Enforcement of Lead Hazard Remediation to Protect Childhood Development

Mary Jean Brown

The nation has an ambitious goal from the Healthy People 2010 objectives to eliminate lead poisoning as a public health problem in the United States by 2010. The Lead Poisoning Prevention Branch of the Centers for Disease Control and Prevention (CDC) takes this goal very seriously

Childhood lead poisoning is a completely preventable illness. We know what the causes are, how chil- ; dren get it, and how to prevent it. Essentially, the way to prevent it is to control or eliminate sources of lead in the environments around children.

Given enough exposure, children and adults can die from elevated blood lead levels. This happens rarely, but it is not impossible. The last child who died from lead poisoning in the United States lived in Manchester, New Hampshire and she died in April of 2000. However, most children with elevated blood lead levels have levels at or above 10 micrograms per deciliter (Mg/dL). Children who have these elevated levels have no overt symptoms. Sometimes they may be tired or may not be eating properly, but for most children, elevated blood levels occur between 18 and 28 months when these behavior trends may occur anyway. The only way to determine if a child has had too much lead exposure is to do a blood lead test. In many places in the country, blood lead testing is required by law. All areas receiving CDC lead prevention grant funds are required to develop a strategy for their jurisdiction to target children most at risk for exposure and ensure that those children are tested. In addition, any child who is enrolled in Medicaid is required to be tested at 12 and 24 months and older children who have never been tested have to be tested when they are identified. Most children with elevated blood lead levels will have some learning and behavioral problems, and some may have emotional problems.

Dr. Herbert Needleman's study,1 looking at 2,000 children in Charlestown and Sommerville, Massachusetts in the late 1970's, collected two teeth from second graders and ranked children on how much lead was in their teeth. Lead is stored deep in the bones and therefore, teeth can be used to determine historic exposure to lead. He ranked the children by the amount of blood lead levels in their teeth and had their teachers evaluate these children on how they were doing in the classroom. The children with the highest tooth lead levels were doing the least well in all evaluative categories except for hyperactivity. The researchers thought that this may have been due to the fact that second grade teachers may not have wanted to diagnose hyperactivity on a checklist. Children in the higher categories are statistically worse off than children in the lower categories.

Lead poisoning follows a step-wise progression called the dose-response curve, which reveals that the toxic chemical that is examined is the cause of the effects that are seen. Similar studies have been conducted across continents, socioeconomic classes, and racial and language groups and consistently it is found that higher blood levels affect children's performance in school and their life achievement. New data suggests that even at blood lead levels less than ten we find that children have subtle but significant neurological effects that affect their ability to sit still in a classroom, learn to read, and understand math. We have not yet found a safe blood lead level for children.

As public health professionals, we are population scientists. In a normal population, about 5% of the population has an intelligence quota (IQ) above 120 and about 5% of the population has an IQ below 80. If you shift the population's IQ by five points, which is about what a child with a blood lead level of 20 Mg/dL has lost in his or her life, no one in that lead poisoned population has an IQ above 120 and there is double the number of people with IQ's below 80 (these are children who qualify for special education). Lead poisoning knocks the natural leaders out which is not only a tragedy for an individual child, but also has enormous effects on populations.

In particular, childhood lead poisoning affects those at most risk, which are low income, African American children living in urban areas. The most common source of lead for children is lead paint that has crumbled and contaminates soil or household dust and then becomes ingested. Children absorb lead through the gastrointestinal track (GI) much more effectively than adults. After absorption, lead enters the bloodstream and continues into the brain because barriers between the blood and the brain are not as mature in children as in adults. Once inside the brain, lead affects a child's intellectual development.

Lead poisoning can be prevented by safely removing lead paint hazards through such actions as limiting children's access to soil and household dust; frequently washing hands; increasing dietary iron and calcium as well as overall food intake to decrease the absorption of lead in the GI track; and using chelation therapy to reduce blood lead levels. There is also evidence that children who have elevated blood lead levels and who are given early childhood education, such as Head Start, will actually be able to mitigate some of the effects of those elevated levels. The brain is more plastic than we sometimes think it is and there is an opportunity with good early childhood education to reverse some of the effects of lead exposure. The CDC's lead branch aims to prevent lead poisoning by funding 42 state and local lead programs. Traditionally, programs make sure that children are tested for lead and then intervene by case for children with elevated blood lead levels. The four basic messages are: keep it clean; put barriers between children and lead paint; talk to people about foods that help; and make sure that children get tested periodically. None of these are a perfect solution. As a result of Dr. Needleman's groundbreaking study of the late 1970's, we learned that we have to regulate the abatement process. Many children have high blood lead levels as the result of the work being done to protect them. Now workers wear protective gear, children are removed from the situation, and all of the dust is cleaned up. At the end of abatement, in most places, children are not allowed to return to the house until the dust lead levels are normal. Other methods for lowering blood lead levels have also been tried. Studies examining chelation therapy, removing household lead paint, and educational strategies found that comparisons between the intervention group and the comparison group were not significantly different indicating that these treatment methods might not be that effective.

