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[107 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
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S. Hrg. 107-984
LEAD-BASED PAINT POISONING:
FEDERAL RESPONSES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HOUSING AND TRANSPORTATION
of the
COMMITTEE ON
BANKING,HOUSING,AND URBAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
ON
AN OVERVIEW OF WHAT FIVE FEDERAL AGENCIES--HUD, EPA, DOJ, CMS, AND
CDC--ARE CURRENTLY DOING TO HELP MAKE HOUSING LEAD-SAFE FOR CHILDREN
__________
JUNE 5, 2002
__________
Printed for the use of the Committee on Banking, Housing, and Urban
Affairs
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COMMITTEE ON BANKING, HOUSING, AND URBAN AFFAIRS
PAUL S. SARBANES, Maryland, Chairman
CHRISTOPHER J. DODD, Connecticut PHIL GRAMM, Texas
TIM JOHNSON, South Dakota RICHARD C. SHELBY, Alabama
JACK REED, Rhode Island ROBERT F. BENNETT, Utah
CHARLES E. SCHUMER, New York WAYNE ALLARD, Colorado
EVAN BAYH, Indiana MICHAEL B. ENZI, Wyoming
ZELL MILLER, Georgia CHUCK HAGEL, Nebraska
THOMAS R. CARPER, Delaware RICK SANTORUM, Pennsylvania
DEBBIE STABENOW, Michigan JIM BUNNING, Kentucky
JON S. CORZINE, New Jersey MIKE CRAPO, Idaho
DANIEL K. AKAKA, Hawaii JOHN ENSIGN, Nevada
Steven B. Harris, Staff Director and Chief Counsel
Wayne A. Abernathy, Republican Staff Director
Jennifer Fogel-Bublick, Counsel
Jonathan Miller, Professional Staff
Sherry E. Little, Republican Legislation Assistant
Mark A. Calabria, Republican Economist
Joseph R. Kolinski, Chief Clerk and Computer Systems Administrator
George E. Whittle, Editor
Frank E. Wright, Assistant Editor
______
Subcommittee on Housing and Transportation
JACK REED, Rhode Island, Chairman
WAYNE ALLARD, Colorado, Ranking Member
THOMAS R. CARPER, Delaware RICK SANTORUM, Pennsylvania
DEBBIE STABENOW, Michigan JOHN ENSIGN, Nevada
JON S. CORZINE, New Jersey RICHARD C. SHELBY, Alabama
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
CHARLES E. SCHUMER, New York CHUCK HAGEL, Nebraska
DANIEL K. AKAKA, Hawaii
Kara M. Stein, Staff Director
Tewana Wilkerson, Republican Staff Director
(ii)
?
C O N T E N T S
----------
WEDNESDAY, JUNE 5, 2002
Page
Opening statement of Senator Reed................................ 1
Prepared statement........................................... 28
Opening statements, comments, or prepared statements of:
Senator Allard............................................... 2
Prepared statement....................................... 29
Senator Corzine.............................................. 14
Prepared statement....................................... 30
Senator Stabenow............................................. 30
WITNESSES
David E. Jacobs, Ph.D., Director, Office of Healthy Homes and
Lead Hazard Control, U.S. Department of Housing and Urban
Development.................................................... 3
Prepared statement........................................... 31
Response to written questions of:
Senator Reed............................................. 46
Senator Carper........................................... 49
Thomas L. Sansonetti, Assistant Attorney General, Environment and
Natural Resources Division, U.S. Department of Justice......... 6
Prepared statement........................................... 34
Response to written questions of:
Senator Reed............................................. 51
Senator Carper........................................... 53
Adam Sharp, Associate Assistant Administrator, Office of
Prevention, Pesticides, and Toxic Substances, U.S.
Environmental Protection Agency................................ 8
Prepared statement........................................... 38
Response to written questions of Senator Reed................ 53
Ruben King-Shaw, Jr., Deputy Administrator and Chief Operating
Officer, Centers for Medicare and Medicaid Services............ 10
Prepared statement........................................... 40
Response to written questions of:
Senator Reed............................................. 67
Senator Carper........................................... 74
Richard J. Jackson, M.D., M.P.H., Director, National Center for
Environmental Health, Centers for Disease Control and
Prevention, U.S. Department of Health and Human Services....... 12
Prepared statement........................................... 42
Response to written questions of Senator Reed................ 74
(iii)
LEAD-BASED PAINT POISONING:
FEDERAL RESPONSES
----------
WEDNESDAY, JUNE 5, 2002
U.S. Senate,
Committee on Banking, Housing, and Urban Affairs,
Subcommittee on Housing and Transportation,
Washington, DC.
The Subcommittee met at 2:45 p.m. in room SD-538 of the
Dirksen Senate Office Building, Senator Jack Reed (Chairman of
the Subcommittee) presiding.
OPENING STATEMENT OF SENATOR JACK REED
Senator Reed. The hearing will come to order.
Good afternoon. Let me welcome everyone to today's hearing
on Federal responses to lead-based paint poisoning. I hope to
bring greater attention to this terrible problem in our
Nation's housing and its effects particularly on children. It
is a follow-up to the Senate Housing Subcommittee hearing held
last year regarding State and local responses to lead-based
paint poisoning.
Over a decade ago, the U.S. Department of Health and Human
Services announced a strategic plan for the elimination of
childhood lead poisoning because it recognized the detrimental,
long-lasting effects on children from exposure to lead. The
efforts to achieve this long-established goal of eliminating
lead poisoning by the year 2010 has stalled and may, in fact,
be moving in the opposite direction.
Not only are Federal laws not being enforced, such as the
requirement that all Medicaid eligible children be screened for
lead, but it also appears that there is currently no
coordinated action to eliminate childhood lead poisoning.
The previous Administration created a Task Force on
Children's Environmental Health and Safety Risks. This task
force was
cochaired by the Secretary of the U.S. Department of Health
and Human Services and the Administrator of the Evironmental
Protection Agency, and developed a set of recommendations to
eliminate childhood lead poisoning in the United States as a
major public health problem by the year 2010.
Specifically, this comprehensive Government-wide strategy
called for making 2.3 million homes where children under the
age of 6 live lead-safe by controlling lead-paint hazards. It also
called for public education programs, strict enforcement of lead-paint
regulations, as well as encouraging early interventions for at-
risk children.
With only 8 years to go until we are to have eliminated
childhood lead poisoning, it is estimated that nearly one
million preschool children living in the United States continue
to have blood-lead levels high enough to impair their ability
to think, concentrate, and learn.
Unfortunately, except for the most severely poisoned
children, there is no medical treatment for this disease. And
even then, treatment may only reduce the level of lead present
in the body, not reverse the harm already caused. The only
effective treatment is preventing exposure, which occurs as a
result of deteriorating paint in our Nation's housing stock.
The Department of Housing and Urban Development estimated
in its latest national survey that lead still remains in about
39 million dwelling units, or 40 percent of all U.S. housing.
Federal efforts to reduce the hazards of lead-based paint
poisoning began 31 years ago, with the enactment of the Lead-
Based Paint Poisoning Prevention Act. This Act required the
Secretary of HUD to establish and implement procedures to
eliminate lead hazards from public housing.
In 1992, Title X of the Housing and Community Development
Act authorized major changes in Federal law on the control of
lead-based paint hazards and the reduction of lead exposure.
Title X defined hazard in such a way that it included
deteriorating lead-paint, and the lead-contaminated dust and
soil that the lead-paint generates. It also mandated the
creation of an infrastructure that would help correct lead-
paint hazards in all of our Nation's housing. In particular,
Title X required coordinated action between
several Federal agencies regarding lead poisoning, including
the Department of Housing and Urban Development, the
Environmental Protection Agency, and the Centers for Disease
Control and Prevention.
While we have made progress in dramatically reducing the
number of children with elevated blood levels, significant
barriers and obstacles to the elimination of this environmental
health hazard remain. It raises significant questions which we
will address in this hearing, significant questions that need
to be addressed. Specifically: Why are we still only evaluating
20 percent of Medicaid eligible children, and why we are not
coordinating better?
I would hope as we go forward with this hearing to develop
all of these issues. We are fortunate to have a distinguished
panel. But before I introduce the panel, let me introduce my
colleague, the Ranking Member, Senator Allard.
COMMENTS OF SENATOR WAYNE ALLARD
Senator Allard. Mr. Chairman, I have a short statement of
only about 30 pages.
[Laughter.]
I have one page, actually. I was trying to get your
attention, Mr. Chairman.
[Laughter.]
Senator Reed. You have my attention.
Senator Allard. I told you I had 30 pages.
Senator Reed. Knowing of your concise and focused comments,
I trusted you did not.
Senator Allard. Very good. I ask unanimous consent that my
statement be made a part of the record. I just have a one-page
statement. I will just make it a part of the record.
Senator Reed. Without objection, it shall be a part of the
record. Now let me introduce the panel.
Dave Jacobs is the Director of the Office of Healthy Homes
and Lead Hazard Control. Before that he was Deputy Director of
the National Center for Lead-Safe Housing, from 1992 to 1995.
He has received a number of awards for his work on lead hazard
reduction.
Mr. Thomas L. Sansonetti is the Assistant Attorney General
in charge of the Environment and Natural Resources Division at
the Department of Justice. Prior to arriving at the DOJ, Mr.
Sansonetti was a partner in the Cheyenne office of Holland &
Hart, where he specialized in natural resource and
environmental law.
Mr. Adam Sharp is the Associate Assistant Administrator,
Office of Prevention, Pesticides and Toxic Substances at the
Environmental Protection Agency. Prior to that, he worked at
the American Farm Bureau Federation on its governmental
relations and regulatory affairs staff. He also served as a
Director at the federation for the last 2 years of his tenure
there.
Mr. Ruben King-Shaw is Deputy Administrator and Chief
Operating Officer, Centers for Medicare & Medicaid Services.
Prior to assuming this responsibility, he was the Secretary of
the Florida Agency for Health Care Administration.
Mr. Dick Jackson is the Director of the National Center for
Environmental Health, one of the centers within the Centers for
Disease Control and Prevention. He is a pediatrician who has
spent the past 25 years working to improve the health of
children. He has also served as a State health official and as
Chairman of the American Academy of Pediatrics Committee on
Environmental Health.
Before you begin, I would like to thank each of you for
your written testimony, which has been shared with the Members
of the Subcommittee. And I would ask that you stick to our 5-
minute time limit, if you would. And you may in fact make your
statements in whole part of the record.
Thank you, and let's begin with Mr. Jacobs.
STATEMENT OF DAVID E. JACOBS, Ph.D.
DIRECTOR, OFFICE OF HEALTHY HOMES
AND LEAD HAZARD CONTROL
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
Mr. Jacobs. Thank you, Mr. Chairman, Senator Allard, for
the opportunity to appear before you today to discuss HUD's
activities in the area of childhood lead poisoning prevention.
My message today is simply this--the Nation has, in fact,
made enormous progress. However, much more remains to be done.
And the science and the practical program experience that we
have accumulated shows that we know how to do it.
Over the past decade, the number of houses with lead-paint
hazards has declined at an astonishing rate--from 64 million
houses in 1990 to 38 million--as you just noted. That is an
enormous decline and it is the best proof yet that what we are
doing is actually working.
Yet, the challenge of eliminating hazards before children
are poisoned remains quite large. And if we fail to finish the
job, hundreds of thousands of children will be unnecessarily
poisoned in the coming decade. That must not be permitted to
happen.
The Administration is committed to eliminating childhood
lead poisoning by the year 2010, and I am pleased to tell you
that the Administration has continued the Executive Order that
established the President's Task Force on Children's
Environmental Health and Safety Risks, which produced the 10-
year plan to eliminate the disease.
I am also pleased to report that HUD Secretary Mel Martinez
has made this a priority of his administration, and it shows.
We are creating thousands of lead-safe houses each year, more
than ever before. We have trained over 28,000 housing rehab and
maintenance workers in lead-safe work practices over the past
year alone.
With Congressional support, we have increased HUD's lead
hazard control budget by 10 percent for 2002, and the
President's budget proposal for 2003 increases it by another 15
percent, which will enable even more houses to be made lead-
safe.
Housing receiving Government assistance, according to our
new national survey, has been made about as safe as the middle-
and
upper-income housing--that is, low-risk housing--evidence that
our lead-paint regulation for Federally-assisted housing works.
We believe that regulation also provides an important model
for the rest of the Nation because it takes action before a
child is poisoned, not just after the child is already
poisoned. And it proves that if we put our mind to it, we can,
in fact, make our houses safe for children across the entire
country.
I want to briefly highlight several key ingredients to what
we think is the solution--local know-how and capacity,
enforcement, proof of what works, and the importance of
partnerships among the Federal agencies. And I want to close
with HUD's new initiative
to leverage private-sector resources, something we call
Operation LEAP.
First, our grant program is the main vehicle in the country
for dealing with the houses with the greatest hazards. These
are low-income, dilapidated, privately-owned houses that
usually receive no other form of Government assistance.
Today, the HUD program is active in over 200 jurisdictions.
In 1990, only one or two jurisdictions had much in the way of a
significant program that actually fixed low-income, privately-
owned houses.
It will come as no news to Senator Reed that Rhode Island
is, in fact, one of our best performers in this area. But there
are hundreds of other jurisdictions now across the country that
have the know-how to get the job done, and that is as a direct
result of the HUD grant program.
Second, on enforcement of the disclosure rule to ensure
that parents get the information they need to protect their
children, we have had what I would describe as a truly
wonderful relationship with the Department of Justice, with
local law enforcement, health and housing agencies, and with
EPA to target our enforcement
actions to the most egregious cases. In fact, the Secretary has
increased our staffing at HUD to further expand our enforcement
activities.
Proof. How do we actually know that any of this really
works? We have conducted the Nation's largest study of modern
lead hazard control techniques. And I could not resist showing
you one scientific slide, at least.
[Slide.]
This slide basically shows that in approximately 2,700
housing units that we studied, dust-lead levels, which are the
main predictor of children's blood-lead levels, have declined
and stayed low, even though all lead-paint has not been
removed. So this is clear evidence that, in fact, what we do
works. We also, I might add, measured children's blood-lead
levels who lived in those units, and that declined by 26
percent in one year.
Coordinating with other agencies makes our work more
focused and productive. For example, in Manchester,
Connecticut, I know that Senator Reed mentioned Medicaid. In
that community, children who have high blood leads are
automatically referred to the HUD lead grant program to make
sure that their housing units are lead-safe.
In Chicago, when the Centers for Disease Control conducts
its high-intensity targeted screening program that Dr. Jackson
will discuss later, HUD's lead-paint grantee was there to make
sure that the units were safe.
HUD and EPA have worked together to target regulations so
that we use abatement contractors only for the highest-risk
houses, not for routine housing rehab and maintenance work. But
we do make sure that rehab and maintenance workers do get the
training they need to get their jobs done safely.
Housing programs not covered by Title X, such as the
Department of Energy's Weatherization Program, and States
administer-
ing low-income housing tax credits that are used for
rehabilitation, can use that training curriculum or the workers
that we have
already trained so that they do not have to reinvent the wheel.
In fact, in California, Wisconsin, and elsewhere, many of our
grantees combine weatherization work with lead hazard control
work to get the job done and stretch the dollars.
And finally, we believe increasing private-sector
involvement is a critical part of the solution. Within the next
2 to 3 weeks, HUD will be releasing a notice for funding
availability for Operation LEAP, which stands for Lead
Elimination Action Program.
Grants will be awarded to entities that can leverage
private-sector investment, and so we hope that banks, hardware
stores, community groups, landlords, and others will respond
favorably to help solve this problem.
In conclusion, let me recognize Senator Reed for his truly
outstanding leadership on this issue. Your resolve and
commitment have been a tremendous help to America's children
over the years. So thank you.
Senator Reed. Thank you, Mr. Jacobs.
Mr. Sansonetti.
STATEMENT OF THOMAS L. SANSONETTI
ASSISTANT ATTORNEY GENERAL
ENVIRONMENT AND NATURAL RESOURCES DIVISION
U.S. DEPARTMENT OF JUSTICE
Mr. Sansonetti. Chairman Reed, Senator Allard, I am pleased
to be here today, along with my colleagues on the panel, to
discuss what the Department of Justice is doing to protect
America's most important resource, its children, from lead-
based paint poisoning.
In my testimony today, I will focus primarily on the
Department's enforcement efforts in connection with the
initiative developed by our colleagues and clients at HUD and
EPA. This initiative is providing tangible improvements in the
lives of some of our most disadvantaged children. Of course, I
would be happy to answer any questions that the Subcommittee
may have.
Mr. Jacobs has pointed out, lead poisoning is a significant
health risk for young children and lead poisoning is especially
acute among low-income and minority children living in older
housing.
This public health problem was the genesis of the Federal
Residential Lead-Based Paint Hazard Reduction Act, which
requires the sellers, owners, and managers of residential
buildings built before 1978 to warn prospective buyers and
tenants about the likely presence of lead-based paint and lead
in dust or soil on the property. It also requires landlords to
give tenants an EPA pamphlet about how to minimize the dangers
to children, and directs them to document their compliance with
the law by keeping tenants' signatures on file using a standard
disclosure form.
In regard to the enforcement initiative, this Act is no
different, frankly, than any other law in that it requires
strong and fair enforcement to ensure that legal goals become
practical realities. It is also important that law-abiding
landlords and management companies have a level economic
playing field on which to compete, and that those who fail to
comply with the law know they will be penalized. Accordingly,
HUD embarked on a civil enforcement initiative to ensure
compliance with the Act's requirements after its effective date
in 1996. It focused its enforcement actions on four major
cities--Los Angeles, Chicago, New York, and the District of
Columbia--and proceeded by targeting large management companies
responsible for buildings which were covered by the Act and had
multiple incidents of lead-poisoned children. EPA also has a
lead coordinator in each of its 10 regions responsible for
lead-paint enforcement.
This simple but effective strategy helped the agencies
quickly identify those who were responsible for some of the
biggest lead-paint related problems. Now based on this
footwork, HUD and the EPA began filing a series of
administrative enforcement actions against violators of the
Act, and then also referring cases to the Department of Justice
for judicial enforcement actions.
The hard-working people at HUD, EPA, and the U.S.
Attorneys' offices have made this initiative a success. I think
they have done a remarkable job in developing investigative
strategies and putting in the many hours that it takes to turn
a good plan into great results. One of the things that Senator
Reed asked me to address was how DOJ can interact more efficiently
with other agencies to eliminate lead-based paint poisoning in
children, and I am happy to tell you that we are already working
very well with them to achieve this important goal.
The State attorneys general and the State and local lead
poisoning enforcement agencies are also essential players in
this enforcement effort. In fact, our cases get started when we
receive reports of elevated blood levels of lead from a local health
department. So thanks to their efforts, I have some major success
stories to talk about, both civilly and criminally.
We have pursued several cases judicially here in the
District and across the country. One big success story came
last October when DOJ, HUD, and EPA announced settlements in
cases against three landlords in Chicago for failure to warn
their tenants that their homes may contain lead-based paint
hazards. These companies controlled nearly 10,000 apartments,
and they agreed to test for and cleanup any lead-based paint
found in their properties, and pay $90,000 in penalties. One of
the companies also agreed to pay $100,000 to Chicago's Health
Department as part of a child health improvement project, and
the other two agreed to give $77,000 to a community-based
health center to provide free blood testing for children living
in Chicago and South Chicago.
We have simultaneously announced settlements in four
administrative cases against landlords in New York and Los
Angeles that own and manage approximately 6,500 units.
In criminal prosecutions, what started out as a civil
enforcement initiative has also produced the first-ever
criminal lead-paint prosecutions in the last year. The first
involved David Nuyen, a
Washington-area landlord who owned and managed 15 low-income
rental properties in the District of Columbia and Maryland. HUD
contacted Nuyen in September of 1998 as part of our enforcement
initiative. His response was to present the Agency with
falsified, forged, and back-dated lead-paint forms that made it
appear that he had given tenants the required hazard warnings
when he had not, even though he had previously received notices
of violation that his apartments had dangerous levels of lead.
He was convicted in July of last year, sentenced to 2 years in
prison, and a $50,000 fine.
Another similar prosecution culminated in March in New
Hampshire, a gentleman named James Aneckstein sentenced in
Federal district court, 15 months of incarceration, $40,000
criminal fine. He also failed to notify his tenants of the
presence of lead-paint. But in this case, one of the tenants, a
2-year-old girl named Sunday Abek, died of that lead poisoning.
In conclusion, tragic deaths such as Sunday Abek's are
completely preventable. We are proud to be working with our
partners at HUD, EPA, the U.S. Attorney's offices, the FBI, and
State and local enforcement agencies, to bring them into this
initiative to protect America's kids, especially those
disadvantaged ones who are at the greatest risk.
And I am pleased to tell the Senator that yesterday, we
lodged another consent decree against a Chicago landlord who
had failed to notify his tenants of lead-paint in his units.
So with your continued support, we believe that we can move
a long way toward eliminating lead poisoning, and I look
forward to working together with the Subcommittee on this
important issue, and to answering any questions that you may
have.
Senator Reed. Thank you, Mr. Sansonetti.
Mr. Sharp.
STATEMENT OF ADAM SHARP
ASSOCIATE ASSISTANT ADMINISTRATOR
OFFICE OF PREVENTION, PESTICIDES, AND
TOXIC SUBSTANCES
U.S. ENVIRONMENTAL PROTECTION AGENCY
Mr. Sharp. Thank you, Senator.
Mr. Chairman, my name is Adam Sharp. I am the new Associate
Assistant Administrator at the Office of Prevention,
Pesticides, and Toxic Substances.
Thank you for the invitation to appear before you today. It
is my privilege to be here today with our partners to discuss
our joint
efforts to prevent lead-based paint poisonings of our Nation's
children. I am going to quickly summarize my testimony and ask
that my full testimony be entered into the record.
Senator Reed. Without objection.
Mr. Sharp. Thank you.
In the almost 10 years since Title X was enacted, EPA,
together with HUD, HHS, and Justice, as well as our State
partners, have made significant progress in eliminating
childhood lead poisoning. While we still have a significant
challenge, particularly with minority children and children
living in low-income housing, EPA is very proud of how the
Federal agencies and our State and private-sector partners have
coordinated their efforts.
For example, the Federal Government has phased out lead in
gasoline, reduced lead in drinking water, reduced lead in
industrial lead pollutants, and banned or limited lead used in
many consumer products, including paint. States and
municipalities have set up programs to identify and treat lead-
poisoned children and to rehabilitate deteriorating housing.
Parents, too, have greatly helped to reduce lead exposures to
their children by cleaning and maintaining homes, having their
children's blood-lead levels checked, and also promoting proper
nutrition.
As you can tell from the individuals at the table today,
combatting lead is a multifaceted and coordinated approach.
EPA, as well as other agencies here today, have a variety of
activities underway. Let me provide an update on those
activities at the Environmental Protect Agency.
EPA's primary goal is to prevent children from being
poisoned and avoiding the consequences associated with it. The
basic program includes a national regulatory infrastructure
involving our State and local partners, developing outreach and
education programs aimed at those most at risk, educating and
assisting those who can help address the problem, and focusing
on how our children can be better protected.
In the area of regulations, EPA, together with HUD, have
been very busy. Let me turn to a few of the highlights.
First, in 1996, EPA and HUD jointly promulgated a rule to
ensure that lead-based paint information is disclosed during
real estate sales and rentals, specifically for those houses
built before 1978. This rule ensures that the homebuyer or
renter has a right to available hazard information and a right
to lead inspection if
desired.
Second, also, in 1996, EPA promulgated a rule covering the
professionals who work in the lead inspection and abatement
profession. It also ensures that a well-trained cadre of lead
inspectors, risk assessors, and abatement personnel are
available. This same rule also allows EPA to authorize States,
Tribes and Territories to develop and administer training and
certification programs. At present, 36 States, Puerto Rico, two
Tribes, and the District of
Columbia are assisted by Federal grants, are authorized to
carry out this program, and EPA is working with others.
Third, in 1998, EPA promulgated another rule to ensure that
all owners and tenants of pre-1978 housing be given basic
information about lead poisoning prevention prior to
renovations that may disturb lead-based paint.
Fourth, in 2001, EPA promulgated another rule to define the
specific levels of lead in dust and soil that are most likely
to pose a health threat to children. These scientific standards
help to determine when and how to clean up lead dust, lead-
paint, and lead soil problems.
Let me now turn to education and outreach.
Education outreach is also a very important component of
our lead program. We work as much as possible with our
customers and our stakeholders in several areas, including the
development of regulations, assisting regulated parties in
complying with regulations, informing citizens of their rights
under these rules, informing the public about lead-based paint
hazards, and providing guidance on how to reduce risks. Our
partners at HUD and CDC
partially fund these activities and provide technical support.
Some of these outreach efforts include the bilingual 1-800
National Lead Information Center. This is a national
clearinghouse to educate workers and the public about lead
hazards and abatement precautions. The development of materials
such as brochures and sample real estate disclosure forms
needed to comply with regulatory requirements. The creation and
distribution of education materials and national lead awareness
campaigns for parents, homeowners, renters, medical
professionals, renovation contractors, and do-it-yourselfers.
EPA also has done important work in scientific capacity.
For example, EPA had conducted numerous studies to define the
levels of exposure that should be regarded as hazardous to
children and identify work practices that successfully reduce
lead-based paint risks. EPA's goal is to better understand lead
exposures, ensure that testing is done appropriately, and
reduce the costs associated with eliminating exposure.
Even though we have accomplished a great deal of things,
there is still more to be done. Let me now turn to a few other
regulatory activities.
EPA anticipates completing the regulatory program mandated
by Title X over the next few years. So what are the next steps?
Our renovation and remodeling activities will address how to
safely remove lead-based paint and debris during remodeling
activities. We anticipate that this proposed rule will be ready
for publication in 2003.
EPA has already developed a model training course and other
materials for renovation contractors and homeowners, which is
intended to provide them with recommended methods to minimize
lead hazards.
Further, of lead-based paint abatement activities on
bridges and structures, we expect to publish a proposed rule in
2004.
The Agency also expects to finalize regulations on
management and disposal of lead-based paint debris by the end
of this year.
