Print version ISSN 1020-4989
Rev Panam Salud Publica vol.22 n.3 Washington Sep. 2007
INVESTIGACIÓN ORIGINAL ORIGINAL RESEARCH
Evaluación dirigida por la comunidad del riesgo de exposición al mercurio de las minas de oro en Suriname
Daniel PeplowI,*; Sarah AugustineII
IUniversity of Washington, Seattle, Washington, United States of America (USA)
IISuriname Indigenous Health Fund, Suriname. White Swan, Washington, USA
OBJECTIVES: The overarching objective of this project was to support the indigenous people in Kwakoegron, Suriname, in self-diagnosis of public and environmental health problems. The specific objectives, defined by the people of Kwakoegron were: (1) to determine for themselves if they are at risk of exposure to mercury (Hg) contamination, (2) to measure the extent of the Hg contamination problem, and (3) to initiate an intervention plan.
METHODS: Field work was conducted from June 2005 to April 2006. Community members were trained to collect hair samples for analysis using methods designed to maximize sample quality and consistency and minimize cross-contamination. Each hair sample, of approximately 20 mg, was weighed, added to the sample boat, and analyzed immediately without preservation or storage. Technicians educated in analytical chemistry and trained in the operation of the portable Lumex Zeeman Hg analyzer measured the total Hg (THg) for each hair sample. Confidential meetings were held with each person sampled and any questions were answered. Afterwards, a community meeting was held to reflect on the process, outcome, and future needs.
RESULTS: Hair samples from 16 of the 22 participants had Hg levels of 2.220.2 µg/g THg, exceeding normal THg levels for hair (2 µg/g THg). During the confidential, individual meetings and the followup community meeting, information was shared regarding the Hg levels found, what the numbers meant scientifically, what the potential health effects could be, and how exposure levels might be brought down. At the conclusion of the followup meeting, the Kwakoegron community proposed an intervention plan that had three principle parts: (1) routine analysis of Hg exposure to monitor trends and track the effects of exposure-reduction efforts; (2) routine health assessments to determine the effects of Hg exposure, particularly in children less than 5 years of age; and (3) fish advisories based on fish biology and trophic level or on the specific measurement of Hg levels in various fish species from various locations and different times throughout the year.
CONCLUSIONS: This project showed that a democratic approach to science does not automatically compromise the orderly search for answers. Specifically, our experience in Kwakoegron suggests that the collaborative relationship that emerges by empowering an indigenous community to initiate its own research projects, and address the needs it identifies, can contribute positively to the risk assessment process. This project showed that when Kwakoegron was acknowledged as an equal partner, the risk assessment process led to an open exchange of information and an intervention plan that was both pragmatic and acceptable in the context of the communitys unique social and cultural needs.
Key words: Mercury, risk assessment, consumer participation, Suriname.
OBJETIVOS: El objetivo central de este proyecto fue apoyar al pueblo indígena de Kwakoegron, Suriname, a hacer su propio diagnóstico de los problemas de salud pública y ambiental. Los objetivos específicos, definidos por la población de Kwakoegron fueron: 1) determinar por sí mismos si están en riesgo de exposición a la contaminación por mercurio (Hg), 2) medir la magnitud del problema de la contaminación con Hg, y 3) comenzar un plan de intervención.
MÉTODOS: El trabajo de campo se realizó entre junio de 2005 y abril de 2006. Se entrenó a miembros de la comunidad para tomar muestras de pelo para el análisis mediante métodos diseñados para optimizar la calidad y la consistencia de la muestra y minimizar la contaminación cruzada. Cada muestra de pelo, de aproximadamente 20 mg, se pesó, se colocó en el bote de muestras y se analizó inmediatamente sin conservar o almacenar. Un técnico en química analítica entrenado en la operación del analizador portátil de Hg de Lumex Zeeman midió el Hg total (THg) de cada muestra de pelo. Se realizaron conversaciones confidenciales con cada persona muestreada y se respondieron sus dudas. Luego se realizó una reunión con la comunidad para exponer el proceso, los resultados y las necesidades futuras.
