While New Hampshire has made progress, young children living in poverty remain at high risk of lead poisoning

By Kathie Ragsdale, Paul Cuno Booth, and John M. Bassett 

When she was apartment-hunting for her family in 2009, Heidi Leno was thrilled to find a spacious unit in an older building on Union Street in Littleton available for rent.

But weeks after she moved in with husband Charles, six-year-old daughter Courtney and twins Matthew and Maureen, not yet two years old, something started to seem terribly wrong with Matthew.

The toddler, who had previously been sounding out his first words, suddenly stopped speaking. He was constantly constipated. He had terrors that would leave him screaming in the middle of the night and unable to go back to sleep. 

“I lived off of two hours of sleep every day,” Leno recalls.

A doctor’s visit showed that Matthew had blood lead levels of 4.6 micrograms per deciliter and Maureen 3.7. Months later, the levels had risen to 17 for Matthew and 18 for Maureen. At the time, the U.S. Centers for Disease Control and Prevention considered lead levels of 10 or higher to be “of concern,” though experts commonly say there’s no safe level of lead exposure in young children.

The Lenos moved out, and for the past 11 years have been engaged in a lawsuit with the landlord claiming that lead poisoning is responsible for the developmental disabilities with which Matthew still struggles. Now 13, he has been found to have an IQ of between 40 and 65. His doctors say he will likely never drive or hold a job. He is now attending virtual school because the bullying he experienced during in-person classes gave him suicidal thoughts, according to his mother.

He is far from alone. While New Hampshire has made progress on the issue in the past half-decade, 580 children were found to have elevated blood lead levels in 2019. 

• With some of the oldest housing stock in the country, 56% percent of New Hampshire’s occupied housing, about 289,651 units, were built before the 1978 ban on lead in residential paint.  

• In some of New Hampshire’s highest risk communities, as much as 80% of housing was built prior to 1978.  

• Unfortunately, about 22% (63,723) of these housing units are home to one or more young children under the age of 6 years old, potentially exposing an estimated 42,057 children across the state to lead hazards in housing structures.

• In 2019, more than 2,500 New Hampshire property owners that own properties where children with elevated blood leads reside were referred to the NHHFA loan fund and our four Housing and Urban Development (HUD) Lead Hazard Control Grants for financial assistance to remove lead hazards in their buildings.

• New Hampshire’s four HUD Lead Hazard Control Grants provide free financial assistance aimed towards owners of pre-1978 properties that rent to low-income tenants or those owners that reside in their own homes and are themselves fall into the low-income criteria.  Many families across the state do not qualify for the free HUD grants due to exceeding  the income level and rely on the NHHFA Loan program as their source of funding to remove lead hazards in their home. 

• For property owners from across the State that do qualify for the free HUD funding are required to have a small financial match.  Many of these property owners rely on NHHFA’s loan funds as their financial match to quality for the HUD funding. 

• On July 1, 2021, through RSA 130-A Lead Paint Poisoning Prevention and Control, New Hampshire lowered the State’s blood lead ‘action limit’ for young children to 5 micrograms per deciliter (mcg/dL).  At 5 mcg/dL and higher, families receive an environmental investigation, nurse case management, and referrals to the HUD grant and NHHFA Loan programs.  The lowering of the action level has increased the number of families identified with the need to remove lead hazards by a factor of four.

Elevated blood lead levels disproportionately found in vulnerable children

The burden falls disproportionately on more vulnerable families, including those living in poverty. Children enrolled in Medicaid made up fewer than 30 percent of those tested in 2019 but represented about half of kids found to have blood lead levels above 5 or 10 micrograms per deciliter. 

According to DHHS, young children living in poverty are at especially high risk of lead poisoning. 

“On average, income status and housing age are the strongest predictors of heightened risk of lead exposure in New Hampshire,” Beverly Drouin, section administrator of Healthy Homes & Environment at New Hampshire DHHS, said.  

Similarly, at a national level, the Centers for Disease Control and Prevention says children in low-income households and in pre-1978 homes face the greatest risk. 

Because of poor housing, some Black children are at higher risk for lead exposure, according to the CDC. Nationwide, their data shows that Black children and children from low-income families are more likely to have blood lead levels above 5 micrograms per deciliter. This mirrors the trend in New Hampshire, where NH DHHS data shows that Black children made up 2.4 percent of those tested in 2019, but 7.1 percent and 8.9 percent, respectively, of those with lead levels above 5 or 10 micrograms per deciliter.

“Families who are economically disadvantaged, people of color, children of color, immigrants and refugees are still disproportionately affected compared to non-minorities because of the living circumstances they find themselves in, in older housing,” says Dr. Alan Woolf, a professor of pediatrics at Harvard Medical School and expert on lead poisoning.

The CDC says U.S. homes built before 1978 are likely to have at least some lead-based paint.

