An independent panel investigating the Flint, Michigan, water crisis laid blame directly on Gov. Rick Snyder's office, concluding that inept state employees in charge of supervising water quality and state-appointed emergency managers ignored mounting problems with the city water supply and stubbornly disregarded signs of widespread contamination.
The task force, which described the effects of the crisis as "long-lasting," also concluded that environmental injustice had contributed to the government's slow-footed response to complaints from Flint residents about the foul and discolored water that was making them sick.
"Flint residents, who are majority black or African-American and among the most impoverished of any metropolitan area in the United States, did not enjoy the same degree of protection from environmental and health hazards as that provided to other communities," the report concluded.
The task force was appointed by the governor, and its report, which was released in Flint on Wednesday, set off a discussion at a news conference about whether race was a factor in the cascade of government missteps that caused and then prolonged exposure to the contaminated water in Flint.
"Environmental injustice is not about overt acts of racism," said Ken Sikkema, a panel member and former state senator, at the news conference. "It's not about motivation. It's not about deliberate attacks on a certain population group. It's not about overt violations, attacks on civil rights. It's about equal treatment."
"Clearly what happened here is a case of environmental injustice," he said.
The 116-page report said blame spread across every level of government, from local Flint officials to the federal Environmental Protection Agency, but concluded that the Michigan Department of Environmental Quality, the state agency responsible for monitoring Flint's water supply, had "primary responsibility for the water contamination in Flint."
"They missed the boat completely," said Chris Kolb, a task force member and the president of the Michigan Environmental Council. "They never backed off on those decisions no matter how many red flags they saw."
As for staff members in the governor's office, they were playing "whack-a-mole," Kolb said.
"Every time an issue came up," he said, "they asked about it, they were told it's being taken care of, it's solved, and then another issue would come up. At some point, though, you have to say: 'Wait a second. My gut's telling me something's wrong.'"
Among its many findings, the task force found:
• A lack of coordination and communication among government agencies.
• The decision to switch the source of Flint's water to the Flint River was made by a state-appointed emergency manager.
• The Flint water plant was not equipped properly.
• Crucial data related to the presence of lead in Flint's tap water was not analyzed correctly.
"The Flint water crisis is a story of government failure, intransigence, unpreparedness, delay, inaction, and environmental injustice," the report said.
The panel met to discuss the findings more than 20 times, conducted some 60 interviews and made 44 recommendations, including that the governor's office review the state's controversial emergency manager law, and that the governor's office improve its method of assessing information.
And it chastised government officials for inadequate funding of government services, urging that all levels of government establish "budgets for public health activities at federal, state, and local levels to ensure that highly skilled personnel and adequate resources are available."
"The consequences of underfunding," it said, "include insufficient and inefficient responses to public health concerns, which have been evident in the Flint water crisis."
Snyder, who has been heavily criticized for the slow response to the crisis, accepted the report at the news conference in Flint. "There are a lot of excellent recommendations here," Snyder said, adding that the state was already putting some of them in place.
The task force was created in October and had been expected to reveal its findings in February. In December, it released an initial report finding that the Michigan Department of Environmental Quality had failed to adequately respond to complaints from Flint residents that their water supply was tainted. The task force called the department's actions "completely unacceptable."
"Throughout 2015, as the public raised concerns and as independent studies and testing were conducted and brought to the attention of MDEQ, the agency's response was often one of aggressive dismissal, belittlement, and attempts to discredit these efforts and the individuals involved," the report said.
Two resignations from that department quickly followed: Dan Wyant, director of the Department of Environmental Quality since 2011, and Brad Wurfel, communications director.
After the task force released its interim findings in December, Snyder said that they were only "initial steps."
"We fully expect to take more actions following the recommendations of our task force," he said. "When it comes to matters of health and quality of life, we're committed to doing everything we can to protect the well-being of our citizens."
The members of the task force, appointed by Snyder, are Dr. Matthew Davis, a pediatrician and professor of public policy; Kolb; Dr. Lawrence Reynolds, a pediatrician in Flint; Eric Rothstein, a water consultant; and Sikkema.
The drinking water in Flint became tainted in 2014 when the city, under control of a governor-appointed emergency manager, switched its water supply from Lake Huron water treated in Detroit to water from the Flint River. State officials failed to use anti-corrosives to treat the water, which caused lead to leach from pipes.
The governor's office was aware of problems with the water but did not tell the public to stop drinking it until October 2015. Many Flint residents have accused the governor of failing to take their claims seriously. At a congressional hearing in Washington last week, Snyder said he was overly reliant on "career bureaucrats" and "so-called experts" who repeatedly told him that the water was safe.