How an underfunded lead poisoning surveillance system failed Flint

A lack of transparency at the state and local level led to criminal charges and civil lawsuits following findings that officials did not act quickly enough to alert residents in Flint, Michigan, that their water had been contaminated.

By Devi Shastri

It could have been any dinner between two longtime friends, were it not for the topic. Elin Betanzo, a water engineer, was telling pediatrician Mona Hanna-Attisha about her suspicions that the public water system in Flint, Michigan, was contaminated with lead. Betanzo urged Dr. Mona, as she is known around the local Hurley Medical Center, to check the blood lead levels of children who were treated at the hospital. They had known each other since their high school days in Oakland, about a 45-minute drive away, so Hanna-Attisha was intrigued.

Above: Flint resident Joy Jones said that no one in the city trusts the state health department. Jones said each of her children (below with her partner, Ernie Woycik​) had been tested for elevated lead levels at least once because it was required through Medicaid, though none tested above the CDC’s reference level of 5 µg/dL. While some symptoms of lead poisoning were apparent, like severe rashes, she worries about what future consequences of the exposure might await the children. (All photos by Devi Shastri.)

The pediatrician spent the next two weeks analyzing the hospital’s data, including samples of about 60 percent of all children the city tests, or about 1,700 children. In August 2015, she compared those results to about 1,650 results from across the state. She found an increase in the blood lead levels of nearly 5 percent of the Flint children — almost double the rate of children tested before the city switched water systems more than a year earlier.

The change in water systems occurred because Flint emergency manager Darnell Earley, appointed in 2011 by Gov. Rick Snyder (R) to try to fix the city precarious finances, thought switching from Detroit’s water system could save money. Flint had used for Detroit’s water for 50 years, but in April 2014, it began drawing water from the nearby Flint River. Almost immediately, residents complained that the water was murky, yellow and smelled like rotten eggs. By October 2014, when General Motors’ Flint plant announced it would no longer use city water because it was corroding car parts, the city already had urged residents — twice — to boil their water. It is now common knowledge in Flint that boiling water makes the lead more potent.

But it would take another year, and studies done by outside researchers Marc Edwards and Hanna-Attisha to prove what Flint residents had suspected, but state officials had denied: Flint’s drinking water was contaminated by harmful amounts of lead, causing rashes, upset stomachs, and a host of other illnesses. A task force commissioned by the governor would conclude in March 2016 that the crisis occurred because the state Department of Environmental Quality did not treat the water with the proper chemicals to prevent lead from leaching into the drinking water, and because the state health department did not act quickly enough to remedy the problems once discovered.

The crisis also had another cause: lack of transparency at the state and local level. State officials did not keep the public informed about their own findings, and were not forthcoming with information and data, even though it subsequently came to light that many officials had known for months that the drinking water had been contaminated. Michigan Attorney General Bill Schuette has since filed criminal charges against eight state officials and a city employee, accusing them of concealing important information, and in some instances, tampering with evidence. One official was accused of ordering the deletion of emails about a July 2015 report that showed problems with Flint’s water, and of interfering with attempts by others to alert top state health officials and the public. The cases were scheduled for trial next year. Civil suits are pending against the two companies that advised Flint about water system issues — Veolia North America, and Lockwood, Andrews & Newnam — that advised officials about Flint water.

Hanna-Attisha’s experiences trying to get important data from state officials, and alert the public about her eventual findings, were emblematic of the secrecy problem. While examining hospital data in August and September 2015, the doctor realized she did not have all the information required for a full analysis. She needed a larger pool of statewide data to be sure that the spike in lead levels she had detected in Flint was, in fact, out of the ordinary. It was then Hanna-Attisha hit a bureaucratic wall. She couldn’t get the data she needed from the state health department, even though it should have been available to her — and to others — as a matter of law.

Flint’s water crisis has also pointed to a pattern of behavior that is often seen when a crisis hits a state or local government. Unable or unwilling to share what they know, officials sometimes hold back important information from the public — including that which the public is entitled to have under state information laws. In Flint, as pressure mounted on the Snyder administration, emails show, government officials ignored entreaties from the public and from Hanna-Attisha to provide more information about possible contamination of the city’s drinking water.

