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October 2, 2016
Ruth Ann Norton
The toxic legacy of lead poisoning continues to undermine the health, economic and social outcomes for so many of our communities, our families and most importantly our children. Decades after ending lead in paint, gasoline, solder and other sources, lead poisoning remains one of the nation’s most devastating environmental health threats. While there has been significant progress in reducing the number of children poisoned by lead, it is clear that millions of American homes, schools and child care centers continue to be points of exposure from paint, water, soil and other sources. This tragic and costly environmental disease still impacts over 535,000 American children under the age of six every year - causing irreversible damage and robbing them from reaching their full potential.
Impacted children enter school with diminished reading and learning abilities and drop out of school at a rate seven times greater than their peers. Additional effects include hearing loss, speech delays, aggressive even violent behavior and long term health impacts on the kidneys, heart and brain costing the U.S. over $50 billion.
Yet, it is imperative to understand that lead poisoning is entirely preventable and it is our collective obligation to deliver, once and for all, on the promise of ending lead poisoning. The business case to implement prevention is clear: for every dollar invested in prevention taxpayers receive $17 to $221 in return. More importantly, children will be able to arrive in the classroom able and ready to learn and will be on a better path to reach their full potential.
We have never had a better opportunity than today to move the arc of public and political will, to act as a nation to end lead poisoning.
The Green & Healthy Homes Initiative presents this Strategic Plan to End Childhood Lead Poisoning – A Blueprint For Action as a roadmap to strategically marshal the financial resources, policies and practices necessary to achieve this goal. This Plan draws on proven practices, feedback from impacted communities, front line service providers and policy makers.
So much has changed since the Presidential Task Force was last convened in 2000 to address lead poisoning. The knowledge from research has grown exponentially and supports what we have long known – that there is no safe level of lead. That fact is now prominent in the Centers for Disease Control and Prevention’s federal guidance; every action we take should be focused on that fact.
As a country, we have proven time and again that we can do anything when we put our collective effort toward a challenge. If we can land a man on the moon, we certainly can protect the American public from this hazard. We understand the steps we need to take and the costs to get there. We present this Plan to help propel action, support the efforts of groups across the country and empower leaders to finish the job.
Since our founding in 1986 as Parents Against Lead, the eradication of childhood lead poisoning has been at the heart of GHHI’s mission and work. This Strategic Plan is designed to bring together diverse sectors and stakeholders toward one common goal – ending lead poisoning. We believe this to be a thoughtful and actionable Plan that will allow future generations of our nation’s children to grow up free of lead and able to pursue their full potential.
Thank you for your consideration of and support for this mission.
Ruth Ann Norton
President and CEO
Green & Healthy Homes Initiative
About the Green & Healthy Homes Initiative
The Green & Healthy Homes Initiative (GHHI), formerly known as the Coalition to End Childhood Lead Poisoning, replaces stand-alone programs with a comprehensive strategy to improve health, economic and social outcomes for children, families and seniors through a proven integrated housing intervention framework. GHHI work is centered on effective service delivery, policy change and developing sustainable funding mechanisms to support the creation of healthy, safe and energy efficient homes.
In addition to its direct service programs, GHHI’s work includes technical assistance and capacity building for the field; training, economic analysis and policy and standards development; and sustainable funding for the creation of healthy, safe and energy efficient homes for low income communities. GHHI is currently leading national efforts to build the case for Medicaid investment in evidenced-based healthy housing interventions as well as the development of Pay for Success/Social Impact Bonds.
Atlanta, Austin, Baltimore, Buffalo, Chicago, Cleveland, Denver, Detroit, Dubuque, Flint, Greater Syracuse, Jackson, Lansing, Lewiston-Auburn, Marin County, Memphis, New Haven, Philadelphia, Pittsburgh, Providence, Salt Lake, San Antonio, Springfield, Staten Island, State of Rhode Island, and Toledo.
Breaking the link between unhealthy housing and unhealthy children and families.
