The Flint water crisis was a major public health emergency in Michigan linked to contaminated drinking water. It began in April 2014 when the city switched from water taken from Lake Huron and the Detroit River supplied by the Detroit Water and Sewerage Department (DWSD) to water drawn directly from the Flint River as a cost-saving measure. Because the Flint River water was not properly treated with corrosion control chemicals, the water became contaminated by high levels of lead, and later, the bacteria that cause Legionnaires' disease. Although the quality of the city's water supposedly met federal purity standards by 2017, the crisis was ongoing as of mid-2018 and was anticipated to continue until 2020, when the replacement of the city's water pipes was expected to be completed.
The Flint water crisis was an environmental disaster of human origin, the ultimate outcome of industrial pollution of a city water supply coupled with political shortsightedness and inadequate oversight on the part of the very agencies tasked with guaranteeing clean and safe water.
According to a 2016 account published in the Journal of the American Water Works Association, Flint's first water treatment company was private, founded in 1883 and purchased by the city in 1912. In 1930, the city's water was still drawn from the Flint River. The construction of a new plant, the Flint Water Service Center (FWSC), began in 1952 and was completed in 1954. It was not until 1967 that Flint began to purchase water from DSWD. Although it was true that the quality of the Flint River water was poor due to the unregulated discharge of industrial wastes, the major reason for the switch was the city's growing population, which reached a high of 196,000 in 1960. The FWSC was maintained as a backup facility.
There were a number of risk factors that preceded the crisis:
Flint in 2014 was typical of many cities in the so-called Rust Belt of the Great Lakes region: Its financial crisis resulted from the loss of the automotive industry jobs and the flight of many middle-class families to warmer climates or safer locations. Flint's population dropped from its 1960 high of 196,000 to an estimated 97,000 in 2016. The city was as of 2018 a majority-minority city, with a population that is 53% African American, 41% White, and 3% Hispanic. The city is poor, with a median household income of $28,000, and 16.4% of the population living below the poverty line.
Another factor that contributed to Flint's ongoing population decline was its notoriously high crime rate; from 2010 to 2012, Flint had the highest violent crime rate among cities with over 100,000 population in the United States. In addition, it had a high rate of unsolved crimes, with less than half of homicides resulting in convictions.
Third, the water crisis contributed to as well as resulted from the instability of the city's government. Although Flint had not been under an emergency financial manager since 2015, it was in financial receivership as of 2018, with a receivership advisory board that had the authority to override the city council's financial decisions.
The fourth demographic factor that contributed to the Flint water crisis was the fact that most of the officials and employees who worked for the Michigan Department of Environmental Quality (MDEQ) and the federal Environmental Protection Agency (EPA) did not live in Flint and were thus insulated from the consequences of inattention to the early signs of crisis. In addition, the complexity of the agency structures and the overlapping of local, country, and state administrations made it difficult for ordinary citizens to know where to report problems or demand answers.
The community assessment conducted by the CDC in May 2016 found that fully half of Flint's households “felt overlooked by decision makers.”
The immediate cause of the water crisis was the failure of the Flint water utility to take corrosion control measures at the time of the water switchover in April 2014 in spite of the fact that engineering studies had been conducted that advised such measures.
Longer-term causes include the city's precarious financial situation, which led to unwise decisions about the source of the water and inadequate supervision of the water treatment facility and its sampling techniques.
Symptoms linked to the city's drinking water began to appear within a few months of the switchover:
The diseases and disorders associated with the Flint water crisis include a waterborne bacterial infection; heavy metal poisoning; and mental health issues ranging from sleep disorders, anxiety, and depression to increased substance abuse in adults and behavioral problems in children.
Legionnaires' disease is an infectious disease caused by bacteria belonging to the genus Legionella, particularly the species Legionella pneumophila. A form of atypical pneumonia, LD takes its name from its initial identification in a group of patients who developed the disease at the 1976 convention of the American Legion in Philadelphia. The bacterium had contaminated the water in the hotel's air conditioning system. Legionella bacteria are found naturally in fresh water and can survive the low levels of chlorine found in many municipal water systems. Symptoms of LD include coughing, painful and difficult breathing, headaches, muscle aches and pains, and sometimes nausea and vomiting. The disease does not usually spread directly from person to person, however.
