F rank Koebel just ignored the instructions. A brooding bull of a man with short black hair and the ruddy complexion of an alcoholic, Frank didn’t like being told what to do. As foreman for the Public Utility Commission (PUC), he was responsible for maintaining the water supply for Walkerton and the surrounding towns. The chlorinator for well 7, the main source of water for the city, hadn’t worked for almost a week. His boss, who happened to be his older brother, Stan, had just left town for a weeklong conference. Before he left, Stan told Frank to install the new chlorinator. Frank decided he had more important things to do.
Installing the new chlorinator just never seemed urgent. After all, it had been sitting in storage for over a year. A few days more or less wouldn’t matter. Besides, chlorine didn’t seem to do much besides ruin the taste of the “cool, clear, crisp water” that flowed from the aquifers deep beneath southern Ontario. Even when the automatic chlorinator was running, Frank rarely set it to add the required amount. If he did, customers complained. In fact, the wells had run for decades without chlorine until a new regulation required it. When he or Stan was thirsty, they liked to drink the raw, unchlorinated water straight from the well.
To be precise, Frank had already taken the first step in installing the new chlorinator. Two days earlier he and two PUC employees had opened the bypass valves and removed the old chlorinator. Up until that point, the old equipment, while fraught with problems, could still chlorinate the town’s water. They left it sitting idle, disconnected, and useless. As they shut the door, the steady whir of the pump meant that well 7 was still running, sending raw water into Walkerton.
On May 8, 2000, three days after Stan Koebel left, rain began to fall. Over the next two days, a steady downpour drenched the town and the farms around it. Along highway 9, the main highway through Walkerton, construction workers slogged through a growing sea of mud. They had exposed the rotten vasculature of pipes and had laid new pipes to replace them. To do that, they would need to cut into the existing water mains to connect the new pipe.
Even Frank Koebel, who had gotten most of his training on the job, understood that opening the pipes in the distribution system posed a risk of contamination, just as a cut in a vein or artery raises the threat of infection. As the spring mud poured into the trenches, the danger increased. If pathogens got into the system, the only thing that would stop them was chlorine.
If the rain worried Frank, it did not convince him to install the chlorinator. It appears that he was not much for vigorous exercise. At forty-one he had already had two heart attacks. The town’s two other wells, 5 and 6, both had chlorinators. (Wells 1–4 had been closed long before.) It is not clear whether Frank Koebel or a lightning bolt did it, but, in the dark of night, wells 6 and 7 shut down leaving just 5 to supply the city.
A small, pious farming community parked halfway between Lake Huron and Lake Erie, Walkerton is the kind of town where nothing ever happens. But Frank Koebel and the storm had just planted a bomb beneath the peace and quiet.
The Koebel brothers’ faith in the quality of groundwater was not entirely misplaced. Thick layers of soil, sand, and clay usually filter out most pathogens from water on its way to a deep aquifer. In fact, the beds of sand at the heart of our water purification systems are little more than minuscule imitations of the immense filters that overlie our groundwater. There is evidence that some microbes, particularly viruses, can survive deep below the surface, but they do not appear to pose a major disease risk. The wells in Walkerton, however, were not as safe as the Koebels imagined.
On May 12, in the midst of a ferocious rainstorm, a newborn foal struggled to his feet under the watchful eyes of David Biesenthal, a farmer and veterinarian. After five days of rain, the skies had opened wide, dumping three inches of water onto the fields where newly planted corn was just breaking the surface. Biesenthal had taken advantage of the warm weather just two weeks earlier to sow his fields. The rain, together with the rich manure from his cows and their young calves he had spread on his fields, would give the new crop a great start.
Most of the rain that fell on the Biesenthal farm drained toward Silver Creek. One field, however, sloped gently toward a clump of trees growing on a piece of land owned by the town. David Biesenthal had never noticed the small cinderblock building hidden in those trees. He never heard the pump that ran inside that building. He never realized that the shaft for well 5 reached down into the groundwater just thirty feet below that pump. He never imagined that the rain that watered his corn was carrying soil and manure and bacteria toward the source of Walkerton’s drinking water.
