer in countries with developing economies and health care infrastructure is critical. 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Trends in blood lead levels and blood ovlume 120 | number 4 | April 2012 • Environmental Health Perspectives