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10 Policies to Prevent and Respond to Childhood Lead Exposure an Assessment of the Risks Communities Face and Key Federal, State, and Local Solutions

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10 Policies to Prevent and Respond to Childhood Lead Exposure an Assessment of the Risks Communities Face and Key Federal, State, and Local Solutions A report from the Health Impact Project Aug 2017 10 Policies to Prevent and Respond to Childhood Lead Exposure An assessment of the risks communities face and key federal, state, and local solutions Contents 1 Overview 5 The history of lead in the United States Lead and the brain 8 Disproportionate Risks and Related Health Disparities 9 12 Methods Quantitative methods 12 Qualitative methods 14 Study limitations 15 17 Total prevention of lead poisoning Lead is ubiquitous; past and present uses challenge eradication efforts 17 Lead in Everyday Items 18 Modeling total prevention 20 23 Drinking water Lead in Water and Infant Health 23 Drinking Water in Schools and Child Care Facilities 25 Residential lead service line replacement 28 Policy in Action: Strategies to Promote Lead Service Line Replacement 29 Policy in Action: Replacing Lead Service Lines 36 38 Lead paint hazards Residential remediation 38 Policy in Action: Local Lead Paint Laws 40 Policy in Action: State Lead Paint Hazard Control Laws 42 Policy in Action: Financing Lead Paint Hazard Control 46 Lead Paint Hazards and Contaminated Soil at Schools and Child Care Facilities 49 Safe renovation, repair, and painting enforcement 52 57 Air emissions and soil contamination Lead smelting and battery recycling facilities 58 Superfund sites 59 Policy in Action: Superfund Cleanup 60 Policy in Action: Imposing a Fee on Emitters to Fund Public Lead Remediation Programs 62 Leaded aviation gas 63 Policy in Action: Safe Soil for Schools and Child Care 66 67 Addressing data gaps 69 Supporting children with a history of lead exposure Blood lead testing 69 Academic and behavioral interventions 70 Policy in Action: Serving Children With a History of Lead Exposure 73 Nutrition 74 Policy in Action: Healthy Diets for Better Long-Term Outcomes 74 79 Recommendations Priority sources 79 Additional sources 82 Poisoning response 83 Data and research 84 86 Conclusion 87 Glossary 90 Appendix: Methodology Policy screening process 91 Literature review 92 Case studies 95 Listening sessions 96 Parent conversations 96 Focus groups 96 Quantitative methods 98 Assumptions for modeled policies 106 Uncertainty in modeling lead impacts and remediation policies 109 Qualitative description of uncertainty 110 Bounding exercises to measure uncertainty in effect sizes 112 Quantitative sensitivity analyses 113 118 Endnotes Figures and tables Figure 1: Exposure Prevention Effectively Lowers Children’s Lead Levels 6 Figure 2: All Children Face Some Exposure Risk, but Racial and Ethnic Disparities Persist 10 Table 1: Keeping Blood Lead Levels of Children Born in 2018 at Zero Would Generate $84 Billion in Benefits 20 Figure 3: Most Benefits of Exposure Prevention Accrue for Children Whose Blood Lead Would Otherwise Be Below 2 g/dL 21 Table 2: Keeping Blood Lead Levels at Zero Among Children Born in 2018 Would Improve Educational μ and Social Outcomes 22 Table 3: Every Dollar Invested in Full Lead Service Line Replacement Would Generate $.42 to $1.33 in Benefits 34 Table 4: Targeting Lead Paint Hazard Control to Older Low-Income Housing Offers the Greatest Per-Dollar Benefits 45 Table 5: Lead-Safe Renovation Could Yield $3.10 Per $1 Invested 55 Figure 4: Piston Engine Aircraft and Industrial Processes Make Up the Majority of Lead Emissions 57 Table 6: Removing Lead From Aviation Fuel Could Prevent a 5.7% Increase in Children’s Blood Lead 65 Table 7: Providing Both Early and Middle Childhood Interventions Could Yield the Greatest Benefits 77 Table A.1: Summary of Research Methods 90 Table A.2: Strength of Evidence Criteria for Literature Review Used in Quantitative Models 94 Table A.3: Focus Group Participant Demographics and Other Characteristics 97 Table A.4: Summary of Effects of Selected Lead-Exposure Prevention Policies 100 Table A.5: Value of Prevention Tool Sensitivity Analysis Results 114 The Pew Charitable Robert Wood Trusts Johnson Foundation Susan K. Urahn, executive vice president Giridhar Mallya, senior policy officer Allan Coukell, senior director Pamela Russo, senior program officer Health Impact Project Rebecca Morley, director Amber Lenhart, senior associate Gabriela Illa, associate Mary Jean Brown, consultant Study partners Child Trends Urban Institute Vanessa Sacks, research scientist Steven Martin, senior research associate Kristin Moore, senior scholar and youth development Gregory Acs, director, Income and Benefits Policy Center director Fadumo Abdi, research analyst Trust for America’s Health Rich Hamburg, executive vice president and chief Altarum Institute operating officer George