Walkerton: Lessons Learned

1. Walkerton: Lessons Learned Walkerton: Lessons Learned Colin Mayfield, Department of Biology, University of Waterloo and United Nations University: International Network on Water, Environment and Health

2. What happened ? Seven people died and over 2,300 became ill from Escherichia coli infections in a small town of 4,800 people. It was caused by many factors and the mistakes of many people and agencies The causes of this outbreak were investigated by a judicial inquiry and the persons and organizations responsible were identified. Escherichia coli O157 H7

3. Perspective Seven people died and over 2,300 became ill from Escherichia coli infections in a small town of 4,800 people. It was caused by many factors and the mistakes of many people and agencies To put this in perspective, it is equivalent to an outbreak in the Greater Toronto Area where over 1.4 million people become infected and over 4,000 die

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

5. THE ORGANISM The Organism 1.5 mM Escherichia coli O157:H7

6. What is E coli o157:h7 • What is Escherichia coli O157:H7? • E. coli O157:H7 is one of hundreds of strains of the bacterium Escherichia coli. Although most strains are harmless and live in the intestines of healthy humans and animals, this strain produces a powerful toxin and can cause severe illness. • E. coli O157:H7 was first recognized as a cause of illness in 1982 during an outbreak of severe bloody diarrhea; the outbreak was traced to contaminated hamburgers. Since then, most infections have come from eating undercooked ground beef The combination of letters and numbers in the name of the bacterium refers to the specific markers found on its surface and distinguishes it from other types ofE. coli.

7. Epidemiology (CDC, Atlanta) Epidemiology The organism can be found on a small number of cattle farms and can live in the intestines of healthy cattle. Meat can become contaminated during slaughter, and organisms can be thoroughly mixed into beef when it is ground. Bacteria may get into raw milk. Eating meat, especially ground beef, that has not been cooked sufficiently to kill E. coli O157:H7 can cause infection. Contaminated meat looks and smells normal. Drinking unpasteurized milk and swimming in or drinking sewage-contaminated water can also cause infection.

8. Symptoms Symptoms E. coli O157:H7 infection often causes severe bloody diarrhea and abdominal cramps; sometimes the infection causes non-bloody diarrhea or no symptoms. Usually little or no fever is present, and the illness resolves in 5–10 days. In some persons, particularly children under 5 years of age and the elderly, the infection can also cause a complication called hemolytic uremic syndrome, in which the red blood cells are destroyed and the kidneys fail. About 2%–7% of infections lead to this complication. In the United States, hemolytic uremic syndrome is the principal cause of acute kidney failure in children, and most cases of hemolytic uremic syndrome are caused by E. coli O157:H7.

9. Bottom Line ? • Bottom Line? • It is a well-known organism (since 1982) • The symptoms of juvenile hemolytic uremic syndrome are often caused by this organism • 10,000–20,000 cases of infection occur in the United States each year • Most illness has been associated with eating undercooked, contaminated ground beef • “Infection can also occur after drinking raw milk and after swimming in or drinking sewage-contaminated water” - CDC, Atlanta

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

11. Well 5 Well 5 was an extremely shallow well and, when the pump was operating, water was drawn down from the surface water around the well. When the pump was not operating, natural springs occurred in the depression around the well. Inother words there was a direct connection between the surface water and the well as it pumped from the shallow groundwater aquifer.

12. Well 5 - 2 • Coupled with these technical issues was the issue of management and reporting of contamination events. • Reports from private laboratories to the Public Utilities Commission that showed the presence of coliforms or Escherichia coli in the drinking water did not have to be sent to the Ministry of the Environment or the Health Unit. • The PUC was  supposed to do that.  It did not.

13. Broken Loop

14. Events 1 • Then the chlorination plant did not inject chlorine at the required level (it had been faulty for some time). • Levels of chlorine in the drinking water are supposed to be at or above 0.5 ppm. Documented cases are in the log books for the wells where these criteria were not met. • In addition, many readings over a long period of time were stated to be at either "0.5" or "0.7" ppm - an unlikely coincidence for all levels to be essentially identical over a long period of sampling. • Stan Koebel (the manager of the PUC)and Frank Koebel later admitted at the inquiry that the results were often fabricated and that samples sent for analysis for water quality were often from the wrong sample sites.

