YOU CAN BE DRAWN TO THE field of public health as a humanitarian, a mathematician, a statistician, or a health provider. It can be a religious calling, or it can spring from a passion for pure science. For me, except the religious business, it’s a combination of all those things, along with my love for a bit of suspense. Addressing a public health crisis or curing a disease is like solving a mystery, usually with just the right mix of instinct, insight, footwork, solid data, strategy, and pure luck. The history of public health is loaded with incredible stories and puzzles, which is why so many books are written about contagions and outbreaks. Even zombie stories are metaphors for epidemics.
Before public health departments became part of government, responsibility for people’s welfare fell on their families and communities. It’s been only fairly recently, over the last couple of centuries, that governments became involved in protecting the health of citizens. As a field of science, public health rose up with the cities that formed around the time of the industrial revolution. As people crowded into smaller geographic spaces, disease spread faster. Wood and coal fires polluted the air. Human waste ran into the streets. Running water was very rare, sewers even rarer.
My favorite sleuth is John Snow, a nineteenth-century physician, inventor, scientist, advocate, and founding father of public health. The son of laborers who worked his way through school, Snow first made his name as an anesthesiologist, before that was even a discipline, by inventing new ways to ease the pain of patients during surgery. He was even called to Queen Victoria’s bedside in childbirth. Snow published dozens of papers on a wide range of public health and medical issues, including lead poisoning. But more than anything, Snow loved systems, networks, demographics, and, most of all, epidemiology—the branch of medicine that deals with the spread and control of disease.
A century ago the biggest threat to life wasn’t cancer or heart attacks—it was infectious disease. Nothing surpassed his obsession with preventing cholera.
The effects of cholera are devastating. In a healthy person, the small intestine absorbs more water than it secretes, which keeps the cells of the body hydrated. But an invasion of Vibrio cholerae reverses that balance. A victim experiences sudden diarrhea, vomiting, and severe dehydration—quickly evacuating all fluid from their body. In a matter of hours after contracting the disease, the victim often dies. In the nineteenth century, the fluids left behind contaminated the sewage systems, then the drinking water, and spread the disease.
In London’s first outbreak, Snow’s own records show that 4,736 lives were lost. Seventeen years later, in 1849, a second outbreak in London claimed another 14,137. When cholera struck yet again, in the summer of 1854, victims in the crowded neighborhood of Soho began dying—eventually 10,530 of them.
A combination of luck, location, hard work, and brilliant instincts led John Snow to a major scientific breakthrough. Learning from his work and experiments with various anesthetics, all inhalants (primarily ether and chloroform gas), Snow doubted the prevailing “miasma” theory that cholera was spread by breathing stagnant air. He argued that people working in all kinds of smelly places weren’t getting sick. He suspected that the disease was spread by unsanitary drinking water instead. Snow conducted research, published papers, and gave presentations to the London Epidemiological Society. But few doctors in London at the time felt comfortable bucking consensus. And politics played a part.
Miasma was the established theory—and had the support of the entire medical establishment and public health community, including the persuasive reformer Edwin Chadwick, who had led a charge to clean up the foul and stinky air in London by creating a drainage system for under-house cesspools, a predecessor of sewage systems. But the expensive new system relied on an ancient drainage network underneath the city that led straight to the River Thames, the source of the water that South London used for cooking, bathing, and drinking. Chadwick’s new drainage system actually left the population far more vulnerable to disease.
When the 1854 cholera outbreak occurred in Snow’s own Soho neighborhood, he once again made his case, this time to the Board of Guardians of St. James’s Parish. He argued that the Broad Street pump, where many people in the parish got their water, was contaminated—and was spreading the disease. As far as the eye could see, the water seemed clean, with no smell or any other sign of danger, but it could kill you if it had enough cholera in it. The board doubted Snow, but the pump handle was removed (just in case). By then, most people had fled the neighborhood or were using water from clean wells nearby. The outbreak was stayed.
