Walkerton Tragedy

Introduction and background information about Walkerton ·

Walkerton was originally part of Brant County and was first settled in 1849 by William Jasper and Edward Boulton who farmed to the east of the river. Other settlers from the same era included John Lundy, Moses Stewart and Thomas Bilkie who farmed to the west of the river. Joseph Walker arrived from Ireland in 1850 and is considered one of the founders of Walkerton. He built both saw mills and flour mills, surveyed the area into a town plot and encouraged businesses to locate here. Years later, Walker was the reeve of Brant for several terms, and was elected as the first mayor or Walkerton.[2] Although Walkerton was never incorporated as a village, it became a town in 1871, with apopulation of just under 1000. That increased to 2,604 by 1881, and to 3,061 by 1891 thanks to the arrival of the railroad which enabled the locals to ship their grain. The population dropped to 2,971 by 1901 Causes and events leading to the disaster of 2003

At the time of the event in May 2000, Stan Koebel was utilities manager for Walkerton, and his brother Frank Koebel was water foreman. Neither had any formal training in this position, retaining their jobs through three decades of on-the-job experience. The water supply, drawn from groundwater, became contaminated with the highly dangerous O157:H7strain of E. coli bacteria.[1] This contamination was due to farm runoff into an adjacent water well that had been known for years to be vulnerable to groundwater contamination.

Starting May 13, 2000, many people of the community of about 5,000 people began to experience bloody diarrhea, gastrointestinal infections and other symptoms of E. coli infection. For days the Walkerton Public Utilities Commission insisted the water supply was “OK” despite being in possession of laboratory tests that had found evidence of contamination. On 21 May, an escalation in the number of patients with similar symptoms finally spurred the region’s Medical Officer of Health, Murray McQuigge, to issue a boil-water advisory, warning residents not to drink the tapwater. The five people who died directly from drinking the E. coli-contaminated water might have been saved if the Walkerton Public Utilities Commission had admitted to contaminated water sooner, and about 2,500 became ill. An experimental drug in Phase III clinical trials, Synsorb Pk, was used to treat 19 children on compassionate grounds under Health Canada’s Special Access Program.[2]

During the time of the tragedy, both Stan and Frank Koebel denied any wrong doing and firmly held that the water at Walkerton was safe to drink. However, as the tragedy grew in severity the two were eventually part of the criminal investigation into the tragedy, and, as a result, both would eventually plead guilty to a charge of common nuisance through a plea bargain. In their plea, they admitted to falsifying reports and Frank admitted to drinking on the job, as a beer fridge did exist at the facility.[3] They were both formally sentenced on December 21, 2004, with Stan receiving one year in jail and Frank Koebel nine months of house arrest. Reaction to their sentencing was mixed. No provincial government politician was charged or found guilty of wrongdoing. As law professor Bruce Pardy notes, “Policy development is not subject to tort liability.”[4] Impacts of the disaster Seven people died and more than 2,300 became ill in the spring of 2000 after the town’s water supply became contaminated with E. coli bacteria.

First symptoms of contaminated water appear, including diarrhea and flu-like illnesses. PUC receives a fax from a lab confirming E. coli contamination in May 15 water sample. The utilities commission does not notify public-health officials, however. May 19, 2000 Region’s Medical Health Office (MHO) first notified about several patients with bloody diarrhea. The MHO later finds out that local doctors had been treating patients with symptoms including bloody diarrhea, vomiting, cramps and fever since May 17. PUC, run by Stan Koebel, assures health officials that the water is safe. MHO begins looking for other source of contamination, such as food.

May 20, 2000. As many as 40 more people report to hospital with bloody diarrhea. · PUC reassures officials at least twice that Walkerton’s water supply is safe.

May 21, 2000. With more cases of illness reported, MHO officially warns residents not to drink untreated tap water. MHO also takes independent water samples, despite being told by PUC there is no contamination.

May 23, 2000. MHO’s own lab confirms water is tainted with E. coli. After confronting PUC with test results, MHO is finally told about May 17 fax. Health officials are also informed that the equipment used to put chlorine into at least one drinking well has not worked for some time. The first four deaths, three adults and a baby, are reported as a result of the E. coli outbreak. Local schools are closed.

