Document RaEVrqmbrGxVr9Ddyv9Nr0k3a

Yale University New Haven, Cohiuci'.cut 06 51 o March 12, 1971 SCHOOL- OF MEDICINE Depit: 'meat, of r.jiideinioJogy and /'. Hie //r.;/;b ' SoGdlegeSfreei - Dr. Jerome Cole Manager, Environmental Health International Lead Zinc Research Organization, Inc. 292 Madison Avenue New York, New York 10017 v Dear Dr. Cole: As you may recall, 1 discussed a proposed research project on Family Opera tional Factors in Childhood Lead Poisoning with you about a month ago. In accordance with your suggestion, I'm enclosing a research proposal on this subject. Since our conversation, I've been in touch with Dr. Bernice Clark at the Social Rehabilitation Service of the Rehabilitation Service Administration in Boston. Dr. Clark has asked me to submit.a proposal encompassing demon stration as well as evaluative research. The outline I'm sending you covers the first two parts of this larger program. Not included here is the third part, involving social and vocational rehabilitation which we are planning with our New Haven. Rehabilitation Center. You will see that the budget is considerably larger than the figures I had in mind when I discussed the subject with you. About half the excess is explained by institutional overhead including fringe benefits. The other expenses are for conducting the field survey that seems essential if we are to answer satisfac torily the question whether family operational stresses are as important in caus ing childhood lead poisoning as they were indicated to be in our preliminary study. The total cost estimate for the two year project to test the hypotheses about family operational stresses is approximately $60,000. I should appreciate consideration by ILZRO of support for half of this amount over a two year period. If your Directors wish to explore this project further. I'll be glad to provide more information. There are several steps we would need to take in relation to a formal application, but informal conversations with our administrative people in dicate approval for use of University resources to carry out the work. With best regards, , Sincerely, JWM :.ctp Enclosure J. Wister Meigs, 'M.D. Assoc.'Clin. Professor of Occupational Medicine N11679 Family: Operational Factors in Childhood Lead Poisoning Proposal, for Evaluation from Records and Field Survey I. Background Statement Childhood lead poisoning has aroused increasing public and professional interest, concern and controversy in recent years, In New Haven and other cities there have been emotional confrontations between citizen groups and public officials, especially health officers. A major demand has been that health officers should see to it that young children not be permitted to continue living inhouses with lead available to them in paint or piaster . of window sills, railings, moldings or wails.. Pressure has also grown to legislate against the inclusion of lead in either interior or exterior paints for any uses except specialized,commercial applications. ' Experience with occupational lead poisoning offers guidance and hope for dealing constructively and rapidly with the childhood syndrome without .immediately changing the total amount of lead in the environment, to any signi ficant degree. This is not to suggest abandoning efforts to reduce hazardous lead in childrens' environments. But that task is enormous and can't con ceivably be accomplished quickly. The lesson from occupational health is that numbers of eases of lead poisoning in workers, have decreased concurrently with increased production and processing of lead. The explanation of this paradox is that the operational characteristics of man-machine systems have been, arranged to maintain minimum and usually.safe degrees of contact between workers and potentially toxic quantities of lead. Particular approaches have been selected and modified periodically according to cost-benefit estimates that take account of employee attitudes, and behavior as well as physical:, chemical and engineering aspects of the problem. Hie proposition that occupational health philosophies and methods.should be applied to the childhood lead poisoning problem is based on several assump tions. First, that children at high risk for lead poisoning live in a setting in which interested third parties have some potential for controlling the chidrens' behavior; second, that'.significant operational differences can be identified between families that experience lead poisoning.among their children, and those that do not; third that such operational differences indicate probable behavioral, psychosocial and/or economic causes for development of the syndrome; fourth