What the Eyes Don't See

by Mona Hanna-Attisha

  Yes, Walling was the same mayor who had supported the switch to the Flint River and had even gone on TV to publicize it—smiling while he drank the water. But if he had made a mistake, or been misled by the EPA and MDEQ, I hoped he would be big enough to admit it and try to get ahead of a potential scandal by coming out in favor of a real solution. As a Democrat, he wasn’t in thrall to, or in the inner circle of, the Republican governor, Rick Snyder, whose administration’s take-no-prisoners budget cuts were behind the water switch. From what I could see, Walling was free to reach his own conclusions and confront the state with me. The governor may have usurped his power, but he was still an important voice in the city and had the moral and leadership power of the office to represent the people of Flint and do what he was supposed to do—serve the public. Also, he was a lifelong friend of Senator Jim Ananich—they had grown up in Flint together—and Kirk Smith had only good things to say about him. I kept replaying all these positive factors in my mind—all so real and clear to me—to buoy my hope.

  I wasn’t just hoping for the best—I expected it. But that didn’t mean I wasn’t nervous. A lot was riding on me now. Kirk, Senator Ananich, and Dr. Reynolds all believed in me—and they hadn’t even seen the data yet. My research and numbers had to be perfect, and so did my presentation. I wasn’t a politician, government official, or trained speaker, but I wasn’t afraid of the spotlight either. The days and nights I had spent in drama club back at Kimball High School were paying off.

  Part of any performance is selecting the right costume. My clothing choices were limited to the things in my closet that still fit me, but I wanted to wear a suit—and found one. I had purchased it years before, back when I was a medical student and doing residency interviews. Otherwise I rarely wore it or needed it. The reason is simple: whatever outfit I’m wearing is usually covered by my white coat. It’s the only thing anybody sees or remembers about me. But I rarely wore the white coat outside a medical setting. And our meeting with Mayor Walling was to be downtown, in the Mott Foundation building on Saginaw Street, where the Greater Flint Heath Coalition had its offices.

  * * *

  —

  THE CONFERENCE ROOM AT the health coalition seemed cavernous, as if it were waiting for twice as many people. About a dozen of us spread ourselves around the long oval table, and I sat down at the head, so I would be next to the screen for my presentation. Dayne Walling arrived with a perfect smile. He sat down next to me, greeted me in a warm and friendly way, and said he remembered my brother from college. Like any accomplished politician, he was great at eye contact and gave off a sense of decency, confidence, and acute interest in what he was about to learn.

  That same sense of openness—or even eye contact—was not happening directly across the table, where Natasha Henderson, the Flint city manager, and Howard Croft, the public works department head, were sitting. Without a word, they made known their feelings about the meeting immediately. Henderson, an über-professional woman, had been city manager for a couple of years already. Due to recent events, and the stepping down of the Flint EM, she arguably had more power than Mayor Walling—certainly more de jure power. She answered to nobody but the governor’s office.

  She was wearing her hair down, perfectly styled, and an elegant suit. She was confident and chilly when she entered the conference room with a very unenthusiastic greeting, then didn’t look at me, or smile, for the next ninety minutes. Croft seemed to care even less; his sleepiness and audible yawns communicated a total lack of interest in the meeting, if not downright disapproval.

  I was feeling anxious until Dr. Reynolds sat down to my right. His presence helped calm my rattled nerves. My resident Allison, who had just started my Community Pediatrics rotation, was on the other side of the mayor, sitting a little stiffly and uncomfortably between him and Senator Ananich, who was flanked by his chief of staff, Andy Leavitt. I gave Allison a warm and protective smile. I could tell she was nervous too—and would probably rather be working in the intensive care unit. Kirk was on the other side of them, which was great, because I could catch his eye and see his expression. A few physicians were scattered in other seats, including no-nonsense Pete Levine, the executive director of the Genesee County Medical Society.

