The Impact of the Flint Water Crisis on Fertility

Association of Public Works Disasters with Substance Use Difficulties: Evidence from Flint, Michigan, Five Years after the Water Crisis Onset

Public works environmental disasters such as the Flint water crisis typically occur in disenfranchised communities with municipal disinvestment and co-occurring risks for poor mental health (poverty, social disconnection). We evaluated the long-term interplay of the crisis and these factors with substance use difficulties five years after the crisis onset. A household probability sample of 1970 adults living in Flint during the crisis was surveyed about their crisis experiences, use of substances since the crisis, and risk/resilience factors, including prior potentially traumatic event exposure and current social support. Analyses were weighted to produce population-representative estimates. Of the survey respondents, 17.0% reported that substance use since the crisis contributed to problems with their home, work, or social lives, including 11.2% who used despite a doctor's warnings that it would harm their health, 12.3% who used while working or going to school, and 10.7% who experienced blackouts after heavy use. A total of 61.6% of respondents reported using alcohol since the crisis, 32.4% using cannabis, and 5.2% using heroin, methamphetamine, or non-prescribed prescription opioids. Respondents who believed that exposure to contaminated water harmed their physical health were more likely to use substances to the detriment of their daily lives (RR = 1.32, 95%CI: 1.03-1.70), as were respondents with prior potentially traumatic exposure (RR = 2.99, 95%CI: 1.90-4.71), low social support (RR = 1.94, 95%CI: 1.41-2.66), and PTSD and depression (RR's of 1.78 and 1.49, respectively, p-values < 0.01). Public works disasters occurring in disenfranchised communities may have complex, long-term associations with substance use difficulties.

Knowledge, confidence, and reported behaviors that promote safe water drinking among women of reproductive age

Introduction

Drinking lead contaminated water during pregnancy is associated with infant mortality. All women of reproductive age are advised by health agencies to adhere to healthy behaviors due to the chance of unintended pregnancy. Our objectives are to understand knowledge, confidence, and reported behaviors that promote safe water drinking and prevent lead exposure among women of reproductive age.

Methods

A survey among females of reproductive age from the University of Michigan - Flint was administered. A total of 83 females who wished to become pregnant one day participated.

Results

Low levels of knowledge, confidence, and reported preventative health behaviors related to safe water drinking and lead exposure prevention existed. Specifically, 71.1% of respondents (59 of 83) were not at all or were somewhat confident in their ability to choose an appropriate lead water filter. Most participants rated their knowledge on how to decrease exposure to lead during pregnancy as poor/fair. No statistically significant differences were detected between respondents residing inside and outside of the city of Flint, Michigan for most variables assessed.

Conclusion

While the small sample size is a limitation, the study adds to an area of scarce research. Despite widespread media attention and resources directed toward reducing the negative health effects of lead exposure following the Flint Water Crisis, significant gaps in knowledge related to safe water drinking remain. Interventions are needed to increase knowledge, confidence, and healthy behaviors that promote safe water drinking among women of reproductive age.

Experiences of the Flint Water Crisis Among Reproductive-Age Michigan Women in Communities Outside of Flint: Differences by Race and Ethnicity

We sought to understand how women in Michigan communities outside of Flint experienced the Flint water crisis, an avoidable public health disaster widely attributed to structural racism. Using survey data from 950 Michigan women aged 18-45 from communities outside of Flint, we examined racial and ethnic differences in personal connections to Flint, perceived knowledge about the water crisis, and beliefs about the role of anti-Black racism in the water crisis factors that could contribute to poor health via increased psychological stress. We found that White (OR = 0.32; 95% CI: 0.22, 0.46) and Hispanic (OR = 0.21; 95% CI: 0.09, 0.49) women had lower odds than Black women of having family or friends who lived in Flint during the water crisis. Compared to Black women, White women were less likely to be moderately or very knowledgeable about the water crisis (OR = 0.58; 95% CI: 0.41, 0.80). White women (OR = 0.26; 95% CI: 0.18, 0.37), Hispanic women (OR = 0.38; 95% CI: 0.21, 0.68), and women of other races (OR = 0.28; 95% CI: 0.15, 0.54) were less likely than Black women to agree that the water crisis happened because government officials wanted to hurt Flint residents. Among those who agreed, White women (OR = 0.47; 95% CI: 0.30, 0.74) and women of other races (OR = 0.33; 95% CI: 0.12, 0.90) were less likely than Black women to agree that government officials wanted to hurt people in Flint because most residents are Black. We conclude that the Flint water crisis was a racialized stressor, with potential implications for the health of reproductive-age Black women.

