Walkerton: Lessons Learned

1
Walkerton Lessons Learned
Walkerton Lessons Learned Colin Mayfield,
Department of Biology, University of Waterloo
and United Nations University International
Network on Water, Environment and Health
2
What happened ?
Seven people died and over 2,300 became ill from
Escherichia coli infections in a small town of
4,800 people. It was caused by many factors and
the mistakes of many people and agencies
The causes of this outbreak were investigated by
a judicial inquiry and the persons and
organizations responsible were identified.
Escherichia coli O157 H7
3
Perspective
Seven people died and over 2,300 became ill from
Escherichia coli infections in a small town of
4,800 people. It was caused by many factors and
the mistakes of many people and agencies
To put this in perspective, it is equivalent to
an outbreak in the Greater Toronto Area where
over 1.4 million people become infected and over
4,000 die
4
Index

• The Organism
• The Events at Walkerton
• The Results
• The Reasons
• The Inquiry
• The Lessons
• The Future
• Overview

5
THE ORGANISM
The Organism
1.5 mM
Escherichia coli O157H7
6
What is E coli o157h7

• What is Escherichia coli O157H7?
• E. coli O157H7 is one of hundreds of strains of
  the bacterium Escherichia coli. Although most
  strains are harmless and live in the intestines
  of healthy humans and animals, this strain
  produces a powerful toxin and can cause severe
  illness.
• E. coli O157H7 was first recognized as a cause
  of illness in 1982 during an outbreak of severe
  bloody diarrhea the outbreak was traced to
  contaminated hamburgers. Since then, most
  infections have come from eating undercooked
  ground beef

The combination of letters and numbers in the
name of the bacterium refers to the specific
markers found on its surface and distinguishes it
from other types of E. coli.
7
Epidemiology
Epidemiology (CDC, Atlanta)

• The organism can be found on a small number of
  cattle farms and can live in the intestines of
  healthy cattle. Meat can become contaminated
  during slaughter, and organisms can be thoroughly
  mixed into beef when it is ground. Bacteria may
  get into raw milk.
• Eating meat, especially ground beef, that has
  not been cooked sufficiently to kill E. coli
  O157H7 can cause infection. Contaminated meat
  looks and smells normal.

• Drinking unpasteurized milk and swimming in or
  drinking sewage-contaminated water can also cause
  infection.

8
Symptoms
Symptoms

• E. coli O157H7 infection often causes severe
  bloody diarrhea and abdominal cramps sometimes
  the infection causes non-bloody diarrhea or no
  symptoms. Usually little or no fever is present,
  and the illness resolves in 510 days.
• In some persons, particularly children under 5
  years of age and the elderly, the infection can
  also cause a complication called hemolytic uremic
  syndrome, in which the red blood cells are
  destroyed and the kidneys fail.
• About 27 of infections lead to this
  complication. In the United States, hemolytic
  uremic syndrome is the principal cause of acute
  kidney failure in children, and most cases of
  hemolytic uremic syndrome are caused by E. coli
  O157H7.

9
Bottom Line ?

• Bottom Line?
• It is a well-known organism (since 1982)
• The symptoms of juvenile hemolytic uremic
  syndrome are often caused by this organism
• 10,00020,000 cases of infection occur in the
  United States each year
• Most illness has been associated with eating
  undercooked, contaminated ground beef
• Infection can also occur after drinking raw
  milk and after swimming in or drinking
  sewage-contaminated water - CDC, Atlanta

10
THE EVENTS
The Events at Walkerton
Well 5
Farm that was the source of the E. coli
11
Well 5
Well 5 was an extremely shallow well and, when
the pump was operating, water was drawn down from
the surface water around the well. When the
pump was not operating, natural springs occurred
in the depression around the well. In other
words there was a direct connection between the
surface water and the well as it pumped from the
shallow groundwater aquifer.
12
Well 5 - 2

• Coupled with these technical issues was the
  issue of management and reporting of
  contamination events.
• Reports from private laboratories to the Public
  Utilities Commission that showed the presence of
  coliforms or Escherichia coli in the drinking
  water did not have to be sent to the Ministry of
  the Environment or the Health Unit.
• The PUC was  supposed to do that.  It did
  not.

