>> NARRATOR: Tonight... >> Multiple people got sick and multiple people died.

>> The doctor asked, he said, "Have you heard of Legionnaire?"

>> NARRATOR: A "Frontline" exclusive investigation.

>> I plotted out each one of those deaths, just to see if anything stood out.

And, in fact, it did.

>> NARRATOR: What did Michigan officials know?

>> A lot of people didn't want us to expose what was happening and why it was happening.

>> NARRATOR: And was there a cover-up?

>> Test the water.

They should have tested the water.

>> NARRATOR: Tonight on "Frontline"-- "Flint's Deadly Water."

♪ ♪ ♪ ♪ >> There is nothing more valuable than water.

And Michigan is blessed to be surrounded by more fresh water than anywhere else on the planet.

>> They're calling it the dawn of a new era, miles of pipeline transporting fresh water to three counties and two cities, but officials say... >> NARRATOR: The idea was to turn all that water into money.

>> A new pipeline could bring economic opportunity, could create regional cooperation, and it could be, you know, an affordable, healthy source of, of water for our city, long-term.

>> NARRATOR: The proposed pipeline was supposed to carry low-cost, high-quality water from Lake Huron to businesses and homes throughout eastern Michigan, including the city of Flint.

>> The $274 million project should be completed in early 2016.

>> And it was a way for this community to take advantage of the natural resources that it's surrounded by, and that could give, you know, our region a competitive advantage.

>> NARRATOR: Instead, the pipeline set in motion a series of events that led to an unprecedented public-health crisis in Flint.

>> It's not safe to drink the water in Flint, Michigan.

>> NARRATOR: The exposure of thousands of children to lead-tainted water would become a national outrage.

>> ...water has been poisoned with lead for months.

>> I think about this every single day, and I still try to figure out what I could have seen or done or asked, you know, differently.

>> Nearly a thousand homes still have dangerous levels of lead in the water... >> But I just didn't ever imagine that there would be a failure at every level of government with something as basic as the safety of drinking water.

>> NARRATOR: And overshadowed by the lead poisoning was another problem with the water.

>> Most people outside of Flint look at the lead issue as the main issue.

But the killer has been Legionnaires', and people don't know that.

>> Two more deaths have been linked to the Legionnaires' disease outbreak.

>> That was the one that I think they tried to hide the most.

That's the one I still don't think that they want people outside of Flint to know.

♪ ♪ >> NARRATOR: In Flint, they still line up for bottled water.

>> Oh, my gosh.

Are you serious?

>> NARRATOR: Jacqui McBride started coming here after her daughter got sick with Legionnaires' disease, a severe and potentially deadly form of pneumonia.

>> I don't want the same thing to happen to me.

I refuse to drink from the faucet.

Ooh, Jay, you should have been here a long time ago.

>> Come on up, come on up.

>> Hey there.

>> NARRATOR: The Legionnaires' outbreak hasn't received much attention outside of Flint, despite being one of the largest in U.S. history.

But "Frontline" has been investigating the outbreak and how state and local officials failed to stop it.

For the past two years, producers Abby Ellis and Kayla Ruble have been reporting in Flint.

>> One, two, three cases of Legionnaires'.

>> And they're a couple of blocks from each other.

>> NARRATOR: With their colleague, reporter Jacob Carah, the team reviewed thousands of pages of health records and government documents; spent months following the legal effort to hold people accountable; and interviewed local officials, residents, infectious-disease specialists, and others to trace the story of the deadly outbreak, which began more than a year before the world even knew there was a water crisis in Flint.

♪ ♪ The outbreak started in June 2014, when the first known patient showed up at a local hospital.

He was 54 years old, suffering from what appeared to be pneumonia.

>> So, for that particular patient, going to the hospital as soon as they had, you know, high fever, cough, diarrhea, you know, they know that something's really wrong.

They order a special diagnostic test, which isn't routinely done, and then they know it's Legionnaires' disease, and it's now sort of a race against time to save that patient.

>> NARRATOR: Janet Stout is one of the nation's foremost Legionnaires' specialists and advised officials in Flint on how to respond to the disease, which is caused by inhaling water droplets contaminated with bacteria.

>> What's distinctive about Legionnaires' disease is its severity.

Almost all cases are admitted to the intensive-care unit.

The other thing that's unique about Legionella, Legionella bacteria, is that it's in water.

So, if you can control the organism in water, you can completely prevent the disease.

>> NARRATOR: Three days later, another man was diagnosed with Legionnaires' at a hospital in Flint.

In the week that followed, three more cases at three different hospitals were reported to the state and county health departments.

>> Because it's a reportable disease going to one centralized location, which is state and county reporting, the people receiving... at the health department receiving this are going, "I've not seen five cases in four weeks, ever."

So now you start to see a pattern.

This is not normal.

>> NARRATOR: By midsummer, more than a dozen Legionnaires' cases had been confirmed, as many as Genesee County would typically see in a year.