that th ese probable causes are amenable to control; fifth, that the ser vices needed to help families deal,with their operational problems are available sixth that funds- are forthcoming to permit these families to use the services. There Is evidence to support the first assumption. The same houses in which children are currently experiencing lead poisoning in New Haven have been the homes of previous generations of children in other families. These former child occupants have not experienced significant lead poisoning. The second . assumption was the subject of preliminary research, (attached hereto) that identi fied operational differences.between families with and without lead poisoning in N11679.01 comparably agbd children.. This. research also incli cated that some, differences' were probably causal, that the causes might be controlled and that some of the needed services were available. With respect to funding, public concern over childhood lead poisoning has forced, governmental expenditures: to identif} high risk through urinary and blood screening programs; to hos pitalize children with even minimal acute or chronic manifestations of lead poisoning; to put high risk children in "half way houses" after treatment and de-leading in hospitals; to rehabilitate houses with large amounts of lead i. available to children in walls, railings, window sills etc; and to relocate [ high risk families in lead free housing. . 1 Public expenditures to prevent childhood lead poisoning: through housing improvements alone haven't been very effective. 5 Families in' poor housing with lead poisoned, children have been moved; to costly rehabilitated.' housing i; `only to get into further trouble with recurrent lead poisoning and housing , problems. Our preliminary research results show why this might happen and suggest that funds spent on job training for fathers, day care for. young children and counseling for families, coupled with limited essential housing assistance, might prevent recurrent lead poisonipg at less cost than the total relocation of families into lead-free houses and districts. Our re- ' . suits indicate further that such measures 'should eventually pay fox themselves through increased productivity of parents and children, whereas housing im provements alone would have far. less and perhaps no long term rehabilitative value for the families. A copy of our report of preliminary.research is attached. In summary, we found: that families of children with lead poisoning, when compared with other families whose,children were hospitalized for other illnesses during the. same period, showed more marital separation, fewer fathers working, more mothers working, more children at home, more evidence of family problems, more evidence of maternal deprivation in the index child and more inadequate housing. Most of the lead poisoned children were black, and the data showed., that black families differed from; white families in the directions, described, but the differences were significantly greater in black families with lead 'poisoned children than in black families whose children were hospitalized for Other reasons. We believe the data support the view that underemployment, know to be more'prevalent"among black than among white men, tends to put black famil under operational stresses, and that when additional stresses are added such as marital discord or large numbers of children to .manage in marginal or in adequate housing,; families fail to operate efficiently and problems such as childhood lead poisoning are likely to follow. II Purposes of Proposed Study-Demonstration The first purpose of the proposed study is to extend our preliminary in vestigation, to learn whether the results on childhood lead poisoning during a limited time, period of 1969 at 'Yale-New Haven ''Hospital were comparable to EPI 000450 other time periods at the same hospital and to the experience at other Connecticut hospitals in recent years. The. second purpose is to conduct a field: survery to learn whether the family operational conditions that were associated with the hospitalized lead poisoning patients; .are associated with higher than expected, lead ingestion in young children of a representative ; sairp:le 'of; inriergeity-families . Ill Methods of Study and Expected'Results The research methods used to try to replicate the preliminary study . will be essentially the same as. those used previously. Families. with children . hospitalized for lead poisoning will be compared with families whose children were admitted during the same time period for other diagnoses. Efforts will be made to use effective epidemiological