13
Broken Loop
14
Events 1

• Then the chlorination plant did not inject
  chlorine at the required level (it had been
  faulty for some time).
• Levels of chlorine in the drinking water are
  supposed to be at or above 0.5 ppm. Documented
  cases are in the log books for the wells where
  these criteria were not met.
• In addition, many readings over a long period
  of time were stated to be at either "0.5" or
  "0.7" ppm - an unlikely coincidence for all
  levels to be essentially identical over a long
  period of sampling.
• Stan Koebel (the manager of the PUC) and Frank
  Koebel later admitted at the inquiry that the
  results were often fabricated and that samples
  sent for analysis for water quality were often
  from the wrong sample sites.

15
Events 2

• Frank Koebel also stated he got complaints
  about excessive chlorination and often dialed
  back the chlorinator.
• They both stated that they did not know much
  about coliform bacteria
• A new chlorinator was supposed to be installed
  but was not
• Then it rained
• Well 5 was contaminated during a heavy rainfall
  in May 2000. Bacteria from a farm manure pile
  entered the well through overland flow and/or
  through transport in groundwater after
  percolating down through the very permeable soil
  to the shallow aquifer.
• Since the chlorinator was not working, the E.
  coli O157H7 entered the towns water system and
  was distributed to everybody.

16
The Events at Walkerton
THE EVENTS
Well 5
Farm that was the source of the E. coli
17
Events 3

• The number of people who became ill was
  approximately 2300.
• In total, 174 people had presumptive laboratory
  evidence of E. coli O157, 167 of which were
  confirmed as E. coli O157H7.
• 116 people were confirmed with Campylobacter
  species
• 65 patients were admitted to hospital, and of
  these, 27 developed hemolytic uremic syndrome.
• Seven people died as a result of the outbreak.

Health Canada Report
18
Events 4

• Stan Koebel lied to the Medical Officer of
  Health about the presence of coliforms in the
  water supply after the start of the outbreak.
• Only when an MoE employee deduced that the
  water was the problem and initiated testing and
  then informed the MoH did action (the boil water
  advisory) begin.

19
Summary
The Reasons

• PUC members
• No-one with any water system expertise, left
  all management and operational decisions to PUC
  staff
• Part-time positions Hydro concerns
  predominated

• Government of Ontario
• Cutbacks driven by ideology
• No risk analysis of decisions
• Ignored expert advice (including Chief Medical
  Officer of Health for Ontario)

PUC oversight failed

• PUC Management (Stan and Frank Koebel)
• Untrained
• Unqualified (grandfathered to position)
• Dishonest reporting
• Attitudes to water system management
• Potential loss of positions upon amalgamation
• Hydro concerns predominated

40 staff decrease

• Ministry of the Environment
• Previous coliform problems at Walkerton (and
  many other places) not dealt with
• Cutbacks to staff leading to lack of inspection
  
• Privatization of laboratory analyses no clear
  guidelines
• Inspection, reporting and remediation processes
  flawed

MoE oversight, training and inspection roles
failed

• Health Unit
• Small staff, large area to cover
• Budget decrease
• E. coli counts were not reported to them
• Municipal water systems rated 2 to 3 of staff
  time

20
The INQUIRY
The Inquiry

• Justice Dennis OConnor conducted a detailed,
  exhaustive and extremely thorough investigation
  including a series of commissioned technical
  reports, expert witness presentations and
  cross-examinations, investigation and examination
  of all players (PUC, Township council, MoE and
  other ministries, Ontario government ministers
  and the Premier of Ontario, and many individuals)
  
• He produced a Part 1 report that detailed
  exactly what happened and why.

