Did a Nocebo Effect Contribute to the Rise in Special Education Enrollment Following the Flint, Michigan Water Crisis?

Abstract

Background: Exposure to waterborne lead during the Flint Water Crisis during April 2014-October 2015 is believed to have caused increased special education enrollment in Flint children.

Method: This retrospective population-based cohort study utilized de-identified data for children under six years of age who had their blood lead tested during 2011 to 2019, and special education outcomes data for children enrolled in public schools for corresponding academic years (2011-12 to 2019-20) in Flint, Detroit (control city) and the State of Michigan. Trends in the following crisis-related covariates were also evaluated: waterborne contaminants, poverty, nutrition, city governance, school district policies, negative community expectations, media coverage and social media interactions.

Results: Between 2011 and 2019, including the 2014-15 crisis period, the incidence of elevated blood lead in Flint children (≥ 5µg/dL) was always at least 47% lower than in the control city of Detroit (p < .0001) and was also never significantly higher than that for all children tested in Michigan (p = 0.33). Nonetheless, special education enrollment in Flint spiked relative to Detroit and Michigan (p < .0001). There is actually an inverse relationship between childhood blood lead and special education enrollment in Flint.

Conclusion: This study failed to confirm any positive association between actual childhood blood lead levels and special education enrollment in Flint. Negative psychological effects associated with media predictions of brain damage could have created a self-fulfilling prophecy via a nocebo effect. The findings demonstrate a need for improved media coverage of complex events like the Flint Water Crisis.

Keywords: Flint Water Crisis; blood lead; lead exposure; nocebo effect; special education.

Figure 1. Childhood Blood Lead and Educational Outcomes

Note. Trends in (A) percentage of children < 6 years of age with elevated blood lead ≥ 5 μg/dL (%EBL), (B) enrollment of public school students in special education programs, (D) special education suspension/expulsion rates, (E) special education dropout rates, and (F) general education 3rd grade reading proficiency*, for Flint, Detroit, and Michigan, 2011-19 (and corresponding school years of 2011-12 to 2019-20). Error bars are +/- 95% confidence intervals and maybe contained within symbols. (C) Scatter plot between %EBL vs. special education enrollment rate for Flint, Detroit, and Michigan by year. 95% confidence bands for the ordinary least squares fits are shown. p value shown is for comparison of slopes. *The State of Michigan followed the Michigan Educational Assessment Program (MEAP) testing standards until 2013-14 and then switched to Michigan Student Test of Educational Progress (M-STEP) starting 2014-15.

Figure 2. Individual Child-Level Blood Lead Measurements ≥ 5 µg/dL During the FWC Period (April 25 2014-October 16 2015)

Note. (A) Detroit and (B) Flint. The data is de-duplicated; i.e., only highest blood lead value per child is shown.

Figure 3. Percentage of Children < 6 Years of Age With Blood Lead ≥ 5 – 40 µg/dL in Flint, Detroit, and Michigan During April 25, 2014 – October 16, 2015

Note. The CDC threshold for elevated blood lead was 40 µg/dL between 1973-75, 25 µg/dL between 1985-90, 10 µg/dL until 2012 and 5 µg/dL until 2021.

Figure 4. Special Education Enrollment in Flint Relative to Detroit and Michigan, 2006-20

Figure 5. Network Mapping of All Posts and Weblinks Shared on Official Facebook Pages of Michigan Local Media With the Keywords “Lead Poisoned,” Jan 2016-Nov 2020

Note. (A) Media outlets arranged by total number of posts/links shared. (B) Media outlets arranged by total interactions (reactions, shares, and comments) on posts/links shared. Raw values for all media bubbles in the maps are provided in SI (Table S4). (i) The size of the media bubbles is relative; i.e., higher the metric of interest, larger the bubble. The numerous links emerging from each bubble indicate resharing of the posts/links to other Facebook pages and the representative bubbles are also relatively sized according to the metric of interest. (ii) The Flint Journal belongs to the parent media company MLive and both have separate Facebook pages. Therefore, while the pages appear separately in the left network map as they do in Facebook, their interaction metrics are aggregated in text.