What the Eyes Don't See

by Mona Hanna-Attisha

  And in an effort to be persistent but pleasant, I added: “I never heard back from anyone. I would love to discuss this further to see what we can do to protect and prevent lead poisoning in our kids.”

  But the county health department was still silent. Tuesday came and went. Wednesday came and went. No word, no response. By then, between Elliott’s humming ice machine and all the conversations going on in my head, my insomnia was full-blown. I couldn’t fall asleep or stay asleep. I had no appetite; I couldn’t remember when I’d last eaten a full meal.

  Elin’s pessimism had seemed outlandish just a week before. But now she seemed spookily prescient. This made me worry even more. What if her prediction came true? This could take two years to be resolved. Those words haunted me. All I cared or thought about was getting somebody to pay attention. But so many days had come and gone, I suspected that it wasn’t just laziness or distraction. I was starting to wonder if they were purposefully not getting back to me. What was really going on?

  * * *

  —

  ON THURSDAY MORNING, SEPTEMBER 3, I wrote to Dean Sienko, a physician, a mentor, and one of the most experienced, serious public health guys I know. He had worked at the CDC years before, but he’d been a chief medical executive for the state, and a county health officer too. So he knew, better than anyone I knew, how public health worked at every level of government. I hoped he’d have some advice for me on how to get the county health department to finally respond.

  Beyond all his mega-qualifications in health, Dean Sienko was a military man. He has a close-cropped buzz cut, broad shoulders, and the posture of a major general—which he actually was. In fact, his last military stint was as commanding general of the U.S. Army Public Health Center at Aberdeen Proving Ground, Maryland. Now he had a gig at Michigan State University as our first associate dean of public health. This meant you could actually refer to him as “Dean Dean”—or at least I did, which always reminded me of Major Major in Catch-22, one of my favorite books. To give Dean Dean an idea of where I was heading, I forwarded my unanswered emails.

  Later that day I finally got a response from the Genesee County Health Department, but I wondered why they’d bothered. It was total gibberish, a foot-dragging nonanswer. They suggested that a research study could be started the following spring—in other words, after six more months of lead-poisoned water!

  I tried another approach the next day, Friday, September 4—a last-minute Hail Mary pass before the long Labor Day weekend descended. Unable to get the blood-lead surveillance data from the county, I reached out to Michael Roebuck, an ER doctor and our chief medical information officer. I hoped he could help me get the blood-lead levels just from our clinic. He was a data dork, like me, and understood the power and potential of big data to improve patient outcomes at a population health level. He led the implementation of the new EMR system at Hurley and had it down cold. He was also a problem-solving type, the kind who said yes without hesitation because he believed anything was possible.

  Beyond that, he and I were friends and loved to banter, often about our size and job differences. I’m barely five foot two, while Roebuck is over six feet. My patients are kids, while he takes care of adults. He liked to tease me with jokes about how “little” pediatricians liked to treat “little” patients, and about how in my office, I probably napped on a little cot, ate cheddar Goldfish, and drank from a sippy cup.

  Omitting our usual jokes, I cut straight to my request. Figuring that food might be a way to get a faster response from him, I threw in an offer of lunch.

  FROM: Mona Hanna-Attisha

  TO: Dr. Michael Roebuck

  SENT: Friday, September 04, 2015, 12:57 P.M.

  SUBJECT: Fwd: report

  I need an Epic report regarding lead levels. I’ll take you to lunch. ;)

  But even Roebuck didn’t write back. That was a shock. Techies are always connected to devices and superresponsive. The time of year was against me. Labor Day weekend had apparently already started.

  That night I drove home with a sick feeling in my stomach, a kind of frustration that I hadn’t experienced before. Usually I’m as excited as Nina and Layla about the start of school and am up for a fun long weekend, our last three days of summer together. I wanted to be an excited mom. But all I could think about were my other kids, my patients, and what might be happening to them. I felt like I was letting them down.

  It was a hot summer afternoon, in the nineties, muggy. The kids of Flint would be playing outside, running through sprinklers. They would be swimming in the pool at the YMCA or University of Michigan–Flint rec center. Maybe they were sipping from a drinking fountain at Kearsley, a fifty-seven-acre city park that had been completely resuscitated in the last ten years with the help of some grant money and a master gardener and theater lover, Kay Kelly, who brought Shakespeare productions and children’s plays there, along with a new bike path, a soccer field, and a new pavilion.

  Nina and Layla were playing together when I got home, arranging stuffed animals in a make-believe zoo. They had amassed an unbelievable collection that included toys from my own childhood, now missing eyes and limbs, like Fifi and Sarah, my poodle and teddy bear. Nina was carefully facing all the animals in one direction so they could be attentive students in her classroom. Layla was dressing a stuffed dog in a ballerina tutu. Sometimes both girls played the same make-believe game, and the animals became their family. The father was a bear. The mother was a cat. The babies were ducks and lambs.

  One day, a month or so back, the stuffed animals were all over the floor, in groups of two and four, multiplied. “What’s going on, my little squid monkeys?” I asked.

  “Parent-teacher conferences.”

