Free Exhibits - District Court of California - California

Case 3:07-cv-05110-WHA

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SPECIAL REPORT ON LEAD POISONING IN CHILDREN

Cost of Child Lead Poisoning to Taxpayers in Mahoning County, Ohio

MA'f'THEW STEFANAI\. JOE DIORIO, MS" LARRY

MI'I-f'"

SYNOPSIS
Lead poisoning In children imposes both immediate and long-term financial burdens on taxpayers. The District Board of Health of Mahoning County, Ohio, quantified some of the airect costs to taxpayers of providing medical care arid public healtr services to the 279 children diagnosed with lead poisoning in the county in 2002, using methods described by Kauina Korfmacher at the Universitv of Rochester. The Board of Health also attempted to quantify the longer-term costs of special pOllcrition and juvenile justice services attributable to lead exposLre. The realization that lead poisoning costs local goverwnent on the order of $0.5 million each year has mobilized community Ipiloprs in education and juvenile justice to demand more aggressive action against rental property owners who fail to remediate lead hazards.

Fmsc:u. J\1D. MPH'"

'Malioning County Distrir r Board of Health, YoungslmHL DB
"Divivion of Commun itv Health Sciences. Northeastern Ohio Urrivcrsitics College of Mc-dirinc, Rootstown. Of-I

Address corrr-sponrlcnr c LO: Mauhr w St.cfan ak, t\IPH, Mahoning Count)' District: Board of Health. ,"j() Westc!lesLcr Dr.. '/OllngsIO\\.n. 01 I ·115 IS; lei. 'l'l()-~7()-2kSr, ext. 141; fax 'l'l()-27()-()(1~'); o-mail .
(~)~iI(),)

Association of Schools of Public Health

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SPECIAL REPORT ON LEAD POISONING IN CHILDREN

Lead poisoning in children irnposcs botl: immediate and long-term financial burdens on taxpavers. The District Board of l lcalrh of Mahoning Countv in northe-astern Ohio at tempted to quantify some of the direct costs to taxpayns of providing medical care and public health services to the 279 childrcn di
For the per-child costs we used Kemper et al.·s COSI esti mates.' inflated 123.8% from 1996 costs based on t.hc medi cal care Consumer Price l nd cx." We included costs for all children listed in the Mahoning County STELLAR database as having received initial blood le:-ld lesting in 'ZOO':!. (STEL LAR is an acronym for Systematic Tracking of Elevated Lead Levels and Remediation. a lead poisoning manugcmcnt da tabase developed by the CDC and 3d;lpted bv the Ohio Department of Health for usc statewidc.) The majority of children tested had reported blood 1c;]d levels < 10 flg/ <11. We auriburcd only t.he actual test cosl to these children. For children with higher lead levels, we included cosLsfor mrdical evaluation, follow-up, ;md-lor Ihe llighesl levels ('Zj) \1g/dl; medical r.rearruenr. Korfmache r caurio ns tlMt cost.s calcu lat cd by this method undcrcstimatr- current direct me(lic:-ll cost, because he haviora l and learnillg problems related to lead poisoning but not directly associated with treatment of lead poisoning may result in additional visits 10 health <:;HC providers. On the other hand. she also observes that be cause some childrcn do not receive all recommended services or testing following initial screening, the actual cornmunirv costs incurred for testing' and follow-up may be somewhat lower than those retlccrcd in Table I.

