We are all Flint – 8 Strategies to Confront the Lead Problem

In 2007, I knew nothing about lead. I was a new analyst for D.C. City Administrator Dan Tangherlini, and I stayed up all night preparing to brief him on the topic. I had a notebook full of facts about blood-lead levels, testing protocols, and legal injunctions, but before I could say a word, he started:

“Here’s the thing about lead poisoning: at seven micrograms per deciliter (µg/dL) some kids are already experiencing neurotoxicity, but the CDC doesn’t recommend action until 10 µg/dL,” he said.

I closed my notebook. There was nothing I could say that he didn’t already know. He had children, lived in a house built before 1950, and the city he managed was no stranger to the topic. In the months that followed, I watched him transform a city’s response to child lead poisoning from worst to best.

By 2007, D.C. was already bruised from a previous mishandling of lead in water, and Washington journalists were still running stories about the D.C. government’s bungled response to lead poisoning, calling the city “dysfunctional” and “full of talk.” Advocates pointed to ongoing gaps in services for lead-based paint. There was a backlog of almost 300 incomplete lead-risk assessments for District children, and the risks to other children were going unchecked. Four years later, those same advocates wrote an article titled Washington, D.C.: A National Model for Lead Poisoning Prevention and Healthy Housing.

So how did Washington, D.C. go from dysfunctional to a national model in just four years? At a time when cities like Flint struggle, it is important to talk about what worked in D.C., so other cities can replicate it.

8 Strategies to Confront the Lead Problem

1. Admit you have a lead problem

Lead poisoning is a perfect example of  a public policy problem often underestimated. It’s complicated  and virtually impossible to eliminate. It is a pervasive threat to a vulnerable population. There is confusing federal guidance, and a patchwork of players across departments and jurisdictions to navigate. There are entrenched interests from the housing, construction, medical and legal communities. It’s a mess.

Anyone pointing fingers at Flint, Michigan right now needs to take a long look in the mirror, because we all have a lead problem. If you live in the United States, chances are you’ve spent time in one of the 70% of homes constructed when one or more unsafe lead practices were still legal or under-regulated. In fact, homes with brass faucets and fittings could contain as much as 8% lead until 2014. So we are all in this together.

When was the housing stock in the US constructed?
Source: US Census Bureau

Who must address this challenge that confronts us all? If you think government must solve the lead problem alone, think again. Yes, the government, or the public utility, controls the lead service pipes on public property and the quality of the water flowing through those pipes. But homeowners and landlords are responsible for any lead-based paint, solder, pipes, and fittings that connect to service lines to homes and businesses. According to research by water quality expert Marc Edwards, a home isn’t fully lead-safe until all of that high-risk material has been replaced and the water flowing through those pipes is non-corrosive.

2. Keep your eye on the right ball

There is a saying in emergency management: “You don’t get a second chance to get it right the first time.” In 2004, D.C. responded to alarm bells by downplaying — even obfuscating — the lead-poisoning risk and attempting to protect the image of the local water/sewer authority. In hindsight, officials in Flint are equally regretting two years of attempts to downplay residents’ water quality concerns. Government leaders appear to have a short-term memory problem regarding lead poisoning. But they cannot afford to take their eye off the only thing that matters — the health of residents.

Lead poisons people, especially children. No turf battle, image problem, or political football will ever justify anything less than a full-throated effort to mitigate risk, reduce harm, and be transparent about the actions taken. Scientific journals are littered with evidence that lead is an insidious long-term threat to our water supply and housing stock. So as a city official, when you see smoke, assume fire. The city should constantly work to maximize testing —  of water, soil, paint, and children — and minimize the number of children with elevated blood levels. Current CDC guidance is ≥5 µg/dL, and children who have reached that threshold live everywhere, not just Michigan. In fact, more children have elevated levels in Pennsylvania than New York City and upstate New York combined.

States whose children have elevated blood lead levels

But children in these states are not doomed to a life of violence and low IQ. Lead affects people very differently, and although serious it is not cause for hopelessness. The number of children who will be shot in an average year is a much more imminent threat to their health and safety – so cities should keep all of these problems in perspective.

3. Prioritize coordination over control

In The PerformanceStat Potential, Bob Behn writes that when responsibility is diffuse, people don’t take individual actions to solve a problem. When D.C. Mayor Adrian Fenty took office, lead advocates wanted him to name a “Lead Czar” — someone with power in City Hall to make city agencies work together. And it wasn’t the only constituency wanting a czar. HIV/AIDS advocates wanted a czar, school-age parents wanted an “Education Czar.” Lead was no different. Fenty’s response? “I’m already the Czar,” he said. The Mayor and City Administrator believed packing city hall with more “issue czars” was a short term tactic without a long-term strategy, and lead is a long-term problem. They wanted to fundamentally change the way city government functioned, and that required relentless coordination.