Flint resident Katherine Hayes stands in the kitchen of her home since childhood. She struggled with headaches following the change in water source, and sought testing to learn if the problem was her diabetes or lead. She called for more information about blood testing for adults — and for free tests. Below: Bottled water fills the store room in her home.

Another issue common across the country hampered officials in Michigan: An aging information infrastructure that leaves government entities with a lot of data and no easy way to analyze it. In one instance, local journalists revealed that the Flint Department of Public Works was storing location information about lead pipes on 45,000 individual index cards, making it difficult to determine where water filters were needed, or if residents were using water drawn from lead pipes in the public system.

Many emails between health department officials hint at this systemic issue, painting a picture of a state agency struggling to analyze its own data, and answer questions from the public. But they also show that officials had enough information to act, and did not do so. Some state officials had expressed concerns about the quality of Flint’s water as early as January 2015, by which time local government agencies had switched to bottled water. But no one told Flint residents that their drinking water might have excessive and dangerous lead levels.

“We had every obstacle in getting the larger sample size,” Hanna-Attisha said. “The first thing I tried to do was to get it from [the county and state health departments], but I couldn’t.”

Even though the state health department had statewide data about Michigan children’s blood lead levels, officials were holding it back from Hanna-Attisha, she said. State health department emails obtained by Edwards, a Virginia Tech researcher, through the Michigan Freedom of Information Act (MFOIA) capture Hanna-Attisha’s frustration with the slow response by state officials to her request for statewide data.

The Genesee County Health Department began hosting free lead testing clinics for all Flint citizens following the announcement of lead in the water supply. It partnered closely with community organizations to expand their reach throughout the city.

Defying normal research procedures that would have had Hanna-Attisha analyzing her own data with a broader sample size, and then asking other scientists to review her findings, Hanna-Attisha, worried that further delay could exacerbate public health problems, decided to go public with the data she did have. Nearly a month had passed since her original Aug. 27, 2015, request to the Genesee County Health Department, and more than two weeks since she had gone beyond the county where Flint is located to ask the state for the data. Flint residents were becoming more and more vocal about their concerns that the water was harming them and their children. Hanna-Attisha produced a statistical analysis that had a dire message: One in four or more children could have elevated blood lead levels in four of the city’s nine wards.

Researchers quickly find themselves under attack

Hanna-Attisha and her fellow researchers released their findings on Sept. 24, 2015. The state’s response was hardly reassuring, as they quickly found themselves under attack from the state, and from government officials who challenged her findings. This occurred even though the data Hanna-Attisha and fellow researchers were using was the same that the state had collected and turned over to the federal Centers for Disease Control. “Right away, we were attacked,” Hanna-Attisha said. “[The state said] that I was causing near hysteria, that I was splicing and dicing numbers and that the state’s data was not consistent with my data.”

Brad Wurfel, spokesman for the Michigan Department of Environmental Quality, said of Hanna-Attisha’s characterization of the findings: “I wouldn’t call them irresponsible. I would call them unfortunate.” And Wurfel insisted, according to the Associated Press in a story published on Sept. 28, 2015, that “Flint’s drinking water is safe.”

Geralyn Lasher, spokeswoman for the Michigan Department of Health and Human Services, told the AP that the state’s own analyses did not show the spike in children’s lead levels that Hanna-Attisha had found. “Our experts want a better sense of how they got there,” she said. “The data that we have is a much larger set of data. … We’re not seeing what those numbers look like.”

The state government’s efforts to try to control the flow of information were evident in other emails made public via various open-records requests from researchers and journalists. In one particularly telling email the day before Hanna-Attisha’s data was released, Dr. Eden Wells, the health and human service’s chief medical executive, told her staff in an email that Hanna-Attisha would not get the data she sought until state officials could reveal it themselves in a news conference. The email stated: “Governor’s Communication Plan states data not to be shared with HURLEY/LHD until I call her/them before 1:30 press conference (about 1 PM) Once Press conference starts at 1:30, that would be fine, I would think!!!!!”

