Lead poisoning of our children: then and now

Back in 2016 much of the country was shocked to learn about widespread lead poisoning among children in Flint, MI. The cause was lead leached from old lead pipes supplying water to people’s homes after the source was changed from Lake Huron to the more corrosive water of the Flint River (to save money, of course). The identification of this problem was largely due to the great work of a committed pediatrician, Dr. Mona Hanna-Attisha, about whom I wrote on Jan 24, 2016, “Flint, lead, medical heroes, O-rings and guns”. That piece also discusses the shameful – probably criminal – denial of both the problem and its cause by the then-governor of Michigan, Rick Snyder, and his politically appointed state health department, until the evidence became too overwhelming to deny. After all, poisoning children is one thing, but getting negative press is another!

Many of us probably assumed – or at least hoped – that this epidemic of lead poisoning of children, as horrible as it was, was an exception, an outlier, something that should not be happening in the 21^st century in the United States. We knew that it was related to the fact that Flint is a poor, largely minority, community, and if we are at all sentient we know that those are the people who suffer the worst from environmental degradation. In the case of lead poisoning, they live in houses that are more likely to have old lead paint, in neighborhoods built closer to heavy automobile and truck traffic areas where the soil (such as, for example, in the playgrounds) has high concentrations of lead. We might have even thought of lead pipes supplying water. But surely this was not something that was happening in many places around the country, even in poor communities?

 

But it was, and is. All over. More in very poor and minority communities.

A few years ago, [Sean] Ryan, now a Democratic state senator, learned that his constituents in Buffalo were sending bottled water to Flint, Mich., where widespread lead contamination in the water supply had drawn national attention. While respecting the gesture to help, he recalled from a Reuters investigation that there were 17 ZIP codes in Buffalo where the rate of children with high lead levels was at least double that of Flint. (Gabler, NY Times, below)

And it is still happening. And still not being addressed. Flint may have stood out because of the sudden increase in children with high lead levels identified by people like Dr. Hanna-Attisha after the change in water to a cheaper source leached lead from the old pipes, but chronic, ongoing lead poisoning of our children, primarily from lead paint in old houses, continues apace. And there is a lot of resistance to doing anything about it.

 

This is covered in depth in a recent (Mar 29, 2022) article in the NY Times by Ellen Gabler, ”How 2 Industries Stymied Justice for Young Lead Paint Victims”. This exposé documents the ongoing and continuing poisoning of America’s children (particularly those of poor and minority people) by lead paint in houses (“about 500,000 children under 6 have elevated blood lead levels in the United States and are at risk of harm”). One of the two industries is the housing industry, which both lies about whether there is lead paint in the homes that they are renting, and, if they are large enough, obstruct those people from finding some sort of (generally financial) justice by hiding the ownership in a web of companies, and fighting culpability.

 

Without insurance, there is little chance of recovering money for a child when a landlord has few resources. Property owners who do have substantial holdings have found ways to legally distance themselves from problem rentals, increasingly using L.L.C.s to hide assets and identities.

 

And the other industry? That would be the insurance industry itself, which places clauses in its homeowner’s policy excluding lead. Why? Well, you see, it would cost the insurance company a lot of money if they had to pay for the mitigation of lead paint in these old houses. So they don’t insure the owners, and the owners are either unable to afford to do the mitigation or are large and wealthy enough that they could afford it but choose not to. In fairness, the quote above about property owners legally distancing themselves from “problem rentals” applies to many “problems” (virtually all of which are the owners’ responsibility), not just lead. Property owners want to collect rent but not maintain the property; insurance companies want to collect premiums but not pay out when there is a problem. What could be more American?

