Lifelong consequences

Millions of California toddlers who should have been tested for lead exposure have not received state and federally mandated blood tests, in part because the health hazard—a particular threat to poor children—has not been prioritized by state public health agencies, according to a recent state audit.

In a searing review of a problem that has persisted for years nationally and in California, state Auditor Elaine Howle found some 1.4 million toddlers enrolled in Medi-Cal had gone untested for lead exposure over the past decade, and another 740,000 missed one of two required screenings—a failure encompassing nearly three-quarters of the 3 million toddlers covered by the state’s publicly funded health insurance program.

Federal and state laws require the state Department of Health Care Services to make sure blood lead level tests are administered to babies enrolled in Medicaid—known as Medi-Cal in California—when they reach the ages of 12 months and 24 months.

Testing is critical in the Medi-Cal cohort because studies show low-income children are most at risk of being exposed to lead via old paint, contaminated soil or air from lead smelters, tainted drinking water, industrial emissions and other lead sources. The Centers for Disease Control and Prevention (CDC) has found that no level of lead is safe—even low levels of lead can affect a child’s IQ and cognitive development and can damage the brain and nervous system.

“Many of these children live in areas of the state with high occurrences of elevated lead levels, making the missed tests even more troubling,” Howle reported.

The California Department of Public Health had data showing where lead exposure was highest, but failed to meet a statutory deadline for publishing it on its website, Howle wrote. Citing that data, the audit found that, between fiscal years 2013 and 2018, among children who actually did get testing, half of those found to have elevated lead levels were located in just 15 percent of the state’s Census tracts.

Democratic Assemblywoman Cristina Garcia, of Bell Gardens, said she is “disappointed but not surprised” that agencies failed to implement a law she and Assemblyman Bill Quirk got passed in 2017 that doubled down on testing and accountability.

“All of these issues are those that affect low-income communities, that affect our most vulnerable populations, and it concerns me that the agencies don’t prioritize these communities,” Garcia said. “We have no problem treating these communities, like where I live, as wastelands. All of this needs to change.”

The Department of Health Care Services agreed with most of the audit’s findings and promised to do more “to ensure that required blood lead tests are occurring.”

In a statement, acting Director Richard Figueroa said the agency expects to implement outreach campaigns by March to better inform Medi-Cal families about lead testing. By June, he said, managed plans will be required to identify all the children who have not been tested and remind their medical providers about the testing requirement. By the end of the year, Figueroa said the agency expects to have established a plan to improve and better enforce screening requirements.

Department of Public Health Director Sonia Angell also released a statement promising to take “corrective” measures, including releasing a map of areas with high rates of lead exposure, helping counties create plans to address the problem, improving oversight of local programs and enhancing data reporting and screening requirements.

The CDC defines an elevated blood lead level to measure 5 micrograms per deciliter—5 millionths of a gram per 3 fluid ounces. In California, the Childhood Lead Poisoning Prevention Branch defines lead exposure even more strictly, rounding up to 5 any measure above 4.5 micrograms per deciliter. A child is considered “poisoned” if he or she measures at 15 micrograms per deciliter.

“Because we know that lead has such harmful effects on kids and the impacts last a lifetime, the state has a responsibility to want to eliminate all exposures so kids are not exposed in the first place,” said Jill Johnston, assistant professor of preventive medicine in the Division of Environmental Health at the USC Keck School of Medicine.

Environmental activists have asked for increased testing and assistance over the years around state hot spots such as the former Exide lead battery recycler in Los Angeles or older neighborhoods in Oakland. USC’s Johnston agreed the state should focus on identifying crisis areas across California and work to eliminate community exposure.

“From a public health perspective, it’s a more broad prevention to reduce exposure to lead,” she said.

Others echoed the auditor’s call for more aggressive oversight and outreach.

“There is no enforcement mechanism, so the situation continues as is,” said Daniel Madrigal, a health educator for the Public Health Institute’s Tracking California program.

“Lead-exposure impacts on a child are irreversible,” said Susan Little, senior advocate for California government affairs for the Environmental Working Group, a nonpartisan nonprofit focused on environmental safety. “It is something a child will have to live with and that emphasizes the importance of preventing the exposure in the first place.”