• Part II of the report followed at the end of
  May 2002 and consisted of recommendations to
  prevent similar occurrences.
• Both are on the Biology 447 website

21
THE LESSONS- Social
The Lessons

• We can learn many lessons from the Walkerton
  tragedy
• Social Lessons
• Citizen awareness and involvement
• Oversight of essential services
• Hiring and employment practices
• Community response
• Health system information and practices

22
Regulatory Lessons
The Lessons

• Regulatory Lessons
• Monitoring is an essential prerequisite for
  regulation
• If results are not reported to the right
  people, regulation cannot occur
• Toothless or un-enforced regulations are more
  dangerous than none at all because of the false
  sense of security
• Political interference, government attitudes or
  ideologies do have effects on regulation
  intensity and quality.
• Sufficient funding is needed to effectively
  monitor and regulate
• Well-informed and educated personnel are
  essential for monitoring/regulation

23
Education Lessons 1
The Lessons

• Education Lessons
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal

24
Education Lessons 2
The Lessons

• Education Lessons
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal

25
Education Lessons 3
The Lessons

• Education Lessons
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal

26 of the people in North America think the Sun
revolves around the Earth
26
Education Lessons 4
The Lessons
The cause of peptic ulcers has been known to
microbiologists for many years it is a bacterial
infection of the stomach lining by
Helicobacterium species. Many health personnel
today still quote stress as the major cause and
prescribe antacids.

• Education Lessons
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal

26 of the people in North America think the Sun
revolves around the Earth
50 of the population of the USA believe that the
position of stars at birth affects a persons
future (Astrology)
27
Education Lessons 5
The Lessons

• Education Lessons
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal
• Health and environmental issues are often of no
  immediate popular concern until problems
  happen. A long history of safety is no guarantee.
• Risk analysis and risk management is not
  commonly taught or known.

28
Education Lessons 6 Risk 1

• Risk Perception
• Activities Perceived as Higher Risk by
• United States Environmental Protection Agency
  (EPA)
• Global warming
• Indoor air pollution, including radon (high
  health risk)
• Exposure to chemicals in consumer products (high
  health risk)
• Surface water pollution (high ecological risk)
• the Public
• Chemical waste disposal
• Water pollution
• Chemical plant accidents

The Lessons

• Education
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal
• Health and environmental issues are often of no
  immediate popular concern until problems
  happen. A long history of safety is no guarantee.
• Risk analysis and risk management is not
  commonly taught or known.

29
Education Lessons 7 Risk 2

• Risk Perception
• Activities Perceived as Higher Risk by
• United States Environmental Protection Agency
  (EPA)
• Global warming
• Indoor air pollution, including radon (high
  health risk)
• Exposure to chemicals in consumer products (high
  health risk)
• Surface water pollution (high ecological risk)
• the Public
• Chemical waste disposal
• Water pollution
• Chemical plant accidents

• Risk Perception
• Activities Perceived as Higher Risk by
• United States Environmental Protection Agency
  (EPA)
• Global warming
• Indoor air pollution, including radon (high
  health risk)
• Exposure to chemicals in consumer products (high
  health risk)
• Surface water pollution (high ecological risk)
• the Public
• Chemical waste disposal
• Water pollution
• Chemical plant accidents

• Education
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal
• Health and environmental issues are often of no
  immediate popular concern until problems
  happen. A long history of safety is no guarantee.
• Risk analysis and risk management is not
  commonly taught or known.

30
Education Lessons 8 Risk 3

• Risk Perception
• Activities Perceived as Higher Risk by
• United States Environmental Protection Agency
  (EPA)
• Global warming
• Indoor air pollution, including radon (high
  health risk)
• Exposure to chemicals in consumer products (high
  health risk)
• Surface water pollution (high ecological risk)
• the Public
• Chemical waste disposal
• Water pollution
• Chemical plant accidents

• Education
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal
• Health and environmental issues are often of no
  immediate popular concern until problems
  happen. A long history of safety is no guarantee.
• Risk analysis and risk management is not
  commonly taught or known.

31
Education Lessons 9 Risk 4

• Risk Perception
• Activities Perceived as Higher Risk by
• United States Environmental Protection Agency
  (EPA)
• Global warming
• Indoor air pollution, including radon (high
  health risk)
• Exposure to chemicals in consumer products (high
  health risk)
• Surface water pollution (high ecological risk)
• the Public
• Chemical waste disposal
• Water pollution
• Chemical plant accidents

One topic where they agree !

