HomeMy WebLinkAbout2020 09 28 Consent 306 - Minutes from the September 14, 2020 City Commission Regular Meeting CITY COMMISSION
Incorporated P E G U LA P MEETING
1959
MINUTES
MONDAY, SEPTEMBER 14, 2020 AT 6:30 PM
CITY HALL- COMMISSION CHAMBERS
1126 EAST STATE ROAD 434, WINTER SPRINGS, FLORIDA
50
CALL TO ORDER
Mayor Charles Lacey called the Regular Meeting of Monday, September 14, 2020 of
the City Commission to order at 6:30 p.m. in the Commission Chambers of the
Municipal Building (City Hall, 1126 East State Road 434, Winter Springs,
Florida 32708).
Roll Call:
Mayor Charles Lacey, present
Deputy Mayor Ted Johnson, present
Commissioner Jean Hovey, present
Commissioner Kevin Cannon, present
Commissioner TiAnna Hale, present
Commissioner Geoff Kendrick, present
City Manager Shawn Boyle, present
City Attorney Anthony A. Garganese, present
Interim City Clerk Christian Gowan, present
A moment of silence was held, followed by the Pledge of Allegiance.
The agenda was adopted without changes.
AWARDS AND PRESENTATIONS
100. Overview of Stormwater/Retention Ponds
Mr. Christopher Schmidt, Director, Community Development Department provided
a brief overview of stormwater and retention ponds and their intended uses.
Brief discussion followed on city responsibilities for private ponds, FDEP guidelines,
natural solutions, and the need for a citywide review of ponds, which included
economic analysis of pond maintenance.
Mr. Schmidt noted a review was currently underway and that results could be
discussed in sixty (60) to ninety (90) days.
INFORMATIONAL AGENDA
200. Current Community Development Project Updates
Not discussed
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 2 OF 12 51
PUBLIC INPUT
Mayor Lacey opened "Public Input."
Commissioner Tony Ortiz, President, Florida League of Cities spoke about the role of
the Florida League of Cities, noted five committees, and announced Commissioner
Geoff Kendrick will be chairing the Transportation and Intergovernmental
Committee and thanked him for hiswork.Thanked Commissioners for their support.
The Mayor and Commission thanked President Ortiz, noted their involvement on
various committees, and expressed excitement at continuing toworktogether in the
future.
Brief discussion followed on a possible constitutional amendment related to home
rule being considered bythe Florida League of Cities and on the mission to reach out
and teach constituents about the importance of home rule.
Mr Art Gallo, 199 Nandina Terrace, Winter Springs, Florida was called to speak and
offered full support for the Winter Springs Police Department. Asked for review of
police training,salaries, abilityto respond appropriately when officers receive verified
complaints, and the ability of officers to handle stress.
Mr Skip Arok, 1104 Pheasant Circle, Win ter Springs, Florida thanked the Commission
for their hard work and spoke about concerns regarding an unsolicited political text
message. Asked for formal response from City.
Ms Elaine Connors, 1121 Pheasant Circle, Winter Springs, Florida shared concerns
about a political text message received by members of her household and asked for
clarification about water quality.
Mr Rob Elliott, 925 Chokecherry Court, Winter Springs, Florida discussed political
signs disappearing or being moved and asked that Cityshare information regarding
that this activity is illegal.
Ms Gina Shafer Winter Springs Village, Winter Springs, Florida asked about a speed
limit reduction. Furthermore, Ms. Shafer asked that the Winter Springs Police
Department be equipped with body cams.
Ms Elaine Johnson, 1107PheasantCircle, Winter Springs, Florida sha red her concerns
about political text messages and the spreading of false information.
Mayor Lacey closed "Public Input."
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 3 OF 12
52
CONSENT ADEN DA
300. Surplus Assets
No discussion.
301. Winter Springs pension Investment policy Update
No discussion.
302. Construction Services for the Central Winds park parking Lot Improvements on
Hicks Avenue
No discussion.
303. Seminole Crossing (Winter Springs) Town Homes- plat
Commissioner Cannon asked if the plat was in compliance with the previously
approved final engineering. Mr. Schmidt confirmed that it was in compliance.
304. City Clerk Compensation
No discussion.
305. Approval of Minutes from the Monday, August 10, 2020 City Commission Pegular
Meeting
"MOTION TO APPROVE." MOTION BY COMMISSIONER CANNON. SECONDED BY
COMMISSIONERR KENDRICK. DISCUSSION.
VOTE:
COMMISSIONERR KENDRICK:AYE
DEPUTY MAYOP JOHNSON: AYE
COMMISSION EP HOVEY:AYE
COMMISSION EP CANNON:AYE
COMMISSION EP HALE:AYE
MOTION CAPPIED.
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 4 OF 12
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PUBLIC HEARINGS AGENDA
400.Tentative Millage Rate for Fiscal Year 2020-2021 and Related Advertising
Ms. Maria Sonksen, Director, Finance Department introduced the item.
Manager Boyle noted a transposition error in the agenda packet regarding the
millage rate that should have been 2.4100 rather than 4.2100.
Mayor Lacey opened the Public Hearing for Item 400.
No one spoke.
Mayor Lacey closed the Public Hearing for Item 400.
"I MOVE TO APPROVE RESOLUTION 2020-14 ESTABLISHING THE TENTATIVE FISCAL
YEAR 2020-2021 OPERATING MILLAGE RATE FOR THE CITY OF WINTER SPRINGS AT
2.4100 MILLS AND PUBLICLY ANNOUNCE THAT THE TENTATIVE OPERATING
MILLAGE RATE OF 2.4100 MILLS IS 4.22% GREATER THAN THE COMPUTED ROLL-
BACK RATE OF 2.3124 MILLS AND AUTHORIZING ADVERTISEMENT OF THE CITY'S
INTENTTO HOLD PUBLIC HEARINGS TO ADOPT THE FINAL MILLAGE RATE AND
BUDGET." MOTION BY COMMISSIONER HOVEY. SECONDED BY COMMISSIONER
KENDRICK. DISCUSSION.
VOTE:
COMMISSIONER HOVEY:AYE
COMMISSIONER HALE:AYE
COMMISSIONER CANNON:AYE
COMMISSIONER KENDRICK:AYE
DEPUTY MAYOR JOHNSON: AYE
MOTION CARRIED.
401.Tentative Budget for Fiscal Year 2020-2021 and Related Advertising
Ms. Sonksen briefly introduced the agenda item.
Mayor Lacey opened the Public Hearing for Item 401.
No one spoke.
Mayor Lacey closed the Public Hearing for Item 407.
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE S OF 12
54
"I MOVE TO APPROVE RESOLUTION 2020-15 ESTABLISHING THE TENTATIVE
BUDGET FOR THE CITY OF WINTER SPRINGS FOR THE FOSCALYEAR COMMENCING
ON OCTOBER 1, 2020 AND ENDING ON SEPTEMBER 30, 2021 AND AUTHORlZlNG
ADVERTISEMENT OF THE CITY'S INTENT TO HOLD PUBLIC HEARONGSTOADOPT
THE FINAL MILLAGE RATE AND BUDGET." MOTION BY COMMISSIONER HOVEY.
SECONDED BY COMMISSIONER KENDRICK. DISCUSSION.
VOTE:
DEPUTY MAYOR JOHNSON: AYE
COMMISSIONER HALE:AYE
COMMISSIONER CANNON:AYE
COMMISSIONER HOVEY:AYE
COMMISSIONER KENDRICK:AYE
MOTION CARRIED.
402. First Reading of the Sand Loch Small-Scale I Future Land Use Map Amendment
and Rezone, Ordinance 2020-06 and 2020-05.
"MOTION TO READ ORDINANCES 2020-06 AND 2020-05 BY TITLE ONLY." MOTION
BY COMMISSIONER CANNON. SECONDED BY COMMISSION HOVEY. DISCUSSION.
MOTION PASSED WITH UNANIMOUS CONSENT.
Attorney Garganese read both ordinances by title only and noted that both
ordinances could he heard under one public hearing.
Mr. Schmidt briefly discussed the property's history and proposed uses should this
change be approved.
Mayor Lacey opened the Public Hearing for Item 402.
No one spoke.
Mayor Lacey closed the Public Hearing for Item 402.
Discussion followed on consistency and compatibility with the surrounding area,
concerns about allowable heights, streetscape requirements, and potential impacts
of traffic projects on this property.
Commissioner Cannon asked that Section 4.0 of the Development Agreement be
revised to reduce maximum allowance to two-story rather than the currently
permissible five stories.
MOTION TO APPROVE ORDINANCE 2020-06 ON FIRST READING." MOTION BY
DEPUTY MAYOR JOHNSON. SECONDED BY COMMISSIONER HALE. DISCUSSION.
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 6 OF 12
55
VOTE:
COMMISSIONER CANNON:AYE
DEPUTY MAYOR JOHNSON: AYE
COMMISSIONER HOVEY:AYE
COMMISSIONER HALE:AYE
COMMISSIONER KENDRICK:AYE
MOTION CARRIED.
MOTION TO APPROVE ORDINANCE 2020-05 ON FIRST READING." MOTION BY
COMMISSIONER CANNON. SECONDED BY COMMISSIONER KENDRICK.
DISCUSSION.
VOTE:
COMMISSIONER HALE:AYE
COMMISSIONER KENDRICK:AYE
COMMISSIONER CANNON:AYE
COMMISSIONER HOVEY:AYE
DEPUTY MAYOR JOHNSON: AYE
MOTION CARRIED.
403. Review of Ordinance 2020-08 amending Chapter 14 of the personnel of the City
Code regarding the duties and responsibilities of the City Clerk and City Manager
pursuant to the City Charter; providing for the repeal of prior inconsistent ordinances
and resolutions; incorporation into the code; severability and an effective date
Mayor Lacey noted this was the first reading of this ordinance.
"MOTION TO READ BY TITLE ONLY." MOTION BY COMMISSIONER HOVEY.
SECONDED BY COMMISSIONER HALE. DISCUSSION.
MOTION PASSED WITH UNANIMOUSE CONSENT.
Attorney Garganese read Ordinance 2020-08 by title only and then explained that
this ordinance would clarify that the City Clerk's Office falls under the
administration of the City Manager regarding all non-charter, day-to-day
responsibilities.
Mayor Lacey opened the Public Hearing for Item 402.
No one spoke.
Mayor Lacey closed the Public Hearing for Item 402.
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 7 OF 12
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MOTION TO APPROVE ORDINANCE 2020-08 ON FORST READING." MOTION BY
COMMISSIONER CANNON. SECONDED BY DEPUTY MAYOR JOHNSON. DISCUSSION.
VOTE:
COMMISSIONER CANNON:AYE
COMMISSIONER KENDRICK:AYE
DEPUTY MAYOR JOHNSON: AYE
COMMISSIONER HALE:AYE
COMMISSIONER HOVEY:AYE
MOTION CARRIED.
REGULAR AGENDA
500. Discussion on Water Quality
Commissioner Cannon introduced the item and discussed social media activity
about water quality, noted current projects underway, and concerns from a variety
of people about the City's water and the firm that now manages the City water
plants.
Commissioner Cannon read thefindingsofthe March 16,2016 Flint Task Force Report
in to the record and asked that this be attached to the end of the minutes for
approval along with emails from Ms. Casey Howard, Director, IT & Administrative
Services Director and a Michigan Circuit Court's Motion of Summary Disposition.
Manager Boyle noted the extensive efforts of the City to improve water aesthetics
and assured everyone there are no health risks related to the City water.
Com m issioners expressed th a n ks for the wor k of City staff, noted improvementsthat
have already made a difference in water aesthetics, and shared concerns about the
spread of false information. Furthermore, several Commissioners encouraged
anyone with data proving the water was not safe to come forward.
"MOTION TO EXTEND THROUGH SECOND PUBLIC INPUT." MOTION BY DEPUTY
MAYOR JOHNSON. SECONDED BY COMMISSIONER HALE. DISCUSSION.
MOTION PASSED WITH UNANIMOUS CONSENT.
"I MAKE A MOTION THAT WE AS A COMMISSION ADOPT A RESOLUTION
REITERATING THE PRESENTATIONS MADE BY STAFF AND PROFESSIONAL
ENGINEERS THAT THE DRINKING WATER QUALITY HAS MET OR EXCEEDED ALL
STATE AND FEDERAL WATER QUALITY STANDARDS DURING 2019-2020,THAT THE
COMMISSION HAS NOT BEEN PRESENTED WITH ANY SCIENTIFIC OR MEDICAL
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 8 OF 12
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EVIDENCE IDENTIFYING HEALTH OR SAFETY CONCERNS WITH THE QUALITY OF
OUR WATER,AND REQUESTING THAT ANY RESIDENT OF THE CITY OF WINTER
SPRINGS WHO HAS SUCH CONCERNS IS URGED TO IMMEDIATELY BRING THE TEST
DATA, SCIENTIFIC INFORMATION,AND MEICAL INFORMATION TO THE
COMMISSION AND CITY MANAGER FOR EVALUATION AND ACTION ACCORDINGLY."
MOTION BY COMMISSIONER CANNON. SECONDED BY DEPUTY MAYOR JOHNSON.
DISCUSSION.
VOTE:
DEPUTY MAYOR JOHNSON: AYE
COMMISSIONER HOVEY:AYE
COMMISSIOENR HALE:AYE
COMMISSIONER CANNON:AYE
COMMISSIONER KENDRICK:AYE
MOTION CARRIED.
Mayor Lacey asked for clarification and it was confirmed that this constituted
passage of the resolution which would be executed after written up by the City
Attorney.
501.Appointment Opportunities for City Boards and Committees
"MOTION TO APPOINT STEPHEN KROHNTOTHE BOARD OF TRUSTEES CONTINGENT
ON RECEIPT AND VERIFICATION OF APPLICATION." MOTION BY COMMMISSIONER
KENDRICK. SECONDED BY COMMISSIONER HOVEY. DISCUSSION.
VOTE:
COMMISSIONER HALE:AYE
COMMISSIONER CANNON:AYE
COMMISSIONER HOVEY:AYE
DEPUTY MAYOR JOHNSON: AYE
COMMISSIONER KENDRICK:AYE
MOTION CARRIED.
"MOTION TO REAPPOINT MICHAEL BURNS TO THE CODE ENFORCEMENT BOARD."
MOTION BY COMMISSIONER KENDRICK. SECONDED BY COMMISSIONER HOVEY.
DISCUSSION.
VOTE:
COMMISSIONER KENDRICK:AYE
DEPUTY MAYOR JOHNSON: AYE
COMMISSIONER HOVEY:AYE
COMMISSIONER CANNON:AYE
COMMISSIONER HALE:AYE
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 9 OF 12
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MOTION CARRIED.
REPORTS
600. City Manager Shawn Boyle
• Invited everyone to attend upcoming food truck events on September 26 at
Torcaso Park and Oct 24 at Trotwood Park.
• Invited public to attend celebration of the Trotwood Pavillion completion on
Wednesday, September 16, 2020 at loam and noted this is the completion of
Phase I.
601. City Attorney Anthony A. Garganese
• No report
602. City Clerk Christian Gowan
• No report.
604. Seat Three Commissioner/Deputy Mayor Ted Johnson
• Recognized Parks and Recreation staff for construction at Trotwood Park.
• Discussed flashing stop signs and suggested several intersections where they
may be useful. Further encouraged looking citywide to determine future
placements.
• Complimented Lena Rivera and her staff for their work on resolving an issue
with a tree on Third Street.
• Shared concerns about political text messages sharing false information and
said he believed Winter Springs residents deserve an apology.
• Encouraged residents to visit Veolia's website for an abridged version of
earlier comments.
605. Seat Four Commissioner TiAnna Hale
• Noted some businesses around town have received CAPES act funding and
shared her appreciation for businesses within the City.
• Noted last week was National Suicide Prevention Week and spoke about
depression's wide reach and impact. Asked that the City make mental
wellness a community-wide priority and potentially discuss at a future
meeting.
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 10 • 59
606. Seat Five Commissioner Geoff Kendrick
• Thanked staff for innovation in keeping several events on the books amidst the
pandemic.
• Noted attendance at the memorial last Friday (9/11/2020) and suggested
opening this up to the community in the future.
• Noted participation in Keeth Elementary's First Responder's Lunch.
• Thanked Commissioner Ortiz for coming to the meeting and recognizing the
work that is being done.
608. Mayor Charles Lacey
• No report
603. Seat One Commissioner Jean Hovey
• Related to Commissioner Kendrick's report, encouraged nomination of Keeth
Elementary PTA for recognition at the county level.
603. Seat Two Commissioner Kevin Cannon
• Asked that we consider doing something around the Veterans Memorial and
opening up for the 20th anniversary of 9/11. (Activated at 02:38:31)
• Encouraged unity and coming together to solve local issues rather than
divisiveness
PUBLIC INPUT
Mayor Lacey opened "Public Input"
Mr. James Evans, 217AImaden Court, Winter Springs, Florida spoke about his own
experience/exposure to suicide, shared thoughts on the resolution that was passed
under Item S00, complimented Lena Rivera on her assistance, and agreed that he
did not believe misinformation should be spread. Concluding, Mr. Evans noted he
believed water was an issue and that it was not bad to bring up until it is fixed.
Mr. JohnJarolim, 1603CougarCourt, Winter Springs, Florida noted his experience
and said there is a problem with the smell and taste of the water. Continuing, he
noted his wife's service on Board of Trustees and offer
Ms Gina Shafer Winter Springs Village, Winter Springs, Florida discussed previous
action taken by this Commission on water, noted her appreciation at the passage of
the resolution and the work done by the Commission and City Manager.
CITY COMMISSION MINUTES I REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 11 OF 12
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Mayor Lacey closed "Public Input"
ADJOURNMENT
Mayor Lacey adjourned the Regular Meeting at 9:21 p.m.
RESPECTFULL YSUBMITTED.'
CHRISTIAN GOWAN
CITY CLERK
APPROVED:
MAYOR CHARLES LACEY
NOTE: These Minutes were approved at the 2020 City Commission Regular Meeting.
CITY COMMISSION MINUTES REGULAR MEETING I MONDAY, SEPTEMBER 14, 2020 1 PAGE 12 OF 12
61
The following items were added
to the record by Commissioner
Kevin Cannon at the Monday,
September 14, 2020 City
Commission Regular Meeting :
• March 2016 Flint Task Force
Report
• Motion of Summary
Disposition
• Emails
62
March 2016
Flint Water Advisory Task Force
FINAL REPORT
Commissioned by the Office of Governor Rick Snyder
State of Michigan
63
March 21, 2016
Governor Rick Snyder
Office of Governor
P.O. Box 30013
Lansing, Michigan 48909
Dear Governor Snyder:
We,the Flint Water Advisory Task Force (FWATF), offer in this report our findings and recommendations
regarding the Flint water crisis. We have come to our conclusions largely through interviews of
individuals involved and review of related documents now available in the public record. Our report
includes 36 findings and 44 recommendations, offered to fulfill our charge of determining the causes of
the Flint water crisis, identifying remedial measures for the Flint community, and safeguarding Michigan
residents.
We hope that our report serves three fundamental purposes:
1. Clarify and simplify the narrative regarding the roles of the parties involved, and assign
accountability clearly and unambiguously.
2. Highlight the causes for the failures of government that precipitated the crisis and suggest
measures to prevent such failures in the future.
3. Prescribe recommendations to care for the Flint community and to use the lessons of Flint's
experience to better safeguard Michigan residents.
We are encouraged by your focus and expressed commitment to address the Flint community's needs,
and to learn from the failures that have transpired. This commitment is appropriate because,though it
may be technically true that all levels of government failed,the state's responsibilities should not be
deflected.The causes of the crisis lie primarily at the feet of the state by virtue of its agencies'failures
and its appointed emergency managers' misjudgments.
