What the Eyes Don't See

by Mona Hanna-Attisha

  I learned that in the last 150 years, there have been numerous water contaminations—random, seemingly one-time special events in a number of U.S. cities—Chicago, New York, and D.C. In the 1890s there was a crisis in my birthplace, Sheffield, England, when the “softness” of the water caused lead contamination. Thereafter the pregnant women of Sheffield began miscarrying, which later led to the invention of a lead-based abortion pill.

  In recent times, water in the United States was supposed to be protected by the Lead and Copper Rule (LCR), first issued in 1991 as part of the Safe Drinking Water Act. But as I was beginning to see, the LCR was grossly inadequate and lagged behind the curve of scientific discovery. There are an estimated six to ten million lead service lines in the country—many of them in older, low-income, minority-populated urban areas. And there are millions more fixtures with lead. The LCR did not require that these lead service lines or fixtures be systematically replaced. Studies done in the last decade have shown how crucial it is to protect developing children from any lead exposure whatsoever, but the LCR still did not deal in any way with lead exposure in daycare facilities and schools that get their water from a public water system. The action level the Safe Drinking Water Act settled on—15 ppb—does not make any sense. It was created with water utility companies in mind—and what was economically feasible for them—rather than the best protection of children.

  Why wasn’t there massive public education about lead in water? Why didn’t the D.C. crisis result in more public debate? And how come pregnant moms are not routinely advised to use water filters, to flush their pipes regularly, and to use only cold tap water for cooking or drinking, as warm water concentrates lead? I couldn’t help but suspect that just as Kettering and Kehoe and the lead industry had won the public relations and public health war decades ago, the water utilities were winning now. Despite the well-documented history and science of lead in water, the issue remained underground and out of sight. And yet unlike any other form of lead exposure, lead in water impacts a much younger and much more developmentally vulnerable age group. Even more insidious than lead in paint, lead in water—colorless, odorless, and invisible—is meant for ingesting. In my most cynical moments, I had to wonder if the water utilities wanted the focus to remain on lead paint. Divide and distract—and conquer. It was a tactic taken straight from the Lead Industries Association’s playbook.

  Back in my training at Children’s Hospital of Michigan in Detroit, we spent time in an outpatient clinic where kids with lead poisoning came for follow-up exams. And in the hospital itself, children were often admitted with lead levels so high that they needed full-time care and treatment. As a resident, I diagnosed and treated those kids. Kids admitted to the hospital for lead poisoning are never discharged until elaborate histories and physicals are done to determine the source of exposure.

  Abdominal X-rays are ordered to detect paint chips in the gut. If they are found, they’re flushed out. Nutritionists are consulted to assess dietary intake. If children who have an empty stomach or are deficient in certain nutrients are exposed to lead, their bodies will absorb more of it.

  Social workers are consulted and home inspections are done, particularly for the presence of lead paint. If it is found, the home will be cleaned, and lead will be eradicated or painted over before the child is returned home. And in cases where we couldn’t find the source of lead exposure, we dug deeper. We looked at lead contamination in herbal remedies, imported makeup (kohl eyeliner), parents’ hobbies or employment (stained glass, gun shops), and imported toys.

  We never checked the water.

  How many kids did I miss?

  The eyes don’t see what the mind doesn’t know.

  * * *

  —

  WHEN I WAS WORKING in Detroit, I cared for an African-American boy, Javonne, who had been shot with a bullet that was designed to fragment in the body in order to cause maximum damage. He was seven at the time, brought to the ER in critical condition, and he underwent extensive surgery, including a colostomy. The surgeons tried to remove all the bullet pieces, but it was impossible to get them all.

  When I met him, several years later, Javonne was thin and lethargic. He was ten—uninterested in eating and doing poorly in school. His lead levels were still climbing. The few remaining bullet fragments were continuing to release lead into his body. So he was sent back to surgery, and more fragments were found and removed.

  My memory of Javonne stayed strong in my mind. Years passed, and I still remembered his stoicism and hesitant smile. I thought about everything he’d been through, largely preventable, all the toxic stresses: violence, fear, bullet wounds, hospital visits, surgeries, and PTSD, and then the effects of lead poisoning. For many people, life isn’t long enough to recover from a childhood like that.

  ELIN MAY HAVE BEEN VEXED ABOUT Marc Edwards and his reputation for trouble, but for the last two days, since his water findings were released on September 8, my gut had been telling me that I should get in touch with him. He was a scientist who had worked on the front lines of the worst lead crisis in history—one that had been covered up by authorities for years. He knew what being stonewalled was like. We couldn’t let that happen in Flint.

  But every time I mentioned reaching out, Elin became anxious. She kept saying it was risky. I kept thinking, My God, he’s a scientist, not Hannibal Lecter. How dangerous could he be? On the morning of September 10, after Jenny and I reviewed the results showing a rise in lead levels, and Brad Wurfel was all over MLive attacking the Virginia Tech team and calling them irresponsible, I nagged Elin into submission. The Hurley clinic’s blood-lead results were way too sensitive to share with anybody—I was too nervous to even email the results to Elin—but I felt emboldened and confident. We were on to something big. It was time to start laying new groundwork.

