This is exactly the sort of cover story you don't want to see about your city in TIME.

This is exactly the sort of cover story you don’t want to see about your city in TIME.

One aspect of science-based medicine that is not covered frequently on this blog, aside from vaccines and antivaccine pseudoscience, but perhaps should be, is the intersection of SBM and public health. Unfortunately, living as I do in southeast Michigan right now, I’ve been on the receiving end of an inescapable lesson in what happens when the government fails in its mission to enforce science-based public health issues. I’m referring, of course, to what has become known worldwide as the Flint water crisis. The Flint water crisis has become so famous that unfortunately it now has its very own Wikipedia page. That is not an “honor” I like to see for my state, and I’m sure the residents of Flint, which is an hour’s drive north of where I live, would agree. This crisis provides an unfortunate illustration of what can easily happen when multiple layers of government fail in a science-based public health task as basic as providing clean water to the citizens they ostensibly serve.

For those of you who haven’t heard of it yet, the Flint water crisis refers to the ongoing contamination of the tap water in Flint, MI with unacceptably high levels of lead that resulted from change in its water supply nearly two years ago to Flint River water. Because river water is more corrosive than the previous supply that came from Lake Huron (why I’ll explain later) and Flint river water was not properly treated to decrease that corrosiveness, the new water leached lead from old pipes. This resulted in the contamination of the drinking water with dangerous levels of lead in many homes in the city. In addition, there has been a marked increase in the number of cases of Legionnaires’ disease thought to be linked to the new water supply.

I was born and raised in Detroit. My parents didn’t move to the suburbs until I was ten years old, and I stayed in southeast Michigan until I graduated from medical school and ended up in Cleveland for my surgical residency and, ultimately, my PhD work. From there I bounced to Chicago and New Jersey. Then, in 2008, nearly twenty years after I had left my hometown, I ended up back in the Detroit area. The point of this story is that my roots in the Detroit area run deep. Michigan is my state, for better or for worse, which is why I get annoyed when bad things happen here. I particularly become outraged when a preventable tragedy occurs here, one that science told us how to prevent but the government went ahead and did anyway. It’s a horrific tale of how science was basically ignored because of politics, and legitimate scientific concerns about a policy that changed the water source for an entire city were downplayed, derided, and even denied by state officials at every level of government. The story has now gone international. Indeed, our state and the city of Flint are featured on the cover of this week’s TIME Magazine.

Genesis: How Flint was poisoned

Until about a month ago, most people outside of Michigan who’ve even heard of Flint at all probably remember the city because it was featured in Flint native Michael Moore’s movie, Roger & Me, a documentary that explored the effects of GM’s closing several auto plants in Flint back in the 1980s. The title of the film derives from the movie’s organizing conceit, in which Moore portrays himself pursuing then-GM CEO Roger Smith to confront him about what these closings did to his hometown. Basically, if you think Detroit’s been in bad shape over the last 20-30 years, you should realize that Flint has been in worse shape. Now, I realize that there are probably a lot of you who don’t like Michael Moore. I’m not that fond of him myself, but his movie did an excellent job of exploring just how messed up Flint was. Things haven’t gotten much better in the 26 years since Roger & Me.

As a result of its longstanding financial problems that lead to the city’s insolvency, in 2011 Governor Rick Snyder appointed an emergency manager of the city’s finances. Michigan has a law that allows the governor to appoint an Emergency Financial Manager to take control of a local financial unit, such as a city or a school district, after a review finds the unit’s financial situation is deemed precarious enough that a financial emergency exists. Emergency managers have broad, some would say undemocratic, powers to reorganize departments, reduce pay, modify employee contracts, and outsource work.

At the risk of becoming too “political” for an SBM post (forgive me if you find this too “inside baseball,” but it gives some context that I consider important), I can’t help but point out that in November 2012, a referendum was held over the previous emergency manager law. Voters clearly rejected the law. Did the voters’ repeal of the law stop our legislature? Of course not. Now here’s why we in Michigan have come to fear lame duck legislative sessions. A mere month later, the legislature passed another very similar emergency manager law, with some different provisions thought to assuage voters’ concerns. Using a quirk in the Michigan constitution that makes bills with appropriations not subject to voter referendum, our legislature tacked on an appropriation to pay emergency manager salaries before passing this new emergency manager law, which was now referendum-proof. Governor Snyder signed the bill right after Christmas.

Under the old law and the new, Flint went through several emergency managers, although two of them were the same. First it was Michael Brown. Then it was Ed Kurtz. Then it was Michael Brown again. The names, however, aren’t important. What they did is.