• Education
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal
• Health and environmental issues are often of no
  immediate popular concern until problems
  happen. A long history of safety is no guarantee.
• Risk analysis and risk management is not
  commonly taught or known.

32
Risk Perception Overview

• Education
• Training and frequent updating of the knowledge
  of personnel at all levels is essential
• Those in oversight positions need to enforce
  this
• Glacially slow rates of knowledge transfer from
  the scientific and management community to the
  on the ground personnel is a serious problem.
  This is a problem that is almost universal
• Health and environmental issues are often of no
  immediate popular concern until problems
  happen. A long history of safety is no guarantee.
• Risk analysis and risk management is not
  commonly taught or known.

• Most people will accept a one in a million risk
  level of dying in a particular year except
• If it is something that is not understood or
  controllable (radiation, nuclear power stations,
  chemical spills, etc.) then any level of risk
  is too high !
• If it applies to them or their loved ones or
  family !
• If it is something they understand and is
  controllable and they have chosen to do such as
  smoking, motorcycling, sky-diving, or driving
  then they will accept a much higher (often an
  incredible) risk !

33
Legal Lessons 1
The Lessons

• Legal Lessons
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.

34
Legal Lessons 2
The Lessons

• Legal Lessons
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.

Walkerton
35
Legal Lessons 3
The Lessons

• Legal
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.

ENRON
Walkerton
36
Legal Lessons 4
The Lessons
Waste Management Inc.

• Legal
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.

ENRON
Arthur Andersen Inc.
Walkerton
Adelphia Inc
Global Crossings Inc.
Varnicolor (Elmira)
37
Legal Lessons 5
The Lessons
Waste Management Inc.
Exxon Valdez
Love Canal

• Legal
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.

ENRON
Arthur Andersen Inc.
Walkerton
Union Carbide Bhopal
Cryptosporidium infections from waterin
Australia, the US andWaterloo Region
Varnicolor (Elmira)
38
Legal Lessons 6
The Lessons
Waste Management Inc.
Exxon Valdez
Love Canal

• Legal
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.

ENRON
UNIROYAL Pesticide Production - Chemical
Disposal Elmira, Waterloo Complied with
allregulations
Arthur Andersen Inc.
Walkerton
Union Carbide Bhopal
Cryptosporidium infections from waterin
Australia, the US andWaterloo Region
Varnicolor (Elmira)
39
Legal Lessons 7
The Lessons

• Legal Lessons
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.
• Often, these companies are the ones that can
  cause the most damage because their costs of
  compliance to regulations are high and so their
  savings by not complying are large

40
Legal Lessons 8
The Lessons

• Legal Lessons
• Passage of good regulations is not sufficient
• Enforcement of regulations and standards is
  often left to the discretion of fairly junior
  personnel
• Without a significant penalty, and without
  strong monitoring and enforcement of regulations,
  some people and companies will choose to ignore
  the regulations.
• Often, these companies are the ones that can
  cause the most damage because their costs of
  compliance to regulations are high and so their
  savings by not complying are large
• New developments and information may make
  regulations obsolete or ineffective. Constant
  vigilance is required.

41

• Scientific (research and information
  dissemination) Lessons
• There is an enormous amount of new raw
  research information and it is more accessible
  than ever before.
• Scientists are becoming more and more
  specialized due to this information explosion
• Anyone who attempts to be a generalist has
  less and less knowledge about any given part of
  their wider expertise
• This is leading to a dichotomy between these
  groups

42
Scientific Lessons 3

• Scientific (research and information
  dissemination) Lessons
• There is an enormous amount of new raw
  research information and it is more accessible
  than ever before.
• Scientists are becoming more and more
  specialized due to this information explosion
• Anyone who attempts to be a generalist has
  less and less knowledge about any given part of
  their wider expertise
• This is leading to a dichotomy between these
  groups
• Research data should be translated more
  effectively into a form that is more accessible
  to the users and to the general public.
• Scientists, engineers and others have to take
  more responsibility for wider dissemination of
  the meaning of their research and development
  work. Many are reluctant to do this.