Stan and Frank Koebel had water in their blood. They had grown up around the pump houses of the wells of the PUC where their father had risen to the rank of foreman. As soon as Frank finished school, he went to work for the Walkerton PUC. Twenty-five years later, in May 2000, he had his father’s old job.
Five years older, with gray hair, a mustache, and a nervous expression, Stan Koebel had always been Frank’s boss in one way or another. After thirty years at the PUC, he was now the general manager. In addition to the water, Stan was responsible for Walkerton’s electricity. The imminent deregulation of the electrical industry meant that electricity, not drinking water, had occupied most of his time. He tended to leave the operation of the water supply to his younger brother.
Stan returned to the offices of the PUC at six A.M. on Monday morning, May 15. His first task was to deal with an employee at the PUC shop with whom he was having a bitter dispute. Stan planned to have him fired. Before he left for the shop, he looked at the computer control system and noticed that well 7 was not running. Assuming the chlorinator was installed and it had been turned off in error, he turned it on.
Stan drove to the PUC shop where he learned that the chlorinator for well 7 was still sitting in its crate. Moments later Frank walked into the PUC shop.
“Mind if I have the day off, being that I worked Saturday?”* Frank asked.
Frank had spent most of that day repairing flooded electrical equipment at the high school. If it crossed Stan’s mind to say anything about the chlorinator, he held his tongue. His bigger, stronger, and smarter younger brother had always chafed under his leadership and Stan knew it.
“Yeah, go ahead,” Stan said. The chlorinator could wait another day, but since it was Monday, they would need new water samples. “Just get Al to sample well seven before you leave.”
Stan then drove over to highway 9 to check the work on the water mains. He arrived to find the excavation trenches filled with mud and rainwater. He called Al Buckle, a maintenance worker for the PUC, and asked him to bring over some sampling bottles. Once those bottles were full, he packed them in a box and sent them to A&L laboratories with a note. “Please rush. Thanks, Stan,” it read.
Four years earlier the provincial leadership had joined the 1990s obsession with privatization and shut down the water testing laboratory at the environmental ministry. Suddenly all water utilities had to find a private laboratory to do their testing. Walkerton had found a lab at the time, but that company had just closed, forcing Stan Koebel to find a new lab. He had just started sending samples to A&L, a Canadian franchise of a large laboratory services company in the United States.
Two days later, on the morning of May 17, Stan Koebel got a call from a supervisor at A&L Laboratories. Tests on the samples from highway 9 had come back positive for coliform bacteria. Water supplies do not test for all bacteria. Instead they use two tests for so-called indicator bacteria. The coliform test is one of the two tests and the positive test simply meant that live bacteria were in the water. It was news of the second test results that got the attention of Stan Koebel. Preliminary results from the second test, which looks for a particular species of bacteria known as E. coli, had come back positive. E. coli come almost exclusively from human and animal feces.
All water suppliers occasionally find E. coli in their water. Often these bacteria are harmless. But they do not normally appear in groundwater. Still Stan Koebel was not overly concerned. He had an abiding faith in the safety of the town’s water. By that afternoon, however, more results arrived. Almost all of their samples were positive for coliform and E coli. Still worse, the quantitative tests showed that the contamination was massive. Stan Koebel couldn’t ignore the results. He decided it was time to install the chlorinator.
Tens of thousands of different strains of E. coli inhabit the colons of vertebrates around the world. Although the majority of those strains are harmless, the remainder can cause gastrointestinal disease of varying severity. One of the most dangerous strains is E. coli O157:H7, a recently evolved form of the bacterium. The poisons it contains can shred the lining of the gut. Blood then pours into the victim’s colon, resulting in the bloody diarrhea that characterizes the disease. Its victim’s stools are often nothing but bright red blood. What follows, however, can be far worse.
As E. coli O157:H7 makes its way into torn blood vessels, it continues to release its poison. In the bloodstream those toxins tear at the delicate cells that line the blood vessels and shower the body with blood clots. In severe cases it destroys the blood vessels in the kidneys causing them to fail. With no way to purify their blood, these patients begin to poison themselves. The normal products of their own body accumulate to toxic levels and they begin to drown in the by-products of their own existence. Many of these patients die. Those that survive the ordeal of intensive care and dialysis often have chronic medical problems.
