Table of Contents
Summary
Hundreds of thousands of children in the UK have preventable lead poisoning, which imposes severe health consequences, and causes irreversible brain damage, reducing educational attainment. World Bank staff has associated lead exposure with annual costs to the UK of a magnitude equivalent to 1.9-4.4% of GDP. This is calculated by estimating the effects of lead exposure on IQ loss, including lifetime income effects, cardiovascular disease, and adult premature mortality.
The UK’s passive surveillance system fails to detect 99.9% of these cases, leaving children to continue to be poisoned and failing to prevent future cases.
To help eliminate childhood lead poisoning, the UK should:
Adopt active surveillance and mandatory reporting
Collect data on exposure sources from identified cases
Require testing and/or notification of lead paint, the most important source of lead poisoning so far identified in the UK
With relatively little investment, the UK can lower healthcare costs, boost educational attainment (especially for the poorest children), and increase economic growth.
Challenge and Opportunity
For centuries, we have known that lead presents a serious health risk. The ancient Greek physician Disocrides was said to have noted that, "Lead makes the mind give way.” In 2021—more than 2000 years since Disocrides wrote of lead—Public Health England has estimated that 2% of children in the UK have lead poisoning.
Lead is an invisible yet potent toxin that causes irreversible harm to children’s brains and vital organs. Typical sources include lead paint and lead pipes, but it can also be found in some consumer products. Lead’s lack of visibility means the attention it receives is not commensurate with the pervasive effects it has on our society. However, lead poisoning has significant effects on healthcare costs, educational attainment, and economic growth.
Lead poisoning leaves a lasting legacy of severe health effects.
Lead exposure increases risk of anaemia, kidney disease, cardiovascular disease, and miscarriage, and may even increase susceptibility to neurodegenerative diseases like dementia. Globally, lead poisoning kills more people than car accidents, tuberculosis, HIV/AIDS, suicide, and malaria combined.
Lead poisoning is likely robbing our most vulnerable children of their educational potential.
Lead exposure reduces educational attainment, and exposure beyond recommended limits is associated with worse maths and reading skills in primary school. This effect occurs through a reduction in cognitive function. Lead exposure prevention efforts in the USA have successfully increased educational attainment in maths and reading. Children with lead poisoning who have their exposure sources remediated have been shown to have better educational and behavioural outcomes than their similarly exposed peers. Addressing lead poisoning could boost educational attainment for children with lead poisoning throughout the UK.
Lead poisoning disproportionately affects those living in the most deprived areas. Therefore solving lead poisoning is an especially powerful way to boost the educational attainment for the poorest children.
Estimates say lead poisoning costs the UK 1.9-4.4% of its GDP.
World Bank staff have associated lead exposure with annual costs to the UK of a magnitude equivalent to 1.9-4.4% of GDP (country level estimates from Larsen and Sanchez-Triana, 2023 available at leadpollution.org). This is calculated by estimating the effects of lead exposure on IQ loss and lifetime income, and the welfare cost of premature mortality from increased cardiovascular disease. Studies also show a relationship between lead exposure in children and high rates of crime in later life.
99.9% of childhood lead poisoning cases in the UK fall through the cracks.
Despite the demonstrable negative impacts and high prevalence, the UK’s passive surveillance system fails to catch 99.9% of childhood lead poisoning cases. In 2022 only 191 cases of lead poisoning were identified.
UK passive surveillance data has so far only highlighted pre-1976 housing, lead paint, and soil to be associated with lead poisoning. However, when surveillance programmes that actively monitor lead levels in blood are implemented, further important sources can be found. For example, in New York City, surveillance programs allowed for the identification of lead-containing consumer products—such as spices, cookware, and cosmetics—as being the second most common potential source of lead poisoning for children.
Without collecting this data, risk reduction is impossible. An active surveillance and tracking system would enable enforcement activities against products containing lead, targeted risk communication to the most exposed populations, bans on non-essential uses of lead, improved regulations on working with lead, and better public information.
These data can also drive solutions in the country of product origin. For example, the New York City data showed very high levels of lead in spices from Georgia. The New York City Department of Health alerted Georgian authorities, leading to a national intervention that significantly reduced lead levels in spices.
The UK’s largest source of lead exposure continues to cause preventable poisoning.
The UK has the oldest housing stock in the world, with over half of homes built before lead paint was restricted and lead pipes were banned. Pre-1976 housing has been associated with lead poisoning in UK data, and lead paint is the most commonly reported source of exposure for children in England.
