Economics of enforcement.

As one of its 467 objectives for improving the health status of Americans by the end of the decade, Healthy People 2010 calls for total elimination of elevated blood lead in children. That goal may be hard to achieve as long as thousands of older, mainly inner-city dwellings remain covered with deteriorating lead-based paint, the primary source of lead exposure for hundreds of thousands of children. But growing evidence shows that, while the cost of remediation may seem high, the cost of doing nothing is far higher.

Elevated blood lead can damage a child's central nervous system, kidneys, and reproductive system, and at higher levels can cause coma, seizures, or death. A strong link has also been shown between low-level lead exposure in early childhood and later decreased cognitive and academic performance. The Centers for Disease Control and Prevention (CDC) currently cites 10 micrograms per deciliter ([micro]g/dL) as its level of concern for blood lead; 25 [micro]g/dL is considered lead poisoning.

Many municipalities have lead paint abatement laws on the books, but the level of enforcement varies, as does that of abatement required. In areas with strict enforcement, failure to remediate lead-contaminated properties can lead to criminal charges, tort relief for victims, publication of the addresses of contaminated buildings, and notification of other tenants and mortgage- and lien-holders. In areas with laxer enforcement, property owners face little incentive to spend the money to clean up their buildings. Yet, a recent econometric study by Mary Jean Brown, then of the Harvard School of Public Health, showed that strict enforcement of lead abatement statutes reaps enormous dividends.

Brown's analysis was based on data she and colleagues collected in a previous study on the effectiveness of lead abatement efforts. That study, published in the April 2001 American Journal of Public Health, looked at 137 homes where children with lead poisoning had lived five years prior. Some of the dwellings were in an area with strictly enforced lead abatement statutes, and the rest were in an area of limited enforcement. In the area of limited enforcement, homes were 4.5 times more likely to house a child with blood lead above 10 [micro]ag/dL than were homes in the strict enforcement area.

In her cost-benefit analysis, published in the November/December 2002 issue of Medical Decision Making, Brown applied econometric modeling to those earlier data and found that the expenses incurred in inspection, abatement, medical care, and special education in homes in the limited enforcement area totaled more than $101,000 over 10 years. In homes in the strict enforcement area, the cost came to less than $57,000. "The cost of cleaning a dwelling of lead paint and dust may look expensive initially," says Brown, "but the research demonstrates that given the long-term costs to the families and to society of recurring cases of lead poisoning in buildings where children were lead-poisoned in the past, not doing anything to eliminate lead exposure is far more costly."

Lead poisoning expert Paul Mushak of the Durham, North Carolina, toxicology and risk assessment consultancy PB Associates calls Brown's research a valuable addition to the body of knowledge regarding the economic benefits of strict lead abatement. "This paper clearly has important potential implications for public health policy," he says. "There can no longer be any doubt that tighter lead paint controls are cost-effective.

Mushak's only criticism of Brown's work is that it did not incorporate a timeline accounting for the expected life of a house. Considering the realistic life of the house would only increase the overall savings of major abatement, he says, because the cost of abatement is loaded in up front and will not change materially. "If you extend [the timeline] out to thirty or fifty years for rental properties," he says, "it's going to be an enormous saving above and beyond what Brown has determined."

Mushak also notes that a 1988 Agency for Toxic Substances and Disease Registry report to Congress on childhood lead poisoning in America estimated that at least 10 successive sets of tenant children would likely experience lead poisoning in unremediated rental housing over 50 years.

Brown herself is now in a position to actively work toward the Healthy People 2010 goal. She recently became chief of the CDC Lead Poisoning Prevention Branch and has shifted her focus from research to action. "There are certain houses out there ... that are truly 'bad actors,'" she says. "We should identify them, and if we could either fix them or [prevent people from living in them], that would be an enormous primary prevention strategy."