Comments from Donald Schwarz, MD, on a New Federal Strategy to Reduce Childhood Lead Exposure and Impacts

    • November 22, 2017

The following were submitted to the U.S. Department of Housing and Urban Development, the U.S. Department of Health and Human Services, and the U.S. Environmental Protection Agency by Donald F. Schwarz, MD, RWJF vice president, Program, in response to the agency’s request for comments.

The Robert Wood Johnson Foundation (RWJF) is pleased to submit comments on a New Federal Strategy to Reduce Childhood Lead Exposure and Impacts. RWJF is the nation’s largest philanthropy dedicated to improving health and health care in the United States. Since 1972, we have worked with public and private sector partners to advance the science of disease prevention and health promotion; train the next generation of health leaders; and support the development and implementation of policies and programs to foster better health across the country. In the last several years, we have embarked on a journey to build a Culture of Health—creating a society in which everybody, no matter who they are or where they live, has a just and fair opportunity to live the healthiest life possible.

For millions of children across the country, lead exposure is serious threat to such opportunity. In 2016, an estimated 500,000 children ages 5 and under had blood lead levels above the Centers for Disease Control and Prevention’s (CDC) reference value of 5 micrograms per deciliter, and decades of research have demonstrated that, even at low levels, lead can have devastating life-long consequences for young children. Lead exposure deleteriously affects brain development, impulse control and information processing, making children more likely to struggle in school, get into trouble with the law, and earn less throughout their lives. And while every child may be at risk, low-income and minority populations suffer disproportionately as they are more likely to live in homes and communities with lead paint, contaminated soil, and lead water pipes. While we have made tremendous progress over the past 40 years, particularly through targeted federal policy actions that phased lead out of gasoline and paint and state and local efforts to remove or mitigate lead risks in homes and water systems, our nation’s response remains fragmented and underfunded.

Therefore, RWJF, in collaboration with the Pew Charitable Trusts, recently released “10 Policies to Prevent and Respond to Childhood Lead Exposure.”1 The report was based on rigorous research, including a review of more than 700 scientific articles, quantitative modeling of the costs and benefits of various lead-related interventions, and qualitative assessments involving parents, community leaders, and health and housing stakeholders. The report was guided by a stellar advisory group of 18 scientists and practitioners and was informed by more than 20 other experts in fields as diverse as economics, sociology, environmental science, housing policy, and law. In our estimation, the report represents the most recent, comprehensive, and consolidated set of recommendations on how to prevent and respond to lead exposure among children.

The report found that eliminating lead exposure for all children born in 2018 would yield $84 billion in discounted future benefits. The federal government would realize $19 billion in benefits and state and local governments would realize $10 billion in the form of increased tax collections and lower health care, education, and safety net expenditures for children. (The remainder of the benefits would accrue to households as higher earnings and to private sector stakeholders.) Other key findings include:

  • Removing leaded drinking water service lines from the homes of children born in 2018 would protect more than 350,000 children and yield $2.7 billion in future benefits, or about $1.33 per dollar invested. The total includes $480 million for the federal government and $250 million for states and municipalities from health and education savings and increased tax revenue associated with higher earnings among the cohort. Replacing these lead pipes would cost an estimated $2 billion.
  • Eradicating lead paint hazards from older homes of children from low-income families would provide $3.5 billion in future benefits, or approximately $1.39 per dollar invested, and protect more than 311,000 children. The total benefits include $630 million in federal and $320 million in state and local health and education savings and increased revenue. Controlling lead paint hazards would cost $2.5 billion for the 2018 cohort.
  • Ensuring that contractors comply with the Environmental Protection Agency’s (EPA) rule that requires lead-safe renovation, repair, and painting practices would protect about 211,000 children born in 2018 and provide future benefits of $4.5 billion, or about $3.10 per dollar spent. This includes $990 million in federal and $500 million in state and local health and education savings and increased revenue. The effort would cost about $1.4 billion.
  • Eliminating lead from airplane fuel would protect more than 226,000 children born in 2018 who live near airports, generate $262 million in future benefits, and remove roughly 450 tons of lead from the environment every year.
  • Providing targeted evidence-based academic and behavioral interventions to the roughly 1.8 million children with a history of lead exposure could increase their lifetime family incomes and likelihood of graduating from high school and college and decrease their potential for teen parenthood and criminal conviction.

