naccho exchange summer 2016-feature article

What’s Inside…

N A C C H O

Promoting Effective Local Public Health Practice

What Really Happened to Flint’s Water and How the City is Moving Forward: An Interview with the Genesee County Health DepartmentBy now, it is safe to assume that few people have not heard about the widespread drinking water crisis in Flint, MI. Stories and images depicting the city’s brown water, sick children, and bottled water shortages engulfed the U.S. and global media throughout the past several months. News coverage became especially prominent at the start of 2016, when President Barack Obama officially declared a federal state of emergency in Flint. Three months later, the city dominated the headlines once more when President Obama visited the community and, during a televised press conference, drank a glass of local filtered tap water as a sign of its restored safety. Unfortunately, the majority of Flint’s ordeal, beginning more than two years earlier, went largely unnoticed by the media and government officials alike. While progress has been made in improving the city’s water quality, the road to recovery is far from over.

In an effort to tell the entire story, NACCHO reached out to the Genesee County Health Department (GCHD). Serving Flint, GCHD staff not only led many of the response efforts, but were also directly impacted by the contamination because they also use the city’s water supply. In fact, starting in spring 2014, it was nearly impossible for GCHD staff—along with the rest of Flint’s residents— to overlook the peculiar properties of their tap water. The liquid coming out of their faucets had an off-putting

Bottled water distribution on Jan. 23, 2016, by the National Guard at Fire Station 6 in downtown Flint, Michigan

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Volume 15, Issue 3Summer 2016

Environmental Health

N A C C H O

7 How Two Local Health Departments Have Responded to the Zika Virus

11 Adopting the Model Aquatic Health Code: A Tale of Two States Leading the Way to Aquatic Safety

14 A Local Health Department’s Journey through the Mentorship Program for the Retail Program Standards

16 NACCHO’s Health Impact Assessment Community of Practice: Advancing LHD Efforts through Collaboration

NACCHO Exchange2

color and smell and there was a severe spike in reported illnesses throughout the community. Yet its request for state and federal support was initially pushed aside. GCHD had no choice but to take action.

Now, as GCHD staff continue to restore their city’s health and well-being, they wanted to share their firsthand experience as a cautionary tale, emphasizing the necessity of local health department (LHD) preparedness capacity and cross-sector collaboration when addressing public health emergencies of a similar magnitude. NACCHO’s Senior Director of Environmental Health and Disability, Jennifer Li, and Communications Specialist Anastasia Sonneman interviewed three GCHD staff members, Suzanne Cupal, Public Health Division Director; Mark Valacak, Health Officer; and Jim Henry, Environmental Health Director, who each played a pivotal role in addressing the contamination. They provided an inside look at how the crisis unfolded and shared their health department’s key lessons learned during the ongoing fight for their city’s health. In telling Flint’s story through a public health lens, GCHD and NACCHO aim to better equip LHDs to preempt or quickly contain similar emergencies in the communities they serve.

NACCHO: What were the key factors and who were major players that set the stage for Flint’s water crisis?Mark Valacak: First and foremost, it is important to understand Michigan’s Emergency Manager Law. This law mandates that if a government entity, city, or county is in financial trouble, they relinquish their decision-making authority to the state—more specifically, a governor-appointed emergency manager. In 2013, both Flint and Detroit were under the direction of an emergency manager due to the deteriorating state of each city’s economy. This factor is so significant because a decision made by Flint’s then-emergency manager about the city’s water source is where our story begins. At that time and for the past 30 years, the city’s water provider was the Detroit Water and Sewage Authority, which came with a big price tag, especially when compared to what Detroit was paying for the same water source, Lake Huron. As a result, Flint and many other Genesee County communities began looking for alternatives, eventually forming the Karegnondi Water Project with the purpose of purchasing land on Lake Huron and installing a pipeline to the city. The process of building a new pipeline from Lake Huron would take a few years and in the interim, Flint’s emergency manager decided the city would use its own river, a significantly cheaper alternative, until the Karegnondi project was completed. From then on, the transition was led by the Michigan Department of Environmental Quality (DEQ), the state’s drinking water regulatory agency, with external contractors supporting engineering efforts necessary to make the switch to the Flint River as the city’s temporary water source.

NACCHO: Describe the first indicators that led you to believe water contamination was a serious health concern for the communities you serve.MV: In April 2014, Flint officially switched to using the Flint River as its primary water source. Our health department received complaints almost immediately because people did not know who else to call. But our hands were tied because the DEQ was in charge and insisted the water met all of the Environmental Protection Agency (EPA) standards. All the while, the problems continued to grow, from broken water mains to a significant spike in Legionella, with 21 cases reported county-wide by the end of August 2014.