Thank you for the opportunity to discuss some of EPA's
contributions to prevent lead-based paint poisonings, just a
part of our successful collaboration on this issue. Again, I
want to thank you for your support and assure you that this
Administration is looking forward to working with this
Subcommittee to achieve our goal of eliminating childhood lead
poisonings by 2010.
Thank you.
Senator Reed. Thank you, Mr. Sharp.
Mr. King-Shaw.
STATEMENT OF RUBEN KING-SHAW, JR.
DEPUTY ADMINISTRATOR AND CHIEF OPERATING OFFICER
CENTERS FOR MEDICARE & MEDICAID SERVICES
Mr. King-Shaw. Thank you very much, Chairman Reed, and to
the Subcommittee, I, too, would like to offer a verbal summary
and submit my written testimony for the record.
Senator Reed. Without objection.
Mr. King-Shaw. It is a pleasure for me to be here to share
with you and the Subcommittee and others what CMS is doing on
this important issue of lead-based paint poisoning in children.
As the providers of Medicaid programs with a partnership
with the State, this is quite an important effort for CMS. This
issue affects low-income children, particularly in underserved
ethnic communities in older housing. As such, it is a part of
our overall effort to eradicate all health care disparities
through our programs.
As you are committed, Chairman Reed, our Secretary, Tommy
Thompson, Administrator Scully, myself, and all of us at CMS
have a true and long-standing commitment to the preservation of
health and the protection of health in children all across
America. We work toward that goal through our Medicaid program
directly, but we also coordinate with my colleagues at other
Federal agencies and community-based organizations that are
active on this issue.
The Medicaid program itself has very specific benefits and
coverage regarding the screening and detection and treatment
for lead-based paint poisoning in Medicaid-eligible children.
Briefly, Medicaid-eligible children must be tested at 1 and 2
years of age as part of the Medicaid benefit. And again, if
there is no record of a test for children between the ages of 2
and 6 years, that that test must also be provided for untested
children in that age group.
Specifically, the Medicaid program pays for the testing,
the diagnosis, the treatment, the case management services, and
a one-time environmental investigation of the primary residence
when a child's test reveals elevated blood levels for lead.
In 1999, you are aware, I am sure, of a GAO report that
identified some challenges and some issues with the Medicaid
program in providing this benefit. And since then, we have done
some things to address some of the issues presented in that
report. I will just share a few of them with you in the time
that I have remaining.
Lead screening is a part of a comprehensive program known
to many of you, Medicaid's Early and Periodic Screening
Diagnosis and Treatment Program, or EPSDT. The EPSDT reporting
system is generated by the States. It is rolled up as a
statewide report and then given to us at CMS. Some time ago, as
a result of some of these struggles, we added a line item that
gives us specific indication of States' compliance with the
lead screening program, and we monitor that rather closely.
We have also communicated directly to the States on two
separate occasions urging them to share information on best
practices along these lines, and also informing and reminding
them of the
responsibilities of State Medicaid agencies to administer the
Medicaid benefit effectively and to adhere to the current
policy of universal screening.
We have joined hands with a community-based organization,
the Alliance to End Childhood Lead Poisoning, to do a couple of
important things.
One, we have developed an education tool that is used
throughout the country to encourage States and local entities,
as well as providers on the importance of this issue. And together,
we have written a guide, an important guide entitled, Track,
Monitor and Respond: Three Keys to Better Lead Screening for
Children in Medicaid. We believe these are positive differences
that we are making in outreach and compliance nationally.
We also have engaged a contractor to conduct site visits
around the country, including Providence, Rhode Island, as you
know, Mr. Chairman, Baltimore, Maryland, Chicago, Illinois, the
State of Iowa, and Oakland and Alameda County, California, to
try to find the best ways to make sure that our programs are
well communicated and in full compliance.
We, too, collaborate on the Federal level, including being
an active part of the President's Task Force on Environmental
Health Risks and Safety Risks to Children, and we hope to build
better relationships with the colleagues around this table. And
we have begun to do great work with our colleagues here as
well.
We remain committed to the current policy until and unless
we receive guidance from our colleagues over at the Centers for
Disease Control that would warrant a change. The Secretary is
awaiting those recommendations; you will hear more about that
work, perhaps, from my colleague at the CDC.
But in the meantime, our challenges remain in the
compliance area and we can talk about some of the things we can
do there. And we remain committed to making sure that, to the
best of our ability, we communicate with our provider partners
and States to administer the current policy effectively for the
better protection of all children in this country.
Again, I want to thank you for the opportunity to share
these comments with you. I look forward to a good discussion
and to providing vital information to you in the period that
follows.
We remain committed to serving all children in America
through the Medicaid program as defined by law and statute.
Thank you.
Senator Reed. Thank you, Mr. King-Shaw.
Dr. Jackson.
STATEMENT OF
RICHARD J. JACKSON, M.D., M.P.H., DIRECTOR
NATIONAL CENTER FOR ENVIRONMENTAL HEALTH
CENTERS FOR DISEASE CONTROL AND PREVENTION
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Jackson. Thank you, Senator. And thank you very much
for the important leadership that you have provided on this
issue of childhood lead poisoning. Many of the comments, even
in my oral testimony, have already been made and I am going to
summarize my comments for you and ask that the written document
be placed in the record.
Senator Reed. All of the statements will be made part of
the record. In addition, Senator Stabenow wished that her
statement be part of the record, too.
Dr. Jackson.
Dr. Jackson. Thank you very much. The five major points I
want to make are.
First, just the clinical, medical importance of lead.
Second, the importance of good data. If you want to make
decisions, you have to have good data.
Third, the importance of primary prevention, not having
lead in the child's environment.
Fourth, will be the importance of partnerships. This is too
big and too hard to do alone by any one Agency or any one
group.
Fifth, some new tools to really grapple with this issue of
childhood lead poisoning in the pocket that is left.
When I was a medical student in New Jersey, I did a
rotation in New York at Mt. Sinai. The first day on the
pediatric ward, they took me around and there were 25 little
kids running around, as hyperactive as could be. This is the
early 1970's. They were receiving kelation. They had blood-lead
levels in the 50, 60, 70 range. They were receiving very
expensive, in-hospital, drug therapy for the treatment of their
lead poisoning. And I said to the senior physician, this is
terrible. He said, wait till you see this. And he took me into
a back room and there was a child with a swollen brain,
convulsing, who ultimately died of lead poisoning.
The city of New York alone had 10 kids a year that would
die of lead poisoning in the late 1960's. This was a desperate
problem. And most of us in the country had blood-lead levels in
the range of about 20--two zero.
We have had, and thanks to the partners at this table, EPA,
particularly with lead coming out of gasoline, FDA, EPA with
paint issues, Consumer Product Safety Commission, and the rest.
This is probably, what I am showing to you here, the
environmental health success story of the last half century.
This is actual measurement of lead in the bodies of Americans.
And I will ask to have this put over on the side.
[Slide.]
But it is a graph of blood leads dropping from an average
of 16 in 1974, to a blood lead of, on average, two right now.
It is lower than was thought to be feasible on the face of the
earth.
The good news is we are not seeing the same extensive level
of poisoning in our population. The bad news is we have between
a half-million and 750,000 children who are left. They are the
most difficult children to reach. They are in the poorest
houses in the poorest neighborhoods. Sitting back and waiting
for them to show up in clinic is not going to be an adequate
approach to dealing with this residual population with lead
poisoning.
My second major point--oh, I want to make one quick other
point about that blood lead.
Our current definition of elevated blood lead is a blood
lead of 10. There is a fair amount of scientific information
and pressure to reconsider that level and to reduce it. We have
asked the Advisory Committee on Childhood Lead Poisoning to
pull all the relevant scientific data to have the experts come
in and speak to that. That is an advisory committee to the
Secretary and they will make formal recommendations as to what
a proper definition would be.
The second issue of good data, and I give you an example
here of just how powerful this is in making decisions. But it
also means that we have to have data from local communities. We
have to know where the hot spots for lead poisoning are, higher
in this area, lower in that area. You cannot make a good
decision about where to either start or stop screening without
good data. The guidelines that we put out in 1997--these are
screening young children for lead poisoning guidelines for
State and local health officials--essentially, we do not want
to stick needles in children.
So the guidance here is when you find out that you have
done enough testing and there is not a problem, you can stop
doing lead testing in parts of the communities that do not have
a problem. And that is the guidance that we have offered.
The third quick point is just primary prevention is
critical. Sitting back and trying to figure out which houses to
clean up by looking at poisoned children is not adequate. We
need to go after the houses, clean up the houses. In Minnesota,
they are now identifying homes where poor women become
pregnant, and do the clean up much earlier rather than waiting
for a child to appear lead-poisoned, and then going in and
retrospectively trying to undo it.
The fourth quick point--partnerships are the only way to do
this. This Federal strategy that was put together by all these
agencies has to occur. This is not going to be done by medical
groups alone. It is not going to be done by housing alone, EPA
or anyone else alone. They all have to work together. This is
much too complicated or difficult for any single, isolated
Agency to do and that national leadership is important.
We, CDC, are funding 43 States and 17 local health
departments for intensive lead programs.
And last, new methods--this is actually a very old method--
the new method is we are calling it HITS--High-Intensity
Targeted Screening. We did it late last year in two inner-city
areas in Chicago where we put teams together, public health
nurses, housing specialists, other community people. We
actually put them out into the community, going house to house,
finding the kids, doing the lead screening, looking at the
paint in those houses.
Sadly, what we are finding is two-thirds of the children in
those homes, in those high-risk homes, have never been screened
for lead. One-third of the children, when we do a lead
screening, have elevated blood leads.
And so, the point I want to make here is that we are
dealing with the hardest and most difficult. The tradition a
lot of times in dealing with public health problems is we push
the levels down, down, down, like the tuberculosis and others,
and we figure, oh, we are almost done, and we lose the
attention on that issue. And that is exactly the wrong time to
stop. That is when you really have to push harder because it is
a harder group to deal with.
Thank you so much for your attention and your leadership on
this, Senator.
Senator Reed. Thank you, Dr. Jackson.
We have been joined by my colleague, Senator Corzine.
Senator, do you have an opening statement, or comments?
COMMENTS OF SENATOR JON S. CORZINE
Senator Corzine. I do, Mr. Chairman, but I will submit it
for the record. The discussion you were having with the panel,
and I thank them for their participation and thoughtful
presentations.
This is a really go-to issue, in my opinion, one that, as
the last panelist just remarked, we are down to the really
tough parts, but it makes a huge, huge difference in the lives
of an important segment of our population.
I think about a number of our urban communities in Newark,
which I have extensive comments on. Estimates are that 9 out of
every 10 houses in the city of Newark are tainted. We have
worse numbers in Camden. The communities that are most
desperately in need in almost all areas show up as the hot
spots with regard to lead-based poisoning of kids.
Then we are concerned about how poorly children do in
school. And we are not looking at how the holistic approach of
dealing with these various problems are. So, I think you are
doing God's work here by making sure that this issue is raised
to a national debate that we stay fixed on it and pushing
forward with it.
Thank you.
Senator Reed. Thank you very much, Senator Corzine. And
your full statement will be made part of the record.
Let me begin the questioning, and I will take some time and
then recognize my colleague, Senator Corzine.
In response to Dr. Jackson's comments about the fact that
they have been looking and finding in low-income neighborhoods
children who have not yet been screened and the overall level
of screening is about 20 percent.
I think, Mr. King-Shaw, you were anticipating my question.
I was quite honestly startled a few months ago when the
Administration was talking about giving the States the option
to screen or not to screen without any type of data. In fact,
all the data suggests that we are not doing enough screening.
Could you just try to indicate what prompted that? I know it
has been reversed by Secretary Thompson, but what was the force
or the emphasis that was leading to even that type of
discussion?
Mr. King-Shaw. First, let me say that there had never been
a decision at CMS or HCFA, prior to our changing the name, to
make a change in that policy.
We were receiving requests from States--Utah, Alaska, among
them--to do something different than what is our current
policy, to develop ways of targeting those resources into the
high-risk areas. And so, the discussion was generated by an
interest that came to us from States and clinical communities
around the country, who asked us to consider doing screening in
different ways. This conversation, then, began in responding to
them. We clearly did not make any specific attempts to change
the policy by rule. In fact, in all of the discussions we were
having with States and clinical communities, we were very clear
about the fact that we were waiting for the Secretary's
advisory commission over at CDC to give us some guidance.
If there were going to be any changes, they would have to
be generated from the advisory panel based on the evidence,
research, and some type of data assessment indicating that
potential existed to do anything different than what we were
doing today.
But absence of that recommendation, until there is a
recommendation, there is no effort on the part of CMS to change
the policy. What you heard was a conversation; CMS responding to
people interested in doing something different than our current
policy. And the States generated that discussion as part of the
waiver or State plan amendment request process.
Senator Reed. Well, we seem to agree that that was a very
bad idea. There is a good idea--in fact, it is the law--that
100 percent of Medicaid children should be screened. We are
only screening approximately 20 percent. So let me ask what
your Agency is going to do to ensure that 100 percent of
children are screened, as required by the law?
Mr. King-Shaw. Some of what I have already shared is a
direct communication effort to remind not just the State
agencies, but also provider groups and community-based
organizations of the importance of doing this.
And so, the outreach, the education is about not only the
clinical importance of this, but also the mandate as part of
the Medicaid benefit and the policy for universal screening.
Now part of what is limiting our ability to achieve full
compliance here is that we currently have very few powers to
enforce this kind of provision, and the enforcement powers we
do have are rather Draconian.
One option would be to withhold Medicaid funds from the
State's Medicaid program. That is a very severe measure to take
because it would not be segmented from most of the other
Medicaid benefits. We are talking about cutting off large
States from Medicaid funding in its entirety for child care
services. And I do not know whether people would like to see
that happen as an enforcement measure.
The other option that we are trying is working with States
to improve their reporting and analysis in both the fee-for-
service Medicaid environment and the managed-care Medicaid
environment.
Our reporting is largely based on claim status. When a
claim is paid for a lead screen, then we pick that up in our
claim system. In cases where we contract with a managed care
organization, we do not receive that claim information, but
rather encounter data. So that we are relying on data that
comes in from the States, which may not be as accurate because,
in part, managed care organizations often struggle to get the
information out of their provider network and to forward it
over to us.
Moreover, a significant number of children get screened in
local health departments, which, for a variety of reasons, may
not bill us at all for the service. And when that happens, we
do not receive good, reliable information on States' screening
performance and what they are finding out from that screening
performance.
But we are working on data collection. We are working
directly with States, provider organizations, community-based
organizations, and our regional offices to try to do a better
job at achieving full compliance.
Senator Reed. Let me ask one additional question before I
move on to the other panelists. In your description of the
managed care arrangement, my presumption would be that part of
their contract is to screen Medicaid children 100 percent.
Would that be a correct assumption?
Mr. King-Shaw. Actually, our information shows that
approximately 42 percent of contracts between managed care
organizations and the State have specific language on lead
screening.
Now there is another body of contracts that address the
EPSDT program in general and this is a part of that program.
So, therefore, by extension, it is addressed.
So our best information would be that virtually all of the
contacts have some provision, either direct or indirect, that
would call for this kind of screening.
States do take the primary responsibility in monitoring and
in compliance with the Medicaid contract; they have teams and
State agencies that do that. Our regional offices get involved
in looking at that data. So the contract between the State and
the managed care organization does give us some contractual
relationship that we can monitor and drive compliance.
Senator Reed. Not only monitor. Enforce. If you are paying
Federal dollars to a managed care company that is not
performing the services that you contracted for, I suspect you
could enforce it. But let me move on.
If you could recommend to this Subcommittee specific
enforcement powers that you think would be appropriate, short
of the Draconian enforcement of denying Medicaid payments, we
would appreciate that very much. In fact, I would ask you to do
that.
Mr. King-Shaw. Now? Here?
Senator Reed. No, at your convenience. Promptly, but not
here.
Mr. King-Shaw. I would be pleased to do so. Thank you,
Senator.
Senator Reed. Thank you.
Let me ask Mr. Sharp. The EPA has been charged over many
years to develop regulations. And you have indicated in your
testimony that you are beginning that process. At least 10
years ago, EPA was asked to create a rule with respect to
remodeling and renovation. A lot--or some, at least--of the
problems encountered are a result of remodeling and renovation.
We were in Maine in field hearings with Senator Collins.
Where a young woman had talked about how she bought the house
of her dreams, an old Victorian, and she had two young children.
And in the process of renovation, poisoned her children. So it
is a real problem. Can you update us now on the process of those
regulations?
Mr. Sharp. Yes. Actually, I outlined four other regulations
of course in my testimony that we have been working on and
completed. We have three more, this being one of those.
We are on target to publish that rule next year. There is a
number of things, of course, we have been working through. And
we have completed a lot of the preliminary work on getting this
rule done. Technical studies have determined the scope of the
problem. It was one of the first major undertakings that we had
to do and have completed those.
Guidance and training courses, identifying best practices
is another portion that we have been working through, and then
prerenovation materials and education of consumers. Materials
like these, Reducing Lead Hazards When Remodeling Your Home.
This is dated 1997. There is a number of materials like this
that already are out there, and I want to make sure that that
is a good, clear point.
There are a number of things that we have been doing even
before this rule comes out to address this issue, particularly
with the remodeling concerns that you have outlined. So there
are a number of things that we are trying to do.
We are also trying to work with our State partners to
identify those particular areas as well, where you may have
more concern, and we have talked about that a lot, where there
may be specific communities of people who are more at risk than
others. We have been trying to work with our State partners. I
mentioned that we have about 35 States now that we are working
with, three Tribes, Puerto Rico, and the District of Columbia,
to achieve that.
So, we are on target with the remodeling and renovation
rule of getting it out next year. We are also going to be
meeting with a number of stakeholders, our States and others,
through the later part of this summer and the fall, to also
further develop and make sure that we have all the right types
of programs in place for this rule. Of course, the bottom line
for putting out a new rule is that it needs to be effective. It
needs to be a rule that is going to have compliance. People
need to be able to look at this and comply with it, be able to
understand it. It needs to be flexible. It needs to be
innovative.
We need to make sure that people in that last portion of
the graph are the people that this works for.
You can put out a rule and if it doesn't have the right
components in it, it can sit there. And what we want to do is
we want to make sure that we have something that is compliable,
that people can look at and work with and make sure that it
does have a benefit at the end. So that is what we are shooting
for. We think we are on a good track, and with your help and
guidance, we are going to have that out next year.
Senator Reed. Well, I would urge you to follow through
because it is important to get the rules out and then we can
evaluate them, you can evaluate them and make changes. But we
have been in this limbo for 10 years now with these rules
required and not being promulgated.
Let me ask another question, Mr. Sharp, and that is from
Mr. Sansonetti's testimony about indicting and convicting
people for failing to disclose the lead presence in rental
apartments.
A survey conducted by HUD in 1998 suggests that very few
renters have ever been informed of the presence of lead. And
there are some egregious cases in which we have taken legal
action. But what are you doing to ensure that this rule, not
through judicial enforcement, but administratively, is being
obeyed?
Mr. Sharp. EPA, in coordination between our office, the
OPPTS
office and our OWECA office, our enforcement office. This has
been something that we have been working, as the gentleman
referred to, of identifying cases in areas. And, of course, you
do need to have these types of activities take place. You need
to have enforcement activities in place, and enforcement
activities taken as well, to make sure that people are
complying.
So, in that arena, we are trying to step up those
approaches. We are trying to work closer with our OWECA office
to make sure that they have a good understanding of these
programs. Not only the four different pieces we put out within
the last 10 years, but also the three more that we are going to
be putting out in the next 2 years. So, I can also look to get
you some more information on that question as well in writing
at a later date here.
Senator Reed. Thank you, Mr. Sharp.
Mr. Sansonetti, let me follow-up on just a couple of
points.
First of all, procedurally, who makes the decision for a
criminal action or for a civil/legal action? Is it the Federal
attorney locally, or is it coordinated through your office here
in Washington?
Mr. Sansonetti. The U.S. Attorney's Offices often have the
lead in these cases. We at the ENRD--Environment and Natural
Resources Division--coordinate with the U.S. Attorney's
Offices. We have meetings with them on a fairly regular basis
to actually discuss the entire spectrum of criminal
enforcement.
Even just recently, last month, I was down in South
Carolina at our National Advocacy Center, where they had
representatives from each of the U.S. Attorney's Offices. We go
through the entire panoply of criminal enforcement cases in the
area of environment and then we provide the U.S. Attorney's
Offices with the training materials to take back to their shops
to help make these decisions.
Senator Reed. Have you coordinated with CDC or HUD to
identify those areas where this is a great problem?
Mr. Sansonetti. Yes.
Senator Reed. And have you made in those Federal districts
the Federal attorneys aware and emphasis or at least suggest
it, that they vigorously prosecute?
Mr. Sansonetti. The answer is yes. As you noted from,
actually, everyone's testimony today, these things really well
up from the initial investigations that go on by the people at
HUD, the EPA, CDC people, and the like.
They do it, as I mentioned, in various and sundry ways. But
one of the ways is to keep track of where sick kids are showing
up. Who has the elevated blood level? Where have there been
problems? Are they concentrated in a particular building, a
particular area, or buildings owned by the same management
company?
From those investigations, the referrals come to our shop
if, indeed, the violators have not literally cleaned up their
act and made sure that the tenants are getting the pamphlets
that they are supposed to get. So it is coordinated.
Senator Reed. I just want to be clear, Mr. Sansonetti. You
seem to be describing a process where, if the information comes
from the field to you, you will take action.
Mr. Sansonetti. Right.
Senator Reed. My question is, have you looked across the
map, if you will, based upon the data of CDC and others, and
said, this area is really epidemic with lead poisoning, and
suggested that the Federal attorneys take vigorous action?
Mr. Sansonetti. The coordination actually has come--it is
not just us to take a look at that. It is one that we take with
EPA and HUD. And that is the core of why the initiative to date
has indeed centered on Los Angeles, Chicago, the District of
Columbia, and New York.
Senator Reed. Just a final question. You have suggested and
you have indicated some serious questions which the Justice
Department has brought. Have you initiated any cases in the
last year and a half ? Or are these cases that are a legacy
from the previous administration?
Mr. Sansonetti. The two cases that I mentioned, the Nuyen
case was prosecuted I believe in 2001. The sentencing was just
earlier this year. Let me make sure. The other one, I believe,
was March. The Aneckstein case, I believe, was March.
[Pause.]
Yes, it culminated this March in New Hampshire, yes.
Senator Reed. Thank you very much. Let me ask one question
of Dr. Jackson, and then ask Mr. Jacobs a question. And then
yield to my very patient colleague, Senator Corzine.
You indicated, Dr. Jackson, that one of the problems is
data collection and reliable data collection.
CDC provides grants to States to establish childhood blood
level surveillance systems--CBLS. Can you describe how
successful that has been? Are the States actively collecting?
Is it consistent? Is it reliable data? And what more do we have
to do to make sure that the data is reliable and consistent
across the country?
Dr. Jackson. One is there is a lot of interest in the whole
issue of environmental health tracking. Maybe you have even
heard of the Pew Commission report. Senator Clinton held a
hearing a while back on this issue of tracking, how we link
what is going on in the environment to what is going on
actually in people.
There is a genuine problem in the health arena that the
data collection systems for tuberculosis, for cancer, for this
and that, are completely inconsistent. It is a Tower of Babel
over here. It is worse than that. Actually, if you start
burrowing into one of our programs, like the lead program, we
have had inconsistency in software and other kinds of computer
collection systems.
The States have the ultimate authority to require
reporting, to demand that the laboratories report, to demand
that the counties and the doctors report. That is not an
authority that resides with the Federal Government. The way we
get that is through our grants process, we then require them to
report.
The State where I worked and had my most experience was
California. I was involved in putting the law in place in the
early 1980's, and foolishly, pushed for a law that required all
blood leads over 25 to be reported to the State. It was a real
mistake because what we really wanted to know was where lead is
not a problem, where the kids have low levels, where did they
have medium- and high-levels?
We need all the lead levels being reported. A lab-based
system is the way to go. They need to be consistent across all
the States. They need to be linked into GIS systems, where one
can actually go to a map and connect it to tax board data with
other economic and social and census data. And by the way, this
is being worked on right now actively. So you can begin to
stack it up and figure out, this is a hot spot. We are in the
process of doing this.
Then when you get positive reports, say, okay, we will put
a HITS team into this community--the nurse, the community
organizer, and other people go house-to-house and do that kind
of aggressive work in those areas. So, we are on track. It is
not as good as it should be, and we are working hard to make it
better.
Senator Reed. Do you have the resources to make it better?
Dr. Jackson. Right now, the program is at about $42
million. It sounds like a lot of money when you are really
after 50 million children and about the 600,000 that are over a
blood-lead level of 10. Most of that money actually goes to the
State and local programs. We withhold some for training and
computer and other kinds of stuff. But most of it goes to the
States.
That is important because it is the management at the State
and local level--the person that knows the housing people, the
enforcement people, and the rest. They are the ones that are
doing the real work. Lead is a local problem. We need to
support them. But the real action is going to happen at a
really local level.
Senator Reed. Thank you, Dr. Jackson.
Mr. Jacobs, let me ask you perhaps not a summary, but a
perspective. How can we better coordinate? HUD is generally
regarded as the lead Agency because it is a housing-based
problem. What can we do better at the Federal level to
coordinate from your perspective? And where should additional
resources that are necessary be applied?
Mr. Jacobs. Lead is one of those issues that is not within
any specific jurisdiction among the different agencies here.
And in that respect, one of the satisfying things that I
have seen in my tenure with the Federal Government has been an
increasing ability to recognize each Agency's expertise, while
at the same time bringing their resources to bear.
I chair the working group in the Federal task force, the
President's Task Force on Children's Environmental Health and
Safety Risks. We look at things such as low-income housing tax
credits, or weatherization programs, and how to bring those
existing programs to bear.
I think we can do better. The Federal Government is a many-
headed beast. But clearly, the major need is to acquire the
resources that are needed to deal with the housing stock that
has lead-based paint hazards. That is the major expense and
that is where the resources need to be focused.
Senator Reed. Thank you, Mr. Jacobs.
Let me recognize Senator Corzine, who has been most
patient. Thank you, Senator.
Senator Corzine. Thank you, Mr. Chairman.
