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Am Fam Physician. 2001;64(4):564-570

to the editor: I have dealt with the problem of lead-poisoned children for more than 40 years now—in family practice, later as a local health director and, finally, as a State Health Commissioner before returning to academia. I appreciated the “Practical Therapeutics” article titled “Lightening the Lead Load in Children”1 for its timely and necessary information.

Your readers should also know about a very successful program of primary prevention that began in Portsmouth, Va., in 1971 and has continued successfully to the present. The Portsmouth program was patterned after one started a decade earlier in Ypsilanti, Mich. In all core cities, the main housing units most likely to be a source of lead poisoning are rental units frequently owned by persons who live out of town.

The Portsmouth program was initiated to protect children from lead poisoning and to avoid treatment. The treatment outlined in the article1 focuses on secondary intervention and occurs because lead-poisoned children in cities are like the canaries that had been used in mines to detect poison gasses. When lead poisoning is detected in a child, then action is taken. Unfortunately, by this time, the child is usually permanently affected.

In Portsmouth, an ordinance was enacted that required all rental units be checked by health department environmentalists to ensure that, prior to occupancy, the rental units were habitable and without danger to children. The Building Code of America (BOCA) Housing standards used included testing for lead paint. To be sure the units were not rented without inspection, the utility companies were required to shut off all service to the unit until it was approved for occupancy by the staff of the health department.

Owners of rental units in Portsmouth are required to reimburse the health department the cost of inspections, so that cost to the general taxpayer is not incurred. Computer connections between the health department and utility companies ensure fast turnaround of habitable units.

During the three subsequent years following 1971, housing compliance (compliance with the entire code, including removal of or protection from lead hazards, based on 1970 standards) went from 45 percent to 90 percent and has improved each year since.2 The accompanying table on page 567 shows the increase in inspections; a significant increase in the number of rental housing unit inspections occurred after the rental code went into effect.

Inspection stage19711974
Initial inspections1,0223,237
Total Initial violations1,0221,241
Remaining in violation at year's end*198

In some states, such as Texas, this approach cannot be used because the state's constitution shelters housing owners.

All physicians should consider urging members of their city and county councils to adopt similar primary prevention programs.3

in reply: We appreciate Dr. Buttery's insights concerning the importance of primary prevention of lead poisoning. Although the main focus of our article1 was secondary prevention and treatment of children with lead poisoning, we agree with Dr. Buttery that additional focus on primary prevention is needed. It is encouraging to read about the success of the Portsmouth program. Unfortunately, the history of lead poisoning intervention is replete with stories of frustrations and failures, as well. For example, Berney2 relates the failure of a 1957 effort in Baltimore to detect and remove lead paint from dwellings before occupation. Among the reasons cited for this failure were opposition of local landlords and health department concerns about the time and effort needed to enforce lead paint removal. These and other factors, such as opposition from the lead, real estate and insurance industries, continue to serve as obstacles to the prevention of lead poisoning. Due, in part, to the pressures from these interest groups, success measures of primary prevention at the federal level have been limited.3 This highlights the importance of physicians' active support of local and state efforts toward primary prevention of lead poisoning.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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