GHHI Recommendations to Address Lead’s Toxic Legacy:
A National Strategic Plan for Ending Childhood Lead Poisoning
*Recommendations noted below with an asterisk are one of GHHI’s Top 15 Recommendations on Eliminating Childhood Lead Poisoning Within Five Years.
The scientific knowledge, best practices, and known scope of lead’s impact on housing, health and communities have dramatically changed in the last several decades. The Commission will coordinate the multi-agency and private sector collaborative, update lead standards and develop a Work Plan for private sector investment in lead hazard reduction activities. The Commission will convene policy makers, economists, programmatic implementers, community stakeholders and best practice leaders across multiple sectors and leverage state, local, and private sector efforts.
The Federal Interagency Healthy Homes Work Group, consisting of eleven federal agencies, should meet regularly with a renewed focus around completing the task of eliminating lead poisoning hazards and consistently assuring adoption of best practices and standards for prevention across all agencies. Some examples are:
This will end any possible federal involvement in passing through residences via sales of foreclosed properties with lead hazards. Veterans families and other families with young children should never be at risk for lead poisoning. This will also open up mortgage resources to be used for lead hazard reduction including FHA, Fannie Mae and Freddie Mac. Where laws exist to require inspection and remediation, they need to be fully enforced.
The administration should add infrastructure to use technology and social media to push information to parents and community stakeholders. In-home checklists, online access to registered rental properties that are lead safe, connections to grant and loan resources to address lead hazards, and specific information about probable sources of lead can all be distributed utilizing technology. Data sets need to be accessible to the public, including possible sources of lead such as pipes and demolition sites. For example, HUD should support its Healthy Homes App and complete the design and launch of “healthyhomes.gov” as a national portal for families, governments and service providers to access information and resources to prevent lead poisoning.
Department of Housing and Urban Development (HUD)
HUD’s Elevated Blood Lead (EBL) action levels need to be updated to reflect current CDC standards. When a lead poisoning unit reveals that lead hazards exist, all other units should be risk assessed to determine if lead hazards exist in other units. This critical change will support primary prevention of lead poisoning in other non-EBL units.
Older water fixtures can exacerbate the leaching of lead into residential water. Permitting HUD grantees to address lead hazards in home water fixtures and replace lead service lines with HUD grant funding will enable lead remediation programs to more comprehensively reduce sources of lead.
In order to advance knowledge on the effects of lead hazards and to inform lead policies, programs, and legislation, PD&R should analyze the likelihood that a property assessed to contain lead hazards will result in an elevated blood lead (EBL) level in a child resident. Additionally, PD&R should evaluate the value added to properties after they receive lead remediation services compared to the cost of remediation. Furthermore, PD&R should analyze the effect of energy efficiency and weatherization on residents’ health and safety outcomes.
Visual assessments are not an accurate method of detecting lead-based paint hazards. Evaluations of HUD-funded lead hazard control programs consistently utilize lead dust clearance swipes to measure lead levels post-intervention, signifying that visual inspections alone are not a trusted or reliable assessment for lead hazards. HUD should require lead dust clearance wipe samplings for all HUD supported activities involving the disturbance of lead-based paint. HUD should also include measures to detect other environmental hazards (asthma trigger, radon, VOCs etc.) that have negative health effects as part of a comprehensive assessment. When possible, residents should be permanently or temporarily relocated if lead-based paint hazards are present or if a child has a BLL ≥5 μg/dL and lead-based paint hazards are present in HUD assisted or owned properties.
The current HUD Housing Quality Standard mandates units participating in the Housing Choice Voucher Program meet 13 performance requirements. While these requirements assess for potential safety hazards, they do not adequately assess for environmental health hazards such as mold, allergens, asthma triggers, radon, and VOCs. Adopting a healthy housing standard will better ensure voucher recipients and their children live in homes that are protected against housing related health and safety hazards.