 

Another recent article, in Medscape, documents how most current adults had elevated lead levels as children, and how, as stated in its title, Half of Adults Lost IQ Points to Lead Toxicity. The culprit in this case is primarily lead in gasoline. Added to gasoline beginning in the early 1920s, lead’s phaseout was accelerated by the advent of catalytic converters, which require unleaded gas, in 1975, but it was probably an additional 20 years before it was gone from most gasoline sold.  And, of course, the residual lead in the soil (including places where children play) remains even today. This graphic from the article demonstrates how ubiquitous high lead levels were when today’s adults were children, what age ranges are most affected, and of course how minority children (and today’s adults) were affected with levels far higher than whites (which were bad enough).

 

 

So we have a situation where the majority of today’s adults, at lead those over the age of 30, probably had high lead levels when they were children, and have lost IQ points as a result, and where poor and minority children then (now adults) had far higher levels than whites. And we have another situation in which children continue to have high lead levels, and to suffer not “just” a loss of a few IQ points but serious brain damage, because of ongoing lead exposure, now primarily in lead paint that still exists, unmitigated, in many houses. And, of course, these children are disproportionately poor and minority. (Some things, sadly, do not change.) When I was a young physician, working at Cook County Hospital in Chicago, we would not infrequently have to treat (often as inpatients) children with high lead levels. I thought, like measles and chicken pox and rheumatic fever and infections from Hemophilus influenza that this was pretty much history, stories of the “old days” that I could tell medical students and young doctors. I am aghast to discover how common it continues to be.

 

But there is another part of the story. It is that lead could be cleaned up. Houses with lead paint could have that lead mitigated. If it were, children would no longer be exposed to it and suffer the kind of brain damage described in the Times article. But it isn’t happening, because of the stonewalling, opposition, and outright blockage by the landlord and insurance industries, and their enablers in Congress and state legislatures. Their profits, of course, are more important than the brains of developing children, especially poor and minority children.

 

You can’t have it both ways — be a big company when it benefits you to generate revenue and business, and then hide behind an L.L.C. when you are sued in an attempt to escape accountability

 

says the attorney for “JJ”, a South Bend, IN, child with brain damage from lead paint in his home.

 

But they do have it both ways – this is how the US treats companies compared to children. And as a result we have the article’s final quote from JJ’s mother:

 

“We know it damaged his brain,” she said. “We know it is irreversible. And we know it is a lifelong thing. No doctor can tell you, ‘This is what is going to be.’”

 

Somehow, this does not make me proud.

Why don't we spend more on public health? It is harder to see the bullets we dodged -- and then there is profit.

“It Saves Lives. It Can Save Money. So Why Aren’t We Spending More on Public Health?”  (New York Times, May 28, 2018). Actually, this is a terrific question. As so often, it is complicated. Let’s start with the benefits that authors Aaron E. Carroll and Austin Frakt describe. First, there are vaccines. They eliminated smallpox and virtually eliminated polio in the United States. They have dramatically reduced the rate of common childhood illnesses including measles, mumps, rubella, chicken pox, and Hemophilus influenza (H. flu) infection. They have the potential for essentially wiping out cervical cancer through immunization against HPV, and liver cancer (as well as many forms of chronic hepatitis and cirrhosis) through vaccines against Hepatitis B.

A huge public health intervention is making our environment safer. This means having good sewage and clean water, and lead-free gasoline and cleaner air. These changes have saved far more lives, and improved health much more, than all of the individual medical care interventions combined. If you have traveled abroad, especially to less developed countries, you know how important these are. Indeed, better sanitation, as well as better surveillance and treatment, have dramatically reduced other infectious diseases that were once terribly feared, notably tuberculosis. And inspection of our food supply, restaurant and otherwise, are another very important part of public health.

The other big public health measure is education. Of course, education can be and is provided to individuals by health professionals as well as populations via public service education, but it is major nationwide public health efforts that have made a big difference. These include the huge decrease in cigarette smoking, and the greater safety of automobiles and their exhausts. Cigarette smoking used to be ubiquitous (see any WW2 movie) and in what would shock young Americans today, widely practiced in restaurants and even college lecture halls. Today that is unimaginable, and smoking in most places is aberrant, with less than 15% of adults currently smoking and most of those trying to quit. Car accidents are still a major cause of death and injury, but deaths from cars are way down. Almost none of this is related to people driving more safely and almost all of it to safer design of cars (think seat belts, air bags, engines that collapse down instead of back in a collision) and roads. Lead poisoning of children is way down in most places in the US thanks to lead being banned from gasoline and paint.

