COMMENTARY

Update on the Flint Water Crisis, From Mona Hanna-Attisha, MD

'A Threat to the Tomorrows of Our Children'

Interviewer: Hansa Bhargava, MD; Interviewee: Mona Hanna-Attisha, MD, MPH

Disclosures

January 30, 2018

Hansa Bhargava, MD: Hi. I'm Dr Hansa Bhargava, senior medical director for WebMD and senior medical correspondent for Medscape. Today I have the privilege of speaking with Dr Mona Hanna-Attisha. We will be talking about the lead crisis in Flint, Michigan. Dr Hanna-Attisha, thank you so much for being here.

Mona Hanna-Attisha, MD, MPH: It's great to be with you.

Lead Crisis in Flint, Michigan

Dr Bhargava: The lead crisis in Flint, Michigan, began in 2014 when the city switched its water supply. It quickly escalated into a national story and prompted then President Obama to declare a federal state of emergency in January 2016. While the change in water supply prompted almost immediate complaints from citizens, it was not until 18 months later that a lead advisory was issued to residents. That advisory, in part, was prompted by a study by Dr Hanna-Attisha and colleagues.[1]

Their study documented a doubling of elevated blood lead levels in children, especially in socioeconomically disadvantaged neighborhoods. Now, almost 2 years following that belated acknowledgement of an emergency, Dr Hanna-Attisha continues to work diligently with the children in Flint. She is here today to speak with us about the current state of this issue and lessons learned for other communities.

Can you tell us the state of affairs in your hometown now? The city has gone back to its original water source. Has that reduced the exposure to lead, or are children still being exposed?

What Is the Current State of the Flint Water Crisis?

Dr Hanna-Attisha: That is a great question. Where are we right now in Flint? We are 4 years past the water switch, so we are on our fourth year after the water crisis started. Yet, to this day, the people of Flint—the kids that I take care of in clinic everyday—are still on filtered and bottled water, even though shortly after our research came out and shortly after the declaration about lead in the water, we went back to treated water. During the 18 months that we were on untreated water, this corrosive water ate up our pipes; and, because of that, the water is still not safe.

It is absolutely getting better, and most importantly the pipes are being replaced. Our lead service lines, which are the pipes that go from a person's house to the water main, are being replaced. But that takes time, and it's not estimated to be completed until 2020. Until then, the people are still on filtered water and on bottled water; however, the quality of the water has improved.

Dr Bhargava: Are most of your patients and the communities aware of this? Are there any families that may not know this and are using the water from the taps?

Current and Continuous Struggles

Dr Hanna-Attisha: Yes. One of our continuous struggles is to keep people informed of the current water situation. There have been a lot of mixed messages throughout the crisis. At the beginning, people were told to boil their water because of bacteria, but boiling water actually concentrates lead in whatever you are cooking.

They were told to flush their water. They were told to filter their water but not to filter hot water. They were told that the filters did not work because there was so much lead in the water that the filters could not clear that lead amount. They were told that the filters were tested, even for super high levels of lead in water, and they still worked, so use your filter.

These mixed messages have caused obvious confusion with our patients. At this point, the message is: The water is still not safe, so you should use filters and bottled water. There are still water delivery programs, and there are still what we call "pods" in the community where people can pick up water.

There is a home door-to-door program where folks come to people's homes to help install water filters because they are not super easy to figure out. They are installed on the end of the kitchen faucet, and they have a light indicator that means that you need to replace your cartridge, depending on how much lead has been through your system. People are on their 12th or 15th replacement cartridge. Our work is ongoing in terms of educating and informing the public to keep taking precautions.

Which Lead Filters Are Recommended?

Dr Bhargava: We know that other parts of the nation are also affected. In fact, more data demonstrate that millions of homes are affected. For physicians who are treating patients who may be in affected areas, what types of filters would you advise physicians to suggest?

Dr Hanna-Attisha: That is a great question. Flint is not an isolated story. There is lead in water everywhere. We were stubbornly slow as a nation to restrict lead in our paint, gasoline, and different things, but especially in our plumbing. The elemental symbol for lead is Pb, and "plumbum" is the Latin word for [lead].

As a nation, we did not restrict lead in our service lines—those main pipes—until 1986, and we did not restrict lead in our brass fixtures until 2014. Testing in schools and communities continues to find lead in water. In addition, the Lead and Copper Rule,[2] which regulates lead in the water and is part of the Safe Drinking Water Act, is very weak. It has no regulations on testing in schools or daycare facilities. It has not caught up with the science of lead.

The treatment for lead is prevention. There is no cure. There is no antidote.

The amazing science of lead has taught us that there is no safe level, yet the action levels are not health-based standards. There is lead in water everywhere. If people want to take maximum precautions, they should be using lead-clearing filters. There is only one specific filter that clears lead, and it's called an NSF 53 certified lead-clearing filter. Make sure that when your patients buy a filter, it is specifically a lead-clearing filter. I would recommend their use for vulnerable populations like pregnant moms and babies who are on formula being mixed with tap water. That is when a child experiences rapid neural development and when you should take the greatest precautions.