RESULTADOS: Las muestras de 16 de los 22 participantes tenían niveles de THg de 2,2-20,2 mg/g, superiores a los niveles normales de THg en pelo (2 mg/g). En las conversaciones confidenciales individuales y en la reunión de seguimiento con la comunidad, se informó sobre los niveles de Hg encontrados, su significado desde el punto de vista científico, los posibles efectos para la salud y cómo se pueden reducir los niveles de exposición. En las conclusiones de la reunión de seguimiento, la comunidad de Kwakoegron propuso un plan de intervención que contaba con tres partes principales: 1) análisis periódicos de la exposición al Hg para monitorear la tendencia y los esfuerzos hechos para reducir la exposición; 2) evaluaciones periódicas del estado de salud para determinar los efectos de la exposición al Hg, particularmente en los niños menores de 5 años de edad; y 3) asesoría pesquera basada en la biología y el nivel trófico o en las mediciones específicas de los niveles de Hg en varias especies de peces de diferentes localidades a lo largo del año.
CONCLUSIONES: Este proyecto demostró que un enfoque democrático en la ciencia no compromete automáticamente la búsqueda ordenada de respuestas. En particular, esta experiencia en Kwakoegron indica que las relaciones de colaboración que surgen al empoderar a una comunidad indígena para que emprenda sus propios proyectos investigativos y responda a las necesidades que ella misma identifica pueden contribuir positivamente al proceso de evaluación de riesgos. Este proyecto demostró que cuando se reconoció a la comunidad de Kwakoegron como socio igualitario, el proceso de evaluación de riesgos llevó a un abierto intercambio de información y a un plan de intervención pragmático y aceptable en el contexto de las necesidades sociales y culturales muy particulares de esta comunidad.
Palabras clave: Mercurio, medición de riesgo, participación comunitaria, Suriname.
Mercury (Hg) is a well known pollutant of terrestrial and aquatic ecosystems that is damaging human health and the environment around the world (13). In Suriname, mercury is still used in gold mining to separate small amounts of gold flakes from large volumes of soil and sediment. Each year, gold mining loses 1060 tons of Hg in Surinames interior rainforest (4). Essentially all of the Hg used in gold mining is released into the environment. The affected area extends through more than 50 villages with approximately 50 000 indigenous and tribal residents (10% of the countrys total population) (5). These villages are home to five, culturally-distinct groups of Maroons (Ndyuka or Aukaner, Saramaka, Paramaka, Aluku or Boni, Matanai, and Kwinti) and five groups of Amerindians (Wayana, Carib, Arawak, Trio, and Akurio) that live along the rivers in the gold-mining region of eastern Suriname (6, 7). Once released, elemental and inorganic Hg are converted to the highly toxic methylmercury (MeHg) form and bioaccumulate in the aquatic food chain. The Hg exposure pathway that dominates all others on a total Hg (THg) exposure per kilogram (kg) body weight basis is (1):
elemental and/or metallic Hg deposition
soil and water contamination
microbial methylation of elemental Hg
methylmercury uptake in periphyton
methylmercury bioaccumulates in fish
human fish consumption
This pathway is considered to be the primary source of methylmercury to humans in Suriname.
Although numerous risk assessments have been performed, few studies have been published on the effects of Hg pollution on public and environmental health. In the only published study on Hg exposure in Suriname, Mohan et al. (8) analyzed Hg levels in hair samples from 39 mothers and their newborns at the Lands Hospital in Paramaribo. Fourteen (36%) of the mothers and 31 (80%) of the newborns had elevated hair Hg levels. A few reports reveal that the risk disproportionately affects the indigenous and tribal communities (8). Since patterns of fish consumption vary by racial and ethnic group, certain subpopulations may consume contaminated fish more frequently and in greater quantities than others (1). It has been suggested that that the policies and practices that permit the continued use of Hg in gold mining racially discriminate against Maroons and Amerindians who subsist on contaminated fish (8, 9). There are unpublished studies that examined Hg exposure patterns among nonmining communities in Surinames gold mining areas1, 2.
While communities such as Kwakoegron are aware of the adverse health effects of Hg exposure and its link to gold mining, the majority remain poorly informed about the precise causes, symptoms, and possible remedies (9). Increasingly, effected communities are suffering from study fatigue. While scientists collect samples and study risk, participating individuals and communities are becoming frustrated because they are not benefiting from the results of these studies. Veiga and Baker (10) note that while biological samples are useful indicators for Hg exposure, in many risk assessment studies, people are seen merely as donors of hair, blood, or urine samples.