In D.C., as in many jurisdictions, lead involved no fewer than six agencies and a typical case of lead poisoning had to touch all of them. Advocates wanted someone in the Mayor’s office to be in charge. Instead, Fenty and Tangherlini hired George Hawkins to direct the newly-established District Department of the Environment (DDOE). At the time, DDOE controlled environmental hazard inspections, but no other part of the process. Despite a lack of broad legal or operational authority, Hawkins had something no one else had —  a rare combination of expertise, charm, and the Mayor’s support.

On his first day on the job, Hawkins was put in charge of figuring out how to make the entire system work for children at risk. Tangherlini told all other agency directors, “If George asks you to do something about lead poisoning, do it.”

With backing from City Hall, Hawkins methodically set out to understand and change the case-management and prevention process for lead.

“Lead is an emotional issue, but we set emotions aside and approached the problem methodically as a coordinated team,” Hawkins said.

Under his leadership, the city achieved the ideal outcomes — an increase in the number of children tested and a decrease in the number of children with elevated blood lead levels. In 2009, Hawkins left city government to become the CEO of DC Water, where he continues to drive lead-safe practices in water management. For his tremendous contributions to the public’s wellbeing, Governing named him Public Official of the Year in 2014.

George Hawkins
George Hawkins, current CEO of DC Water and former director of DDOE. (Photo credit: Governing Magazine)

4. Get serious about data and transparency

One of Hawkins’s first moves was to make a strong commitment to the lead advocates. He would provide them a biweekly report showing where each case was in the process. To get this done, he hired Jill Wohrle, a Capital City Fellow who, like me, knew very little about lead when she started. So she used data to light her path.

“I saw a rudimentary spreadsheet with all of the children with elevated lead levels, so I picked one case and went to every agency until I understood the process,” she said.

When a blood test comes back, how does the case move through D.C. government? Where are the possible stopping points that delay a case? Why does it take months for a family to see any action on its house? She quickly learned that five separate agencies had to touch a single case. At each one of those handoff points, a new delay would begin.

Wohrle’s data discovery process also revealed how the city was duplicating efforts across agencies.

“DDOE and the health department were both sending caseworkers to homes but were not coordinating their visits. There wasn’t a clear strategy to approach families in a cohesive way,” she said.

The city decided to put both units in DDOE, and Wohrle says, “that’s when the cases started to move much faster. The nurse and the inspector could schedule their visits together. We also had much better data about the source of poisoning.”

Even though the District relied mostly on basic spreadsheets, data sources were hugely important to implementing its strategy. Children’s case data — where you see incidents reported — helps cities see signs of improvement in areas where children have already been affected. Housing stock data helps you understand where the repeat offender properties are likely to be. The poorest wards in D.C. had fewer pre-1978 houses than Capitol Hill, where almost every property is pre-1978 and more families were moving in each year. With better data on housing inspections trends, the city could see which inspectors were identifying more hazards and use that data to do more targeted neighborhood outreach.

Unfortunately, the data on water service lines is bad almost everywhere because those lines were installed more than 100 years ago. Maps can often be “best guesses” and cities often wait until there is a breach to do a replacement and update the maps. Boston officials have made progress mapping their city’s water lines and the University of Michigan is now helping Flint map its lead service lines. But it’s slow-going. Even D.C. water service line maps are still largely unavailable to the general public — something the local, state, and federal governments should work together to change. If we can’t replace all the pipes, we should make location data easily available to the public.

DC Trends in Child Lead Poisoning
Source: District Department of the Environment, Lead and Healthy Housing Division, September 2015 report.

5. Proactively attack the problem from every angle

Waiting for children to show signs of elevated blood lead levels before taking action is not an ethical strategy. From an operational standpoint, cities must proactively identify at-risk locations and populations. They must intervene early with awareness, education, and preventive measures. When a risk is identified, cities must ensure testing and treatment protocols are executed accurately and that case management is carried out with the best interest of the child and parent(s) in mind. Legally, the city should be aggressive in challenging property owners who routinely put families and children at risk.

In D.C., the Attorney General increased the number of lawsuits filed against delinquent landlords — a tactic that sent a strong signal to the rental housing market. Legislatively, the city should work with state counterparts to ensure a legal environment that works to protect children. In 2008, the D.C. Council passed the Lead Hazard Prevention and Elimination Act, enabling DDOE to conduct lead-hazard inspections based on a reasonable suspicion that such a hazard might exist, instead of waiting for a child to test positive before taking action. It also required landlord provision of a lead clearance report to at-risk families renting pre-1978 units.