There are still many challenges on the public health front. Reducing the rate of chronic diseases though education around eating huge numbers of empty calories still have a long way to go. The terrible infectious disease epidemic of recent decades, HIV, has been greatly reduced by treatment, but until there is a vaccine, high-risk sexual behaviors persist. The opioid epidemic is killing more and more people, and it is only through societal approaches that this is going to be reduced.

The epidemic of gun death is not abating; many studies and articles in the press have recently discussed the increase in the suicide rate, often prompted by recent high-profile suicides such as those of Kate Spade and Anthony Bourdain (How Suicide Quietly Morphed Into a Public Health Crisis; 5 Takeaways on America’s Increasing Suicide Rate, ). While neither Spade or Bourdain used a gun, guns are the cause of death in at least half of suicides, and suicide far exceeds homicide in terms of numbers of gun deaths. Those who believe it is not the availability of guns that causes deaths from both causes, and other methods could be used to kill oneself or others, are simply wrong. Easy availability of guns, far more effective and efficient at killing oneself or others than any other method, absolutely has been demonstrated to increase both homicide and suicide. Suicide by gun is over 90% effective; by drugs less than 5%. “Successful” suicide rates are far higher in high gun states (e.g., Montana) than in low-gun states (e.g., Massachusetts). Homicides are also more common where guns are at hand. And, in regard to school and other mass shootings, while you can kill someone with a knife or a baseball bat, but it is hard to commit mass murder with them.

So, why do we not spend more on public health? Why do we spend so much more on what is, from a societal point of view, much less effective individual health interventions, and less than 5% of that on public health? One reason, of course, is that when each of us is sick, we (usually) want treatment, as much as possible, especially if there is a chance that it could cure us, or at least ease our suffering. This is understandable, and it is tied to the fact that we have much greater awareness of treatment of something ailing us (curing our infection, relieving our pain) than of not having disease because of the presence of public health practices. As I would tell students, how often do we wake up thankful that we do not have cholera because we have a clean water supply? Indeed, when we find that the water in Flint, MI, is contaminated with lead, we are shocked because we assume our water is safe; when we find an E. coli outbreak from a restaurant, we are shocked because we assume our food is safe.

There is also, unsurprisingly, the issue of the money that to be made. The provision of public health is rarely a big profit center, and it is usually, therefore, done by government – local, state, and federal. Individual health care, however, is a huge money-maker for insurance companies, hospitals, doctors, pharmaceutical and device manufacturers, nursing home companies, and on and on. All that money – over $3.3 TRILLION by recent estimate -- spent on your and other individuals, while it may (or may not) have a salubrious impact on you, is going into someone’s pocket. On the flip side, public health interventions often reduce profit, especially when they are very effective. The struggle against tobacco, which killed more people than any other cause by far, was fought long and hard by the tobacco companies (currently now plying their wares in the less-developed world).Each of the changes to cars that led to the great increases in safety was fought by the industry. Today, we continue to see tremendous opposition to rules that make our environment (air, water) clean and safe; sadly, under the current administration, many of these rules are being rolled back, which will absolutely decrease our society’s health.

I guess I also need to address the people who believe that vaccines are unsafe. They are a major threat, and presumably haven’t seen children dying of measles, of the suffering of chicken pox and mumps, of the morbidity from H. flu infections of the middle ear (my students have never seen it!) or deaths from H. flu epiglottitis. Yes, there can be minor side effects from some vaccines, but the benefit is overwhelming.

