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David Chenoweth, PhD, Chris Estes, MSW, MRP and Christopher Lee, MA

David Chenoweth is with Chenoweth & Associates Inc, New Bern, NC, and the Department of Health Education and Promotion, East Carolina University, Greenville, NC. Chris Estes is with the North Carolina Housing Coalition, Raleigh. Christopher Lee is with ViQuest Inc, Greenville, NC.

Correspondence: Correspondence should be sent to David Chenoweth, PhD, FAWHP, 128 St. Andrews Circle, New Bern, NC 28562-2907 (e-mail: hmacheno{at}coastalnet.com). Reprints can be ordered at http://www.ajph.org by clicking on the "Reprints/Eprints" link.

	ABSTRACT

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 

Objectives. We quantified the economic cost of selected environmental factors among North Carolina children living in substandard housing.

Methods. We gathered data on direct medical care costs for specific childhood medical conditions associated with environmental factors commonly found in substandard housing. Medical claims data for 2006 and 2007 were obtained from BlueCross BlueShield of North Carolina and the North Carolina Department of Health and Human Services. Indirect costs were based in part on nonmedical data obtained from several previous studies.

Results. Total (direct and indirect) costs for the conditions assessed exceeded $92 million in 2006 and $108 million in 2007. Neurobehavioral conditions contributed to more than 52% of all costs, followed by lead poisoning (20%) and respiratory conditions (12%). Neurobehavioral conditions were the largest contributor to direct medical costs (44%), followed by respiratory conditions (38%) and accidental burns and falls (10%).

Conclusions. Direct and indirect costs associated with environmental factors appear to be increasing at about twice the rate of medical inflation. More aggressive policies and funding are needed to reduce the substantial financial impact of childhood illnesses associated with substandard housing in North Carolina.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
In the past few years, there has been an increasing emphasis on various environmental issues and the impact of the physical environment on human health. One particularly challenging task is to gain an understanding of how, and to what extent, specific environmental factors affect human health. The burden of many childhood illnesses and chronic diseases, including asthma, developmental problems, birth defects, and some types of cancer, is increasing.¹ Although the causes of these conditions are complex and multifactorial, a large body of research points to environmental factors as important contributors.^1–20

A growing number of studies have focused on the economic costs of specific environmental factors that contribute to childhood illnesses, disabilities, and poor health status. These costs include expenditures for direct health care and long-term health care as well as other miscellaneous costs (e.g., lost productivity in adulthood). For example, Landrigan et al., assessed the annual cost to the United States of childhood lead poisoning, asthma, cancer, and neurobehavioral disorders and very conservatively estimated that these 4 childhood environmental diseases cost the nation as a whole an estimated $54.9 billion per year (in 1997 dollars).⁴ (Landrigan et al. obtained data on the rates of the 4 conditions and then convened a panel of experts that used these rates to estimate annual costs. They then estimated the proportion of cases for which each condition was likely to be caused or aggravated by environmental factors, that is, the "environmentally attributable fraction" [EAF].)

Research on environment-related childhood diseases in Minnesota in 2004 showed that the combined cost of asthma, cancer, lead poisoning, birth defects, and neurobehavioral disorders was approximately $1.57 billion.⁵ A Washington State study in 2004 estimated that the cost of environment-related childhood disease was $1.875 billion.⁶ A Massachusetts study in 2002 estimated a $1.6 billion cost for childhood diseases attributable to the environment,⁷ and, finally, a 2002 study conducted in Montana (which included adults) estimated the cost of environmentally attributable conditions at $404.6 million per year.⁸

Although the studies just described involved different methodological approaches, each of these investigations generated cost calculations on all children, regardless of their housing status. However, housing status can have a marked impact on health status and thus on health care costs.