HUD should provide competitive incentives to (or support private sector support of) states who create comprehensive lead poisoning prevention strategies that align, braid and coordinate programs to advance lead safe housing and create data systems to maintain transparent mapping of work. Having local prevention activities at or below the CDC level as a threshold requirement for all HUD lead grant applicants as in years past strongly incentivizes state and local action.
Despite the CDC’s issuance of a new reference level of 5 µg/dl in 2012, few states have adopted this new standard for environmental investigation and medical case management – leaving hundreds of thousands of children languishing in lead poisoning properties without proper intervention occurring. By setting these local actions as a requirement to be eligible for federal lead poisoning prevention support, local jurisdictions will quickly enact these needed changes to improve the environmental health response being provided to children who are identified with elevated blood lead levels. Many states developed 2010 Childhood Lead Poisoning Elimination Plans but have not updated their plans or designed prevention strategies that reflect the new CDC lead reference level.
Environmental Protection Agency (EPA)
The American Water Workers Association estimates there are 6.1 million leaded service lines. According to a study published in the Journal of AWWA, if water samplings were done properly, roughly 70 percent of homes with lead service lines would have tap water registering above the federal action level and up to 96 million people would find out their water is contaminated with lead. The EPA should use its regulatory authority to spur adequate management of water systems.
Lead inspection, lead dust clearance testing, lead safe work practices and other standards need to be updated based upon current research findings in the field. Lead dust clearance standards for floors, window sills and window wells should be health-based standards that sufficiently protect children and occupants in properties from lead exposure that will cause lead poisoning.
EPA capacity is currently inadequate to enforce the RRP Rule in the 36 states that are not authorized to enforce and oversee the Rule in their local jurisdictions.
Department of Health and Human Services (HHS)
HHS should increase the amount of LIHEAP funding that can be used for weatherization services from the current 15% by removing the waiver process and establishing 25% as the standard allowance for weatherization services. HHS should include the monetized health benefits of window replacement of any leaded window when LIHEAP programs are calculating the Savings to Investment Ratio (SIR) of priority measures for weatherization services. This change would allow more of the $3.4 Billion LIHEAP annual budget to be used proactively to improve home energy efficiency while also conducting activities such as replacing leaded windows with lead free, Energy Star windows that also address lead hazards and improve health outcomes.
Centers for Medicare and Medicaid Services (CMS)
Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit covers screening for lead exposure, but does not include activities to remediate identified lead hazards. The effects of childhood lead poisoning significantly burden society with the total societal cost between $192-270 billion, with healthcare costs alone of $11-53 billion. The impact of lead on healthcare costs and the potential benefits of remediation support Medicaid reimbursement for lead hazard remediation providers. The remediation would not only improve the health of the identified child, but protect other children who may be exposed in the future from that residence.
Internal Revenue Service (IRS)
Nonprofit hospitals use community benefit funds to provide charitable services that improve the health of their immediate community. Nonprofit hospitals use Part I and Part II of Schedule H on IRS Form 990 to report charitable community activities. In Part I, hospitals report all community benefit activities with the “purpose of improving community health”. In Part II, hospitals report community building activities that “protect or improve the communities’ health or safety, and that are not reportable in Part I”. Most nonprofit hospitals prefer to direct resources towards efforts that easily meet community benefit (Part I) requirements, such as providing charitable care to the un/under-insured. Despite the IRS clarifying that “some community building activities may also meet the definition of community benefit”, nonprofit hospitals are still reluctant to invest more in community building activities (Part II). Classifying lead hazard reduction investments as community benefits will incentivize hospitals to direct more resources toward lead poisoning prevention.
Department of Energy (DOE)
WAP does not currently recognize the health benefits of lead free Energy Star window replacement in the calculation of the Savings to Investment Ratio (SIR) that determines the priority of WAP measures undertaken in a home. The SIR should include the monetized health benefits of lead free window replacement, which are $6,847 in housing units built before 1940, $2,847 in units built from 1940-1960, and $632 in units built from 1960-1978 (in 2005 dollars).