In light of the overwhelming evidence about the effects of lead at low levels and the urgency of sending our next generation of children to school ready and able to learn, the report provides 10 policy recommendations and implementation tactics for various sources of lead exposure, including paint, water systems, air emissions, soil, and consumer products. The ultimate success of these policies will depend on a number of factors: taking a comprehensive approach, rather than focusing on individual sources of lead; fostering collaboration across federal agencies and levels of government; and sustaining a commitment of financial and intellectual resources to this completely preventable public health threat.

1. Priority Risks and Goals

a. What priority risks, for example, exposures from housing, air, water, soil, food, etc., and issues should be addressed in a new federal lead strategy?

As described in our report, no recent conclusive epidemiologic evidence exists on the relative contribution of different sources of lead exposure to children’s blood lead levels.2 Therefore, the Federal Lead Strategy should take an inclusive approach, addressing all major sources of lead exposure. Moreover, the federal government should invest in research that would help elucidate which sources of lead create the greatest risks for most children, and which sources represent risks to specific communities or sub-populations. In the absence of these data, the Federal Lead Strategy should prioritize sources that affect the largest number of young children and substantially increase their blood lead levels. This would include water and lead paint hazards in and around homes, child care facilities, and schools. It should also address other sources that contribute to the overall amount of lead in the environment, including air emissions and non-essential uses of lead in health remedies, pottery, wheel weights, ammunition, and even baby food and fruit juices. Given the federal government’s unique role in regulating lead in air, food, and consumer products, these other sources of exposure are ripe for action.

b. Should any of the suggested goals above be deleted or revised, and/or should any goals be added? Within the suggested goals above (as stated, or as you would revise them), or additional goals, what specific objectives should be identified?

We support the inclusion of all five goals: 1) Reducing sources of lead exposure in children's environments; 2) Improving identification and monitoring of lead exposed children; 3) Improving the health of children identified as lead-exposed; 4) Communicating effectively and consistently with stakeholders about childhood lead exposure; and 5) Supporting or conducting research to advance our scientific understanding of the effects, evaluation, and control of lead hazards in children's environments.

Please see our response to question 2a regarding specific objectives that we recommend including in goals 1, 2, 3, and 5, and our responses to questions 2c and 3a regarding recommendations related to goal 4.

2. Strategy Development and Implementation

a. What actions should be implemented to address these priority risks and issues?
Below are excerpts from the report’s 10 policy recommendations that specifically address the role of federal agencies.

