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Senator HUGHES. Is it your intention to continue these surveys to try to build a body of evidence which we all realize has been nonexistent?

Mr. FINGER. Yes, it is. In fact, we are proposing a much broader survey. This first test was really to define the methods by which we would make a nationwide survey.

We wanted to get some screening work done to establish the procedures before we launched out on a very costly national survey.

Senator HUGHES. Is there any determination at all as to whether the retail outlets which are doing the blending and mixing are the real problem?

Mr. FINGER. That is in the case of the custom mixed paints, negligence in applying warning labels when pigment is added, but still we think we have to go back,

and Senator Dominick so indicated, to the source organizations of both the manufacturers of the base paints and the pigments in order to try to assure that their technology has advanced to the point that lead content is so low in the paint no matter what the retailer does he does not add an amount beyond what is allowed.

I think, Senator Hughes, it goes back to the point you made too. Though the warning is on the can, that does not automatically transfer the warning to the wall. Therefore the only way of controlling this is to cut the lead out of the paint at the source, so that we no longer have to worry about the wall warnings.

But for the existing units that have been painted with lead, the warning process is one of the ways we have to at least alert people to the fact that this is something they have to worry about in those units.

Senator DOMINICK. Would the chairman yield at that point ?
Senator HUGHES. Yes,

Senator DOMINICK. Just following along the chairman's idea, what percent of the total building is represented by federally assisted housing per year?

Mr. FINGER. It has been high over the past few years. We have had in the last year about 400,000 to 500,000 subsidized units and another couple of hundred thousand federally insured units included in the 2,000,000 units that were produced in 1971. So federally assisted housing went up to 30 percent of the overall housing production.

It is a fairly large percentage of the housing that is produced and a very large percentage of housing in the central cities.

Senator DOMINICK. In other words, you are taking into account in the term “federally assisted” both VA and FHA housing ?

Mr. FINGER. Yes, we are.

Senator HUGHES. Are you including the housing with loans that are guaranteed by the Federal Government ?

Mr. FINGER. In any way, yes. This is all considered, and that does offer quite a leverage in this process. That is really the point I think Senator Dominick was seeking.

The point I would make is with the great surge in the amount of assisted housing, the leverage is offered for us to say that lead-based paint will not be permitted to be used in our assisted housing and, thereby, have it eliminated in all housing.

We are proposing that the list of high lead paints by manufacturer and brand name would be distributed to all of our Insuring and Area offices so they can implement the requirements of the Act under the circulars that we have issued to them.

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Senator Hughes. I would like to thank you, Mr. Secretary and Dr. Billick, for your statement, your appearance, and your responses.

You have made notes to follow up on the material you are going to supply for the record ?

Mr. FINGER. Yes, we have. Senator Hughes. I would like to say it is possible there are members of the committee who might want to submit questions to you in writing if it is absolutely essential.

Mr. FINGER. Thank you.

Senator HUGHES. The Chair would like to welcome Dr. J. Julian Chisolm, Jr., associate professor of pediatrics, Johns Hopkins University School of Medicine, in Baltimore. Dr. Chisolm is also associate chief of pediatrics at the Baltimore City hospitals. Dr. Chisolm has worked with lead poisoning in children for most of his career and is a member of the Committee on Environmental Hazards of the American Academy of Pediatrics.

He is accompanied today by Mrs. Louis Burton and Mrs. Emma Haskins.

Welcome to the subcommittee, Dr. Chisolm. You may proceed with your testimony as you desire.

STATEMENT OF J. JULIAN CHISOLM, JR., M.D., ASSOCIATE PROFES

SOR OF PEDIATRICS, JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE, BALTIMORE, MD., ACCOMPANIED BY MRS. LOUISE BURTON AND MRS. EMMA HASKINS

Dr. Chisolm. Thank you, Mr. Chairman. As a member of the American Academy of Pediatrics, I am here to testify on behalf of the academy in support of S. 3080.

The American Academy of Pediatrics supports this bill because we feel that these amendments are essential to carry out the intent of the Lead-Based Paint Poisoning Prevention Act.

Of first importance is the matter of time. We feel that very little can be accomplished within the span of 1 or 2 years under Public Law 91-695 as it now stands without the amendments contained in S. 3080.

It is fair to assume that it would take up to 1 year for units of local governments to set up or arrange for the necessary laboratory support facilities.