techniques to minimize the variety of possible biases involved in making these comparisons. Records from other Connecticut hospitals as well as additional records from Yale-New Haven Hospital will be used. The field survey is planned with primary cooperation.from the staff of the Newhallville Mental Health Project, through their Executive Director, Mrs, Margaret Leslie. We expect to work closely also with staff of the New Have:- Health Department and the United. Newhallville Organization in field work of,interest to them. A basis for cooperation is. suggested by a community survey for childhood lead poisoning carried out in the summer of 1970. The Newhallville Organization, the Mental Health Project, the.Health Department and a number of private pediatricians as well as staff of Yale New Haven Hospital worked together. In the`Newhallville area, 104 children living in poor housing were examined. ' Blood lead levels of 0.04 mg/lOOgm or higher were found in 22. The highest level wras 0.075 and 8 others wfere 0.05 or more. This information gives a basis for the anticipated survey method, when coupled with the know ledge that about 750 of the estimated 10,000 residents of Newhallville are under 5 years of age. IVe plan to select several high risk, medium risk and low risk areas, to yield a 20-25% sample of children under 5. Every family in each area will be visited to identify their health needs and problems, with special em phasis on mental health and family operational characteristics that might in fluence the childhood lead poisoning risks. This special program will be consistent with purposes of the;Newhallville Mental Health Project, and should be acceptable to local residents, who have been instrumental in establishing that Project and recommending personnel to operate it. Families with young children will be asked to take part in screening pro grams to determine amounts of lead in blood. The Tesults of such screening wl 11 be correlated with survey information to test the hypothesis that families;under severe operational stresses, i.e,: father not working; marital problems; mother working; large numbers of children at home; housing problems; welfare problem:-, should have more cases of excess lead ingestion among the children than other families. An additional hypothesis will also be tested: that families with operational problems will have excess numbers of children with other pediatric difficulties. ,c EPI 000451 : . - . -..4. IV Estimate of Project Staff Needs ,The "hospital-record study and the<field survey will be directed by J. Wister Meigs,. M.D., Assoc. Clinical Professor of.Occupational Medicine. The major cork of the project will be carried out by Mrs. E.L. Elaine Whitmire, B.S., M.P.H., Research Associate. Secretarial help will be needed on a half time basis ,!, partly in 'the-medical center and partly at Newhallville.Mental Health Project. In addition, the field work will require a part time staff services, including overhead, at the Newhallville Project. Statistical services will also be needed. V Budget Estimate First Year Personnel Project Director - J. Wister Meigs, 7.5% Research Associate E.L. Elaine Whitmire, 100% Secretary - Dept. Epid. 8 Public Health Sub-total Yale personnel Fringe benefits 16.6% x 11,500 (faculty salaries) Fringe benefits 6.8% x 1,500 (non-faculty salary) Institutional overhead @ 60 x 13,000 (total salaries) Total personnel ' Statistical services Coding and keypunching Computer time Consultation Sub-total statistical services ,. Supplies, postage Telephone Travel (record work in Hartford) "' Services, including overhead, purchased from Newhallville Mental Health Project Staff services Secretarial Office space V.:. .' Xy. b.'dv. y . .1 1,500 10,000 1,500 13,000 1,909 102. < 7,800 2.2,811 1,500 250 250 2,000 . .200 200 300 5,000 2,000 500 7,500 lead poisoning -'survey costs 200 blood lead determinations:@ $10 Transporation of children to and from screening, 4 mornings @ $50 Recruiters to bring children _. / 10/morning @ $6, 4 mornings j Physicians`to .draw,blood j 16 hr. @ $15 '. . ` . ' ;` : " 2,000 200 * 240 240 2,680- Equipment Portable lead survey meter rental . 500 Budget re-cap Personnel Statistical services Supplies .. - Telephone Travel- , Services purchased 1 'from Newhallville Blood lead survey Equipment rental 22,811 2,000 200 200 300 7,500 2,680 . 