The Lenos’ former landlord declined to comment for this story, but court documents show she denies responsibility for his condition, with her lawyer arguing that studies on elevated blood levels and intelligence indicate his exposure “would in no way account” for the severity of his disabilities. On the other hand, a report by the Lenos’ psychology expert, Dr. Peter Isquith, concludes “it is more likely than not that the lead exposure is a substantial contributing factor to Matthew’s deficits.”

While no definitive standards exist for assessing the connection between lead exposure and neurological damage in individual cases, Woolf says experts can make probable correlations.  

“In an individual child, you can’t tell what caused what. But you can certainly suspect it,” he says. 

Why children are so susceptible to lead contamination 

  Woolf explains that children, especially preschoolers, are particularly susceptible to the effects of lead because their organ systems—notably their brains and nervous systems—are still developing. The most concerning effects are neurological, he says, adding that exposure to lead is associated with later development of attention deficit disorder, hyperactivity and learning disabilities. Some studies have also shown an association with lower IQs, he notes.

Lead-containing paint dust is the usual mode of entry in children, Woolf says, with actions like opening windows or doors releasing contaminated dust that toddlers pick up on their hands and feet, then ingest. 

“At about nine months, they start standing and walk holding on,” he says, “and if they’re holding on to a wall or a windowsill, that’s when they’re going to get exposed.”

Children with autism are at particular risk because they continue to put their hands in their mouths longer than other children.

A comorbidity for lead poisoning is iron deficiency, Woolf says, because toddlers run out of the store of iron they received from their mothers in the womb by the time they reach the age of eight or nine months. 

“Lead and iron are absorbed the same way in the gut,” he explains. “Kids who are iron-deficient are particularly vulnerable to lead poisoning because they run out of maternal stores (of iron). One of the reasons we have universal screening in New Hampshire is, they can present with higher lead levels and have few, if any, symptoms.”

Addressing Lead in New Hampshirehire: 

A Brief History 

Lead exposure used to be a far bigger problem in the United States. In the late 1970s, 88 percent of children ages one to five had blood lead levels of 10 micrograms per deciliter or higher. Phasing out leaded gasoline resulted in huge declines —by 2015-2016, that number was 0.2 percent.

Today, the primary cause of lead poisoning is lead paint, which still lingers in many homes built before it was banned in 1978. That’s a particular concern in places like New Hampshire, where more than half of homes were constructed before that date.

According to the New Hampshire Department of Health and Human Services, about one-fifth of those homes house a child under six, meaning tens of thousands of kids may be living in structures with lead hazards. 

For years, New Hampshire had “a real knowledge gap” about how large the risk of lead exposure was and whom to test for lead poisoning, says Gail Gettens, a child development specialist with DHHS’ lead poisoning prevention program.

In 2015, the year she joined the program, just 52.6 percent of one year-olds and 26.3 percent of two year-olds in New Hampshire were tested for blood lead levels. 

There were two main barriers, according to an article Gettens later co-authored with her colleague Beverly Drouin—insufficient awareness and a cumbersome testing process.

At the time, medical providers in the state mostly relied on venous blood draws to test for lead. Often, that meant pediatricians would refer parents to labs at other locations — where they’d have to deal with an already-cranky two year-old being stuck with a needle. That lowered follow-through.

“You had to leave my office, I had to put in the order for you, then you had to go from my office to the lab in order to get it done,” says Dr. Erik Shessler, a Manchester pediatrician and president of the New Hampshire chapter of the American Academy of Pediatrics. “And if I’ve already given your kid a bunch of shots today and they’re already mad and upset, a lot of families wouldn’t do it the same day, and then they’d forget to come back.”

A patchwork of requirements—universal testing in some places, a targeted approach in others—also made it confusing for doctors, according to Gettens.

In 2016, DHHS rolled out a strategy to improve lead-testing rates by educating providers about lead poisoning and promoting point-of-care testing — a much more convenient option done right in the doctor’s office. Over the course of the year, 25 training sessions reached more than 300 pediatricians, nurses and other staff in the state’s highest-risk areas. DHHS also used federal money to buy 10 point-of-care testing machines for community health centers around the state and distributed educational materials.

That year, about 2,100 more children were tested than the year before—a jump of 15 percent—and 2017 saw another rise.

Meanwhile, the issue was gaining steam in the state legislature. In 2015, lawmakers created a commission to study lead poisoning and testing rates. Three years later, they passed SB 247, which mandated universal testing for one and two year-old children, lowered the blood lead level that triggers intervention, and created a loan fund to help pay for lead removal in homes.

“That legislation was just a monumental step forward in moving the public health needle, to get children tested, and to do more to prevent lead exposure in the first place,” Gettens says.

Statewide test rates continued to rise after the universal testing requirement. In 2019, about 73 percent of one year-olds and 62 percent of 2-year-olds were screened for blood lead levels. 

The increase for two year-olds is especially important, Gettens says. Even if a child’s lead level isn’t elevated as a one year-old, they should still be tested again at age two, she says. Changes in their behavior, like becoming more mobile, mean they can become newly exposed to lead at that age.