HEALTH CARE EXPENDITURES
The direct health care costs of lead poisoning include the cost of screening. 1JC
SPECIAL EDUCATION EXPENDITURES
Long-tenn srud ie« of children cxl'o.,,·(! 10 )";ld c;lr1l· in lilr: have a5socialed lead poisoning with lower class staltding in high school, greater absenteeism, lower voc.ibularv and gram matical-reasoning scores. and poorer hand-eye coordination rr.lat ive to other children." This impaired ncurobr-hnvioral function accounts for lTlany lead-poisoned children rC'-jui,' ing special education services. Schwarz has csrim.ucd that 20% of children with bloocllead levels >2S pg/dl will need special education (assistance hom reading teacher, psycholo gist. or other specialist) (or an averagc of three VG1Is. 10 II! 200:), the average annual cost of special edllcltion IV.IS $lS,OOO per pupil in the city of Youngstown (compared with $7.700 per pupil overall), aceording to the xupcrim cndc nt of th« Youngstown Citv School District (Personal communication, Ben McGee, January 2, 20(4). Table 2 presents our estima«: of special education costs for 20% of the 2'1 J\.L1honing County children with blood lead levels >25 Jig/ dl reported in 2002 as well as 20% of the estimated 5,1 children wiill blood lead >25 f-lg/dl not detected by screening programs. '10 estimate this latter number. we obtained from the local STELLAR dat abase the percentage of children aged 12-71 months in calendar veal' 2002 whose maximum venous blood lead lev els recorded were >25 Itg/dl: 1.0% of children aged 12-71 months. Since the majority of ihes« children in the database re sided in the city of Youngstown. we :lpplied this perc('ntage to the 2000 Census population ages 12-71monl1ls of Young srown.!' For the remaining- count.y populat.ion. we used the 2001 National Health and Nutririon Examination Survey (NIIANES) csrimatc" that. O.CJ% of children <72 1110mhs had blood lead concentrations >2') l-lg/ dl and reduced this number by 33% to reflect rhc secular decline in high blood levels that bas likely OCC\.l1 red since rhe NHA_>l\[ES d3t;] were collected as well ;IS to compcnsarr- fo r OlU- use of >25 pg/dl

Table 1. Estimated cost to screen and treat children for lead poisoning. Mahoning County. Ohio. 2002

Blood lead level
10-19 i-lg/dl ?0-4S fJg/dl Total

Number of children
2,498 232 47 2,777

Estimated per-child cost to screen and treat
$29 $69 $%9

Estimated total cost
$73,102 $6,008 $45,543 $124,653

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COST OF (;tHLD LEAD POISONING. MAHONING COUNTY. OHIO

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Table 2. Estimated cost of special education services for children with blood lead levels >25 fJg/dl, Mahoning County, Ohio, 2002
Aricitiona. special education cost per child per year Estirnateo number of children ages 12-71 months with blood lead >2') ~g/dl in 2002 Estimated number of children needing special education services' Total cost per year of r'eeded services Discounted cost per year Discounted cost for three years of special
ech.cation services

$10,330

79
16 $164800

$142158 $426474
$85,295

Discounted cost for each one-year cohort of children "20% of children with blood lead '/25
~g/dl

(Ior consistency with Sc hw.uz!") in contrast 10 the NHANES cutoff of ?:2'i flg/dl. These special education costs have been discoun ted at a ~~(X: rate for five veal'S on the ,lssurnprio11 tha1 they ar« in rurrcd an average of five years in the Iururr.. The discount ing for speci;ll education and juvenile justice COoLs (sec be low) was base-d on a "discount factor"!" c.ilcu larcd as th c inverse of (1+discOUlll ratc)flluJllw[ ot)nr'~ which for educa rional costs (based on a :ifl" discount rate) was the inverse of (l.03/, or O.862(j. The annual special education cost of $;16,1.800 was d iscountcd by O.fJi26. leading 10 ih« figure of $142,158 shown in "lahle ~. Since the Hi children requiring special education would need an average of three years of service, their lifetime special education cost is three times die discounted value shown in Table 2, or $426,'17,1. This cost, however, ;lpplies to the entire five-year cohort of children ages 12 to 71 months, so that the cost for a onc-vcar cohort is one-fifth ofthe total, or $85,295. The special education cost'; in Table 2 are based only on the prob.ibilirv of a learning disability for children with blood lead >28 f-lg/cll. Since LJ child's ability to learn is impaired by kad ('xposure at levels far below 25, Table 2 likely underes timates Ihe truc cost of special education, altbough no long term studies have yet been published on whether children with non-zero blood lead levels <25 pg/dl incur signifi cantly more special education costs than non-lead-poisoned children.

