Document npZaqKzwanQeDgB3NZ2w9bK7X

8052 EE761 P 5 70 FEE J HIST MED ALL SCI Public Health in Practice: An Early Confrontation with the `Silent Epidemic' of Childhood Lead Paint Poisoning ELIZABETH FEE | HILDHOODlead paint poisoning has been called the silent epidemic of American cities. Childhood expo sure to lead occurs through inhaled air, ingested food, water, leaded paint, dust, and soil, but of these, lead65153" paint is the most concentrated common source of lead exposure for children. The problem was dis cussed in the medical literature by 1914, and recognized in at least a few medical centers by the 1920s, but did not become the focus of broad y public concern until the late 1960s and 1970s when popular movements in several cities drew attention to the issue. For about thirty years, be tween 1931 and i962,4MlGN|& was the only American city to develop an extensive public health program on childhood lead paint poisoning.1 Whereas most accounts of the struggle to reduce lead poisoning begin with the organized efforts of die late 1960s, this article will focus on that earlier period, between 1930 and 1962, when Baltimore's pioneering program tested new methods in health education, free diagnostic testing, housing inspection, paint labeling, and lead abatement. 1. Richard Rabin. "Warnings unheeded; A history ofchild lead poisoning," Am.J. Public Health. 19*9. 79. 1668-74. 1 would like to thankJeremy Black, j. Julian Chisolm, Jr., Mark Farfel, Daniel M. Fox, Bonnie S. Rancor, Vicente Navarro, and George Silver for their helpful suggestions on an earlier draft of this paper. I am graceful to the Program on Ethics and Values in Science and Technology ofthe National Science Foundation for a giant which providedsupport for a project on "Social and Scientific Values in the Development of Public Health Research and Practice" from which this paper derives. O 1990 BY THE JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES, INC. is s n ooaa--304 j v o l u me 45 f a c e s 570 t o 606 [ 570 ] N39087 i Fee : Childhood Lead Paint Poisoning 571 Although Baltimore was an undisputed early leader in this field, the translation of research findings into public policy was a slow and often ineffectual process because of political and economic pressures. The first efforts ofthe Health Department were oriented to popular health educa tion, a relatively noncontroversial approach. When the Health Depart ment introduced free diagnostic tests for lead poisoning in 1935, this had the effect of making childhood lead poisoning newly visible as a public problem. The main issue then, as now, was how to assign responsibility, given the large economic costs of a truly preventive approach. As the limits of health education became evident to Baltimore's health officials, the city expanded its program to include housing inspections, paint labeling laws, and lead abatement. In so doing, it challenged the eco nomic interests of landlords, paint manufacturers, and retailers. The relative success of the Health Department is the ruV>re remarkable in that it was willing, in the 1950s, to challenge these pfj\yl*rfi interests in order to protect the health of the most powerless and disenfranchised members of the population, the poorest children of the inner city. By seeing the way in which Baltimore Struggled with the lead paint problem we can understand more about the constraints facing a city health department in dealing with a chronic environmental problem but also about the ingre dients necessary to success. Baltimore is one of America's oldest industrial cities, built around the port, railroads, steel, canning, and textile industries and associated com mercial activities. As the largest East Coast city south of the MasonDixon line, Baltimore has always had a relatively large black population. In the words of one historian, Baltimore was the "nineteenth-century black capital"; on the eve of the Civil War, it sustained the largest free black urban community in the country.2 The dry has also been home to white immigrant workers: Irish, Germans, Italians, Poles, Finns, and many other ethnic groups have created their own settled communities. Although at times black and white workers have competed for an economic niche in the dry, and occasionally have cooperated to improve their collective lot, in general the two groups have operated in two separate labor markets; until the last thirty years, most black men were restricted to laboring jobs and most black women to domestic service. Since the 1930s the city has had an active dvil rights movement and a progressive labor movement. In the twentieth century, at least since the 2. Leroy Graham, Baltimore: The Nineteenth Century Black Capital (Washington, D.C.: University Press of America, 1982). 572 Journal of the History of Medicine : Vol. 45, October iggo New Deal, the city has overwhelmingly voted for Democratic Party candidates and liberal Republicans; its popular mayors have included Howard Jackson, Tommy D'Alesandro, Jr., and the liberal Republican, Theodore Roosevelt McKeldin. In the health sector, Baltimore has sev eral strong and influential medical institutions, especially theJohns Hop kins School of Hygiene and Public Health and thejohns Hopkins School of Medicine. At times, when these institutions have worked closely with the Baltimore City Health Department, the combination has been both scientifically effective and politically powerful. This account emphasizes the importance of enlightened public health leadership on the local level of urban politics. It illustrates an ideal of public service that is as much part of the American tradition as the more often vaunted va'ues of individualism and entrepreneurial risk-taking. It demonstrates that public health in practice is not only a matter ofscientific knowledge, although that may be essential, but is equally a matter of social commitment, political will, and the kinds of political skills neces sary to building constituencies and public support. In this latter realm, a careful cultivation of the media and a flair for public relations may be essential characteristics of the successful public health practitioner. For the public health officer, both insider and outsider skills are important; insider skills for dealing with the political and scientific establishment, and outsider skills for building broad public interest and support. Childhood lead paint poisoning is in many ways a classic public health problem, reaching beyond science into politics, economics, education, and race. It has been a problem without any simple, effective, and inex pensive solution: there is no magic bullet for lead paint poisoning. The long favored methods ofpopular health education have not been particu larly effective; the environmental effort to remove the sources of lead in the environment is technically difficult, politically controversial, and ex pensive. The history of lead paint poisoning as a public health problem is not yet a success story: it has been estimated that forty-two million homes nationwide (twenty-one million of those built before 1940), cur rently contain leaded paint and between three and four million children have elevated blood lead levels and experience adverse health effects.3 Lead has been characterized as the most important toxicological hazard 3. Agency for Toxic Substances and Disease Registry. The Nature amt Extent ofLead Poisoning in Children in the United States: A Report to Congress. Public Health Service, U. S. Department ofHealth and Human Services, July 1988, pp. I-40,1-47. Fee : Childhood Lead Paint Poisoning 573 facing children in the United States, and lead from paint and dust as the most expensive sources of lead exposure and toxicity.4 From a strictly scientific point of view, the problem of childhood lead poisoning seems straightforward. The Centers for Disease Control in Atlanta state that the goal of prevention must be "identification and removal of lead in the environment before it enters the child."5 Once a child has been poisoned by ingestion oflead paint, he or she can be treated in the hospital, but the treatment may be lengthy and expensive. In 1986 in Baltimore the average cost per hospitalization of children with lead paint poisoning was over $10,000 and many of these children had multi ple recurrences with multiple hospital admissions.6 In 1984 Maryland spent over $3.9 million for treatment and special education of children with lead poisoning.7 In the United States a? a whole, nicdicJ ousts and the costs of special education for children with lead poisoning have been estimated at up to $1 billion annuallv.3 - '' ; The more we have learned about the issue oflead poisoning, the more we have become concerned about the toxic effects of relatively low levels of blood lead on children.9 Before i960, however, the only visible lead poisoning cases resulted from high levels of blood lead, often resulting in coma, convulsions, and even death. In Europe lead poisoning had been' recognized as a cause ofconvulsions since at least the seventeenth century, but American observers had generally ignored the European findings.10 4. Ibid., p. I-42,1-jo. j. Preventing Lead Prisoning in Yourg Children--A Statement by the Centers for Disease Control, Atlanta. U.S.D.H.EW., 197S. p. 1. 6. Mark Brfei. "Evaluation of health and environmental effects of two methods for residential lead paint removal," Sc.D. Dissertation, School of Hygiene and Public Health. Johns Hopkins University, 1987, pp. j8, i67;J.Julian Chisolm,Jr., E. D. Meilits. and S. A. Quaskey, "Relationship between level oflead absorption in children and type, age, and condition ofhousing." Environ. Res., 198J, 3d. 31-437. Science and Health Advisory Group, Maryland Department of Health and Mental Hygiene, "Lead poisoning: Strategies for prevention," Report to the Maryland General Assembly, December >984. P- 30; see also Citizens' Planning and Housing Association ofBaltimore, "Lead paint poison ing," 4 December 1984, Maryland Room, Vertical Files, Enoch Pratt Free Library. 8. George Provenzano, "ThesedalaJstsofexwssitreleadesposureduringchildhood,"mHerbert L, Needleman, ed.. Low Level Lead Exposure: The Clinkal Implications ofCurrent Research (New York: Raven Press. 1980), pp. 299-3 > j; see also D. Berwick and A. Komaroff, "Costeffectiveness oflead screening," N. Engl.J. Med., 1982,306, 1392-98. 9. Mark FarfH, "Reducing lead exposure in children." Atm. Rev. Public Health, 1985, 6, 333-60. 10. The most comprehensive account ofthe history oflead poisoning is Lloyd G. Stevenson. "A history oflead poisoning, " Ph. D. dissertation,Johns Hopkins University, 1949; for a briefsummary ofthe early uses and knowledge oflead toxicity, see Marjorie Smith, "Lead in history," in Richard Lamdown and William Yule, eds,, Lead Toxicity: History and Environmental Impact (Baltimore:Johns Hopkins University Press, 1986), pp. 7-24. In the United States, the pioneer in studying industrial lead poisoning was, of course, Alice Hamilton, Exploring the Dangerous Trades: The Autobiography of Alice Hamilton, MD (Boston: Little, Brown, and Company, 1943); Alice Hamilton, Industrial 574 Journal of the History of Medicine : Vol. 45, October tggo Lead-based paints were popular for both industrial and household uses because they were easy to apply and highly durable: they held their color well, dried quickly, and resisted cracking. Occupational lead poisoning of painters and other lead workers was widely recognized by the end of the eighteenth century and, throughout the nineteenth century, many individuals and organizations had called for the prohibition of lead paint.11 One of the most influential was Tanquerel des Planches who published a comprehensive statistical study of 1,217 lead workers ob served in the wards of the Charite hospital in Paris, Traite' des Maladies de Plomb ou Satumines, in 1839.12 - Several European countries did regulate or prohibit the use of lead paint, some for the interior of buildings, some for all applications.13 In 1920, for example, France prohibited all use oflead paints on the exterior or interior of buildings. At the White Lead Convention of 192.^ Justin Godard, a delegate of the French government, stated the French position on industrial lead poisoning with considerable eloquence: Faced with all these private interests which are pleading their own cause--and I repeat that they have a right to do so--we have to consider a higher interest, the interest ofhumanity. I by no means admit the accusation ofsentimentality which business men and industrialists often hurl at those who talk of the interests of humanity. I believe that by protecting human life, especially at the present time, by preserving the health of hundreds upon thousands of workers, we shall do better service to the economic world and the wealth of all than by permitting the use of white lead, even if it is proved to give a longer life to the materials which it covers, even if its cost is lower.14 Had this sentiment been more widely shared by other governments. Poisons in the United States (New York: Macmillan, 1925); for a very brief account of Hamilton's work, see Lewis J. Amsrei; "Gentlewoman explorer of the dangerous trades." Hospital Practice, 1986, ai. 206-1 J. 11. Lloyd G. Stevenson. "A history oflead poisoning," (n. 10) pp. 296, 329-403. 