Given the extensive investigative reporting on the Flint water crisis (from which we have benefited
greatly), we have limited our explanatory narrative. Rather, our report builds on the ample public record
and information yielded through over 60 interviews and discussions to prescribe recommendations that,
we hope, will ultimately safeguard and benefit Michigan residents for years to come. We have
approached our work with a solemn commitment to the charge you invested in us:to place Michigan
residents' well-being first.
Respectfully,
Matthew M. Davis, MD, MAPP Chris Kolb Lawrence Reynolds, MD
Eric Rothstein, CPA Ken Sikkema
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FLINT WATER ADVISORY TASK FORCE—FINAL REPORT
MARCH 2016
Table of Contents
ExecutiveSummary...........................................................................................................................1
SummaryStatement...............................................................................................................................1
A Series of Government Failures.............................................................................................................1
FWATF Membership, Charge and Scope of Review................................................................................2
Acknowledgements.................................................................................................................................5
Findingsof the Task Force ......................................................................................................................6
Recommendations of the Task Force....................................................................................................10
Background.....................................................................................................................................15
Flint, Michigan......................................................................................................................................15
WaterCrisis ..........................................................................................................................................15
Summary Timeline of Key Events..........................................................................................................16
RegulatoryContext...............................................................................................................................22
PublicHealth Context...........................................................................................................................23
Roles of Government Entities in the Flint Water Crisis.....................................................................26
Michigan Department of Environmental Quality(MDEQ)..............................................................26
DefinedRole..........................................................................................................................................26
Discussion.............................................................................................................................................27
Findin gs.................................................................................................................................................28
Recommendations................................................................................................................................29
Michigan Department of Health and Human Services(MDHHS)....................................................30
DefinedRole..........................................................................................................................................30
Discussion.............................................................................................................................................31
Findin gs.................................................................................................................................................33
Recommendations................................................................................................................................34
Michigan Governor's Office...........................................................................................................35
DefinedRole..........................................................................................................................................35
Discussion.............................................................................................................................................36
Findin gs.................................................................................................................................................38
Recommendations................................................................................................................................38
State-Appointed Emergency Managers.........................................................................................39
DefinedRole..........................................................................................................................................39
Discussion.............................................................................................................................................39
Findings.................................................................................................................................................40
Recommendations................................................................................................................................41
Cityof Flint...................................................................................................................................42
DefinedRole..........................................................................................................................................42
Discussion.............................................................................................................................................43
Findin gs.................................................................................................................................................44
Recommendations................................................................................................................................45
Genesee County Health Department(GCHD) ................................................................................46
DefinedRole..........................................................................................................................................46
Discussion.............................................................................................................................................46
Findin gs.................................................................................................................................................48
Recommendations................................................................................................................................48
U.S. Environmental Protection Agency(EPA)Oversight and the Lead and Copper Rule.................48
DefinedRole..........................................................................................................................................48
Discussion.............................................................................................................................................50
65
FLINT WATER ADVISORY TASK FORCE—FINAL REPORT
MARCH 2016
Findin gs.................................................................................................................................................52
Recommendations................................................................................................................................52
Issues Presented by the Flint Water Crisis........................................................................................53
The Reality of Environmental Injustice..........................................................................................54
Discussion.............................................................................................................................................54
Findin gs.................................................................................................................................................55
Recommendations................................................................................................................................55
Perspectivesfrom Flint .................................................................................................................55
Flint Recovery/Remediation........................................................................................................56
Recommendations................................................................................................................................57
State-Wide Initiatives...................................................................................................................58
Recommendations................................................................................................................................58
Conclusions.....................................................................................................................................62
APPENDIX I: Flint Water Advisory Task Force(FWATF)
APPENDIX II: FWATF Letters
APPENDIX III: Interviewee Listing
APPENDIX IV: Questions of Lockwood,Andrews, & Newnam
APPENDIX V: Detailed Timeline
APPENDIX VI:Abbreviations and Acronyms
66
Executive Summary
Summary Statement
The Flint water crisis is a story of government failure, intransigence, unpreparedness, delay,
inaction, and environmental injustice.The Michigan Department of Environmental Quality
(MDEQ) failed in its fundamental responsibility to effectively enforce drinking water regulations.
The Michigan Department of Health and Human Services (MDHHS) failed to adequately and
promptly act to protect public health. Both agencies, but principally the MDEQ, stubbornly
worked to discredit and dismiss others' attempts to bring the issues of unsafe water, lead
contamination, and increased cases of Legionellosis (Legionnaires' disease)to light. With the City
of Flint under emergency management,the Flint Water Department rushed unprepared into full-
time operation of the Flint Water Treatment Plant, drawing water from a highly corrosive source
without the use of corrosion control.Though MDEQ was delegated primacy (authority to enforce
federal law),the United States Environmental Protection Agency (EPA) delayed enforcement of
the Safe Drinking Water Act (SDWA) and Lead and Copper Rule (LCR),thereby prolonging the
calamity. Neither the Governor nor the Governor's office took steps to reverse poor decisions by
MDEQ and state-appointed emergency managers until October 2015, in spite of mounting
problems and suggestions to do so by senior staff members in the Governor's office, in part
because of continued reassurances from MDEQthat the water was safe. The significant
consequences of these failures for Flint will be long-lasting.They have deeply affected Flint's
public health, its economic future,' and residents'trust in government.
The Flint water crisis occurred when state-appointed emergency managers replaced local
representative decision-making in Flint, removing the checks and balances and public
accountability that come with public decision-making. Emergency managers made key decisions
that contributed to the crisis,from the use of the Flint River to delays in reconnecting to DWSD
once water quality problems were encountered. Given the demographics of Flint,the
implications for environmental injustice cannot be ignored or dismissed.
The Flint water crisis is also a story, however, of something that did work:the critical role played
by engaged Flint citizens, by individuals both inside and outside of government who had the
expertise and willingness to question and challenge government leadership, and by members of a
free press who used the tools that enable investigative journalism. Without their courage and
persistence,this crisis likely never would have been brought to light and mitigation efforts never
begu n.
A Series of Government Failures
Flint water customers were needlessly and tragically exposed to toxic levels of lead and other
hazards through the mismanagement of their drinking water supply.The specific events that led
to the water quality debacle, lead exposure, heightened Legionella susceptibility, and
' Direct and indirect economic impacts of the Flint water crisis include,for example,financial consequences to
individuals and homeowners; impacts on economic development opportunities and on the revenue base for public
services;and the costs of exacerbated requirements for water infrastructure repair and rehabilitation as well as long-
term public health and social services.
67
FLINT WATER ADVISORY TASK FORCE—FINAL REPORT
MARCH 2016
infrastructure damage are a litany of questionable decisions and failures related to several issues
and events, including, but not limited to:
• Decisions related to the use of the Flint River as an interim water supply source.
• Inadequate preparation (for example, staffing,training and plant upgrades) for the switch
to full-time use of the Flint Water Treatment Plant using the Flint River as the primary
water supply source.
• Inadequate and improper sampling of distribution system water quality, potentially in
violation of the Safe Drinking Water Act.
• Intransigent disregard of compelling evidence of water quality problems and associated
health effects.
• Callous and dismissive responses to citizens' expressed concerns.
• Persistent delays in coordinating appropriate responses to the resultant public health
crises once irrefutable evidence of exposure and poisoning was presented.
We cannot begin to explain and learn from these events—our charge—without also highlighting
that the framework for this decision-making was Michigan's Emergency Manager Law. This law
replaces the decision-making authority of locally elected officials with that of a state-appointed
emergency manager. While one must acknowledge that emergency management is a mechanism
to address severe financial distress, it is important to emphasize that the role of the emergency
manager in Flint places accountability for what happened with state government.
Our complete findings and recommendations are provided throughout this report and also are
summarized at the close of this Executive Summary. They are formulated to offer specific
measures to better safeguard public health, enhance critical water system infrastructure,
improve governmental decision-making and regulatory oversight, and mitigate the many negative
health and economic effects facing the people of Flint. We hope that our findings and
recommendations serve as a guide and template for remediation and recovery in Flint, and for
safeguarding the health and well-being of residents across our state.
FWATF Membership, Charge and Scope of Review
The FWATF—composed of five members with experience and backgrounds in public policy, public
utilities, environmental protection, public health, and health care—was appointed by Governor
Rick Snyder on October 21, 2015.2 We were charged with conducting an independent review of
the contamination of the Flint water supply: what happened, why it occurred, and what is
needed to prevent a reoccurrence in Flint or elsewhere in the state. We assessed ongoing
mitigation efforts to help assure that short and long-term public health issues and water
management concerns will be properly addressed to safeguard the health and well-being of the
Flint community. We have developed findings and offer recommendations on the following:
• Roles of Government Entities in the Flint Water Crisis
o State of Michigan
■ Michigan Department of Environmental Quality (MDEQ)
■ Michigan Department of Health and Human Services (MDHHS)
■ Michigan Governor's Office
■ State-Appointed Emergency Managers
z Paragraph summaries of the FWATF members'backgrounds and experience are provided as Appendix I.
2
68
FLINT WATER ADVISORY TASK FORCE—FINAL REPORT
MARCH 2016
o City of Flint
o Genesee County Health Department (GCHD)
o United States Environmental Protection Agency and the Lead and Copper Rule
• Issues Presented by the Flint Water Crisis
o The Reality of Environmental Injustice
o Perspectives from Flint
o Flint Recovery
o State-Wide Recommendations
Before completing this report,the Task Force issued three interim letters to Governor Snyder
offering findings and recommendations requiring immediate response, as follows:3
1. The first letter, issued December 4, 2015, identified our concerns about coordination of
response measures and the need for a framework to measure results and clearly
delineate responsibilities for continuing actions to protect public health.
2. The second letter, issued December 29, 2015, addressed the critical and urgent need to
establish responsibility and ensure accountability for what happened in Flint.
3. Our third letter, issued January 21, 2016, addressed the need for the state to engage the
scientific experts who overcame state and federal agency intransigence to expose the lead
poisoning, and similarly to engage trusted, scientific experts drawn from independent
institutions to address the implications of the Legionellosis outbreak.
In conducting our interviews, we have had complete independence and largely4 unfettered
access to local, state and federal government personnel. Interview subjects were not compelled
to participate in our review, and the FWATF held no subpoena or judicial enforcement powers.
We are grateful to the parties involved for their forthright willingness to discuss the events that
transpired and their perspectives.
We acknowledge that other reviews and investigations are taking place, some with tools that the
FWATF did not have, such as the subpoena and judicial enforcement powers mentioned above.
We appreciate and support these reviews because the magnitude of this tragedy warrants deep
and detailed investigation. It is our hope that these or other reviews examine certain issues we
had neither the time nor investigative tools to fully explore, and that fell outside our immediate
scope given the accelerated timeframe for our information gathering and rendering of
judgments. These issues include, but are not limited to:
• State approval and permitting of the Karegnondi Water Authority (KWA) in a region that
had ample water supply and treatment capacity, yet faced economic distress sufficient to
warrant emergency management in its two largest urban centers.
• The appropriate role of regulatory agencies and the water utility industry in addressing
the dangers presented by widespread use of lead in public and private plumbing systems.
a The FWATF's interim letters to Governor Snyder are provided as Appendix II.
4 The FWATF was not successful in scheduling an interview with representatives of the firm Lockwood,Andrews,&
Newnam (LAN)despite several requests.LAN requested that questions be submitted to them in writing,and the
questions we submitted are included in Appendix IV.As of the time of publication,the FWATF has not received
responses to these questions.
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Historically, regulatory agencies and the water utility industry at large have been
reluctant to address these dangers beyond use of corrosion control treatment.5 Though
the industry now endorses strengthening of the Lead and Copper Rule and ultimate
replacement of lead service lines (LSLs),6 the industry has not (with notable exceptions)
been proactive in reducing risk through full LSL replacement programs and has
highlighted utility customers' obligations to manage lead risks on private property. While
the recommendations of the National Drinking Water Advisory Council (NDWAC) advance
objectives of full LSL replacements, enhanced monitoring, and improved public
education, concerns persist about accountability, oversight and enforcement.7,8
• Protocols for environmental compliance enforcement when EPA has delegated primacy
(authority to enforce federal law)to state agencies,yet retains ultimate responsibility for
protection of public health and management of environmental risks.
• Budgets for public health activities at federal, state, and local levels to ensure that highly
skilled personnel and adequate resources are available.The consequences of under-
funding include insufficient and inefficient responses to public health concerns, which
have been evident in the Flint water crisis.
• The need for greater clarity on local and state processes and procedures for declaring
emergencies in response to man-made catastrophes (in contrast to natural disasters). The
efforts of local, state, and federal emergency operations teams in Flint beginning in
s Historically,water industry groups have maintained that removing lead from water and plumbing systems is not
necessary and would involve significant difficulty and expense(see,for example, "Controlling Lead in Drinking
Water,"Water Research Foundation,2015). Notably,when EPA's Lead and Copper Rule(LCR)was published in 1991,
it required replacement of entire LSLs,and in 1994 the water industry sought in court to limit this requirement to
only the publicly owned portions of service lines(40 F.3d 1266,AWWA vs.EPA,1994).In response,EPA revised the
LCR in 2000 to allow for partial service line replacement—a practice the CDC later maintained was associated with
increases in blood lead levels("Important Update:Lead-Based Water Lines,"Howard Frumkin, MD;CDC,May 2010).
The water industry historically has focused on controlling lead exposure risks through use of chemical corrosion
control methods and has offered a number of related studies(as compiled in "Lead and Copper Corrosion:An
Overview of WRF Research,"Jonathan Cuppett,Water Research Foundation,updated January 2016).The American
Water Works Association(AWWA)also has published communications guides on lead-in-water issues(see,for
example, "Communicating About Lead Service Lines:A Guide for Water Systems Addressing Service Line Repair and
Replacement,"AWWA,2014;and "Strategies to Obtain Customer Acceptance of Complete Lead Service Line
Replacement,"AWWA,2005).Yet industry guidance has taken the position that managing lead-related risks
associated with LSLs and plumbing fixtures on private property is largely the utility customers' responsibility. Many
water utilities have not informed customers proactively(if at all)about the presence of LSLs.As a result,customers
generally have limited awareness of the potential need to take action to protect themselves from lead in drinking
water.
6 See,for example,AWWA press release:"AWWA Board supports recommendation for complete removal of lead
service lines,"March 8,2016.
For example,there are concerns that the voluntary,customer-initiated sampling approach recommended by the
NDWAC will substantially decrease public water systems'ability to track presence of lead over time, identify
emerging public health threats,and inform LSL replacement programs. For more information on additional concerns,
see,for example, "Strength of New EPA Lead Rule Depends on Accountability,"by Brett Walton,Circle of Blue,
February 10,2016,www.circleofblue.org/2016/world/strength-of-new-epa-lead-rule-depends-on-accountability/.
8 NDWAC and water utility industry representatives have highlighted concerns about the significant financial
resources and time required to effect full LSL replacement,suggesting the need to support reasonable yet aggressive
scheduling of LSL replacement through both enforcement measures(within the LCR)and resource commitments of
local,state and federal entities.
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January 20169 have demonstrated that emergency operations can be deployed
appropriately and with multi-level coordination. However, delays in Flint occurred due to
reluctance to elevate concerns, confusion and disagreement among authorities about
how and what levels of emergency status were appropriate, and extensive application
requirements.
We also note and acknowledge that additional information will continue to be revealed as other
investigations and reviews of the crisis are conducted. The narrative,findings and
recommendations in this report are based on our interviews and the public record available
through February 2016. We believe this information alone warrants urgent and thorough
response and supports our recommendations.
We hope that our earlier letters and this report contribute to the collective understanding of
what transpired, evoke thoughtful consideration of our recommendations, and—most
importantly—further motivate sustained response and support for the Flint community and more
earnest and effective protection of all Michigan residents.
Acknowledgements
The FWATF would not have been able to complete its work without the support of many
individuals and organizations that dedicated their time, resources and passion to facilitate our
review. We are indebted to the Michigan State University's Center for Local Government Finance
and Policy for their administrative support and insights, particularly with regard to Michigan's
emergency manager laws; and to Chris DeWitt of DeWitt Communications for keeping the task
force informed regarding media coverage. We have been aided by technical insights from
individuals in the water utility and public health communities,too numerous to name individually
here, who have educated us on a broad range of issues. Where we have accurately stated the
technical attributes of specific issues, it reflects on their guidance. We are responsible for any
technical inaccuracies or unintentional misstatements of fact.
Perhaps most notably, we are deeply indebted to the members of the Flint community and safe
drinking water and public health advocates who ultimately entrusted us with profound
expressions of their frustrations, concerns, perspectives and hopes for the future. We are
especially thankful to Flint residents for giving voice to the searing personal costs that are too
often muted in the discourses about public policy implications. We are acutely aware that as we
are a task force commissioned by the State of Michigan,their forthrightness was a leap of faith
given what happened in Flint. We hope that our report honors their trust, advances their hopes
for the future, and helps ensure that Michigan communities are safer.
9 The FWATF recommended to the Governor's office that an emergency be declared as early as November 2015 and
issued its first letter to the Governor on December 4,2015 noting the acute need for more effective coordination of
activities.
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Findings of the Task Force
Note:Footnotes and text supporting these findings and recommendations are provided in the
individual sections of the report. The footnotes and text provide substantive detail and important
context for our findings and recommendations.Also please note that the findings and
recommendations are independent lists; the findings do not correlate one-to-one to the
recommendations.
Michigan Department of Environmental Quality(MDEQ):
F-1. MDEQ bears primary responsibility for the water contamination in Flint.
F-2. MDEQ specifically its Office of Drinking Water and Municipal Assistance (ODWMA),
suffers from cultural shortcomings that prevent it from adequately serving and protecting
the public health of Michigan residents.
F-3. MDEQ misinterpreted the LCR and misapplied its requirements. As a result, lead-in-water
levels were under-reported and many residents' exposure to high lead levels was
prolonged for months.
F-4. MDEQ waited months before accepting EPA's offer to engage its lead (Pb) experts to help
address the Flint water situation and, at times, MDEQ staff were dismissive and
unresponsive.
F-5. MDEQfailed to move swiftly to investigate, either on its own or in tandem with MDHHS,
the possibility that Flint River water was contributing to an unusually high number of
Legionellosis cases in Flint.
Michigan Department of Health and Human Services(MDHHS):
F-6. MDHHS's lack of timely analysis and understanding of its own data on childhood blood
lead levels, along with its reliance on MDEQ and reluctance to share state data with Dr.
Mona Hanna-Attisha and Professor Marc Edwards, prolonged the Flint water crisis.
F-7. MDHHS bears ultimate responsibility for leadership and coordination of timely follow-up
efforts in Flint and across the state regarding childhood lead poisoning. While local
entities (for example, healthcare professionals, GCHD, health insurance plans) are
partners in efforts to protect children from lead poisoning, MDHHS has the lead role and
failed to exercise its responsibility.
F-8. The consequences of lead exposure for Flint residents are expected to be long-term and
will necessitate sustained investments in education, public and mental health,juvenile
justice, and nutrition needs over the next 10 to 20 years.
F-9. Too few children in Michigan are screened for lead through routine blood tests as
recommended for children ages 1 and 2. Statewide screening goals for children enrolled in
Medicaid are met in very few instances at the county level or within Medicaid health
plans.This lack of information leaves parents, healthcare professionals, and local and
state public health authorities uninformed about the possibility of lead poisoning for
thousands of Michigan children.
F-10. Coordination between MDEQ and MDHHS was inadequate to properly address the public
health issues related to water quality in Flint. Communication was infrequent, and when it
did occur,the default position was to conclude that the health problems were not related
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to the water supply switch —rather than to assume that the problems might be related to
the switch.
F-11. Communication and coordination among local and state public health staff and leadership
regarding Legionellosis cases in 2014-2015 was inadequate to address the grave nature of
this outbreak.The fact that these cases occurred while there were several simultaneous
concerns about quality and safety of water in Flint should have caused public health staff
and leadership at local and state levels to coordinate their actions to ensure a prompt and
thorough investigation.