In response to studies characterized by a lack of communication between researchers and the study population, various institutions have adopted ethical research guidelines that encourage indigenous and tribal communities to participate (1113). Typically, new guidelines include checklists, emphasize full disclosure, and require written documentation of consent and support from community leaders and participants. Young (14) said that research is generally conducted in an environment that is not only cross-cultural, but it is also influenced by the relationship between researchers and subjects, and there is often an imbalance of power. Because of this inequity, indigenous peoples are increasingly taking control of their own affairs and are resisting research studies that ignore their community needs and priorities. This situation, combined with our first-hand observation of indigenous communities being marginalized by the research process, led us to propose that a new approach is necessary.
The "Principles for Community-based Research," produced by the University of Washington (Seattle, Washington, United States of America), provides guidelines for socially responsible research and a framework for mutually beneficial relationships between researchers and community members (15). According to these guidelines, there are six principles for Community-Based Research (CBR) that serve as a starting point for defining the relationship between researchers and community members:
(1) Community partners should be involved at the earliest stages of the project, helping to define research objectives and having input into how the project will be organized;
(2) Community partners should have real influence on project direction, that is, enough leverage to ensure that the original goals, mission, and methods of the project are adhered to;
(3) Research processes and outcomes should benefit the community. Community members should be hired and trained whenever possible and appropriate, and the research should help build and enhance community assets;
(4) Community members should be part of the analysis and interpretation of data and should have input into how the results are distributed. This does not imply censorship of data or of publication, but rather, the opportunity to make clear the communitys views about the interpretation prior to final publication;
(5) Productive partnerships between researchers and community members should be encouraged to last beyond the life of the project. This will make it more likely that research findings will be incorporated into ongoing community programs, and therefore, provide the greatest possible benefit to the community from research; and,
(6) Community members should be empowered to initiate their own research projects that address needs they identify themselves (15).
The overarching objective of this project was to employ the sixth principle and support the indigenous people in Suriname in self-diagnosis of public and environmental health problems. The assumption was that, if given access to the tools, information, scientific advice, and technical support, an indigenous community would generate its own pragmatic and culturally-appropriate research and intervention strategies. In support of the overarching objective, portable Hg analyzersrecently developed and sold commerciallyprovided the tools by which an indigenous people in Surinames interior, might perform real-time testing to determine for themselves the status of their alleged Hg-exposure. Within the overarching objective, the Kwakoegron community defined the objectives of the project itself: to determine for themselves whether they were at risk from exposure to Hg contamination, measure the extent of the Hg contamination problem, and initiate an intervention plan, if needed. The process to accomplish their objectives was to measure and report the Hg levels in their hair and compare those levels to guidelines that indicate risk of adverse effects.
MATERIALS AND METHODS
Suriname is located in northern South America, bordered by the Atlantic Ocean to the north, Guyana to the west, French Guiana to the east, and Brazil to the south (Figure 1). The population of Suriname is 481 146 (2.9 per km2) (5). Nearly three-quarters of the population lives on the coastal plain that extends inland approximately 30 km; half of the population lives in the capital, Paramaribo (16). The interior is inhabited mainly by indigenous and tribal people. Gold mining, both a source of subsistence for tens of thousands of people and the cause for environmental degradation, occurs mainly in the area inhabited by indigenous and tribal communities (17).
Kwakoegron is located 45 km south of Paramaribo, on the east bank of the Saramacca River near Mindroneti Creek. Kwakoegron is a small village of approximately 25 households. Its inhabitants are Maroon; the descendants of escaped African slaves who established independent societies in the Suriname rainforest in the 17th and 18th centuries. The village features a health clinic operated by Primary Health Care Suriname (a government-sponsored clinic), an elementary school, a telephone center, and local government offices.
The Kwakoegron community was selected because it had requested access to Hg hair-analysis tools and had been part of a previous mercury assessment effort by the United States Embassy in Suriname.3 Kwakoegron community leaders had also stated that past risk assessments performed by outsiders had not considered the research needs and priorities of the people; as such, they requested assistance with their own risk assessment program.4 The study protocol was preapproved by the University of Washington Human Subjects Review Board.