43
Scientific Lessons 5

• Scientific (research and information
  dissemination) Lessons
• There is an enormous amount of new raw
  research information and it is more accessible
  than ever before.
• Scientists are becoming more and more
  specialized due to this information explosion
• Anyone who attempts to be a generalist has
  less and less knowledge about any given part of
  their wider expertise
• This is leading to a dichotomy between these
  groups
• Research data should be translated more
  effectively into a form that is more accessible
  to the users and to the general public.
• Scientists, engineers and others have to take
  more responsibility for wider dissemination of
  the meaning of their research and development
  work. Many are reluctant to do this.

Most of the people involved in Walkerton didnot
know that some forms of E. coli could kill Those
people included some microbiologists !
44
Economic Lessons
The Lessons

• Economic Lessons
• We have a reasonable infrastructure of roads,
  sewers, water pipes, electricity, telephones and
  communications systems in place
• General taxation has funded these
  infrastructure costs in the public sector
• Repair costs have not been adequately funded
  and are now very large
• These costs will have to come from increased
  taxes, increased cost recovery (eg - metered
  water supplies), downloading of costs to lower
  level governments or privatization
• Future generations will have to pay for the
  repairs as well as their on-going maintenance

45
Economic Lessons
The Lessons

• Economic Lessons
• We have a reasonable infrastructure of roads,
  sewers, water pipes, electricity, telephones and
  communications systems in place
• General taxation has funded these
  infrastructure costs in the public sector
• Repair costs have not been adequately funded
  and are now very large
• These costs will have to come from increased
  taxes, increased cost recovery (eg - metered
  water supplies), downloading of costs to lower
  level governments or privatization
• Future generations will have to pay for the
  repairs as well as their on-going maintenance

The World Bank has a policy of requiring
countries applying forfunding of water projects
to have their citizens pay for their water
use Is access to clean, safe water a right or
is water a commodity ?
46
Economic Lessons
The Lessons

• Economic Lessons
• We have a reasonable infrastructure of roads,
  sewers, water pipes, electricity, telephones and
  communications systems in place
• General taxation has funded these
  infrastructure costs in the public sector
• Repair costs have not been adequately funded
  and are now very large
• These costs will have to come from increased
  taxes, increased cost recovery (eg - metered
  water supplies), downloading of costs to lower
  level governments or privatization
• Future generations will have to pay for the
  repairs as well as their on-going maintenance

The cost of bringing the water systems in
Ontario to the level at which another Walkerton
isunlikely to happen will be hundredsof
millions or billions of dollars
47
Governance/Political Lessons
The Lessons

• Governance and Political Lessons
• The Walkerton tragedy and inquiry highlighted
• Governance for infrastructure such as water
  supply
• Political cost of failure versus economic cost
  of success
• Corporate, government and individual legal
  liabilities
• The positive effect of an rigorous, impartial
  and complete judicial inquiry into these kinds of
  events

48
Governance/Political Lessons
The Lessons

• Governance and Political Lessons
• The Walkerton tragedy and inquiry highlighted
• Governance structure for infrastructure such as
  water supply
• Political cost of failure versus economic cost
  of success
• Corporate, government and individual legal
  liabilities
• The positive effect of an rigorous, impartial
  and complete judicial inquiry into these kinds of
  events

• The Walkerton Inquiry was wide-ranging and
  comprehensive. It allowed the citizens of
  Walkerton to see that all avenues were being
  investigated, all experts were being consulted
  and no-one was allowed to hide what had happened.
• It was accompanied by detailed investigations
  that included the examination of thousands of
  documents and interviewing hundreds of people.