Negative Outcomes of Lead Ingestion

Dr Bhargava: Absolutely. Let's talk about what impact lead may have. It's been long recognized as a neurotoxin, but the wide-scale exposure that occurred in so many children, and could occur [in the future], highlights the significance. Can you speak to some of the previously less well-recognized negative outcomes?

Dr Hanna-Attisha: We have known what lead does for centuries. Back in the day, we used to see kids with severe neurologic disorders, seizures, convulsions, and coma because of super-high lead levels, probably from lead in gasoline, which had polluted our entire environment.

We used to not really worry about lower serum levels of lead. But over the last few decades, some really brave, heroic environmental health superstars and pediatricians like Herb Needleman, Phil Landrigan, and Bruce Lanphear have taught us about the effects of lower levels of lead. Lower levels can drop IQ levels, lead to behavior problems like attention-deficit/hyperactivity disorder (ADHD) or conduct disorder,[3] and cause hematologic disorders.[4] It's now been linked to things like hypertension, kidney disease, gout,[5] and early dementia.[6]

It affects almost every organ system and every age range, but because of their rapidly growing development, we worry about children the most. Biophysically, whenever calcium is in any metabolic profile, lead replaces calcium and limits neuronal connections. It has a wide array, but the most worrying part is what it does to the nervous system, especially the developing nervous system.

Dr Bhargava: As pediatricians, we are seeing a rise in ADHD, so the question becomes: How much does environment influence this? It's hard to distinguish, is it not?

Dr Hanna-Attisha: Absolutely. As with all environmental health issues, proving causation is very difficult. Lead is described as a silent pediatric epidemic because we do not see the consequences right away. There is a lag time. We see it years, decades, and maybe generations later. We are now learning about the epigenetics of lead as moms are exposed to lead. You can see DNA methylation changes in their grandchildren.[7]

In addition, the consequences of things like lead exposure are multifactorial. If I see a kid in clinic this afternoon and diagnose him with ADHD, was he always supposed to have ADHD? Did he have a family history of ADHD? Could this water or the lead exposure contribute to that? It is very difficult to pinpoint the causation with all environmental health issues, but, fortunately, the management is the same. Most importantly in environmental health, it's primary prevention. It's making sure those children are never exposed.

What Support Systems Are Available for Lead-Exposed Children?

Dr Bhargava: Let me ask you about the management of these children because there are long-term cascading consequences. Once you see children with lead levels, do we have the support systems available to help them?

Dr Hanna-Attisha: Nationally, those support services really are not in place. The treatment for lead is prevention. There is no cure. There is no antidote. There is not much that we can do to reverse or eliminate that exposure. However, we can do a lot to buffer, mitigate, and make sure that we do not see those consequences. In public health, we call this secondary prevention.

Now that you already have this exposure, what do we do to not see the consequences? That is where my work is every day in Flint. We put in place the services that science has taught us promote development. In Flint, we have robust early education services, high-quality childcare, universal preschool, early literacy investment, parenting support, healthcare access, and nutrition support. Nutrition plays a critical role in [mitigating the effects of lead exposure].

These are common-sense things. These are things that all children need. All children need home visiting programs, breast-feeding support, great nutrition, early education, and access to books. We are leveling the playing field for these children to make sure that we do not see the consequences of this lead exposure.

Improving Primary Prevention

Dr Bhargava: This question is obviously tongue in cheek—but if you were in charge of everything, would you put your resources into the services you've described? Or would you put resources into testing the children? Is routine screening of children at 1 and 2 years of age sufficient?

We are really using children as canaries of environmental exposure.

Dr Hanna-Attisha: I have thought a lot about testing children recently, and it's come up a lot since Flint because testing rates are so low. Over a decade ago, the Centers for Disease Control and Prevention (CDC) recommended universal testing—that every kid be tested at 1 and 2 years of age—and as those rates of elevated lead levels came down, they moved to more targeted and high-risk testing.[8]

Not that many kids are tested anymore. In Flint, where most children should be tested because Medicaid mandates testing at 1 and 2 years old, our screening rates before the crisis were only about 40%. We are not identifying the children who are exposed.

We are really using children as canaries of environmental exposure. We should not be testing children; we should be testing environments. Before we ever detect lead in a child, we should be testing their water, paint, soil, dust. Because, like I said, when we find lead in a child, it is too late.

This is the whole point of primary prevention. There are some really innovative best practices out there. For example, in Massachusetts, before a child moves into a home, that home needs to be checked for lead exposure. There are some home visiting programs that check the child's environment before the child is diagnosed. This is where we need to be heading.

Yes, we do need to increase testing of children as well, but more importantly, we need to be shifting our paradigm. We need to be checking environments rather than checking children and checking environments before a child is exposed rather than after a child is exposed and thus devoting resources after the exposure.

There Is No Safe Level of Lead in a Child

Dr Bhargava: There is really no scientific evidence in terms of what is and is not a high level of lead in water. Even the lead levels that the Environmental Protection Agency (EPA) deems to be safe in water are not based on amazing science. Am I right about that?

