In a recent opinion piece in the Detroit Free Press, David Fukuzawa of the Kresge Foundation suggests that improving the performance of Detroit’s public school children requires tackling lead poisoning. Federal and state funds to prevent lead poisoning have dropped, and the millions of dollars spent to improve Detroit schools “cannot succeed without improving the public health of the city’s children, especially young children.” Reducing lead exposure can be costly and complicated, but the payoff is worth it.

Even though the Consumer Product Safety Commission banned lead paint in 1978, housing-based lead hazards are the top source of lead exposure for US children. As Elizabeth Grossman noted in her recent piece about Gerald Markowitz and David Rosner’s book Lead Wars, more than 30 million US homes contain lead paint, and poorly maintained housing puts occupants at higher risk of lead exposure. (Exposure generally occurs by ingestion of lead dust, which results from peeling paint or friction of lead-painted surfaces like a window and sill rubbing against each other – or, from improperly performed renovation.) Children exposed to this potent neurotoxicant can suffer developmental, behavioral, and cognitive problems.

Housing and building codes often require lead hazards to be controlled, at least when young children live on the property in question, but enforcement is a challenge. Philadelphia, where 92% of housing units were built before 1978, was struggling with this issue in 2002. At that time, children with elevated blood lead levels were living in 1,400 properties for which lead remediation work had been ordered but not conducted. Then, the city developed a program – the Philadelphia Lead Abatement Strike Team (LAST) – that took a multi-pronged approach to reducing lead poisoning. A key component was improving compliance with lead-related health code requirements by establishing the Philadelphia Lead Court. In a recent article in the Journal of Health Politics, Policy and Law, Carla Campbell and her co-authors write about the Lead Court, which is a collaboration between public health and legal entities:

Health code enforcement was strengthened considerably with the November 2002 development of the Philadelphia Lead Court (PLC), a judicial court created specifically for cases involving property owners’ noncompliance with PDPH [Philadelphia Department of Public Health] lead hazard remediation orders under sections 5-301(b) and 6-403 of the Philadelphia Health Code … In preparation, judges hearing and city lawyers prosecuting these cases received training on childhood lead exposure and poisoning, its prevention, and treatment. Following an initial failed home inspection and a ten-day reinspection, a hearing is scheduled if the reinspection reveals noncompliance and lack of remediation plans. After the hearing date is set, the complaint is hand-delivered to the property owner, who is expected to appear in court or face significant fines. Occasionally, if work is not progressing, the judge can order the PDPH to complete the lead remediation at the owner’s expense.

Property owners appearing in court receive education about the importance of controlling lead hazards and the availability of grants from the US Department of Housing and Urban Development (HUD) and local low-interest loans to assist lower-income owners with lead hazard control work. In addition to receiving lead training, judges in the Lead Court can use preprinted court disposition forms to quickly designate the hearing results and next steps. Campbell et al explain:

The fifteen options, indicated with checkboxes, include giving the city’s health department permission to enter the property; ordering the owner to bring the property into full compliance prior to the next court date (with an option to order relocation of the tenants); authorizing the health department to enter and abate the property; authorizing the city to place a lien on the property for the cost of abatement expenses; imposing both conditional and absolute fines; referring the property to the Department of Licenses and Inspections; and declaring that the matter is discontinued and ended when full compliance has been achieved.

Owners could be fined for failing to appear in court or for failing to abate hazards as ordered by a judge, but one key informant explained to Campbell and colleagues that the fines were designed more to encourage lead remediation than to generate revenue:

‘‘The primary purpose of the fine was to be a hammer, to be an incentive to get the property owner to understand that they needed to do it [abate and remediate the property]. And so, for probably 95 to 98 percent of the fines, we eliminated them once the property was abated. It was not a moneymaker [or] anything like that. The primary goal was to get the owner to realize that that was going to be a real problem and we were not going away, that they needed to comply with the order. And once people got those fines and started to panic then we would make them understand that if they got it abated, we would reconsider those fines at the next hearing. And that almost always worked. So it was sort of a hammer that then became a carrot later on.’’

Of the 15 key informants the researchers surveyed, several suggested that having more funding available for lead abatement and remediation would be helpful. (Abatement either removes the lead-paint hazard or contains it for 20 years, while remediation is a less permanent form of control; so, properties remediated today may need further remediation after several years elapse.) The Lead Court program helps property owners access federal HUD funds and also uses local funds for program staff as well as remediation and abatement. One survey respondent suggested the average per-home remediation cost is around $15,000, which can be hard for homeowners to afford without assistance. While Campbell et al don’t go into detail about PLC costs, they do note that investing in lead control can lead to substantial future savings:

Jacobs et al. 2000 and Jacobs, Kelly, and Sobolewski 2007 reviewed various data demonstrating that the cost of lead hazard control work is far less than the cost of benefits reaped. They estimate the elimination of lead-based paint hazards in all high-risk US housing from 2000 to 2010 at $2.3 billion, with benefits estimated at least at $11.2 billion; these benefits would include the savings on medical care (for children with EBLLs [elevated blood lead levels]) and special education, the increased lifetime earnings based on improved cognitive ability, and the market benefits of improved housing.

Investing in programs like Lead Courts only makes sense if they’re demonstrated to be effective at achieving the desired outcome – in this case reduction of lead-paint hazards. In a study published in the American Journal of Public Health, Campbell and her colleagues investigate whether Philadelphia property owners complied with lead hazard remediation orders more quickly after the city launched its Lead Court.

Using data from the Philadelphia Department of Public Health, researchers created a data set of properties with an initial failed home inspection for lead hazards, plus one year of follow-up inspection data, during either the precourt period (1998 – 2002) or court period (2003 – 2008). The difference was striking: In the precourt period, only 6.6% of properties (106 out of 1,544) were compliant one year after the initial failed inspection, and only 18% were compliance four years post-inspection; in the court period, the one-year compliance rate jumped to 76.8% (1706 out of 2220). “The development of a specialized court as an innovative law enforcement strategy has been very effective in Philadelphia, markedly increasing the number of properties with lead hazards that became compliant after remediation work,” Campbell et al conclude.

The Lead Court model could help other cities with significant housing-based lead hazards, and it’s also a good reminder that it’s not enough to have good public-health laws if you don’t have sufficient enforcement. Having an adequate number of inspectors is necessary but not sufficient; the entire process also needs to work efficiently so that failed inspections quickly turn into abatement of the hazard in question. Providing carrots, like education and low-interest loans, in addition to sticks can also be helpful when the person responsible for abating the hazard has limited resources.

Given the childhood lead exposure can have lasting harmful impacts, funding lead abatement is a wise use of both federal and local funds. Of course, I’d rather see such programs funded by the companies that continued to use lead in paints long after they had evidence of its harmful health impacts. As Markowitz and Rosner explain in Lead Wars, though, appeals courts have overturned past verdicts against lead-paint manufacturers, and we’ll have to wait for the results of ongoing lawsuits to see if any lead-paint company will be held liable.