Michigan Governor's Office:
F-12. Ultimate accountability for Michigan executive branch decisions rests with the Governor.
F-13.The Governor's knowledge, and that of Governor's office staff, of various aspects of the
Flint water crisis was compromised by the information—much of it wrong—provided by
MDEQand MDHHS.
F-14.The Governor's office continued to rely on incorrect information provided by these
departments despite mounting evidence from outside experts and months of citizens'
complaints throughout the Flint water crisis, only changing course in early October 2015
when MDEQ and MDHHS finally acknowledged the extent of the problem of lead in the
public water supply.
F-15.The suggestion made by members of the Governor's executive staff in October 2014 to
switch back to DWSD should have resulted, at a minimum, in a full and comprehensive
review of the water situation in Flint, similar to that which accompanied the earlier
decision to switch to KWA. It was disregarded, however, because of cost considerations
and repeated assurances that the water was safe. The need to switch back to DWSD
became even more apparent as water quality and safety issued continued and lead issues
began to surface in 2015, notwithstanding reassurances by MDEQ.
F-16.The Flint water crisis highlights the risks of over-reliance—in fact, almost exclusive
reliance—on a few staff in one or two departments for information on which key
decisions are based.
F-17. Official state public statements and communications about the Flint water situation have
at times been inappropriate and unacceptable.
State-Appointed Emergency Managers:
F-18. Emergency managers, not locally elected officials, made the decision to switch to the Flint
River as Flint's primary water supply source.
F-19.Treasury officials,through the terms of the local emergency financial assistance loan
executed by the Flint emergency manager on April 29, 2015, effectively precluded a
return to DWSD water, as Flint citizens and local officials were demanding, without prior
state approval.
F-20.The role of the emergency managers in Flint (in combination with MDE(Xs failures) places
primary accountability for what happened with state government.
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F-21. Emergency managers charged with financial reform often do not have, nor are they
supported by,the necessary expertise to manage non-financial aspects of municipal
government.
F-22. Michigan's Emergency Manager Law and related practices can be improved to better
ensure that protection of public health and safety is not compromised in the name of
financial urgency.
City of Flint:
F-23. Flint Public Works personnel were ill-prepared to assume responsibility for full-time
operation of the Flint WTP and distribution system.
F-24.The Flint Water Treatment Plant (WTP) and installed treatment technologies were not
adequate to produce safe, clean drinking water at startup of full-time operations. Flint's
lack of reinvestment in its water distribution system contributed to the drinking water
crisis and ability to respond to water quality problems.
F-25. Flint Public Works personnel failed to comply with LCR requirements, including the use of
optimized corrosion control treatment and monitoring for lead. Flint personnel did not
identify residences with LSLs, secure an adequate number of tap water samples from
high-risk homes, or use prescribed sampling practices (for example, line and tap flushing
methods and sample bottle sizes).
F-26. Flint Public Works acted on inaccurate and improper guidance from MDEQ.
F-27. Many communities similarly rely on MDEQto provide technical assistance and guidance
on how to meet regulatory requirements. In the case of Flint, MDEQ assistance was
deeply flawed and lax, which led to myopic enforcement of regulations designed to
protect public health.
F-28.The emergency manager structure made it extremely difficult for Flint citizens to alter or
check decision-making on preparations for use of Flint River water, or to receive
responses to concerns about subsequent water quality issues.
Genesee County Health Department(GCHD):
F-29. Communication, coordination and cooperation between GCHD,the City of Flint and
MDHHS were inadequate to protect Flint residents from public health threats resulting
from inadequately treated Flint River water.
F-30.The rate of follow-up on children with elevated blood lead levels through January 2016
was unacceptable, illustrating a low level of coordination between GCHD and MDHHS and
insufficient resources devoted to this task.
F-31. Management of the Flint River-sourced water supply may have contributed to the
outbreaks of Legionellosis in 2014 and 2015 in Genesee County. Although the definitive
cause of the outbreaks is uncertain at the time of publication, GCHD and MDHHS did not
notify the public of the outbreaks in a timely fashion in order to urge caution.
United States Environmental Protection Agency(EPA):
F-32. EPA failed to properly exercise its authority prior to January 2016. EPA's conduct casts
doubt on its willingness to aggressively pursue enforcement (in the absence of
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widespread public outrage). EPA could have exercised its powers under Section 1414 and
Section 1431 of the SDWA or under the LCR,40 CFR 141.82(i).
F-33. Despite the clear intent of the LCR, EPA has accepted differing compliance strategies that
have served to mute its effectiveness in detection and mitigation of lead contamination
risks.These strategies have been adopted at water systems and primacy agencies across
the country.Though there may be some ambiguity in LCR rule, none of it relates to what
MDEQ should have done in Flint. There was and remains no justification for MDEQ not
requiring corrosion control treatment for the switch of water source to the Flint River.
F-34. EPA was hesitant and slow to insist on proper corrosion control measures in Flint. MDEQ
misinformation notwithstanding, EPA's deference to MDEQ,the state primacy agency,
delayed appropriate intervention and remedial measures.
F-35. EPA tolerated MDEQ's intransigence and issued, on November 3, 2015, a clarification
memo on the LCR when no such clarification was needed.
Issues Presented by the Flint Water Crisis:
F-36. The Flint water crisis is a clear case of environmental injustice.
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Recommendations of the Task Force
Note:Footnotes and text supporting these findings and recommendations are provided in the
individual sections of the report. The footnotes and text provide substantive detail and important
context for our findings and recommendations.Also please note that the findings and
recommendations are independent lists; the findings do not correlate one-to-one to the
recommendations.
Michigan Department of Environmental Quality(MDEQ):
R-1. Implement a proactive, comprehensive cultural change program within MDEQ, specifically
its ODWMA,to refocus the department on its primary mission to protect human health
and the environment. MDEQ should aspire to become a national leader through a
proactive program designed to detect and address contaminants in public water supplies
in a timely manner.
R-2. Establish an apprenticeship/certification program for MDEQ ODWMA employees that
requires direct, hands-on experience with public water system operations. MDEQ
ODWMA employees responsible for water system regulation and SDWA enforcement
should be, or have access to, certified operators and subject matter experts (including, for
example,those at EPA).
R-3. Strengthen SDWA enforcement, most notably for the LCR. The state has the ability to
strengthen its own enforcement of the SDWA and not wait for action to occur at the
federal level.
R-4. Participate in the Flint Water Inter-Agency Coordinating Committee's (FWICC's) work
team established to oversee conversion from DWSD-supplied to KWA-delivered water.
MDEQ should draw from that work to revise its policies and procedures for approval of
water treatment and distribution system operating regimens, particularly when source
water changes are contemplated.
R-5. Participate in EPA's ongoing review and revision of the LCR, conveying lessons learned
from the Flint water crisis.
Michigan Department of Health and Human Services(MDHHS):
R-6. Establish policies and procedures at MDEQ and MDHHS to ensure input by health experts
and scientists when permit decisions may have a direct impact on human health.
R-7. Establish and maintain a Flint Toxic Exposure Registry to include all the children and adults
residing in Flint from April 2014 to present.
R-8. Re-establish the Michigan Childhood Lead Poisoning Prevention and Control Commission.
R-9. Ensure that MDHHS is transparent and timely in reporting and analysis of aggregate data
regarding children's blood lead levels. MDHHS data regarding lead levels shall be provided
to individuals and organizations, based on their expertise, upon request and in cases
when the interpretation of data by MDHHS is questioned.
R-10. Establish a more aggressive approach to timely clinical and public health follow-up for all
children known to have elevated blood lead levels, statewide. MDHHS should expand its
local efforts and partnerships to accomplish this goal. Whenever possible, routine
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screening for lead and appropriate follow-up should occur in children's primary care
medical homes.
R-11.Strive to be a national leader in monitoring and responding to exposure of children to lead
by converting the Childhood Lead Poisoning Prevention Program (CLPPP) from passive
collection of test results into an active surveillance and outreach program.
R-12. Improve screening rates for lead among young children through partnerships with county
health departments, health insurers, hospitals, and healthcare professionals.
R-13.As the state authority on public health, and as the organization that conducted the
epidemiologic study of Legionellosis cases in Genesee County in 2014-15,take
responsibility for coordinating with GCHD and CDC to protect Michigan residents from
further outbreaks of Legionellosis.
R-14. In cases of switches in drinking water supplies in the future, assume that outbreaks of
Legionellosis cases may be related to changes in water source and communicate the
potential risk to the public, rather than assuming and communicating the opposite.
Michigan Governor's Office:
R-15. Expand information flow to the Governor so that information providing the foundation for
key decisions comes from more than one trusted source—and is verified.
R-16.Create a culture in state government that is not defensive about concerns and evidence
that contradicts official positions, but rather is receptive and open-minded toward that
information. View informed opinions—even if critical of state government—as an
opportunity for re-assessing state positions, rather than as a threat.
R-17. Ensure that communications from all state agencies are respectful, even in the face of
criticism, and sensitive to the concerns of diverse populations.
R-18.The Governor must assume the leadership of, and hold state departments accountable
for, long-term implementation of the recommendations in this report, including but not
limited to the need for cultural changes across multiple state agencies,the need for
health mitigation and LSL replacement in Flint, and the need for a funding strategy to
address replacement of LSLs statewide.
R-19. Review budget requests for MDEQto ensure adequate funding is provided to the
ODWMA. EPA audit and interviews indicate that Michigan's drinking water program might
have one of the lowest levels of financial support within EPA Region V while having one of
the largest, if not the largest, number of community water systems to regulate.
State-Appointed Emergency Managers:
R-20. Review Michigan's Emergency Manager Law(PA 436) and its implementation, and identify
measures to compensate for the loss of the checks and balances that are provided by
representative government.
R-21.Consider alternatives to the current emergency manager approach—for example, a
structured way to engage locally elected officials on key decisions; an Ombudsman
function in state government to ensure that local concerns are a factor in decisions made
by the emergency manager; and/or a means of appealing emergency manager decisions
to another body.
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R-22. Ensure proper support and expertise for emergency managers to effectively manage the
many governmental functions of a city. Decisions on matters potentially affecting public
health and safety,for example, should be informed by subject matter experts identified
and/or provided by the state.
City of Flint:
R-23. Establish and fund a team of subject matter experts in water system operations
(treatment and distribution system management)to support and train water system
personnel,guide safe system operation under current conditions, and prepare for
successful conversion to KWA.
R-24. Implement a programmatic approach to Flint WTP and distribution system operations,
maintenance, asset management, water quality, capital improvements and public
engagement (including risk communication) to ensure that the disparate ongoing efforts
to address Flint water system infrastructure needs are coordinated,fully documented,
and structured to sustain high-quality potable water service over the long term.
R-25. Implement a robust public engagement and involvement program in conjunction with the
anticipated conversion to KWA-delivered water and provide for regular reporting to the
Flint Water Inter-Agency Coordinating Committee (FWICC).
Genesee County Health Department(GCHD):
R-26. Improve follow-up on public health concerns between GCHD, MDHHS and the City of Flint
now and in the future,to effect timely, comprehensive, and coordinated activity and
ensure the best health outcomes for children and adults affected.
R-27. Presume that the risk of Legionella may remain elevated in the Flint water distribution
system and must take appropriate steps with public and private partners to monitor and
mitigate that risk as concerns about water quality continue in the City of Flint.
R-28.Coordinate with state officials (MDHHS) and with local healthcare professionals and
healthcare institutions in Genesee County and the City of Flint to mitigate the risk of
Legionellosis in 2016 and beyond.
United States Environmental Protection Agency(EPA):
R-29. Exercise more vigor, and act more promptly, in addressing compliance violations that
endanger public health.
R-30. In collaboration with the NDWAC and other interested partners, clarify and strengthen
the LCR through increased specificity and constraints, particularly requirements related to
LCR sampling pools, sample draw protocols, and LSL replacements—and, more generally,
strengthen enforcement protocols with agencies delegated primacy.
R-31. Engage Michigan representatives in ongoing LCR revisions and development of
enforcement protocols at EPA and MDEQ.
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Issues Presented by the Flint Water Crisis
Environmental Injustice:
R-32. Issue an Executive Order mandating guidance and training on Environmental Justice
across all state agencies in Michigan, highlighting the Flint water crisis as an example of
environmental injustice.The state should reinvigorate and update implementation of an
Environmental Justice Plan for the State of Michigan.
Flint Recovery and Remediation:
R-33.Sustainably fund the Flint Water Inter-Agency Coordinating Committee (FWICC)to provide
adequate resources to engage supporting sub-committees for delivery of public health
and water system services.
R-34.Clarify and effectively communicate the roles, work and expected outcomes of the City of
Flint, FWICC and Mission Flint.
R-35.Through collaboration among MDHHS, GCHD, local healthcare professionals, and health
insurance plans, ensure 100 percent clinical and environmental follow-up with Flint
families whose children have been found to have elevated blood lead levels since April
2014, and work together to ensure that follow-up occurs in children's medical homes.
R-36.Offer all children listed in the recommended Flint Toxic Exposure Registry timely access to
age-appropriate screening and clinically indicated follow-up for developmental and
behavioral concerns by licensed healthcare professionals, as well as access to early
childhood education and nutrition services.
R-37.Consider establishing a dedicated subsidiary fund in the Michigan Health Endowment
Fund to facilitate funding of health-related services for Flint.
R-38. Establish a comprehensive Flint public health program, coordinated with county and
state-level public health initiatives,that can serve as a model for population health across
the state. This program should provide assessment, interventions, and support not only
regarding the health effects of water contamination but also more broadly regarding the
health effects of chronic economic hardship and other social determinants of poor health.
State-wide Recommendations:
R-39.Conduct an investigative review of the development and approval of the Karegnondi
Water Authority and of the City of Flint's commitments to KWA water purchases.
R-40. Institute a school and daycare water quality testing program (which could serve as a
model for the U.S.), administered collaboratively by MDEQ and MDHHS,that includes
appropriate sampling and testing for lead contamination for all schools and childcare
centers in the state and effective reporting of test results.
R-41. Develop a model LSL replacement program and funding mechanisms for financing work
on private property.
R-42. Revise and enhance information distributed by public water systems on the implications
of widespread use of lead in public and private plumbing.
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R-43. Use the occasion of the Flint water crisis to prompt local and state re-investment in
critical water infrastructure, while providing mechanisms to advance affordability and
universal access to water services.
R-44. Prioritize health matters across all state agencies with establishment of a new Cabinet-
level post focused on public health.
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Background10
Flint, Michigan
The beleaguered history of Flint, Michigan overt he last several decades is well known,11 yet some
facts are particularly important to provide context for our findings and recommendations.
The City of Flint has suffered dramatic declines in population. From a peak of more than 200,000
in 1960, Flint's population had fallen below 100,000 residents by 2014. Since 2000, Flint has lost
over 20 percent of its population.12 Of the remaining residents, approximately 57 percent are
Black or African American.13
Poverty is endemic in Flint, with 41.6 percent of the population living below federal poverty
thresholds-2.8 times the national poverty rate. The median value of owner-occupied housing is
$36,700, roughly one-fifth of the national average.14 Crime plagues the community; for 2013,
Flint's crime index was 811 as compared to a national average of 295.1s
Even before the Flint water crisis, Genesee County(in which Flint is the largest population center)
exhibited poor health statistics. In a 2015 study,the county ranked 81St out of 82 Michigan
counties in health outcomes. It ranked 78th in length of life, 81St in quality of life, 77th in health
behaviors, 78th in social and economics factors, and 75th in physical environment measures. Only
the quality of clinical care, for which the county ranked 22"d, is not a cause of acute community
concern.16
Water Crisis
The Flint Water System was first organized in 1883 under private ownership, and the City
purchased the water system in 1903. Before 1967, Flint treated Flint River water at its Water
Treatment Plant (WTP). To ensure adequacy and reliability of water supplies, in 1967 Flint signed
a long-term water supply contract with the Detroit Water and Sewerage Department (DWSD).
From 1967 through 2014,the Flint WTP served as an emergency backup to DWSD-supplied
water. As such,the Flint WTP was not operated on an ongoing day-to-day basis, but rather four
times per year to maintain readiness as an emergency backup. The WTP was also upgraded
periodically to keep it ready for use as an emergency backup.
10 The series of events and decisions that led to the Flint water crisis are(now)well documented,thanks to the
tireless efforts of local activists and journalists. In addition,the public record has been supplemented by the release
of e-mails and other documents by the Governor's office and key state agencies.We are indebted to this
construction of a substantial public record.We believe that this public record, in combination with insights obtained
through our interview process, provides more than ample basis for our findings and recommendations.
11 For extensive information on Flint's economic decline and troubled circumstances,see the report and endnotes
provided in"Long-Term Crisis and Systemic Failure:Taking the Fiscal Stress of America's Older Cities Seriously:Case
Study,Flint Michigan,"by Eric Scorsone, Ph.D.and Nicolette Bateson, Michigan State University Extension,
September 2011.
12 BiggestUSCities.com,www.biggestuscities.com/city/flint-michigan
13 U.S.Census,Quickfacts for Flint,Michigan and the United States,
www.census.gov/quickfacts/table/PST045215/00
14 Ibid
15 City-Data.com,www.city-data.com/crime/crime-Flint-Michigan.html
16 County Health Rankings,
www.countyheaIthrankings.org/app/michigan/2015/rankings/genesee/county/outcomes/overall/snapshot
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DWSD provided water to Flint under a 35-year contract signed on December 20, 1965.The initial
contract term expired in 2000 and renewed each year unless it was terminated by either party.
As one of DWSD's wholesale customers, Flint was subject to the terms and rate-setting practices
applicable to all of DWSD's wholesale customer communities. During the final 10 years that Flint
received contractual service from DWSD,the average annual increase in water charges to Flint
was 6.2 percent. DWSD's water supply has been treated for corrosion control for over 20 years
and is deemed optimized for corrosion control treatment.
On April 16, 2013, after a symbolic Flint City Council vote that accompanied the Flint emergency
manager's decision,the City joined the Karegnondi Water Authority (KWA), which had been
established to develop a raw water supply pipeline from Lake Huron. After being advised of the
City of Flint's intent, DWSD notified the City of the termination of its then-current water supply
contract terms, effective April 2014. DWSD and the City of Flint, both under emergency
management, continued unsuccessfully to negotiate alternative water supply terms. Although
the State of Michigan was in control of both cities at the time, efforts to arrive at an agreement
between the parties during the final year of service to the City of Flint ultimately failed.
In April 2014,the City of Flint began treating Flint River water at the Flint WTP on a full-time basis
and distributing the treated water to its customers. A critical element of that treatment—
corrosion control, as required under EPA's Lead and Copper Rule (LCR)—was (incorrectly)
determined by MDEQ not to be required immediately; instead, Flint could complete two 6-month
monitoring periods and MDEQ would then determine whether corrosion control was necessary.
Soon after the City began distributing treated water from the Flint WTP, Flint residents began to
complain about its odor,taste and appearance. Numerous water quality problems and
operational challenges resulted in water quality violations related to E coli contamination and
disinfection by-products (total trihalomethanes or TTHMs). Ultimately,the corrosiveness of the
drinking water leached lead from pipes and plumbing fixtures, and it may have increased the
likelihood of water contamination with Legionella.17
Summary Timeline of Key Fvents
In this economically disadvantaged and ethnically diverse Michigan community, a series of
disastrous decisions and events occurred. Following are the events most critical to development
of our findings and recommendation s:18
1. 1967: City of Flint enters into long-term water supply contract with the Detroit Water and
Sewerage Department (DWSD).
2. 1991: U.S. Environmental Protection Agency (EPA) issues the Lead and Copper Rule to
ensure routine local testing of drinking water and assurance of safe levels of lead and
copper.