  “Okay,” I said, sitting on the floor, grabbing a stuffed animal, and joining in the playacting.

  But not this weekend. When I saw them playing, my heart tugged to join them, but I was soon distracted by more thoughts of lead-tainted water.

  The rest of the weekend was a blur—long, agonizing hours of pacing with my phone and being distracted. Elliott did his best to keep the girls occupied, but we could both see they were starting to notice. I was increasingly anxious and preoccupied. I reread reports about lead exposure, found more studies about water treatment, and looked again at the coverage of the D.C. crisis. On Tuesday morning, at the end of three days in purgatory, I sped to the hospital as if I were rushing headlong into battle.

  * * *

  —

  ROEBUCK WROTE ME BACK, first thing. Hallelujah.

  FROM: Dr. Michael Roebuck

  TO: Mona Hanna-Attisha

  SENT: Tuesday, September 8, 2015, 9:54 A.M.

  SUBJECT: RE: report

  Should have this by end of day today, depending on the complexity once we dive.

  It didn’t take the whole day. In a couple of hours, I had the blood-lead levels for my clinic patients. I instantly wrote to Kay Taylor, the director of our research department, with a request: “I need help with a data set. It’s fairly urgent and fairly important—lead levels for our patients in response to Flint water stuff. Let me know who can help me.”

  Over the weekend, I had come up with another possible way to get the surveillance data—not from the county but directly from the state health department. They had the blood data for all kids in Michigan. A year before, a nurse in the agency’s Childhood Lead Poisoning Prevention Program who was in charge of “lead education” visited Hurley and had given a Grand Rounds one-hour lecture to our residents and faculty about lead poisoning and how to screen for it.

  At my desk, I searched my email in-box and found her name, Karen Lishinski, MDHHS. And I saw that her email signature included a phone number. I was tired of not getting responses to emails, so I called her.

  She answered the phone.

  I couldn’t believe it. A live human being.

>   After some quick small talk, I got to the point: “I’m concerned about lead. High levels are being found in some water testing. There should be some indication of this in the blood-lead levels. Has anyone looked at that?”

  Matter-of-factly, without even a pause, she answered, “Yes, we looked at the lead levels over the summer, and we did see a spike.”

  They saw a spike? Did she really just say that?

  My heart beat faster, but I tried to mask my excitement and horror with my doctor’s deadpan. I asked, very politely, very calmly, if I could see those results.

  “Sure,” she said, “I’ll send them to you.”

  “You have my email address?”

  “Yes.”

  “Thanks.”

  And that was it. Suddenly I was on a roll. As soon as we got off the phone, I stared at my computer screen for ten minutes straight, and I don’t think I blinked. A spike? The state saw a spike? Why wasn’t this front-page news? I began doing breathing exercises, like the ones pregnant women are taught for childbirth. Inhale, then start counting. Exhale slowly. I took another breath and counted.

  Nothing arrived after twenty minutes, then thirty. Perhaps she was still searching around the data docs and other reports in her computer, trying to find the summer lead levels. It wasn’t as if she had to go to some underground storage vault like the one in Indiana Jones where the Ark of the Covenant was hidden.

  To pass the time, I answered other emails. The array and amount of things going on would almost have been laughable if I hadn’t been too stressed out about lead to notice. I was on a national committee that had revised online educational guidelines for residents, and there was a lot of back-and-forth about this. Our residency program had also just received a grant from the American Academy of Pediatrics (AAP) to establish a toxic-stress-intervention program for kids in the community—one of the few in the country. In the program we would teach positive parenting concepts to pediatric residents and Head Start teachers. National community pediatrics experts and AAP staff would visit our site in early October—three days of tours, meetings, and discussions. Lots to plan.

  I made a little headway on those, then answered an email from a medical student in Cairo who wanted an interview, and another from a former medical student who was having a lonely and stressful transition to her residency at Children’s National Medical Center in D.C., thanking me for a resident’s “survival book” that I sent. Finally, there was an email from a resident who wanted to change her schedule because she was pregnant. (I tell my new residents that this is a perfect time to have babies—and we do our best to accommodate the schedules of new moms and dads in our program.)

  My mom always said, “Mona, you’re too busy.” She complained that I pushed myself to the limit, signed up for too many boards and leadership positions, forged new programs, and took on extras. She wasn’t the first to notice. Why did I do this to myself?

  I had a sense that all my work was heading somewhere. It wasn’t just a passion for training new pediatricians. It felt bigger than that, almost as if the more I did, the more I worked, the more creative and efficient I was, the more chances I’d have to make children’s lives better.

  But now, piling the work and weight of the Flint water issue onto the rest of what I normally take on threw off my sense of balance.

  Meanwhile, the hours passed.

  I kept clicking on my in-box and refreshing.

  Nothing from the MDHHS.

  Then Elliott wrote me. He had to go to the shoulder doctor for a cortisone shot—and hoped I could give him a ride.

  I clicked on my in-box again.

  Still nothing from the MDHHS.

