I remember learning about lead poisoning and its consequences back in medical school. At the time, I thought it was historically relevant but unlikely to have much practical significance. After all, over the past 40 years, lead has been removed as an additive to gasoline and paint, and blood lead levels have reached historic lows in the United States. Lead poisoning seemed to be an archaic threat.
And then Flint happened.
The tragedy still unfolding in Flint, Michigan is a reminder that often, the greatest threat to public health is human indifference. Environmental and public health catastrophes are not merely accidents. They erupt along the fault lines of race and poverty, and are the direct result of decades of negligence towards our most vulnerable communities.
It is no coincidence that the majority of people living within two miles of hazardous waste facilities in the United States are people of color. Which means Flint is almost certainly not the anomaly we have so far assumed it to be.
Indeed, recent evidence suggests that Flint is just the tip of the iceberg. Recently, New Jersey’s Department of Environmental Protection found elevated water lead levels in at least 30 of Newark’s 66 public schools. A USA Today analysis revealed a much more pervasive problem of excessive lead levels in 2,000 water systems across the country. While lead poisoning rates have fallen dramatically over the past few decades, black children remain disproportionately more likely to be at risk of exposure.
Public health is about more than just health care. It relies on principled governance and accountability, which seem more likely to falter in communities of color. Notably, in 2013, over half of African Americans in Michigan lived under unelected emergency management, compared to only 2% of whites. This type of management by an unelected official creates perverse incentives that allow fiscal austerity to trump the health and well-being of children. As such, evidence suggests that city officials repeatedly ignored complaints regarding Flint’s water supply for many months before acknowledging the public health emergency.
The Flint crisis began when the city changed its water supply from Lake Huron to the Flint River in April 2014 while awaiting a new pipeline. The new water supply was 19 times more corrosive than the previous supply given it’s composition of high chloride, high chloride-to-sulfate mass ratio, and no corrosion inhibitor. The city, under state appointed emergency management, opted against treating the water for corrosivity, which cost roughly $100 per day. The untreated water eroded the city’s aging pipelines causing lead, a soluble metal, to leach into the water supply.
In terms of magnitude, the EPA requires action when water lead levels reach above 15 parts per billion. In the most recent testing in Flint, many homes registered levels of 150 parts per billion, 10 times federally regulated thresholds. The highest concentrations measured up to 4,000 parts per billion. Infants and children absorb up to 50% of an oral dose of soluble lead. The metal is a potent neurotoxin which causes developmental delays and cognitive deficits. And while the direct health effects are evident, immediate problems are compounded by downstream indirect and social costs.
Children that have been exposed to lead are more likely to underperform in school, which in turn impacts their long-term careers and earning potential. Evidence also shows that the neurobehavioral changes associated with lead exposure can increase criminal behavior and incarceration rates. If we consider the costs of such a crisis as Flint, we realize that the loss of human potential embodied in an entire generation of children–coupled with the impact on society that comes with an increase in crime–far outweigh the money saved by not treating the city’s water supply.
Such downstream social and indirect costs are particularly poignant given the extent of social deprivation that already exists in Flint. With a population that is majority African American, Flint remains one the nation’s poorest cities with over 40% of the city’s population living in poverty. Greater Flint ranks at the bottom of all counties in Michigan in metrics such as unemployment, violent crime, illicit drug use, domestic violence, preterm births, infant mortality, and overall health outcomes.
What we witness in places like Flint is a reality where the health of primarily African-American communities is seen expendable by city authorities, for the sake of budget considerations. It reflects not simply a water supply that has been contaminated by lead, but a local government immersed in inhumanity.
In medicine, we seek to identify risk factors that are modifiable in order to improve health outcomes. To understand the Flint tragedy is to recognize that lead is just the symptom. The greatest risk factor responsible for human suffering in cities like Flint, and perhaps the disease itself, is racism.