What the Eyes Don't See

by Mona Hanna-Attisha

  Given the rejection of lead in 1922 by most of the world, it’s kind of amazing that just a year later it was added to gasoline in America. It was heralded as a giant technological breakthrough, a “gift from God.” It’s funny how we talk about “unleaded” gasoline now, as if lead were a natural component of gas and removing it required a complicated chemical process, maybe even at great expense.

  The entire concept of “unleaded” is a misnomer, in fact. Lead was mined from the earth and added to gasoline. The reason? To stop engine knocking, an annoying noise in early car engines that occurred when the mix of fuel and air burned unevenly. According to GM legend, it took Kettering a decade of intense experimentation to find his antiknock compound. He had alternatives, like ethanol, but it could not be patented and profited from, unlike tetraethyl lead (TEL), for which GM obtained the patent. The health hazard of TEL, over and above normal lead, was no secret. Fat-soluble and easily absorbed by the skin, TEL was even tested by the U.S. War Department as a nerve gas. Just five teaspoons applied to healthy skin could be fatal.

  Five teaspoons on the skin…this didn’t stop GM or even slow the company down, it seemed. It collaborated with DuPont and Standard Oil/Exxon on a new “high octane” style of gas, dubbed “ethyl,” that allowed cars to drive better and engines to work more efficiently, never to knock or ping.

  As soon as the coming of a new “improved” gasoline was announced, public health experts began writing about the dangers of lead. An anti-lead movement rose up and gained ground, as always seems to be case, only in the aftermath of a tragedy. In October 1924, noxious fumes poisoned and killed workers in a section of a Standard Oil refinery in New Jersey where the new gasoline with TEL was being made. Several exposed workers were straitjacketed after exhibiting paranoid behavior, experiencing delusions, and becoming violent. When the first death occurred—seventeen people died in all—the local district attorney called for an investigation, which launched a media frenzy. The tabloids referred to the lead fumes as “loony gas.”

  For the remainder of 1924 and most of 1925, the public health debate about tetraethyl lead in gasoline was one of the sharpest of the early century—much more heated than what eventually transpired over lead in paint, or than what has yet to transpire over lead in plumbing.

  Now I get to my favorite (and the only uplifting) part of this story. It’s about Alice Hamilton, who lived in the time of Kettering—and fought him with everything she had. Hamilton was a social justice pioneer, medical doctor, and professor who had specialized in lead toxicology cases among factory workers before turning her attention to GM. She pushed the company to find a better, safer alternative to TEL—and insisted that the introduction of lead on a widespread basis would have a catastrophic impact on public health.

  “I would like to make a plea to the chemists to find something else,” she said at one public hearing. “I am utterly unwilling to believe that the only substance which can be used to take the knock out of a gasoline engine is tetraethyl lead.” She was right—there were alternatives. But public health wasn’t foremost in the corporate mentality; profits were.

  Hamilton is now one of my heroes, a stubborn badass who devoted her life to improving the lives of workers, the poor, and children. When things became stressful for me in Flint—and there were some tough days to come—I thought of how hard she tried to right a wrong, to make the world safer for kids, and to prevent a totally preventable public health scourge. Hamilton was a visionary who studied medicine at the University of Michigan at a time when there were few women in the field. In her memoir, she said that her studies in Ann Arbor had been transformational. (I could say the same thing about my time as an undergrad there.) Michigan gave Hamilton “my first taste of emancipation,” she said, “and I loved it.” Ditto that.

  From there, Hamilton studied bacteriology and pathology in Germany from 1895 to 1897, just a few years before Paul Shekwana was in England, and she returned to the United States to continue her postgraduate studies at the Johns Hopkins University School of Medicine. Then she moved to Chicago to become a professor of pathology at the Woman’s Medical School of Northwestern University.