Suzanne Cupal: In a typical year, we have six to 16 individuals at most who are affected by Legionnaires’ disease. So you can imagine that having that number nearly double in less than a year was very disconcerting. Adding fuel to the fire, the city

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What Really Happened to Flint’s Water and How the City is Moving Forward

“That fall, in addition

to the Legionnaires’

cases, we began

getting complaints of

gastrointestinal illness

and skin rashes.”

NACCHO Exchange 3

on municipal water supply at Michigan’s Epidemiology Conference and was instantly inundated with questions about Flint’s water. After the session, we spoke about what was happening in the city, which helped to establish an open line of communication between our health department and the CDC on this issue. In collaboration with the Michigan Department of Health and Human Services, we developed an extensive patient questionnaire to better identify common patterns related to the Legionnaires’ disease cases. Additionally, as a result of conversations with CDC staff, our health department was also able to make necessary updates to guidance documents for physicians about Legionnaires’ disease.

MV: Around the same time, the city also exceeded the EPA standards for trihalomethanes, a chemical by-product of disinfecting drinking water. The EPA sets maximum levels for these compounds because, when found in high quantities, they can have adverse health effects. As a result, the city was legally obligated to notify the public, which was done by mailing a standard EPA template letter to all affected residents. This method of communication caused a great deal of confusion because it provided minimal information and instructed all questions be directed to the individual’s primary care physician, many of whom were largely uninformed on this topic. In an effort to educate the community and local healthcare providers on the risks associated with trihalomethanes, our health department created a fact sheet, physician guidance, and facilitated in-person health education sessions.

NACCHO: Looking back, do you feel your health department had the adequate resources and support to successfully implement a timely and effective response plan? If not, were there specific gaps or barriers that delayed or prevented your progress? Jim Henry: As far as resources, our health department itself was very limited in knowledge about Flint’s water distribution system due to our restricted jurisdiction and scope over municipal water as a whole. In terms of support, we experienced a great deal of difficulty acquiring information from the city and the state. What was worse is that we eventually discovered that the system was plagued with problems long before the switch to Flint River. It was built when the city had a booming economy and was home to 200,000 residents. However, after the decline of General Motors, the city’s largest employer, and other financial difficulties, the present-day population shrank to 100,000. As a result, large amounts of water are not moving properly because the system’s design was never updated to accommodate the 50% decrease in its users. In addition to its outdated design, a general lack of maintenance and continuous water main breaks are major contributors to the system’s challenged state and recurring reports of brown water.

issued multiple water boil advisories— first in July and again in August—urging the community to boil tap water prior to consumption. That fall, in addition to the Legionnaires’ cases, we began getting complaints of gastrointestinal illness and skin rashes. Based on the similarity of comments from individuals experiencing these issues and the timing of the complaints, particularly the skin rashes, we were concerned that city water could be the cause. You also have to remember that our office is located in downtown Flint so, unlike the state officials, our staff was using this water. Aside from the terrible smell and taste, you could literally see the particulate matter swirling around inside your water glass. Honestly, it was not until January 2015, when the city formed a technical advisory group, that we truly understood the magnitude of the situation. Each meeting seemed to reveal new challenges, from the harsh chemicals being used to treat the water, which could have caused the skin rashes, to the fact that information about the city’s water system was maintained via 45,000 index cards. Yes, you heard that correctly: absolutely nothing was computerized, with no electronic means for monitoring or collecting data.

NACCHO: What initial steps did you take when it became evident that the city’s drinking water was a health risk to its residents? Which measures or actions do you think were most effective?SC: In 2014, as a direct response to the increase in Legionnaires’ disease and the city’s boil advisories, our staff developed fact sheets and conducted various community outreach activities, ensuring residents were informed on both topics. But what you have to remember is that we are a health department and our staff has very limited knowledge when it comes to municipal water. So the majority of our efforts centered on connecting with experts in this field and seeking their guidance and support. In March 2015, Julia Gargano of the Centers for Disease Control and Prevention (CDC) presented

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NACCHO Exchange4

SC: To clarify, water sample lead data was altered to show that it complied with the Safe Drinking Water Act. However, since there was no way to analyze citywide data at the local level, it was impossible to provide evidence that Flint’s water was in fact contaminated. This remained the case until Dr. Mona Hanna-Attisha conducted a study indicating increased blood lead levels in children treated within her practice, the Hurley Pediatric Clinic.

