文章基本信息

标题：Public Health and Law Collaboration: The Philadelphia Lead Court Study
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作者：Carla Campbell ; Ed Gracely ; Sarah Pan 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2013
卷号：103
期号：7
页码：1271-1277
DOI：10.2105/AJPH.2012.301076
语种：English
出版社：American Public Health Association
摘要：Objectives. We determined whether Philadelphia Lead Court is effective in enforcing lead hazard remediation in the homes of children with elevated blood lead levels. Methods. We created a deidentified data set for properties with an initial failed home inspection (IFHI) for lead hazards from January 1, 1998, through December 31, 2008, and compared compliance rates within the first year and time to compliance for lead hazard remediation between 1998 and 2002 (precourt period) and between 2003 and 2008 (court period). We evaluated predictors of time to compliance. Results. Within 1 year of the IFHI, 6.6% of the precourt and 76.8% of the court cases achieved compliance ( P < .001) for the 3764 homes with data. Four years after the IFHI, 18% had attained compliance in the precourt period compared with 83.1% for the court period ( P < .001). A proportional hazard analysis found that compliance was 8 times more likely in the court than the precourt period ( P < .001). Conclusions. Lead court was more effective than precourt enforcement strategies. Most properties were remediated within 1 year of the IFHI, and time to compliance was significantly reduced. This model court could be replicated in other cities with similar enforcement problems. Lead toxicity and elevated blood lead levels (EBLLs; defined by the Centers for Disease Control and Prevention since 1991 as a blood lead level [BLL] ≥ 10 μg/dL) are among the major environmental problems affecting US children. 1 As a result of increasing evidence for the harm caused by even low-level lead exposure, the Advisory Committee on Childhood Lead Poisoning Prevention 2 recently recommended to the Centers for Disease Control and Prevention that they abandon the so-called “level of concern” previously used and instead use a reference value representing the BLLs in the 97.5th percentile for children participating in the National Health and Nutrition Examination Survey (which the data presently show to be 5 μg/dL) to identify children needing more clinical and public health follow-up. EBLLs can cause impairment of development, behavior, attention and cognition, anemia, and, rarely, death; new data have shown that intelligence and cognitive function can be affected at BLLs less than 5 micrograms per deciliter. 1–5 Children are more affected than adults because many organ systems are developing during infancy and childhood, including the nervous system, and they absorb more lead, relative to adults. Children are exposed to lead primarily through contact with deteriorating lead-based paint and lead-contaminated house dust and soil, mostly by ingestion of dust or paint chips through routine hand-to-mouth activity practiced by most infants and toddlers. 6,7 US homes were painted with lead-based paint until 1978, when its residential use was banned by the Consumer Product Safety Commission. A recent study by the US Department of Housing and Urban Development (HUD) found that 38 million houses in the United States had lead-based paint, and 24 million had significant lead paint hazards. 8 According to the 2009 American Housing Survey data, 91.6% of the housing units in Philadelphia, Pennsylvania, were built before 1978. 9 Because 27% of Philadelphia families live in poverty, some owners may defer routine maintenance and repair, leading to property deterioration and the generation of lead hazards, mostly from peeling paint. The prevalence of EBLLs based on the results of children’s screening tests reported to the Philadelphia Department of Public Health (PDPH) has always been higher than the corresponding national data. However, it has declined markedly over recent years, from 52% of screening tests in 1993 10 having a BLL of 10 micrograms per deciliter or greater to 2.3% (n = 810 tests), 2.2% (n = 797), and 2.3% (n = 824) of venous lead tests for 2009, 2010, and 2011, respectively. Percentages and numbers of venous lead tests of 5 micrograms per deciliter or greater were higher and were 15.5% (n = 5418), 14.2% (n = 5010), and 10.3% (n = 3666) for 2009, 2010, and 2011, respectively (Claire Newbern, PhD, MPH, personal communication, June 21, 2012). The trend in BLLs of 5 micrograms per deciliter or greater (the recommended reference value) is a downward one but represents a significant number of Philadelphia children for whom additional clinical and public health management would be recommended by the recent Advisory Committee on Childhood Lead Poisoning Prevention recommendations. 