What the Eyes Don't See

by Mona Hanna-Attisha

  But protecting his neighborhood—and his own reputation—wasn’t enough for Snow. His passion for science led him to try to uncover how cholera is transmitted, to prevent more outbreaks in the future. So he set about proving his theory, teaming up with Henry Whitehead, a young clergyman from another local church who believed the miasma theory. Working parallel tracks, they conducted parallel investigations and the two men created a “ghost map” where each black square or bar (later modified to dots) represented a cholera case in London. The map demonstrated an undeniable and predictable pattern: the black squares appeared in clusters close to the Broad Street water pump. Some black squares showed cholera victims who lived farther away, but Snow was able to prove they’d consumed the water from the Broad Street pump too.

  SNOW AND WHITEHEAD’S NEIGHBORHOOD MAP

  If it weren’t for Snow’s science, stubbornness, persistence, and passion for the truth, cholera might have raged on for another decade or more, taking thousands or even millions of lives. When I think about Snow and his accomplishment, what has always grabbed me most—and impressed me—is the way he insinuated himself into the epidemic. Nobody hired or paid him—or even asked him—to solve this epidemic. But he had a crucial tool at his disposal, epidemiology, and a problem right in front of him, in his own neighborhood, and that was enough for him to get started. He didn’t stop his research after the pump handle was removed. He kept going, kept pushing, kept researching to prove his theory and leave a lasting contribution. As a citizen and physician, he felt duty bound to share his work and make a difference, to prevent future epidemics and save lives.

  It may have been his humble background that drove him. He never blamed the less fortunate for their predicaments; instead, he understood and studied the way that their environment—whether it was poor light or lack of running water—contributed to their condition.

  Rather than standing on the sidelines, Snow got passionately involved. His work wasn’t about abstract scientific discovery alone. It was about people and community. That’s what science is supposed to be about—not an academic exercise for the ivory tower, or racking up publications, grants, and offers of tenure. It’s about using the tools and technology available to make lives better, no matter what articles of faith obstruct the path.

  Speaking science to power, Snow was a disrupter of the status quo, not for disruption’s sake alone, but for people. Snow was so far ahead of his time, his work wasn’t totally vindicated until years after his own premature death.

  * * *

  —

  I LOVE STORIES ABOUT people who can—simply by being persistent, methodical, and dedicated—change the trajectory of a life or even an entire population and generations to come. And what I love in particular is a good, engrossing public health mystery, perhaps because I have one in my family. The person at the center of it isn’t famous like John Snow, but a distant cousin of mine, a bacteriologist named Paul Shekwana. He was one of the first public health scientists from the Middle East, from present-day Iraq, to work in America. He was a “bacteriologist” back in 1904, which is—I’m pretty sure—what we would call a microbiologist, epidemiologist, or infectious disease expert today. After studying at the Royal College of Physicians and Surgeons in England—where he worked on sewage and water testing for bacteria and might have even traded water samples with John Snow—he was hired in 1904 by the department of pathology at George Washington University in D.C.

  DR. PAUL SHEKWANA, MY DISTANT COUSIN, 1904

  Almost immediately after he got to America, he was called to Iowa City, where a deadly outbreak of typhoid fever had struck. Shekwana was brought in to work with the Iowa State Board of Health bacteriology lab—an entire floor of the new Iowa City Medical Building was given over to his lab team. There Shekwana investigated, among other things, the tie between unpasteurized milk and typhoid. But he didn’t stop there; he promoted new public health regulations in Iowa and beyond.

  His most important contribution may have been an article published in the New York Medical Society Journal in 1906 (which was excerpted in the Journal of the American Medical Association), urging all doctors to wash and disinfect their hands throughout the day, particularly before and after seeing patients. It’s almost impossible to imagine how much this simple practice improved patient care, prevented the spread of infection, and saved lives, lots of them. But even so, hand-washing rates in hospitals still have to be monitored and have much room for improvement. According to a recent review, as many as one million lives could be saved worldwide each year if more people washed their hands.

  From typhoid fever to hand hygiene, Shekwana was a roving public health warrior throughout the Midwest. His comings and goings were regularly reported by the Iowa City Press-Citizen and the Iowa City Daily Press, as well as newspapers in other cities that he visited. He wrote articles about sanitation, food safety, and even drinking water. Amazingly, my family has a letter in which Shekwana urges residents not to use a certain well because of the “variations in quality” of the water.

  Hopefully the eerie similarities between his career and mine don’t include an untimely and mysterious death. In the summer of 1906, Shekwana announced he was returning to England—there is no record of why—and resigned his position at the Iowa State lab. One afternoon before he left, he went fishing and walked back home along a railway trestle outside Cedar Rapids. He was found below the trestle—having leaped to his death or been thrown there by an oncoming train. A broken rib had pierced his lungs. He died hours later. The conductor of the train that may have killed him claimed he wasn’t able to stop soon enough to avoid hitting Shekwana, nor did Shekwana try to step away. An investigation was conducted. There was no proof that the train hit Shekwana, who, it was suggested, may have killed himself.

