Professionalism/Mona Hanna-Attisha and Lead Exposure in Flint, Michigan

On April 25th, 2014 Flint, Michigan switched its water source from the Detroit Water and Sewage Department to the Flint River. Shortly thereafter residents began to complain about the taste, smell, and appearance of the water because contaminants in the new water supply caused lead to leach from the aging pipe system and expose around 100,000 residents in Flint. This could have been avoided if the officials in charge had properly treated the water with corrosion inhibitors and then people like Dr. Mona Hanna-Attisha got involved and raised the alarm about this situation. Eventually the Federal government got involved when President Obama declared a state of emergency for the city in 2016 and authorized 5 million dollars in aid via FEMA to help repair the damage. For a more detailed review of the Flint water crisis review The Flint Water Supply.

Discovering the Issue
In August 26, 2015, 43 year-old Dr. Mona Hanna-Attisha was at a barbecue with her family and friends when she first heard about the lead problem. Her friend Elin Betanzo, a water-quality engineer, asked "what are you hearing about the Flint water?...the water isn't being treated properly. It's missing something called corrosion control... Without that corrosion control, there is going to be lead." She raised the issue the next day at the Genesee County Health Department; the person responded "water isn’t our department... It’s under public works." Hanna-Attisha sent emails to multiple health experts including county health director Mark Valacak and physician Dean Sienko but was ignored. She continued to exchange information with Elin Betanzo and attempted to gather data on the blood-lead levels of children in Michigan from Karen Lishinski. When Lishinki did not respond, Hanna-Attisha made the mistake of adding Sienko to her emails about the Flint Water Crisis. Sienko replied "we never had a child with elevated lead where water was the principal or even minor concern."

Miguel Del Toral's Report
Miguel Del Toral, Elin Betanzo’s former colleague and “regulations manager of the Midwest water division of the Environmental protection agency,” wrote an eight-page interim report on the lead issue in Flint. The subject of the report, LeeAnne Walters, noticed multiple issues after switching to the new water supply. After bathing, her 3-year-old sons, Gavin and Garrett, broke out in red bumps; Gavin stopped growing. LeeAnne Walters' eyelashes started disappearing, and her daughter lost clumps of hair while showering. Walters' children had low blood lead levels (2 ug/dL) prior to changing the water supply and elevated blood lead levels (6.5 ug/dL) afterwards. Walters notified city officials of her children’s high blood-lead levels. City officials blamed the plumbing and told Walters “tests of city water showed lead levels in compliance with regulations”. The governor’s office later stated the water supply “met all the state and federal standards,” so Walters decided to contact Miguel Del Toral. In April 2015, Del Toral traveled from Chicago to Flint to personally investigate Walters' house. He concluded her pipes were leaching lead, "the [Michigan Department of Environmental Quality] was using faulty testing procedures, [and] Flint wasn’t using corrosion control." Del Toral reported his findings to Thomas Poy, chief of the Ground Water and Drinking Water Division of the EPA, but received harsh criticism from his supervisors. The EPA reprimanded Del Toral for "overstepping his responsibilities and referred him to the agency’s ethics office...The regional manager at the EPA even apologized to the MDEQ for Del Toral’s memo, describing it as premature and incomplete."

Analyzing the Data
Hanna-Attisha worked with Jenny LaChance, a research coordinator, to organize the blood-lead data from her clinic. "Comparing children under five years of age with elevated lead levels (greater than or equal to 5 μg/dl) for about the same duration of time pre–water switch (January 1, 2013, to April 24, 2014) to post–water switch (April 25, 2014, to September 9, 2015), the percentage increased from 1.5 percent to 8.5 percent." She found "more kids with higher lead levels since the water switch in 2014;" her results were statistically significant (p=0.007). However, Hanna-Attisha only had 341 samples. She and LaChance applied to the Institutional Review Board (IRB) for approval. After getting approval, her sample size increased to almost 2,000. With her new data, Hanna-Attisha found the percentage of elevated lead level for kids under fives years old increased from 2.1 percent to 4.0 percent to be statistically significant (p=0.024).

Publications
Dr. Mona Hanna-Attisha brought the issue to light on September 24, 2015 at press conference at Hurley Medical Center in Flint, Michigan. In November 15, 2015, Hanna-Attisha published her findings. Hanna-Attisha published her account of the Flint Water Crisis in her book “What the Eyes Don’t See” in 2018. The reason for the title is because "we literally cannot see lead in water... [or the] consequences for years, if not decades, later... It's about the people, the places and the problems that we choose not to see."

State Response
After Hanna-Attisha presented her case at the press conference, Flint officials tried to discredit her and insisted that the water was safe. After Hanna-Attisha and her team released their study, the City of Flint issued a lead warning and advised residents to drink and cook with cold tap water. However, Flint officials still asserted that the water treatment complied with federal regulations. The Michigan's governor at the time, Rick Snyder, claimed that the unsafe levels of lead may be from lead plumbing in homes, but the water leaving the Flint water facility was completely safe. After pressure from Flint City residents and Hanna-Attisha's continued efforts, Governor Snyder finally declared a state of emergency at the beginning of 2016. Flint City switched back to Detroit Water, and an investigation was launched. However, the damage was already done at that point and Flint would not have clean water until years later. The State said I was an unfortunate researcher, that I was causing near-hysteria, that I was splicing and dicing numbers. It’s very difficult when you are presenting science and facts and numbers to have the state say that you are wrong.

Public Response
Flint experienced a breach of trust, as officials have been continuously reassuring the residents that their water was safe. There was a community-wide trauma about drinking water, and Flint residents felt betrayed by the government that was supposed to protect them. Governor Snyder lost favor due to his attempts to cover up the crisis. Four years after the crisis, Flint residents still protested against Snyder and other Flint officials. The state had decided to end a free bottled water program, angering the residents and causing them to rally against Snyder.

Impact
The Flint Water Crisis made major impacts on the Flint community. More initiative was put into public health in Flint. The city gained new childcare centers, school health services, Medicaid expansion, nutrition services, literacy programs, and more. A US senator for Michigan decided to put a nutrition prescription program into the 2018 U.S. Farm Bill after visiting Hanna-Attisha's clinic. In response to the crisis in Flint, Congress also funded the Centers for Disease Control and Prevention (CDC) to establish a federal advisory committee, enhance Childhood Lead Poisoning Prevention Program activities, and support a voluntary Flint lead exposure registry.

Michigan implemented stricter water monitoring rules. Due to more care in water monitoring, lead and copper levels in Flint's water have been gradually decreasing. Since late-2016, Flint's water have been meeting federal standards.

Ethics
During the crisis, Hanna-Attisha faced ethical dilemmas. She considered doing the press conference "disobedient in the academic doctor world," because sharing research is usually a long process. The research has to be thoroughly investigated and examined by other researches. However, because there was no time, Hanna-Attisha decided to take her research directly to the press conference.

After the state's response, Hanna-Attisha had the choice to ignore the issue and return to her life as a mother, pediatrician, and wife. However, Hanna-Attisha remembered her oath to protect the children of Flint City, and decided to increase her efforts and continue to speak up. She describes that it is trust that motivated her to continue her efforts. The trust that families put in me, and in this profession, is overwhelming. It is that trust that drove me to do what I did and continue to do what I do.

Conclusion
Hanna-Attisha’s situation raises the question: should doctors prioritize speed over safety? Further work can examine how others before Hanna-Attisha tried to bring awareness to this issue. Researchers might consider examining Marc Edwards who brought awareness to elevated lead levels in Washington, DC.