2 This problem requires a public health solution because lead exposure of children involves multiple stakeholders, including the child and parents, the property owner, and the local authorities who make and enforce laws, ordinances, and codes. Workers from the PDPH inspect the homes of children with EBLLs for lead hazards. In April 2002, an inventory was prepared and resulted in the assessment that 1400 “backlog” properties housing children with EBLLs had identified lead hazards for which remediation work had been ordered by the health department but had not been conducted by the property owner, in violation of the health code and presumably because of the PDPH’s lack of authority to force the owners to comply with departmental orders. The City of Philadelphia did not have any type of separate administrative hearing conducted by either the PDPH or any other city office for those who were out of compliance with health department regulations. In short, owners faced no negative consequences if they were noncompliant with the departmental orders. The only course of action that the PDPH’s Childhood Lead Poisoning Prevention Program could take was to send out its own crews into the homes to do the remediation work and send the owner an invoice, which was usually not paid. The Childhood Lead Poisoning Prevention Program has had limited staff to do this—generally 2 abatement teams—and it could only remediate 2 to 4 homes per month. In addition, before 2002, they were limited to doing paint stabilization and lead dust cleaning, so they could not do carpentry work, roof or plumbing repair, or any other basic systems work that might help decrease future peeling of old lead-based paint. Presumably, other cities may have a more formal process for issuing violations, holding administrative hearings, issuing judgments, and levying penalties or fines in situations in which remediation of lead hazards has been ordered for a particular property. Before 2002, attempts were made to bring enforcement of orders to remediate properties through the Philadelphia court system, but it usually resulted in the judge ordering the PDPH to do the remediation work, without prioritization by resident children’s BLLs or other factors and without supplemental funding. Because of this typical response, the aforementioned strategy was not commonly used in the decade or 2 before the creation of Lead Court. The Philadelphia Lead Abatement Strike Team (LAST) program was developed by the PDPH in 2002 in response to community concern about the failure to remediate identified lead hazards. 10 A number of advocacy and community-based groups expressed deep concern about this failure, and Public Citizens for Children and Youth was a leader in advocating for improvement of the lead remediation process. A LAST policy group was regularly convened by the office of the city’s managing director and included staff from the PDPH, key housing agencies, and the city’s Law Department for improvement of health code enforcement for lead hazards 11 and development of an infrastructure for remediation and temporary occupant relocation. Enforcement was strengthened considerably with the November 2002 creation of the Lead Court through a partnership among the PDPH, the Office of the City Solicitor, and the Court of Common Pleas. The creation of the LAST program, enabling much easier collaboration and coordination among the various city agencies, was instrumental in creating a climate in which Lead Court could be created. The Lead Court was created specifically for cases involving owner noncompliance in response to remediation orders issued by the PDPH. 10,12,13 As part of its function, PDPH staff members gave a formal presentation to the judges and Law Department staff on causes of lead exposure, information on the toxic effects of lead, and how remediation of the home is instrumental to stopping and preventing further lead exposure. On reinspection in the first month of a property with an initial failed home inspection (IFHI), cases in which remediation work has not been started are referred to the Law Department to be logged into the Lead Court system. In this article, we report on a quantitative study of the Philadelphia Lead Court that evaluated whether the court was effective as an innovative law enforcement strategy in (1) reducing time to lead hazard remediation compliance compared with the precourt period and (2) increasing the rate of compliance within 1 year of the IFHI. A Lead Court successful on both of these measures would result in fewer properties with lead hazards (and thus fewer children exposed to them) than would otherwise be the case. In a qualitative analysis, we interviewed Lead Court staff members; results will be reported elsewhere.