12. Over $00 of the workers studied were involved in die manufacture of ted or white lead pigments or were house painters. Louis Tanquerel des Planches, Traiti des Maladies de Plomb ou Satumines (Paris: feta, 1839). For a slightly abridged English translation, see L. Tanquerel des Planches, Lead Diseases: A Treatise. With Notes and Additions on the Use ofLead Pipe and its Substitutes. translated by Samuel L. Dam (Lowell, Mass.: Daniel Bixby, 1848). 13. For a derailed account of the technical, medical, and legislative aspects oflead paint poisoning and regulation, see White Lead: Data Collected by the International Labour Office in Regard to the Use of White Lead in the Painting Industry, Studies and Reports, Series F (Industrial Hygiene), No. 11. Geneva, International Labour Office. 1927. The White Lead Convention of 1921. regulating the use of white lead paint, had been ratified by 13 countries, not inducting the United States. For an interesting discussion of state responses to occupational lead poisoning in Britain, see Barbara Harrison. ""Some ofthem gee lead poisoned': Occupational lead exposure in women, 1880-1914." Sodal History ofMedicine, 1989, 2,171-93. 14. JustinGodard, White LeadConvention, Geneva, 1921, as quotedin WhiteLead, (n. I3)p. 303. Fee : Childhood Lead Paint Poisoning 575 much of the subsequent problem of childhood lead paint poisoning could have been avoided. By 1922, at least three thousand publications already dealt with various aspects oflead poisoning.15 Noting the toxicity oflead and its continued use in America, Benjamin Franklin had lamented "how long a useful truth may be known to exist, before it is generally received and practiced on."16 RECOGNIZING THE PROBLEM OF CHILDHOOD LEAD PAINT POISONING Since at least 1904 it vyafknown^iat children could be poisoned by lead paint. In that year J. bockfiart Gibson in Australia had found that ten children had died in Queensland after nibbling lead paint on the porch railings oftheir homes. Gibson concluded that "the houses in fact formed a simple lead trap" and suggested that this form oflead poisoning was. easily preventable by banning the use of lead-based paints.17 In 1917 Kenneth Biackfan of theJohns Hopkins Hospital gave a vivid clinical description of the symptoms oflead poisoning he had observed in children at the Harriet Lane Children's Home in Baltimore: In the early cases a change in disposition is often the first symptom which is noted. The child becomes fretful, peevish, and often very restless at night. The appetite becomes poor, the breath foul, and frequently hemorrhages occur from the gums. The child may complain of pain in the epigastrium and legs. In the cases of longer duration the pains in the abdomen become continuous and more severe. . . . The muscles are often so painful as not to permit of the weight of the bed-clothing. . . . The gait of the patients is described as being characteristic. It is a waddling gait; they walk on the outside of the feet, the toes are dragged, and with each step the legs are swung sideways before the feet are placed on the ground..'.. The macroscopic changes most frequently seen in the brain are an edema and anemia, with flattening of the convolutions. ... All types of convulsions are seen. . . . They are very persistent, they show a great tendency to recur, and they are attended by a high mortality,18 1 j. Else BlSnsdorf, Bkilitmtur (Berlin, Springer; 19). As died by Stevenson, (n. to) p. 301. 16. C. P. McCord, "Lead poisoning in early America: Benjamin Franklin and lead poisoning." lad, Med. Surg., 1933, J94-99- As cited injaneLin-Fu, "Lead poisoning and undueleadexposure in children: History and current status." in Herbert L. Needletnan, ed., (a. 8) Lew Level Lead Exposure, p. 6. :?. It is interesting to note that Gibson emphasized the dangers of leaded dust as well as paint chips; the hazards oflead dust have recently received increasing attention. J. L. Gibson, "A plea for painted railings and painted, walls of rooms as the source of lead poisoning among Queensland children," Astsmdim Medkd Gazette, 1904,13, 149-33. i. Kenneth D. Bladd&n, "Lead poisoning in children with especial reference to lead as a cause SJ6 Journal of the History ofMedicine : Vol. 45, October iggo Of the four young patients described by Blackfan in 1917, one recov ered and three died following convulsions. Blackfan readily traced the lead poisoning of the children he had observed to lead paint. One child was found dead, his lips covered with white lead paint chips from the railings ofhis'jrU>H two brothers had died after chewing on lead-covered parlor-famiturgt Blackfan concluded: "I would urge that energetic pro phylactic measures be taken with children who habitually eat painted articles in order to guard against the development of lead poisoning-----I have found a number of children who nibble the white paint from enameled cribs."19 But what were the "energetic prophylactic" measures to be applied? The cause of lead paint poisoning in children had been identified and would be repeatedly confirmed by other investigators-- the lead paint on .the furniture, toys, and woodwork frequendy bitten and nibbled by small children, especially at the teething stage.20 Toddlers very frequently pul things into their mouths and will tend to taste anything left within their reach, especially small objects. Since lead-based paint has a some what sweet taste, a child who has tasted lead paint may feel encouraged to continue. Flaking paint and paint chips found in old and dilapidated housing offer special attractions for children and are easily ingested. But who was to take responsibility? Was lead poisoning the responsibility of the parents, the landlords, the paint manufacturers, the paint retailers, the health department, the housing bureau, the medical profession, or the mayor? Although researchers in the 1920s continued to publish papers on childhood lead poisoning, it was not yet widely recognized as a public health problem.21 Since lead poisoning was not a reportable disease, physicians did not report it to the health department, and it thus remained largely invisible. In this period, health departments were still primarily concerned with infectious diseases such as typhoid fever and diphtheria; of convulsions." Am. J. Med. Sci.. 1917, 153, 877-87. See also H. M. Thomas and Kenneth D. Blackfan, "Recurrent meningitis due to lead in a child of five years," Am. J. Ois. Child., 1914, 8. 277-380. I9> Kenneth D. Blackfan. (n. [8) p. 887. 20. See J. C. Ruddock, "Lead poisoning in children with special reference to pica," J.A.M.A., 19*4,82.1682-84; C. R McKhann and E. C. Vogt, "Lead poisoning in children,"/A.Af.A. 1933, tot. 1131-35. 2t. R. A, Strong, "Meningitis caused by lead poisoning in a child of nineteen months," Arch. Ped., 1920, J7, 532-37; J. C. Ruddock, (n. 20); C. F. McKhann, "Lead poisoning in children," Am. j. Dis. Child., 1926.32,386-92: C. F. McKhann, "Lead poisoning in children: Theeetebral manifes tations," Arch. Neural. Psych., 1932, 27, 294-304; C. F. McKhann and C. Vogt, (n. 20). / -.-4" Fee : Childhood Lead Paint Poisoning 577 they had few resources to spare for problems that seemed less urgent. Commissioners of health were political appointees; they were expected to cope with existing health problems and were not rewarded for discov ering new ones. The fact that Baltimore devoted unusual attention to childhood lead paint poisoning was largely due to Huntington Williams, the new com missioner of health appointed in 1931. Williams received the appoint ment at the urging ofWilliam Henry Welch, the senior statesmanofboth medicine and public health and a dominant force in Baltimore, as in the nation. Welch's word was close to law on medical matters, and Welch had long been grooming Williams for the most important public health position in the city. Huntington Williams had grown up practically at Welch's feet; Williams's mother and Welch were dose friends and would often have dinner together, Welch talking through the problems ofpublic health and Williams listening with close interest. Welch persuaded the young man to attend theJohns Hopkins Medical School and devote him self to a career in public health. Williams did as Welch suggested, becom ing one of the first dass of students to enter the Johns Hopkins School of Hygiene and Public Health when it opened in 1918. Welch now told Williams that he should go to New York State to gain experience by working with Hermann M. Biggs, the master of public health adminis tration, politics, and practice.22 Again, Williams followed Welch's advice. Finally, Welch told Williams it was time for him to return to Baltimore and become the next commissioner of health of the dty. Baltimore's mayor, the popular HowardJackson, also did what Welch suggested, and prompdy offered the young man the position.23 Williams brought new energy to thejob. Whereas some commission ers of health owed their loyalty to a political leader, a party machine, or to the economically powerful, Williams owed his first loyalty to Welch who had groomed Mm, to his Hopkins professors who had taught and inspired him, and to the example of Hermann.Biggs who had dem onstrated what an effective public health organization should be. Wil liams was determined to show them all what he could do if given the chance. 22. Cfaarles-Edwawl A. Winslow, The Life of Hermann M. Biggs: Physician and Statesman of the Public Health (Philadelphia: Lea and Febiger, i9z9). 23. Suzanne Greens called Jackson "one of Baltimore's most popular mayors and the masterful leader during the depression of the 1930s." Jackson served as mayor for four terms from 1931 to 1943. Suzanne Ellery Greene. Baltimore: An Illustrated History (Woodland Hills, CaEL:.Windsor Publications. 1980), pp. 190-91. 578 Journal of the History of Medicine : . Vol. 45, October tggo One of Williams's old Hopkins professors soon handed him the prob lem of lead paint poisoning. Williams later remembered how he became involved: "Dr. Edwards A. Park, Professor of Pediatrics at the Hopkins Medical School continued to have children brought to his clinic with lead paint poisoning that was not recognized. He spotted this (the lead line on the gum) and came down to my office and said to me, `you should do something about this.' I said `you're absolutely right, and we'll go to work on it at once'. "34 Williams realized that Park had not given him an easy task. Both knew that the children were being poisoned by lead paint in their homes. Williams, whose motto in public health work was "educate, don't legis late," began with an educational program to warn parents about the dangers of lead paint. He had already learned a number oflesson about the politics of public health through his experiences in New York State; as a result, he used public health authority only reluctantly,- he avoided any direct confrontation with local medical practitioners, he activated and perhaps manipulated the media to his own ends, he nurtured good relationships with successive mayors, and he brilliantly exploited the techniques of health education to promote both the public's health and his own public image.23 On his return to Baltimore, Williams started a weekly health program on WBAL, a local radio station, and began a constant stream of health education messages through leaflets, newspap ers, and a popular health department monthly magazine, the Baltimore Health News. When, for example, the Health Department produced a pamphlet, "Lead Poisoning in Children--A Disease You Can Prevent," twenty thousand copies were distributed in well-baby clinics and public places around the city. Later, film and television programs were used in addition to radio shows. The Baltimore Health Department thus became an early leader in its innovative use of the media to communicate health information to the public. H- Huntington Williams, personal Interview, iz September 1984. 