	INJURIES FROM FALLS, FIRE, AND BURNS

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Accidental falls resulting in childhood injuries are more likely to occur in unsafe housing conditions.^21,22 Some research suggests that falls are related to a host of sociodemographic factors. For example, a 3-year-long population-based study involving children aged 0 to 17 years showed that young people at the highest risk of falls were male, Hispanic, living in a single-parent household or crowded household, and of low socioeconomic status.²³

In another study of preschoolers, the researchers found that Caucasian children whose mothers were unemployed and whose homes needed repair were at higher risk of injury than other children.²⁴ In particular, preschoolers whose homes needed repair had an estimated risk of injury nearly 4 times that of preschoolers whose homes did not need repair.

Burns from fires are more likely to occur in substandard housing conditions. Nationally, the groups at highest risk for death due to fire and burns include children younger than 5 years, adults 65 years or older, people living in poverty, African Americans, Native Americans, people living in rural areas, and people living in manufactured homes or substandard housing.²⁵

Scalding water and other liquids are the cause of most nonfatal burn injuries. Scalds are the leading cause of burn hospitalizations among children younger than 5 years, followed by contact burns.²⁶ Scalds include kitchen-related injuries from tipping very hot liquids and bathtub-related injuries often associated with lack of supervision or child abuse, both of which are more common among those living in substandard housing environments.^26,27

	HUNGER

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Poverty is associated with substandard housing and inadequate childhood nutrition and growth, as well as the mother's childhood health status and the mother's perception of her health.²⁸ Considering that 18.3% to 21.3% of all children in North Carolina (the state in which the study described here was conducted) live in households with incomes at or below the poverty level,^29,30 it is not surprising to find that their nutrient intakes are reportedly worse than national norms on 22 of 23 nutritional indices.³¹ Moreover, the rate of inadequate nutrition in the state as a whole is reportedly higher than the national norm.³¹ Because there are approximately 1.79 children in a given North Carolina household^32,33 and approximately 76 000 households are affected by hunger,³³ approximately 136 451 children in North Carolina are currently victims of hunger.

	LEAD POISONING

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Lead poisoning of children has received much publicity, which is well justified considering that even a small amount of lead in a child's bloodstream can result in physical and intellectual impairments. For example, lead levels as low as 10 µg/dL are associated with impaired intelligence, reduced physical stature, impaired hearing, and behavior issues.³⁴ Although lead poisoning crosses all socioeconomic, geographic, and racial boundaries, the burden of this disease falls disproportionately on low-income families and families of color living in older, poorly maintained housing.³⁵ Lead-based paint, which is a primary risk factor for lead poisoning among children, was used in approximately 80% of homes built before 1978. In fact, more than 38 million US homes and apartments contain lead-based paint, and more than 24 million of them contain substantial lead hazards, according to the US Department of Housing and Urban Development.³⁶

Many communities throughout North Carolina have taken aggressive steps to attack the prevalence of lead poisoning. Although the incidence of lead poisoning in North Carolina has diminished since the North Carolina Childhood Lead Poisoning Prevention Program was formed in 1994, it is still a problem that can affect children for their entire lives. North Carolina surveillance data indicate a substantial decrease in the number of children with elevated blood lead levels since 1995, when 895 children were confirmed to have exposures at or about 10 µg/dL. In 2003, only 505 children were confirmed at the same exposure level, even though the total number of children tested had grown nearly 40 %: from 87 884 in 1995 to 121 971 in 2003. In 2004, 124 257 children younger than 6 years (1 of 5 children in North Carolina) were screened for lead poisoning; 1489 (more than 1% of those screened) had elevated lead exposures.³⁷

	NEUROBEHAVIORAL CONDITIONS

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Over the past decade, mental health has gained more nationwide attention in the environmental health arena. At least 3 neurobehavioral conditions have been identified as having a partial environmental basis and thus have been included in previous cost analyses: autism, cerebral palsy, and mental retardation. The National Academy of Sciences has estimated that 3% of neurobehavioral disorders in American children are caused directly by exposure to environmental toxins; an additional 25% are caused by interactions between environmental factors (defined broadly) and genetic susceptibility.³⁸

