When the pediatrician recommended Lisa Pascoe have her then-toddler tested for lead poisoning, she thought there was no way he could be at risk. Everything in her St. Louis, Mo., home had been remodeled.
But then the nurse called to say her son's blood lead level was dangerously high — five times the level federal health officials then deemed elevated.
Pascoe said she was "completely shocked."
"After you hang up on the phone, you kind of go through this process of 'Oh my gosh, my kid is lead poisoned. What does that mean? What do I do?'" she said.
That same week, St. Louis city health workers came out to test the home to identify the source of the lead.
The culprit? The paint on the home's front window. Friction caused by opening and closing the window caused lead dust to collect in the mulch and soil outside of the house, right where her son played every day.
A decade later, the psychological scars remain. Pascoe and her toddler ended up leaving their home to escape lead hazards. To this day, she's extra cautious about making sure her son, now a preteen, and her two-year-old daughter aren't exposed to lead so she doesn't have to relive the nightmare.
Pascoe's son was one of almost 4,700 Missouri children with dangerous levels of lead in their blood in the state's 2012 report — decades after the U.S. started phasing lead out of gasoline and banned it in new residential paint and water pipes. Missouri's lead-poisoning reports run from July through June. Though cases have fallen precipitously since the mid-20th century, lead is a persistent poison that impacts thousands of families each year, particularly low-income communities and families of color.
Eradicating it has been a decades-long battle.
No safe level
Omaha, Neb., has been cleaning up contaminated soil from two smelters for more than 20 years. The Argentine neighborhood of what is now Kansas City, Kan., grew up around a smelter that produced tens of thousands of tons of lead, as well as silver and zinc. About 60% of homes in Iowa were built before 1960, when residential lead-based paint was still used. Missouri is the number one producer of lead in the United States.
The four states have some of the most lead water pipes per capita in the country. While representative data on the prevalence of lead poisoning is hard to come by because screening rates lag in many areas, one study published last year found that the four states struggled with some of the highest rates of lead poisoning.
Over the next few months, the Missouri Independent and NPR's Midwest Newsroom are collaborating to investigate high levels of lead in children of Iowa, Kansas, Missouri and Nebraska. By analyzing scientific research, delving into state and local data, and interviewing parents, experts and advocates from across the country, the project will shed light on a public health disaster that continues to poison children every year.
"We know that there is no safe level, that even at really low levels, it can affect intellectual growth, cognitive development. And we can prevent that type of harm," said Elizabeth Friedman, a physician and director of the Pediatric Environmental Health Specialty Unit for Kansas, Missouri, Nebraska and Iowa. "So why wouldn't we?"
David Cwiertny, director of the Center for Health Effects of Environmental Contamination at the University of Iowa, said it's "unacceptable" for anyone to be exposed to lead.
"We should go to the ends of the Earth to invest in staff and prevent it from happening if we can," Cwiertny said.
At Pascoe's home, workers encapsulated the flaking paint and replaced the top layer of tainted soil outside the home. During encapsulation, lead paint is coated and sealed to prevent the release of lead dust or paint chips. Her toddler's blood lead level began to drop from its high of 25 micrograms per deciliter.
But that wasn't enough to keep his lead level low.
Even though Pascoe kept her son from playing outside, cleaned regularly with a vacuum cleaner equipped with a HEPA filter provided by the health department, and wiped off everything that could track lead dust into the home — from shoes to the family dog's feet — her son's level hovered at six micrograms per deciliter for nearly a year.
In 2013, Pascoe and her son moved out of the city and into a home without lead in St. Louis County. Finally, his levels dropped to below one.
An invisible toxin
Lead is a dangerous neurotoxin commonly used in water pipes, paint, gasoline and household products until the late 20th century, decades after scientists began sounding the alarm about its danger.
In high doses, lead can be fatal. Women in the 19th century used it to induce abortions and sometimes ended up poisoning themselves. Children who are lead poisoned now, however, have much lower levels and don't show blatant or immediate symptoms.
Even after the source of the exposure is eliminated, long-term effects of the toxin linger.
Officials with the World Health Organization warn there is no safe level of lead in blood. Even levels as low as five micrograms per deciliter can cause behavioral difficulties and learning problems in children.
Lead-poisoned children may have trouble with language processing, memory, attention and impulsivity, said Dr. Justina Yohannan, a licensed psychologist based in Atlanta. Many require special education services in school.
Now in sixth grade, Pascoe's son has been diagnosed with autism and ADHD.