The state’s emails showed that the decision to continue to delay releasing data came directly from Snyder’s office. The governor and aides had had been trying to tamp down concerns and had not yet publicly acknowledged that Flint’s water was tainted.

The lack of transparency was not limited to Hanna-Attisha’s request. State officials knew earlier that summer that there were serious problems in Flint, but these concerns were not disclosed until more than six months later, in early 2016, after her findings were disdained by state officials, and only in response to public information requests from Edwards of Virginia Tech.

State epidemiologist Cristin Larder said in an internal report on July 28, 2015, that the state’s data showed elevated lead levels in Flint children, but her findings were not made public until January 2016 via Edwards’ information request. Nick Lyon, director of the state health and human services department, also acknowledged this report describing elevated lead levels, but did not do so until April 2016, in his written responses to questions from State Senator Jim Stamas prior to a public hearing.

The secrecy had done little good. In the end, Hanna-Attisha was vindicated, and the state looked as if it had deliberately withheld important information about a serious public health issue. “In July of 2015, we now know that they had done very detailed analysis by ZIP code of what was going on and had seen similar increases,” she said. “If they had released that in July, then this would have been resolved in July.”

In his April 2016 statement, Lyon said the delay stemmed from departmental uncertainty about the data, and said he had thought the state’s environmental agency was on the case. “I cannot recall precisely when I became aware of Flint’s water troubles, believed at the time that (the Michigan Department of Environmental Quality) was addressing these issues,” wrote Lyon. “I have since learned that over time personnel at the MDHHS were looking into the matter, and it was not until they analyzed data using the same methodology as Dr. Mona Hanna-Attisha at the end of September 2015 that they could come to a firm conclusion that there was an issue with elevated lead levels.”

Karen Weaver, Flint’s new mayor, addresses citizens in one of her monthly town hall meetings. Those in attendance expressed their concerns and anger about the implications of lead exposure and what the government would be doing to help the city.

The independent task force commissioned by the governor reiterated the impact of the delays of disclosing what the government had known for months: The final report of the Flint Water Advisory Task Force said that before the July 2015 internal report from Larder, there had been no analysis of 2014 lead levels, because the state’s Childhood Lead Poisoning Prevention Program assumed that elevated blood lead levels were being addressed on the local level by children’s doctors. The task force reported that the Michigan health department was too slow to act, and that even the Larder analysis in July 2015 was not conducted until after Snyder’s chief of staff, Dennis Muchmore, expressed his concern about residents’ complaints.

Wells, the top doctor at the state health department, said she did not know precisely why the state had delayed giving Hanna-Attisha the data she was seeking. “I was not involved with that and I know that there’s been all of the email FOIAs, but I personally can’t speak to that because I didn’t get involved until after (Hanna-Attisha’s) press conference,” she said. “I wish I could give you more, but I just don’t have that detail.”

Hanna-Attisha said that Wells was the key to eventually getting the state to release the data. The two now work closely to get test results to Hurley Medical Center in real time, so both the hospital the state health department can continue to monitor levels together. Wells said that the department has learned a lot needs to change about how it monitors the test results, and it has already started to improve how the data is analyzed — they will be looking at it more closely, rapidly and frequently to catch any spikes. Wells said that there was a need now to look even more closely at areas with greater risk of lead poisoning, to consider alternate sources of lead and to account for the fact that overall, lead poisoning rates have dropped drastically. But, she said, funding is still a challenge.

“This is reflective (of the fact that) funding has been drastically cut to support lead programming across all of the states and territories,” Wells said. “That can reflect on decreased capacity. We have a data analyst, we have an epidemiologist … and we have a nurse case manager and a nurse leader, but that represents probably half or so of what the lead program used to be, at least at the state level, compared to the late 2000s.”

