Concern about lead exposure in her pediatric patients thrust Mona Hanna-Attisha, MD, director of the pediatric residency program at Hurley Medical Center in Flint, Michigan, into the eye of a growing public health scandal surrounding lead contamination in Flint’s water supply.
In January, President Obama declared a federal state of emergency in Flint to help the municipality grapple with drinking water contamination. The announcement drew national attention to a crisis that began in April 2014, when a state-appointed emergency manager switched Flint from Lake Huron water supplied by Detroit to water from the Flint River, according to the state of Michigan. Soon after, residents complained of discolored or foul-smelling water.
In August 2015, a team of Virginia Tech researchers led by Marc Edwards, PhD, found that the river water was corroding Flint’s water pipes, risking the possibility of lead leaching into the water (http://bit.ly/1OzD5ED). When Edwards and his colleagues tested water samples from Flint homes, they found that 40% of samples contained lead levels more than 5 parts per billion, and the 90th percentile of homes were above 25 parts per billion (http://bit.ly/1ZgkMco). Some homes exceeded 100 parts per billion, suggesting many were well above the World Health Organization’s lead limit for safe drinking water of 10 parts per billion (http://bit.ly/1nTPUB3).
The public health implications of Flint’s contaminated water became apparent when Hanna-Attisha, also a professor of pediatrics at the Michigan State University College of Human Medicine, and her colleagues tested children’s blood lead levels. At the Hurley Medical Center, elevated lead levels doubled from about 2.4% to 4.9% after the changeover to Flint River water (Hanna-Attisha M et al. Am J Public Health. 2016;106:283-290. ).
Though the city switched back to Detroit water in October 2015, concerns about water safety continue. More than 80 cases of Legionnaires’ disease, including 10 deaths, have been reported between 2014 and 2015. These cases haven’t been causally linked to the water supply, but the Virginia Tech researchers say that corrosive pipes could have led to bacterial growth and water contamination (http://bit.ly/1SHex0y). According to the researchers, the corrosion that occurred in Flint could promote Legionella growth (http://bit.ly/1m1Mzyd).
Hanna-Attisha spoke recently with JAMA about this ongoing public health emergency. The following is an edited version of that conversation.
JAMA:What raised your suspicions about lead exposure levels among Flint children?
Dr Hanna-Attisha:We were hearing about elevated levels of lead in the water, from the Virginia Tech group. When pediatricians hear about lead anywhere [we are concerned]. We know the consequences of lead. That mobilized us to do the research to see if the lead in the water was getting into the bodies of children.
JAMA:How high were the elevated blood levels you detected in the children?
Dr Hanna-Attisha:It ranged all over the place from 0 to 40 μg/dL. But it doesn’t really matter how high because there is no safe level. What matters is that we saw an increase. We have done such a great job decreasing lead exposures that every year the percentage of lead poisoning goes down in our nation, in our state, and even in our city.
We got lead out of paint and out of gasoline. We learned so much about lead’s neurotoxicity. We know that lead has a multigenerational impact. In mothers exposed to lead, you can see [epigenetic] changes in their grandchildren. That is why there is no safe level of lead.
JAMA:What are the health consequences at this level?
Dr Hanna-Attisha:A child with [low-level] lead poisoning presents with nothing [no overt clinical symptoms]. That’s why we screen for it. We are mandated by Medicaid to screen children at the ages of 1 or 2. So a [lead-exposed] kid now is physically and developmentally fine. But the consequences of lead exposure are forever. It [has long-term] impacts [on] cognition and behavior: those are the 2 we care about most. It affects every organ system. It drops IQ. Imagine what we have done to our entire population: we have shifted the IQ curve down. It impacts behavior, so it causes lots of problems with learning, focusing, conduct disorder, impulse disorder, and it has even been linked to criminality. Lead has these life-damning consequences.
JAMA:What about children who are not currently testing high, but who have been exposed?
Dr Hanna-Attisha:Lead has a short half-life in your blood, just 20 to 30 days. This exposure has been going on for almost 2 years. Even our research and the state data underestimate the exposure because we screen all children age 1 and 2. That is when children have hand-to-mouth behavior. It is when they are at risk of household lead exposure.
Lead in water affects a different and even more developmentally vulnerable population. It affects unborn children and babies on formula. That baby’s blood level could have peaked at 3 months, 4 months, or 5 months, and when we screen that child at 1 or 2, it is no longer elevated. But the neurotoxicity has already happened [even though there may be no overt signs]. Anyone who lived in Flint from April 2014 until now, who drank or cooked with this water, has been exposed. Cooking actually concentrates lead in the water, and we’ve had 3 boil advisories because of high bacteria levels in our water.
JAMA:What was your reaction to the state initially insisting your analysis was wrong?
Dr Hanna-Attisha:As a physician-researcher, you believe your data. You do it the right way; you check and triple check. The numbers didn’t lie. But when the state with a team of 50 epidemiologists and an arsenal of resources tells you are wrong, it’s hard not to second-guess yourself. However, that lasted only a couple hours. We quickly [showed] why they were wrong. Actually, their data were showing the same thing as ours.