1. Reduce lead in drinking water in pre-1986 homes and other places children frequent (i.e., schools and child care).

  • By 2019, EPA and states should require water utilities to submit plans for full lead service line replacement (LSL), including specific efforts by utilities to reduce the financial burden on low-income customers. The plans should include strategies for ensuring customer safety following replacement, such as flushing, monitoring and provision of water filters. For example, Lansing, Michigan; St. Paul, Minnesota; and Madison, Wisconsin, have nearly completed replacement of their LSLs.
  • EPA should develop an action level for lead in a home’s drinking water. Health Canada’s proposed maximum allowable concentration of 5 ppb could serve as an interim level with the goal of getting to 1 ppb over time.
  • EPA should increase the number of household drinking water taps that are tested for lead under its Lead and Copper Rule requirements.
  • EPA and states should require utilities to take immediate protective steps when partial LSL replacements occur, including optimized corrosion control, flushing, monitoring, sampling, and clear and timely communication to affected residents.
  • EPA should assist state and local water system personnel through training to improve the consistency and effectiveness of corrosion control across systems of different sizes and water chemistries.
  • To increase the number of water samples drawn from places where vulnerable children spend time, EPA’s Lead and Copper Rule should require utilities to collect and test water from schools and licensed child-care facilities in their service districts.
  • The Department of Housing and Urban Development (HUD) and EPA should require drinking water sampling as part of lead risk assessment procedures. And, both agencies should coordinate funding for addressing lead in low- income housing so it includes the replacement of LSLs and plumbing as well as removal of paint hazards.
  • The U.S. Department of Agriculture (USDA) should work with EPA to define water quality for the National School Lunch Program (NSLP) and the Child and Adult Care Food Program (CACFP). And, for schools and child- care sites participating in NSLP and CACFP, the USDA should establish a fund for testing and remediation costs. The USDA should ensure that schools and child-care facilities meet water quality standards through its NSLP Administrative Reviews and CACFP Monitoring.

2. Remove lead-paint hazards from low-income housing built before 1960.

  • HUD, EPA, and CDC should work with states and local governments to replace windows coated with lead paint, fix peeling paint, clean up contaminated dust and treat toxic soil in and around low-income homes built before 1960. HUD should also make sure that these homes remain affordable.
  • The U.S. Department of Energy should encourage the replacement of lead-painted windows with new energy-efficient ones by including the benefits of preventing lead exposure under its Weatherization Assistance Program.
  • The Centers for Medicare & Medicaid Services (CMS) and Title V Maternal and Child Health Services Block Grant Program should support the training of home healthcare workers and other home- based aides to identify potential lead hazards in houses with children.
  • EPA and state and local governments should offer funding to schools and child-care providers to support lead paint hazard identification and mitigation.
  • EPA should update its standards for lead paint, dust and soil and work with state and local governments to fund efforts to identify and mitigate lead-paint hazards in schools and child-care facilities.

3. Enforce the federal Renovation, Repair and Painting Rule, requiring contractors to control the amount of lead dust and debris created by workers.

  • EPA should use its power to regulate the over 4 million renovation jobs each year and work with states and local agencies to ensure compliance. It should require that contractors perform dust testing after completing work to make sure that the home is safe.
  • EPA should fund state and local agencies to support compliance and educate businesses and consumers about the hazards of unsafe renovation.
  • The Occupational Safety and Health Administration (OSHA) should enhance protections for workers and their children by updating standards for lead exposure to reduce on-the-job risks and the hazards of bringing lead home from their jobsites.

4. Remove lead from food and consumer products.

  • The federal government, through participation in the Codex committee, should encourage expedited reduction of international limits on lead in foods, particularly those that young children and babies are likely to consume.

5. Reduce air lead emissions.

  • The Federal Aviation Administration (FAA) should expedite efforts to find suitable alternatives to leaded fuel and eliminate its use.
  • EPA could help to expedite the elimination of lead in aviation fuel by using its authority under the Clean Air Act to issue an "endangerment finding," indicating that leaded aircraft fuel emissions are polluting and harmful to public health, which would then require the FAA to adopt regulations.
  • EPA should implement the Children's Health Protection Advisory Committee's recommendation to reduce the National Ambient Air Quality Standard for lead to 0.02 μg/m3.

6. Clean-up contaminated soil.

  • EPA and other federal agencies should collaborate with each other and businesses to remediate dangerous conditions near homes, factories and facilities that extract lead from batteries and electronics.
  • EPA and states should further investigate neighborhoods near current and former lead smelter sites and other industrial and hazardous waste facilities. Findings should be shared in partnership with organizations trusted by local communities.
  • EPA and HUD should coordinate Superfund efforts and lead hazard control so that when an area is treated for contaminated soil, home interiors are also made lead-safe.

7. Improve blood lead testing among children at high-risk of exposure and find and remediate the sources of their exposure.