  One hundred years later, the mayor of Iowa City honored him with an official proclamation for his work in public health. Was he murdered? Was it a suicide? The Paul Shekwana story has mesmerized my family for years. At the time, his friends and colleagues described him as cheerful and excited about returning to England. Perhaps he had a love interest they never knew about. Perhaps his heart was broken. Or maybe he had caused too much trouble with all his bad news about germs, the spread of infectious disease, and water quality. As with all things, there is so much more to know.

  * * *

  —

  SNOW’S AND SHEKWANA’S DAY, so different from our time, is best captured by Charles Dickens, who as a novelist was also a social critic and child advocate. His eyes wide open to the dark alleys of the industrial revolution, Dickens captured the gross inequities of his time and always kept the most innocent at the center of his stories.

  “In the little world in which children have their existence,” he wrote in Great Expectations (1861), “there is nothing so finely perceived and so finely felt, as injustice. It may be only small injustice that the child can be exposed to; but the child is small, and its world is small.” The feelings of children are as vulnerable as their health. And the injustices of Dickens’s time played out over a lifetime. In 1842 the average life span of an upper-class “gentleman” in London was forty-five years, the average tradesman lived to be twenty-five, and an average member of the working poor died at sixteen. Among the recorded deaths of the same year, 62 percent were children under the age of five.

  Urban poverty is less lethal now, but in some respects, nothing has really changed. The environments of the cities we live in—their dirt and air, their violence and hopelessness and stress, their water—can still predict how long a life we will have. What we ingest or experience or inhale will make a difference to our health—literally the number of minutes allotted us to live. The small boy in Dickens’s novel may feel injustices keenly and remember them for the rest of his days, but so does his body. It carries the injustice forward with him, always.

  * * *

  —

 
; AFTER MY MEETING WITH the powerless county health guy, I had a full day of work. It was a Thursday, which meant that I was supervising the residents who saw patients that afternoon. My phone kept pinging and buzzing throughout the morning as Elin and I exchanged texts and emails. Our night of talking had sent her into a dark tunnel, reliving her experiences in D.C. It was like she was suffering from Drinking Water Crisis PTSD.

  She asked how my meeting went, and I quickly texted back my plan B: I was going to follow up with the Genesee County health officer and medical director. The pattern of mistakes was already becoming clear to me. It was like we were reenacting the error of Edwin Chadwick’s mission to clean up London’s air by draining all the human waste into the drinking water of the Thames. But in this case, the mistake had been made in an attempt to save not lives but dollars.

  As our exchanges went on, Elin and I started to finish each other’s sentences in a mash-up of guilt and fury.

  ME: It’s an ignorance-is-bliss system

  ELIN: Too expensive to replace the lead service lines

  ME: But everyone thinks their tap water is safe

  ELIN: The system is supposed to work

  ME: But it doesn’t

  * * *

  —

  LATER THAT SAME DAY, August 27, I sent my email to the county health guy and copied in a bunch of his bosses, including Mark Valacak, the county health director. I explained that even though the water might not be under the health department’s jurisdiction (“however, I don’t understand why it wouldn’t be”), I was concerned about the potential for an increase in childhood lead poisoning from Flint’s drinking water.

  “This is strikingly similar to what happened in Washington, D.C.,” I wrote—a crisis that had “resulted in significant childhood lead poisonings.”

  I urged them to collaborate with me to stop what could be another crisis. Our children were already dealing with so much, every measurable health disparity. Adding avoidable lead exposure to their burden was unconscionable. Just to make sure they paid attention, I attached a link to Curt Guyette’s scary Deadline Detroit article.

  Poisoning is poisoning. I couldn’t imagine how the county health department could turn a blind eye, or even a partially blind eye, to the situation simply because of bureaucratic walls and red tape. This wasn’t the kind of issue where you can shrug and pass the buck. We were literally talking about the systematic poisoning of our children.

  “What about the lead levels of kids?” I asked in my email. “Have you noticed any changes?”

  Then I forwarded the email to Elin, who responded with more news from the water front.

  Marc Edwards, the corrosion expert from Virginia Tech and warrior scientist of the D.C. crisis, had come to Flint. He had been invited by both LeeAnne Walters and Miguel Del Toral and was collaborating with homeowners on something he called “citizen testing.” Just that day, he had posted new numbers on his Flint Water Study website. Scrolling down the numbers, I was upset to see that the citizen testing had found very high levels of lead in the water.

  One sample, collected after forty-five seconds of flushing, exceeded 1,000 ppb—sixty-five times the federal action level of 15 ppb. The numbers were frightening.

  Almost immediately, the spokesperson for MDEQ, Brad Wurfel, a confident, smooth-talking, square-faced corporate type (who happened to be married to the governor’s spokesperson, which somehow gave him more credibility), began pushing back very hard. “Flint drinking water meets state and federal safe drinking water standards,” Wurfel said.

  This didn’t bode well. Marc Edwards was a world expert on pipe corrosion and recipient of a “genius grant” for his visionary work and doggedness. As a scientist, he had been willing to stake his own retirement money to save kids from lead poisoning when the D.C. utility, the D.C. government, the EPA, and the CDC all denied there was a problem. Was MDEQ really going to totally dismiss his findings?

