Learning from Flint.

The past few weeks have seen a torrent of articles written about the drinking water of Flint, Michigan, including a recent New York Times editorial calling for an immediate resolution to the Flint water system problem. At core the problem has been the corrosion of water pipes in an aging city infrastructure that has resulted in contamination of the city water supply with a range of pathogens, not the least of which is lead. President Obama met with the mayor of Flint during a visit to Michigan and recently declared a state of emergency in Flint.

This current problem seems to have started in 2011, when Flint, together with many other cities in the area, was facing a financial emergency necessitating cost-cutting. One cost-cutting solution was to stop paying the Detroit Water and Sewerage board for water from Lake Huron and convert to a different supply line. This could not be done immediately, however, and so Flint started to source water from the Flint River in April 2014 as a temporary measure. Soon after, residents started to complain about the taste, smell, and appearance of the water and voiced health concerns such as skin rashes.

Despite substantial and increasing public protests about the Flint water problem, it was not until January 2015 that Flint sought an independent review of the water supply due to concerns regarding high levels of trihalomethanes, a byproduct of disinfecting efforts. By then protestors had started to bring samples of dirty and discolored water from their faucets to public meetings. The Environmental Protection Agency (EPA) was engaged after protests by Lee-Anne Walters, a mother of four, who persistently complained about the effects of the water on the health of her children. Eventually, the water at her home was tested and found to contain alarming levels of lead. City officials continued to insist that the water supply was safe and stated that there may have been issues with her plumbing. Dissatisfied with the response, Walters complained to the EPA.

A research team led by Dr. Marc Edwards of Virginia Tech conducted a study of the water conditions in Flint. Edwards’ report found that the Flint River water contained eight times the amount of chlorine as compared to Lake Huron water and was highly corrosive. This caused pipe corrosion and leaching of dangerous levels of lead into the water supply. Concurrently, Dr. Hanna-Attisha from the Hurley Children’s Hospital in Flint called attention to significant increases in the blood lead levels of children, showing that this increase followed the change in the water supply source. Lead, of course, is a potent neurotoxin, and lead toxicity can cause developmental delay in children in addition to a host of other effects, including mood disorders, memory impairment, and miscarriages.

Flint reconnected to Detroit’s water supply in October last year. In December 2015, the director of the Department of Environmental Quality resigned shortly after the City of Flint declared an emergency. In the wake of revelations about multiple efforts by elected and appointed officials to avoid dealing with the issue, Michigan Governor Rick Snyder issued a very public apology, with promises to fix the problem.

The New York Times editorial mentioned earlier rests its outrage on the notion that “no Americans should have to live with poisoned water that is a direct result of the government’s decisions and neglect.” That in some ways is an important reiteration of resolution 64/292 passed by the United Nations General Assembly on July 28, 2010, recognizing that clean drinking water and sanitation are essential to the realization of all human rights. This then suggests broad agreement that what happened in Flint should not have happened—certainly not in the US, and one would argue not anywhere in the world. And yet it did. Why did it happen, and what can the Flint events teach us about how we need to act to promote the health of the public?

First, it seems that the core etiology of today’s Flint problems go back 18 years, but all center on efforts to cut costs and hoping that these cost-cutting measures do not affect the health of the public. The Michigan Department of Environmental Quality never enforced the installation of corrosion control systems in accordance with the Federal Lead and Copper Rule of 1998. This set the stage for severe corrosion in the water pipes that was then accelerated dramatically by the change in the water supply in 2014. A subsequent offer to revert to the original water supply from Detroit was rejected due to cost concerns in January 2015 despite the growing drumbeat of concerns about water quality in Flint. It goes without saying that elected and appointed officials are charged with balancing budgets, with the responsible use of public resources in the face of multiple competing demands. However, the clear challenge that informed all that went on in Flint was the notion that short-term cost-saving measures to infrastructure that is necessary to public health can be implemented without consequence. There are ample historical examples that roundly reject this idea. Some years ago, my colleagues and I published an analysis of the impact of the New York fiscal crisis in 1975 on the tuberculosis, HIV, and homicide epidemics in New York City, showing that cuts to public infrastructure and resources that aim to protect the public’s health contributed to the amplification of these health conditions. Further highlighting the folly of short-term cost-cutting that threatens public health, we estimated that $10 billion in cuts to services were followed by costs that exceeded $50 billion to then control the epidemics, not counting of course the human costs of these events.

Second, as the Flint story becomes clearer, it is readily apparent that there was ample opportunity at several steps along the way to reverse course as local residents raised the alarm about water quality in Flint. These concerns were ignored, and there are several instances where warnings that could have been actionable were put aside. For example, the findings of Dr. Edwards and Dr. Hanna-Attisha were refuted and ignored until October 2015, when the Department of Health and Human Services urged residents to stop drinking the water. This represents in many ways a failure of responsive governance, as well as a set of responses by elected and appointed officials that considered the public concerns to be a nuisance at best seen as a public relations problem, and at worst ignored. This highlights the role of governance as a determinant of the health of populations. I have previously referred to governance as a macrosocial determinant of population health, seeing governance as core to the distribution of the social, political, cultural, and economic factors that are the foundational determinants of population health. This suggests that we need to engage good governance as a core aspect of what we study and what we aim to inform.

Third, it has been well noted that this issue raises concerns about environmental racism, where a clear challenge coming from a predominantly minority and marginalized community went unheeded. There is little doubt that the consequences of racism are deep and pernicious; I have written notes previously both about racism and about the persistent racial health gaps in the US. The Flint episode highlights yet another way in which race, class, and power influence the health of the public. It is that much easier for those in positions of power to ignore concerns raised by populations that are already marginalized, who wield little effective power. This reinforces both the role of power as a foundational cause of health and the responsibility of public health to be alert to the challenges that are disproportionately faced by marginalized, frequently minority, populations.

Fourth, but not least, the Flint issue brings to the fore the importance of values, and how values inform what we do—how and why we find some circumstances unacceptable, even if they were formerly acceptable. It highlights the notion that values must underlie how we act and how we prioritize, and that health is an unassailable value that needs to animate governance and the decisions we collectively make about the society in which we wish to live. This underlines the responsibility of public health to be clear about the values that should animate public action, and highlights the core role that the promotion of the public’s health should play in public discussions about the social, economic, cultural, and financial conditions that shape what we drink, eat, and breathe, and how we feel, think, and behave.

I note that our recently completed Strategic Thinking Initiative articulated principles to inform our work that included significance, diversity, equity, and collaboration. All of these principles are resonant to an analysis, and action around, the situation in Flint. Tackling problems that have profound impact for populations suggests a significant problem that merits our attention, which is concerned with diversity and equity, and that requires cross-sectoral work to find effective solutions. Our clear engagement with important aspects of this challenge gives me hope for our own focus; the very existence of the challenges Flint has faced is enough to fill one with despair.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful for the contributions of Revathi Penumatsa, MBBS, to this Dean’s Note, and to Lisa Chedekel for suggesting it.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/