Autism is a physical condition linked to abnormal biology and chemistry in the brain.³⁹ There are many factors that lead to autism. Although most research points to the significance of genetic factors, one of the largest case–control studies ever conducted in this area showed that a mother's environment and mental health may be associated with autism.⁴⁰ Moreover, it can be argued that the prevalence of poor mental health among parents of behaviorally challenged (e.g., autistic) children is higher in poverty-stricken, substandard housing.⁴¹ It is unknown how many children living in North Carolina have autism,⁴² but it is estimated that 1 of 166 people born today in the United States has some form of the condition.⁴³

Cerebral palsy and mental retardation are also more common in children living in substandard housing conditions, partly as a result of these children's increased risk of incurring head injuries. Cerebral palsy, characterized by an inability to fully control motor function, occurs in approximately 1.4 to 2.4 of every 1000 people.⁴⁴ Each year, approximately 5000 infants are born with the condition, and approximately 1200 to 1500 young children acquire cerebral palsy as a result of head injuries.⁴⁵ Causes of mental retardation (defined as below-average general intelligence accompanied by impairment in one's ability to acquire the skills necessary for daily living⁴⁶) are numerous, but a specific cause is determined in only 25% of all cases.

	ASTHMA AND BRONCHITIS

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Rates of asthma and acute bronchitis are high among children living in substandard housing.^47–50 Approximately 134 000 North Carolina children suffer from asthma, which is one of the most common causes of emergency department visits and hospitalizations in the state.⁵¹ Although asthma has no single cause, there appears to be a strong inherited (genetic) component.⁵² Environmental factors also play an important role in determining whether a child will develop asthma. In their earlier-described study, Landrigan et al. estimated that environmental factors are responsible for about 30% of asthma cases.⁵

One of the strongest environmental contributors to asthma is living in substandard housing. However, it is difficult to separate people's housing status from their socioeconomic status because there is usually a correlation between the two. Unquestionably, poverty forces families to live in substandard housing, whether in urban, suburban, or rural areas.^49,50 Older homes and those in crowded areas are often fertile breeding grounds for cockroaches and other asthmatic "triggers."⁵³

The same viruses that cause colds often cause acute bronchitis, a condition in which the bronchial tubes are inflamed.⁵⁴ Substandard housing conditions predispose children to higher rates of asthma and acute bronchitis (and possibly chronic bronchitis).^48–50

	CANCER

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Cancer is a rare childhood disease, with 14.1 cases per 100 000 children; an estimated 240 new pediatric cancer cases (i.e., cases among those younger than 15 years) occur in North Carolina each year.⁵⁵ The cause of most childhood cancers is unknown. In fact, confirmed clinical and epidemiological associations explain only about 10% of disease incidence, leaving 90% of cases with an unclear etiology.⁵⁶

Despite overwhelming evidence suggesting that genetics is the predominant cause of most childhood cancers,^56–58 environmental factors may also be partially responsible for the increase in some childhood cancers, especially lymphoma. For example, exposures to certain chemicals (e.g., dioxin, polychlorinated biphenyls, pesticides, solvents, fertilizers), ionizing radiation, and elevated nitrate levels in drinking water are believed to increase a child's risk of incurring lymphoma and related conditions such as leukemia.^57–59 Various forms of childhood leukemia are also believed to have a strong genetic as well as a partial environmental etiology.⁶⁰ Although specific environmental factors associated with certain childhood cancers can exist in any type of household, some research suggests that exposures to potentially dangerous chemicals and unsafe drinking water are more likely to occur among children living in substandard or unhealthy housing.^1,2,61,62

	BIRTH DEFECTS

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Genetic and environmental factors, as well as combinations of such factors, can cause birth defects. However, in approximately 70% of cases, the cause is unknown.¹⁵ Although some birth defects are inherited, many are reportedly caused by nutritional deficiencies, maternal alcohol or drug use, and exposure to environmental toxins.¹⁶ Exposures to mercury, dioxins, polychlorinated biphenyls, plasticizers, certain pesticides, organic solvents, and air pollution have conclusively been linked to an increased risk of birth defects.^1,16 The factors just described are more common among people living in substandard living conditions.