  Elin emailed Edwards and his team, using the addresses listed on his Flint Water Study website. She thought it was much better if she played go-between, so if things became dicey, and Edwards became difficult, I would not be implicated. Besides, Elin had her own reasons to be in touch with him: she was an alum of Virginia Tech, an environmental engineer—and a water expert herself. The fact that she had never met Edwards personally didn’t matter. She knew of him. Everyone in the water world did.

  That morning she wrote to Edwards and his assistant, a graduate student named Siddhartha Roy, saying that she had a friend, a doctor, who was looking at blood-lead levels in Flint and was designing a study.

  Edwards replied right away:

  FROM: Marc Edwards

  TO: Elin Betanzo; Siddhartha Roy

  SENT: Thursday, September 10, 2015, 9:44 A.M.

  SUBJECT: RE: Flint—Blood Lead Level data

  Hi Elin,

  Excellent. The information I think she should know is that there are three time periods of interest. Obviously, before the switch to Flint water. Then, after the Flint River water was introduced, lead did not rise immediately. While we cannot be sure exactly how fast it rose and when, it was starting to become a problem by late 2014 for sure. But it became a much bigger problem by February 2015 to the present. As a rough linear estimate of the risk for each time period based on the data I reviewed, I would guess that Detroit water is a 5, Flint from the switch to late 2014 is a 10, and Flint from early 2015 to present is a 25.

  The other thing is that unlike lead paint, the risk from lead in water is highest in children under age 15 months, and is especially high for infants drinking formula. The normal blood-lead monitoring program is concentrated on children with the highest lead paint risks. So to the extent she has data for the at-risk children under age 15 months, they should focus on that if they want to find the true health impacts.

  Marc

  I was impressed. He was worried about the littlest kids. In the afternoon, when my name was included on an email exchange that Elin had started with Sid an
d Edwards, I couldn’t stop myself and just jumped in.

  FROM: Mona Hanna-Attisha

  TO: Elin Betanzo; Sid Roy; Marc Edwards

  SENT: Thursday, September 10, 2015, 2:56 P.M.

  SUBJECT: RE: Flint—Blood Lead Level data

  Thank you all for the below info! We are currently analyzing the blood-lead levels of our patients. We routinely do blood-lead levels at both the one-year and two-year well child visits for all kids. We see the largest number of Medicaid kids in the county—and yes we are focusing on the infants in the attached zip codes and comparing those levels from the pre-switch period to the most current period. We hope to have some analysis back in the next day or so. FYI we still have quite a few kids with chipping paint issues and retained bullets that cause elevated leads.

  I also explained to him our difficulty in getting the larger sample from the county and state and closed with:

  Mr. Edwards, I understand that you will be in Flint next week. Let me know if you have any free time—would love to meet and discuss more.

  Thanks!

  Elin was horrified and back-channeled me immediately: What are you doing? But in less than five minutes, Edwards replied.

  FROM: Marc Edwards

  TO: Mona Hanna-Attisha; Elin Betanzo; Sid Roy

  SENT: Thursday, September 10, 2015, 3:00 P.M.

  SUBJECT: RE: Flint—Blood Lead Level data

  Great. Two weeks ago I submitted a formal research request on blood-lead records, to the health department, for the records in Detroit, Flint, and Genesee County. If I get it will let you know.

  Yes, Sid and I will be coming up, and we have some availability on Tuesday afternoon. Is there a time that works for you? Maybe we could do lunch?

  Marc

  So Edwards was going after the same data—and hadn’t gotten anywhere either. And he accepted my invite. A lunch date! My heart was pounding as I responded. We quickly settled on a place and time to meet. Elin continued back-channeling me with warnings. But I needed to meet this guy, see him face-to-face, to figure out whether he was trustworthy and legit. Whenever I pictured him, in my mind he was wearing the panda necktie. I couldn’t help but smile. He must be brave to wear something like that.

  * * *

  —

  JENNY AND I WERE talking every hour and emailing and texting throughout the day about the research we were trying to design. Every hour or two, I’d have a new thought about the study—and how to make it as accurate as possible. Impatient, I would jump out of our text exchanges and, unable to type as quickly as I could talk, just call her. “Jenny, I’m so sorry to bother you, but…”

  The study had to be perfect, otherwise it would be tossed out and dismissed or else cause unnecessary alarm in a city that was facing too many challenges already. We kept improvising our way through trial and error to get it as tight as possible, based on every idea and piece of information that came our way—there were new developments and twists every few hours. Jenny and I talked between meetings, while composing other emails, while driving, while walking, while in the grocery store, and while she was breastfeeding. When we couldn’t speak, we texted. We made plans to work over the weekend, getting the IRB application ready and preparing to run the data. It was a short period of time to design such an important study, but we didn’t have a choice. Every day mattered.