JUVENILE JUSTICE EXPENDITURES
A recent study by Herbert Needleman at the Universi ty of Pittsburgh has made it pmsihle to estimate the extent of lead's couuibuuon to juvcu ile delinq ue ncv.!' Needleman calculated an adj ustcd odds ratio of 4.0 (95% CI lA" 1l.1) for having bone lead levels :..-:-:25 ppm (measured by K-line X-ray j] uoro mcuv) for adolescents aged 12-18 who had been arrested
about 30 days and reflcr.r veil' recent exposures) wit.h bone levels. hut we assumed for the .malyscs reported here rh.u Mahoning Counrv children with documented blood lead levels 2]0 ftg/dl have ncuroiogica] damage eompar;lb1c to th.u experienced by the subjects of Needleman's stuck ,"Ve used two csljm"tes of the rnun bor of children 12-7J months of age in M;lllOning Counrv VI~lh blood lead levels 2]0 I,lg/cll in 2002 to quantify the popLl]atioll at risk for later delinquency. One estimate ('190 children) was based Oil an assessmenl bv Ibe Enviroruncrual \Vorking (;'-o\lP, which estimated conservativclv 111atH % or children with blood lead levels 2: I 0 Ilg/ ell were "missed" in Mahoning Counrv in :!002 bccaus« of incomplete screening,'" 'Ne per formed a separate analysis for Mahonint; County based on 7,1')0 children in the 2002 age cohort of 12-71 months who h.id blood lead levels recorded in the local STELLAR data base, Eleven percent of rh es« r.hild rcn-c-most of whrnn liverl ill the city olYounusrown-c-had ley(:1s :0: I0 JIg/ dL Applying this fraction to the 5.9'lO rhi ldrr-r: ages 12-71 months re poned by the 2000 Census as rcsiden L, or Youngstown." we derived an e"iimatc of li;")3 plev;Jknl kad-poisoned drildren ages 12-71 months within the city with blood lead conccn uation-. 2>10 JIg/ell. For the rcma indcr of the rountv pOpLl Iariori "gcs 1.2-71 months (9,7',5), wc Il.scd the nariona! NJ-L\NES rate of 2.2% to produce ,lIl csrimatc or 131 chil d i en , for a 11)[;)1 couruv-vviclc csum.u c or 7fH children." Whil« we believe that the higher of these two c::;rilllatcs is a more accurate jWCV;llell«(" nW'lSU1"e. we chose conservatively to use the me.in of the two estilll;ltes, G'\7 children, for the calculations ,lJaf.l<)!Je)\\'. Applying Levin's form ul.i for pop' ila tion a I rribura ble risk ,]S o'.ltlined by G'Jldis"" ;mcl tbc prevalence cstimatr: of 637 children, '\ie csrim.ued a popllblion arrribiuahk- risk of 11% for lead poisoning arnong adjlldicared delinque-nts. Lcvins form.u la calcu lnrcs pop'tlation ;\(uibLtLl.bk risk froru the odds ratio of the exposure in adjudicatcd vs. non-adjudicated children (in t.h is e;rse, ·1.0 lor elevated bo n e lc.id and delin quency) and the proportion of the pnpLllation wit h the risk factor (in this case, blood lead levels 2> lO jlg/dl: 637 01 1').715 childrcn). Auriuurabl« risk. is, strictly speaking, a measure of association rather tban causation. Studies such as Needleman et al.'s that show a strong association between lead poisoning anrl delinquency do not establish with ccr raintv that lead poisoning causes delinquent behavior, noi do they offer any guarantee that in ih« absence of lead hazards the risk of dcli nquen cv would he redllccd by It % (or at all). Nonetheless, based on the results of Needleman's multivariate a nalvsis. it is reason.rblc to calculate ;) popula tion arrriburable risk on the assumption thai coufounding by other social variables was reduced by multivariate analysis. Table 'I presents our estimate of tJ1C future costs imposed on rhc juvcnilejusricc system in Mahoning Cou nrv for lead poisoncd childrcn who were 12-71 months of age in ~002 lL';ing this value: for attribLlI.ahlc risk. We discoumcdjuvonile jllsticf' COSb;17 by g% over 15 years using t.h c discount factol formula cited earlier." The IS-year period for discollllting was chosen beca «scjuvenilcj ustice ('0.11.1 "r(' most cornmoulv accrued in the 15-] 8 year age range (Personal conuuunica lion, Keith (vI. Hanni, 1\1A. Probation Offl('er. tllahoning County COUll of COllllUOn Pleas .f"veni]e Comt Division.