Consumer Product Safety Commission (CPSC)
Lead in consumer products, especially products coming from other countries, remains a source of lead poisoning and should be banned. The use of lead in manufacturing also contributes to increases in ambient air levels and other environmental exposure for humans and animals. Use authority under TSCA and FHSA to ban its use, such as lead in wheel weights, as safer alternatives exist. Further, the Consumer Product Safety Commission should tighten enforcement around the manufacture or import of items containing lead such as toys, costume jewelry, food and cosmetic products.
Congressional Legislative Actions
Federal funding is inadequate to address lead-based paint in the 1.1 million most at risk homes in the U.S. with lead hazards where low income children under age 6 reside. At $11,300 per home (including addressing lead paint hazards and lead service lines) this investment would lead to the remediation of 220,000 residences per year. Federal investment also needs to be supplemented by incentivized private market contributions. Congress should amend HUD’s Lead Hazard Control budget from $110 million annually to at least $2.5 billion per year for the next five (5) years to adequately fund the targeted remediation of the nation’s most hazardous properties. The lead hazard control work would not only return $17-$221 for every dollar invested, it would also provide at least 52,000 jobs in the housing sector.
New funding is needed at the state and local level to provide critical surveillance, environmental investigation and case management services for the 535,000 children with elevated blood lead levels in the U.S. Prior funding levels were based on a smaller number of children at a higher blood lead level than the current CDC reference level of 5 µg/dl. Funding at this level will allow states to conduct responsive lead inspection and in-home lead poisoning prevention education activities and provide sufficient resources for cities and local jurisdictions with critical needs to have direct CDC financial support.
The current Title X Disclosure Law is primarily centered on disclosure and education and needs to be enhanced to include mandatory inspections of properties that will trigger additional financing for owners for lead remediation measures. The current provision in Title X allowing for optional lead testing by purchasers prior to sale has not been effective as a voluntary prevention tool. The zero bedroom dwelling unit exemption does not account for efficiency units where young children can commonly reside in urban areas in particular. High performing nonprofits like community action agencies have the capacity to conduct lead hazard remediation activities.
Several bills have been introduced or re-introduced in response to the tragic events in Flint, Michigan and the myriad of reports from cities, counties and states throughout the nation.
Additional resources and financing tools are needed to assist low to moderate income homeowners and small market rental property owners afford lead hazard remediation in their homes. Individuals often do not have the capital on hand to make the initial investment to replace windows and remediate other lead hazards.
The effects of childhood lead poisoning significantly burden society with the total societal cost between $192-270 billion. However, every dollar invested in lead paint hazard control produces an ROI of $17-$221 or a net benefit of $181-269 billion. The tax credit will incentivize owners of eligible dwelling units to reduce lead hazards, bringing critical private resources to the national effort. The long term gains to society will more than make up for the tax credits to spur this investment.
Federally assisted housing should not pose a threat to children residing in those properties. Lead hazards should be remediated through stronger enforcement of the LSHR. LIHTCs are a vital tool in affordable housing development, and should be effectively utilized to ensure affordable housing is lead safe.
State and Local Actions
In 2012, the CDC replaced its blood lead level (BLL) of concern of 10 μg/dL with a reference level of 5 μg/dL, but currently only 24 states and Washington, DC have adopted the CDC’s recommendations. Research indicates there is no safe level of lead in a child’s body. Therefore, failure to follow the CDC guidelines will potentially enable millions of poisoned children to go undetected and untreated. All states and local governments should allocate sufficient resources and adopt protocols establishing medical case management and environmental investigation at 5 μg/dL.
Local communities bear the impact of families poisoned by lead. Local jurisdictions should raise standards to ensure affordable housing is lead safe. The National League of Cities, U.S. Conference of Mayors, National Governor’s Association, and other membership groups are ideal to focus on for technical assistance. Those groups can facilitate the training of cities on lead paint, housing, soil and water standards and in how to develop key elements of strategic lead poisoning prevention plans. Establishing a forum for city managers as part of the ICMA to share the difficulties associated with lead hazard control and prevention will allow participants to crowd source solutions from their fellow city managers and enable managers to swiftly tackle lead problems in their cities.
