This is the first installation of a three-part series entitled “Ten Lessons from Flint” in which I speak with Professor Marc Edwards of Virginia Polytechnic Institute and State University, pediatrician Dr. Mona Hanna-Attisha of Hurley Children’s Hospital, and Michigan State University and interim Dean Dr. Aron Sousa of Michigan State University. Many thanks to the public health heroes who took time to contribute their thoughts. Please continue on to Part 2 and Part 3.
“It took evidence that children were being lead poisoned for people to finally get heard. They could have listened to General Motors who stopped using this water in October of 2014, who said it was corroding their engine parts — they could have listened to the activists, who were complaining since day one. They could have listened to the pastors, they could have listened to Dr. Edwards, who was clearly showing lead in the water.” –Dr. Mona Hanna-Attisha, Hurley Children’s Hospital & Michigan State University, February 5, 2016
The Flint water crisis is a tragedy, but also a learning opportunity for the next generation of public health professionals. For the uninitiated, the public water supply for this low-income, predominantly black area was switched from Lake Huron to the Flint River as a cost-cutting measure in April 2014 without a proper water treatment plan. This oversight put Flint in violation of the federal Lead and Copper Rule and Safe Drinking Water Act, which required implementation of a corrosion control plan when the water source was switched. The Michigan Department of Environmental Quality (MDEQ) also failed to properly test the water, evaluating fewer samples than initially required and not sampling enough high-risk homes containing lead pipe. The federal government also made a number of missteps, described in various of media outlets including The Huffington Post and the Detroit News. Emails obtained via the Freedom of Information Act between government officials can be found here. While the water source has been switched back, irreversible corrosion will require replacing the pipes to the tune of $1.5 billion.
Chloride levels in the Flint River and iron chloride coagulants used in water treatment made the water particularly corrosive, causing pipes to leach lead and iron into the public water supply, while also contributing to elevated levels of E. coli-form and Legionella bacteria. Researchers have confirmed that among children who drank the water, there is a higher incidence of elevated blood lead levels (BLL). While officials now recognize they may have been hasty in switching the water source without adhering to federal guidelines, the damage has already been done. Despite immediate complaints from residents after the switch and attempts by a few government employees to advocate on their behalf, the water was not switched back to Lake Huron until October 2015, thanks in large part to public health advocacy.
Physician and scientist advocates have partnered with Flint residents and local organizations using shoeleather epidemiology, the Freedom of Information Act, media and publications in academic literature to advocate for these patients. I had the privilege to ask a few of these professionals about what students should take away from the crisis — engineering Professor Marc Edwards of Virginia Tech, pediatrician Dr. Mona Hanna-Attisha of Hurley Children’s Hospital, and Michigan State University and interim Dean Dr. Aron Sousa of Michigan State University. In this three-part series, we discuss the work done to expose issues in the Flint water, the public response, and how the next generation of public health professionals can train themselves for such crises in the future.
Lesson one: “Curiosity is important”
Dr. Sousa stressed that maintaining curiosity is crucial in protecting patient and public health: “Curiosity is important. Citizens and activists of the community knew the water was bad. And then Marc Edwards came in and actually demonstrated that it was tainted with lead — amongst other problems. Then [Dr. Hanna-Attisha] and others were thinking ‘I wonder if this is showing up in kids?’ … You’ve got to make sure that you don’t lose your sense of curiosity, that you don’t stop thinking about what you’re seeing … if we hadn’t had those people in Flint looking at this — people there would still be drinking contaminated water and kids would be developing higher and higher levels of lead in their blood.”
Curiosity means getting outside of your comfort zone and asking questions when what you see doesn’t add up, as Dr. Hanna-Attisha did. Her team released preliminary data at a press conference in September of 2015 to describe the impact of lead exposure in Flint’s children, despite governmental data saying otherwise: “Don’t trust everything. Be a scientist. Do what you were trained to do. Digest it. Be a critical thinker. Don’t take everything for face value.”
Curiosity in this case protected kids and saved lives. Public health professionals like Professor Marc Edwards hope that Dr. Hanna-Attisha’s combination of quality research and advocacy represent the next generation of public health professional, “who is willing to advocate for the truth and for her patients regardless of the possible short-term consequences to her career and at the risk of offending the powers that be. The world desperately needs more Dr. Monas.”