But most people in Flint knew nothing about the growing outbreak, including Jacqui McBride, whose daughter Jassmine was its youngest known victim.

>> I walked into that room, all I see is this machine, these tubes, my daughter laying there stiff, you know, just stiff.

The doctor asked, he said, "Have you heard of Legionnaire?"

And I'm, like, "No.

What the hell is that?"

>> NARRATOR: Jassmine was 26 and had diabetes, which made her vulnerable.

She was admitted to the intensive-care unit.

>> The first doctor kept saying, "Well, we don't know if she's going to make it or not."

I didn't want to hear that.

♪ ♪ I think the same day she was there, somebody had passed, maybe next to her, and had the same thing she had, Legionnaires'.

>> NARRATOR: Scientists we've spoken to who have examined the Legionnaires' outbreak point to a fateful decision, months before Jassmine got sick, to switch Flint's water to a new source.

>> The first dirt turn for the pipeline, ladies and gentlemen!

>> Crews break ground on the Karegnondi Water Pipeline.

>> ...74 miles of large-diameter pipeline will stretch... >> NARRATOR: For decades, Flint-- one of the poorest cities in America-- had bought its water from Detroit.

>> ...pipeline is expected to cost about $230 million.

>> NARRATOR: Water from the proposed pipeline was supposed to be cheaper.

>> Thank you, Mr. Councilman, and the rest of the council... >> NARRATOR: A point the county's top water official stressed when he came to Flint.

>> Once it's completed, there will be several-million-dollar cost reduction to all of the communities involved...

I saw a great opportunity for this poor community to save money.

They would have a savings of two million their first year from what they were spending just to purchase water.

>> Keep it on file so that we can begin the committee... >> NARRATOR: Flint's city council eventually backed the plan, but officially, they had little say, because, at the time, the nearly bankrupt city's finances were controlled by the state, which went ahead and approved the pipeline.

>> And so we didn't have control of the water, the decisions-- nothing.

>> NARRATOR: To help finance it all, Flint's state-appointed managers had another plan.

>> It has been five decades since Flint used the river for drinking water.

Today, they opened up the gates to start that process again.

>> NARRATOR: Instead of staying on the Detroit water supply while the pipeline was being built, the city would temporarily get its water from the Flint River.

>> ...until a new water pipeline is finished from Lake Huron.

>> NARRATOR: That decision-- without a vote from the city council-- would force the city to activate an old water-treatment plant that had barely been used in half a century.

>> I certainly still expected that the same safeguards would be in place no matter what the drinking water source was.

>> NARRATOR: But inside the plant, we've learned that a foreman named Matt McFarland was having concerns.

>> He said, "We're not ready."

He said the plant wasn't ready.

The funding just wasn't there.

The staffing wasn't there.

There was a lot that would need to be done, and it would take time.

>> NARRATOR: McFarland died in 2016, but while working at the water plant, he regularly confided in his sister Tonja Petrella.

This is the first time she's spoken publicly about her brother's concerns.

>> He would call me, and he would just be so upset, and he would leave me messages that were just frantic, like, "Tonja, you have to call me right away.

Please call me right away."

I mean, he knew that they weren't ready for this.

>> NARRATOR: As the deadline approached, McFarland expressed his concerns to his supervisors.

One of them, Mike Glasgow, had concerns, too.

He wouldn't speak to us, but in an email, he told state regulators that if the plant were to open on schedule, "it will be against my direction."

He later told investigators he never received a response.

>> The city right now is just testing and treating this water.

They're not using it in the drinking water yet.

They hope to start doing that in the next few days.

>> NARRATOR: With the opening of the plant just hours away, Petrella began texting friends-- at her brother's behest-- that the water wasn't safe.

>> I remember specifically the day before they actually flipped the switch, he called me, and he said, "Tonja, contact everyone that you know in Flint, anybody you care about, and tell them, 'Do not drink the water.'"

>> This is our moment: three, two, one.

>> He said, "It's not safe.

We're not ready," he said, "and people are going to die."

>> Here's to Flint!

>> Here's to Flint!

>> Hear, hear.

>> NARRATOR: Within weeks, the problems McFarland had been worried about began to appear.

>> Flint is now getting its water from the Flint River.

It's not sitting well with some residents and businesses... >> And this is what is coming out of the tap.

>> Water's brown, has a bad odor... >> I was covering Flint City Hall at the time.

It was a regular sight, like, every week, someone was bringing in a bottle of water that was discolored.

>> People were telling me as a councilperson that they was breaking out with rashes.

>> We cannot drink the water, we can't cook with the water, let alone brush our teeth.

>> That was real quick after the switch, some of those signs.

>> The city says residents won't notice a change in quality.

>> The message we keep getting back over and over and over again is, "It's really not anything to worry about."

>> Flint city officials say drinking water from the Flint River is now safe to drink for the entire city... >> It was, "Not a problem, not a problem, not a problem."

>> NARRATOR: But what most of Flint didn't know at the time was that the state hadn't required the plant to protect the city's water pipes from corrosion.

