Lead Astray: Is Your Child At Risk?

California's Broken Promise to Protect Children from Lead Poisoning

By Bill Walker, Zev Ross, Richard Wiles, April 2000

• Despite a 1991 lawsuit settlement in which the State of California promised to ensure blood testing and treatment for lower-income children threatened by lead poisoning, since 1992 the state has failed to identify or provide care for an estimated 200,000 lead-poisoned children ages 1 to 5. About 212,000 one-to-five-year-olds in California had harmful blood lead levels between 1992 and 1998, but the state identified only 14,900.
• More than 43,700 California children ages 1 to 5 live in critical lead risk "hot spots" with the highest percentage of older housing, poverty and people of color. These hot spots are found in San Francisco, Alameda County, Los Angeles, Long Beach, San Diego, Sacramento and Fresno. An additional 239,000 children live in very high risk areas.
• Statewide, no more than 1 in 5 children is tested for lead poisoning. This abysmal performance in dealing with a serious, yet entirely preventable, public health problem is primarily the result of the Department of Health Services' failure to enforce state and federal law requiring blood tests for all young children receiving public assistance and to require reporting of all blood test results to the state. Doctors and health maintenance organizations (HMOs) are also failing in their legal responsibility to provide testing for all lower-income children; the state is complicit in this neglect because it has yet to adopt standards to hold health care providers accountable.
• This tragedy costs the state vast sums for special education, medical care and lost earnings for lead-poisoned children. Reducing the average level of lead in California children's blood by just 10 percent would save more than $800 million a year.
• EWG urges the state to adopt regulations requiring blood tests for all children and reporting of all blood lead levels. All health care providers must comply with state laws on testing and reporting, and the state must adopt standards that will allow health officials to enforce compliance. The state should increase its funding of lead poisoning prevention programs, should take legal action against health care providers who do not obey the law, and should consider joining lawsuits by Santa Clara County and the State of Rhode Island against lead polluters to recover damages to fund lead programs.

In 1991, after a federal lawsuit by civil rights advocates and environmentalists, the State of California promised to overhaul its lead-poisoning prevention program, which had systematically failed to protect thousands of high-risk children. But according to a 10-month computer-assisted investigation by Environmental Working Group (EWG), nothing has changed: Since 1992, the state has failed to identify or provide care for an estimated 200,000 lead poisoned children ages 1 to 5.

EWG calculates that about 212,000 one-to-five-year-olds in California had dangerous blood lead levels between 1992 and 1998, the latest year for which data are available. In that period, state records show that the California Department of Health Services (DHS) has identified only about 14,900 of the children with elevated blood levels - about 7 percent of the total.

These are conservative estimates. DHS' Childhood Lead Poisoning Prevention Program (CLPPP) estimates that the number of lead poisoning cases statewide increases by as many as 70,000 children a year - since 1992, a total of half a million kids who may have suffered learning impairment, reduced IQ, hearing loss or other severe effects of lead poisoning.

This abysmal performance in dealing with a serious, yet entirely preventable, public health problem is primarily due to two serious policy failures by the state: failure to enforce state and federal law requiring blood testing of all children who are statistically at risk of lead poisoning and failure to require reporting of all blood lead levels that meet the U.S. Centers for Disease Control threshold for lead poisoning.

In fact, the blood lead level (BLL) at which California requires health care providers to report a poisoning case to the state is 2.5 times higher than the lead poisoning threshhold recognized by the CDC (Figure 1). Local programs in some cities and counties attempt to identify and treat children with lower BLLs, but they lack the authority and resources needed to enforce universal testing of at-risk children by health care providers or lead-hazard mitigation by landlords.

Applying federal lead poisoning criteria to California census tracts, EWG has produced the first detailed, neighborhood-level estimates of lead poisoned children throughout the state. This report also makes public for the first time local maps of the neighborhoods where children are at the highest risk of lead poisoning. (Figures 2-7, pgs. 21-26.) The maps - based on risk formulas used by the Alameda County lead program, considered one of the best in the state - identify the census tracts that rank highest in factors CDC says are are accurate predictors of high rates of lead poisoning: percentage of housing built before 1950, percentage of residents whose income falls below poverty levels and percentage of residents who are people of color.

