What the Eyes Don't See

by Mona Hanna-Attisha

  When the meeting ended, I got up slowly, gathered up my laptop, coffee, and phone, and made my way over to Kirk. “The water situation is not good,” I said.

  “Tell me more,” he said.

  “I’m looking at the lead levels in Flint kids’ blood.” Then I shared some of my research. Just enough.

  Kirk and I had gone through the same public health program more than a decade ago, and he had known me long enough to know that I am never inflammatory or impulsive. But I am passionate and expressive. He was studying my face, which had become a road map of anxiety.

  “I’m getting nowhere with the county and state,” I said. “They keep blowing me off.” While standing, I forwarded him the emails I had sent to the county and the state.

  He sighed.

  Dr. Reynolds wandered over and joined our chat in a corner of the boardroom. Then Jamie Gaskin from United Way came over and listened in. Somebody mentioned having seen “that water guy from Virginia Tech” on TV.

  “I met with Marc Edwards,” I said.

  All eyes turned to me.

  “He’s the real deal, as far as I can tell. And the testing he’s doing shows very high amounts of lead in the tap water. Very high.”

  I could see Kirk’s mental wheels spinning. Then Jamie Gaskin spoke up. He lived in Flint and had a seven-year-old son. Within a span of only minutes, he was talking about solutions: distributing bottled water and obtaining filters. Then I raised my most serious concern—the powdered formula mixed with tap water.

  The only solution was getting someone to declare a state of emergency or issue a “health advisory,” which we hoped would kick into gear a number of governmental responses, including bottled water deliveries, water filters, and maybe premixed baby formula. But nothing could happen without this official action. We talked about the quickest way to get it done.

  I said that I was in touch with Representative Kildee’s office, and a staffer there was working the USDA angle for premixed formula. What other options were there? Kirk and Dr. Reynolds were as worked up and engaged as I’d ever seen them. They were talking twice as fast as usual, interrupting each other, and tossing out new ideas at a breathtaking pace. Kirk was writing things down in his little notebook, and Jamie was channeling his frustration into action.

  I could also see that I wasn’t alone anymore. A team was coming together.

  * * *

  —

  THAT NIGHT, AS LUCK would have it, I dropped in on a hotbed of pediatricians, the perfect place to find more supporters. The annual meeting of MIAAP was just beginning.

  At the board meeting that first night, after a few opening remarks, the agenda was to discuss the dismal immunization rate in the state of Michigan and some solutions to improve it. There were about ten pediatricians on the board, including me.

  I am passionately pro-vaccination, and convincing parents to have trust in the science on vaccines is one of the most important tasks facing pediatricians today. Combatting this dangerous trend of science denial, I always explain to my patients the concrete evidence about vaccine safety and efficacy—literally how many millions of lives have been saved—and I share that I have no hesitation immunizing my own daughters.

  I was called on to describe a press conference that I had attended, as a representative of the MIAAP, a month earlier for a back-to-school immunization campaign throughout the state. I delivered a quick summary of that event, then remembered that at the conference I had met the new chief medical officer for the Michigan health department, Dr. Eden Wells, a sensible, no-frills woman who also directed the University of Michigan’s preventive medicine fellowship. Since doctors would be talking about the importance of vaccination at the press conference, I brought my white coat, even though I am usually reluctant to wear it—or scrubs, for that matter—outside the clinic or hospital. Flaunting the white coat is something only medical students and new doctors do. But I was supposed to give media interviews that day on camera, where the white coat screams credibility. Eden told me she was sorry she didn’t think to wear hers. She also noted that, in addition to the Hurley Children’s logo, my coat had an MSU green S. She teased me about being a Spartan while she was a Wolverine, rival schools.

  Remembering that encounter got me thinking about the health department and made me wonder again about Karen Lishinski, the agency’s lead-poisoning nurse. Six days had passed since I’d reached out to her, but I still had received no reply. Lead colonized my mind again. While the rest of the MIAAP board discussed vaccination rates, I kept thinking about blood-lead screening rates. How many Flint kids who were required to get a Medicaid-mandated screening, I wondered, actually got one? The number of at-risk kids who never got screened would dramatically impact our sample as well as the findings.

  The more I learned, the more I saw how wrongheaded the public health approach to lead was. It was ass backward. When we test a child for lead, we are testing the child’s environment. Children become the proverbial canaries in the coal mine, as we use their bodies, their lives, as instruments to test the world around them. If they test high, that means there’s lead in their environment. This is useful to know, but for the child, it’s already too late.

  “Primary prevention” means preventing harm from occurring before a child moves into a house, before a mom gets pregnant. A truly visionary program would be methodically identifying and eliminating the lead from our environment completely before a child is exposed.

  As the board meeting came to a close, the MIAAP executive director asked if anyone on the board had something else to share, a concern or development. It was late. People were packing up.

  I looked around. No hands were going up.

  I blurted it out, my heart pounding: “Well, we may have a lead problem in Flint.” I was sitting in a room with the leading pediatricians in the state, after all. These were my peeps. If I had to go public, this was the place.

  All heads turned to me, awaiting more information.

