Flint, Michigan: Three years after the water crisis, where are we now?

Full text

Research Article
Clinical Obstetrics, Gynecology and Reproductive Medicine
Clin Obstet Gynecol Reprod Med, 2019 doi: 10.15761/COGRM.1000245 Volume 5: 1-5
ISSN: 2059-4828
Flint, Michigan: ree years after the water crisis, where
are we now?
M Craft-Blacksheare*
Department of Nursing, University of Michigan-Flint, Flint, Michigan, USA
Abstract
In April 2016, the nation shined a spotlight on Flint, Michigan where the news of contaminated river water resulted in elevated blood lead levels in the city’s children.
Flint residents and community organizers had complained about the brown, smelly water for months before public ocials and news organizations came to town.
Flint-area healthcare providers and academics held forums and established research groups to investigate potential health problems related to the water crisis. Nurses
at the University of Michigan-Flint, the local health department, and Federal health agencies collaborated to hold lead blood-drawing clinics for Flint community
residents, including children. is article reports on three topics: a water crisis overview, where Flint is two and a half years later, and clinical implications for nurses
and other healthcare providers.
*Correspondence to: M Cra-Blacksheare, Assistant Professor, Department of
Nursing, 2180 William S. White Building, 303 E. Kearsley Street, Flint, Michigan
48502-1950, USA, E-mail: melvagcb@umint.edu
Received: February 11, 2018; Accepted: February 22, 2019; Published: February
28, 2019
Water crisis overview
Due to a nancial crisis in the city of Flint, the governor of Michigan
appointed an emergency manager (EM) to nd cost savings measures
for the city (Table 1). In April 2014, the EM terminated a contract
with Detroit to use ltered water from Lake Huron and the city began
using the Flint River as their primary source of drinking water [1]. Less
than a month aer the switch to the new water source, residents began
complaining about the water’s color, smell, and taste. Several boil alerts
were issued due to elevated E. coli and total coliform levels in the water.
Because the red corrosive water was damaging car parts at the Flint
General Motors Corporation plant [2], the company’s management
decided to switch from Flint River water to Flint Township water, which
still came from the Detroit water system. Despite complaints, Flint
residents continued using Flint River water until October 16, 2015,
when they switched back to water from the Detroit Water and Sewage
Department due to elevated blood lead levels (BLLs) discovered in the
city’s children.
Dangers of lead exposure
According to the Agency for Toxic Substances & Disease Registry
[3], lead is a dangerous toxin. e main target for lead toxicity in
humans is the nervous system. Elevated lead levels (≥10µg/dl) pose
health eects that include the following: seizures, stupor, delirium,
coma, or death. Lead toxicity may manifest as hypertension, behavioral
changes, decreased concentration, peripheral neuropathy, ataxia,
tremor, headache, loss of appetite, weight loss, fatigue, muscle and
joint aches, gout nephropathy lead colic, and anemia. In addition, the
American College of Obstetricians and Gynecologist (ACOG) [4], pose
that the nervous systems of children and developing fetuses are most
susceptible to the damaging eects of this neurotoxin.
Vulnerable populations
Research indicates [5] that the way lead is stored in the body makes
prenatal and postnatal exposure especially dangerous for the pregnant/
lactating woman, fetus and nursing infants. Lead exposure during
pregnancy and lactation can have lasting adverse eects distinct from
exposure during other life stages, which includes the ability to conceive,
maintain a healthy pregnancy, and to have a healthy infant.
Approximately 99% of the lead taken into the adult’s body excretes
as waste within a couple of weeks in comparison to 32% of lead taken
into a child’s body [3]. Additionally, childhood lead exposure can later
eect females in their childbearing years, due to lead stored in the
bone as a results of prior exposure, which mobilizes (in pregnancy and
lactation) into maternal blood and breast milk, and adversely aects the
developing fetus or nursing infant [5].