Child Lead Screening Behaviors and Health Outcomes Following the Flint Water Crisis

BACKGROUND

There is little research on lead (Pb) screening behaviors and outcomes and possible health sequelae of children in Flint, Michigan in the years following the city's 2014 water crisis, which included widespread tap water contamination with elevated levels of heavy metals and other environmental contaminants.

METHODS

Between June and November 2019, we collected and analyzed cross-sectional data on Flint children's demographics and self-report of screenings of blood lead levels (BLLs) and results and various potential water contamination-related health symptoms and outcomes. We calculated descriptive statistics to summarize the prevalence of health outcomes and screenings in children, and fit multivariable models using generalized estimating equations to characterize the association between baseline traits and health symptoms and outcomes in children.

RESULTS

A total of 244 children (mean age 8.6 ± 4.8) were included in the analysis. Overall, 76.6% of the children were reported to have been screened for elevated BLLs after the water source switch. In total, after the water source switch, 25.0% of children were reported as having clinician-diagnosed elevated BLLs. Overall, 43.9% of children experienced hyperactivity, 39.3% had emotional agitation, 29.1% had comprehension issues/learning delays, while 38.9% of children had skin rashes and 10.7% experienced hair loss. A child having elevated BLLs also significantly increased the odds of experiencing adverse cognitive/behavioral outcomes (comprehension issues/learning delays OR = 4.0, hyperactivity OR = 6.6, emotional agitation OR = 3.5).

CONCLUSION

Child BLL screening following the crisis initiation was moderate, and BLLs and potential water contamination-related morbidity outcomes appeared heightened. Further research is needed to contextualize epidemiologic factors contributing to BLL screening patterns and results and the potential water contamination-associated sequelae observed here.

Blood Lead Testing in Flint Before and After Water Contamination

OBJECTIVE

Lead is a neurotoxicant that negatively affects health. Reducing lead exposure and early detection among children are important public health goals. Our objective with this study was to determine if the September 2015 lead advisory in Flint, Michigan affected lead testing among children when possible exposure was widely publicized.

METHOD

This study included 206 001 children born in Michigan from 2013 to 2015 and enrolled in Medicaid, using 2013 to 2017 claims data to determine if and at what age an individual received a lead test. Difference-in-differences regression models were used to compare the receipt of lead tests among children in Flint with other cities in Michigan before and after September 2015, when a lead advisory was issued for the city warning about potential exposure to lead in publicly supplied water.

RESULTS

Before the lead advisory, approximately 50% of children in Flint received a lead test by 12 months of age and nearly 75% received a lead test by 24 months of age. After the September 2015 advisory, the receipt of lead tests among children in Flint increased 10 percentage points by 12 months compared with other cities. Effects by 10-month cohorts, as of 2016, revealed a 20-percentage-point increase for children in Flint compared with other cities.

CONCLUSIONS

Despite a highly publicized lead advisory, children in Flint enrolled in Medicaid received lead tests earlier, but the proportion of Medicaid-eligible children who were tested did not change. This suggests that increasing lead testing is a difficult policy goal to achieve and, therefore, supports recent efforts focusing on primary prevention to reduce lead exposure.

The effects of environmental prenatal program on environmental health perception and behavior using internet-based intervention in South Korea: A non-randomized controlled study

PURPOSE

This study aimed to develop and examine the effects of an internet-based intervention program on environmental perception and behavior among Korean pregnant women based on revised protection motivation theory.