Despite this, there are no regulations requiring homes to be tested for lead paint, or for buyers and renters to be informed of the risk and how to reduce it. This is a requirement in many other countries. For example, in France, sellers and landlords are required to conduct and share a lead assessment by a registered professional on any home built before 1949.
When old lead paint is sealed over with non-lead paint and maintained in good condition, the risk of exposure is substantially reduced. However, with no testing or notification, and residents unaware of the presence and harms of lead paint, degrading/flaking paint and dust-generating renovations pose a severe hazard, particularly to young children who spend time on the floor and frequently put their hands in their mouths.
Tackling lead poisoning is an excellent return on investment.
Efforts to reduce lead poisoning have consistently been shown to be highly cost-effective. The Biden administration’s $30 billion plan to remove all lead pipes in the US is expected to generate a return between $10 billion and $35 billion each year through reduced cognitive impairment and health disorders.
The UK can learn from these examples and adopt similar measures to protect its population. The proposed actions for the UK to begin to address its lead poisoning epidemic require only a modest investment that is more than justified by the costs of continued inaction.
Plan of Action
1) In the first 100 days, the Secretary of State for Health and Social Care should declare that childhood lead poisoning is a threat to public health and issue a directive to the UK Health Security Agency (UKHSA) to:
Institute active blood lead surveillance and mandatory reporting.
All children should be tested for lead poisoning twice in their earliest years, and have further testing based on risk screening up until age 6. Testing at 1 year and 3 years may be most practical in the UK, to coincide with the vaccine schedule. At testing, an information leaflet on lead exposure and how to reduce the risks should be provided to parents. Testing should be conducted with a capillary test (finger- or heel-prick), and if elevated, confirmed with a venous sample, as is the norm in the United States. Evidence shows that universal screening is the most cost-effective method to deliver lead testing.
Pregnant women should also be tested for lead poisoning as part of their routine antenatal blood tests if they have risk factors, such as living in pre-1976 housing or having immigrated from a high-prevalence area. If lead poisoning is identified, pregnant women should be informed on how to remove lead source and given calcium supplements to reduce the foetus’ exposure and lifelong consequences.
All blood lead test results above 3.5ug/dL should be required to be reported to the UKHSA by the laboratory analysing the test result. Currently, case notification to the UKHSA is voluntary, which means that even when lead poisoning cases are identified, they may remain unreported and hence unaddressed.
The level for reporting and action should be lowered from 5ug/dL to 3.5ug/dL, as has been done in the US, due to the evidence for significant harms at this lower level.
Develop a data repository on sources identified through the blood lead surveillance program.
When a child with lead levels > 3.5 ug/dL is identified an investigation should take place to determine their exposure sources so that they can be removed or remediated. This is already a requirement for the tiny fraction of > 5 ug/dL cases that are caught by the current system.
Data on exposure sources and the lead content of consumer products tested in the investigations should be stored in an open repository, available to researchers and the public. This can be modelled after New York City’s database.
2) The proposed Renter’s Reform Bill should be amended to include provisions requiring landlords to test for and report the presence of lead paint to renters. In particular:
Sellers and landlords should be required to provide information about the safety of their properties, including details about the presence of lead paint. Reporting on whether any lead paint is present should be a requirement in home reports. For properties built before 1992 that have not been previously tested, an instant, low-cost, non-invasive, and user-friendly lead test should be mandatory. The same reporting should be a standard component of most surveys, and integrated into guidelines from the Royal Institute of Chartered Surveyors (RICS).
Landlords should also be required to report to renters on whether lead paint is present. A report on test results, along with an information leaflet on controlling lead hazards, should be provided to all renters, in a similar system to the United States.
Estimated Budget
The proposed policy changes in this paper that require associated budgets are as follows:
FAQs
How do we define ‘lead poisoning’?
‘Lead poisoning’ is often, and in this document, defined as having a blood lead level above 5 ug/dL (0.24μmol/L). However, even blood lead levels below this are associated with harms such as decreased intellectual function, behavioural difficulties, and learning problems. The US uses a blood lead reference value of 3.5μg/dL, although the CDC and WHO consider no level of lead in blood to be without risk.
Why is lead poisoning much more discussed in the US than the UK?
