What the Eyes Don't See_A Story of Crisis, Resistance, and Hope in an American City

by Mona Hanna-Attisha

  Edwards and Dean Dean had had heated exchanges about Lansing’s lead service lines, and publicly traded letters to the editor. But ultimately Virg Bernero and Edwards won the battle and put in a plan to get Lansing’s lead pipes replaced. It took a decade, but Lansing is now the only city in the country besides Madison to have replaced all its lead service lines. And that was only sixty miles from Flint. In 2010 Virg Bernero ran against Snyder for governor and obviously lost. But what if he hadn’t? I couldn’t help but think that the Flint water switch never would have happened.

  “This is Dean Sienko, from Michigan State University’s public health program,” I said to Edwards and Sid. Edwards leaned in and nodded blankly, not making the connection to the battles in Lansing. He was nice enough, pleasant but a little awkward, perhaps uncomfortable or just untrusting. He was focused on Flint now anyway. He was pessimistic when describing the press conference and how little he felt he’d accomplished.

  When I mentioned fixing things and making a difference and trying to get everyone positive and motivated, his fixed stare cried out, Get real! or What sunshine have you been drinking? “This kind of thing takes a long time,” he said more than once while shaking his head. “I’d be surprised if anything we do makes a difference.” He expressed such a strong distrust of government—the state, the federal players like the EPA and the CDC—that it shocked me. He seemed bitter and wounded—and angry.

  I could feel the weight of his baggage almost instantly. The doctor in me wanted to heal him, to calm him, to take the pain away. If only I had something in my doctor’s bag that could help.

  Dean Dean, on the other hand, sat quietly, pleasantly, and just listened. I tried to guess what he was thinking but couldn’t. We ordered lunch and I got my usual, a veggie melt on pumpernickel, which I doused with the Cholula Hot Sauce that was on the table. I was a vegetarian in college and throughout medical school—not really for health reasons; I just didn’t want to eat anything that had to be killed. But eventually I had caved and consumed the occasional piece of chicken or seafood to please Elliott’s mom, Mama Jeeba, a prodigious cook who puts meat in basically every dish she makes. It felt rude, and kind of selfish, not to.

  The restaurant was busy, full of noise and distraction. We all leaned forward to hear one another, so we wouldn’t have to talk so loudly that we could be overheard. Edwards said the lack of MDEQ oversight violated both the Safe Drinking Water Act and the Lead and Copper Rule. He was pretty sure of that. He explained that after the D.C. crisis in the early 2000s, new regulations had been put into place, ensuring that anytime a water source is switched, significant sampling needs to be done before and after. This didn’t happen in Flint. Instead, the agency was gaming the system and sampling in a way to get the results it wanted. It was unclear why federal rules had not been followed, he said, but they should have been.

  “Why isn’t the EPA taking over from MDEQ?” I asked Edwards.

  “The way the law is written, MDEQ is in charge,” he explained. “It’s called primacy.”

  I half-remembered that word, primacy, from my environmental policy classes at the University of Michigan. It had to do with how much control states were given in enforcing federal environmental protection laws. It had come up in recent conversations with Elin, but with so many other things to learn about water, I hadn’t asked for clarification.

  “The EPA gives state environmental departments a pretty wide latitude,” Edwards continued, “and often defers to them, even when it shouldn’t. I would argue, given all we know, that the EPA has the authority to take over now from MDEQ, but it probably won’t.”

  “Why not?” I studied his face for signs of where he would go next, but he was hard to read.

  “My experience is,” he replied, “the EPA and the states work hand in hand to bury problems. EPA rarely challenges the states.”

  I had feared that but hated hearing it.

  Edwards went on to explain the water science to us, easily going from small but important details to the big picture. The Flint River’s water was innately corrosive, he said, which presented a lot of challenges that the city didn’t have the capacity to handle, in terms of personnel or expertise. He knew of a similarly corrosive water supply in Maryland, where even a staff of thirty water engineers couldn’t manage to control it properly. Compare that with Flint, where only one half-time person had worked on the city water prior to the switch. Supposedly more people were working at the treatment plant now, but still not enough.

  The water from Detroit, which is Great Lakes water, was less corrosive, but even it was treated with corrosion control. Edwards felt that until Flint was restored to treated Detroit water, its old source, its tap water would remain dangerous.

  Plates of food came, and nobody ate. I suspected I wasn’t the only one with a big knot in my stomach, and my knot got tighter every time Edwards spoke. The water in our glasses still sat undisturbed. It was too sad to even make a joke about.

  We leaned in closer and tighter, trying to hear and be heard. I think we were trying to decide if we trusted one another. I had to marvel at how different Edwards and I were, basically opposites. He is a tall, older white guy who looks like his ancestors came over on the Mayflower. I’m short and brown, an immigrant from a country that the United States has basically been at war with for three decades. He resided in a place that was in the heart of the Confederacy. I lived so far north, it was practically Canada. He talked skeptically of government, while I believe in government’s capacity to help people—and even to remedy historic wrongs and injustices.