15. Events 2 • Frank Koebel also stated he “got complaints” about excessive chlorination and often “dialed back” the chlorinator. • They both stated that they did not know much about coliform bacteria • A new chlorinator was supposed to be installed but was not • Then it rained • Well 5 was contaminated during a heavy rainfall in May 2000. Bacteria from a farm manure pile entered the well through overland flow and/or through transport in groundwater after percolating down through the very permeable soil to the shallow aquifer. • Since the chlorinator was not working, the E. coli O157:H7 entered the town’s water system and was distributed to everybody.

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

17. Events 3 • The number of people who became ill was approximately 2300. • In total, 174 people had presumptive laboratory evidence of E. coli O157, 167 of which were confirmed as E. coli O157:H7. • 116 people were confirmed with Campylobacter species • 65 patients were admitted to hospital, and of these, 27 developed hemolytic uremic syndrome. • Seven people died as a result of the outbreak. Health Canada Report

18. Events 4 Stan Koebel lied to the Medical Officer of Health about the presence of coliforms in the water supply after the start of the outbreak. Only when an MoE employee deduced that the water was the problem and initiated testing and then informed the MoH did action (the “boil water advisory”) begin.

19. Summary The Reasons • PUC members • No-one with any water system expertise, left all management and operational decisions to PUC staff • Part-time positions – Hydro concerns predominated • Government of Ontario • Cutbacks driven by ideology • No risk analysis of decisions • Ignored expert advice (including Chief Medical Officer of Health for Ontario) PUC oversight failed • PUC Management (Stan and Frank Koebel) • Untrained • Unqualified (“grandfathered” to position) • Dishonest reporting • Attitudes to water system management • Potential loss of positions upon amalgamation • Hydro concerns predominated 40% staff decrease • Ministry of the Environment • Previous coliform problems at Walkerton (and many other places) not dealt with • Cutbacks to staff leading to lack of inspection • Privatization of laboratory analyses – no clear guidelines • Inspection, reporting and remediation processes flawed MoE oversight, training and inspection roles failed • Health Unit • Small staff, large area to cover • Budget decrease • E. coli counts were not reported to them • Municipal water systems rated 2 to 3% of staff time

20. The INQUIRY The Inquiry Justice Dennis O’Connor conducted a detailed, exhaustive and extremely thorough investigation including a series of commissioned technical reports, expert witness presentations and cross-examinations, investigation and examination of all “players” (PUC, Township council, MoE and other ministries, Ontario government ministers and the Premier of Ontario, and many individuals) He produced a Part 1 report that detailed exactly “what happened and why”. Part II of the report followed at the end of May 2002 and consisted of recommendations to prevent similar occurrences. Both are on the Biology 447 website

21. THE LESSONS- Social The Lessons • We can learn many lessons from the Walkerton tragedy • Social “Lessons” • Citizen awareness and involvement • Oversight of essential services • Hiring and employment practices • Community response • Health system – information and practices

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

23. Education Lessons 1 The Lessons Education “Lessons” Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:

24. Education Lessons 2 The major cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacteriumpylori. Some health personnel today still quote “stress” as the major cause and prescribe antacids rather than an antibiotic The Lessons Education “Lessons” Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:

25. Education Lessons 3 The major cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacteriumpylori. Some health personnel today still quote “stress” as the major cause and prescribe antacids rather than an antibiotic The Lessons Education “Lessons” Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: 26% of the people in North America think the Sun revolves around the Earth

26. Education Lessons 4 The major cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacterium pylori Some health personnel today still quote “stress” as the major cause and prescribe antacids rather than an antibiotic The Lessons The cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacterium species. Many health personnel today still quote “stress” as the major cause and prescribe antacids. Education “Lessons” Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: 26% of the people in North America think the Sun revolves around the Earth 50% of the population of the USA believe that the position of stars at birth affects a person’s future (Astrology)

27. Education Lessons 5 The Lessons Education “Lessons” Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee. Risk analysis and risk management is not commonly taught or known.

28. Education Lessons 6 Risk 1 • Risk Perception • Activities Perceived as Higher Risk by: • United States Environmental Protection Agency (EPA) • Global warming • Indoor air pollution, including radon (high health risk) • Exposure to chemicals in consumer products (high health risk) • Surface water pollution (high ecological risk) • the Public • Chemical waste disposal • Water pollution • Chemical plant accidents The Lessons Education Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee. Risk analysis and risk management is not commonly taught or known.