It is true that high-profile cases such as the 2014 Flint Water Crisis have raised the salience of lead poisoning in the collective consciousness of Americans. However, the US’ active surveillance systems, informational awareness campaigns, and regulations on testing and disclosing lead paint—none of which the UK currently enforces—are themselves what allow lead poisoning to be identified and discussed as an issue. The UK actually has a higher proportion of homes with lead paint and lead pipes, as well as a higher estimated proportion of children with lead poisoning than the US (1.8% vs 1.5% according to the IHME). Yet discussion and awareness of lead poisoning in the UK remains extremely low due to lack of public information, regulation, and surveillance.
Who is likely to be most at risk?
Due to limited data, it is difficult to identify risk factors specific to the UK. However, based on patterns in other countries, the most at risk of lead poisoning are likely to be children who:
Live or spend time in a house or building built before 1976.
Are from low-income households.
Are immigrants, refugees, or whose parents/caregivers are immigrants or refugees (an estimated 50% of children in low- and middle-income countries have elevated exposure levels).
Live or spend time with someone who works with lead, such as painters/decorators.
Live near aviation fields where leaded aviation gasoline is used.
Use potentially lead-containing consumer products from high-risk countries, such as aluminium cookware, traditional cosmetics (e.g. surma and kohl), ceramics, and spices.
Why are young children the most vulnerable?
Lead is most dangerous to young children as their brains are still developing and lead harms this development. Children are also more likely to be exposed than adults by eating paint dust/chips or putting contaminated fingers in their mouths. Pregnant women are also particularly vulnerable as lead exposure can affect their baby in utero. Lead is of course also of concern for adults, with documented links to serious health conditions and even death due to cardiovascular disease.
Why did the UK National Screening Committee decide not to recommend screening?
In 2018, the UK National Screening Committee (UK NSC) decided against recommending universal lead exposure screening. Although a review of this decision was due in 2022, it has not yet taken place. There are compelling reasons to believe that a re-evaluation could lead to a different conclusion.
The UK NSC's decision was based on concerns about the reliability of blood lead tests and the lack of definitive proof regarding the effectiveness of treatments. While it's true that no test is perfectly reliable, many countries, like the US and Canada, have successfully implemented screening using existing tests. Capillary blood lead testing, which is both affordable and minimally invasive, has proven effective. Although slightly less accurate than venous testing, the accuracy of capillary tests improves significantly when basic contamination precautions (such as wiping the child’s finger with an alcohol swab) are taken. For capillary blood testing, sensitivity is 87%-91% and specificity >90% compared to venous testing. Combining initial capillary blood lead testing with confirmatory venous testing, as practised in other countries, would ensure reliable results.
Evidence suggests that universal screening is the most cost-effective method for lead testing. The primary strategy for combating lead poisoning is prevention—identifying and eliminating sources of lead exposure. The main goal of universal screening is to pinpoint these sources and remove them to prevent ongoing and future poisoning of children and their families. Treating lead exposure that has already occurred, while important, is a secondary objective. Therefore, screening is appropriate even in the absence of definitive proof of treatment effectiveness.
Moreover, there are additional benefits of universal lead screening that the committee did not fully consider. Identifying children with lead poisoning allows schools to provide targeted educational support. Additionally, understanding the prevalence of lead poisoning in the UK can be significantly enhanced by identifying affected children, which would contribute to more informed public health strategies.
Why should we implement universal, and not targeted, screening?
Universal screening for lead poisoning is preferable to targeted screening for several compelling reasons. Firstly, there's significant uncertainty in accurately identifying which groups of children are at higher risk, making targeted approaches potentially ineffective. This uncertainty is compounded by evidence suggesting that lead risk assessment questionnaires, often used in targeted screening, are unreliable in detecting elevated blood lead levels in children. Surprisingly, a study in the US has even shown that children who would typically not be tested based on questionnaire responses had slightly higher average blood lead levels than those who would be flagged for testing.
From a practical standpoint, ensuring consistent administration of risk assessment questionnaires by doctors can be challenging. In contrast, implementing and monitoring a universal screening program is more straightforward and systematic, reducing the likelihood of at-risk children falling through the cracks.
While the costs of universal testing and follow-up are substantial, they pale in comparison to the long-term economic burden of undetected lead poisoning. The estimated top-end cost for universal screening and follow-up in the UK is £160 million, but this investment could yield significant returns. Consider that the annual costs attributed to lead poisoning in the UK amount to a staggering £121 billion. If universal screening were to reduce these costs by even 20%, it would result in net savings of £24.04 billion – translating to £151.25 saved for every pound spent on the policy.
Do we need more research before starting universal screening?