Lesson two: “The costs of scientific misconduct are extremely high and they’re often borne by the poorest among us”
The Flint water crisis was not the first time Professor Edwards had seen children poisoned with lead because government agencies dropped the ball. In 2003 through 2004, he worked with others to expose toxic lead levels in the District of Columbia (DC) water supply, which were essentially being ignored by major agencies like the DC Water & Sewer Authority and the Center for Disease Control (CDC). These agencies sat on information about the lead-tainted water and the CDC downplayed the impact in children in a Morbidity and Mortality Weekly Report (MMWR) that has since been criticized. Eventually, research and reporting by The Washington Post lead to a congressional investigation, which agreed that the CDC’s flawed reports were “scientifically indefensible.” This is described in their report “A Public Health Tragedy: How Flawed CDC Data and Faulty Assumptions Endangered Children’s Health in the Nation’s Capital.” The CDC has kept a low-profile in Flint, perhaps as a result of this previous incident of scientific indiscretion. Now, some clinicians are calling for the CDC to re-establish the charter of the Advisory Committee on Childhood Lead Poisoning Prevention, which was disbanded shortly after they recommended that the 10 microgram per deciliter (ug/dL) “level of concern” be lowered to the current action level of 5 μg/dL in 2013.
Professor Edwards talked about his experiences in both DC and Flint: “When I saw what the Centers for Disease Control did in Washington, DC in 2004 — I was just appalled … The costs of scientific misconduct are extremely high and they’re often borne by the poorest among us — and that’s what you’re seeing in Flint.”
Because residents and advocates did not back down from their complaints, independent researchers showed that the data provide by governmental agencies was inaccurate. The result of this research has not only saved lives, but will be used in the ongoing civil and criminal investigations. If the water quality issue is tied to 10 deaths by Legionnaires’ disease, then it is possible that officials may face manslaughter charges.
Lesson three: “You have to use science in a rigorous and sophisticated way because otherwise you’re just another voice yelling into the wilderness”
Dr. Sousa, Dr. Hanna-Attisha and Professor Edwards all described the potential impact of responsible science in public health advocacy. Dr. Sousa commented on the unique ability of physicians to advocate with data-driven tools: “Our advocacy has to be science based … You have to use science in a rigorous and sophisticated way because otherwise you’re just another voice yelling into the wilderness.”
Dr. Hanna-Attisha made sure to avoid being just another voice. She and her team looked at aggregated data using sophisticated mapping techniques. Their final findings, published in the February 2016 volume of the American Journal of Public Health, showed that incidence of elevated blood lead levels (≥ 5 μg/dL) increased from 2.4 percent prior to the water switch to 4.9 percent after, with the most significant elevations seen in disadvantaged neighborhoods.
Conducting rigorous and sophisticated research requires researchers across a number of fields. Allowing cross-collaboration gave researchers the opportunity to learn of analytical methods they may not have used if left to their own devices. This multi-disciplinary approach allowed both Dr. Hanna-Attisha and Professor Edwards’ groups to use high-quality data collection and statistical analysis methods. Dr. Sousa suggests that prioritizing the makeup of the team is crucial to advocacy research: “Nobody would have figured out that the high lead water areas had the kids with high blood lead levels if the health geographer [Rick Sadler] had not been around. The pediatricians couldn’t have done the kind of analysis that Rick Sadler did. You have to have multidisciplinary teams in order to sort out the science.”
The Virginia Tech researchers espoused this high-quality approach to scientific inquiry, finding the right team, conducting quality research and presenting relevant results. They tested home water samples from Flint homes with new and old plumbing, with preliminary data showing 101 of 252 (40.1 percent) homes with lead levels above 5 parts per billion (ppb). Now, there is no “safe” lead level in water, and above 5 ppb is particularly concerning. The lower lead levels reported by the Michigan Department of Environmental Quality were then called into question. Virginia Tech’s research, conducted door-to-door with community partners, supported the residents’ anecdotal claims and concerns voiced by public health professionals. Importantly, Professor Edwards and his team took any previous data with a grain of salt: “You really have to be open-minded and not have this hierarchical mindset that what governmental agencies tell you is necessarily the truth. You have to look and see what’s going on right before your eyes and listen to people and not be afraid to advocate for people who cannot speak for themselves.”
Virginia Tech’s research was not limited to quantitative data collection. They amassed inter-agency emails via the Freedom of Information Act, which showed not only insufficient water sampling, but also serious miscommunication between the Michigan Department of Environmental Quality and the US Environmental Protection Agency. More damning evidence in these emails showed major agencies willfully and incorrectly collected water samples, and broke the law by failing to adhere to the federal Lead & Copper Rule.
Rigorous scientific investigation was essential ammunition for the advocates when they brought their findings to governmental officials. Still, using effective science with diverse teams was not enough in Flint, at least not initially. The researchers and advocates had to continue to voice their concerns until someone listened. In Part Two, Flint professionals discuss how they were finally heard so change could begin.