29. Education Lessons 7 Risk 2 • Activities Perceived as Lower Risk by: • the EPA • Hazardous waste sites - active and inactive • Underground storage tanks • the Public • Indoor air pollution • Exposure to chemicals in consumer products • Global warming • Risk Perception • Activities Perceived as Higher Risk by: • United States Environmental Protection Agency (EPA) • Global warming • Indoor air pollution, including radon (high health risk) • Exposure to chemicals in consumer products (high health risk) • Surface water pollution (high ecological risk) • the Public • Chemical waste disposal • Water pollution • Chemical plant accidents • Risk Perception • Activities Perceived as Higher Risk by: • United States Environmental Protection Agency (EPA) • Global warming • Indoor air pollution, including radon (high health risk) • Exposure to chemicals in consumer products (high health risk) • Surface water pollution (high ecological risk) • the Public • Chemical waste disposal • Water pollution • Chemical plant accidents Education Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee. Risk analysis and risk management is not commonly taught or known.

30. Education Lessons 8 Risk 3 • Activities Perceived as Lower Risk by: • the EPA • Hazardous waste sites - active and inactive • Underground storage tanks • the Public • Indoor air pollution • Exposure to chemicals in consumer products • Global warming • Risk Perception • Activities Perceived as Higher Risk by: • United States Environmental Protection Agency (EPA) • Global warming • Indoor air pollution, including radon (high health risk) • Exposure to chemicals in consumer products (high health risk) • Surface water pollution (high ecological risk) • the Public • Chemical waste disposal • Water pollution • Chemical plant accidents Education Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee. Risk analysis and risk management is not commonly taught or known.

31. Education Lessons 9 Risk 4 • Activities Perceived as Lower Risk by: • the EPA • Hazardous waste sites - active and inactive • Underground storage tanks • the Public • Indoor air pollution • Exposure to chemicals in consumer products • Global warming • Risk Perception • Activities Perceived as Higher Risk by: • United States Environmental Protection Agency (EPA) • Global warming • Indoor air pollution, including radon (high health risk) • Exposure to chemicals in consumer products (high health risk) • Surface water pollution (high ecological risk) • the Public • Chemical waste disposal • Water pollution • Chemical plant accidents One topic where they agree ! Education Training and frequent updating of the knowledge of personnel at all levels is essential Those in oversight positions need to enforce this Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee. Risk analysis and risk management is not commonly taught or known.

32. Risk Perception Overview • Education • Training and frequent updating of the knowledge of personnel at all levels is essential • Those in oversight positions need to enforce this • Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal: • Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee. • Risk analysis and risk management is not commonly taught or known. • Most people will accept a “one in a million” risk level of dying in a particular year except: • If it is something that is not understood or controllable (radiation, nuclear power stations, chemical spills, etc.) – then any level of risk is too high ! • If it applies to them or their loved ones or family ! • If it is something they understand and is controllable and they have “chosen” to do such as smoking, motorcycling, sky-diving, or driving – then they will accept a much higher (often an incredible) risk !

33. Legal Lessons 1 The Lessons Legal “Lessons” Passage of good regulations is not sufficient Enforcement of regulations and standards is often left to the discretion of fairly junior personnel Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.

34. Legal Lessons 2 The Lessons Legal “Lessons” Passage of good regulations is not sufficient Enforcement of regulations and standards is often left to the discretion of fairly junior personnel Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. Walkerton

35. Legal Lessons 3 The Lessons Legal Passage of good regulations is not sufficient Enforcement of regulations and standards is often left to the discretion of fairly junior personnel Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. ENRON Walkerton

36. Legal Lessons 4 The Lessons Waste Management Inc. Legal Passage of good regulations is not sufficient Enforcement of regulations and standards is often left to the discretion of fairly junior personnel Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. ENRON Arthur Andersen Inc. Walkerton Adelphia Inc Global Crossings Inc. Varnicolor (Elmira)

37. Legal Lessons 5 The Lessons Waste Management Inc. Exxon Valdez Love Canal Legal Passage of good regulations is not sufficient Enforcement of regulations and standards is often left to the discretion of fairly junior personnel Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. ENRON Arthur Andersen Inc. Walkerton Union Carbide Bhopal Cryptosporidium infections from waterin Australia, the US andWaterloo Region Varnicolor (Elmira)