The people from Kwakoegron work cooperatively within their community, therefore, they requested that scientists and health professionals work cooperatively with their community to develop culturally appropriate Hg intervention programs. Field work took place from June 2005 to April 2006. The initial visit to Kwakoegron focused entirely on defining roles and responsibilities. Kwakoegron identified four commitments that were critical to establishing an effective, cooperative partnership between the scientists/ health professionals and the community:
(1) Self-determination. The participating community was free to participate in, as well as withdraw from the project at any time without reprisal;
(2) Study design. Although we suggested a scientifically-valid plan for collecting samples, the community took into consideration its preferences and needs and decided which sample type would be collected;
(3) Intellectual property. The community was the first to see the final results and these became their intellectual property; and
(4) Data analysis. After the participants saw the results, they were asked in several public meetings to interpret them and draw conclusions from their own perspective.
An anthropologist familiar with the languages and customs of tribal communities in Suriname was employed and instructed in the principles of community-directed risk assessment, and then engaged to observe the study and prepare a narrative describing the activities and conversations. All meetings were conducted in Dutch, the official language of the Surinamese government, or Sranan Tango, the creole language most commonly spoken in the countrys interior.
Generally speaking, biological samples can be used to estimate Hg exposure and bioaccumulation. Possible biological indicators include blood, urine, hair, finger/toe nails, and teeth. Of the five potential indicators considered, four were eliminated for the following reasons: finger/toe nail samples are too often contaminated; teeth samples were not readily available; blood is only an indicator of recent or current Hg exposure, particularly from Hg vapors or high fish ingestion, and its collection is invasive; and urine samples require acidification and additional testing, including the need to correct for creatinine excretion and proteinura. In addition, urine indicates the amount of Hg excreted from the body and is best for recent and intermittent high-intensity inorganic Hg exposure, such as from the elemental Hg vapor produced by amalgam burning.
There were three reasons that hair was determined to be the best bioindicator of long-term exposure to MeHg contamination, particularly from ingestion of Hg-contaminated fish. First, it is the least invasive to collect; second, there are fewer cultural issues involved with collecting it rather than blood or urine; and third, there is less risk of transmitting blood-borne diseases (10).
Based on the rate of hair growth in an individual, the analysis of a 3-cm hair strand provides an average concentration of an individuals diet over the period of time required for the hair to grow that length. Although Hg concentrations can fade slightly over time or can be overestimated if contaminated with Hg that accumulates on the surface from atmospheric sources, the Hg content in a 3-cm hair sample is a useful indicator of Hg exposure. It is not, however, a precise measurement of lifetime exposure nor can it be expected to correspond to blood Hg levels at any particular point in time. Although hair is not as accurate an indicator of Hg vapor exposure as urine is, the community of Kwakoegron was not concerned about elemental Hg-exposure from burning amalgam. They chose hair because it is the best indicator of dietary exposure to MeHg from fish (10).
Three community members received hair-collection training. The training was designed to maximize sample quality and consistency and minimize cross-contamination. The hair collectors wore powderless surgical gloves. Scissors were cleaned with alcohol swabs and dried with kimwipes between samples.
Each hair sample, of approximately 20 mg, was weighed, added to the sample boat, and analyzed immediately without preservation or storage. When long hair strands (> 3 cm) were collected, the hair tips were discarded and only the proximal 3 cm were used because MeHg levels can decrease during hair growth under certain conditions, such as treatment with artificial hair-waving (i.e., "perm"). Some difficulties were encountered when attempting to collect samples from men who were either bald or had very short hair. Hair washing procedures were not used to differentiate between airborne and internal Hg.
Analysis of Hg levels in human hair
Group discussions were held to avoid the cultural issues that have become obstacles between scientists and the indigenous communities in the past. In general, active learning methods rather than didactic instruction were used. All the necessary Hg-analysis materials were provided; however, because Hg analysis of biological samples requires advanced skills, technicians educated in analytical chemistry and trained in the operation of the Hg analyzer handled the equipment.