But protecting his neighborhood—and his own reputation—wasn’t enough for Snow. His passion for science led him to try to uncover how cholera is transmitted, to prevent more outbreaks in the future. So he set about proving his theory, teaming up with Henry Whitehead, a young clergyman from another local church who believed the miasma theory. Working parallel tracks, they conducted parallel investigations and the two men created a “ghost map” where each black square or bar (later modified to dots) represented a cholera case in London. The map demonstrated an undeniable and predictable pattern: the black squares appeared in clusters close to the Broad Street water pump. Some black squares showed cholera victims who lived farther away, but Snow was able to prove they’d consumed the water from the Broad Street pump too.
SNOW AND WHITEHEAD’S NEIGHBORHOOD MAP
If it weren’t for Snow’s science, stubbornness, persistence, and passion for the truth, cholera might have raged on for another decade or more, taking thousands or even millions of lives. When I think about Snow and his accomplishment, what has always grabbed me most—and impressed me—is the way he insinuated himself into the epidemic. Nobody hired or paid him—or even asked him—to solve this epidemic. But he had a crucial tool at his disposal, epidemiology, and a problem right in front of him, in his own neighborhood, and that was enough for him to get started. He didn’t stop his research after the pump handle was removed. He kept going, kept pushing, kept researching to prove his theory and leave a lasting contribution. As a citizen and physician, he felt duty bound to share his work and make a difference, to prevent future epidemics and save lives.
It may have been his humble background that drove him. He never blamed the less fortunate for their predicaments; instead, he understood and studied the way that their environment—whether it was poor light or lack of running water—contributed to their condition.
Rather than standing on the sidelines, Snow got passionately involved. His work wasn’t about abstract scientific discovery alone. It was about people and community. That’s what science is supposed to be about—not an academic exercise for the ivory tower, or racking up publications, grants, and offers of tenure. It’s about using the tools and technology available to make lives better, no matter what articles of faith obstruct the path.
Speaking science to power, Snow was a disrupter of the status quo, not for disruption’s sake alone, but for people. Snow was so far ahead of his time, his work wasn’t totally vindicated until years after his own premature death.
I LOVE STORIES ABOUT people who can—simply by being persistent, methodical, and dedicated—change the trajectory of a life or even an entire population and generations to come. And what I love in particular is a good, engrossing public health mystery, perhaps because I have one in my family. The person at the center of it isn’t famous like John Snow, but a distant cousin of mine, a bacteriologist named Paul Shekwana. He was one of the first public health scientists from the Middle East, from present-day Iraq, to work in America. He was a “bacteriologist” back in 1904, which is—I’m pretty sure—what we would call a microbiologist, epidemiologist, or infectious disease expert today. After studying at the Royal College of Physicians and Surgeons in England—where he worked on sewage and water testing for bacteria and might have even traded water samples with John Snow—he was hired in 1904 by the department of pathology at George Washington University in D.C.
DR. PAUL SHEKWANA, MY DISTANT COUSIN, 1904
Almost immediately after he got to America, he was called to Iowa City, where a deadly outbreak of typhoid fever had struck. Shekwana was brought in to work with the Iowa State Board of Health bacteriology lab—an entire floor of the new Iowa City Medical Building was given over to his lab team. There Shekwana investigated, among other things, the tie between unpasteurized milk and typhoid. But he didn’t stop there; he promoted new public health regulations in Iowa and beyond.
His most important contribution may have been an article published in the New York Medical Society Journal in 1906 (which was excerpted in the Journal of the American Medical Association), urging all doctors to wash and disinfect their hands throughout the day, particularly before and after seeing patients. It’s almost impossible to imagine how much this simple practice improved patient care, prevented the spread of infection, and saved lives, lots of them. But even so, hand-washing rates in hospitals still have to be monitored and have much room for improvement. According to a recent review, as many as one million lives could be saved worldwide each year if more people washed their hands.
From typhoid fever to hand hygiene, Shekwana was a roving public health warrior throughout the Midwest. His comings and goings were regularly reported by the Iowa City Press-Citizen and the Iowa City Daily Press, as well as newspapers in other cities that he visited. He wrote articles about sanitation, food safety, and even drinking water. Amazingly, my family has a letter in which Shekwana urges residents not to use a certain well because of the “variations in quality” of the water.