  Jenny was at the far end of the table, directly across from me. Good old Jenny. It felt like she and I had gone over our numbers a million times. She came as my data backup, if I needed one.

  Before I’d arrived, Kirk had texted to tell me some stunning news. He’d held a board meeting for his health coalition earlier that morning, during which he announced that new data showed elevated levels of lead in Flint water. He had insisted that the community be informed. His health coalition board included Mark Valacak, the county health officer, who pushed back immediately when the Flint water was questioned. Valacak claimed it was in alignment with the Safe Drinking Water Act—and besides, no health advisory could be issued without a directive from MDEQ. When Kirk asked his board to vote on a resolution urging a health advisory, Valacak stayed silent, abstaining from casting a vote. The resolution passed without him.

  * * *

  —

  THE MEETING WITH THE MAYOR got under way after some awkward introductions, which included patching in Dean Dean on the speakerphone of his car. I began my formal presentation with an explanation that under normal circumstances, this kind of data would not be offered publicly until it was published in a peer-reviewed journal. But that usually took months, and we didn’t have months. The information was too urgent to sit on.

  With the laptop open before me and the screen behind me, I stood while the PowerPoint slides were projected onto the screen. The first slide showed these words in large boldfaced type—in red.

  PEDIATRIC LEAD EXPOSURE IN FLINT, MICHIGAN:

  A FAILURE OF PRIMARY PREVENTION

  My presentation was mostly science, data, and data analysis, so I started it with something human and real: a photograph of a little girl who looked just like little Reeva, one of our Hurley patients, when she was one year old. I described her as a baby who lived in Flint. To protect my patients’ privacy, she was a composite of several kids I knew. I named her Makayla, not an uncommon name in Flint.

  “Makayla lives with a single mom and two older siblings on the west side of the city. Every morning her mom wakes up and makes a warm bottle of formula for her. The powdered formula comes from WIC, and it’s mixed with warm tap water. Babies like warm bottles.

  “She has just come into the Hurley clinic for her one-year checkup. She is smiling, looks great, and seems robust. Her physical exam and development appear to be normal. She receives her one-year-old vaccines and routine lead and hemoglobin screening. A couple of days later her lead level comes back as 6 μg/dl. It’s elevated. There is no safe level, but 5 micrograms per deciliter (μg/dl) is the current reference level set by the CDC.”

  My next slide showed a quote from a 2012 report of the CDC Advisory Committee on Childhood Lead Poisoning Prevention: “Because no measurable level of blood lead is known to be without deleterious effects, and because once engendered, the effects appear to be irreversible in the absence of any other interventions, public health, environmental, and housing policies should encourage prevention of all exposure to lead.”

  I looked up at the faces around the oval table. Everybody was staring at the slides and listening intently. Even Howard Croft and Natasha Henderson were paying attention, although they had both perfected a look of politely enduring a pointless exercise. The mayor was writing in a notebook.

  “What will happen to Makayla?” I asked. I didn’t inflate or exaggerate the answer. Even a conservative estimate was scary enough. And just looking at the information on the screen made me angry, but I stayed pleasant—and tried to channel my passion and rage into just being as forceful as I could.

  “The vast evidence supports an increased likelihood of a decrease in IQ. Even a blood
level of 1 to 4 μg/dl—which is not yet considered above the reference level—drops the mean IQ by 3.7 points. This reduces the number of high achievers, or those with an IQ over 130, and increases the number with low IQ, at 70—shifting that bell-shaped curve to the left. This impacts not only life achievement expectations but special education services and employment prospects. This has drastic implications at the population level.

  “Elevated lead levels in childhood also increase the likelihood of ADHD behaviors, juvenile delinquency, and rates of arrests involving violent crimes.

  “In terms of health, it impacts almost all systems of the body, the hematologic, cardiovascular, immunologic, and endocrine.”