Let me ask Dr. Jackson. If the science took up to a point
where we thought that the blood level of five, as opposed to
10, micrograms, was the standard, how much would the population
of those be registering relative to what I am hearing, 700,000,
800,000?
Dr. Jackson. Senator, I apologize for not being able to
answer that, and I will get back to you on it. The question
about acceptable levels below 10, the toxicity of lead, there
is no safe level of lead. The number 10 was picked partly
because that was as good as
our laboratories were for running a lot of specimens at that
time. The levels and values became relatively unstable below that.
It was something that the programs could understand. It was in
many ways like a speed limit. You pick a number that people can
understand.
But the less lead, the better. I will be happy to get back
to you with an estimate on what a cut-off of five would
generate in terms of numbers of millions of people.
Senator Corzine. Do we have any preliminary understanding
of what the implications of five might be?
Dr. Jackson. What the neuro-toxicologists and other
specialists in toxicology assert is actually that, when you get
these high levels, you have saturated the brain to such a
degree, that you do not see as big a change at the higher lead
levels as you do at the lower lead levels. In other words, not
a little bit is doing a fair amount of harm. And that is why
they are pushing so hard to reexamine what is the safe
threshold.
From a practical standpoint--I will be very direct--I do
not want to see the attention pulled away from the children who
absolutely need it most in these high-risk areas by going
after, at least from a programmatic standpoint, these much
lower lead levels.
We really think we have to start with the highest-risk
kids, the kids at 20, 30, and 40, and push the program hardest
in that direction, and then we can move to these lower levels.
So, I am just a little worried that if the definition of an
elevated level greatly increases it, and now we have a vast
middle class that is chasing after it and we lose the attention
on the kids that need it most.
Senator Corzine. It sounds like a conundrum that I hope we
do not have to face. I would hope that we would be committed to
finding out and dealing with these hot spots in a more serious,
disciplined way.
Mr. Jacobs, if I have read the statutes right--I should
honestly say, if my staff has----
[Laughter.]
The Lead-Based Paint Poisoning Prevention Act, which I
think we instituted in 1992, established procedures to
eliminate lead-based paint hazards in all public housing.
I apologize if you spoke to this in your opening testimony.
But can you give us, or give me, your view on whether we have
solved this problem in public housing, to your knowledge, with
regard to Section 8 housing, have we addressed this?
Mr. Jacobs. In 1992, Congress authorized HUD to review its
current regulations across all of our housing programs, not
just public housing, but other assisted housing, to enable the
implementation of modern forms of lead hazard control. That
changed the way in which we had approached it in the past.
We implemented that rule. There was a lengthy transition
period to enable all of our program recipients to get up to
speed. The Deputy Secretary ended that transition period last
January and that rule is now in effect across the country.
The data that we have from our housing survey show,
surprisingly, I might add, that 17 percent of Federally-
assisted housing has lead-paint hazards. In upper- and middle-
income housing, the prevalence rate is 18 percent. The
prevalence rate in low-income, unassisted housing is 41
percent. And those are the houses that we target with the HUD
grant program. Most of those houses receive no other form of
assistance.
So the Federally-assisted housing rules appear to work. We
have evaluated them over time. They are based on the real-world
experience of the HUD lead hazard control grantees across the
country.
It took us a while to get there. Frankly, in the mid-
1980's, it was not known, for example, that lead in settled
dust was an important pathway of exposure. And until that was
made clear through scientific research, we did not impose dust
testing at the end of Federally-assisted rehab or maintenance
work or housing finance.
That requirement is now in place. And that is why I said
earlier that we believe the Federal rule provides important
lessons to the Nation as EPA moves to develop regulations to
apply to rehabilitation activities in privately-owned housing.
But we have done that and the evidence that we have to date
is that it appears to be working well. It was a substantial
undertaking. We ended up training 28,000 maintenance and rehab
workers in the last year alone, to enable local communities to
get up to speed so that they could comply with the rule. But
compliance is a reality at this point.
Senator Corzine. Section 8 vouchers, those housing units
need to be approved with respect to lead-paint poisoning before
the vouchers are allowed to be used in those circumstances? Is
that correct?
Mr. Jacobs. That is correct. The new regulation requires a
visual examination and then if the deteriorated paint is above
a certain de minimus level, we require the paint to be repaired
and then dust testing at the end of the job to make sure that
the unit is safe for children to occupy. In fact, the
Department pays for that dust testing so that it does not fall
to the private landlord to absorb that additional cost.
Senator Reed. Mr. Jacobs, do you have an estimate of either
how long or how much resources are going to be necessary to
deal with that 41 percent? And what kind of timeline society
should have an expectation that that should be dealt with?
Mr. Jacobs. In the 10-year plan that was published by the
President's task force last year, we did estimate the
resources, the expenditures, I should say, that are needed to
eliminate lead-based paint poisoning from our Nation's housing
stock.
That document showed that it would take a total
expenditure, not necessarily a Federal expenditure, but a total
expenditure of $230 million a year for the next 10 years. That
takes into account ongoing housing demolition, ongoing housing
rehab, and the effect of the regulation for Federally-assisted
housing.
That is why Operation LEAP is so important, because we
think that that will help bridge the gap between the current
Federal appropriation and where we need to be in terms of total
expenditures to make our housing stock lead-safe.
That figure is based on interim controls, which means a
method of making housing safe and then requiring management of
lead in an ongoing way.
Abatement, which is a more permanent corrective measure, is
more costly. In that report, we estimated what the costs would
be for abatement of low-income housing, which would be $2.1
billion per year for 10 years.
Senator Corzine. We are actually getting a different
number, at least kicked out of my reading of that report,
although, whatever the number, $2.1 or the $10 billion that I
actually have here, what is the amount that has been asked for
in the budget for 2003, with regard to lead-based paint hazard
control?
Mr. Jacobs. The President's request this year is $126
million, which is an increase from $110 million the previous
year. If you go back to 1998, 1997, the figure was set at $60
million. So, basically, the appropriation figure has doubled in
the last few years.
The capacity is built. And I have to tell you, one of the
hardest decisions I make each year is to look at the grant
applications that we receive each year. Most of them
demonstrate need, have a good program in place, and have the
capacity to handle the resources. We have to choose a fraction
of them to actually receive the funds that are necessary.
Senator Corzine. And what, in fact, happens to the ones
that are not?
Mr. Jacobs. They apply the following year. We encourage
them to apply, and we try and make the wisest, most targeted
use of the grant dollars that have been appropriated to us.
Senator Corzine. This is one of those things where
sometimes we wonder, or at least have to question our
priorities, because sometimes--and this is not personal--when
those elements are left out, we end up paying for it in a whole
series of other venues because of the kind of implications that
the lead-based poisoning can bring to bear on our children and
families and health. I appreciate very much your response.
Senator Reed. Thank you very much, Senator Corzine. I have
a few more questions, and if you have additional questions, I
will recognize you.
Mr. Jacobs, just a follow-up to Senator Corzine's line of
questioning. You mentioned the regulations that are promulgated
with respect to the 1992 Act. I understand that the HUD Single-
Family Mortgage Insurance Program was the only program not
updated in those regulations. Is there any particular reason
for that?
Mr. Jacobs. That is correct. There are regulations for that
program that have been in place for 15 or 20 years that require
visual assessment and correction of deteriorated paint and
clean up, no clearance testing.
I should note that Multifamily Mortgage Insurance is
covered by that regulation. A subpart of that rule remains
reserved for the Single-Family Mortgage Insurance Program. But
beyond that, I need to get back to you with a more complete
answer.
There are some significant concerns about costs, the impact
on homeownership, and the impact on other secondary mortgage
institutions such as Fannie Mae and Freddie Mac.
Senator Reed. Is there a significant incident of lead
exposure and contamination in those particular units?
Mr. Jacobs. Well, of course, FHA finances low-income
housing, for the most part. And certainly, in low-income
housing, we know that the prevalence of lead-based paint
hazards is higher. And the likelihood of lead paint in the
older housing stock is certainly greater. So, clearly, there is
a potential threat there that needs to be examined and looked
at.
Senator Reed. Thank you.
Dr. Jackson, you indicated in your testimony that there is
between 500,000 and 750,000 children with elevated blood-lead
levels. How many of these children can the CDC, together with
States, effectively track today with the level of resources you
have? Are we close or are we just getting a mere fraction in
terms of monitoring, testing, and giving you the information?
Dr. Jackson. The last time we did the calculation for kids
over 10, the number came in at about 850,000. But that was in
1990. Our guess right now is that we are in the 500,000 to
700,000 range.
We are really going through a real transition with this
program where we are--at one point, we wanted to fund every
single State and every locality and we spread the money very,
very thinly. That is not going to work.
There are hot spots and we are pulling back and we are
going after the areas and using the money that we have as
effectively as possible, and will use them in the cities and
urban areas with the oldest housing, with the record of kids,
and with good, solid management. Putting it into a place that
does not want to invest its own State or local money, is not
going to take authority and responsibility for the program and
have a coalition of housing and enforcement people. It is not
worth doing.
And so, honestly, our approach is, here is what we have and
we are going to apply it in the most effective way possible,
rather than--I have not really thought about it from the way
you have asked the question, Senator. I am sorry.
Senator Reed. But, essentially, your first constraint is
the resources.
Dr. Jackson. We do the best we can with the resources we
have.
Senator Reed. In that respect or regard, too, your HITS
program, which is an innovative way to target, given your
resources, how broadly can you expand this program, or how
quickly?
Dr. Jackson. I will be honest, HITS is expensive, in the
sense that it requires people.
The good news is you get community engagement, and you have
residual interest. The one in Chicago got a lot of media and
political interest. And so, the community became invested in
this. It had a lot of secondary benefits.
The other benefit is, if you are in that house looking at
that child, you might be able to check an immunization record.
You could look at some cockroach or asthma or other kinds of
problems at the same time.
So looking very, very narrowly at lead in this population,
I think what we are really coming to, and it is what Mr. Jacobs
deals with a lot, is a healthy homes approach, where lead is
part of a larger strategy for the homes of the poor.
Senator Reed. But I think what you suggest, this is an old
public health model, where a public health nurse walks in the
door and checks for everything.
Dr. Jackson. It absolutely is an old model. If you talk to
the public health nurses of 30 years ago, they say it worked
great. But it is not cheap.
Mr. Jacobs. If I might add.
Senator Reed. Mr. Jacobs, please.
Mr. Jacobs. One of the things that our rule requires is
actually a data match between lists of poisoned children that
are held by local health departments and lists of subsidized
housing that HUD grant recipients maintain. And so, one of the
major changes in my view that needs to occur is that we should,
in addition to tracking children, track houses.
In all too many cases, there are, ``repeat offenders''
where the same house will be responsible for multiple
poisonings. And in fact, that is how we launched our
enforcement initiative. We took a look at the cities that had
the highest numbers of dilapidated, pre-1940 rental stock, and
combined that with some CDC data, and came up with where we
should go.
Senator Reed. You have anticipated a question I had, and I
think Mr. Sansonetti might comment also. If the child is
poisoned and then he or she is treated, and then the next
family moves in and that child is poisoned, and the next, that
seems to me a pretty good indication that action should be
taken. Is that a principle that you are following in the
Justice Department, Mr. Sansonetti?
Mr. Sansonetti. It certainly is. Our job, of course, is to
be the backstop to people like investigators at EPA and HUD.
And it is when they come upon violators that choose to go ahead
and be obstinate and being unwilling to do what needs to be
done, that they then come to us and say, well, maybe the person
wants to answer to a Federal judge rather than do the right
thing. But as far as deciding when you do something civilly or
criminally, obviously, if it is a repeat offender, if you have
a death involved--the magnitude and the number of the case is
going to help decide whether we put it into the civil or into
the criminal bailiwick.
Two other things I would actually follow-up on in regard to
some of the questions you have asked today, is the fact that
publicity about what we are talking about today is absolutely
key.
One of the reasons that, frankly, as an Assistant Attorney
General, I was anxious to come to participate today, was
because this is one of the initiatives that I am pushing.
Now, admittedly, I had only been there about 155 days. But
the fact is that this is stuff that we can put into my speeches
to the different groups, real estate conventions, as part of
their continuing education as a real estate entity, that they
realize that this is one of the things that they have to make
sure happens.
They could potentially be held responsible for themselves,
if they are the owners of some of these buildings, we are going
to start to get the word out.
We have 4,500 active cases going right now across the board
in the ENRD.
It is no accident that I have taken cases like that Nuyen
case here in Maryland, and the Aneckstein case for our key
publicity roles. We now actually have a person in our office of
public affairs assigned to my division to help get the kind of
publicity out so that we can leverage a conviction like the
Nuyen case, and the one up in New Hampshire.
So maybe it was just one conviction in a particular site.
But if we trumpet it out, as we have in those cases, and it
ends up in The Wall Street Journal, as well as the local paper,
then we are getting more bang for our buck because more people
are saying, whoa, I did not realize that I could go to jail for
2 years.
Pay that kind of fine? Maybe we had better make sure that
our darned pamphlets have been distributed and signed off on.
So the fact that you are having this hearing today is one
of the things that attracted me, because this is the kind of
publicity that we need on this topic.
Senator Reed. One final general question. A lot of the
regulatory apparatus is based upon disclosure of lead risks and
hazards by the landlord. Sometimes that prompts landlords to
know as little as they can about their property since they are
held only, I believe, to the standard of what they know about
the property, which raises a real problem. I wonder if that
approach is denying us effectively reaching children where
landlords will deliberately not test their property, or not
want to know about what is going on. Your experience, Mr.
Jacobs? Anyone on the panel can comment.
Mr. Jacobs. You are referring to a potential chilling
effect for disclosure.
Senator Reed. Right.
Mr. Jacobs. That it is better not to know than to know.
Senator Reed. Is that a real issue out there or this is
just something hypothetical that we can dismiss?
Mr. Jacobs. I guess I would answer it this way. By looking
at what has happened in our project-based Section 8 inventory,
which is privately-owned, but subsidized.
In that program, we required risk assessment and an
inspection and then made a voluntary program available to
owners to participate if they wished. Now if they wanted to put
their heads in the sand and not participate, we did not require
them to use our program to obtain free lead-paint inspections.
But most of them have, in fact, come in and tried to determine
where their hazards are and how to best correct them.
It is more advantageous for a property owner to know
exactly where their lead-paint hazards are so that they can
minimize both their liability exposure and their ongoing
maintenance and rehab activity so that they are property
targeted. If they do not know, then, of course, the liability
would increase.
But you are correct. The existing disclosure rule does not
require an inspection and in most cases that I am aware of, we
know that, in fact, people generally check the I-Don't-Know
box. And in that sense, the real information that a parent
needs--where is the paint? Where are the hazards?--is not
provided.
Senator Reed. Let me just raise one final question because
a vote has been called, apparently, and I will conclude the
hearing. But we have heard today that the vast majority of
exposure to lead is in the home. Medicaid allows States to
cover the cost of one-time environmental assessments of the
home. However, I understand that Medicaid will not pay for
testing the dust, soil, or water as part of this assessment. I
was, in my early days, when I became familiar with this
problem, shocked to learn that it is not just the home, it is
outside in the soil, particularly in low-income neighborhoods.
And yet, those areas are not tested. Might you comment, Mr.
King-Shaw?
Mr. King-Shaw. Yes, and that is a problem. We are limited
by the fact that we are bound to reimburse testing for human
specimen only, by Medicaid rule, by policy, by limitation. For
us to test anything more than that would require a change in
our authority, which is not present today.
Senator Reed. Thank you for the response.
Let me thank all of you for your testimony today and thank
my colleagues, Senator Allard and Senator Corzine, for
participating. We appreciate certainly your time and the effort
you have put into this hearing this afternoon.
It is apparent from today's testimony, we have a great task
before us. We need to find the will and the resources to
eradicate lead hazards that affect hundreds of thousands of
children, perhaps even millions. We also need to make more
Americans aware of the dangers of lead poisoning.
At the same time, though, we have heard about how much
progress we have made on this issue and what Federal officials
are doing to continue this progress.
That is good news, and I look forward to continuing to work
with you. I would ask, if you have any additional statements,
to please submit them. And also, if there are additional
questions, we will provide them to you and ask for your
response no later than next Monday--10 days from today.
Thank you very much for your testimony.
The hearing is adjourned.
[Whereupon, at 4:05 p.m., the hearing was adjourned.]
[Prepared statements and response to written questions
supplied for the record follow:]
PREPARED STATEMENT OF SENATOR JACK REED
This hearing is one in a series I hope to have to bring greater
attention to the terrible problem of lead poisoning in out Nation's
housing and its effects on children. The hearing is a follow-up to the
Senate Housing Subcommittee hearing held last year regarding State and
local responses to lead-based paint poisoning.
Over a decade ago, the U.S. Department of Health and Human Services
announced a strategic plan for the elimination of childhood lead
poisoning because it recognized the detrimental, long-lasting effects
on children from exposure to lead. The efforts to achieve the long-
established goal of eliminating lead poisoning by the year 2010 has
stalled and may in fact be moving in the opposite direction.
Not only are Federal laws not being enforced, such as the
requirement that all Medicaid eligible children be screened for lead,
it also appears that there is currently no coordinated action to
eliminate childhood lead poisoning.
The previous Administration created a Task Force on Children's
Environmental Health and Safety Risks. This task force was cochaired by
the Secretary of the Department of Health and Human Services and the
Administrator of the EPA and developed a set of recommendations to
eliminate childhood lead poisoning in the United States as a major
public health problem by the year 2010.
Specifically, this comprehensive Government-wide strategy called
for making 2.3 million homes where children under the age of six live
lead-safe by controlling lead-paint hazards. It also called for public education programs, strict enforcement of lead-paint regulations as
well as encouraging early interventions for at-risk children.
With only 8 years to go until we are to have eliminated childhood
lead poisoning, it is estimated that nearly one million preschool
children living in the United States continue to have blood-lead levels
high enough to impair their ability to think, concentrate and learn.
Unfortunately, except for the most severely poisoned children,
there is no medical treatment for this disease. The only effective
treatment is preventing exposure.
The Department of Housing and Urban Development estimated in its
latest national survey that lead still remains in about 39 million
dwelling units or 40 percent of all U.S. housing.
Federal efforts to reduce the hazards of lead-based paint poisoning
began 31 years ago with the enactment of the Lead Paint Poisoning
Prevention Act. This Act required the Secretary of HUD to establish and
implement procedures to eliminate lead-hazards from public housing.
In 1992, Title X of the Housing and Community Development Act
authorized major changes in Federal law in the control of lead-based
paint hazards and the reduction of lead exposure.
Title X defined ``hazard'' in such a way that it included
deteriorating lead-paint, and the lead contaminated dust and soil that
the lead-paint generates. It also mandated the creation of an
infrastructure that would help correct lead-paint hazards in all of our
Nation's housing.
In particular, Title X required coordinated action between several
Federal agencies regarding lead poisoning, including the Department of
Housing and Urban Development (HUD), the Environmental Protection
Agency (EPA) and the Centers for Disease Control and Prevention (CDC).
While we have made progress in dramatically reducing the number of
children with elevated blood levels, significant barriers and obstacles
to the elimination of this environmental health hazard remain.
<bullet> Why are only 20 percent of children enrolled in Medicaid being
screened for lead poisoning, when Federal law requires that all
children be tested?
<bullet> If a child tests positive for high levels of lead in their
blood, why aren't their homes being reported and screened for lead?
<bullet> Why hasn't the Environmental Protection Agency promulgated
regulations on the safe renovation and remodeling of housing
containing lead-based paint?
<bullet> How many new cases has the Department of Justice filed against
landlords who are violating laws designed to protect tenants from
lead poisoning?
<bullet> Why is HUD's single family mortgage insurance program the only
program not to be updated in HUD's new lead-paint regulations for
assisted housing?
We expect today's hearing to provide some of the answers to these
questions. We will get an overview of what a number of Federal
agencies--HUD, EPA, CDC, DOJ, and CMS--are currently doing to help make
housing lead-safe for children; how well these agencies are
coordinating with one another; and what additional tools each agency
needs to achieve the national goal of eliminating lead poisoning by
2010.
This hearing is only the second in a series of Senate Housing
Subcommittee hearings on lead-based paint-poisoning. It is my hope that
these hearings will help shine a light on this terrible problem,
energize the Federal Government into playing a greater role, and
improve local, State and Federal partnerships to eliminate lead-based
paint-poisoning by 2010.
Federal taxpayers and low-income children and families are paying
the price for these deficiencies in terms of added costs for special
education and the long-term health and developmental problems in lead
exposed children.
More needs to be done. No child should have to live with the
consequences of this preventable disease.
Senator Jack Reed's Efforts to End Lead Poisoning
Senator Reed has worked in Congress to increase funding to combat
lead poisoning and to ensure that children are screened for lead in
their blood before entering kindergarten. Senator Reed secured a 25
percent increase in 2001, and a 10 percent increase in 2002 in the
Department of Housing and Urban Development (HUD) budget to remove
lead-based paint, educate families about the dangers of lead, help
cities comply with new Federal lead-safety regulations, test low-income
housing units for the presence of lead and train inspectors and workers
to identify lead contamination in housing.
He has sponsored legislation to require all children covered under
Federal health programs to be screened and treated for lead poisoning.
Reed's provision was included in the Children's Health Act of 2000,
which was signed into law in October 2000. It also authorizes the
Centers for Disease Control & Prevention to issue recommendations to
ensure uniform reporting requirements for blood-lead levels at State
laboratories and to improve data collection on the number of children
screened for lead poisoning annually.
He introduced legislation to give the Federal Government the
authority to sue the lead-paint industry to recover costs related to
the lead poisoning of children and the removal of lead-paint from
homes.
In October, 1999, Mrs. Tipper Gore, the national spokeswoman for
the Campaign for a Lead-Safe America, dedicated a lead-safety center in
the Elmwood section of Providence, Rhode Island in recognition of
Senator Reed's national leadership to protect children from the dangers
of lead poisoning.
The Reed Center, which is run by the Greater Elmwood Neighborhood
Services (GENS) and the Health Education Leadership for Providence
(HELP), is for those families who are dealing with the legacy of lead.
Through counseling and treatment, the Center had helped more than over
500 families cope with the effects of lead poisoning since October
1998.
For the past 3 years Senator Reed has successfully sponsored a
resolution designating a week in October as ``National Childhood Lead-
Poisoning Prevention Week,''
Senator Reed has also held Senate hearings in Rhode Island and
Maine with Senator Susan Collins (R-ME) to highlight the important
successful approaches being undertaken by State organizations, such as
the Greater Elmwood Neighborhood Services (GENS), the Health and
Education Leadership for Providence (HELP) and the Childhood Lead
Action Project.
On discovering that the Rhode Island Housing Authority was not
implementing Federal regulations regarding the elimination of lead-
hazards in Federally subsidized housing (Section 8 Housing), Senator
Reed secured an agreement between the Federal Government and the
Housing Authority to ensure greater oversight and coordination of the
Housing Authorities efforts.
----------
PREPARED STATEMENT OF SENATOR WAYNE ALLARD
I would like to thank Chairman Reed for holding this hearing on the
hazards of lead-based paint. Childhood lead poisoning is the most
common environmental disease of young children. It affects nearly every
system in the body and even low
levels of contamination can cause debilitating damage to children,
impairing intelligence, muscle control, hearing, and emotional
development.
The lead-paint in older housing and contaminated dust and soil it
generates is the most common source of lead exposure for children. In
the United States today, nearly one million children ages 1 to 5 have
elevated blood-lead levels.
According to HUD's National Survey of Lead and Allergens in
Housing, an estimated 40 percent of all homes have lead-based paint
somewhere in the building, whether it be on the inside or outside of
the structure. Twenty-six percent of all homes have significant lead-
based paint hazards, and of the 16.4 million homes with one or more
children under the age of 6, 27 percent have significant lead-based
paint hazards.
All of this is the bad news, but the good news is that lead
poisoning is preventable and that is why we are convening here today. I
look forward to hearing about what each of the five Federal agencies is
doing to help in this prevention effort.
I thank the Chairman for holding this hearing and giving us the
opportunity to learn more about the issue, what is currently being
done, and what more can be done with regard to lead-based paint
hazards.
Thank you, Mr. Chairman.
----------
PREPARED STATEMENT OF SENATOR JON S. CORZINE
Mr. Chairman, I want to commend you for holding this important
follow-up hearing on the Federal responses to lead-based paint
poisoning. This is an issue of great concern to me and to my State,
which is struggling to find the resources it needs to fund lead-paint
abatement programs and ensure access to early detection of childhood
lead poisoning.
This is a public health problem of enormous consequence for our
cities, States, and our Nation. At least one million children
nationwide are victims of lead poisoning. These children have reduced
IQ, hearing, growth, behavioral problems, and impaired nerve function.
Many of them suffer from severe brain damage.
It is estimated that as many as two million homes in New Jersey
that were built before 1978 contain toxic lead. Nine out of every 10
houses in the city of Newark are tainted with the poison. Some
estimates show that up to 50 percent of Newark's children may be
affected by lead poisoning. Because screening efforts have been slow,
only 4,000 children in the city have been identified as having elevated
blood-lead levels. As a rule, these children come from low-income
minority households.
While lead-based paint poisoning is a very local problem, it is
also a Federal problem. States and localities are unable to bear the
costs of lead abatement, which amount to about $15,000 per unit.
Funding for the Federal Lead-Based Paint Program must be dramatically
increased if we are to adequately remove the paint that continues to
plague millions of low-income homes in this country.
Despite the fact that 80 percent of children with elevated blood-
lead levels receive Medicaid assistance, a 1999 GAO report found that
only 20 percent of children receiving Medicaid benefits had been
screened for lead poisoning. This is a national disgrace. In 1989,
Congress required that all children receiving Medicaid be screened for
blood-lead levels, however, enforcement of this law has been minimal. I
am deeply troubled by recent comments made by CMS staff that this
Administration finds the Medicaid childhood lead screening requirement
overly burdensome and costly for States. Unfortunately, the learning
disabilities and public health costs associated with lead poisoning are
much greater.