Nicholson and Cleeton [6] reported the policy changes, which
reects a continuous reduction in the Blood Lead Level (BLL) requiring
public health initiatives, to reduce and monitor a child’s lead level
exposure. In the 1960’s public health, intervened when a child’s BLL
was 60 µg/dl, which changed to 30µg/dl in 1975, 25 µg/dl in 1985, and
10 µg/dl in 1991. In 2012, the Advisory Committee on Childhood
Lead Poisoning Prevention recommendation was 5ug/dl or more as an
unhealthy exposure. Presently, the CDC reference value (≥5µg/dl) is
the standard for identication of children with elevated BLL. ACOG
[4] acknowledges the identied lower BLL and its eects on maternal
health and infant outcomes.
Even though child BLLs have declined over the last 30 years,
current estimates suggest that 4.5 million homes in the U.S. are exposed
to high levels of lead and that half a million preschool aged children
have elevated BLLs [7]. Lead a signicant hazard, particularly in older
homes (built before 1978) due to concentration of lead paint are oen
located in urban areas. Additionally, residual lead in soil from former

Craft-Blacksheare M (2019) Flint, Michigan: ree years after the water crisis, where are we now?
Clin Obstet Gynecol Reprod Med, 2019 doi: 10.15761/COGRM.1000245 Volume 5: 2-5
industrial sites and high trac areas (lead gas deposits) are more
profound in urban areas.
Prenatal exposure
According to Weiszecker [8], lead absorption primarily occurs in
the respiratory, gastrointestinal and integumentary systems. Lead binds
to hemoglobin carried in blood plasma. Its half-life is approximately 1
month in blood and 20 to 30 years in the bone. Greater than 90% of lead
incorporates into the skeleton. Conditions that cause demineralization
like pregnancy and lactation can lead to lead mobilization from
maternal bone. Research ndings from the CDC [5] indicates that
lead crosses the placenta by passive diusion and detected in the fetal
brain by the end of the rst trimester. Bijoor, Sudha and Venkatesh
[9] identies the central nervous system of the developing fetus as a
principle target to lead toxicity. Xie and colleagues [10] examined
low-level prenatal lead exposure of 252 mother-infant pairs. ey
concluded even low lead exposure (2.52 µg/dl-3.20 µg/dl) is associated
with decreasing birth weights and lengths. Grossman and Slusky [11]
reviewed detailed geocoded data containing births in Michigan from
2008 to 2015. Exploiting variation in timing of births, they found that
the overall general fertility rates decrease12 percent and fetal death rates
increased by 58 percent in Flint following the water change [11,12].
eir ndings indicate that the sex ration of babies born in Flint skewed
slightly to more females following the water change. Results from other
scientic research have shown that male fetuses were more fragile than
were female fetuses aer the water switch. Additionally, babies born in
Flint during this time; were born a half-week earlier, weighed nearly
150 grams lighter, and gained 5 grams per week less, than babies born
in other areas at the same time.
Aizer et al. [7] studied the relationship of children BLL’s and future
test scores. e study concluded that by reducing lead levels from 2.7
µg/dl (below the CDC value of 5µg/dl) to zero micrograms per deciliter,
would increase mean reading and math scores to 9 and 6 percent of a
standard deviation.
In Flint, 4 in 10 families live below the poverty line, unemployment
is high, and the majority population is Black. According to Bellinger
[13], an elevated water lead concentration adds to an environment that
Date Event
2011 Michigan Takes over Flint’s budget; A nancial manager takes over; A study nds that making Flint River water drinkable would require treatment with an
anti-corrosion agent at a cost of $100/day
April 2014 Flint River becomes new water source; Public ocials publicly drink int River water
May 2014 Foul water starts coming into homes
January 12, 2015 Detroit Water and Sewerage Department oers to reconnect Flint to its water supply and waive the $4 million connection fee; Flint ocials decline this oer
February 26, 2015 The Environmental Protection Agency (EPA) and Michigan’s Department of Environmental Quality discuss the high levels of Lead (Pb) found in water
July 2015 Internal EPA memo leaked showing high Pb levels at one woman’s home which gave her son Pb poisoning; Regional EPA ocial states that “conclusions
would be premature”
August 2015 Virginia Tech (VT) researchers launch their own investigation
Early September 2015 DEQ disputes VT researchers’ ndings about corrosion and lead leaching
September 2015 State publicly disputes a doctor’s ‘ndings of elevated Pb levels in children; After a week, they change course and say she was right.
