In 1854, British physician John Snow famously wrote, “The most terrible outbreak of cholera
which ever occurred in this kingdom, is probably that which took place in Broad Street,
Golden Square, and the adjoining streets, a few weeks ago.” (http://bit.ly/1TUQnje). Snow linked cholera to polluted water flowing
from the Broad Street pump. City officials removed the pump handle and the cholera
epidemic suddenly ended. Cholera is one of many gastrointestinal illnesses caused by
drinking water carrying disease-causing microbes. In 2000, for example, hundreds of
Milwaukee residents became ill when they drank city water contaminated with
Lawrence O. Gostin, JD
Pathogens are not the only health hazard lurking in drinking water. Tap water can also contain lead, which is devastating to children’s developing brains. A deteriorating water system infrastructure built in the 19th century is the culprit; drinking water service pipes were often lined with lead (http://1.usa.gov/1d0071F). As David Bellinger, PhD, of Harvard Medical School in Boston, explains, the very word “plumbing” derives from the Latin for lead because lead-based water distribution systems date back to Roman times (http://bit.ly/1TIGZ36). Over the years, corrosive water running through lead-lined pipes has caused many of these old pipes across the country to leach lead into our drinking water.
We now know there are no safe levels of lead exposure. Even small amounts of lead can have serious developmental effects, particularly for young children and pregnant women (http://mayocl.in/1YmSj24). Yet, approximately 4 million households across the country are exposed to elevated lead levels (http://1.usa.gov/1Neg8Zr).
The population of Flint, Michigan, is among the poorest in the land and disproportionately African American. Since 2014, Flint citizens had complained bitterly that their tap water was foul and discolored. But city, state, and federal officials took no heed. It would have been possible to prevent corrosion in the pipes for around $100 per day simply by treating the source of their drinking water, the Flint River, with federally mandated anticorrosives (http://cnn.it/1SJDVlk). But today the cost of repairing the Flint water system is estimated at $1.5 billion, and fixing the broken system across the United States would cost at least $1.3 trillion (http://nyti.ms/1MBhpFf).
I predict little will be done once memories of Flint fade. Although water is a basic human need, the Flint independent task force found that race and economic status played an outsized role in explaining government neglect (http://1.usa.gov/1T8cJLT). Iron- and lead-contaminated water may be the most vivid image of social and environmental injustice, but it is hardly the only one. Throughout the country, the poor and social minorities live in the most dangerous places, prone to floods, and disproportionately affected by air and soil pollution, trash and vermin, and cancer-causing toxins.
The Flint water crisis is a tale of systematic “government failure, intransigence,
unpreparedness, and environmental injustice” (http://1.usa.gov/1T8cJLT).
After the Michigan auto industry crisis, the courts put Flint into receivership and
the governor appointed an emergency financial manager. The emergency
manager—who was not democratically accountable for the health of
inhabitants—ignored citizens’ pleas about the water supply. To save
money, the manager switched Flint’s water source from Lake Huron to the Flint
River. He failed to consider a 2011 study finding the Flint River was unacceptably
corrosive (http://bit.ly/1SdEdzD). State officials took no action until a local
pediatrician demonstrated 2 to 3 times higher lead levels in Flint’s children
than in other parts of the state (http://1.usa.gov/1MwZDZm).
Independent experts also tested the drinking water and found that lead was leaching
into the water supply. Changing the water supply back to Lake Huron could not undo
the damage and indeed researchers believe that it many not be possible to ever
rectify the lead issues with the current piping system, so Flint residents have had
to use bottled water for all their cooking and hygiene needs (http://bit.ly/1XyH73h).
The Flint tragedy should never have happened. Federal law is designed to ensure accountability
for testing drinking water and ameliorating high lead levels. The Safe Water
Drinking Act (http://1.usa.gov/1VtjdsO) and associated primary regulations
(http://1.usa.gov/22ykQ6U) require the Environmental Protection
Agency (EPA) to set and enforce maximum contaminant levels in drinking water, along
with monitoring and reporting requirements. States must have regulations that meet
or exceed EPA standards and must analyze water samples, with enforcement authority
to compel water systems to comply. If EPA finds an “imminent and substantial
endangerment,” it has the power to act, supplanting local and state officials.
The Flint task force found deficiencies at every government level; the Michigan Department of Environmental Quality failed to sample tap water quality as mandated by the Lead and Copper Rule (http://1.usa.gov/1qKMLVE); the agency sent disingenuous reports to EPA, certifying wrongly that water quality met federal standards. The Michigan Department of Health and Human Services did not consider the consequences of changing the city’s water source. The governor’s office did not listen to and act on the residents’ concerns.
Although Flint was a story of government neglect and discrimination, it was also a story of heroism. Citizens rose up and illustrated the power of bottom-up social mobilization; health and environmental experts bravely challenged government leaders; and a free press exposed government cover-ups. After repeatedly failing to take responsibility, Michigan’s governor, Rick Snyder, apologized profusely.
The story of Flint may be a cautionary tale, but it is not unique. The city of Baltimore found elevated lead levels in schools in 1992, but rather than replacing lead-bearing pipes, city officials simply changed to bottled water, citing cost-effectiveness (http://n.pr/1S3yVqa). In 2004, Washington, DC, faced a public health crisis when reports emerged that lead levels in drinking water from lead-based utility lines servicing approximately 11.5 million people were very high (http://bit.ly/264JdxS). Most of the affected residents lived in Washington’s impoverished southeast quadrant. In 2008, Los Angeles schools were discovered to have lead levels hundreds of times above EPA standards (http://bit.ly/1AUpGBX). And in 2016, the media published a memo showing that Newark, New Jersey, officials knew full well about the risks of lead to schoolchildren (http://nyti.ms/1RO7Xjl).
Approximately 7.3 million lead service lines are in service across the country. The EPA National Drinking Water Advisory Committee Working Group has recommended removal of all lead service lines as a public health priority (http://1.usa.gov/1RXDNhT). This is an undertaking that would entail mammoth efforts logistically and financially, involving private landowners as well as public spaces. So far it hasn’t happened.
Regulatory action for public health, like sealing of the Broad Street Pump, is not always politically expedient. This is particularly so when those most affected are the most marginalized or when the cost of repair is exorbitant. Put simply, the infrastructure for ensuring safe, clean water is falling apart. Communities already suffering from compounding injustice feel the brunt. Lead poisoning will affect the next generation of inner city children.
The facts are clear that our water system is leaching lead and that contamination is profoundly hazardous to human health. The solutions are also clear, even if they will cost a great deal. But given pervasive social and environmental inequalities, can anyone say with confidence that a tragedy like the one in Flint won’t happen over and over again?
Corresponding Author: Lawrence O. Gostin, JD (email@example.com).
Published Online: April 13, 2016, at http://newsatjama.jama.com/category/the-jama-forum/.
Disclaimer: Each entry in The JAMA Forum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association.
Additional Information: Information about The JAMA Forum is available at http://newsatjama.jama.com/about/. Information about disclosures of potential conflicts of interest may be found at http://newsatjama.jama.com/jama-forum-disclosures/.
Gostin LO. Lead in the Water: A Tale of Social and Environmental Injustice. JAMA. 2016;315(19):2053-2054. doi:10.1001/jama.2016.5581