When a good policy is also overwhelmingly popular, great things can happen. As part of the infrastructure package now under consideration before the US Congress, the Biden administration has proposed a “moonshot” plan to finally address a shameful national scourge: lead poisoning that robs (mostly poor and minority) children of normal cognitive and social development, locking families in cycles of avoidable poverty and hardship. By eliminating lead in all pipes and service lines, Biden’s plan would reduce lead exposure in 400,000 schools and childcare centres and in millions of homes, affecting more than 500,000 children under the age of 6.
The proposal comes with a hefty price tag: $45 billion. But despite deep partisan divides in the US, it turns out “not poisoning children” remains popular across the political spectrum (figure 1), with 74 percent of all Americans backing the plan in one recent poll by Data for Progress. It’s also good value for money, with benefits of around $1.33 per dollar invested.
Figure 1. Voters support Biden $45 billion plan to eliminate lead pipes
Source: Data for Progress, graphic by Vox
We applaud this effort. But we suggest Biden adopt an even more ambitious goal: not just national elimination, but global eradication of lead poisoning, especially in children. A global eradication campaign—modelled loosely on prior and ongoing global efforts to eradicate smallpox, polio, and guinea worm, mixed with inspiration from the WHO’s Framework Convention on Tobacco Control—would offer a tremendous contribution to global welfare, economic growth, and even world peace. An American-led effort to eliminate lead poisoning globally could be an international moonshot elevating the Biden administration’s international statue and legacy.
Lead poisoning robs hundreds of millions of children of their health and potential
An estimated 800 million children around the world suffer from lead poisoning—that means one third of all children have lead in their blood at or above the level that requires intervention.
Most of these children live in Africa and Asia. And in low-income countries the majority of children, 59 percent, are at risk (above the theoretical minimum risk exposure level value (TMREL) of 2 micrograms per decilitre of blood). In some countries, lead poisoning is a near-universal blight; 80 percent of children in India and 99 percent in Afghanistan are at risk (Figure 2).
Figure 2. Population at risk of lead poisoning (% of population)
Source: Institute of Health Metrics and Evaluation (IHME)
Lead poisoning mounts a multi-pronged and permanent attack on children’s health and development during their vulnerable and formative early years—with devastating lifelong effects. A recent UNICEF report offers a succinct summary of research evidence, which demonstrates that lead exposure is associated with cognitive deficits, lower educational attainment, behavioural disorders, and reduced lifetime earnings. Even relatively low lead levels in blood have been associated with 3-5 point drops in IQ; extrapolated across an entire population, such losses imply a 57 percent increase in children living with intellectual disability.
Increasingly, evidence also points to lead poisoning as a root cause of violence and crime. In St. Louis, census-tract-level concentrations of lead have been associated with meaningful increases in firearm crimes, assault, robbery, and homicide; in Rhode Island, lead levels were strongly predictive of school detention. The evidence base in low- and middle-income countries remains limited and demands further investigation, but—given the robust evidence on the link between lead poisoning and violence in the USA—it is entirely plausible that lead exposure could be driving at least a portion of the world’s violent conflict, from street gangs in South Africa to extremism in Central Asia and the Sahel.
Beyond the devastating effects on health and development, lead poisoning has high economic costs. Estimates of lost lifetime economic productivity due to lead exposure in childhood in low- and middle-income countries suggests a total cost of $977 billion, with economic losses equal to $134.7 billion in Africa alone.
Children encounter lead in the air, soil, and water
In the US, most childhood exposure to lead comes via two sources: first, lead pipes that supply drinking water; and second, chips and dust from older lead paint, which remains common in sub-standard, unrenovated housing units built before 1978 (when lead paint was banned). Biden’s plan focuses on the former, by replacing the lead pipes that lead to water contamination with safer alternatives.
In poorer countries, where many children lack access to any improved water source, readers could be forgiven for thinking that lead abatement is a lower-order challenge. And these children do receive some significant lead exposure via lead pipes. But at least some of the sources of exposure are also different—and in some cases more easily addressed. Here are some big ones:
Lead paint: In the US, residential use of lead paint has been banned since 1978—but as of 2020, at least 76 WHO member states still lacked legally binding controls on its production, import, sale, or use.
Lead recycling: Lead remains a common (and lucrative) component of the batteries used for vehicles and in industrial applications—and demand continues to grow. Most lead used in batteries can typically be recovered and recycled. In poor countries, this often happens at small-scale, unregulated facilities with limited safety or containment measures, leading to direct occupational exposure and local environmental contamination. E-waste, including vehicle batteries, from rich countries is often exported to poor countries, and most of it ends up in informal sites in Southeast Asia.
Pottery and cookware: Lead glaze is often used to seal traditional pottery and cookware, leading to food contamination in the household.
Beyond these major sources, children in low- and middle-income countries may also encounter lead directly via contaminated spices, toys, and cosmetics; and indirectly via soil and air contaminated by leaded petrol and electronic waste.
A global push for global eradication
President Biden recognizes that America’s children deserve the opportunity to reach their full potential, free from the burden of toxic chemicals. The world’s children deserve the same—and a Biden Administration global push can help orient the world on a path toward global eradication.
We propose that President Biden elevate global lead eradication as a central foreign policy and assistance goal, marrying the ambition of disease eradication campaigns (like polio, smallpox, and guinea worm) with the multi-sectoral approach used for tobacco control:
Drive and adopt a Global Framework Convention on Lead Control: The Biden administration could push for a global treaty, modelled after the WHO’s Framework Convention on Tobacco Control (FCTC), to set global health and safety standards for cross-sectoral lead usage and abatement across the different sources of contamination. Progress towards a global ban on lead petrol—from 82 countries still using lead petrol in 2002 to just one (Algeria) in 2020—suggests potential political will at the national level to tackle some of these challenges, if given the right push. Like the FCTC, the Framework Convention on Lead Control should include a robust monitoring and accountability component to help track progress.
Provide financial support to infrastructure upgrades and abatement: USAID should support developing countries to eliminate exposure to lead, for example through safer recycling practices; upgrading schools, homes and other infrastructure that contain lead paint; and training investigators to identify and make safe toxic waste sites. A programme run by nongovernmental organization Pure Earth has identified 5,000 sites in 50 countries, which is almost certainly only scratching the surface. The Biden administration could also encourage the World Bank and other development banks to provide policy lending in support of lead abatement reforms.
Support the remediation of effects caused by lead poisoning: Eliminating exposure to lead should be the focus, since the effects caused by lead poisoning are irreversible. But where children have been exposed, USAID should provide support to mitigate effects through health and education systems, including behavioral therapy to children who have high blood levels of lead.
Promote a global learning agenda on lead levels, impacts, and abatement strategies: The Biden administration should support development of a comprehensive surveillance system for lead exposure and lead poisoning, allowing us to better understand who has been exposed; the source of exposure; and the effectiveness of interventions to tackle lead poisoning. One concrete option would be inclusion of a blood-testing module within the USAID-led Demographic and Health Surveys (DHS), which has already been trialled in two previous surveys (India 1998-99 and Uzbekistan 2002), but not rolled out more widely.
By making the elimination of lead poisoning a central pillar of its foreign policy and assistance program, the Biden Administration can make a historic contribution to children’s health and wellbeing globally. Lead poisoning is a national disgrace and a global scourge. The time to act is now.
Thanks to Aisha Ali and Ana Minardi for research assistance and to Justin Sandefur for helpful comments.