Blood lead levels are measurements of the amount of lead (in micrograms per deciliter or mcg/dL) in human blood. People can take in lead by inhalation, ingestion, or dermal (skin) contact. Children can ingest lead by chewing on paint chips containing lead as well as from drinking water contaminated by lead. Children are more susceptible than adults to elevated BLLs from drinking water, however; their bodies will absorb about 50% of the lead in a glass of drinking water whereas an adult will absorb only 10%.
There was no level of lead in human blood that is considered safe as of 2018 because lead is a known neurotoxin; that is, it damages both the peripheral and central nervous systems. Symptoms of lead poisoning in children include delayed puberty, decreased growth in height, hearing loss, below-average IQ, lowered academic achievement, attention deficit hyperactivity disorder, and other behavioral issues. In 2012, the Centers for Disease Control and Prevention (CDC) set a BLL of 5 mcg/dL in children as an indication that children are at risk and a public health response should be initiated. It was this standard that was used by Mona Hanna-Attisha, a local pediatrician, in investigating the BLLs of Flint children below the age of five before and after the 2014 switch to using water from the Flint River.
In May 2016, a group of organizations, including the Flint Community Resilience Group, the county health department, the Genesee Health System, the University of Michigan-Flint, and the CDC, conducted a Community Assessment for Public Health Emergency Response or CASPER. The CASPER was conducted citywide in order to evaluate not only the level and types of mental health issues in the community but also people's access to mental health services and how they obtained information about the water crisis.
The CASPER findings included the following: 40% of Flint residents rated their sleep quality as either poor or only fair; 34% reported symptoms of anxiety; 29% reported symptoms of depression; 54% reported that at least one child in the family was having behavioral difficulties; 66% reported that at least one adult in the family was having a greater than usual degree of difficulty with substance abuse or other behavioral health issues; and 51% reported that at least one family member's physical health had deteriorated because of the water crisis. In addition, 22% reported that they had difficulty gaining access to mental health services.
Elevated BLLs in Flint children were initially treated by ensuring that the children had access to healthful food, as adequate nutrition and calcium and iron supplementation are commonly recommended first measures. After Hanna-Attisha's report of increased BLLs in Flint children following the 2014 change of water source was released in September 2015, the governor of Michigan signed a bill to reconnect Flint to water supplied from Detroit; the switch to water treated by the DWSD was made on October 16. The mayor of Flint declared a state of emergency on December 15, 2015; in January 2016, the Michigan National Guard began distributing bottled water to Flint residents.
Mental health issues in Flint were not addressed until October 2016.
The effects of elevated blood lead levels in Flint children will take years to resolve, as lead can be stored in the bones as well as the blood and soft tissues. The half-life of lead storage varies considerably, however, from days in the bloodstream to weeks in soft tissue and years in bone. What this difference means is that lead stored in the bones in childhood can be released into the bloodstream years after the initial exposure. It is estimated that between 6,000 and 12,000 children in Flint were exposed to lead poisoning during the water crisis. In 2016, the United Way of Genesee County began a fundraising campaign to raise $100 million over the next 10–15 years to cover the costs of the children's medical treatment. The total cost of treatment was expected to be much higher, however, as many of the developmental effects of lead poisoning will not appear for years.
To improve access to mental health services for Flint residents, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) awarded a five-year $4,860,530 million grant to the Flint Resiliency in Communities after Stress and Trauma (ReCAST) program in October 2016. The purpose of the ReCAST program is to provide mentoring programs and other youth development services for children and adolescents traumatized by the water crisis.
Public health specialists were delayed in their response to the Flint water crisis by a number of factors. As outlined in an article in the AMA Journal of Ethics, one reason for this slowness was the increased specialization of medical education and practice, which means that many doctors in clinical practice have relatively little training in the methods and concerns of public health specialists. Second, departments of public health have increasingly been absorbed into local and state-level governments, which results in most practitioners of family medicine or internal medicine paying little attention to population health. In the case of Flint, local physicians did not perceive such events as the GM plant's switch to Detroit water and the 2014–2015 spike in the number of cases of Legionnaires' disease as warning signs of a public health crisis related to the water supply.
According to the AMA Journal of Ethics article, only a chance encounter between Mona Hanna-Attisha, a physician with a background in environmental health as well as a specialty in pediatrics, and a friend who was a water engineer led to the recognition of the crisis. The friend told Hanna-Attisha that there was no corrosion control in the Flint drinking water; that lead might be leaching into the water; and that she might consider testing the blood lead levels of Flint's children. The result was a study that Hanna-Attisha undertook in 2015 in which she compared BLLs in Flint children below the age of five years in 2013 (prior to the change in water supply) with those after the switch. She found that the incidence of elevated blood lead levels increased from 2.4% to 4.9% after the water source change and that neighborhoods with the highest water lead levels experienced a 6.6% increase. Economically disadvantaged neighborhoods showed the highest rates of increase.
