Old Paint: A Medical History of Childhood Lead-Paint Poisoning in the United States to 1980 (review)

2001 was a busy year for Peter English, a pediatrician and historian of medicine at Duke University, with the publication of Rheumatic Fever in America and Britain and Old Paint. These books explore two diseases that shaped American pediatrics in the twentieth century in very different ways. The first examined an infectious and autoimmune disease whose mysteries inspired research at the bench and at the bedside. The second, and the subject of this review, analyzes lead-paint poisoning, a topic that demonstrates how the health of children has been intertwined with their environment. Seen together, these books offer wonderful case studies of the young field of pediatrics in the late nineteenth and twentieth centuries. Old Paint investigates how the fields of pediatrics and public health interfaced and shows how pediatricians negotiated the sometimes conflicting roles of child advocate, public health reformer, and medical scientist.

The story of childhood lead poisoning brings up many fascinating issues in the history of pediatrics and childhood disease. A fundamental tenet of pediatrics is that one must understand child development to fully understand disease in children. Thus, lead toxicity came to be seen not only as a disease ironically worsened by normal childhood behaviors like mouthing and oral exploration, but also a disease that adversely and sometimes permanently impacted child development. Similarly, the history of pediatrics has often dealt with the changing role of the child in the family and with the pediatrician’s often ambiguous responsibilities to children and their families. Lead poisoning is an excellent example of this tension; it is inexorably tied to the home, not merely to the amount of peeling paint on the walls and windowsills, but also to the amount of dust, the kind of pipes, and even parenting styles. With lead toxicity, the home became a potentially unsafe place for children; and pediatricians had to decide how to advocate for their patients.

One of the most fascinating chapters in the book describes how the urban ecology of the mid-twentieth century allowed childhood lead poisoning to surface. As the middle class moved to the suburbs, they left behind older houses that gradually turned into slums rented out by absentee landlords. The typical occupants of these decaying buildings were Blacks who had migrated to northern cities in search of jobs or recent immigrants, neither of whom had been educated in the dangers of lead toxicity. Lacking routine upkeep, the walls and ceilings that had been painted with high lead paint began to deteriorate, and curious toddlers began mouthing the chips that fell to the floor. English cogently argues that the combination of these vulnerable populations and the altered urban ecology created an upsurge in lead toxicity.

The recent history of lead poisoning has illustrated what English has termed its “paradoxical effect on public health”—as lead levels decreased, doctors became more concerned about the problem. The idea that our conception of risk changes over time is central to understanding much of the history of disease in the twentieth century. In English’s story, risk is not merely a reflection of changing scientific knowledge, but has political, economic, and cultural implications as well. Although English addresses each of these issues, I would have liked him to address it in broader analytical and historical contexts. Our ideas of risk were influenced by contemporaneous concepts of risk, as recent work on environmental toxins, such as cigarette smoke or genetic screening, suggest.

Another fascinating aspect of the lead story is the issue of diagnosis. English is at his best telling how diagnostic criteria were contingent on changing scientific, professional, economic, and social factors. He demonstrates how in the first half of the twentieth century only symptomatic children...