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March!!
2016!
Flint!Water!Advisory!Task!Force!
FINAL!REPORT!
1
Commissioned!by!the!Office!of!Governor!Rick!Snyder!
State!of!Michigan!
Flint Water Advisory Task Force
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
! ! !
Table!of!Contents!
!
Executive!Summary!...........................................................................................................................!1!
!"##$%&'!($()#)*(!...............................................................................................................................!1!
+'!)%,)-'./'0.1)%*#)*('2$,3"%)-!.............................................................................................................!1!
24+52'6)#7)%-8,9:';8$%<)'$*='!>.9)'./'?)1,)@!................................................................................!2!
+>A*.@3)=<)#)*(-!.................................................................................................................................!5!
2,*=,*<-'./'(8)'5$-A'2.%>)!......................................................................................................................!6!
?)>.##)*=$(,.*-'./'(8)'5$-A'2.%>)!....................................................................................................!10!
Background!.....................................................................................................................................!15!
23,*(:'6,>8,<$*!......................................................................................................................................!15!
4$()%';%,-,-!..........................................................................................................................................!15!
!"##$%&'5,#)3,*)'./'B)&'C1)*(-!..........................................................................................................!16!
?)<"3$(.%&';.*()D(!...............................................................................................................................!22!
E"73,>'F)$3(8';.*()D(!...........................................................................................................................!23!
Roles!of!Government!Entities!in!the!Flint!Water!Crisis!.....................................................................!26!
!!!Michigan!Department!of!Environmental!Quality!(MDEQ)!..............................................................!26!
G)/,*)='?.3)!..........................................................................................................................................!26!
G,->"--,.*!.............................................................................................................................................!27!
2,*=,*<-!.................................................................................................................................................!28!
?)>.##)*=$(,.*-!................................................................................................................................!29!
!!!Michigan!Department!of!Health!and!Human!Services!(MDHHS)!....................................................!30!
G)/,*)='?.3)!..........................................................................................................................................!30!
G,->"--,.*!.............................................................................................................................................!31!
2,*=,*<-!.................................................................................................................................................!33!
?)>.##)*=$(,.*-!................................................................................................................................!34!
!!!Michigan!Governor’s!Office!...........................................................................................................!35!
G)/,*)='?.3)!..........................................................................................................................................!35!
G,->"--,.*!.............................................................................................................................................!36!
2,*=,*<-!.................................................................................................................................................!38!
?)>.##)*=$(,.*-!................................................................................................................................!38!
!!!State-Appointed!Emergency!Managers!.........................................................................................!39!
G)/,*)='?.3)!..........................................................................................................................................!39!
G,->"--,.*!.............................................................................................................................................!39!
Findings!................................ .................................................................................................................!40!
?)>.##)*=$(,.*-!................................................................................................................................!41!
!!!City!of!Flint!...................................................................................................................................!42!
G)/,*)='?.3)!..........................................................................................................................................!42!
G,->"--,.*!.............................................................................................................................................!43!
2,*=,*<-!.................................................................................................................................................!44!
?)>.##)*=$(,.*-!................................................................................................................................!45!
!!!Genesee!County!Health!Department!(GCHD)!................................................................................!46!
G)/,*)='?.3)!..........................................................................................................................................!46!
G,->"--,.*!.............................................................................................................................................!46!
2,*=,*<-!.................................................................................................................................................!48!
?)>.##)*=$(,.*-!................................................................................................................................!48!
!!!U.S.!Environmental!Protection!Agency!(EPA)!Oversight!and!the!Lead!and!Copper!Rule!.................!48!
G)/,*)='?.3)!..........................................................................................................................................!48!
G,->"--,.*!.............................................................................................................................................!50!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
! ! !
2,*=,*<-!.................................................................................................................................................!52!
?)>.##)*=$(,.*-!................................................................................................................................!52!
Issues!P re s e n te d !b y!t h e !Flin t !Water!Cr isis!........................................................................................!53!
!!!The!Reality!of!Environmental!Injustice!..........................................................................................!54!
G,->"--,.*!.............................................................................................................................................!54!
2,*=,*<-!.................................................................................................................................................!55!
?)>.##)*=$(,.*-!................................................................................................................................!55!
!!!Perspectives!from!Flint!.................................................................................................................!55!
!!!Flint!Recovery!/!Remediation!........................................................................................................!56!
?)>.##)*=$(,.*-!................................................................................................................................!57!
!!!State-Wide!Initiatives!...................................................................................................................!58!
?)>.##)*=$(,.*-!................................................................................................................................!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!
!
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!MDEQ!that!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,
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!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!
begun.!!
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!H)<,.*)33$!susceptibility,!and!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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!Direct!and!indirect!economic!impacts!of!th e!F lin t!w a te r!c risis !in clu d e ,!fo r!ex a mple,!financial!conseque nces!to!
individua ls!a n d !h o meowners; !impacts!o n!e c o n o m ic !d ev e lop ment!opp o rtu n itie s!a n d !o n !th e!reven ue !bas e!for!p ub lic!
services;!and!the!costs!of!exacerbated!requirements!for!water!infrastructure!repair!and!rehabilitation!as!well!as!long-
term!public!health!and !soci al!services.!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
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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.
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!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!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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!Paragraph!summaries!of!the!FWATF!members’!background s !a n d !e x p er ie n c e !ar e !provided!as!Appendix!I.!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
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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!largely
4
!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.!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
3
!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!App e n d ix!IV.!As!of!the!time!of!publication,!the!FWA T F!has !not!rece ived !
responses!to!thes e!qu estio ns .!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
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4!
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!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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!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!re p la ce ment!of!entire !LS L s,!and!in!1994!the!water!industry!sought!in!court!to!limit!this!requirement!to!
only!the!publicly!owned!portions!o f!service!line s!(40!F .3d!12 66 ,!AW WA!vs.!EPA,!1994).!In!respo nse ,!EPA !revised !the!
LCR!in!2000!to!allow!for!partial!service!line!replacement—a!practice!the!CDC!later!maintained!was!associated!with!
,*>%)$-)-!in!blood!lea d !lev e ls!(“ Im p o r tan t !U p d at e:!L ea d-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!m an agin g!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.!
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!See,!for!example,!AWW A!press!release:!“AWWA!Board!supports!recommendation!for!complete!removal!of!lead!
service!lines,”!March!8,!2016.!
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!For!example,!there!are!concerns!that!the!vo lunta ry,!customer-initiate d !sa mpling!app ro a ch !r ec o m mended!b y !th e!
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/.!!!
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!NDWAC!and!water!utility!industry!representatives!have!highlighted!concerns!about!the!significant!financial!
resources!and!tim e!req u ired!to !effect!fu ll!LSL!rep lace m en t,!sugg estin g!the !need!to!support!reasonable!yet!aggressive!
scheduling!of!LSL!replacement!throu gh !both !enfo rcem e nt!m eas ures!(w ithin !the!LC R)!an d!resource!co m m itm en ts!o f!
local,!state!a n d !fed e ra l!en t ities .!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
! ! !
5!
January!2016
9
!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!le tte r!to !th e !G o v ern o r !o n !D ec ember!4,!201 5!n o t ing !th e !a cu te !n e ed !fo r!m ore!effective!coordination!of!
activities.!
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Findings'of'the'Task'Force'
Note:'2..(*.()-'$*='()D('-"99.%(,*<'(8)-)'/,*=,*<-'$*='%)>.##)*=$(,.*-'$%)'9%.1,=)=',*'(8)'
,*=,1,="$3'-)>(,.*-'./'(8)'%)9.%(I'58)'/..(*.()-'$*='()D('9%.1,=)'-"7-($*(,1)'=)($,3'$*=',#9.%($*('
>.*()D('/.%'."%'/,*=,*<-'$*='%)>.##)*=$(,.*-I'+3-.'93)$-)'*.()'(8$('(8)'/,*=,*<-'$*='
%)>.##)*=$(,.*-'$%)',*=)9)*=)*('3,-(-J'(8)'/,*=,*<-'=.'*.('>.%%)3$()'.*)K(.K.*)'(.'(8)'
%)>.##)*=$(,.*-I''
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. MDEQ!failed!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!i nad equate!to!p roperly!address!the!pub li c!
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!coo rdin ation !among!l ocal!an d!state!pu bl ic!heal th!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!@8,3)!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!Michi gan!executive!branch!d ecisio ns!rests!with!th e!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!
MDEQ!and!MDHHS.!!
F-14. The!Governor’s!office!continued!to!rely!on!inco rrect!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!ri s ks!of!over-reliance—in!fact,!almost!)D>3"-,1)'
reliance—on!a!few!staff!in!one!or!two!departments!for!information!on!which!key!
decisions!are!based.!
F-17. Official!state!publi c!statements!and!commun icati ons !abou t!the!Fl in t!water!situati on!h ave!
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!ass istan ce!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 !combi nati on!wi th!MDE Q’s!failu res)!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!f ail ed!to!compl y!with!L CR!requirements,!inclu di ng!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!i naccurate!and!i mproper!guid ance!from!MDEQ. !!!
F-27. Many!communities!similarly!rely!on!MDEQ!to!p rovide!techni cal!ass istan ce!and!gui dance!
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,!coordinati on!an d!co operation !between!GCHD,!the!City!of!F li nt!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!ch il dren!with! elevated!bloo d!l ead!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!th e!
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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! ! !
9!
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:'2..(*.()-'$*='()D('-"99.%(,*<'(8)-)'/,*=,*<-'$*='%)>.##)*=$(,.*-'$%)'9%.1,=)=',*'(8)'
,*=,1,="$3'-)>(,.*-'./'(8)'%)9.%(I'58)'/..(*.()-'$*='()D('9%.1,=)'-"7-($*(,1)'=)($,3'$*=',#9.%($*('
>.*()D('/.%'."%'/,*=,*<-'$*='%)>.##)*=$(,.*-I'+3-.'93)$-)'*.()'(8$('(8)'/,*=,*<-'$*='
%)>.##)*=$(,.*-'$%)',*=)9)*=)*('3,-(-J'(8)'/,*=,*<-'=.'*.('>.%%)3$()'.*)K(.K.*)'(.'(8)'
%)>.##)*=$(,.*-I'
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!publ ic!h ealth!f oll ow-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!respond in g!to!exposu re!of!chil dren!to!l ead!
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!th at!con ducted!th e!
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!futu re,!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!inf ormation! providing!the!fou ndati on !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!MDEQ!to!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!distributio n!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!conjunctio n!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!th e!City!of! Fl int!
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!H)<,.*)33$!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!wi th!l ocal!h ealthcare!professio nals !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.!
! !
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
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13!
Issues!Presented!by!the!Flint!Water!Crisis!
!!!Environmental!Injustice:!
R-32. Issue!an!Executive!Order!mandating!guidance!and!training!on!Environmental!Ju stice!
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 !provid e!
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!health care!professional s,!and!h ealth!
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 !F li nt!T oxi c!Expo sure!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!subsidi ary!fund! in! the!Michi gan!Health !End owment!
Fund!to!facilitate!funding!of!health-related!services!for!Flint.!