The hair samples were analyzed for THg using the Portable Zeeman Lumex mercury analyzer (model RA915+/RP-91C, Ohio Lumex Co., Twinsburg, Ohio, United States of America). Hg analysis was by the cold-vapor technique. This Hg analyzer is an atomic absorption (AA) spectrophotometer with a 10-m multipath optical cell and Zeeman background correction. Among its features is the direct detection of Hg without preliminary accumulation on a gold trap. The RA915+ includes a built-in zero-mercury supply and test cell for field performance verification. The analyzer was calibrated using NBS traceable standards. The instrument detection level was 0.2 µg/g and the matrix quantitation level was 0.002 µg/g. All concentrations were expressed in parts per million THg (equal to µg/g THg). Measurement of total Hg levels in hair using the Lumex RA915+/ RP-91C portable analyzer had been previously confirmed by laboratory analysis using a modified National Institute for Occupational Safety and Health (NIOSH) 6009 method. Regression results showed that Lumex and NIOSH data were comparable (RMS error 0.032, P < 0.0001). In this study, the Lumex was operated in software "On Stream" mode using the procedure in the manufacturers operation manual.
Immediately following the analysis of the hair sample, confidential meetings were held with each person sampled and any questions were answered. Afterwards, a community meeting was held to reflect on the process, outcome, and future needs. The guidelines used to interpret the significance of an individuals results were:
(1) If the laboratory result was less than 1 µg/g, the participant was informed that the Hg level in their hair was below the recommended upper limit of 1 µg/g established by the United States Environmental Protection Agency (EPA) and the National Academy of Sciences (NAS) (1, 18)
(2) If the laboratory result was from 1 µg/g to 11 µg/g, the participant was informed that their Hg level was above the recommended limit and that they could be at elevated risk if pregnant, planning to become pregnant, or nursing a baby. They were advised to seek the advice of a medical professional for any health concerns.
(3) If the laboratory result was greater than 11 µg/g, the participant was told that their Hg level was above the benchmark dose set by the EPA. The benchmark dose for mercury indicates that it is a near certainty that 10% of the births will show neurological defects. They were advised to seek the advice of a medical professional for any health concerns.
Community members in Kwakoegron welcomed the opportunity to learn more about the mercury problem and test the levels of Hg in their hair. The results of the sampling and analysis are given in Table 1. The average level of THg in hair (4.1 ± 4.3 µg/g THg, n = 22) was the same as the levels found in Kwakoegron by another study.5 Pollack et al. found an average level of 3.8 ± 2.8 µg/g THg in children 06 years of age (n = 18) and an average of 4.0 ± 2.2 THg in pregnant women (n = 9).6 The overall mean value of THg content in Kwakoegron hair samples was 4.1 µg/g, with the highest value being 20.2 µg/g.
During the confidential data review and the follow-up community meetings, community members recounted that several Hg assessments had taken place prior to this study. One previous assessment had focused on pregnant women. While some results had been shared with the community, the scientists or health care workers conduct-ing these previous studies had not explained what the numbers meant nor were prior assessments part of a longer-term strategy to reduce exposure.
The community self-reported that fish is its main source of protein and it was feared to be the main pathway for Hg exposure. The people tend to eat whatever they catch or may buy fish from neighbors. Some obtain fish from the Brokopondo Lake, which is likely to contain high levels of Hg because it accumulates in this sink from surrounding mines. One alternative, obtaining animal products from the city, is cumbersome and expensive, and bushmeat is sparse.
During the confidential, individual meetings and the followup community meeting, information was shared regarding the Hg levels of the hair samples, what the numbers meant scientifically, what the potential health effects could be, and how exposure levels might be brought down. Comments made during the meetings revealed the Kwakoegron community was committed to developing a strategy for Hg mitigation. At the conclusion of the community meeting, members requested that the Hg analysis team return to assist with a long-term Hg intervention program.
The intervention plan developed by the people of Kwakoegron had three principle parts:
(1) Routine analysis of Hg exposure to monitor trends and track the effects Hg exposure reduction efforts. The community suggested an "Hg Testing Center" be setup, modeled after the Public Health Offices malaria testing center (a laboratory in Paramaribo where individuals can be tested and results are available within a day). Access to an "Hg Testing Center" would help people track their own levels and those of their children, and assist them in evaluating the effects of dietary and behavioral changes. The community would like an Hg analyzer be made available to this proposed center.
