How could thousands of people fall ill anywhere in New Zealand from drinking tap water? How could that happen in a First World country?
More than a third of Havelock North residents - 5500 people - were infected with a serious condition, 45 were hospitalised and the lives of three elderly people were lost.
Havelock North businesses suffered financially, and the cost to local agencies was nearly $4 million. Some of those infected with campylobacter will struggle with the consequences for the rest of their lives.
As well as Guillain-Barre syndrome, campylobacter sufferers could still develop reactive arthritis.
As so often happens in crises like this, the community rallied together and we saw courage and leadership. Lawrence Yule, as the mayor of Hastings District, and Dr Nicholas Jones, the medical officer of health for Hawke's Bay, were impressive and resolute in their fronting of the crisis.
I remember thinking how the leadership shown locally at that time contrasted with the total lack of leadership shown by the Minister of Health.
The crisis had national repercussions, and there was simply no leadership from the government. No state of emergency, no timely announcement of an inquiry, no assurances given to the public.
We eventually got an inquiry and we now have a comprehensive 230-page report on Stage 1 of the inquiry.
The inquiry has found multiple failings led to this crisis and the report is a damning indictment of how the Hastings District Council and Hawkes Bay Regional Council have failed in their responsibilities.
The Regional Council failed to meet its responsibilities, as set out in the Resource Management Act 1991 to act as guardian of the aquifers under the Heretaunga Plains.
As a public drinking-water supplier, the Hastings District Council failed, especially considering the high number of positive E.coli readings in the Havelock North and Hastings water supplies over the years. An outbreak of campylobacter also occurred in 1998 in two Brookvale Road bores, the same location as last year's event.
The report also discusses the failure of the two councils to work together due to a strained relationship.
The report says the failings on the part of the two councils did not directly cause the outbreak, but, crucially, there may have been a different outcome without those failings.
New Zealanders are a reasonable and forgiving people.
We accept mistakes and appreciate it when sincere apologies are made, and appropriate responsibility taken. The report shows the two councils have performed well below our expectations, but since these findings have been released I have yet to see the same level of responsibility, accountability and leadership we all saw at the outbreak of the crisis.
Leaders, especially elected representatives, should and must take responsibility for fundamental failings in their organisations.
We now look to Stage 2 of the inquiry which will address lessons learned for the future and, we all hope, ensure systems are improved to avoid this ever happening again. Surely part of ensuring this never happens again involves demanding appropriate accountability.
As the inquiry got under way, it was important that the focus remained squarely on information gathering and finding answers.
But now is the time for justice, for all of us who were so badly let down by the failures which led to this crisis, for those who fell ill, for those whose lives were lost and their whanau.
Meka Whaitiri is the MP for Ikaroa Rawhiti and the Labour Party's Local Government representative.
