Once-Discounted Flint Physician Heads Lead Poisoning Response

January 22, 2016

President Barack Obama said this week he will have the back of Flint, Michigan, and its 100,000 residents, who are beleaguered by lead-contaminated drinking water.

He will be joining a pediatrician there who has had the back of the community all along. After having her warnings about high blood lead levels in children initially dismissed, Mona Hanna-Attisha, MD, MPH, was appointed last week to head a multidisciplinary task force that seeks to blunt the harm done to children there.

Dr Mona Hanna-Attisha

This group, called the Pediatric Public Health Initiative, will look beyond the immediate problem of safe drinking water and focus on the "tomorrow problem," as Dr Hanna-Attisha puts it, of lead's neurotoxic effects on young children and their budding brains. These effects include lower IQ, developmental delays, and behavioral issues such as hyperactivity and even criminality. The team, roughly 30 strong, will include experts in pediatrics, child development, psychology, epidemiology, nutrition, toxicology, and education.

"If we don't do something now to build this model public health program, we will see lifelong consequences," Dr Hanna-Attisha told Medscape Medical News.

The initiative represents a collaboration between the Michigan State University College of Human Medicine, where Dr Hanna-Attisha teaches, and Hurley Medical Center in Flint, where she directs a pediatric residency program. Other participants include the state and local health departments.

Dr Hanna-Attisha brings many qualifications to her job, and not just her medical resume. As a high schooler, she worked with others to shut down a trash-burning incinerator in her town that was triggering asthma. "I guess I have always known the power of people," she said. Majoring in environmental health at the University of Michigan was a natural follow-up to her youthful activism.

"I felt like all my prior training and experience were setting me up for this," she said about the Flint initiative.

As a mother of two daughters, aged 7 and 9 years, and the wife of a pediatrician, Dr Hanna-Attisha can empathize with Flint parents whose young children have been exposed to unhealthy levels of lead. "In my clinic today, you could see the fear and trauma in their eyes," she said. "They don't know what tomorrow will bring."

"As a Scientist, You Trust Your Data"

The stage was set for the lead crisis in Flint in 2013, when the city, under a state-appointed emergency manager, agreed to stop buying Lake Huron water from nearby Detroit and get it from the lake through a new water authority. The move was supposed to save millions of dollars, a boon to a mostly African-American, Rust Belt city, where four in 10 residents fall under the poverty level.

Although it awaited completion of a new Lake Huron pipeline, the city began to draw water from the Flint River in April 2014. Residents soon complained about smelly, brown water coming out of their faucets as well as skin rashes, hair loss, and respiratory problems after the switch. Amid reassurances from state and city officials that the water was safe to drink, red flags about lead poisoning emerged. In August 2015, for example, researchers from Virginia Polytechnic Institute and State University announced that in 42% of water samples they collected in Flint, lead levels topped 5 parts per billion (PPB), "which suggests a serious lead-in-water problem." Levels in roughly 20% of samples topped 15 PPB, the threshold set by the Environmental Protection Agency for remedial action.

The problem, according to the Virginia Tech researchers and others, is that Flint River water is far more corrosive than Lake Huron water, leaching lead from the city's aging pipes and plumbing fixtures. Nobody was treating the river water with the necessary corrosive inhibitors to avoid that problem.

About this same time, Dr Hanna-Attisha started investigating the lead issue. She compared medical records of children treated at Hurley Medical Center before September 2013 with those treated in 2015 through September 15. The percentage of children with elevated blood-lead levels (5 μg/dL or higher) had nearly doubled, increasing from 2.1% before September 2013 to 4% in 2015. In some neighborhoods, the percentage of children testing positive for elevated lead levels topped 6%. She came out with her findings in late September 2015 (revised figures released in December 2015 revealed the lead problem to be even worse).

At first, Michigan officials challenged the pediatrician's original analysis, saying her numbers did not match theirs. One state regulator was quoted as calling her warnings about lead poisoning "unfortunate."

"As a scientist, you trust your data," Dr Hanna-Attisha said. "When [a] state team of epidemiologists tells you you're wrong, it's hard not to second-guess yourself. It's emotionally jarring."

She stood her ground, however, and in early October, the Michigan Department of Health and Human Services announced it had taken a second look at its data on blood lead levels among Flint children. Its conclusion? The agency detected the same spike Dr Hanna-Attisha had.

With that admission, state and local officials began treating Flint's drinking water as a public health crisis. The city switched back to Detroit's water system that month, which lowered lead levels in tap water, but did not bring them back to normal, said Dr Hanna-Attisha. In January, Governor Rick Snyder declared a state of emergency in Flint and ordered the National Guard to distribute bottled water and lead filters. Obama followed suit with his own declaration of emergency last week, mobilizing federal assistance under the direction of the US Department of Health and Human Services.

Water contamination in Flint now has morphed into a political issue. Democrat presidential candidates Hillary Clinton and Sen. Bernie Sanders (D-VT), among others, have chastised state and local officials for responding to the health hazard too slowly. Comparisons have been drawn with the much maligned federal response to Hurricane Katrina in New Orleans 11 years ago.

Michigan's governor issued a mea culpa earlier this week in his State of the State address.

"To you, the people of Flint, I say as I have before, I am sorry and I will fix it," said Snyder.

No Pill for Lead Poisoning

When it comes to fixing Flint, the easiest part is handing out bottled water and replacing old plumbing fixtures. Dr Hanna-Attisha and her Pediatric Public Health Initiative have the hardest part: mitigating the long-term effects of lead poisoning on the city's children. That task will stretch on for years, if not decades.

The first order of business is identifying Flint children who have been exposed. Of prime concern are the 8000 to 9000 children younger than 6 years whose developing brains are the most vulnerable to lead's neurotoxicity. However, testing for elevated blood levels only reflects a recent exposure to lead, which is cleared from the blood in 1 to 2 months, according to the Centers for Disease Control and Prevention. Because Flint's exposure to contaminated water dates back to April 2014, the Pediatric Public Health Initiative will study archived blood samples from newborn heel pricks that are stored on Guthrie cards.

In addition to lead testing, the Flint initiative will monitor the city's children going forward for signs of developmental and behavioral problems that stem from lead poisoning, but do not show up immediately. "You don't recognize lead poisoning at first because it's largely asymptomatic," said Dr Hanna-Attisha.

When her lead response team identifies children who show the ill effects of lead, it will intervene as soon as possible to limit the damage. Early education and parenting programs, for example, can help children "build resilience and overcome these adversities," she said.

One nutritional intervention targets children who currently have high blood lead levels. Foods rich in iron, calcium, and vitamin D help block the absorption of lead and increase its excretion. Accordingly, members of the initiative have begun to conduct cooking classes and distribute recipes to encourage Flint parents to prepare meals with antilead ingredients.

"There's no pill for lead," said Dr Hanna-Attisha. "Mitigation spans all these disciplines."

Like others, she laments the failure of state and local government to protect the people of Flint. "You expect that when you turn on your tap, your water is safe," she said. She also finds it galling that even in her struggling community, lead poisoning had been on the wane before 2014. "This [current] exposure bucks every trend," she said.

However, she views the drinking water crisis as an opportunity to make sorely needed investments in Flint's children that address more than just lead poisoning. "We are trying to make lemonade from lemons," she said.

The job of heading the Pediatric Public Health Initiative "fell into my lap," said Dr Hanna-Attisha, but she nevertheless considers it part and parcel of her medical calling.

"Children can't vote," she said. "They have no voice.

"As pediatricians, our job is to be advocates for children."


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