While it is important to continue to intervene with these secondary methods, since childhood lead levels did go down for both groups, we are trying to push programs in states to focus on primary prevention. This includes intervening before a child's blood lead levels are elevated by identifying high risk communities and incorporating lead poisoning prevention activities into health and community services that reach families at high risk for lead poisoning. Additionally, there are easy remedial housing elements that can be taken care of such as removing chipping paint and replacing older windows. It is better to take care of these situations before children are exposed as we know that there are islands of risk in large urban areas. After examining seven cities we found that 50% of the cases with elevated blood lead levels live in a small number of zip codes and this is fairly uniform across the country. We know where these children live and we know what to do. It is four times more likely to have another lead poisoned child in a house that has had a lead poisoned child in the past if there is not strict enforcement capacity. Thirtyfive percent of children live at addresses where a child has been identified in the recent past; 18-20% of these addresses account for the bulk of the children identified in a certain time period; and 40% of these addressed have had some form of federal subsidy. We are observing repeat offender houses that are being federally subsidized. The HUD, EPA, CDC, and state and local partners are working hard to take care of these houses. If we can get these houses taken care of, we will eliminate about 35-40% of the problem in this country. Controlling or eliminating lead hazards in these addresses could save $45,000 in lifetime earnings for the children who move into them over the next ten years. An educated consumer can force some changes to occur. Lead poisoning is a problem that we can and need to fix.

Anne Evens

In Chicago, we have a big problem. We have the largest number of lead poisoned children for any city in the nation reported each year due to the fact that we are a large, midwestern city with a lot of older housing. If one lives in a house that was built before 1978, he or she also has a big lead problem and might as well recognize it. In Chicago in 2001, we had neighborhoods where 30% of the children had elevated blood lead levels and if we went down to the block level, we had blocks where half of the children had lead poisoning. A map of failing schools is very consistent with these elevated blood lead level rates.

There are a lot of model ordinances or state laws out there. Chicago has had its lead bearing substances ordinance2 since 1994 because there are a lot of strong childhood health advocates in the city. There are three important components to this ordinance. First, we require that all properties must be maintained free of lead hazards to achieve primary prevention. We do not want to wait until a child has been lead poisoned to take action. The property owners and their agents are required to maintain their properties free of lead hazards. Second, we have the right to inspect all residential units and child-occupied facilities, such as daycare centers and schools, in the city. We do not have to wait for the authority to inspect or until a lead poisoned child is present, which allows us to target repeat offenders or high risk properties. Third, we have an effective enforcement system. When we find a violation, we are now allowed to use the courts to get that violation remediated. We do that locally through an administrative hearing process and we find it to be very effective for increasing compliance. Prior to having instituted our Lead Court in 1996 and 1997, we would write violations and send them to court and that would give the property owner an extra year before they had to do anything. Currently, we have an 85% compliance rate with the orders that we write. One can target this enforcement to be effective in a way that does not overwhelm a public health agency.

In Chicago, and this is true in many states, it is really the houses built in the 1950's that are the most hazardous. These account for 600,000 of the 1,100,000 housing units in Chicago. Chicago has 24 lead inspectors, which is considerably more than other locations. If the inspectors could do 4,000 inspections a day, we could get through those 600,000 units. This is not feasible so, we worked with federal partners and received a lot of technical assistance both from the CDC and HUD to really identify the highest risk housing. Based on 2000 estimates, we have identified that there are 88,000 housing units that are the most hazardous to children where low income children are living and are likely to get exposed to lead. We also understand that two thirds of these housing units are multi-family rental properties and a third are single family properties. It is critical to understand ownership patterns when developing lead prevention strategies.

Our strategies to eliminate and control the presence of lead in homes include enforcements (sticks) and incentives (carrots). Our municipal code allows us to levy significant fines and these fines can add up to a significant amount of money. Our enforcement is based on the health department's building approach with inspections triggered by high risk housing data, complaints, or the involvement of a lead poisoned child. We also have a particular strategy for repeat offenders. We have worked to identify those properties which are poisoning multiple children over time and use both stepped up local enforcement and the Lead Disclosure Law (Section 1018) enforcement by the HUD/ USEPA with these cases. Finally, we are trying to ensure that our publicly funded properties do not poison kids, so we are working with sister city agencies to assure that all section 8 and Community Development Block Grants (CDBG)/ HOME Investment Partnership (HOME) funded units are lead-safe as well as all other federally assisted programs.