Dr Hanna-Attisha: The scientific community, the CDC,[8] and the American Academy of Pediatrics (AAP)[9] agree that there is no safe level of lead in a child. There is no high level or low level. There is no safe level of lead in a child. Currently the reference level for lead in blood is 5 mcg/dL.[2] This does not mean that this is an elevated level. This is just the reference level. Based on national data, 2.5% of children who are tested are above that level.[8]

There is no safe level in a child. However, the levels that the EPA and the CDC have set for lead in water, paint, soil, and dust have not caught up with the science of no safe level. For example, the EPA's action level for lead in water is 15 parts per billion (ppb).[2] The World Health Organization's action level for lead in water is 10 ppb.[10] The US Food and Drug Administration, which actually regulates lead in water, has set a standard of 5 ppb for bottled water.[11]

What we have at the EPA is a standard based on the feasibility of water utilities meeting this guideline. It is not a health-based standard. If it was a health-based standard, it would be 0 or 1 ppb. That is what the AAP has recommended in their most recent guideline on lead exposure,[9] which states that lead in water should not exceed 1 ppb in childcare facilities and in daycares.

That is where we need to be going. We need to advocate for stronger regulations to cut these action levels down to match the science; we now know that there is no safe level of lead.

Before the Flint crisis, I was not naive, but I trusted that when I turned on my tap in America in this century, that the water was safe, and it was tested....I no longer believe that.

Lead Exposure During Pregnancy

Dr Bhargava: Let's steer away from children and talk about pregnant women. You talked about how in Massachusetts homes are tested before a child moves in. What about pregnant women? Should their environment or they be routinely screened?

Dr Hanna-Attisha: Absolutely. The American Congress of Obstetricians and Gynecologists does have some guidelines.[12] I think that they need to be restrengthened as really it should be preconception testing of lead exposure.

Pregnancy and childbirth are big moments in people's lives, and it's often the times when people embark on, for example, renovation projects. "Let's fix up a nursery. Let's do it ourselves and learn how to fix up a nursery on YouTube." They scrape the paint off the wall, sand things down, and get all this dust exposure. It's often because of these projects that the most high-risk folks are being exposed to more lead.

A lot of education needs to be done to limit exposure for these really critical points of a child's development and obviously in utero. Yes, there is an opportunity for education and screening at preconception.

Dr Bhargava: Do you think that pregnant women should just universally be told to drink bottled water?

Dr Hanna-Attisha: I do, or they should drink filtered water if they have a lead-clearing filter. Before the Flint crisis, I was not naive, but I trusted that when I turned on my tap in America in this century, that the water was safe, and it was tested. I imagined people in white coats who were charged with protecting our drinking water supply. I no longer believe that. I know that these regulations are not strong. I know that there is a lot of gaming of the regulations, the gaming of the sampling of lead in water. If you can guarantee that there is no lead in your entire distribution system from when the water leaves the water treatment center until you turn on your tap, that there is no lead in your solder, your brass fixtures, in your service line, then you are okay. If you cannot guarantee that, why not protect the health and development of your child and ensure that you are drinking filtered water?

Ensuring the Health of Our Kids Today... and Tomorrow

Dr Bhargava: I suspect that you did not plan to become a nationally recognized champion for public health, but we are really glad that you are. What were your biggest lessons, and what message would you convey to family doctors, pediatricians, and nurse practitioners who are taking care of all of these children?

Dr Hanna-Attisha: What I did and what I continue to do every day is part of my job. I am a pediatrician. I took an oath when I became a doctor to protect my community, to be their healer, to fight for my kids. I have done nothing that is not part of my job description, especially as a pediatrician. I use my voice and my skill set to make sure that my children, either the children I see individually in clinic or the children that are part of my larger community, are protected.

As pediatricians, so much of what we do is prevention. We see a kid for their well-child visit; we talk about eating well and exercise. We talk about helmet use and car seat safety. So much of what we are doing is making sure that our children are healthy today, but really more than that, all that anticipatory guidance is making sure that our children are healthy tomorrow.

This crisis was a perfect example of a threat to the tomorrows of our children. It was definitely in my professional duty, in everyone's professional duty as a physician, to stand up, to walk out of our clinics, to walk out of our classrooms, to walk out of our labs, and advocate for our communities. I think that physicians should take that oath again and remember that this is our duty. It's very comfortable for us often to stay in our offices, our clinics, our exam rooms, our classrooms, and our labs. If there ever was a time, it's a time for us to get out there and to fight because there are quite a few injustices out there that are threatening the health and development of our patients.

Dr Bhargava: Thank you very much, Mona. We really appreciate your time and your incredible efforts in this area. As a pediatrician myself, I do think that prevention is key, and activism is really important, as you suggested, to get out and make sure that the messages are being heard and policies are changing. I want to thank you, and Medscape thanks you. We congratulate you on your efforts and hope to see a lot more from you. Thank you again for your time.

Dr Hanna-Attisha: Thank you. Thanks for having me. It's been great.

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