We must not only ensure that children are screened early, but also
that they are screened through age 6. The Centers for Medicare and
Medicaid currently only requires that children be screened through age
2, despite the fact that lead poisoning poses a clear danger to
children up to age 6. Additionally, children participating in the Head
Start Program should be screened for lead poisoning. While children who
participate in the Head Start Program are screened for many
developmental disorders, they are not screened for the blood-lead
levels that so often cause these
disabilities. Mr. Chairman, I know you have introduced legislation,
which I have
cosponsored, to make screenings available through the Head Start
Program. I hope to see passage of this bill in the near future.
The public health and societal costs of this problem are enormous.
This Administration must affirm its commitment to enforcing lead
disclosure laws, Medicaid screening laws, and lead abatement programs.
I am pleased that the President has made ending lead-based paint
poisoning in the next 10 years a priority and I look forward to working
with the Administration toward that end.
----------
PREPARED STATEMENT OF SENATOR DEBBIE STABENOW
Mr. Chairman, thank you for calling this second hearing on lead-
based paint poisoning. This is an incredibly important topic and I am
glad that today we are examining the Federal Government's role in
eliminating this problem.
Lead-based paint poisoning remains a serious problem for too many
children. And, we in Congress have an obligation to increase our
efforts to combat this problem. Lead-based paint poisoning can be
abated and even eliminated if we are willing to pay the price and
implement the necessary measures. This is precisely why I was happy to
join the Chairman and several other colleagues last month in writing to
Senate appropriators, urging them to provide $200 million for the
Department of Housing and Urban Development's lead safety grant program
and for $110 million for the Primary Prevention Initiative.
I worry a great deal about lead-based paint poisoning because I
know it is a serious problem for many children, but it is particularly
a problem in my home State of Michigan. Indeed, according to the
Alliance to End Childhood Lead Poisoning, Detroit ranks third in number
of cases of children identified as having severe lead poisoning. And
last year, the Detroit News reported that children in several Detroit
neighborhoods had lead levels that were 10 times the national average.
This is truly outrageous and disturbing.
The Federal Government's responsibility in regard to this problem
is clear and I want us to do more. To help address this problem back in
Michigan, I am already working to obtain critical Federal funding for
the CLEARCorps program in Detroit and in Grand Rapids.
As the Chairman knows, CLEARCorps is an innovative nation-wide
network of public-private partnerships that has a proven record of
offering cost-effective methods of fighting childhood lead poisoning.
Mr. Chairman, I look forward to hearing from our witnesses today
and, again, I thank you for your leadership on this. The day when no
child is at risk for lead-based poisoning is conceivable and I want to
work with you so that we make that day happen sooner rather than later.
----------
PREPARED STATEMENT OF DAVID E. JACOBS, Ph.D.
Director, Office of Healthy Homes and Lead Hazard Control
U.S. Department of Housing and Urban Development
June 5, 2002
Thank you for the opportunity to discuss HUD's activities in the
area of childhood lead poisoning prevention. The evidence shows that
while the Nation has made much progress, much remains to be done to
meet the goal of eliminating the disease by 2010.
I am the Director of the HUD Office of Healthy Homes and Lead
Hazard Control. Before joining HUD 6 years ago, I was Deputy Director
of the National Center for Lead-Safe Housing and a scientist on the
faculty at the Georgia Institute of Technology, where I conducted
research on residential lead hazard detection and control. I am also a
board-certified industrial hygienist.
HUD Secretary Mel Martinez has made childhood lead poisoning
prevention one of the priorities of his administration. As a result of
this commitment, we have trained over 28,000 housing rehab and
maintenance workers and others in the past year alone in lead-safe work
practices. We have increased HUD's lead hazard control budget by 10
percent for fiscal year 2002 and the President's budget proposal for
fiscal year 2003 increases it further still, from $110 million to $126
million. The Secretary has also increased our Office's staffing to
improve our grant delivery,
enforcement, public education, and research efforts.
The most current nationwide estimates from the Centers for Disease
Control and Prevention (CDC) show that 890,000 children had blood-lead
levels above the CDC level of concern during the time of the survey
(1991-1994). That study also showed that 21 percent of African-American
children living in older housing where lead-based paint is most
prevalent were poisoned, compared to 4.4 percent for the general
population. In December of 2000, the CDC provided more recent data
showing that while some counties had prevalence rates as high as 27
percent, the average blood-lead level in young children declined by 25
percent from 1996-1999 to 1.9 micrograms per deciliter, suggesting
our efforts to make U.S. housing lead-safe are successful.
The reason for this success is that the Nation took action. Lead
exposures from food canning, gasoline, and new paint were eliminated.
Lead in air emissions, occupational exposures and water all were
controlled and older housing with lead-paint is continually being
rehabilitated, abated, or demolished. Studies of the numerous, but
often subtle, harmful effects of lead were completed and a consensus
emerged. All of these actions have caused average blood-lead levels to
decline by over 80 percent since the 1980's, an achievement that ranks
as one the Nation's most successful public health stories.
Nevertheless, the evidence is clear that the major high dose source
for most children today is existing lead-based paint in older housing
and the contaminated dust and soil it generates. More must be done to
prevent hundreds of thousands of additional children from being
poisoned in the decades to come. HUD's new survey of lead-based paint
in housing shows that the estimated number of homes with lead-paint
declined from 64 million in 1990 to 38 million in 2000. Of the 38
million units with lead-paint, 25 million have lead hazards. Of those
25 million, 5.6 million house children under the age of 6, 1.6 million
of those units house low-income families with children under 6, the
population most at-risk of elevated blood-lead levels. Forty-one
percent of low-income housing has lead-paint hazards, compared to 18
percent of middle- and upper-income housing. HUD expects to repeat the
survey of housing with lead hazards in 2004, which will help better
determine long-term trends of lead hazard reduction.
Importantly, Government-supported housing, which is almost all low-
income housing, has a prevalence rate of 17 percent, about the same as
the middle- and upper-income housing. Therefore, from a lead-safety
perspective, Government-supported housing is also the safest housing,
the strongest indication yet that the Federal standards are effective.
The data also show that the problem is most severe in privately-owned
low-income housing that is or will be occupied by families with young
children. These are precisely the houses that are targeted by HUD's
Lead Hazard Control Grant Program.
HUD has worked closely with other Federal agencies to protect
children from lead poisoning. We must work more closely with other
agencies to match families with young children and houses that have
been made lead-safe through our various programs. We should find ways
to get this information to families who need it most, such as Medicaid-
eligible families. One option could be to make more information about
HUD lead hazard control programs available to State Medicaid agencies
through Centers for Medicare & Medicaid Services (CMS), CDC, and other
components of the Department of Health and Human Services (HHS). When
CDC conducted its High Intensity Targeted Screening effort in Chicago
recently, HUD was there to provide resources needed to eliminate lead-
based paint hazards for children who had not been previously identified
as being at risk.
After a transition period, HUD's new lead-based paint regulation
for Federally-assisted housing is now in effect across the country.
Federally-assisted housing now includes modern, more effective, and
scientifically proven hazard identification and control methods to
ensure that it is safe for children. This regulation brings lead hazard
control procedures into routine housing finance, maintenance, and rehab
systems and therefore represents a change from the way the Nation
approached the problem in the past, which was largely reactive and
inadequate. In short, we take action before a child is poisoned,
instead of only acting after the damage has been done. HUD's procedures
for Federally-assisted housing provide a template for promoting lead
safety in other housing with lead-paint hazards. Furthermore, the
capacity we have built to implement lead-safe work practices among
painters, remodelers, renovators and maintenance personnel can be used
more broadly, because many contractors often work in both assisted and
nonassisted housing.
In addition to all this, we have:
<bullet> Developed a 10-year strategy to eliminate childhood lead-paint
poisoning, which was published by the President's Task Force (this
marked the first time that Federal agencies developed a coordinated
approach and documented the resources needed).
<bullet> Linked lead safety to other children's health hazards that may
be caused by underlying housing conditions through HUD's Healthy
Homes Initiative.
<bullet> Created an effective lead hazard control grant program to
eliminate lead-based paint hazards in privately-owned low-income
dwellings where hazards are greatest. Today, HUD's program is
active in over 200 jurisdictions across the country.
<bullet> Together with State and local law enforcement, health and
housing departments, the Department of Justice and EPA, enforced
the lead-based paint disclosure regulation (so far, we have brought
cases that have resulted in compliance and lead-paint abatement in
over 158,000 high-risk dwelling units, as well as two criminal
convictions against landlords who failed to comply).
<bullet> Conducted the Nation's largest study of modern lead hazard
control techniques to determine the effectiveness of the HUD grant
program (the results show that children who live in units where
hazards have been eliminated have a 25 percent lower blood-lead
level and their homes have a sustained 50-88 percent decline in
dust-lead levels).
<bullet> Conducted research to reduce the cost and increase the
effectiveness of hazard identification and control technologies.
<bullet> Completed the inspection and risk assessment of tens of
thousands of units receiving HUD Section 8 project-based subsidies.
<bullet> Paid for clearance testing in public housing and in HUD-funded
rehab programs covered by HUD's lead-safe housing rule.
<bullet> Performed public education and outreach services through
private sector organizations such as Sears.
<bullet> Has been recognized by the Office of Management and Budget as
an ``effective'' program.
<bullet> Published technical guidelines, in the form of a 500 page
compendium of
best practices that is regarded by practitioners in the field as
state of the art and
widely referenced in Federal, State, and local regulations.
Another opportunity for collaboration is between HUD and the
Environmental Protection Agency (EPA). HUD and EPA have worked together
to target our regulations so that abatement contractors are used for
the most dangerous jobs, not routine housing rehab, and so that housing
rehab workers get the training they need to do their jobs safely. For
example, EPA developed a curriculum for lead-safe renovation work
practices, which HUD adopted for use in assisted housing programs.
HUD and HHS already collaborate on the National Health and
Nutrition Examination Survey (NHANES), where HHS pays for analysis of
children's blood-lead samples and HUD pays for analysis of dust-lead
samples in children's homes. It is possible that this partnership could
be expanded to permit NHANES to characterize the extent of lead hazards
in the Nation's housing.
HUD has also coordinated with the Department of Energy's
weatherization programs. Weatherization measures are intended to make
homes more energy efficient and may include window replacement, door
repair, and restoration of deteriorated walls. Unfortunately, such
measures may also involve disturbing lead-based paint. If contaminated
dust and paint chips are not properly controlled and cleaned up,
weatherization may inadvertently increase children's exposures. When
weatherization is performed as suggested in such weatherization
programs, it can eliminate lead-based paint hazards--a win-win
opportunity. Many HUD grantees leverage lead hazard control and rehab
funding with DOE weatherization funding. For example, replacement of
windows is both a key weatherization practice and an effective lead
hazard control method. While Title X of the 1992 Housing and Community
Development Act does not cover DOE weatherization programs, we believe
weatherization work practices must be consistent with lead-safe work
practices to ensure children are protected in homes undergoing
weatherization.
I would like to close by discussing the Secretary's new effort to
increase the involvement of the private sector in lead poisoning
prevention. HUD will soon release a Notice of Funding Availability for
Operation LEAP (Lead Elimination Action Program). Grants will be
awarded to entities that can demonstrate they can leverage additional
funding and resources for local lead hazard control programs. Congress
appropriated $6.5 million for this new effort for fiscal year 2002. We
are hopeful the private sector will respond to this opportunity to help
solve this problem.
Finally, let me recognize Senator Jack Reed for his resolve and
commitment to this important issue.
END NOTES
1. Centers for Disease Control and Prevention, ``Update: Blood Lead
Levels--United States 1991-1994,'' Morbidity and Mortality Weekly
Report, U.S. Department of Health and Human Services/Public Health
Service, Vol. 46, No. 7, February 21, 1997, pp. 141-146 and erratum in
Vol. 46, No. 26, p. 607, July 4, 1997.
2. Centers for Disease Control and Prevention, Blood lead levels in
young children--United States and Selected States, 1996-1999, Morbidity
and Mortality Weekly Report 49(50): 1133-1137, December 22, 2000.
3. Agency for Toxic Substances and Disease Registry, The Nature and
Extent of Childhood Lead Poisoning in the United States: A Report to
Congress, July 1988.
4. Brody et al., Blood lead levels in the U.S. Population: Phase 1
of the Third National Health and Nutrition Examination Survey, 1988 to
1991, Journal of the American Medical Association 272(4): 277-283, July
27, 1994; and Pirkle et al., The decline in blood-lead levels in the
United States, Journal of the American Medical Association 272(4): 284-
291, July 27, 1994.
5. National Academy of Sciences. Measuring Lead Exposure in
Infants, Children, and Other Sensitive Populations, Report of the
Committee on Measuring Lead in Critical Populations, Board on
Environmental Studies and Toxicology, Commission on Life Sciences,
National Academy of Sciences. Washington, DC: National Academy Press,
1993.
6. Jacobs DE. Lead-based paint as a major source of childhood lead-
poisoning: A review of the evidence. In: Lead in Paint, Soil and Dust:
Health Risks, Exposure Studies, Control Measures and Quality Assurance
(Beard ME and Iske SDA, eds). Philadelphia: ASTM STP 1226, American
Society for Testing and Materials, 1995; 175-187.
7. McElvaine MD, DeUngria EG, Matte TD, Copley CG, Binder S.
Prevalence of radiographic evidence of paint chip ingestion among
children with moderate to severe lead poisoning, St. Louis, Missouri,
1989-1990, Pediatrics 89:740-742 (1992).
8. Clark CS, Bornschein R, Succop P, Roda S, Peace B. Urban lead
exposures of children in Cincinnati, Ohio, Journal of Chemical
Speciation and Bioavailability, 3(3/4):163-171.
9. Jacobs et al., The Prevalence of Lead-Based Paint Hazards in
U.S. Housing, accepted for publication in Environmental Health
Perspectives, 2002. Also see HUD, National Survey of Lead and Allergens
in Housing, 2001 (available at www.hud.gov/offices/lead).
10. President's Task Force on Environmental Health Risks and Safety
Risks to Children. Eliminating Childhood Lead Poisoning: A Federal
Strategy Targeting Lead-Based Paint Hazards. Washington DC: U.S.
Department of Housing and Urban Development and U.S. Environmental
Protection Agency, February 2000.
11. Galke W, Clark S, Wilson J, Jacobs D, Succop P, Dixon S,
Bornschein B, McLaine P, Chen M. Evaluation of the HUD lead hazard
control grant program: early overall findings. Env Res 86A:149-156
(July 2001).
12. Guidelines for the Evaluation and Control of Lead-Based Paint
Hazards in Housing. HUD 1539-LBP, Washington, DC: U.S. Department of
Housing and Urban Development, 1997.
----------
PREPARED STATEMENT OF THOMAS L. SANSONETTI
Assistant Attorney General
Environment and Natural Resources Division
U.S. Department of Justice
June 5, 2002
Chairman Sarbanes, Senator Reed, and Members of the Subcommittee, I
am pleased to be here today, along with my colleagues on this panel. I
would particularly like to thank Senator Reed for his invitation to
discuss what the Environment and Natural Resources Division of the
Department of Justice is doing to make housing in America lead-safe.
This hearing provides a wonderful opportunity to educate the public
about the Federal Government's efforts to protect America's most
important resource, its children, from the evil of lead-based paint
poisoning.
In my testimony today, I will focus primarily on the U.S.
Department of Justice's enforcement efforts in connection with the
Residential Lead-Based Paint Hazard Reduction Act. I will give some
background on the genesis of the Act and the enforcement initiative
developed by our colleagues and clients at the Department of Housing
and Urban Development (HUD) and the U.S. Environmental Protection
Agency (EPA), talk about our role in that initiative, and briefly
discuss a few success stories from the last year in both the civil and
the criminal enforcement context. I will also touch upon the work of my
Division in reaching out to the U.S. Attorneys Offices and State and
local enforcement agencies to help them to be more effective in their
lead-paint enforcement efforts. I would also be happy to answer any
questions that the Subcommittee may have about our efforts in this
important area.
The Federal Residential Lead-Based Paint Hazard Reduction Act of 1992
Lead poisoning is a significant health risk for young children--it
can impair a child's central nervous system, kidneys, and bone marrow
and, at high levels, can cause coma, convulsions, and death. Of course,
ingesting lead is not good for anyone, but children under 6 years of
age are at the greatest risk of lead poisoning. This is true for two
reasons. First, humans are very vulnerable to the effects of lead
during these formative years, when lead in the bloodstream interferes
with and retards normal development. Second, as any parent knows, small
children will put almost anything in their mouths, including paint
chips, dust and soil containing lead, regardless of how many times you
tell them not to do it. In fact, lead-contaminated dust generated from
deteriorated lead-based paint in housing is the single largest source
of lead poisoning. Lead poisoning is especially acute among low-income
and minority children living in older housing.
This public health problem was the genesis of the Federal
Residential Lead-Based Paint Hazard Reduction Act, 42 U.S.C.
Sec. 4852d, which requires the sellers, owners, and managers of
residential buildings built before 1978 (the year that lead was banned
from residential paint) to warn prospective buyers and tenants about
the likely (and known, if any) presence of lead-based paint and lead in
dust or soil on the property. It also requires landlords to give
tenants an EPA pamphlet about how to minimize the dangers to children,
and directs them to document their compliance with the law by keeping
tenants' signatures on file, using a standard disclosure form.
Regulations implementing the statute are located at 24 C.F.R. part 35
and 40 C.F.R. Sec. 745.100 et seq.
With regard to civil enforcement actions, the Act authorizes EPA
and HUD to assess an administrative civil penalty in the maximum amount
of $10,000 for each violation. (For violations occurring after January
31, 1997, this amount has been adjusted to $11,000 per violation under
the Civil Monetary Penalty Inflation Adjustment Rule.) Although the Act
provides no authority for judicial civil penalties, it does authorize
injunctive relief for violations of the Act.
With regard to criminal enforcement, the Act states that failure to
comply with the notification requirements is a prohibited act under the
Toxic Substance Control Act (TSCA) Section 309 (15 U.S.C. Sec. 2689).
The criminal enforcement provision of TSCA, in turn, provides for a
criminal fine up to $25,000 for each day of violation and/or a term of
imprisonment up to 1 year. 15 U.S.C. Sec. 2615(b). As modified under
the Alternative Fines Act, the maximum criminal fine for this Class A
Misdemeanor is $100,000 for an individual, 18 U.S.C. Sec. 3571(b)(5)
and $200,000 for an organization, 18 U.S.C. Sec. 3571(c)(5), per count,
or the greater of twice the gross gain or loss. 18 U.S.C. Sec. 3571(d).
Lead-Based Paint Enforcement Initiative
Strong and fair enforcement of the law is necessary to ensure that
legal goals become practical realities. It is also important that law-
abiding businesses have a level economic playing field on which to
compete, and that those who fail to comply with the law know they will
be penalized. In the case of the Lead Hazard Reduction Act, the
Department of Housing and Urban Development embarked on a civil
enforcement initiative to ensure compliance with the Act's requirements
after its effective date in 1996. HUD focused its enforcement actions
on four major cities--Los Angeles, Chicago, New York, and the District
of Columbia--and proceeded by targeting large management companies
responsible for buildings which were covered by the Act and had
multiple incidents of lead-poisoned children. Among other investigative
methods, it contacted local health departments and asked them to
provide the Department with a list of addresses of properties where
children had been poisoned. It then zeroed in on sites where multiple
lead-poisoned children appear in a single building or a single owner or
management company is associated with multiple poisoned children in
several buildings. EPA also has a lead coordinator in each of its 10
regions responsible for Lead Hazard Reduction Act enforcement.
This simple but effective strategy helped the agencies quickly
identify those companies and individuals who were responsible for some
of the biggest lead-paint related problems. The agencies could then
focus their investigative resources on cases that would give the
biggest bang for the buck, both in terms of the number of housing units
at issue and in terms of getting the word out about the need to comply
with the law. Based on this footwork, HUD and EPA began filing a series
of administrative enforcement actions against violators of the Act.
Before I go on to talk about our role in this initiative, I would
like to credit my colleagues and the hard-working people at HUD and EPA
that have made this initiative such a success. They have done a
remarkable job in developing investigative strategies and putting in
the many hours it takes to turn a good plan into great results. One of
the things Senator Reed asked me to address was how DOJ can interact
more efficiently with other agencies to eliminate lead-based paint
poisoning in children, and I am happy to tell you that we are already
working very well with them to achieve this important goal. Thanks to
their efforts, and also the efforts of the good people in the U.S.
Attorneys Offices, the Federal Bureau of Investigation, and the State
and local agencies responsible for this issue, I have some major
success stories to tell you on the judicial front.
The Department of Justice's Role in the Initiative
Civil Judicial Enforcement
And the judicial front is where we at DOJ come in. One way of
thinking of our role in this initiative is that we provide a backstop
and a big stick to the agencies. For example, when HUD has confronted a
violator, but the violator is choosing to be obstinate and unwilling to
do what needs to be done to make amends for the violations, HUD has the
option of telling that person that it will refer the case to us and he
can then answer to a Federal judge instead.
Also, some cases call out for more than just administrative
enforcement for a variety of reasons, for example magnitude and
seriousness of violations, the type of relief that the agencies want to
obtain from the violators, or the need to get the word out to a broader
audience about the problem and the need to comply with the law. In
these cases, the agencies come to us and ask us to pursue actions in
court.
We have pursued several cases judicially, beginning with the first
ones that the Division and HUD filed here in the District in 1999.
These first actions filed in the U.S. District Court for the District
of Columbia included four settlements totaling more than $1 million
worth of lead-paint abatement in close to 4,000 dwelling units, and
$259,000 in fines and other commitments.
Our most recent success came last October, when the DOJ, HUD, and
EPA announced settlements in cases against three landlords in Chicago
for failure to warn their tenants that their homes may contain lead-
based paint hazards. The three companies in question controlled nearly
10,000 apartments in Chicago and Cincinnati, and they agreed to test
for and cleanup any lead-based paint found in their properties, and
have also paid $90,000 in penalties. One of the companies also agreed
to pay $100,000 to Chicago's Health Department as part of a child
health improvement project, and the other two agreed to give $77,000 to
a community-based health center to provide free blood-lead testing for
children living in Chicago and South Chicago. These settlements will
not only get these companies back into compliance with the law, but
will also provide benefits to the community that would not otherwise
have been available.
At the same time, HUD also announced settlements in four
administrative cases against landlords in New York City and Los Angeles
that own and manage approximately 6,500 units. The landlords in the
administrative cases agreed to pay $61,000 in penalties and to test for
lead-based paint in their properties and cleanup any lead-based paint
that is found.
Taken together, these and the many other judicial and
administrative actions that we have brought demonstrate that this
enforcement strategy is working--we are getting thousands of units
cleaned up and the word is getting out to management companies and
landlords across the country that we are serious about making sure they
comply with the disclosure requirements. And we have more civil cases
in the pipeline across the country, from California to Senator Jack
Reed's home State of Rhode Island.
Another group that I want to be sure to credit is the U.S.
Attorneys Offices. To leverage our resources and enhance our
effectiveness, the Division has forged partnerships with U.S.
Attorneys' Offices around the Nation and provided them with materials
and training so they can be more effective in bringing their own lead-
paint cases. They now carry out much of the enforcement of the lead
rules, which encompasses working with HUD and EPA to investigate
violations, conducting file inspections to determine compliance with
the law, and leading the negotiations with violators. In addition to
the training and materials we provide them, the Division's role in
cases where the USAO is providing the lead is to assist in drafting the
settlement document, developing the scope of injunctive relief, and
determining an appropriate penalty. In doing so, we help to maintain a
consistent and fair remedial
approach to lead disclosure cases nationwide.
We also work with State Attorneys General and other State and the
local officials across the Nation to increase cooperation among local,
State, and Federal lead
poisoning enforcement agencies. The State and local people are
essential players in this enforcement effort--in fact, our cases often
get started when we receive reports of elevated blood levels of lead
from a local health department. Working with the States also gives us
the advantage of being able to use State and local laws, such as
Maryland's, which may be more protective than Federal law.
Criminal Prosecutions
The U.S. Attorneys Offices and the State and local enforcement
agencies deserve credit in the criminal as well as the civil
enforcement context. There have been some especially egregious cases
which have warranted criminal prosecutions. The U.S. Attorneys Offices
in Maryland and New Hampshire, working with the Justice Department's
Environmental Crimes Section, have brought the first two criminal
cases. Their good work has been aided by special agents with HUD's
Office of the Inspector General, the EPA--Criminal Investigations
Division, and the FBI, and by others at HUD and EPA. In fact, the
Division will be presenting them with certificates of commendation
later this month.
Consider, for example, the case of David D. Nuyen, a Washington-
area landlord, who owned and managed 15 low-income rental properties in
the District of Columbia and Maryland. HUD's Office of General Counsel
contacted Nuyen in September 1998 as part of the civil enforcement
initiative because his name appeared on a list of landlords with the
most housing code violations and a list of landlords with multiple
cases of lead-poisoned children. When first contacted, Nuyen did not
have any of the required lead-paint disclosure forms, but 2 months
later, he presented the Agency with lead-paint forms.
The problem with the forms that he presented to HUD was that they
were falsified, forged, and backdated. They made it appear that Nuyen
had given tenants the required hazard warnings when in fact he hadn't,
even in those instances where he had previously received notices of
violation from the District of Columbia that an apartment was found to
have dangerous levels of lead. Moreover, Nuyen was
familiar with the requirements of the law because he had attended
classes on the Lead-Based Paint Hazard Reduction Act in 1997 and 1998
as part of his continuing education requirement for being a licensed
real estate broker.
Nuyen's criminal conduct did not stop with the submission of false
records to HUD. For example, during the course of the criminal
investigation, Nuyen lied at a meeting with civil enforcement officials
from HUD and the Department of Justice, he lied to Federal agents, he
made his tenants sign affidavits under the penalties of perjury falsely
saying that they had received the lead-paint disclosure forms, and he
provided false testimony to a Federal Grand Jury on two separate
occasions.
Nuyen's outrageous behavior made his case an appropriate one for
the first criminal prosecution involving the Lead Hazard Reduction Act.
His conviction last July in Greenbelt, Maryland, for obstruction of
justice, false statements, and the Lead Hazard Reduction Act, earned
him a 2-year prison sentence and a $50,000 criminal fine. Under the
terms of a plea agreement, Nuyen's sentence also required him to
provide all tenants with new notices about lead-paint assessments
performed by an independent contractor approved by the Government.