(2) Health assessments to determine the effects of Hg exposure, particularly in children less than 5 years of age. Due to the uncertainty of adverse health effects at different levels of Hg exposure as indicated hair, breath, blood, or urine, people generally wanted answers to the question, "What is it [mercury] doing to me and my family?" Because of this, they emphasized that health assessments should focus on minimizing adverse health conditions, particularly in children less than 5 years of age.
(3) Fish advisories based either on fish biology and trophic level or on the specific measurement of Hg levels in various fish species from a variety of locations at different times of the year. Community members wanted to know how to adjust their diets to eating low-risk species of fish.
The community concluded the meeting by drafting a letter to the Suriname Indigenous Health Fund with the following statement and three requests: The community is "tired of scientists studying them," and requests (1) access to Hg self-monitoring resources to detect changes in exposure levels over time, (2) health assessment tests to determine the adverse effects of Hg exposure, especially in their children, and (3) fish advisories so that they may select species that will reduce Hg exposure.
Hair samples from 16 of the 22 individuals had Hg levels of 2.220.2 µg/g THg, levels which exceed normal THg levels for hair (2 µg/g THg) (18). Another study reported that Hg-levels in hair samples from people of uncontaminated areas of Baghdad, Iraq, were 0.14.0 µg/g (19). Baseline levels for Hg in the hair of fish-eating populations in the Amazon River basin and Guiana shield are not available because, even in areas where there are no known inputs, current exposures could have begun with contamination that occurred centuries ago. It is possible that Hg released during the colonial period is now being disbursed throughout the food chain by natural processes. Another potential contribution is contamination by airborne Hg (10, 20, 21).
In Kwakoegron, the highest THg concentration found in hair (20.2 µg/g) surpassed the WHO threshold of 10 µg/g (18) for neurotoxicity in adults and children. The highest concentration in Kwakoegron is equal to the lowest observed effect level (LOEL) of 20 µg/g reported by Label et al. (22) who reported decreased visual acuity (color discrimination loss, contrast sensitivity, and visual field reduction) with increased Hg concentrations in the hair of residents 200 km downstream from gold-mining sites on the Tapajos River in the Amazon. All results were below the threshold (50 µg/g) for parasthesia at the 10% risk level.
In Kwakoegron, total hair Hg in children from 212 years of age ranged from 2.3 µg/g to 11.7 µg/g. One child exceeded the benchmark dose estimates for all effects combined (late walking, late talking, mental symptoms, and seizures) corresponding to the 10% extra risk levels (11.1 µg/g) (3). Two children exceeded the lower bound for the 5% risk level (5.4 µg/g) and all seven children exceeded the 1% risk level based on modeling all effects in children.
Although a no observed adverse effect level (NOAEL) does not exist for estimating thresholds for all development endpoints in the developing fetus, data indicate sensitivity 510 times that of adults (23). In Minimata, Japan, where consumption of fish with high concentrations of MeHg by pregnant women resulted in at least 30 cases of cerebral palsy in children, exposed women were minimally affected (24). The vulnerability of the developing brain to MeHg reflects the ability of lipophilic MeHg to cross the placenta and concentrate in the central nervous system. Moreover, the blood-brain barrier is not fully developed until after the first year of life, and MeHg crosses this incomplete barrier (25). One complicating factor is that the signs of neurodevelopmental impacts, specifically loss of intelligence, may begin to be manifested several years after exposure when the subclinical effects of mercury toxicity are unmasked by aging (3).
The National Academy of Sciences (NAS, Washington, D.C., United States of America) assessed three, large-scale, prospective epidemiological studies that examined children who were exposed in utero to methylmercury. The studies assessed by NAS took place in New Zealand, the Seychelles Islands (Indian Ocean), and the Faroe Islands (North Atlantic). The NAS concluded that the most credible of the three studies was the Faroe Islands investigation, which gave strong evidence indicating that fetal neurotoxicity and delayed brainstem auditory responses occurred at MeHg exposure levels of approximately 1 µg/g Hg in hair (2629).