  • CDC should work with the American Academy of Pediatrics and other professional organizations to determine the factors that contribute to the lack of appropriate testing of high-risk children.
  • CMS should work with state Medicaid agencies to increase the number of states that include blood lead testing at ages 1 and 2 for Medicaid-enrolled children as a Healthcare Effectiveness Data and Information Set (HEDIS) measure. HEDIS monitors and incentivizes improvements in the performance of more than 90 percent of America’s health insurance plans.
  • The U.S. Department of Health and Human Services (HHS) and CDC should assist state and local health agencies in upgrading and improving blood lead surveillance at the state and local levels.

8. Ensure access to developmental and neuropsychological assessments and appropriate high-quality programs for lead-exposed children.

  • HHS and the U.S. Department of Education should work with state agencies to improve access to high-quality early and middle childhood education programs for children with a history of lead exposure.
  • CMS should provide adequate reimbursement for comprehensive follow-up services for children affected by lead, including lead hazard remediation and developmental and neuropsychological assessments.

9. Improve public access to local data.

  • CDC should work with community organizations, local health agencies and private philanthropy, to collect census tract level data on blood lead level results; the presence of leaded drinking water pipes; and lead in water, dust, paint and soil of homes, schools, child-care facilities and other places children spend time.
  • CDC should use data to produce culturally competent and accessible community reports on sources of lead and prevalence rates that are broadly disseminated to healthcare providers, school administrators and child-care operators.

10. Fill gaps in research to better target state and local prevention and response efforts.

  • The federal government should support a national survey of children's blood lead levels and sources of environmental exposure.
  • EPA should develop and validate a standardized method for sampling water for homes, schools and child-care facilities that can be implemented in the field by environmental health professionals.
  • EPA should identify barriers to optimal corrosion control and methods to overcome them, including widespread education of the public and water utilities.
  • HUD should work with EPA to design and implement a study of water from a representative sample of housing to estimate how much lead is getting into water systems and undertake large-scale studies to test the effect of soil treatments over time to inform cleanup programs.
  • HUD should research the effectiveness of various lead hazard control treatments in preventing blood lead level increases.
  • Federal, state and local agencies and philanthropy should conduct small-area population-based studies to identify relative risks among communities compared to the general population.
  • The National Institute for Environmental Health Sciences should fund studies on the relationship between prenatal and early childhood lead and high-incidence adult conditions, including hypertension, cardiac disease and stroke.

b. What obstacles should be considered in determining which actions to include in the strategy? What obstacles pertain to one or more goals, objectives, or actions? Please be specific about the anticipated impact of the obstacles.

  • Obstacles that should be considered include the following:
    Inadequate awareness and prioritization of lead as an ongoing problem among the public and policymakers;
  • Industry opposition to tighter standards for air, food, water, gasoline, and consumer products and industry concerns about costs and regulatory burden;
  • Budget constraints at federal, state, and local levels for significant infrastructure investments in housing and water systems; and
  • The current siloed nature of investments in and strategies for lead prevention and mitigation.

c. How can the obstacles be overcome? What effect, if any, would the effort to overcome these obstacles have on the ability to achieve the goals of the strategy?

To increase awareness of lead exposure as a significant, ongoing public health threat, the federal government and its partners in state and local government and the private sector could pursue a number of strategies. First, the crisis in Flint, Michigan, demonstrated to the public, policymakers, and even health leaders that LSLs pose a substantial threat to health and safety in diverse communities across the country. While lead pant hazards are concentrated in older industrial cities in the Northeast, LSLs are present in towns big and small, urban and rural. This offers an opportunity to further engage parents, schools, water utilities, elected officials, pediatricians, hospitals, and health insurers in advocating for and investing in solutions. (We offer specific messaging strategies in response to question 3a.) Second, lead prevention should be framed as a challenge that is winnable and able to generate benefits for children and families, government, and taxpayers. As our report demonstrates, replacing LSLs and removing lead paint hazards saves money and helps achieve other societal goods, such as improved school performance and lower criminal justice involvement.