METHOD

This study was a non-equivalent control group pre-post-test design. The experimental program consisted of prenatal education, reduction of fine dust, birth education, environmental health promotion, and postnatal management education using zoom video conferences. The face-to-face interventions were provided through regular prenatal classes at public health services for the control group. The total participant was 49 pregnant women: 25 in the experimental group and 24 in the control group. The program adaptation was conducted between April 2021 and November 2021 in Korea. The data were analyzed by ANCOVA and t-test to examine the effects using SPSS 26.0 program.

RESULTS

After intervention of the program, environmental severity (F = 17.96, p < .001), response efficacy (F = 15.69, p < .001), and total environmental perception (F = 7.80, p = .008) were higher in the experimental group than in the control group. There were no significant differences in feasibility, accessibility, satisfaction, susceptibility, self-efficacy, barrier, personal environmental behavior, and community environmental behavior between the two groups.

CONCLUSION

The internet-based educational program can be the alternative for the face-to-face prenatal class to promote environmental health perceptions during pregnancy in the pandemic situations.

Lead in drinking water and birth outcomes: A tale of two water treatment plants

The recent lead-in-water crisis in Newark has renewed concerns about the crisis being a widespread problem in the nation. Using data on the exact home addresses of pregnant women residing in the city combined with information on the spatial boundary separating areas within the city serviced by two water treatment plants, we exploit an exogenous change in water chemistry that resulted in lead leaching into the tap water of one plant's service area, but not the other's, to identify a causal effect of prenatal lead exposure on fetal health. We find robust evidence of adverse health impacts, which has important policy implications in light of the substantial number of lead water pipes that remain in use as part of our aging infrastructure and the cost-benefit calculus of lead abatement interventions.

Determinants of Disparities in Early COVID-19 Job Losses

This study examines the sociodemographic divide in early labor market responses to the U.S. COVID-19 epidemic and associated policies, benchmarked against two previous recessions. Monthly Current Population Survey (CPS) data show greater declines in employment in April and May 2020 (relative to February) for Hispanic individuals, younger workers, and those with a high school diploma or some college. Between April and May, the demographic subgroups considered regained some employment. Reemployment in May was broadly proportional to the employment drop that occurred through April, except for Black individuals, who experienced a smaller rebound. Compared to the 2001 recession and the Great Recession, employment losses in the early COVID-19 recession were smaller for groups with low or high (vs. medium) education. We show that job loss was greater in occupations that require more interpersonal contact and that cannot be performed remotely, and that pre-COVID-19 sorting of workers into occupations and industries along demographic lines can explain a sizable portion of the demographic gaps in new unemployment. For example, while women suffered more job losses than men, their disproportionate pre-epidemic sorting into occupations compatible with remote work shielded them from even larger employment losses. However, substantial gaps in employment losses across groups cannot be explained by socioeconomic differences. We consider policy lessons and future research needs regarding the early labor market implications of the COVID-19 crisis.

Domain Knowledge-Based Evolutionary Reinforcement Learning for Sensor Placement

Reducing pollutant detection time based on a reasonable sensor combination is desirable. Clean drinking water is essential to life. However, the water supply network (WSN) is a vulnerable target for accidental or intentional contamination due to its extensive geographic coverage, multiple points of access, backflow, infrastructure aging, and designed sabotage. Contaminants entering WSN are one of the most dangerous events that may cause sickness or even death among people. Using sensors to monitor the water quality in real time is one of the most effective ways to minimize negative consequences on public health. However, it is a challenge to deploy a limited number of sensors in a large-scale WSN. In this study, the sensor placement problem (SPP) is modeled as a sequential decision optimization problem, then an evolutionary reinforcement learning (ERL) algorithm based on domain knowledge is proposed to solve SPP. Extensive experiments have been conducted and the results show that our proposed algorithm outperforms meta-heuristic algorithms and deep reinforcement learning (DRL).

Drinking water, fracking, and infant health

This study assesses the health risks associated with drinking water contamination using variation in the timing and location of shale gas development (SGD). Our novel dataset, linking health and drinking water outcomes to shale gas activity through water sources, enables us to provide new estimates of the causal effects of water pollution on health and to isolate drinking water as a specific mechanism of exposure for SGD. We find consistent and robust evidence that drilling shale gas wells negatively impacts both drinking water quality and infant health. These results indicate large social costs of water pollution and provide impetus for re-visiting the regulation of public drinking water.