They soon became a breeding ground for Legionella, and people were getting sick.

Throughout the summer of 2014, cases of Legionnaires' disease kept appearing, reaching over 30 by the fall.

>> By October of 2014, there would have been enough information to really understand that there was a significant problem in Flint.

That would be considered a large outbreak, and that would be an investigation that we'd want to do right away.

>> NARRATOR: The county health department had started looking into the problem.

And in emails, state officials were already speculating that Flint's new water supply may be to blame and worrying that word might get out.

>> Everybody that knows anything about Legionnaires' disease knows it's in the water.

So you go and test the water.

And then you disinfect the water.

That's what's been done virtually everywhere else, except in Flint.

>> NARRATOR: No one from the state health department would be interviewed on camera.

But a spokeswoman told us the outbreak could not be definitively connected to the water because, she acknowledged, the water was never tested.

By the end of 2014, there were 40 confirmed cases of Legionnaires', and three people had died.

Jassmine McBride had been lucky.

After three months in the hospital, she was able to go home.

>> When I got out, I had to learn how to walk, talk, eat.

I mean, it was just like being reborn all over again.

>> The oxygen, you're on that all the time, or do you ever get to take it...?

>> Sometimes I take it off just to see myself, but I'm on it all the time.

>> Yeah.

>> NARRATOR: Her battle with Legionnaires' left her heart and lungs weakened.

Her kidneys were severely damaged.

When we met her in 2018, she needed a transplant, but wasn't healthy enough to be eligible for one.

>> You just had dialysis just now, right?

Your lungs are clear.

They've cleared out the fluid.

>> NARRATOR: Her doctor, Marcus Zervos, had been treating a chronic skin infection that her weakened immune system couldn't control.

>> My goal with you is to try to get those wounds healed up so that you can get your transplant.

>> Mm-hmm.

>> What we're doing with this is tissue grafting.

I'm really happy with them.

They are doing a lot better.

>> I'm ecstatic.

>> You know, if I can get them healed over a little bit more, I'm going to get you an appointment with those transplant doctors.

♪ ♪ >> NARRATOR: While Jassmine was recovering back in early 2015, the head of Michigan's health department, Nick Lyon, met with one of his epidemiologists and was shown this graph of the Legionnaires' outbreak.

The epidemiologist noted that it coincided with the switch of the water supply.

Lyon asked to be kept informed.

>> Neighbors in Flint joined together today to rally against the city's treatment... >> NARRATOR: Residents were still unaware of the outbreak.

>> City officials say the water is safe and there's no need to worry.

>> NARRATOR: But at the suggestion of the state health department, county officials drafted an alert to medical providers.

It was never sent, according to internal emails, because the person in charge wasn't there that day.

Instead, just 15 people were notified by email.

No one in the county or state health departments would explain why the alert never went out.

>> It's totally unacceptable.

There was no notification sent to the medical society.

So that... (chuckles) I'm trying not to be profane, but that's utter rubbish.

>> NARRATOR: Around the same time, county health officials trying to confirm if the water was the source of the outbreak reached out to Dr. Stout.

>> And I said, "Call the Center for Disease Control and Prevention.

They will come, they will do the testing that needs to be done."

And I thought...

"Done."

>> NARRATOR: Emails show the county health department wrote to the CDC right away, saying they were now up to 47 cases of Legionnaires' disease and needed help.

But state health officials had a very different response.

They told the CDC they didn't need its help.

If they did, they'd get in touch.

The CDC persisted, saying they felt a sense of urgency.

It was one of the largest outbreaks in years, they said, and they recommended a full investigation.

>> Looking through the emails and starting to see how things were evolving, that kind of resource on the ground-- boots on the ground, particularly helping the Genesee County Health Department, which was understaffed at the time-- would have been a game changer for the Legionella outbreak.

>> NARRATOR: But the call to the CDC never came, even as more top officials became aware of the problem.

Though Governor Rick Snyder would insist he didn't know about the outbreak until 2016, emails show that by March 2015, at least three of his aides-- and two of his cabinet members-- had been told about it.

And into the summer, it continued.

Three cases in May, seven more in June, 13 in July, 13 in August.

>> Tick, tick, tick, case after case after case.

There's another one, there's another one, there's another one.

>> NARRATOR: There'd been 90 confirmed cases in the year and a half following the water switch.

12 people had died.

>> It is a very big epidemic, one of the largest epidemics of Legionnaires' disease that we know of.

>> We heard rumors that there were outbreaks of Legionella that we could not confirm, and we weren't getting any communication from our county health department, definitely no information from the state department.

They were strangely silent.

>> Developing now, a public-health emergency... >> People in Flint being told not to drink... >> NARRATOR: But once high lead levels in the water system became public in late 2015, state officials had to confront the fact that the water switch was having grave consequences.

>> ...levels of lead in kids' blood has risen... >> I think that really was a pivotal point, where people paid attention to a community that just used common sense and knew water shouldn't be brown and rusty-looking.