Another criminal case, United States v. James T. Aneckstein and JTA
Real Estate Brokerage and Property Management, Inc. (D-NH), culminated
in March in New Hampshire. This prosecution began with the tragic death
2 years ago of Sunday Abek, a 2-year-old girl who died of lead
poisoning while residing in a rental apartment managed by Aneckstein,
the owner of JTA Real Estate Brokerage and Property Management, Inc.
(``JTA''). Shortly after the City of Manchester Health Department and
New Hampshire Department of Health and Human Services announced that
Sunday's fatal lead poisoning was most likely caused by exposure to
lead-paint in the apartment in Manchester, New Hampshire, EPA officials
visited JTA's office to determine whether Aneckstein and JTA had
complied with the Lead Hazard Reduction Act. Aneckstein presented EPA
with forged, backdated, and otherwise falsified lead-paint disclosure
forms that falsely certified that Sunday's mother and other tenants in
her building had been given the required lead-paint warnings.
Aneckstein forged the tenants' signatures by reproducing the tenant's
real signatures from their leases and transposing them onto the lead
forms in an attempt to conceal his violations of the lead hazard
disclosure requirements. Aneckstein signed an affidavit falsely
swearing that all of the documents he provided to EPA were true and
accurate. When the same information was sought by a Federal grand jury,
Aneckstein and JTA again submitted false, forged, and backdated
documents.
In March of this year, Aneckstein was sentenced in Federal district
court in Concord, New Hampshire, to 15 months incarceration and a
$40,000 criminal fine. Again, prosecutors required Aneckstein and his
company, as part of a plea agreement, to perform a lead assessment,
properly notify tenants, and take other remedial measures.
The conduct of Nuyen and Aneckstein was particularly serious
because it involved deliberate attempts to disobey the law. Both
engaged in numerous, well-planned, and repetitive violations. Both
engaged in affirmative acts to obstruct regulators and grand juries in
an effort to cover-up their underlying failure to provide the lead
hazard warnings required by the Lead Hazard Reduction Act. Both
substantially undermined the investigative and prosecutorial process.
My message to the James T. Anecksteins and the David D. Nuyens of the
world is that landlords and property managers have an obligation to
inform tenants of lead-paint. Deliberately failing to notify tenants of
lead hazards, especially in those instances where actual hazards are
known, and lying to agencies entrusted with protecting public health
and safety, are serious crimes. The Department of Justice is committed
to working with our partners at HUD and EPA to fully investigate and
prosecute such violations.
Conclusion
Childhood lead poisoning is a completely preventable threat to
children. I believe that most of the real estate and housing community
are law-abiding citizens who want to do the right thing, and the civil
and criminal enforcement actions taken to date have helped to educate
them so that we can have better compliance with the law and lead-safe
housing for our children. We are proud to be working with our partners
at HUD, EPA, and State and local enforcement agencies on this effort,
and look forward to bringing more successful actions to protect
America's kids, especially those disadvantaged ones who are at greatest
risk. With your continued support, we believe that we can move a long
way toward eliminating lead poisoning.
I look forward to working with the Subcommittee on this important
issue and will be happy to answer any questions that you may have.
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PREPARED STATEMENT OF ADAM SHARP
Associate Assistant Administrator
Office of Prevention, Pesticides, and Toxic Substances
U.S. Environmental Protection Agency
June 5, 2002
Introduction
Good afternoon, Mr. Chairman and Members of the Subcommittee. Thank
you for the invitation to appear before you today. It is my privilege
to represent the U.S. Environmental Protection Agency (EPA) and to
discuss the Agency's efforts to prevent lead-based paint poisoning of
our Nation's children.
Background
In the almost 10 years since the Residential Lead-Based Paint
Hazard Reduction Act of 1992 (Title X) was enacted, the U.S.
Environmental Protection Agency, together with the U.S. Departments of
Housing and Urban Development (HUD), Health and Human Services (HHS),
and Justice, as well as our State partners, has made significant
progress in eliminating childhood lead poisoning. In fact, interagency
coordination within the Federal Government had started even earlier,
dating to the 1980's, and now continues with a Presidential task force
to ensure effective collaboration. How much progress have we made? In
1978, there were nearly three to four million children with elevated
blood-lead levels in the United States. In the 1990's, that number had
dropped to 890,000 kids, and it continues to decline. While we still
have a significant challenge, particularly with minority children and
children living in low-income housing, EPA is very proud of how the
Federal agencies and our State and private sector partners have
coordinated their efforts with the public to better protect our
children.
The Federal Government has phased out lead in gasoline, reduced
lead in drinking water, reduced lead in industrial air pollution, and
banned or limited lead used in consumer products, including toys, mini-
blinds, food cans, glazed china and ceramic wear, crystal, and
residential paint. States and municipalities have set up programs to
identify and treat lead-poisoned children and to rehabilitate
deteriorated housing. Parents, too, have greatly helped to reduce lead
exposures to their children by cleaning and maintaining homes, having
their children's blood-lead levels checked, and promoting proper
nutrition.
Current Activities
Many of the remaining cases of elevated blood-lead levels in
children are caused by leaded paint and related sources in older
housing. EPA has an active, multi-
pronged program to combat this problem. EPA's primary goal is to
prevent children from being poisoned and avoiding the consequences
associated with it. The program includes creating a national regulatory
infrastructure, developing outreach and education programs aimed at
those most at risk, and educating those who can help address the
problem. The program also conducts technical studies to determine the
overall risk of exposure and how our children can be better protected.
Regulations
<bullet> On March 6, 1996, EPA, together with HUD, promulgated the
Residential Lead-based Paint Real Estate Disclosure Rule (Toxic
Substance Control Act (TSCA) Sec. 1018). This rule mandates lead-
based paint disclosure requirements for all sales and rentals of
pre-1978 housing, thus ensuring that homebuyers and renters are
made aware of lead-based paint hazards before deciding on a
dwelling, and, in the case of homebuyers, guarantees the right to a
lead inspection before purchase.
<bullet> On August 28, 1996, EPA promulgated a rule covering Training
and Certification for Lead-Based Paint Professionals in Target
Housing and Child-Occupied Facilities (TSCA Sec. 402(a)). This rule
ensures that a well-trained cadre of lead inspectors, risk
assessors, and abatement personnel is available. In addition, this
rule allows EPA to authorize individual States, Tribes, and
Territories to develop and administer training and certification
programs, thus extending the reach of these efforts. At present, 36
States, Puerto Rico, two Tribes, and the District of Columbia,
assisted by Federal grants, are authorized to carry out this
program, with EPA retaining direct authority in the remaining
areas.
<bullet> On June 1, 1998, EPA promulgated the Pre-Renovation Education
Rule (TSCA Sec. 406(b)). This rule implements a very simple
concept: All owners/tenants of pre-1978 housing (about 15 million
housing units) should be given basic information about lead
poisoning prevention before paint-disturbing renovations are
started. EPA is continuing to work closely with advocacy groups and
the regulated community to ensure that this rule is effective and
not overly burdensome.
<bullet> On January 5, 2001, EPA promulgated a rule on the
Identification of Hazardous Levels of Lead in Dust and Soil (TSCA
Sec. 403). This rule defines certain locations and conditions of
lead-based paint, and specific levels of lead in dust and soil that
are most likely to pose a health threat to children. These
standards effect disclosure provisions, the need to use trained,
certified lead workers, and control and abatement requirements for
Federally-owned and Federally-assisted housing.
Outreach and Education
EPA conducts extensive outreach with potentially affected parties
in the development of regulations, to assist regulated parties in
complying with regulations, to inform citizens of their rights under
these rules and to inform the public about the nature of lead-based
paint hazards and provide guidance on how to reduce risks. Our partners
at HUD and HHS' Centers for Disease Control and Prevention (CDC)
partially fund these activities and provide technical support. This
outreach includes:
<bullet> A bilingual National Lead Information Center (1-800-424-LEAD).
The Center
operates a national hotline handling over 60,000 contacts per year,
distributes
1.6 million documents annually and operates a national
clearinghouse where best practices are shared.
<bullet> Development of materials, such as brochures and sample real
estate disclosure forms, needed to comply with regulatory
requirements.
<bullet> Creation and distribution of educational materials and
national lead awareness campaigns for parents, homeowners and
renters, medical professionals, renovation contractors and ``do-it-
yourselfers,'' and others. This includes the award-winning,
bilingual ``Get the Lead Out'' campaign to increase the awareness
of lead-paint
hazards.
<bullet> Partnership programs with nonprofit groups and other
Government agencies to conduct lead awareness/education activities,
particularly targeted to minority and urban populations often most
at risk.
<bullet> Cooperative programs with retail stores to distribute EPA
materials where painting or renovation supplies are sold.
Technical Studies
EPA has conducted numerous studies to define the levels of exposure
that should be regarded as hazardous to children and identify work
practices that successfully reduce lead-based paint risks. EPA's goal
is to better understand lead exposures, ensure that testing is done
appropriately and reduce the cost associated with eliminating exposure.
EPA's technical program includes:
<bullet> Technical studies, including risk assessments to support
regulatory decisions.
<bullet> Reports on lead testing and methodologies.
<bullet> Management of a national lead laboratory accreditation
program.
Even though we have accomplished a great deal, there is still more
to be done. The EPA is looking for better technologies to make lead
hazard control work more
affordable. For example, the Agency is working with HUD on spot test
kits for lead detection. As EPA Administrator Christine Todd Whitman
has stated, the Agency must base its decisions on sound science. To
that end, EPA is now engaged with HUD in peer review of the new spot
test kit work. We are also working with the National Association of
Realtors, the National Multihousing Council, and others to reassess and
streamline our prerenovation education requirements.
New Regulatory Activities
EPA anticipates completing the regulatory program mandated by Title
X over the next few years. Our renovation and remodeling activities,
which include new rulemaking, will address how to safely remove lead-
based paint and debris during remodeling activities. The Agency has
completed the Small Business Advocacy Review panel process and plans
additional consultation with States and the business community this
Autumn. We anticipate that a proposed rule will be ready for
publication in 2003.
In the meantime, EPA has developed a model training course for
renovation contractors, which is intended to provide them with
recommended methods to minimize lead hazards. The Agency is also
developing an outreach campaign to expand acceptance and use of the
model course. The goal is to promote lead-safe work practices among all
home remodelers, both professionals and ``do-it-yourselfers,'' and to
ensure proper training.
EPA anticipates publishing a proposed rule addressing lead-based
paint activities on bridges and structures in 2004. We are looking
closely at guidance for containing paint debris developed by the
Society for Protective Coatings (formerly the Steel Structures Painting
Council--SSPC), an association for users and suppliers of industrial
protective coatings and related products and services. SSPC's guidance
is increasingly being relied on by public and private entities engaged
in deleading activities, and is referenced in State regulations
governing these activities.
In addition, because of the impact the regulation could have on
small communities, EPA is conducting outreach in several States through
the Small Communities Outreach Project for Environmental Issues, under
a cooperative agreement with the National Association of Schools of
Public Affairs and Administration. This initiative is a community-based
approach to engaging elected officials and local government staff at
the early stage of regulatory development.
EPA expects to finalize regulations on management and disposal of
lead-based paint debris by the end of 2002. The Agency proposed the
rule in 1998 to address concerns expressed by HUD, HHS, some States,
advocacy groups and the regulated community that the costs of testing,
management, and disposal of lead-paint debris can be a significant
obstacle to abatement financing. EPA's Office of Solid Waste
is completing a rule that allows this debris, including chips, dust,
and sludge, to be disposed of in construction and demolition landfills.
This will result in significantly lower waste management and disposal
costs. EPA is also now working to introduce common-sense controls for
on-site storage of lead-based paint debris prior to disposal.
Conclusion
Thank you for the opportunity to discuss some of EPA's
contributions to prevent lead-based paint poisoning, just a part of our
successful Federal collaboration on this issue. Again, I want to thank
you for your support and assure you that this Administration is looking
forward to working with the Subcommittee to achieve our goal to
eliminate childhood lead poisoning by 2010. I would be pleased to
answer your questions.
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PREPARED STATEMENT OF RUBEN-SHAW, JR.
Deputy Administrator and Chief Operating Officer
Centers for Medicare & Medicaid Services
June 5, 2002
Chairman Reed, Senator Allard, distinguished Subcommittee Members,
thank you for inviting me to this hearing today to discuss the Centers
for Medicare & Medicaid Services' (CMS) efforts to address lead-based
poisoning in children. Specifically, I would like to discuss CMS' role
in providing screening and treatment for at-risk children. Despite
dramatic reductions in blood-lead levels over the past 20 years, lead
poisoning continues to be a significant health risk for young children,
particularly those from low-income families or who live in older
housing. I know that you, Chairman Reed, have a keen interest in this
issue, and we recognize and appreciate your efforts and the work of
this Subcommittee.
Although lead poisoning is a preventable condition, it remains a
health concern for America's children. Administrator Scully and I share
your concern regarding the very real dangers posed by lead poisoning,
and I want to emphasize CMS' commitment to protecting the health and
well-being of America's children. We are committed to following
Secretary Thompson's lead on prevention efforts and to working with our
sister agencies at the Department of Health and Human Services,
especially CDC, to eradicate this health concern. To this end, we are
engaged in a number of efforts to address lead poisoning in children,
which I will detail for you today.
CMS' Role in Preventing Lead Poisoning
The fight to eradicate poisoning from lead-based paint and dust is
a collaborative effort, and CMS works closely with other HHS agencies,
such as the Centers for Disease Control and Prevention (CDC), as well
as the Environmental Protection Agency (EPA), the Department of Housing
and Urban Development (HUD), the Department of Justice (DOJ), and other
community-based organizations. Medicaid plays a distinct role in
addressing lead poisoning by providing funding for four important
services: Screening, treatment, investigation, and case management for
eligible Medicaid beneficiaries.
Medicaid's Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) benefit specifically requires that all Medicaid-eligible
children receive a screening blood-lead test at 1 and 2 years of age,
as recommended by the CDC. Also, any child over age 2 up to age 6 for
whom no record of a test exists must receive a screening blood-lead
test. In addition to paying for the screening tests, Medicaid pays for
any additional diagnostic and/or treatment services required for a
child with elevated blood-lead levels. This includes any case
management services necessary to ensure that the child and family are
directed to the appropriate agencies and resources they may need, such
as the local health department and housing agencies, medical care, and
facilities. Once a child is diagnosed as having an elevated blood-lead
level, Medicaid also will pay for a one-time investigation. During this
investigation, a health professional visits a child's home (or primary
residence) and inspects the area to determine the source of lead. We
believe that Medicaid has contributed to the dramatic decline in blood-
lead levels over the last two decades, however, we are
continuing to make improvements in data collection and education with
our State
partners, as well as health care providers.
CMS' Collaborative Efforts and Improvement Strategy
As you may know, the General Accounting Office (GAO) released a
report in January 1999 that detailed problems in the Federal response
to children at risk for elevated blood levels. This report provided a
roadmap for improvement, and following its publication, CMS entered
into a number of activities to improve our services and commitment to
helping at-risk children. For example, in 1999, we began efforts to
improve the way we collect data on screening tests by adding a line
item to the annual EPSDT report that States submit to us. This line
item indicates the number of children under the age of 6 that received
a screening blood-lead test. We began collecting this data in April
2000 for fiscal year 1999. However, the reporting of tests and test
results always presents a challenge for the Agency. We only gather
information on the tests we help to fund. Some tests provided by local
health departments through health fairs and other venues are not
generally billed to Medicaid. When no Medicaid claim for the test
exists, accounting for these tests for the purpose of our annual EPSDT
report is made more difficult. We have continued to encourage State
Medicaid agencies to participate in data sharing activities so that the
local health department and the Medicaid Agency are both aware if a
test has been performed on a Medicaid-eligible child. Moreover, our
Regional Offices work with State and local agencies to help coordinate
and support grassroots efforts to educate providers on the importance
of blood-lead screening, reporting, and data
collection.
Also in 1999 in response to the GAO report, we sent a letter to all
State Medicaid directors that detailed the findings of the report and
reiterated the responsibilities of each State Medicaid program under
the Federal Medicaid screening policy. This letter also encouraged
States to develop model interagency agreements to share best practices
information among the agencies in their State governments. That way,
States can better assess the areas and children that lead may affect,
and how to prevent and detect lead poisoning.
Building on these efforts, we also have entered into a Cooperative
Agreement with the Alliance to End Childhood Lead Poisoning, awarding
them $250,000 to develop an educational tool to be used by regional,
State, and local Medicaid offices, and other entities who work closely
with health care providers and managed care plans involved in screening
children. The tool is intended to improve awareness of and compliance
with the CMS policies on childhood lead poisoning prevention. Our
collaborative effort resulted in the development of a guide entitled,
Track, Monitor and Respond: Three Keys to Better Lead Screening for
Children in Medicaid, which was disseminated to State Medicaid Agencies
and is available on the Alliance website. This guide is intended to be
an educational document that States can use to reach out to their
providers in order to resolve some of the difficulties in the provision
of the blood-lead screening tests.
In addition to our work with the Alliance, we have awarded a
contract for approximately $750,000 to Abt Associates to develop a
study titled, Moving Toward Elimination of Lead in High-Risk Children.
The purpose of this study is twofold: To improve screening among low-
income children by assessing the impact and effectiveness of current
screening criteria in reaching high-risk, low-income children (with a
particular emphasis on Medicaid-eligible children); and to identify
State and local innovations for the elimination of lead hazards facing
low-income children. The study is ongoing and will identify and analyze
current screening policies and practices for low-income children to
determine the extent to which Medicaid and other high-risk children are
being screened and whether programs are achieving successful results.
The project will include site visits to five locations to provide an
in-depth picture of the screening and prevention/remediation activities
in five areas--Providence, Rhode Island; Baltimore, Maryland; Chicago,
Illinois; the State of Iowa; and Oakland/Alameda County, California. We
expect a final report by Fall 2002. We plan to share this report with
State Medicaid agencies to assist them in developing the types of
processes and practices that will result in more high-risk Medicaid-
eligible children receiving the lead screening test to which they are
entitled. We believe that the study will show that if local housing and
health departments and State Medicaid agencies work together, a child's
chances of being screened for lead poisoning and being able to live in
lead-safe housing greatly improve.
Just as local and State agencies need to cooperate, Federal
agencies must work together, too. We collaborate with many other
Federal agencies on the President's Task Force on Environmental Health
Risks and Safety Risks to Children. In February 2000, the Task Force
published ``Eliminating Childhood Lead Poisoning: A Federal Strategy
Targeting Lead Paint Hazards.'' The report presents a program for
eliminating childhood lead poisoning by 2010 based on coordinating the
efforts of various Federal agencies, including HUD, EPA, CDC, and CMS
to improve early intervention and follow-up services for at-risk
children and to remove lead hazards from homes. We look forward to
working with our partner agencies and departments and the States to
address the full array of issues surrounding the elimination of
childhood lead poisoning.
As we strive to develop a number of strategies to better protect
America's at-risk children, we remain committed to our current policy
addressing the very real threat posed by lead hazards. Moreover, while
we work to ensure that at-risk children, particularly those who are
Medicaid-eligible, receive early intervention and treatment for lead
poisoning, we will continue to rely on the expertise of the CDC for
policy recommendations on lead screening.
Conclusion
National health surveys conducted periodically by the CDC have
shown a marked decline in the prevalence of elevated blood-lead levels
in children, primarily due to regulatory bans on lead in gasoline and
paint. However, lead poisoning still presents a serious developmental
health risk for many American children, including those from low-income
families or who reside in older housing that may contain lead-based
paint. Under the Secretary's leadership, Administrator Scully and I
remain committed to helping eradicate this preventable health
condition. Although our particular role in the fight to eliminate lead
poisoning in children lies in reimbursing for secondary preventive
services such as lead screening and any additional diagnostic and
treatment services required by those Medicaid-eligible children with
lead poisoning, we here at CMS are dedicated to working with State
Medicaid Agencies, local organizations and our sister agencies and
other Federal departments to develop innovative strategies to combat
lead poisoning in the 21st Century. I want to thank the Subcommittee
for your interest in this important health problem that
affects primarily underserved children, and I would again like to thank
Chair-
man Reed for his leadership regarding this issue. I look forward to
answering your
questions.
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PREPARED STATEMENT OF RICHARD J. JACKSON, M.D., M.P.H.
Director, National Center for Environmental Health
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
June 5, 2002
Good afternoon. I am Dr. Richard Jackson, Director of the National
Center for Environmental Health (NCEH), of the Centers for Disease
Control and Prevention (CDC), U.S. Department of Health and Human
Services. I would like to thank Senator Reed and the Senate Banking
Subcommittee on Housing and Transportation for inviting me here today.
It has been an honor for me to take part in the collabo-
ration between CDC, CMS, HUD, EPA, and DOJ that has formed around this
effort. I am pleased to be here to discuss CDC's Childhood Lead
Poisoning Prevention Program.
In 1991, the U.S. Department of Health and Human Services (DHHS)
called for a society-wide effort to eliminate childhood lead poisoning
in 20 years, and 11 years later, we remain committed to this goal. The
elimination of this preventable disease will be one of the major public
health accomplishments of this century.
It is clear that lead can do great harm, especially to young
children. A child's exposure to lead can produce serious health
consequences, including a variety of neurologic and behavioral
disturbances, as well as delayed development. Over the past 25 years,
we have been successful in reducing our children's blood-lead levels
nationwide. The CDC's analysis of children's blood-lead levels as part
of the National Health and Nutrition Examination Survey (NHANES II)
conducted between 1976 and 1980 revealed that 88 percent of American
children between the ages of 1 and 5 had elevated blood-lead levels
(EBLL) (*10 g/dL). Further, CDC analyses were instrumental in revealing
that decreasing lead in gasoline resulted in parallel declines in
blood-lead levels. This information contributed to the subsequent U.S.
Environmental Protection Agency (EPA) decision to remove lead from
gasoline. This decision, along with the removal of lead from paint and
other sources, has resulted in a dramatic decline in the amount of lead
in the blood of all Americans. According to CDC's NHANES data from
1991-1994, the proportion of children age 1-5 years with elevated
blood-lead levels had fallen from 88 percent to 4.4 percent.
Through this work, CDC has recognized that having good measures of
the actual exposure of the American public to lead was going to be
critical to achieving our goals. NHANES has allowed us to focus on
identifying children who are at higher risk for lead poisoning.
Children who have been found to be at higher risk include children from
low-income families who live in older deteriorated housing; many are
minority children. CDC data also indicate that there are currently an
estimated 890,000 American children under the age of 6 who have
elevated blood-lead levels.
I will now turn to describing the activities of CDC's Childhood
Lead Poisoning Prevention Program. This program was authorized under
Section 317A of the Public Health Service Act as amended in 1988. The
program was reauthorized in 1992 as part of the Preventive Health
Amendments Act, and in 1998, reauthorization was extended to 2002. The
program received its first appropriation in 1990, and is currently
funded at $41 million for fiscal year 2002. With these funds, CDC
provides guidance, technical support, and resources to 43 States and 17
local health departments for childhood lead poisoning prevention and
surveillance efforts. These CDC supported programs include three main
components which I will describe in detail, in addition to other
elements. The main components are: (1) Primary Prevention; (2)
Effective Screening and Surveillance; and (3) Public and Professional
Health Education and Communication.
Primary Prevention
CDC supports innovative approaches to identifying children at risk
for lead exposure and ensuring their housing is lead-safe before they
are exposed to lead. In addition, CDC supports the development,
improvement, and oversight of policies and strategies to bring about
primary prevention within all funded programs. For example, Maryland
law mandates a paint maintenance standard-of-care for all rental units
built before 1950, with third-party inspection prior to each rental
turnover. Over half of the Maryland's 159,000 pre-1950 rental units
have registered with the Maryland Lead Rental Registry. Over 75,000
third-party inspections to certify that pre-1950 rental units meet the
lead standard-of-care have been conducted and reported to the State.
Tenants can now call to check if a property has been registered and
inspected before they rent. Through its cooperative agreement with
Maryland, CDC provides expertise and funding to assist the State with
this innovative approach.
Effective Screening
CDC provides national guidance for the prevention of childhood lead
poisoning, including Screening Young Children for Lead Poisoning:
Guidance for State and Local Public Health Officials. This document
provides general guidelines about the roles and responsibilities of
child health-care providers in preventing childhood lead poisoning,
screening and follow-up testing, clinical management, chelation
therapy, and family education about EBLL's. For example, as recommended
by CDC guidance, North Carolina has a statewide screening plan that
targets 1- and 2-year-olds and other high-risk populations, especially
Medicaid and Women, Infants, and Children (WIC) program recipients.
Since the targeted screening plan was adopted in October 1998, the
annual screening rate among all 1- and 2-year-olds in the State has
increased from 25 percent (53,390 tested in 1998) to 35 percent (81,988
tested in 2001). Essential to this effort have been promotional efforts
by the State Medicaid Agency and a statewide WIC screening initiative
targeting children who have never been tested.
However, a U.S. General Accounting Office (GAO) report from
February 1998 entitled, ``Medicaid: Elevated Blood Lead Levels in
Children,'' suggests that many States are not screening children at
risk for lead exposure. CDC recognizes this challenge, and the new
screening guidance addresses the issue of reaching children enrolled in
Medicaid and other health care programs.
One way CDC is addressing this issue is by providing technical
assistance to funded States for developing and enhancing the States'
Childhood Blood Lead Surveillance (CBLS) system. The inclusion of State
data in CDC's CBLS database provides a national picture of childhood
blood-lead levels. Establishing childhood lead surveillance systems at
the State levels allows the use of surveillance data to estimate the
extent of EBLL's among children, assess the follow-up of these
children, and help allocate resources for lead poisoning prevention
activities within each specific State. Minnesota's Department of Health
(MDH), for example, maintains an extensive blood-lead surveillance
system for monitoring trends in blood-lead testing and BLL's in
children. MDH matches lead surveillance data with Medicaid data to
analyze screening trends and determine the percentage of Medicaid
children screened with EBLL's. Through this analysis, MDH has been able
to determine that in Minnesota 72 percent of children with EBLL's were
enrolled in Medicaid. In addition, Medicaid-enrolled kids had nearly
twice the rate of EBLL's than kids not enrolled in Medicaid (9.8
percent vs. 5.0 percent).
