Ecology

The NEW YORK TIMES reported in 1999 that, "Federal investigators say most states are flouting a 1989 law requiring that young children on Medicaid be tested for lead poisoning. As a result, they say, hundreds of thousands of children exposed to dangerously high levels of lead are neither tested nor treated."[1]

The TIMES explained that, "The General Accounting Office [GAO], an investigative arm of Congress, found that 'few Medicaid children are screened for blood-lead levels,' even though the problem of lead poisoning is concentrated among low-income children on Medicaid."

Medicaid is a federal medical insurance program for poor people. In the U.S. today, more than 40% of all poor people are children.[2] Nearly a million children (983,000) in the U.S. younger than 5 are believed to suffer from low-level lead poisoning, according to the federal Centers for Disease Control.[3]

Low-level lead poisoning can cause permanent learning disabilities, hyperactivity, poor motor coordination, and other developmental deficits. Indeed, reduced IQ, hearing loss and diminished stature are associated with lead levels considerably lower than the 10 micrograms of lead per tenth-of-a-liter of blood now deemed "acceptable" by the U.S. government.[4]

Supplementing and corroborating the GAO study, the state auditor of California, Kurt R. Sjoberg, reached a similar conclusion about Medicaid compliance in a separate 1999 report. "'Thousands of lead-poisoned children have been allowed to suffer needlessly,' because California has not complied with the federal requirement to test them for lead poisoning, Mr. Sjoberg said," according to the TIMES.[1]

Federal rules require that children in the Medicaid program be tested for lead poisoning at age 12 months and again at age two years. The GAO report found that states varied considerably in their compliance with this federal law. Washington State tested fewer than 1% of eligible children; New Jersey tested 40%. Alabama performed best, testing the highest proportion but still fewer than half (46%) of all eligible children.

The TIMES also reported that many states simply don't keep the necessary records to know whether they are complying with federal law or not. "Many states, including Connecticut [the wealthiest state in the Union] said they did not have statewide data on testing rates or the prevalence of lead poisoning," the TIMES reported.

The question occurs, why would a state not maintain records to assess the size of this problem and the steps being taken to solve it?

From a state's perspective, the problem isn't one of cost. A lead poisoning test is relatively cheap at $10 or less and besides the federal Medicaid program pays 100% of the costs of testing. If a child is found to have elevated lead levels, Medicaid will pay 100% of the costs of treatment. (Medicaid will NOT pay to test water, paint or house dust to find the source of the contamination, however.)

To summarize: An 11-year-old federal law requires all children up to age 2 in the Medicaid program to be tested for lead poisoning. Medicaid pays all the costs. The purpose of the law is to catch signs of lead poisoning early in hopes of limiting the damage to the child's central nervous system. Lead poisoning, even at low levels, can leave a permanent legacy of slow learning, hearing impairment, cardiovascular disease, behavioral problems and delinquent behavior.But the states are thumbing their noses at the federal law, thus allowing these debilitating medical conditions to develop in tens of thousands of American children each year.

Why? Why are governments refusing to comply with a public health law intended to protect children? Here are a few preliminary reasons:

** Dr. Maxine D. Hayes, the acting health officer for Washington state, gave a states-rights explanation: "We don't think it's right for the Federal Government to dictate what states should do," she told the NEW YORK TIMES. Dr. Hayes seems to be asserting a state's right to ignore the poisoning of its children and to disregard federal law if it chooses to do so, a dubious legal proposition at best (leaving aside the ethical issues it raises).

The question still remains, why would a state government choose to do such a thing?

** Washington state does participate in the federal Medicaid program. The state's Medicaid director gave the TIMES a different explanation: "We don't believe we have much of a problem with lead exposure here." However, this is speculation and the purpose of the lead-testing program is to lay such speculation to rest by producing hard evidence.

Bitter experience shows that testing is likely to identify some lead-poisoned children who live in homes built prior to 1978, particularly homes that have been poorly maintained. Eighty percent of housing built before 1978 contains some lead-based paint, which in poorly-maintained buildings is by now probably turning into a fine powdery dust, which toddlers may get on their hands and then into their mouths. But of course without testing, a state official is free to speculate that his or her state is, miraculously, an exception to this general rule.

The question remains, why would a state medical officer choose to speculate rather than acquire hard data?

** Many states have turned over their Medicaid responsibilities to health maintenance organizations (HMOs) but have neglected to specify the full range of services they expect HMOs to provide, so lead testing has often slipped through the cracks. The question remains: since Uncle Sam is picking up the tab, why don't states require lead testing when they negotiate contracts with HMOs?

The long and the short of it seems to be that most state governments have designed policies that assure that the lead-poisoning of children continues, and the federal government seems paralyzed in the face of this rebellion.

The question remains, Why?

* * *

There are two major sources of lead in the environment, both of them human in origin. The first is leaded gasoline, which was outlawed in the U.S. in 1976 but which left a residue of about 5.9 million metric tonnes (13 billion pounds) of lead in the environment in the form of a fine, toxic dust.[2] Much of that powdery lead is still moving around in soil and house dust.