6. Understand sampling bias

The website FiveThirtyEight published an excellent piece called What Went Wrong in Flint explaining how officials took too few samples in the wrong places and excluded some of the results — all of which underestimated the risk. This kind of problem is rampant with lead poisoning and the guidance is confusing. Experts used to recommend flushing the line before testing, a practice proven to underestimate the risk. The bottom line for city leaders is that sampling is complicated and understanding how your protocol might be biasing results is critically important.

In D.C., there was very strong disagreement about the testing protocols for water (the protocols for paint are much stronger). For example, government inspectors had a different testing process than the one used in homeowners’ test kits, which led to serious mistrust and disagreements. DC Water, where George Hawkins is now the CEO, has totally revamped its testing protocol and aligned it with protocols designed to most accurately detect lead — an approach every city should take.

Water sampling is not the only place where bias matters. Testing the right children is also critical. Cities should focus on those who live in or near older housing stock and who rely on tap water more than bottled water. If a city pushes non-targeted testing to all children, it is entirely possible to increase testing numbers while lowering the percent of children with elevated blood lead levels – making a city look successful while the real risk goes unchecked.

7. Communicate, engage, and include

Lead is a contentious issue with a long history of government getting it wrong, leading to strained relationships between cities, advocates, and academia. That was certainly the case in D.C. between 2004 and 2007, and Flint is experiencing the same tension today. But Hawkins believed in the old adage that: “the enemy of my enemy is my friend.” He never forgot that lead is the true enemy, not the distrusting advocates. In D.C., Hawkins fundamentally changed the relationship between the city and the advocates. He believed getting their buy-in would help him get to solutions much faster. He was right. One of his first moves? Hire someone they trust.

Hawkins partnered with advocates and academics to agree on improvements to the pending Lead Hazard Prevention and Removal Act, the bill sailed past fierce opposition from landlords. When deciding on testing protocols or case management processes, he would ask advocates what approaches made the most sense to them and made them feel the safest. In Hawkins’s new role as CEO of DC Water, he regularly appears with the nation’s leading experts in water treatment and corrosion, making it clear the city is as interested in being a leader on the science of lead poisoning.

8. Confront the immediate crisis, but play the long game

Lead is an immediate crisis and a long-term threat – and cities must respond to both. In D.C. and Flint, a specific action resulted in an increased risk to residents – and those mistakes were not corrected quickly. D.C.’s crisis started getting noticed in 2001, but didn’t get fully addressed until 2004 when they mitigated the impacts of a switch from chlorine to chloramine with the introduction of orthophosphate. Flint’s crisis began in April 2014 after switching their water source to the Flint River, which was not properly treated for corrosion control. Officials did not switch back to the Detroit River until October 2015. In both cities, officials at all levels of government failed to respond to the immediate crisis effectively – a mistake cities should learn from because lead is always going to be a looming threat.

For many years, it looked like lead poisoning among children in the U.S. was being eliminated. The number of children testing at 10 µg/dL kept decreasing since 1997. But then, for reasons that were both political and scientific,  the CDC changed its action level to 5 µg/dL and suddenly a whole new population of children are at greater risk than previously thought. This increase will put pressure on cities to case manage more children. In a world of scarce resources, targeting the highest risk children for screening will help ensure those who need help the most, get the most help.

Long Term Crisis
Source: Centers for Disease Control

There are countless things individuals and governments can do to mitigate the risks of lead poisoning, but lead is here to stay. Until all service lines are completely replaced and every house is stripped of its original paint and re-plumbed, we will always have a lead problem. City strategies and tactics should seek to address the crisis at hand and lay the groundwork for long-term gains. It seems easy, during a crisis, to name a Czar. But for D.C., it wasn’t that simple.

In Memoriam 

The progress cited in this article would not have been possible without the tireless work of Ralph M. Scott, Jr. who passed away in 2012 after a lifetime of advocacy. I can think of no more fitting tribute than to end this article with his words from a 2008 interview with Washingtonian magazine:

“I have a lot of hope about what the District government is doing right now, and I could not have said this two years ago,” says Ralph Scott, community projects director for the Alliance for Healthy Homes and longstanding member of the Lead Screening Advisory Committee. “The first step in fixing something as broken as the city’s child-lead programs is to have people in charge who have a genuine wish to solve the problem and have the intelligence to know how to do it, and we now have that.”