My copy of What the Eyes Don’t See
Last Tuesday I saw eight patients in my morning clinic; I felt like I did a lot. I saw Ms. S, a sixty-two-year-old lady with high blood pressure and diabetes; we chatted about her cats while I checked her feet and titrated her insulin. I treated my 9:30 am patient with some antibiotics for a hot, painful skin infection; my 10 am patient needed a pap smear and a vaccine, and so it went. However, I know that the interventions I offer can’t compare with the societal forces outside the four walls of my clinic that shape my patients’ health. A patient’s zip code, the amount of money in their checking account, the air they breathe, and the food they can afford to buy – are far more critical to health outcomes than anything I can prescribe. Academically, we call these larger forces social determinants of health. Until recently, most physicians met social determinants with a shrug: these are forces beyond our walls, and beyond our responsibility.
Dr. Mona Hanna-Attisha’s most affecting refrain – or rather, the most strident battle cry in her breathtaking new memoir, What the Eyes Don’t See, is that social determinants of health are never academic to our patients; they are deeply personal. Dr. Hanna-Attisha makes the case that fighting for health, equity and justice outside the clinic is a central part of our role as caregivers and public health professionals.
Dr. Hanna-Attisha is a pediatrician in Flint, Michigan. Through research and advocacy, she demonstrated that the water in Flint was contaminated with lead and had poisoned thousands of children in the community. Crucially, her advocacy forced the local government to acknowledge the contaminated water. What the Eyes Don’t See tells her story. Hanna-Attisha focuses most of her fast-paced narrative on the 28 days between when she found out about the lead content in the water until local officials conceded that all of her research findings were correct in September of 2015.
As Dr. Hanna-Attisha unfurls the story of those 28 chaotic days, she illuminates the entrenched structural violence and social determinants that burden the children she serves – separate and apart from the poisoned tap water. She does this with a white-hot undercurrent of rage: the racial segregation of housing and schools, the collapse of GM and ravages of unemployment and poverty, a local government in receivership, unresponsive and uncaring to its most vulnerable constituents, and misguided austerity policies. As she points out bluntly in the opening chapter, “[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 mean.” It’s painful to imagine what those fifteen years might mean for each child we meet in her pages. But the reader comes away with no question of what is eroding those fifteen years away: poverty, poor diet, lack of access to high-quality education, and systemic racism to name only a few factors.
The book brings readers vivid scenes from her life during those frenzied days, such as her afternoon seeing patients with her resident trainees in the clinic after learning of the lead contamination (information that the government at that point systematically covered up). Every encounter drives her increasingly fraught internal dialogue. Is Brandon’s ADHD being driven by lead poisoning? What should she tell 12-year-old Chanel, so proud of a recent 10-pound weight loss – achieved mostly by substituting tap water for sugary beverages? What of little Nevaeh, only three days old, fed exclusively formula mixed with tap water?
In a riveting chapter, “The Press Conference,” Dr. Hanna-Attisha describes standing in front of a room of over 100 people and dozens of cameras. During the press conference, she carefully laid out her research findings that showed dramatically elevated levels of lead in Flint children’s blood samples, tying the increased lead to a recent change in the Flint water supply. She issued a public warning for residents to stop drinking water from their taps. As one might imagine, the next chapter is devoted to the backlash: she is dismissed condescendingly by Flint officials as a “local pediatrician” who was “irresponsible” and “spliced and diced” her data. Parts of these chapters are tough to read; Dr. Hanna-Attisha is open with her feelings of vulnerability and self-doubt, and as a woman reader, the dismissiveness of her detractors is familiar.
Her family’s story of immigration is another thread woven throughout the book, adding an essential perspective to our current discourse about immigration. Born in England to Iraqi parents, Dr. Hanna-Attisha writes about how the violence that has engulfed the region affected her and her family. Her parents had intended to return to Iraq after her father completed his studies in England but ultimately moved to Michigan when conflict erupted. She writes about images from the 1988 Halabja chemical weapons massacre seared into her memory as a twelve-year-old: innocent people dead on the ground with children limp in their arms. It is clear that witnessing such horror in her parents’ homeland was formative; it helped imbue her with a strong sense of justice and duty to protect the vulnerable, and an early, clear-eyed understanding that government can be negligent and even malicious.
In her prologue, Dr. Hanna-Attisha writes: “[t]his is the story of the most important and emblematic environmental and public health disaster of this young century. More bluntly, it is the story of a government poisoning its own citizens, and then lying about it. It is a story about what happens when the very people responsible for keeping us safe care more about money and power than they care about us, or our children.”
We would all like to think that the catastrophe in Flint is an utterly exceptional failure of government, but it is not. Dr. Hanna-Attisha gives the history of a little-known and eerily similar crisis of lead-contaminated water in Washington DC in 2001. And more recently, almost 3000 people were lost in the aftermath of the hurricanes in Puerto Rico last year, where the recovery efforts were paltry in comparison to the support provided to storm-ravaged Texas. Appalingly, and even more recently, our public servants ordered border officers to separate immigrant children from their parents with no regard for their welfare or plan for reunification. The trauma of those separations will likely result in permanent, enduring harm to those children, hundreds of whom are still alone in government custody. These situations exemplify public officials’ disregard for the health and well-being of minority communities. What happened in Flint is unique, but the neglect and carelessness that allowed the Flint crisis to happen echoes through every vulnerable and minority community across our nation.
Shortly after the press conference announcing her research findings, as Dr. Hanna-Attisha wrestled with self-doubt, her husband reassured her: “[t]he kids of Flint needed you at that podium today.” The children of Flint did need Dr. Hanna-Attisha – others had been sounding the alarm about contaminated water in the press and online for months, but none had broken through. None had the credibility of a physician in a white coat, her professional life dedicated to the care of children, standing at the front of the room armed with data and holding a baby bottle full of poisonous tap water aloft. This is one area of the story where I wished for more from her. She writes a bit about the community activists and journalists who had spoken out about the contaminated water. I wanted to know more – why hadn’t she listened to them earlier?
Nevertheless, Dr. Hanna-Attisha’s book holds lessons for every reader – especially for those of us in medicine and public health. While her story of Flint is the spine of the book, her over-arching message is that we must look for ways to fight the everyday injustices that harm the most vulnerable among us. Few others possess the influence that medical professionals can wield as advocates for our patients. She has challenged us to look for the profound effect that social determinants can have on our patients – and then ask ourselves: what can I do about this? She has asked us to look beyond our exam room walls for what we do not typically see.
Audrey Provenzano