Poisoned young: Lead exposure goes undetected in Sacramento children, endangering them
Pediatrician Deepti Rastogi moved from the Wellspace clinic in Oak Park to their offices in Arden Arcade three years ago and was struck by the problems she saw in her new patients: Small children with disturbingly elevated lead levels.
“It is a change,” said Rastogi, sitting at a long conference table. She didn’t recall flagging a single patient for lead in Oak Park. That changed in Arden Arcade.
“We started seeing all our high lead levels,” she said.
The children she catches are the lucky ones: A majority of California’s 1- and 2-year-old Medi-Cal beneficiaries miss one or both required lead tests, according to a damning 2020 state audit that found lackluster outreach by the state and flawed oversight of counties. The gaps leave an unknown number of kids to grow up with the subtle or serious effects of an undetected toxin.
Sacramento County, the audit found, has some of the worst testing rates in the state. Looking at the kids who do get tested, it also had the second-highest number of vulnerable children under 6 with concerning lead levels.
More than 18 months later, the response, according to advocates and state audit follow-ups, has fallen short in attempts to reach the residents affected. In Sacramento County, this has been especially true in refugee communities.
More than half of Rastogi’s patients are children in refugee families, she said, many having fled violence in Afghanistan. This year, an estimated 2,000 refugees will likely resettle in the Sacramento area in the aftermath of the U.S. withdrawal from the country.
Rastogi said most of the kids she treats live in the surrounding neighborhood and walk to doctors’ appointments with their parents.
The clinic, tucked back from the road, lies in a sun-baked stretch of Arden Arcade about 7 miles northeast of downtown Sacramento that has an unwanted distinction. It was singled out as the census tract with the state’s largest number of young children with elevated lead levels.
The audit released early last year found that, from 2013 to 2018, 153 children under 6 had concerning amounts of lead in their blood in census tract 62.01, a pocket of Arden Arcade that is less than a square mile, crisscrossed by buzzing power lines and trees that shade parking lots and medians but not people.
Limited efforts to reach out to refugee families
Local doctors and county health officials agreed that many of the kids had something in common beyond the lead in their blood: They were the children of refugees. At the Arden Arcade Wellspace, providers order around 42 tests a month, three to four times the amount ordered at their other clinics. They’re responding to the community’s risk level, said Francisco Aguirre, Wellspace’s head of pediatrics.
Afghan children in particular are overrepresented among those with serious lead poisoning. Records released by the California Department of Health show that in the fiscal year 2017-2018, 493 young Californians had such dangerously high lead levels that their families accepted state case management; 134 of those kids, or 27 percent, were California children with Afghan heritage.
“Sacramento is home to the largest population of Afghans in the United States,” said Jessie Tientcheu, CEO of the refugee resettlement nonprofit Opening Doors. After the chaotic U.S. military withdrawal led to a Taliban takeover, hundreds of thousands are trying to flee Afghanistan. “We expect that the existing Afghan community will be joined by those who are now seeking refuge,” Tientcheu said.
In the past, Sacramento County’s lead experts have made only limited efforts to reach out to its refugee families.
According to records released by the California Department of Public Health, from July 2019 through June 2020, Sacramento’s local childhood lead prevention program gave presentations to only 43 refugee women from Afghanistan.
In a progress report to the state describing the three talks given in February 2020, a county staffer wrote that “most of the women (in attendance) have no or low literacy skills.”
Still, the county’s other targeted outreach to refugees consisted entirely of distributing pamphlets and flyers to community-based organizations in Arabic, Pashto and Dari.
Since those three presentations, the pandemic has undermined in-person events.
“Due to COVID-19, outreach has been limited to conducting virtual presentations to refugee families in partnership with resettlement agencies,” said county Department of Public Health public information officer Laurie Slothower in a statement.
Asked via email about how the county tailors its approach to refugees, Slothower said: “Multi-lingual educational materials are provided to families in their spoken language. We utilize interpreters at-home visits and for phone calls with parents, and we use bi-lingual staff at resettlement agencies to help interpret Childhood Lead Poisoning Prevention Program presentations.”
“This issue, it is not brought up to the public, and it’s not being taken care of,” said Usama Khalil, the founder and president of the nonprofit Refugee Enrichment and Development Association (REDA), based in Arden Arcade.
He believes that this public health problem isn’t dealt with urgently because officials sometimes don’t know how to approach people who are refugees, and also because authorities have the mindset that “they arrived to this land with this issue in their blood. OK, because they’re refugees, it’s not our problem, it’s their problem, because it’s associated with ‘back home.’”