  The mood in the room shifted from intense interest to concern, even despair. Senator Ananich shook his head in disbelief. He was probably thinking about the foster baby at their home in Flint that he and his wife had fallen in love with—and were now hoping to adopt. Next to the state senator, Andy, his chief of staff, was grimacing—and huffing in frustration. His cheeks were turning redder and redder. Kirk also looked shaken.

  Dr. Reynolds was nodding in approval. He knew about the long-term effects of lead—he was an expert. I couldn’t see Mayor Walling’s face. He had stopped me twice for some clarifications, but now he was looking down at the table, perhaps morosely, maybe penitently, and still calmly taking notes.

  Then I got to the costs, because this was what the city, the county, the state, and the federal government would pay attention to. People listen to dollar signs. (Wasn’t that how we got into this mess?) You had to factor the number of children who had been exposed and make a forecast of costs. It was about probabilities and estimates, but that is how governments plan ahead and prepare. When there’s a hurricane, the estimates of economic cost begin almost instantly. When there’s a viral outbreak, the CDC and FEMA don’t just make survival plans and prevention strategies, they immediately begin determining what it’s going to cost to implement them.

  I quoted from the latest figures I could find, based on a 2011 Health Affairs report by Leonardo Trasande and Yinghua Liu, “Reducing the Staggering Costs of Environmental Disease in Children,” which estimated that in 2008 alone, $76.6 billion was spent on environmental diseases. “For childhood lead poisoning, it was $50.9 billion in lost economic productivity resulting from reduced cognitive potential.”

  Looking at costs to the state, I cited a report, “The Price of Pollution,” published by the Michigan Network for Children’s Environmental Health. Based on a 2009 study of a group of five-year-olds with household lead exposure—paint and paint dust, not water (because nobody had studied that yet)—it showed economic losses attributable to lead exposure ranging from $3.19 billion to $4.85 billion per year in future lifetime earnings.

  Now I got to the heart of the matter: water. I cited research showing that when lead was in drinking water, the greatest impact was on pregnant mothers and developmentally vulnerable formula-fed infants:

  For about 25% of infants drinking formula made from tap water at 10 ppb, blood lead would rise above the CDC level of concern of 5 μg/dl

  Increase in fetal death and reduced birth weights

  I brought it all home to the water in Flint. I referred to the work of Marc Edwards and his results from testing the Flint water. His team had provided three hundred water-testing kits to residents in specific wards or districts. Citizen participation had been incredible. A record number of those kits, 252, or 84 percent, had been mailed back to the Virginia Tech lab in Blacksburg.

  Then I went into my own research. I described the methodology and approach, how we had used data processed at Hurley Medical Center, received IRB approval for our research, and zeroed in on blood-lead levels of all children five years of age and younger in seven Flint zip codes.

  Two periods of study were compared: pre-switch blood-lead levels from January 1 to September 15, 2013, and post-switch levels during the same months of 2015. The sample used was 1,746 Flint children pre- and post-switch.

  Post-switch, the percentage of children with blood-lead elevation was almost double. I emphasized that this increase was contrary to every national and state trend. Elsewhere the percentage of kids with elevated lead levels had been coming down every year. Then I looked closely at water-lead levels in each zip code (based on Marc Edwards’s work), to prove a causal relationship. The zip codes with the highest water-lead levels saw the greatest increases in the percentage of children with elevated blood-lead levels. To show the dramatic contrast between Flint water pre- and post-switch, Jenny and I had created a few more graphs showing comparisons.

  Senator Ananich rocked forward in his seat, taking an audible deep breath. He was stunned. He leaned over to speak to Kirk and seemed distressed. His eyes were brimming with tears.

  Dr. Reynolds was nodding, his mouth tight, as if fire would come out if he opened it. The mayor looked concerned and was nodding too. Henderson was still going with her stony-faced thing, but for a second Howard Croft seemed to be caving—or maybe he was falling asleep. I couldn’t tell.