The other important research study that took place in 2015 was a water sampling study led by Marc Edwards, a professor of civil and environmental engineering at Virginia Tech, and a group of students from the university who came with him to Flint in September to assist residents in testing the water in their homes. In addition to assisting with water testing, the students hoped to encourage residents to become citizen-scientists able to gather information for themselves about the quality of their water. The students collected 271 samples and reported that in one ward alone, 51% of the samples showed lead higher than 5 ppb, and 20% were above 15 ppb. Under federal law, these figures should have triggered public warnings. Edwards himself later discovered that Flint and MDEQ officials had known about the level of lead contamination but took no action either to correct the situation or inform the public.
Emergency responses in Flint included the following:
Long-term responses to the Flint water crisis included:
While it was unlikely that there would be another outbreak of Legionnaires' disease in Flint linked to the city water supply, the long-term effects of lead exposure in children and the mental health issues in adults were difficult to predict in regard to either their severity or their duration. At best, many of the physical and psychological aftereffects of the tainted water would take years and millions of dollars in healthcare costs to resolve.
It is also likely that the city's population would continue to decline. Some observers estimated that about 2,000 people had moved away from Flint since 2015, and the city had already lost 18% of its population just between the 2000 and 2010 censuses.
Prevention of water crises like the one in Flint was perceived as difficult as of 2018. To begin with, Flint was not the first city in the United States to experience lead contamination in the city water; previous cases included Washington, DC (2001); Columbia, South Carolina (2005); and Durham, North Carolina (2006). Although lead water pipes had been banned by Congress in the 1980s, many older cities across the United States are still struggling to replace lead water pipes in the midst of their own budgetary problems. A study by researchers at Columbia University and the University of California–Irvine reported in early 2018 that 21 million Americans rely on water systems “that violated health-based quality standards.” The researchers found that the water systems in the continental United States at greatest risk as of 2018 were those in the Southwest and those in rural rather than urban areas. The researchers also found that private ownership of water companies and purchased water sources are associated with a higher degree of compliance with federal standards for water purity.
The Flint water crisis could have been prevented by three actions: the simple addition of orthophosphates to the city's water at the time of the switchover in April 2014, at a cost of about $140 per day; obtaining a full understanding of the complex variations in the quality of the Flint River's water before deciding to switch to using it; and having the MDEQ use adequate water sampling techniques after the switchover. While the characteristics of the local river water may be unique to Flint, most municipalities can take measures to lower the risk, if not completely prevent, an environmental disaster on the scale of the Flint water crisis. Some suggestions on prevention appeared in a 2016 article published in The Atlantic:
See also Cancer ; Lead ; Lead poisoning ; Legionnaires' disease ; Mercury ; Mercury poisoning ; Water pollution ; Water quality ; Water quality standards .
Flinn, Gary. Hidden History of Flint. Charleston, SC: History Press, 2017.
Hanna-Attisha, Mona. What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City. New York: One World, 2018.
United States Congress. House Committee on Energy and Commerce, Subcommittee on Environment and Economy. Flint Water Crisis: Impacts and Lessons Learned: Joint Hearing before the Subcommittee on Environment and the Economy and the Subcommittee on Health of the Committee on Energy and Commerce, House of Representatives, One Hundred Fourteenth Congress, Second Session, April 13, 2016. Washington, DC: Government Publishing Office, 2017.
Allaire, M., H. Wu, and U. Lall. “National Trends in Drinking Water Quality Violations.” Proceedings of the National Academy of Sciences of the United States of America 115 (February 27, 2018): 2078–83.
Carravallah, L. A., L. A. Reynolds, and S. J. Woolford. “Lessons for Physicians from Flint's Water Crisis.” AMA Journal of Ethics 19, no. 1 (October 1, 2017): 1001–10.
Fortenberry, G. Z., et al. “Assessment of Behavioral Health Concerns in the Community Affected by the Flint Water Crisis—Michigan (USA) 2016.” Prehospital and Disaster Medicine. Published electronically April 19, 2018. doi: 10.1017/S1049023X18000250.
Fournier, Ron. “How to Prevent the Next Flint.” The Atlantic, February 2016. Available online at https://www.theatlantic.com/politics/archive/2016/02/preventing-flint/463404/ (accessed May 1, 2018).