In addition to humans, E. coli O157:H7 can also infect cows, although it does not make them noticeably ill.
On May 18, 2000, Kristen Hallet, one of only two pediatricians working in the region, was called to the emergency room of the Owen Sound Hospital to see a seven-year-old girl from Walkerton. Aleasha Reich had fallen ill the day before and spent the evening drinking fluids as her family doctor recommended. She arrived in the emergency department with intense cramps, vomiting, and bloody diarrhea.
Bloody diarrhea has only a handful of possible causes, none of them common. Dr. Hallet had seen this particular constellation of symptoms only twice before in her career. One was a child she had seen six months earlier who was suffering from an infection with E. coli O157:H7. The other, a nine-year-old boy, was lying in a hospital bed just upstairs.
One patient with bloody diarrhea is an unfortunate victim in need of medical care. The simultaneous appearance of two such patients, however, suggests something worse and demands action on a broader scale. Dr. Hallet worried she might be seeing the results of a foodborne outbreak. By the time she called the regional public health official the next morning, all hell was beginning to break loose in Walkerton.
On the afternoon of Friday, May 19, just before the start of the holiday weekend, Dave Patterson, assistant director of regional public health, learned about Dr. Hallet’s phone call and asked his staff to investigate. They soon discovered that something was indeed happening in Walkerton. At Mother Teresa School, the town’s Catholic elementary school, twenty-five students were home sick. Eight students were sent home from the public school. The disease had also begun to strike the local nursing and retirement homes. Eight people with bloody diarrhea arrived at the emergency room of the small local hospital. A local physician had seen twelve more people with diarrhea. It was Victoria Day weekend with a holiday on Monday, but as Dave Patterson listened, he could see his plans for the long weekend evaporate. He picked up the phone and called Stan Koebel.
The tiny seeds of concern in Stan Koebel’s brain began to grow as he answered the call from Dave Patterson. Those seeds had been planted by two earlier calls from people in town worried that the water might have caused the growing outbreak. Just as he had with the other callers, Koebel insisted that the water was fine. Patterson asked if the heavy rain and flooding could have had any effect on the water, and Koebel reassured him that this was unlikely. He never mentioned the problems with the chlorinator or the positive test results.
If there was a problem, Stan Koebel believed he could fix it. He worked late into the night, scuttling furtively between well 7 and a fire hydrant near Mother Teresa School. He collected water samples and tested them for residual chlorine beneath the light of an oblong moon. Driving home with midnight approaching, he still failed to fully understand that the house of cards he had constructed was collapsing all around him.
That same night Tracey Hammel’s heart sank as she opened the diaper of her two-year-old son, Kody. He had been vomiting all day, but she was not prepared for a diaper full of blood. Through a miserable night, she hoped he would improve, but Kody only got worse. By ten o’clock the next morning, he was weak and listless. When she called the emergency room at the Walkerton Hospital, the nurse told her that the hospital was “backed up.”
“When can I come?” she asked, unsure how much longer her son could wait. The nurse suggested she come at four that afternoon. In the meantime she advised her to keep Kody hydrated. On the advice of the nurse at the hospital, Tracey Hammel had spent the next two hours forcing water into her son’s mouth with a syringe. By noon Kody was limp and his eyes seemed to roll back in his head.
Stan Koebel, meanwhile, had returned to well 7 before sunrise and continued to push chlorine into the system. Most of the passersby who saw the hose connected to the fire hydrant outside Mother Teresa School had no idea what Stan Koebel was doing. Bob McKay, however, knew all to well. He had worked under Stan for the past two years. He knew about the test results. He wanted to make sure someone else knew as well. Later that morning Christopher Johnston, one of the few people working through the holiday weekend at the Ontario Ministry of the Environment, received an anonymous phone call. The water in Walkerton, he learned, seemed to have a problem.
Early Saturday afternoon Christopher Johnston called Stan Koebel. He told Koebel he simply wanted to “find out what’s going on.”