May 25, 2000. A fifth person dies after being infected with E. coli. Dr. Murray McQuigge, the region’s medical officer of health, stuns the country with his revelation on CBC Radio that the PUC knew there was a problem with the water several days before they told the public. The regional police force asks the Ontario Provincial Police to conduct a criminal investigation into the origins of the outbreak.

May 26, 2000 Ontario Premier Mike Harris visits Walkerton, saying, “We have a terrible tragedy here.” The rest of his comments — including blaming the previous, NDP government — anger residents. Within the week, he orders a public inquiry.

May 27, 2000 The president of water-testing firm GAP EnviroMicrobial Services, Garry Palmateer, says that sampling done in January turned up evidence of coliform bacteria — an indication that surface water was seeping into the well water. He says his company notified the Ontario Environment Ministry about the problem five times.

May 29, 2000 A clearly shaken Environment Minister Dan Newman calls a news conference to announce changes to ensure that the province’s water supply remains safe. · May 30, 2000 · The deadly bacterial outbreak claims its sixth victim, an elderly patient who was being cared for at a local hospital.

May 31, 2000 A hospital 140 kilometres south in London, Ont., confirms that a 56-year-old woman has died, bringing the final fatality count in the contaminated-water catastrophe to seven. Nearly 2,300 people fall ill at some point from the water.

Aftermath of the event and how it was resolved

The Ontario Clean Water Agency was put in charge of the cleanup of Walkerton’s water system. An inquiry, known as the Walkerton Commission led by Court of Appeal for Ontario Associate Chief Justice Dennis O’Connor, wrote a two-part report in 2002. Part 1 was released in January 2002.[5] The Walkerton Report, Part One, described events in the community and a series of failures, both human and systemic, that led to contamination of the water supply. The report made recommendations based on the circumstances of the tragedy. It estimated that the Walkerton water tragedy cost a minimum of C$64.5–155 million and laid much of the blame at the door of the Walkerton Public Utilities Commission:

The Walkerton Public Utilities Commission operators engaged in a host of improper operating practices, including failing to use adequate doses of chlorine, failing to monitor chlorine residuals daily, making false entries about residuals in daily operating records, and misstating the locations at which microbiological samples were taken. The operators knew that these practices were unacceptable and contrary to Ministry of Environment guidelines and directives.[5]

The Ontario government of Mike Harris was also blamed for not regulating water quality and not enforcing the guidelines that had been in place. The water testing had been privatized in October 1996.[6] · Part 2 of the report made many recommendations for improving the quality of water and public health in Ontario.[6] Part Two discussed water safety across the province and the steps needed to prevent similar tragedies. It made ninety-three recommendations. All of its recommendations have been accepted by succeeding governments of the province. The recommendations have also influenced provincial policies across Canada. Key recommendations touched on source water protection as part of a comprehensive multi-barrier approach, the training and certification of operators, a quality management system for water suppliers, and more competent enforcement. In Ontario, these requirements have been incorporated into new legislation.

The lessons learned from this incident were described by Kim Vicente in his book The Human Factor. A 2005 CBC Television docudrama called Betrayed was based loosely upon the Walkerton tragedy. In 2001 a similar outbreak in North Battleford, Saskatchewan caused by the protozoan Cryptosporidium affected at least 5,800 people. Progressive Conservative MPP Lisa Thompson stated in 2014 that the regulations put in place after the inquiry have done nothing but increase costs for municipalities and called for a reduction in water-quality testing regulations while increasing enforcement.[7]

What can be done to prevent this sort of event in the future (new regulations and standards, implementation of them, etc)

It has been made known that Municipal Well 5 did not have a continuous chlorine dosage or turbidity monitoring system; therefore, two possible preventative systems did not alarm for an appropriate action of whether to increase the chlorine dosage to kill the pathogens or make a decision to send out a boil water advisory. Unfortunately, in Walkerton’s case, the boil water advisory was not initiated until many days after the contamination entered the distribution system.

Having code of conduct and safety principles are important and crucial for assuring safe, potable water. Learning from past experiences and dealing with the greater risks first to the lesser last would be a more rational method in risk protection. A preventative approach, instead of a reactive one with some foresight would have been ideal way of preventing the tragedy in Walkerton. An example of foresight would be to implement environmental protection over the regional watersheds to protect the sources of drinking water. If the watersheds are not protected, then the water treatment processes become stressed due to extreme unforeseen conditions put on it.