This is the second installation of a three-part series entitled “Ten Lessons from Flint.”
“There is a desperate need for the next generation of public health professionals who are willing to advocate for those who cannot speak for themselves, who are willing to challenge authority and not be willfully blind to what’s occurring right before their eyes.” –Professor Marc Edwards, Virginia Polytechnic Institute and State University, January 23, 2016
Researchers like Professor Marc Edwards and Dr. Mona Hanna-Attisha were not the first people to speak up about the water crisis in Flint. In June of 2015, regional EPA employee Miguel Del Toral, Regulations Manager of the Ground Water and Drinking Water Branch, issued an internal memorandum entitle “High Lead Levels in Flint, Michigan – Interim Report.” This document described the lack of corrosion control protocol and high lead levels. It was released to officials within the Environmental Protection Agency (EPA), Professor Edwards and Flint resident Lee Ann Walters, whose home water contained extremely high lead levels, as confirmed by city officials. The memo was quickly redacted by an EPA official who said the report was not final and should not have been released, and a Michigan Department of Environmental Quality (MDEQ) official said it had been issued by a “rogue employee.” Those officials have resigned, and Del Toral’s report has proven to be accurate.
Professor Edwards and Dr. Mona Hanna-Attisha had marginally better luck getting heard. The governmental officials at the EPA and MDEQ claimed they had not found such high lead levels in their assessments, and initially dismissed both groups’ data. If Professor Edwards, Dr. Hanna-Attisha and others had not kept speaking up and using their networks to force someone to listen, Flint residents might still be drinking tainted water.
Lesson four: “Use your voice”
Dr. Edwards and Dr. Hanna-Attisha had to cross the line from clinical care and research into advocacy, which meant using their voices. Crossing this line is difficult, but when those in power do not listen to patients, crossing that line may become necessary, as Professor Edwards has learned through his career: ”To successfully confront scientific corruption and agency abuse of power, at some point you will have to cross that line into advocacy and activism … People will say you’re emotionally involved and your science is no good. Well yeah. I was emotionally involved, because kids were getting poisoned and people were even dying. We realized that the EPA and the state were not going to help these people.”
With so many residents speaking out, why did it take independent researchers and physicians speaking up for change to happen? While Dr. Hanna-Attisha’s data was not initially well-received, it was eventually listened to. This speaks to the value placed (fairly or unfairly) on the physician’s voice. Keeping this in mind is important through a clinician’s training and practice, as Dr. Hanna-Attisha described: “I’m glad they finally listened to me, but it took too long. It speaks to the very credible voice of the physician in the community … This should empower other physicians to know that you still have a really credible voice in your community — that your voice is powerful.”
Speaking up does not necessarily mean uncovering a major public health crisis. Using your voice can mean speaking up to a colleague about a patient safety issue, or bringing up concerns with attendings. Regardless of the venue, using your voice can be a major asset to your patients.
Lesson five: “You need to work with people on the ground”
The voice of researchers and clinicians may have been what forced the hand of government officials, but Flint residents were an integral part of addressing the water crisis. Professor Edwards stressed the need for collaboration: “You need to work with people on the ground who have a stake in this — like we did in Flint. We collaborated with Flint residents — they had our back, we had theirs.” This collaboration encouraged residents to submit water samples for testing and provided a network to inform community members about available resources or updates.
Professor Edwards’ approach is admirable, but not new. In 1854, Dr. John Snow — the so-called father of epidemiology — introduced “shoeleather epidemiology” when he went “upstream” to find the cause of clustered cholera cases in London, tracking the source of contamination to a single water pump, which he promptly shut down by ingeniously removing the handle of the pump. Edwards’ sees him as the public health professional we should aspire to be: “The guy got out there — he talked to people. He listened to local knowledge. He talked to the people afflicted with the cholera. He was open-minded enough to challenge the conventional wisdom of the day — the miasma theory. He got partners in the community. He essentially invented a whole field and wrote the truth in a paper. No one believed him until decades after he died.” Much like John Snow, advocates in Flint stuck with their science and didn’t back down as they supported the community with their results.
Lesson six: “There aren’t many people who can go this path”
Though the outcome was eventually in favor of the two studies and Flint residents, the initial response to Dr. Hanna-Attish’s preliminary data was not so warm: “Our information was not received initially … I was not listened to.”
Luckily, her extended professional network connections paid off in the next two weeks: “The Chief Medical Officer at the state, who is also an MD, MPH, called me. I had met her a few months prior … She knew me … She said, ‘You know, I apologize — I want to have a physician to physician conversation.’ And I shared my data, and I shared how we did our research … That’s kind of how the state re-looked at their data, and then a couple weeks later kind of said — yeah, there’s something going on here.” Though her networking did pay off, and Dr. Hanna-Attish’s willingness to stay with an issue is a necessary skill when others shoot you down.
This dedication to advocacy and to exposing the truth is not easy. “It’s not for everyone,” said Professor Edwards. “There aren’t many people who can go this path. It takes an enormous personal toll … For Dr. Mona, it worked out. I cannot say enough in praise of her, and it gives me great hope that she’s getting the accolades she deserves. But that is the exception and not the rule. For every person like Dr. Mona who’s vindicated within a week after they first engage and gets the accolades they deserve, there are 999 people who do not get so lucky due to circumstance and it cost some of those people their professional lives.”
Professor Edwards, Dr. Hanna-Attisha and Dr. Sousa all took the advocacy path. In Part Three, they help us understand how we can hone our skills as advocates in future practice.