Hopefully the eerie similarities between his career and mine don’t include an untimely and mysterious death. In the summer of 1906, Shekwana announced he was returning to England—there is no record of why—and resigned his position at the Iowa State lab. One afternoon before he left, he went fishing and walked back home along a railway trestle outside Cedar Rapids. He was found below the trestle—having leaped to his death or been thrown there by an oncoming train. A broken rib had pierced his lungs. He died hours later. The conductor of the train that may have killed him claimed he wasn’t able to stop soon enough to avoid hitting Shekwana, nor did Shekwana try to step away. An investigation was conducted. There was no proof that the train hit Shekwana, who, it was suggested, may have killed himself.
One hundred years later, the mayor of Iowa City honored him with an official proclamation for his work in public health. Was he murdered? Was it a suicide? The Paul Shekwana story has mesmerized my family for years. At the time, his friends and colleagues described him as cheerful and excited about returning to England. Perhaps he had a love interest they never knew about. Perhaps his heart was broken. Or maybe he had caused too much trouble with all his bad news about germs, the spread of infectious disease, and water quality. As with all things, there is so much more to know.
SNOW’S AND SHEKWANA’S DAY, so different from our time, is best captured by Charles Dickens, who as a novelist was also a social critic and child advocate. His eyes wide open to the dark alleys of the industrial revolution, Dickens captured the gross inequities of his time and always kept the most innocent at the center of his stories.
“In the little world in which children have their existence,” he wrote in Great Expectations (1861), “there is nothing so finely perceived and so finely felt, as injustice. It may be only small injustice that the child can be exposed to; but the child is small, and its world is small.” The feelings of children are as vulnerable as their health. And the injustices of Dickens’s time played out over a lifetime. In 1842 the average life span of an upper-class “gentleman” in London was forty-five years, the average tradesman lived to be twenty-five, and an average member of the working poor died at sixteen. Among the recorded deaths of the same year, 62 percent were children under the age of five.
Urban poverty is less lethal now, but in some respects, nothing has really changed. The environments of the cities we live in—their dirt and air, their violence and hopelessness and stress, their water—can still predict how long a life we will have. What we ingest or experience or inhale will make a difference to our health—literally the number of minutes allotted us to live. The small boy in Dickens’s novel may feel injustices keenly and remember them for the rest of his days, but so does his body. It carries the injustice forward with him, always.
AFTER MY MEETING WITH the powerless county health guy, I had a full day of work. It was a Thursday, which meant that I was supervising the residents who saw patients that afternoon. My phone kept pinging and buzzing throughout the morning as Elin and I exchanged texts and emails. Our night of talking had sent her into a dark tunnel, reliving her experiences in D.C. It was like she was suffering from Drinking Water Crisis PTSD.
She asked how my meeting went, and I quickly texted back my plan B: I was going to follow up with the Genesee County health officer and medical director. The pattern of mistakes was already becoming clear to me. It was like we were reenacting the error of Edwin Chadwick’s mission to clean up London’s air by draining all the human waste into the drinking water of the Thames. But in this case, the mistake had been made in an attempt to save not lives but dollars.
As our exchanges went on, Elin and I started to finish each other’s sentences in a mash-up of guilt and fury.
ME: It’s an ignorance-is-bliss system
ELIN: Too expensive to replace the lead service lines
ME: But everyone thinks their tap water is safe
ELIN: The system is supposed to work
ME: But it doesn’t
LATER THAT SAME DAY, August 27, I sent my email to the county health guy and copied in a bunch of his bosses, including Mark Valacak, the county health director. I explained that even though the water might not be under the health department’s jurisdiction (“however, I don’t understand why it wouldn’t be”), I was concerned about the potential for an increase in childhood lead poisoning from Flint’s drinking water.
“This is strikingly similar to what happened in Washington, D.C.,” I wrote—a crisis that had “resulted in significant childhood lead poisonings.”
I urged them to collaborate with me to stop what could be another crisis. Our children were already dealing with so much, every measurable health disparity. Adding avoidable lead exposure to their burden was unconscionable. Just to make sure they paid attention, I attached a link to Curt Guyette’s scary Deadline Detroit article.