Finally, as always finally, it is the poor and disenfranchised who suffer the worst. While sometimes we have the perverse satisfaction of outbreaks of vaccine-preventable diseases in well-to-do communities, anti-vaxxers unconscionably campaign in immigrant/refugee communities telling people to not vaccinate their children. The poor and minority city of Flint suffers a poisoned water supply. The oldest, cheapest houses are likeliest to have peeling lead paint and be located near polluting factories and dumps. Tobacco and junk food manufacturers advertise most heavily in minority neighborhoods. And, of course, the murder rate is highest in poor and minority communities.

Good medical care for individuals is valuable when it is needed, and could be less expensive. Public health measures are even more valuable and cost-effective. We need to increase the money and effort spent upon public health interventions, and certainly not scale them back.

Benjamin Franklin said an ounce of prevention is worth a pound of cure. It’s true, and is a great argument for greater investment in public health.

Flint, lead, medical heroes, O-rings and guns

In January, 1986, 73 seconds after lift-off, the space shuttle Challenger exploded, killing all 7 astronauts on board, including one of the first civilians to go up, New Hampshire teacher Christa McAuliffe. It was a disaster; indeed the words are now paired so that we always say “Challenger disaster”. The cause was a flaw in the design of the solid rocket boosters (“SRB”s) and in the now famous “O-rings”, flexible rubber seals, like max versions of the ones we see on a lot of home tools. It was perhaps the worst domestic disaster of its time, nine years before the 1995 domestic-terrorist white-power bombing in Oklahoma City, almost 16 years before the attack on 9/11. It was a disaster in two ways; the obvious one, the explosion, and in that it could have been prevented; NASA and the company that produced the SRBs, Morton Thiokol, knew about the problem.

Morton Thiokol engineers, and particularly one named Roger Boisjoly, had been worried about the problem for years; Boisjoly had expressed his particular concerns in 1985. Morton Thiokol managers considered telling NASA to scrap the launch, and then decided not to. After the disaster, Boisjoly testified before a commission about the problem, and about the warnings that he had sent to his bosses. In 1988 he was awarded the Award for Scientific Freedom and Responsibility by the American Association for the Advancement of Science. He was shunned and at Morton Thiokol, and resigned. He was right; Morton Thiokol and NASA were wrong, and it led to a disaster. And he was out of a job.

In 2014, Michigan Governor Rick Snyder appointed an emergency manager named Darnell Earley, for the bankrupt city of Flint. One of his cost-cutting measures was to stop buying treated Lake Huron water from the Detroit system and instead supply water from the Flint River. The river was full of corrosives, from decades of industrial discharge, and one effect was to degrade the old lead pipes in many Flint homes, dramatically increasing the lead levels in the water. And in the bodies of Flint’s children. The politics of the decision are continuing to play out, with calls for Snyder’s resignation, and it would have been corrupt and evil even if the problem had been identified and remedied earlier. It wasn’t, and thus became a disaster. Good piece on it in Rolling Stone.

Again, we have a hero, a Flint pediatrician named Mona Hanna-Attisha. Dr. Hanna-Attisha had heard that a team from Virginia Tech had found high lead levels in Flint’s water, and noted that she was seeing a rise in the number of children with high lead levels. She led a team doing “the easiest research project I have ever done”; because Medicaid requires children to be tested for lead at 1 and 2 years of age, she was able to compare the prevalence of high levels from 2013 to 2015.  The percentage of children with elevated lead levels “doubled in the whole city, and in some neighborhoods, it tripled. And it directly correlated with where the water lead levels were the highest” she noted in an interview on “Democracy Now”. She announced it at a press conference, and was immediately attacked by the powers-that-be (I call them the “PTB”); in this case both the political leaders of the state and the state health department.

Well, that evening, we were attacked. So I was called an "unfortunate researcher," that I was causing near hysteria, that I was splicing and dicing numbers, and that the state data was not consistent with my data. And as a scientist, as a researcher, as a professional, you double-check and you triple-check, and the numbers didn’t lie. And we knew that. But when the state, with a team of like 50 epidemiologists, tells you you’re wrong, you second-guess yourself. But that lasted just a short period, and we regrouped and told them why, "No, you were wrong." And after about a week and a half or two weeks, after some good conversations, they relooked at their numbers and finally said that the state’s findings were consistent with my findings.