R-38. Establish!a!comprehensive!Flint!publi c!health! program,!coordinated!with!co unty!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!finan cin g!work!
on!private!property.!
R-42. Revise!and!enhance!information!distributed!by!publ ic!water!systems!on!the!impli cation s!
of!widespread!use!of!lead!in!public!and!private!plumbing.!
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14!
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.! !
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
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15!
Background
10
!
Flint,'Michigan'
The!beleaguered!history!of!Flint,!Michigan!over!the!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.
15
!
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!81
st
!out!of!82!Michigan!
counties!in!health!outcomes.!It!ranked!78
th
!in!length!of!life,!81
st
!in!quality!of!life,!77
th
!in!health!
behaviors,!78
th
!in!social!and!economics!factors,!and!75
th
!in!physical!environment!measures.!Only!
the!quality!of!clinical!care,!for!which!the!county!ranked!22
nd
,!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!journ alists.! In!a d d itio n ,!th e !p u b lic !re co r d !h as !b e e n !su p p le mented!by !th e !re le a se !
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 !pro cess,!pro vide s!m ore!th an!am p le!ba sis!for!our!find ing s!and !recom m e nd ation s.!
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.countyhealthrankings.org/app/michigan/2015/rankings/genesee/county/outcomes/overall/snapshot!!!!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
MARCH!2016!
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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!C'>.3,!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!H)<,.*)33$.
!17
!
Summary'Timeline'of'Key'Events'
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!recommendations:
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.!G)(%.,('L)@-,!January!23 ,!2 0 1 6 ,!
www.detroitnews.com/story/news/politics/2016/01/22/legionnaires-bacteria-found-tests-mclaren-medical-centers-
water/79183428/.!!
18
!Appendix!V!provides!a!further,!more!detailed!timeline!that!attempts!to!synthesize!numerous!timelines!develo ped !
by!other!sources,!including!loc al!media!and !g ov e rn ment!agenc ies .!!
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17!
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:!CI'>.3,!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!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
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! ! !
18!
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.!MDEQ!fails!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:!H)<,.*)33$,!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."!!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
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! ! !
19!
29. February!27,!2015:!Stephen!Busch/MDEQ!e-mails!Jennifer!Crooks!and!Miguel!Del!
Toral/EPA!saying!that!the!90
th
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!$12!million!in!costs!associated!with!
returning!to!DWSD.!
31. March!12,!2015:!Stephen!Busch/MDEQ!e-mails!colleagues!stating!that!there!is!no!
confirmation!of!H)<,.*)33$!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!H)<,.*)33$!at!the!Flint!WTP,!but!that!water!main!breaks!and!leaks!may!permit!entry!
of!H)<,.*)33$!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!Legionellos is!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.”
19
!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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!MDEQ!talking!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!m ad e!a!de finit iv e!lin k !to !th e !w a te r!su p p ly !as !a !so u rc e!o f!H)<,.*)33$.!It!indica tes !th at!th e re!
should!be!vigilance!in!2015!regarding!possible!new!cases!of!Legionellosis,!includin g !c o lle c tio n!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!90
th
!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!G)(%.,('2%))'E%)--!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.!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
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Regulatory'Context'
The!federal!Safe!Drinking!Water!Act
20
!(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:!
'M58)'+>('$"(8.%,N)-'CE+'(.')-($73,-8'#,*,#"#'-($*=$%=-'(.'9%.()>('($9'@$()%'
$*='%)O",%)-'$33'.@*)%-'.%'.9)%$(.%-'./'9"73,>'@$()%'-&-()#-'(.'>.#93&'@,(8'
(8)-)'9%,#$%&'P8)$3(8K%)3$()=Q'-($*=$%=-I'58)'RSST'$#)*=#)*(-'(.'!G4+'
%)O",%)'(8$('CE+'>.*-,=)%'$'=)($,3)='%,-A'$*='>.-('$--)--#)*(:'$*='7)-('$1$,3$73)'
9))%K%)1,)@)='->,)*>):'@8)*'=)1)3.9,*<'(8)-)'-($*=$%=-I'!($()'<.1)%*#)*(-:'
@8,>8'>$*'7)'$99%.1)='(.',#93)#)*('(8)-)'%"3)-'/.%'CE+:'$3-.')*>."%$<)'
$(($,*#)*('./'-)>.*=$%&'-($*=$%=-'P*",-$*>)K%)3$()=QIU
VR
'
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:!
58)'<.$3'./'(8)'H;?',-'(.'9%.1,=)'#$D,#"#'8"#$*'8)$3(8'9%.()>(,.*'7&'%)=">,*<'
3)$='$*='>.99)%'3)1)3-'$('>.*-"#)%-W'($9-'(.'$-'>3.-)'(.'(8)'X6$D,#"#'
;.*($#,*$*('H)1)3'0.$3-Y'6;H0-'$-',-'/)$-,73)I'5.'$>>.#93,-8'(8,-'<.$3:'(8)'H;?'
)-($73,-8)-'%)O",%)#)*(-'/.%'>.##"*,(&'@$()%'-&-()#-'P;4!-Q'$*='*.*K(%$*-,)*('
*.*K>.##"*,(&'@$()%'-&-()#-'PL5L;4!-Q'(.'.9(,#,N)'>.%%.-,.*'>.*(%.3'$*='
>.*=">('9)%,.=,>'#.*,(.%,*<I'!&-()#-'$%)'%)O",%)='(.'9)%/.%#'9"73,>')=">$(,.*'
@8)*'(8)%)'$%)'3)$='$>(,.*'3)1)3')D>))=$*>)-'$('#.%)'(8$*'RZ'9)%>)*('./'(8)'($9-'
(8$('$%)'-$#93)=:'(%)$('-."%>)'@$()%',/',('>.*(%,7"()-'-,<*,/,>$*(3&'(.'3)$='$*='
>.99)%'3)1)3-'$('(8)'($9:'$*='%)93$>)'3)$='-)%1,>)'3,*)-',*'(8)'=,-(%,7"(,.*'-&-()#',/'
(8)'3)$='3)1)3'$('(8)'($9'>.*(,*")-'(.')D>))='(8)'$>(,.*'3)1)3'$/()%'.9(,#$3'
>.%%.-,.*'>.*(%.3'$*=['.%'-."%>)'@$()%'(%)$(#)*('8$-'7))*',*-($33)=I
V\
'
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-regulation s/su m m a ry- sa fe-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!
FLINT!WATER!ADVISORY!TASK!FORCE—FINAL!REPORT!
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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)!;.*(,*")='.9)%$(,.*'$*='#.*,(.%,*<I!All!systems!optimizing!corrosion!control!shall!continue!to!
operate!and!maintain!optimal!corrosion!control!treatment,!including!maintaining!water!quality!parameters!at!or!
above!minimum!values!or!within!ranges!designated!by!the!State!under!paragraph!(f)!of!this!section,!in!accordance!
with!this!paragraph!for!all!samples!collected!under!§141.87(d)!through!(f).!
26
!Citations!offered!in!“Elevated!Blood!L ea d !Le v els !in !Ch ild r en !A ss o cia te d !With!the!Flint !D rin kin g !Water!Crisis:!A!
Spatial!Analysis!of!Risk!and!Public!Health!Response,”!by!Mona!Hanna-Attisha,!MD,!MPH;!Jenny!LaChance,!MS;!
Richard!Casey!Sadler,!PhD;!and!Allison!Champney!Schnepp,!MD,!+#)%,>$*']."%*$3'./'E"73,>'F)$3(8:!November!2015.!
27
!For!a!discussion!of!the!prevalent!use!of!lead!in!the!United!States!and!the!lead!industry’s!conduct!in!light!of!the!
determination!of!its!toxicity,!see!H)$='4$%-^'58)'E.3,(,>-'./'!>,)*>)'$*='(8)'2$()'./'+#)%,>$W-';8,3=%)*'(2013),!by!
Gerald!Markowitz!and!David!Rosner,!who!are!interviewed!on!National!Public!Radio’s!2%)-8'+,%!in!a!Ma rc h !3,!2 0 16 !
episode!titled,!“America's!'Lead!Wars'!G o!Beyond!Flint,!Mi ch.:!‘It's!Now!R e ally !E ve ry where.’”!!
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!H)<,.*)33$!bacteria!can!cause!relatively!mild!illness!in!generally!healthy!
adults!but!can!cause!life-threatening!illness!and!even!death!in!elderly!and!immune-compromised!
patients.!Such!infections!almost!never!occur!in!children.!Legionellosis,!the!name!given!to!
infections!caused!by!H)<,.*)33$!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!H)<,.*)33$!must!be!reported!to!
local!and!state!public!health!authorities.!Public!health!specialists!known!as!epidemiologists!
conduct!analyses!of!cases,!especially!when!the!pattern!of!cases!exceeds!historical!levels!in!a!given!
jurisdiction.!!!
Prior!to!the!switch!to!the!Flint!River!as!a!source!of!drinking!water!in!2014,!the!number!of!cases!of!
Legionellosis!in!Genesee!County!had!not!exceeded!10!cases!per!year!for!several!years.!From!June!
2014!to!March!2015,!there!were!45!cases!of!Legionellosis!in!Genesee!County,!with!5!deaths.!This!
was!described!by!an!expert!from!the!CDC!in!2015!as!“one!of!the!largest![outbreaks!of!
Legionellosis]!in!the!past!decade.”!About!40!percent!of!the!cases!had!known!exposure!to!possible!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
29
!Prior!to!the!Flint!water!crisis,!environmental!assessments!were!not!performed!for!children!with!blood!lead!levels!
of!5!to!9!micrograms!per!deciliter,!but!on ly!f o r!c h il d re n !with!blood !le a d !le v e ls !o f!1 0 !micrograms!per!dec ilit e r!o r!
higher.!!!!
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25!
healthcare!sources!of!H)<,.*)33$;!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!H)<,.*)33$!from!patients!diagnosed!
with!the!disease!in!2014-15.!It!is!speculated!that!clinical!respiratory!specimens!(sputum)!were!not!
available!because!antibiotic!treatment!was!started!presumptively!after!a!positive!urine!test!for!
H)<,.*)33$,!rendering!any!subsequent!specimens!indeterminate.!Although!urine!specimens!can!
confirm!a!diagnosis!of!Legionellosis,!urine!specimens!cannot!be!used!for!determining!the!source!
of!H)<,.*)33$.!
Subsequent!data!reported!publicly!by!MDHHS!on!January!21,!2016,!indicated!that!there!were!42!
additional!cases!of!Legionellosis!from!May!2015!through!October!2015,!with!4!deaths.
31
!Taking!
the!2014-15!data!together!with!additional!2015!data,!MDHHS!reported!that!36!percent!of!cases!
likely!were!exposed!to!Flint!River-sourced!drinking!water,!and!that!again!there!were!too!few!
clinical!specimens!to!draw!definitive!conclusions!about!contaminated!water!as!the!source!of!
infection!in!these!cases.!!!
At!the!time!of!this!report,!the!pattern!of!an!abrupt!increase!in!cases!of!Legionellosis!in!Genesee!
County!in!2014-15!that!occurred!after!a!shift!to!the!Flint!River!strongly!implicates!the!water!
source!and!treatment!of!the!water!as!a!potential!cause!of!higher!Legionellosis!case!incidence.!!