There are great technical difficulties involved in the measurement of lead in biological samples which must be resolved first, so that testing programs in the field are not going to start right away. Each supporting laboratory must have time to develop its proficiency in these measurements. I note, particularly, that the bill contains a provision to make State agencies eligible for the purpose of establishing centralized laboratory facilities. This, I think, is an excellent provision.

Centralization of laboratory facilities is likely to be both more economical and to insure better quality control. High-quality laboratory data will, in turn, assure better medical care of the children involved.

Certainly, while there are some large cities which can support adequate facilities, there are smaller ones that may not be able to do this so well.

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I think once the laboratories have been set up and the organizational work has been done, experience in the city of Chicago would indicate that it takes up to 5 years to bring an existing problem under control, that is reduce the incidence of childhood lead poisoning in the screening area to a minimum.

It is my informal understanding that the screening program in Chicago does not yet cover all of the high risk areas of that city, so I think that 5 years is a conservative estimate of the time that it might take. At that future point one might better estimate future needs beyond 5 years. We obviously do not have all the necessary informa

5 tion at the present time to project beyond 5 years.

Due to the interdisciplinary and collaborative nature of the childhood lead poisoning problem, the academy I think would recommend that the intent of Public Laws 91-695 and S. 3080 should be carried out as a categorical collaborative program, and that it probably should be continued as such for at least 5 years.

In terms of funding the only information that I can offer is contained in my written statement and is based on a study of some of my patients. I would like to point out that this group of children spent an average of 100 days in acute and convalescent hospital care. Thereafter, they were followed as out-patients.

The point I wish to make is that very little of this in-patient hospital care is required for the medical aspects of their care. The main component of it is related to the great delay in getting housing repair done or in relocating families into safe housing when you have affected children.

In the particular case of this group of 45 children most of whom had been ill we thought it very urgent that they not be returned to their homes prior to adequate repair. I hope that the committee will

I take this aspect of the housing problem into consideration in its deliberations.

In terms of lead content of paint I see that the academy statement has been a subject of much discussion earlier. I would like to provide some additional background.

First, the daily permissible intake or "DPI” for a small child is thought to be approximately 300 micrograms of lead per day and is approximately twice what they would get in ordinary food and water. Why twice? It is estimated that this level would allow them, without harm, to take in small additional amounts of lead from air and, particularly from dust and paint chips. It would allow for about 150 micrograms on the average per day from all of these varied nondietary sources.

It is further estimated that this DPI would not allow the level of lead in the blood to rise above a level that might be associated with any adverse effect. We would find virtually no physiologic abnormality if we were to examine children whose average daily intake were beneath this DPI.

So the DPI is set from the point of view of preventive medicine and from the point of view of protection of the children's health. The sa fety factor of five that is mentioned in the attached AAP statement, is the increase in intake of lead over the normal food intake that should bring almost every child to a level of lead absorption at which one could demonstrate some important adverse metabolic effects.

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Such effects include evidence of storage of excess lead in bone and abnormality in bone formation. One might also be able to demonstrate anemia. Certainly, we would be able to demonstrate a number of abnormalities in the synthesis of acne if daily lead intake were raised five times above the usual dietary intake.

When you deal with large numbers of people you are apt to find some variation. In setting this DPI we attempt to take this biologic variation into account and set the DPI at the upper

limit of what we think would have a negligible effect. Any intake in excess of this DPI should have a demonstrable effect in an increasing proportion of the children.

If total lead intake increases to five times normal dietary lead intake virtually all children should show some adverse effects. This opinion is not based entirely on the academy's deliberation. It is also based very largely upon a report of the National Academy of Sciences, the National Research Council, and upon a report of an ad hoc committee set up by the Bureau of Environmental Management of the USPHS to consider the question of what would be a safe daily intake for young children.

Mr. Finger is quite right in saying, when we project from a health standard to the paint on the wall, that a lot of assumptions must be made which are not easy to document. The assumption used to reach the 0.06 percent limit in paint is based upon an estimate of the amount of lead that will accumulate over a period of time in 10 layers of paint during the 10, 20 or so years after the house is built and painted. Ten layers of paint containing 0.06 percent should not provide an intake that is in excess of the daily permissible intake unless average daily intake of such paint exceeded one square inch weighing 400 milligrams.

Now, how much intake? Estimates of intake are based upon eating an average of one square centimeter of multilayer paint chips per day; in other words, something about the size of my thumb nail.

Physicians do not know actually how much paint children eat. We see X-ray films that appear to show very large amounts in the intestine. There are certainly a number of assumptions in this. Even so, I think that this is the best estimate that we can arrive at from a health point of view on the basis of available information.