25. District Health Officers who worked under Williams in the Baltimore Health Department had a less favorable evaluation of his leadership than is generally presented in this article. Abraham Lilienfeid and George Silver each complained that Williams would cake no major step if it meant incurring the wrath ofthe organized medical profession. In George Silver's worth, he "neverstrayed far from obsequious response to the mandates of the State Medical Society. He had to be dragged reluctantly to the full execution ofhis duty" (personal communication. February 1990). Members of theJohns Hopkins School of Hygiene and Public Health were frequently irritated by Williams's caution in dealing with what he deemed to be politically sensitive matters. At the same time, it is perhaps a point in Williams's fevOt that he was willing to employ talented and aggressive young health officers who had few compunctions about making waves; he preferred the "radicals" in the health department to those he referred to as "dead wood." Fee : Childhood Lead Paint Poisoning 579 THE DEPRESSION DISEASE As attention began to be paid to the danger of lead paint poisoning, dty hospitals and clinics increasingly reported cases of small children admit ted unconscious or with convulsions. In 1932 there seemed to be a sudden epidemic of such cases: more than forty cases were reported in less than three months and many seemed unrelated to lead paint poison ing. Several patients developed acute encephalitis while others experi enced headaches, vomiting, and dizziness. Most had the characteristic "lead line" at the gums, stippling of the red blood cells, and lead deposits visible by X-ray examination of the wrists.26 Miriam E. Brailey, an intern at the Harriet Lane Children's Home, was asked to investigate. Brailey visited the home of one of the sick children and discovered the cruse of "depression disease." In a "squalid Negro quarter" in west Baltimore, she met "a large Negro, Melrose Easter, whose eyes were bloodshot and whose breath was strong with whisky.... He proved to be the most important informant in the investigation." Melrose "won dered if they could get sick from burning pieces of old batteries; `the smell was bad, even made the food taste'; it appeared to him it might be bad `breathing in the vapors.' Melrose explained that discarded storage battery casings were used as fuel by colored people all through that dty block. They cost nothing and burned very quickly with a smokey flame and a penetrating odor."27 He brought bade a large piece to show the investigator; when analyzed, it gave a positive test for lead. Baltimore junk dealers confirmed that they had been allowing poor people to take discarded storage batteries! to use for stove fuel. Although the lead plates had been removed for salvage, the batteries still contained large deposits of lead salts. Melrose Easter had been right; when the batteries were burned, they released massive clouds of lead vapors, thus poisoning the children.28 Health officials immediately warned junk shop proprietors against 26. Robert A. Kehoe, "The diagnosis crf'lead poisoning, " BaltimoreHealth News, 1941, it, 134-55, discusses some ofthe difficulties ofdiagnosing lead poisoning. This artide is excerptedftom fCehoe's address to the Industrial Health and Welfare Study Group of die Medical and Chirurgical Faculty ofMaryland, 17 March 1941. 27. Huntington Williams, Wilmer H. Schulze; H. B. Rothchild, A; S. Brown, and Frank R. Smith, jr., "Lead poisoning Bom the burning ofbattery casings,"J.A.Af.A.. 1951,100, 1485-89. Seealso "Lead poisoning from burning ofbatterycasings," BaltimoreHealthNews, 1932,9,73-74. 28. The lead hazard ofstorage batteries had previously been recognized as a problem in occupa tional healths see, for example, L. Gteenhurg, A. A. Shsye, and H. Shlionsky, "A ssudy of lead poisoning in a storage-battery plane," PuUk Health Rep., 1929,44, 666-98. 580 Journal of the History of Medicine : Vol. 45, October lggo distributing the batteries. Public health nurses made home visits to warn families against using them; local newspapers and radio stations broadcast the cautions; the city engineer arranged for truckloads of batteries to be disposed of at city incinerators; and, perhaps most importantly, the Fam ily Welfare Association in 1932 and 1933 distributed safe fuel to needy homes.29 Williams related this experience as "an example of widespread cooperation between hospitals, dispensaries, city health, police and en gineering departments, junk shop owners and civic reliefagencies for the protection of the poor in times of economic distress."30 The "depression disease" ofjunked batteries had drawn increased at tention to lead poisoning. But for many years after the battery casings had been eliminated as a source of fuel, the problem of lead poisoning would persist. When hospitals continued to report cases and health de partment officials to investigate them. Park and Williams decided it was time to offer an expanded program of blood lead testing.. FREE DIAGNOSTIC TESTS Until 1935 Park had sent specimens to be tested for lead to Harold Blumberg, a student at theJohns Hopkins School ofHygiene and Public Health, who was skilled in doing lead determinations using a spectro graph.31 When Blumberg graduated, Park lost this diagnostic resource, and he went to Williams at the City Health Department, asking him to take over the task of determining blood lead levels in children. During the depression, the city could not afford to buy a spectrograph, so Wil liams sent Emanuel Kaplan, then a recent Sc.D. graduate from the School of Hygiene and Public Health, to the DuPont Chemical Company in Wilmington, Delaware, to leant a new chemical method for detecting blood lead, the dithizone technique.32 It is interesting to note that DuPont 29. Williams, Schulze. Rothcbild. Brown, and Smith. Jc, (n. 27), pp. 1487-88. jo. Ibid., p. 1489. 31. Harold Blumberg and T. R McNair Sow, "The quantitative determination ofblood lead and its value in the diagnosis oflead poisoning," Bulletin oftheJohns Hopkins Hospital. 1935, 56,276-293. The spectrograph was an expensive and somewhat exotic piece ofscientific equipment in the 1930s and was mainly used to test for trace amounts ofmetals. It had been given to the School ofHygiene and iPublk Health by the Calumet Baking Powder Company, which had been accused by the Royal Baking Powder Company of adding sodium aluminum sulphate to their product; in an effort to solve the dispute, members ofthe department had used thespectrograph to test forany physiological effects of aluminum salts. The same apparatus could be used for Wood lead measurements. A brief account ofthe baking powder controversy is given in Elmer V. McCollum, Elsa Orem-Keiles. and Harry G. Day, The Newer Knowledge ofNutrition, jth ed. (New York: The Macmillan Company, 939), PP- 273-78. 32. Emanuel Kaplan, peraonal communkaaon, 3 June 1990. For details of the technique, see Elwood S. Wilkins,Jr.. Carl E. Willoughby, Elmer O. Kraemer, and E L. Smith, n, "Determination Fee : Childhood Lead Phint Poisoning 581 was involved in an effort to persuade the public that tetraethyl lead was not an environmental toxin; in 1924 DuPont and General Motors had created the Ethyl Corporation to manufacture and market leaded gasoline which wduld later become an important source oflow-level lead poison ing.33 The dithizone technique, recendy developed in Germany and being used at DuPont, provided the first sensitive quantitative method for measuring lead in blood and other types ofbiological samples. Kaplan studied the technique with the DuPont chemists and returned to Balti more where he immediately began to measure the lead in children's blood samples.34 In 1935 the City Health Department took the unprecedented step of offering free laboratory diagnostic tests to assess the blood lead levels of any person with suspected lead poisoning.35 The service, offered to physicians as an aid in clinical diagnosis, was an immediate success: within the first three years, more than twenty hospitals and one hundred physicians requested the tests. Interest grew so rapidly that the Health Department decided to use its data to study lead poisoning and potential preventive measures. Baltimore thus became the only city in the United States with a central diagnostic and reporting mechanism for lead poison ing--the first step toward determining the real extent ofthe problem.36 Health Department officials soon discovered that lead poisoning of young children was far more frequent than anyone had realized. In three of minute amounts of lead in biological materials: A ritrimetric-extraction method." Industrial and Engineering Chemistry, Analytical Edition, 1935, 7, 53-36. 33. David Rosner and Gerald Markowitz, "A 'Gift ofGod'!: The public health controversy over leaded gasoline during (he 1920s," Am.J. Public Health, 1985, 75, 344-52.1 had initially supposed that DuPont had brought the dithizone technique from Germany in order to test the blood lead level of workers involved in the production of leaded gasoline; Kaplan says, however, that the DuPont chemists. Carl Willoughby and Elwood Wilkins, wo* mainly concerned with testing the blood of an executive's wife who had been treated for cancer with colloidal lead phosphate. He believed it - was the wife of Elmer O. Kraemen It may be noted that by 1938, Willoughby and Wilkins were working at the Department of Neoplastic Diseases. Jefferson Medical College Hospital, Philadel phia. The department was supported by die Elizabeth Storcfe Kracmer Memorial Fund, sponsored by Pierre S. and Latnmot du Pont. Elmer O. ECiaemer served as consulting chemist. See note, p. 639. Carl E Willoughby and Elwood S. Wilkins. Jr., "The lead content ofhuman blood,"/. Biol. Chan., 1938, 134, 639-57. 34. Emanuel Kaplan andJohn M,, McDonald "The blood lead value as an aid in the diagnosis oflead poisoning, "/oumitf ofPharmacol. Exp. Tker., 1938, 63, 17. 3 5. Emanuel Kaplan andJohn M. McDonald "Blood lead determinations as a health department laboratory service." Am.}. Public Health, 1942.32, 481-86. 36. j, Julian Chisolm, Jr., notes that, at die time, one could only get blood samples from children analyzed for lead in Boston. Baltimore, and Cincinnati. Baltimore was the only health department with the interest and ability to run the tests as a regular diagnostic service; testing could Ire done in Boston and Cincinnati only on a research basis, j. Julian Chisolm, Jr., personal communication, t June 1990. 5 82 Journal of the History of Medicine : VoL 45, October 1990 years, fifty-seven cases of lead paint poisoning were confirmed, with twenty-two fatalities.37 Improved methods ofdetecting lead in the blood and body fluids and a growing "lead consciousness" among the medical profession led to ever-increased reporting of the problem over the next twenty years. Approximately equal numbers of adults and young children were diagnosed as having been poisoned by lead; the adults ail hadoccupational exposures to lead, while the children all had a history ofchewing objects painted with lead-based paints. The incidence of lead poisoning was highest among children of "teething age"; inspections by the Health Department's Bureau of Environmental Hygiene revealed that in each case of lead poisoning the child had a "perverted appetite" which man ifested itself in chewing paint from cribs, high chairs, woodwork, and window sills.38 Laboratory examinations of paint scrapings taken from the suspected at rides proved the source beyond a doubt: many came from children's furniture and cribs that had been repainted at home with a lead-containing paint.39 The early health information and newspaper accounts suggested that parents, previously unaware of "the danger of the paint-eating habit in their children," must now take responsibility for exposing their children to lead-based paints. The "typical" example of lead poisoning, widely tited in the popular press, was that ofa workman who had unknowingly poisoned his child by repainting the furniture: A dramatic incident which recendy occurred in the southern section of the city is typical of the entire problem. A workman painted the fence of the factory where he was employed. Having some paint left over, he painted his child's high chair and bed. Several months later the infant was dead of lead poisoning.40 The main preventive measures ofthe 1930s were these public warnings / issued to parents--not to paint furniture with lead-based paints or allow ^ young children to engage in the "unnatural" act of chewing on painted 37. "Lead poisoning in children." Baltimore Health News. 1937. 14. 109-10. 3*. Marcia Cooper, an assistant professor at the Johns Hopkins School of Hygiene and Public Health, would later study the phenomenon of pica among the population of the Eastern Health District of Baltimore. She found that adults as wdl as children sometimes ate dirt, day, and plaster, and suggested that the behavior was caused by nutritional deficits; in children, it could lead to, or be associated with, mental retardation. Matcia Cooper, Pica; A Survey of the Historical Literature as well as BepmuJtim the FieUs of Uterinary Medicine and Anthropology, the Present Study ofPica in Young Children, and a Discussion of its Pediatric and Psychological Implications (Springfield. III.: Charles C. Thomas. 1957). 39- "Lead poisoning in cWdreo." (n. 37) p. 110. 