Unsafe Harbor? Elevated Blood Lead Levels in Refugee Children

Abstract

Two years ago, a doctor at Boston Children’s Hospital gave a routine physical to a 6-month-old baby boy who appeared to be wearing cosmetic eyeliner. His parents, recent immigrants from Nigeria, had been applying this folk remedy, known as tiro,1 under the baby’s eyes since he was 2 weeks old, believing it would improve his visual development. The baby was later found to have a blood lead level (BLL) of 13 µg/dL, more than twice the reference level of 5 µg/dL at which the Centers for Disease Control and Prevention (CDC) recommends action to reduce exposure.2 Analysis later showed the tiro consisted of more than 80% lead. When the baby’s parents stopped using the product at the hospital’s urging, his BLL dropped to 8 µg/dL within three months.3 This anecdote illustrates a problem that persists despite bans on lead-based paint and leaded gasoline that have drastically reduced rates of elevated BLL among children. Overall, just 2.6% of U.S. children aged 1–5 years now have BLLs above the CDC reference level.4 In contrast, with BLLs often many times the national average, refugee children from developing countries constitute stubborn pockets of elevated BLLs in the United States. Refugees are defined as individuals who have fled their home countries because of war, persecution, or the demonstrable threat of persecution. Their refugee status, for which they must apply, makes them eligible for medical and cash assistance within the United States.5 The CDC recommends that all refugees aged 6 months to 16 years be screened for BLL, anemia, and nutritional status upon arrival in the United States, with followup lead testing three to six months after placement in permanent housing.6 Lead screening is not mandated for immigrant children, who are not fleeing safety threats that could otherwise afford them refugee status. Because the CDC doesn’t report BLLs specifically by immigration status, the evidence for high BLLs in these groups comes mainly from a limited number of studies using refugee health screening data. However, much of what will be discussed in this story could be expected to apply to immigrant children as well. The most recently reported lead poisoning fatality caused by lead-based paint in this country was a 2-year-old Sudanese girl, who died in 2000 in Manchester, New Hampshire, just weeks after her arrival from a refugee camp in Egypt. An autopsy showed a large increase in lead exposure in the preceding month. Among other potential routes of exposure, the child had been observed eating plaster from holes in a wall in her home. Testing showed the paint on the wall contained high levels of lead.7 Sudanese refugees in their living room in Kansas City, Missouri. Although some refugees come to the United States with elevated blood lead, others are exposed only after their arrival. For these people, living in older housing with lead-based paint is ... “Refugee kids in particular can be malnourished and anemic, and that boosts lead absorption and heightens the potential for neurological effects,” says Mary Jean Brown, chief of the CDC’s Healthy Homes/Lead Poisoning Prevention Branch. She adds that refugee parents may have no idea about the risks posed by lead toxicity. But with day-to-day survival a pressing concern, lead toxicity—especially if its effects aren’t outwardly apparent—can rank low on a refugee’s list of concerns, according to Rosemary Caron, an associate professor at the University of New Hampshire in Durham. “If there’s no rash or fever or something they can see, they tend not to worry about it,” she says.