October 8, 2015 Flint is reconnected to Detroit water supply
October 19, 2015 State environmental chief admits mistake; States that adding the anti-corrosion agent that would have cost the state $100 a day would have prevented 90%
of Flint’s water problems
November 2015
Federal lawsuit led by residents against governor, state of Michigan, the city of Flint, and other defendants; DEQ was not treating the river water with an
anti-corrosive agent, in violation of federal law resulting in the water eroding the iron water mains, turning the water brown, and causing the seepage of
lead into tap water.
December 29, 2015 DEQ chief quits
January 2016
Governor ask for FEMA’s help; Water distribution activated by Michigan National Guard; Governor asks for federal aid, apologizes saying, “I will x it”;
Releases 250 pages of emails about Flint, dating back to 2014; One DEQ email explains that General Motors suspended use of Flint River water as “It was
rusting car parts”
January 22, 2016 Legionnaires; disease bacteria found in water; Flint hospital ocials say they noticed an increase in Legionnaires’ cases coming in after Flint switched its
water supply to Flint river.
January 28, 2016
Senators propose $600 million in federal funding for Flint with $200 million for healthcare of those aected by lead and $400 million for infrastructure;
State gives $28 million in aid to Flint;$4 million used to treat children aected by lead; Other monies used for unpaid water bills, study of water system
infrastructure, nine more school’s nurses and supplies.
February 1, 2016 EPA regional administrator quits
February 9, 2016 Flint mayor says “$55 million needed to replace lead pipes”
February 19, 2016 Signs of Improvement, according to VT research group “Lead levels in drinking water are much better, but people should keep using lead lters and bottled
water.”
February 27, 2016 Governor’s sta knew about Legionnaires’ cases; The governor’s oce was warned by a DEQ ocial not to call the drinking water safe because of an
increase in Legionnaires disease in the county almost a year before Gov. Snyder publicly disclosed the emergency.
April 20, 2016 Charges led included tampering with evidence, willful neglect of duty, misconduct in oce, evidence tampering, and violating the Safe Drinking Water
Act
April 25, 2016 $229 million class action complaint led representing 514 residents seeking more than $220 million from EPA due to negligence
July 29, 2016 Six state workers charged with crimes ranging from misconduct in oce to willful neglect of duty; One ocial allegedly told an employee to delete emails
about blood Pb data from July 2014
November 10, 2016 Judge orders bottled water to homes
December 20, 2016 Four ocials charged with felonies; Two former emergency managers and two water plan ocials accused of misleading the state’s treasury department
into letting the city borrow millions of dollars to participate in a pipeline project that required it to switch temporarily to Flint River water.
January 24, 2017 Lead levels are within standards; The MDEQ stats that lead levels in the city’s water tested is below the federal limit in a six-month study
February 17, 2017 Report states institutional racism contributed to Flint’s crisis; The Michigan Civil Rights Commission issues a 129-page report saying, “deeply embedded
institutional, systemic, and historical racism’ indirectly contributed to the ill-fated decision to tap the Flint River for drinking water as a cost-saving measure.
Table 1. The Flint Water Disaster Timeline

Craft-Blacksheare M (2019) Flint, Michigan: ree years after the water crisis, where are we now?
Clin Obstet Gynecol Reprod Med, 2019 doi: 10.15761/COGRM.1000245 Volume 5: 3-5
is already at risk. e incident of BLL concentration 5 µg/dl was more
than three times as high among Flint children compared to neighboring
municipalities [14].
Legionella outbreak
Legionella pneumophila bacterium (L. pneumophila: hereaer
referred to as Legionella) received its name from an American Legion
Convention in 1976 where attendees developed a new type pneumonia
later named Legionnaires’ disease [15]. e disease oen goes
undiagnosed, causing its incidence to be underestimated. Legionella
bacteria, is naturally found in fresh water environments; however it can
become a health concern when allowed to grow and spread in potable
water systems [16].
Risk factors
Most healthy people exposed to Legionella do not acquire the disease
[17]. However, risk factors that increase the chance of contracting the
disease: being 50 years of age or older; being a former smoker; having
a chronic lung disease such as emphysema or chronic obstructive
pulmonary disease (COPD); and having a weakened immune system
from medication or immune system diseases such as diabetes, cancer,
or kidney failure.