>> State officials say their testing shows lead in the water.

>> NARRATOR: With the crisis building, the governor ordered the city to stop using the Flint River and return to Detroit water.

Within months, Snyder and his top officials would address the Legionnaires' outbreak.

An aide to the governor called an environmental engineering professor at Wayne State University.

>> He said that the governor was about to go onstage to announce a Legionnaires' disease outbreak, and he wanted to know whether or not I could determine if the change in the water supply was the cause of the Legionnaires' disease.

And I basically told him that I thought I could pull together a team to look at this, but that I would have to make some calls.

And he said, "No, no, no.

"The governor is going on in, like, 15 minutes.

I need an answer in 15 minutes."

♪ ♪ >> Well, thank you for coming today.

I'm going to share information that has been shared with the health-care community in the past, but hasn't really been put out to the public.

Over the course of 2014 and 2015, we saw a spike in Legionnaires' disease.

I believe the numbers for the preceding years, before 2014, we had six cases, 11 cases, 13 cases, and eight cases.

In 2014, we had 45 cases.

And then in 2015, there were 42 cases.

>> I'd been writing about Flint water for more than a year, and I never heard anything about Legionnaires' disease until the governor went on TV that day.

>> Thank you.

>> NARRATOR: The Republican governor was joined by the state's top health officials: Nick Lyon and the chief medical executive, Dr. Eden Wells.

>> Most of the time, what it's going to manifest is as a pneumonia.

This pneumonia would not... >> They say, "We can't conclude that the water was the source of Legionnaires' disease in this outbreak."

>> MDHHS cannot conclude that this increase is related to the water switch, due to the lack of clinical isolates during the time period and because not all of the cases had exposure to the City of Flint water.

>> Well, let's ask the question, "What would be necessary in order to make that link?"

They should have tested the water.

>> This is part of our efforts to be transparent and share information as quickly as possible as we can with the public... >> NARRATOR: At the press conference, no one mentioned that the CDC had urged a full investigation eight months earlier.

>> This is certainly a bombshell, a game changer... >> There was an outbreak of Legionnaires' disease that quite frankly none of us knew about... >> ...just shocking, because we found out about a totally different disease and deaths.

>> NARRATOR: Within weeks, Michigan's Republican attorney general announced he was appointing a special counsel to lead a criminal investigation into the water crisis.

>> I'm announcing today that Todd Flood, a tough former Wayne County prosecutor, will be joining me and working with me in an investigation to determine what Michigan laws, if any, may have been broken in the Flint water crisis.

>> People got sick, terribly so, and the water was contaminated.

And the public was in an outcry.

I have never seen a case like this in the history of the United States before.

There needs to be an answer where people understand and can hold accountable those, if any, who are at fault.

We didn't know if there was criminality or not.

It's always about who knew what and when, and what did they do about it?

You take your evidence, and you follow that evidence down the path.

>> NARRATOR: As the criminal investigation was getting underway, the scientific investigation into the Legionnaires' outbreak was also getting organized.

>> We started meeting with the state regularly.

And when we first started meeting with them, they were very collegial, and it was pretty much, "We will open the keys to anything if it can help understand this."

>> NARRATOR: Shawn McElmurry had pulled together a team of 23 scientists and experts from around the state.

>> We were all focused on making sure that we didn't have another outbreak, another season outbreak.

And so there was a lot of pressure to get this done by the time summer started.

>> NARRATOR: But as the months went by, the team says the state wouldn't authorize them to start the search for the source of the outbreak.

Dr. Zervos was the infectious-disease expert, and he was worried about the delay.

>> It was critical to start right away, because by June, we expected to see more cases of Legionnaires' disease, and there would be more deaths, which is what we expressed in a meeting that included top leadership at MDHHS.

>> NARRATOR: The scientists say they met with Nick Lyon to urge him to step up surveillance for Legionnaires' cases.

>> I remember my colleague telling him that if he didn't do that, you know, people could die.

Unfortunately, Nick Lyon's response was that, "Well, they have to die of something."

>> I, I was, you know, I was flabbergasted, and I didn't say anything right then.

Although it was a situation where you're just, I mean, you're just in shock as a result of him saying that, the director of the health department.

>> NARRATOR: Nick Lyon declined to be interviewed.

In a letter, his attorney said, "Director Lyon did not make that crass remark."

He said the team's work was one of Lyon's top priorities and blamed any delays on the scientists.

♪ ♪ Special Prosecutor Todd Flood was also clashing with state officials, as his investigation began turning up evidence of misconduct and negligence and an effort within the government to cover up the water crisis.

>> Every single witness had a paid-for attorney by the government.

Whether or not you were a suspect or a defendant or a witness, every single one had a government-paid-for attorney.

So we were going up against Goliath.

A lot of people didn't want us to expose what was happening and why it was happening.

>> Breaking news right now from Flint, Michigan, we've been following this all day long.