49
THE FUTURE
The Future

• Other issues
• Heightened public awareness of vulnerability
• New Technologies (eg - membrane filtration for
  water, household water purification units)
• Factory farms and manure disposal practices and
  regulation
• Right to farm
• Sewage sludge disposal practices and regulation
• Pharmaceutical products in groundwater supplies
• Groundwater protection
• Rural versus urban water contamination

50
Have the Lessons been learned ?

• Have the lessons been learned ?
• Yes the technical aspects were already known by
  the people and companies in the water treatment
  and supply business.
• The financial and political means to upgrade and
  inspect water treatment systems were put in
  place.
• It is unlikely that there will be a repeat of
  Walkerton in Ontario.

51
Have the Lessons been learned 2 ?
Have the lessons been learned ? Yes the
technical aspects were already known by the
people and companies in the water treatment and
supply business. The financial and political
means to upgrade and inspect water treatment
systems were put in place. It is unlikely that
there will be a repeat of Walkerton in
Ontario. But it was a series of unlikely events
that caused the problem in the first place !
52
North Battleford
Have the lessons been learned ? Yes the
technical aspects were already known by the
people and companies in the water treatment and
supply business. The financial and political
means to upgrade and inspect water treatment
systems were put in place. It is unlikely that
there will be a repeat of Walkerton in
Ontario. But it was a series of unlikely events
that caused the problem in the first place !
After the Cryptosporidium outbreaks in Milwaukee,
the Region of Waterloo and other places, it
happened again in North Battleford, Saskatchewan.
About 7,000 people were infected Their water
intake was downstream from the sewage outlet
system, the chlorinator was working, but
Cryptosporidium is resistant to chlorination.
53
River/Sewage/Water Treatment Plant
Sewage Treatment
Water treatment
Flow direction
54
Summary of Inquiry NB
The Report of the Inquiry into North Battleford
maybe says it all As the commission counsel
stated at one point in the hearings, there were
no villains in this story. There was simply a
great deal of indifference to the public health
safety aspects of drinking water on the part of
the city who had the responsibility to produce
potable water, and on the part of the
Saskatchewan Environment and Resource Ministry
who had the mandate to regulate it
55
BLANK PAG E
56
ADDENDA
Addenda 1. Summary conclusions of Part 1
Walkerton Inquiry 2. Helicobacterium pylori and
peptic ulcers 3. Web site addresses
57
Summary of Walkerton Inquiry
Full text at - http//www.inweh.unu.edu/biology447
/modules/module4/Walkerton_Materials/WalkertonSumm
ary.htm
Part One A Summary Report of the Walkerton
Inquiry The Events of May 2000 and Related Issues
In May 2000, Walkertons drinking water system
became contaminated with deadly bacteria,
primarily Escherichia coli O157H7.1 Seven people
died, and more than 2,300 became ill. The
community was devastated. The losses were
enormous. There were widespread feelings of
frustration, anger, and insecurity. The tragedy
triggered alarm about the safety of drinking
water across the province. Immediately, many
important questions arose. What actually happened
in Walkerton? What were the causes? Who was
responsible? How could this have been prevented?
Most importantly, how do we make sure this never
happens again?
58
Summary Page 1
Summary of Conclusions Page 1

• Seven people died, and more than 2,300 became
  ill. Some people, particularly children, may
  endure lasting effects.
• The contaminants, largely E. coli O157H7 and
  Campylobacter jejuni, entered the Walkerton
  system through Well 5 on or shortly after May 12,
  2000.
• The primary, if not the only, source of the
  contamination was manure that had been spread on
  a farm near Well 5. The owner of this farm
  followed proper practices and should not be
  faulted.
• The outbreak would have been prevented by the
  use of continuous chlorine residual and turbidity
  monitors at Well 5.
• The failure to use continuous monitors at Well
  5 resulted from shortcomings in the approvals and
  inspections programs of the Ministry of the
  Environment (MOE). The Walkerton Public Utilities
  Commission (PUC) operators lacked the training
  and expertise necessary to identify either the
  vulnerability of Well 5 to surface contamination
  or the resulting need for continuous chlorine
  residual and turbidity monitors.