Continuing to question and reevaluate existing data

National efforts to prevent childhood lead poisoning have taken several hits over the years, and researchers continue to question and reevaluate the existing data to get more specific results.

The Flint water crisis had many causes. Even though there is a formal system in place — known as a surveillance system — to track lead levels in Michigan, it didn’t seem to work. Some say it is a chronic lack of funding, due partly to congressional trims to funding for the program, which is federally funded. Before Hanna-Attisha’s data request, the state health department was the only entity collecting the numbers to pull off such an analysis, but many say the issue was missed due to program funding cuts.

The CDC funds childhood lead surveillance programs in 29 states, five major cities and the District of Columbia. From 2000–2011, the program was allocated about $30 million each year to monitor childhood lead exposure in each state and D.C. State health departments distributed the money to counties. But in 2012, that amount was slashed by Congress to $2 million and combined with an asthma control program, according to the National Center for Healthy Housing (NCHH). Two years later, funding was increased to $15 million, where it hovers today.

The cuts were made following a congressional request to increase focus on “evidence-based best practices for policy interventions.” The move to combine lead surveillance with the federal asthma program was a CDC transitional effort to consolidate the program focusing on health hazards in homes overall. The CDC would provide software and technical assistance to implement the Healthy Homes and Lead Poisoning Surveillance System to states, and each state would maintain and support its respective database.

“I think the main reason is that Congress has been cutting programs like this pretty much across the board,” said David Jacobs, chief scientist at the National Center for Healthy Housing, a nonprofit that works on lead issues. “There is a lack of investment in infrastructure, whether it’s lead in water pipes or lead in housing and that decline has proceeded to pace, and you see the result in Flint and elsewhere. I wish I could say it was a rational decision, that the funding was reduced because the problem has been solved, but that’s clearly not the case. With half a million poisoned children it’s clear that much more remains to be done.”

Officials at the Centers for Disease Control did not respond to multiple requests for comment.

On Aug. 15, 2013, the American Academy of Pediatrics sent a five-page letter to President Barack Obama. The professional society of 60,000 doctors, surgeons and specialists were making clear where they stood on a major public health issue: the funding for lead poisoning prevention. “With such limited funding,” the letter stated, “most of the activities which provided federal leadership and oversight and a public health framework for lead poisoning prevention and healthy housing work, as well as funding to approximately 35 state and local grantees for lead poisoning, cannot be carried out at this time.”

“Frankly, health departments are overwhelmed just keeping up with the poisoned kids who are already out there,” said Jacobs, a former director of the federal Office of Lead Hazard Control and Healthy Homes, who also directs the U.S. Collaborating Center for Research and Training on Housing Related Disease and Injury for the Pan American Health Organization.

April Swartout and Toni Larocco (right) stand in the New Jerusalem Full Baptist Church, where the health department held its largest free lead testing clinic in Flint.

Back in Flint, though, the data collection does little for the Genesee County Health Department, which is dealing with the water crisis on the front lines. “When people ask for broader pictures of what the data looks like, I refer them back to the state, because I don’t have all of that,” said Toni Larocco, the county’s director of nursing services. “We are following up on the elevated ones, but I don’t have the broader (sets). Really, I’m relying on them for that kind of stuff.”

For Jacobs, one of the world’s most experienced authorities on household lead exposure, the need for monitoring childhood lead exposure is urgent. “The surveillance program is absolutely essential,” Jacobs said. “That basically enables the nation to have an estimate of how many kids are at risk. I’m old enough now to remember the 1980s, when we also stopped counting children, and because lead poisoning is largely an asymptomatic disease, if you don’t count the number of children with lead poisoning, then the problem disappears.”

But as the Flint crisis showed, the problem did not go away.

Devi Shastri, a junior majoring in biomedical science and journalism at Marquette University, reported this story while spending the 2015–16 academic year working alongside Miranda Spivack, an independent journalist focusing on state and local government transparency — or lack thereof — with support from the O’Brien Fellowship in Public Service Journalism. Devi earlier also wrote of her experience reporting from Flint during spring break 2016.

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