38. Legal Lessons 6 The Lessons Waste Management Inc. Exxon Valdez Love Canal Legal Passage of good regulations is not sufficient Enforcement of regulations and standards is often left to the discretion of fairly junior personnel Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. ENRON UNIROYAL Pesticide Production - Chemical Disposal Elmira, Waterloo Complied with allregulations Arthur Andersen Inc. Walkerton Union Carbide Bhopal Cryptosporidium infections from waterin Australia, the US andWaterloo Region Varnicolor (Elmira)

39. Legal Lessons 7 The Lessons • Legal “Lessons” • Passage of good regulations is not sufficient • Enforcement of regulations and standards is often left to the discretion of fairly junior personnel • Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. • Often, these companies are the ones that can cause the most damage because their costs of compliance to regulations are high and so their savings by not complying are large

40. Legal Lessons 8 The Lessons • Legal “Lessons” • Passage of good regulations is not sufficient • Enforcement of regulations and standards is often left to the discretion of fairly junior personnel • Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations. • Often, these companies are the ones that can cause the most damage because their costs of compliance to regulations are high and so their savings by not complying are large • New developments and information may make regulations obsolete or ineffective. Constant vigilance is required.

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

42. Scientific Lessons 3 • Scientific (research and information dissemination) “Lessons” • There is an enormous amount of new “raw” research information and it is more accessible than ever before. • Scientists are becoming more and more specialized due to this “information explosion” • Anyone who attempts to be a “generalist” has less and less knowledge about any given part of their wider expertise • This is leading to a dichotomy between these groups • Research data should be translated more effectively into a form that is more accessible to the users and to the general public. • Scientists, engineers and others have to take more responsibility for wider dissemination of the meaning of their research and development work. Many are reluctant to do this.

43. Scientific Lessons 5 • Scientific (research and information dissemination) “Lessons” • There is an enormous amount of new “raw” research information and it is more accessible than ever before. • Scientists are becoming more and more specialized due to this “information explosion” • Anyone who attempts to be a “generalist” has less and less knowledge about any given part of their wider expertise • This is leading to a dichotomy between these groups • Research data should be translated more effectively into a form that is more accessible to the users and to the general public. • Scientists, engineers and others have to take more responsibility for wider dissemination of the meaning of their research and development work. Many are reluctant to do this. Most of the people involved in Walkerton didnot know that some forms of E. coli could kill Those people included some microbiologists !

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

45. Economic Lessons The Lessons • Economic “Lessons” • We have a reasonable infrastructure of roads, sewers, water pipes, electricity, telephones and communications systems in place • General taxation has funded these infrastructure costs in the public sector • Repair costs have not been adequately funded and are now very large • These costs will have to come from increased taxes, increased cost recovery (eg - metered water supplies), downloading of costs to lower level governments or privatization • Future generations will have to pay for the repairs as well as their on-going maintenance The World Bank has a policy of requiring countries applying forfunding of water projects to have their citizens pay for their water use Is access to clean, safe water a “right” or is water a “commodity” ?

46. Economic Lessons The Lessons • Economic “Lessons” • We have a reasonable infrastructure of roads, sewers, water pipes, electricity, telephones and communications systems in place • General taxation has funded these infrastructure costs in the public sector • Repair costs have not been adequately funded and are now very large • These costs will have to come from increased taxes, increased cost recovery (eg - metered water supplies), downloading of costs to lower level governments or privatization • Future generations will have to pay for the repairs as well as their on-going maintenance The cost of bringing the water systems in Ontario to the level at which another Walkerton isunlikely to happen will be hundredsof millions or billions of dollars

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

48. Governance/Political Lessons The Lessons • Governance and Political “Lessons” • The Walkerton tragedy and inquiry highlighted: • Governance structure for infrastructure such as water supply • Political cost of failure versus economic cost of success • Corporate, government and individual legal liabilities • The positive effect of an rigorous, impartial and complete judicial inquiry into these kinds of events • The Walkerton Inquiry was wide-ranging and comprehensive. It allowed the citizens of Walkerton to see that all avenues were being investigated, all experts were being consulted and no-one was allowed to hide what had happened. • It was accompanied by detailed investigations that included the examination of thousands of documents and interviewing hundreds of people.

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

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