	STUDY OBJECTIVES

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Previous studies of the economic effects of environmental factors have not grouped children according to housing status. By contrast, in this study, an expansion of our original 1-year cost analysis (for the year 2006),⁶³ we calculated the economic costs of environmental risk factors only among North Carolina children living in substandard housing.

Our primary objective was to calculate the direct and indirect costs of environmentally attributable risk factors among North Carolina children living in substandard housing over 2 consecutive years (2006 and 2007), focusing on children whose health was believed to be particularly vulnerable to factors related to living conditions. Of the approximately 2.15 million children (i.e., younger than 18 years) living in North Carolina in 2006, approximately 20% (430 426) lived in substandard housing.^30,33

	METHODS

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
To determine the types of health conditions that should be included in our study, we reviewed the professional literature to identify conditions reportedly more likely to occur in substandard housing. We selected specific health conditions for our analyses according to 3 criteria: they had been included in one or more previous cost analyses,^5–8 they had been cited in the professional literature as having an etiological basis, and they could be subjected to health care use and cost valuations. The medical conditions we selected included neoplasms (lymphoma and leukemia), congenital birth defects (anencephaly, cleft lip, cleft palate, cleft palate with cleft lip, heart defects, hypospadias, limb reduction, omphalocele, and spina bifida), accidental falls, accidental burns, lead or metal poisoning, neurobehavioral disorders (autism, cerebral palsy, and mental retardation), and respiratory conditions (acute bronchitis and asthma).

The substandard housing–related environmental factors we included in our analyses met 4 criteria: they originated in or on an environmental medium (e.g., air, water, soil, surface); they had been classified as a generally accepted precursor or risk factor that, upon exposure, can adversely affect a child's health status; they had been classified as a chemical, metal, pesticide, gas, toxic substance, thermal hazard, flying object, unstable surface, or human activity to which a child or the child's mother could be exposed; and they commonly existed in substandard housing.

We estimated the costs for specific types of childhood illnesses, disabilities, and diseases that could be attributed, to some degree, to environmental and cultural factors known to predominantly exist in substandard housing. In addition to using a portion of the framework employed by Landrigan et al. in their study,⁴ we used other methods designed to factor in actual demographic, socioeconomic, and health care use and cost trends specific to North Carolina children.

To estimate the extent to which each medical condition was attributable to substandard housing conditions, we used EAFs (defined as the percentage of a particular disease category that would be eliminated if environmental factors were reduced to their lowest feasible levels¹¹) within a proportionate risk factor cost appraisal (PRFCA) framework. PRFCA is an analytical framework that measures the financial cost of specific risk factors associated with certain types of medical conditions. An EAF is a composite value, the product of the incidence of a risk factor multiplied by the relative risk of disease associated with that risk factor. The EAF cost equation is expressed as follows:

(1)

In addition to being used to assess the costs of environmental and occupational diseases, the EAF model has been used by the Institute of Medicine to assess the fractional contribution of the environment to causes of illness in the United States.

Direct Medical Care Costs
Direct medical care costs included per-encounter payments for outpatient medical care treatment, medications, and supplies and per-admission payments for inpatient medical care treatment, medications, facilities, and supplies. To estimate the direct medical care costs of selected childhood medical conditions attributed to substandard housing conditions in North Carolina, we initially reviewed the various cost analysis approaches used by other researchers. We then obtained, from the Division of Medical Assistance of the North Carolina Department of Health and Human Services and BlueCross BlueShield of North Carolina, relevant medical claims and cost data for 2006 and 2007 on children aged 0 to 18 years with 1 or more of the targeted medical conditions.

Next, we incorporated claims data into a PRFCA framework customized to account for the estimated percentage of each targeted condition occurring in individuals living in substandard housing along with estimated risk factor weights (e.g., level of influence of environmental factors on each targeted condition). We then incorporated appropriate prevalence, risk factor, and health care use data for each targeted birth defect into the PRFCA framework and tabulated the respective columns of data within the framework to compute the direct medical cost of each environmental factor (Figure 1).

