Tag Archives: lead

Root Cause Analysis

The water crisis in Flint, Michigan

By Kim Smiley

The quality of tap water, or rather lack thereof, in Flint, Michigan has been all over headlines in recent weeks. But prior to a state of emergency being declared and the National Guard being called up, residents of the town reported strangely colored and foul tasting water for months and were largely ignored. In fact, they were repeatedly assured that their water was safe.

Researchers have determined that lead levels in the tap water in Flint, Michigan are 10 times higher than previously measured. Forty-three people have been found to have elevated lead levels in their blood and there are suspected to be more cases that have not been identified. Even at low levels, lead can be extremely damaging, especially to young children under 6. Lead exposure can cause neurological damage, decreased IQ, learning disabilities and behavior problems. The effects of lead exposure are irreversible.

The water woes in Flint, Michigan began when the city switched their water supply to the Flint river in April 2014. Previously, the city’s water came from Lake Huron (through the city of Detroit water system). The driving force behind the change was economics. Using water from the Flint river was cheaper and the struggling city needed to cut costs. Supplying water from the Flint River was meant to be a temporary move to hold the city over while a new connection to the Great Lakes was built within a few years.

The heart of the problem is that the water from the Flint river is more corrosive than the water previously used. The older piping infrastructure in the area used lead pipes in some locations as well as lead solder in some joints. As the more corrosive water flowed through the piping, the lead leached into the water.

A Cause Map, a visual root cause analysis, can be built to document what is known about this issue. A Cause Map intuitively lays out the cause-and-effect relationships that contributed to an issue. Understanding the many causes that contribute to an issue leads to better, more detailed solutions to address the problem and prevent it from reoccurring. The Flint water crisis Cause Map was built using publicly available information and is meant to provide an overview of the issue. At this point, most of the ‘whats’ are known, but some of the ‘whys’ haven’t been answered. It isn’t clear why the Flint river water wasn’t treated to make it less corrosive or why it took so long for officials to do something about the unsafe water. Open questions are noted on the Cause Map by including a box with a question mark in it.

This issue is now getting heavy media coverage and officials are working on implementing short-term solutions to ensure safety of the residents. The National Guard and other authorities are going door-to-door and handing out bottled water, water filters, and testing kits. Michigan Governor Richard Snyder declared a state of emergency in Flint on January 5, 2016 which allows more resources to be used to solve the issue. However, long-term solutions are going to be expensive and difficult.

The city’s water supply was switched back to Lake Huron in October 2015, but it will take more than that to “fix” the problem because there is still a concern about lead leaching from corroded piping. Significant damage to the piping infrastructure was done and the tap water in at least some Flint homes is still not safe. It is estimated that fixing the piping infrastructure could cost up to $1.5 billion. A significant amount of resources will be needed to undo the damage that has been done to the infrastructure of the city, and there is no way to undo the damage lead poisoning has already done to the area’s residents, especially the children.

Root Cause

Lead Poisoning Still An Issue for US Children

by Kim Smiley

Lead poisoning has once again hit the news with scary headlines such as “Blood Lead Levels High In 535,000 Kids In The USA” and “Despite Big Progress, Many Kids Have High Lead Levels in Blood“.   But what do these articles actually mean in context?  What does “many kids” refer to and how alarmed should we be?

A tool like a Cause Map, a visual method for performing a root cause analysis, can be useful to analyze issues like this one.   The first step in the Cause Mapping process is to define the problem and that alone can help clarify an issue.   Part of defining the problem is to determine which overall organizational goals are being impacted by the problem.   In this example, it becomes clear that there are really two different, but related goals that need to be considered.  The most basic goal is the safety goal.  The safety goal is being impacted because children are still being negatively impacted by exposure to lead in the United States, despite decades of work to dramatically reduce lead in the environment.  The second issue is that 2.6% of children in the US have blood lead levels (BLLs)  higher than the levels set by the Center for Disease and Control (CDC), an impact to the regulatory goal.

It’s clear why exposure to lead remains a concern. Ingestion of lead is dangerous, especially to small children. High levels of lead in the body can have severe and immediate consequences such as coma, convulsions and even death.  Lower levels of lead have been shown to cause lower IQs, behavior issues, hearing problems and a number of problems in organs in the body.  Problems with lead exposure are well known and the use of lead has been dramatically reduced.  Use of lead in household paints, one of the most common sources of ingested lead, was banned in 1978.  However, paint is still one of the primary sources of lead contamination because many children live in houses built before 1978.  Paint chips containing lead can still be an issue, especially if an older house has loose paint or is undergoing a renovation.  Use of lead in gasoline, a common source of soil contamination, was phased out by the end of the 1980s.

The second issue of concern is that 2.6% of children have blood lead levels above the limit set by the CDC.  What does this mean?  If this problem is hitting headlines, are things getting worse?  One important piece of data is that the CDC lowered the limit for young children in 2012 to 5 µg/dL from 10 µg/dL.  Why was the limit lowered?  The limit was lowered because no amount of lead has been determined to be safe for young children and less lead is always better.  The new limit of 5 µg/dL was based on lead levels in the 2.5% of children with the highest levels.  It was a way to target the children most at risk and it marked a shift towards a more prevention-based approach.

Is it okay that 2.6% of children still have blood lead levels above the target?  Of course not.  Is there still work to do in preventing lead exposure?  Many people believe there is.  But the alarming headlines may not tell the whole story.  Here are some other facts that help put the issue of lead exposure in historical context: an estimated 88% of children aged 1 to 5 had blood lead levels at or above 10 mcg/dL from 1976 to 1980; from 1991-1994 it was 4.4% , from 1999-2002 it was 1.6% and it dropped to 0.8% in 2007-2010.    Lead exposure is a still an issue, but it’s an issue that has been drastically improved.

To view a Cause Map of this issue, click on “Download PDF” above.  For more information, click here to visit the CDC’s information page about lead.