Title X, sec.1018 requires the disclosure of known information on lead based paint hazard before a property built before 1978 is leased or sold. Some states have more stringent lead disclosure procedures, in particular when a property has an outstanding lead violation or is not in compliance with a local lead or housing law. More stringent disclosure rules will help reduce the incidence of lead poisoning and ensure properties are made lead safe. Information on possible lead hazards in water and soil should be included as part of standard disclosures.
The Maryland Annotated Code, Title 6, Subtitle 8, for example, requires that owners of rental properties built before 1978 register units annually with the Maryland Department of Environment (MDE), and have them treated and lead inspected by an MDE accredited lead paint inspector after every change in occupancy. If the property fails the inspection, the owner must perform lead hazard reduction treatments until it can meet the risk reduction standard. States around the country should implement similar registration and inspection codes that require lead hazard treatment and independent, third party inspection.
State and local jurisdictions should develop sufficient enforcement personnel resources and consistent Lead Violation enforcement mechanisms to ensure the timely enforcement of violations that are issued to properties where lead poisoned children reside. Housing code enforcement must also be conducted vigorously for chipping paint and structural defect violations that contribute to hazardous housing and lead poisoning.
Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit covers screening for lead exposure, but does not include activities to prevent lead poisoning or remediate identified lead hazards. Medicaid pilots should be established at the state level that will provide Medicaid funding for lead hazard reduction interventions in homes where children with elevated blood lead levels reside.
Some contractors across the country performing demolition work fail to use safe work practices to contain lead dust emissions, fail to remove lead debris in a timely manner or not at all, and fail to prevent lead dust and debris from being disbursed throughout the community as debris is hauled from the property. The unsafe demolition of older homes threatens the immediate health of children and residents who live near demolition sites while also leaving behind potential hazards for years. In most jurisdictions there is no lead safe demolition standards at all for the demolition of properties constructed prior to 1978. Statewide or local lead safe demolition standards should be adopted that will improve lead safety practices during demolition.
In jurisdictions with low blood lead testing rates of children, universal blood lead testing of children under age 6 should be adopted or at least implemented over a period of 3-5 years in order to: increase lead testing rates, better evaluate the actual rate of lead poisoning in the particular state and test the accuracy of the state’s prior targeted blood lead testing/screening methodology. Previous targeted testing methods created gaps in prevention and treatment for children living in other parts of the state.
Public utilities and infrastructure often require both federal and local support. To ensure local communities have safe drinking water, states, cities, and other local jurisdictions should direct funds to infrastructure improvement that includes the replacement of leaded water pipes.
Lead poisoning stakeholders, both national and local, should coalesce around a broad campaign that leverages community-based and faith-based organizations to increase public awareness of risk, testing, and prevention of lead poisoning. Collectively, these organizations should amplify identified needs to prevention in their communities and nationally and work together to achieve results by sharing information that aligns with an agreed upon national strategy. The campaign should be targeted to reach specific stakeholders that play key roles in prevention strategies.
Private Sector / Philanthropic Actions
Just as DOE’s WAP and HHS’ LIHEAP programs should include the benefits of eliminating lead hazards through the replacement of leaded windows with lead free, Energy Star windows in its weatherization assistance programs, utilities and public service commissions should likewise include these measures in their programs that improve energy efficiency and have quantifiable health benefits. State utility programs do not currently recognize the health benefits of lead free Energy Star window replacement in the calculation of the Savings to Investment Ratio (SIR) that determines the priority of weatherization measures taken in a home. State and utility programs’ SIR calculations should include the monetized health benefits of lead free window replacement, which are $6,847 in housing units built before 1940, $2,847 in units built from 1940-1960, and $632 in units built from 1960-1978 (in 2005 dollars, Nevin et.al., 2008).
