AAA&Drinking waterborne outbreaks still occur in the developing world. However, it is not always the utility at fault. As the events of Flint continue to unfold, it is worth looking back at our waterborne outbreak history and whether we are doomed to keep repeating the governance errors of the past.

The issue

The World Health Organization calls for a catchment to consumer approach to drinking water management. Part of this approach includes understanding the governance framework in which the water supplier operates.

In many cases, water suppliers are required to get approval from their water supply regulator that all is in order before drinking water can be supplied to customers. Suppliers are also required to have in place and continuously monitor the effectiveness of controls to assure the quality of drinking water that they provide. In other words, provision of safe drinking water is not ‘set and forget’ – systems change, sources change, regulations change, disease causing agents change – and human resources change. So why are preventable outbreaks and contamination incidents still occurring? Why are we not learning from past mistakes? Is our water supply governance broken?

Waterborne incidents – a repeating occurrence

In 2000, Walkerton’s (Ontario, Canada) water supply was contaminated with toxic E. coli O157:H7 and Campylobacter bacteria. Seven individuals lost their lives from simply drinking tap water, one was a two year old child. The impact did not stop there. Several people had to move to larger conurbations so they could be in close vicinity to good health care for their children, whose kidneys were damaged by the disease.

In 2001, an outbreak of cryptosporidiosis occurred in North Battleford (Saskatchewan, Canada). Raw water for North Battleford was supplied from either groundwater or from the North Saskatchewan River. The river was known to have high concentrations of cryptosporidia and was recognised as a difficult water to treat. An inquiry found that the outbreak cause was the presence of human infectious cryptosporidia in the treated surface water supplied from the North Battleford plant. A study estimated that 5,800 to 7,100 people in the Battlefords area had been affected.

Governance failings

While the culpability of the Walkerton Public Utilities Commission (PUC) was not in doubt, a subsequent inquiry also found respective governments and agencies responsible. Budget cuts were found to be a major factor in the tardiness of monitoring and issuing corrective actions to the outbreak. Cuts instigated by the provincial government made it less likely that the Ministry of the Environment would have identified the need for continuous monitoring at the contaminated well as well as the improper operating practices of the Walkerton PUC. The cuts also affected monitoring of utility performance with reductions in government laboratory testing services for municipalities occurring in 1996.

In the North Battleford case, the body responsible for the licensing of water works was Saskatchewan Environment and Resource Management (or SERM) under the Environmental Management and Protection Act. The Laing Commission found several gaps in the SERM water supply regulation framework. Permits issued with the approval of water works were found to be inconsistently applied. There were no legislated drinking water standards at the time of the outbreak. Budget cuts were a founding factor in a reduction in SERM water works inspections – the last inspection of North Battleford being 10 years before the outbreak. Justice Laing commented that:

“SERM was an inadequate and ineffective regulator of drinking water as a result of its policy to gradually withdraw from active regulation in 1997.”

For both Walkerton and North Battleford, health regulators were largely found to have been competent. It was the water supply regulators who were found wanting.

So how does Flint compare?

Flint had originally sourced its water from the Detroit Water and Sewerage Department (Lake Huron source water). As a cost-cutting move, while under the control of a state-appointed emergency manager, the city began temporarily drawing its drinking water from the Flint River and treating it. In April 2014, Flint’s drinking water became contaminated with lead due to the corrosive effects of the new water source causing lead to leak out of fittings and fixtures. Up to 9000 children (a susceptible group to lead poisoning) have been estimated exposed to the contamination. One could say that the water was a ‘difficult source to treat’ – but known to be so. The state Department of Environmental Quality has conceded it failed to require needed chemicals to be added to the corrosive Flint River water.

What can we learn?

“Cost cutting”, “regulator failure”, “not understanding the treatment implications of changing the source of water”, “difficult water to treat”.

The disastrous outcomes of these common elements of the above drinking water supply incidents could have been avoided if considered from a ‘source to enduse – Corporate to Coalface’ system perspective. Who is collating and synthesising these risks and feeding the information back into good governance outcomes?

Why should we care?

Drinking water supply outbreaks are almost always foreseeable and preventable, yet they keep happening. Have our politicians and public servants forgotten how to govern – have we got political and policy amnesia? It is sobering that measures implemented under the umbrella of cost-cutting, have nearly always cost more in the end in terms of righting the unintended consequences. Perhaps it is time to use that money in supporting our public service and policy makers, to allow them time to make and implement good policy and to make sure we retain a memory of what works and what doesn’t. Good, evidence-based governance equals good outcomes for our communities.


Annette is a highly experienced certified auditor and award-winning risk manager in the water, environment, policy and mining fields. She has helped utilities implement water safety and risk management plans both in Australia and overseas. She has a multitude of journal, book chapter, books, technical papers, reports and other publications in several fields including bioremediation, biodiversity, microbial ecology, water utility due diligence and risk management. Annette is in demand as a conference and workshop presenter, for auditing of statutory and certified risk management plans, for developing utility risk management plans, ERM consultation and development and as a facilitator for board workshops.

M: 0411 049 544
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E: annette@riskedge.com.au
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