View larger version (18K): [in this window] [in a new window] [Download PPT slide]   FIGURE 1— Sample proportionate risk factor cost appraisal of congenital birth defects. Note. The commercial group was children with employer-provided or privately purchased health insurance.

Indirect Costs
Indirect costs are nonmedical expenses incurred before, during, or after direct medical care services are provided. No data were available on indirect (nonmedical) cost items specific to North Carolina children; thus, we used data obtained from several peer-reviewed research studies. These data were then applied to North Carolina children living in substandard housing.

Indirect costs identified throughout the literature associated with the conditions assessed included school days lost, costs associated with home and auto modifications and developmental services, parental and lifetime wages lost, and premature death. Indirect costs included in cost-of-illness estimates were based on the value of disease-related lost income and productivity, which are typically valued according to age- and gender-adjusted average wages.^64,65 The total value of lost income and productivity was estimated on the basis of the distribution of disease-related outcomes across age and gender categories.

Indirect morbidity costs were based on lost income and productivity for nonfatal disease-related outcomes (e.g., lost work days, lost school days, and days spent in bed). Indirect mortality costs were based on the present value of expected future earnings lost as a result of disease-related death.

Although indirect cost measurements on asthma have been provided by Landrigan et al.,⁴ Davies and Hauge,⁶ and Massey and Ackerman,⁷ the genesis of these efforts actually evolved from the earlier efforts of Chestnut et al.⁶⁴ and Weiss et al.⁶⁵ In particular, these researchers were primarily responsible for establishing quantification metrics to calculate indirect costs relating to school days lost and lost productivity resulting from premature death tied to childhood asthma.

In addition, indirect cost measurements for birth defects have been provided by Schuler,⁵ Davies and Hauge,⁶ and Waitzman et al.⁶⁶ Indirect cost measurements for specific childhood cancers such as lymphoma and leukemia have been offered by Landrigan et al.,⁴ Schuler,⁵ and Davies and Hauge.⁶ Indirect cost measurements on autism, cerebral palsy, and mental retardation have been provided by Landrigan et al.⁵ and Honeycutt et al.⁶⁷ The metrics just described made up a major portion of the methodological base used in quantifying estimated costs among North Carolina children.

To calculate the costs associated with lead poisoning, it was essential to have a representative norm comparing different groups of affected North Carolina children with the condition. On the basis of a compilation of community-wide lead poisoning rates, it was determined that North Carolina children closely reflected those at the national level. Nationally, the mean blood lead level in a sampled birth cohort of 5-year-old children was reported to be 2.7 µg/dL.⁶⁸

Based on an earlier Schwartz et al.⁶⁹ analysis of the indirect costs of childhood lead poisoning in which Landrigan et al.,⁴ Salkever,⁷⁰ and Lanphear et al.⁷¹ provided indirect cost measurements, we considered each microgram per deciliter of blood lead concentration to be associated with a reduction in IQ of 0.25 points at these levels of lead exposure.⁴ Applying this value assumes implicitly that there is no threshold blood lead level below which cognitive effects are seen. This assumption appears reasonable, because to date cognitive deficits have been associated with all ranges of blood lead concentration studied, and no evidence of a threshold has been found.⁷¹ Moreover, according to Salkever, the loss of 1 IQ point is associated with an overall reduction in lifetime earnings of 2.39%.⁷⁰ This corresponds to a loss of 1.61% of earnings potential for an IQ deficit of 0.675 points.

To calculate indirect lead poisoning costs among North Carolina children, we used the framework shown in Figure 2, which closely resembles the framework developed by Landrigan et al.⁴ and comprises largely cost accounting methods and data from Schwartz et al.⁶⁹ and Salkever.⁷⁰ Because blood lead levels have reportedly dropped substantially over the past decade, we chose to use the national norm of 2.7 µg/dL as an estimated mean for North Carolina children with elevated blood lead levels.