EPA!experts!Del!Toral!and!Lytle!have!suggested!that!the!treated!water!from!Flint!WTP!has!
disrupted!the!previously!stable!lining!and!“biofilm”!of!water!lines!to!such!an!extent!that!chlorine!
in!the!water!supply!has!been!excessively!depleted.!Del!Toral!also!suggested!that!the!flushing!of!
fire!hydrants!may!have!stripped!the!biofilm!and!released!bacteria!(H)<,.*)33$)!that!the!biofilm!
had!contained.!!If!true,!this!may!have!led!to!a!situation!where!H)<,.*)33$!may!grow!more!
abundantly!than!in!a!distribution!system!conveying!properly!treated!drinking!water.!!!
Unfortunately,!these!are!hypotheses.!Definitive!data!for!the!analysis!of!cases!in!2014!and!2015!
are!not!available,!so!it!is!not!possible!to!be!conclusive!about!the!cause.!Nonetheless,!great!
concern!should!remain!about!the!clustering!of!cases!among!patients!potentially!exposed!in!
healthcare!facilities!in!the!City!of!Flint!and!cases!among!individuals!whose!homes!receive!water!
from!the!Flint!WTP.!
MDHHS!and!GCHD!have!indicated!that!they!will!have!a!high!level!of!vigilance!in!monitoring!for!
cases!of!Legionellosis!in!2016.!They!have!reminded!healthcare!professionals!treating!patients!in!
Genesee!County!to!obtain!appropriate!clinical!(respiratory)!specimens!in!suspected!cases!of!
Legionellosis!before!initiating!treatment.!This!cooperation!between!public!health!and!medical!
professionals!will!be!crucial!to!identifying!the!cause!of!future!Legionellosis!cases!in!Genesee!
County!and!controlling!outbreaks!in!the!future.!In!addition,!a!team!of!scientists!from!multiple!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
30
!Some!of!these!cases!had!exposure!to!both!Flint!River!water!and!to!healthcare!facilities.!
31
!Twenty-two!of!the!42!cases!reported!from!May-October!2015!had!known!healthcare-related!exposu res!in!th e!tw o!
weeks!prior!to!development!of!symptoms,!and!21!of!these!were!from!the!same!healthcare!facility.!Sixteen!of!the!42!
cases!of!Legionellosis!in!Genesee!C o un t y!fr om!May-October!2015!were!in!individuals!who!had!neither!exposure!to!a!
healthcare!facility!nor!exposure!to!Flint!River-sourced!water.!
!
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Michigan!universities!is!expected!to!test!Flint!drinking!water!in!2016!to!assess!whether!conditions!
in!the!system!created!an!environment!that!heightened!the!likelihood!of!H)<,.*)33$!
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!standards.”
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.”
33
!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,”!Jun e!4,!2 01 5.!!
Prepared!by!the!Michiga n!O ffice!o f!the!G rea t!Lake s,!in!c o llab o ra tio n !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/deq/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!problematic
34
!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,!2 0 13 !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!Hu ro n!so urc e!w ate r),!Pos e!an !incre ase d!risk !of!d isinfec tion !by-product!(carcinogen)!expo su re!to!
public!health!(Flint!River!vs.!Lake!Huron!source!water),!Trigger!additional!regulatory!requirements!under!the!
Michigan!Safe!Drinking!Water!Act.”!!
35
Internal!M a rc h !2 7 ,!20 1 3 !MDEQ!e-mail!(Sygo!to!Busch)!no tin g,!am o ng !oth er!p oin ts:!!“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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28!
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!
MDEQ!to!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 MDEQ!failed!(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 MDEQ!failed!to!promptly!require!corrosion!control!even!after!the!initial!6-month!
monitoring!period!results!were!received!and!90
th
!percentile!lead!sampling!results!
were!at!6!ppb,!which!would!have!disqualified!Flint!from!being!exempted!from!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
36
!See!Appendix!II!for!co p ies !o f!th e !F WATF’s!lette rs !to !G o v er n o r!R ick !S n yd e r.!
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29!
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,!proh ibitin g!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!
!!!
Michigan Department of Health and Human Services (MDHHS)
Defined'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!appropria te!m ed ical!ca re.!
!
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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!
H)<,.*)33$!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!H)<,.*)33$:!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.!
H)<,.*)33$!bacteria!live!in!water!supplies!and!flourish!in!warmer!temperatures!and!standing!
water,!present!in!locations!such!as!cooling!towers!for!air!conditioning!systems.!It!is!a!reportable!
disease,!meaning!that!any!healthcare!professional!who!makes!the!diagnosis!must!report!the!case!
to!the!local!health!department.!In!turn,!the!local!health!department!reports!cases!to!the!state!
health!department.!Fewer!than!10!cases!of!Legionellosis!per!year!were!reported!by!GCHD!in!
years!immediately!preceding!the!switch!of!water!source!to!the!Flint!River.!
MDHHS!assisted!GCHD!with!evaluation!of!the!Legionellosis!outbreak!that!began!in!2014!and!
extended!into!early!2015,!at!GCHD’s!request.!!When!the!initial!evaluation!report!was!issued!by!
MDHHS!epidemiology!team!in!May!2015,!it!is!unclear!why!they!asserted!the!“the!outbreak!is!
over”;!subsequent!reports!released!in!January!2016!indicated!that!additional!cases!occurred!
beginning!in!May!2015.
42
!MDHHS!indicated!in!its!May!2015!report!that!data!were!inconclusive!
regarding!a!community!source!such!as!the!water!supply!because!of!a!lack!of!clinical!specimens.!!!
While!MDHHS’s!statement!regarding!the!absence!of!conclusive!evidence!of!a!community!source!
has!scientific!merit,!it!is!evident!that!MDHHS!was!not!calibrating!its!evaluation!for!the!unusual!
circumstance!of!the!switch!to!the!Flint!River!in!April!2014.!In!fact,!although!the!report!mentions!it!
as!a!possible!source,!there!is!no!explicit!mention!of!the!switch!to!a!new!raw!water!source!in!Flint,!
and!new!water!treatment!protocols,!as!possible!causal!factors.!Although!there!was!a!January!
2015!meeting!that!included!MDHHS,!MDEQ!and!GCHD!regarding!cases!of!Legionellosis!in!
Genesee!County,!subsequent!discussions!of!Legionellosis!appear!to!have!occurred!within!the!silos!
of!MDEQ!and!MDHHS!until!late!2015,!and!remained!uncoordinated!until!the!Governor’s!
announcement!about!ongoing!H)<,.*)33$'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!i nad equate!to!p roperly!address!the!pub li c!
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!coo rdin ation !among!l ocal!an d!state!p ubl ic!h ealth!staf f!and !leadershi p!
regarding!Legionellosis'cases!in!2014-2015!was!inadequate!to!address!the!grave!nature!of!
this!outbreak.!The!fact!that!these!cases!occurred!@8,3)!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!infec tio n s!g o in g !fo rw a rd ;!(b )!t ak e !timely!steps!
to!minimize!those!risks !in!Flint!drink ing!w ate r!by!w orkin g!w ith!EP A,!M D EQ !an d!Flint!W T P;!(c)!coo rdina te!w ith!
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!-.#)!aspects!of!the!crisis!and!briefed!on!-.#)!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!9.--,73)'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!dec ision!to !contra ct!
with!LAN!to!upgrade!the!Flint!WTP!to!treat!water!from!th e!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!o f!Flint!d rink ing !wa ter!situ atio n!(b o il!
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:!H)<,.*)33$.!
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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!Michi gan!executive!branch!d ecisions!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!
MDEQ!and!MDHHS.!!
F-14. The!Governor’s!office!continued!to!rely!on!incorrect!informatio n!p rovided!b y!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!highli ghts!th e!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!MDEQ!to!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
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
!Impose d !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 !rep e ale d!P A !4!in !
November!2012,!but!a!subsequent!statute!was!passed!by!the!legislature !in !D ec e m b e r!2 0 12 :!PA!436!of!2012.!That!
statute!is!not!subject!to!a!voter!referendum!and!has!been!in!effec t! since !March!201 3.!
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 !aga in!in!Jun e!2 01 3;!Da rne ll!Earle y!replaced!Brow n!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.
53
!
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!Question s!and!Answ ers,"!Fe bruary!16,!2015,!posted!to!
City!of!Flint!website!at!www.cityofflint.com/wp-content/uploads/W ater- 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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41!
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!MDEQ’s!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,!Resolutio n !1 5 0 3 02.1,!conta in e d !n o!
informat io n !reg a rd in g!t he !D WSD!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!C'>.3,!
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!WTP.
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!includ ed !in!Ap p en dix!IV);!res po ns es!w ere !no t!receiv ed !prio r!to!p ub licatio n!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.
60
!
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!
instruction s!t o !pu b lic !w a te r!sy st ems)!this!clears!p a rt icu la te !lea d !o u t!o f!th e !p lu mbing!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!MDEQ!to!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!H)<,.*)33$!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!H)<,.*)33$:!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!
H)<,.*)33$.!!!
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,!
H)<,.*)33$'and!other!bacteria!may!have!been!released.!In!addition,!EPA!experts!Del!Toral!and!
Lytle!believe!that!corroding!pipes!likely!absorbed!chlorine!in!the!water,!leading!to!extremely!low!
chlorine!levels!that!were!insufficient!to!kill!H)<,.*)33$!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!
H)<,.*)33$'in!healthcare!facilities.!McLaren!Medical!Center!in!Flint!responded!to!the!incident!by!
hiring!a!H)<,.*)33$'expert,!spending!$300,000!for!systems!to!eliminate!the!bacteria,!and!changing!
practices!on!their!wards!to!instruct!patients!not!to!take!showers!(because!aerosols!can!spread!
H)<,.*)33$).!
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!H)<,.*)33$!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,!@8,>8',-'$3@$&-'$--.>,$()='@,(8'@$()%'-"993,)-:!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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48!
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!H)<,.*)33$!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'H)<,.*)33$!specimens!that!will!permit!tracing!of!
H)<,.*)33$'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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49!
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:!
CE+_-'$*='-($()-_'9%,#$%&'#)$*-'./'#.*,(.%,*<'9"73,>'@$()%'-&-()#'>.#93,$*>)'@,(8'(8)'
!G4+'$*=',(-',#93)#)*(,*<'%)<"3$(,.*-',-'(8)'%)1,)@'$*=')1$3"$(,.*'./'$*$3&(,>$3'%)-"3(-'
./'@$()%'-$#93)-'>.33)>()='7&'9"73,>'@$()%'-&-()#-I'58)-)'%)9.%(-'9%.1,=)'(8)'@$()%'
-&-()#-'$*='%)<"3$(.%-'@,(8'(8)'=$($'(8)&'*))='(.')*-"%)'(8$('=%,*A,*<'@$()%'#.*,(.%,*<'
,-'.*<.,*<'$*='(8$('(8)'=%,*A,*<'@$()%'-($*=$%=-'$%)'7),*<'#)(I'48)*'%)-"3(-',*=,>$()'
(8$('$'>.*($#,*$*(',-'9%)-)*('$('$'3)1)3'(8$(')D>))=-'-($*=$%=-:'-($()-'$*='CE+'@.%A'@,(8'
9"73,>'@$()%'-&-()#-'(.'($A)'-()9-'(.'9%)1)*('.%'%)#.1)'(8)'>.*($#,*$*(-:'$*='*.(,/&'
>.*-"#)%-'-.'(8$('(8)&'>$*'#$A)',*/.%#)='>8.,>)-I
TV
'
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-com pliance- monitoring!!