500 ' ', \ 36,191 2nd year budget estimated at $36,000 of which about 2/3 would be used to complete. the, .field.work, data processing and analysis,and 1/3 would be for evaluation of an on, going social and vocational rehabilitation program for families identified by the field survey. Therefore the estimated total cost for identifying and , evaluating:family operational factors In,childhood lead poisoning would be $60,000 over the two year-period. / EFi 000453 4 ^/Epidemiology of Lead Poisoning in New Haven Children Operational Factors. J. IVistcr Meigs, M.D. and E.L. Elaine 'Whitmire, B.S. Introduction , Childhood lead poisoning is caused, in New Haven as elswhere, by lead. If lead doesn't get into the system of a child in toxic amounts, he cannot develop lead poisoning. Despite the unassailable logic of these statements,, there .are other etiological factors in the syndrome. Occupa tional health and safety;experience may offer, useful comparisons. Industrial managers and their health;and safety advisers must design and engineer work systems;to maximize the probability that all employees will work'safely in spite of potentially hazardous conditions. By analogy, the raising of * children is a complex task, with operational components. Childhood lead poi soning may result from malfunction of the systems in,which certain children live. The mothers are the major contributors to successful child rearing, therefore the operational problems of mothers should be studied systematic ally. Perhaps the mothers of lead poisoned children arc like overloaded telephone circuits that give a busy signal. This study was designed to test the hypothesis that childhood lead poisoning was significantly more common in families with operational problems that impaired the ability of mothers to perform some of their child rearing tasks. A .Brief Review Chisolm has described the circumstances under which lead poisoning occurs in inner city children. The key elements are a young child-a N11679.02 2- - . toddler witli exaggerated oral tendencies; a mother with inadequate re-' sources'to.cope with eher multiple; problems; and a housing unit with lead-containing paint or plaster within reach of the child.'*' Recurrent 'lead poisoning in children returned to their oldenvironments has led to recommendations for long stays in halfway houses. 2 ' 3 Persistent pica.is often a reason, although this symptom is uncharacteristic of other kinds of childhood poisoning.^ The psychological, socioeconomic and geographical associations of pica were reviewed recently.-- Operational problems in families where children had both pica and lead poisoning have been mentioned^ for example, the tendency of families with lead poisoned children (most.of whom had pica) to have more than four children in the household. 6 7 Black children with pica* have been compared with agd and race matched controls. The pica families averaged 4.2 children compared g to 3.3 for the controls. ... The disproportionate occurrence of childhood lead poisoning among black families in the United States is often accepted -without' further in quiry except into the housing coalitions of thesefamilies although: a . kg' disproportionate.incidence in minority races was recorded in London also. One author noted "the larger community factors that are operating" to cause childhood lead poisoning. . . ."the. .:. .racism that permeates our entire .society- both in attitude and, more important , in behavior 'toward-, specifid groups of people who are thereby commitied to closed, poisoned housing." '* The general term racism does not identify specific operational factors Systematic analysis of recent experience in New Havenwith childhood lead poisoning, which has occurred chiefly in black children/ should giro a valid . EPI 000455 -3test .of. the hypothesis t'nat family'operational problems can cause the condition to develop. jf SOj prevention might be made easier. a :"v. ;V-Materials and Methods Paired Comparison Samples: The data for these samples were taken from the records of patients in the Yale-New Haven Hospital from 1968-1970, Patients admitted because of excessive loaf absorption (Diagnostic code #961.1) were matched against others admitted during the same general time period with two other conditions, inguinal he-rhia, treated surgically (code 560.0) and pneumonia (code .493.9). Seventeen patients with lead poisoning aged between. 12 and 47 months were matched by sex, and by age..within. 