Article courtesy of Amy Lieberman of The Lancet. View the article here.

"Testing for lead poisoning is underway in the US city of Flint following a water contamination crisis that might have affected thousands of people. Amy Lieberman reports.

Before she dealt with the rashes, malaise, and endless cases of bottled water, Tammy Lawrence saw brown water spurting from fire hydrants during a walk in her neighbourhood in Flint, MI, USA. It was spring 2014, around the time her financially strapped city switched to a new water source-the Flint River, the sort of place Lawrence would never dream of taking her children to swim.

About 6 months later, city health officials quietly voiced internal concerns about a boost in Legionnaires' disease cases after the April, 2014, water supply change from the Huron to the Flint River. No publicly known state or other scientific evaluation for health risks associated with the water would occur for another year.

Lawrence, among the other parents of about 9000 Flint children now considered exposed to lead, started to boil her strange-smelling water-a process that condenses the potent neurotoxin. "If I had known then what I know now, the kids never would have touched it. They [government officials] were telling us they were basically flushing the system", said Lawrence, whose four sons range in age from 10-14 years. "We boiled huge pots of water for months and months and it still had a funny smell to it and we knew something was wrong but we just didn't have no one to turn to [to] find out the truth."

System failure

Nearly 4 months after President Barack Obama declared a state of emergency to respond to the Flint water crisis, some signs point to disaster relief efforts moving towards recovery. However, the road back to normalcy for Flint will likely be prolonged, taking on a complexity as intricate as the political failings that led to the lead exposure. Issues like loss of trust in public officials, lack of reliable transportation, and ongoing public infrastructure weaknesses could make identification and treatment of many residents challenging over the next several decades. "The system [was] meant to work and it failed. There is extreme anxiety and apprehension about what is going on", said Sania Zainuddin, the clinical director of the Mott Children's Health Center, which treats newborn babies to children aged 8 years in Flint. "As physicians we have a special relationship with our patients, but it is hard to help them regain trust."

Flint is one of the 12 cities in the Midwestern state of Michigan currently governed by an emergency manager system-a department of unelected officials put in place to help financially ground municipalities. The independent Flint Water Advisory Task Force recently reported that the Flint emergency manager department bears the primary responsibility for the water contamination. It failed to act swiftly on the high number of Legionnaires' disease cases, waited months to engage lead experts, and was deemed "dismissive and unresponsive" to other warning signs. The physical contamination with lead and other chemicals from pipes stems from the improper treatment of the water-not the water itself.

Monitoring and follow-up

Zainuddin, who has seen many patients complaining of rashes, says there is now a need to follow-up on most patients long term and carefully watch for emerging symptoms. She considers every child living in affected areas at risk. Many of these kids reside in the city's poorest neighbourhoods. That's because depopulation in these areas reduced water demand and pipe use, making the system more susceptible to corrosion, according to Shawn McElmurry, a civil and environmental engineering associate professor at Wayne State University, Detroit, MI, USA. He is investigating a "sizable outbreak" of Legionnaires' disease in the past 2 years-an observed uptick of 88 cases and ten deaths from June, 2014, to November, 2015, from the average four to six cases. Although water ripe with bacteria that can lead to Legionnaires' disease can be treated with chlorine or boiled water, boiling water could, ironically, further concentrate lead in water.

Lead has a half-life and can stay in the body for up to 30 days. Children, in particular, are most vulnerable, partly because of their ongoing brain development and ability to absorb more of the material. Tests for lead that show a negative result at 1 month might not reveal the high levels that were present in a child or adult's body 2 or 3 months before. They could still have lasting effects, ranging from learning disabilities and attention deficit hyperactivity disorder, to abdominal pain, body aches, and more. "From a physicians perspective, we need to look at every kid who was exposed during this time and follow-up on their developmental abilities", Zainuddin said. "We need to intervene and unless we do that we will never know which kids are involved."