63
!Before!the!federal!EPA!was!established,!states!regulated!drinking!water.!The!SDWA!kept!that!regulatory!structure!
in!place!an d !a ss ign e d !E PA !o v er sig ht !res p o n sib ility !fo r!s ta te!re g u lat o ry!a c tivit ies .!!!
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!E%.>))=,*<-,!Water!Quality!T e c h n o lo g y !C o n f er e n ce ,!L o n g !B e a c h ,!C A ,!N o v e mber!3- 7,!
2013,!American!Water!Works!Association,!Denver,!CO!(2013).!
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50!
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.!
Discussion'
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!MDEQ!that!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!MDEQ!to!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,!sub m itted !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/ndwaclcrstatementofdissent.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/NEM W I-LCR-recomm en d atio ns.p d f.!
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!
90
th
!percentile!lead!level!results!to!be!6!ppb,!and!the!second!6-month!monitoring!period!results!
showed!the!90
th
!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!90
th
!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:!
M`*')//)>(:'(8)';,(&'./'23,*('-(.99)='9%.1,=,*<'(%)$(#)*('"-)='(.'#,(,<$()'3)$='$*='>.99)%'
3)1)3-',*'(8)'@$()%I'`*'$>>.%=$*>)'@,(8'(8)'H)$='$*=';.99)%'?"3)'PH;?Q:'$33'3$%<)'-&-()#-'
P-)%1,*<'<%)$()%'(8$*'aZ:ZZZ'9)%-.*-Q'$%)'%)O",%)='(.',*-($33'$*='#$,*($,*'>.%%.-,.*'
>.*(%.3'(%)$(#)*('/.%'3)$='$*='>.99)%I'`*'(8)'$7-)*>)'./'$*&'>.%%.-,.*'>.*(%.3'(%)$(#)*(:'
3)$='3)1)3-',*'=%,*A,*<'@$()%'>$*'7)')D9)>()='(.',*>%)$-)I''
58)'3$>A'./'#,(,<$(,*<'(%)$(#)*(',-')-9)>,$33&'>.*>)%*,*<'$-'(8)'8,<8'3)$='3)1)3-'@,33'3,A)3&'
*.('7)'%)/3)>()=',*'(8)';,(&'./'23,*(W-'>.#93,$*>)'-$#93)-'=")'(.'(8)'-$#93,*<'9%.>)="%)-'
"-)='7&'(8)';,(&'./'23,*('/.%'>.33)>(,*<'>.#93,$*>)'-$#93)-IU
Tb
''
However,!with!the!exception!of!the!strident!e-mails!and!interim!report!by!Del!Toral,
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!MDEQ!to!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!90
th
!percentile,!see!the!YouTube!video:! ”How%to%
!"#!$#"%&'(#)*%+,'90th#percentile#lead#level#with#EMU #ma th#pro fesso r#Chris#G ard iner ,”!
www.youtube.com/watch?v=9pql00zr700&feature=em-share_video_user. !
68
!“Interim!Report:!High!Lead!Levels!in!Flint,!Michigan,”!by!Miguel!del!Toral,!transmitted!to!Tho m as!P oy,!Ch ief,!
Ground!Water!and!Drinking!Water!Branch,!on!June!2 4,!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!NDW A C !LCR !W G ,!Diss en ting!O p inio n,!O ct.!20 15 ”),!www.epa.gov/sites/production/files/2015-
11/documents/ndwaclcrstatementofdissent.pdf.!
71
!The!current!LCR!language!requires!corrosion!control!for!small!and!medium-sized!systems!only!if!water!testing!
indicates!a ct io n!le v el!e xc e ed a n ce s,!a n d !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!)*-"%)!
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!
LSLs
72
!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!Wo rking !Gro up:!?)9.%('./'
(8)'H)$='$*=';.9 9) %'?"3)'4.%A,*<'0%."9'5. '(8)'L $(,.* $3'G %,*A,* <'4 $ ()%'+= 1,-.%& ';. "*> ,3:'+"<" -('24,!2015.!
https://www.epa.gov/sites/production/files/2016-01/documents/ndwaclcrwgfinalreportaug2015.pdf!
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the!Flint!water!crisis,!evoke!collective!empathy!for!the!Flint!community,!and!speak!to!the!
opportunties!for!the!crisis!to!improve!the!conduct!and!performance!of!government.!
The Reality of Environmental Injustice
Discussion'
Environmental!justice!embraces!two!fundamental!principles:!(1)!the!fair,!non-discriminatory!
treatment!of!all!people;!and!(2)!the!provision!for!meaningful!public!involvement!of!all!people—!
regardless!of!race,!color,!national!origin!or!income—in!government!decision-making!regarding!
environmental!laws,!regulations!and!polices.
73
!Environmental!justice!or!injustice,!therefore,!is!not!
about!intent.!Rather,!it!is!about!process!and!results—fair!treatment,!equal!protection,!and!
meaningful!participation!in!neutral!forums!that!honor!human!dignity.!!
Environmental!injustice!is!not!about!malevolent!intent!or!deliberate!attacks!on!specific!
populations,!nor!does!it!come!in!measures!that!overtly!violate!civil!rights.!Environmental!
injustices!as!often!occur!when!parties!charged!with!the!responsibility!to!protect!public!health!fail!
to!do!so!in!the!context!of!environmental!considerations.!
The!facts!of!the!Flint!water!crisis!lead!us!to!the!inescapable!conclusion!that!this!is!a!case!of!
environmental!injustice.!Flint!residents,!who!are!majority!Black!or!African!American!and!among!
the!most!impoverished!of!any!metropolitan!area!in!the!United!States,!did!not!enjoy!the!same!
degree!of!protection!from!environmental!and!health!hazards!as!that!provided!to!other!
communities.!Moreover,!by!virtue!of!their!being!subject!to!emergency!management,!Flint!
residents!were!not!provided!equal!access!to,!and!meaningful!involvement!in,!the!government!
decision-making!process.!
The!occurrence!of!environmental!injustice!in!the!Flint!water!crisis!does!not!indict!or!diminish!
other!public!and!private!efforts!to!address!Flint’s!many!challenging!circumstances.!However,!
irrespective!of!the!intent!of!the!parties!involved,!the!simple!reality!is!that!the!Flint!water!crisis!is!a!
case!of!environmental!injustice.
74
!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
73
!From!the!Environmental!Justice!Plan!for!the!State!of!Michigan!and!Department!of!Natural!Resources!and!
Environment,!December!17,!2010:!!!
M58)'()%#'c)*1,%.*#)*($3'd"-(,>)c',-'=)/,*)=',*'CD)>"(,1)'G,%)>(,1)'L.I'VZZeKVf'$-'/.33.@-^'
C*1,%.*#)*($3'd"-(,>)'#)$*-'(8)'/$,%:'*.*K=,->%,#,*$(.%&'(%)$(#)*('$*='#)$*,*</"3',*1.31)#)*('./'
6,>8,<$*'%)-,=)*(-'%)<$%=,*<'(8)'=)1)3.9#)*(:',#93)#)*($(,.*:'$*=')*/.%>)#)*('./')*1,%.*#)*($3'
3$@-:'%)<"3$ (,. * -:'$ *= '9 . 3,>,)-'7&'(8,-'-($()I'58)'(@.'c9,33$%-c'./')*1,%.*#)*($3'd"-(,>):'(8"-:'$%)'(8)'
/$,%'(%)$(#)*('./'$33'9). 93) '$*= '9%. 1,=,* <'/. %'# )$* ,*< /"3'9" 73,>',* 1.31 )# ) *(',*'< .1) %*# ) *('= )>,-,. *K
#$A,*<IU'
2%.#'(8)'gI!I'CE+'P@@@fI)9$I<.1[)*1,%.*#)*($3d"-(,>)Q^'
'MC*1,%.*#)*($3']"-(,>)',-'(8)'/$,%'(%)$(#)*('$*='#)$*,*</"3',*1.31)#)*('./'$33'9).93)'%)<$%=3)--'./'
%$>):'>.3.%:'*$(,.*$3'.%,<,*:'.%',*>. # )'@ ,(8'%)- 9)> ('(.'(8)'= )1)3. 9#)*(:',#93)#)*($ (,.* :'$*='
)*/.%>)#)*('./')*1,%.*#)*($3'3$@-:'%)<"3$(,.*-:'$*='9.3,>,)-I'CE+'8$-'(8,-'<.$3'/.%'$33'>.##"*,(,)-'
$*='9)%-.*-'$>%.--'(8,-'L$(,.*I'`('@,33'7)'$>8,)1)='@8)*')1)%&.*)')*d.&-'(8)'-$#)'=)<%))'./'
9%.()>(,.*'/%.#')*1,%.*#)*($3'$*='8)$3(8'8$N$%=-'$*=')O"$3'$>>)--'(.'(8)'=)>,-,.*K#$A,*<'9%.>)--'
(.'8$1)'$'8)$3(8&')*1 ,%.* # )*( ',* '@ 8 ,> 8'( .'3,1 ) :'3)$ %* :'$* = '@ . %A IU !
74
!There!is!ample!evidence!that!the!lead!poisoning!crisis!is!one!in!a!series!environmental!injustices!visited!on!the!
citizens!of!Flint.!See,!for!example,!“Th e!Racist!Roots!of!Flint’s!Water!Crisis,”!by!Julia!Craven!and!Tyler!Tynes,!
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Findings'
F-36. The!Flint!water!crisis!is!a!clear!case!of!environmental!injustice.!!!
Recommendations'
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.!!
Perspectives from Flint
The!FWATF!believes!that!by!characterizing!some!of!the!prevailing!perspectives!of!Flint!residents,!
its!members!can!provide!valuable!context!for!effectively!implementing!the!recommendations!
herein.!
From!the!viewpoint!of!medical!services!providers!charged!with!responsibility!to!mitigate!heath!
consequences,!there!is!both!depression!and!anxiety!associated!with!understanding!what!is!
occurring!in!Flint.!The!Flint!water!crisis!is!a!chronic!toxic!exposure!of!an!entire!population!in!a!
sharply!demarcated!geographic!area.!Several!key!aspects!point!to!the!long-term!health!and!social!
consequences:!
a. The!manifestations!of!this!toxic!exposure!depend!on!where!along!the!life!course!a!person!
may!be.!At!different!ages,!critical!structures!and!functions!are!injured!or!altered!to!
different!degrees.!These!changes!may!not!manifest!in!functional!derangements!for!
months!or!years!after!exposure.!The!science!of!epigenetics!addresses!the!interaction!
between!genes!and!the!environment,!suggesting!that!some!of!these!changes!can!be!
passed!on!from!one!generation!to!the!next.!!
b. Blood!lead!levels!do!not!indicate!peak!lead!exposures!beyond!a!30-!to!35-day!window.!