MV: When Dr. Attisha first identified her findings, the state refuted her data. However, after additional communication with the state officials, it was later agreed that their data was skewed because it included individuals that had Flint addresses but were not using water from the Flint River. After adjusting their sampling methodology, the state confirmed Dr. Attisha’s original findings. The presence of lead meant the water was not safe to drink and was particularly harmful to pregnant mothers, nursing women, and children under the age of six. As a result, GCHD officially declared a public health emergency in October 2015, making immediate efforts to provide residents with water filters, through the support of local philanthropic organizations.

NACCHO: It sounds like when you had trouble garnering adequate resources from city and state entities, you relied quite a bit on engaging the support of the local academic community. Can you share how you were able to initiate and facilitate these partnerships?MV: One of our strategic plan objectives is to serve as an academic health department. As a result, we already had formal relationships with dozens of universities. So, after our multiple failed attempts to get information from the city, or any action from the DEQ, we reached out to our contacts at the University of Michigan, University of Michigan-Flint, Michigan State University, and many

SC: A lot of things happened that we were not prepared for, to say the least. All of the data for 600 miles of water distribution piping was housed via 45,000 index cards. There were no searchable databases or maps pinpointing areas with the slowest moving water. All the while, there are hundreds of water main breaks, boil water advisories indicating the presence of bacteria in the water, and dangerously high levels of trihalomethane. All things considered, I would say we certainly had a lot of questions but very few leads on where to find the necessary answers. This all comes back to the importance of incorporating Health in All Policies to predict and, hopefully, avoid serious health risks as a part of the initial decision-making process. To reiterate Jim’s point, our biggest hurdle was accessing enough information to identify the root cause behind the mounting pile of water-related issues. Even more frustrating was our struggle to satisfy the burden of proof for agencies with actual jurisdiction over Flint’s municipal water that would compel them to acknowledge the concerns about Flint’s water contamination.

The lack of cooperation was remarkably surprising. None of us go into public health thinking that the biggest barrier to protecting the health of a community would be other people.

NACCHO: A lack of cooperation and outdated data systems seem to be recurring themes described by each of you as challenges your health department had to overcome. Aside from the lack of an electronic database for monitoring the city’s water, were there any other barriers related to data evaluation and analysis? MV: Well, I think it is a combination of things. The benefits of information stored in an electronic format, rather than, say, index cards, greatly increase the potential for a quicker and more efficient emergency response. The situation is further optimized when the electronic data storage system allows users to access the complete data set, which they can easily search, sort, analyze, and evaluate. For example, one of the most significant consequences, as well as a crucial piece of evidence proving our city’s water contamination, is the high lead blood levels found in the majority of Flint’s children. However, this type of data is compiled and housed at the state level by the Michigan Department of Health and Human Services and is not readily available to local agencies. Furthermore, although some information on a child’s blood lead levels may be in the form of an attachment in the Michigan Care Improvement Registry, which is locally accessible to our health department, there is a major caveat. Unlike the immunization records, lead-blood level testing results are included in a separate PDF document and are neither searchable nor editable. This factor makes it impossible for GCHD or any other health provider or institution to identify emerging patterns or widespread health issues without direct access to state-housed data.

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NACCHO Exchange 5

others as an alternate method of seeking out experts in the field. Marc Edwards, a professor at Virginia Tech, became a very important academic partner in supporting our efforts. Dr. Edwards and his team came to Flint after being contacted by a local mother, who became a Flint community water activist, as a result of the ongoing contamination crisis. This woman and other advocates reached out to Dr. Edwards in particular, due to his earlier work identifying a very similar case in Washington, DC, nearly 10 years ago. His team’s sampling results were instrumental in providing evidence of a widespread lead contamination problem with Flint’s municipal water, specifically tied to a lack in corrosion control treatment.

SC: Luckily, we have a tremendous network of academic partners, many of whom were crucial in helping us make progress. For example, Dr. Janet Stout, an associate professor at the University of Pittsburgh, provided us with her extensive knowledge as an expert in Legionnaires’ disease. The University of Michigan-Flint submitted a proposal to the National Institute of Health’s environmental sciences group, aiming to increase knowledge about Flint’s water system and improve environmental health literacy throughout the community.

JH: The University of Michigan-Flint also conducted water sampling throughout their university water system. Their research was especially helpful, providing our health department with data on their facility levels of trihalomethanes, bacteria, and lead from areas sourced by the Flint River. Dr. Joan Rose of Michigan State University took part in the city’s technical advisory group and helped put us in touch with Dr. Janet Stout. As a health department, we worked diligently to build relationships with all of these individuals and reach out to other experts. We continue to seek their guidance on a regular basis.