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SPECIAL REPORT ON LEAD POISONING IN CHILDREN

Table 3. Estimated cost of juvenile justice services for children with blood lead levels >25 IJg/dl, Mahoning County, Ohio, 2002
2002 juvenile Justice expenditures Fraction attributable to lead poisoning' Lead poisoning-attributable cost per year Discounted cost per year Discounted cost for three years of juvenile Justice services Discounted cost for each one-year cohort of children "Lead poisoning defined as blood lead; 25 [Jg/dl $5,276,967 11% $580,466 $372,560 $1,117,680 $223,536

May 20FH) , i.c., ] 2 to 15 years bcvond the mean age of rhis study's CO]lOrI of 12- to 71-month-old children. \Ve do not currcnr ly have data about the length of time childrcn remain involved with the juvenile justice system in Mahoriing County, but county probation and intakeofficers report rh.u scriou» cases remain opcn for at least three years. Consequently, as with special education, we assumed that these delin quc nt children would need an :werage of three years of intervention: thus, the total cost would be three times $372,560, or $1,1] 7,680. This cost, however, upplics 10 the c nrire five-year cohort of children :1ged 12-71 months, so~,'Ls with the special education cost,-lhe cost for a onc year cohort is one-fifth of the total. or $22'UJ36,

PUBLIC HEALTH EXPENDITURES
The state of Ohio funds local effort'; ill Mahoning Counry to educate residents about lead poisoning and prevent .md respond to cases of childhood lead poisoning Lhrough tar grled outreach 10 prenatal clinics, preschools, and elemen tary schools; lead awareness horne visits: and abatement programs. Funding provided to the Mahoning County District Board of Health in 2002 for these purposes iotaled $bo,OOO. Most of this public Funding would no longer be necessary if lead poisoning were eliminated. In addition to these public health expenditures, the U.S. Department of Housing and Urban Development provides a sign ifica 11I amount of fr de-ral fund ing to Mahoning County to assist low-income homeowners and landlords in remediating lead hazards.