The!damage!from!lead!toxicity!may!be!done!months!before!the!first!blood!lead!level!is!
taken!or!after!the!last!is!drawn,!especially!for!newborns!and!children!younger!than!6!years!
of!age.!This!suggests!that!the!findings!related!to!elevated!lead!levels!measured!in!Flint!
children!are!merely!the!tip!of!the!iceberg!of!actual!exposure!across!children!living!in!Flint.!
c. Documented!risks!of!learning,!behavioral,!and!cognitive!problems!are!present!for!all!
potentially!exposed!children!in!Flint.!Aggressive!and!impulsive!behaviors!that!can!emerge!
in!adolescence!related!to!lead!exposure!put!children!in!the!crosshairs!of!the!criminal!
justice!system,!unemployment!and!underachievement.!!
d. The!risk!of!kidney!problems,!hypertension,!gout!and!stillbirths!may!affect!exposed!adults!
in!Flint!over!the!coming!years!and!decades.!!
For!those!serving!in!Flint’s!already!distressed!schools!and!mental!health!agencies,!new!and!
unprecedented!challenges!derive!from!balancing!the!need!to!track!children!and!adults!in!a!toxic!
exposure!registry!for!preventative!and!supportive!services,!while!being!mindful!of!the!stigma!of!
low!expectations!for!those!listed!in!the!registry.!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Huffington!Post,!February!3,!2016,!www.huffingtonpost.com/entry/racist-roots-of-flin ts- water-
crisis_us_56b12953e4b04f9b57d7b118 .!
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For!well-intentioned!parents,!there!is!a!need!for!significant!sensitivity!and!expertise!as!they!
struggle!to!address!and!understand!the!guilt!and!depression!that!derive!from!unknowingly!
exposing!their!children,!based!on!the!hollow!reassurances!of!those!appointed!and!elected!at!city!
and!state!levels!that!the!water!was!safe.!!
For!non-English-speaking!Flint!residents,!equally!subject!to!the!toxic!effects!of!lead!and!related!
psychological!trauma,!communications!and!instructions!regarding!water!use!were!not!available,!
especially!for!those!not!literate!in!their!native!language.!The!sight!of!uniformed!state!troopers!
and!National!Guardsmen!entering!neighborhoods!in!convoys!with!flashing!lights!frightened!many!
who!did!not!open!their!doors!to!accept!filter!or!water!distributions.!Initial!requirements!for!
identification!scared!many!families!away!from!distribution!sites.!There!has!been!no!provision!for!
necessary!medical!and!behavioral!services!for!undocumented!residents,!regardless!of!age.!There!
is!fear!that!those!presenting!for!extensive!medical!services!will!be!deported,!potentially!dividing!
families.!While!there!are!several!organizations!that!provide!services!regardless!of!status,!it!is!
essential!that!trusted!members!of!the!community!can!vouch!for!those!organizations!and!help!
with!appropriate!documents!which!are!unfamiliar!to!local!service!providers.!
Among!African!American!seniors,!the!protracted!Flint!water!crisis!echoes!the!tragic!Tuskegee!
syphilis!study!and!the!decision!not!to!treat!smallpox!among!freedmen!in!the!aftermath!of!the!
American!Civil!War.!From!this!perspective,!it!is!noted!that!measuring!blood!lead!levels!without!
removing!the!sources!of!lead!from!the!environment—in!this!case,!lead-tainted!water—appears!
the!equivalent!of!using!Flint’s!children!(and!adults)!as!human!bioassays.!!!
From!the!perspective!of!Flint!community!leaders,!these!consequences!are!traumatic!and!
contribute!to!a!dynamic!that!requires!care!and!interventions!as!for!any!survivors!of!a!traumatic!
event.!These!interventions!must!occur!for!individuals,!neighborhoods!and!the!community.!
Leaders!must!work!to!counter!the!doubtful!views!of!many!residents!that!public!health!and!
political!systems!do!not!have!the!will!to!sustain!primary!prevention!but,!rather,!are!willing!to!
consign!some!people!by!virtue!of!their!home!address!to!the!long-lasting!neurodevelopmental!and!
health!impacts!of!lead!exposure.!Flint!will!have!to!engage!in!self-care!and!healing!as!it!dissects!
the!implications!of!what!has!occurred!and!is!reminded!of!how!much!further!we!must!go!to!
become!a!just!society.!
Flint Recovery / Remediation
In!light!of!the!damage!done,!and!the!long-term!health,!economic,!and!social!consequences!for!
the!Flint!population,!the!Flint!Water!Advisory!Task!Force!endorses!the!visions!of!responsive!
model!public!health!and!infrastructure!renewal!programs!outlined!by!Dr.!Mona!Hanna-Attisha,!
Professor!Marc!Edwards!and!Miguel!Del!Toral.!Flint’s!population,!exposed!to!toxic!levels!of!lead,!
must!be!provided!mitigating!health!services,!public!health!infrastructure!and!skilled!personnel.!
Flint’s!water!system,!damaged!by!corrosive!water,!must!be!renewed!and!rehabilitated!with!high-
risk!LSL!replacements!prioritized.!The!State!of!Michigan!must!bear!the!primary!responsibility!for!
funding!and!securing!federal!funding!for!mitigation!efforts!in!light!of!the!responsibilities!of!state!
agencies,!as!well!as!the!fact!that!state-appointed!emergency!managers!governed!Flint!as!key!
decisions!were!made!that!led!to!the!water!crisis.!!
As!our!initial!letter!to!Governor!Snyder!called!for!a!coordinated!response!to!the!Flint!water!crisis,!
we!are!gratified!to!see!the!efforts,!now!coordinated!through!emergency!management!personnel,!
to!the!immediate!problems!imposed!by!uncertainty!regarding!the!safety!of!Flint’s!tap!water.!!
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Recommendations'
Our!final!recommendations!look!beyond!the!most!immediate!challenges!of!the!unsustainable!and!
expensive!bottled!water!and!filter!distribution!program!that!was!needed,!but!clearly!must!serve!
as!an!interim!emergency!response.!We!offer!the!following!mid-term!and!long-term!Flint-specific!
recommendations:!!!!
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.!!
The!FWICC!has!been!charged!with!developing!an!incident!action!plan;!reviewing!our!
recommendations;!establishing!routine!protocols!for!communications!at!the!local,!
executive!and!legislative!levels;!making!recommendations!regarding!the!health!impacts!of!
the!affected!population;!and!assessing!the!status!of!infrastructure!and!determining!
feasible!actions!for!upgrading!Flint’s!water!system.
75
!The!FWICC!also!should!ensure!
transparent,!public!reporting!of!the!status!of!various!Flint-related!measures,!including!the!
sources!and!uses!of!local,!state!and!federal!funds.!Charitable!organizations!should!be!
asked!to!provide!accounting!of!their!Flint-related!activities!to!facilitate!comprehensive!
reporting!and!information!dissemination!on!available!services.!
R-34. Clarify!and!effectively!communicate!the!roles!and!work!of!the!City!of!Flint,!Flint!Water!
Inter-Agency!Coordinating!Council!and!Mission!Flint.!
While!many!of!the!current!efforts!and!investigations!are!critically!important!to!safeguard!
Flint!residents,!address!immediate!challenges,!and!further!establish!accountability,!the!
FWICC!and!Mission!Flint!are!now!in!place!to!work!with!the!City!of!Flint!in!coordinating!
sustained!service!delivery!and!remediation!measures.!These!entities,!and!accompanying!
committees!and!work!teams,!have!complementary!roles!and!responsibilities!that!should!
be!clearly!delineated!and!communicated!to!all!Flint!residents.!Communication!must!
include!efforts!to!reach!Flint!residents!for!whom!English!is!not!the!primary!language,!and!
residents!whose!literacy!in!any!language!is!limited.!The!status!of!the!projects!and!
programs!that!these!entities!are!shepherding!should!be!clearly!communicated!and!
measured!against!aspirational!goals!and!objectives.!
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!such!follow-up!occurs!in!children’s!medical!
homes.!!!
For!the!majority!of!>200!children!residing!in!Flint!and!known!to!have!elevated!blood!lead!
levels!(≥5!micrograms!per!deciliter)!from!April!2014!to!present,!appropriate!clinical!and!
public!health!follow-up!has!not!been!timely.!Such!limitations!in!follow-up!reflect!a!lack!of!
coordination!among!state!and!county!public!health!authorities,!health!insurance!plans,!
local!healthcare!professionals,!and!parents.!These!children,!and!others!who!have!elevated!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
75
!Drawn!from!January !11 ,!201 6!Press!Release:!“Gov.!Rick!Snyder:!Flint!Water!Interagency!Coordinating!Committee!
will!support!long-term!needs!in!Flint.”!
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blood!levels!on!testing!after!this!report!is!issued,!will!need!long-term!monitoring!and!
access!to!a!support!services!that!include!focused!public!health,!nutrition!and!educational!
services.!
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.!!
Importantly,!all!children!in!the!recommended!Flint!Toxic!Exposure!Registry!are!at!risk!for!
toxic!lead!exposure,!even!if!they!were!not!screened!for!blood!lead!levels!during!the!time!
period!of!April!2014!to!present.!Therefore,!all!children!listed!should!have!access!to!the!
same!screening!and!appropriate!follow-up!services!as!children!who!were!found!to!have!
elevated!blood!lead!levels.!!
R-37. Consider!establishing!a!dedicated!subsidiary!fund!in!the!Michigan!Health!Endowment!
Fund!to!facilitate!funding!of!health-related!services!for!Flint.!
The!Michigan!Health!Endowment!Fund!(MHEF)!statute!created!eight!areas!of!focus!for!the!
fund,!including!several!that!are!pertinent!to!the!Flint!water!crisis.!The!MHEF!focuses!on!
access!to!healthy!food!(known!to!offset!children’s!absorption!of!environmental!lead),!
wellness!programs!(such!as!those!known!to!encourage!primary!and!secondary!
prevention),!access!to!mental!health!services!(such!as!behavioral!therapy!for!children!
adversely!affected!by!lead!exposure),!and!foodborne!illness!prevention!(such!as!averting!
exposure!to!lead!in!food!prepared!with!lead-contaminated!drinking!water).!Given!the!
substantial!overlap!between!the!focus!areas!of!the!fund!and!the!areas!of!short-!and!long-
term!activity!for!the!people!of!Flint,!it!is!appropriate!to!establish!a!subsidiary!fund!that!
would!be!administered!to!facilitate!funding!of!health-related!services!for!children!and!
adults!in!the!Flint!Toxic!Exposure!Registry.!Because!Michigan!has!been!successful!in!
securing!federal!funds!to!expand!Medicaid!coverage!for!persons!under!age!21!years!in!