CDC provides screening and case management guidelines to all CDC
funded programs. Working in conjunction with CDC, all funded programs
develop, implement, and evaluate their activities to assure that
children receive the best care possible. For example, Rhode Island uses
the KIDSNET system, an automated tracking and follow-up tool, that
links pediatric public health programs to each other and to health care
providers. KIDSNET provides contextual information about the number of
children who should be screened to determine screening rates and
provides data which enables the State to evaluate the quality of
screening and follow-up at the provider level.
Public and Professional Health Education and Health Communication
CDC conveys the negative health effects of elevated blood-lead
levels to a child and the importance of screening through public
outreach and professional education. CDC supports and provides
oversight to funded programs to target audiences such as parents,
doctors, nurses, public health professionals, and rental property
owners. Information is dispersed through TV and radio announcements,
educational pamphlets, training courses, and policy briefings. Salt
Lake Valley (UT) Health Department's Lead Free Kids program has
identified realtors and landlords as a target audience. The goals of
the project include providing unaware landlords and realtors with
information on disclosure regulation requirements and raising tenant
awareness of lead-based paint hazards. Some of the outreach components
include direct mailing of a lead disclosure brochure to area realtors,
pre-1978 multifamily property owners and members of the Utah Apartment
Association (UAA), and submitting articles in the realtor and apartment
owners' trade journals.
CDC's activities in these areas have evolved over time, and one of
the lessons that we have learned is that in order to meet our goal, we
must pay attention to changes in our environment and adopt new
approaches. In 2001, CDC developed the High-Intensity Targeted
Screening (HITS) approach for improving the Nation's ability to target
and screen children for lead poisoning and prevent exposure to lead.
The goals of HITS are to identify children missed by routine screening;
improve surveillance and estimate the burden of lead poisoning in a
specific locale; evaluate current screening plans; develop
partnerships; and increase local capacity. HITS teams, which are made
up of the staffers from local childhood lead poisoning prevention
programs and community members, assisted by CDC, visit homes in high-
risk communities to screen children for lead. When children are found
to have EBLL's, the families are offered appropriate medical treatment
and a home lead evaluation. Local programs will use HITS data to
improve lead screening plans, better direct resources, increase
technical capacity, and monitor progress toward lead poisoning
elimination. The HITS approach requires partnerships to be developed
between community members and multiple Federal, State, and local
agencies resulting in a more comprehensive approach to eliminating
childhood lead poisoning at the local level.
In November 2001, the first HITS project in two inner-city
communities in Chicago was completed. Preliminary analyses indicate
that 67 percent of the children had never been previously tested, and
approximately 30 percent of the children who were tested had EBLL's.
Data analysis is ongoing. CDC plans to implement HITS in additional
communities over the next several years in order to improve the
Nation's ability to target and screen children for lead poisoning and
prevent exposure to lead.
Just as we have emphasized the importance of collaborative
activities at the State and local level to develop a successful
statewide screening plan, we have redoubled our efforts to collaborate
with other Federal agencies to make the goal of eliminating childhood
lead poisoning a reality. Since 1990, there has been a Federal
partnership to focus our efforts toward this goal, with the DHHS
(particularly CMS),
EPA, and U.S. Department of Housing and Urban Development (HUD) taking
leadership roles.
CDC and its grantees work very closely with HUD and HUD's grantees
to ensure the prevention of childhood lead poisoning. The close
coordination maximizes the
resources of each organization without duplicating services. Each grant
program draws upon its unique expertise and service delivery networks.
CDC grantees have expertise in technical issues related to screening
and blood-lead testing, as well as programmatic expertise in following
up on the needs of high-risk children. HUD grantees have expertise in
lead-based paint and lead dust hazard identification and in the
physical interventions needed to make homes lead-safe.
HUD grantees concentrate their primary prevention activities in
neighborhoods where children are at risk for lead poisoning. Data from
CDC and its grantees are essential for HUD grantees to appropriately
target their primary prevention efforts. Furthermore, HUD grantees work
closely with CDC grantees to reduce lead hazards in housing where
children are identified as lead-poisoned. This serves the goal of
secondary prevention, as well as the goal of preventing additional
children from being lead-poisoned. CDC also funds 35 States to track
the problem of adult lead exposure through the Adult Blood Lead
Epidemiology and Surveillance (ABLES) program. This program helps
prevent lead exposures in children whose parents are exposed to lead at
work and who may inadvertently bring contaminated clothing into the
home. Together, CDC and HUD can identify and intervene with both at-
risk children and at-risk home environments, moving us closer to
eliminating childhood lead poisoning by 2010.
In closing, I would like to emphasize that we will continue to face
challenges in the elimination of childhood lead poisoning prevention,
but CDC and our partners in this effort have learned many lessons over
the past decade that have prepared us well. In any public effort such
as this, one of the biggest challenges we face is to keep resources and
attention focused on a problem over time. It is important to remember
that no child in this country should be adversely impacted by
environmental exposure to lead. The improvement in quality of life for
the children freed from the threat of possible damage caused by
exposure to lead cannot be overstated. Our children, the most important
resource for the future, deserve our every effort. We have come a long
way in making children lead-free, and I appreciate your interest and
support in continuing to make this vision a reality.
That concludes my written statement. At this time, I would be happy
to answer your questions.
RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED
FROM DAVID E. JACOBS
Q.1a. What is HUD doing to make sure its new lead-safety
regulations are being followed or enforced?
A.1a. HUD has prepared several tools and training activities to
ensure that the new HUD lead-safety regulation is being
followed in each program area. HUD implemented a transition
assistance period that lasted from September 15, 2000 until
January 10, 2002 to enable local jurisdictions to build the
necessary capacity to comply with the rule. Now that the
transition period has ended, HUD is ensuring that its routine
program monitoring includes an evaluation of compliance with
the new regulation in its housing maintenance, rehabilitation, and
other subsidy programs covered by the regulation. In addition,
HUD staff in the Office of Healthy Homes and Lead Hazard
Control will be combining compliance checks for both the lead-
paint disclosure regulation and the new HUD lead-safety
regulation in selected geographic areas where lead hazards are
most prevalent. Increased staff are now on board to handle this
increased workload.
Q.1b. Why is HUD's Single-Family Mortgage Insurance Program the
only program not to be updated in HUD's new lead-paint
regulations for assisted housing? Is there a significant
incidence of lead exposure and contamination in these units?
A.1b. HUD's Single-Family Mortgage Insurance Program currently
requires that properties have a visual inspection, paint repair
if lead is present, post repair clean-up, and disclosure to the
buyer. An analysis completed in the late 1990's estimated that
the imposition of the new assisted housing lead-paint
regulations would cost an estimated $93 million annually, costs
that could be passed on to the homebuyer and have the effect of
diminishing new homeownership opportunities. HUD does not have
data on the specific incidence of lead-paint hazards in homes
served by the Single-Family Mortgage Insurance Program.
Q.2a. How much funding would Congress have to provide you with
in order to fund all of the applications you have received?
A.2a. For fiscal year 2001, the Office of Healthy Homes and
Lead Hazard Control received 181 applications totaling $290
million. Each applicant was limited to requesting no more than
$3 million each. Congress appropriated $100 million for fiscal
year 2001, $110 million for fiscal year 2002, and the
President's budget request for fiscal year 2003 is $126
million.
Q.2b. Have requests for such assistance increased as a result
of the promulgation of new HUD lead-based paint regulations
(September 15, 2000)?
A.2b. There does not appear to be a large increase in requests
for assistance as a result of the new HUD lead-based paint
regulations.
Q.3a. What tools are needed to encourage the practice (of
leverag-
ing lead hazard control and rehabilitation funding with the
Department of Energy's weatherization funding)?
A.3a. A better system of identifying those lead hazard control
practices that promote energy efficiency and vice versa is
needed to
enable an improved estimate of the benefits of such leveraging.
Window replacement is perhaps the most common work activity
that accomplishes both improved energy efficiency and lead
hazard control simultaneously, but there are undoubtedly other
opportunities as well.
Q.3b. What tools are needed to make weatherization work
practices consistent with lead-safe work practices to ensure
that our children are protected in homes undergoing
weatherization?
A.3b. A uniform training curriculum is needed to ensure
weatherization workers receive consistent messages in DOE-
sponsored training courses. This could be achieved by adapting
EPA's lead-safe remodeling and renovation work practices course
to weatherization, in much the same way that HUD adapted this
course for use in assisted housing. Clearance testing should
also be made an eligible weatherization expense for those jobs
that disturb lead-based paint above de minimis levels.
Q.4. How many (Project-Based Section 8) owners have actually
used this program (of free lead-paint inspections/risk
assessments)? What percentage of the total inventory do these
owners make up?
A.4. There are approximately 11,000 properties built before
1978 in the Project-Based Section 8 inventory. To date, 3,131
properties have enrolled in the HUD program providing free
lead-based paint risk assessments and lead inspections. This
constitutes approximately 29 percent of the inventory. In
addition, HUD is aware that some owners have contracted for
their own lead-based paint inspections, either voluntarily or
as a result of local lead-based paint enforcement activities.
Recently, HUD sent to each owner a letter and certification
form to document each property's lead-safety status. The
compliance deadline for completing risk assessments for the
project-based units built between 1960 and 1977 (which
constitutes about 9,000 of the 11,000 properties covered by the
regulation) is September 15, 2003.
Q.5. How many HUD cases have been referred to DOJ in the last
year and a half ? What is the status of those cases?
A.5. In the past year and a half, HUD has pursued 15 cases with
the Department of Justice, four of which have been formally
referred to DOJ. Ten other cases have been completed with DOJ
since 1998. HUD is also currently investigating dozens of other
cases administratively. These cases are in various stages of
investigation and negotiation. HUD and DOJ expect to continue
to announce resolution of cases of noncompliance as consent
decrees or other legal actions are completed.
Q.6. Do you believe that visual inspection, lead-safe work
practices and clearance testing offer the potential to expand
lead-safety on a broad enough scale to make U.S. housing lead-
safe?
A.6. Yes, this strategy is likely to be effective for most
housing with low risk and adequate cash flow to support good
maintenance practices. HUD has developed a short web-based
training course for visual assessment to help meet this need.
Together with EPA, we have also developed several maintenance
courses to teach lead-safe work practices. But for unassisted
low-income housing where cash flow and maintenance is
inadequate and where deteriorated paint is extensive, other
strategies are needed. Risk assessments and/or inspections will
enable a more targeted approach so that lead-based paint
hazards are correctly identified and controlled at minimum
cost. Most deteriorated paint, even in older housing, is not,
in fact, lead-based paint and therefore does not need to be
addressed in order to make a property lead-safe. A visual
assessment alone cannot determine the presence of lead in
paint, or dust-, or soil-lead hazards.
For example, the high-risk housing treated under HUD's Lead
Hazard Control Grant Program is always given a risk assessment
and/or inspection to ensure that a targeted approach is used.
Properties that have consistently high rates of deferred
maintenance will need to be abated; other properties can be
assessed visually, with follow-up lead-safe work practices and
with clearance testing completed. The degree of hazard control
should reflect the degree and extent of hazard. In the worst
cases, demolition may be the best option.
Q.7. What do you believe your Agency can do to help stop houses
from poisoning more than one child?
A.7. HUD's new lead-safe housing regulation requires that
houses with lead-poisoned children and lead-based paint hazards
must be made lead-safe before the unit can qualify for
continued subsidy, even if the lead-poisoned child has been
relocated to another unit. In addition, HUD program recipients
and local health departments are required to compare lists of
subsidized housing units with lists of lead-poisoned children
on a quarterly basis. If there is a match, then HUD's lead
hazard control requirements apply to that unit as a condition
of continued subsidy. Also, some of HUD's lead hazard control
grantees, such as Milwaukee, use HUD funds to leverage
substantial private-sector investment in properties where
children have been poisoned if the owner agrees to act quickly
to eliminate the hazards.
The State of Rhode Island, which has received substantial
funding from HUD for lead hazard control, recently passed a new
State law that increases an owner's responsibility in houses
that have poisoned more than one child. Finally, in last year's
appropriation, Congress created an earmark to the National
Center for Lead-Safe Housing to develop a database of lead-
based paint activities. Through that organization, HUD is
working with several cities to pilot-test a database that could
include information on houses that have poisoned more than one
child, after resolution of issues regarding confidentiality of
medical records.
Q.8. What does your Agency believe might be appropriate
statutory changes to make the Federal disclosure law regarding
lead more meaningful?
A.8. HUD does not currently have subpoena authority under Title
X of the 1992 Housing and Community Development Act to enforce
the Federal disclosure regulation. Because the disclosure
regulation is a joint HUD/EPA regulation, HUD has relied on
EPA's subpoena authority under the Toxic Substances Control
Act. While the collaboration between the two agencies has worked
well, the lack of HUD subpoena authority creates unnecessary
administrative obstacles. HUD currently has subpoena authority
to investigate other statutory requirements, such as the Real
Estate Settlement Procedures Act (RESPA).
Also, HUD does not have statutory authority to delegate to
local jurisdictions the environmental review function for the
Healthy Homes and Lead Hazard Control programs. Environmental
reviews are required under the National Environmental Policy
Act. Local jurisdictions are best able to make the most
informed assessments. Other HUD programs, such as the Community
Development Block Grant (CDBG) and Housing Opportunities for
People With AIDS (HOPWA), currently have statutory authority to
delegate the environmental review function to local
jurisdictions.
Q.9. What does your Agency think about this strategy (of moving
beyond screening children's blood-lead levels to actually
screening high-risk housing to identify hazards before a
child's health is harmed)? What about the idea of developing
registries of hazardous properties?
A.9. HUD supports the strategy of screening high-risk housing,
which is at the heart of HUD's lead-safe housing regulation.
Several HUD lead hazard control grantees maintain lead-safe
housing registries as a way of informing the public on where
lead-safe housing is located (see answer to question 7 above).
HUD does not currently have the statutory authority to create a
national registry of hazardous properties.
Q.10. Does your Agency believe that lead-based paint and dust
hazards in housing are the overwhelming cause of childhood lead
poisoning in the United States? If not, what other causes
should the Congress be looking at?
A.10. Lead-based paint hazards and the contaminated dust and
soil it generates are clearly the major cause of childhood lead
poisoning in the United States today. The President's Task
Force Report references the available scientific evidence on
this question.
Q.11. Does your Agency support the goal of stopping children
from being poisoned in the first place? If so, how is your
Agency planning to achieve this goal?
A.11. Yes, HUD supports the goal of stopping children from
being poisoned in the first place. We are planning to achieve
that goal by creating lead-safe housing that children are
either born into or in which they are expected to reside in the
future. HUD's Lead Hazard Control Grant Program, leveraged private
sector funding and resources through Operation LEAP (Lead Elimination
Action Program), HUD's lead-safe housing regulation for Federally-
assisted housing, enforcement of both that regulation and the
lead disclosure regulation, public education, research,
training, and coordination with other Federal, State, and local
governments are the principal vehicles through which we expect
to achieve the goal.
RESPONSE TO WRITTEN QUESTIONS OF SENATOR CARPER
FROM DAVID E. JACOBS
Q.1. Both HUD and EPA have repeatedly endorsed a ``lead-safe''
standard for lead hazard remediation, rather than ``lead-
free.'' These findings seem definitive and are based on good
science, yet the issue continues to get attention. What is
HUD's position on ``lead-safe'' versus ``lead-free?''
A.1. The two standards are not mutually exclusive; there are
circumstances where one or the other is most sensible. Each
standard is capable of eliminating excessive lead exposure and
protecting children. A ``lead-safe'' standard means that while
a property may have lead-based paint, it has no lead-based
paint hazards; in other words, the mere presence of lead-based
paint does not in itself constitute an immediate hazard. In
order for the ``lead-safe'' standard to be effective, the lead-
based paint must be monitored and managed over time to ensure
that it remains in a nonhazardous condition. Also, any
activities that disturb the lead-based paint, such as
renovation, remodeling, repainting, or maintenance, must be
performed using lead-safe work practices and clearance testing
to ensure cleanup has been adequately performed. Several
studies, including HUD's study of its Lead Hazard Control Grant
Program, have shown that this approach is effective in reducing
both dust-lead levels and blood-lead levels in resident
children.
A ``lead-free'' standard may also be appropriate in cases
where the lead-based paint will not be properly managed, where
``gut'' rehabilitation will eliminate all surfaces coated with
old paint, or where only a few surfaces in a given housing unit
are coated with lead-paint. In these circumstances, it may make
more sense to simply remove lead-based paint, rather than pay
for the on-going management and maintenance of surfaces coated
with lead-paint. Since the lead-based paint is removed, no on-
going maintenance or management is needed, because there is no
potential for exposure to hazards. Furthermore, there is no
additional disclosure or regula-
tory burden for properties that are free of lead-based paint.
Under both standards, removal of either deteriorated or
intact lead-based paint above de minimis levels should be
performed using lead-safe work practices, followed by
specialized cleaning and clearance testing. HUD and several
local jurisdictions have banned the use of certain methods of
paint removal, such as open flame burning, abrasive blasting,
large scale dry scraping, and other methods known to produce
high levels of contaminated dust and/or fumes.
Q.2. As I understand it, HUD's Lead Hazard Control Grants are
awarded to cities on a competitive basis. Would it be a more
effective use of Federal dollars to provide grants based upon
the severity of lead poisoning, say targeting the top twenty
cities with the most severe and widespread lead hazards?
A.2. Need, as documented by lead poisoning prevalence, is
already a key factor used in making awards. The result is that
HUD's grants are, in fact, targeted to local jurisdictions with
the greatest problem. However, awarding grants based solely on
need would have the unintended consequence of providing
resources to some cities that lack the will or capacity to use
them well. In fact, building capacity in numerous jurisdictions
has enabled the program to address lead-based paint hazards in
many more units than those it finances directly. Also, data
from HUD's National Survey of Lead and Allergens in Housing
show that urbanization is not a key factor in the prevalence of
lead-based paint hazards, so restricting awards to larger
cities ignores the need in other areas. In cities with
populations above 2 million, 29 percent of the houses have
lead-based paint hazards; in small cities, 23 percent have
hazards; and in rural areas, 31 percent have hazards. None of
these differences are statistically significant. To deny
assistance to children simply because they do not reside in the
largest cities raises issues of fairness and equity. HUD has
considered whether the maximum amount requested by a
jurisdiction should be equal or should be
related to some combination of the number of poisoned children
within a given jurisdiction and its capacity. The latter would
increase the complexity of the program. This past year, HUD has
implemented a new grant renewal system that streamlines the ap-
plication process for high-performing grantees, which are in
areas of highest need as a further way of targeting resources.
HUD will make a final decision regarding the maximum grant
amount when the fiscal year 2003 Notice of Funding Availability
is released.
RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED
FROM THOMAS L. SANSONETTI
Q.1. How many lead cases do you currently have pending? Could
you provide data on the number of cases referred by each Agency
and the date these cases were referred? How many of these cases
have DOJ chosen to prosecute?
A.1. We have 15 lead-paint related matters pending. Of the 15
matters that are pending, 14 have been or are being jointly
developed by Environmental Protection Agency (EPA) and Housing
and Urban Development (HUD). The remaining matter is being
developed by HUD, with anticipated participation by EPA at the
appropriate time. We cannot meaningfully identify when each of
these matters was referred because our initial involvement in
these matters typically arose out of informal contacts with our
Division over the course of time; formal referrals have then
been submitted by the EPA and HUD following the informal contacts.
We have not rejected any formal referrals.
Q.2. What statutory changes do you believe could be made to
Federal disclosure law regarding lead-based paint and lead-
based hazards that could make it more meaningful?
A.2. Although the disclosure law provides for administrative
penalties, it does not provide for judicial penalties. The
addition of such penalties would strengthen enforcement of the
law. Also the law currently excludes zero-bedroom housing from
the disclosure requirements. Our experience has been that this
excludes coverage for a significant portion of housing stock
(that is studio apartments) in which poor children live and
which contains lead-paint. Inclusion of such units in the
disclosure law would better protect such children from the risk
of lead poisoning.
Q.3. What plans does DOJ have to begin working more closely
with other agencies such as HUD and EPA to help keep children
from being poisoned by lead-based paint in housing?
A.3. As we testified at the June 5, 2002 hearing before the
Subcommittee, we have already developed close working
relationships with both HUD and the EPA and these relationships
have resulted in a number of successful enforcement cases over
the last 4 years. We look forward to continuing to work with
them and also improving our outreach and training with the
local U.S. Attorneys' Offices to protect children across the
United States from lead poisoning.
Q.4. While abatement is essential in high-risk properties, in
which cash flow is insufficient to support maintenance, most
leaded properties can be made lead-safe through other
strategies. Research and experience over the past decade has
demonstrated the importance of visual inspection for peeling
paint; lead-safe work practices to control, contain, and clean
up lead dust in painting and remodeling projects; and clearance
testing to ensure that lead-dust hazards are not left behind.
Do you believe that visual inspection, lead-safe work practices
and clearance testing offer the potential to expand lead-safety
to a broad enough scale to make U.S. housing lead-safe?
A.4. We support the goal of preventing lead poisoning by making
housing lead-safe, but respectfully defer to the expertise of
our client agencies on how this can best be accomplished.
Q.5. While consistent data are not widely available, it is
clear that in the majority of cases lead hazards are not
corrected even after a child is identified as lead-poisoned.
The same hazardous house often poisons multiple children as new
families move in (that is, a Syracuse, New York, newspaper
identified 47 houses that had poisoned multiple children in
just 18 months). Even when health departments succeed in
ordering repairs, in many States there is no oversight, no
requirement for lead-safe work practices, and no clearance
testing. While no house should poison a child, it is simply
unconscionable that any house should poison a second, third,
and fourth child. What do you believe your Agency can do to
help stop houses from poisoning more than one child?
A.5. One significant way that the ENRD can help stop multiple
children from being poisoned by the same property is by
continuing to consider evidence of such a problem as a factor
in enforcement decisions, that is in the decision of whether to
pursue a matter criminally rather than (or in addition to)
civilly, how much of a criminal fine or civil penalty to seek,
and what other relief may be appropriate.
Q.6. What does your Agency believe might be appropriate
statutory changes to make the Federal disclosure law regarding
lead more meaningful?
A.6. See response to question 2.
Q.7. Many advocates and some health departments are convinced
that ending childhood lead poisoning will require moving beyond
screening children's blood-lead levels to actually screening
high-risk housing to identify hazards before a child's health
is harmed. What does your Agency think about this strategy?
What about the idea of developing registries of hazardous
properties?
A.7. We support the strategy of screening high-risk housing,
and are already using it as an effective tool for identifying
appropriate targets, for enforcement action. Depending on the
information it contained, a registry of hazardous properties
might assist us in targeting our enforcement efforts to where
they would have the most impact.
Q.8. Does your Agency believe that lead-based paint and dust
hazards in housing are the overwhelming cause of childhood lead
poisoning in the United States? If not, what other causes
should the Congress be looking at?
A.8. Based on information that we have received from those
agencies that have expertise in this area, we believe that
lead-based paint and dust hazards are the major cause of
childhood lead poisoning in the United States.
Q.9. As a result of our hearing last November on lead
poisoning, it was clear that primary prevention is a very
important part of eliminating childhood lead poisoning. First
of all, does your Agency support the goal of stopping children
from being poisoned in the first place? If so, how is your
Agency planning to achieve this goal?
A.9. Yes, we support the goal of stopping children from being
poisoned in the first place. Working in concert with our
clients at HUD and EPA and State and local health agencies, we
plan to achieve this goal by deterring violations of the lead-
paint laws through continued vigorous enforcement of those laws
and by seeking broad abatement that covers entire building
inventories, not just an individual unit where disclosure
wasn't made.
RESPONSE TO WRITTEN QUESTION OF SENATOR CARPER
FROM THOMAS L. SANSONETTI
Q.1. I understand that a student at Brown University performed
a study that showed that 204 identifiable landlords owned the
housing units which more than 2,600 cases of elevated blood-
lead levels were reported over the last 9 years in Rhode
Island. This suggests that a small group of landlords are
responsible for a disproportionate amount of the lead
exposures. As you enforce lead disclosure laws, are you also
coordinating with State or local departments of health so as to
better target your enforcement?
A.1. Yes. As we testified in greater detail at the June 5, 2002
hearing before the Subcommittee, State and local departments of
health have been invaluable partners in our enforcement
efforts.
RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED
FROM ADAM SHARP
Q.1. Several years ago it became clear that clearance dust
testing is a simple procedure that can be easily learned in one
day. As a result, EPA developed a one-day training course for
Sampling Technicians and HUD regs allow State certified sampling
technicians to perform clearance testing after paint repair and
remodeling projects. If the science makes clear the paramount
dangers of lead-contaminated dust, why has EPA decided not to
encourage expanded dust testing and expanding capacity for dust
testing?
A.1. EPA does encourage expanded dust testing and increasing
the number of individuals qualified to perform dust sampling.
This policy was articulated to our State and Tribal colleagues
in a letter dated August 17, 2000 (Attachment). The Agency
stated that sampling technicians should play a principal role
in conducting dust testing following nonabatement activities
where lead-based paint is disturbed. In addition, the Agency
encouraged the use of sampling technicians in other settings
such as presale home inspections, unit turnovers, or at the
request of homeowners. The letter also emphasizes that while
EPA does not currently regulate nonabatement activities that
disturb lead-based paint, the Agency does recommend dust
testing (by a trained risk assessor, inspector, or Sampling
Technician) following these activities. The Agency also
encouraged States and Tribes to do the following:
<bullet> Allow Sampling Technicians to conduct nonabatement
clearance testing according to Housing and Urban
Development's (HUD) requirements.
<bullet> Permit trained and/or certified sampling technicians
to perform sampling to identify lead contaminated dust.
<bullet> Encourage accredited training programs to offer this
course.
<bullet> Develop a plan for upcoming legislative sessions that
would address the incorporation of the Sampling Technician
discipline in their authorizing legislation.
<bullet> Communicate regulatory policy regarding the use of
sampling technicians to their accredited trainers and
certified firms.
In addition to these outreach activities, EPA will continue
to emphasize the role of the sampling technician as we move
forward with developing our renovation and remodeling program.