The state's attorney general... >> NARRATOR: By the end of July 2016, Flood had charged nine state and local officials with crimes related to the lead and Legionnaires' crises, including conspiracy, misconduct, neglect of duty, and tampering with evidence.

>> Today three men face the very first criminal charges in connection with the Flint water crisis.

>> We were starting very low and we worked out plea deals with most of them to cooperate and move up the chain.

>> NARRATOR: As the criminal investigation continued, behind the scenes, the team of scientists who were supposed to be investigating the outbreak was running up against resistance.

>> As we kept meeting with state officials, there was increasing pushback about the extent of data we would have access to, and more constraints being, in our view, put on the scientific investigation.

>> We're not allowed, for example, to talk to patients that had Legionnaires' disease.

We were not allowed to go into the homes of patients that had Legionnaires' disease, which was really a, a very big, very serious limitation.

>> NARRATOR: They clashed with Dr. Eden Wells over testing residents' water filters for evidence of bacteria.

>> This turned out to be a really contentious issue with the state.

They didn't want me to collect those filters because they thought it might just cause more... um.... might scare people more than it would provide valuable information.

>> At one point, I felt personally that it might even be impossible to be able to objectively do the project.

>> NARRATOR: They also felt it was critical to examine pneumonia deaths during the water crisis, in case any had been misdiagnosed.

>> So there are some cases of Legionnaires' disease that are not necessarily diagnosed as Legionnaires' disease, but just diagnosed as pneumonia.

>> Okay, so did you guys look into pneumonia deaths?

>> Ultimately, that was one thing that we weren't allowed access to.

It was deemed as beyond the scope of what they wanted us to look into.

But as time went on, I, I came to realize that maybe their interest in understanding things wasn't the same as my interest in understanding things, and that there were potential liabilities to the state and to the people I was talking with.

>> NARRATOR: Dr. Wells declined to comment.

Nick Lyon's attorney denied the health department had blocked the scientists' requests and told us Lyon was simply trying to ensure the state was "funding necessary and appropriate research."

With the scientists and state at odds, "Frontline" was doing the pneumonia research that McElmurry and his colleagues were seeking.

>> I kind of tasked myself to kind of just start looking through the electronic death records system at the clerk's office, because the only place to start, the only evidence you can find, is pneumonia deaths.

So I started looking in the timeframe of the switch to the Flint River.

>> I recognize you.

You've been here before, right?

>> Yeah.

>> Cool, thank you, you're all set.

>> NARRATOR: Over several months, "Frontline" reporters analyzed every death record in the county during a seven-year period, looking for people whose cause of death had been listed as pneumonia.

>> You have to go through every single death certificate one by one.

Because there was really no other way to do it.

You can't go digging up bodies, and, you know, doing antigen tests on bones.

I started just going through just the timeframe of the switch, and I started counting the pneumonia deaths that I found.

I thought I was crazy when I was looking at it, because I kept finding more, not less.

>> NARRATOR: The state had put the death toll from the Legionnaires' outbreak that ran from 2014 to 2015 at 12 people.

But "Frontline" found dozens who were said to have died of pneumonia in the same period.

>> There was this spike during the switch.

It was almost three times more than prior years.

>> NARRATOR: As McElmurry and his team feared, there were signs the outbreak's toll could be higher than anyone knew.

>> Why wasn't a thorough investigation launched from the state?

I mean, this raises some very critical questions, if you knew at the time that people were dying.

♪ ♪ >> NARRATOR: We would spend many months in Flint trying to find the true extent of the Legionnaires' outbreak.

But by late 2016, McElmurry and the other scientists had begun testing the water and getting results back.

>> It didn't take us too long to start finding Legionella in some of the water entering people's homes.

>> NARRATOR: Believing they should share their findings with the public, the scientists held a meeting at a local library and said they'd found Legionella and other bacteria in people's water filters.

The next day, Shawn McElmurry heard from Rich Baird, a top aide to Governor Snyder.

>> I was under no illusion that every time I talked to Rich Baird, it was as if I was talking to the governor, and he said, well, he wasn't upset at my guy, "but he wasn't on message."

You know, he needed to be on message.

He needed to "lead with public health," whatever that meant, and basically said that, you know, he didn't want to take away funding from the university if I wasn't able to get on message.

I viewed that as just a threat to me and my team about the work we were doing, that we needed to better align our results with what their position was.

>> And what did you understand that position to be?

>> That there were no more problems with the water in Flint at that time.

>> NARRATOR: In an email, Baird told us that he never tried to influence or pressure the team "to do anything except abide by the terms and conditions of their contract."

And that they failed to stay within the scope and parameters of the project.

>> Just up today on the criminal investigation into the Flint water crisis.

>> NARRATOR: By 2017, the allegations of misconduct had reached inside the governor's cabinet.

>> ...in a startling revelation, in-court documents from the state attorney general... >> NARRATOR: Nick Lyon and Eden Wells were now facing involuntary manslaughter charges for failing to alert the public and covering up the Legionnaires' outbreak.