Poisoning is poisoning. I couldn’t imagine how the county health department could turn a blind eye, or even a partially blind eye, to the situation simply because of bureaucratic walls and red tape. This wasn’t the kind of issue where you can shrug and pass the buck. We were literally talking about the systematic poisoning of our children.
“What about the lead levels of kids?” I asked in my email. “Have you noticed any changes?”
Then I forwarded the email to Elin, who responded with more news from the water front.
Marc Edwards, the corrosion expert from Virginia Tech and warrior scientist of the D.C. crisis, had come to Flint. He had been invited by both LeeAnne Walters and Miguel Del Toral and was collaborating with homeowners on something he called “citizen testing.” Just that day, he had posted new numbers on his Flint Water Study website. Scrolling down the numbers, I was upset to see that the citizen testing had found very high levels of lead in the water.
One sample, collected after forty-five seconds of flushing, exceeded 1,000 ppb—sixty-five times the federal action level of 15 ppb. The numbers were frightening.
Almost immediately, the spokesperson for MDEQ, Brad Wurfel, a confident, smooth-talking, square-faced corporate type (who happened to be married to the governor’s spokesperson, which somehow gave him more credibility), began pushing back very hard. “Flint drinking water meets state and federal safe drinking water standards,” Wurfel said.
This didn’t bode well. Marc Edwards was a world expert on pipe corrosion and recipient of a “genius grant” for his visionary work and doggedness. As a scientist, he had been willing to stake his own retirement money to save kids from lead poisoning when the D.C. utility, the D.C. government, the EPA, and the CDC all denied there was a problem. Was MDEQ really going to totally dismiss his findings?
Wow. It took my breath away.
Brad Wurfel was just a PR guy, a mouthpiece, not the brains behind these audaciously wrongheaded remarks. I wondered about the people he worked for. How can anybody who knows about lead not be concerned?
“WHAT’S GOING ON AT MDEQ?” I wrote to Elin.
It seemed like lunacy to deny water test results like these. But Elin predicted more problems to come. Based on her experience in D.C., she felt things would get much worse before they could get better—or drag on for years and never reach clear resolution.
In my mind, it wasn’t a coincidence that D.C. and Flint are both places, in different ways, that lack adequate political representation—places where democracy is far from complete. Flint had been taken over by the governor’s emergency manager, but at least the residents could still vote, in Senate and House elections, for politicians who—if we could get them to pay attention—would represent them. D.C. was a different story. Even though D.C. is more populous than half the states in the union, it has no representation in Congress. The people of D.C. cannot fight battles the way people elsewhere can.
In Flint, with an unelected emergency manager in charge, the citizens experienced a similar disconnect and powerlessness. Layers of accountability and responsibility had been stripped away.
Politics is about how we treat one another, how we sustain and share our common spaces and our environment. When people are excluded from politics, they have no say in the common space, no sharing of common resources. People may think of this as benign neglect, but it isn’t benign. It is malignant—and intentional.
Elin had another concern: Marc Edwards. The fact that he was sampling water in Flint meant something serious was going on, but his involvement could also make things more complicated. He had a reputation in the water world for making scenes and grabbing headlines. “He sometimes uses inflammatory methods to get attention,” Elin said. “People mock him for that, but I think they are afraid of him too.”
I noted her alarm, but felt like we had more to be afraid of than an eccentric water genius. We were alone in Flint, left behind, and maybe even targeted. We needed every ally we could get.
I AM ALWAYS HAPPIEST on Thursday afternoons. Finally free of my crazy meeting schedule, my calendar grid, and my paperwork, I can do what I love more than anything: see kids.
The end of summer is always busy in pediatrics. We’re flooded with back-to-school physicals. That afternoon the pediatric residents were bouncing from one exam room to the next, trying to stay on schedule while still getting used to the routine of our new clinic.
Allison, my resident, saw the first patient, Brandon, an active eight-year-old white boy, and shared his case with me. Brandon’s mom, a thin young woman with short hair and arm tattoos, was concerned that he couldn’t sit still. She said her son’s school, where he’d been going for three years, had been shut down last spring—a consequence of starved budgets and population loss. In a couple of weeks, Brandon would be starting a new school, an event that is definitely stressful for any kid. I tried to soothe his new-school nerves with a few comments about second grade and the stuff he was going to be learning.