This is how it was reported right after the holidays:

Flint’s drinking water became contaminated with lead in 2014 after switching its supply source from Lake Huron to the more polluted and corrosive Flint River. The move — a cost-cutting measure while the city was under the control of a state-appointed emergency manager — resulted in a spike in lead levels in children, which causes permanent brain damage. A recent preliminary report from a task force appointed by Snyder placed most of the blame on the state Department of Environmental Quality and prompted the Dec. 29 resignation of DEQ Director Dan Wyant.

So what had happened? There were higher concentrations of salt in Flint River water, which led to corrosion of the lead pipes that carried water from main pipes to individual houses. Detroit’s less corrosive water had flowed through the same pipes for decades without a problem, but it didn’t take long after the switch was made in April 2014 for elevated lead content to be noticed.

Why was the switch made? Here the story gets complicated. In 2010, the Flint City Council voted to join the new Karegnondi Water Authority, which would supply many communities in the Flint area. Construction of a pipeline from Lake Huron to Flint was begun and is still scheduled to be completed in 2016. In the meantime, Flint continued to get its water from the Detroit system. In April 2014, a decision was made. It’s been argued back and forth whether it was the Flint city council that made the decision or the then-emergency manager, Darnell Earley, who is currently the emergency manager for the Detroit Public Schools—I kid you not—and has been frantically trying to deny that he had anything to do with this decision, painting it as his predecessor Ed Kurtz signing off on a city council decision in 2013, even though the city council had no authority anymore and even though that vote was only to switch to the Karegnondi Water Authority in 2016 when the new pipeline was completed, not to use Flint River water in the meantime.

Another argument defending emergency managers is that Detroit left Flint with no choice but to switch to Flint River water temporarily because it canceled the long term contract with Flint to supply water. This is where an interesting wrinkle is in what happened next:

When Flint notified Detroit in April 2013 that it had opted to switch to the Karegnondi Water Authority, Detroit gave it one year’s notice that it was terminating its contract to supply Flint with Lake Huron drinking water. Detroit’s decision to cut Flint off before the Karegnondi pipeline to Lake Huron would be completed — a decision made one month after Detroit was placed under the control of its own former emergency manager, Kevyn Orr — is what precipitated Flint’s move to the Flint River as a drinking water source pending completion of its own water provider.

Walling [Flint’s mayor in 2013], who takes ownership of the decision to switch to the Karegnondi Water Authority, told the Flint Journal he had no direct involvement in the decision to draw drinking water from the Flint River.

A March 7, 2014, letter from then-Flint emergency manager Darnell Earley to the DWSD, obtained by the ACLU of Michigan, shows Earley declined the DWSD’s offer to continue selling water to Flint after the termination of the contract in April of 2014, saying “the Flint Water Treatment Plant will be fully operational and capable of treating Flint River water prior to the date of termination.”

So at the time, both cities, Detroit and Flint, were under the control of an emergency manager. Both, presumably, were trying to save money when Earley switched from purchasing treated Lake Huron water from Detroit, as it had done for decades, to getting water from the Flint River as a temporary measure until the pipeline was completed. The reason? When Flint joined the Karegnondi Water Authority, the Detroit Water and Sewerage Department terminated its 35-year contract with the city. To continue to purchase Detroit water, Flint would have to renegotiate a short-term contract, at a higher cost, which Detroit was willing to do, justifying the higher cost as helping to pay for improvements it had made in the pipeline supplying Flint with the expectation that it would be used long term. On the other hand, recent evidence has suggested that even the short term deal that Detroit was offering would have been less expensive than using Flint River water. Whether that is true or not is beyond the scope of this post.

The effect of the change in source on Flint’s tap water was rapid. The switch was made with great fanfare in late April 2014, and by June there were stories of residents complaining about the water all over the local press. As can be seen in this excellent time line, report, and overview, residents almost immediately started complaining about the water, saying that it was causing skin problems, including rashes and hair loss. Others complained of a foul odor and cloudiness. By summer, three boiled water advisories were issued because of high levels of coliform bacteria. By October a GM engine plant announced that it would stop using Flint water because it was too corrosive. Last year, it got to the point where avoiding tap water became a way of life in Flint.

The switch is made. Have a big glass of lead!

The switch is made. Have a big glass of lead!

The Flint Water Study

Up to this point, it might be possible to view the decision to temporarily use Flint River water as somewhat forgivable, given the fog of politics and the 100% accuracy of the retrospectoscope. That was before officials started denying that there was a problem and in fact actively working to cover up evidence that there was a problem. There’s plenty of guilt to go around, although most of it appears to be the state’s problem. First, though, city officials denied that the water was unsafe, even as a year ago they issued a notice that the levels of trihalomethanes (TTHM), a group of four chemicals formed as a byproduct of water disinfection, were too high.

