I read an online news story a couple of days ago that said that the city of Flint, Michigan recently completed the replacement of almost all of the lead pipes providing water to the people living there. The project was ambitious in scope, and long overdue, lasting almost 10 years from start to finish. While the lead pipe replacement project closes one chapter of this story, the long-term public health impact of this incident is far from clear.
I wrote about the Flint Water crisis in a brief editorial for the journal Current Treatment Options in Pediatrics in 2016. I wrote then, "For its entire history, the city of Flint's fortunes have been closely tied with the fortunes of the automobile industry." The automobile manufacturer General Motors was founded in Flint, and both the company and the city grew considerably during World War II and beyond. However, when General Motors declared bankruptcy in 2008, so too did the city of Flint fall into hard times. The city ranks near or at the bottom of the state of Michigan in almost every social (unemployment, domestic violence, violent crime, drug abuse) and public health (preterm birth, infant mortality, life expectancy) statistic. However, it was after then Governor Rick Snyder declared a state of financial emergency in 2011 that Flint's problems with lead in the water began. Governor Snyder appointed an Emergency Manager who was charged with cutting costs and reducing the city's $15 million budget deficit.
Flint previously obtained its water from the city of Detroit, whose source of water was nearby Lake Huron and the Detroit River. The cost of water had nearly doubled by 2013, prompting Flint's city council to approve a proposal to switch to the Karegnondi Water Authority on March 25, 2013, which would allow the city to obtain its water directly from Lake Huron, bypassing Detroit (essentially, they were cutting out the middle man in the deal). While the new deal would save the city approximately $19 million over an 8-year period, the new proposal would require completion of a new regional water pipeline, which would not be completed until 2016. At the same time, the Detroit Water and Sewerage Department gave the Flint city council a one-year termination of contract notice. The city council scrambled and signed a contract to use the water from the nearby Flint River until the new regional pipeline could be completed.
Almost immediately after the switch occurred in April, 2014, Flint residents began to complain and express concerns about the color, taste, and odor of their water. Notably, the water from the Detroit Water and Sewerage Department was far less corrosive than the water from the Flint River. City officials had failed to apply corrosion inhibitors to the water, possibly in yet another cost-cutting move. In fact, General Motors had recently stopped using the Flint River water at one of their nearby engine assembly plants because the water quickly corroded the engine parts. The corrosive water leached lead from the city's aging network of lead-based waterpipes, which had two adverse effects. First, the lead levels in the water rose to dangerous levels. Second, the lead and other heavy metals inhibited the chlorine-based disinfectants in the water, causing bacterial contamination. Just four months after the switch, the city government put out a warning to residents to boil their water due to high levels of E. coli and Legionella.
As detailed in two outstanding books, The Poisoned City: Flint's Water and the American Urban Tragedy by journalist Anna Clark and What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City by pediatrician Mona Hanna, MD, MPH, local pediatricians started to report increased blood lead levels in children under 5 years of age, with neighborhoods with the highest water lead levels reporting the greatest number of cases. Lead's neurotoxic effects can adversely impact a child's motor and cognitive development, so the disturbing increase in blood lead levels was a public health nightmare. Dr. Hanna was instrumental in helping to make the connection between the increase in lead concentrations in the city water supply and the increase in the number of lead poisoning cases in Flint's pediatric population (notably, there were at least three separate studies establishing this link).
Somewhere between 6,000 to 14,000 children were exposed to drinking water contaminated with high levels of lead. Children are particularly susceptible to the long-term effects of lead poisoning, so we will likely not know the true impact of this incident until several years from now. Dr. Hanna, who is currently the Associate Dean for Public Health and and C. S. Mott Endowed Professor of Public Health at Michigan State University College of Human Medicine was named one of Time magazine’s 100 Most Influential People in the World and recognized as one of USA Today’s Women of the Century for her role in uncovering the Flint water crisis and leading recovery efforts. She stated, "Investment in our children's future, and in their health, is not just an economic necessity, but it is the bedrock of public health and a just society."
After nearly $400 million in both state and federal spending, the city of Flint has finally secured a clean water source and laid modern, safe, copper-based pipes to nearly every home in the city. The late Reverend Allen C. Overton of Concerned Pastors for Social Action, one of the plaintiffs in the subsequent federal lawsuit said, "Thanks to the persistence of the people of Flint and our partners, we are finally at the end of the lead pipe replacement project. While this milestone is not all the justice our community deserves, it is a huge achievement."
For me, the story of the Flint water crisis perfectly illustrates the critical linkage between public health and medicine. As the health economists David Cutler and Grant Miller suggested in an article published in the journal Demography in 2005 ("The role of public health improvements in health advances: The twentieth century United States"), "clean water was responsible for nearly half the total mortality reduction in major cities" during the late 19th and early 20th century. Similarly, Marcella Alsan and Claudia Goldin published an article in the Journal of Political Economy in 2019 ("Watersheds in child mortality: The role of effective water and sewerage infrastructure, 1880-1920") and concluded that one-third of the decline in child mortality from 1880 to 1920 was directly related to investments in clean, safe water. As I have stated many times in the past, health delivery is not just about health care. The so-called social determinants of health account for anywhere between 30-50% of reported health outcomes, particularly mortality. As these studies - and the Flint water crisis - prove yet again, you can't drive improvements in health by focusing only on health care.
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