>> The department's chief medical executive, Dr. Eden Wells, accused of threatening to stop funding... >> The allegations are health director Nick Lyon knew more than a year before this announcement.

>> Nick Lyon is presumed innocent, but it was plain as day that the Department of Health and Human Services' state epidemiologist, along with others, had talked to the director about the Legionella outbreak.

We're saying he had a duty to tell the people.

He failed to do that duty.

He then kept things under wrap.

The spike was continuing to go up, and sure enough, in the summer of 2015, multiple people got sick and multiple people died.

>> These charges all center around the deadly Legionnaires' disease outbreak.

>> NARRATOR: Prosecutors also accused Lyon and Wells of interfering with Shawn McElmurry's investigation.

McElmurry and other scientists were subpoenaed to testify about it during pre-trial hearings.

>> The crux of their testimony came down to, "We were stopped or prevented because they didn't want "to know the truth-- the government, "they didn't want us to find Legionella.

"They didn't want us to find bacteria.

"They didn't want us to test samples.

They didn't want us to collect from filters in homes."

Why?

Why?

Because they didn't want them to show that the water was the actual source of the Legionella.

>> NARRATOR: Throughout, the state health department insisted that the biggest source of the Legionnaires' outbreak was not the city's water, but Flint's McLaren Hospital, which it said was linked to nearly 60% of the cases.

>> First of all, not every case of Legionnaires' disease came out of McLaren.

And second of all, if the state believed that there was a Legionnaires' outbreak in McLaren Hospital, the state had every duty to do something about it and inform people about it.

That's not what the state did.

>> NARRATOR: McLaren officials declined to be interviewed, citing ongoing lawsuits by Legionnaires' victims, but pointed out that the hospital gets its water from the city.

They hired Dr. Stout to provide testimony, and to help them test for and prevent Legionella.

>> Somewhere around 30% or so of cases had absolutely no healthcare association.

That means they were never, not only at McLaren, but never at any of the other hospitals, either.

So the argument that the problem is the hospital doesn't hold weight.

>> NARRATOR: Shawn McElmurry and his team came to the same conclusion, and in early 2018, published their findings in a peer-reviewed journal.

>> The outbreak is associated with the change in the water supply.

When they switched to the Flint River, they didn't properly treat the water.

And as it went through the distribution system, they also had reactions and things that... with corroding pipes.

And so there are pockets of the city where you had high amounts of iron, low chlorine, high organic matter.

And in those places, it is very likely that they had biological growth.

So there's all sorts of indicators that there was massive water-quality problems throughout the time in which they were on the Flint River.

>> NARRATOR: The state health department publicly rejected the paper, saying in a statement the scientists had "only added to the public confusion," and that an outside consulting firm the state hired was critical of their work.

Nick Lyon's attorney went even further in a letter to "Frontline," questioning the credibility and expertise of the team.

The state eventually released its own report insisting there was "only one common source" for most of the cases-- McLaren Hospital.

♪ ♪ As for Jassmine McBride, by the summer of 2018, just shy of her 30th birthday, she was still suffering from the effects of the Legionnaires' disease.

>> 28th.

>> 28th of...?

>> July.

Celebrating my 30th birthday, seeing that I was supposed to be gone in 2014 due to the Legionnaire, so... >> Mm-hmm, okay.

>> And I just want to be around family and friends.

>> That's good.

Mm-hmm.

We're just here for some paperwork?

>> Well, yeah, but when I leave here, I'm going to the hospital.

>> Okay.

>> (weakly): I'm having, um... some trouble breathing.

♪ ♪ >> NARRATOR: She was on 24-hour-a-day oxygen, suffering frequent respiratory failure.

>> I'm about to just pass out.

>> Do you need something?

>> (breathing shallowly) This is what I go through when I'm having trouble breathing.

It's like I can't-- I can barely talk, I can barely function.

I can barely walk.

(knock at door) (door opens) It's a scary feeling.

♪ ♪ >> NARRATOR: On this day, she was taken to the hospital for emergency dialysis.

But because of her condition, she was no closer to getting on the kidney transplant list.

>> This feels so... (sighs) This is not where I wanted to be.

♪ ♪ >> Nick Lyon faces involuntary manslaughter charges in connection with the death of two men in the Flint Legionnaires' outbreak.

>> NARRATOR: That summer, 11 months of pre-trial testimony was coming to an end in the case against Nick Lyon... >> Did Lyon fail to warn about the outbreak?

>> NARRATOR: ...with a long-awaited ruling on whether the evidence was strong enough to send his case to trial.

>> All rise.

>> You have a member of the governor's cabinet who is still on the job as the top health official in the state of Michigan on trial for poisoning people.

>> The prosecution has charged Mr. Lyon with involuntary manslaughter.

>> I think maybe that is unprecedented.

>> Based upon all of the evidence in its totality, I find that the prosecution has established that the following crimes have been committed and probable cause exists to believe that Nicholas Lyon has committed these offenses.