  ALICE HAMILTON, AT HER MEDICAL SCHOOL GRADUATION, 1893

  In Chicago, she also became a member and resident of Hull House, the first settlement established by Jane Addams and Ellen Gates Starr, where newly arrived and impoverished European immigrants were given full or “wrap-around” services—from healthcare to education and advocacy—and a safe place to live. Hamilton opened a well-baby clinic and eventually expanded care to include children up to eight years old. While at Hull House, she began touring city slums, mineshafts, and factories, researching industrial diseases and occupational hazards. She discovered more than seventy industrial processes and jobs that exposed workers to lead.

  When she was offered a position at Harvard Medical School in 1919, she was the foremost American authority on lead poisoning, and one of only a handful of specialists in industrial disease. But when Harvard University offered to hire her as its first woman professor, it made three stipulations:

  She was forbidden to enter the Faculty Club.

  She could not have tickets to football games.

  She was not allowed to march in the commencement procession.

  She took the job anyway. It’s a lesson in strategic thinking, something she was especially good at. During Hamilton’s years fighting lead in gasoline, she was adept at feeding tragic stories of lead poisoning to the popular media, knowing this would light fires that no academic study could.

  Between 1924 and 1926, the lead-in-gasoline controversy was debated in 124 daily newspaper articles in the New York City dailies that were picked up in hundreds of wire-service stories around the country. When GM and Standard Oil pushed back, they claimed that Hamilton and other anti-lead activists were “hysterical”—that code word for “stupid woman, overreacting”—while the industry’s work to improve gasoline was based purely on rational science.

  The main medical expert defending GM’s use of lead was its own in-house toxicologist, Dr. Robert Kehoe. At a conference called by Surgeon General Hugh Smith Cumming to resolve the conflict in May 1925, Kettering told his dramatic story of how he had experimented with dozens of additives and eventually discovered the wonders of TEL. As Alice Hamilton and other public health advocates looked on in horror and disgust, this mendacious testimony was followed by a succession of industry reps and medical experts backing up Kehoe’s claims that TEL was totally safe and that there was no suitable alternative. He insisted that lead was naturally occurring in the environment and could be processed and eliminated by the human body without any health risk or danger.

  During a break in the conference, Hamilton is supposed to have confronted Kettering in a hallway and said, “You’re nothing but a murderer!” I’m not sure this story is true; it doesn’t really go with her style, which was stubborn and persistent but always polite. But I can only imagine how angry she might have been that day, face-to-face with such a liar.

  To conclude his testimony about the safety of ethyl, Kehoe made a diabolical offer: GM would discontinue use of TEL immediately if it could be proven to be harmful. This established a new precedent—later used by the asbestos and tobacco industries for decades—that forced public health advocates to prove harm before action could be taken. It goes against prudence and any sort of good judgment to allow dangerous practices to continue until enough evidence mounts to stop them—putting lives, even the planet, at risk. It was a turning point, not just in the history of lead but in so many other aspects of public welfare and safety. “Safe until proven dangerous” became known as Kehoe’s Paradigm, or the Kehoe Rule. The approach was later taken by climate change deniers.

  The public health approach, however, is far wiser than the Kehoe Rule. The Precautionary Principle holds that a product or chemical should be considered unsafe
unless the manufacturer can prove otherwise.

  To reach a decision in 1925, the surgeon general called a small committee to investigate the hard evidence on leaded gasoline—and to test workers for lead levels in their bodies. In seven months of study, the committee found that those who had worked with ethyl gasoline did have slightly elevated levels but none demonstrated clinical poisoning. It determined that TEL could not be proven to be harmful. Kehoe won. TEL went on the market.

  I can imagine how devastated Alice Hamilton must have been, and how she must have despaired for the future, while Kettering celebrated his victory. The use of lead continued. Leaded gasoline, or “ethyl,” became phenomenally successful, appearing in virtually all major-brand gasoline sold in the United States and around the world throughout the ensuing three decades. The costs of the surgeon general’s decision have been incalculable. By 1960, almost 90 percent of all gasoline contained TEL. By 1965, according to the work of geochemist Clair Patterson at Caltech—who inadvertently stumbled onto the man-made contamination of lead in the environment while on a quest to determine the age of the earth—the average American had one hundred times more lead in her body than her ancient ancestors did.