4 months, with 17 patients wTith inguinal hernia and 17 with pneumonia. All patients had been admitted between 4/2/68 and 2/12/70. Tlie .patients with lead poison ing were from the same 17 families for the 2 sets of comparisons, but a . "brother and a sister were used for. a hernia and a: pneumonia pair respectively Information was sought about the; following indicators of family opera tional characteristics or problems; intact marriage, divorced. Separated, never married;, work status of father and mother; quality of .housing; private medical insurance, vrelfare or oilier public insurance; presence or absence of a formal Social Service Department report; number of siblings under age 19 in the home in addition to tlu patient; presence of major chronic illness in the patient; death or severe illness of near relatives; maternal depriva tion of the patient; and the span fie diagnoses for "the particular admission, Clinical and laboratory, inform"-;'on about lead poisoning cases was noted in detail. PI 000456 .. . . -4 -. Results of Matching Pair Comparisons ' Table ,1.: lists .demographic am! operational characteristics, of the, families ''selected, for matching. - Among lead poisoned patients, the median age was about a yearhand a half!; Slightly more than half were-males, more than four fifths were black. Less than half of the families had a father .. in the home and almost one fourth of the mothers were working. The mean, . number of.children at home was 4.6. Six families had persons other than the mother responsible at home for the management of the of the. lead poison ing patient. The quality of housing -was poor for 14 and only average for the remaining three families with'-lead poisoning.. If there, was. no specific, housing quality report in the record, evaluation was based on inspection of the outside of the dwelling by one of the authors. Eleven families v.-ere re ceiving welfare payments and 14 had significant family operational problems in addition to trying to manage a lead poisoned child. The mean number of diagnoses per patient for this admission was a little.over 2 1/2. The families whose children had hernia or pneumonia were predominantly white,.'-.with: intact'; family' units and fathers who were working. The mean number of children at home were 2.2 and 2.9 for the hernia ana pneumonia families respectively. Almost all mothers were the principal supervisors of their children. More than half the housing was good and less than 1/5 was poor. Five of the,hernia, and one pneumonia family received welfare payments and , . only two families, both in the hernia group had serious operational problems as listed in the medical or social service report. The mean number of diag noses per patient, a cr'udb-indicator, of the severity of the patient 's - management problems was less than for lead poisoning in the hernia group and more in the pneumonia group. . *4 EPI 000457 Table 1. : Demographic and operational factors in ."fa toilies,of children selected, fox matching sets, admitted for lead poisoning, inguinal hernia and pneumonia, Yale-New: Haven Hospital 1968-70 Hospitalised, children : Age selected for matching I by age and sex 2 ''. 3 , . Sex M 'F Total families Racial-ethnic Spanish-speaking Black White Marital status Intact Separated Never: married ' . Parental employment. Father Mother `, , ' . ? ; Children per family Supervision of index , child , Mother Older 1 rel. Sibling , Sitter Quality of housing Good Average Poor Welfare recipient Family; problems. Number of diagnoses. this admi.ssi on . Lead poisoning # Inguinal.; hernia # Pneumonia # 8(9) 7 2(1) 89 77 2 f1 9(10) 8 ( 7) 17 2 14 1'" 9' 8 17 1 4 12 10 7 17 1 "2 14 x2 p 23.6 . ..001 ",. 6 7 12 2 15 1 > 4 3 1- 11.4 .03 6 4 4.65 PC.02 12 : K o( 2.18 (PC.05) 2.88 8.7 .02 8.7 .02 11 4 1" 1 0 3 14 11 14 45 (46) 16 0 0 1 10 4 3 5 2 27 , 17 0 0 0 12.5 .05 10 4 2 22.6 .001 1 .13.4 ' .002 0 31.3 .001 . 5S Numbers in ( ) apply to load-pneumonia pairs'-. EPI 000458. Table 2. Numbers of patients (total and detailed samples) discharged from YaleNew Haven Hospital, April 1-September 30, 1969, by Sex and RacialEthnic Classification. Racial-Ethnic Classification Sex Male Female Total Sample Detailed Total Sample Sample Detailed Sample Both Total Sample Detailed Sample Spanish-speaking Black White t- 9 33 139 9 4 ' ; 4 33 28 28 68 102 46 13 / 61 241 13 61 114 All 181 110 134 78 315 188 000459 Table3. Demographic and operational factors in all Spanish-speaking (S.S.) black ..(B) and a sample of white (W) families with children aged 1-3 years discharged from Yale-New Haven Hospital 4/1/69 - 9/30/69. . S.S. B. W. All ;. It ## X2 P Hospitalized children M 9 33 68 110 by sex F 4. 25 46 75 Total families Operational factors Marital status # with information Intact Divorced Separated Never married 13 58 .114 ' 185 13 9 0 3 1 58 31 0 11 , 16 107 100 3 3 1 178 140 3 17 18 ' 49.3 .001 Family size # with information. Mean S children/famlly Parental occupation # with information Father at work Mother at work or school Social Service #with information # formal reports Severity of case # with information # with major chronic .disease Insurance status # with information Private `Welfare Both 12 3.58 . 