3. January 23, 2013: Mike Prysby/MDEQ e-mails colleague Liane Shekter Smith and others
about feasibility of Flint switching to the Flint River, highlighting water quality concerns.
17 Bouffard K.Hospital ties Legionellosis to Flint water.Detroit News,January 23,2016,
www.detroitnews.com/story/news/politics/2016/01/22/legion na i res-bacteria-fou nd-tests-m cla ren-med ical-centers-
water/79183428/.
18 Appendix V provides a further, more detailed timeline that attempts to synthesize numerous timelines developed
by other sources, including local media and government agencies.
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4. March 26, 2013: Stephen Busch/MDEQ e-mails MDEQ Director Dan Wyant with Liane
Shekter Smith and other MDEQ staff copied, with warnings about public health risks
associated with Flint River water.
5. March 28, 2013: State Treasurer Andy Dillon e-mails Governor Snyder notifying him of his
approval of Flint joining Karegnondi Water Authority (KWA) and MDEQ concurrence.
6. April 16, 2013: Flint Emergency Manager(EM) Ed Kurtz signs agreement with KWA and
informs the State Treasurer that the City will join KWA (decision officially announced May
1, 2013).
7. April 17, 2013: DWSD issues letter to Flint notifying termination of contract to provide
water service. Negotiations continue to establish alternative contractual arrangements for
DWSD service to Flint.
8. June 26, 2013: Flint EM Ed Kurtz authorizes a sole-source contract with the firm of
Lockwood, Andrews, & Newnam (LAN) for professional engineering services to place the
Flint Water Treatment Plant (WTP) into operation using the Flint River as a primary
drinking water source.
9. March 26, 2014: Stephen Busch/MDEQ e-mails Liane Shekter Smith and Richard
Benzie/MDEQ on clarifying what Flint will be required to do before beginning full-time
Flint WTP operation.
10. April 16-17, 2014: Michael Glasgow/Flint Utilities Department e-mails MDEQ, noting
unpreparedness of Flint WTP and apparent political pressure to start distributing water.
11. April 29, 2014: Flint EM Darnell Earley notifies Detroit EM that Flint has switched water
supply sources to the Flint River. Genesee County Drain Commission remains as a non-
contract customer of DWSD.
12. July 1, 2014: Flint begins first 6-month monitoring period for lead and copper in drinking
water.
13. August 15, 2014: E. coli bacteria violation in water sampled from the Flint distribution
system leads to local boil water advisory.
14. September 10, 2014: MDEQ requests pre-emptive operational evaluation for disinfection
byproducts called trihalomethanes (THMs).
15. October 1, 2014: MDEQ submits briefing paper to Governor's office re: City of Flint
drinking water situation (boil water notices). Genesee County Health Department (GCHD)
expresses concern to Flint Public Works regarding increased incidence of cases of
Legionellosis since April 2014, and the possible relationship to use of the Flint River as the
water supply. MDHHS epidemiology staff expresses concern but there is no further state-
level evaluation.
16. October 13, 2014: General Motors (GM) announces that it will cease to use Flint WTP-
sourced water for its Flint Engine Operations facility until the KWA connection is
completed, due to corrosion concerns related to the chloride levels in water from the Flint
WTP. MDEQ notes chloride in Flint WTP-treated water is within public health guidelines.
17. October 14, 2014: Valerie Brader, State Deputy Legal Counsel and Senior Policy Advisor, e-
mails Governor's Chief of Staff Dennis Muchmore and other top aides arguing for a return
to DWSD because of water quality problems. Michael Gadola,then the Governor's Legal
Counsel, responds by agreeing with Brader. Brader and Rich Baird, another senior aide to
17
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the Governor,then discuss the idea with Emergency Manager Darnell Earley, who
maintains the water quality problems can be solved and it would be cost-prohibitive to
return to DWSD.
18. December 16, 2014: MDEQ notifies Flint of initial quarterly violation of SDWA Disinfection
Byproducts (total trihalomethane, or TTHM) requirements.
19. December 31, 2014: First 6-month round of LCR monitoring ends. Using 100 samples not
necessarily drawn from highest risk homes (as the LCR intends),the 90th percentile lead
level result is 6 parts per billion with 2 samples above action levels for lead (15 parts per
billion). Given the 6 ppb result, Flint is disqualified from being exempted and will have to
implement corrosion control treatment under the LCR, irrespective of subsequent 6-
month monitoring results. MDEQfails to properly advise Flint WTP of this regulation.
20. January 12, 2015: In response to water quality concerns,the state installs water coolers in
state offices in Flint, and state employees are given the option in their offices to use
bottled water and provide bottled water to visitors.
21. January 27, 2015: MDHHS epidemiology staff member contacts Genesee County Health
Department (GCHD)to recommend that they construct a map of Legionellosis cases and
correlate them to the City's water service area.
22. January 2015 (date unclear): Staff from Genesee County hospitals, MDHHS, MDEQ and
GCHD meet, and MDHHS Director Nick Lyon directs GCHD to conduct and complete its
evaluation of the causes of the increased Legionellosis cases that had begun to occur in
2014.
23. January 27, 2015: FOIA request sent by GCHD environmental hygienist James Henry to
Flint DPW and Flint Mayor for information on water treatment to support the county's
investigation of Legionellosis cases.
24. January 30, 2015: Brad Wurfel/MDEQ e-mails Dave Murray, Governor Snyder's deputy
press secretary, re: Legionella, saying said he didn't want MDEQ Director Wyant "to say
publicly that the water in Flint is safe until we get the results of some county health
department traceback work on 42 cases of Legionellosis in Genesee County since last
May."
25. February 25, 2015: LeeAnne Walters contacts EPA Region V regarding high levels of lead
(104 ppb) found in drinking water at her home.
26. February 26, 2015: Initial EPA-MDEQ correspondence regarding elevated lead in sample
collected from LeeAnne Walters's house. Jennifer Crooks/EPA speculates Flint River water
chemistry is leaching contaminants from pipes;this prompts the EPA's initial query of
MDEQ about whether optimized corrosion control treatment (OCCT) is in place at the Flint
WTP.
27. February 26, 2015: Mike Prysby/MDEQ emails Jennifer Crooks/EPA indicating that all
other samples in the monitoring period for July 1, 2014 through December 31, 2014 are
below the EPA action level of 15 ppb.
28. February 27, 2015: Miguel Del Toral/EPA, in e-mails to MDEQ and EPA staff, mentions
possibility of biasing lead results low by collecting samples after flushing water through
the taps; asks again about Flint OCCT, saying "they are required to have OCCT in place."
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29. February 27, 2015: Stephen Busch/MDEQ e-mails Jennifer Crooks and Miguel Del
Toral/EPA saying that the 90th percentile is 6 ppb for the monitoring period July 1-
December 31, 2014 and that Flint has an optimized corrosion control program, and talks
about EPA regulations requiring targeted sample pool to focus on highest risk homes.
30. March 3, 2015: In response to local complaints regarding drinking water quality and
related health effects, Flint EM Ambrose cites$12 million in costs associated with
returning to DWSD.
31. March 12, 2015: Stephen Busch/MDEQ e-mails colleagues stating that there is no
confirmation of Legionella in the water supply. No test data are provided to substantiate
this statement.
32. March 13, 2015: Brad Wurfel/MDEQ e-mails Harvey Hollins/Governor's office and Dan
Wyant/MDEQ noting uptick in Legionellosis cases, placing responsibility for follow-up on
GCHD, and discounting GCHD environmental hygienist Jim Henry's concerns about a
possible relationship between uptick in Legionellosis and change in water source.
33. March 13, 2015: Stephen Busch/MDEQ e-mails Jim Henry/GCHD stating there is unlikely
to be Legionella at the Flint WTP, but that water main breaks and leaks may permit entry
of Legionella into the water supply. Busch advises contacting MDHHS, but does not
himself contact MDHHS.
34. March 30, 2015: MDEQ notifies Flint of results of first 6-month lead and copper
monitoring period (July-December 2014) showing 6 ppb result.
35. March 31, 2015: Jennifer Crooks/EPA corresponds with MDEQ regarding a conference call
that focused on increased cases of Legionellosis.
36. April 25, 2015: Miguel del Toral/EPA e-mails Pat Cook/MDEQ, questions how a large water
system can be deemed to have optimal corrosion control without treatment, cites federal
regulations that provide the only two scenarios for large systems to be deemed to have
optimized corrosion control, and shows that Flint does not meet either of the two
scenarios.
37. April 27, 2015: Miguel Del Toral/EPA e-mails Tom Poy/EPA and other colleagues stating
that Pat Cook/MDEQ has confirmed the Flint WTP has no corrosion control treatment
(CCT), which is "very concerning given the likelihood of lead service lines in the city."
38. April 27, 2015: Laurel Garrison/CDC e-mails GCHD stating that the Legionellosis outbreak
in Genesee County is "very large, one of the largest in the past decade."
39. April 27, 2015: Miguel Del Toral/EPA visits LeeAnne Walters's house to inspect plumbing
and deliver sampling bottles.
40. April 27, 2015: Pat Cook and Stephen Busch/MDEQ exchange e-mails complaining about
Del Toral/EPA's questions on corrosion control treatment.
41. May 29, 2015: MDHHS's Surveillance of Infectious Diseases and Epidemiology team
produces a report regarding Legionellosis cases in Genesee County in 2014-2015;the
conclusion of the report is that "the outbreak is over.i19
19 Of the Legionellosis cases in 2014-2015,42 percent had healthcare(hospital)contact;47 percent had contact
with the Flint water supply.The report indicates that the lack of clinical specimens from patients prohibited
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42. June 24, 2015: Miguel Del Toral (EPA) provides Tom Poy/EPA his "Interim Report: High
Lead Levels in Flint, Michigan," summarizing information and concerns about lead levels in
drinking water in Flint.
43. June 10, 2015: EPA/MDEQ conference call includes discussion of the fact that Flint does
not have CCT in place.
44. June 25, 2015: Adam Rosenthal/MDEQ e-mails Mike Glasgow and Brent Wright/Flint
Utilities Department (copying Mike Prysby and Stephen Busch/MDEQ) reminding them
that 61 more lead and copper samples need to be collected and sent to the lab by June
30, 2015, "and that they are will be [sic] below the AL [action level] for lead. As of now
with 39 results, Flint's 90th percentile is over the AL for lead."
45. July 7, 2015: MDEQ is contacted by the American Civil Liberties Union regarding a draft
letter from Miguel Del Toral/EPA to LeeAnne Walters that raises concerns about possible
leaching of lead from service lines without appropriate corrosion control.
46. July 10, 2015: Susan Hedman/EPA Region 5 (based in Chicago) writes to Flint Mayor
Walling to say that EPA will work with MDEQ on issues related to lead in water.
47. July 22, 2015: Governor Snyder's chief of staff Dennis Muchmore e-mails director of
MDHHS expressing that many members of the Flint community are raising concerns about
water but feel they are not being heard.
48. July 23, 2015: Linda Dykema/MDHHS e-mails Deputy Director of Population Health and
Community Services Susan Moran and others at MDHHS (though not Director Lyon)
stating that she has corresponded with MDEQ and that there has been no change in
compliance regarding Flint water quality and appropriate state and federal law, and that
Miguel Del Toral/EPA "acted outside of his authority" (these are MDEQtalking points).
49. July 24, 2015: In response to Muchmore e-mail, Brad Wurfel/MDEQ writes, "The bottom
line is that the residents of Flint do not need to worry about lead in the water supply, and
MDEQ recent sampling does not indicate eminent [sic] health threat from lead."
Muchmore responds, "Thanks."
50. July 28, 2015: MDHHS epidemiologist Cristin Larder finds that children's blood lead tests
conducted in summer 2014 "lie outside the control limit" compared with prior years and
that this finding "does warrant further investigation." On the same day, CLPPP data
manager Robert Scott analyzes the data over a 5-year period and concludes that "water
was not a major factor." Later that day, CLPPP manager Nancy Peeler concludes that the
lack of persistently elevated blood lead levels in children in Flint beyond the summer
months indicates no connection to the change in water in Flint in 2014. Larder then
receives email communication from Peeler: Peeler has concluded from CLPPP data and
communicated with MDHHS leadership that there is no problem with children's lead
levels in Flint.
51. August 27, 2015: Virginia Tech professor Marc Edwards releases his first set of findings
regarding tests of water in Flint. Over half of 48 samples have lead levels of more than 5
parts per billion (ppb) and 30 percent of samples have lead levels greater than 15 ppb.
testing that could have made a definitive link to the water supply as a source of Legionella. It indicates that there
should be vigilance in 2015 regarding possible new cases of Legionellosis,including collection of clinical
specimens.
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52. August 31, 2015: EPA/MDEQ conference call: second 6-month monitioring test results for
January 1-July 31, 2015 indicate 901h percentile at 11 ppb. It is determined that CCT is
needed and implementation steps are delineated.
53. August 31, 2015: Brad Wurfel/MDEQ raises concerns about Professor Edwards's tests and
accompanying media coverage to MDEQ, Muchmore, Harvey Hollins, Dave Murray and
Sara Wurfel of Governor's office. There is no apparent communication with MDHHS
regarding this issue.
54. September 8, 2015: Virginia Tech posts to FlintWaterStudy.org sample testing results on
252 samples of 300 sample kits provided. The Virginia Tech researchers concluded that:
"mathematically, even if the remaining 48 samples returned have non-detectable lead...
FLINT HAS A VERY SERIOUS LEAD IN WATER PROBLEM." Of the 252 water samples, 101
have lead in excess of 5 ppb. Flint's 90th percentile in Edwards' survey was 25 ppb.
Several samples were over 100 ppb and one of the samples as over 1,000 ppb.
55. September 9-12, 2015: MDHHS begins to develop educational program materials for the
public regarding reducing the risk of lead exposure for children, in response to media
coverage of Professor Edwards's water testing results.
56. September 22, 2015: Dr. Mona Hanna-Attisha, director of the pediatric residency program
at Hurley Medical Center, contacts Robert Scott/MDHHS to request access to the state's
childhood lead testing records.This is a similar request to one filed by Professor Edwards
several weeks before,to which the state had yet to respond. No data are shared.
57. September 23, 2015: Nancy Peeler/MDHHS, director of the state's Childhood Lead
Poisoning Prevention Program (CLPPP), e-mails Robert Scott/MDHHS to consider re-
running the analysis that had been conducted in July, and asks for formal epidemiologic
help. Later that day, Mikelle Robinson/MDHHS writes to colleagues that the Governor's
office briefing maintains that Flint water does not represent an "imminent public health
problem."
58. September 24, 2015: Dr. Hanna-Attisha presents her findings about children tested for
lead in a press conference at Hurley Medical Center, reporting that the proportion of
children with elevated blood lead levels has increased since the switch to the Flint River
water source in April 2014. MDHHS issues comments emphasizing differences between
the Hurley analysis and preceding internal analyses by MDHHS that were not shared
publicly. That same day, Robert Scott/MDHHS writes in an internal memo that he sees
patterns in blood lead levels similar to what Dr. Hanna-Attisha has reported.
59. September 28, 2015: MDHHS Director Nick Lyon calls for analysis of the blood lead levels
in order to "make a strong statement with a demonstration of proof that the blood lead
levels seen are not out of the ordinary." No such analysis is ever provided. Later that day,
Governor Snyder is briefed by staff that the Flint water system is in compliance.
60. September 29, 2015:The Detroit Free Press publishes an analysis of Flint blood lead tests,
concluding that Dr. Hanna-Attisha's analysis is correct. GCHD issues a health advisory
regarding the water quality. Governor Snyder's office contacts Director Wyant and
Director Lyon to consider emergency responses.
61. October 1, 2015: MDHHS issues a statement confirming Dr. Hanna-Attisha's analysis.
62. October 16, 2015: Flint switches back to DWSD as source of drinking water for the city.
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Regulatory Context
The federal Safe Drinking Water Act20(SWDA) was enacted in 1974 and governs regulation of
drinking water throughout the United States. It has been amended multiple times since its
enactment, most recently in 2015. From the United States Environment Protection Agency (EPA)
website:
'The Act authorizes EPA to establish minimum standards to protect tap water
and requires all owners or operators of public water systems to comply with
these primary(health-related)standards. The 1996 amendments to SDWA
require that EPA consider a detailed risk and cost assessment, and best available
peer-reviewed science, when developing these standards. State governments,
which can be approved to implement these rules for EPA, also encourage
attainment of secondary standards(nuisance-related).i21
Michigan enacted the state Safe Drinking Water Act (PA 399) in 1976. It establishes state
authority for regulating drinking water supplies in Michigan. It also provides the statutory basis
for the EPA's delegation to the Michigan Department of Environmental Quality (MDEQ)to
implement the federal SWDA, including the Lead and Copper Rule (LCR).
Lead and Copper Rule
The Lead and Copper Rule (LCR), promulgated in 1991,22 falls under the SDWA. Short-term
revisions, prompted following the incidence of elevated lead levels in the District of Columbia's
water distribution system, were published in the Federal Register in 2007.23 From the guidance to
the states on the rule:
The goal of the LCR is to provide maximum human health protection by reducing
lead and copper levels at consumers'taps to as close to the[Maximum
Contaminant Level Goals]MCLGs as is feasible. To accomplish this goal, the LCR
establishes requirements for community water systems(CWSs) and non-transient
non-community water systems(NTNCWSs) to optimize corrosion control and
conduct periodic monitoring. Systems are required to perform public education
when there are lead action level exceedances at more than 10 percent of the taps
that are sampled, treat source water if it contributes significantly to lead and
copper levels at the tap, and replace lead service lines in the distribution system if
the lead level at the tap continues to exceed the action level after optimal
corrosion control and/or source water treatment has been installed.24
The MCLG for lead in water is 0 milligrams per liter(mg/L);the action level requiring public
notification of exceedance is 0.15 mg/L(also expressed as 15 parts per billion).
Large water systems, defined as those serving over 50,000 people, were required to have optimal
corrosion control treatment (OCCT) by 1997. The rule requires large water systems that have met
20 42 U.S.C.§300f et seq., 1974
21 www.epa.gov/laws-regulations/summary-safe-drinking-water-act
22 56 FR 26460,June 7,1991
23 72 FR 57782,October 2007
24 LCR Short-Term Revisions State Implementation Guidance-Final June 2008
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the OCCT requirements through the installation of corrosion control treatment to continue to
operate and maintain that treatment.25
Currently, EPA is in the process of reviewing and revising the LCR through its established
rulemaking procedures.
Public Health Context
Flint is now confronted by public health challenges: mitigating the effects of toxic lead exposure
and ensuring an appropriate case-tracking and containment response to the outbreak of
Legionellosis in Flint. Several attributes of these public health challenges are particularly
noteworthy and informed our findings and recommendations:
Lead Exposure
Lead is a potent neurotoxin. For any given exposure, lead has more profound health effects in
children because the exposure is distributed throughout the body's volume. Children's smaller
body volumes convey larger risks from lead exposure;these effects are concentrated in brain
cells.
One of the most concerning aspects of lead exposure is that once it has been deposited in the
nervous system, lead cannot be removed.The impact of lead poisoning on neurological
development is permanent. Recent research has indicated that, with each 1 microgram per
deciliter increase in blood lead level, children demonstrate decreasing performance on
intelligence tests.26
Given the neurotoxicity of lead,for many decades medicine and public health experts have
focused on how to reduce lead exposure, particularly for children. Known historical sources of
lead include lead in paint, lead in gasoline, and lead in water sources.27 Major federal laws have
addressed these sources by prohibiting lead in paint, prohibiting lead in gasoline, and requiring
corrosion control and testing of public drinking water sources to identify lead contamination in
water(via the LCR, above).
In Michigan, prior to the Flint water crisis,trends in lead test results for children had told a story
of public health progress. As recently as the late 1990s, almost 50 percent of young children (ages
1 to 2) in Michigan had blood lead levels of 5 micrograms per deciliter or above. By 2013, fewer
than 5 percent of young children in Michigan had levels of 5 micrograms per deciliter or above.28
This downward trend mirrors similar improvements in communities across the United States.