  Wow. It took my breath away.

  Brad Wurfel was just a PR guy, a mouthpiece, not the brains behind these audaciously wrongheaded remarks. I wondered about the people he worked for. How can anybody who knows about lead not be concerned?

  “WHAT’S GOING ON AT MDEQ?” I wrote to Elin.

  It seemed like lunacy to deny water test results like these. But Elin predicted more problems to come. Based on her experience in D.C., she felt things would get much worse before they could get better—or drag on for years and never reach clear resolution.

  In my mind, it wasn’t a coincidence that D.C. and Flint are both places, in different ways, that lack adequate political representation—places where democracy is far from complete. Flint had been taken over by the governor’s emergency manager, but at least the residents could still vote, in Senate and House elections, for politicians who—if we could get them to pay attention—would represent them. D.C. was a different story. Even though D.C. is more populous than half the states in the union, it has no representation in Congress. The people of D.C. cannot fight battles the way people elsewhere can.

  In Flint, with an unelected emergency manager in charge, the citizens experienced a similar disconnect and powerlessness. Layers of accountability and responsibility had been stripped away.

  Politics is about how we treat one another, how we sustain and share our common spaces and our environment. When people are excluded from politics, they have no say in the common space, no sharing of common resources. People may think of this as benign neglect, but it isn’t benign. It is malignant—and intentional.

  Elin had another concern: Marc Edwards. The fact that he was sampling water in Flint meant something serious was going on, but his involvement could also make things more complicated. He had a reputation in the water world for making scenes and grabbing headlines. “He sometimes uses inflammatory methods to get attention,” Elin said. “People mock him for that, but I think they are afraid of him too.”

  I noted her alarm, but felt like we had more to be afraid of than an eccentric water genius. We were alone in Flint, left behind, and maybe even targeted. We needed every ally we could get.

  * * *

  —

  I AM ALWAYS HAPPIEST on Thursday afternoons. Finally free of my crazy meeting schedule, my calendar grid, and my paperwork, I can do what I love more than anything: see kids.

  The end of summer is always busy in pediatrics. We’re flooded with back-to-school physicals. That afternoon the pediatric residents were bouncing from one exam room to the next, trying to stay on schedule while still getting used to the routine of our new clinic.

  Allison, my resident, saw the first patient, Brandon, an active eight-year-old white boy, and shared his case with me. Brandon’s mom, a thin young woman with short hair and arm tattoos, was concerned that he couldn’t sit still. She said her son’s school, where he’d been going for three years, had been shut down last spring—a consequence of starved budgets and population loss. In a couple of weeks, Brandon would be starting a new school, an event that is definitely stressful for any kid. I tried to soothe his new-school nerves with a few comments about second grade and the stuff he was going to be learning.

  “It’s going to be fun! You’ll meet new people, make new friends, and I’m sure a lot of your old classmates will be going there too.”

  Brandon looked at me skeptically. He couldn’t hide his feelings, another thing I love about kids: it was clear he was anxious. His mom continued to describe his difficulties. His summer school teacher said he was a “space cadet.” Even at home, he was fidgety, had trouble focusing and paying attention. Allison and I dug into possible explanations: new-school nerves, summer boredom, a hearing issue? I looked in his chart. Last year, his school physical made no mention of hyperactivity. I found myself wondering about the water.

  “Do you live in Flint?” I asked him.

  “Yes.”

  “Have you been drinking the tap
water?”

  “Yes.”

  Ughhh. We always see a lot of kids with ADHD, but lead exposure can increase its likelihood. Maybe Brandon was going to have ADHD no matter what—it has so many causes. We gave Brandon’s mom the questionnaire to complete for ADHD screening and asked her to bring Brandon back in two weeks. Allison ordered a blood-lead test. Before they left, I asked Allison to go back into their exam room and recommend bottled water to Brandon’s mom. Allison shot me a perplexed look but followed instructions.

  With another resident, I saw Chanel, a twelve-year-old white girl with a plump and slightly flushed face. Four years ago she was diagnosed with obesity and pre-diabetes. In the last year, her mom had died young of a heart attack—after years of being overweight with high blood pressure—and Chanel’s effort to lose weight became much more serious. Besides a back-to-school exam, she was in the clinic for a weight check.

  After the medical assistant weighed Chanel, I looked over her records on the computer and saw she had lost ten pounds in the last six months.

  “Way to go, Chanel!” I called out, and raised my hand for a fist bump.

  She beamed, a bright sunrise of a smile breaking on her face.

  “How’d you do that?” I asked. “So awesome! Did you cut back on sugary drinks and pop?” We had talked about that at her last visit—most of her caloric intake had been from sugar in drinks.

  Chanel nodded, feeling proud. And then her dad chimed in that they were both drinking more water.

  More water.

  Of course they were drinking more water.

  It was something we recommended to all our patients. Flint, like many communities, was in the midst of a childhood obesity epidemic. Soda and juices don’t help, which is why there are national campaigns encouraging more water.