The Centers for Disease Control and Prevention last year updated its blood lead reference value to 3.5 micrograms per deciliter from five. The reference value represents the 2.5% of children with the most elevated blood lead levels who should be prioritized for investigations and resources. It's not a health standard, and CDC leaves it to the state and local authorities to determine at what levels they will take action depending on state laws, local ordinances and the resources they have available.
The Healthy Homes program in St. Louis County, where Pascoe now lives with her husband, Daniel Pascoe, only follows up with a home inspection if a child's blood lead level exceeds 10 micrograms per deciliter, unless a family makes a request for an assessment below that level. The city of St. Louis separated from St. Louis County in the late 19th century and operates as a separate local government.
Follow-up on lower levels of exposure is focused mostly on educating parents and families about the risks and dangers of lead.
For higher levels of exposure, health workers use an X-ray fluorescence analyzer during assessments to test components of the home for lead.
"The most common source of lead exposure in the county is lead-based paint. So the majority of the time, that's our main focus," said Tammi Holmes, supervisor of the Healthy Homes program.
"We're looking for anything that's original to the house — original windows, original doors, door casings, things like that, that may have lead-based paint on them."
Pascoe said she never saw her son eat lead paint chips. And while lead poisoning due to consumption of paint chips is fairly common, Holmes said it's not always a factor.
"A lot of times people think that the only way kids are exposed is just by eating and ingesting lead-based paint," Holmes said. "But that's not always the case. The main route of exposure a lot of times is inhalation, and it's the dust."
Lead poisoning disproportionately affects Black children and kids in low-income neighborhoods.
In predominantly Black neighborhoods of north St. Louis, across town from Pascoe's old home, children suffer some of the highest rates of lead poisoning in the city. Black children in Missouri are nearly twice as likely to suffer lead poisoning as their white peers.
"And this has happened because of the racist historical practices and policies that continue to segregate children and families of color into older, sometimes less-maintained, overburdened and under-resourced neighborhoods where lead exposures are more common," Friedman said.
Philip Landrigan, a lead researcher for 50 years, did research and testing near an enormous smelter in Kellogg, Idaho, in the early 1970s.
"And the doctor who was the doctor for the lead company ... told me one time in a meeting that the only kids in Kellogg, Idaho, who got lead poisoning are 'the dumb and the dirty,'" Landrigan said. "Even though that was 50 years ago, that line of thinking is still alive and well."
While many cities have grants or loans available to help remediate homes, low-income families in rental housing don't always have the final say.
Amy Roberts, who runs the lead-poisoning prevention program in Kansas City, Mo., said landlords are often cooperative and allow for repairs when their tenants' children are lead poisoned. But not always.
"Sometimes we get pushback from landlords who don't want to do it, or they'll do a little bit, or they'll just take a long time," Roberts said. "Or they'll evict the family."
It's illegal to evict a family because of lead exposure. But if a landlord has cause to evict a family that they haven't acted on, they might do so rather than deal with the health department coming in, Roberts said.
"They'll say, 'Well, we didn't evict them because of the lead. We evicted them because they were behind on their rent,'" Roberts said. "And so would they have allowed them to stay if we hadn't gotten involved because of the lead? It's hard to know."
In Omaha, where an old lead smelter left behind contamination of over 27 square miles centered around downtown, local ordinances have more teeth. Naudia McCracken, the lead program supervisor for Douglas County, Neb., said landlords are required to repair any lead hazards.
"There's no ifs, buts, maybes," McCracken said. "They have to fix it."
While Omaha has struggled with contamination brought on by the smelters, she said that legacy has allowed the county and city to be more aggressive in remediating contamination and preventing lead poisoning.
Omaha provides a home inspection to any family with a child whose blood lead level is greater than 3.5 micrograms per deciliter. And the city provides inspections to families in any house built before 1978.
Speaking only for herself, McCracken said she'd like to see more money go into removing lead paint and improving housing nationwide.
"In the majority of the country, in the way that the programs are, we're waiting for there to be a child with (an elevated) lead level for action to take place," she said. "And I think that's kind of backward."
An overdue conversation
The water crisis in Flint, Mich., shone a light on the devastating effects of lead. Scientists' conclusion there is no safe level of lead and President Joe Biden's pledge to remove the estimated 10 million water service lines underground add momentum toward finally eradicating the metal.
Bruce Lanphear, a longtime lead researcher and professor at Simon Fraser University in Vancouver, said the U.S. has typically made progress on lead when crises or new research galvanized public support. But regulations and action to clean up lead contamination often depend on what is considered feasible.