View larger version (12K): [in this window] [in a new window] [Download PPT slide]   FIGURE 2— Sample framework of indirect costs of lead poisoning in North Carolina. aNumber of children multiplied by lifetime earnings multiplied by percentage of IQ loss; cost is in 1997 dollars. bEmployment cost index inflation rate. cApproximate proportion of North Carolina children living in substandard housing. dThe value 1.00 indicates that 100% of lead poisoning cases are attributable to the environment. eIndirect cost of lead poisoning in North Carolina in 2006 dollars.

Injuries among children and adolescents impose a financial burden on many segments of society.⁷² As recommended by the Panel on Cost-Effectiveness in Health and Medicine,⁷³ we adopted a societal perspective in which we attempted to estimate all costs associated with unintentional falls and unintentional burns. Specifically, these costs are borne by victims, families, government, insurers, and taxpayers alike.

	RESULTS

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
Among North Carolina children, the costs of the medical conditions related to substandard housing assessed here totaled $9.70 million in 2006 and $23.95 million in 2007. However, these figures reflected only direct medical care costs tied to North Carolina children who had some form of health insurance coverage; they did not include any medical care costs among children in the state who did not have health insurance.

Thus, a multiple was applied to factor in the percentage of North Carolina children without health insurance, a population for whom medical claims data are not readily available. An itemized breakdown of this aggregate liability revealed the cost distribution shown in Table 1. Overall, when all of the selected medical conditions were included and estimated costs presumably tied to the percentage of North Carolina children (11%) without health insurance coverage were factored in, total direct medical costs were $10.90 million in 2006 and $26.91 million in 2007.

Indirect costs were substantially higher than direct costs for 4 of the 6 targeted conditions highlighted in Table 2, with ratios ranging from 4:1 for accidental burns and falls to 99:1 for lead poisoning. (Because all of the costs assessed had been adjusted to reflect 2006 and 2007 dollars, the figures listed in Table 2 closely reflect approximate present-day costs of the targeted conditions among North Carolina children living in substandard housing.) Respiratory conditions and childhood cancer were noticeable exceptions. Some researchers have postulated that indirect costs associated with childhood cancer constitute a small percentage of total costs because the life spans of young people with cancer are generally far shorter than those of children with other conditions.^4–6

Total costs for neurobehavioral conditions (autism, cerebral palsy, and mental retardation) constituted approximately 52% of all costs, followed by lead poisoning (20%) and respiratory conditions (12%). This distribution was similar to that of direct medical care costs, for which neurobehavioral conditions were the largest cost contributor (44%) followed by respiratory conditions (38%) and accidental burns and falls (10%). Surprisingly, we found no reportable medical care claims or costs tied primarily to inadequate nutrition.

	DISCUSSION

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
In this study, we calculated the direct, indirect, and combined costs of environmental factors among North Carolina children living in substandard housing conditions. However, we did not account for the significant human toll (emotional, psychological, social, and physical) as individuals and families grappled with developmental and lingering problems on a daily and often ongoing basis.

Neurobehavioral conditions were clearly the most expensive aggregate cost entity. Although direct medical care costs associated with these conditions were slightly higher than those related to the second-ranked set of conditions (respiratory conditions), indirect nonmedical costs tied to the neurobehavioral conditions assessed were approximately 8 times higher than those associated with respiratory conditions.

Researchers^4,6,40 contend that neurobehavioral conditions generate high costs because they typically require extensive life maintenance services over a long period of time. Moreover, neurobehavioral conditions (as well as lead poisoning) often result in significant intellectual deficits that compromise a person's employment prospects and lifetime earning potential. In contrast, the respiratory conditions assessed (asthma and acute bronchitis) are generally not lifetime conditions and can usually be well managed via lifestyle, environmental, and medication interventions.

Limitations
Similar to cost estimates reported by other researchers, our cost estimates on the impact of substandard housing conditions are conservative, primarily because we considered only 6 categories of childhood morbidity and only certain categories of neurobehavioral dysfunction. In addition, although we recognized that the costs of caring for children with coexisting conditions such as autism, mental retardation, cerebral palsy, and lead poisoning are greater than the costs of caring for children with only one condition, we did not adjust costs for these children.