53 3.21 89 2.77 13 10 2 i 13 4 58 29 12 * .58 24 . 107 100' 2 114 10 154 2.99 178 139 16 185 38 BvsW .05 A 41.6 17.0 .001 .001 26.0 .001 13 58 114 185 .V /. . 1 9 34(27*) 44 y- 13 58 106 177 5 31 93 129 ` 8 27 7 42 0 06 6 46.0 .001 . (*) Adjusted figure to correct for sampling method. / 4 EPI 000460 Chi square analyses for marital status; supervision of the patient; employment of father; employment of mother; racial-ethnic; welfare recipient; family problems; and quality of housing all showed significant deviations from expected distributions. The mean number of children in families v/ith lead poi soning was significantly greater than in the families whose children had either hernia or pneumonia. These results demonstrated important operational differences between fami lies of children with lead poisoning and other families, however the high propor tion of black children with lead posioning raised the possibility that black families in general might have operational problems like those of families with lead poisoned children and different from what would be found among white fpiilic Accordingly, we studied a second sample. ' Study of Families of Black, White and Spanish Speaking Children Hospitalized for all Causes. Charts of all patients listed as age 1, 2 and 3 in the hospital diagnostic file for the period 4/1/69-9/30/69 were examined. Charts of all 61 black (B) and 13 Spanish speaking (S.S.) children were analyzed in detail. A stratified random sample of charts of 241 white (W) children were also examined in detail. This sample included all 33 W children with 3 or more discharge diagnoses (Dx) 35 of 70 with 2Dx and 46 of 138with 1 Dx. Three charts were unavailable and one list ing was incorrect. ` Table 2 lists the samples by sex and racial-ethnic classifications Table 3 summarizes selected demographic and operational factors in t'ye sample by racial-ethnic groups. This shows significant differences between black and white families with respect to the proportions of intact marriages, parental employment, families receiving welfare payments and patients for whom formal social service reports were made. Despite the significantly greater than expected social service workups for black children, there were proportionately fewer of them with major chronic diseases than among white children. After :. . 'V " e f t , ooo46i 6 adjustment of results among white children to take account of 33f and 50% samples from patients with one Dx and two Dx respectively, the trend remained but was not statistically significant. Trends among the small number of Spanish speaking families were somewhat similar to those among black families. Where siblings were identified as being in the hospital during the study period, their familieswere counted only once. The black children with lead poisoning included three sets of siblings, there fore the total black families in Table 3 is reduced to 58. Table 3 Confirms the confounding effect of racial-ethnic difference on the comparison of family operational problems in relation to lead poisonging. It establishes the baseline for the final analysis, namely the operational characteris tics of black families with children hospitalized for lead poisoning comj/ared writh black families whose children were admitted for other diseases. The characteristics of all the lead-poisoned children can be summarized as follows. There were 18 black children from 15 families, one Spanish speaking and one white child. Age range was from 13 to 40 months. Nine were males and 11 were females. Blood lead levels were determined in all cases. The number of determinetions per patient ranged from 1-18 for black children. The white child had one de termination which was normal (0.015 mg Pb/100 gm blood), the Spanish speaking child had two, with a high of 0.07 mg Pb/100 gm blood (mg , and the black children all had at least 0.04 rag% on admission, with highest values ranging from 0.04-0.185' mg%, with a median of 0.08 mg%. The sources of lead were all believed'to be from paint, plaster or other materials available for the children to chew or eat. Excessive chewing or.eating of foreign materials was noted in 10 patients. In several of these, older relatives had provided clay. Since many patients were under 18 months of age and some observers refuse to diagnose pica before that age, pica was hot used as a factor in statistical comparisons. EPI 000462 Table 4. ,... . - : .. . /, Demographic and operational factors in all black families with children aged 1-3 years discharged from Yale-New Haven Hospital 4/1/69 - 9/30/69 "lead poisoning" vs. "all other diagnoses." Children Lead poisoning All other diagnoses Total Hospitalized children M by sex and age F Mean age in mo. # Mean age in mo . ,# ;. ' 8 21.6 7 21.1 25 31.0 18 28.8 33' 25 : r. Families Total families Lead poisoning # : .