25 40 CFR 141.82 (g)Continued operation and monitoring. All systems optimizing corrosion control shall continue to
operate and maintain optimal corrosion control treatment, including maintaining water quality parameters at or
above minimum values or within ranges designated by the State under paragraph (f)of this section, in accordance
with this paragraph for all samples collected under§141.87(d)through (f).
26 Citations offered in "Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis:A
Spatial Analysis of Risk and Public Health Response," by Mona Hanna-Attisha, MD, MPH;Jenny LaChance,MS;
Richard Casey Sadler,PhD;and Allison Champney Schnepp,MD,American Journal of Public Health, November 2015.
27 For a discussion of the prevalent use of lead in the United States and the lead industry's conduct in light of the
determination of its toxicity,see Lead Wars:The Politics of Science and the Fate of America's Children (2013), by
Gerald Markowitz and David Rosner,who are interviewed on National Public Radio's Fresh Air in a March 3,2016
episode titled, "America's'Lead Wars'Go Beyond Flint,Mich.:'It's Now Really Everywhere."'
28 Known as the"reference level"as stated by the federal Centers for Disease Control and Prevention.
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These improvements have largely been attributed to reductions in lead paint in households
rather than reductions in lead exposure through drinking water.
In Michigan, routine blood lead level checks are recommended for children 1 to 2 years old who
live in communities that are known to have historically high proportions of children with levels at
the reference level or higher, and for all children with Medicaid health coverage. For the past
decade, Flint has been one of 14 Michigan communities that have been identified by MDHHS as
"focus communities" because of historically high levels of children with elevated blood lead
levels. Local and state health agencies are responsible, in coordination with children's healthcare
providers (physicians, nurse practitioners, etc.),for following up on elevated blood lead levels.
Appropriate follow-up includes:
o Providing advice to families regarding increasing the nutritional quality of the child's diet
to increase the amount of foods with high levels of iron, calcium, and vitamin C;
o Rechecking blood lead levels within 3 to 6 months to see whether the level has decreased
below 5 micrograms per deciliter, and continuing interventions and re-testing at this
interval to assure progress; and
o Performing in-home assessments for environmental sources of lead (for example, lead
paint, lead in dust) for children with blood lead levels of 10 micrograms per deciliter or
more.29
Of note, before the Flint water crisis, in-home assessments did not routinely include testing of
drinking water as a potential source of lead exposure.
Legionella
Infections caused by Legionella bacteria can cause relatively mild illness in generally healthy
adults but can cause life-threatening illness and even death in elderly and immune-compromised
patients. Such infections almost never occur in children. Legionellosis,the name given to
infections caused by Legionella bacteria, has been recognized since the 1970s as often occurring
in environments with self-contained air supply systems (such as healthcare facilities) during non-
winter months when cooling towers for air conditioning can serve as breeding grounds for the
bacteria. Historically, Legionellosis is fatal in approximately 10 percent of cases.
Legionellosis is a reportable disease, meaning that infections with Legionella must be reported to
local and state public health authorities. Public health specialists known as epidemiologists
conduct analyses of cases, especially when the pattern of cases exceeds historical levels in a given
jurisdiction.
Prior to the switch to the Flint River as a source of drinking water in 2014,the number of cases of
Legionellosis in Genesee County had not exceeded 10 cases per year for several years. From June
2014 to March 2015,there were 45 cases of Legionellosis in Genesee County, with 5 deaths. This
was described by an expert from the CDC in 2015 as "one of the largest [outbreaks of
Legionellosis] in the past decade."About 40 percent of the cases had known exposure to possible
29 Prior to the Flint water crisis,environmental assessments were not performed for children with blood lead levels
of 5 to 9 micrograms per deciliter, but only for children with blood lead levels of 10 micrograms per deciliter or
higher.
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healthcare sources of Legionella; almost 50 percent of cases had known exposure to Flint River-
sourced water supply.30
According to the MDHHS report issued on May 29, 2015, it was not possible for the state
epidemiologists to draw definitive conclusions that the change in water supply was related to the
outbreak of disease, given the lack of clinical specimens of Legionella from patients diagnosed
with the disease in 2014-15. It is speculated that clinical respiratory specimens (sputum) were not
available because antibiotic treatment was started presumptively after a positive urine test for
Legionella, rendering any subsequent specimens indeterminate. Although urine specimens can
confirm a diagnosis of Legionellosis, urine specimens cannot be used for determining the source
of Legionella.
Subsequent data reported publicly by MDHHS on January 21, 2016, indicated that there were 42
additional cases of Legionellosis from May 2015 through October 2015, with 4 death S.31 Taking
the 2014-15 data together with additional 2015 data, MDHHS reported that 36 percent of cases
likely were exposed to Flint River-sourced drinking water, and that again there were too few
clinical specimens to draw definitive conclusions about contaminated water as the source of
infection in these cases.
At the time of this report,the pattern of an abrupt increase in cases of Legionellosis in Genesee
County in 2014-15 that occurred after a shift to the Flint River strongly implicates the water
source and treatment of the water as a potential cause of higher Legionellosis case incidence.
EPA experts Del Toral and Lytle have suggested that the treated water from Flint WTP has
disrupted the previously stable lining and "biofilm" of water lines to such an extent that chlorine
in the water supply has been excessively depleted. Del Toral also suggested that the flushing of
fire hydrants may have stripped the biofilm and released bacteria (Legionella)that the biofilm
had contained. If true,this may have led to a situation where Legionella may grow more
abundantly than in a distribution system conveying properly treated drinking water.
Unfortunately,these are hypotheses. Definitive data for the analysis of cases in 2014 and 2015
are not available, so it is not possible to be conclusive about the cause. Nonetheless,great
concern should remain about the clustering of cases among patients potentially exposed in
healthcare facilities in the City of Flint and cases among individuals whose homes receive water
from the Flint WTP.
MDHHS and GCHD have indicated that they will have a high level of vigilance in monitoring for
cases of Legionellosis in 2016.They have reminded healthcare professionals treating patients in
Genesee County to obtain appropriate clinical (respiratory) specimens in suspected cases of
Legionellosis before initiating treatment.This cooperation between public health and medical
professionals will be crucial to identifying the cause of future Legionellosis cases in Genesee
County and controlling outbreaks in the future. In addition, a team of scientists from multiple
30 Some of these cases had exposure to both Flint River water and to healthcare facilities.
31 Twenty-two of the 42 cases reported from May-October 2015 had known healthcare-related exposures in the two
weeks prior to development of symptoms,and 21 of these were from the same healthcare facility.Sixteen of the 42
cases of Legionellosis in Genesee County from May-October 2015 were in individuals who had neither exposure to a
healthcare facility nor exposure to Flint River-sourced water.
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Michigan universities is expected to test Flint drinking water in 2016 to assess whether conditions
in the system created an environment that heightened the likelihood of Legionella
contamination.
Roles of Government Entities in the Flint Water Crisis
Many individuals, agencies and groups participated in the events leading to the Flint water crisis
and the subsequent response. Their various roles and responsibilities have been subjects of
considerable discussion and debate. In the subsequent sections, we describe the defined (or
statutory) roles of many of these parties, as well as the nature of their involvement in the Flint
water crisis. Findings and recommendations are also provided.
The water crisis in Flint is effectively elevating public awareness of the latent dangers associated
with lead in water systems, which regulators and many water utilities historically have been
reluctant to address beyond the addition of corrosion control treatment. As it responds to the
acute crisis in Flint,the State of Michigan is in a position to set important precedents that may
have application well beyond the state, as more utilities and regulatory agencies prepare for
more aggressive approaches to address the problem of lead in water. This opportunity is noted in
several of the recommendations provided below.
Michigan Department of Environmental Quality (MDEQ)
Defined Role
MDEQ is responsible for enforcement of the SDWA (including the Lead and Copper Rule (LCR)),
the Clean Water Act (CWA) and other environmental regulations in the State of Michigan. With
respect to drinking water, MDEQ's stated goal is that "Michigan's water resources are clean and
safe" and a measure of success towards that goal is that "100 percent of the population has safe
drinking water with no reported violations of health based standard S.,,32 The agency's
responsibility for SDWA compliance enforcement derives from it, like all other states except
Wyoming, being delegated "primacy" by the EPA.
Within the MDEQ,the Office of Drinking Water and Municipal Assistance (ODWMA) has
responsibility for SDWA enforcement and lending assistance to public water suppliers.The
ODWMA Community Water Supply Program's "primary function is regulatory oversight of
approximately 1,425 community public water supplies in Michigan.03 The Community Water
Supply Program provides capacity development and operator training and certification, operates
certified laboratories, and monitors and reports on public water system violations. ODWMA staff
who regulate compliance with the SDWA are not required to be licensed operators or have
experience with drinking water treatment plant or distribution system operations.
For many communities, ODWMA has been and continues to be relied upon to provide technical
assistance and guidance on water treatment processes, approaches to managing distribution
32 "Sustaining Michigan's Water Heritage:A Strategy for the Next Generation, Draft for Public Review,"June 4,2015.
Prepared by the Michigan Office of the Great Lakes,in collaboration with Michigan Department of Environmental
Quality, Michigan Department of Natural Resources, Michigan Department of Agriculture and Rural Development,
and Michigan Economic Development Corporation, p.6.
33 www.michigan.gov/deg/0,1607,7-135-3313_3675_3691---,00.html
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system water quality, and overall utility management. ODWMA historically has taken a
collaborative approach with public water suppliers, offering guidance on technical requirements
for compliance with environmental regulations.
Discussion
MDEQ is responsible for ensuring that community water systems comply with the SDWA.
According to EPA Region V, ODWMA, which was originally within the state Department of
Community Health, has more community water systems to regulate than other Region V states.
Additionally, while all states' water system regulators in Region V are stretched financially,
Michigan is particularly challenged because fees to operate the program are generally lower than
fees charged by other states, requiring the state to rely more heavily on general funds and
federal revenue.
For a variety of reasons, MDEQ discounted use of the Flint River as a permanent water source in
2013. However, it did agree to use of the river as a temporary source, conditioned upon
completion of identified improvements to the Flint Water Treatment Plant (WTP). Flint was
granted two permit modifications in April 2014 that allowed the treatment plant to operate full-
time with the Flint River as the water source.
In advance of the City of Flint's conversion from DWSD water supply to use of Flint River water,
MDEQ had multiple communications and meetings with Flint Utilities Department staff and their
consultants. A plan of treatment of Flint River water was discussed and covered numerous issues
including dosing of chemicals, use of polymers, and unit process performance. When asked by
Flint water plant personnel about adding phosphate in the treatment process, as DWSD does for
corrosion control, MDEQ said that a corrosion control treatment decision would be made after
two 6-month monitoring periods were conducted to see if corrosion control treatment was
needed. Similarly, distribution system operations requirements were outlined, including sampling
and testing for compliance with the LCR that involved obtaining tap water samples from high-risk
residences. ODWMA anticipated that use of Flint River water would be problematic34 but
deferred to state emergency manager decisions to proceed.35 Subsequently:
o MDEQ advised Flint WTP staff, in contradiction to longstanding federal policy under the
LCR,that corrosion control treatment was not required.
o MDEQ did not require appropriate sampling of tap water quality as mandated by the LCR.
o MDEQ obstinately used water quality test results based on flawed sampling and insisted
on the accuracy of the erroneous data.
o MDEQ dismissed expressed concerns of Flint residents, elected officials, and external
subject matter experts (as well as EPA).
34 Internal March 26,2013 MDEQ e-mail(Busch to Wyant,Shekter Smith,and others) noting,among other points:
"Continuous use of the Flint River at such demand rates would:Pose an increased microbial risk to public health
(Flint River vs. Lake Huron source water), Pose an increased risk of disinfection by-product(carcinogen)exposure to
public health(Flint River vs. Lake Huron source water),Trigger additional regulatory requirements under the
Michigan Safe Drinking Water Act."
35InternalMarch 27,2013 MDEQ e-mail (Sygo to Busch) noting,among other points: "As you might guess we are in a
situation with Emergency Financial Managers so it's entirely possible that they will be making decisions relative to
cost.The concern in either situation is that a compliant supply of source water and drinking water can be supplied."
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o MDEQ inaccurately reported information about Flint's corrosion control to EPA, stating
that Flint had an optimized corrosion control program when, in fact, it was not employing
corrosion control treatment.
o MDEQ deferred requiring Flint to implement CCT until after the second 6-month
monitoring period was completed and showed lead levels of 11 ppb,though EPA advised
MDEQto require Flint to have CCT as early as April 2015.
o MDEQ waited on legal opinions about SDWA compliance requirements and delayed
admission of its incorrect interpretation of SDWA compliance requirements for(at least) 2
months.
o MDEQ insisted, even after compelling evidence of lead poisoning of children was
presented,that Flint water quality met applicable SDWA standards.
o MDEQfailed (for more than a year)to work with MDHHS leadership and staff to ensure
an appropriate and comprehensive public health response to repeated requests to
address health concerns related to drinking water. MDEQ continued to insist the water
was safe and met all federal requirements, and discouraged any statements that would
imply that the water was not safe.
The obvious question that MDEQ along with the City and its consultants, should have asked was:
"What will happen without corrosion control treatment?" Similarly,they could have asked why a
less corrosive source of water(Lake Huron water) would be required to have corrosion control
treatment, but not the more corrosive Flint River source. In Flint,the more corrosive water
source ultimately destroyed the protective scaling on pipes and plumbing that orthophosphate
addition had provided through the water supplied by DWSD.
Findings
The FWATF, as stated in our second letter to Governor Snyder,36 places primary responsibility for
the Flint water crisis on the MDEQ, and specifically its ODWMA.This finding is based on
numerous interviews and reviews of publicly available documents. Nothing in our subsequent
interviews or our review of thousands of pages of related documents has dissuaded us from this
fundamental conclusion. We found that:
F-1. MDEQ bears primary responsibility for the water contamination in Flint.
F-2. MDEQ specifically its ODWMA, suffers from cultural shortcomings that prevent it from
adequately serving and protecting the public health of Michigan residents.
F-3. MDEQ misinterpreted the LCR and misapplied its requirements. As a result, lead-in-water
levels were under-reported and many residents' exposure to high lead levels was
prolonged for months. Specifically:
o MDEQ's misinterpretation of the LCR and lack of due caution resulted in the
decision not to require corrosion control upon the switch to the Flint River but,
rather,to begin two consecutive 6-month water quality monitoring periods.
o MDEQfailed to promptly require corrosion control even after the initial 6-month
monitoring period results were received and 90th percentile lead sampling results
were at 6 ppb, which would have disqualified Flint from being exempted from
36 See Appendix II for copies of the FWATF's letters to Governor Rick Snyder.
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having to have corrosion control treatment—even under MDEQ's flawed
interpretation.
o MDEQ's guidance to Flint on LCR compliance sampling techniques (calling for pre-
flushing, use of small-mouthed bottles, etc.), while possibly technically
permissible, was not designed to detect risks to public health. MDEQ failed to take
adequate steps to correct Flint water operations staff's inaccurate LCR sampling.
o MDEQ ODWMA advised Flint Utilities Department personnel to make sure the rest
of the water samples in the second 6-month monitoring period were clean, since
the samples they had already submitted exceeded EPA's action level for lead.
o MDEQ conveniently, and without adequate investigation, excluded LeeAnne
Walters's water quality test results for purposes of determining whether Flint
sampling results exceeded EPA's action level.
F-4. MDEQ waited months before accepting EPA's offer to engage its lead (Pb) experts to help
address the Flint water situation and, at times, MDEQ staff were dismissive and
unresponsive.
F-5. MDEQ failed to move swiftly to investigate, either on its own or in tandem with MDHHS,
the possibility that the Flint water system was contributing to an unusually high number
of Legionellosis cases in Flint.
MDEQ caused this crisis to happen. Moreover, when confronted with evidence of its failures,
MDEQ responded publicly through formal communications with a degree of intransigence and
belligerence that has no place in government. These failures are not diminished, nor should focus
on them be deflected, by the fact that other parties contributed to the disastrous decisions or the
prolonging of their consequences.
Recommendations
R-1. Implement a proactive, comprehensive cultural change program within MDEQ specifically
its ODWMA,to refocus the department on its primary mission to protect human health
and the environment. MDEQ should aspire to become a national leader through a
proactive program designed to detect and address contaminants in public water supplies
in a timely manner.37
o ODWMA should heighten its focus on protection of public health and provide
technical assistance to advance public water system performance.
o Technical assistance should not be oriented toward defining minimum requirements
to achieve technical compliance with regulatory requirements.
o In the event that regulatory requirements are ambiguous, ODWMA should default to
public health protection.
37 For example, in the case of lead detection,ODWMA's program should have adopted water quality sampling
procedures that maximized the potential for detection by identifying high-risk homes,prohibiting pre-flushing of
service lines,and improving sample draw procedures.
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o MDEQ's program restructuring should address the findings of this and other program
and incident reviews, and commit to transparent, accessible reporting on
implementation of associated recommendations.
R-2. Establish an apprenticeship/certification program for MDEQ ODWMA employees that
requires direct, hands-on experience with public water system operations. MDEQ
ODWMA employees responsible for water system regulation and SDWA enforcement
should be, or have access to, certified operators and subject matter experts (including, for
example,those at EPA).
R-3. Strengthen SDWA enforcement, most notably for the LCR. The state has the ability to
strengthen its own enforcement of the SDWA and not wait for action to occur at the
federal level:
o Reiterate (and clarify where necessary) appropriate sampling procedures, and
establish them in rule revisions or guidelines such that they are clear for all to
understand. Provide resources for public water systems to obtain authoritative
guidance in the event of questions or concerns.
o Make water sample test results required under the Lead and Copper Rule available to
the public while protecting personally identifiable information.
R-4. Participate in the Flint Water Inter-Agency Coordinating Committee's (FWICC's) work
team established to oversee conversion from DWSD-supplied to KWA-delivered water.
MDEQ should draw from that work to revise its policies and procedures for approval of
water treatment and distribution system operating regimens, particularly when source
water changes are contemplated.
R-5. Participate in EPA's ongoing review and revision of the LCR, conveying lessons learned
from the Flint water crisis.38
Michigais oeparu-nent of Health and Human Services (MDHHS)
Definer!Role
The Michigan Department of Health and Human Services (MDHHS)39 is responsible for addressing
all matters of public health for the population of the state. MDHHS works to achieve this goal
through a combination of primary prevention—preventing illnesses before they occur 40—and
secondary prevention—reducing the burden of disease once it has occurred.41
Meeting the responsibilities of MDHHS requires constant attention through surveillance
programs and effective communication and coordination with public health partners at multiple
levels of government (city, county, federal). MDHHS conducts surveillance for dozens of diseases
38 Also applicable for recommendations related to the LCR offered in the report section on the EPA and LCR.
39 Created from the combination of the Department of Community Health and Department of Human Services in
2015.
40 For example, promoting and facilitating childhood vaccination against diseases such as measles and influenza.
41 For example,conducting screening programs to identify individuals who have developed cancer so that they can
receive appropriate medical care.
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and health conditions through a wide variety of efforts. For instance, MDHHS is recognized for a
high-quality system of tracking childhood vaccination through the Michigan Care Improvement
Registry (MCIR). MCIR allows state officials to assess children's vaccination levels on a regular
(weekly) basis, and to identify neighborhoods and schools where vaccination levels may be so low
that outbreaks of vaccine-preventable diseases are possible. As a result, MDHHS can then
communicate with healthcare professionals who administer vaccines, and with parents of
children who are not up-to-date on their vaccinations,to encourage them to protect their
children against disease.
MCIR is a very positive example of the public health function of MDHHS. In the case of Flint,
however, MDHHS's response to two public health concerns, related to lead exposure and cases of
Legionella infection, did not meet the agency's own standard of performance.