Furthermore leaded gasoline is still being used in many countries outside the U.S., so contamination of the atmosphere continues, producing a steady toxic fallout.[5] Without human help, nature does produce some lead dust, but humans now produce 19 times as much as nature produces each year -- a startling reminder of how numerous market-based decisions can add up to an intractable problem of enormous proportions.[5]

The second major source of lead dust is lead in paint. Lead, the soft, gray metal makes an excellent white pigment, and paint made with white lead pigment provides a high-quality, durable protective coating. Eventually, however, even lead-based paint deteriorates. It begins to flake, peel and disintegrate into a fine, powdery dust, which is toxic.

Lead in paint was restricted on a voluntary basis by the paint industry in 1955, but voluntary compliance proved ineffective so, in 1970, Congress outlawed leaded paint for interior uses. However there is evidence that leaded paint was used illegally inside buildings until at least 1978.

Between 4 and 5 million metric tonnes (approximately 10 billion pounds) of lead were used in paint in the U.S. between 1889 and 1979 and much of it remains where it was originally put, slowly deteriorating into a toxic dust. An estimated 42 million families live in homes containing an average of 140 pounds of lead in paint. If it has not been covered, this paint is a constant danger to toddlers who often pick up the dust on their hands, then transfer it into their mouths.[3]

The danger of lead in paint was first identified 96 years ago when J. Lockhart Gibson, an Australian physician, published the first report in a medical journal describing children poisoned by lead-based paint. Gibson specifically described the dangers to children from lead-based paint on the walls and verandas of houses.[1] The following year Gibson urged that, "[T]he use of lead-based paint within the reach of children should be prohibited by law."[6] Australia finally took Gibson's advice in 1922, 50 years before the U.S. took similar action.

Unfortunately, lead is extremely toxic, especially to children whose developing nervous systems are particularly susceptible to lead poisoning. As little as 10 micrograms ingested daily can poison a child;[2] a microgram is a millionth of a gram and there are 28 grams in an ounce. With 10 micrograms being a toxic daily quantity, the 10 million metric tonnes of lead introduced into the environment by humans during the 20th century creates an almost unbelievably large "sink" of toxic powder available in soil and in house dust, waiting to cause brain damage in toddlers.

Lead poisoning of children in the U.S. was first described in medical literature in 1914.[7] In 1917, a physician at Johns Hopkins University in Baltimore suggested that, if physicians looked harder for lead poisoning in children, they would find more of it. A pediatric textbook in 1923 described 8 cases of childhood lead poisoning: "The poisoning was caused in each instance by the child's nibbling and swallowing the paint from his crib or furniture."[7] In 1924 an article in the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION said, "There are many mild cases of lead poisoning in children, manifested by spasms or colic."[7] The article pinpointed the source of the problem as window sills, porch railings, and crib railings coated with lead paint. In 1926, an article in the AMERICAN JOURNAL OF DISEASES OF CHILDREN said, "Lead poisoning is of relatively frequent occurrence in children."[7]

Jane Lin-Fu, a well-known lead researcher, summarizes the early history of childhood lead poisoning in the U.S. this way: "By the 1920s... severe forms of childhood lead poisoning were recognized, and it became obvious that the illness was quite common in the U.S."[7] The federal Centers for Disease Control concurred in 1979, saying, "Lead poisoning in children from paint was recognized early in this century."[7] But recognizing a problem and acting upon it are two different things.

[1] Robert Pear, "States Called Lax on Tests for Lead in Poor Children," NEW YORK TIMES August 22, 1999, pg. A1. [Return to article]

[2] Laura E. Montgomery and others, "The Effects of Poverty, Race, and Family Structure on US Children's Health: Data from the NHIS, 1978 through 1980 and 1989 through 1991," AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 86, No. 10 (October 1996), pgs. 1401-1405. [Return to article]

[3] Howard W. Mielke and Patrick L. Reagan, "Soil Is an Important Pathway of Human Lead Exposure," ENVIRONMENTAL HEALTH PERSPECTIVES Vol. 106, Supplement 1 (February 1998), pgs. 217-229. [Return to article]

[4] Institute of Medicine (U.S.) and National Institute of Public Health (Mexico), LEAD IN THE AMERICAS (Washington, D.C. and Cuernavaca, Morelos, Mexico: Institute of Medicine and National Institute of Public Health, 1996), pg. 62. [Return to article]

[5] Jerome O. Nriagu and Jozef M. Pacyna, "Quantitative assessment of worldwide contamination of air, water and soils by trace metals," NATURE Vol. 333 (May 12, 1988), pgs. 134-139. [Return to article]

[6] Gerald Markowitz and David Rosner, "'Cater to the Children:' The Role of the Lead Industry in a Public Health Tragedy, 1900-1955," AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 90, No. 1 (January 2000), pgs. 36-46. [Return to article]

[7] Richard Rabin, "Warnings Unheeded: A History of Child Lead Poisoning," AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 79, No. 12 (December 1989), pgs. 1668-1674.} [Return to article]

--Peter Montague

(National Writers Union, UAW Local 1981/AFL-CIO)

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