The Lead Disclosure Law3 (Section 1018) requires individuals to disclose any knowledge of lead hazards during every real estate transaction. This law was created in 1992, but enforcement began more recently. The reason that this law is so important is that it allows the HUD and EPA to have the authority to seek civil money penalties of $10,000 per violation with the potential for multiple violations per transaction. This law is enforced through the leverage of these fines. If owners are willing to abate their properties, the fine will be reduced as long as the money is used to fix the problem. Business owners see the value of applying that money back into their own buildings to address their lead hazards rather than writing a check to the U.S. Treasury. Chicago cases have been jointly enforced by the federal, state, county, and city agencies and this has become a good way to collaborate. It is also really effective to talk to the property owners with four government agencies in order to enforce change. Because the process involves a lot of lawyers, it does take a long time (it took two years to get the first settlements).

Owner incentives (carrots) are also very important as well. First, there is education. A lot of property owners do not know that their properties contain lead-based paint nor do they consider themselves in business. Property owners need to know that if their property is pre-1950, they have a lead problem while if their property is pre-1978, they are likely to have a lead problem. The important carrot is a financial incentive. We have been fortunate to approve a property tax benefit, which reduces a property owner's tax assessment by one half for a period of ten years if he or she keeps their rent affordable and abates lead hazards. We also use the federal grant and matching grant funds that are made available for lead abatement through the HUD as well as some local money to assist property owners. The goal is to make a property lead-safe for families in an affordable manner. We want to ensure that families remain at their homes rather than setting up a situation where families relocate to other leaded homes.

In 2004, we inspected 1,140 homes with a very high compliance rate and 1,039 of these inspections were due to our administrative hearing process. We also began doing a quarterly database matching between section 8 and the health department to identify hazardous housing and have reduced the lead poisoning rate by 50% in these communities. Public housing units have also been addressed primarily through demolition as part of a larger city transition plan. Through section 1018 enforcement, we have been able to target 8,700 units since the year 2000. Today more than 5,000 units have been abated; 3,100 units are in the process; and 108 units resulted in fines (no abatement). An additional 5,000 units are generated each year as a result of the compliance with the leadsafe housing rule in publicly funded properties. We have been relatively successful in getting lead hazard control grant funds for low-income owners ($8.6 million). Due to effective enforcement, we now have some property owners coming to us stating that they would like to address their lead hazards. In 2004, there were 962 housing units made lead-safe proactively by private landlords. Lead poisoning rates are declining both in the city overall and in the highest risk neighborhoods. Although the rates are still too high in these neighborhoods, progress is being made.

It is important to understand that a strong primary prevention, regulatory framework requires that properties be maintained lead-safe, which gives health departments the right to an inspection, and includes an effective enforcement mechanism. Partnership is critical and in lead abatement, it is extremely critical. The City of Chicago Lead Committee includes representatives from all sectors. Strong advocates are important and needed to push the agenda forward. Lead-Safe Chicago includes over 150 community based organizations including housing groups, child advocates, universities, property owners, and government agencies. Lead-Safe Illinois is a statewide task force which includes Lead-Safe Communities all over the state. Lead poisoning is a problem that we can fix and is a problem that we absolutely have to fix. There are so many social problems that affect a child's school performance and their ability to succeed in life, and this is one circumstance that we know how to fix.

Beverly J. Gard

Administrative rulemaking directed on reducing blood lead levels has existed both federally and at the state level since 1988. In 1997, the Indiana Department of Environmental Management (IDEM) established a children's health initiative including lead prevention efforts and by the next year, had launched "2000 Families by 2000" to train 200 risk assessors to conduct 2000 risk assessments. In 2003, the attorney general joined an agreement with paint manufacturers to put warning labels on paint cans about the risk of lead paint exposure.

Indiana's legislative history concerning lead began with The House Enrolled Act (HEA) 11810/1997.4 This law directed IDEM to adopt EPA lead-based paint activities and lead licensing rules and gave the Indiana State Department of Health (ISDH) broad coordination responsibilities. Next, Senate Bill 320 was introduced in 2001 to the Indiana legislature. This proposed bill would require social security numbers; extend lead abatement license duration from one to four years; establish a clearance examiner license; prohibit dangerous work practice on pre1960's homes and child facilities; require exterior clean up of these homes; and direct the Air Pollution Control Board (APCB) to revise their rules. SB 320 did not pass the Indiana Senate conference committee because Indiana state legislators were and are concerned about individual property rights infringement and because this law asked for social security numbers.

