What the Eyes Don't See

by Mona Hanna-Attisha

  Holding my breath, I asked, “Are you drinking Flint tap water?”

  “Yes. Eight glasses a day!”

  My heart sank. When I mentioned there were concerns about the water, Chanel’s dad said, “But they say everything’s okay.”

  “Yes”—I nodded—“but to be extra safe, you should switch to bottled water.” Then, trying to pivot to a positive note, I applauded Chanel for her hard work and gave her another fist bump. I ordered another blood-lead level test.

  A few exam rooms down, Allison and I saw Jasmine, a grumpy fifteen-month-old black toddler who had pretty serious eczema. Her mom said it got worse after bathing. That didn’t necessarily mean anything—almost all rashes get worse after bathing. And we have so many kids with eczema. The atopic triad of eczema, allergies, and asthma runs in families, is more prevalent in inner cities—and is worsened by a variety of environmental conditions.

  When I asked where they lived and if they were on Flint water, Jasmine’s mom said they were. Sometimes, she said, the water smelled like a bottle of bleach. I prescribed hydrocortisone cream for the rough spots to calm down the inflammation, lots of moisturizing ointment to help it heal, oral medicine to limit her itching—and no more baths in Flint water.

  “How am I supposed to bathe her?” Jasmine’s mom asked.

  “What about using bottled water?” I offered.

  Jasmine’s mom just stared at me, until it became almost uncomfortable. “You want me to bathe her in bottled water?”

  She had a point, and I scrambled to think of better advice, something—anything. “Is there someone you know who lives outside of Flint where you can give Jasmine a bath?”

  Her mom shook her head. “We don’t have a car,” she said.

  I was running out of ideas. Bathing a child is not supposed to be this complicated. And it was getting hard to stay calm.

  Without taking a moment to breathe, I next went to see Nevaeh, a child with one of my favorite names—it’s heaven backward. She was a three-day-old black newborn who was coming to the clinic for her first checkup. Immediately I saw that I had a chance to get on my soapbox about breastfeeding—and gave it with added urgency. But that was a lost cause. Nevaeh’s mom had made up her mind and was already giving her baby formula. The hospital had sent her home with a short supply of premixed formula. Knowing that she’d likely switch to the powdered version soon, I tracked down an extra case of the ready-to-feed formula and sent it home with her. Then I said, “And when you are finished with this, be sure to mix her powdered formula with bottled water.”

  Usually my afternoons in the clinic are a tonic, a chance to forget my own woes and worries and hang out with Flint kids—to provoke smiles and laughs, to chart the kids’ growth, and to make their parents, grandparents, and caregivers less anxious. But that day, as the afternoon wore on, my frustration continued to build. Patient after patient seemed to be dealing with some kind of water-related issue.

  In the teaching space, where the doctors type up their notes and talk to their supervisors, I asked everyone I could find—medical students, residents, and other supervising physicians who were in clinic more than I was—about the water. Were they seeing kids whose blood-lead screenings were coming back elevated?

  They were. One physician’s assistant said she’d gotten back a level of 7 μg/dl just the week before, from a one-year-old boy. Follow-up interviews with the family didn’t produce any answers. They couldn’t figure out the source of the lead.

  “Actually, siblings we just saw two days ago had levels of 14 and 22 μg/dl,” a resident told me. “We are just about to call the family to bring them back in.”

  “Keep me posted,” I told her. “Be sure to ask if they’re drinking Flint water.”

  I kept thinking about the difference between individual health and population health—treating one patient versus treating many. A doctor might see an individual child with an elevated blood-lead level, but it would take a study of many patients—a population—to figure out what was happening to all the kids. If one doctor alone could see all the Flint kids, maybe that doctor could start to make helpful connections. But with so many doctors in our clinic, and throughout the city at other clinics, that connection couldn’t happen. Each doctor might see a few higher-than-usual lead results, but they wouldn’t be able to see it as an epidemic on their own. This is why training in public health is so critical for all physicians. We need to be able to step back from the individual patient and look at the bigger picture.

  What the eyes don’t see. That is precisely why public health surveillance programs are crucial. They regularly monitor population-wide trends that individual doctors can’t detect on their own—whether it is the flu, HIV, cancer, or blood-lead levels. This is what government public health people are charged to do. It is an invaluable way of discovering paradigms. It’s Epidemiology 101. John Snow taught us this.

  But even when lead exposure is demonstrated across a population, it is almost impossible to prove causation. Did lead in the water cause Brandon’s ADHD? We will never know for sure. Did the water cause Jasmine’s rash? Maybe. Exposure to environmental toxins usually doesn’t come with glaring symptoms, like purple spots or even a rash. The symptoms are things like learning disabilities that have a time lag. Sometimes they don’t show themselves for years or even decades. For a pediatrician on the front lines, often the most you can hope for is establishing a correlation.

  The more I thought about it, the angrier I got.

  Before leaving the clinic, I went digging online again and discovered a couple of things about the water switch in Flint. First, in October 2014, just six months after the switch, General Motors stopped using the water at its engine plant. The company got a waiver to go back to the Lake Huron water as its source. “You don’t want the higher chloride water (to result in) corrosion,” the GM spokesperson said. “We noticed it some time ago.”