  But we shared so many things too—a fierce love of good government, transparency, ethics, and integrity in science, and most important of all, an abiding, almost debilitating concern for children. We were allies. The way I cared about our kids in Flint, he cared about kids everywhere. And he knew they were in danger. He could see colossal lead-in-water problems in cities all over the country. And he could see that they weren’t being addressed.

  Trust. For me, it took only a few minutes to develop. Edwards’s philosophy was not just about righting wrongs—it was broader and bigger. He was a deeply moral person. And he wouldn’t be a bystander to injustice. He was in Flint because he took it as his duty. Solving a public health crisis should have been the business of the people we’d empowered and entrusted and funded with our tax dollars to keep our air and food and water supplies safe—and not left to an out-of-state engineering professor or a pediatric residency director. But for Edwards, it wasn’t a choice.

  He and Elin started talking about water engineering stuff. It was water geek jargon, almost incomprehensible to me. I understand medicine and science, but the technical engineering lingo is slightly out of my comfort zone. Percentage of water leaks, types of corrosion inhibitors, disinfectant by-products…

  I kept peering into my bag, looking down at the copy of my clinic results, the preliminary numbers. I wanted so badly to show him—or tell him. I thought about Jenny—would she have been able to resist this moment? I looked at Elin, who knew what I had in my bag. As did Dean Dean.

  But rather than say anything, I asked a hypothetical: “What if someone looked at the blood-lead levels and saw an increase after the water switch? Would that make a difference?”

  Without a pause, he spoke with total confidence. “That would be a game changer.”

  Elin and Dean Dean and I shared a look.

  I tried to catch my breath, while Marc—because he was Marc to me now, not Professor Edwards—began talking again about how the most vulnerable children are babies on formula, because it is most often mixed with tap water.

  The proper ratio of powder to water is one scoop for every two ounces of water. But some new moms found it confusing and diluted the formula with too much water, sometimes on purpose, hoping to make it last a little longer. Watery formula can result in poor growth, low sodium, and sometimes even seizu
res. Now, on top of those concerns, in Flint at least, adding more water also increased an infant’s exposure to lead.

  There were ready-to-feed formula options, something I mentioned to Marc, who seemed very interested and asked for more information. He was an incredible listener, always leaning in closer. I explained that the ready-to-feed formula came in bottles and was already mixed—no water needed—but it was also more expensive and not usually covered by federal food programs for the poor.

  This got us brainstorming. Was there a way to get the ready-to-feed formula to Flint babies? We talked about getting a waiver from the USDA to give out ready-to-feed formula at the clinic. Elin mentioned that she might try Representative Kildee’s office for help with that.

  As the lunch was coming to an end, and totally out of the blue, in sort of a non sequitur, Marc blurted out the words “I trust you” to me. He hadn’t been sure he could when we first set up the meeting. He assumed we were cut from the same cloth as the other “public health folks” who’d undermined his work and kept lead in water for years. But to his surprise, he’d come to Steady Eddy’s and found allies.

  And I had a new friend.

  * * *

  —

  I RAN BACK UP TO CLINIC—sometimes I still can’t get over the fact that I work above a farmers’ market—and quickly sent an email to the folks who run the Genesee County Health Department’s Women, Infants, and Children (WIC) program, which provides pregnant moms and young kids with nutritional support. Could they help us get ready-to-feed formula? I thought of little Nakala, now on her fourth week of powdered formula. The clock was ticking, not just for her but for all the babies in Flint. If there was ever a time I wished we had more breastfeeding moms, it was now.

  “Babies who are drinking formula mixed with tap water (especially warm tap water) are at greatest risk for lead exposure,” I wrote. “Water is such a huge proportion of their diet and their brains are still developing. Until we have definitive information about lead exposure, we should err on additional prevention, especially for our most vulnerable kids.”

  I received a response that they were concerned, but “don’t have the means to provide either water or vouchers.” Angry, I texted Elin to see if she could follow up with Jordan in Kildee’s office, hoping he could pressure the USDA to provide ready-to-feed formula now. She did, and Jordan tried but was told that the USDA couldn’t do a waiver unless there was actually a health advisory or official emergency.

  So that was it: we were back in the Bizarro World of the Kehoe Rule, where we had to prove there was danger and harm before anything could be done. The onus was on us.

  I summarized my lunch meeting in a long email to Melany. Thanks to all my talks with Elin and now Marc, I felt like I had taken a crash graduate school course on lead and water. “We’re facing a disaster,” I wrote. “It could be seen a mile away, but now that it’s in our faces, we have to act, and soon.”

  Melany responded quickly. She thanked me for the recap and said she was already thinking about the next steps. Then she said the magic words.

  “I want us to be part of the solution.”

  * * *

  —

  THAT NIGHT AT HOME, Elliott was happy to hear how the meeting had gone—and how Melany had responded. After he fell asleep in the recliner in the corner, I opened my laptop. It was still September 15, after all. Even without Marc Edwards, the meetings, the emails, and the submission of the IRB application, it was one of the biggest days of the year for me.

  It was the day ERAS opened.