In January 2015, a public meeting was held during which hundreds of Flint residents attended, many complaining loudly about the “bad water,” its taste, smell, and appearance. They complained about skin problems, particularly in children, as they had been doing for months. Over the next few months, state and city officials, including the Department of Environmental Quality (DEQ), kept insisting that the water was safe and reporting that lead levels were within Environmental Protection Agency (EPA) guidelines. As we will learn, they went beyond that and tried to make sure they were below the guidelines.

Real water samples from Flint collected for the Flint Water Study. Drink up!

Real water samples from Flint collected for the Flint Water Study. Drink up! Yum.

Complaints about Flint water eventually lead to a local physician and a water scientist taking matters into their own hands. In September, Virginia Tech University researchers led by engineering professor Marc Edwards, an expert on water safety, tested water samples from 271 Flint homes and found high lead levels in the tap water in homes throughout the city. This recent article in the Washington Post provides what I consider to be the best explanation of what Edwards found. First, it notes what the lead levels were in cities near Flint. For instance, in Troy, which is about a 45 minute drive from Flint, the 90th percentile reading for lead in 2013 was 1.1 part per billion (ppb). For Detroit, it was 2.3 ppb, a bit higher, but still well below the EPA level for concern of 5 ppb.

In comparison, for Flint the 90th percentile was 27 ppb:

At 27 parts per billion, it’s five times as high as the level of concern, and nearly twice as high as the EPA’s already-generous guidelines. According to the researchers who ran these tests, the health effects of lead levels this high “can include high blood pressure and other cardiovascular problems, kidney damage and memory and neurological problems.”

Recall, though, that 10 percent of the homes in the sample had lead levels even higher than this. Here’s the highest lead reading in that sample, from a home in the city’s 8th Ward:

158 ppb

That’s more than 10 times the EPA limit. It’s 30 times higher than the 5 ppb reading that can indicate unsafe lead amounts.

But that 158 ppb reading is far from the worst one that turned up in Flint, unfortunately. In the spring of 2015, city officials tested water in the home of LeeAnne Walters, a stay-at-home mother of four and a Navy wife. They got a reading of 397 ppb, an alarmingly high number.

But it was even worse than that. Virginia Tech’s team went to Walters’ house to verify those numbers later in the year. They were concerned that the city tested water in a way that was almost guaranteed to minimize lead readings: They flushed the water for several minutes before taking a sample, which often washes away a percentage of lead contaminants. They also made residents collect water at a very low flow rate, which they knew also tended to be associated with lower readings.

So the Virginia Tech researchers took 30 different readings at various flow levels. What they found shocked them: The lowest reading they obtained was around 200 ppb, already ridiculously high. But more than half of the readings came in at more than 1,000 ppb. Some came in above 5,000 — the level at which EPA considers the water to be “toxic waste.”

The highest reading registered at 13,000 ppb.

The professor who conducted the sampling, Dr. Marc Edwards, was in “disbelief.”

“We had never seen such sustained high levels of lead in 25 years of work,” he said.

According to Edwards, the team retested the water with extra quality controls and assurance checks, and obtained the exact same results.

Edwards has set up a website with the details of the Flint Water Study that he and his research team had carried out, as well as its complete dataset for anyone who wants to examine it.

To its discredit, the DEQ immediately set about trying to discredit Edwards’ study, first by accusing him of dishonest motives. For instance, MDEQ’s Communications Director Brad Wurfel wrote to The Flint Journal‘s Ronald Fonger:

…the state DEQ is just as perplexed by Edwards’ results as he seems to be by the City’s test results. When I said we were unsure how the Virginia Tech team got its results, that’s not the same as being surprised that they got them. …this group specializes in looking for high lead problems. They pull that rabbit out of that hat everywhere they go. Nobody should be surprised when the rabbit comes out of the hat, even if they can’t figure out how it is done…..while the state appreciates academic participation in this discussion, offering broad, dire public health advice based on some quick testing could be seen as fanning political flames irresponsibly. Residents of Flint concerned about the health of their community don’t need more of that.

This is but a sample of the sort of attacks that were aimed at Edwards and his team in order to try to discredit their work and results. In fairness, Edwards is an activist. However, his finding elevated lead levels should not have resulted in attacks; it should have resulted in the DEQ rechecking its results. But that’s not all. It also appears that the DEQ went beyond attacking Edwards and into manipulating its results to eliminate inconvenient findings:

Lead levels in Flint’s drinking water would have spurred action months sooner if the results of city testing that wrapped up in June had not been revised by the Michigan Department of Environmental Quality to wrongly indicate the water was safe to drink, e-mails show.