  If the water was corroding metal engine parts, what was it doing to the ancient lead pipes under the city? This happened almost a year ago, but mysteriously no alarms bells were ringing. I texted Elin with the link to the story.

  ME: See this?

  ELIN: Didn’t know—wow.

  ME: Those bastards

  ELIN: You never swear

  ME: Maybe I do now

  ELIN: How was this allowed?

  ME: GM knew the water was bad. GM screws Flint again.

  My second discovery was more idiocy from MDEQ and their spokesperson, Wurfel. Just a month before, when Curt Guyette’s stories for the ACLU about the leaked EPA memo broke, Wurfel had responded with this statement: “Let me start here. Anyone who is concerned about lead in the drinking water in Flint can relax.”

  The man was a menace. If I could remove his microphone, the way John Snow got the Broad Street pump handle removed, I thought of all the people I could help.

  Relax?

  Does anyone relax when they are told to relax?

  Has that ever worked?

  Someone should do a study.

  THE LAST DAYS OF AUGUST ARE sleepy for most people, the final breath of summer before school starts and regular life returns. But there was no settling down for me.

  There were some complications at home that were going to make those last days more difficult for me. Elliott was not better. He was still in pain, despite spending the last five days in a new Dynasplint that was supposed to help but didn’t. A follow-up appointment with his orthopedist gave him worse news: he might need a second surgery.

  Both my parents were traveling. My dad was in Yantai, China, working on a project meant to improve the metal quality in Chinese automotive parts—a consulting gig he had taken after retirement and loved. He was also indulging in his other passion: researching how our religious ancestors, the Nestorians, branched into China in the seventh century. He wrote excitedly to Mark and me saying that he’d made arrangements to s
ee a Nestorian stele from A.D. 635. The carved stone was inscribed in both Chinese and Aramaic, the ancient but dying language still spoken by Chaldeans, the language Jesus spoke. Honestly, it was hard to respond enthusiastically about such an esoteric passion—it all seemed so old and so dead—but I did my best. And since my dad makes a PowerPoint about virtually anything he’s up to, I wrote back quickly: “Can’t wait to see your presentation.”

  Meanwhile my mom was in D.C., helping out Mark and his two boys for a week while my sister-in-law was working on a conservation project to improve national parks in Patagonia. Without Bebe, my childcare support system was on a narrow tightrope. Skull Island was over, and the girls had nothing to do. That alone wasn’t a problem. In the life of an overscheduled, privileged child, a little do-nothing time can be great. But it was difficult for Elliott alone to fill the void left by Bebe. He wasn’t supposed to drive. It was hard enough for him just to sleep through the night.

  Monday came: August 31, 2015. I woke early and sat alone in the kitchen drinking coffee while everyone slept. The house was quiet. I was waiting for a response from the county health authorities. I was sure it would come. Over the weekend, there had been more water stories in the news. My mind couldn’t let go. Elin’s stories about D.C. were frightening, but I couldn’t see something like that happening here, not to my kids in Flint.

  These are responsible folks, I told myself. Why would anybody go into public health if they didn’t care deeply about something this important? The weekend hadn’t even been a “long” one. And wasn’t toxic water more important than playing golf or mowing the lawn?

  I set down my iPad and stared at the screen. The workweek had begun.

  I imagined all the health folks arriving at their offices. Sitting down at their desks. Scrolling through their in-boxes. Surely I’d hear from somebody. Any second now, they’ll write me back.

  Any second now, I’d hear from them. Any second. Any second.

  I changed the notification and alert settings of my phone so it would beep with every new email and text. All day I carried it around with me from room to room. It made the minutes pass even more slowly and painfully.

  On my way to work, I had called my mom in D.C. to check in. She immediately jumped into questions about logistics for the week—who was filling in for her, who was picking up whom, when, where. She asked what I was making for dinner. “Are you ready for soccer?” she asked, unconvinced that I knew where the cleats, uniforms, and shin guards were put away. And she was right, I didn’t.

  My mom is amazing, but sometimes, despite being happily married, professionally successful, and intellectually stimulated, I have the feeling that I will never meet her expectations.

  “I have a lot going on,” I said, and quickly changed the subject. I made a note to find the cleats.

  The hours dragged by.

  Monday had come and gone.

  Not a word.

  * * *

  —

  THAT NIGHT I SLEPT FITFULLY—almost not at all. I could tell from his restless shuffling that Elliott was also uncomfortably awake. At some point around two in the morning, I looked over in the dark, and our insomniac eyes met.

  “Are you awake?” he said softly.

  “Yes.”

  “Are you going to tell me what’s going on at work?”

  I sighed.

  “What is it?”

  “It’s bad, Nunu. Really bad. I think my kids in Flint are in danger. Nobody seems to care.”

  “It can’t be that bad. What is it?”

  “You heard about the complaints about the Flint water?”

  “Yeah, sorta.”

  “It’s real. And it’s bad.”

  “How bad?”

  “Lead-in-the-water bad. Leaching from the old pipes. The Flint River water is corrosive—and apparently no anticorrosive treatments were used.”