As a result of the confidential data review and the follow-up community meetings, it became clear that there is a difference in the way that scientists and the Kwakoegron people view risk. Visiting experts typically see Hg exposure as a science question to be approached in a rational, objective, and value-free manner, while amassing knowledge for its own sake. In contrast, the people of Kwakoegron integrated all technical, social, and cultural factors and used the accumulated data to advocate for a plan to reduce exposure and mitigate adverse health effects. They sought out information that was personally relevant, asking "What will Hg do to me, my family, and my community?" and "How can I reduce its effects?" People potentially exposed to Hg were not passive recipients of information; rather, they adapted the data to meet their needs in the context of their existing beliefs. Communities change when they can plan and own the information over time (30).
The attempt by Pollak et al.7 to combine assessment and the introduction of retorts to recover Hg from the gold amalgamation process illustrates the problems that occur when there are cultural differences or a history of tension. In Pollaks study, miners did not incorporate the simple, inexpensive technology that would improve their standard gold-processing habits. Henderson et al. (11) attribute failure to a lack of community control, lack of local benefits, and the interpretation of data in isolation from social context.
Real change occurs when experts provide information that is appropriate and allot time for practicing new skills, listening to individual and community concerns, and considering obstacles to success. Failure to affect real change may arise because health professionals are paralyzed by the magnitude of the problem and because vested interests, including those that control development and international health policy, have a stake in observations about causality and are not free to seek real change. Just as data interpreted "out of context" leads to conclusions that lack relevance to scientists, information given to the communities without the opportunity to ask questions leads to efforts that lack relevance to the community.
In the present study, acknowledging the community as an equal partner in the risk assessment process led to an exchange of information and an intervention plan that was both pragmatic and acceptable in the context of the communitys unique social and cultural needs. An important factor that contributed to the development of the intervention plan was that community members possessed a basic knowledge of the Hg cycle. They knew, for example, that mercury was acquired from eating fish, and that carnivorous fish (roofvis) had higher levels. How Hg had entered the food chain to start with, what mercury could do to people, and how to reduce exposure, were not well understood. It was emphasized to the community that they should not stop eating fish, because excluding this important source of protein from the diet would create other health problems; yet intake of the high-risk species should be limited, especially by young children. The self-diagnosis of Hg bioaccumulation and the potential for adverse health effects from Hg exposure culminated with an intervention plan that detailed three specific needs: (1) access to technology for self-monitoring Hg levels and detecting changes in exposure over time; (2) health assessment tests to determine the adverse effects from Hg exposure, especially in children; and (3) fish advisories that enable people to choose fish species to eat that will reduce exposure.
It became clear to everyone involved that the health concerns related to Hg exposure from gold mining are not being adequately addressed in Suriname. The persistence of Hg in the environment, the pattern of biomagnification as it moves up the food chain, and the extreme toxicity of MeHg on the human nervous system are putting medical, public health, and science professionals under pressure to acquire new knowledge and technology to solve the problem. In developing countries, such as Suriname, however, access to advanced technologies is limited and must be imported. The Portable Zeeman Lumex (RA915+/RP-91C) Hg analyzer is a significant technological development that has made it possible to analyze Hg in hair at remote locations.
So far, intervention programs in Suriname have failed because they have not incorporated the values, research needs, and priorities of the community. Conflicting values and the magnitude of the problem, havemany health professionals feeling paralyzed. In our study, we found the community-driven approach to risk assessment ensured community values were the driving force behind the process of discovery.
This project showed that the democratic approach to science does not automatically compromise the orderly search for answers. Specifically, our experience in Kwakoegron suggests that the collaborative relationship that is created when indigenous communities are empowered to initiate their own research projects, and address needs they identify themselves, contributes positively to the risk assessment process. This project showed that when the community of Kwakoegron was acknowledged as an equal partner, the risk assessment process led to an open exchange of information and resulted in an intervention plan that was both pragmatic and acceptable in the context of the communitys unique social and cultural needs.
Acknowledgements. This paper reflects the work done at the invitation of the people of Kwakoegron, who, through their collective wisdom, experience, and knowledge, provided the leadership necessary to accomplish this difficult project.
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Manuscript received 18 July 2006.
Revised version accepted for publication 14 July 2007.
* Send correspondence to: Daniel Peplow, 3500 Island Road, White Swan, WA 98952; tel.: 001 509 848-2021; fax: 001 206 543-3254; email: email@example.com.
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