>> NARRATOR: The judge ordered Lyon to stand trial.

Another judge would order the same for Eden Wells.

Both appealed the decisions, delaying the start of any trials.

And while the appeals were dragging on... >> Change in political landscape for our state... >> The biggest midterm election in a generation... >> NARRATOR: The political landscape in Michigan was changing with a new governor.

>> It was a dominating night for Democrats, winning a number of key races, including governor, attorney general... >> NARRATOR: And a new attorney general, a Democrat who'd criticized the investigation for not producing results.

>> I think we have to take a very close look at those investigations, we have to re-evaluate, and I think we should have career prosecutors handling those cases.

>> NARRATOR: By the beginning of 2019, the fate of the investigation was uncertain.

With the criminal cases in limbo, we were still trying to determine the toll of the Legionnaires' outbreak.

>> It's kind of like detective work: You look at the evidence, you evaluate the circumstances, and then you start putting these pieces together.

>> NARRATOR: After months of reporting and analysis, "Frontline" had documented 115 pneumonia deaths that happened in Flint during the outbreak.

In response to our findings, a spokeswoman for the state health department told us they'd noticed an increase, too, and concluded it was due to influenza.

But independent scientists were telling us that in all likelihood, some of them were actually due to Legionnaires'.

>> I took the information from the death certificates, and I plotted out each one of those deaths on a map, just to kind of see if anything stood out.

And in fact it did.

In particular, the older parts of the city.

We found these clusters of people that, around the same timeframe as the switch, were dying of pneumonia and dying of Legionnaires' disease.

♪ ♪ We're in Mott Park.

>> NARRATOR: Mott Park is a neighborhood on the west side of Flint where we found six deaths attributed to pneumonia in the beginning of the outbreak-- triple what it had been during that time the previous year.

>> Did you guys ever think there was something wrong with the water?

>> No, I didn't know anything was wrong with the water.

>> NARRATOR: Loree Moore lived here with her nephew Marcus Wilson during the summer of 2014, when Marcus was recovering from cancer treatments.

>> He was weak, but he wasn't weak-weak.

He was walking, he was doing everything on his own.

>> Did Marcus use the water here a lot, did he...?

>> Yes, he did.

He drunk a lot of water.

He would take showers and he would sit in there for a long time and just let the water run in his face.

And I was, like, "Marcus, you okay?"

And he was, like, "Man, that water feel good."

And he would always just sit in there and just, you know, let the water hit him in his face, you know, in the chair.

>> So he's sitting in there, hot water, breathing it in right in his face?

>> Yes, yes.

He would just sit there in the chair and hold his face like this.

>> NARRATOR: Back when the outbreak was erupting in August 2014, Marcus went to the hospital.

Doctors diagnosed him with pneumonia, never testing for Legionnaires'.

A few weeks later, he was dead.

Without testing, there was no way to know for certain if Marcus Wilson or any of the 115 people we'd found had died of Legionnaires'.

But what were the chances that some of them had?

>> I'm a beat reporter, I'm not an epidemiologist.

You can talk to families, you can put dots on a map and make assumptions about clusters, but at the end of the day, you really do need an objective, independent review of that data.

>> NARRATOR: So we took our reporting to Atlanta, to Emory University, where a team of independent epidemiologists we'd commissioned built their own statistical model to analyze the data we'd been collecting.

>> What a statistical model allows us to do is to really see the forest for the trees, to look at whether or not the difference that we saw in Genesee County was actually statistically meaningful.

>> NARRATOR: The team compared the pneumonia deaths to a control group.

>> The control group that we chose for this analysis was counties that were similar to Genesee County in many respects in terms of their size, and income, and education level, and socio-economic profile, but were both in Michigan and in surrounding states.

And so what we see here is that when we start in 2011, we follow this mortality rate, they're pretty similar between Genesee County and the controls.

And they're pretty similar, they're quite similar, and this continues until we get to about the middle of 2014.

And this is sort of where the inflection point happens here.

>> NARRATOR: The increase was most pronounced in the first six months of 2014, and less so in 2015.

It's not clear why, since Flint was still on river water then.

>> Right when the Legionnaires' epidemic starts, the pneumonia death rate in Genesee goes up, while in the other counties, it's going down.

So, we got this very clear divergence when you plot that over time.

>> NARRATOR: After running the numbers, the team concluded there'd been about 70 more pneumonia deaths than normal.

>> That means that there could have been a little bit more than 70 and there could have been fewer.

However, the most plausible number that we came up with from our models is 70.

>> This is definitely consistent with the idea that there were some Legionnaires' cases that did not get diagnosed and therefore did not get included in the official count for the outbreak.

It's likely that the Legionnaires' outbreak was bigger than that reported by official authorities.

>> If physicians had a higher level of awareness about the Legionnaires' disease outbreak earlier than they did, it's possible that that could have ultimately led to fewer cases and fewer deaths due to Legionnaires'.

