What the Eyes Don't See Read online

  On that August day, we had been in the new Hurley Children’s Clinic for only a few weeks and were still settling in. But I was looking ahead already, to September 15, when applications would come in from next year’s residents.

  Recruitment can be difficult when your program is in Flint. Top medical residents want to live in Chicago, San Francisco, Boston, or New York. Luring them to an economically troubled community like Flint takes powers of persuasion, finesse, and assurances that they will be bountifully rewarded, but in ways that are as spiritual and personal as they are practical. But it works. Each year the residents we attract are better, more competitive, and more committed.

  So while it’s true that as a residency director, I don’t get to care directly for kids as much as I want, I get to spend most of my days with a group of smart, compassionate young doctors who love kids—and believe in Flint—as much as I do.

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  PEDIATRIC RESIDENCY TAKES THREE YEARS. Each of those years is divided into four-week rotations called “blocks,” and each block is focused on a different pediatric skill. I direct a rotation called Community Pediatrics, designed specifically to open the eyes of first-year residents to the powerful, but not always immediately apparent, environmental and community factors that affect the lives and health of their patients. There’s an expression I have always liked, a D. H. Lawrence distillation: The eyes don’t see what the mind doesn’t know. The first time I heard that phrase was during my own pediatric residency, when it was uttered by Dr. Ashok Sarnaik, a legendary pediatrician at Children’s Hospital of Michigan in Detroit. He challenged residents to know every possible disorder or genetic syndrome under the sun and its underlying pathophysiology. When discussing a case and trying to figure out a diagnosis, he watched us run through our limited supply of options, and he always criticized us for not reading enough and therefore not knowing enough, for not seeing the whole picture.

  “How can your eyes see something,” he’d say, “that your mind doesn’t know?”

  Community Pediatrics is meant to widen the focus of pediatricians beyond whatever is immediately visible. Sure, a nosebleed is a nosebleed. An ear infection is an ear infection. But beyond the common fevers and colds, many children are facing other struggles.

  Compared to nationwide averages, Flint families are on the wrong side of every disparity: in life expectancy, infant mortality, asthma, you name it. Flint is a struggling deindustrialized urban center that has seen decades of crisis—disinvestment, unemployment, racism, illiteracy, depopulation, violence, and crumbling schools. Navy SEALs and other special ops medics train in Flint because the city is the country’s best analogue to a remote, war-torn corner of the world.

  The city compares badly not just to the rest of the country but to neighboring communities. The median household income is half the Michigan average, and the poverty rate is nearly double. The more adversities a child experiences, the more likely she will grow up to be unhealthy in ways that are completely predictable.

  A kid born in Flint will live fifteen years less than a kid born in a neighboring suburb. Fifteen years less. Imagine what fifteen years of life means. In a country riven by inequalities, Flint might be the place where the divide is most striking.

  This is why the routine work of pediatrics—immunizations and well-baby care and the rest—is not enough for a child in Flint. Our children need much more than routine primary care just to get an even shot at the rest of their lives.

  I give my Community Pediatrics residents this Bertolt Brecht poem from 1938, “A Worker’s Speech to a Doctor,” which lays out the stakes better than I ever could:

  When we’re sick, we hear

  You are the one who will heal us.

  When we come to you

  Our rags are torn off

  And you tap around our naked bodies.

  As to the cause of our sickness

  A glance at our rags would

  Tell you more. It is the same cause that wears out

  Our bodies and our clothes.

  Physicians need to be trained to see symptoms of the larger structural problems that will bedevil a child’s health and well-being more than a simple cold ever could. But these problems are harder for even a well-trained physician to identify. A child doesn’t come to my exam room for “food insecurity.” Their moms don’t call the clinic for an appointment because “we can’t make ends meet” or “there aren’t any safe places to play outside.” They make appointments because of nosebleeds and ear infections, like other moms, or for well-baby checkups. And when we see them, if we don’t ask about the situation at home or learn to notice the clues on our own, we’ll never find out what these larger problems are. When we know about the child’s environment, we can treat these kids in the best, most holistic way, which will leave them with much more than just a prescription for amoxicillin.

  Years ago we talked about these environmental factors as “social determinants of health.” Today we call them “adverse childhood experiences” (ACEs) or “toxic stresses.” These new concepts take things a step further than the old model in two ways. First, they emphasize the importance of adversity in the developmentally vulnerable window of early childhood. A child’s first years are the most critical in her development and set her up for the rest of her life. It’s crucial to understand this. The other new concept is our realization that a child’s neuro-endocrine-genetic physiology can be altered. Prolonged, extreme, and repetitive stress or trauma—due to exposure to an ACE, including poverty, racism, violence—chronically activates stress hormones and reduces neural connections in the brain, just at the time in a child’s development when she should be growing new ones.