Discussion
Children's Exposure to Lead in Drinking Water
MDHHS includes the Childhood Lead Poisoning Prevention Program (CLPPP), which is responsible
for tracking the results of all children's blood lead tests, and the Healthy Homes program, which
is responsible for coordinating remediation of homes when high levels of environmental lead
exposure are found for a child with an elevated blood lead level. All blood lead tests conducted in
the state must be reported to CLPPP, under state law. For many years, CLPPP has functioned as a
registry of blood lead tests, comparing aggregate results at the state level in the most recent year
to levels in prior years—typically in annual reports released in the summer following the end of a
given calendar year.The primary outcomes reported have been the proportions of children with
blood lead levels>_10 micrograms per deciliter and proportions with blood lead levels>_5
micrograms per deciliter. For more than a decade, CLPPP has also specifically tracked local lead
testing results in 14 "focus communities" known to have higher proportions of children with
elevated blood lead levels than in other communities in Michigan. Flint is one such focus
community.
The CLPPP operated under the assumption that children with elevated blood lead levels were
being managed by their respective healthcare professionals.Therefore, no urgency was given to
performing the comparisons that they published in annual reports, which were posted online
without any public announcements. For this reason,there is no evidence that MDHHS conducted
an analysis of blood lead levels in 2014 prior to late July 2015, after Governor Snyder's chief of
staff Dennis Muchmore wrote to MDHHS officials expressing concern about many complaints
from Flint residents about water quality in Flint.
On July 28, 2015, a MDHHS epidemiologist (Larder) performed a classic epidemiologic analysis of
2014 blood lead test data versus prior years and found a concerning pattern of elevated levels in
Flint. On the same day,the CLPPP data manager(Scott) compared data over the preceding 5
years and concluded that the 2014 data were not substantially different than several preceding
years. Scott's analysis was fundamentally flawed because he failed to consider that the
proportions of children with high blood lead were declining over the years 2011-2013, and
therefore 2014 levels represented a clear deviation from the improving trend in previous years.
For unclear reasons,these conflicting conclusions of Scott and Larder were not elevated to higher
levels of authority within MDHHS. Rather,the explanation that there was no difference (from a
data manager rather than an epidemiologist) was allowed to persist for another 2 months.
Messages from other MDHHS officials over that subsequent time period indicated that they were
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aware of the MDEQ narrative that the water in Flint was "safe" and did not present "an imminent
public health problem."
By September 2015, Dr. Mona Hanna-Attisha released her analysis of blood lead tests performed
at Hurley Medical Center, showing that children's blood lead levels were clearly abnormal at a
higher rate than in prior years. Of note, Dr. Hanna-Attisha and Professor Marc Edwards of Virginia
Tech had formally requested release of CLPPP data from MDHHS (Scott) in previous weeks and
months, but had never received such data, leading Dr. Hanna-Attisha to analyze data from Hurley
Medical Center only. When the Hurley data were released, MDHHS issued statements indicating
that the Hurley data were analyzed using different methodology than the state would employ,
and MDHHS did not endorse the Hurley findings. A few days later, MDHHS Director Lyon sent a
memo to MDHHS staff asking them to "make a strong statement with a demonstration of proof
that the blood lead levels seen are not out of the ordinary."Within a few days, MDHHS
epidemiologists had re-analyzed the data and reversed course, agreeing publicly with the Hurley-
based analysis by October 1, 2015.
Subsequently, MDHHS changed its approach and began to analyze blood lead level data in the
CLPPP database on a basis closer to "real time." In a series of reports released approximately
every 2 weeks since November 2015, MDHHS has communicated with the public regarding the
proportion of children in Flint with blood lead tests>_5 micrograms/deciliter. This is a promising
step in transparency and timeliness.
However, excessive and likely harmful lead exposure already has occurred for hundreds and
perhaps thousands of children in Flint, and it is now MDHHS's responsibility to follow up with
comprehensive secondary prevention. MDHHS reports that about 200 children in Flint are known
to have had childhood lead levels>_5 micrograms/deciliter when they were tested since April
2014 (the month of the water switch to the Flint River).This number of children is likely a
profound underestimate of the number of children exposed; based on Census estimates and
Medicaid records,the number of children under 6 years old living in the City of Flint is
approximately 10,900. Given the known risks of lead neurotoxicity for young children,
appropriate near-term, middle-term, and long-term follow-up for children exposed to lead in
Flint will include:
o Neurodevelopmental assessments,
o Timely access to early childhood education,
o Behavioral assessments and interventions in preschool years,
o Educational assessments in preschool and school years accompanied by appropriate
learning support, and
o Appropriate counseling and medical therapy to address attentional and behavioral
concerns at school age and into adolescence.
Such comprehensive approaches to secondary prevention for children in Flint are consistent with
a model framework for medical and public health response proposed by Dr. Mona Hanna-Attisha
at Hurley Medical Center.
Despite the unmistakable connection between the quality of drinking water and public health,
there is no liaison between MDEQ and MDHHS to ensure that complaints or concerns about
water are brought to the attention of MDHHS staff in a timely fashion to prompt investigative
action. The lack of a liaison function within state government also adversely affected the
response to cases of Legionellosis, as described below.
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Cases of Legionella Infection
Legionellosis is an infection with species of bacteria called Legionella, so called because it came to
prominence when many attendees at an American Legion conference fell ill in 1976.
Legionellosis has a broad spectrum of severity, causing relatively mild illness in some individuals
who are generally healthy and causing much more severe illness in seniors and patients whose
immune systems are weakened. It is generally fatal in about 10 percent of cases.
Legionella bacteria live in water supplies and flourish in warmer temperatures and standing
water, present in locations such as cooling towers for air conditioning systems. It is a reportable
disease, meaning that any healthcare professional who makes the diagnosis must report the case
to the local health department. In turn,the local health department reports cases to the state
health department. Fewer than 10 cases of Legionellosis per year were reported by GCHD in
years immediately preceding the switch of water source to the Flint River.
MDHHS assisted GCHD with evaluation of the Legionellosis outbreak that began in 2014 and
extended into early 2015, at GCHD's request. When the initial evaluation report was issued by
MDHHS epidemiology team in May 2015, it is unclear why they asserted the "the outbreak is
over"; subsequent reports released in January 2016 indicated that additional cases occurred
beginning in May 2015.42 MDHHS indicated in its May 2015 report that data were inconclusive
regarding a community source such as the water supply because of a lack of clinical specimens.
While MDHHS's statement regarding the absence of conclusive evidence of a community source
has scientific merit, it is evident that MDHHS was not calibrating its evaluation for the unusual
circumstance of the switch to the Flint River in April 2014. In fact, although the report mentions it
as a possible source,there is no explicit mention of the switch to a new raw water source in Flint,
and new water treatment protocols, as possible causal factors. Although there was a January
2015 meeting that included MDHHS, MDEQ and GCHD regarding cases of Legionellosis in
Genesee County, subsequent discussions of Legionellosis appear to have occurred within the silos
of MDEQ and MDHHS until late 2015, and remained uncoordinated until the Governor's
announcement about ongoing Legionella investigations in January 2016.
Findings
F-6. MDHHS's lack of timely analysis and understanding of its own data on childhood blood
lead levels, along with its reliance on MDEQ and reluctance to share state data with Dr.
Mona Hanna-Attisha and Professor Marc Edwards, prolonged the Flint water crisis.
F-7. MDHHS bears ultimate responsibility for leadership and coordination of timely follow-up
efforts in Flint and across the state regarding childhood lead poisoning. While local
entities (for example, healthcare professionals, GCHD, health insurance plans) are
partners in efforts to protect children from lead poisoning, MDHHS has the lead role and
failed to exercise its responsibility.
F-8. The consequences of lead exposure for Flint residents are expected to be long-term and
will necessitate sustained investments in education, public and mental health,juvenile
justice, and nutrition needs over the next 10 to 20 years.
42 This may have been related to delays in reporting between local healthcare professionals,GCHD,and MDHHS.
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F-9. Too few children in Michigan are screened for lead through routine blood tests as
recommended for children ages 1 and 2. Statewide screening goals for children enrolled in
Medicaid are met in very few instances at the county level or within Medicaid health
plans.This lack of information leaves parents, healthcare professionals, and local and
state public health authorities uninformed about the possibility of lead poisoning for
thousands of Michigan children.
F-10. Coordination between MDEQ and MDHHS was inadequate to properly address the public
health issues related to water quality in Flint. Communication was infrequent, and when it
did occur,the default position was to conclude that the health problems were not related
to the water supply switch —rather than to assume that the problems might be related to
the switch.
F-11. Communication and coordination among local and state public health staff and leadership
regarding Legionellosis cases in 2014-2015 was inadequate to address the grave nature of
this outbreak.The fact that these cases occurred while there were several simultaneous
concerns about quality and safety of water in Flint should have caused public health staff
and leadership at local and state levels to coordinate their actions to ensure a prompt and
thorough investigation.
Recommendations
R-6. Establish policies and procedures at MDEQ and MDHHS to ensure input by health experts
and scientists when permit decisions may have a direct impact on human health.
R-7. Establish and maintain a Flint Toxic Exposure Registry to include all the children and
adults residing in Flint from April 2014 to present.
The Flint Toxic Exposure Registry will serve as an authoritative reference source of
information (including contact details [for example, primary contact information, back-up
contact information, and preferred mode of contact]) for purposes of timely health
assessments in the short-term and long-term, as well as subsequent communication
regarding policies and scientific findings. Timely assessments will include clinical
evaluations and re-evaluations in healthcare settings, appropriate follow-up conducted by
public health professionals, and longitudinal assessments of the impact of environmental
exposure on children's and adults' health (including among pregnant women).
R-8. Re-establish the Michigan Childhood Lead Poisoning Prevention and Control Commission.
The Commission would perform a comprehensive review of the state's lead poisoning
prevention program; evaluate the effectiveness of the program, including its ability to
satisfy federal law requiring that 100 percent of all young children enrolled in Medicaid be
screened with a blood lead test; and make recommendations for the program's
improvement. The Commission would also conduct public hearings, review information
from other sources, and study other states' experiences.The Commission must also
develop short- and long-range strategic recommendations for childhood lead poisoning
prevention and control in Michigan.
R-9. Ensure that MDHHS is transparent and timely in reporting and analysis of aggregate data
regarding children's blood lead levels. MDHHS data regarding lead levels shall be provided
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to individuals and organizations, based on their expertise, upon request and in cases
when the interpretation of data by MDHHS is questioned.
R-10. Establish a more aggressive approach to timely clinical and public health follow-up for all
children known to have elevated blood lead levels, statewide. MDHHS should expand its
local efforts and partnerships to accomplish this goal. Whenever possible, routine
screening for lead and appropriate follow-up should occur in children's primary care
medical homes.
R-11.Strive to be a national leader in monitoring and responding to exposure of children to
lead by converting the Childhood Lead Poisoning Prevention Program (CLPPP) from
passive collection of test results into an active surveillance and outreach program.
Performance of the surveillance program should be reported to the public. MDHHS
should be prepared to amplify its efforts if performance targets are not met.
R-12. Improve screening rates for lead among young children through partnerships with county
health departments, health insurers, hospitals, and healthcare professionals.
R-13.As the state authority on public health, and as the organization that conducted the
epidemiologic study of Legionellosis cases in Genesee County in 2014-15,take
responsibility for coordinating with GCHD and CDC to protect Michigan residents from
further outbreaks of Legionellosis.43
R-14. In cases of switches in drinking water supplies in the future,the state must assume that
outbreaks of cases of Legionellosis may be related to changes in water source and should
communicate the potential risk to the public, rather than assuming and communicating
the opposite.
Michigan Governor's Office
Defined Role
The Governor of Michigan heads the executive branch of Michigan state government and has the
power to reorganize state departments and appoint department heads. All executive branch
departments of state government report to the Governor, including the three key departments
involved in the Flint water crisis: MDEQ, MDHHS, and Treasury.The Governor also appoints
personal staff to keep him informed of issues and events. Among other responsibilities,the
Governor(through the Michigan Department of Technology, Management and Budget) submits
an annual budget and has a line-item veto for appropriations bills.
Rick Snyder, Michigan's 48th Governor,took office in January 2011. He began his second term in
January 2015.
43 Specific steps should include: (a)anticipate the risks of Legionellosis infections going forward;(b)take timely steps
to minimize those risks in Flint drinking water by working with EPA,MDEQ and Flint WTP;(c)coordinate with
healthcare facilities to minimize risks of healthcare facility-acquired Legionellosis;(d)communicate with the public
about steps being taken and cases of Legionellosis that occur.
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Discussion
The Flint water crisis occurred during Governor Snyder's tenure.The Governor and his office
were directly involved in some aspects of the crisis and briefed on some of the major decisions
surrounding Flint drinking water. Emergency managers that he appointed made key decisions
that led to and prolonged the crisis. He appointed the directors of the three state departments—
MDEQ MDHHS, and Treasury—that bear differing degrees of responsibility for what happened.
The Governor and the Governor's office must rely heavily on information from state departments
to make decisions, set directions, and take action. In this case,the individuals and departments
on which the Governor relied for guidance provided wrong information, particularly on the issues
related to lead in the drinking water and elevated blood lead levels in children. In particular,two
state agencies attempted to dismiss and discredit credible evidence of threats to public health.
MDEQ did not acknowledge the true extent of the Flint water problems until late September
2015. Likewise, MDHHS, which misread its own data on children's blood lead levels in Flint, did
not inform the Governor of lead poisoning related to use of the Flint River as a water source until
late September 2015.
However, Governor Snyder and certain executive staff members were aware before late
September 2015 of several issues that are noteworthy and relevant. For example:
o The Department of Treasury approved the Flint emergency manager's decisions
(supported by Flint City Council)to switch to KWA after negotiations across two entities
under emergency management failed. Members of the Governor's staff—and the
Governor himself—participated in some of those discussions.
o The Governor's office received citizen complaints and was well aware of numerous press
stories about water quality problems as early as May 2014 and continuing throughout
2015.44,45
o The decision by General Motors (GM) in October of 2014 to use Flint Township water
instead of Flint WTP-sourced water for its Flint Engine Operations facility was not only
known to executive staff members of the Governor, but was also cited as a reason to
switch back to DWSD (see below).
o In late January 2015, at least one member of the Governor's office was informed that
concerns were being raised in the MDEQ about the Legionellosis outbreak in Genesee
County and possible connection to the Flint water supply.46
o In March 2015, at least one of the Governor's office staff members was advised of the
Legionellosis outbreak in Flint and local health department concerns of a potential link to
the Flint water conversion.47
44 This was subsequent to Department of Treasury's approval of the Flint emergency manager's decision to contract
with LAN to upgrade the Flint WTP to treat water from the Flint River as the primary drinking water supply, instead
of purchasing water from DWSD.
45 The October 1,2014 MDEQ briefing paper to Governor's office regarding City of Flint drinking water situation (boil
water notices)ascribes problems to aged, inadequately maintained,cast iron pipe in the distribution system.
46 See January 30,2015 e-mail from Brad Wurfel/MDEQ to Dave Murray,Governor Snyder's deputy press secretary,
re:Legionella.
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o In March 2015,the Governor's chief of staff proposed buying and distributing bottled
water in Flint because of citizen concerns about water quality.
o In mid-summer 2015, an aide to Governor Snyder arranged for the donations of water
filters to be distributed in Flint to address concerns about water quality.
o In mid-summer 2015,the Governor and senior staff discussed Flint water issues; lead was
apparently part of those discussions.
The switch to the Flint River as the primary source of drinking water for the City of Flint occurred
in late April 2014. On October 14, 2014, after citizen complaints about the water's odor, color
and taste 48 and the decision by GM to leave the Flint water system,two key executive staff
members traded emails suggesting that,given these problems, it was time to switch back to
DWSD for Flint's drinking water. Other executive staff members received these emails, and—
according the Governor's chief of staff at the time—the Governor was informed of the concern
and the suggestion. A phone conversation occurred between key staff members Valerie Brader
and Rich Baird and the Flint emergency manager about the suggestion.The emergency manager
assured these Governor's office staff members that the water quality problems were not of a
permanent nature and asserted that it would be too costly to switch back to DWSD.That
conversation ended any serious discussion about switching back to DWSD at that time.
The suggestion to switch back to DWSD was revisited in mid-summer 2015. However, MDEQ
continued to provide reassurances that the treated water reaching homes in Flint was both safe
and in compliance with SDWA requirements.These continuing reassurances, as well as the cost
issue, apparently prevented any systemic or comprehensive review of the water situation in Flint.
According to Governor Snyder, it was not until after September 28, 2015,that he was personally
advised that MDEQ and MDHHS had been wrong for months about the reality of lead in the
water and children's blood lead levels.
Discussions about the Flint water situation were also conducted in the context of overarching
discussions about financially distressed cities served by emergency managers, and Flint in
particular. Flint water issues were a focal point for senior staff and were discussed with the
Governor. Considerable frustration was apparent due to new issues arising just as immediate
problems seemed on the road to improvement. Continued reliance on MDEQ drove poor
decisions—or the lack of decisions.
As the Flint water crisis unfolded, certain state agencies' perceived need to defend the original
decision to switch to the Flint River and resist a return to DWSD resulted in public relations and
communications efforts that have, at times, been inappropriate. In the spring and summer of
2015,for example,this perceived need to defend a flawed decision manifested itself in attempts
by MDEQ and MDHHS to discredit accurate information on lead in drinking water and elevated
blood lead levels provided by outside experts. Citizen concerns were at times derided and
dismissed, in spite of the fact that various members of the Governor's staff had expressed—and
were expressing—concerns about the water situation in Flint at the same time.
47 See March 13,2015 E-mail from Brad Wurfel/MDEQ to Harvey Hollins/Governor's office.
48 Though not,at that time, related to lead or TTHMs.
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To some extent, inappropriate official public relations efforts continue to this day. Even as the
state is aggressively engaged in mitigation efforts in Flint,the statement that the Flint water crisis
was a local, state, and federal failure implies that blame is attributable equally to all three levels
of government. Primary responsibility for the water contamination in Flint lies with MDEQ. In
addition, at the time of the water crisis, Flint was under the control of state-appointed
emergency managers, who made key decisions that contributed to the crisis. Because of these
two facts,the state is fundamentally accountable for what happened in Flint.
Though delayed, we acknowledge and support the many steps the Governor has taken to date to
address the implications of lead in the Flint water supply—the state declaration of emergency,
the establishment of both the Flint Water Inter-Agency Coordinating Council and Mission Flint,
additional funding for addressing the health issues faced by lead-poisoned children in Flint,
partial reimbursement for water bills paid during the time of lead contamination, and progress on
a plan to replace LSLs.
Findings
F-12. Ultimate accountability for Michigan executive branch decisions rests with the Governor.
F-13.The Governor's knowledge, and that of Governor's office staff, of various aspects of the
Flint water crisis was compromised by the information—much of it wrong—provided by
MDEQand MDHHS.
F-14.The Governor's office continued to rely on incorrect information provided by these
departments despite mounting evidence from outside experts and months of citizens'
complaints throughout the Flint water crisis, only changing course in early October 2015
when MDEQ and MDHHS finally acknowledged the extent of the problem of lead in the
public water supply.
F-15.The suggestion made by members of the Governor's executive staff in October 2014 to
switch back to DWSD should have resulted, at a minimum, in a full and comprehensive
review of the water situation in Flint, similar to that which accompanied the earlier
decision to switch to KWA. It was disregarded, however, because of cost considerations
and repeated assurances that the water was safe. The need to switch back to DWSD
became even more apparent as water quality and safety issued continued and lead issues
began to surface in 2015, notwithstanding reassurances by MDEQ.
F-16.The Flint water crisis highlights the risks of over-reliance—in fact, almost exclusive
reliance—on a few staff in one or two departments for information on which key
decisions are based.
F-17. Official state public statements and communications about the Flint water situation have
at times been inappropriate and unacceptable.