% / 15 100 All other diagnoses #% 43 100 Total #% 58 100 x2 P Operational factors Marital V Status 1 Intact Separated Never married Parental occupation Father at work Mother at work or school Social service report - .5 6 4 6 v7 11 33 40 27 40 47 73 26 60 5 12 12 28 23 53 5 12 13 30 31 5j3 11 19 16 29 6.4 .05 29 50 n.s. 12 21 6.3 .02 24 41 6.8 .01 Major chronic disease in index child 2 13 7 16 9 16 n.s. Maternal deprivation in index child Private insurance Welfare 12 80 7 47 8 53 6 14 24 56 19 44 18 31 19.7 .001 31 53 27 47 n.s. Family size # with information Mean # children/ , ` family 15 4. 33 38 2. 76 53 3.21 ;os Quality of housing it with information Good Average Poor 15 100 33 100 00 26 0 0 .... - ... 10 .30 15 100 21 64 . 48 2 _____10 56 100. 4 21 75 7.2 .05 EF'l 000463 - In illustration of the operational problems of these families, the re cord of one described the separation of the parents, and the mother's disapproval of visits by her .husband. She was away from home from 9 AM to 6PM in. preparation, to become self supporting and get off welfare and was under great pressures. She had had notable weight loss. She believed that eating dirt was normal for chil dren but discouraged them from eating paint. For other families, notes on family structure and relationships indicated serious.interpersonal problems between husband and wife in all cases except where the mother had never married. Table 4 shows that families of black children with diseases other than lead poisoning were significantly less likely to have a mother separated from her husband, or at work- or school, or to have had a social service report in the re cord, or to have had as many children in the family, or to have had poor housing. In these housing comparisons, all judgements were based on residence area and external appearanQe of the house, since no other information was available for non-lead poisoning cases. The children with diagnoses other than lead poison ing were less likely to have suffered from maternal deprivation. There were non-significant trends toward more working fathers and fewer families receiving welfare payments in the non-lead poisoning group. Discussion These findings encourage further study of childhood lead poisoning from the occupational health viewpoint that demands objective analysis of the 8 operational system as a prerequisite for prevention of injury and disease. Before pursuing this viewpoint, however, one should appraise the reliability of the data. Age, sex, race and insurance status of all patients were deter mined independently of diagnosis. Marital- and occupational status of parents and family size information should not. have been biased in relation to diag- nosis, although sometimes incomplete for patients with minor illnesses. Housing comparisons were objective. Social service workups and estimates of maternal deprivation in the index child may have been more common in lead poi soned children than in- others because of hospital staff concern. Sufficient ,> ' bias to invalidate the results seems unlikely. The differences between black and white families in this small sample are similar to black-white differences, noted in U.S. Census and other reports. The view that malfunctions of family operation maybe important under lying causes of childhood lead poisoning is consistent with studies on work performance by iVelford 11 and others 12 . When subjects are gi.ven- i.ncreasingly complex tasks their efficiency decreases. "Especially in cases where family or social demands are greater than the individual's ability enables him to meet, there is likely to be. frustration and conflict which may lead to the; disruption of efficient performance." "* Ihe black families with lead poisoned children would fit this model. They share with all black families a greater probability that the father will not be working, or if working, will be-working at a lower economic level than his white fellow citizens. The lead poisoning families have added to these performance handicaps the further pro bability of marital problems and separation, more children to be cared for. EPI 000465 9- and a mother away from home..' Maternal task performance should be improved by providing these families with a range of family, job, and housing services through a coordinated team, analagous to the rehabilitation team; The com bination of day care for older children, or the patient if