The records — obtained by the Michigan ACLU and by Marc Edwards, a Virginia Tech researcher who helped raise concerns about Flint’s water — show how state officials first appear to have encouraged the City of Flint to find water samples with low lead levels and later told Flint officials to disqualify two samples with high readings. The move changed the overall lead level results to acceptable from unacceptable.

That’s right. The DEQ appears to have fudged the report it filed by eliminating the samples with the highest concentration and thereby produce the result that it wanted: The appearance that the water was safe. More specifically, it invalidated two high lead results to keep the 90th percentile below 15 ppb, the level set by the EPA to trigger action. Unlike 5 ppb, which indicates a need for concern, at 15 ppb federal law requires residents be provided information about how to protect themselves and their children from lead in water. That, of course, never happened in Flint.

It’s even worse than that, though. Flint water officials also appear to have misrepresented water samples. When lead levels are suspected to be too high, water systems are required to seek out the highest risk homes to test their water for lead. It turns out that water samples sent to the state labs for testing in the first six months of 2015 were all marked as having come from homes with lead piping serving them. However, nearly all of them came from homes at lower risk, homes with pipes made of copper or galvanized steel, according to documents obtained through the Freedom of Information Act by The Flint Journal-MLive.

Then there were the reactions to a physician who did a study.

Dr. Mona Hanna-Attisha does a study

Last fall, at the same time Edwards was studying lead levels in Flint water, Dr. Mona Hanna-Attisha, a pediatrician at Hurley Medical Center, announced the results of a study that she had done, which was just published in the American Journal of Public Health, accompanied by an editorial by David Rosner entitled “Flint, Michigan: A Century of Environmental Injustice.” Her results could also be found in a slide presentation from when she announced her findings. Basically, Hanna-Attisha and her team found that the incidence of elevated blood levels of lead had increased from 2.4% before the water source change to 4.9% afterwards. In some districts, the incidence had increased by nearly three-fold. Meanwhile, no significant change was seen outside the city (click to embiggen):

Lead levels as measured before and after the switch to Flint River water.

Lead levels as measured before and after the switch to Flint River water.

So what was the reaction to these findings? You already know that. Wurfel tried to slime Hanna-Attisha, characterizing the water controversy as “near hysteria” and saying:

I wouldn’t call them irresponsible. I would call them unfortunate,” Wurfel said of the doctors’ comments.

“Flint’s drinking water is safe in that it’s meeting state and federal standards,” he said. “The system has an aging portion that needs to be addressed. They haven’t had meaningful maintenance for four decades or more.”

At the same time, Health and Human Services spokeswoman Geralyn Lasher was characterizing Hanna-Attisha’s data as “data” in e-mails to Gov. Snyder and other state officials. (She now denies she was being condescending with the scare quotes.) She was attacked publicly, too:

“We were attacked,” Hanna-Attisha recalls.

She was labeled an “unfortunate researcher” and accused of causing hysteria. Critics said her figures did not line up with the state’s findings. Governor Snyder’s press secretary accused her of “splicing and dicing” her data to get the results she wanted.

Even though General Motors stopped using the city’s water supply because it was corroding engine parts, the official reaction, Hanna-Attisha says, was one of “denial, denial, denial.”

The criticism, she says, took its toll.

“I was physically ill. I think my heart rate went up to 200. You know, you check and you double-check, and you know your research is right. The numbers didn’t lie, but when the state is telling you you’re wrong, it’s hard not to second-guess yourself.”

The state finally had to admit that its data showed the same thing when it analyzed it the same way that Hanna-Attisha did.

By October, Genesee County, which includes Flint, declared a public health emergency, and the City of Flint developed plans to distribute thousands of water filters. Finally, in October, Flint reconnected to Detroit water. Ultimately, several Flint residents filed a class action lawsuit, and in December the new mayor, Karen Weaver, declared a state of emergency, declaring that the elevated lead levels had caused irreversible damage to the health of the children of the city. And, finally, long after he should have done it, earlier this month Governor Rick Snyder declared a state of emergency as well, after DEQ director Dan Wyant and communications director Brad Wurfel resigned.