Miller, fellow Albert Lang, senior communications officer Paul Hughes-Cromwick, co-director, Center for Sustainable Health Spending National Center for Healthy Housing Corwin Rhyan, health care research analyst David Jacobs, chief scientist External experts and reviewers This report was reviewed by Morri E. Markowitz, M.D., the Children’s Hospital at Montefiore, and professor of pediatrics, Albert Einstein College of Medicine; and Steven Teutsch, M.D., M.P.H., senior fellow, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, senior fellow, Public Health Institute, and adjunct professor, UCLA Fielding School of Public Health. Although they found the approach and methodology to be sound, neither they nor their organizations necessarily endorse the report’s findings or conclusions. Acknowledgments The team thanks the following people for their contributions to this report as partners, subject matter experts, and case study reviewers: Christine Stanik, Altarum Institute; Jonathan Schwabish, Urban Institute; Jonathan Wilson and Amanda Reddy, National Center for Healthy Housing; Jonathan Cuppett, Water Research Foundation; Maida Galvez, M.D., Mount Sinai; Todd Grindal, Ed.D., Abt Associates; Cheryl Johnson, People for Community Recovery; Linda Kite, Healthy Homes Collaborative; Patrick MacRoy, M.A., Environmental Health Strategy Center; Howard Mielke, Ph.D., Tulane University School of Medicine; Deborah Nagin, M.P.H., New York City Department of Health and Mental Hygiene; Tom Neltner, J.D., and Ananya Roy, Sc.D., Environmental Defense Fund; Rick Nevin, ICF International; Ruth Ann Norton and G. Wesley Stewart, Green & Healthy Homes Initiative; Janet Phoenix, M.D., The George Washington University; Lisa Ragain, Metro Washington Council of Governments; Jay Schneider, Ph.D., Thomas Jefferson University; Lynn Thorp, Clean Water Action/Clean Water Fund; Steven Via, American Water Works Association; Kamillah Wood, M.D., Stewards of Affordable Housing for the Future; Laura Brion, Childhood Lead Action Project; Valerie Charlton, M.D., Lauren Rice, and Rick Kreutzer, M.D., California Department of Public Health; Julia Robey Christian and Lisa A. Gilmore, Government of the District of Columbia; Dale Clarkson, Peoria City/County Health Department; Kara Eastman, M.S.W., Omaha Healthy Kids Alliance; Angie Goodman, Lansing Board of Water and Light; Gary Kirkmire, City of Rochester Inspection and Compliance Services; Elisabeth Long, Washington State Department of Health; Lisa Smestad, City of Minneapolis; Amber A. Sturdivant, District of Columbia Department of Energy and Environment; Claire Barnett, M.B.A., Healthy Schools Network; Don Farquhar, J.D., National Conference of State Legislatures; Perry Gottesfeld, M.P.H., Occupational Knowledge International; Paul Haan, Healthy Homes Coalition of West Michigan; and Christina Hecht, Ph.D., Nutrition Policy Institute at the University of California. Many thanks also to the concerned citizens, parents, community-based organizations, community health professionals, landlords, and federal, state, and local agency staff who served as key sources of information for this project. Finally, the team thanks current and former Pew colleagues Dan Benderly, Gaby Bonilla, Stefanie Carignan, Erika Compart, Jennifer V. Doctors, Richard Friend, Tami Holzman, Carol Hutchinson, Bronwen Latimer, Mary Markley, Bernard Ohanian, Jennifer Peltak, and Peter Wu, as well as our fact check team, for their assistance in preparing this document for publication. Advisory Group This report benefited from the guidance of a formal advisory group with diverse perspectives and expertise. Although the research team gave substantial weight to the committee’s input and advice, it retained final authority over and responsibility for the process, findings, and recommendations. Additionally, although the committee members found the approach and methodology to be sound, neither they nor their organizations necessarily endorse the findings or conclusions. Committee members Nancy Andrews, M.S., president and chief executive officer, Low Income Investment Fund John Bartlett, executive director, Metropolitan Tenants Organization Jeanne Brooks-Gunn, Ph.D., M.Ed., Virginia and Leonard Marx Professor of Child Development, Columbia University Mona Hanna-Attisha, M.D., M.P.H., director, Pediatric Residency Program, Hurley Medical Center, Michigan State University Mark Hayward, Ph.D., professor of sociology, The University of Texas at Austin Ruth Katz, J.D., M.P.H., executive director, the Aspen Institute Bruce Lanphear, M.D., M.P.H., professor, Simon Fraser University Marie Lynn Miranda, Ph.D., M.A., provost, Rice University Brenda Music, co-director, Iowa Parents Against Lead Damon Music, co-director, Iowa Parents Against Lead Michèle Prévost, Ph.D., professor, Department of Civil, Geological and Mining Engineering, Polytechnique Montréal Queen Zakia Shabazz, director, United Parents Against
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