  Modern history tells us the story of how powerful industry is—from cigarette companies to gun manufacturers—all over the world, more powerful than the collective voices and protests of individuals. The lead industry used its towering advantage over its victims to silence them and shame them for their lack of power. In 1955 the director in charge of “health and safety” for the Lead Industries Association described childhood lead poisoning as primarily a “slum problem” and a “major ‘headache’…the only real remedy lies in educating a relatively uneducable category of parents.”

  Twenty years later, still blaming the victims, the industry’s “health” director was making even less-veiled racist remarks. “The basic solution is to get rid of our slums, but even Uncle Sam can’t seem to swing that one. Next in importance is to educate the parents, but most of the cases are in Negro and Puerto Rican families, and how does one tackle that job?”

  The story of lead is like the story of tobacco in some ways, except the lead industry was never forced to pay a price for its greed, for the damage it caused, or for its attempts to ruin and discredit the great scientists who spent their professional lives fighting on behalf of its victims. Those victims were more than simply innocent—they were kids. They were babies.

  Now I knew, as I browsed online, why there are so many books and journal articles about the public health history of lead—from Lead Wars, by Gerald Markowitz and David Rosner, to Toxic Truth, by Lydia Denworth. It is because the story has so many twists and turns, and so many great characters.

  Based on 2015 data, the Institute for Health Metrics and Evaluation (IHME) estimates that lead exposure accounts for 494,550 deaths and the loss of 9.3 million disability-adjusted life years due to its long-term effects on health. The IHME also estimates that lead exposure accounts for 12.4 percent of the global burden of developmental intellectual disability, 2.5 percent of the global burden of heart disease, and 2.4 percent of the global burden of stroke.

  PUBLIC HEALTH ENEMY #1

  That is the legacy of Charles Franklin Kettering, the American inventor, engineer, businessman, and philanthropist, a holder of 186 patents and a man of platitudes and corporate pop-optimism. His work added more lead to the environment and to children’s blood than any other application of the metal. It is one of the largest environmental crimes ever. Tell me again why we’re naming universities after him?

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  THANKS TO A HANDFUL of environmental health superstars, the government began phasing out the use of lead in paint in the 1970s—first with the passing in 1971 of the Lead-Based Paint Poisoning Prevention Act, followed in 1978 by the federal ban on consumer uses of all lead paint.

  Lead was finally restricted—but not totally outlawed—in plumbing in 1986. The same year, leaded gasoline was taken off the market in the United States, and it was banned in Europe by 2000. The 2002 Earth Summit called for a worldwide ban on all leaded gasoline, with a goal of total elimination by 2006. The United Nations conducted a ten-year campaign to eliminate it from developing countries, but according to the UN environment program, in 2016 three Arab countries—Algeria, Yemen, and Iraq—still added TEL to gasoline. Ugh. And for some inexplicable reason, it is still allowed in airplane fuel.

  Before industrialization, children rarely had lead in their bodies. It was due only to industrial greed and convenience that it was mined and released into the environment. Even the ancient Romans suspected it was dangerous, even deadly, but we in the modern age allowed it—we looked the other way and let convenience drive policy.

  Environmental health scientists continue to demonstrate the cruel impact of lead on the bodies and brains of developing children—and how even low levels of exposure can have dramatic consequences. Each new study has played a part in keeping the antilead movement going in the face of resistance from the evil and, for a time, powerful industry lobby.

  Today we have a more complete picture of the neurotoxin’s evil effects. Thanks to the work of scientists and pediatricians like Clair Patterson, Herbert Needleman, Philip Landrigan, Bruce Lanphear, David Bellinger, and so many more, we know lead’s potential to twist behavior, attack every system in the body, erode cognition, and possibly even warp one’s DNA.