Cwiertny noted the issue of lead poisoning through drinking water had risen in prominence following crises.
"The concern I have is people — through the rhetoric of politicians talking about what great progress we're making by getting $15 billion here and allocating recovery funds there to address this — will think it's a problem that gets solved and there won't be any accountability," Cwiertny said.
By the time the U.S. started phasing lead out of gasoline, banned it in residential paint in the 1970s and outlawed lead water pipes in 1986, scientists had been warning of the dangers of lead for decades.
In 1925, as use of lead in gasoline gained momentum, Yandell Henderson, a professor at Yale University, told a gathering of engineers that it would slowly poison vast numbers of Americans.
"He said that if a man had his choice between the two diseases, he would choose tuberculosis rather than lead poisoning," the New York Times wrote at the time.
A concerted effort by the lead industry staved off regulations, Lanphear said.
Lanphear said he was invited to speak to Omaha residents 20 years ago about lead poisoning. At the end, he took questions.
"There was this big burly guy with a flannel shirt, beard (who) got up — trucker's hat — and he got teary and he said, 'I worked at the smelter for years, and every morning, I was ordered to reverse the flow and discharge all the contaminants that they had scrubbed out during the day.'"
There are stories that "just break your heart" showing how flawed regulation was, Lanphear said, and how "irresponsible" the industry was.
The legacy of the lead is well documented among adults who grew up surrounded by the metal.
Forty years ago, more than 90% of children had blood lead levels above 10 micrograms per deciliter, almost triple the Centers for Disease Control and Prevention's new reference value.
Researchers estimated last month that just over half of Americans alive today were exposed to high lead levels as children, especially those born between 1951 and 1980. On average, lead cost those people 2.6 IQ points.
Childhood exposure to the metal causes a 70% increase in the risk of cardiovascular disease mortality.
"But it was largely overlooked, largely forgotten," Lanphear said. "All of the focus was on lifestyle choices, which was convenient. Industry didn't have to do anything. Government didn't have to change regulations."
Acute lead poisoning results in noticeable symptoms, including loss of appetite, constipation and stomach pain, fatigue and a blue tinge around the gums.
But lead poisoning now is nearly always chronic, low-level poisoning that may not show obvious symptoms. It can manifest later in behavioral challenges, lowered IQ and increased risk of cardiovascular disease.
Scientists in the second half of the 20th century started documenting links between low-level lead poisoning and lowered IQs. In the early 1970s, there were children with lead levels above 40 micrograms per deciliter who experienced convulsions and comas, Landrigan said. Some children died of lead poisoning at that time.
Before 1970, blood lead levels were considered elevated above 60 micrograms per deciliter. The surgeon general reduced that to 40 in 1970. The CDC reduced it to 30 in 1978; 25 in 1985; 10 in 1991; five in 2012; and 3.5 last year.
"So we were really breaking new ground when we tested those children around the El Paso smelter and the Kellogg, Idaho, smelter and determined that children with no obvious symptoms had reduced IQs and slow reflexes," Landrigan said.
Lanphear said it was difficult for researchers to come to grips with the fact that they had all been exposed to dangerous levels of lead when they were children.
"So there was sort of this disbelief, and I think that happened almost at every level," he said. "How could it be that in the '70s, virtually, by today's standards, all kids were lead poisoned?"
The Pascoes are vigilant about researching the products the family uses now. Their two-year-old daughter only uses toys and crayons that are lead-free, and the family eats from glass dishes to avoid contact with lead that could leach into food from ceramic plates and bowls.
Lisa avoids wearing jewelry her toddler might put in her mouth and doesn't visit older or recently renovated homes that could contain lead hazards.
Other parents are often shocked when Pascoe tells them about her son's lead poisoning.
"Some people probably think kind of like I did initially. Like, 'Oh well, that will never happen to me,'" she said. "Well that happened to my son and we weren't thinking it could happen to him at all."
She warns other families, especially in older houses, to get a home lead assessment.
"I thought it was a thing of the past," she said, "that lead poisoning had just been something I'd heard about in the '90s."
Parents often blame themselves for their children's lead poisoning, Lanphear said. And there are steps families can take to avoid lead and other contaminants: adding landscaping to bare soil, dusting surfaces, avoiding plastic and canned foods. But he said it's primarily up to federal health officials.
Once, Lanphear said, he was being interviewed for a book. The author asked him about his own family.
"He says, 'You do this for a living, right?'
I said yes.
'You have kids.'
'Can you protect your own children?'
The Iowa Capital-Dispatch's Jared Strong contributed to this report.