• More than 43,700 California children ages 1 to 5 live in critical lead risk "hot spots" - areas with the highest percentage of older housing, poverty and people of color (Table 1). These hot spots are found in south-central and east Los Angeles; the Mission and Tenderloin districts of San Francisco; east and west Oakland and south Berkeley; near Long Beach Harbor; San Diego's Barrio Logan; in south Sacramento; and west Fresno. An additional estimated 239,000 children statewide live in very high risk areas.
• More than 645,000 California children ages 1 to 5 live in ZIP codes where, based on the percentage of pre-1950 housing, the CDC recommends that all children be tested for lead poisoning (Table 2).
• In no county has the state identified more than 13 percent of the estimated number of lead poisoned children. Only in Kern, Santa Cruz, Santa Barbara and Sierra counties has the state identified at least 10 percent of lead poisoned children (Table 3). In Los Angeles County alone, more than 78,000 lead poisoned children - 91 percent of the estimated total - have not been identified.
• Not surprisingly, among the state's larger cities, Los Angeles has the highest estimated number of lead poisoned kids, with more than 35,000. But Oakland, with an estimated 7,900 lead-poisoned children, and San Francisco, with more than 6,500, have the highest percentages of lead-poisoned children compared to population (Table 4). Compared to the rest of the state, the two Bay Area cities have a much higher percentage of housing built before 1950, and Oakland has a higher concentration of low-income neighborhoods and communities of color.
• The percentage of lead-poisoned children who have not been identified by state or local officials is very high even in the three wealthiest counties in the state - Contra Costa (98 percent), Marin (99 percent) and San Mateo (98 percent). This lack of action may reflect the common belief, still promoted by the lead industry, that lead poisoning is primarily a problem of inner-city or minority children - when in fact, says the CDC, "no socioeconomic group, geographic area, or racial or ethnic population is spared." According to EWG's calculations, more than 10,000 children in those three counties have elevated blood lead levels.
• Most doctors, health maintenance organizations (HMOs) and other medical providers in California fail to test children for lead poisoning. Federal and state law require health care providers who participate in Medicaid, Medi-Cal or the Child Health and Disability Prevention (CHDP) program to test all 1- and 2-year-olds covered by those programs, and 3- to 6-year-olds who have not previously been tested. Approximately 70 percent of California's 1- to 5-year-olds are covered by one of the two programs (State Auditor 1999). Children not covered by the programs are also supposed to be tested if they match known risk factors in a verbal screening questionnaire. But DHS estimates that no more than 1 in 5 children in any risk category are actually tested.
• The state is complicit in this neglect by health care providers because it has failed to establish, as required by law, a minimum and mandatory "standard of care" which could be used to hold providers accountable. In the 1991 legislation establishing the state lead prevention program, adoption of a standard of care was required by 1993.
• The state's Childhood Lead Poisoning Prevention Program is woefully underfunded. Almost three-fourths of its budget comes from fees paid by companies who formerly made leaded paint or gasoline or whose operations emit lead. In 1995 and again this year, these companies sued to avoid paying the fees, undermining the program's financial stability, and today DHS collects only three-fourths of the $16 million it is authorized to collect from lead polluters annually. The program receives less than 20 percent of its funding from the state treasury.
• California's failure to protect children from lead poisoning costs the state hundreds of millions of dollars annually in special education, medical care and lost earnings for children who suffer learning impairment or other conditions as a result of lead poisoning. Based on calculations by national experts, EWG estimates that by reducing the statewide average level of lead in children's blood by just 10 percent of the CDC's risk level, California could save more than $800 million a year - enough to test every 1- to 5-year old in the state and have $576 million left over. (Schwartz 1994).

No Safe Level of Exposure

Although average levels of lead in the blood of America's children have dropped dramatically in the last 20 years, few people realize that, according to the CDC, lead paint remains the number one environmental threat to children's health. For young children, there is no known safe level of exposure to lead; even low levels can cause reduced IQ and attention span, learning disabilities, and a wide range of other health effects. Lead is most dangerous to children under six, whose brains and nervous systems are still developing and whose outdoor activities and tendency to put things in their mouths can expose them to a disproportionate amount of lead in soil, paint and dust.

CDC estimates that nationwide, about 4.4 percent, or 900,000, of children ages 1 to 5 have harmful levels of lead in their blood. But national averages mask the severity of the problem in many communities. Children from poor families are eight times more likely to be lead poisoned than kids from higher-income families. Nationally, African-American children are five times more likely, and Mexican-Americans almost twice as likely, to be poisoned than Anglo children. Of the approximately 15,000 surnames in DHS' limited state database with elevated blood levels, about 70 percent appear to be Latino.

Even if health care providers complied with state law requiring testing of the lower-income children covered by Medi-Cal or CHDP, the vast majority of lead poisoning cases would not be reported to the state health department. California requires reporting if a child's blood lead level is at least 25 micrograms per deciliter of blood (µg/dL), but since 1991 CDC has defined lead poisoning cases at 10 µg/dL.

The state's failure to identify the overwhelming majority of children with dangerous levels of lead in their blood makes it impossible to develop an effective statewide program to reduce lead poisoning. As a result, despite significant advances in the diagnosis and prevention of lead poisoning, a generation of high-risk California children have suffered needlessly.

This tragedy is intolerable, not only for its effect on public health but on other areas of public policy. Continuing to allow hundreds of thousands of children to suffer from lead poisoning has serious consequences for the future of California's schools, health care, economy and criminal justice system. Gov. Gray Davis has repeatedly declared that education is his utmost priority; if so, the Davis Administration could make no better investment than ensuring that all lead-poisoned children are identified and treated.

Recommendations

• The state should immediately codify regulations requiring the screening of all children and adopt regulations that require reporting of all blood levels, at least until health officials have enough information to design a comprehensive, effective statewide program of lead poisoning prevention, treatment and abatement.
• All health care providers must comply with existing state law to test low-income and other at-risk children and report the results to the state. The state should adopt an official standard of care that can be used by DHS and local lead programs to enforce compliance. The state should take HMOs and other providers who fail to follow the law to court.
• The state should take a leading role in legal efforts to ensure adequate funding for a comprehensive program of testing, reporting and treatment. In March 2000, Santa Clara became the first county in the U.S. to sue paint manufacturers --including Los Angeles-based Atlantic Richfield Co.-- for damages, on the model of the nationwide lawsuits against tobacco companies. Santa Clara has asked that the suit be certified as a class action, meaning all California jurisdictions could be awarded damages. Last year Rhode Island filed a similar suit, and has invited other states to join.
• Regardless of legal strategies, the Davis Administration and the Legislature should significantly increase public funding for the state lead program and to local programs. This must include increased funding for programs to educate the public and health care providers about the causes, prevention and treatment of lead poisoning. Many low-income Californians have little or no contact with the health care system, where they might learn about lead hazards. Unfortunately for those with health-care access, a 1996 DHS survey found that fully half of California doctors did not even know that peeling house paint is the most common source of lead poisoning.