Finally, last week, Governor Snyder used the State of the State address to apologize to the citizens of Flint, and promised to release his e-mails, even though the state’s Freedom of Information Act exempts lawmakers and the Governor. The EPA issued an emergency order requiring Michigan and the city of Flint to take immediate steps after determining that their response to the crisis had been “inadequate to protect human health,” while Susan Hedman, head of the Midwest region of the EPA, resigned after having played down a memo by an EPA employee that said tests had shown high levels of lead in the city’s water, telling Flint and Michigan administrators it was only a draft report. Meanwhile, Michigan Attorney General Bill Schuette, after having resisted doing so for a long time, has launched an investigation, and Governor Snyder might be required to testify before the U.S. House Oversight and Government Reform Committee. President Obama has lit a fire under the FDA and promised aid.

Clean, uncontaminated water: Science-based public health

When I decided to write this, I realized that our readers might question why this would be an appropriate topic for science-based medicine. After all, the effects of lead poisoning are very well known. Lead can result in developmental delay, decreased IQ, decreased hearing, and ADHD. The children of Flint who were affected with this will likely have behavioral problems, and lead exposure has even been linked to violent crime.

Besides outrage, what motivated me to write was a desire to point out how SBM interfaces with public health in ways not involving vaccines. Science-based water treatment is science-based medicine through its effects on public health, and, arguably even more so than vaccination policy, is a product of politics, which can lead to disasters like this. Everybody knows that clean, uncontaminated water is important for the health of the people using it. What’s not so well known is how difficult it is to produce. For instance, before this crisis, I did know that our state had an aging infrastructure. I was not, however, aware of how widespread lead pipes still are in city water supplies. Even though my bachelor’s degree was in chemistry before I went to medical school, I was still also blissfully unaware of the chemistry of water treatment, because that’s a rather specialized field of applied chemistry. I had no idea that there would be a big difference in the ability of water to leach lead from lead pipes depending on its salt concentration and pH, much less what needs to be done to prevent it from doing so.

Water from the Detroit Water and Sewerage Department has a very low corrosivity for lead because of its low chloride, low chloride-to-sulfate mass ratio, and addition of an orthophosphate corrosion inhibitor. In marked contrast, Flint River water is very corrosive to lead because it had high chloride (92 mg/L, compared to 11.4 mg/L in Detroit water), high chloride-to-sulfate mass ratio (1.6, compared to 0.45 in Detroit water), and no corrosion inhibitor. Worse, in response to the finding of high TTHM levels, the city was adding ferric chloride; the problem is that ferric chloride makes water even more corrosive to lead. Add to that a city with an aging infrastructure containing a high proportion of lead pipes that the city can’t even keep track of because data regarding which homes have lead pipes or not are kept on 45,000 index cards, and you have a recipe for disaster. As a result, after the switch to Flint River water, the corrosiveness level as measured by the Larson Iron Corrosion Index rose from 0.54 (low corrosion) to 2.3 (very high corrosion) and the chloride to sulfate mass ratio (CSMR) index for lead corrosion increased from 0.45 (low corrosion) to 1.6 (very high corrosion). The city didn’t add phosphates to reduce the corrosiveness of the water, and as a result the corrosive Flint River water corroded the scale that had built up on the pipes and released lead into the water.

Here’s the even bigger kicker. Even using the Flint River water, the City of Flint could have prevented the corrosion of its copper and lead pipes relatively inexpensively:

Marc Edwards, a professor at Virginia Tech who has been testing Flint water, says treatment could have corrected much of the problem early on — for as little as $100 a day — but officials in the city of 100,000 people didn’t take action.

It’s not clear whether incompetence or saving money was the imperative here. Whatever the reason, the city failed to treat the Flint River water, leaving it corrosive and able to leach lead and copper from the aging pipes used to transport it. As a consequence, an as-yet unknown number of children have been poisoned with lead, which is most damaging to the developing brain. This is all straightforward science. We know what levels of lead are safe and what levels are not. We know what the effects of lead poisoning are in children. We know how to prevent them. Chemists specializing in water purification know that corrosive water placed in old copper and lead pipes will leach lead and copper out of them. They even know how to treat the water to prevent this leaching! Yet that wasn’t done.

Now we will now be forced to use science-based medicine to treat potentially thousands of children for lead poisoning and science to try to fix the problems caused by this colossal failure of science-based public policy. Worse, it’s still going on, as The Guardian just reported on Friday that water authorities across the US are systematically distorting water tests to downplay the amount of lead in samples.

As I think about that, seeing the Governor throwing mid-level bureaucrats under the bus and other politicians saying that the Flint water crisis is a hoax does not give me confidence in how this crisis will ultimately turn out or that the aging infrastructure that allows such a catastrophe to occur will be fixed any time soon.



Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.