Lead is a toxic heavy metal that has been extensively used in modern society, causing widespread environmental contamination, even in isolated parts of the world. There is now overwhelming evidence associating lead exposure with wideranging health effects, including reductions in intelligence scores, hyperactivity, shortened concentration spans, poor school performance, violent/aggressive behaviour, hearing loss, delayed onset of puberty, anaemia, and in severe cases, coma and death. In recent years consensus has been reached in respect of the absence of a threshold of safety for key health effects associated with lead exposure, and the permanent and irreversible nature of many of the health and social consequences of exposure to lead. The public health problem of environmental lead exposure has been widely investigated in developed countries such as the United States of America where, since the 1970s, policies and interventions have been followed by significant reductions in blood lead levels amongst children. In developing countries, and in African countries in particular, there is a relative dearth of information on the sources, mechanisms of exposure and blood lead distributions in children, and little action has been taken to protect children against lead poisoning. This study was undertaken to determine the current distribution of blood lead concentrations, and associated risk factors, amongst selected groups of first grade school children in the South African urban settings of Cape Town, Johannesburg 7 and Kimberley, a lead mining town (Aggeneys) and two rural towns in the Northern Cape province. A further objective of the study was to compare blood lead distributions determined in the current study with the findings of similar studies undertaken prior to the introduction in 1996 of unleaded petrol in South Africa. The results show that over the past decade, blood lead concentrations amongst first grade school children have declined considerably, but that large proportions of children, especially those living or attending school in impoverished areas, continue to have intolerably high blood lead concentrations, within a range that puts them at risk of detrimental health and social outcomes. The major sources of exposure to lead in the samples studied were leaded petrol, lead-based paint used to decorate homes and schools, lead solder used in “cottage industries” and other home-based lead-related activities, as well as the transfer of lead particles from lead-related work settings into homes. Recommendations for policy and relevant interventions for the South African context are discussed.