There is a long and distinguished tradition of doctors making breakthrough discoveries that helped cure or prevent disease in thousands or millions of people. Some of the most storied are Edward Jenner, the 18^th century physician who invented the vaccine to prevent smallpox, 19^th century physicians John Snow, who discovered that the contaminated water from a particular pump in London was the cause of a cholera outbreak, Ignaz Semmelweis, who showed that doctors washing their hands could prevent deaths in post-partum women, Rudolf Virchow, the “father of social medicine”, who showed an outbreak of typhus among miners was the result of the social conditions they lived in, Louis Pasteur, Robert Koch, and Joseph Lister who proved that germs caused those diseases, and 20^th century doctor Jonas Salk, who found the vaccine against polio. Does Mona Hanna-Attisha’s work rise to this standard?

Well, it may not in terms of the total lives saved, although it is worth noting that, like the work noted above, it is about public health, about populations, not individual interventions, and thus has a great impact on so many (despite the fact that in the US at least 95% of all “health spending” is on individual medical care, not public health). But she is heroic in that she stood for the truth and for the health of the children in defiance of the powerful who were trying to minimize or cover up the problem, and who tried for a while the “best defense is a good offense” strategy of attacking her, shamefully. Indeed, this is what it takes to be a hero, to not only do something important that has an impact on many, but even more to do it when you have to stand against the establishment, the PTB, the powers-that-be. This takes a great deal of courage, as well as commitment.

In Kansas, the legislature legalized concealed-carry of guns a couple of years ago, but exempted schools and hospitals until July 2017. As that date approaches in 18 months, there is little indication that the exemption will be extended, and there is great concern. A recent survey found that 70% of faculty and staff at the 6 state Regents universities oppose the law. Faculty are worried about telling students that they are failing them while they sit in their offices armed; doctors worry that if a crazy person pulls a gun in clinic, several others will draw down and make it more dangerous, police worry that they won’t even know who created the original threat. The data shows that there is a real risk of more homicide with more access and carriage of guns; “natural studies” of homicides showed a marked increase after Missouri eliminated its permit laws in 2007 and decrease after Connecticut tightened its laws after Sandy Hook.[1] [2] Moreover, 60% of gun deaths are suicides, and these are also dramatically decreased by making guns less easily accessible.[3]  Doctors and researchers need to speak out about the public health implications of easier access to guns. Luckily, many are; others are worried that perhaps the notoriously-vindictive Kansas legislature may respond by cutting funding for the university. These people will not become heroes, but they may keep their jobs and their funding.

Being a whistleblower is not easy. It is not a way to have a calm, peaceful life. Some folks have made a lot of money and retired far from those they blew the whistle on, but many more I know of are, like Roger Boisjoly, are shunned, forced out of their jobs, threatened, and may even suffer PTSD. It is not easy to take on the PTB. Better to work in their interests; for his great work as emergency manager in Flint, Darrell Earley has just been named emergency head of the Detroit Public Schools!

The full impact of the Flint lead-poisoning disaster is not yet known, because the full impact of these elevated lead levels on the brains and bones of Flint’s largely poor and African-American children will take years to take their toll. Even then, and even if, because they are treated the damage is limited, we will never know what kid who grew up seemingly ok and normal might otherwise have been brilliant.

She might have become a doctor, maybe even a heroic one like Dr. Hanna-Attisha.

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[1] Rudolph, KE et al., Association Between Connecticut’s Permit-to-Purchase Handgun Law and Homicides Am J Public Health. 2015;105:e49–e54. doi:10.2105/AJPH.2015.302703

[2] Webster D, et al., Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 91, No. 2, doi:10.1007/s11524-014-9865-8

[3]  Crifasi CK et al., Effects of changes in permit-to-purchase handgun laws in Connecticut

and Missouri on suicide rates, Preventive Medicine 79 (2015) 43–49