Recommendations
R-15. Expand information flow to the Governor so that information providing the foundation
for key decisions comes from more than one trusted source—and is verified.
R-16.Create a culture in state government that is not defensive about concerns and evidence
that contradicts official positions, but rather is receptive and open-minded toward that
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information. View informed opinions—even if critical of state government—as an
opportunity for re-assessing state positions, rather than as a threat.
R-17. Ensure that communications from all state agencies are respectful, even in the face of
criticism, and sensitive to the concerns of diverse populations.
R-18.The Governor must assume the leadership of, and hold state departments accountable
for, long-term implementation of the recommendations in this report, including but not
limited to the need for cultural changes across multiple state agencies,the need for
health mitigation and LSL replacement in Flint, and the need for a funding strategy to
address replacement of LSLs statewide.
R-19. Review budget requests for MDEQto ensure adequate funding is provided to the
ODWMA. EPA audit and interviews indicate that Michigan's drinking water program might
have one of the lowest levels of financial support within EPA Region V while having one of
the largest, if not the largest, number of community water systems to regulate.
State-Appointed tmer gency Managers
Defined Role
The role of the emergency manager(EM) under the Emergency Manager Law, PA 436, is clear
and unambiguous.Though they report directly to the Department of Treasury, EMs have
complete authority and control over municipal decisions. In that context,the EMs had the
responsibility to ensure that Flint water system operations were adequately resourced and
supported by personnel and consultants with adequate training and expertise.
Discussion
Owing to significant declines in economic vitality and substantial outmigration since (at least)the
1990s, Flint was first placed in financial receivership under an emergency "financial" manager
between 2002 and 2004.49 Since 2011,the City has been under some form of state-ordered and
controlled emergency financial management.50 During this time,four different EMs have served
for varying lengths of time, one serving twice.51
Our interviews confirmed the EMs reported to and interacted regularly with Treasury officials.
They discussed issues such as public safety, staffing requirements, and financial matters. The
EMs, working through Treasury, also would contact other state agencies for assistance on a
regular basis, such as the State Police on law enforcement matters.
49 Imposed under PA 72 of 1990.
50 In 2011, PA 72 was replaced by PA 4,which amplified the powers of an appointed EM.The voters repealed PA 4 in
November 2012, but a subsequent statute was passed by the legislature in December 2012: PA 436 of 2012.That
statute is not subject to a voter referendum and has been in effect since March 2013.
51 Ed Kurtz served as Flint's emergency financial manager under PA 72 of 1990 from May 2002 to 2004; Michael
Brown was appointed in December 2011 under PA 4;Ed Kurtz became EM again in August 2012; Michael Brown was
reappointed again in June 2013;Darnell Earley replaced Brown In October 2013;Jerry Ambrose replaced Earley in
January 2015;and Ambrose left in April 2015 when control over the city's finances was assigned to a city
administrator under the supervision of a Receivership Transition Advisory Board.
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Numerous decisions were made between December 2011 and April 2015 that had some impact
on the decision to use the Flint River as the primary source of drinking water for the City of Flint.
Various state-appointed EMs served during this timeframe and it was these EMs who made these
decisions, not locally elected officials. Although it is true that some locally elected officials
supported, acknowledged, embraced, and even celebrated some of the decisions,the decisions
were not theirs to make. The state-appointed EMs made the decisions.
Specifically, Flint EM Ed Kurtz authorized use of the Flint River as a water source for Flint, as
clearly indicated by his approval of a sole-source contract for the engineering firm Lockwood,
Andrews, & Newnam (LAN)to prepare the Flint WTP for full-time treatment of Flint River water.
Darnell Earley was the incumbent Flint EM and presided over the switch of water sources in April
2014. He and later EM Jerry Ambrose were in place during periods when citizens requested a
return to DWSD because of health problems they were experiencing. Neither Darnell Earley nor
Jerry Ambrose seriously considered a return to DWSD in part because MDEQ, local staff and their
consultants assured the EMs that the water quality problems were manageable and that there
was nothing seriously wrong with the water.52 In March 2015, nearly one year after the source
water conversion,Jerry Ambrose stated that a reconnection to DWSD would cost the City$10.1
million per year and that water purchases could be as high as$1 million per month—essentially
asserting that it was unaffordable.ss
In any event,the facts in this case point to the reality that state government, as the entity in
charge of Flint decision-making, failed to protect the health of the city's residents. Regardless of
any successes of the EM process in other Michigan cities,this failure must force us to review the
EM law and the general approach to financial problems. Government approaches to cities in fiscal
distress must balance fiscal responsibility with the equally important need to address quality of
life, economic development, and infrastructure maintenance and provision.
Findings
F-18. Emergency managers, not locally elected officials, made the decision to switch to the Flint
River as Flint's primary water supply source.
F-19. Treasury officials,through the terms of the local emergency financial assistance loan
executed by the Flint emergency manager on April 29, 2015, effectively precluded a
return to DWSD water, as Flint citizens and local officials were demanding, without prior
state approval.
The Emergency Manager Law is predicated on the provision that any ongoing
accumulated local government deficit is resolved prior to the termination of receivership
(P.A. 436 of 2012). As the city of Flint neared the end of its Emergency Manager status in
March 2015,the city still retained an $8 million accumulated deficit in the General Fund.
To resolve this accumulated deficit,the state and the Flint EM, with the concurrence of
Flint's City Council, signed an emergency loan agreement between the City of Flint and
52 See,for example,"City of Flint Water System Update with Questions and Answers," February 16,2015,posted to
City of Flint website at www.cityofflint.com/wp-content/uploads/Water-Sysytem-FAQ-Update-2-16-151.pdf,as
confirmed in FWATF interviews of Flint's former EMs.
53 Memorandum dated March 3,2015,to Deputy State Treasurer Wayne Workman.
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Michigan's Local Emergency Financial Assistance Loan Board for nearly$8 million.54 This
emergency loan included a provision that the City of Flint could not, without prior state
approval, return to DWSD or lower water rates.
F-20. The role of the EMs in Flint (in combination with MDE(Xs failures) places primary
accountability for what happened with state government.
Trying to assign responsibility to an individual EM for the decision to use the Flint River is
pointless—and the answer ambiguous. One EM set it in motion, another presided over
the actual event, and two EMs did not seriously entertain reversing the decision in the
face of public protest.The latter refusals were for simple reasons: they received "expert"
advice that the water was safe to drink, and they concluded that switching back to DWSD
would be too costly.
We believe the larger issue is one of accountability. Who is accountable for the decisions
made by the EMs in Flint?We believe the state must assume that accountability. If the
state does not assume that responsibility,given the role the state has in both the
appointment of EMs and the line of accountability to the Department of Treasury,then no
accountability exists at all.
F-21. EMs charged with financial reform often do not have, nor are they supported by,the
necessary expertise to manage non-financial aspects of municipal government.
F-22. Michigan's Emergency Manager Law and related practices can be improved to better
ensure that protection of public health and safety is not compromised in the name of
financial urgency.
The EM Law is predicated on the concept that a local financial crisis—such as that which
occurred in Flint in 2011—is due to the inability of local officials to address the problem.
The EM is supposed to be able to better handle the situation, make better and faster
decisions, and resolve the crisis.The EM law states "[t]hat the fiscal stability of local
governments is necessary to the health, safety, and welfare of the citizens of this state
and it is a valid public purpose for this state to assist a local government in a condition of
financial emergency."55 The EM is deemed necessary not only to resolve the fiscal
problem but also to protect the public health and safety.
Yet in the case of Flint, while other state and local officials were involved, EMs were at the
heart of decision-making processes that prolonged lead exposure occasioned by MDEQ's
failure to prescribe appropriate treatment for the Flint water system.
Recommendations
R-20. Review Michigan's Emergency Manager Law(PA 436) and its implementation, and
identify measures to compensate for the loss of the checks and balances that are
provided by representative government.
54 Note that the Resolution presented to Flint City Council by the Flint EM,Resolution 150302.1,contained no
information regarding the DWSD and water rates conditions contained in the emergency loan.
55 Michigan Public Act 436 of 2012,Section 3 (c).
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Although we acknowledge that controversy will always accompany state receivership in
whatever form, we recommend a review of PA 436. While some of the checks and
balances inherent in democratic decision-making are necessarily and by definition absent
under emergency management—as is also true under bankruptcy—proper and efficient
checks and balances per se should not be a casualty of state receivership. Neither should
avenues for citizens to voice their concerns, particularly regarding matters of public health
and safety.
R-21.Consider alternatives to the current EM approach—for example, a structured way to
engage locally elected officials on key decisions; an Ombudsman function in state
government to ensure that local concerns are a factor in decisions made by the EM;
and/or a means of appealing EM decisions to another body.
R-22. Ensure proper support and expertise for EMs to effectively manage the many
governmental functions of a city. Decisions on matters potentially affecting public health
and safety,for example, should be informed by subject matter experts identified and/or
provided by the state.
EMs are asked to ensure the protection of the public health and safety and yet are not
provided adequate tools and resources to achieve this objective. EMs are empowered to
effect cost-cutting measures such as the ability to terminate contracts and restructure
budgets. However,they are given little or no priority access to state or federal resources
or assistance in undertaking the complex activities of running a municipality. Other states
take different approaches that may do a better job of balancing the need for fiscal
discipline with the need to provide basic public services, especially when scientific, health,
and/or engineering expertise is involved.
City of Flint
Defined Role
As the owner of its public water system,the City of Flint has responsibility for compliance with
the SDWA under Act 399.These responsibilities include "ensuring proper design, construction,
operations and maintenance, so that contaminants in tap water do not exceed the standards
established by law."The City is "required to employ properly certified water operators that are
trained and experienced to operate the treatment and distribution system."
The City must "test its water routinely for specified contaminants and report the results to
MDEQ." If a water system is not meeting these standards, it is the water supplier's responsibility
to notify its customers when there is a problem with water quality.56 With a planned change in
water source, it is the City's responsibility to carefully plan and test water treatment techniques,
ensure staff is knowledgeable about treatment protocols, and monitor distribution system water
quality. We note that decisions affecting these responsibilities, particularly those that had
financial implications, were ceded to Flint's EMs throughout the course of the Flint water crisis.
56 Quotes are from the MDEQ's"Outline of Flint Drinking Water Issues for Flint Water Task Force," p.3.
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Discussion
City of Flint Public Works executive leadership and staff were immediately responsible for
treating Flint River water and for monitoring water quality in the distribution system. SDWA
compliance is the obligation of the public water supplier, and it is their hands that public trust is
placed. Flint was responsible for ensuring that its WTP was adequately upgraded and tested to
perform full-time operations,that operations staff members were adequately trained and
familiar with treatment processes,that the treatment technologies used were adequate to
produce safe drinking water, and that the water quality throughout the distribution system (all
the way to consumers'taps, in the case of the LCR) was in compliance with regulatory
requirements, as confirmed using appropriate sampling procedures. These standards of practice
were not met in Flint.
The City relied on Flint Utilities Department staff's limited experience, consultant advice, and
most substantially MDEQ for technical support. In this respect, Flint was similar to many
communities in Michigan that rely on MDEQ for technical assistance and advice on regulatory
compliance requirements. However, in Flint,that reliance was tragically misplaced.
Our interviews underscored several troubling aspects of the inexorable drive to leave the DWSD
system and use the Flint River as an interim supply source for drinking water. Most obviously,the
parties simply failed to adequately appreciate (or signal)the complexities involved in treating
Flint River water, or the potential implications of water chemistry changes to the city's water
distribution network. We note that Flint endured a series of water quality threats—from E coli
contamination to high total trihalomethane (TTHM) levels—that could have been prevented.
Increased lead exposure and increased incidences of Legionellosis likely are the most serious
health consequences of a sustained period of water quality problems that clearly overwhelmed
Flint staff. At best, consultant support for Flint River water treatment, and later for redress of
distribution system water quality problems, focused on specific issues without adequate
consideration for latent public health dangers.
The Flint Utilities Department personnel were under-trained, inexperienced with full-time plant
operations, and ill-prepared to manage complex water chemistry issues. We note that selected
staff members conveyed concerns as events unfolded, only to have those concerns discounted.
Several aspects of the situation are particularly troubling.
o Less than one month before startup of full-time Flint WTP operation, MDEQ was uncertain
about its requirements for the transition. MDEQ staff noted internally that Flint would
face complexities in treating Flint River water and challenges with full-time operation of
the dated WT p.57
o It is not clear that Flint's resident consulting engineers, LAN, had adequate expertise and
experience with river water treatment,yet the firm was engaged through a sole-source
contract.58
57 See,for example,Stephen Busch e-mail of March 26,2014–and his e-mail of exactly one year earlier.
58 LAN representatives were not made available for interview. Questions were provided in writing and sent to LAN
(and are included in Appendix IV); responses were not received prior to publication of this report.
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o Flint WTP operators were hired too late in plant ramp-up efforts to enable full-time
staffing, which precluded adequate training on plant operations.
o MDEQ misinterpreted the Lead and Copper Rule (LCR) in determining that corrosion
control treatment was not necessary with commencement of full-time WTP operation.
Neither Flint Utilities Department staff nor their consulting engineers were given either to
question this misinterpretation, or to institute rigorous distribution system water quality
monitoring to safeguard against corrosion-causing water quality issues.
We note that Flint WTP supervisory personnel's expressed concerns regarding readiness to begin
full time operations—including appropriate LCR-mandated sampling—and these concerns went
unheeded.59 However, it seems clear that these concerns were voiced in an environment that
was unreceptive to reconsideration of the City's chosen course, mandated by its EMs.6o
We also are dismayed by the inadequate and technically flawed efforts Flint Utilities Department
personnel undertook, based on MDEQ's instructions,to assess distribution system water quality.
As a result, Flint's water quality sampling was fundamentally flawed, giving false assurances and
an untenable basis for MDEQ's claims that Flint's system was delivering safe water. The series of
missteps and outright errors is well documented'61 including sampling of pre-flushed lines, use of
narrow-mouthed bottles, and perhaps most egregiously failure to select high-risk homes for
testing, as required by the LCR. It is hard not to attribute this conduct to a misguided objective of
securing nominal LCR compliance irrespective of what conditions might actually exist in the
homes of Flint residents.
Also troubling,though not altogether uncommon among U.S. water systems, is Flint's admission
that it had not conducted a census of LSLs as required by the LCR. Without this information, Flint
was not in a position to identify high-risk homes to properly monitor lead levels and comply with
the LCR.
In summary, while we cannot begin to explain or excuse MDEQ's transgressions in its oversight of
the conversion to the Flint River water supply,the Flint Public Works role in the crisis appears
attributable to an inexperienced and poorly resourced organization struggling to take on
enormous, untenable responsibilities. Flint's EM, relying on sole-sourced consultant support, held
responsibility for ensuring adequate staffing,training, and preparation for conversion of Flint's
drinking water source.Those responsibilities were not met.
Findings
F-23. Flint Public Works personnel were ill-prepared to assume responsibility for full-time
operation of the Flint WTP and distribution system.
59 April 17,2014 e-mail from Flint Utilities Department's Michael Glasgow to Adam Rosenthal, Mike Prysby,and
Stephen Busch at MDEQ.
60 See,for example,April 24,2014 e-mail from Daugherty Johnson,City of Flint Utilities Administrator,and Mike
Prysby and Stephen Busch/MDEQ, including Flint Public Works Director Howard Croft.
61 See,for example,"COMMENTARY: MDEQ Mistakes and Deception Created the Flint Water Crisis,"September 30,
2015,Siddhartha Roy, Flintwaterstudy.org,and February 27,2015 e-mail from Miguel Del Toral/EPA to MDEQ:"If
systems are pre-flushing the tap the night before collection of LCR compliance samples(MDEQ still provides these
instructions to public water systems)this clears particulate lead out of the plumbing and biases the results low by
eliminating the highest lead values."
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F-24. The Flint WTP and installed treatment technologies were not adequate to produce safe,
clean drinking water at startup of full-time operations. Flint's lack of reinvestment in its
water distribution system contributed to the drinking water crisis and ability to respond
to water quality problems.
F-25. Flint Public Works personnel failed to comply with LCR requirements, including the use of
optimized corrosion control treatment and monitoring for lead. Flint personnel did not
identify residences with LSLs, secure an adequate number of tap water samples from
high-risk homes, or use prescribed sampling practices (for example, line and tap flushing
methods and sample bottle sizes).
F-26. Flint Public Works acted on inaccurate and improper guidance from MDEQ.
F-27. Many communities similarly rely on MDEQto provide technical assistance and guidance
on how to meet regulatory requirements. In the case of Flint, MDEQ assistance was
deeply flawed and lax, which led to myopic enforcement of regulations designed to
protect public health.
F-28. The EM structure made it extremely difficult for Flint citizens to alter or check decision-
making on preparations for use of Flint River water, or to receive responses to concerns
about subsequent water quality issues.
Recommendations
R-23. Establish and fund a team of subject matter experts in water system operations
(treatment and distribution system management)to support and train water system
personnel,guide safe system operation under current conditions, and prepare for
successful conversion to KWA.
In addition to creating water quality problems,the switch to the Flint River may have
precipitated conditions in Flint's water system that increase the potential for Legionella to
occur. With warmer temperatures in 2016,there is a heightened need for multi-agency
coordination on testing of the Flint water system for the presence of Legionella, and on
public health monitoring for the incidence of Legionellosis and determinations of sources.
R-24. Implement a programmatic approach to Flint WTP and distribution system operations,
maintenance, asset management, water quality, capital improvements and public
engagement (including risk communication)to ensure that the disparate ongoing efforts
to address Flint water system infrastructure needs are coordinated,fully documented,
and structured to sustain high-quality potable water service over the long term.
Though not the subject of the FWATF's review, it is apparent that the Flint water utility
faces acute financial challenges due to earlier financial management practices, as well as
successful challenges to EM-ordered rate increases.These circumstances impose an
unprecedented context for establishing defensible water rates and collection practices in
a community that was already facing difficult water affordability challenges. Careful
financial planning and management will be required to secure and effectively deploy
external funding assistance, and to gradually stabilize water system revenues to sustain
water utility operations over the long term.This must be complemented by an effective
public education and engagement program, and innovative water affordability strategies
to advance universal access to potable water service.
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R-25. Implement a robust public engagement and involvement program in conjunction with the
anticipated conversion to KWA-delivered water and provide for regular reporting to the
Flint Water Inter-Agency Coordinating Committee (FWICC).
Genesee County Health Department (GCHD)
Defined Role
As a local health department,the Genesee County Health Department (GCHD) is responsible for
all government public health functions for residents in their jurisdiction, including the City of
Flint. Like the vast majority of cities in Michigan, Flint does not have its own public health officials
and instead relies on its county health department (GCHD)to perform public health functions.
GCHD must coordinate and communicate effectively with city officials and the public. Specific to
the Flint water crisis, GCHD responsibilities include investigating outbreaks of reportable diseases
such as Legionellosis and conducting timely in-home assessments of potential sources of lead
exposure for children found to have elevated blood lead levels.
Importantly,the functions of local health departments also include cooperative coordination with
state public health authorities (MDHHS), and in turn with federal public health authorities (for
example, Centers for Disease Control and Prevention [CDC]) as needed.The expectation is that
local health departments manage issues that arise in their jurisdictions. State public health
authorities become involved at the request of local authorities and/or when events such as an
outbreak involve more than one jurisdiction (that is, more than one local health department). In
turn, MDHHS requests help from the CDC as needed.This local-to-state-to-federal sequence is
designed to facilitate communication, coordination, and follow-up among officials at multiple
levels of authority, and it requires mutual trust, collaboration and effective communications
across agencies.
Discussion
In summer 2014, after the change of water source for the City of Flint,there were two public
health problems that arose within the jurisdiction of GCHD: exposure to lead and exposure to
Legionella.