“That two year-old test is critical,” she says. “And so the trajectory that we’ve had for our two year-olds is just something we should be really proud of.”

Variations in testing rates, COVID-19, and lead testing kit recalls

Testing rates continue to vary across the state, however, according to the most recent available data from DHHS. 

While 80 percent of one year-olds were tested in the Monadnock Region and Greater Nashua area in 2019, the rates were 66 percent in Carroll County, 64 percent in the North Country and 44 percent in the central New Hampshire public health region, which covers eastern Grafton County.

The two year-old testing rates show similar disparities; just 30 percent of children that age in central New Hampshire were tested, according to the DHHS data.

While point-of-care testing has been key to boosting uptake, some families still face barriers to accessing health care in the first place, Shessler says. That affects a child’s likelihood of getting a blood lead test and other primary care.

“Whether I have a point of care test or whether I have the lab do it, I can only test your lead if I can see you,” he says.

Meanwhile, external factors have hindered progress on screening kids for lead in the last two years. 

Testing for blood lead levels, like so much other routine health care, dropped during the COVID-19 pandemic as practices closed and then, even after they reopened, concerns about the virus kept many families away. According to preliminary DHHS data, about 3,100 fewer Granite State children were tested in 2020, compared to 2019.

Then, this year, the company that makes the widely-used LeadCare point-of-care testing machines issued a recall of many test kits due to a “significant risk of falsely low results.” The issue remains unresolved.

Three-quarters of blood lead testing in New Hampshire is done on LeadCare equipment, Gettens says. “New Hampshire has the recent experience and data to know, if our only option is to [go] back to a venous draw, our testing rates will drop.”

Lead abatement programs

Sullivan County is home to one of four lead-abatement grant programs in the state. When it comes to removing lead-paint hazards from New Hampshire homes, Kate Kirkwood, who oversees Sullivan County’s lead-abatement grant program, says more money than ever is being spent.  

“We’ve all got more money than we’ve ever had before,” she says.  

Sullivan County, the cities of Manchester and Nashua, and the New Hampshire Housing Finance Authority currently have U.S. Department of Housing and Urban Development grants totaling more than $16 million.

The programs offer aid to landlords and homeowners to remove lead from their properties. Those grants can be paired with zero-interest deferred loans from the state fund established by SB 247 in 2018. (The federal grants and state loans are limited to homes with residents earning at or below 80 and 90 percent of area median income, respectively.)

Sullivan County’s program—which has received $1.7 million from HUD to remove lead from 60 homes over three years—grew out of local efforts in Claremont to deal with the city’s lead problem. 

The program has seen strong interest, Kirkwood says. As of late September, 10 units had been completed and 11 were in progress, with 12 more in the application phase.

The New Hampshire Housing Finance Authority is also seeing high demand for its program, which covers all of New Hampshire outside Sullivan County and Manchester and Nashua, says Paul Chalifour, who manages the agency’s Lead and Healthy Homes program. 

One reason for the demand relates to the changes implemented by SB 247 in 2018. Not only are more children being tested, but the bill also lowered the blood lead level at which children are considered “poisoned,” from 10 micrograms per deciliter before the bill to 7.5 in 2019, and then 5 this past July. 

When a child living in a rental unit has an elevated blood lead level and lead hazards are found in the home, the landlord is ordered to abate the hazards before continuing to rent it.

“We have a lot of applications rolling in,” Chalifour says. “A lot more rental properties are being placed under orders of lead hazard reduction by DHHS, and those owners are reaching out to us.”

New Hampshire Housing aims to address lead in 226 homes in the current grant cycle, prioritizing units where a child has had an elevated lead test.

That may seem like a drop in the bucket; the agency estimated in 2017 that 250,000 units statewide contained lead hazards. But money’s not the only hurdle.

Contractors are generally in short supply, and lead abatement requires a specialized certification. Kirkwood says the Sullivan County program has done okay between local contractors and contractors drawn in from Massachusetts. But that capacity needs to grow if the program is to expand, she says. 

“We can get as much money as we can spend,” Kirkwood says. “The limiting factor, honestly, is contractors. We don’t have enough contractors.”

More than 60 percent of Sullivan County’s housing stock was built before the lead paint ban, according to the county’s HUD grant application.

“There’s work here for me for the rest of my life, and my kids and their kids,” Kirkwood says. “This is not going away.”

Meanwhile, the Lenos and their attorney, Chris Seufert, say they expect a jury to hear their case sometime next year.

“We don’t want this happening to anybody else because we know what he had to go through,” Heidi Leno says of her son. “It’s going to be a lifetime.”

This story is part of The Environmental Justice series. Produced in partnership with the NH Bar News and the Granite State News Collaborative, this ongoing series examines both the impacts of environmental change on vulnerable communities in New Hampshire and potential solutions. To download any of the data used in these articles visit our www.collaborativenh.org/data-library. 

These articles are being shared by partners in The Granite State News Collaborative as part of our race and equity project. For more information visit collaborativenh.org.