Q.2. Most Americans still view peeling paint in older housing
as merely an eyesore and do not understand the significant
danger of lead-contaminated dust. In January 2001, EPA
finalized national standards for dangerous levels of lead in
deteriorated lead-based paint, lead in dust, and lead in soil.
What has EPA done to publicize these standards and highlight
these dangers?
A.2. The Agency understands that to be effective, we must
communicate the Agency's new lead hazard standards to the
public. When the rule was released, the Agency launched its 403
Rule Communication Plan, which consisted of the following:
<bullet> Press Release distribution and announcement on EPA's
website.
<bullet> Release and distribution of a 403 Rule Fact Sheet
through EPA's toll-free nationwide hotline and website.
<bullet> Notification of all other Federal agencies, and State
and tribal governments.
<bullet> Incorporation of the Hazard Standards in EPA's Protect
Your Family disclosure brochure, the most widely
distributed document (more than 500,000/yr.) in our
program.
<bullet> Education to EPA's hotline staff on the Hazard
Standards to better prepare them for public inquiries.
Since the Rule was published, the Agency has been
incorporating the standards into all of our public education
materials. The first document that we revised was ``Protect
Your Family From Lead,'' the Agency's main lead hazard
pamphlet. This is the pamphlet required by law to be provided
to buyers and lessors of all residential property built before
1978. The Agency also requires that the pamphlet be distributed
before most renovations in residential property built before
1978. The EPA has incorporated the standards into our lead
certification exams and will be formally updating our model
training courses.
Q.3. Many researchers are convinced that EPA's standard for
lead-contaminated dust of 40 micrograms per square foot is much
too high. Has EPA analyzed any of those researchers' data yet?
A.3. Yes, the Agency continues to monitor the state of the
science regarding environmental lead and its impact on
children's health. In establishing the 40 micrograms per square
foot dust standard, the Agency considered both the relationship
between dust-lead and children's blood-lead levels and the
health impacts associated with blood-lead levels. When we
determined our standard, we considered the 10 ug/dl benchmark
for elevated blood-lead levels currently defined by the Centers
for Disease Control and Prevention. As far as the relationship
between environmental lead and blood-lead, the Agency
considered all of the studies of this relationship and
continues to believe that the approach taken and the models
used are the best currently available.
Q.4a. In 1998, HUD funded a survey conducted through the Bureau
of the Census which showed poor compliance with the Residential
Lead-Based Paint Real Estate Disclosure Rule, which mandates
disclosure requirements for all sales and rentals of pre-1978
housing. Thirty-six percent of survey respondents were
uncertain whether they had received the required information
when they bought or rented housing. What have you done to
ensure that both buyers and renters are receiving the appropriate
information as required by the Rule?
A.4a. To ensure widespread knowledge of the Rule requirements,
EPA, in the development of the Rule, worked closely with HUD,
realtors, real estate associations, property management
companies, and landlord associations to publicize requirements
through newsletters, meetings, pamphlets, public service
announcements, and billboards. For example, EPA has:
<bullet> Worked with industry to include information on the
Disclosure Rule requirements in the real estate training
that real estate brokers need to complete as part of their
licences requirements.
<bullet> Undertaken mail-out campaigns to licenced real estate
operators to make them aware of the Rule.
<bullet> Attended national real estate meetings to train
people.
<bullet> Developed lead-paint websites to provide information
on rules and EPA regulations.
Q.4b. What additional ideas do you have to help protect
families who are renting or buying housing and ensure that
owners of housing are complying with this requirement?
A.4b. EPA has discussed several options, including expanding
efforts to work with the real estate community through a
sustained partnership. For families, the process of homebuying
is complex, and lead is only one of many issues a family might
consider when deciding where to live. For families in poor
urban areas, where lead risks are greatest, competing interests
(acute safety concerns) are even more pressing. In addition, in
a tight housing market, many may feel that any apartment that
they find will be good enough. That makes EPA's role in
ensuring that lead issues are appropriately disclosed and
considered even more challenging. We are considering multiple
ways to meet this challenge, such as working with the real
estate community to ensure that the information is disclosed in
a way that will be most meaningful to the recipient, working
with other parts of the housing industry (home inspectors,
etc.) to encourage them to broadly distribute and reinforce
this information, and working with organizations involved in
low-income housing to address lead issues in a holistic
fashion.
Q.5. What has been EPA's lead poisoning prevention funding over
the past 5 years? Is this amount of funding sufficient for EPA
to be an active participant in eliminating lead poisoning by
2010?
A.5. Over the past 5 years, EPA has committed more than $169
million to its lead poisoning prevention program. More than $80
million of these funds have been distributed to States, Tribes,
and U.S. Territories to assist them in establishing and
administering their own lead poisoning prevention programs.
This level of funding is sufficient to ensure that we are an
active participant in the Federal Governments efforts to
eliminating lead poisoning.
Q.6. Your testimony talks about the 1996 Rule covering training
and certification for lead-based paint professionals. How many
people have been trained since the Rule was passed? Are there
enough trained professionals to meet the need? What efforts has
EPA been engaged in to increase participation beyond the 35
States who have obtained training grants and what tools might
be needed to help achieve this goal?
A.6. In 1996, EPA issued a regulation to establish a nationwide
network of trained and certified lead professionals. Since
then, we have authorized 34 States, three Tribes, Puerto Rico,
and the District of Columbia to administer and enforce this
program. EPA is running the program in all nonauthorized States
and Tribal lands.
EPA estimates that to date there have been more than 20,000
individuals certified by either EPA or our authorized State
partners to identify and abate lead hazards. We believe that on
a national basis, there are a sufficient number of certified
individuals. Admittedly, in certain regions of the country,
there are fewer certified contractors than we would like to
see. For our part, EPA is constantly refining and updating our
certification and accreditation systems to make them more
responsive to the needs of the regulated community. For
example, within a year, individuals seeking certification will
have the ability to pay online via credit card and submit their
application forms online.
With respect to the number of authorized programs, EPA is
pleased with the fact that we have authorized as many States
and Tribes as we have. The Agency has always believed that this
program is best administered at the local level. We continue to
encourage unauthorized States and Tribes to develop programs,
and we provide technical and financial assistance to any State
or Tribe that wishes to seek authorization. At the same time,
we recognize that financial considerations often determine
whether a State or Tribe seeks authorization. We will continue
to solicit input from the States and Tribes so that future
regulatory elements of the program create incentives to State
and Tribal authorization. EPA is more than capable of
administering and enforcing this program in the States and
Tribes that have chosen not seek authorization.
Q.7. Your testimony states that parents have greatly helped to
reduce lead exposure to their children by cleaning and
maintaining homes. Do you have any specific data highlighting
the positive effects of these efforts?
A.7. Results from studies of educational interventions and
cleaning by residents show that there is evidence that cleaning
by residents can reduce lead levels. In an East St. Louis,
Illinois study, 50 percent declines in dust-lead levels were
reported in the 44 percent of the homes where the family
reported that cleaning had been done according to instruction.
In a study in Boston, Massachusetts, a 36 percent decline in
blood-lead levels and a 38 percent decline in window sill lead
levels were reported for a control group that received an
outreach visit, cleaning instructions, and a free sample of
cleaning solutions. In this study, floor and window well levels
were essentially unchanged. In a study in Rochester, New York,
30-60 percent declines in most surfaces were reported following
cleaning, but blood-lead levels did not decrease. Blood-lead
levels decreased by 15 percent in a Milwaukee, Wisconsin study
of educational interventions that included a demonstration of
clean up and maintenance measures by outreach workers.
Additional information on the effectiveness of lead
interventions and abatement in residential housing can be found
in the EPA report, ``Review of Studies Addressing Lead
Abatement Effectiveness: Updated Edition'' (EPA 747-B-98-001,
December 1998). This report is available through the Internet
at the URL: http://www.epa.gov/lead/finalreport.pdf
There has been a decline in children's blood-lead levels
from 1976 to 1999 that coincides with efforts by the Federal
Government and other parties to reduce exposure to lead and to
increase the public's awareness of the dangers of lead.
Specifically, the geometric mean blood-lead level for children
aged 1-5 years was 18.0 micrograms per deciliter ( g/dL) in
1976 based on data collected in the National Human Health and
Exposure Study II (NHANES II). By 1980, the geometric mean
level for this group of children had declined to 9.3 g/dL,
again based on data from NHANES II. The trend of declining
geometric means continued in the late 1980's and in the 1990's.
The geometric mean blood-lead level for children aged 1-5 years
was 3.6 g/dL for the period 1988 to 1991, as reported from
NHANES III Phase 1. For the period 1991 to 1994, the geometric
mean for this group of children was 2.7 g/dL from NHANES III
Phase 2. NHANES 1999, which was based on a smaller size sample
than previous NHANES studies, estimated the geometric mean to
be 2.0 g/dL. In addition, when the 1999 NHANES geometric mean
was published, CDC published statistics based on data from 19
States with blood surveillance programs. These statistics
showed that the proportion of children less than 6 years old
with elevated blood-lead levels declined in the period from
1996 to 1999 in this group of States.
Q.8. Your testimony discusses the National Lead Awareness
Campaign. Please describe the program and its positive effects.
What is the current status of the program?
A.8. The EPA's National Lead Awareness Program has five
components. They are:
<bullet> Targeting high-risk communities.
<bullet> Having material available in languages other than
English.
<bullet> Working extensively and cooperatively with other
Federal partners such as CDC, HUD, USDA, and the
Administration of Children and Families (HHS).
<bullet> Funding community-based organizations to provide
education at the grass roots level.
<bullet> Developing culturally-sensitive materials particularly
for Native Americans.
The program has taken several steps to ensure a positive
impact on the populations most at-risk. Two years ago, EPA
launched the ``Runs Better Unleaded'' campaign featuring
posters, mass transit, billboard, and movie theater
advertising, and radio public service announcements. The
campaign, designed to raise awareness, received an award from
the International Association of Business Communicators, and
has been replicated in several cities and States.
Over the past 2 years, EPA has developed a WIC (Women,
Infants, and Children Program) Nutritionist Educational
Campaign. The initiative is more focused than previous efforts
because it targets WIC's seven million clients and the staff
they rely on for nutritional and general health information.
The materials were created in cooperation with the CDC and
USDA/WIC staff at the national, State, and local levels. The
materials are designed to help the nutritionists get out the
message of testing children and their homes for lead, and to
highlight the lead poisoning/nutrition connection. The
cornerstone of this effort, EPA's ``Fight Lead Poisoning With a
Healthy Diet'' brochure, provides not only prevention and
detection messages, but also WIC-approved recipes. A Spanish-
language version is currently being printed. EPA also developed
a Media Outreach Kit, an adaptable guide for State and local
health, housing, and environmental programs to assist them in
working with the press to get information out about lead
poisoning prevention. Updates to this guide are available in
CD-ROM format and on EPA's website.
Currently EPA is developing an outreach initiative with the
Head Start program to provide educational materials and empower
this high-risk population. Specifically, we will share
information with Head Start educators and the children's
parents on the health hazards of lead-based paint, lead's
deleterious developmental
effects, and how to avoid these problems.
Q.9a. Your testimony talks about cooperative programs with
retail stores to distribute materials, and partnership programs
with nonprofits and other agencies. Do you believe that these
efforts are enough to spread the word about the dangers of
peeling paint and paint dust?
A.9a. EPA has partnered with several organizations to provide
outreach and education to the public on the dangers of lead-
based paint hazards. However, EPA believes that its lead
outreach activities should be continuous and has planned
several future efforts. In particular, our planned Renovation
and Remodeling Outreach Campaign will spread the messages of
lead-safe work practices and training possibilities directly to
contractors who do the work, nonprofits who support the various
industries that work with lead, and the owners of homes who
would benefit from lead-safe housing. A sustained,
multifaceted, multimedia approach is key to not only getting
the public aware of lead issues, but also to get them to take
action to prevent lead poisoning.
Q.9b. The Task Force recommended an expansion of these efforts,
what have you done to increase outreach?
A.9b. EPA has been involved in several outreach efforts, as
well as having many planned for the future including: (1)
participating in the ``National Lead Poisoning Prevention
Week.'' This includes partnering with Centers for Disease
Control and Prevention, Department of Housing and Urban
Development, and the District of Columbia Health Department;
(2) working with the Department of Agriculture's Women,
Infants, and Children (WIC) Program to develop and distribute
fact sheets and the document ``Fight Lead Poisoning With a
Healthy Diet,'' which links nutrition and lead prevention; (3)
partnering with the Centers for Disease Control and Prevention,
Department of Housing and Urban Development, and the Agency for
Disease Registry and Toxic Substances to cosponsor a national
lead health education conference with representatives from
Federal, State, and Tribal governments; (4) working with a
national community-based volunteer organization, Hope For Kids,
to educate parents in several cities across the United States
on lead poisoning prevention; (5) working with the Department
of Justice's Weed and Seed Program, a national community
organization that focuses on keeping juveniles out of the
justice system, to educate parents and community members on
lead poisoning prevention; (6) providing a grant for the
development and distribution of Spanish-language public service
announcements; and (7) establishing Tribal lead outreach
campaigns and blood-lead screening of Tribal children.
Q.9c. How much money has been spent on this effort?
A.9c. EPA has committed nearly $4 million to this effort.
Q.9d. What additional ideas does EPA have that might help
increase public awareness of lead-based paint hazards in the
home?
A.9d. General awareness messages of the past have been
successful, but more can be done to target the most at-risk
populations, often low-income, minority children living in
older urban housing. Whether it is to motivate a parent to get
their child tested, a property owner to get his rental property
inspected, or a contractor to take proper health-protection
steps, EPA is always looking for the best way to approach those
most in need of our information. We are providing more
resources electronically through EPA's website and the National
Lead Information Center. However, EPA realizes that the most
vulnerable communities may not have Internet access, and to
that end, we continue to produce hard copies of our educational
materials. EPA also plans to continue its partnerships with
nonprofit organizations that serve those populations. Through
these partners, we learn more about our audiences and adjust
our efforts accordingly.
``Do-it-yourselfers,'' homeowners that perform renovations
in their own properties, are a group that may damage not only
their own health, but also the health of any children and
families that live in their properties. Due to the potential
for increased lead exposure, we are discussing an educational
outreach plan to promote lead-safe activities by these owners.
Q.10. How many cases have been referred to DOJ in the last year
and a half ? What is the status of those cases?
A.10. During the last year and a half, EPA has referred a dozen
cases to the U.S. Department of Justice for civil judicial
enforcement: Six for injunctive relief for Section 1018 (Lead
Disclosure Rule) violations, and six for judicial enforcement
subpoenas under the Toxic Substances Control Act (TSCA). Eleven
of these cases have been resolved in the United States' favor.
The three biggest injunctive relief settlements required
inspections, risk assessments and remediation of the lead-based
paint hazards for 13,000 dwelling units in Chicago and
Cincinnati. One TSCA subpoena case is currently pending in the
U.S. District Court for Rhode Island. In addition, EPA has also
issued more than 50 civil administrative complaints with
proposed monetary penalties over this time period. In one
administrative settlement, a property management firm agreed to
conduct inspections, risk assessments, and lead-based paint
hazard remediation in 132,000 dwelling units nationwide.
Q.11. While abatement is essential in high-risk properties, in
which cash flow is insufficient to support maintenance, most
leaded properties can be made lead-safe through other
strategies. Research and experience over the past decade has
demonstrated the importance of visual inspection for peeling
paint; lead-safe work practices to control, contain, and clean
up lead dust in painting and remodeling projects; and clearance
testing to ensure that lead dust hazards are not left behind.
Do you believe that visual inspection, lead-safe work
practices, and clearance testing offer the potential to expand
lead-safety to a broad enough scale to make U.S. housing lead-
safe?
A.11. This approach has the potential to expand lead-safety to
make many more homes lead-safe. Visual inspection and the
prompt lead-safe repair of deteriorated lead-based paint can
reduce the number of homes in this country with existing paint
lead hazards.
Pursuant to the direction of Title X, the EPA is developing
a program to introduce lead-safe work practices in the
renovation and remodeling industry. Through education and
outreach and regulation, the Agency hopes to increase the use
of these practices during renovations in homes with lead-based
paint to prevent the introduction of new hazards. This program
can also be used to reduce existing paint lead hazards in homes
that are unlikely to be abated.
Clearance testing is still the best indicator to ensure
that dust-lead hazards do not remain after an abatement or
renovation event. EPA is evaluating a range of regulatory and
technical alternatives to make dust clearance testing even more
affordable and widely available.
Q.12. While consistent data are not widely available, it is
clear that in the majority of cases lead hazards are not
corrected even after a child is identified as lead-poisoned.
The same hazardous house often poisons multiple children as new
families move in (that is, a Syracuse, New York, newspaper
identified 47 houses that has poisoned multiple children in
just 18 months). Even when health departments succeed in
ordering repairs, in many States there is no oversight, no
requirement for lead-safe work practices and no clearance
testing. While no house should poison a child, it is simply
unconscionable that any house should poison a second, third,
and fourth child. What do you believe your Agency can do to
help stop houses from poisoning more than one child?
A.12. Once a house has been determined to be the cause of a
child's lead poisoning, the hazards should be addressed to
ensure that the house does not poison other children. EPA
regulations clearly state that when work is done to eliminate
lead hazards due to the presence of a lead-poisoned child, the
work must be done following EPA abatement regulations,
including requirements for lead-safe work practices and
clearance testing. The EPA has authority over such actions in
all nonauthorized States and Tribes. In authorized States and
Tribal lands, equally protective State or Tribal regulations
would apply.
However, EPA itself has no general authority to order
abatements, or to ensure that abatements ordered by State
health departments are actually carried out. EPA authority
begins once an abatement activity begins. Therefore, while EPA
can ensure that abatement, when performed, is performed
correctly, we cannot force abatements to be performed in the
first place.
EPA is able to encourage abatement and other lead hazard
control activities as part of settling administrative and
judicial enforcement cases for violations of the Lead
Disclosure Rule requirements. EPA enforcement settlements have
resulted in over 150,000 housing units becoming lead-safe, as
defined under the HUD guidelines. EPA intends to continue to
encourage landlords and property managers to review their
compliance with the Lead Disclosure Rule and to conduct lead
abatement activities in settling enforcement
actions to address lead-paint hazards. Also, settlements have
included projects aimed at reducing the future risk of harm
from lead-based paint. For example, violators have funded
clinical blood-lead testing of children and pregnant women at
risk for lead-paint poison, and funded a seminar on the Lead
Disclosure Rule requirements for real estate agents and
brokers.
In individual, extreme cases, EPA has authority under the
Resource Conservation and Recovery Act (RCRA) to address
imminent and substantial endangerment arising from lead-based
paint. Under RCRA, Section 7003, EPA can order property owners
to take immediate action to minimize lead exposure to tenants,
including removing lead-based paint and paint wastes, if EPA
has determined that the tenants may be in imminent and
substantial danger of lead poisoning.
Q.13. What does your Agency believe might be appropriate
statutory changes to make the Federal disclosure law regarding
lead more meaningful?
A.13. EPA does not believe that any statutory changes to
Section 1018 are needed. Our continuing enforcement actions
coupled with our outreach efforts are accomplishing the goal of
informing the public so that they can take appropriate actions.
Q.14. Many advocates and some health departments are convinced
that ending childhood lead poisoning will require moving beyond
screening children's blood-lead levels to actually screening
high-risk housing to identify hazards before a child's health
is harmed. What does your Agency think about this strategy?
What about the idea of developing registries of hazardous
properties?
A.14. One key benefit of EPA's lead hazard standards is to
enable exactly what you are suggesting--to screen housing for
hazards before children are poisoned. These protective, health-
based standards provide a criterion to identify this high-risk
housing. Our real estate disclosure regulations also support
this strategy by providing prospective tenants and buyers the
opportunity to uncover hazards or potential hazards before
moving into a dwelling.
EPA has not analyzed how such a registry program would
work. Nevertheless, EPA is considering establishing a program
to encourage landlords to maintain their buildings in a lead-
safe manner, and then to recognize and publicize their efforts.
We believe this approach may have a better chance of
accomplishing our goal, because we can highlight lead-safe
properties for the consumer, and we hope to also have landlords
formally agree to long-term maintenance of their buildings in
order to participate.
Q.15. Does your Agency believe that lead-based paint and dust
hazards in housing are the overwhelming cause of childhood lead
poisoning in the United States? If not, what other causes
should Congress be looking at?
A.15. Yes, the Agency continues to believe that lead-based
paint and dust hazards in housing are the primary sources of
lead exposure for most children. Certainly, multiple other
sources of lead exist (folk remedies, consumer goods, etc.) and
may be responsible for individual cases of lead poisoning, but
housing-related sources are by far the predominant cause of
lead poisoning in the United States today.
Q.16. As a result of our hearing last November on lead
poisoning, it was clear that primary prevention is an extremely
important part of eliminating childhood lead poisoning. First
of all, does your Agency support the goal of stopping children
from being poisoned in the first place? If so, how is your
Agency planning to achieve this goal?
A.16. Yes, EPA, for years, has unequivocally supported the goal
of primary prevention. We plan to achieve this goal via many
routes. Our regulatory program is designed to provide criteria
for identifying lead hazards to give consumers the knowledge
and tools to address lead hazards before their children are
poisoned, and to have qualified people available to identify
and fix lead hazards. Our public education program is designed
to reach people most at risk, at points in their life where
they can most easily take action to prevent lead poisoning,
rather than simply providing information after the damage has
been done. One key goal of our technical program is to lower
the cost of lead hazard assessment and repair activities, to
encourage more people to use these services. We hope that we
are already seeing the fruits of our labors by the continuing
decline in the numbers of lead-poisoned children.
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RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED
FROM RUBEN KING-SHAW, JR.
Q.1. States like Alaska have long argued they should be excused
from universal screening because they believe they have low
lead concentrations. Have these States presented any data,
either in terms of their housing stock or screening rates for
Medicaid-eligible children that would substantiate their
position?
A.1. The States of Alaska and Utah have both submitted material
that they suggest supports discontinuing universal lead
screening for all Medicaid eligible children in their State.
This material was submitted in 1998 and CMS (then HCFA) was not
in a position at that time to consider allowing States to
discontinue universal screening. However, we reviewed the
information from both the States and informed them of our
conclusions as follows:
We reviewed the study and data submitted by Alaska and
concluded that it was insufficient to be used to allow the
State to discontinue universal screening based on several
drawbacks of their study. For example, while the study was
well-designed, there was a very low response rate from a
particular group (urban respondents) and this made data
comparisons difficult. Another limitation was that the State
tested children between the ages of 1 and 6 but did not include
children under the age of one from the study. We believe the
State should have attempted to obtain data on this age group,
either by looking at Medicaid claims or pediatrician records,
since the State felt performing the venipuncture on these young
children was too difficult.
The State of Utah submitted a study from Salt Lake County
that was performed by offering blood-lead tests to families
enrolled in the WIC Program. The study data was collected from
seven WIC clinics dispersed throughout Salt Lake County. In
this instance we felt the study was too limited to be able to
make a statewide recommendation.
Q.2a. The 1999 GAO report on the lead poisoning prevention
efforts at Federal health care programs pointed out several
deficiencies, including the fact that only 20 percent of
Medicaid-eligible children are currently screened for lead
poisoning. In your testimony, you noted that CMS sent letters
to all State Medicaid directors detailing the findings of the
GAO report and reiterating their responsibilities with regard
to lead screening. Has CMS taken any other definitive action to
address these problems?
A.2a. CMS has continued to work on the lead screening issue
since the GAO report. In April 2000, CMS, the Centers for
Disease Control and Prevention (CDC), the Health Resources and
Services Administration (HRSA), and the Administration for
Children and Families (ACF) cosigned a letter to State Medicaid
Directors, CDC grantees, Head Start programs, and numerous
other ACF and HRSA contacts transmitting our October 1999 State
Medicaid Director letter and information on CMS' strategy for
assuring that States comply with our lead screening policy. We
also encouraged States to work together at the State and local
level as we were doing at the Federal level.
CMS currently participates on the CDC's Advisory Committee
for Childhood Lead Poisoning Prevention as an ex-officio Member
of the Committee. CMS has been extensively involved in the
Committee's work and deliberations related to lead screening of
Medicaid children and other aspects related to lead poisoning
of Medicaid children. In December 2000, the Committee published
``Recom-
mendations for Blood Lead Screening of Young Children Enrolled
in Medicaid: Targeting a Group at High Risk.'' Currently the
Committee is developing a report to Secretary Thompson
recommending ways that State Medicaid agencies can target lead
screening to those Medicaid children at highest risk for lead
poisoning.
CMS also participates with many other Federal agencies on
the President's Task Force on Environmental Health Risks and
Safety Risks to Children. In February 2000, the Task Force
published ``Eliminating Childhood Lead Poisoning: A Federal
Strategy Targeting Lead Paint Hazards.'' The report presents a
program for eliminating childhood lead poisoning by 2010 based
on coordinating the efforts of various Federal agencies
including the Department of Housing and Urban Development
(HUD), the Environmental Protection Agency (EPA), CDC, and CMS.
The report identified the
efforts and activities undertaken by CMS since the publication
of the 1999 GAO study on lead poisoning to improve the
screening, diagnosis, and treatment of Medicaid children with
lead poisoning. The report also highlighted the work of an
interdepartmental work group consisting of CMS, CDC, HRSA, and
other DHHS agencies to improve access and the provision of
these services.
CMS will continue to play a major role in Federal
activities designed to reduce and eliminate lead poisoning of
young children in this country. CMS' particular focus is in
covering the secondary and tertiary preventive services needed
by Medicaid children (for example, screening, diagnosis, and
treatment services). Probably the most effective strategy we
can employ is to encourage our State Medicaid agencies/partners
to work together with their local health, housing, and
environmental agencies toward the common goal of eliminating
lead poisoning.