40. "Lead poison kills 22 here in three years," Baltimore Sun, 4 April 1937. i Fee : Childhood Lead Paint Poisoning 583 surfaces. Health department officials may not have spent much time looking after young children, for their reports suggested that infants did not "naturally" chew on nonfood objects. Inspectors from the Depart ment of Environmental Hygiene followed all cases of lead poisoning in 1936, for example, and revealed that in each of the cases, "the child had a perverted appetite" manifested by sucking or chewing on painted sur faces.41 The language of their reports sometimes implied that not only the parents, but the children themselves were at fault. In the 1930s land lords and paint companies were conspicuously absent from discussions of the causes of lead paint poisoning. GATHERING STATISTICS AND ANALYZING THE PROBLEM In their first decade of work in the field of lead poisoning, heakh officials gathered statistical data on repotted cases and followed uf> r.ich case in the community. Now that the Health Department offered free blood lead testing, health officials were abie to identify many cases of previously unreported, nonfatal, lead intoxication. Eighty-nine percent of the 117 cases found between 1935 and 1941 were identified only as a result ofthe free laboratory testing service.42 Adults with high blood lead levels were reported to the Bureau of Occupational Diseases which was thus able to identify numerous cases of industrial lead exposure. Baltimore's statistics on lead poisoning were startlingly high--much higher than those from any other region of the country. John McDonald, director of the Bureau of Occupational Diseases, and Emanuel Kaplan, now chief chemist at the Bureau of Laboratories, noted that, according to the United States Bureau 6f the Census, 202 deaths from childhood lead poisoning had been reported from the whole of the United States between 1931 and 1940. Forty-nine deaths, or 24.3 percent of the total, came from the city ofBaltimore, although the city constituted only 0.65 percent of the population of the United States.43 Based on reported rates, the death rate from childhood lead poisoning in Baltimore appeared to be about fifty times higher than in the rest of the country. Clearly, these figures did not mean that Baltimore alone suffered from a lead paint problem but that the city's system of reporting was far superior to that in the rest of the country; Baltimore was playing an important role in 41. "Lead poisoning in children," (n. 37) p. 109. 42. John M. McDonald and Emanuel Kaplan, "Incidence of lead poisoning in the dry of Balti more,"JAMA, 1942, 119, 870-72. 43. Ibid., p. 871. 584 Journal of the History ofMedicine : Vol. 45, October 1990 making the problem visible to medical and public health personnel. It is an interesting paradox in public health that the best public health pro grams may sometimes display the highest disease rates. Statistics are the language of public health; problems can only be perceived when they can be counted, and problems cannot be dealt with until they are perceived to exist. Making the problem visible, through statistical data as well as by radio shows and publications, was a first necessary, though certainly not sufficient, step toward its solution. From their analysis of the data, Baltimore city health officials con cluded that fatal lead poisoning was in fact far more prevalent among children than adults; 86 percent of the recorded deaths were those of children, with an average age of death of two and one half years. It was immediately dear that black children were at the highest risk for lead poisoning. The mortality rate for black children (13.7/100,000) was five times higher than that for white children (2.5/ioo.oouViH the first five years of data collection.44 Of the 293 cases of childhood lead poisoning reported in Baltimore between 1931 and 1951, 200 were blade children, despite the fact that in this period only 18 to 24 percent of the dty's population was black.45 Although health department statistics were gathered by race and not by income levels, it was clear that the problem was directly linked to poor housing rather than to race per se.46 Since health department inspec tors had to visit the homes ofthe poisoned children to confirm the source of lead poisoning, they could not escape the observation that these chil dren lived in the most dilapidated slum housing in the rity.47 Rents were low, and landlords did not attempt to keep the properties in good repair, old lead paint peeled from the ceilings, walls, window frames, and fumi- 44- Ibid. 45. Huntington Williams, "Lead poisoning killed 83 children," Baltimore Health News, 1951.28, 113. 46. Various efforts had been made in the 1920$ and 1930s to deal with the effects ofsubstandard housingon health although health departments, in the main, wen still reluctant to deal with housing issues. The leaden ofthe "health and housing" efforts were the members of the Committee on the Hygiene of Housing of the American Public Health Association. Charies-Edward A. Winslow. professor of public health at Yale University, was chairman of the committee and Huntington Williams was a member. See Committee on the Hygiene ofHousingofthe American Public Health Association, Housingfor Health (Lancaster; Pa.: Science Press, 1941). The issue ofhealth and housing was not yet associated with the question of lead paint: the "Basic principles of healthful housing" published by the American Public Health Association in May 1939. contain many details about ventilation, lighting, etc. but make no reference to lead. 4?. Emanuel Kaplan notes that inspectors were only sent out when a child had a Wood lead level ofat least 6s or 70 micrograms per too grants of whole blood--in extremely high level by current standards. Emanuel Kaplan, personal eommunkarion, 3 June 1990. Fee : Childhood Lead Paitu Poisoning 585 ture and fell to the floor in the form of flakes and chips that the children found and put in their mouths.48 A chip of paint analyzed under the microscope might show many layers of leaded paint accumulated over the life of the house. The lead poisoning cases were concentrated in two areas in west and east Baltimore. In 1936 a committee on housing had described the west Baltimore area as "a residential center, long since abandoned by whites, and its ancient three and one-half and four story dwellings packed with Negro families.... Bad social conditions are reported by both the Police Department and the Family Welfare Association over a period of ten years or more. Health conditions are poor. Infant mortality was 131.6 for the year 1931, nearly twice the city wide rate.... This area is certainly only usable for Negro habitation unless commerce and industry can absorb it, which seems doubtful. . .',49 From a preventive, public health point of view, the obvious need was to remove lead paint from the homes. In 194.1, with the assistance of a housing survey showing chat 70 percent of the housing in low-rent areas was "substandard," Huntington Williams persuaded Mayor Howard Jackson that a new city ordinance was needed to deal with the problem.50 Mayor Jackson signed the Hygiene of Housing Ordinance on 6 March 1941.31 The ordinance, which constituted a major advance in the public health control of Housing conditions, stated that "Whenever any dwell ing, or any building, structure, excavation, business pursuit, matter, condition or thing in of about a dwelling. . .is found by the Commis sioner of Health to be dangerous or detrimental to life or health, the Commissioner of Health may order that the matter, condition or thing be removed, abated, suspended, altered or otherwise improved, as his order shall specify.n5Z The question in Baltimore, as in other cities, was, who was to pay for the removal of the lead paint? Since slum dwellings usually had many layers ofpeeling paint, removing the paint could be time consuming and 48. Williams, (n. 45) p. t14. 49- W. W. Emmart, Chariman, Report of theJoint Committee on Blighted Districts and Housing in Baltimore (Baltimore, December 1936), pp. 5-6, Maryland Room, Enoch Pratt Free Library. jo. The Housing Authority of Baltimore City, with the Assistance ofthe Health Department of Baltimore City, the School of Hygiene, Johns Hopkins University, and the United States Works Projects Administration. Baltimore: Low Rent Housing Survey: 1941 (Baltimore: Housing Authority of Baltimore City. 1941). Si. "Chronology oflead paint poisoning control: Baltimore, 1931-1971." Baltimore Health News. 1971. 48. J$. js. Hygiene of Housing Ordinance # 3843s deed in "Chronology" (n. j 1). w 586 Journal ofthe History of Medicine : Vol. 45, October 1990 expensive. Landlords were obviously antagonistic to any requirement that they pay the costs; an attempt to enforce the existing ordinance by requiring the removal ofall lead paint from apartment houses would have meant confronting most of the large property owners in the city, includ ing much of the city's political power structure. In 1948 the commissioner of health began a much more modest pro gram ofremoving lead paint from apartments where children had already been poisoned by ingesting lead paint. Even in these apartments, land lords would not be required to remove all the lead paint, but only the flaking sections, and paint from surfaces that the child had already chewed. The Health Department made an effort to locate and notify the landlords of properties where a child had been poisoned, asking them to remove flaking paint from all surfaces accessible to children.53 This lim ited effort was highly successful; within four years, ninety-six notices .were sent to landlords and ail but two of them complied. The two resisting property owners were summoned to Magistrate's Court, where they were both found guilty and fined; only then did they make the necessary corrections.54 In 1948, when a new high of thirty-one cases of lead poisoning was reported, the Health Department stepped up its program of popular health education. A leaflet, "Lead Poisoning in Children--A Disease You Can Prevent," told parents to observe their children closely, to prevent them from chewing painted surfaces, to remove old paint from wood work, to repaint only with lead-free paint, and to take children suspected of lead poisoning for immediate examination by the family physician-- assuming that these impoverished families had a family doctor,55 In 1949, the city began to dispatch public health nurses to slum neighborhoods to distribute these leaflets and educational materials to the parents of young children. The nurses also explained the hazards of lead paint to mothers attending the city Health Department's well-baby duties.56 A popular radio broadcast, "Not fit to Eat," explained the dangers oflead paint and asked parents to warn their friends and neighbors about the problem. 53. Huntington Williams. Emanuel Kaplan. Charles . Couchman, and R. R. Sayers. "Lead poisoning in young children," Public Health Rep., 1952, 67, 230-36. 54- Ibid., p. 233. $3. "Lead poisoning in children--A disease you can prevent," Baltimore City Health Department leaflet, (949. Reprinted as "Suggestions for parents," in Baltimore Health News, 1949, 26, 124. 56. George W. Schucfcer, Edward H. Vail, Elizabeth Kelley, and Emanuel Kaplan, "Prevention oflead paint poisoning among Baltimore children," Public Health Rep., 1965, So, 969. Fee : Childhood Lead Paint Poisoning 587 Just as previous publicity in the 1930s had suggested that parents were responsible for lead poisoning when they repainted children's cribs, toys, and furniture, die popular press in the 1940s suggested that parents could be responsible for lead poisoning when theyfailed to repaint their walls, woodwork, or windowsills. Each time the figures were reported on lead poisoning, the Health Department warned parents to be "on the lookout for this dangerous health hazard," to prevent children from chewing painted objects, and to repaint apartments with lead-free paint or to make sure that the landlord did so.57 Unfortunately, lead paint production and advertising was so weakly regulated that it was often difficult to know whether a given can of paint contained lead or not. Popular health education, while no doubt useful in alerting parents to the hazards of the home, was hardly an adequate response to the problem of lead poisoning. Tenants of the most dilapidated slum housing were forced to put.up with peeling walls and decaying apartments because they were hovering on the edge of subsistence and struggling to feed their families; they had no extra cash available for repairing and repainting their homes. Landlords had little incentive to keep the apartments in good repair since rents were usually too low to provide for both repairs and a healthy margin of profit. Neither tenants nor landlords were likely to do much repainting--whether with leaded or lead-free paint--but even ifthey had been inclined to follow the Health Department's sugges tions, there was usually no way ofknowing whether paint cans contained lead or not. As Maryland law did not require that lead be identified on paint labels, even the well-intentioned painter had no way of being sure that a given paint was lead-free. In 1951 health officials witnessed a record number of lead poisoning reports; local physicians reported seventy-seven cases and nine fatalities, with 90 percent oftheaffected children living in rental properties in slum or "blighted" areas.58 When the Health Department made maps of the distribution of lead poisoning in the city between 1931 and 1951, the pattern was curiously familiar: the distribution of cases was essentially the same as for tuberculosis and venereal diseases. "Lung block," the term used for areas with high rates of tuberculosis, was virtually synon ymous with "lead alley. " Despite quite different scientific analyses ofthe S7- "Lead poisoning in children is preventable and can be fetal." Baltimore Health Nears, 1949, 26, 123-24. 