“It’s going to be fun! You’ll meet new people, make new friends, and I’m sure a lot of your old classmates will be going there too.”
Brandon looked at me skeptically. He couldn’t hide his feelings, another thing I love about kids: it was clear he was anxious. His mom continued to describe his difficulties. His summer school teacher said he was a “space cadet.” Even at home, he was fidgety, had trouble focusing and paying attention. Allison and I dug into possible explanations: new-school nerves, summer boredom, a hearing issue? I looked in his chart. Last year, his school physical made no mention of hyperactivity. I found myself wondering about the water.
“Do you live in Flint?” I asked him.
“Yes.”
“Have you been drinking the tap water?”
“Yes.”
Ughhh. We always see a lot of kids with ADHD, but lead exposure can increase its likelihood. Maybe Brandon was going to have ADHD no matter what—it has so many causes. We gave Brandon’s mom the questionnaire to complete for ADHD screening and asked her to bring Brandon back in two weeks. Allison ordered a blood-lead test. Before they left, I asked Allison to go back into their exam room and recommend bottled water to Brandon’s mom. Allison shot me a perplexed look but followed instructions.
With another resident, I saw Chanel, a twelve-year-old white girl with a plump and slightly flushed face. Four years ago she was diagnosed with obesity and pre-diabetes. In the last year, her mom had died young of a heart attack—after years of being overweight with high blood pressure—and Chanel’s effort to lose weight became much more serious. Besides a back-to-school exam, she was in the clinic for a weight check.
After the medical assistant weighed Chanel, I looked over her records on the computer and saw she had lost ten pounds in the last six months.
“Way to go, Chanel!” I called out, and raised my hand for a fist bump.
She beamed, a bright sunrise of a smile breaking on her face.
“How’d you do that?” I asked. “So awesome! Did you cut back on sugary drinks and pop?” We had talked about that at her last visit—most of her caloric intake had been from sugar in drinks.
Chanel nodded, feeling proud. And then her dad chimed in that they were both drinking more water.
More water.
Of course they were drinking more water.
It was something we recommended to all our patients. Flint, like many communities, was in the midst of a childhood obesity epidemic. Soda and juices don’t help, which is why there are national campaigns encouraging more water.
Holding my breath, I asked, “Are you drinking Flint tap water?”
“Yes. Eight glasses a day!”
My heart sank. When I mentioned there were concerns about the water, Chanel’s dad said, “But they say everything’s okay.”
“Yes”—I nodded—“but to be extra safe, you should switch to bottled water.” Then, trying to pivot to a positive note, I applauded Chanel for her hard work and gave her another fist bump. I ordered another blood-lead level test.
A few exam rooms down, Allison and I saw Jasmine, a grumpy fifteen-month-old black toddler who had pretty serious eczema. Her mom said it got worse after bathing. That didn’t necessarily mean anything—almost all rashes get worse after bathing. And we have so many kids with eczema. The atopic triad of eczema, allergies, and asthma runs in families, is more prevalent in inner cities—and is worsened by a variety of environmental conditions.
When I asked where they lived and if they were on Flint water, Jasmine’s mom said they were. Sometimes, she said, the water smelled like a bottle of bleach. I prescribed hydrocortisone cream for the rough spots to calm down the inflammation, lots of moisturizing ointment to help it heal, oral medicine to limit her itching—and no more baths in Flint water.
“How am I supposed to bathe her?” Jasmine’s mom asked.
“What about using bottled water?” I offered.
Jasmine’s mom just stared at me, until it became almost uncomfortable. “You want me to bathe her in bottled water?”
She had a point, and I scrambled to think of better advice, something—anything. “Is there someone you know who lives outside of Flint where you can give Jasmine a bath?”
Her mom shook her head. “We don’t have a car,” she said.
I was running out of ideas. Bathing a child is not supposed to be this complicated. And it was getting hard to stay calm.