We have awarded two contracts that we believe will assist
in improving screening rates. The contract with the Alliance to
End Childhood Lead Poisoning resulted in an outreach and
educational document for States to assist them in dealing with
providers and managed care organizations. The final document
from the Alliance contract published in August 2001, Track,
Monitor and Respond: Three Keys to Better Lead Screening for
Children in Medicaid, is intended to be an educational document
that States can use in their outreach to their providers in
order to resolve some of the difficulties in the provision of
the blood-lead screening tests. The second contract with Abt
Associates is expected to produce a final report providing us
with good information and key elements for screening the
highest risk children. The Abt Associates final report will
also shed more light on how State Medicaid agencies are
successfully working with other State and local agencies to
address this problem. We intend to share this information with
State Medicaid agencies.
We continue to encourage State Medicaid agencies to
participate in data sharing activities so that the health
department and the Medicaid Agency know which Medicaid eligible
children have been tested and which have not. We do know that
many States are beginning to work on these data sharing
agreements.
Q.2b. If not, what tools or authority does CMS need to help it
remedy these deficiencies and ensure that Federal law is being
followed?
A.2b. We continue to work with the States and other Federal
agencies such as CDC on this issue and believe that this is the
best way to continue addressing the problems. We hope to
distribute the final report from the Abt contract to all States
to provide them with information on what has worked, or has not
worked, in other States. We believe sharing information is one
of the best ways to encourage States to continue to focus on
this important issue.
While our only enforcement tool against States is to take a
compliance action that could result in the withholding of
Federal Financial Participation (FFP), we do not believe
withholding money from the entire program is a practical or
effective approach to the problem. Additionally, the compliance
process is a lengthy ordeal that can take years to complete.
CMS has never withheld monies from a State as a result of a
compliance action.
Q.2c. In addition, what additional enforcement powers may be
helpful to CMS to ensure that managed care companies that are
not performing screening comply with their contract
requirements?
A.2c. The States monitor managed care organization (MCO)
performance through their contracts, and the MCO's report lead
screenings to the State, which then includes them in the
State's report to us.
Interestingly, in the managed care arena there is more
accountability than in fee-for-service because the State has
the ability to hold the MCO accountable through the contract,
whereas in FFS it is very difficult to hold all providers
accountable. An increasing number of States are incorporating
into their contracts with MCO's specific language and
requirements pertaining to lead screening. A 1999 study found
that 42 percent of Medicaid MCO's contracts had specific lead-
screening requirements. More recently, George Washington
University developed under contract with the CDC sample
purchasing specifications for use by States in their contracts
with Medicaid MCO's. Sample specifications for lead poisoning
prevention were developed in this process. A number of States
also require their Medicaid managed care contractors to report
lead screening as part of their Health Plan Employer Data and
Information Set (HPEDIS) performance measures.
Q.3. As we heard during testimony, the cause of the vast
majority of lead poisoning in the United States is the home
environment. For this reason, Medicaid allows States to cover
the cost of a one-time environmental assessment of the home.
However, Medicaid will not pay for testing of the dust, soil,
or water at the house as part of this assessment. Could you
please explain to the Committee the rationale behind Medicaid's
policy? Would CMS support changing this policy so that Medicaid
could pay for the testing of dust and other samples in the
homes of lead-poisoned children?
A.3. The role of Medicaid is to reimburse for the delivery of
medical services directly to eligible individuals. Using
Medicaid funds to do other environmental remediation is beyond
the bounds of Medicaid and would not be an appropriate use of
these funds. Extending coverage under Medicaid to other
environmental interventions such as testing of environmental
substances would have tremendous im-
plications for State and Federal Medicaid budgets. Therefore,
we would not support a change in this policy.
One factor that impacts this decision is that under the
Medicaid program, laboratory tests must be performed in CLIA
certified laboratories. CLIA certified laboratories are only
certified to perform testing on human specimens. This
requirement is stated in the statutory language in the Public
Health Act, as well as CMS' regulations. Testing of
environmental specimens is not performed in CLIA certified
labs. Therefore, we cannot pay for these types of laboratory
tests under the current law.
Even if it were possible to pay for environmental testing
for lead under another coverage category, it would be extremely
difficult to limit this coverage to only lead, absent specific
legislative authority. There are many other diseases and
conditions that are affected by environmental conditions in the
home, for example, asthma. We, as well as States, would be put
under pressure to then begin reimbursing for these other types
of environmental interventions such as air filters or special
bedding.
Housing agencies, as well as homeowners and landlords need
to be responsible for their dwellings. Medicaid funds should be
used for medical services to screen, diagnose, and treat lead-
poisoned children. Our other partners in this area, such as
HUD, and State and local governments, are better situated to
address the housing issue.
Q.4. In your written testimony, you discuss a cooperative
agreement between CMS and the Alliance to End Childhood Lead
Poisoning to develop an educational guide to improve awareness
of and compliance with CMS' policies. It is my understanding
that the original $250,000 agreement was funded by the previous
Administration. When the Alliance submitted a proposal to
extend this valuable outreach program an additional 18-months,
CMS denied the request, despite report language in the fiscal
year 2002 Labor-HHS-Education Appropriations bill encouraging
CMS to support outreach and education. What was the reason for
CMS' turnaround in supporting this cooperative agreement with
the Alliance? What is CMS currently doing to support outreach
and education as encouraged in the fiscal year 2002
Appropriations bill?
A.4. When the Alliance's unsolicited proposal was received in
2000, the Senate and House Appropriations Report recommended
that CMS take appropriate steps to ensure that screening rates
among children enrolled in Medicaid substantially increase. At
that time, CMS had some discretionary funds available for this
type of project. Therefore, we funded the Alliance $250,000 for
the education and outreach project and also awarded a contract
to Abt Associates for approximately $750,000 for an additional
study on lead screening activities. At the time the Alliance
requested additional funding, CMS was unable to accommodate
this request due to the lack of additional discretionary funds.
This funding situation has not changed.
Q.5a. You also describe in your testimony a study your Agency
has commissioned to improve the lead screening of low-income
children by assessing the impact and effectiveness of current
screening criteria in reaching high-risk, low-income children.
While I applaud the Agency for its continued work to ensure
that screening criteria are appropriately targeting those
children at greatest risk of lead exposure, I am concerned that
this might mean the bigger picture is being missed. Could you
please describe for the Subcommittee what specific steps or
actions CMS is taking to ensure that all States are meeting the
blood-lead screening requirement under the EPSDT benefit for
Medicaid-eligible children?
A.5a. The latest data that we have from our CMS-416 EPSDT
report indicates that nationally about 60 percent of Medicaid
children under 21 are receiving all of the age-appropriate
medical screening services. Unfortunately, the data on lead
screening reported on the CMS-416 since fiscal year 1999
continues to be problematic. However, CMS is actively involved
in collaborating and working with our State partners to improve
compliance through conferences, meetings, technical assistance
sessions, and work groups and dissemination of materials
including ``State best practices'' produced with Federal funds.
We feel that we will be more successful through these
collaborative activities rather than taking punitive action
against the States.
We also believe the two contracts we have undertaken, with
the Alliance to End Childhood Lead Poisoning and Abt
Associates, will assist us in improving screening rates. The
Alliance contract has provided an outreach and educational
document to States to assist them in dealing with the providers
and managed care organizations. We also expect the final
product from the Abt contract to provide us with some good
information of successful programs States have implemented to
improve their screening rates.
Q.5b. What is CMS doing to encourage States to take creative
approaches to lead poisoning prevention and detection, such as
my home State of Rhode Island, which received a waiver to use
Medicaid funds to pay for window replacements in homes where
lead-poisoned children reside?
A.5b. We encourage States to be innovative in their approach to
the lead screening issue. We believe the Abt study will
highlight some of these innovations and we will share that
information with all the State Medicaid agencies. In the case
of Rhode Island, the State already had an approved statewide,
comprehensive section 1115 demonstration to expand Medicaid
eligibility within a managed care delivery system. The
amendment to include the window replacement was in the context
of the larger demonstration project but targeted to expand the
effectiveness of an ongoing State effort using lead centers.
Through the comprehensive demonstration the State is able to
achieve the savings necessary to make the lead amendment budget
neutral. Achieving such budget neutrality absent a
comprehensive demonstration would be very difficult. However,
CMS is willing to review any innovative State proposals using
this approach.
Q.5c. What can be done to change the perception among health
care providers that lead poisoning screening is not necessary
and important?
A.5c. I do not think the issue is one of perception of
importance but rather of risk of exposure based on one's
professional judgment. The final document from our Alliance to
End Childhood Lead Poisoning contract, Track, Monitor and
Respond: Three Keys to Better Lead Screening for Children in
Medicaid, was intended to be an educational document that
States could use in their outreach to their providers in order
to resolve some of the difficulties in the provision of the
blood-lead screening tests.
We hope that the final Abt Associates product will also
shed more light on how State Medicaid agencies are successfully
working with other State and local agencies to screen the
highest risk children, including provider groups and managed
care organizations. National provider organizations could also
be encouraged to remind their members about the importance of
lead screening.
Q.6. While abatement is essential in high-risk properties, in
which cash flow is insufficient to support maintenance, most
leaded properties can be made lead-safe through other
strategies. Research and experience over the past decade has
demonstrated the importance of visual inspection for peeling
paint; lead-safe work practices to control, contain, and clean
up lead dust in painting and remodeling projects; and clearance
testing to ensure that lead dust hazards are not left behind.
Do you believe that visual inspection, lead-safe work
practices, and clearance testing offer the potential to expand
lead-safety to a broad enough scale to make U.S. housing lead-
safe?
A.6. The Federal Medicaid program makes funding available for a
one-time investigation to determine the source of lead. We
believe this inspection is an important first step to making
many houses lead-safe. However, the other issues raised here,
lead-safe work practices and clearance testing, are beyond the
purview of the Medicaid program. Other Federal agencies such as
CDC, HUD, and EPA are better suited to addressing the importance
of these practices.
Q.7. While consistent data are not widely available, it is
clear that in the majority of cases, lead hazards are not
corrected even after a child is identified as lead-poisoned.
The same hazardous house often poisons multiple children as new
families move in (that is, a Syracuse, New York, newspaper
identified 47 houses that had poisoned multiple children in
just 18 months). Even when health departments succeed in
ordering repairs, in many States there is no oversight, no
requirement for lead-safe work practices, and no clearance
testing. While no house should poison a child, it is simply
unconscionable that any house should poison a second, third,
and fourth child. What do you believe your Agency can do to
help stop houses from poisoning more than one child?
A.7. The role of Medicaid is to reimburse for the delivery of
medical services directly to eligible individuals. Using
Medicaid funds to do lead abatement or any other environmental
remediation is beyond the bounds of Medicaid and would not be
an appropriate use of these funds. Extending coverage under
Medicaid to lead abatement and other environmental
interventions would have tremendous implications for State and
Federal Medicaid budgets. However, as stated earlier, Medicaid
does reimburse for a one-time investigation to determine the
source of lead. This includes the time and activities of a
health professional to visit the home of a Medicaid eligible
child with an elevated blood-lead level to help determine the
source of lead poisoning.
Housing agencies, as well as homeowners and landlords need
to be responsible for their dwellings. Medicaid funds should be
used for medical services to screen, diagnose, and treat lead-
poisoned children. Our other partners in this area, such as
HUD, and State and local governments, are better situated to
address the housing issue.
Q.8. What does your Agency believe might be appropriate
statutory changes to make the Federal disclosure law regarding
lead more meaningful?
A.8. The Federal Medicaid program has no authority to enforce
nor interpret the Federal disclosure law. We believe this
question is more appropriately directed to the HUD.
Q.9. Many advocates and some health departments are convinced
that ending childhood lead poisoning will require moving beyond
screening children's blood-lead levels to actually screening
high-risk housing to identify hazards before a child's health
is harmed. What does your Agency think about this strategy?
What about the idea of developing registries of hazardous
properties?
A.9. We believe that CDC and State and local governments have
indeed compiled a great deal of data regarding hazardous
housing. CDC would be a better source of identifying what gaps
remain.
Q.10. Does your Agency believe that lead-based paint and dust
hazards in housing are the overwhelming cause of childhood lead
poisoning in the United States? If not, what other causes
should
the Congress be looking at?
A.10. CMS relies on the CDC for its information and
recommendations on lead screening. We believe CDC along with
HUD and EPA may have additional ideas on what, if any, other
hazards that Congress could address.
Q.11. As a result of our hearing last November on lead
poisoning, it was clear that primary prevention is an extremely
important part of eliminating this childhood lead poisoning.
First of all, does your Agency support the goal of stopping
children from being poisoned in the first place? If so, how is
your Agency planning to achieve this goal?
A.11. CMS does support the goal of preventing children from
being poisoned by lead in their environment. However, due to
the statutory requirements of our program that direct our
funding be used for medical purposes, we are unable to focus
our resources on this type of prevention. We are focused,
however, on the early detection of children who have been
exposed to lead and providing any additional medical services
they need.
RESPONSE TO WRITTEN QUESTION OF SENATOR CARPER
FROM RUBEN KING-SHAW, JR.
Q.1. The Administration recently reiterated its commitment to
screening the blood-lead levels of children under age 6
enrolled
in Medicaid. How will you ensure that States comply with this
requirement?
A.1. CMS is committed to continuing our work with States and
our Federal partners to ensure that children at highest risk
are screened for lead poisoning. We continue to reiterate to
State Medicaid agencies the importance of working with other
State and local agencies to ensure that children are screened
and that the data is reported. We will continue to require
States to report their lead screening data on the CMS-416 Early
and Periodic Screening, Diagnosis, and Treatment (EPSDT) form
and monitor States continued progress in this area.
We also intend to publish the final report prepared by our
contractor, Abt Associates, that is looking at innovative State
and local models for the elimination of lead hazards facing
low-income children, as well as assessing the impact and
effectiveness of current screening criteria in reaching high-
risk, low-income children. We believe this document will be
useful to State Medicaid agencies in focusing their resources
effectively to address this problem.
RESPONSE TO WRITTEN QUESTIONS OF SENATOR REED
FROM RICHARD J. JACKSON, M.D., M.P.H.
Q.1. In your testimony you talk about the CDC's analysis of
children's blood-lead levels as part of the National Health and
Nutrition Examination Survey (NHANES) between 1976 and 1980,
and again between 1991 and 1994. Are there any more recent
NHANES data available on children's blood-lead levels, and if
not why?
A.1. There are more data that have not been released yet
because they are still being analyzed. We hope the data will be
ready sometime this summer and we will be happy to get it to
you as soon as it is ready.
Q.2a. Last spring, I, along with several of my colleagues in
the Senate, wrote to Secretary Thompson to urge the CDC to
initiate a review of the current blood-lead level (BLL)
standard of 10 micrograms per deciliter to determine whether
the national standard needs to be lowered. Last fall, this
Subcommittee heard about research at the Children's Hospital
Medical Center in Cincinnati indicating that children exposed
to lead at levels currently considered ``safe'' scored substantially
lower on intelligence tests and may be suffering other adverse
health effects from exposure to lead. What is the status of the
CDC's review of the current blood-lead level standard and when
can we expect a report on the outcome of this important review?
A.2a. CDC has requested that the National Advisory Committee on
Childhood Lead Poisoning Prevention (NACCLPP) study the health
effects of blood-lead levels less than 10 g/dL (that is, IQ,
academic performance/achievement, behavior, attentiveness/
reaction time, hearing threshold, growth, renal function, etc.)
among young children. To support this activity, CDC is funding
an exhaustive search of the literature on this topic. The
information will be culled, and the most relevant literature
will be provided to the ACCLPP ``Less Than 10'' Work Group.
This Subcommittee of the ACCLPP will review and assess the
information to determine whether the national standard should
be lowered. The contract stipulates that a litera-
ture review synopsis will be delivered to the ``Less Than 10''
Work Group by May 2003. The work group will consider this
information and report back to CDC on its findings.
Q.2b. If the blood level standard was changed to five
micrograms per deciliter, how many more people would be
estimated to have elevated blood levels?
A.2b. Approximately 3 million based on the 1988 to 1994 NHANES
data. Again, these data will be updated this summer and we will
provide a revised estimate when the data are available.
Q.3a. The GAO, in its 1999 report on the lead poisoning
prevention efforts of Federal health care programs, cited the
lack of reliable data collection as a significant barrier to
targeting appropriate services to at risk children. As you
highlight in your testimony, CDC provides grants to States to
establish Childhood Blood Lead Surveillance (CBLS) systems. At
present, how many States have active CBLS systems that are
collecting screening and elevated blood-lead levels (EBLL) data
and reporting that data to agencies such as CDC and CMS?
A.3a. All 43 States and 17 local health departments that
receive funds from CDC for childhood lead poisoning prevention
programs collect and submit screening and elevated blood-lead
level data to CDC. Some States, however, do not have laws that
require that all blood-lead levels be reported. CDC is working
with those programs to ensure that all blood-lead levels are
reported in their States. CDC has urged State and local
childhood lead-poisoning prevention programs to work with their
State Medicaid offices to link data so we will know what
percentage of Medicaid enrolled children have been screened for
lead poisoning.
Q.3b. What kind of oversight or monitoring does CDC conduct to
ensure that States are maximizing their efforts to develop and
implement these systems?
A.3b. The CDC lead staff are assigned to work with specific
States to assess individual childhood lead poisoning prevention
program's surveillance systems. CDC offers ongoing technical
assistance to help programs improve their surveillance and use
of data. CDC is also enhancing its website to highlight model
programs so that others can learn from the successes. CDC has
created work groups with State representatives to address different
surveillance issues. The work groups recommendations will be
shared with all lead programs. A childhood lead surveillance
meeting will be held in September 2002 to provide a forum for
discussion of priority surveillance topics.
Q.4. I understand that the Childhood Lead Poisoning Prevention
Program's authorization expires this year. As a Member of the
Senate Health, Education, Labor, and Pensions Committee, I
would be interested in working with your office to ensure that
this critical program is reauthorized. What recommendations
would you offer to help guide the reauthorization of this
important program?
A.4. [CDC staff discussed with the Reed staff to resolve this
question . . . authorization was extended by the Children's
Health Act until 2005.] CDC would be happy to work with you in
the future to ensure the best reauthorization of the Childhood
Lead Poisoning Prevention Program.
Q.5a. Primary prevention means making housing lead-safe,
focusing attention and resources on the ``vector of disease.''
However, many health departments are stuck in the rut of
educating parents about hand washing, nutrition, and wet
mopping, while science shows that it is not within parents'
power to protect their children if they live in a highly
contaminated home. Thus, what is your Agency doing to help deal
with the vector of disease and help make our housing stock
lead-safe?
A.5a. CDC is providing supplemental funding specifically
targeting primary prevention in urban areas of highest need.
For example, health departments have prenatal clinic and some
have programs that target new mothers at high-risk for many
health problems. By identifying these pregnant women and new
mothers, the health department can go to their homes and
collect dust samples and offer counseling about lead poisoning.
If the dust samples are found to have lead, then more intensive
environmental investigations can be conducted and remediation,
if appropriate, may occur. This ``primary prevention'' approach
can prevent young, high-risk children from becoming lead-
poisoned. CDC encourages its programs to apply for HUD grants
to fund remediation. CDC will require programs in 2003 to begin
to develop primary prevention programs such as those described
above.
Q.5b. What more can it do within existing law? Do current laws
need to be amended to help better deal with primary prevention?
A.5b. Primary prevention, as defined by CDC, is allowed under
the existing law. However, primary prevention activities will
be both time and resource intensive, considering these
activities will be most effective when conducted as a
complement to the existing lead screening and case management
activities, which are critical elements in our national
elimination strategy.
Q.6a. What has CDC done to raise the sights of its grantees
above screening and case management (reacting to poisoned
children) and parent education?
A.6a. The CDC has required grantees with the heaviest estimated
burden to include primary prevention activities in their
programs. These grantees have implemented the following primary
prevention activities:
<bullet> California has implemented a lead-related construction
accredi-
ation and certification program that provides individuals
who
are certified to conduct residential lead inspections and
risk
assessments.
<bullet> Ohio's Childhood Lead Poisoning Prevention Program
collaborates with the Help Me Grow--Home Nursing Program.
Nurses in the Home Nursing Program visit the homes of
newborn children and conduct a lead-risk assessment in the
home. If risk factors are identified, an environmentalist
will follow-up with an
environmental inspection.
<bullet> New York State is examining the five highest risk
counties' Medicaid/Social Service Activities and local
agencies housing policies to find ways to revise policies
and leverage existing funding to reduce the number of lead-
contaminated dwellings for low-income families. New York
City's program conducts special inspections of one and two
family homes when a parent/guardian files a complaint
because the landlord has not repaired peeling paint. As a
result of these inspections, Commissioner's Orders to Abate
can be issued and enforced.
<bullet> The Houston CLPPP staff is working on a plan to work
with ClearCorps to receive referrals for homes that require
hazard reduction.
<bullet> In Pennsylvania, the Commonwealth participates in and
encourages participation in the ``Lead-Safe Initiative''
which brings together representatives of housing,
environmental, social agencies, and others who focus on
providing services to children and families incrisis and in
adoptive and foster care. In Philadelphia, the city
partners with community-based and other Government
organizations to visit the homes of expectant and new
mothers living in areas at high-risk for lead poisoning.
These visits include an assessment of the home including
dust-wipe sampling, as well as education and cleaning
supplies for the mothers.
In 2003, all childhood lead poisoning prevention programs
will need to address primary prevention.
Q.6b. How is CDC helping to keep new children from living in
the same unsafe housing?
A.6b. CDC has developed a patient tracking and surveillance
system for childhood lead poisoning. Health departments that
use this software collect information on where a child lives,
which allows the health department to identify addresses where
multiple children/families have been found to have elevated
blood-lead levels. CDC encourages its grantees to work with
local housing officials to remediate the homes of children with
elevated blood-lead levels.
Q.7. In your testimony you talked about the need for lead level
reporting across all States that would help determine ``hot
spots.'' You went on to say that this type of data was being
collected right now. Could you provide additional details about
this effort including its time line for development and what
types of information the system will eventually provide?
A.7. CDC is currently receiving blood-lead data for children
from all the childhood lead poisoning prevention programs.
CDC's new funding strategy for childhood lead poisoning
prevention programs will include performance measures. One of
the new performance measures will be a requirement that States
require that all blood-lead levels be reported to the State
health department in a timely manner.
Q.8. While abatement is essential in high-risk properties, in
which cash flow is insufficient to support maintenance, most
leaded properties can be made lead-safe through other
strategies. Research and experience over the past decade has
demonstrated the importance of visual inspection for peeling
paint; lead-safe work practices to control, contain, and clean
up lead dust in painting and remodeling projects; and clearance
testing to ensure that lead dust hazards are not left behind.
Do you believe that visual inspection, lead-safe work practices
and clearance testing offer the potential to expand lead-safety
to a broad enough scale to make U.S. housing lead-safe?
A.8. Yes, recent studies conducted for the Department of
Housing and Urban Development (HUD) indicate that lead hazards
can be controlled with visual inspection, lead-safe work
practices, and clearance testing can expand lead-safety on a
broad scale.
Q.9. While consistent data are not widely available, it is
clear that in the majority of cases lead hazards are not
corrected even after a child is identified as lead-poisoned.
The same hazardous house often poisons multiple children as new
families move in (that is, a Syracuse, New York, newspaper
identified 47 houses that had poisoned multiple children in
just 18 months). Even when health departments succeed in
ordering repairs, in many States there is no oversight, no
requirement for lead-safe work practices and no clearance
testing. While no house should poison a child, it is simply
unconscionable that any house should poison a second, third,
and fourth child. What do you believe your Agency can do to
help stop houses from poisoning more that one child?
A.9. It is essential for States to be able to identify lead
hazards and ensure clean-up. With CDC funding, States have the
capacity to identify the houses where more than one child has
been poisoned. Health departments should then use this
information to work with local housing authorities to assist
with remediation and enforcement if landlords do not remediate.
Q.10. What does your Agency believe might be appropriate
statutory changes to make the Federal disclosure law regarding
lead more meaningful?
A.10. CDC believes that increasing community awareness
particularly among renters and homeowners about the hazards of
lead and how lead poisoning can be prevented is important.
Q.11. Many advocates and some health departments are convinced
that ending childhood lead poisoning will require moving beyond
screening children's blood-lead levels to actually screening
high-risk housing to identify hazards before a child's health
is harmed. What does your Agency think about this strategy?
What about the idea of developing registries of hazardous
properties?
A.11. CDC completely supports the strategy to move toward
screening high-risk housing to identify hazards before a
child's health is harmed. Nevertheless, CDC believes that an
important component of the lead elimination strategy is
screening for children with elevated blood-lead levels and
offering medical and environmental interventions when
appropriate. Registries of homes with hazards, as well as lead-
safe homes should be a part of a comprehensive primary
prevention strategy.
Q.12. Does your Agency believe that lead-based paint and dust
hazards in housing are the overwhelming cause of childhood lead
poisoning in the United States? If not, what other causes
should Congress be looking at?
A.12. Lead-based house paint contaminates dust and soil and
these sources are the most common high dose source of lead
exposure for young children in this Nation. While there are
other sources of lead exposure for young children, such as
certain folk remedies, cultural cosmetics, and water, CDC
believes that addressing leaded house paint will make a huge
impact on protecting our Nation's children from the life-long
affects on their health. Elimination will require identifying
all potential sources of exposure for a child and making the
environment lead-safe.
Q.13a. As a result of our hearing last November on lead
poisoning, it was clear that primary prevention is an extremely
important part of eliminating childhood lead poisoning. First
of all, does your Agency support the goal of stopping children
from being poisoned in the first place?
A.13a. CDC has been emphasizing the importance of preventing
children from ever becoming lead-poisoned, since the
publication of its 1991 document, Preventing Lead Poisoning in
Young Children. CDC support of primary prevention is stressed
in its 2002 document, Managing Elevated Blood Lead Levels Among
Young Children.
Q.13b. If so, how is your Agency planning to achieve this goal?
A.13b. The CDC has already required grantees with the heaviest
estimated burden, California, Illinois, Ohio, Pennsylvania, and
Texas, to address primary prevention, but in 2003 all programs
will be required to address primary prevention. Funding will
help childhood lead poisoning prevention programs introduce
more primary prevention activities. CDC will facilitate
networking among programs, so grantees can learn from each
others experiences. CDC will enhance its website to provide
more information on existing and past primary prevention
activities. As we increase primary prevention activities, we
must remember that screening and case management must remain
strong and effective. Primary prevention, screening and case
management are critical to achieve our 2010 elimination goal.