Another similarity to previous studies is that we were hampered in our modeling by the lack of research quantifying the possible etiological contributions of substandard housing conditions to many pediatric diseases and by the lack of knowledge of the possibly toxic effects of most chemicals to which North Carolina children may be exposed. In future years, as more etiological research is undertaken and as better information becomes available on possible associations between environmental (substandard housing) exposures and pediatric diseases, this area of study can be expanded.

Our estimates were also conservative because we did not consider late complications of toxic exposures that could not reliably be attributed to exposures sustained during childhood. We did not examine the possible late cardiovascular consequences of childhood lead poisoning, nor did we consider the costs of adult asthma that might be a direct consequence or continuation of asthma that began in childhood. Finally, our estimates were low because lifetime costs assigned to certain conditions were based on inflation and discount rates constricted to the (lower) monetary value of dollars spent over the past decade.

Although we made extensive efforts to acquire specific types of data, some of the data we sought do not exist in the desired format, at the level of precision or accuracy desired, or at the degree of completeness needed to ensure maximum reliability. Thus, our cost figures should be viewed in light of several limitations and precautions.

First, because it is likely that environmental risk factors coexist in substandard housing, it is difficult to determine the exact (exclusive) influence of a particular environmental factor on a child's predisposition to sustain a specific illness, injury, or disease. Second, because 11% of all North Carolina children are reportedly uninsured, we applied a multiple to calculate a statewide cost estimate; however, considering the strong evidence linking lack of insurance coverage to poverty and linking poverty to poor risk factor status, even a higher multiple may be warranted to account for the prospect that members of this uninsured population might, in fact, incur more severe conditions because they postpone medical care.

Third, although we obtained medical cost data on unintentional falls among North Carolina children, prevalence rate data were not available. This prompted us to use prevalence rates from other states, which may be higher or lower than those for North Carolina. Fourth, national inpatient (hospital discharge) frequency and cost norms were applied to the population insured through a commercial or individual health insurance plan; thus, it is possible that national norms are higher or lower than North Carolina norms.

Fifth, the EAFs used in this analysis were based, in large part, on the opinions of several expert panels convened by Landrigan et al.⁴ and the US National Academies of Science. Finally, the indirect cost estimates applied to each of the targeted conditions were based in part on cost measurements reported by other researchers.^4–8

Conclusions
As more children continue to grow up in substandard housing conditions, it is likely that direct and indirect costs associated with environmentally attributable medical conditions will also increase. Although lead poisoning cases have declined over the past decade in North Carolina, many young people living in substandard housing conditions continue to be at increased risk for many other environmentally attributable conditions. Overall cost estimates associated with these conditions among North Carolina children are not significantly different from cost estimates among children in other states. Our findings demonstrate the need for more aggressive policies and funding designed to reduce the substantial impact of environment-related childhood illnesses in North Carolina associated with substandard housing.

	Human Participant Protection

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
No protocol approval was needed for this study.

	Footnotes

 
Peer Reviewed

Contributors

D. Chenoweth and C. Estes originated the study. D. Chenoweth gathered and analyzed the data in preparing the cost estimates. D. Chenoweth and C. Lee were responsible for conducting all of the background research.

Accepted for publication August 16, 2008.

	References

TOP ABSTRACT INTRODUCTION INJURIES FROM FALLS, FIRE,... HUNGER LEAD POISONING NEUROBEHAVIORAL CONDITIONS ASTHMA AND BRONCHITIS CANCER BIRTH DEFECTS STUDY OBJECTIVES METHODS RESULTS DISCUSSION Human Participant Protection References

 
1. America's Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses. Washington, DC: Environmental Protection Agency; 2003.

2. Schettler T, Stein J, Reich F, Velenti M, Wallinga D. In Harm's Way: Toxic Threats to Child Development. Boston, MA: Greater Boston Physicians for Social Responsibility; 2000.

3. Centers for Disease Prevention and Control. Healthy Homes Initiative. Available at: http://www.cdc.gov/healthyplaces/healthyhomes.htm. Accessed May 18, 2009.

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