Mona Hanna-Attisha was one of the first public health officials to raise the red flag about high lead levels across Flint's young population in October, 2015. Hanna-Attisha, the director of Hurley Medical Center's Pediatric Residency Program, led a study that showed concentrations of lead in the blood of children younger than 5 years increased from 2·4% to 4·9% after the change in water source. Neighbourhoods with the highest levels of lead in their water experienced a 6·6% increase.

Her trajectory for recovery work spans the next 20 years. These efforts will include implementing public intervention programmes to extend public early childhood development programmes for low-income families. "We believe if we invest as much as we can early on, we are not going to have to pay for this years later when it is too late. There is an urgency to get things in place", she said.

Impoverished population

Already on any given day about 30% of Hanna-Attisha's patients do not show up to their appointments. Many people in Flint, where 57% of the population is black and the poverty rate is nearly 42%, do not have cars and find public transportation irregular. Transportation is also a major barrier for patients frequenting the Genesse Community Health Center, which treats people living at 200% above the national poverty level, according to Honor Potvin, interim executive director. Patients there have reported a general malaise-a complicated symptom to pin to lead exposure. The health centre has begun creating a database of young patients. It is also working to provide transportation for patients, in the form of bus passes and pick-ups from home.

Some Flint citizens remain homebound, unable to access any medical care or the free water filters and bottled water available across the city. The volunteer grassroots organisation Crossing Water has undertaken more than 7000 home visits over the past 3 months, according to director Michael Hood. About 75% of visited homes had water filters that were improperly installed or not working. "The poverty is so bad in some areas that people don't have cell phones and they have yet to hear there is lead in the water and they are still giving it to their kids", Hood said. "No one is telling residents about the water in a meaningful way."

These families may soon see some reprieve with the anticipated May arrival of medical mobile clinics from the Children's Health Fund. The health clinics can stay indefinitely, says chief medical officer Delaney Gracy, as some still remain in Louisiana following a response to Hurricane Katrina in 2005.

Tracking all exposed children is now at the forefront of various health practitioners' minds. Discussions surrounding a database have taken off, but no formal plans have launched. An estimated 8000-10"ˆ000 children might make its ranks, all with the target of receiving at least yearly assessments. There have also been calls-including those made by the US Centers for Disease Control and Prevention-for all Flint children to be tested for lead. As of March, 2016, 14"ˆ000 Flint citizens have been tested, according to Eden Wells, the chief medical executive of Michigan's Health and Human Services Department. "That does not tell us about the burden of who has been exposed. They can be negative or positive and that is why the public health effort is so long term and complicated", Wells said.

Testing can come with some risks. If a child misleadingly tests negative, his or her parents could then see less of a need for regular primary care. If testing positive, there can be stigma associated with a diagnosis of lead poisoning.

Lawrence's children know they have experienced lead poisoning. Their levels in 2014 ranged from 9-26 μg/dL-all within or above the average rates of exposure observed in Flint, and considered to lead to various long-term health issues. Her 12-year-old has been consistently sick since 2014 with stomach, chest, and head pains. Her other sons have had itchy rashes and have watched their grades plummet at school. The family now drinks, cooks, and bathes with bottled water. "To sit up and watch your kids deteriorate physically and mentally where there is nothing you can do is so difficult", she said.

There might not be an easy fix. The corrosion of Flint's pipes could require the entire city, home to about 100"ˆ000 people, to replace its water system, McElmurry says.

Since news of Flint's water contamination made the headlines, stories of lead contamination in other poor US cities, including in New Jersey, Jackson, and Mississippi, have circulated. The specific breed of alleged government corruption that led to the Flint scenario is unique, but the end result might not be so rare in the USA-home to an ageing water system. "This may be the worst public health deal in recent memory…The Pandora's box is now wide open", said Irwin Redlener, co-founder and president of the Children's Health Fund. "There are going to be a lot of other cases like this, not only lead but others showing contaminants in the water."