  In a landmark study analyzing the health data of more than 17,000 HMO members, researchers found that the more ACEs a child has, the greater the chances of long-term physical and behavioral health issues. ACEs even impact mortality; six or more ACEs drop a child’s life expectancy by twenty years. More recently, research has found that just one ACE puts a child at a 28 percent increase in risk for asthma; four ACEs put her at a 73 percent increase. This new understanding of the health consequences of adverse experiences has changed how we practice medicine by broadening our field of vision—forcing us to see a child’s total environment as medical. We aren’t just looking at a child’s physical condition on the day of an exam or clinic visit. We are looking for the larger factors in the child’s world that can impede development and diminish an entire life—and may put her at risk as an adult for diabetes, heart disease, or substance abuse. This is the most important concept in pediatrics and public health today.

  Science also shows us there’s cause for hope. We may not be able to give every child a happy, healthy, and safe childhood—though we should keep trying. But we can mitigate the effects of adversity and toxic stress by building resilience. It’s the key to development, the deciding factor between a child who learns to cope and thrive and one who never makes it to a healthy or productive adulthood. Resilience isn’t something you have or don’t have. It’s learned. While the stress hormone response in a child overloads the child’s system, it can reset to normal if she is soothed by caring adults in a nurturing, stable environment and community. The brain can heal.

  It’s important for my pediatric residents to read the most up-to-date literature and science from the leaders in the field about ACEs, toxic stress, neurodevelopment, and resilience. They watch tutorials on brain development and the impact of toxic stress from Harvard’s Center on the Developing Child and watch Nadine Burke Harris’s TEDMED talk, a fan favorite in the curriculum. But it’s important and much more galvanizing if they see it firsthand in the community where our children live.

  So at the beginning of the Community Pediatrics block, residents go on a tour of the city and learn the history of Flint, from its days as a GM boomtown and the birthplace of union
contracts and the middle class to its decades of dire decline. They record the number of blighted neighborhoods, liquor stores, neglected playgrounds, and boarded-up schools.

  I can’t assume all our residents know the history of racial injustice in this country, let alone the historic racism in medicine. So the curriculum includes webinars on race and health and a discussion of the story of Henrietta Lacks. (Everyone in medicine knows HeLa cells, but many of them don’t know about their namesake, a woman whose life vividly illustrates medical racism and its consequences.) And our residents view Unnatural Causes, a seven-hour PBS documentary about socioeconomic and racial disparities in healthcare in America and their root causes.

  We discuss the Tuskegee syphilis experiment, the infamous clinical trial that the U.S. Public Health Service conducted on six hundred African-American men between 1932 and 1972. Tuskegee participants were told that they were getting free healthcare for life, but in reality they were enrolling in a study of the natural progression of untreated syphilis. Even after the discovery and widespread use of penicillin, which cures syphilis, this inhumane experiment continued. The men—who were selected because they were poor sharecroppers with little education or recourse to the law—were still not treated. Untreated syphilis is gruesome, causing lasting damage to the body, with symptoms including nasty lesions and eye damage, as well as nervous system and cardiovascular breakdown.

  Some of our white students, and some of our international ones—who make up a significant number of residents—find it hard to believe that this kind of racism ever existed or that it persists. But our African-American residents know different. Even if they don’t know the specifics of these stories, they are all too familiar with the outlines of this ugly history and enduring reality.

  Residents also meet with community leaders and activists, and they visit nonprofits and schools and daycare centers. They are sent to home visits, to court hearings and trials, to state protective services and community events. They meet Professor Rick Sadler, a recently hired MSU nutrition geographer and Flint history buff whose Flint “food desert” maps illustrate the role of nutrition access and food security in children’s health. That summer Rick was helping me figure out if relocating the Hurley Children’s Clinic to the space above the Flint Farmers’ Market would help our patients improve their diets.

  My objective for this Community Pediatrics rotation is to get the residents out of the hospital and into the city, into the lived experience and environment of our kids. They would become familiar with the city’s weaknesses and needs but also feel a sense of solidarity and empathy with the people of Flint—and see the city’s deeper potential. That’s the feeling I wanted to imbue them with most of all: that there’s hope in this town, not hopelessness. It just needs some nurturing and care to build. And they needed to see their privileged role as builders, shoulder to shoulder with our neighbors.

  Flint has been through so much—after decades of downward spiraling, it has become beleaguered and almost bankrupt. But the spirit of the community never collapsed.

  More than fifteen years ago, I fell in love with Flint as a medical student at Michigan State University. MSU, a pioneer land-grant university, founded the country’s first community-based medical school in 1964 and reaffirmed its commitment to Flint in 2014, when it moved all public health programming to the city and expanded it. The medical school’s motto is “Service to People.” This sense of community investment and hope drew me back there when it was time to find a place to plant my own roots, and it drew others back too, like Dayne Walling, who at twenty-five was elected mayor in 2009, a couple of years before I returned to Flint.

  I knew Walling by reputation. A Flint native, he had gone to MSU’s James Madison College, a political science residential college, and graduated a year ahead of my brother, Mark (who is now a public-interest lawyer in Washington, D.C.). Walling went on to study at Oxford on a Rhodes Scholarship and followed that with a master’s degree in urban studies from the University of London. As soon as he got back to Flint, he got involved in local politics.