I think Mr. Finger already mentioned, and I would certainly concur with him, that examining paint on the wall is quite a different thing from examining paint in the can. Hopefully, different sorts of standards will be applied to each. Mr. Finger also mentioned the difficulty in finding out how to repair houses.

I would like to make one final statement. In the academy's memo to the FDA we took a very pessimistic view about pica. We really do not know how medically to control this habit in children. This is an area in which we really lack information.

We do not know too much about the basic behavioral background of it. I think it might therefore be worthwhile to consider whether some special consideration for the study of pica might not be appropriate.

It certainly would facilitate educational efforts, because if we do not understand the dynamics of pica, then it makes it very difficult for us to tell educators, health professionals, and parents how

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to cope with pica, which is at the root of not only lead poisoning but many other accidental poisonings in young children.

I think in the interest of time I will not summarize my remarks. I think I will end right here, Mr. Chairman.

Senator HUGHES. Dr. Chisolm, your entire statement will be included in the record as though given.

(The prepared statement of Dr. Chisolm follows :)

PREPARED STATEMENT OF DR. J. JULIAN CHISOLM, ASSOCIATE PROFESSOR OF

PEDIATRICS, JOHNS HOPKINS UNIVERSITY OF MEDICINE; ASSOCIATE CHIEF PEDIATRICIAN, BALTIMORE, MD.

Mr. Chairman and members of the committee, I am Dr. J. J. Chisolm, Jr., Associate Professor of Pediatrics at The Johns Hopkins Medical School and Associate Chief of Pediatrics at the Baltimore City Hospitals. I have devoted much of my professional career to the study of lead exposure and lead poisoning in children and have been a member of several committees and panels convened to consider various aspects of human lead exposure. I am a member of the Committee on Environmental Hazards of the American Academy of Pediatrics and am here today to testify on behalf of the American Academy of Pediatrics in support of S. 3080.

In previous testimony before Congressional bodies in support of P.L. 91-695, I outlined the medical aspects of childhood lead poisoning. (1, 2) The disease is preventable. In its more severe forms, it can cause permanent brain damage and death. Treatment instituted at a severe or late stage of the disease is not effective in reversing such permanent brain damage.

Today, I will confine my remarks to S. 3080, a bill to amend P.L. 91–695 which is now before this Committee. The American Academy of Pediatrics takes a strong, positive position in support of this bill because these amendments are essential to carry out the intent of the Lead-Based Paint Poisoning Prevention Act. In particular, we feel that there is a real need to extend the authority of the Lead-Based Paint Poisoning Prevention Act beyond one year. Little can be accomplished toward an effective solution of this health problem within the span of one year. For example it will require up to one year for recipients of grants under Titles I and II of P.L. 91–695 to set up or arrange for the necessary laboratory support facilities for reliable testing programs in the field. This is owing largely to the technical difficulties inherent in measuring very small amounts of lead. Once technical support services become operational, experience in Chicago (3a) indicates that it probably requires five years to bring the existing problem in children under control. When other cities without prior lead paint poisoning prevention programs institute such programs, it is probable that they too will require about five years to bring the initial problem in children under control (Title 1). Thereafter, one can concentrate a relatively greater effort on the housing and environmental aspects of the problem (Title II) which will be more difficult to solve.

Prevention of lead poisoning-in common with other environment-related problems—requires a cooperative interdisciplinary approach. The coordinated efforts of local health department personnel, physicians, paramedical personnel, medical-social workers, volunteers, community workers, housing inspectors, legal counsel and other must be brought to bear on this problem. (4) Because of the interdisciplinary nature of the problem, I would recommend to the Committee that P.L. 91-695, as amended by S. 3080, be extended as a categorical program for at least five years. Then, one can chart future needs more realistically on the basis of that experience.

The amounts authorized under S. 3080 to fund the Lead-Based Paint Poisoning Prevention Act appear realistic. My own limited experience in this area may be helpful to the Committee in this regard. In 1970, I was able to summarize direct medical costs in a group of children with increased lead absorption and lead poisoning whom I had followed medically for some years. In this group of 45 children, the average period of acute and convalescent hospital care was 100 days: The average cost at 1970 basic hospital rates was calculated as $5,486/100 days/patient (see Attachment #1 (3b)). Seventy-five of thess days were, in the main, determined by the length of time required to complete adequate repair of their homes. The details of this analysis may be found in Appendix F, "Airborne Lead in Perspective" (3b). I would further comment that an effective

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