58. Baltimore City Health DepartmentAnnuel Reportforthe Year Ending 1931 (Baltimore, City Health Department. 1952), p. 44. 588 Journal of the History ofMedicine : Vol. 45, October iggo causes of these diseases, all obeyed the same geographic and economic rules.39 John McDonald, head of the Bureau of Occupational Diseases, commented with curious indirection that "although the disease (lead paint poisoning) does not appear to be poverty-connected, it does not occur where houses are repainted regularly every three years."5609 The Health Department now stepped up its case finding efforts and began to reassess its past efforts. Reviewing twenty years of data collec tion, Commissioner Williams noted that 60 percent of the cases had occurred among children between the ages ofone and two, at the teething age when children readily put objects in their mouths, perhaps the first clear admission that this behavior was natural for small children and not simply the result of "perverted appetite."6' Perhaps it was time to stop blaming the infants and their parents and to place more of the responsi bility on the landlords and paint manufacturers. AN ENVIRONMENTAL APPROACH The poisoning rate was now y. 5 times higher among black children than white, a racial difference that Williams attributed to environmental fac tors and economic disadvantage--in other words, to poor housing con ditions. Health officials assessed the neighborhoods where multiple cases of lead poisoning had been reported and concluded: "The problem in Baltimore at present involves chiefly slum or blighted-area properties. The cases are concentrated in two areas which are of known slum status and where the houses are old and have many coats of paint, usually lead paint, applied throughout several decades."62 The health commissioner now adopted a new regulation adding to the existing ordinance on the hygiene of housing. This regulation stated: "No paint shall be used for interior painting of any dwelling or dwelling unit or any part thereof unless the paint is free of any lead pigment."63 This was a unique effort to control through legislative means the applica tion of leaded paint; such a step seems not to have occurred to health commissioners in other dries, or if it did, was not acted upon. 59. Housing Authority of Baltimore City. Baltimore's Housing Situation in Chans: Based on 1950 Census ofHousing (Baltimore: Housing Authority of Baltimore City, 1954). This publication shows dearly that the oldest housing was the most dilapidated and was in the most overcrowded, largely black areas in west and east Baltimore. 60. "7 children poisoned in July from nibbling lead paint," Baltimore Sun, 12 August 1946. (Si. See Huntington Williams et aL, (n. j j ). 62. Ibid., p. 233. 63. Regulation 17, adopted 29June 1951, pursuant to the authority ofBaltimore City Ordinance 384, as cited in Williams, (n. 45) p. t id. Fee : Childhood Lead Paint Poisoning 589 The new regulation, if enforced, would insure that the existing prob lem would not be exacerbated by the addition of new layers of leaded paint but it did not deal with the major problem of peeling layers of old paint. Putting a layer of lead-free paint on top of old leaded paint was at best, a temporary measure, adequate only until the paint again cracked, chipped, or peeled. Another problem with the new regulation was, again, the fact that no content labeling was required of paints. The Maryland State Legislature in 1949 had passed a law making it compul sory to attach warning labels to any toy or children's furniture decorated with lead paint, but the law was said to be unenforceable and had been repealed a year later.64 Some paint manufacturers advertised paints free from lead pigment or voluntarily provided content labels on paint cans, but these were often more misleading than infoi,native: content labels with terms such as "chrome yellow," "chrome green," and "chrome orange" concealed the fact that these p.gmenr. contaired substantial amounts of lead chromate."5 The Health Department now recom mended that parents stay away from all yellow, green, and orange paints, and that they try to find paints specifically advertised as lead-free. It would be another twenty-seven years before the United States Consumer Product Safety Commission limited the lead content of residential paint sold in interstate commerce to trace amounts (0.06 percent), thus virtu ally eliminating the problem of new lead-based household paints on a national level.66 Even this regulation would apply only to household paint and children's toys manufactured after 1 March 1978, leaving un touched the problems created by old and existing household paints.67 With increasing attention being given to lead paint poisoning, other major cities were beginning to discover and report similar problems. The common findings demonstrated that "childhood lead poisoning was inextricably related to dilapidated housing where peeling lead paint and broken painted plaster were readily available: the high risk areas or `lead belts' were practically synonymous with large inner city slums."68 64. Huntington Williams et ai, (n. $3) p. 234. 6j. Ibid., p. 235. 66. "Consumer Product Safety Commission: Controls on lead-based paint and coys and (urmture bearing lead-based paint,'' in National Research Coundi. Lead in the Human Environment (Washing ton, D.C.: National Academy of Sciences, 1980), pp. 463-68. 67. For a detailed discussion of recent findings and dilemmas in Baltimore see: David Brown, "Debate on lead paint: Vital public health issue. " Baldmote Sun, 29 May 1983; David Brown. "City inspects, scrapes, prods; Lead paint problem persists," Baldmote Sun, 30 May 1983. 68. Jane S. Lim-Fu, "The evolution of childhood lead poisoning as a public health problem." in J.Julian Chisolm, Jr., and David M. O'Hara, eds.. LeadAbsorption in Children: Management, Clinical, and Environmental Aspects (Baldmote: Urban and Schwarzenberg, 1982), p. 4. 59 Journal ofthe History of Medicine : Vol. 45, October 1990 Baltimore health officials were proud of their relatively advanced po sition in promoting new housing regulations, and health education; in 1952 they prepared a comprehensive exhibit on "Lead Poisoning in Chil dren" for the annual meetings ofthe American Public Health Association and the American Medical Association.69 Huntington Williams and his co-workers published a review of Baltimore's experience in Public Health Reports, concluding with the confident hope that "the application of principles involving education and the enforcement of measures regulat ing the use of lead-containing paints will result in a material reduction and the eventual eradication ofchild lead poisoning in Baltimore City. "70 Such optimism was to be short-lived. At the time, health officials still had little idea of the real extent of childhood lead poisoning. Reported cases were running at between thirty and eighty a year-- a serious prob lem, but not yet a monumental one. In 1956, howey-r. a group of researchers from the University of Maryland Schoot of Medicine and the Baltimore City Health Department began to screen infants brought to the city's well-baby clinic and the Pediatric Outpatient Department of the University of Maryland Hospital--both clinics serving predomi nantly low-income patients. They used a diagnostic test, qualitative uri nary coproporphyrin III, then being widely used in industry to test workers for undue lead absorption; this was the first time the test had been ui^d.&^ee:alag.riumbers ofchildren.711. Edmund Bradley and TSsco-workers found that the test did not provide an adequate indicatSt'' of blood lead levels; about 40 percent of the children who tested negative on the coproporphyrin test had blood lead levels over 0.05 mg. percent when retested by the dithizone method. At the time, 0.05 mg. percent (50 micrograms per too grams ofwhole blood) was considered the upper limit of "normal" blood lead. Bradley found a frighteningly high inddetice of abnormal blood lead values: ofthe 333 children he studied, 44.4 "percent had elevated blood lead levels.72 Although some ofthese children J weraigporeed-as^ asymptomatic by their parents, eight previously^ 69. "Chronology, "(n. 51) p. 36; Huntington Williams also gave a talk at the Annual Conference oftheMilhankMemoriaiFundin 1950: Huntington Williams, "Lawenforcement and the `Baltimore Plan'," Housing and Health (New York: Milbank Memorial Fund, 1951), pp. 19-30. 70. Huntington Williams et at., (n. $3) p. ajs. 7t. Rudolph K. Waldman and Roy M Seideman. "Reliability of the urinary porphyrin test for lead absorption,'' Arch, Indust. Hyg. Ocatp. Med., 1950, t, 290-95; Clarence C. Maloof, "Role of porphyrins in occupational diseases." Arch, lndust. Hyg. Occup. Med., 1950, 1, 296-307. 72. J. Edmund Bradley, Albeit E. Powell. William Niermasnt. Kathleen R. McGrady, and Emanuel Kaplan. "The incidence ofabnormal blood levels oflead in a metropolitan pediatricclinic," J. Pedate., 1956, 49, t-6. J i ' Fee : Childhood Lead Paint Poisoning 591 asymptomatic children were admitted to the hospital with acute symptoms of lead poisoning during the course of the study, thus unhap pily confirming the usefulness of blood lead tests for diagnosing previ ously unrecognized lead poisoning.73 It was obvious that the extent of lead poisoning was greater than had yet been recognized, and that a high proportion of inner city children were at risk. In response to these findings. Commissioner Williams appointed a Lead Poisoning Prevention Committee that quickly assumed a dominant position in formulating Baltimore's response to the lead paint problem.74 * The first chairman ofthe committee, William Sallow, was assistant direc tor of the Housing Bureau, a choice suggesting that the problem was now seen as primarily a question of housing rather than of clinical ser vices, laboratory testing, or public health education. The other memb'a",$ of the committee represented the full range of health department ac tivities from public health nursing and statistics to industrial hygiene. The new lead poisoning program of 1957 began with a massive pre ventive effort conducted by 22$ sanitarians, public health nurses, and housing inspectors. In a two-part program, sanitarians and housing in spectors took paint samples from one hundred inner city blocks; public health nurses visited about three thousand poor families whose children, aged three years or younger, had been registered as recipients of medical care.73 The study found that between 50 percent and 70 percent of the homes had dangerously high levels of chipped and flaked lead paint; paint with a lead content in excess of one percent was found in 70 percent of the 667 houses tested.76 All public health and housing personnel in Bal timore were urged to pay dose attention to the lead paint threat; the Health Commissioner's new slogan, "No Baltimore Child Should Die \J of Lead Ironing, " was constantly repeated in mass niedia advertising, radio health broadcasts, newspapers, and pamphlets.77 In 1958, despite--or perhaps because of--the publirity, reported cases ofchild lead poisoning reached a record high of 133 cases and ten reported 73. Bradley al (n. 72) noted that serious lead intoxication could sometimes occur at lower blood levels than the then accepted "normal" limit of 0.05 mg. percent. Ibid., p. 5. 74. See "A new health department committee on the prevention of lead poisoning," Baltimore Health News, 1956, 33, 80-Si. 7J. "Prevention of lead poisoning," Baltimore Health News. 1957.34, (25-27. ?6. Emanuel Kaplan and R. S, Schauil, "Determination of lead in paint scrapings as an aid in the control of lead paint poisoning in young children." Am. J. Public Health, 1961, 51. 65-69. 