JAMA:What was the reaction from your colleagues?
Dr Hanna-Attisha:The bright spot is everybody had my back. I’m on the board of the Michigan Chapter of the American Academy of Pediatrics. The greater Flint health community, the Genesee County Medical Society: everybody was behind me.
I have a background in environmental health, a master’s in public health and health policy. I’ve done research. I know the community. Eventually, the state knew this wasn’t a quack. This was somebody who might have real information to share. My institution was also very supportive. Even though we are city-chartered and we get state funding and this was politically messy, there was never a question that we had to do what was best for the community.
JAMA:How does this added lead factor into the health challenges already facing the children of Flint?
Dr Hanna-Attisha:Our population was already rattled with toxic stresses. We have a 40% poverty rate, high rates of unemployment, high rates of violence, and high rates of single parents. We have no grocery stores in Flint. The people in Flint have a 20-year lower life expectancy than people in a neighboring suburb. We were already struggling with every barrier to our children’s success. Then we gave them lead. This is added toxic stress to the toxic stresses we already had.
JAMA:How will the new Pediatric Public Health Initiative help?
Dr Hanna-Attisha:It gives us the opportunity to do something. These kids did nothing wrong. We have to intervene now, or in 10 or 20 years they will become statistics of lead poisoning. We have a unique opportunity to create a model public health program. That is our focus right now.
In January, Michigan State University and Hurley Children’s Hospital announced the initiative. I’ll be leading it, and we will bring in a team of experts—epidemiologists, toxicologists, environmental health specialists, nutritionists, developmental assessment folks, child psychologists, and geographers. We are working with the community to do 3 things: to continue our research on the assessment of this exposure, to do long-term neurodevelopment epidemiologic follow-up with these children, and to intervene.
JAMA:What are some examples of the interventions?
Dr Hanna-Attisha:Giving these kids early literacy programs, universal preschool, and school health services. We had a preexisting poor nutritional status and poor breastfeeding rates that made this worse. So we are supporting programs that bolster nutrition. Kids need long-term developmental follow-up. So driving kids to their medical homes, building robust mental health services… it is all of these wraparound things we can do for our children that will hopefully mitigate—we can’t reverse—but mitigate the impact of the exposure.
JAMA:What has been the reaction of parents to this crisis?
Dr Hanna-Attisha:Parents are traumatized. For almost 2 years, we were betrayed. There is a huge lack of trust in the government and a fear of the unknown. What we do best as pediatricians is reassurance. We tell the parents: not every kid is going to have every problem. Love them. Read to them. Sing to them. Put them in preschool. Give them [nutritious] food. We give them the practical tools to make sure their children succeed.
JAMA:Are there other possible health threats with the water?
Dr Hanna-Attisha:At the onset, there were bacteria in the water. Then they dumped a lot of chlorine in the water. Then we had 9 months where we had safe drinking water violations with elevated levels of trihalomethanes, a byproduct of chlorine. It’s a long-term carcinogen that can also cause maternal-fetal complications. This water was terrible. It was a toxic soup, but lead by far is the most damning.
JAMA:Is the water safe now?
Dr Hanna-Attisha:The 18 months we were on this corrosive water and did not have corrosion control damaged our infrastructure. The protective seal of corrosion control is gone. It’s like drinking through a lead-painted straw: you never know when that piece of scale will come off into the water. It takes time to get the [corrosion control protection] optimized, and hopefully the damage is not so bad. They are definitely looking into replacing the lead plumbing.
This has national implications. Communities have not invested in their infrastructure. There is lead plumbing throughout the nation. As we have done such a good job decreasing lead from other sources, lead in water will be an increasing source of child lead exposure.
JAMA:What do you think is the state’s responsibility going forward?
Dr Hanna-Attisha:There is a lot of responsibility because the city had lost control of its governance and was under the control of a state-appointed emergency manager. There is state responsibility. There is federal responsibility. Everyone needs to be responsible for this. I’m working with the state and everybody to get the kids the resources that they need.
JAMA:What advice would you have for other physicians taking on a whistle-blower role?
Dr Hanna-Attisha:This is our job. This is why we went to medical school—to help people. As we progress through medical school and training, we get jaded. We focus on reimbursement and EMRs [electronic medical records], and we lose focus of what we are called to do.
It’s even more of a calling as pediatricians. Kids can’t vote. They can’t tell you, give me immunizations. They can’t tell you they need a car seat or better gun control. It’s our job to be their voice, even more so in communities that are voiceless and underserved. I think pediatricians no longer think they are credible in their communities. [But] this change [in the state and federal response to Flint water contamination] happened because of physicians, not because of public health or other community voices.
Moms were complaining. Activists were complaining. Pastors were complaining. The water experts were complaining. But it took the voice of physicians to make change. Physicians need to realize their powerful role in communities, to do good for their communities.