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89–475 PDF 2003

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

(

COMMITTEE ON BANKING, HOUSING, AND URBAN AFFAIRS

PAUL S. SARBANES, Maryland, Chairman

CHRISTOPHER J. DODD, Connecticut

TIM JOHNSON, South Dakota

JACK REED, Rhode Island

CHARLES E. SCHUMER, New York

EVAN BAYH, Indiana

ZELL MILLER, Georgia

THOMAS R. CARPER, Delaware

DEBBIE STABENOW, Michigan

JON S. CORZINE, New Jersey

DANIEL K. AKAKA, Hawaii

PHIL GRAMM, Texas

RICHARD C. SHELBY, Alabama

ROBERT F. BENNETT, Utah

WAYNE ALLARD, Colorado

MICHAEL B. ENZI, Wyoming

CHUCK HAGEL, Nebraska

RICK SANTORUM, Pennsylvania

JIM BUNNING, Kentucky

MIKE CRAPO, Idaho

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

DEBBIE STABENOW, Michigan

JON S. CORZINE, New Jersey

CHRISTOPHER J. DODD, Connecticut

CHARLES E. SCHUMER, New York

DANIEL K. AKAKA, Hawaii

RICK SANTORUM, Pennsylvania

JOHN ENSIGN, Nevada

RICHARD C. SHELBY, Alabama

MICHAEL B. ENZI, Wyoming

CHUCK HAGEL, Nebraska

KARA M. STEIN, Staff Director

TEWANA WILKERSON, Republican Staff Director

(II)

CONTENTS

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)

(1)

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, longlasting 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.

2

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 leadbased paint hazards and the reduction of lead exposure. Title X defined hazard in such a way that it included deteriorating leadpaint, 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.

3

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.

4

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 lowincome, 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

5

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 administering 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.

6

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 leadpaint 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

7

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

8

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

9

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.

10

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 onetime environmental investigation of the primary residence when a

child’s test reveals elevated blood levels for lead.

11

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.

12

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.]

13

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 leadpoisoned, 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

14

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

15

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.

16

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

17

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.

18

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.

19

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.

20

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.

21

I think we can do better. The Federal Government is a manyheaded 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.]

22

The Lead-Based Paint Poisoning Prevention Act, which I think

we instituted in 1992, established procedures to eliminate leadbased 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

23

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

24

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.

25

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.

26

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 proVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 89475.TXT SBANK4 PsN: SBANK4
27

gram 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:]

28

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.

• Why are only 20 percent of children enrolled in Medicaid being screened for lead

poisoning, when Federal law requires that all children be tested?

• If a child tests positive for high levels of lead in their blood, why aren’t their

homes being reported and screened for lead?

• Why hasn’t the Environmental Protection Agency promulgated regulations on the

safe renovation and remodeling of housing containing lead-based paint?

• How many new cases has the Department of Justice filed against landlords who

are violating laws designed to protect tenants from lead poisoning?

• 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.

29

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 leadbased 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

30

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 bloodlead 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

31

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 leadbased 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 leadbased 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.

32

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 leadpaint 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 upperincome 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 Federallyassisted 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:

• 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).

• Linked lead safety to other children’s health hazards that may be caused by underlying housing conditions through HUD’s Healthy Homes Initiative.

• 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.

• 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 leadpaint abatement in over 158,000 high-risk dwelling units, as well as two criminal

convictions against landlords who failed to comply).

• 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).

• Conducted research to reduce the cost and increase the effectiveness of hazard

identification and control technologies.

33

• Completed the inspection and risk assessment of tens of thousands of units receiving HUD Section 8 project-based subsidies.

• Paid for clearance testing in public housing and in HUD-funded rehab programs

covered by HUD’s lead-safe housing rule.

• Performed public education and outreach services through private sector organizations such as Sears.

• Has been recognized by the Office of Management and Budget as an ‘‘effective’’

program.

• 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.

34

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.

35

This public health problem was the genesis of the Federal Residential Lead-Based

Paint Hazard Reduction Act, 42 U.S.C. § 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. § 745.100 et seq.

With regard to civil enforcement actions, the Act authorizes EPA and HUD to as- sess 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. § 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. § 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. § 3571(b)(5) and $200,000 for an organization, 18 U.S.C. § 3571(c)(5), per count, or the greater of twice the gross gain or loss.