The Sacramento region, Khalil said, is home to upward of 3,000 Afghan families, many of whom have small children.
County one of the state’s worst for lead levels
Meanwhile, the state provides limited aid, forcing many to live in some of the oldest, cheapest housing in the county. Many of the homes and apartments were built well before lead-based paint was banned in 1978, putting the families’ children at greater risk of exposure.
Lead testing rates across the state are abysmal – so low that significantly more children likely are at risk of developmental delays, learning difficulties and other serious health problems than the state will ever recognize.
In that same Arden Arcade neighborhood where Rastogi works and where those 153 children who got tests had troubling lead levels, small children were supposed to get 1,135 tests between 2013 and 2018.
Only 392 tests were recorded, the state auditor found. Children in the neighborhood only received 35% of the tests they should have, and the total number of children with lead in their blood is unknowable.
In its January 2020 report, the auditor named Sacramento County as one of the state’s worst when it comes to children with elevated lead levels. California has more than 8,000 census tracts, and the auditor teased out the 50 worst tracts. Nine tracts were in Sacramento County.
In 2019, 2.98% of the county’s children under 6 on Medi-Cal were known to have levels above the threshold for intervention, according to CDPH.
Only two sparsely populated, underfunded rural counties had worse rates for their kids. Sacramento County’s rate is nearly three times as high as the rate in Los Angeles County. In 2019, 16,000 children that got tested revealed 469 young Sacramentans’ brains were exposed to harmful levels of lead, according to CDPH. In the preceding five years, Sacramento County children in the most at-risk census tracts missed nearly 70% of their required tests, the audit found.
Families feel alienated from a complicated system
DHCS has made efforts to increase lead testing numbers across the state since the audit was published more than 18 months ago. But a major element of its new outreach plan – a round of reminder letters – didn’t target the families of children who actually missed their tests.
Instead, the letters went to all Medi-Cal families and included lead tests among other preventative care measures that families can access. In April 2021, DHCS started making quarterly reports to managed care plans identifying children who missed their tests, and the plans are then supposed to alert the doctors.
Lead tests are often administered at a different location from the family’s normal physician, leaving low-income families with few financial resources, limited transportation options and little time off work in a bind. Refugee families have especially big hurdles when it comes to accessing care, said REDA’s Khalil.
“The lucky ones are the ones with Kaiser,” Khalil said, noting that all services there are centralized and families don’t have to travel to a second location to get a blood test for their child.
He has accompanied many clients and friends to medical appointments, and said he sees why these families feel alienated from a complicated system. They come to Sacramento, usually from Afghanistan, Syria, Iraq or Ukraine, and face a new world.
“They are totally ignorant about the system of living in the United States,” he said. “The first challenge is transportation for many of them. Next, making appointments.”
At Wellspace, a clinic that accepts Medi-Cal and serves hundreds of refugee families in Arden Arcade, staff try to help patients by scheduling follow-up testing appointments for them. But the Quest Diagnostics laboratory is nearly three miles away.
Not all providers treating refugees have the same procedures as Wellspace. “They give them referral just to the lab — a corporate name,” Khalil said. Families “don’t know where to go.”
As an English- and Arabic-speaker, Khalil has also witnessed firsthand the shortcomings of some translators, recalling one time in particular when he had to interrupt the translation “to clarify something that I saw was extremely erroneous.”
Although many kids are exposed to lead in the U.S., refugee children could be exposed before their emigration — a study published in 2019 in the Journal of the American Academy of Pediatrics found that 55% of Afghan children coming to the U.S. as refugees had elevated lead levels in their blood.
Rastogi, the pediatrician at Wellspace, said that many of the elevated lead levels in her patients are linked to surma, one name for an eye makeup that Central and South Asian and Middle Eastern families use for spiritual and health purposes on children. Surma or kohl often contains lead, she said, and she counsels her patients to use a different black eyeliner if they want to continue the practice.
Her personal interventions have worked pretty well, Rastogi said. Earlier that day, she’d seen an 8-month-old patient who came in with black smudges around her eyes.
“At birth, the mom used to put (surma on the baby’s eyes), and then I talked to her enough about surma, and she said she stopped, and then I saw her today and I was like, ‘What happened?!’ ” Rastogi said. “She said no, her eyes were watering, so she put eyeliner, she was very specific. She said, ‘Not surma, not surma.’” The mother’s shift likely saved the baby’s brain from continuous lead exposure.
This story was originally published November 17, 2021 at 5:00 AM.
