title: A simplified risk-ranking system for prioritizing toxic pollution sites in low- and middle-income countries.
abstract: BACKGROUND
  In low- and middle-income countries (LMICs), chemical exposures in the environment due to hazardous waste sites and toxic pollutants are typically poorly documented and their health impacts insufficiently quantified. Furthermore, there often is only limited understanding of the health and environmental consequences of point source pollution problems, and little consensus on how to assess and rank them. The contributions of toxic environmental exposures to the global burden of disease are not well characterized.
  
  
  OBJECTIVE
  The aim of this study was to describe the simple but effective approach taken by Blacksmith Institute's Toxic Sites Identification Program to quantify and rank toxic exposures in LMICs. This system is already in use at more than 3000 sites in 48 countries such as India, Indonesia, China, Ghana, Kenya, Tanzania, Peru, Bolivia, Argentina, Uruguay, Armenia, Azerbaijan, and Ukraine.
  
  
  METHODS
  A hazard ranking system formula, the Blacksmith Index (BI), takes into account important factors such as the scale of the pollution source, the size of the population possibly affected, and the exposure pathways, and is designed for use reliably in low-resource settings by local personnel provided with limited training.
  
  
  RESULTS
  Four representative case studies are presented, with varying locations, populations, pollutants, and exposure pathways. The BI was successfully applied to assess the extent and severity of environmental pollution problems at these sites.
  
  
  CONCLUSIONS
  The BI is a risk-ranking tool that provides direct and straightforward characterization, quantification, and prioritization of toxic pollution sites in settings where time, money, or resources are limited. It will be an important and useful tool for addressing toxic pollution problems in LMICs. Although the BI does not have the sophistication of the US Environmental Protection Agency's Hazard Ranking System, the case studies presented here document the effectiveness of the BI in the field, especially in low-resource settings. Understanding of the risks posed by toxic pollution sites helps assure better use of resources to manage sites and mitigate risks to public health. Quantification of these hazards is an important input to assessments of the global burden of disease.
authors.affiliation: Blacksmith Institute, New York, NY; City University of New York, School of Public Health, New York, NY. Electronic address: jcaravan@hunter.cuny.edu.
authors.forename: Jack
authors.initials: J
authors.lastname: Caravanos
authors.affiliation: Blacksmith Institute, New York, NY.
authors.forename: Sandra
authors.initials: S
authors.lastname: Gualtero
authors.affiliation: Blacksmith Institute, New York, NY.
authors.forename: Russell
authors.initials: R
authors.lastname: Dowling
authors.affiliation: Blacksmith Institute, New York, NY.
authors.forename: Bret
authors.initials: B
authors.lastname: Ericson
authors.affiliation: Blacksmith Institute, New York, NY.
authors.forename: John
authors.initials: J
authors.lastname: Keith
authors.affiliation: Blacksmith Institute, New York, NY.
authors.forename: David
authors.initials: D
authors.lastname: Hanrahan
authors.affiliation: Blacksmith Institute, New York, NY.
authors.forename: Richard
authors.initials: R
authors.lastname: Fuller
mesh_terms: D000393:Air Pollutants / Q000032:analysis; D001151:Arsenic / Q000032:analysis; D003906:Developing Countries; D004781:Environmental Exposure / Q000009:adverse effects / Q000145:classification*; D005506:Food Contamination; D005869:Ghana; D064371:Hazardous Waste Sites / Q000145:classification*; D006801:Humans; D007194:India; D007623:Kazakhstan; D019216:Metals, Heavy / Q000032:analysis; D010568:Peru; D018570:Risk Assessment / Q000379:methods; D012989:Soil Pollutants / Q000032:analysis; D014873:Water Pollutants / Q000032:analysis
chemical_list: D000393:Air Pollutants; D019216:Metals, Heavy; D012989:Soil Pollutants; D014873:Water Pollutants; D001151:Arsenic
keywords: children’s health; environmental health; global burden of disease; global health; hazard ranking system; hazardous waste sites; legacy pollution; low- and middle-income countries; risk assessment; toxic pollution