  Lead exposure has been linked to almost every kind of developmental and behavioral problem, including school dropout rates and criminality. A recent study looked at six U.S. cities that could provide good crime data and blood-lead-level data going back to the 1950s. Going neighborhood by neighborhood in New Orleans, it found that a rise in blood-lead levels matched a rise in incidence of violent crime. Econometrics studies looking at worldwide crime trends also show an astonishing correlation between a “lead curve” and a “crime curve.” Where consumption of leaded gasoline declines, so does violent crime. The connection between lead and crime is still speculative, but the correlations are there.

  And what have we learned about how much lead the body can safely handle? Medical science has now concluded there is no safe level of lead in the human body.

  But here’s something beautiful: this graph shows a steady and significant decline in lead in kids over the last several decades. These kinds of charts give us public health folks super-serotonin highs. When people tell you that government is inept and ineffective, all you have to do is remind them of the good work that the right policies can achieve.

  DECREASE IN ELEVATED BLOOD-LEAD LEVELS OVER TIME

  Unfortunately, I must point out, the perceived “victory” over lead can create new problems. I run into older pediatricians all the time who believe the battle over lead has been won because they no longer see kids comatose from lead exposure in ICU beds. To them, the problem is fixed. Lead is a problem of yesterday. But given that we now know that even low levels of lead exposure can change our brains and bodies, our concern should be heightened and our resources increased, not reduced. In fact, given what I was learning about lead in water, the lead battle had a new front.

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  A PAINT CHIP, as anybody who’s lived in an old house knows, comes off the wall with all its layers together. If you look at a cross-section, you can see all the layers of paint like tree rings, with the oldest paint at the bottom. And when a child who is crawling or walking finds a paint chip on the floor, it is usually put directly into their mouth, just like they put everything into their mouth.

  When you open an old window, one that was painted long ago with lead paint, lead paint dust—and other small particles of lead paint—rise into the air and can be inhaled. And in summertime, the elevated outside air temperature puts more lead into the air, and more dust rises to be inhaled. Even the heat retained in the ground increases
the amount of lead that is released from plumbing.

  Soil is another place where lead can linger. Over the decades when lead was used in gasoline, car exhaust settled in surface soils in city schoolyards, playgrounds, and backyards, leaving them with accumulated and concentrated lead. This is why today’s urban gardens on vacant land in Detroit, Flint, and elsewhere have to import their soil and often grow produce on raised beds.

  These days, when we talk about lead exposure in children—in a medical setting or as a public health issue—almost always we are talking about paint and paint dust. No matter how much we hand out cleaning supplies and tell people to vacuum, mop, wash hands, or wipe the windowsills, children who have lead in their environment will be exposed to it. The problem is that lead is incredibly durable, even all these years after it was banned. It is still found in older homes. Its use was often required in public housing until 1978.

  But in all my training and clinical care, both in pediatrics and in public health—and in all my work in communities disproportionately impacted by lead—I don’t recall ever hearing about the possibility of lead in water.

  Never. Not until the summer of 2015.

  Not until the night of the barbecue, when Elin first mentioned it.

  The D.C. crisis had come and gone—and since it was suitably covered up, I knew nothing about it. I didn’t even know that water pipes were made of lead or were soldered together with it. I didn’t know that lead is still found in most kitchen faucets, because even supposedly “lead-free” brass could contain up to an average of 8 percent lead until 2014, when regulations changed again.

  To catch up on what I had missed in my environmental health education, I started reading Werner Troesken’s gripping book, The Great Lead Water Pipe Disaster, which covers more than a century of lead-in-water disasters and the lack of political will to do anything about it. As far back as the eighteenth century, when lead pipes were installed to carry water, we’ve had kids with mysterious illnesses, moms with miscarriages, and adults with neurological complaints. The poisoning can affect so many systems of the body, it’s hard for doctors to diagnose.