Later in 2001, the Indiana legislature introduced the HEA 1171, similar to the SB 320, but dropped the social security number requirements and instead of extending licenses for a period of four years it extended them for a period of three years and had provisions for refresher courses. This legislation also required the reporting of childhood blood lead tests, which continues to be a problem. The Indiana legislature also started requiring information sharing of blood lead test results collected after January 1, 1990 between health agencies, families, and Social Services Agency (FSSA) because it found that the information may have been collected and might eventually get shared, but there was no direct manner of sharing the information to perhaps do an intervention that would make a difference. It also required that the information collected after July 1, 2002 is shared between the health agencies, FSSA, and local housing agencies. In 2003, Senate Act 36? expanded the blood lead test reporting to include all tests not just tests on children and it added an annual reporting requirement. Senate Bill 367 was a very comprehensive piece of legislation, which was meant to refine a number of things that we had done presently.

In a 2004 report, the ISDH found that Indiana was only able to identify that 8% of Medicaid children were actually being reported as being tested. That was down from 8.9% in 2003 and 11% in 2002. As a result of those low test rates, the Indiana legislature passed the Senate Enrolled Act (SEA) 538 in 20055 to develop measures and report performance incentives to improve Medicaid blood level testing rates. This act also required the ISDH to adopt rules regarding the case management of lead poisoned children and to determine whether case management was being paid for either at the local level or through funds designated for some other purpose. This law also mandated that labs report blood lead test results electronically, if they submit more than 50 test reports a year. Currently, about 40,000 test results are reported annually in Indiana. In the previous calendar year, about 14,000 of those were submitted manually and not electronically, which is a huge problem. It takes time and increases reporting error rates. Electronic submissions will amplify cost savings, improve the reliability of these results, and increase the number of results retrieved. Also, Indiana is expanding its information sharing for data collected after January 1, 1990 to include the HUD. This aspect only requires that information be disclosed that is necessary to determine the prevalence of lead poisoning, which confronts the issue that legislators face, confidentiality of individual information. Additionally, the HEA 538 also expanded information sharing for data collected after July 1, 2002 to include federal agencies that administer housing programs and again, it limits the sharing to the extent necessary to ensure that the children are protected from lead poisoning. It also mandated ISDH to submit an annual report by March 15th of each year for the previous year on ten categories. Some of these categories include a count of the days it took to confirm a test, assessments done for children identified as lead poisoned, housing units for assessments identified for lead hazards, housing units ordered to eliminate lead hazards, children tested, children with results greater than 10 Mg/dL, confirmatory tests done, actually lead poisoned children tested at less than 10 Mg/dL, and housing units where lead hazards had been eliminated. This will be a comprehensive report that is going to help us move forward in the future.

One challenge associated with the SEA 523 included data sharing with our environmental agency. In the legislation, we required that data be shared that had never been shared before. This required IDEM to give notice of potential legal action if they had information about lead hazard specific sites that were not being abated. In the past, however, the statute never required them to get that information. When this legislation was filed, IDEM became upset in part due to the new prioritization required with the new administration. IDEM estimated that there would be thousands of cases for them to litigate. An advocacy group, Improving Kid's Environment, negotiated with our attorney general's office and as a result, the attorney general's office will now take care of these cases after the property owners have been given adequate notice and there is a well documented lead hazard. As a result of that commitment from the attorney general's office, the legislation did not require that this information be given to IDEM. Their responsibilities would continue as before, but they would not handle the enforcement actions.

The fiscal constraints that states have are another real challenge particularly with these programs which involve so many different state and local agencies. States are going to have to begin to make a stronger commitment to financial resources. States, and this includes Indiana, do not have the money to meet the match for federal funds. Getting lead prevention programs implemented at the state and local levels are Indiana's next challenge.

It is also important to have the support of advocacy groups and other legislators. Improving Kid's Environment has an annual lead-safe conference every year and has done a lot of work with retail establishments to train them on educating customers. We have been fairly successful due to their assistance in the general assembly. Certainly, victims can also be strong advocates and having their testimony truly helps.

For Indiana, the next steps are more administrative than legislative. ISDH and FSSA must develop systems to comply with the provisions of the new statute which includes the report, the incentives for compliance with lead testing, and a system to provide reimbursement for case management investigation of lead poisoned children. FSSA will also need to establish performance standards for blood level testing for managed care and then set up those performance incentives. ISDH needs to assess compliance for lab reporting requirements and take enforcement actions for noncompliance. IDEM must enforce rules for abatement and non-abatement projects, which will be the biggest challenge statutorily due to dealing with our environmental agency. It will continue to utilize the attorney general's office. The general assembly is going to have to make controlling lead poisoning more of a priority with funding. Programs also need an overall coordinator to work with all state and local agencies rather than someone under the department of health. Lastly, state and local agencies need to be more aggressive in pursuing the HUD funds to reduce lead hazards.