Factors that led to the Walkerton tragedy.

In May 2000, bacterial contamination of municipal water in Walkerton, Ontario, resulted in the worst public health disaster involving municipal water in Canadian history. At least seven people died and 2300 became ill. A public inquiry led by judge Dennis O'Connor examined the events and delineated the causes of the outbreak, including physical causes, the role of the public utilities operators, the public utilities commissioners, the Ministry of the Environment (MOE), and the provincial government. Improper practices and systemic fraudulence by the public utility operators, the recent privatization of municipal water testing, the absence of criteria governing quality of testing, and the lack of provisions made for notification of results to multiple authorities all contributed to the crisis. The MOE noted significant concerns 2 years before the outbreak; however, no changes resulted because voluntary guidelines as opposed to legally binding regulations governed water safety. The inquiry concluded that budgetary restrictions introduced by the provincial government 4 years before the outbreak were enacted with no assessment of risk to human health. The ministers and the cabinet had received warnings about serious risks. Budgetary cuts destroyed the checks and balances that were necessary to ensure municipal water safety.