>> NARRATOR: We presented our findings and Emory's to former governor Rick Snyder, who declined to comment.

The state health department also declined, citing pending litigation.

The official death toll from the outbreak remains 12 people.

♪ ♪ >> The Lord is your keeper.

The sun shall not smite you by day, nor the moon by night.

>> Amen.

>> NARRATOR: Looking further into our data, we made another discovery: Of the people who were diagnosed with Legionnaires' during the outbreak and initially survived, at least 20 had since died.

>> Jassmine D. McBride departed this life on February the 12th, 2019, at St. Mary Mercy Hospital.

>> NARRATOR: In the end, Jassmine McBride couldn't overcome the damage that had been done by the Legionnaires' disease.

>> What was the cause of her death were complications as a result of Legionnaires' disease.

She had heart problems, she had lung problems, she had kidney problems, and that resulted in her having a cardiac arrest.

>> If she could get up right now, she would say, "I'm not suffering anymore from Legionnaires' disease.

"I'm not suffering waiting to get a transplant.

Thank God I'm free."

Jassy, you're free.

Rest in peace.

(congregation applauding) >> She fought a good fight.

She finished her course.

And the victory is hers.

>> (singing) >> She was angry and she forgave them.

She just wanted justice to be served.

(hymn continues) >> A big story we are following tonight, outrage in the city of Flint, Michigan.

>> People of Flint, Michigan, say they are horrified again.

>> A shocking decision from the newly Democratic attorney general's office.

>> NARRATOR: Four months later... >> A lot of us are really angry.

And we want to see some justice.

We want justice.

>> NARRATOR: Michigan's new attorney general had ousted Todd Flood and most of his team, and appointed new prosecutors, who dropped all the charges against Nick Lyon, Dr. Eden Wells, and the other officials.

>> When we first came into the investigation, we had some very real concerns.

>> Some major, major concerns.

And when I looked at it, like I told Fadwa-- and I think I may have told the attorney general-- "We're going to have to start from the beginning.

We're gonna have to start from scratch."

>> NARRATOR: Despite two judges ruling the cases should go to trial, the new prosecutors say the previous investigation was "fundamentally flawed" and failed to collect all available evidence.

>> If we know the investigation was not complete, you just simply cannot proceed.

It's very important when we say we dropped the charges is that these charges are dismissed without prejudice, which means these charges could be brought up again today.

We're supposed to have everything, look at it, and make a decision.

That's not the way things happened in this case.

Millions and millions of dollars have been spent on the Flint water investigation.

They've wasted three years for zero.

For nothing.

>> Here's the thing.

I know we worked tirelessly to put a great case together and continue the investigation.

I know that, right?

And I can say that without equivocation.

And candidly, look, the facts speak for themselves.

We won.

We got the cases bound over.

We did things the old-fashioned way of moving from the bottom and going up in the investigation.

And the investigation for us was far from over.

♪ ♪ >> NARRATOR: More than five years after the start of the outbreak, it remains to be seen whether any of the officials at the center of the Flint water crisis will be held responsible.

>> Flint happened.

People have to live with this for years, and years, and years, and years, and years to come.

We are interested in justice, no matter how hard that is.

We did not choose the easy route, but we chose the route that the people of Flint deserve.

>> I'm more than skeptical.

It makes no sense to drop the charges, dismiss the investigation, to start from scratch with the clock ticking.

I guess time will tell, but I suspect that justice delayed is going to be justice forgotten.

♪ ♪ >> Believe me, it's been a long five years.

It's been five years too long.

This is something that has not really happened before.

It was man-made.

This was not a coincidence.

This was thought out.

It was calculated.

It was decisions made.

And those people must be held accountable.

♪ ♪ >> NARRATOR: He was embraced as a reformer... >> He sold himself, he sold his vision.

>> People were mesmerized.

>> NARRATOR: But there was another side... >> There were dissidents who were tortured.

>> Princes and big businesspeople put under constant observation.

>> He seemed to get committed to going after his enemies the more powerful he became.

>> NARRATOR: And then, a brutal murder... >> Did the regime kill Jamal Khashoggi?

>> NARRATOR: "Frontline" investigates... >> Even the President said, "This is the worst cover-up I've ever seen."

>> Go to pbs.org/frontline for more on the analysis of pneumonia deaths in Flint.

>> Right when the Legionnaires' epidemic starts, the pneumonia death rate in Genesee goes up while in the other counties it's going down.

>> This is sort of where the inflection point happens here.

>> And what we know about the safety of the water now.

Connect to the "Frontline" community on Facebook and Twitter, and watch "Frontline" anytime on the PBS Video app or pbs.org/frontline.

>> For more on this and other "Frontline" programs, visit our website at pbs.org/frontline.

♪ ♪ To order "Frontline's" "Flint's Deadly Water" on DVD, visit ShopPBS, or call 1-800-PLAY-PBS.

This program is also available on Amazon Prime Video.

♪ ♪