To address potential industry opposition, the federal government and its partners in state and local government should develop incentives to accelerate the reduction of lead in the environment. For high-performing companies or industries (i.e. those that lead efforts to dramatically curtail lead in the environment), these incentives could include tax credits and other financial inducements, regulatory relief, and opportunities to advance corporate social responsibility objectives. The report details a number of incentives-based strategies for moving industry to act, particularly on lead paint hazard remediation. For example, Massachusetts offers income tax credits and low interest loans to assist property owners to remove or securely cover lead paint hazards in homes built before 1978 and occupied by a child under 6.

Budget constraints and siloed investments could be addressed simultaneously by promoting cross-sector efforts that reduce costs, combining funds creatively from multiple agencies and levels of government, and generating new revenues from public and private sources. To replace LSLs, communities have leveraged EPA’s Drinking Water State Revolving Loan Fund (DWSRLD)—a federal fund offering grants to states that provide a 20% match—and higher local water service fees, while identifying more cost-efficient ways of doing the work. Lansing, MI, for example, has replaced more than 12,000 LSLs since 2004 through a novel process that cut costs and time from 8 hours and $9,000 per replacement to 4 hours and $3,600. The Green and Healthy Homes initiative, with 17 sites across the country, has developed a model for blending lead hazard reduction, weatherization, and home remediation funds to address health risks holistically.3 Additionally, communities have found ways to finance remediation of lead paint and other environmental lead hazards through fees on emitters and regulatory enforcement actions.

At the federal level, the Children’s Health Insurance Program (CHIP) offers matching funds to states for certain non-coverage-related expenditures, including lead remediation. In November 2016, CMS authorized an amendment to allow Michigan’s CHIP to pay for the replacement of water pipes and fixtures in the homes of low-income families with children who are covered by CHIP or Medicaid. Properties in Flint with contaminated water received first priority. Other federal strategies to consider include: making it easier for communities to braid or blend funds from multiple programs (e.g., Superfund, DWSRLD, lead hazard control) and enabling savings in one federal account that result from investments in another to serve as a credit to the account that made the initial investment. For example, savings in special education in the federal budget resulting from lead hazard control could be directed to additional lead exposure reduction efforts.

3. Messaging and Outreach

a. What federal agency messaging regarding lead exposure in children, including information on where lead is found and how to avoid exposure, have been useful in the past and to which audiences? How could such messaging be improved?

In all 16 focus groups that informed our report’s development, participants consistently noted that awareness of lead hazards was lacking and that more needed to be done to inform parents, schools, contractors, landlords, and others about the dangers of lead. Focus group participants also regularly expressed distrust of industries contributing to lead pollution and government agencies. They cited industries’ practice of downplaying lead pollution risks and even manipulating data on blood lead levels in children. Participants criticized government agencies for not providing accurate and timely information, being unresponsive when residents raised concerns, and aligning with special interests more than the community.

Given these findings, we would suggest that any outreach and communications efforts be grounded in sound risk communication research and delivered via trusted messengers such as pediatricians, nurses, school teachers, faith leaders, and civic groups. Several participants generated specific ideas for use in schools, such as classroom curricula and letters home to parents about lead risks. Prior research conducted and published by HUD found that mass media—including radio and TV were more effective at reaching high-risk audiences than pamphlets and brochures delivered through public health professionals.4 Since the time of that study, social media has become a key method for reaching broad and diverse audiences and, therefore, should be considered as a key dissemination channel for future communications campaigns.

Efforts to drive the public to take action should be paired with resources that can help them do so. For example, giving residents the ability to look up property- and neighborhood-specific information on lead risks and then connecting them directly to blood lead testing, testing of water, paint, and soil, and remediation services can be particularly helpful. For example, several municipalities, including Cincinnati, the District of Columbia, and Boston, have inventoried their LSLs and made the information publicly available, and California and Ohio have passed laws requiring the creation of such records.5,6,7,8,9

b. Which non-federal partners should the Task Force consult with to address the environmental health risks and safety risks of lead exposure to children, and why? Please identify specific organizations, or categories of organizations.