Are there excess fetal deaths attributable to waterborne lead exposure during the Flint Water Crisis? Evidence from bio-kinetic model predictions and Vital Records

BACKGROUND

Flint, Michigan had elevated water lead (Pb) levels during the 2014-15 Flint Water Crisis (FWC) and reports claim the exposures caused excess fetal deaths.

OBJECTIVE

To model the likelihood of excess fetal deaths occurring from FWC lead exposure and compare results to Vital Records.

METHODS

We used an established bio-kinetic model to predict relative blood lead trends in pregnant women from characteristic exposure to 90th percentile water lead levels (WLLs), and another established model to then estimate characteristic miscarriage (<20 gestation weeks) odds ratios (OR) in Flint (2011-17). For comparison, we made similar predictions for exposures during (1) Washington DC's worst water lead crisis year (2001), (2) Flint "Resident Zero" home with anomalously high WLLs, and (3) 19th century lead-based abortifacients. Data on stillbirths (≥20 gestation weeks) and total fertility rates were obtained from the State of Michigan.

RESULTS

The models predicted that pregnant women drinking water with representative 90th percentile WLLs had a miscarriage OR during the worst FWC period (June-August 2014) of 1.21 (95% CI = 1.02,1.60), versus 1.66 (95% CI = 1.07, 3.56) during a time of high water lead 3 years before the FWC and 1.00 (95% CI = 1.00, 1.01) post-FWC. The corresponding predicted OR in late-2001 for Washington D.C. when higher fetal death rates were statistically associated with very high WLLs was 3.01 (95% CI = 1.16, 16.23). No apparent differences were revealed in overall and race-specific stillbirth rates before, during, or after the FWC. Total fertility rates dropped 6.8% during the FWC (April 2014-October 2015 versus April 2012-October 2013), but this is now revealed to be within the normal annual variation (-9.4% to +15%) observed post-FWC when residents were protected from water lead exposure.

SIGNIFICANCE

Neither model simulations nor Vital Records data are consistent with the hypothesis that there was an uptick in fetal deaths or decreased fertility attributable to water lead exposure during the FWC.

"We're Still Here": A Photovoice Study of Mothers' Perspectives 6 Years after the Flint Michigan Water Contamination Event

Purpose: This study explored the lived experiences of pregnant and parenting women after the water contamination event in Flint, Michigan (Flint Water Contamination Event [FWCE]), by helping them visualize their everyday challenges, assets, and family health concerns.

Methods: The photovoice methodology was utilized in this study. Individual participants met with researchers to discuss their photos using the SHOWeD method. Researchers analyzed the photographs, accompanying narratives, and discussion session transcripts using descriptive coding and thematic analysis.

Results: Data analysis revealed five themes: (1) having a healthy pregnancy and well children is a central concern in everyday life, (2) children serve as social and practical resources for family, (3) meeting children's need for safe water is a significant concern, (4) the community and its households battle to get safe affordable water, and (5) there are resources available in the community to support mothers.

Conclusion: While much information is still being collected and published in the aftermath of the FWCE, this study was the first to use the photovoice method to allow pregnant and parenting women to express their concerns about how the FWCE continues to affect the health and care of their families.

A Population-Based Assessment of Physical Symptoms and Mental Health Outcomes Among Adults Following the Flint Water Crisis