justice costs in Tables 2 and .11 are lime-limited, del;lyed in onset. and occur over scvcra) years. To make these COSIS more xtrictly comparable, we chose 10 express educational andjuvenile justice costs in Table 4 per one-year age cohort. As we have stressed, these caJculatiolls .ilmosr cx-rrainlv underestimate some costs and do not include other direct and indirect short- and long-rerm costs imposed on taxpay ers and society by childhood lead poisoning. As Schwarz has noted, property owner concerns about the cost of lead haz arc! remediation must be balanced wir.h the burdens placed on taxpayers by properly owners' failure to rr.mcd i.u c t hcsc hazards in the homes of children who become lead-poi soncd.!" Wh ilc th er« is a VelY wide r:1ngc of cost estimates for lead abatement, Needleman cites a 1991 CDC :\O-ve3r cost estimate of $3:').7 billion to n-rued iarc 18A minion housing unit, ($2,519 per unit in ZOO"l dollars l.!" A cost-hcncfu an:llvsis suggests that under vorue assumprions. strict enforcclnerH of housing orriin.mccs can be signifiGlIltlv cosI·s;J\,ingY' \~'c have used these estimates to brier members of ;\ local coal itjon of public and private organizations Ih~H serve chil chen (the Mahoninu County Family Fn Sf Counril): Young stown City Council and Board of Education rncm bcrs; juve nile court officials: child welE\re adl'OGlleS; and orhr.rs who have
COMMUNITY IMPACT OF THIS ANALYSIS
Table 4 presenls a summary of yearly costs to l,lxpayers of childhood lead poisoning in Mahoninj; Counrv in 2002 based on Korfmarbcrs model.' 'We have calculated costs both for lead-poisoned children actually detected by screening and for those who remained undetected because of incomplete screening. Summing these costs provides the total 2002 and future costs for the cohort of lead-poisoned children (widl blood lead :",1 0 l.lg/ dl) aged 12-71 mon ths in 200:? ($LG10,154). However, this simple summation is problem a tic because medica I and public health COSls in Table 4 accrue ve:Hly, whereas the special education and juvenile

Table 4. Estimated costs to screen and treat children for lead poisoning, Mahoning County, Ohio, 2002, including projected future costs
SCI"eening and treatment' Special education services'<
Juvenile justice services-"

$124,653 $85,295 $223,536 $66,000 $499,484

Public health services tor all screened children Total 'Lead poisoning defined as blood lead 2:10 f-lg/dl "Per one-year cohort of children 'Lead poisoning defined as blood lead 25 [Jg/dl
c

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COST OF CHILD LEAD POISONING, MAHONING COUNTY, OHIO

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Onr esrimatcs of the burden on taxpayers Crom lead poi soning. however incomplete. have helped to mobilize key stakeholders in our IOCCiI educational .ind juvenile justice cornmunirics to demand action on behalf of lead-poisoned children. Subsequent to the involvement of these key stake holders, the mavor of Youngstown appointed a special pros ecutor to pursue noncompliant landlords; we l1;we also docu mented a H% reduction from Ma) 2003 to rVfay 2()(H in the number of rental properties wirh unremediated lead haz ards, the most sig·niflCanl. decline since the Boai-d of Hcalrh began enforcing lead hazard rcriuc.r ion measures in 199').

REFERENCES
Korfrnacher KS. Long-term costs of le.«! poisoning: how much can Nc\\' York save b~' ~topping lead? rci!"cd 2004 ;'I,'by 2!)J. Available fro rn: U RL: 11ttp://w\\'\\'.al""11h.org /aa/ a~,I_SI a lC' 9~ ~O_Ioc;ll_lead _cnsts_NYrep. pdf 2. Census Bureau (US) .vnnual estimates of the population for COUll r.ics of Ohio: April 1. 2000, [0 Ava ilable from: URL: iW""','.C,cll;lI.';.QO\·,' nn,v'''' """" "p, /tablc
2002