59
Summary Page 2
Summary of Conclusions Page 2
The scope of the outbreak would very likely
have been substantially reduced if the Walkerton
PUC operators had measured chlorine residuals at
Well 5 daily, as they should have, during the
critical period when contamination was entering
the system. For years, the PUC operators
engaged in a host of improper operating
practices, including failing to use adequate
doses of chlorine, failing to monitor chlorine
residuals daily, making false entries about
residuals in daily operating records, and
misstating the locations at which microbiological
samples were taken. The operators knew that these
practices were unacceptable and contrary to MOE
guidelines and directives. The MOEs
inspections program should have detected the
Walkerton PUCs improper treatment and monitoring
practices and ensured that those practices were
corrected. The PUC commissioners were not aware
of the improper treatment and monitoring
practices of the PUC operators. However, those
who were commissioners in 1998 failed to properly
respond to an MOE inspection report that set out
significant concerns about water quality and that
identified several operating deficiencies at the
PUC. On Friday, May 19, 2000, and on the days
following, the PUCs general manager concealed
from the Bruce-Grey-Owen Sound Health Unit and
others the adverse test results from water
samples taken on May 15 and the fact that Well 7
had operated without a chlorinator during that
week and earlier that month. Had he disclosed
either of these facts, the health unit would have
issued a boil water advisory on May 19, and 300
to 400 illnesses would have been avoided.
60
Summary Page 3
Summary of Conclusions Page 3
In responding to the outbreak, the health unit
acted diligently and should not be faulted for
failing to issue the boil water advisory before
Sunday, May 21. However, some residents of
Walkerton did not become aware of the boil water
advisory on May 21. The advisory should have been
more broadly disseminated. The provincial
governments budget reductions led to the
discontinuation of government laboratory testing
services for municipalities in 1996. In
implementing this decision, the government should
have enacted a regulation mandating that testing
laboratories immediately and directly notify both
the MOE and the Medical Officer of Health of
adverse results. Had the government done this,
the boil water advisory would have been issued by
May 19 at the latest, thereby preventing hundreds
of illnesses. The provincial governments
budget reductions made it less likely that the
MOE would have identified both the need for
continuous monitors at Well 5 and the improper
operating practices of the Walkerton PUC. The
Part 1 report contains some recommendations
directed toward ensuring the safety of drinking
water in Ontario. However, the majority of my
recommendations in that respect will be in the
Part 2 report of this Inquiry.
61
Helicobacterium pylori
Helicobacter pylori
Peptic ulcer disease is a common clinical
ailment, once thought to be caused by
oversecretion of acid and pepsin, an enzyme of
the stomach that promotes digestion by breaking
down proteins. Researchers have found, however,
that although the injury caused by acid and
pepsin is necessary for the formation of ulcers,
acid secretion levels of the majority of patients
with gastric or duodenal ulcers are normal. An
ulcer is now known to be the result of an
imbalance between aggressive and defensive
mechanisms in the stomach and duodenum. Part of
that imbalance can be attributed to infection by
H. pylori. Humans are the only known host of
Helicobacter pylori. Its prevalence in healthy
people increases with age to over 50 in people
over the age of 60. Studies have shown that
Blacks are more susceptible to infection than are
Whites, and incidents of infection increase with
decreasing socioeconomic status. Evidence of H.
pylori infection in families, prisons, and
nursing homes suggest that H. pylori is spread by
close personal contact. However, the exact
mechanism for transmission of the bacteria is not
well understood.
62
Web Sites
Web Sites
The full part 1 Walkerton Inquiry Report can be
found at http//www.inweh.unu.edu/biology447/mod
ules/module4/Walkerton_Materials/walkerton_inquiry
_report_FRAMES.htm As well as at the Walkerton
Inquiry Web Site at http//www.inweh.unu.edu/bio
logy447/modules/module4/Walkerton_Materials/walker
ton_inquiry_report_FRAMES.htm Background
materials on E. coli and Walkerton http//www.in
weh.unu.edu/biology447/modules/module4/enteropatho
genic.htm Risk Analysis Mini-course and
overview http//risk.lsd.ornl.gov/minicourse/rap
_whatisra.shtml