  I went on.

  The next slide compared Flint to the rest of Genesee County, where the water was the same as ever. This comparison made it clear that there was no statistically significant increase in elevated blood-lead levels in the rest of Genesee County—only in Flint.

  Next, I really wanted to bring home that my blood-lead results, although striking, underestimated the potential exposure. Medicaid mandated lead screenings at a child’s one- and two-year checkups, but that was way too late if you were worried about lead in water. “Infants are not screened for lead exposure,” I said, and “lead has a short window of detection in blood—a half-life of twenty-eight days.” Also, many children who are supposed to be screened never are.

  I reiterated the concept of primary prevention, our most basic obligation—to keep children away from sources of harm. “The moment when a child’s medical doctor learns of an exposure to this powerful toxin, it is too late. We grossly failed at primary prevention.”

  The next slide described next steps:

  Encourage breastfeeding

  No tap water for high-risk groups such as infants on formula and pregnant mothers

  Declare a health advisory

  Distribution of lead-clearing NSF-approved water filters

  Public education regarding precautions

  Reconnect to Lake Huron water source ASAP

  I ended my presentation with the photograph of the little girl I called Makayla. I figured if I didn’t get them with data, facts, and numbers, I could get them with emotion. Makayla looked at the camera with such trust and innocence. “She seems great now,” I said. “She’s smiling and looks perfectly healthy. But what will her future hold?” Leaving absolutely nothing on the table, I said, “And what does it hold for an entire generation of Flint children?”

  * * *

  —

  AS SOON AS I FINISHED, the mayor asked a few questions. He was polite and not defensive at all. He wanted clarification about a few things and seemed appropriately concerned. “I hope this is part of an awakening,” he said, “that Flint does have a lead problem, something I’ve been concerned about for years.”

  He continued on this note for a minute or two. Flint had even gotten an award for excellence in lead remediation, an achievement for which he felt responsible, and he was proud of it. But he was talking about lead paint and lead in the environment—he never actually said the word water. He referred to a public statement he had made just the week before that Flint would be “lead-free” by 2016. Huh? Now, having seen my presentation, he seemed excited that finally, finally, the rest of us were jumping on the lead-awareness bandwagon he’d been driving for years.

  I was confused.

  Andy looked noticeably disturbed. He leaned over to Jim and s
poke in his ear, what I was sure was a choice profanity. They both shook their heads.

  Dr. Reynolds jumped in to affirm the seriousness of the problem. That beautiful man is quite a talker, an epic rambler who goes on and on. That’s his style, and it works. The room was captivated. He spoke of a crisis. He said it was an emergency. I was a young pediatrician no one had heard of, but Dr. Reynolds was a famous face and name in the city.

  While he spoke, I looked discreetly around the table again, to see if this powerful soliloquy was shaking up the city officials.

  It also mattered that Dr. Reynolds is African American and lives in Flint, the eighth-largest “majority minority” city in the United States—57 percent black, 37 percent white, and 6 percent other, mostly Latino. The installment of the EM, even a black one, rather than an elected official to represent Flint, had been the last straw. Black Flint residents knew how the city had lured their great-grandparents and grandparents with promises of industry jobs and prosperity, and that they had often had to accept lowly jobs, crappy housing, and segregated neighborhoods while their white counterparts were offered management positions, home mortgages, and eventually the chance to flee Flint for a nice all-white suburb just outside the city limits.

  And then there was me, somewhere in the middle. I wasn’t black, and I wasn’t white either. I felt, as I often do, like an outsider, straddling but never completely or comfortably inside either world. My professional life now felt the same way: straddling. I work in Flint, and all my patients live here, and so do many of my pediatric residents, but I don’t live in Flint myself, so I worried that I wasn’t an entirely credible Flint voice. But Dr. Reynolds was. He exuded wisdom and credibility. And as pediatricians, we both had a professional obligation to speak up for kids.