  Flint seemed pretty lucky to have the leadership of someone so young, optimistic, and even telegenic. But things went downhill on the day of Walling’s reelection in 2011, when Michigan governor Rick Snyder declared that nearly bankrupt Flint was in a state of “local government financial emergency” and appointed an unelected emergency manager (EM) to run the city, taking all real power away from Walling.

  Snyder, a new governor, was popular at the time. He dubbed himself “one tough nerd” and had a history as a successful business executive. He was a Republican who ran as a moderate—a technocrat—but he was soon pushed to the right by a Tea Party–controlled state legislature. Flint wasn’t the first Michigan city to have its democratically elected government replaced by an EM who demanded draconian budget cuts: Snyder had appointed EMs in Detroit and Pontiac. By 2013, half of all African-American citizens in Michigan were living under an EM, compared with 2 percent of white residents. In other words, half of the African-American population in Michigan did not have elected representatives running their cities—the cities had been effectively colonized by the state. This seemed grossly undemocratic to me and hardly an accident.

  EMs didn’t answer to the people. They answered to Snyder.

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  ONE OF THE BUDGET-CUTTING brainchildren of Snyder’s emergency manager regime was to change the source of Flint’s tap water. For half a century, Flint had bought safe, pretreated drinking water from the Detroit Water and Sewerage Department, a massive public utility that pumped water from Lake Huron and lucratively sold it to dozens of communities in southeastern Michigan. Tired of its “water dependency” and the steep prices charged by the Detroit utility, a team of elected officials from Flint and Genesee County—the county that contains Flint—along with members of the governor’s office, decided that they should build a new parallel pipeline to Lake Huron. To save even more money, the state determined that until the pipeline to Lake Huron was finished, the stopgap water source would be the Flint River. This was the crucial mistake.

  You didn’t have to be a water expert to know what everyone in the area knew: the Flint River had been a toxic industrial dumping site for decades, even if in recent years the river water didn’t look quite as brown or as thick and flammable (it was said to have twice caught fire) as it had before the 1972 Clean Water Act.

  But was the water safe to drink?

  That’s why we have agencies like the Michigan Department of Environmental Quality (MDEQ) and the federal Environmental Protection Agency (EPA) in Washington—to answer that question. In my head, I pictured these agencies as populated by diligent bureaucrats in white lab coats with test tubes, studying water quality to ensure that what came out of our taps was safe. It was their job to protect our health and safety. And nothing is more fundamental to our health and safety than our water. I believed they took that responsibility seriously.

  On April 25, 2014, I watched the news as Mayor Walling pressed a button at the Flint Water Treatment Plant to shut off the valve to close the Detroit water supply. When the pipes opened to the Flint River, he toasted by drinking a glass of the water. After that, I assumed that those people with their white lab coats and test tubes were doing their jobs—and that life in Flint would carry on with little difference. But almost immediately, complaints began to appear in the local media.

  MAYOR DAYNE WALLING SWITCHING THE WATER SOURCE, APRIL 2014

  People said their tap water smelled bad and tasted worse. It was brownish. It was greenish. It was disgusting. The agencies did their testing. Soon the city released boil alerts because of bacteria, which didn’t inspire confidence. So much chlorine was added to kill the bacteria that the tap water began irritating people’s skin and eyes. And it also led to a buildup of a disinfectant by-product called total trihalomethanes (TTHMs)—a carcinogen if inhaled.
The city of Flint was found in violation of safe drinking water levels of TTHMs, but then that was apparently cleared up. The alerts ended and an all-clear announcement was made. The debut of the new water source wasn’t flawless, but I had no reason to suspect that the agencies we’d entrusted to look after our water weren’t doing their jobs. We were in America, not a developing country. It was the twenty-first century. And Flint was literally in the middle of the Great Lakes region, the largest source of freshwater in the world. Why doubt the safety of what was coming out of the tap?

  What little I knew about drinking water I knew from my high school friend Elin Betanzo. After graduating from Kimball High as class valedictorian, she studied engineering and music performance at Carnegie Mellon, then drifted into the field of environment science, eventually clocking some mostly unhappy years in the EPA’s Office of Ground Water and Drinking Water. I didn’t remember all the details of her departure. And to be totally honest, when Elin brought up her work—with its details about “distribution systems” and “compliance” and “sampling variability”—sometimes I found myself mentally checking out. She was so in the weeds. And there were a lot of weeds in drinking water.

  BY THE TIME I GOT HOME that night, August 26, 2015, Elliott had started dinner. Chicken had been smothered in some kind of super-secret barbecue rub. On the deck, his exotic egg-shaped Kamado grill was heating up and Elliott was struggling a little with its heavy lid. His right arm was in a sling.

  Just a month before, he’d undergone shoulder surgery for various injuries that had compounded over the years from playing baseball and racquetball, then lifting weights. He was still in pain and probably shouldn’t have been grilling at all. But Elliott loved his Kamado grill so much, it was hard to keep him away—sometimes we joked that it was the son he never had. He insisted he didn’t need help, and truthfully I didn’t know anything about barbecuing, so I rushed upstairs with just enough time to change into jeans and ask the girls about their time at Skull Island day camp.