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As a privately practicing dermatologist in Flint for 33 years, I am used to interacting with patients, one-on-one in my office, diagnosing and treating a variety of skin ailments, including puzzling rashes and hair loss. Ask any primary care or emergency room physician and they will tell you that figuring out what’s causing a patient’s intensely itchy rash can be challenging.
This past winter, like everyone who lives in Genesee County, I heard the reports in the media of people with severe rashes and hair loss who were using Flint municipal water. Despite the switchback from the Flint River as a water source to Lake Huron in October, 2015 these reports seemed to be escalating.
In February of this year, every physician in Genesee County received an email Health Alert initiated by officials at Michigan Department of Health and Human Services (MDHHS). This Health Alert regarded an investigation that was being undertaken and it asked physicians to refer people with rashes and/or hair loss possibly related to Flint Municipal water to the state’s “211” number so that they could be studied.
As I read this Health Alert, perhaps in a weak moment, I decided to contact MDHHS and volunteer to help diagnose and treat my fellow community members who were suffering from these skin disorders. And what I thought might involve a few spare afternoons of my time soon turned into a major collaborative effort of the State of Michigan (MDHHS) and the federal government (HHS, EPA, CDC, ATSDR) that lasted six months and culminated in The Flint Rash Investigation, which was released on August 23, 2016.
When it became clear in just a few weeks that there might be hundreds of people who had rashes and hair loss that needed to be seen, I called on my fellow Genesee County Medical Society dermatology colleagues Robert Soderstrom, MD, Bishr Al Dabagh, MD, and Kevin Gaffney, MD. I’m proud to say that they did not hesitate and each readily gave up 11 half-days between March 3 and May 12 to see a total of 122 people with rashes and hair loss.
“The Flint Rash Investigation” set out with three goals: “to better understand and characterize rashes and hair loss; to explore causes and possible associations with Flint Water, and to make recommendations for public health interventions.” Unfortunately, we weren’t in a position to study the water that was coming into homes when the Flint River was the source. We could only study the current water after the October 2015 switchback, and only diagnose people who had an active rash or hair loss issue.
Through a number of press releases, public awareness efforts and home visits from the EPA, over 600 people contacted the MDHHS and about 70 percent had a current or worsening rash or hair loss after the switchback. The CDC and MDHHS created a comprehensive questionnaire to gather info about participant’s rashes and their exposure to Flint water. Eventually, 390 people were interviewed with the help of state and federal people from MDHHS, the CDC, and the ATSDR. All of these people were offered extensive home water testing done by the EPA, as well as a free skin exam by one of the four volunteer dermatologists.
Some of the most notable findings of the interviews were that over half of people who had rashes experienced onset before the switchback; 77 percent of people reported changes in their tap water quality at the time their rash or hair loss began; and most respondents had changed their routine bathing or showering habits because of concern about a possible association.
The doctors found that about 20 percent of the rashes were definitely unrelated to Flint water, leaving about 80 percent that were felt to be “possibly related.” The most common type of rash in the latter group was eczema, which is a common condition with a genetic basis but also known to have a variety of aggravating factors including irritation, dryness and stress. We did not find any rashes that were related to bacterial or viral infections. The rashes were indeed very real; but overall, the dermatologists felt that the severity and spectrum of rashes seen during the study were similar to what they saw in their everyday practice during a typical Michigan winter. They were most impressed by the general level of anxiety and stress among the participants, most of whom had stopped using Flint water for bathing or showering.
The EPA looked at every metal, mineral, and water quality parameter in homes that was even potentially associated with skin irritation, rash or hair loss and they did not find any significant abnormalities in over 170 homes tested. Flint homes tested had enough chlorine to protect against microbial contamination but not to cause skin irritation. They did find elevated lead levels in 16 percent of homes tested, although there is no precedent for lead being associated with rash, skin irritation or hair loss. They also found several homes with elevations of a few metals and minerals like iron and manganese that could definitely explain complaints by study participants about the taste, color, and texture of the water. These were thought likely due to release from water service lines, internal plumbing, and fixtures resulting from lack of corrosion controls when the Flint River was the water source.
As a separate part of the investigation, an analysis was performed of the limited historical Flint Water Plant data from the period of time when the Flint River was used as a source (April 2004 – October 2015). We found significant fluctuations in water hardness, pH/acidity, and free chlorine levels throughout this time. Since many rash complaints began while residents were using the Flint River water source, these fluctuations provide one possible explanation for the most common type of rash seen by dermatologists, which was eczema. Unfortunately, no home water testing data is available from this period, which means this very plausible explanation could not be confirmed.
Some would say that this was not a scientific study and that the findings cannot be automatically applied to the entire Flint community – and they would be right. That kind of study would have taken years to complete. This was a pilot study initiated to examine the participants while their rashes were still present and designed to look for red flags that may lead to further study.
So, what about the people whose rash began after the switchback or who still have a rash now? It may sound simple, but the first thing needed to successfully treat any rash is an accurate diagnosis. One of the major recommendations of the study suggests that anyone with an active rash who is concerned about a possible association with Flint water see their primary care physician (PCP). Efforts have been underway to educate PCPs to better diagnose and treat rashes and to facilitate referrals to dermatologists if needed.
With the recent expansion of Medicaid and the presence of several government funded health care centers here, (Genesee Community Health Center and Hamilton Community Health Network), almost everyone in Genesee County should be able to get established with a PCP. While some rashes may go away on their own, others can be difficult to get rid of without proper treatment. People who need to see a dermatologist can self-refer or be referred by their PCP.
From my point of view, some very good things came out of this experience. It brought a lot of different people together who had to cooperate to address an issue that a large community like Flint had never faced before. It taught me to look beyond my one-on-one office interactions with patients and see the health of the community as a whole. I got to know my fellow Genesee County Medical Society dermatologists in a way that was not possible before, and I am proud of the way they and the whole GCMS stepped up to help our community at a time of great need.
About the Author: Walter Barkey, MD, FAAD was born and raised in the Flint area. He received his Bachelor of Arts degree from the University of Michigan (With High Distinction) where he was Phi Beta Kappa his junior year. He attended medical school at U of M, where he was a member of the honorary fraternity Alpha Omega Alpha. He did a one-year flexible internship at St. Joseph Mercy Hospital in Ann Arbor, and his dermatology residency at the University of North Carolina in Chapel Hill where he was chief resident his final year. He became Board Certified in Dermatology in 1983. Dr. Barkey has regularly made the “Best Doctors” list since it was started by the Detroit Free Press in 1999.
For over 17 years, he regularly taught residents from St. Joseph Mercy Hospital, McLaren Regional Medical Center, and Flint Osteopathic Hospital. A clinical assistant professor at MSU College of Human Medicine, he teaches medical students from MSU and PA students from a variety of schools both in state and out of state. He is a member of The Michigan Dermatological Society and has served on the Ethics Committee for over 20 years. Dr. Barkey is a member of the Genesee County Medical Society.