I

Kemper, AR... Bordlev Wt", Downs SlYJ. Cost-effectiveness an-;dysis of lead poison ing screening str-;Hegies follmving ih« 1997 gl.liddine~ of the Center-s for Disease Control and Prevention. Arch I'ccliatr Adolcsc Med lr;%;1~2:1202-R. H. Department of Labor eus) , Bureau of Lahor Sraristics. Table 1 Consumer Price l nrlcx for all urban consumers (CPI-U): U.S. city ewerage, by expenditure category and cormnoditv and service group I cited 2004 .lillie '\0]. Available 110m: l'RL: !Jtljl:/ j\,,\w.bls.gm , cpi icpid040.').pdf ~l. Needleman HL, Riess]A. Tobin ]\1], Biesecker GE. GreclliJ'lll'cJB. Bone lead levels and delinqnem behavior, JA~'IA 199(i;27!)::16;)-~L 10. Schwar-z J Societal benefits \)[ re-clucing- lead exposlllT. Environ Res 1994:fifi:1W>-24. 11. Census B-ul-eau (US). American Factlinrlcr; CCllSU<; data su rrunarv file 1 [cited 2004Jllnc 30]. Available from: l!RL: Iwp:/ / factfindercci isus. gm/servlct.z Da rase LJ\1 ~'1 illPi-lgcSt:-rdcL'!_progra m::: IJEC&_lang=ell 12. Meyer PA, Pivetz T. Dignam T,~, Homa DM. Schoonovcr], Brodv D Ceu te rs for Dise-ase Control and Preventiou. Slll"i'eiUaJlcc for ek vated blood levels amona childrcn-e-Unitec) Sl;ue:;;, l~F)7-~[)(Jl. 1\fiv[\,VR SuryeilJ Surnrn ~OO:i;:)2:1-21. lL National Library or Mcd iciuc (US), National Information CClIUT on Health Servic-es Research and Health Care Tcrhuologv. Health economic,", information resources: ;;1 self-st nrlv course. Module 4: an introduction to rho principle::: of critical apprC-li.-.::-tl of lIc;:llth economic evaluation studies. Key areas for cri tical ;ipprai"o..;;ll-'-1:. Disrountiug (c.ired 2004 June 30J. Available from: Ll~,L: hlr.r:/,' W\V\v.ll}nLI1 ill.gov/ ni chsr: cd u/ hcah.hecon .' 04_11c,JJ7.ft mil 14. Needleman HL, ?v'IcFarland C, Nes:'\ RD, Fi(·.'nhf:r~ SF, Tol)ln j\,JJ. Bone lead levels in :.tdjudiGlt,ed rlelinquenls. A ca's'r. .ourrol sUlci)' NC1.lrl}l"():\.icol Tcratoi 2002;'2~1:711-7. l~. Environmental \,vorkLng- Group. Esumatcr: risk 0[" lead p()i~ollitlg. County and local data: L\'bhoning COU}H} [circe. ~nn4 1:1J. Available [rom: URI.: hnp:/ 'W\l-\\·.ew~,.()l'g /figures ,/rnap_:,:r-.d.l:c_risk.pbp J. 6. Cordi.. L. Fpidcrniolo~-{y. Philadelphia: \"' . n. Saunrk-is: 1~1~J(). p.

7.

:J. Genera; Accouruing Office (CS). Lear! j!oi:"oning: fr-deral health care prc>gr;.\nl~' -;lre not cifecrtvclv re;ichillg .u-risl. children. Pub. No.: GAO/HEJIS-99·lR. Wdshil1gWl1: CA(); 199''1, Also a""i!;tI,\e fronl: lJR.1.: hnp:/ /\\'w"w.gao.goY/,u clli\'c/1999/"hcq~"l018.pdf 6. Centcrs for Disease Control and PIT\'Ctnion (US), Nation;;ll Center for Enl"irolllHenut! Health. AhouT. childhood lead poisoning [ciIed 2004JuI12]. A'",ildble from: l'RL lmp://\\w,\·cdc.go"incch/lead 'reselrcJt/ kidsBLLhun#Dcfinj Ilg%20lhc?n20problClll

](,2.
l 7. Tablack ~J. NIahoning COlHHY, Ohio, comprehensi\re ,Hlllual finan ci;·1.1 rcp(,n for the fiscal ?car cnding· DeccO"tber ?~ 1, :2()O:~. YOUllg s[O\','n (OH): j\,lahoning County, O[flc,,~ (If lJH~ AudIl.oJ-; ~OO:1 Necdlem;Hl H. Lead poisonillg. A.I1HU Rcy l\,1cd 2n()4/)r):2nq~'22. Bnnvn )'\,'lJ. Co:-;[<.; and benefiL"l or enforcing housing policics to prevent. childhood lead pni:,:;olling. j\lcd Dc-cis ]\rbkiug ~n()2:~~:4S~
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