Flint,!the!subsidiary!MHEF!Fund!would!be!designed!to!focus!on!facilitating!and!supporting!
services!not!explicitly!covered!by!Medicaid.!The!Fund!should!also!provide!funding!to!
support!timely!and!transparent!evaluation!of!the!health!impact!of!these!supplementary!
services!for!the!people!of!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 Initiatives
Beyond!remediation!of!the!impacts!inflicted!upon!Flint,!outstanding!issues!and!lessons!learned!
from!the!Flint!water!crisis!provide!an!opportunity!to!improve!public!water!supplies!and!
coordination!of!institutions!charged!with!safeguarding!public!health.!!!
Recommendations'
Our!recommendations!include:!
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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.!!
The!development!of!the!KWA!and!the!decision!by!the!City!of!Flint!to!join!it!is!complicated!
by!an!array!of!factors!related!to!regional!water!system!capacities,!utility!capital!project!
contracting!and!financing,!and!local!control!over!the!implementation!of!facilities!to!
promote!economic!development.!As!noted,!issues!related!to!state!approval!and!
permitting!of!the!KWA!are!beyond!the!scope!of!our!review.
76
!However,!the!specific!
attributes!of!the!decisions!related!to!KWA!warrant!investigative!review.!We!note:!
o
State!and!local!officials!repeatedly!characterized!Genesee!County!and!Flint!leadership,!
including!Flint’s!emergency!managers,!as!adamant!in!their!promotion!of!KWA!and!
desire!for!independence!from!DWSD.!
o
Several!firms,!each!with!ties!to!the!respective!and!effectively!competing!parties,!
issued!conflicting!studies!as!to!the!merit!of!KWA.!Independent!review!was!requested!
of!MDEQ,!an!agency!ill-equipped!to!render!judgments!regarding!economic!feasibility.!
o
Contracting!related!to!Flint’s!water!purchase!commitments!and!to!use!of!the!Flint!
WTP!on!an!interim!basis!were!effected!through!action!of!Flint’s!emergency!managers.!
An!entity!with!proper!tools!and!resources,!such!as!the!Michigan!Attorney!General!or!the!
U.S.!Attorney’s!office,!should!do!a!complete!and!thorough!review!of!the!development!and!
approval!of!KWA!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.!
Drinking!water!and!water!available!for!food!preparation!in!schools!and!may!be!sources!of!
lead!and!other!hazards!for!school!children.!Currently,!federal!and!state!regulations!do!not!
require!city,!county!or!state!authorities!to!routinely!test!water!in!school!buildings.!!
Furthermore,!there!is!no!state!law,!guidance!or!regulation!regarding!testing!of!drinking!
water!in!various!childcare!and!pre-school!settings!(children!below!kindergarten-age).!!
Michigan!should!institute!a!school!and!day!care!water!quality!testing!program,!
administered!collaboratively!by!MDEQ!and!MDHHS,!that!includes!appropriate!sampling!
and!testing!for!lead!contamination!in!all!schools!and!childcare!centers!in!the!state.!
Findings!from!such!testing!should!be!made!available!to!all!parents!of!children!enrolled!in!
the!facilities!where!testing!is!performed.!If!lead!is!discovered!through!this!testing,!
immediate!remediation!of!the!situation!(for!example,!replacement!of!LSLs!and!lead-
containing!fixtures)!must!be!required.!!!
School!testing!requirements!also!should!be!applied!to!licensed!day!care!settings!across!
the!state,!given!that!young!children!are!at!the!highest!risk!of!profound!health!effects!from!
lead!exposure.!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
76
!These!issues!may!(and!perhaps!should)!prompt!general!inquiry!into!how!utility!regulation!may!better!promote!
regional!optim izatio n!of!in frastru ctu re!inv estm e nts.!
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A!“Safe!Water!in!Schools!for!Health!(SWISH)!program”
77
!would!include!regular!testing!
(and!re-testing)!of!tap!water!at!school!and!licensed!day-care!facility!faucets!and!water!
fountains!for!regulated!contaminants!and!for!bacteria!growth!(like!H)<,.*)33$)!known!to!
be!contained!in!plumbing!systems.!For!schools!found!to!have!unsafe!water,!the!program!
would!provide!funding!and!implementation!support!for!either!lead!pipe!replacements!or!
installation!of!filters!capable!of!treating!the!water!to!federal!standards.!The!program!
could!establish!goals!to!install!high-quality!water!fountains!that!facilitate!effective!water!
quality!monitoring!(as!well!as!student!use!with!refillable!bottles).!For!some!schools,!this!
program!could!include!the!participation!of!science!programs!and!students,!working!with!
independent!testing!laboratories.!In!any!event,!all!water!quality!testing!results!should!be!
posted!both!at!the!facilities!and!online,!and!communicated!to!parents.!
R-41. Develop!a!model!LSL!replacement!program!and!funding!mechanisms!for!financing!work!
on!private!property.!
Notwithstanding!the!water!industry’s!historical!reluctance!to!advocate!for!full!LSL!
replacements,!the!state!should!develop!a!funding!mechanism!and!program!to!evaluate!
and!replace!LSLs!statewide,!recognizing!that!some!communities!already!have!replaced!
their!LSLs.
78
!The!state!should!develop!a!model!statewide!LSL!replacement!program!that!
could!serve!as!a!national!model,!in!collaboration!with!EPA,!with!the!following!attributes:!
• Requirement!for!developing!censuses!of!LSLs!in!utility!service!areas!that!are!accessible!
on!utility!systems’!computerized!Geographical!Information!Systems!(GIS)!and!asset!
management!systems.!Censuses!should!be!comprehensive,!covering!full!lengths!of!
service!lines!and!ownership!status,!and!be!made!publicly!available!to!facilitate!
satisfaction!of!customer!queries.!
• Evaluation!of!lead!line!conditions!and!associated!risks!(placing!high!priority!on!
replacements!of!lines!to!high-risk!properties!(for!example,!schools,!childcare!centers,!
hospitals,!older!neighborhoods!and!residences!of!vulnerable!populations).!!
• Programming!of!full!LSL!replacements!in!federal-!and!state-sponsored!public!housing.!
• Provision!of!health!risk!information!to!customers!with!LSLs!when!homeowners!are!
presented!with!the!option!to!pay!for!the!private!part!of!their!LSL!replacement.!
• Explicit!incorporation!of!LSL!risk!considerations!in!utility!renewal!and!replacement!
programs!to!enable!orderly,!yet!expeditious,!full!LSL!replacement!(including!
replacement!of!LSLs!on!private!property).!
• Establishment!or!enhancement!of!funding!mechanisms!to!facilitate!full!LSL!
replacements!by:!
o Reviewing!strategies!used!by!other!communities!and!approaches!to!addressing!
funding!of!improvements!on!private!property;!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
77
!These!recommendations!are!drawn!from!(and!reflect!our!substan tive!c on cu rren ce!w ith )!reco m m e ndations!offered!
by!Peter!Gleick,!president!of!the!Pacific!Institute,!and!Professor!Marc!Edwards,!Virginia!Tech.!See!“One!step!to!help!
restore!trust!in!Flint,”!G)(%.,('2%))'E%)--,!March!6,!2016.!
78
!Informa tio n !o n !in d u s try !e xp e rie n c e !an d !p e rs p e ct ive s !is!p ro v ided!in'“Strategies!to!Obtain!Customer!Acceptance!of!
Complete!Lead!Service!Line!Replacement,”!American!Water!Works!Association,!2005.!
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o Facilitating!public!water!systems’!access!to!LSL!replacement!funding,!including!
through!provisions!in!drinking!water!state!revolving!loan!fund!program!
administration;!
o Facilitation!of!public!water!system!customer!funding!for!replacement!of!LSLs!and!
lead-containing!fixtures!on!private!property;!!
o Review!of!LCR-established!authority!to!require!full!service!line!replacements;!and!!!
o Mitigation!of!low-income!water!affordability!challenges!through!financial!
assistance!and!innovative!financing!mechanisms.!
The!program!should!provide!for!MDEQ!to!require!annual!reporting!and!tracking!of!the!
census!of!LSLs!as!part!of!regular!reporting!requirements.!MDEQ!should!compile,!analyze!
and!publicly!report!on!the!submitted!data,!enabling!state!legislature!and!the!general!
public!to!readily!access!information!on!progress!of!LSL!replacements!throughout!the!state!
while!protecting!personal!information.!
R-42. Revise!and!enhance!information!distributed!by!public!water!systems!on!the!implications!
of!widespread!use!of!lead!in!public!and!private!plumbing.!
Independently,!or!in!conjunction!with!the!model!LSL!replacement!program!recommended!
above,!the!state!should!improve!dissemination!of!accurate!information!on!the!dangers!
presented!by!lead!in!water!systems!and!plumbing.!Readily!accessible!information!should!
be!broadly!provided!about!potential!sources!of!high!levels!of!lead!in!water,!including,!for!
example,!the!potential!for!the!release!of!lead!particulates!from!piping!disturbed!by!
construction!activities,!as!well!as!lead!solder,!galvanized!plumbing,!and!brass!fixtures.!!
Consider!and!model!successful!public!engagement!(and,!more!generally,!LSL!replacement)!
programs!used!in!countries!such!as!the!Netherlands!that!have!more!successfully!managed!
lead!risks.
79
!
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.!
Nationally,!water!system!infrastructure!renewal!and!rehabilitation!requirements!are!
expected!to!exceed!$1!trillion!over!the!next!generation.
80
!Michigan!is!no!exception!in!
facing!a!significant!infrastructure!funding!gap,!even!without!prospective!funding!of!full!LSL!
replacements.!State!and!local!decision-makers,!water!utility!representatives,!and!
community!groups!should!partner!to!garner!support!for!water!system!re-investment!
(through!local!service!rates!and!state!funding!mechanisms),!while!balancing!potential!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
79
!Refer!to!“Water!production!and!distribution!in!the!Netherlands,”!Andr.!Struker,!Waternet,!Jan!Vreeburg,!KWR,!Jan !
Peter!van!der!Hoek,!Delft!University,!Waternet,!February!2016!–!presentation!to!Flint!Water!Inter-Agency!
Coordinating!Committee.!
80
!See,!for!example:!
• “Report!Card!for!America’s!Infrastructure,”!American!Society!of!Civil!Engineers!(ASCE),!2013,!
www.infrastructurereportcard.org/a/#p/grade-sheet/americas-infra s tru ct u re-investmen t-needs!!!
• h"%,)='L.'H.*<)%^';.*/%.*(,*<'+#)%,>$_-'4$()%'`*/%$-(%">("%)';8 $ 33) * < ):'AW WA,!2012,!
www.awwa.org/Portals/0/files/legreg/documents/BuriedNoLonger.pdf!!!
• G%,*A,*<'4$()%'`*/%$-(%">("%)'L))=-'!"%1)&'$*='+--)--#)*(:'2,/(8'?)9.%('(.';.*<%)--:!U.S.!EPA,!2011:''
www.epa.gov/sites/production/files/2015-07/documents/epa816r13006.pdf!'
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impacts!on!low-income!populations.!Stakeholders!should!work!to!define!new!and!
innovative!water!service!pricing!and!funding!approaches
81
!to!advance!water!affordability!
and!universal!access!to!service.!
R-44. Prioritize!health!matters!across!all!state!agencies!with!establishment!of!a!new!Cabinet-
level!post!focused!on!public!health.!