NACCHO: What concrete steps or measures have been taken in the past six months to move the city forward, while continuing to address the needs of those directly affected by the contamination?SC: Our health department is in the process of implementing a long-term communication plan with the Michigan Department of Health and Human Services, made up of four components:

r The first phase will provide community education on basic water-related infor-mation. The outreach will emphasize the importance of using water filters and testing tap water and explain the signs to watch for and steps to take in the event of lead exposure or contracting Legionnaires’ disease.

r Phase two will focus on nutrition outreach and education as a means to boost community health and mitigate lead exposure, particularly for those directly impacted by contaminated water.

r The third phase is about encouraging early childhood education in an effort to increase community literacy as well as identifying and responding to developmental delays potentially resulting from exposure to contaminated water.

r Finally, phase four centers on promoting the community use of the medical home model and ensuring impacted individuals in need of long-term care receive proper case management services and support.

Additionally, the Red Cross has established six groups to further facilitate and support the community’s recovery process.

JH: Another big push for us has been Legionella prevention. Our health department has been active in promoting the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) guidelines on preventing and reducing the risk of Legionella in building water systems. We also assisted the CDC in the development

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The presence of lead

meant the water was

not safe to drink and

was particularly harmful

to pregnant mothers,

nursing women, and

children under the age

of six

NACCHO Exchange6

What Really Happened to Flint’s Water and How the City is Moving Forwardcontinued from page 5of an online toolkit, created specifically to support the implementation of the ASHRAE guidelines. Additionally, we worked with the Michigan Public Health Training Center at the University of Michigan to host a webinar on Legionella prevention, with Dr. Janet Stout as a presenter. In the future, we are planning to collaborate with the National Sanitation Foundation on further prevention and training strategies. Finally, we continue to work with local hospitals to increase surveillance and testing for Legionnaires’ disease and pneumonia.

NACCHO: What are some key takeaways your health department has gained in addressing this crisis? SC: In order to prevent situations like this from happening in the future, there needs to be better integration of water and public health. Steps need to be taken to grant LHDs at least some authority over municipal water. Furthermore, LHD staff should be trained on monitoring the local water system and responding to water contamination emergencies. We should also work to do away with any policies directly impeding communication between federal entities like the CDC and LHDs. Another important discovery we made as a result of our extensive experience with Legionnaires’ disease is the substantial gap between research and practice in the field of public health. For public health to keep moving forward, there’s no time to waste when it comes to translating new knowledge, procedures, and approaches into public health practice.

MV: I want to reiterate the importance of incorporating health as a formal consideration to help decision-making of policy development, revision, and removal. Perhaps the most difficult pill to swallow about our story is that it by no means is original, and hardly the first to be told. In fact, nearly an identical water contamination emergency happened in Washington, DC, and dozens of other American cities. Ohio is one of the most recent victims, with contaminated water affecting multiple cities across the state. To put it bluntly, this is not a Flint issue, it is an American issue. The solution will take time, because it largely calls for systemic change, especially cross-sector transparency and collaboration. All I can hope for is that Flint does not end up another story swept under the rug after the media finds a new story to chase down. I truly believe our city’s experience can be a catalyst in propelling health equity as an essential puzzle piece in the future of policy decisions at the local, state, and federal level.

NACCHO: What advice can you pass on to LHDs who may be faced with a similar emergency in their own community? SC: Do not give up and do not be afraid to question the status quo or go beyond your jurisdiction. Start by listening and collaborating with your community members. It is really a balancing act; to be effective you have to work with everybody and you cannot be afraid to seek out more information. Finally, we all have to strive towards policy change. The fact that LHDs like ours have no jurisdiction over municipal water, a factor so closely tied to local public health, needs to change.

JH: We have all talked about the need for policy changes to adequately protect public health. The EPA Safe Drinking Water Act is a perfect example, and unfortunately, we experienced this disaster to get a full understanding of inadequacies of the law. Legionella, along with many other pathogens and contaminants commonly found in drinking water, are not violations of the Safe Drinking Water Act. The law even allows for a percentage of our population to be lead poisoned without requiring action by the regulatory authority. As Suzanne mentioned, LHDs do not have jurisdiction over municipal water. There needs to be a shift and we need to move forward with policies based upon risk, not engineering standards. Also, we need to understand that there is a significant price tag that accompanies zero tolerance standards for public health risks. Like Suzanne said, it is really a balancing act, but not just in the context of community engagement: there is also the matter of sustaining partnerships and support from the state. We as LHDs are dependent upon taxpayer dollars, which the state agencies have authority to allocate. It really comes down to knowing how to walk the line between protecting your community while maintaining your LHD’s capacity to do so.

naccho exchange summer 2016-feature article

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