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Point a finger in any direction and you’ll identify a government agency or actor that failed in the Flint water crisis. The Flint Water Advisory Task Force concludes rightly that a series of government failures triggered the events that allowed lead to seep into the city’s drinking water, and then hampered the response.

The task force, appointed by Gov. Rick Snyder, highlights for particular blame the state’s emergency manager law and the Michigan Department of Environmental Quality.

While Gov. Rick Snyder got ahead of the report by a day with a 75-point plan for fixing Flint, the report clearly indicates this was not just a water contamination crisis. It is also a government crisis. Fixing the bureaucracy and the things that are wrong in his own administration will be just as big a job, and should be the preoccupation of Snyder’s final three years in office.

Based on the task force’s findings, here’s what must happen:

The group concludes the MDEQ is primarily responsible for the water contamination in Flint, and cited cultural problems within the agency that subverted its role of protecting the public. The agency misinterpreted the federal lead and copper rule, and stubbornly resisted calls to reconsider its methods. It also failed to provide adequate advice and monitoring to the city of Flint as it switched to a new water source. As the report recommends, the department must prioritize its role in assuring clean drinking water, should hold to higher lead and copper standards (as Snyder’s plan also recommends), provide better training to its staffers and strengthen enforcement.

The Department of Health and Human Services’ performance was not much better. It is cited in the report for a lack of timely and effective analysis of data on childhood blood lead levels; failing to coordinate follow-up remediation efforts; poor communication with other departments and the governor’s office and not doing enough screening for lead in children statewide. MDEQ also suffers from a broken culture that places process over a nimble response to a threat. The department must be reorganized in a way to stress a more urgent response to emergencies and foster greater input from outside experts when a crisis unfolds.

Snyder’s office failed miserably. It relied on bad information provided by state departments, and didn’t challenge the civil servants even when outside evidence indicated they were wrong. Top staffers failed to pass on critical information to the governor. Citizen complaints were not acted on in an urgent fashion. The culture in the governor’s office, too, is broken. He must revamp the way he operates. Those serving him should not be reluctant to carry a problem into his office. Snyder must be more hands-on and responsive to citizens.

The task force concludes the various state-appointed emergency managers of Flint made the final decision to switch to the Flint River as an interim source of water. It recommends revisiting the law and its impact on local decision-making, and that is obviously necessary. When the EM law works well, as it did in the city of Detroit, Allen Park and Wayne County, it is an efficient tool for getting past a financial emergency. When it fails, as it did in Flint and Detroit Public Schools, it serves to alienate citizens and erode trust in government. The law needs to be rewritten.

Finally, the task force questions why a community with an ample supply of drinking water pressed so hard to build and switch to the new Karegnondi Water Authority. This seems fertile ground for an investigation by the state attorney general.

Fixing Flint’s infrastructure is a major challenge for Snyder. But an even bigger task is fixing the infrastructure of a state government that is not working for the good of its citizens.

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