77. The Health Department mated that although children's toys made in the United States were / generally fie of lead paint, imported toys often used high lead-content paints: the department publicized this fact and alerted the United States Public Health Service to the danger. i ( 1 592 Journal of the History of Medicine : Val. 45, October iggo deaths. This was more than twice the rate of 1957 or of any previous year. The increase in reporting led to even more publicity and to growing public concern. In a positive spiral of interest, increased reporting and increased public concern in turn produced a political demand for more aggressive Health Department action. The Lead Poisoning Prevention Committee now decided to tackle the problem of the labeling of paint cans. The Health Commissioner adopted a new ordinance requiring label warnings on ail paint containing more than one percent lead. The warn ing labels were to read: WARNING--Contains Lead. Harmful if Eaten. Do not apply on any interior surfaces of a dwelling, or on a place used for the care of children, or on wondow sills, toys, cribs, or other furniture.78 Since the first warning labels printed by manufacturers were so small as to be unnoticeable, thiv first regulation was followed in 1959 by another, specifying the size of the warning labels and leaving no detail ambiguous: Lid labels. No lid label bearing the warning as required by this ordinance shall be less than 3 inches in diameter for pint and larger size containers or less than 1 Vi inches in diameter for cans smaller chan pint size. In addition to the warning statement the lid label shall contain the name and address of the manufacturer. The word "warning" preceding the warning statement shall be of larger letters than the name and address ofthe manufacturer. The warning statement shall be as large as the lid label will permit. The lid label shall adhere firmly to the lid of the container.79 Radio broadcasts and the popular press warned parents to read lid labels, to be cautious of any paint not specified as free of lead pigment, and to avoid all yellow, green, and orange paints.80 The Health Depart ment surveyed all the city's paint dealers and manufacturers to ensure compliance with the new regulations; in some cases, repeated visits, threats oflegal action, and newspaper publicity were necessary to ensure that the labeling regulation was taken seriously. As Williams explained his method of persuading the paint manufacturers: "We'd write a story 78. The Baltimore City Lead ftint Labeling Ordinance, no. 1504. 9 June 1.95S; Huntington Williams, "Letter to persons concerned with the manufacture, sale, or useoflead paint in Baltimore. " to June 1958, Maryland Room, Enoch Pratt Free Library; "Lid labels for lead paint." Baltimore Health News. 1959,36, 122-13. 79. "Lid labels." (n. 78) p. 122. 80. Huntington Williams andJoseph Gordon. "Death at the window sill." Baltimore Afro-Amerkm, 13 May 1958. Fee : Childhood Lead Paint Poisoning 593 in the newspapers that such-and-such a paint was not living up to the laws and was putting in lead for children to chew on--the publicity did - the work."81 The struggle over the labeling of paint in Baltimore cer tainly confirms the claim that leaded paint continued to be manufactured and sold for interior use long after the problem ofchildhood lead poison,, ing had been widely recognized.82 At least in Baltimore, flooded as it had been by Health Department publicity and warnings about lead paint poisoning, no paint manufacturer, dealer, or construction company could plausibly claim to be unaware of the hazard. INTERFERING WITH THE RIGHTS OF PROPERTY OWNERS The Lead Poisoning Prevention Committee now decided that effective prevention had to go to the source of the hazard: the existing lead paiv on tenant housing. The idea, as Williams announced it, was to create "a new and truly preventive program" by removing lead paint from homes before, rather than after, the children were poisoned.83 To do this, the Health Department would first have to gain access to tenant housing; this proved no easy matter. The right of city officials to inspect housing without a search warrant was bitterly contested by landlords and prop erty owners. Williams explained: "the landlords fought us tooth and nail because we were costing them money . .. they went to the city council and fought our ordinance but they lost because the city council knew that it was good politics to pass that kind of ordinance... every step was a struggle."84 The landlords now claimed that the article ofthe Baltimore City Code allowing health inspection of any house where a nuisance was suspected was unconstitutional and a violation of their property rights. A test case was brought by Abraham Givner, the owner of an apartment building on 173 5 Linden Avenue.85 With Givner standing on the sidewalk outside his property, representatives of the Health Department, the buildings' inspection engineer, and the fire department had requested permission to enter. Givner had refused. Tried in the Baltimore Criminal Court, Givner was found guilty of violating three provisions of the Baltimore City 81. Huntington Williams, personal interview. 12 September 1984. 82. Richard Rabin, (n. 1) pp. 1671-73. 83. "Drive on lead paint opened by dry," Baltimore Evening Sun, 9 February i960. 84. Huntington Williams, personal interview. 14 September 1984. 8j. This summary of the case is taken from "Court of Appeal of Maryland upholds right of entry," Baltimore Health News, 1956,33, 93, and from the report of the case in The Daily Record, 28 August 1936. 594 Journal of the History of Medicine : Vol. 45, October lggo Code relating co inspection of buildings. He was fined fifty dollars and costs, but given a suspended sentence. Despite the suspended sentence, he appealed, contending that the proposed or threatened inspection con stituted a violation ofhis constitutional rights against "unlawful" searches and seizures. The attempted search of Givner's property had not been directly re lated to the lead paint poisoning program; it was part of a project to eliminate rats, headed by David Davis of the Johns Hopkins School of Hygiene and Public Health. Davis testified that he had studied the 1700 block of Linden Avenue, that there were fifty or so rats in this particular block, and that he could tell from the rats going in and out of the house in question that there were plenty of rats in the basement and other areas of the building. He thus had sufficient cause to suspect the existence of a "nuisance" as defined by the public healthcodes. FranrJ. Vidor, director ofthe Housing Bureau, testified that the buildings in this block ofLinden Avenue were poorly maintained, lacked facilities, and were rat infested. He had inspected 264 properties in the area and found building code violations in 260 of them. The Court of Appeals of Maryland heard the case inJuly 1956.86 The court considered that the central question was whether the intended searches were illegal--did the prohibitions against "unreasonable" searches and seizures also prohibit "reasonable" searches and seizures? The court concluded that inspections carried out for the preservation of the health and safety ofthe public were "reasonable" and legal; it affirmed thejudgment of the lower court against Givner. Another suit filed by Aaron Frank went all the way to the Supreme Court of the United States. In this case, a Health Department inspector had responded to the complaint of a resident of the 4300 block of Reisterstown Road that there were rats in her basement. Inspector Gentry began examining the houses m the area looking for the source ofthe rats. On ay February 1958 he knocked on the door of Aaron Frank's home at 4335 Reisterstown Road. Receiving no response, he looked around the area outside the house, noted that the house itself was in an "extreme state of decay" and that, in the rear of the house, there was a pile later identified as "rodent feces mixed with straw and trash and debris to approximately halfa ton. "87 While Gentry was looking around the prop- 86. The appeal process and outcome is described m "Court of Appeal of Maryland," (a. 85) PP- 8J-9S* 87. "Aaron D. Frank, Appellant, vs. State of Maryland, On Appeal from the Criminal Court of BaldmoK, Maryland, Supreme Court of the United States," The Daily Record, 23 May 1959, p. 2. Fee : Childhood Lead Paint Poisoning 595 erty, Aaron Frank had appeared and asked his business. Gentry explained there was evidence of rodent infestation and asked permission to inspect the basement; Frank refused. The next day. Gentry reappeared with two police officers and swore out a warrant for Frank's arrest on grounds that he had violated the section of the Baltimore City Code permitting health department inspections whenever there was "cause to suspect that a nuisance exists in any house, cellar, or enclosure.,,8S Frank was arrested, found guilty, and fined twenty dollars. On appeal, the Criminal Court of Baltimore also found him guilty; so did the Maryland Court of Ap peals. Frank then challenged the constitutionality of the section of the Baltimore City Code under which he had been charged, claiming viola tion of the Fourteenth Amendment. The Supreme Court split five to four on the decision against Frank. In the opinion of the majority, as stated by Justice Frankfurter; the City Code did not violate constitutional rights; the inspection was designed and pursued solely for the protection of the community's health, made only the slightest restriction on the subject's claims of privacy, and was conducted with due regard for every convenience of time and place. The prohibition against unreasonable searches did not therefore apply to the Health Department's efforts "to locate the habitat of disease-carrying rodents." In the dissenting opinion, fourjustices declared that the decision vio lated "the right of privacy which every home owner had the right to believe was part of our American heritage." In this view, an inspection could only be made with a search warrant issued by a magistrate after a showing of probable cause. The magistrate in each case must weigh the need to invade privacy against the need to enforce the law. In this way, "even the lowliest home in the land" would be protected "from intrusion on the mere say-so of an official."898 Had this minority view prevailed, it would have been extremely difficult for an already overworked and understaffed health department to inspect buildings for lead paint hazards. But with the Supreme Court decision in its favor, the Baltimore City Health Department decided to begin a more extensive program of building inspections.90 After several years ofdelay created by the legal challenges to its powers, the Health Department now decided to inspect housing for the presence 88. Rule #120 of Article 12 of the Baltimore City Code. 89. "Aaron D. Frank, Appellant, vs. State ofMaryland," (n. 87) p. 3. 90. "U. S. Supreme Court upholds Baltimore health code--Right of entry," Baltimore Health Nem, I9S9.36, ill. u 596 Journal of the History of Medicine : Vol. 45, October 1990 of lead paint before children became sick. Since the prospect ofinspecting all housing was overwhelming, the Lead Poisoning Prevention Commit tee decided to concentrate on the Druid Hill District in west Baltimore which had the largest number of reported cases oflead poisoning. Inspec tors were to visit every home where there was a child of about one year of age. About 25,000 homes would be visited by teams ofhealth, build ing, and urban renewal inspectors: samples of paint would be taken from each apartment and, if these were found to contain lead, the Health Department would then order the landlord to remove the hazard. To begin the new campaign, Huntington Williams himself visited several homes, trailed by reporters, and collected twenty-six paint sam ples, sixteen of which were found to contain lead. In one apartment, a tenant was found painting the walls with leaded paint, and Williams dramatically confiscated the paint--providing good copy for the report ers, and also tacitly making the point that the program was not a vendetta against landlords: both landlords and tenants would be held responsi ble.91 The drive against lead poisoning was presented as a complete community activity in which all were expected to do their part: Paint manufacturers will need to make available the widest possible selection of paints free of lead pigment. Paint dealers or general store agents will be expected to be sure all their lead paint carries the warning label as required by city ordi nance, to question customers concerning the proposed use of the paints they purchase and sell only lead free paints for interior use. Home owners, occupants and painters it is hoped will check the labels of the paints they apply inside dwellings to be certain that they contain no lead. Mothers will need to be more careful in watching their small children to see that they do not eat paint, in the same way that they, guard than from dashing into a busy street or playing.with matches.... The lead paint poisoning menace can be overcome ifeach person learns to do Ms pari in preventing it.2 In 1961 the Lead Paint Poisoning Committee reviewed the progress made. The Bureau of Industrial Hygiene reported that when paint sam ples were taken from homes in west Baltimore, there was a 98 percent probability of finding lead. When lead was found in homes with small children, landlords were required to remove the lead paint to a height of four feet In the areas where lead paint removal was enforced, however, it was found that most families moved out of their apartments within a year--either because they simply wanted to move away from the danger, 91. "True prevention: Lead paint pojsoming," Baltimore Health Naas, 92. fcM., p. l}. 