18 U.S.C. § 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

36

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 communitybased 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 leadpaint 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 ColumVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6621 89475.TXT SBANK4 PsN: SBANK4
37

bia 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

38

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.

—————

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, multipronged 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

• On March 6, 1996, EPA, together with HUD, promulgated the Residential Leadbased Paint Real Estate Disclosure Rule (Toxic Substance Control Act (TSCA)

§ 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.

• 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 § 402(a)). This rule ensures that a well-trained cadre of lead inspecVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00042 Fmt 6633 Sfmt 6621 89475.TXT SBANK4 PsN: SBANK4
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tors, 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. • On June 1, 1998, EPA promulgated the Pre-Renovation Education Rule (TSCA

§ 406(b)). This rule implements a very simple concept: All owners/tenants of pre1978 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.

• On January 5, 2001, EPA promulgated a rule on the Identification of Hazardous

Levels of Lead in Dust and Soil (TSCA § 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:

• 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.

• Development of materials, such as brochures and sample real estate disclosure

forms, needed to comply with regulatory requirements.

• 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.

• 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.

• 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:

• Technical studies, including risk assessments to support regulatory decisions.

• Reports on lead testing and methodologies.

• 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 comVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 89475.TXT SBANK4 PsN: SBANK4
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munity 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.

—————

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 DisVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6621 89475.TXT SBANK4 PsN: SBANK4
41

ease 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

42

(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 leadbased 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 Chairman Reed for his leadership regarding this issue. I look forward to answering your

questions.

—————

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 collaboration between CDC, CMS, HUD, EPA, and DOJ that has formed around this

43

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) (≥10μg/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

44

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 HighIntensity 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

45

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 atrisk 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.

46

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 leadsafety 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 leveraging lead hazard control and rehabilitation funding with the Department of Energy’s weatherization funding)?

47

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 leadsafe 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 leadbased 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

48

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

49

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.’’

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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 dustlead 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 regulatory 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 facVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6601 89475.TXT SBANK4 PsN: SBANK4
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tor 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 application 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

52

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 highrisk 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

53

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

54

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:

• Allow Sampling Technicians to conduct nonabatement clearance

testing according to Housing and Urban Development’s (HUD)

requirements.

• Permit trained and/or certified sampling technicians to perform

sampling to identify lead contaminated dust.

• Encourage accredited training programs to offer this course.

• Develop a plan for upcoming legislative sessions that would address the incorporation of the Sampling Technician discipline in

their authorizing legislation.

• 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:

• Press Release distribution and announcement on EPA’s website.

• Release and distribution of a 403 Rule Fact Sheet through EPA’s

toll-free nationwide hotline and website.

• Notification of all other Federal agencies, and State and tribal

governments.

• 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.

• 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 pamVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6601 89475.TXT SBANK4 PsN: SBANK4
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phlet 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 leadcontaminated 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:

• 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.

• Undertaken mail-out campaigns to licenced real estate operators

to make them aware of the Rule.

• Attended national real estate meetings to train people.

• 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

56

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

57

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 (μg/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

μg/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 μg/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 μg/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 μg/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.

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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:

• Targeting high-risk communities.

• Having material available in languages other than English.

• Working extensively and cooperatively with other Federal partners such as CDC, HUD, USDA, and the Administration of Children and Families (HHS).

• Funding community-based organizations to provide education at

the grass roots level.

• 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?

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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

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cess, 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.

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Clearance testing is still the best indicator to ensure that dustlead 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 bloodlead 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 deterVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00065 Fmt 6633 Sfmt 6601 89475.TXT SBANK4 PsN: SBANK4
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mined 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 highrisk 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

63

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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67

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

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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 ‘‘Recommendations 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

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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 onetime 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

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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 implications 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.

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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 leadpoisoned 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.

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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

73

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 highrisk 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.

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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 μg/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

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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 literature 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?

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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:

• California has implemented a lead-related construction accrediation and certification program that provides individuals who

are certified to conduct residential lead inspections and risk

assessments.

• 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.

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• 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.

• The Houston CLPPP staff is working on a plan to work with

ClearCorps to receive referrals for homes that require hazard

reduction.

• 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 bloodlead 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 remodVerDate 11-MAY-2000 14:24 Sep 26, 2003 Jkt 000000 PO 00000 Frm 00081 Fmt 6633 Sfmt 6601 89475.TXT SBANK4 PsN: SBANK4
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eling 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 highrisk 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?

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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.