Symptoms and diagnostic testing
Typically, two to 14 days aer exposure patients with Legionnaires’
disease oen presents with pneumonia symptoms that include, cough,
shortness of breath, headache, muscle aches, fever and radiographic
pneumonia [18]. Since the above symptoms are oen present with
pneumonia caused by other organisms, it is necessary to conduct a
conrmatory diagnostic test for Legionnaires’ disease. Conrmatory
test include; sputum culture, bronchoalveolar lavage and the Legionella
urinary antigen test [18]. Additionally, screening is also encouraged
for patients who failed outpatient antibiotic treatment for community-
acquired pneumonia (CAP), patients with a severe pneumonia requiring
intensive care; immunocompromised patients with pneumonia;
patients who traveled away from home within 10 days before illness
onset; and all patients with pneumonia in the setting of a Legionnaires’
disease outbreak. In a study by Rathore [19], he found that pneumonia
patients with prominent extrapulmonary manifestations, including
diarrhea, confusion and neurologic symptoms should also be assessed
for a Legionella infection.
Legionnaires disease and maternal child health
Vimerati et al. [20] published a case report in the Journal of
Perinatal Medicine of a 32-year-old white woman, gravida 1, para 1 at
28 weeks gestation that presented with a ve-day history of dyspnea,
back pain, productive cough, and two days of fever (38ºC). e patient
received uids and cephalosporin aer a chest x-ray showed right sided
pneumonia and a sputum gram stain indicative of an inammatory
process. e treatment lead to an initial decrease in temperature.
Even though the initial ultrasound showed normal fetal biometry
and morphology, 36 hours aer maternal complaint of decreased fetal
movement, an ultrasound diagnosed fetal death. ree weeks aer
the fetal demise and patient transferred to the chest disease service a
serum specimen tested positive for Legionella bacterium. e authors
concluded that when acute pneumonia complicates a pregnancy;
consider Legionella as a possible pathogen. However rare, it is the
second most common etiology of CAP.
Yiallouros et al. [21] identied a nosocomial Legionella infection in
term neonates caused by cool mist ultrasonic humidier in a hospital
nursery. e atypical symptoms of Legionellosis seen in the neonates-
such as lethargy, food denial, abnormal temperature, fever and
respiratory distress-were detected for the rst time in this population.
e CDC advises against the use of large-volume, room humidiers
that create aerosol in hospitals. CDC suggest daily disinfection, and ll
only with sterile water. Hines et al. [22] calculated exposure dosages
from six common in-home water sources and estimated that the
ultrasonic and cool-mist humidier exposure pathways produced the
highest exposure doses of the bacteria.
In January 2016, a Flint area hospital indicated they noticed an
increase in Legionnaires’ disease cases aer Flint switched its water
supply to the Flint River (Table 1). Ninety-one cases of and 12 deaths
from Legionnaires’ disease brought attention to the already recovering
community. Environmental engineers from Virginia Tech University
hypothesized that certain factors resulting from the Water Crisis would
stimulate an abundance of Legionella [23]. ese factors are as follows:
• Loss of residual disinfectant due to the high chlorine demand of iron
corrosion;
• Elevated levels of iron and other microbial nutrients present in water
(due to the lack of anti-corrosive use in the water plant);
• Increased temperature due to warmth of the Flint Water Source; and
• e conduciveness to Legionella growth and survival in water found
in large buildings as Legionella known to be problematic in hot
water lines.
According to Yan’s [24] Flint Water Disaster Timeline (Table 1), in
February 2016—almost a year before the governor publicly declared a
state of emergency—the governor’s sta was warned by the Department
of Environmental Quality not to declare the drinking water safe due to
the increase in Legionnaires’ disease cases in the county.
Soon, city, county, state, and national health agencies coordinated
an investigation into the cause of the crisis. e chief medical
inspector and his associates came to town to coordinate clinics,
health information sites, and water distribution centers. Neighboring
universities, health agencies, healthcare workers, and volunteers
helped distribute vital information, bottled water, and household tap
lters. e local university held community informational forums to
disseminate information about the dangers of lead-tainted water. Some
neighborhoods had a replacement of six thousand service lines before
work ceased, due to the cold Michigan winter weather. Work resumed
in the spring of 2018 to replace the 9,000 remaining service lines. No
other U.S. city has completed such a comprehensive water service line
replacement. Aer declaring the Flint public water was safe to drink,
the state of Michigan no longer supplied bottled water to the residents.