37, 1 t-i j. Fee : Childhood Lead Paint Poisoning 597 or because their landlords or an urban renewal program forced them out.93 It seemed likely that many of these families were simply moving from one hazardous apartment to another, The committee reviewed the statistics suggesting that the lead paint problem was almost universal in inner dty tenant housing and concluded that "while urban renewal and the reformulation of paints could be expected to reduce the amount of lead ... the presence of lead paint in older homes would continue to be a problem for many years."94 The removal of ail lead paint from existing housing, the obviously desirable preventive action, seemed an overwhelming task. The committee mem bers then discussed the possibility of enforcing paint removal only in those census tracts having the highest incidence of lead poisoning. Even this limited goal, they decided, would be impossible in economic terms. Estimating the number of Health Department personnel needed to in spect one thousand homes and ensure that landlords complied with lead paint removal, they came up with the following calculation: Operation Initial inspections (5 per man per day) Reinspections (7 per man per day ofthe 90 percent found positive) Second inspection (70 percent ofpositives) Third reinspection (20 percent ofpositives) Additional teinspeccions including court appearances (5 percent ofpositives) Follow-up aftercourt action (2 percent of positives) TOTAL Man-days pa-i,ooo units 200 129 90 26 9 26 480 Table taken from George Schucker ct al., "Prevention of lead paint poisoning among Baltimore children," Public Health Reports, 1965, jo, 970. The committee concluded: "Since the average sanitarian works 225 days a year, 2.1 sanitarians per year for 1,000 dwelling units, or 155 sanitarian-years, would be required to effect removal of lead paint from the 73.726 dwelling units in the 44 census tracts ofBaltimore that showed 93. George W. Schucker, Edward H. Vail, Elizabeth B. Kelley, Emanuel Kaplan, "Prevention of lead paint poisoning among Baltimore children," Public Health Rep., 1963, 8a, 969-74. 94. Ibid., p. 970. u 598 Journal of the History of Medicine : Vol. 45, October iggo 10 or more cases of lead poisoning or abnormal lead absorption in chil dren from 1956 through 1962. Comparing this manpower requirement with the total of 64 people on the sanitarian staff assigned to all sanitary surveillance activities of the city showed the economic unfeasibility of this approach to the prevention oflead paint poisoning. This pessimis tic conclusion failed to consider the possibility ofan approach on targeted areas ofthe city, with a few widely publicized court cases and fines against the landlords responsible--tactics that Williams had already used to good effect. But Williams, who was almost seventy years old and had now headed the Health Department for thirty years, had reached retirement; the city would not easily find another leader who combined his zeal for health improvement with the political skills needed to undertake imagi native programs and guarantee their success. THE HABD-SELL EDUCATIONAL PLAN In 1962 Huntington Williams was succeeded by Robert E. Farber, previ ously the assistant commissioner for preventive medicine. Under Farber, the orientation ofthe lead paint poisoning program became more conser vative. We have seen how Williams, after working on the problem for several decades, had moved away from the health education approach targeted at parents. Although health education had never been aban doned, the prevention program had steadily broadened to include hous ing surveys, diagnostic tests, paint regulations, new legislation, and lead abatement. Williams had grown willing to challenge established com mercial and financial interests, including those of paint sellers and land lords, and he had successfully survived major legal suits against the Health Department. He had certainly not been able to remove all lead paint from slum housing--a huge task--but he had demonstrated the department's ability to act effectively against specific hazards and had built a lead paint program more advanced than any other in the country. Williams's flair for the media and understanding of the importance of publicity to health department work had made him a highly visible person in the community and had brought considerable popularsupport. Landlords were beginning to take health department regulations seri ously and to factor the possible costs of lead paint removal into their economic calculations. In 1962, at this point of relative success, the Health Department re-9 9S- Ibid. Fee : Childhood Lead Paint Poisoning 599 treated. The Lead Paint Poisoning Committee announced a three-year "hard-sell educational pilot study." The effort to remove lead paint from housing would be abandoned: "Instead of removing the paint from the child's reach, the new program is intended to impress the person who cares for the child with the importance ofwatching it and keeping it from nibbling the paint.'m In a "person-to-person" approach, a health worker would explain to the parents the hazards of lead exposure. At six-month intervals, health workers would visit each home in the census tracts where lead poisoning was most prevalent and send letters to parents warning of the dangers of lead poisoning.97 This study was to be scien tifically designed, with census tracts divided into study and control areas; the results were to be measured by comparing the relative numbers of children with elevated lead levels in each area. In. the meantime, most other preventive activities, such as housing inspections and paint analy ses, were allowed to lapse. The assumptions On which the study was built were the old ones of die 19jos: that the main problem was parental igno rance. Ifparents were only educated about the dangers oflead paint, they would be able to control the hazard by closely observing the children, keeping the home scrupulously dean, and repainting with lead-freepaint. In fact, the "hard-sell" educational program was a complete failure. After three years of the project, investigators were unable to find any difference in blood lead levels between children in the "study" and "con trol" areas.98 Probably Williams's many years of avid publidty had paid off; parents in both the study and control areas were already aware of the hazards of lead paint and were doing what they could to minimize the danger. The failure of this particular project may thus have reflected a broader pattern of success--both physicians and community members had already become "lead conscious. They did not need more health education; they needed a concerted environmental effort to remove the hazard from people's homes. In 1965, while the Health Department continued some health educa tion efforts, responsibility for enforcing housing code regulations was turned over to the Department of Housing and Community Develop ed. Donald Bremnet, "New method used to fight poison by lead paint. " Baltimore Evening Sun, lyjuly 196a. 97. Schucker. Vail, Kelley, and Kaplan, (n. 93) pp. 970-72. 9*- Ibid., p. 97399. Despite the failure of this project, {96s was the first year since 1931 in which Baltimore repotted no child death from lead paint poisoning. See "lour children poisoned by lead paint m '66," Baltimore Evening Sun, 13 June 1966. 600 Journal of the History of Medicine : Vol. 45, October tggo merit.100 In 1967 the Supreme Court actually reversed the earlier decision giving health officials the right to inspect housing for health hazards; from this date, a search warrant would be required for housing inspec tions.101 The appellant in this crucial case had leased the ground floor of an apartment building in San Francisco and had refused to admit a hous ing inspector; an amicus curiae brief in the case had been filed by an organization, "Homeowners in Opposition to Housing Authoritarian ism."102 The discussion of the Court's decision was framed entirely in terms of protecting the individual privacy rights ofhomeowners against "warrantless administrative searches"--there is no hint of a suggestion that renters, or the children of renters, had any specific interests or rights to nontoxic housing that might also need protection. Despite the claims of the Court to the contrary, the requirement of a search warrant for housing inspections now made such inspections, for widespread health hazards extremely difficult, expensive, and rimo-consuming. In Baltimore, as in other cities, children with high blood lead levels continued to be admitted to hospitals for treatment. When a child was identified with high blood lead, health department officials would order landlords to remove lead paint from peeling surfaces accessible to chil dren. The response was essentially after-the-fact, and it could take weeks or even months before the hazard was removed. Indeed, the removal of peeling paint was often inadequate: most of the houses had new areas of peeling paint within a year and many of the children were readmitted to the hospital several times after being returned to their homes.103 Not surprisingly, in 1970, the Health Department stated that child lead poisoning was still a significant problem in Baltimore: a total of i* 143 children had been reported poisoned, of whom 205 were white and 93 8 were blade.104 In 1973, when the Department of Health, Education, and Welfare appropriated $150,000 for the dty's lead paint poisoning pro- 100. For 3 sample of popular health education materials on lead paint poisoning, see Lead Paint'. The Silent Kilter (Child Lead Paint Poisoning Project, Baltimore City Health Department), Using a lively comic book format, the publication makes dear that parents have primary responsibility for protecting their children from lead paint poisoning. More than 100,000 copies of this comic book went distributed. See "City child lead poisoning drops by 35 percent," Baltimore Evening Sun, 2 January 1975. . 101. "Camara vs. Municipal Court of the City and County of San Francisco.* Appeal from the District Court of Appeal of California, First Appellate District, no, 92, Argued 15 February 1967; decided $ June 1967. 3S7 U. S.: 523-40, 1967. 102. Ibid., p. 524. 103. Chisolm, MeOits. and Quaskey, (n. 6). 104. "Child lead paint poisoning sriU a threat,' Baltimore Health News, (970, 47, 120. See also Larry Lewis, "The quiet epidemic," Baltimore News American, 17January 1971. u Fee : Childhood Lead Paint Poisoning 601 gram, the number of diagnoses doubled--again, the problem seemed to grow when anyone paid close attention.105 By this time, landlords were being given ten days in which to bum away existing lead paint and apply a fresh coat.106 As the city had only two X-ray lead analyzers, each costing $4,750, the program could deal with only a few houses at a time. Health officials waited until a child was diagnosed with lead poisoning before inspecting the home for lead. LEAD PAINT: a NEW NATIONAL CONCERN While Baltimore's efforts against child lead poisoning were slowing down in the 1960s, other cities were beginning to direct increased atten tion to the problem. Jane Lin-Fu and others have attributed the sudden recognition, in foe mid-1960s, of lead poisoning as a massive health threat to an `'awakening of social conscience."107 As encouragement to this awakening, theJohnson Administration's War on Poverty channeled funds from the OtFice ofEconomic Opportunity through local commu nity action agencies, and thus forced health departments to become more responsive to local communities, especially those organized around neighborhood health centers and welfare rights. The civil rights move ment and the politically mobilized inner-city black populations pressured health departments to pay more attention to the appalling health condi tions of city slums and ghettos; but for the most part, recognition of the problem of lead paint poisoning still depended on the case-finding ap proach. When Chicago in 1966 and New York in 1970 began prospective mass screening programs, they found that 25 to 45 percent ofthe children in high-risk areas showed elevated blood lead levels.108 At this point, more than 4,000 scientific papers had been published on the subject of lead poisoning, but/oacside Baltimore, few efforts had been made to communicate this body of knowledge to the inner-city communities roj. "Found out 43 years ago, baby-killer is still around," Baltimore Sun, 22 August 1973106. Mark Farfd (n. 6) notes that the traditional methods of lead abatement by open Same burning, sanding, and scraping actually increase children's risk of lead poisoning. See also E. Chamey, B. Kessler, M. Fatfel, and D. Jackson. "Childhood lead poisoning: A controlled trial of the effect of dust-control measures on blood lead levels," N. Engi.J. Med., 198], 309, 1689-93: Chisolm, Mellies, and Quasbey. (n. 6). toy. Jane Lin-Fu, "The evolution of childhood lead poisoning as a public health problem," in J. Julian Chisolm, jr,, and David O'Hara, eds.. (re. 68) Lead Absorption in Children. pp. 1-10; Jane Lin-Fu, "Lead poisoning and undue lead exposure in children: History and current status," m H. L. Needlethatt, ed., (n. 8) Low Lard Lead Exposure, pp, 3-16. 108. National Research Council. Committee on: Biologic Effects of Atmospheric Pollutants. Lad; Airborne Lead in Perspective {Washington, D.C.: National Academy of Sciences. 1972), pp. 132-40. 