  As briefly as possible, I explained the history of the water issue. And I knew one story would drive it home: I told them how GM had stopped using the water a year before because it was corroding engine parts, but we were still expecting the kids of Flint to drink it. I said we were looking at blood-lead levels at the Hurley Children’s Clinic, and our findings were “concerning.” I knew not to share numbers, or describe much else beyond saying that we were currently analyzing a larger data set.

  A long silence fell over the room. I didn’t want to alarm them, not yet, so I just repeated that we were still looking at the numbers, but I was concerned. I looked around the room and met the eyes of the other pediatricians. Pediatricians seem to wear compassion on their sleeve—and have trouble hiding emotions. Without needing any further explanation, they knew what was at stake. I could see that in their eyes.

  Denise Sloan, the executive director, said she had just spoken with Dr. Reynolds about possible topics for our “advocacy lunch” on Saturday. He had mentioned Flint’s water too—and suggested that we raise the subject on Saturday with the larger group of pediatricians in attendance.

  “Sounds good,” I said. “I won’t have any numbers to share. But I would like to strategize.”

  * * *

  —

  THE NEXT DAY I attended the all-day MIAAP conference on toxic stress, and later had no memory of most of it. Sitting in a hard-backed chair in another characterless meeting room, I tried to pretend that I was watching the PowerPoint presentations on the big screen. (I call it “death by PowerPoint.”) But I could have been anywhere and nowhere.

  Every half-minute or minute, my phone sounded or buzzed with a new text.

  I ignored the usual incoming tide of work-related stuff and pulled out anything from Kirk, Elin, Melany, Dean, Jordan, Jenny, or Marc for immediate consideration. My attention went to Jenny first and foremost.

  We were furious
ly texting as we analyzed the data, and going over and over the design of our study. We were facing a few crucial decisions.

  We couldn’t decide what to do about children who had multiple blood-lead levels. For the study, we needed only one level per child. But if a child was diagnosed with an elevated level, the protocol was to take their blood levels repeatedly. Should we use their highest lead level or their first lead level? The literature seemed to contain both kinds of examples. We were constantly going back to published research, reading article after article, to see how other studies were done.

  After some reluctance, we decided to ask Marc for advice—to tap his scientific expertise. He didn’t seem to answer texts, but he replied to emails almost instantly. He recommended that we use the highest blood-lead level for each child. This was what he did when he looked at blood-lead levels in D.C. But more important, he emphasized that the fact that a child’s first lead level may not be elevated does not “protect” him or her from future elevated lead levels.

  And looking over our study design, he questioned one aspect: the time frame. We had a comparison of levels before and after the water switch. While we used the same number of months, we didn’t use the exact same months of the year. And that was a problem. Water-lead levels are affected by heat and the seasons of the year. Lead in water peaks when the outside temperature is higher. That’s why you’re never supposed to use hot water from your tap.

  What? Crap. Of course seasonality was a factor. While I wrestled with anxiety from the possibility that I could have gotten other things wrong, Jenny and I moved quickly. We were facing another do-over. But what would have been a painstaking, time-consuming, and months-long endeavor just five or ten years ago was a pretty quick undertaking. Due to advances in statistics software and algorithms for sorting and analyzing data, she was able to run the new study and send me the new numbers while I was sitting at a lecture at the MIAAP conference.

  I thought we had it right this time—we controlled for seasons, and we used the highest lead level if a child had more than one.

  I looked over the results. The number of elevated blood-lead levels was still higher after the water switch—markedly higher.

  It was clear.

  We had the proof we’d been looking for: kids were being harmed every day, with every sip of water they drank, with every bottle of formula.

  I forwarded the preliminary results to Marc.

  FROM: Mona Hanna-Attisha

  TO: Marc Edwards

  SENT: Friday, September 18, 2015, 11:51 A.M.

  SUBJECT: Prelim results—confidential

  FYI

  We changed pre and post dates to remove seasonal impact and we used highest lead for duplicate leads.

  EBL* % for kids less than 5

  2.1% pre vs 4.0% post - p=0.024

  We will soon break down to the higher risk zip codes where you saw higher water-lead levels.

  * Elevated Blood Levels

  Marc responded immediately:

  I’m ashamed for my profession.

  Marc would say those words many times in the coming weeks and months. He took the responsibilities of his engineering profession seriously and personally. Just as I knew, without any doubt, that pediatricians are entrusted with the health and welfare of children above all, Marc saw the main responsibility of water treatment experts—whether they worked at a utility, a city treatment plant, a state health department, a university, or the EPA—as providing safe drinking water, one of the central foundations of any society, from the humblest prehistoric settlement to modern nations. For him, what was happening in Flint wasn’t just a Flint problem. It tarred his entire profession.

  * * *

  —

  DURING A BREAK BETWEEN LECTURES, Dr. Reynolds found me—and we walked out to a corridor to take a call from the Flint state senator, Jim Ananich, who had heard news of my research.

  “Talk to Dr. Mona,” Dr. Reynolds said to Senator Ananich. “She’s the pediatrician doing the study.” Then he turned his phone on speaker so we could do a mini-conference.