The Elevated Childhood Lead Prevalence Study (ECLIPS) is aiming to conduct a sample-based study to assess lead prevalence levels in the UK. Despite the need for more detailed data, the significant harm suggested by existing estimates justifies immediate action. Waiting for further research before implementing universal screening would lead to prolonged exposure and increased health risks for children.
How robust is the evidence for lead’s harms?
Harms associated with lead exposure have been demonstrated by academic and scientific studies, and are widely recognised by national and international health groups including UKHSA, WHO, IHME, and CDC. Lead exposure has been shown to negatively impact cognitive performance (Larsen et al., 2023; Lanphear et al., 2005; Attina and Trasande, 2013; GBD, 2021; Schnaas et al., 2006; Schwartz, 1994); behavioural issues (Liu et al., 2014; Needleman et al., 1990); cardiovascular disease mortality (Lanphear et al., 2018; Larsen et al., 2023; GBD, 2019), renal function (Harari et al., 2018; GBD, 2021); mental health (Reuben et al., 2019; Bouchard et al., 2009); and possibly crime rates (Nevin et al., 2007; Higney et al., 2022; Needleman et al., 1996). Many of these studies involve scientific meta-analyses or longitudinal analyses of large cohorts, providing robust evidence of lead’s harms.
What are other countries doing about lead?
The UK was an early leader in regulatory action. One review shows that, in 1994, the UK had implemented regulatory measures across a wider range of lead sources than any country except the United States. However, since then, it has fallen behind. The following table is a non exhaustive list of actions other countries are taking.
What else should the UK do to reduce lead poisoning beyond the three priority actions listed?
Better health information: Many GPs are unaware of the scale of the problem of lead poisoning in the UK.
Address lead in pipes:
Replace all lead water pipes, including in schools
Require sellers and landlords to notify buyers and tenants if lead pipes are present
Reduce the lead in water limit to from 10 ppb to 5 ppb (this would be inline with Canada’s limit and the EU’s recommendation)
Improve sampling protocols to detect lead in drinking water. Many water companies testing guidelines require water to be left stagnant for just 30 minutes, which does not represent realistic conditions or scientific evidence on leachability.
Product regulation: Ban use of leaded fuel in aircraft and use of lead ammunition. 370,000 homes may be at risk of exposure from leaded aircraft fuel.
Services regulation:
Require decorators, renovators, and other relevant contractors to have lead-safe training accreditation
Require DIY and trade stores should to provide information on lead hazards
More and better testing:
Test schools and playgrounds for lead in paint, dust, soil and water
Screen residential soil for elevated lead levels near aviation sites, shooting grounds, lead industry, and old housing stock
Add blood lead testing to the Health Survey for England and the Our Future Health project
Require employers to ensure blood lest testing for employees at risk of occupational exposure (as is done in Canada)
Dr Lucia Coulter is co-executive director and co-founder of Lead Exposure Elimination Project (LEEP), a health-policy nonprofit working to reduce childhood lead poisoning in LMICs through applied research and targeted advocacy. LEEP works in partnership with local governments, researchers, civil society, and industry to bring about the implementation of policies that protect children from lead poisoning. Lucia is a Schmidt Futures Innovation Fellow and previously worked as a doctor in the UK’s National Health Service. She has published peer reviewed research in the field of public health and taught as an academic supervisor at the University of Cambridge. She holds a Bachelor of Medicine, Bachelor of Surgery, and a Master’s degree in Natural Sciences from the University of Cambridge.
Lee Crawfurd is a research fellow at the Center for Global Development, a think tank based in London and Washington DC. His research focuses on the economics of education and health policy, including on lead exposure internationally. Previously he was an advisor with governments in the UK, Rwanda, and South Sudan, and a consultant for international organisations and NGOs such as the World Bank, AfDB, and ADB. He has a PhD in economics from the University of Sussex and degrees from the University of Oxford and the School of Oriental and African Studies (SOAS) in London.
Tammy Tan
Tammy Tan is a researcher at Lead Exposure Elimination Project (LEEP) who has been working on the organisation’s cost-effectiveness analysis and researching opportunities for LEEP to expand its impact. She was previously a research fellow at the United States Environmental Protection Agency (US EPA), and National Bureau of Economic Research (NBER), investigating a range of questions in environmental and health economics. At the US EPA, Tammy was involved in a number of high-profile projects, including the release of the Biden Administration’s 2021 updated Social Cost of Greenhouse Gases (SC-GHG) estimates. She has led and co-authored papers published in Nature and Science. Tammy graduated from the Wharton School of the University of Pennsylvania with a degree in Economics, concentrating in Statistics.