CNN  — 

Government failed Flint at every single level and, in turn, shaped a “clear case” of environmental injustice against the majority African-American community, a task force commissioned by Michigan Gov. Rick Snyder to study the city’s water crisis found.

A final report issued this week found that nearly every agency tasked with protecting people acted with “intransigence, unpreparedness, delay, inaction.” Among the groups singled out by the report: the governor, his office and his various state agencies, the county health department, the city government, and even the federal Environmental Protection Agency.

The task force included a wide variety of experts, ranging from healthcare professionals to business consultants.

The Flint water crisis began to unfold in spring 2013 when the city opted to switch to the Flint River as a temporary water source. When authorities failed to implement proper corrosion control, lead began to leach into residents’ drinking water.

Over time, the public not only learned about the lead in the water, but about the state and government’s knowledge – for months – of the problem. Though the city last autumn switched back to its original water source, the Detroit water system, the city is not out of the woods yet. Lead levels have begun to drop, but the long-lasting impacts on the community are still to be seen.

Environmental injustice at the heart of crisis

“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 states.

Race and economic inequality percolated as underlying issues as the crisis unfolded. Some groups alleged that action would have been taken more quickly had the community been affluent, or if it had fewer minority residents.

“Would more have been done, and at a much faster pace, if nearly 40 percent of Flint residents were not living below the poverty line? The answer is unequivocally yes,” the NAACP said in a January statement.

U.S. Rep. Dan Kildee, who represents Flint and the surrounding area, said had the crisis happened in a wealthier community, “Governor Rick Snyder would have ran out of blue ribbons for all of the commissions he would have appointed to see how this happened. While it might not be intentional, there is an implicit bias against majority-minority communities like Flint.”

In a section of the report about various community reactions to the water crisis, the task force writes that among African-American seniors, the situation “echoes the tragic Tuskegee syphilis study and the decision not to treat smallpox among freedmen in the aftermath of the American Civil War.”

“From this perspective,” the report continues, “it is noted that measuring blood lead levels without removing the sources of lead from the environment…appears the equivalent of using Flint’s children (and adults) as human bioassays.”

Blame is shared among many

Primary blame lands with the Michigan Department of Environmental Quality, which the report says suffered from “cultural shortcomings” and was deliberately determined not to follow federal law that requires corrosion control for drinking water in Flint. MDEQ also continued to tell residents the water was safe when it was not.

MDEQ Director Keith Creagh says that the agency is taking a number of steps to remedy the problems in Flint, including water testing in schools and collaboration with city and federal partners.

“We won’t stop our work in Flint until our goal is met, to ensure that every resident has access to safe drinking water,” he said in a statement to CNN.

The task force also went after Michigan’s emergency manager law, which allowed cities like Flint to have key decisions made by an outsider, overruling the locally elected officials.

It was those three emergency managers who made the initial decision to switch to the corrosive Flint River to save money, and then ignored the city’s pleas to abandon the plan when it became clear there was a problem.

One of the emergency managers, Darnell Earley, testified at Capitol Hill about his involvement in the crisis, stating that while he was “very deeply hurt” that the crisis happened on his watch, great blame lies – with the MDEQ and EPA.

“As we all know, we were grossly misled by the DEQ and the EPA,” he said. “And while I don’t have any great pride in knowing that, I do think it is important, because not only does the city of Flint rely on regulatory agencies, but every city in the state of Michigan as well as the United States of America.”

Almost no one escaped some sort of blame in the report.

City officials failed to follow the regulations of the Lead and Copper Rule on multiple levels, including in the water system’s lack of corrosion control, the report said.

When the state Department of Health and Human Services and the county health department learned of an outbreak of Legionnaires’ disease at the local hospitals – likely linked to the water – no one immediately alerted the public to stay away, according to the report.

The report also found several instances of poor of communication between agencies. Agencies bickered over responsibilities rather than working together to solve problems.

And it found, “neither the Governor nor the Governor’s office took steps to reverse poor decisions.”

Snyder, who has repeatedly said he acted as soon as he learned of the high lead levels, maintains he was unaware that his staff was informed of the problems many months before he was.

“Many of the recommendations made in this report are already being implemented, both within my own office and in various state departments, the governor wrote in a statement about the report. “We are taking dozens of actions to change how we operate – not just to hold ourselves accountable, but to completely change state government’s accountability to the people we serve.”

When members of his staff raised concerns in October 2014 and recommended the water be switched, the task force found it was immediately dismissed by the emergency manager, when it should have led to a “a full and comprehensive review of the water situation in Flint.”

“It was disregarded, however, because of cost considerations and repeated assurances that the water was safe,” the report said. “The Flint water crisis highlights the risks of over-reliance – in fact, almost exclusive reliance – on a few staff in one or two departments for information on which key decisions are based.”

Praise for Flint residents’ ‘courage and persistence’

Finally, the report went after the EPA, which it is said failed to exercise authority over Flint until January of this year. Instead it was “hesitant and slow” to insist that the state correct the problems.

“The agency’s conduct casts doubt on its willingness to aggressively pursue enforcement,” the report found.

In congressional testimony, EPA Administrator Gina McCarthy said that state agencies’ slow actions hindered the EPA’s response.

“EPA appreciates the efforts of the Flint Water Advisory Task Force,” an agency spokesman said in a statement to CNN about the report. “We are carefully reviewing the findings and recommendations of the report as we move forward on implementation of the Lead and Copper Rule and consider steps to strengthen it in the future.”

The only group the task force praised? The residents in Flint.

“Without their courage and persistence, this crisis likely never would have been brought to light and mitigation efforts never begun,” the report states.