Without taking a moment to breathe, I next went to see Nevaeh, a child with one of my favorite names—it’s heaven backward. She was a three-day-old black newborn who was coming to the clinic for her first checkup. Immediately I saw that I had a chance to get on my soapbox about breastfeeding—and gave it with added urgency. But that was a lost cause. Nevaeh’s mom had made up her mind and was already giving her baby formula. The hospital had sent her home with a short supply of premixed formula. Knowing that she’d likely switch to the powdered version soon, I tracked down an extra case of the ready-to-feed formula and sent it home with her. Then I said, “And when you are finished with this, be sure to mix her powdered formula with bottled water.”
Usually my afternoons in the clinic are a tonic, a chance to forget my own woes and worries and hang out with Flint kids—to provoke smiles and laughs, to chart the kids’ growth, and to make their parents, grandparents, and caregivers less anxious. But that day, as the afternoon wore on, my frustration continued to build. Patient after patient seemed to be dealing with some kind of water-related issue.
In the teaching space, where the doctors type up their notes and talk to their supervisors, I asked everyone I could find—medical students, residents, and other supervising physicians who were in clinic more than I was—about the water. Were they seeing kids whose blood-lead screenings were coming back elevated?
They were. One physician’s assistant said she’d gotten back a level of 7 μg/dl just the week before, from a one-year-old boy. Follow-up interviews with the family didn’t produce any answers. They couldn’t figure out the source of the lead.
“Actually, siblings we just saw two days ago had levels of 14 and 22 μg/dl,” a resident told me. “We are just about to call the family to bring them back in.”
“Keep me posted,” I told her. “Be sure to ask if they’re drinking Flint water.”
I kept thinking about the difference between individual health and population health—treating one patient versus treating many. A doctor might see an individual child with an elevated blood-lead level, but it would take a study of many patients—a population—to figure out what was happening to all the kids. If one doctor alone could see all the Flint kids, maybe that doctor could start to make helpful connections. But with so many doctors in our clinic, and throughout the city at other clinics, that connection couldn’t happen. Each doctor might see a few higher-than-usual lead results, but they wouldn’t be able to see it as an epidemic on their own. This is why training in public health is so critical for all physicians. We need to be able to step back from the individual patient and look at the bigger picture.
What the eyes don’t see. That is precisely why public health surveillance programs are crucial. They regularly monitor population-wide trends that individual doctors can’t detect on their own—whether it is the flu, HIV, cancer, or blood-lead levels. This is what government public health people are charged to do. It is an invaluable way of discovering paradigms. It’s Epidemiology 101. John Snow taught us this.
But even when lead exposure is demonstrated across a population, it is almost impossible to prove causation. Did lead in the water cause Brandon’s ADHD? We will never know for sure. Did the water cause Jasmine’s rash? Maybe. Exposure to environmental toxins usually doesn’t come with glaring symptoms, like purple spots or even a rash. The symptoms are things like learning disabilities that have a time lag. Sometimes they don’t show themselves for years or even decades. For a pediatrician on the front lines, often the most you can hope for is establishing a correlation.
The more I thought about it, the angrier I got.
Before leaving the clinic, I went digging online again and discovered a couple of things about the water switch in Flint. First, in October 2014, just six months after the switch, General Motors stopped using the water at its engine plant. The company got a waiver to go back to the Lake Huron water as its source. “You don’t want the higher chloride water (to result in) corrosion,” the GM spokesperson said. “We noticed it some time ago.”
If the water was corroding metal engine parts, what was it doing to the ancient lead pipes under the city? This happened almost a year ago, but mysteriously no alarms bells were ringing. I texted Elin with the link to the story.
ME: See this?
ELIN: Didn’t know—wow.
ME: Those bastards
ELIN: You never swear
ME: Maybe I do now
ELIN: How was this allowed?
ME: GM knew the water was bad. GM screws Flint again.
My second discovery was more idiocy from MDEQ and their spokesperson, Wurfel. Just a month before, when Curt Guyette’s stories for the ACLU about the leaked EPA memo broke, Wurfel had responded with this statement: “Let me start here. Anyone who is concerned about lead in the drinking water in Flint can relax.”
The man was a menace. If I could remove his microphone, the way John Snow got the Broad Street pump handle removed, I thought of all the people I could help.
Relax?
Does anyone relax when they are told to relax?
Has that ever worked?
Someone should do a study.