  “I just heard about the research you’re doing,” Senator Ananich said in a quiet, even tone. I didn’t really know him. He was a burly, bearded guy with a reputation for being bighearted and kind. He had grown up in Flint with Flint politics—his dad was a local city official who had died at a young age.

  “My staff has been prodding the state for more information about the water for months,” he said. After Marc Edwards released his findings, they’d tried harder but still never got anywhere. They were told that Edwards was a quack, that he had baggage and grudges. They were told he was scaring Flint with invented numbers.

  “I’ve met with him,” I said. “And his science is solid.”

  I could hear the frustration rising in Senator Ananich’s deep voice. “God, I am so sad to hear that. That’s all the kids in Flint need, right?”

  “I know.”

  “Can I ask a question about my new baby?”

  “Of course.”

  “What should we be feeding him?”

  “Breastfeeding is the best option,” I said.

  The senator responded with a long silence, then finally replied in a quieter voice, “That’s not possible.” He and his wife were foster parents and were now trying to adopt the baby, who was on formula. He also mentioned that the baby was stuffy with a cold.

  “Get the ready-made formula,” I told him. “It’s premixed with water. Or use only bottled water with the powdered formula. Use a humidifier for his cold—that will help with his congestion—but be sure to put bottled water in that too. Avoid anything coming out of the tap.”

  As Dr. Reynolds and I walked back to the conference, both of us were fuming. He turned to ask me a question. “Have you heard about the concept of environmental injustice?”

  I nodded. “Of course. I studied with Professor Bunyan Bryant.”

  More than twenty years ago, back when I was a tree-hugging environmentalist at the University of Michigan’s School of Natural Resources and Environment, the legendary Bunyan Bryant was one of my early mentors. He was a pioneer of the environmental justice (EJ) movement—a movement that looked at environmental and public health issues through the lens of place, race, and poverty. Bryant was a Flint native—with family still there—and focused much of his research and advocacy on the city and its long history of polluting poor and brown neighborhoods. Bryant had even fought lead pollution in Flint decades ago, when a plant that burned lead-painted wood chips was built in a predominantly African-American neighborhood.

  As an undergrad, I took courses, listened to lectures, and participated in workshops led by Bryant and other EJ academic groundbreakers like his colleague Paul Mohai. Bryant’s work showed me how racial minorities and low-income communities faced a disproportionate share of environmental and public health burdens.

  Sitting in those EJ classes, I began to see that the environmental disparities I’d first witnessed in high school weren’t random. The dirty incinerator we had fought so hard wasn’t in Grosse Pointe or Birmingham, affluent suburbs. It was in Madison Heights, one of the poorer communities in our county. Bryant backed up his many examples of environmental injustice with hard-core research, showing how industrial waste, incinerators, trash dumps, and chemical plants were often located in neighborhoods where residents had fewer resources to fight them.

  Informed by these lessons, I dove into service learning, fieldwork, social justice organizing, and environmental health research. On one spring break, I went to maquiladoras in Mexico, where many of the auto jobs that had fled Michigan went—and saw that they were now troubled by the same pollution, poverty, and labor issues that pockmarked our history in Flint.

  Bryant’s work stayed with me as I went off to study medicine and public health—and, eventually, when I came to work in Flint. He wa
s on my mind now more than ever. In lectures, Bryant had specifically called out the persistence of lead in paint and paint dust in black and brown and poor communities as a form of “environmental racism.”

  Bryant wasn’t one to dwell on the problems. A central tenet of EJ is that local communities must have control over their environments—and decide whether a pipeline gets a permit, or a wind turbine gets built instead of a natural gas plant. When people have a say, smarter decisions are made—both for the environment and for public health.

  “Our Flint kids,” I said to Dr. Reynolds, “already have higher rates of lead exposure—just like kids in Detroit, Chicago, Baltimore, and Philadelphia. And now on top of all that, they’ve got lead in their water to worry about.”

  Lead shifts down the entire bell curve of intelligence, as Dr. Reynolds and I knew, not only adding more people with severely reduced intellectual capacity but also reducing the number of exceptionally gifted people. We knew that lead is more prevalent in poor and minority communities, and thus lead exposure exacerbates our horrible trends in inequality and the too-wide racial education gap. We knew that if you were going to put something in a population to keep people down for generations to come, it would be lead.

  “Environmental injustice,” Dr. Reynolds said, shaking his head in disgust.

  “I know,” I said. “Some things don’t change.”

  OUR GOAL WAS NOW CLEAR: GET a health advisory issued and alert the public. Kirk Smith at the health coalition knew the system and he knew how to work it. And he knew that the first email should go out to Howard Croft, the director of public works in Flint. I didn’t know Croft. Honestly, I didn’t even know there was a public works department or what it did. But on Thursday, after our meeting, Kirk began drafting an email to him, saying there was concern that children in Flint had elevated blood-lead levels and urgent action was required.

  Croft replied at 3:50 A.M.—the middle of the night, or early morning, depending on how you look at it. It was a truly remarkable demonstration of cover-your-ass and cluelessness all at the same time.