602 Journal of the History of Medicine : Vol. 45, October ippo most affected by the "silent epidemic," nor had the knowledge been translated into effective prevention programs.109 As the Baltimore Health Department became less activist, other cities took the lead in the 1960s. In Philadelphia, the Welfare Rights Organiza tion worked with concerned professionals to demand funding for a lead abatement program; after a march on City Hall, the city used federal Model Cities funds for this purpose.110 In New York, the Coalition to End Lead Poisoning led a successful movement tor broad-based com munity education, mass screening of children, treatment programs, and lead abatement.111A conference on childhood lead poisoning at the Rock efeller University helped stimulate congressional interest in a national program for lead control. Between 1969 and 1974 seven states enacted lead poisoning prevention legislation. Perhaps the best known was the Massachusetts program initiated by the Citizens' Committee to End Lead Poisoning, the Massa chusetts Law Reform Institute, and the Massachusetts Advocacy Center. As in Baltimore, the main resistance to the housing deleading program came from landlords and property owners who acted through rental housing associations and a paid lobbyist at the state house. Richard Clapp, director of the Massachusetts program in 1977 and 1978, described the program's struggles with landlords.112 In cases where the families of lead-poisoned children were behind on their rent, a lead paint violation often served as the trigger to initiate eviction proceedings. Property owners stalled on action, did token and ineffective deleading, and even in a few instances, set fire to buildings in an effort to avoid spending money on improvements. The mobilization oflocal community groups in cities across the coun try finally brought national attention to the issue of childhood lead poisoning. In 1970 the United States Surgeon General advocated mass screening and identification ofchildren with elevated blood lead; in 197 r, the Lead-Based Paint Poisoning Prevention Act provided federal fund ing to help communities carry out screening and treatment programs. 109. Jonathan M. Stem, "An overview of the lead abatement program response to the silent epidemic." in H. L. Needlemaw. ed, (n, 8) Low Lard Lead Exposure, p. 280. no. Ibid., p. 281. 111. Nicholas freudenberg and Maxine Golub. "Health education, public policy and disease prevention: A case history ofthe New York City Coalition to End Lead Poisoning." Health Education Quarterly, 1987,14, 387-401. 1IX Richard W. Clapp, "The Massachusetts childhood lead-poisoning prevention program," in H. L. Neetfleman. ed., (n. 8) Low Lord Lead Exposure, p. 288. See also Stephen Bing, "The Massachusetts childhood lead-poisoning prevention program: An advocate's view." op dt,, pp. 198-97. Fee : Childhood Lead Paint Poisoning 603 Amendments to the Lead Paint Poisoning Act in 1973 directed the Con sumer Product Safety Commission to set a limit of 0.5 percent lead in paint unless some other safe limit could be found. The Consumer Prod uct Safety Commission in turn asked the National Research Council to study the problem. The report of the National Research Council, pub lished in 1976, found that no level of lead in paint could be considered safe; it recommended that no lead be deliberately added to paint and that, for regulatory purposes, an upper limit be set of 0.06 percent of lead in dried paint products.113 The head of the committee responsible for the ^ report, J. Julian Chisolm, Jr., noted that the principal opposition to these recommendations came from the National Paint, Varnish, and Lacquer Association, an industry group.114 The Consumer Product Safety Com mission. accepted the recommendations ofthe National Research Council in genera!, but allowed some exceptions in the case of household appli ances, bicycles, and other specific cases where an exemption appeared justified.115 The problem of new leaded paint had largely been solved--but old paint with a far higher lead content remains on the wails and woodwork of millions of homes in the United States. Federal regulations now pro hibit leaded paint in federally owned properties or those constructed with federal assistance, and require the reduction of lead paint hazards in the homes of children poisoned by lead; these actions reduce new inputs of lead into the environment but do little to eliminate the large reservoir of lead in nonfederally owned urban housing. Continued research on lead paint poisoning has shown that even asymptomatic children and those with low levels of lead exposure could sustain neurological damage, reduced I. Q. levels, learning disabilities, delayed speech development, and mild mental retardation.116 One solution to an intractable problem was to render it less visible by stopping research; in 1982, the United ttji. National Research Council. Recommendations for the Prevention of Lead Rant Prisoning in Children. Commission on Toxicology, Assembly of Life Sciences (Washington. D.C.: National Academy of Sciences. 1976). p. to. 114- J- Julian Chisolm. Jr,, personal communication. 1 June 1990. its- For a brief history of these decisions, see National Research Council, (n. 66) Lead in the Human Environment, pp. 463-68. nd. H. Necdleman al., "Deficits in psychologic and dassroom performance ofchildren with elevated dentine lead levels," N. Engl.J. Med., 1979, joo, 689-95. A recent follow-up study ofthe children in this first report found that the deficits were long-lasting; see Herbert L. Needleman et aL, "The long-term effects ofexposure to low doses of lead in childhood." N. Engl.J. Med., 1990. 3aa, 83-88; see also, E. Chimey, "Sub-eneephalopathie lead poisoning: Central nervous system effects in children, " in Chisclm and O'Hara eds., (n. 68) Lead Absorption m Children, pp. 35-42. For another discussion f the vast and growing Utennne on low-level lead caxidcy, see Lansdovra and Yule. eds.. (ti. to) Lead Toxicity: History and Environmental Impact. 604 Journal of the History of Medicine : Vol. 45, October iggo States Department of Housing and Urban Development dismantled its lead poisoning research office. ^ CONCLUSION What had been achieved in Baltimore in more than fifty years of discus sion and debate around the problem of lead paint poisoning in children? As children continue to be diagnosed with lead poisoning, tenants blame landlords for the problem, and landlords often blame the city. In this account, we have seen that although Baltimore in the late 1950s had started a truly preventive lead paint program, the impetus to tackle the problem aggressively was lost in the early 1960s with the retirement of Huntington Williams. The new mayor elected in 1971, William Donald Schaefer, despite his populist image, displayed little interest in lead paint poisoning or in preventive efforts. Community-based concern about lead poisoning increased in the early 1980s but met with disinterest from the mayor's office; the city Commissioner of Health, John DeHoff, was put in the position of defending inaction rather than being able to pro mote effective preventive measures.117 Property owners fully supported the passive attitude ofthe mayor and commissioner toward the lead paint issue.118 In 1981 Councilman Kweisi Mfume, representing west Balti more, called for new legislation to require the removal of all leaded paint from residential units in Baltimore. Stanley Sugarman, a representative of the Property Owners' Association, responded: "To get all the layers ofpaint offevery house would be very expensive and counterproductive. . . . You might as well pass a law eliminating February from the calendat."m Oscar Zurwitz, a Baltimore realtor and property manager, suggested the traditional method of holding parents responsible for the hazard: "The parent is die culprit in failing to protea a child from eating paint chips."120 In 1982, sixty-five years after Kenneth Blackfan had called for "ener- 117. John DeHoffexplained the lead paint poisoning issue as largely the responsibility of parents who failed to keep their homes sufficiently dean or to prevent their children from putting paint chips in their mouths. John DeHoff, "Health sums in East Baltimore: Lead poisoning among children," Seminar Series in Ediks and Public Health. HieJohns Hopkins School of Hygiene and Public Health. 4 March 1982- 118. Drafts of the Lead Based Punt Abatement Requirements were routinely shared with and approved by the Property Owners Association of Baltimore City. Inc. See, for example, letter from John DeHoff. Commissioner of Health, to Hon. Thomas Waxren Jr., Chairman of Policy and Planning Committee. t8 February 1982. 119. As quoted in "Lead-poisoning results dted atCity Council hearing on paint laws." Baltimore Evening Sun, 12 June 1981. 120. As quoted in Baltimore Evening Sun, (n. 119). ^ Fee : Childhood Lead Paint Poisoning 605 getic prophylactic measures," Bob Cheeks, then head of the Baltimore Welfare Rights Organization, accused the City Health Department of subordinating the health of children to the interests of slum landlords.121 In 1982, 61 percent of the rental housing in Baltimore was considered substandard, but the vacancy rate was so low and the housing crisis so acute that low income tenants were economic hostages of the housing market.122 One Baltimore landlord complained that local government should long ago have forced removal of lead paint from houses in the way it forced removal ofoutdoor privies and required indoor plumbing: "If the city had taken any preventive measures, these problems wouldn't be here. The city should have long ago had a game plan, sent out inves tigators, inspected for lead paint. Before anything ever came of this it should have been taken care of. TL.c's all water under the bridge. But I think they ought to do it now."123 In 1984 a Citizens' Planning and Housing Association issued a report noting that, although only one-fourth of Baltimore's children under six years of age had been screened for lead, it could be projected from these data that 6,000 city children had been poisoned by lead paint. Approxi mately 75 percent ofthe city's housing was believed to contain lead-based paint. At a meeting of the Maryland State's Lead Study Group on 14 September 1984, a member of the Property Owners' Association had testified: "In a pure economic sense, the costs of eradicating lead paint from houses is more onerous than the costs to treat persons diagnosed to have lead poisoning. "124 This tacit assumption, rarely so clearly stated, has been the basis for the continuing problem of lead paint poisoning in Baltimore as in all the older cities of the United States. A black candidate running for mayor of Baltimore in 1983, Billy Murphy, made lead paint poisoning one ofhis campaign issues. Murphy was unsuccessful in challenging Schaefer, but when Schaefer was elected Governor of Maryland in 1987, Baltimore's growing black population saw the chance for a shift in political alignments. Clarence Du Bums, Baltimore's first black mayor, succeeded Schaefer in 1987, and Baltimore 121. Bob Cheeks. Executive Director. Baltimore Welfare Rights Organization. "Health status in East Baltimore: Lead poisoning among children." Seminar Series in Ethics and Public Health, The Johns Hopkins School of Hygiene and Public Health, 4 March 1981. 121. Since chat point, the ever-deteriorating housing situation has made homelessness a greater priority than lead poisoning; any housing is preferable to none. 12J. Charles Morgan, as deed in David Brown, "A i-year old gets lead poisoning: Who is to blame?" Baltimore Sun, 29 May 198]. 124. Citizens' Planning and Housing Association of Baltimore, "Lead paint poisoning," 4 De cember 1984, pp. 4--5, Maryland Room, Vertical Files, Enoch Pratt Free Library. 606 Journal of the History of Medicine : Vol. 45, October 1990 now once again moved co the forefront of lead poisoning prevention efforts. The City of Baltimore issued new lead paint regulations on 1 July 1987. These regulations changed the old methods of lead paint abate ment-burning, sanding, and scraping--that had long since proved inef fective.123 They required new and more effective abatement techniques, abolished the old abatement limit of four feet, set clearance standards for the amount of lead dust left behind, laid down requirements for post abatement cleanup, and insisted that abated surfaces be repainted. Fol lowing Baltimore's leadership, the State of Maryland issued new regula tions that also drastically upgraded the level of abatement of lead paint hazards in comparison with previous practices. These regulations in turn set the tone for the development ofnew national guidelines for lead paint abatement. In the last few years, Baltimore and Maryland have on their earlier pioneering history and are once again leading the national effort; to deal more effectively with the still persistent problem of lead paint poisoning. School of Hygiene and Public Health TheJohns Hopkins Univeristy Baltimore, MD 2120s 125. W. J. Soboleski, "Some problems associated with die environmental phases ofa childhood lead poisoning prevention program," in Chisolm and O'Hara, eds., (n. 68) Lead Absorption in Children, pp. 135-41; see also, Farfel, {n. 9).