Realtors are required to present all the facts pertinent to a property honestly to their clients. Lead paint hazards frequently present as chipping paint and dust which may cause realtors to classify them as cosmetic problems and not disclose the potential lead hazard. It is therefore vital that realtors are educated on all aspects related to assessing for and preventing lead hazards.
Under Title X, landlords and sellers must provide any known information concerning lead-based paint testing or lead-based paint hazards in the property. This disclosure normally happens late in negotiations between sellers/landlords and buyers/tenants. Thereafter, homebuyers also have 10 days to conduct their own lead assessment, unless they negotiate for more time. Homebuyers and renters are also growing more energy efficiency conscious and favor such homes when choosing amongst properties. NAR should develop a lead hazard scoring system (i.e. Lead Safe and Lead Free) that is visible on the listing. A more accessible and visible rating would encourage sellers and landlords to invest in lead remediation to improve property values and marketability. This could also align with and encourage state lead safe registries.
BPI sets standards and quality assurance requirements for home performance professionals. The HPC, a new organization forged by the merger of Affordable Comfort, Inc. and the National Home Performance Council, supports the education and business development of home performance contractors and the weatherization industry. Both organizations should be involved in the development of stronger credentials, and should facilitate the proliferation of the new standards amongst home performance professionals. Networks such as Energy Efficiency for All (EEFA) are developing closer ties between energy efficiency and health and safety improvements, and would be valuable partners to advance this effort.
The home performance industry sector should increase the scale of adequately trained and certified contractors to meet the need for lead hazard reduction services around the nation. All rehabilitation activities should be done with contractors who are certified under the Renovation, Repair, and Painting (RRP) rule.
To reach the $2.5 billion a year for five years necessary to end childhood lead poisoning, resources are needed from Congressional appropriations, state and local governments, and the private sector. Philanthropy should contribute to this cross-sector investment through establishing a national fund for lead safe communities. The $500 million philanthropic lead fund ($100 million/year for five years) would be utilized for matching funds, leveraging public sector resources, capacity building, data support, and education needed to remediate the 1.1 million most at risk low income homes occupied by young children.
Pay for Success (PFS) would allow philanthropic and private entities to provide capital to scale lead hazard control efforts. The PFS model also ensures that federal funds are used cost effectively because up-front costs are borne by the private sector, and are reimbursed by the government only if agreed upon outcomes are met. The high return on investment from lead poisoning prevention efforts makes this topic a good fit for this financing model.
National health organizations such as the American Public Health Association and the American Academy of Pediatrics should sign on to a robust 5 year campaign to increase awareness, screening, and testing for elevated blood lead levels (EBLL). Current point of care blood lead testing, which is required for all Medicaid children, falls far short of requirements. Healthcare provider groups, managed care organizations, and health professional training centers should increase awareness among health professionals of the vital role they hold in identifying EBLL children.
The scale of the lead hazard remediation funding needed to address lead-based paint in 37 million homes requires that lead paint and lead pigment manufacturers contribute to the solution. A designated Lead Hazard Remediation Fund needs to be created to produce private sector contributions that increase the scale and expediency of lead hazard reduction interventions nationally.
 Gould, Elise. "Childhood lead poisoning: conservative estimates of the social and economic benefits of lead hazard control." Environmental Health Perspectives 117, no. 7 (2009): 1162
 Ibid, 4
 Nevin, Rick. “Monetary benefits of preventing childhood lead poisoning with lead-safe window replacement.” Environmental Research. 2008 Mar 106(3):4
 Gould, Elise. "Childhood lead poisoning: conservative estimates of the social and economic benefits of lead hazard control." Environmental Health Perspectives 117, no. 7 (2009): 1162
 Facts About : Maryland’s Lead Law Summary of Compliance Requirements Residential Rental Properties http://www.mde.state.md.us/programs/Land/Documents/LeadFactSheets/LeadfsStandardofCare.pdf