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die,” listeners were told, “but those who live are almost equally unfortunate because lead poisoning leaves behind it a trail of eyes dimmed by blindness, legs and arms made useless by paralysis, and minds destroyed even to complete idiocy.”²¹

      The response of Johns Hopkins to the epidemic was, however, fraught with practical and institutional problems emblematic of a larger crisis over lead poisoning and other ubiquitous toxic pollutants that continue to plague us today. Lead poisoning was both a medical and a social problem of inordinate proportions. Hopkins could treat the problem by allowing children who came to its attention a brief respite from the environmental assault on their bodies and brains, but such respites were typically just that, and not adequate to stop these assaults. John was returned to his home following the acute episode of lead poisoning that had nearly paralyzed him. But Hopkins, in no position either to compel the landlord to repair the home or to provide the family with a lead-free house, had no answer to the problem of how to protect John from further lead dosings other than to have his desperate mother promise to keep him pent up in a playpen, away from what was assumed to be the major sources of lead.

      We may look back on John’s treatment and the “discharge protocol” as inadequate (although in many ways it is similar to what occurs in numerous localities today). And we may assume that John would have likely returned to the hospital with a fresh, and possibly fatal, episode of lead ingestion: despite the well-intentioned advice to his parents, no well-functioning toddler could remain for long in a four-by-four pen. But we would be wrong to write off the John Hopkins’s effort as an anomaly or proof of special inadequacy of the medical and social service system of the time. True, unlike the Harriet Lane Home, which generally saw its responsibility as treating the acute symptoms of lead poisoning as best it could, the Kennedy Krieger Institute, facing similar problems in serving Baltimore’s children a half century later, took as its responsibility finding the means to protect children from lead exposure, treating them when evident symptoms began to appear and planning for their return to a safe environment. But, in the end, despite this wider purview, KKI, like its predecessor, could not overcome the huge social and economic issues that frame the long, troubling, and desperate history of lead poisoning in Baltimore, and in the nation.

      The story of John and the public health response to cases such as his are indicative of the entire history of lead poisoning in particular and the crisis of environmental and industrial pollution in general. The root of John’s disease lay in the physical conditions in which he and his family lived—poor housing whose walls were covered with a poison. But the only response was from the public health and medical professions, and they could only provide medical care to the individual child. That was important, of course, but the broad social problems that affected huge numbers of children living in similar conditions were left unaddressed, virtually guaranteeing that there would be many more children like John in urgent need of help. John was suffering from more than an environmental exposure to a known neurotoxin, caused by shoddy landlords and peeling paint. He suffered from a social and economic system that condemned his family to poverty and racial discrimination, as well as to the urban decay that put him in harm’s way. John’s parents could hardly be blamed for the constraints he and his entire family were forced to endure in, for example, the limited choices in housing they would have had. And even vague attempts to “explain away” John’s situation by pointing to his color and poverty could not counter the observations that his mother was a hard-working, sincere, and dedicated parent who, according to the social worker at Harriet Lane, was “genuinely interested and concerned about the children” and, using the racist language of the period, “more intelligent than the average negro.” Nor could John’s well-educated and industrious father be blamed for the family’s economic plight and thereby somehow explain away the disease as a family failing. Public health agencies, without such traditional explanations for the diseases of poverty to fall back on—and with no ability to confront the socioeconomic relationships among lead producers, paint manufacturers, housing officials, and landlords that had produced the epidemic of lead poisoning—lacked the tools and the will to control the epidemic effectively as well as the clout to effect much change.

      The good doctors of the Harriet Lane Home faced an impossible situation. On the one hand their responsibility was to treat disease and they did so to the best of their abilities. But, in the context of such a glaring threat—children being poisoned by a toxin in their home—one would hope they would have gone beyond that role to advocate more forcefully for housing reforms and rehabilitation as a means of prevention. Public health administrators, advocates, and policy-oriented academics, though, faced a classic dilemma: how does one prevent disease and premature or unnecessary death when the means of effecting such prevention are controlled by a political and economic system over which one has limited influence and that profits from the existing social relationships that produce disease? In this respect, the public health problems of the 1940s are no different than what we face today, though the political climate is quite different. In fact, given the growing attention to the impact of chronic illnesses and low-level environmental exposures to a host of toxic chemicals and industrial products whose chemistry, much less whose health effects, is largely not understood, the problem is only magnified.²²

      Acute lead poisoning, the kind of poisoning John suffered, perhaps the oldest and best understood environmental disease, has been for the most part successfully contained in the United States over the past half century through judicial, legislative, and regulatory decisions as well as scientific discoveries and medical interventions. Removing some of the most obvious sources of lead from the world of children and adults—from gasoline, paint, canned foods, and other widely available consumer products—was an outstanding public health achievement, which in aggregate lowered the average exposure to lead by orders of magnitude. During the 1960s and 1970s, public health authorities joined with various social movements and thereby were instrumental in shaping these regulatory actions and bringing to the nation’s attention the huge number of childhood poisonings. Through coalitions with social reformers, public health authorities were able to press national, state, and/or local authorities to enact legislation and authorize agencies to achieve reforms. Because of reduced exposure consequent to those reforms, children in the United States today rarely go into convulsions or suffer massive brain damage from lead poisoning, although this is still a major problem in many areas of the developing world. Similarly, because of other regulatory action, Americans rarely suffer from the most acute symptoms of mercury poisoning, arsenic poisoning, or radiation exposure.

      Concern over acute lead poisoning has given way to recognition of the subtler but often still devastating problems induced by lead ingestion, problems only vaguely considered a generation or two ago. Indeed, researchers in the past few decades have changed our understanding of the effects that comparatively low levels of lead exposure have on the brain of the developing child, and with that our understanding of the potential low-dose dangers of other toxins. Mercury, chromium, and other heavy metals still cause damage to children (and adults) even if exposure is rarely fatal; the level of arsenic in some of our water supply is with good reason a cause of concern to the U.S. Environmental Protection Agency and state health officials.

      Low-dose effects of such toxins are not new problems; they occurred in the acute age as well. But they typically went unrecognized as toxic because of the glaring damage that accompanied acute poisonings and the limited technological tools available for identifying very low levels of exposure. Today, though, we need only read the newspaper headlines to see the growing alarm over the potential harmful health effects of, for example, bisphenol A, a chemical additive that mimics estrogen and other human hormones and that is found in a myriad of children’s toys, baby bottles, plastic containers, adhesives, computer-generated taxi and credit card receipts, and a host of other consumer products.²³ Or we may point to the emerging controversies over the use of nanoparticles in skin creams and cosmetics, or the chemicals used in flame retardants in children’s clothing and other consumer items. In these and many other instances, it will require broad population-based public health actions to prevent damage, not just direct individual treatment to deal with these substances’ effects.

      The decline of the various social movements in the 1970s and 1980s had a telling effect on the public health profession, as it was deprived of the power and energy of political and social allies that could influence legislators and bureaucrats in local, state,

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