10 Policies to Prevent and Respond to Childhood Lead Exposure

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Overview

The ongoing lead contamination crises in Flint, Michigan, and East Chicago, Indiana, as well as the surge of news reports about lead risks in communities across the country have shone a national spotlight on the problem of childhood lead exposure. The increased public awareness and scientific evidence that lead poisoning is completely preventable make this a critical moment for action to protect the nation’s children, enhance their opportunities to succeed, and reduce costs to taxpayers.

With that background, the Health Impact Project convened a team of researchers to assess the implications of childhood lead exposure and perform a cost-benefit analysis of various policies to prevent and respond to the problem. The study team conducted a literature review, case studies, interviews, national listening sessions, focus groups, and quantitative analyses using models developed by Altarum Institute and by the Brookings Institution, Child Trends, and Urban Institute. The team included staff from Altarum, Child Trends, Urban Institute, Trust for America’s Health, the National Center for Healthy Housing, and the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts.

The study team analyzed existing policies for their impacts on public health and health equity—the concept that every person should have the same opportunity to be healthy. The effort was guided by a diverse group of advisers and experts from fields including environmental and public health, child development, economics, housing, health care, environmental and social justice, and drinking water engineering. In addition, input from stakeholders, including families whose children have suffered the toxic effects of lead, provided valuable insights.

Where economic benefits are estimated, they are referred to as “future benefits”—meaning they are discounted at a rate of 3 percent per year to account for changes in the value of money over time. The cost-benefit analyses are based on the lifelong impacts of interventions for a single cohort of U.S. children, those who will be born in 2018. Where appropriate, the analysis includes benefits that would accrue for additional children born into the same households within 10 years. In some cases, costs were unavailable so a cost-benefit ratio is not provided. 

Key Findings

• 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. Of those benefits, about $2.2 billion in higher lifetime earnings, better health, and other gains would accrue to 272,000 children born in the 2018 cohort, and $550 million would come from protecting the roughly 80,000 other children born into those homes over the next 10 years. 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. About $2.8 billion of those benefits would accrue to roughly 244,000 of the 4 million children in the 2018 cohort. The other $670 million in benefits would accrue from protecting approximately 67,000 additional children born into those homes over the next 10 years. 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 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. No studies have specifically assessed the effectiveness of such programs for lead-exposed children. However, research shows that for children at similar developmental risk from trauma, poverty, and other adverse experiences, certain high-quality interventions can increase the likelihood of earning a high school diploma and a four-year college degree and reduce the chance of becoming teen parents. The estimated benefits presume comparable impacts on lead-exposed children.

The costs and benefits outlined in the bullets above are based on a targeted approach to implementing the interventions, such as focusing on older homes with the highest probability of having lead hazards, and on populations at greatest risk, including low-income families. These economic calculations do not include emotional distress or other potentially large costs to families, such as time away from work.

Preventing childhood lead exposure will require significant policy and regulatory action, coordination across levels of government, and public and private investments, but it has the potential to generate substantial economic and public health gains in the short and long terms. The maximum potential future benefits of preventing all lead exposure for the 2018 birth cohort, such that those children’s blood lead levels could be kept from rising above zero, could reach $84 billion, not including the costs to achieve such total prevention. This figure includes nearly $18.5 billion for the federal government and $9.6 billion for states in the form of increased revenue and savings to the health care, education, and criminal justice systems. Calculating the cost of such hypothetical total prevention was beyond the scope of this study, but as shown above, the models for the individual interventions, which together could address a significant share of children’s exposure risk, do include cost estimates.

No recent conclusive epidemiologic evidence exists on the relative contribution of different sources to children’s blood lead levels, so based on the results of its research, the study team has prioritized policies that the research literature strongly indicated could have the greatest positive population-wide effect on blood lead levels and could protect the most children. Secondarily, the team proposes focusing on other sources that contribute to the overall amount of lead, including nonessential uses of lead, which may cause individual acute cases of lead poisoning, but account for a smaller proportion of lead in children’s blood overall. Concurrent with efforts to prevent exposure, the team also encourages the adoption of policies for intervening with children already poisoned by lead and for improving the data available to policymakers and the public.