Despite this declaration, many nonprot organizations and churches
continue to support Flint residents with bottled water. According to Dr.
Mona Hanna-Attisha, a pediatrician instrumental in uncovering the
lead crisis in children, “residents are encouraged to stay on ltered and
bottled water until all lead pipes are replaced” [25].
Aer all that has transpired, naturally, there is a lack of trust
between the Flint’s citizens and its public ocials. Many questions
remain. In April 2014, only a month aer the initial switch to Flint River
water, residents complained of the foul-smelling, reddish-tinged water
owing from their taps. However, the complaints were ignored. Flint
has a postindustrial economy with 40% of the population living at the
poverty level. If Flint were an auent suburb with a median family gross
income of $100,000, would public ocials have been more responsive

Craft-Blacksheare M (2019) Flint, Michigan: ree years after the water crisis, where are we now?
Clin Obstet Gynecol Reprod Med, 2019 doi: 10.15761/COGRM.1000245 Volume 5: 4-5
to the constituents? e search for answers to these questions likely will
continue for years.
Where we are now
Flint residents returned to using Huron Lake water from the City
of Detroit on October 16, 2015. Two and a half years later, residents
continue to drink bottled water as their trust in their water quality and
safety and some public ocials have been lost. Meanwhile, researchers
are still counting the human costs of this crisis.
From May 2017 through September 2017, dredging of the Flint
River began to remove contaminated sediments, specically coal tar by-
products from the operation of a manufacturing gas plant in the 1920s.
e plant converted coal and oil to gas and distributed it to the public
for heating and cooling. e manufacturers were not responsible for
disposal of the plant’s by-products, resulting in coal tar discarded in
the river. During the dredging, 75,000 cubic yards of river bottom was
removed and replaced with sand, clay, and gravel. e restoration of the
river bottom is now in a natural state for macro- and micro-invertebrate
habitat [26]. Presently, there are no mechanisms in place to determine
ill eects from possible consumption of coal tar by-products during the
use of the Flint River as a water source.
Clinical implications
Healthcare professionals who work in areas with publicly
announced environmental contaminations due to unsafe water (lead
levels, Legionella, contaminated sediments) must be prepared to
assess their patients’ health presentations and home environments.
Any patients arriving at clinics or hospital emergency centers with
complaints of pneumonia that have not responded to routine antibiotics,
an assessment for Legionnaires’ disease is crucial. Incorporation
of assessments for stress and anxiety levels into the plan of care and
referral to appropriate health services is paramount. Employing
interdisciplinary teams of nurses, physicians, public health educators,
and social workers is fundamental to keeping a community healthy.
As nurses, we must continue to see our patients as complex
individuals and care not only for their immediate health but also inquire
about their family, environment, nutritional, and educational needs.
We must seek and be willing to learn about specic environmental and
health issues in the communities we serve. For example, Flint’s north
side was designated a food desert when the only full-sized grocery
store closed in 2014. is situation eliminated easily accessible healthy
nutrition options, particularly for low- income people. However,
residents are pleased about several recent additions to the community:
a grocery store with a plethora of healthy nutritional selections, which
provided 80 new jobs to the community. e grocery store recently
opened a “Soul Food Restaurant” within the building to provide
nutritional selections of culturally specic food. Additionally a Dollar
Store opened providing the community with low cost products in
comparison to higher end drug and grocery chains [27]. e newly
renovated Flint Farmers Market, open three days a week, oers fresh
fruits and vegetables at aordable prices. As healthcare professionals,
we must continue to collaborate and support the residents of the
communities we serve. Being empathetic to their needs can help rebuild
the trust lost during the horric, human-manufactured water crisis.
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Craft-Blacksheare M (2019) Flint, Michigan: ree years after the water crisis, where are we now?
Clin Obstet Gynecol Reprod Med, 2019 doi: 10.15761/COGRM.1000245 Volume 5: 5-5
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Copyright: ©2019 Craft-Blacksheare M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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