Little is known about the physical and mental health outcomes of adults in the low-income, predominantly Black city of Flint, Michigan, following the city's water crisis which began in April 2014 after austerity policies led to the city switching its water source. We investigate these dynamics using data from a longitudinal community-based cohort in Flint. Between June and November 2019, surveys were administered at nine public sites across Flint. Nested models were employed to assess relationships between respondent demographics, including race/ethnicity, and self-report of clinician-diagnosed blood lead levels (BLLs) and various physical symptoms and mental health outcomes, including depression/anxiety (PHQ-4) and psychological trauma (PC-PTSD-5). Of the 331 respondents (mean age: 47.9 + 16.5), most were women (58.6%) and Black (57.7%). In total, 10.0% self-reported elevated BLLs, with borderline significantly higher reports among Blacks (p = 0.07). Skin rashes (58.1% vs. 33.9%, p < 0.01), hair loss (45.5% vs. 30.3%, p = 0.01), and nausea (35.6% vs. 20.2%, p = 0.1) were significantly higher among Blacks versus Whites. Additionally, 29.0% and 26.3% of respondents met trauma and depression/anxiety criteria, respectively. Increasing physical symptoms was associated with psychological trauma (OR 2.1, p < 0.01) and depression/anxiety (OR 1.9, p < 0.01). In closing, Flint adults, particularly Blacks, experienced deleterious physical and mental health outcomes following the city's water crisis that appear to represent a substantial burden of excess cases. Further research is needed on how austerity impacts community health in economically distressed urban cities and ways to generate capacity to identify and curb adverse consequences.

What Do Childcare Providers Know about Environmental Influences on Children's Health? Implications for Environmental Health Literacy Efforts

Children are uniquely vulnerable to toxicant exposures in their environment, which can have long-lasting impacts on their health. Childcare providers are an important population to target for environmental health literacy, as most children in the United States under five years of age spend a significant number of waking hours in non-parental care. There is an increasing body of evidence that children are exposed to toxicants in the childcare environment, and yet little is known about what childcare providers know about environmental influences on the health of children in their care. We conducted semi-structured interviews with 36 home- and center-based Illinois childcare providers to better understand their knowledge, attitudes, and behaviors as they relate to environmental influences on children’s health. We found that the majority of providers had a low level of understanding of potential sources of exposure in the childcare environment, and they did not feel that environmental exposures posed a significant risk to children. Future efforts to increase environmental health literacy should focus on raising awareness and knowledge of environmental health issues for childcare providers before addressing ways that providers can reduce or prevent toxicant exposures to children in their care.

Rolling back the gains: Maternal stress undermines pregnancy health after Flint's water switch

Environmental disasters impact disadvantaged communities disproportionately both through the epidemiological challenge of exposure, but also by undermining the progress of public health efforts. This paper studies changes to smoking cessation, breastfeeding, and weight gain during pregnancy in the period following the switch in water supply in Flint, Michigan, in April 2014. As the switch resulted in immediate and significant deterioration in water quality, eventually leading to its contamination with lead, we estimate a 10.5 percentage point increase in smoking and a 2.1 percentage point decrease in breastfeeding. We show evidence that these changes in maternal behavior are linked to increased stress due to changing water quality. We estimate that the increase in smoking alone is responsible for most of the increase in incidence of low birthweight among infants in Flint, resulting in $700 additional costs per birth. Increased smoking during pregnancy and lower breastfeeding rates in Flint roll back years of public health efforts, resulting in lifetime higher rates of cardiovascular disease, diabetes, and cancer for mothers in the community.

Detecting the Effects of Early-Life Exposures: Why Fecundity Matters

Prenatal exposures have meaningful effects on health across the lifecourse. Innovations in causal inference have shed new light on these effects. Here, we motivate the importance of innovation in the characterization of fecundity, and prenatal selection in particular. We argue that such innovation is crucial for expanding knowledge of the fetal origins of later life health. Pregnancy loss is common, responsive to environmental factors, and closely related to maternal and fetal health outcomes. As a result, selection into live birth is driven by many of the same exposures that shape the health trajectories of survivors. Lifecourse effects that are inferred without accounting for these dynamics may be significantly distorted by survival bias. We use a set of Monte Carlo simulations with realistic parameters to examine the implications of prenatal survival bias. We find that even in conservatively specified scenarios, true fetal origin effects can be underestimated by 50% or more. In contrast, effects of exposures that reduce the probability of prenatal survival but improve the health of survivors will be overestimated. The absolute magnitude of survival bias can even exceed small effect sizes, resulting in inferences that beneficial exposures are harmful or vice-versa. We also find reason for concern that moderately sized true effects, underestimated due to failure to account for selective survival, are missing from scientific knowledge because they do not clear statistical significance filters. This bias has potential real-world costs; policy decisions about interventions to improve maternal and infant health will be affected by underestimated program impact.