  Perhaps Karen Lishinski had been distracted by another call, or something else had come up, although I couldn’t imagine anything, of any kind, anywhere, being more important than high lead levels in drinking water. How could a nurse at the state health department be unconcerned about a public health crisis? I was obviously finding it hard to think about anything else. Of course, it was possible that Nurse Lishinski was having some kind of terrible personal crisis in her own life.

  Or maybe my request was perceived as above her pay grade.

  Or below it?

  Three hours later: nada.

  I no longer cared about Karen Lishinski’s workload, personal crises, or pay grade, or whatever else might be going on in the mysterious offices of the MDHHS. She needed to send that email. In my mounting restlessness, I turned my attention once again to the Genesee County Health Department. I needed a better answer from them. Something that was real and not gibberish.

  Hoping to light a fire in their underwear with what the MDHHS’s lead nurse had admitted about a “spike,” I wrote to them again, for the third time.

  And on a whim, I did something provocative and strategic. I added Dean Sienko’s name to the list of email recipients, hoping to frighten them into action. The man was a major general, after all, and exuded integrity and leadership from every pore. They couldn’t possibly ignore me now. Dean Dean had credibility and clout. I was proud of myself for coming up with this diabolical idea. I was launching a two-pronged attack.

  FROM: Mona Hanna-Attisha

  SENT: Tuesday, September 08, 2015, 2:30 P.M.

  SUBJECT: RE: Emailing: Lead Prescription

  FYI I just got off the phone with Karen Lishinski from the state’s lead program and I asked her for Flint blood-lead levels. She said that in response to the concern about lead in Flint’s water, they have already looked at the lead levels with their epidemiologist and it “appears” that there may be an increase, but they cannot comment on causality. I asked her to send me the raw data to take a look. I’ll let you know if I get it….

  Lastly, I spoke with Dr. Dean Sienko about this issue last week….[He is] with the MSU Public Health program in Flint now…[and] has offered additional MSU resources and his expertise as needed.

  Mona

  My strategic inclusion of Dean didn’t go as planned, though. He was the only one to reply. Even worse, he hit “reply all.”

  To my knowledge, we never had a child with elevated lead where water was the principal or even minor concern; rather, it almost always came down to chipping lead paint.

  Arrghhhh. The greatest obstacles to good science are assumptions and biases. Dean Dean was revealing his. I really liked him. And I couldn’t really blame him. From the perspective of the public health community, the threat of lead exposure was connected exclusively to lead paint and paint dust, which were thought to be the gravest and most common threats. But particulate chunks of lead that break off inside a water pipe and find their way into a drinking glass or baby bottle can be just as loaded with lead as a chip of paint. Unfortunately, the dismissals and distortions of the CDC during the D.C. water crisis—and its refusal for years to admit that lead in water caused harm to children—had misled Dean Dean and many others in public health, just as Edwin Chadwick had persuaded a posse of do-gooders in the nineteenth century that miasma was spreading cholera.

  It was bad enough to take on a county health department, but now I suspected that my battle might be much bigger, taking on preconceived notions and established dogma in the entire field of public health. It was incredible how little impact the D.C. crisis had. You mean we need to worry about lead in water?

  By the next morning, when Karen Lishinski still hadn’t written, I sent her an email reminder. I asked once again for the state blood data from the summer—and inquired if there was someone else at the MDHHS I should contact to help with this request. Maybe she wants to shift responsibility elsewhere. I was trying to think like a bureaucrat.

  MY FIRST VISIT TO FLINT WAS on a childhood trip to AutoWorld, an amusement park that was one of the city’s many revitalization schemes. Flint had once been a shining example of America’s industrial prowess, a city known for the high
est average income and lowest unemployment. But by the 1980s, Flint had fallen on hard times. Deindustrialization had hit, along with the oil crisis. The joblessness rate was the highest in the country, prompting the media to give Flint one of its awful but catchy monikers—the “unemployment capital of America.” So when AutoWorld opened in 1984, the promoters said it would draw one million visitors a year—and most important, employ 650 Flint residents.

  As a loyal GM family, of course we went to AutoWorld. I was eight years old, so the Ferris wheel and carousel were my most vivid memories—and a bizarre ride that took my brother and me through a “humorous history of automobility” narrated by a talking horse. It wasn’t very funny.

  The park was planned as a way of honoring the automobile, as a testament to American prosperity, ethos, and mobile way of life. Amusement park rides were designed and built, along with tacky souvenir shops and fast-food restaurants, all with a car theme. The year the park opened, the Detroit Tigers won the World Series (a far, far bigger deal). James Blanchard, the governor at the time, heralded AutoWorld as “the rebirth of the great city of Flint.”

  And just like Disney World, AutoWorld had a cutesy Victorian Main Street with shops and eateries—in this case, a replica of Saginaw Street circa 1900 that included the Flint River. But the first attraction you saw, upon entering the theme park, was a history lesson: a rustic cabin and a terrible mannequin of Jacob Smith, the man who bought the land that became the city of Flint from the Ojibwa tribe in 1819. Interestingly, Smith married an Ojibwa woman and lived with her people as an Ojibwa himself. But the exhibit completely ignored the darker tale of the Treaty of 1819 and subsequent treaties that forced Native Americans off their land and pushed them into Canada.