Exposure to Lead
In contrast to Legionellosis, which has involved GCHD as a front-line responder, GCHD was not
extensively involved in responding to exposure of children to lead from the Flint water supply.
Elevated blood lead level records are maintained as part of a regularly updated listing of test
results by MDHHS in the statewide Childhood Lead Poisoning Prevention Program (CLPPP). GCHD
was involved as a coordinating organization for conducting tests and relaying test results to the
state.
Clinicians are responsible for testing children's blood for lead in early childhood on a routine
basis. Health insurance plans (especially those that contract with state Medicaid) are responsible
for encouraging families and clinicians to have children screened at the appropriate ages and
then following up with children whose blood lead levels are elevated. GCHD would get involved
for children with elevated lead levels that prompted in-home assessments of possible sources of
environmental lead exposure.
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Since the switch to the Flint River, a higher proportion of children in Flint have had elevated lead
levels that would prompt in-home assessments. Several aspects of the GCHD-MDHHS response
are noteworthy:
o GCHD was overwhelmed with the need for in-home assessments, and MDHHS
supported training and placement of outreach nurses in GCHD to supplement its
workforce.
o GCHD had been asked only to reach out to pregnant women who might have had lead
exposure, rather than performing their usual in-home assessment duties. MDHHS
tasked an outside firm with performing the in-home assessments.
o As of late January 2016, only about one-fifth of children known to have had elevated
blood lead levels in Flint since April 2014 had received in-home environmental
assessments (including water testing).
Legionella
After the switch to the Flint River in 2014,the Flint Utilities Department began flushing water
mains citywide to address brown-colored water resulting from corrosion of pipes in the
distribution system. Many fire hydrants ran for days, which may have disrupted the "biofilm," a
slime coating(which is distinct from the scaling provided by corrosion control treatment) on the
inside surface of the water mains and water service lines. When the biofilm was disrupted,
Legionella and other bacteria may have been released. In addition, EPA experts Del Toral and
Lytle believe that corroding pipes likely absorbed chlorine in the water, leading to extremely low
chlorine levels that were insufficient to kill Legionella in the water. Also,given the small
population in Flint compared to the large water distribution system developed to serve the city's
larger population in decades past, water likely pooled in the system for excessively long periods,
providing an ideal environment for bacterial growth.
As noted above, several cases of Legionellosis occurred in patients who likely were exposed to
Legionella in healthcare facilities. McLaren Medical Center in Flint responded to the incident by
hiring a Legionella expert, spending$300,000 for systems to eliminate the bacteria, and changing
practices on their wards to instruct patients not to take showers (because aerosols can spread
Legionella).
During this timeframe,the City of Flint (Mayor Dayne Walling, EM Jerry Ambrose and others)
asserted the water was safe. Even while outbreak investigations were ongoing, GCHD and
MDHHS did not issue a bulletin to the medical community or the public.The Legionella expert
hired by the hospital and other water quality experts cannot dismiss the possibility of a link
between the Legionellosis outbreaks and lack of proper corrosion control and disinfection in the
City's water system.
In Flint, neither the Flint EM nor his appointed City Administrator, GCHD, or MDHHS fully
disclosed the Legionellosis outbreak to local medical professionals or the general public.
Moreover,this outbreak, which is always associated with watersupplies, was not communicated
by MDEQ with sufficient urgency to the Governor's office.
In contrast, New York City experienced an outbreak of Legionellosis attributed to several hospital
cooling systems in different parts of the city in summer 2015. Public health officials made
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announcements to City residents about the cases and the outbreak was reported in the media,
along with health advice for the public.
Findings
F-29. Communication, coordination and cooperation between GCHD,the City of Flint and
MDHHS were inadequate to protect Flint residents from public health threats resulting
from inadequately treated Flint River water.
F-30. The rate of follow-up on children with elevated blood lead levels through January 2016
was unacceptable, illustrating a low level of coordination between GCHD and MDHHS and
insufficient resources devoted to this task.
F-31. Management of the Flint River-sourced water supply may have contributed to the
outbreaks of Legionellosis cases in 2014 and 2015 in Genesee County. Although the
definitive cause of the outbreaks is uncertain at the time of publication, GCHD and
MDHHS did not notify the public of the outbreaks in a timely fashion in order to urge
caution.
Recommendations
R-26. Improve follow-up on public health concerns between GCHD, MDHHS and the City of Flint
now and in the future,to effect timely, comprehensive, and coordinated activity and
ensure the best health outcomes for children and adults affected.
R-27. Presume that the risk of Legionella may remain elevated in the Flint water distribution
system and must take appropriate steps with public and private partners to monitor and
mitigate that risk as concerns about water quality continue in the City of Flint.
R-28.Coordinate with state officials (MDHHS) and with local healthcare professionals and
healthcare institutions in Genesee County and the City of Flint to mitigate the risk of
Legionellosis in 2016 and beyond.
It is not clear whether the switch back to DWSD in October 2015 and subsequent addition
of corrosion control will change the conditions for Legionella growth in the Flint water
distribution system. In addition,the strong predominance of cases linked to healthcare
exposure at one particular hospital in Flint underscores the critical importance of
appropriate and timely antiseptic use by healthcare facilities to reduce the risk of
Legionellosis.
To facilitate appropriate collection of Legionella specimens that will permit tracing of
Legionella species in the setting of any further outbreaks, healthcare professionals in
Genesee County should be vigilant and err on the side of collecting respiratory specimens
before initiating therapy in cases of presumed Legionellosis.
U.S. Environmental Protection Agency (EPA) Oversight and the Lead and
Copper Rule
Defined Role
EPA has responsibility under the Safe Drinking Water Act to set and enforce health-based
drinking water quality standards. EPA establishes National Primary Drinking Water Regulations
that set enforceable maximum contaminant levels in drinking water and prescribe treatment
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requirements. Each standard also includes requirements for water systems to test for
contaminants in the water to make sure standards are achieved.
EPA regulates public water systems through its Public Water System Supervision (PWSS) program.
From the description of that program:
EPA's and states'primary means of monitoring public water system compliance with the
SDWA and its implementing regulations is the review and evaluation of analytical results
of water samples collected by public water systems. These reports provide the water
systems and regulators with the data they need to ensure that drinking water monitoring
is ongoing and that the drinking water standards are being met. When results indicate
that a contaminant is present at a level that exceeds standards, states and EPA work with
public water systems to take steps to prevent or remove the contaminants, and notify
consumers so that they can make informed choices.62
EPA is required to oversee the regulatory actions of state and local agencies and ensure that local
public water suppliers adhere to the standards set under the SDWA.63 The SDWA authorizes the
EPA to delegate primary enforcement responsibilities to the states. Forty-nine states, including
Michigan, have this delegated authority.
While the states are delegated regulatory primacy,there are two sections of the SDWA that give
EPA authorization to act:
a. Sec. 1414 of the Act says that when the agency finds a public water system out of
compliance,the EPA must notify the state and public water system of the violation. If
after 30 days the state has not commenced enforcement action,then the EPA must issue
an order to comply. In the case of Flint, EPA did not use this authority as required by the
SDWA.
b. Sec. 1431 of the Act grants emergency powers to the EPA when the Administrator is
aware of a contaminant or threat "which may present an imminent and substantial
endangerment to the health of persons, and that appropriate state and local authorities
have not acted to protect the health of such persons,the EPA Administrator may take
such actions as he or she may deem necessary in order to protect the health of such
persons."The EPA used this authority when it issued its emergency order on January 21,
2016.
Lead and Copper Rule:
The Lead and Copper Rule (LCR) is intended to protect public health by reducing lead and copper
in drinking water at customers'taps. For the rule to be effective, and for lead and copper
contamination to be detected, water sampling practices must be rigorous. Ample industry
guidance 64 emphasizes the requirements for this rigor, which include selecting residences at high
62 www.epa.gov/compliance/safe-drinking-water-act-sdwa-compliance-monitoring
63 Before the federal EPA was established,states regulated drinking water.The SDWA kept that regulatory structure
in place and assigned EPA oversight responsibility for state regulatory activities.
64 See,for example,"A Field Comparison of Sampling Protocols for Measuring Lead in Drinking Water,"Porter,A.,M.
Del Toral,and M.Schock. In Proceedings,Water Quality Technology Conference,Long Beach,CA, November 3-7,
2013,American Water Works Association, Denver,CO(2013).
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risk for lead exposure, prohibiting pre-flushing and aerator removal, and observing minimum
stagnation times. More fundamentally, public water systems must identify the LSLs in their
service areas, advise customers of their presence and potential implications, and facilitate full
service line replacements in the event of action level exceedances.The LCR also requires public
water systems to minimize lead and copper levels in drinking water by controlling corrosion in
the distribution system, which is achieved by implementing corrosion control treatment (CCT).
Unfortunately, despite the clarity of its intent,the LCR's language has been subject to various
interpretations from one state, and one water system,to another. Though MDEQ's
misinterpretations may be among the most egregious examples of lax and myopic compliance
practices,there are pronounced concerns that the effectiveness of the rule has been
compromised.65 EPA is in the process of reviewing and revising the LCR through its established
rulemaking procedures.
While the states are delegated regulatory primacy,40 CFR 141.82(i) gives the EPA Regional
Administrator authority to review treatment decisions made by a state and issue federal
treatment determinations consistent with the LCR.
Nscussion
Prior to Flint's water supply conversion, EPA's delegation of primacy for enforcement of the
SDWA in Michigan had been challenged by a series of disagreements and concerns over
compliance requirements and sampling practices.66 These were heightened with the series of
events that precipitated the water crisis. EPA Region V was first notified of a potential problem in
Flint by resident LeeAnne Walters, who called to inform them of the high lead level (104 ppb)
found in her drinking water. In early 2015, EPA's Miguel Del Toral worked with Walters to
diagnose water quality problems at her residence. During this time, EPA inquired (repeatedly)
about CCT at the Flint WTP, advised MDEQthat the LCR unambiguously requires CCT, and were
told incorrectly that Flint had an optimized corrosion control program.
In this timeframe, EPA was trying to determine whether the high lead levels at LeeAnne Walters's
house represented an isolated or system-wide problem. Ultimately, it required LeeAnne
Walters's inquiry of Flint Utiliites Department personnel for EPA to learn that Flint did not have
CCT in place. It took 2 months from EPA's first inquiry for MDEQto acknowledge that Flint was
not implementing CCT.
Given this information, EPA tried to convince MDEQ by persuasion and forthright referencing to
the LCR that Flint needed to add CCT(as DWSD had been doing for decades) However, MDEQ was
entrenched in its (incorrect) position that two 6-month monitoring periods are allowed before a
decision on CCT is required. MDEQ forestalled imposing the requirement for CCT pending
issuance of a legal opinion.
65 See,for example,Dr.Yanna Lambrinidou's dissenting opinion on long-term revisions for the LCR,submitted to the
EPA National Drinking Water Advisory Council in October 2015("EPA NDWAC LCR WG,Dissenting Opinion,Oct.
2015"),www.epa.gov/sites/production/files/2015-11/documents/ndwacicrstatementofdissent.pdf;and the
Northeast-Midwest Institute's Elin Betanzo's article,"Clarifications Needed to Strengthen the Lead and Copper Rule
Working Group's Recommendations for Long Term Revisions to the Federal Lead and Copper Rule,"November 17,
2015,www.nemw.org/wp-content/uploads/2015/11/NEMWI-LCR-recommendations.pdf.
66 FWATF interviews with Miguel Del Toral.Also see April 27,2015,e-mail exchanges among MDEQ's Cook,Busch
and Prysby regarding Del Toral's question on corrosion control treatment.
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EPA was similarly hampered by poor information derived from Flint's flawed water quality
sampling for LCR compliance. Not only did MDEQ persist in prescribing sampling methods that
limited opportunities for detection of lead contamination, it did not ensure that a proper sample
pool was obtained from the Flint system.The first 6-month monitoring period results showed the
90th percentile lead level results to be 6 ppb, and the second 6-month monitoring period results
showed the 90th percentile to be 11 ppb. Both of these outcomes fell beneath the lead action
level of 15 ppb. Unfortunately, because of the flawed sampling pool and sampling techniques,the
extent of the lead problem was under-reported. It came to light in September 2015 with the
results of Dr. Marc Edwards's lead sampling program. After testing 252 water samples taken in
Flint,the 90th percentile 67 of Dr. Edward's samples was found to be 25 ppb, and more than 100
samples had lead over 5 ppb.
Even given the City's flawed sampling program, EPA staff did become aware of the potential risks
in April 2015 when MDEQ's failure to require CCT was revealed, and EPA leadership was advised
of acute concerns in an interim report by Miguel del Toral in June 2015:
"In effect, the City of Flint stopped providing treatment used to mitigate lead and copper
levels in the water. In accordance with the Lead and Copper Rule(LCR), all large systems
(serving greater than 50,000 persons) are required to install and maintain corrosion
control treatment for lead and copper. In the absence of any corrosion control treatment,
lead levels in drinking water can be expected to increase.
The lack of mitigating treatment is especially concerning as the high lead levels will likely
not be reflected in the City of Flint's compliance samples due to the sampling procedures
used by the City of Flint for collecting compliance samples.i68
However, with the exception of the strident e-mails and interim report by Del Tora1,69 EPA
refrained from elevating concerns or taking action. EPA did not insist on implementation of CCT
between the end of April 2015, when it learned CCT was not in place, and July 21, 2015, when the
second round of LCR monitoring results ended MDEQ's misinformed interpretaton of the LCR.
Only after broad public revelation of the magnitude of the crisis and of MDEQ's multiple
failures—and, not coincidentally,the opportunity to garner positive recognition—did EPA
exercise its authority under the SDWA and issue its Emergency Order on January 21, 2016.
EPA did not cause the problem in Flint, and it was EPA employees (in particular Del Toral) who
asserted the need for Flint to have CCT in place. Unfortunately, EPA was not insistent or forceful
enough to prompt MDEQto require Flint to add CCT for almost 3 months after EPA was aware of
its absence. This needlessly extended the time during which Flint residents were exposed to
corrosive drinking water with potentially high levels of lead.
Finally, EPA entertained and acquiesced to MDEQ's request for a legal opinion regarding the long-
standing and well-understood requirement for corrosion control, ultimately issuing a clarification
memo on LCR compliance requirements that suggested ambiguities.
67 For a discussion of the arithmetic related to calculation of the 90th percentile,see the YouTube video:"How to
calculate Flint's 90th percentile lead level with EMU math professor Chris Gardiner,"
www.youtube.com/watch?v=9pqlOOzr7OO&feature=em-share video user.
68"Interim Report: High Lead Levels in Flint, Michigan,"by Miguel del Toral,transmitted to Thomas Poy,Chief,
Ground Water and Drinking Water Branch,on June 24,2015;p.2.
69 See,for example,Miguel Del Toral's e-mail to Jennifer Crooks MDEQ dated April 25,2015.
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Findings
F-32. EPA failed to properly exercise its authority prior to January 2016.The agency's conduct
casts doubt on its willingness to aggressively pursue enforcement (in the absence of
widespread public outrage). EPA could have exercised its powers under Section 1414 and
Section 1431 of the SDWA or under the LCR,40 CFR 141.82(i).
F-33. Despite the clear intent of the LCR, EPA has accepted differing compliance strategies that
have served to mute its effectiveness in detection and mitigation of lead contamination
risks.These strategies have been adopted at water systems and primacy agencies across
the country.Though there may be some ambiguity in LCR rule, none of it relates to what
MDEQ should have done in Flint. There was and remains no justification for MDEQ not
requiring corrosion control treatment for the switch of water source to the Flint River.
F-34. EPA was hesitant and slow to insist on proper corrosion control measures in Flint. MDEQ
misinformation notwithstanding, EPA's deference to MDEQ,the state primacy agency,
delayed appropriate intervention and remedial measures.
F-35. EPA tolerated MDEQ's intransigence and issued, on November 3, 2015, a clarification
memo on the LCR when no such clarification was needed.
Recommendations
R-29. Exercise more vigor, and act more promptly, in addressing compliance violations that
endanger public health.
R-30. In collaboration with the NDWAC and other interested partners, clarify and strengthen
the LCR through increased specificity and constraints, particularly requirements related to
LCR sampling pools, sample draw protocols, and LSL replacements—and, more generally,
strengthen enforcement protocols with agencies delegated primacy.70
The LCR should be modified to address a host of issues that have been the subject of
ongoing debate and were tragically exemplified by the Flint water crisis. In particular,the
LCR should be revised to:
o Unambiguously require optimized corrosion control treatment as a default practice for
all large public works systems, and consider extending this requirement to small and
medium-sized public water systems.71 EPA should remove any loopholes or flexible
provisions that could be misinterpreted as allowing utilities to defer or avoid corrosion
control, as was done in Flint. Optimized corrosion control will continue to be
important in the long term, even after LSLs are replaced, due to other sources of lead
in the distribution system such as lead solder and brass fixtures.
70 For a further discussion of opportunities to strengthen the LCR,see Dr.Yanna Lambrinidou's dissenting opinion on
long-term revisions for the LCR,submitted to the EPA National Drinking Water Advisory Council in October 2015
("EPA NDWAC LCR WG,Dissenting Opinion,Oct.2015"),www.epa.gov/sites/production/files/2015-
11/documents/ndwacicrstatementofdissent.pdf.
71 The current LCR language requires corrosion control for small and medium-sized systems only if water testing
indicates action level exceedances,and it allows cessation of treatment if subsequent testing is below action levels.
EPA should define procedures for small and medium-sized systems to safeguard public health and water quality
through evaluation of corrosion control treatment requirements.
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o Reiterate (and clarify) lead-in-water tap monitoring and sampling protocols to ensure
that lead sampling will capture the worst-case lead levels in the highest risk homes, as
the LCR intends.
o Clarify requirements for full LSL replacement, avoiding or eliminating language that
allows utilities to count a LSL as "replaced" if water from a service line tests under the
lead action limit in a one-time sample.
o Ban partial LSL replacements, which have been found by the CDC to increase risks of
elevated blood lead levels.
In addition,the 15 ppb lead action level in the LCR should be revisited given that It is
widely acknowledged that no lead is safe, and that the CDC recently lowered its 10
micrograms/deciliter"blood lead level of concern"to a 5 micrograms/deciliter"reference
level."
Also,the LCR should call for frequent and accessible public outreach and education on
lead-in-water risks, including instructions on steps consumers can take to protect
themselves.The LCR should require utilities to provide customers with explicit and urgent
public notification of lead risks associated with activities that may cause physical
disturbance of LSLs; inform customers when a LSL is present at their home; and provide
customers clear information on how to request testing of lead-in-water levels in their
homes.
Perhaps most fundamentally,the LCR should mandate proactive,full replacement of
LSLS72 in a manner that appropriately balances risks and financial impacts. The LCR should
require LSL replacements to be explicitly incorporated into water utilities' renewal and
replacement programs with required (and monitored)timelines that preclude undue
(multi-decade) delays in replacements.
R-31. Engage Michigan representatives in ongoing LCR revisions and development of
enforcement protocols at EPA and MDEQ.
EPA is conducting a process to define revisions to the LCR, which provides an opportunity
to clarify ambiguities in requirements and to strengthen measures to protect public health
and safety. State and local representatives, chastened by Flint's experience, should
participate in this revision process and ensure lessons learned are clearly and effectively
communicated to decision-makers, including the National Drinking Water Advisory
Council and EPA.
Issues Presented by the Flint Water Crisis
While our review has enabled us to draw a number of findings and conclusions about respective
roles, it also occasions us to speak to issues and consequences that transcend the accountabilities
assigned to individual agencies or entities. These issues convey many of the lessons learned from
72 This recommendation is consistent with recommendations of the Lead and Copper Rule Working Group:Report of
the Lead and Copper Rule Working Group To the National Drinking WaterAdvisory Council,August 24,2015.
https://www.epa.gov/sites/prod uction/fi les/2016-01/documents/ndwacicrwgfi na I reporta ug2015.pdf
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