Koebel struggled for an answer. “We had a fair bit of construction and there is some concern—I’m not sure, we’re not finding anything…but I am doing this [flushing and chlorinating] as a precaution…”
Then Johnston put the question to him directly, “So you haven’t had any adverse samples, then?”
Koebel’s web had grown tangled, but he hoped he could continue to deceive. “We’ve had the odd one,” he conceded, “you know, we’re in the process of changing companies, because the other company, it closed the doors, so we are going through some pains right now to get it going.”
As Stan Koebel tried to evade the probing questions, Tracy Hammel held her son, Kody, in her arms, the strength seeping out of his tiny body. She and her husband had finally rushed him to the Walkerton hospital to find it overflowing. The nearest empty hospital bed, they discovered, was in Owen Sound. They raced along the long straight roads that sliced through the farms of southern Ontario. When they finally reached Owen Sound, the hospital laboratory would confirm the presence of E. coli O157:H7.
One of the perverse twists of E. coli O157:H7 is its response to antibiotics. As the drugs destroy the bacteria in the bloodstream, they burst open and release the poisons within. This sudden release of toxins dramatically increases the risk of kidney failure. The doctors in Owen Sound knew this and told Mrs. Hammel there was little they could do but give him fluids, watch, and wait. Then Kody’s kidneys failed.
The Owen Sound Hospital was not equipped to manage kidney failure. The nearest hospital that could perform dialysis was more than a hundred miles away in London, Ontario. Paramedics rushed Kody to a waiting helicopter.
Time and chance seemed to be conspiring against the tiny boy as the powerful motor of the helicopter spun into action and lifted him into the spring sky. The people of Walkerton who saw the helicopter flash overhead on its way to London had no idea that it carried one of their children. As the week wore on the red and white emergency helicopters continued to come, pounding the air like giant angry insects.
As the helicopters rose, hovered for a moment, and veered to the south again and again, it seemed for a time as if Walkerton were at war. Among their passengers was two-year-old Mary Rose Raymond, the daughter of a physician from a neighboring town who had taken her daughter to Walkerton for a Mother’s Day dinner just one week earlier, and Lenore Al, a retired librarian. They would not return to Walkerton alive.
In the end Stan Koebel’s frantic struggle to erase disaster failed. In a town of just 5,000 people, 2,300 fell ill during the outbreak. Hundreds were hospitalized, many in intensive care. In what his doctors termed a miracle, Kody Hammel survived the weeks of dialysis. Mary Rose Raymond, Lenore Al, and five other victims would die from their infections.
A government inquiry would eventually trace the cause backward from well 5 to the manure on David Biesenthal’s farm. The invisible world beneath the surface of the farm did not provide the homogeneous thirty-foot-thick filter that the Koebels had imagined. It now appears that death had come to Walkerton through ribbons of gravel and fractured rock that allowed water and manure to pour into the aquifer beneath the well.
The story of Walkerton might seem to hold few lessons for the future of water. How could the poor judgment of two brothers in a rural town be relevant to the safety of our entire water supply? This tragic tale offers a window into many of the challenges we face as we try to maintain safe drinking water into the future. The problems in Walkerton began with complacency and misplaced confidence in the safety of source water. Those problems were compounded by a failure of water treatment driven, in this case, by a failure of the plant operators. Perhaps most stark is its demonstration of the deadly threat posed by emerging pathogens and the potential for those pathogens to be waterborne.
In the United States new rules for drinking water were still on hold as events in Walkerton unfolded. It had taken the EPA five years just to issue rules making the turbidity levels that preceded the Milwaukee outbreak illegal. Until then a utility could have produced water identical to the water that caused the cryptosporidiosis outbreak without violating federal standards.
The final rules, the first rules to actually require communities to test for cryptosporidium oocysts in their water together with more stringent rules for chlorination by-products were due for release in 2002. As 2002 approached, with a new administration in place, the EPA balked. For three years, unseen hands held the final implementation of the new rules in limbo.
In the summer of 2005, Erik Olson from the NRDC filed suit to force the release of the new rules on pathogens and disinfection by-products. The process ground slowly forward. Then, with their release still pending, a new, unprecedented disaster struck at America’s drinking water.