The Social Determinants of America’s Lead Crisis

The dangers of lead contaminations are well known. Federal guidelines exist to ensure the safety of water supplies across the nation, but in Flint, Michigan — and numerous other municipalities all over the country — a number of overlapping socioeconomic factors complicated the issue to put residents in harm's way.

Both the Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC) recommend intervention by public agencies when water reserves surpass a certain threshold of lead contamination. The EPA's 1991 Lead and Copper Rule regulates drinking water and requires water companies to sample tap water in homes and private wells and notify the public when more than 10 percent of the sample pool contains levels exceeding 15 parts per billion. The CDC recommends intervention when blood levels exceed five micrograms of lead per deciliter of blood. Although neither the CDC nor EPA offers specific guidance about when a "do not drink" order should be issued, they both say that no amount of lead in drinking water is safe.

Yet, the residents of Flint were exposed to levels of lead contamination so severe and for such a long period of time that a federal state of emergency had to be declared in the city in January. Social determinants of health, which we defined and examined in our first blog post, play a role in the ongoing crisis. In localized situations such as this, they create a web of complex interactions that must be considered.

In Flint, city budget deficits caused leaders to switch the drinking water source to the Flint River, which is highly corrosive. When E. coli showed up in the water, additional chlorine was added, exacerbating the corrosive effect. Since the required corrosion-protecting agent wasn't included, lead-lined pipes were permanently damaged and continued to leach lead into tap water even after the city switched back to its original water supply.

The failures in Flint are not unique, but the case is illustrative. Nursing@USC created the following timeline shows the details of how the crisis, which is far from over, developed.

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The dangers of lead exposure — which is commonly caused by sources like house paint, soil, and tap water — are real. In a recent interview with USA Today, lead-poisoning researcher Bruce Lanphear, who studied children exposed to lead in Rochester, N.Y., said that contaminated water is the primary source of direct lead exposure across the country. It’s also the most detrimental.

"You should assume you're absorbing most of it. It's not like the house dust over there," Lanphear said in the interview. "This is what you put into your mouth or you're cooking with it. It's direct exposure."

The EPA cautions that exposure to lead in drinking water can cause delayed physical or neurological development in infants and children, and high blood pressure, kidney disease, and cancer in adults.

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With this in mind, lead contamination should be dealt with seriously and swiftly. For cities and towns with budgetary challenges, like Flint, this kind of action may be prohibitively expensive. However, some municipalities have the wherewithal to get ahead the problem. This is exactly what happened in Lansing, Michigan, which is located less than 60 miles from Flint. Lansing spent most of the last decade working to replace its entire water supply system after discovering slightly elevated levels of lead in their water. In contrast to Flint's budget-cutting environment, Lansing earmarked $42 million for the project. It was a drastic, but appropriate, response. Flint, which has a poverty rate of 26.4 percent (10 percent higher than Lansing), could not have afforded such an undertaking and needed support of the local, state, and federal government to ensure that the drinking water was safe.

Not Just Flint

Other incidents of lead contamination around the country show that it is a widespread problem with a variety of factors at play. A recent investigation by USA Today identified excess levels of lead contamination over the past four years in almost 2,000 additional water systems across all 50 states. In these cases, race and poverty have a dramatic effect on health outcomes. A city with inadequate resources is just one example of how social factors can amplify the problem of lead poisoning among vulnerable populations.

To start, the age and level of renovation in a home's pipes are a consideration, and lower-income families may only be able to afford homes that are in greater states of disrepair. For example, in Jackson, Mississippi, lead plumbing in residents' homes was identified as the culprit for lead contamination. However, the city has a median household income of just $29,811, which is more than $20,000 below the national median household income of $53,657, and most residents cannot afford to replace the pipes in their homes.

Resources of local school districts — or lack thereof — also affect whether water is being tested at all. In Sebring, Ohio, children in the public school system were put at risk of exposure when the city failed to conduct quality testing. Upper-middle-class or private schools may have more testing capabilities than low-income districts, which puts low-income children at higher risk.

Finally, as the residents of Flint can attest, city and state resources influence budget priorities in determining how water is delivered and tested, as well as how worrisome results are addressed.

"The situation in Flint is an unfortunate example, but an example nevertheless, of the importance of recognizing that social determinants of health are just as important as biomedical aspects of health," noted Dr. Ellen Olshansky, chair of the USC Department of Nursing. "In order to improve the health of community members such as those in Flint, Michigan, we must address the social forces that are impacting health."

Moving forward, it is important to recognize that the social determinants of health affect communities in a variety of ways, and addressing them will take a multifaceted approach.

Remedies Take a Team

There are a number of potential solutions to deal with the risk of lead in drinking water, and social factors have a significant influence on their viability, both for individuals and for municipalities.

For individuals, the most obvious solution is to use bottled water or water filters designed to remove lead. Additional solutions include replacing lead pipes, installing filtration systems, or even moving to a new home. Such options may be available to families of higher socioeconomic status, but low-income families likely cannot afford to use bottled water regularly, let alone choose other, more expensive options.

In a broader sense, public crises also may be dealt with differently based on the economy in which they occur. The contrast between Flint and Lansing would suggest that might be the case. On a larger scale, Washington, D.C.'s lead crisis in the early 2000s was for the most part publicly handled. Water mains were replaced and filtration methods were changed. In higher-income regions such as these, there may be a greater possibility that response will be faster and more effective than in lower-income towns.

"Thus, one of the important roles of health care providers, such as nurse practitioners, is to work on a health policy level to improve government response to such public health crises," Dr. Olshansky said.

Lead contamination in water is a complex and diverse problem, and is influenced by many overlapping social factors. That's why solving a lead crisis requires a team effort. It includes the involvement of federal entities to set national safety standards, local public health officials to develop testing standards, on-the-ground advocates to empower those in poverty, and primary care providers to educate their communities about health risks.

"It's easy to forget that before the 1991 Lead and Copper Rule, many communities had very high levels of lead consistently in tap water. The process leading up to the Rule, and the regulation itself, helped usher in nationwide use of water treatment to prevent pipe corrosion and thus lead at the tap," wrote Lynn Thorp, the national campaigns director of Clean Water Action, in a recent blog post. "How we measure lead, whether we are doing enough to prevent corrosion, how we communicate with consumers about lead sources, and whether we can do more to get lead out of contact with drinking water — these are the challenges and our work will need to be as ambitious as that set out twenty-five years ago.

Although addressing the problem may seem daunting, it can be done, and as a community interested in improving health outcomes for all, we must do it together. Primary care providers in particular will play a crucial role in facilitating a more coordinated treatment approach to communities affected by contaminated drinking water and other widespread health challenges.

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