  ERAS is the Electronic Residency Application Service, which transmits medical student applications to prospective residency programs. So on September 15 we learn who has applied to become a resident at Hurley Medical Center. The fruit of all my work during the year ripens—and I can see who is applying to our program. Every year we want more and better applications. In recent years, since we had been working hard to upgrade the program, we were up to thirteen hundred or so applications per year. That number is whittled down to a list of two hundred applicants whom we invite for interviews to fill our seven slots.

  I’m the one who does the whittling. As soon as ERAS opens, I start searching for the best applicants. In order to get a running start, I try to read one hundred applications a day between September 15 and the end of the month.

  When I came to Hurley, the pediatric residency program was falling apart. Some unhappy residents were transferring out. Now with a revamped curriculum and several key hires—mostly women faculty—our morale was fantastic. Our residency theme song was taken from The Lego Movie: “Everything Is Awesome.” We were attracting a more competitive and diverse group of residents, ones who increasingly looked like our patients. They came from all over—caring, idealistic, and passionate new docs who wanted to change the world. And they wanted to live and work in Flint, which shows how dedicated they were. Lying in bed, I began reviewing applications, but it was hard to turn any of them down. I loved them all. How could I not?

  With my laptop open on my bed, I quickly fell asleep.

  * * *

  —

  THE NEXT DAY OUR IRB application was approved. We had submitted it on Tuesday, and it was approved on Wednesday, an unheard-of turnaround time. Hurley may not have dozens of NIH-funded researchers and an entire building dedicated solely to research, but we don’t have the sputtering and stalling bureaucracy that often comes with all that either. We are small and lean and responsive. Everyone knows everyone. And the credibility that Jenny and I had built over the years carried weight.

  “Mona,” Jenny teased me, “has anybody ever said no to you?” After two weeks of hearing “no” from everyone I spoke to, I could only laugh.

  WITH THE IRB APPROVAL LETTER IN hand, Jenny and I now could access the blood-lead levels obtained by other clinics and doctors in Flint—at least all the labs processed at Hurley.

  In a matter of minutes after we submitted our data request, at exactly 7:53 A.M. on September 17, 2015, our IT department sent us a full data set pulled from the Epic electronic medical records. We went from a sample size of about 350 to one of almost 2,000. Before EMRs, this kind of study would have taken months, possibly years. It would have been painstaking work, reviewing paper chart by paper chart by hand. An analysis still took time now, but getting the data itself took only minutes.

  I didn’t know what the exact results would be, but waiting wasn’t an option. About ten minutes after looking over the new data set, without permission or even any hesitation, I blasted out an email advisory to my residents and faculty at Hurley. My biggest concern was the babies, who were the most vulnerable. I sent out a set of instructions for the clinic to provide to all the moms, dads, and other caretakers:

  All,

  There has been a lot of news recently about the possibility of lead in the City of Flint water….

  Until more information is garnered, I think it would be best to take some precautions for our most vulnerable patients. Babies on formula consume a huge amount of water. So at your clinic visits and in the newborn nursery, please continue to recommend 1) breastfeeding! and 2) if using formula, do NOT mix with tap water and especially not with warm tap water.

  This was the best I could do for now. I knew I had to do something, even though no one at the state or county health department seemed particularly interested in the subject of lead in the water, or had done much to take action. Never mind that I was a lifelong progressive and believer in government—and was quickly losing faith. A sea of red tape lay between me and an official health advisory, which would hopefully free up resources and qualify the city for bottled water, filters, and other aid.

  For the hundredth time, I wondered: Is the official indifference because these are Flint kids? Poor kids? Black kids? Kids who already have every adversity in the world piled up against them?

  I was getting really mad. At times
I could feel myself physically shaking.

  * * *

  —

  LUCKILY, I HAD TWO meetings on my calendar that day. At the first one, I had a chance to see my old friend Kirk Smith, CEO of the Greater Flint Health Coalition (GFHC), which was leading a new community-based initiative called Children’s Healthcare Access Program (CHAP) to improve healthcare access and reduce medical costs for kids.

  I was on the planning committee of CHAP, which had just gotten funded by a grant from the United Way. Our meeting was to discuss implementation. United Way runs a program called 2-1-1, through which people can obtain free information and support for essential health and human services around the clock, via phone or website. It connects people in need with critical services that save lives and support health.

  But CHAP was going to take 2-1-1 a step further. Instead of just referring a child who needs a car seat to a resource, CHAP would then call that family back and make sure they got the car seat, and offer them transportation services, social work services, and enrollment in other eligible programs. But there were things to sort out. What should CHAP take on? Where should we start? We decided to pilot the program in the handful of pediatric clinics that see the most Medicaid kids in Flint. Hurley was number one on that list.

  Kirk ran the meeting skillfully, raising several concerns and ideas, while the rest of us—a couple of local pediatricians, a school nurse, an asthma management specialist, and health coalition staff—chimed in. We were joined by Dr. Reynolds, who was serving as the medical director for the program, a totally volunteer position, and Jamie Gaskin, the CEO of Genesee United Way, whom I had never met before.