  Of course, the rest of life didn’t vanish while I obsessed over our study. The stiffness and pain had returned to Elliott’s right shoulder and were possibly even worse. He was still unable to sleep, drive, or return to work. He’d even given up trying to lift the heavy lid of his beloved Kamado grill. And when the girls had soccer practice, the job fell to me—which was the case on this evening.

  I’d missed a few games already—and my absence was noticed. This was a dramatic change from the previous year, when I was the assistant coach for Nina’s team, a job that I was qualified for because for a couple of years in high school I’d been a goalie (and a terrible one) and because I knew the girls’ names. This year, thankfully, another dad stepped in who truly knew the sport.

  The practice was at a local high school—it was practically in Elin’s backyard. So before leaving for the field, I printed out the clinic blood results, thinking that I’d swing by her home and show them to Elin in person. It seemed too sensitive to email. I hadn’t even wanted to go over the results on the phone. I stood by the printer and waited for the pages to come out, then put them inside an envelope and dropped it into my bag.

  I did my best to track down and gather up all the assorted soccer gear the girls would need. (In a future lifetime, I’d like to invent an all-in-one soccer cleat, shin guard, and sock combo that also functions as a water bottle.) Elin texted that she was going to meet me at the high school field instead and bring her eight-year-old son, Vincent, who had a crush on one of the girls on Layla’s team.

  As soon as I arrived at the high school, there was another text waiting from Elin, a sweet picture of her daughter Gabriella standing by the front door in a pink ballet leotard and tutu. It was one of those mom-to-mom moments, old friend to old friend, that grounded me. I’ve known Gabriella since she was born. I am one of her godmothers, in fact. Seeing her smiley young face was just the tonic I needed.

  ELIN: What field are you on?

  ME: 3

  ELIN: Coming

  As the kids were scrambling onto the grass, learning how to pay attention and kick the ball, and the other moms on the sidelines were talking about piano lessons, school recess dramas, and homework struggles, Elin and I stood at the intersection of many fields with folding soccer goals set up. Hundreds of little kids were running around, kicking balls, cheering.

  I looked around nervously, as though that awful Brad Wurfel might suddenly appear at any moment and hit us with a demoralizing quip.

  Then I pulled the printout from my bag and handed it to Elin.

  I watched her closely as she read—and waited for her reaction.

  * * *

  —

  MOST OF MY PROFESSIONAL LIFE is pretty predictable—to me, at least. Clinics, meetings, presentations, red tape, trainings, and lots of talking with faculty and residents and patients. It’s the life of a doctor, the life of a healthcare professional, the life of an educator. But now it was becoming something else—the life of a renegade and detective. And standing there on Field 3, with our backs to the kids, huddled like two spies, my life was suddenly beginning to feel like an episode of Scandal.

  I’m not much of a TV person. I don’t have time—and we don’t even have cable at home. But Elliott and I had just binge-watched all the past episodes of Scandal, getting ready for the new season that was supposed to start later that month. I love the main character, the fixer, Olivia Pope, and how strong, smart, and beautiful she is. And I love how, in each episode, problems arise and go deeper and darker and more wide-reaching than first imagined. But then, in every episode, a solution is found. Just as in an episode of Scandal, the deeper I dug into the Flint water issue, the darker it got. I was hoping the scriptwriters had a bang-up solution coming.

  Elin finally looked up from the printout—and grabbed me.

  She was too stunned to speak.

  Back at Kimball High in the environmental club, we had wanted so passionately to save the planet, to right wrongs, to make a difference. That seemed so long ago. As the years passed, in our own quiet and methodical ways, step by step, we pointed ourselves in that direction, always tried to do good work and to make a difference. We stayed activists in college, and in our careers, but accomplishments in the adult world turned out to be harder to achieve and far less exciting than our wide-eyed, swashbuckling teenage activism. The problems we found now were mired in complexity, and victories were faded by trade-offs. So far very little of it had felt as good as keeping the incinerator in Madison Heights shut down, organizing a
Greenpeace conference, or protesting a nuclear storage facility adjacent to the Great Lakes.

  But in that moment, as we stood on the sidelines of Field 3 and looked at the clinic results, I think we both realized that all our calls, emails, texts, and strategizing of the past two weeks had been for something. Something important.

  Elin is usually pretty reserved, not a screamer or crier, but her reaction now—her hand squeezing my arm tightly—was as demonstrative as I’d seen her since those old days.

  “Numbers don’t lie,” I said.

  “No, they don’t.”

  “Flint kids are being poisoned.” All my rage and sadness returning, I became so upset that tears welled up in my eyes.

  Elin nodded. I could see she was angry too, enough to cry with me. It wasn’t just about Flint. It was also about D.C. and all the things she’d seen there, the negligence and butt-covering, the wrongful actions by people in positions of public trust. She had been living with what she knew—and maybe even with a sense of guilt for having been at the EPA while the crisis was unfolding but not doing more about it.

  “What are you going to do?” she asked me.

  “I don’t know,” I said, thinking for a second. “I can’t share this—not with anyone. Not yet. I need more data, a bigger sample. I’m working on that. I don’t want to get it wrong and blow my chance.”