indicated, counseling for the parents, job training for the father and housing assis tance would need to be offered in ways that would continue long enough to have a .reasonable chance of success. , -- The differences between black and white citizens in marital and family status, occupational activities and housing opportunities have prac- ' tical significance for preventive medicine. An operational vIewpoint~would explain why a few years ago, there were only sporadic cases of lead poison ing among white -children who lived in the same houses that are currently associated with childhood lead poisoning in black children. Furthermore white children living today in houses with lead available for them to chew have a far lower incidence of lead poisoning than black children. These white mothers have a range of operational assets not available to large numbers of black mothers. Ihere is no evidence to suggest that they are ''better" mothers in any biological sense. The limited information in the literature about family situations among white children with lead poisoning suggests that operational problems are major determinants there also.. Employment and housing opportunities must be provided for racial-ethnic minority groups with parti cular attention to black people, if we are to prevent the kinds of family .breakdown that create the climate for childhood lead poisoning. In the meantime the health professionals must demand the specific and often costly C* ` EPI 000466 .. services required to treat, rehabilitate, and prevent recurrence in the families suffering from this complex disorder. Summary Childhood lead poisoning in New Haven was studied from the standpoint | of operational characteristics of families whose; children had the condition. : A sample of families with lead poisoned children was matched by age and sex against families with children with two other conditions, inguinal hernia ; treated surgically, and pneumonia. Families with lead poisoned children "!' were: significantly more likely than the matched control's to: be black; have ; marital separation; have a father unemployed; have a mother employed or at I school; have more children in the family; have the index child supervised by someone other than the mother; to live in poor housing; be a recipient of 'public assistance; have serious family problems. A second sample, drawn from 'all children hospitalized from April-September 1969 was studied similarly. i.Black'families in general differed from white families with respect to the foregoing variables.' Within the group of 58 black families those with lead ipoisoned children differed significantly from all other black families and in rthe directions previously described. It is concluded that black families gen erally are coping with operational problems that are significantly less .iprcvalent among white families, When the overload becomes too great childhood . lead poisoning is likely if children have access to lead. Control of this [syndrome will require attention to family operation as well as improvement... of-.. . the physical environment. .. i -* References 1; Chisolm, J.J., Jr. and Kaplan, E. Lead poisoning in childhood- comprehensive management and prevention. J. Pediatrics 73:942-50. December 1968. ' .' . .' 2. Barltrop, D. Lead poisoning in childhood. Post Grad. Med. Jv `44:537-48, 1968. `. 3. Greengard, J., Zollar, L. and Sharifi, M. Medical progress in the ' - prevention of childhood lead intoxication. , Illinois Med. J. * '-133:615-618,650, 1968. / - . ' -v' '' ; ; /... V !/. ' v 4. Coleman, A.B. Accidental poisoning. New Eng.J. Med. 277:1135-7 .November 23, 19671 . ' .b;;' .i 5; Wiener, G. Varying psychological sequelae of lead ingestion in children Public Health Rep. 85:19-24, 1970. 6. Mellins, R.B. and Jenkins, C.D. Epidemiological and psychological study : 'of lead poisoning in children. Journal Am. Med. Assn. 158:15-20, 1955. ; .v: ... V- V 7. Chisolm, J.J., Jr. and Harrison, H.E. The exposure, of children to lead.' -Pediatrics 18:943-958, 1956. . " v .-/ p -- 8. - Gutellus, M.F., Millican, F.K., Layman, E.M., Cohen, G.J., and Dublin,G.C. e Nutritional studies of children with pica.' Pediatrics 29:1012-1023, 1962. 9. Moncrieff, A.A., Koumides, O.P., Clayton, B.E., Patrick, A.D., Renwick,A.G.C and Roberts, G.E. Lead poisoning in children. Arch. Dis. Childhood 39:1-13, 1964. . y' _ !y.' 10. Moore, J.E. Community aspects of childhood lead poisoning. Am. J. Public - Health 60:1430-4,1970. y, ' 11. ' Welford, A.T. Ageing and Human Skill. Oxford Univ. Press, p.43, 1958. 12. - Floyd, W.F. and Welford, A.T. Fatigue, H.K. Lewis $ Co., Ltd., p.181. . 1953. . ' i. . EPI 00Q46B