  “For how long?”

  “Months. Maybe eighteen months.”

  Elliott was silent, the kind of silence that meant his heart was breaking. But his wheels were also turning. For the last five years, he had worked directly inside Detroit schools, practicing in mobile health clinics—vans—seeing an array of inner-city kids. So he knew the health issues that came along with poverty. And he knew how interconnected a child’s environment, education, and health are—and how poverty brings innumerable toxic stresses that compound anything you’re treating, whether it’s asthma, allergies, diabetes, or lead exposure.

  “This is all Flint kids, right?” he said finally.

  “Yes, all the kids.”

  “So unbelievably sad.”

  “I know.”

  I rolled over in bed and felt tears coming. The beauty of being married to another pediatrician is how little we have to explain. But Elliott being Elliott, and me being me, we tend to fall quickly into brainstorming and debate about practicalities and solutions, rather than indulging our feelings. We spent the next few minutes trying to look into the future—to see what a population-wide lead exposure in Flint could mean, specifically for the kids.

  Elliott wanted to know exactly how the government was dealing with it.

  “That’s just it. Nobody’s dealing with it. Nobody’s even answering my emails.”

  He could hear the despair in my voice. “You’re the most stubborn person I know. Keep at it.”

  I’m definitely hardheaded, maybe persistent, and kind of competitive, but I’m not sure I’m stubborn.

  Elliott knew the obstacles I was facing. Working in Detroit, he had been frustrated when he tried to make headway in treating kids with asthma. An asthmatic himself, an inhaler always in his pocket, he knew how disruptive the disease can be. Kids with asthma were missing school and falling behind. They needed doctors. They needed to be properly diagnosed—which isn’t as simple as that sounds. And after diagnosis, they needed treatment: medication.

  But for lots of different reasons, including transportation problems, the kids who needed a doctor the most had the least access to one. Detroit’s once-great public transit system had collapsed, and roughly 25 percent of homes in the Motor City lack a vehicle. Just getting to a pharmacy to pick up medication could be impossible.

  In the late-night conversations that Elliott and I had at the time, our brainstorming sessions, we always tried to be creative and look for unexpected solutions. Elliott eventually came up with an idea for how to overcome obstacles to asthma treatment—to team up with hospital pharmacists to get medication delivered directly to kids at their schools.

  “You will think of a way forward. You always do.”

  “I hope so. I have to.” I sighed.

  We said nothing for a while, both of us trying to drift off to sleep.

  Then he spoke again, as if he couldn’t stay silent. “Remember, you’re the most stubborn person I know.”

  “No, I’m not.”

  “Yes, you are.”

  “No, I’m not.”

  * * *

  —

  IT WAS TUESDAY, SEPTEMBER 1. It had been four days since I sent my email to the county health people. I got to my office early that morning. As soon as I got settled at my desk, I wrote to Elin:

  FROM: Mona Hanna-Attisha

  TO: Elin Betanzo

  SENT: Tuesday, September 1, 2015, 8:43 A.M.

  Do you have the exact date the water switch happened?

  I’ll try to get a report run on our patients’ lead levels done before and after.

  I knew the switch happened in April 2014, but I needed the exact date. I’m sure I could have googled it, but I liked keeping Elin in the loop. I liked having my old friend beside me, and I could tell she found our collaboration gratifying.

  At Hurley, we routinely took blood samples and tested every child on Medicaid for lead—or at least we were supposed to. We d
id it only for high-risk populations—kids on Medicaid, kids in older homes, kids who had parents with lead-related hobbies.

  Years ago the CDC recommended that all kids have their lead levels tested, but the public health victory that got lead out of gas and paint—and caused rates of lead exposure to go down steadily—also caused the recommendations to relax. That should never have happened. Because just as the CDC relaxed its recommendations, new research revealed that even the smallest levels of lead in a child’s blood were more damaging than we ever thought possible. We should have been doing more screening, not less.

  And the blood-lead screening rates, even in Flint, were low. As in Detroit, many kids had trouble getting to their regular pediatrician due to an array of poverty-induced obstacles, from inadequate transportation to complicated childcare arrangements. I have Flint patients who’ve never left the city limits; they’ve gone only as far as the unreliable and limited bus line allows.

  Even so, Hurley had the screening data for children treated at our clinic, and it wouldn’t be that hard to get it, thanks to our sleek electronic medical record (EMR) system. In 2011 we started using Epic, the Cadillac of EMR software, and being the early-adopter tech dork that I am—the first one I knew to buy a PalmPilot, even though I had no one to use it with—I had taken the training and fooled around with the system’s cool features.

  But our clinic data is part of an even larger pool of blood-lead data that includes most of the children in the county: the Michigan health department’s surveillance program, the Childhood Lead Poisoning Prevention Program, collects, tracks, and reports children’s lead levels. Unluckily, the only way I could get those numbers, I thought, was through the county health department.

  It was time to follow up with them again. “Hope all is well,” I wrote in an email that morning. “I’m not sure if you saw today’s article on MLive regarding the extreme corrosivity of Flint Water.”