Report 98117 Summary - April 1999
Department of Health Services:
Has Made Little Progress in Protecting California's Children From Lead Poisoning
RESULTS IN BRIEF
When children under the age of six are exposed to lead, a highly toxic metal, the consequences can be very serious. Childhood lead poisoning can interfere with the development of the brain, organs, and nervous system; even relatively small amounts of lead in blood can result in learning disabilities, behavior problems, and lower IQ scores. The United States Centers for Disease Control and Prevention (CDC) considers lead poisoning to be a major, preventable environmental health problem for children. Although nationwide blood-lead levels have been declining in recent years, many children throughout the country still suffer from this problem.
For over a decade, California has struggled to identify and protect these lead-poisoned children. As early as 1986, the Legislature charged the Department of Health Services (department) with determining the extent of lead poisoning among children in the State. Moreover, in 1991 the Legislature set specific goals for protecting children from lead poisoning: It asked the department to evaluate all children for their risk of poisoning; to test those children who were at risk; and to provide case management for children who were found to suffer from lead poisoning. Yet the department has failed to meet these goals. It has not ensured that all at-risk children are tested, nor tracked the results of testing to determine the extent of the problem lead poisoning presents throughout the State.
As a result, thousands of lead-poisoned children have been allowed to suffer needlessly. The department itself estimates that more than 130,000 children between the ages of one and five have elevated blood-lead levels, with 40,000 having levels that would warrant case management. Yet, as of January 1999, the department reported that it was providing case management to a mere 3,500 children-the only lead-poisoned children at that time whom it had identified as requiring these services. Thus, the department is clearly not fulfilling its responsibilities as mandated by the Legislature.
Specifically, despite a legislative directive, the department has failed to adopt regulations establishing a standard of care that requires health care providers to evaluate all children to determine their risk of lead poisoning during periodic health assessments. In addition, the department did not follow initial federal guidance on the appropriate approach to blood-lead testing. Moreover, it has not ensured that the health care providers who participate in its Medi-Cal and Child Health and Disability Prevention (CHDP) programs and provide services to about 70 percent of the State's one- and two-year-old children order blood-lead tests in accordance with program requirements. Thus far, the department's records indicate that less than 25 percent of the children in this age group who access services from these programs have received blood-lead tests.
Perhaps as importantly, the department has yet to develop a reporting system that tracks the results of all blood-lead tests, despite a 1991 legal settlement requiring it to do so. As a result, the department is unable to report accurately on where and to what extent lead poisoning exists in the State. Furthermore, this lack of adequate tracking has hampered the department's ability to ensure that children suffering from lead poisoning receive appropriate care. Because the department requires labs to report only those blood-lead test results that exceed 25 micrograms of lead per deciliter (ug/dL) of human blood, it cannot ensure that it receives blood-lead results at the lower level of 15 ug/dL. Yet children who have blood-lead levels as low as 15 ug/dL require case management.
In addition, the department has not appropriately monitored the case management of those lead-poisoned children whom it has identified. This case management, primarily handled by city and county lead poisoning prevention programs (local programs), consists of follow-up medical care for the children and investigation of the sources of the lead poisoning. Although the department requires the local programs to report all their case management activities, it does not enforce this requirement. Consequently, many case management reports are never submitted. Moreover, when the department does receive these reports, it does not review the information contained within them to determine if the care given to a child was appropriate and if the source of the poisoning was eliminated or reduced. Fortunately, we found in our review of selected cases that local programs have provided adequate care. However, in a number of instances, the local programs were unable to ensure that the source of the poisoning was eliminated or reduced because they require assistance in their efforts to compel property owners to do so.
The department has made progress towards protecting children from lead hazards. For instance, it has established a program aimed at reducing lead exposure caused by unsafe renovations or removal of lead-based paint, and it has also conducted a study of school and day care facilities throughout the State to determine the prevalence of lead hazards within them. Yet, in both of these examples, the department must take immediate further action to achieve the best possible results. Although the program aimed at reducing lead exposure has qualified the State and local agencies for federal funding, these funds are currently threatened because the department has not demonstrated that it has dedicated adequate funding and staff to enforce the program. Similarly, until the department completes a curriculum to educate school and day care facility staff on appropriate steps to eliminate or reduce lead hazards, the children at these facilities remain at risk for lead poisoning.
The department has many tasks ahead of it to identify and protect children with lead poisoning. For this reason, it must organize its efforts and move into a higher gear to fulfill its responsibilities to the Legislature and the children in the State. If it does not, thousands of children remain vulnerable to the serious effects of lead poisoning.
To ensure that the department properly focuses its efforts and resources to identify and protect children with lead poisoning, the Legislature should require the department to report on its progress annually. Additionally, the Legislature should amend existing state law to require labs to report the results of all blood-lead tests. Finally, the Legislature should grant California's cities and counties the authority to compel property owners to eliminate or reduce lead hazards.
To obtain adequate data on where and to what extent lead poisoning is a problem in the State and to ensure that it identifies and protects lead-poisoned children, the department should take the following actions:
- Adopt regulations requiring labs to report all blood-lead test results.
- Adopt standard-of-care regulations as previously directed by the Legislature.
- Take immediate action to identify and educate those providers participating in its Medi-Cal and CHDP programs who are not ordering blood-lead tests as required.
- Ensure local programs submit to it all case management information outlining the services provided to lead-poisoned children.
- Monitor local programs' activities to ensure lead-poisoned children receive appropriate care. This should entail a high-level review of all follow-up reports to ensure their completeness and a more detailed assessment of the care given for a representative sample of cases.
- Ensure that homeowners and property owners properly eliminate or reduce lead hazards identified as a source of a child's lead poisoning by assisting the local programs with issuing orders to control these hazards if the Legislature does not grant this specific authority to them.
- Seek legislation granting it enforcement authority that will allow it to impose administrative, civil, and criminal sanctions against those who violate state requirements governing activities to eliminate or reduce lead hazards.
- Complete the training curriculum for eliminating or reducing lead hazards in California's school and day care facilities so that children do not remain at risk for lead poisoning.
The Department of Health Services (department) concurs, for the most part, that our recommendations would improve California's Childhood Lead Poisoning Prevention Program. However, the department does not agree that it should report on its progress annually to the Legislature, believing that this would add work but no benefit to the program. Additionally, the department does not believe that it should adopt standard-of-care regulations as directed by the Legislature in 1991. Instead, the department recommends that the Legislature repeal this mandate. Finally, it does not agree that the department should assist the local programs with issuing lead hazard abatement orders if the Legislature does not grant this specific authority to cities and counties.