The study team recommends:

Priority sources

• Reduce lead in drinking water in homes built before 1986 and other places children frequent. States and municipalities, with support from federal agencies, should fully replace lead service lines, from street to structure, that provide drinking water to homes built before the EPA banned their use. The EPA should strengthen its requirements to reduce the corrosivity of drinking water, improve water sampling protocols, and create a science-based household water lead action level—the amount that requires intervention—to help families and communities assess their risks. States and localities should investigate and mitigate drinking water hazards in schools and child care facilities.
• Remove lead paint hazards from low-income housing built before 1960 and other places children spend time. According to the Department of Housing and Urban Development, about 3.6 million homes nationwide that house young children have lead hazards such as peeling paint, contaminated dust, or toxic soil. HUD, the EPA, and the Centers for Disease Control and Prevention should work with states and local governments to support replacement of windows coated with lead paint, fix peeling paint, clean up contaminated dust, and treat toxic soil in and around those homes. States should require school districts and child care facilities to identify and remediate lead paint hazards.
• Increase enforcement of the federal renovation, repair, and painting rule. The EPA and its state agency partners should conduct more investigations to ensure that contractors are in compliance with federal regulations requiring training and certification to minimize dust and debris when working with lead-based paint. The EPA and states should emphasize enforcement for work done at child care facilities and in housing built before 1960.

Additional sources

• Reduce lead in food and consumer products. The federal government, through participation in the international Codex Alimentarius Commission—a cooperative effort of the United Nations and World Health Organization—should encourage expedited reduction of international limits on lead in foods, particularly those that young children and babies are likely to consume. Further, where local data indicate that children are being exposed to lead from sources such as candy, health remedies, or cosmetics, state and local agencies should target education and outreach to at-risk neighborhoods; support cultural awareness among physicians; and increase investigation and enforcement of small retailers.
• Reduce air lead emissions. The EPA and other federal agencies should collaborate to curtail new discharges by reducing concentrations of lead into the environment, such as from aviation gas and lead smelting and battery recycling facilities.
• Clean up contaminated soil. The EPA should collaborate with business to remediate dangerous conditions at and near facilities that extract lead from batteries and other electronics.

Poisoning response

• Improve blood lead testing among children at high risk of exposure and find and remediate the sources of their exposure. Federal and state health agencies should work with parents of lead-poisoned children, providers, Medicaid, and the Children’s Health Insurance Program to remove barriers to blood lead testing and reporting, and to reduce sources of lead in children’s home environments.
• Ensure access to developmental and neuropsychological assessments and appropriate high-quality programs for children with elevated blood lead levels. The U.S. Departments of Health and Human Services and Education and state and local health and education agencies should invest in education and care programs, and the federal Centers for Medicare & Medicaid Services should increase children’s access to developmental assessments and neuropsychological testing so that the services provided address each child’s individual needs.

Data and research

• Improve public access to local data. Federal, state, and local authorities should work together to make lead-risk data available to families, policymakers, and other stakeholders who need information about sources of exposure, such as property-specific information on leaded drinking water pipes and lead in the water, dust, paint, and soil at or near homes, schools, and child care facilities.
• Fill gaps in research to better target state and local prevention and response efforts. Federal, state, and local agencies and philanthropic organizations should support new studies and conduct their own research to identify sources of lead exposure and populations at greatest risk.

Policy initiatives such as these, while ambitious, are not without precedent, and this report includes illustrative case studies from states and municipalities that have tackled significant lead-exposure problems.

The report begins with a brief history of lead in the U.S. and the policies enacted to address it, a discussion of the impact of lead on children’s brains and the disproportionate risks to low-income children and children of color, and a description of the study methods and limitations. It then examines policies to prevent exposure, including interventions focused on lead in drinking water, paint, dust, air emissions, and soil, as well as research gaps revealed during the study of those policy options. Later sections look at strategies for improving blood lead testing in children and at nutritional, educational, and behavioral programs to help mitigate the effects of lead in children already exposed. Each policy discussion includes literature review findings; case studies; input from stakeholders; potential challenges; and, when possible, costs, benefits, and simulated effects on children’s lifetime outcomes. The study concludes with a detailed list of actions federal, state, and local policymakers can take to implement the above recommendations. (See Page 79.)