The!Flint!water!crisis!illustrates!that!MDEQ!and!MDHHS!failed!to!coordinate!and!
collaborate!in!responding!to!multiple!health-related!concerns!raised!by!members!of!the!
Flint!community!and!by!public!health!partners!such!as!GCHD.!Governor!Snyder!indicated!
that!there!is!no!liaison!function!at!the!Cabinet!level!in!Michigan!state!government!to!
connect!inter-agency!actions!regarding!health!matters.!Although!the!FWICC!is!designed!to!
function!in!an!inter-agency!manner,!its!purpose!is!Flint-centric.!There!is!a!strong!argument!
that!such!inter-agency!functionality!for!health!should!be!instituted!at!the!state!level,!to!
help!safeguard!the!health!of!all!Michigan!residents.!!
The!sheer!size!of!the!current!MDHHS!potentially!dilutes!the!role!of!the!state!in!important!
public!health!matters.!The!Task!Force!recommends!that!a!physician!or!nurse!with!public!
health!and/or!health!policy!credentials!serve!on!the!Governor's!Cabinet,!and!be!
supported!by!a!staff!and!budget!appropriate!for!the!activities!of!this!role.!This!person!
would!serve!an!overall!supervisory!and!inter-agency!liaison!role!for!all!activities!that!have!
a!bearing!on!health!for!Michiganders.!Given!the!suboptimal!health!status!of!the!Michigan!
public!on!a!wide!array!of!matters!(for!example,!infant!mortality,!obesity,!life!expectancy,!
smoking),!not!to!mention!the!health!concerns!that!are!now!paramount!in!Flint,!this!
person!would!have!a!broad!mandate.!!
Conclusions
The!conclusion!we!made!in!December!2015!that!primary!responsibility!for!causing!the!Flint!water!
crisis!rests!with!the!MDEQ!has!only!been!substantiated!by!our!subsequent!interviews!and!
research.!This!final!report,!however,!documents!the!failings,!shortcomings!and!problems!in!other!
agencies!and!entities!as!well,!such!as!MDHHS,!GCHD,!the!local!water!treatment!plant,!the!EM!
structure,!the!Governor’s!office,!and!the!U.S.!EPA.!These!failures!reflect!the!discounting!of!
profound!public!health!concerns!and!indifference!to!Flint!residents’!plight.!
The!value!in!documenting!what!went!wrong!is!not!to!ascribe!blame!for!blame’s!sake,!but!to!
establish!the!foundation!for!moving!forward,!both!in!Flint!and!throughout!the!state.!The!state!
clearly!must!respond!with!dedicated!and!systematic!attention!to!health!concerns!for!people!of!
Flint.!But!it!also!has!the!opportunity!to!demonstrate!that!lessons!have!been!learned!from!the!
Flint!experience—as!traumatic!as!it!has!been!and!will!continue!to!be—and!develop!model!
infrastructure!renewal!and!public!health!programs!that!will!serve!all!Michigan!residents!for!
generations!to!come.!
Flint!residents!and!their!fellow!Michigan!citizens!deserve!no!less.! !
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
81
!See,!for!example,!“Blue!Ribbon!Panel!on!Affordability!Final!Report,”!City!of!Detroit,!2016,!
www.detroitmi.gov/brpa.!!
! ! !
APPENDIX!I:!Flint!Water!Advisory!Task!Force!(FWATF)!
! !
! ! !
Flint!Water!Advisory!Task!Force!(FWATF)!
Matthew!Davis,!MD,!MAPP,!is!professor!of!pediatrics!and!internal!medicine!at!the!University!of!
Michigan!Health!System!and!professor!of!public!policy!at!the!Gerald!R.!Ford!School!at!the!
University!of!Michigan,!having!joined!the!faculty!in!2000.!Davis!also!is!a!professor!of!health!
management!and!policy!at!the!School!of!Public!Health.!He!previously!served!as!the!chief!medical!
executive!of!the!Michigan!Department!of!Community!Health/Department!of!Health!and!Human!
Services.!
Chris!Kolb!(Co-Chair)!is!president!of!the!Michigan!Environmental!Council,!a!statewide!coalition!of!
70!environmental,!public!health!and!faith-based!nonprofit!groups.!Before!joining!the!MEC,!Kolb!
represented!Ann!Arbor!in!the!state!House!for!six!years!and!served!six!years!on!the!Ann!Arbor!City!
Council.!He!has!been!president!of!the!MEC!for!seven!years!and!has!more!than!12!years!of!
experience!in!the!environmental!management!field.!
Lawrence!Reynolds,!MD,!is!a!pediatrician!in!Flint!who!serves!as!president!of!the!Mott!Children’s!
Health!Center.!He!received!his!medical!degree!from!Howard!University!College!of!Medicine!and!
has!been!in!practice!for!36!years.!He!has!served!as!president!of!the!Genesee!County!Medical!
Society!and!the!Michigan!Chapter!of!the!American!Academy!of!Pediatrics.!He!has!been!honored!
for!his!humanitarian!and!advocacy!efforts!on!behalf!of!children!from!the!Community!Foundation!
of!Greater!Flint.!
Eric!Rothstein!is!a!national!water!issues!consultant!and!principal!at!the!Galardi!Rothstein!Group.!
He!served!as!an!independent!advisor!on!the!creation!of!the!Great!Lakes!Water!Authority.!
Rothstein!also!has!served!as!Jefferson!County,!Alabama’s!rate!consultant!and!municipal!adviser!
for!litigation!related!to!the!county’s!bankruptcy!and!issuance!of!$1.7!billion!in!sewer!warrants!
and!led!strategic!financial!planning!for!the!City!of!Atlanta’s!Department!of!Watershed!
Management.!He!has!more!than!30!years!of!experience!in!water,!wastewater!and!stormwater!
utility!finance!and!rate-making!assessments.!
Ken!Sikkema!(Co-Chair)!is!a!senior!policy!fellow!at!Public!Sector!Consultants,!where!he!specializes!
in!public!finance,!environment,!and!energy!policy.!Prior!to!joining!the!firm,!Sikkema!served!in!
both!the!Michigan!House!and!Senate,!culminating!with!four!years!as!Senate!majority!leader.!He!
has!also!served!as!both!an!adjunct!and!visiting!professor!at!Grand!Valley!State!University.!
!
!
! !
! ! !
APPENDIX!II:!FWATF!Letters!
! !
December 7, 2015
Dear Governor Snyder:
On Wednesday, November 18, 2015, the Flint Water Advisory Task Force met with representatives of
the Michigan Department of Environmental Quality (MDEQ) and the Michigan Department of Health
and Human Services (MDHHS) to discuss elements of the 10-point Action Plan designed to address
various issues related to the ongoing public health protection challenges precipitated by lead in the Flint
water supply. These discussions were held at our request as part of our task to make recommendations
to prevent a similar occurrence in Flint or elsewhere, and also to monitor ongoing mitigation efforts.
Subsequent to those meetings, on Tuesday, November 24, 2015, members of the Task Force
participated in a conference call with yourself, members of the Administration, and representatives of
these agencies to discuss the progress to date on the 10-point Action Plan, as well as several other
related issues.
We want to acknowledge the steps that have already been taken to implement the action plan,
specifically in the areas of outreach efforts to facilitate blood lead testing for children, communication
with health care providers in the Flint community about the importance of testing children for lead, and
the training of additional public health nurses in the Genesee County Health Department. We do
believe, however, that additional steps need to be taken to reach additional children for blood lead
testing, assure proper follow-up with children found to have elevated blood lead levels, and to continue
water testing. We will continue to assess state and local efforts and make recommendations regarding
specific steps that we believe are warranted.
One primary concern we have at this point is that the current efforts appear to be taking place in the
absence of a larger project coordination framework that measures results and clearly delineates
responsibilities for continuing actions to protect public health. We believe the state is best positioned to
facilitate this larger framework, which should address the following:
1. The need for MDHHS and MDEQ—and, possibly, other state agencies--to set goals for actions in
collaboration with local and federal agencies and organizations.
2. The need for a set of corresponding timelines for the goals.
3. The need to establish responsibility for meeting the goals in a timely fashion and for
contingency plans for the state if the goals are not being met.
4. The need for clear, regular communication with the Flint community and stakeholder groups
regarding action steps and updates.
We also believe it important that a single person or entity—potentially independent of any one
particular state agency and mutually agreeable to this Task Force and you, Governor—be established to
provide effective coordination of ongoing activities and reporting on the status of mitigation measures.
For this, we also believe a readily understood “dashboard” should be developed that reports on the
goals, timelines and assignments. This will enable members of the Flint community, public health
providers, and state agencies to know about the status of the Flint water crisis mitigation program, as
well as promote coordination and accountability. The Task Force is prepared to assist in the
development of that dashboard.
We believe it is vitally important that trusted members of the Flint community be engaged in
communication on this issue, as well as the distribution of information conveyed by our suggested
dashboard reporting. Accordingly, in advance of our final report, we would like to ensure the
independent coordinator suggested above engage trusted community groups to begin rebuilding
community trust in state actions.
We appreciate your personal interest in this issue, commitment to assisting the Task Force in our
review, and—most importantly—commitment to ensuring that the full measure of state resources are
brought forward to protect the public health in Flint and throughout the state.
Respectfully yours,
Flint Water Advisory Task Force:
Dr. Matt Davis
Chris Kolb
Dr. Larry Reynolds
Eric Rothstein
Ken Sikkema
('
`'
Flint Water Advisory Task Force
January 22, 2016
Governor Rick Snyder
Office of Governor
P.O. Box 30013
Lansing, Michigan 48909
Dear Governor Snyder:
The Flint Water Advisory Task Force (FWATF) appreciates your recent efforts to secure federal
and mobilize state emergency response resources to address the immediate water supply
issues in Flint.
This letter is to encourage a similarly robust response to the challenges of re-establishing a
reliable, trusted potable water distribution system in Flint. This is required as soon as possible
to replace the unsustainable and expensive bottled water and filter distribution program that
has been necessitated, but which clearly must serve as an interim, emergency response.
Consistent with the priorities identified in the Safe Drinking Water Emergency Order issued by
the EPA on January 21, 2016, we recommend the following actions to address scientifically
grounded concerns that the water system in Flint remains unsafe because of lead
contamination and Legionella. Public trust in the safety of the water supply may only begin to
be re-established through the state’s forthright engagement of the scientific experts who
overcame state and federal agency intransigence to expose the lead poisoning.
Our recommendations are:
Engage US EPA staff experts versed in Lead and Copper Rule (LCR) requirements –
specifically Miguel del Toral, Darren Lytle and Michael Shock. These individuals should
be empowered to guide implementation of a comprehensive LCR sampling program in
Flint that will monitor lead levels now and throughout the conversion to raw water
supply by the Karegnondi Water Authority (KWA) and full-time use of the Flint Water
Treatment Plant.
Establish an inter-disciplinary work group comprising subject matter experts drawn from
respected public utility associations and institutions of higher learning in Michigan and
elsewhere (including Marc Edwards of Virginia Tech), to oversee the conversion to KWA-
supplied raw water.