Key public health stakeholders include: the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of City and County Health Officials, the National Environmental Health Association, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Congress of Obstetricians and Gynecologists. A special effort should be made to consult with organizations representing tribal communities, such as Seven Directions, A Center for Indigenous Public Health. Other important stakeholders to engage include parent associations, tenants’ rights groups, hospitals and health insurers, child health experts, housing and community development organizations, environmental health and justice groups, education and criminal justice advocates, real estate developers, property owners and landlord associations, water utilities, and national and local philanthropies.

Many of these stakeholders and sectors were involved in the development of our report including: Child Trends, Altarum Institute, Urban Institute, Trust for America’s Health, National Center for Healthy Housing, Mott Foundation, Low Income Investment Fund, Stewards of Affordable Housing for the Future, Metropolitan Tenants Organization, Healthy Homes Collaborative, Green & Healthy Homes Initiative, Iowa Parents Against Lead, United Parents Against Lead, People for Community Recovery, Childhood Lead Action Project, American Academy of Pediatrics, Healthy Schools Network, Nutrition Policy Institute, Metro Washington Council of Governments, National Conference of State Legislatures, Water Research Foundation, Environmental Health Strategy Center, Environmental Defense Fund, Clean Water Action/Clean Water Fund, American Water Works Association, Hurley Medical Center at Michigan State University, Simon Fraser University, Rice University, Thomas Jefferson University, and Tulane University School of Medicine.

Conclusion

Again, we appreciate the opportunity to submit comments on a New Federal Strategy to Reduce Childhood Lead Exposure and Impacts. We are happy to continue conversations with HUD, HHS, EPA, and the Lead Exposure Subcommittee of the President’s Taskforce about what we are doing to help improve the health and well-being of individuals, families, communities, and the nation.

 

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

 

References

1 Pew Charitable Trusts and the Robert Wood Johnson Foundation, “10 Policies to Prevent and Respond to Childhood Lead Exposure,” August 2017, Washington, D.C., www.pewtrusts.org/en/research-and-analysis/reports/2017/08/10-policies-to-prevent-and-respond-to-childhood-lead-exposure.

2 Ronnie Levin et al., “Lead Exposures in U.S. Children, 2008: Implications for Prevention,” Environmental Health Perspectives 116, no. 10 (2008); 1285-93, dx.doi.org/10.1289/ehp.11241.

3 National Academy of Public Administration, “Achieving Green and Healthy Homes and Communities in America: A Report Following the National Dialogue on Green and Healthy Homes,” 2011. www.greenandhealthyhomes.org/sites/default/files/11-01.pdf

4 Joey Zhou, PhD, “Public Awareness of Lead-Based Paint Hazards,” Abstract #49113, Presented at the 130th Annual Meeting of the American Public Health Association Conference, November 11, 2002, apha.confex.com/apha/130am/techprogram/paper_49113.htm.

5 Greater Cincinnati Water Works, “Lead Awareness” (2007), cincinnati-oh.gov/water/lead-information

6 DC Water, “Service Map, Lead” (2017), www.dcwater.com/servicemap

7 Boston Water and Sewer Commission, “Lead Service Map” (2017), www.bwsc.org/COMMUNITY/lead/leadmaps.asp

8 Lead Materials, California Health and Safety Code 104 Part 12, Ch. 5 Art 4, leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=104.&title=&part=12.&chapter=5.&article=4

9 Ohio House of Representatives Bill 512, 131st General Assembly (Sept. 9, 2016), search-prod.lis.state.oh.us/solarapi/v1/general_assembly_131/bills/hb512/EN/05?format=pdf