Hanna-Attisha, M., et al. “Elevated Blood Lead Levels in Children Associated with the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response.” American Journal of Public Health 106 (February 2016): 283–90.
Jennings, B., and L. L. Duncan. “Water Safety and Lead Regulation: Physicians' Community Health Responsibilities.” AMA Journal of Ethics 19 (October 1, 2017): 1027–35. Available online at http://journalofethics.ama-assn.org/2017/10/pdf/pfor1-1710.pdf (accessed May 1, 2018).
Kennedy, C., et al. “Blood Lead Levels among Children Aged Below 6 Years—Flint, Michigan, 2013–2016.” Morbidity and Mortality Weekly Report 65 (July 1, 2016): 650–54.
Kruger, D. J., G. D. Kodjebacheva, and S. Cupal. “Poor Tap Water Quality Experiences and Poor Sleep Quality During the Flint, Michigan, Municipal Water Crisis.” Sleep Health 3 (August 2017): 241–43.
Masten, S. J., S. H. Davies, and S. P. Mcelmurry. “Flint Water Crisis: What Happened and Why?” Journal of the American Water Works Association 108 (December 2016): 22–34.
Pieper, K. J., M. Tang, and M. A. Edwards. “Flint Water Crisis Caused by Interrupted Corrosion Control: Investigating ‘Ground Zero’ Home.” Environmental Science and Technology 51 (February 21, 2017): 2007–14).
Reynolds, K. “Waterborne.” AMA Journal of Ethics 19 (October 1, 2017): 1036–1042. This is a series of photographs and captions about the Flint water crisis made by a photographer who lives in the city. Available online at http://journalofethics.ama-assn.org/2017/10/imhl1-1710.html (accessed May 1, 2018).
Zahran, S., et al. “Assessment of the Legionnaires' Disease Outbreak in Flint, Michigan.” Proceedings of the National Academy of Sciences of the United States of America 115 (February 20, 2018): E1730–E1739.
Centers for Disease Control and Prevention, Community Assessment for Public Health Emergency Response. “Flint Water Crisis.” https://www.cdc.gov/nceh/hsb/disaster/casper/pdf-html/flint_water_crisis_pdf.html (accessed April 25, 2018).
Flint Water Response Team. “Lead in Flint Water.” https://www.michigan.gov/documents/deq/LeadInWaterInfoSheetV2a_511710_7.pdf (accessed April 27, 2018).
Medscape Reference. “Legionnaires' Disease.” https://emedicine.medscape.com/article/220163-overview (accessed April 26, 2018.
National Library of Medicine PubChem Open Chemistry Database. “Lead.” https://pubchem.ncbi.nlm.nih.gov/compound/5352425 (accessed April 25, 2018).
National Library of Medicine TOXNET. “HSDB: Lead, Elemental.” https://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~dyZc6G:3 (accessed April 26, 2018).
PBS NOVA. “Poisoned Water.” http://www.pbs.org/wgbh/nova/body/poisoned-water.html (accessed April 25, 2018). This is an hour-long documentary about the Flint water crisis first aired by PBS in May 2017.
University of Michigan-Flint, School of Public Health and Health Sciences. Flint Water Crisis Course. https://www.youtube.com/playlist?list=PLXTcWgqRYbI15MwCzeQhFK1ASsxoI416u (accessed April 26, 2018). This is a set of twelve videotaped community forums and lectures, each about two hours in length, offered in 2016 to community residents as well as students. The twelve videos are archived on YouTube.
Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30329, (800) CDC-INFO, CDCINFO, http://www.cdc.gov/ .
Michigan Department of Environmental Quality (MDEQ), PO Box 30473, Lansing, MI, 48909-7973, (800) 6629278, https://www.michigan.gov .
National Institute of Environmental Health Sciences (NIEHS), 111 T. W. Alexander Dr., Durham, NC, 27709, (919) 541-3345, Fax: (301) 480-2978, firstname.lastname@example.org, https://www.niehs.nih.gov .
University of Michigan-Flint, Department of Public Health and Health Sciences, 3124 William S. White Bldg., 303 E. Kearsley St., Flint, MI, 48502, (810) 762-3172, PHHS-Info@umflint.edu, https://www.umflint.edu .
U.S. Environmental Protection Agency (EPA), 1200 Pennsylvania Ave., NW, Washington, DC, 20460, (202) 564-4700, https://www.epa.gov .
Rebecca J. Frey, Ph.D.