Commission and/or contract with an unbiased third-party organization or consortium
(hereafter: Flint water safety scientific assessment team [FWSSAT]) that will be
responsible for assessing the quality and safety of drinking water in residences, schools
and child care settings in Flint, and hospitals and other healthcare facilities served by the
Flint Water Advisory Task Force
Flint water system. The explicit focus of FWSSAT activities will be lead and Legionella;
however, the FWSSAT may include other considerations in its work.
The FWSSAT will be invested with the responsibility of declaring when the public water
supply in Flint is safe for routine consumption. The FWSSAT will employ the most
rigorous scientific standards, using a sampling strategy that is designed to optimize
detection of water contamination in home, school, and child-care settings, and
healthcare environments. All schools and healthcare facilities must be included in the
sampling approach. Rigorous sampling of residences and child-care settings (whether
centers or in-home) will also be implemented, using any and all available information
about lead water service lines. In addition, if a homeowner or renter whose dwelling
has not been included in sampling wishes to have the dwelling included, they will also
be sampled. The sampling efforts and reporting process of the FWSSAT will be fully
transparent to the public; results of testing should be published on local, state, and
federal (EPA) websites.
To assure the re-building of community trust and assure sufficient expertise for future
water quality and safety, the FWSSAT should partner with local (Flint Water Treatment)
and state (MDEQ) personnel in its activities. The FWSSAT should have an inter-
disciplinary advisory committee that includes local community leaders, local and state
officials, national scientific authorities regarding water quality and safety and public
health, and the leader of the interagency state effort regarding the Flint water crisis.
When the FWSSAT advisory committee is satisfied that the FWSSAT scientific
procedures have thoroughly assessed water quality and safety in Flint residences,
schools and child care settings, and healthcare facilities and found the water to be
sufficiently free of contamination, then the committee will advise the public of the
findings. The FWSSAT will then organize the transfer of responsibility to local and state
authorities to sustain the sampling and reporting methods thereafter, including the
conversion to KWA raw water in the future.
We also believe that a forthright response to the Legionella outbreak must similarly engage
trusted, scientific experts drawn from independent institutions. Accordingly, we recommend:
The Michigan Department of Health and Human Services (MHHS) should make a formal
request to the federal Centers for Disease Control and Prevention (CDC) for assistance in
assessing the outbreak of Legionnaire’s disease in Flint, if they have not already done so.
MHHS, working with CDC, should develop a strategy for improving prevention, rapid
detection, and timely treatment of cases of Legionellosis in Michigan in 2016 and
beyond. While the MDHHS evaluation of the dozens of cases of Legionellosis in 2014
and 2015 has strongly suggested a link to the shift to drinking water from the Flint River
in 2014, further and more intensive evaluation of clinical isolates (i.e., samples from
infected patients) is necessary to understand the route(s) of transmission from
contaminated water to humans. The unique set of outbreak circumstances in the
setting of a change in water source strongly indicates that support from federal public
Flint Water Advisory Task Force
health authorities would be a welcome way to amplify the public’s collective
understanding of risk of contracting Legionella in residences served by the Flint water
system, and in Flint healthcare facilities.
The state should specifically request federal support from the CDC – and, as
appropriate, additional federal experts and agencies – to advise and assess Flint
healthcare facilities and Flint-based healthcare providers regarding: (a) appropriate
application and timely re-application of biocides to air treatment systems and cooling
towers in all healthcare facilities in Flint, in order to prevent colonization with
Legionella; and (b) proper assessment and timely diagnosis of Legionella among patients
in Flint who present with characteristic signs and symptoms and have a history of
potential exposure to contaminated water. Of note, the risk of resurgent Legionellosis
in Spring 2016 is on the horizon; the first cases of Legionellosis in the 2014 and 2015
outbreaks were diagnosed in June and May, respectively, and Legionella is known to be
much more common in the spring, summer, and fall than in the winter months. Time is
of the essence.
MDHHS should work with its federal partners to assure that investigative efforts related
to Legionella regarding quality and safety of water are conducted in coordination with
the FWSSAT described above. Furthermore, MDHHS should regularly communicate its
findings to the Flint community regarding its efforts to prevent, detect, and treat cases
of Legionella until case levels return to pre-2014 levels.
We expect that these measures will provide members of the Flint community with assurance
that the quality of their tap water is being appropriately monitored and that forthcoming
announcements that Flint’s tap water is safe to drink are well-founded. Notwithstanding
earnest state agency actions, we believe that the engagement of independent subject matter
experts, whether to assess drinking water quality or public health concerns, is critical to
overcome, over time, the understandable skepticisms that prevail in the Flint community.
We hope that you will receive these recommendations in the same spirit with which they are
offered – to advance the recovery and reinvigoration of the Flint community.
Respectfully,
Matthew Davis, M.D.
Chris Kolb
Lawrence Reynolds, M.D.
Eric Rothstein, CPA
Ken Sikkema
! ! !
APPENDIX!III:!Interviewee!Listing!
! !
No. Last(Name First(Name Organization
1 Kildee Daniel(T. U.S.(House(of(Representatives
2 Ananich James Michigan(State(Senate
3 Snyder Rick Michigan(Governor's(Office
4 Muchmore Dennis Michigan(Governor's(Office
5 Baird Rich Michigan(Governor's(Office
6 Hollins Harvey Michigan(Governor's(Office
7 Dillon Andy Treasury(Department
8 Workman Wayne Treasury(Department
9 Saxton Thomas Treasury(Department
10 Byrne Randall Treasury(Department
11 Sampson Jeremy Treasury(Department
12 Ambrose Jerry City(of(Flint
13 Earley Darnell City(of(Flint
14 Kurtz Ed City(of(Flint
15 Brown Michael City(of(Flint
16 Weaver Karen City(of(Flint
17 Walling Dayne City(of(Flint
18 Henderson Natasha City(of(Flint
19 Freeman Josh City(of(Flint
20 Lundquist Jody City(of(Flint
21 Brown Inez City(of(Flint
22 Croft Howard City(of(Flint
23 Johnson Daugherty City(of(Flint
24 Wright Brent City(of(Flint
25 Glasgow Mike City(of(Flint
26 Mays Melissa Flint(Citizen
27 Overton Allan Flint(Citizen
28 Shariff Nayyirah( Flint(Citizen
29 Wyant Dan MDEQ
30 Sygo Jim MDEQ
31 Creagh Keith MDEQ
32 Krisztian George MDEQ
33 Anderson Madhu MDEQ
34 Shekter(Smith Liane MDEQ
35 Rosenthal Adam MDEQ
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38 Lyon Nick MDHHS
39 Becker Tim MDHHS
40 Wells Eden MDHHS
41 Larder Cristin MDHHS
42 Lasher Geralyn MDHHS
43 Moran S usan MDHHS
44 Hyde Tinka EPA
45 Crooks Jennifer EPA
46 Hedman Susan EPA
47 Kaplan Bob EPA
48 Del(Toral Miguel EPA
49 Porter Andrea EPA
50 Blair Rita EPA
51 Poy Tom EPA
51 Betanzo Elin Northeast]Midwest(Institute
52 Edwards Marc Virginia(Tech
53 Sullivan Laura Kettering(University
54 McElmurry Shawn Wayne(State(University
54 Hanna]Attisha Mona Hurley(Medical(Center
55 Valacak Mark Genesee(County(Health(Dept.
56 Doerr Kay Genesee(County(Health(Dept.(](Board(of(Health
57 Henry James Genesee(County(Health(Dept.
58 Guyette Curt ACLU
59 Fonger Ro n MLive
59 Wright Jeff GCDC
60 O'Brien John GCDC
61 Jansen Dave GCDC
62 Wolfson William GLWA(/(DWSD
63 Koesters Laurie GLWA(/(DWSD
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! ! !
APPENDIX!IV:!Questions!of!Lockwood,!Andrews,!&!Newnam!
!
Flint Water Advisory Task Force
Flint Water Advisory Task Force
! ! !
APPENDIX!V:!Detailed!Timeline!!
!
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! ! !
APPENDIX!VI:!Abbreviations!and!Acronyms!!
! !
! ! !
!
Abbreviation!
Definition!
ACLU!
American!Civil!Liberties!Union!
AG!
Attorney!General!
AJPH!
American!Journal!of!Public!Health!
AWWA!
American!Water!Works!Association!
CAC!
Citizens!Advisory!Committee!
CCT!
Corrosion!control!treatment!
CDC!
Centers!for!Disease!Control!and!Prevention!
CLPPP!
Childhood!Lead!Poisoning!Prevention!Program!
Cu!
Copper!
DBPs!
Disinfection!byproducts!
DEQ!
Department!of!Environmental!Quality!
DHHS!
Department!of!Health!and!Human!Services!!
DNR!
Department!of!Natural!Resources!
DPW!
City!of!Flint!Department!of!Public!Works!
DWSD!
Detroit!Water!and!Sewerage!Department!
EBLL!
Elevated!blood!lead!level!
EFM!
Emergency!financial!manager!
ELL!
Elevated!lead!level!
EM!
Emergency!manager!
EPA!
U.S.!Environmental!Protection!Agency!
FAQs!
Frequently!Asked!Questions!
FOIA!
Freedom!of!Information!Act!
FWATF!
Flint!Water!Advisory!Task!Force!
FWICC!
Flint!Water!Interagency!Coordinating!Committee!
GCBOH!
GCHD!Board!of!Health!
GCDC!
Genesee!County!Drain!Commission!
GCHD!
Genesee!County!Health!Department!
GCMS!
Genesee!County!Medical!Society!
GFHC!
Greater!Flint!Health!Coalition!
GM!
General!Motors!
HMC!
Hurley!Medical!Center!
KWA!
Karegnondi!Water!Authority!
LAN!
Lockwood,!Andrews,!&!Newnam ,!Inc.!
LCR!
Lead!Contaminant!Rule!
LSL!
Lead!service!line!
MCIR!
Michigan!Care!Improvement!Registry!
MCL!
Maximum!Contaminant!Level!
MDCH!
Michigan!Department!of!Community!Health!
MDEQ!
Michigan!Department!of!Environmental!Quality!
MDHHS!
Michigan!Department!of!Health!and!Human!Services!
mgd!
Million!gallons!per!day!
NAN!
National!Action!Network!
! ! !
NDWAC!
National!Drinking!Water!Advisory!Council!
NRDC!
National!Resources!Defense!Council!
OAG!
Office!of!the!Auditor!General!
OCCT!
Optimal!Corrosion!Control!Treatment!
ODMWA!
Office!of!Drinking!Water!and!Municipal!Assistance!
O&M!
Operations!and!maintenance!
Pb!
Lead!
ppb!
Parts!per!billion!
SDWA!
Safe!Drinking!Water!Act!
TAC!
City!of!Flint/Veolia!Technical!Advisory!Committee!
TTHMs!
Total!trihalomethanes!
TYJT!
Tucker,!Young,!Jackson,!Tull!Inc.!
UAW!
United!Auto!Workers!Union!
µg/l!
Micrograms!per!liter!
VT!
Virginia!Tech!(Virginia!Polytechnic!Ins titute !and !State !Un ive rsity !
WTP!
Water!Treatment!Plant!
!