The large and multidisciplinary literature on water for domestic use and gender has two primary foci: (1) the negative health and well-being impacts of inadequate access to safe water, and (2) the effects of women’s participation in water allocation and management decisions. These foci are reflected in both the research and policy literatures. Smaller bodies of work exist on water and social power, and on nonmaterial values and meanings of water. The term “gender” refers to the socially constructed roles and identities of girls, women, boys, men, and nonbinary people, but the literature on water and gender to date is mainly concerned with women and girls, on whom inadequate water access places a disproportionate burden.
The water and health literature during the Millennium Development Goals era focused overwhelmingly on the consequences of unsafe drinking water for child health, while paying less attention to the health of the water carriers and managers. Studies on women’s participation in water-related decisions in the household or community were (and to some extent remain) mixed with respect to their effects on equity, access, and empowerment. Both the health and participation strands often assumed, implicitly or explicitly, that water work was women’s work. Yet data on access was mainly collected and presented by household or community, with little effort to disaggregate access and use by gender.
In keeping with the spirit of the Sustainable Development Goals, the post-2015 literature has gone beyond a focus on infectious diseases to include the psychosocial stresses of coping with unreliable or inadequate water supplies. These stresses are acknowledged to fall disproportionately on women. A relatively small literature exists on the health impacts of carrying heavy loads of water and on the hard choices to be made when safe water is scarce. The negative impacts of inadequate domestic water access on girls’ education opportunities, on the safety of those who walk long distances to collect water, and on family conflicts have also been studied. Access is being defined beyond the household to prioritize safe water availability in schools and in healthcare facilities, both of which serve vulnerable populations. Both are institutional settings with a majority-female workforce. The definition of domestic water post-2015 has also broadened beyond drinking water to include water for cooking, sanitation, and basic hygiene, all of which particularly concern women’s well-being.
Intersectionality with respect to gender, class, ability, and ethnicity has started to inform research, in particular research influenced by feminist political ecology and/or indigenous values of water. Political ecology has drawn attention to structural inequalities and their consequences for water access, a perspective that is upstream of public health’s concerns with health impacts. Research on participation is being augmented with studies of leadership and decision-making, both within communities as well as within the water sector. Critical studies of gender, water, and participation have argued that development agencies can limit modes of participation to those that “fit” their larger goals, e.g., efficiency and cost-recovery in drinking water systems. Studies have also analyzed the gendered burden of paying for safe water, especially as the pressure for cost recovery has grown within urban water policy.
These are significant and growing new directions that acknowledge the breadth and complexities of the gender and water world; they do not simply call for gender-disaggregated data but attempt, albeit imperfectly, to take water research towards the recognition of gender justice as a foundation for water justice for all.
Small, low-income communities in the United States disproportionately lack access to safe drinking water (i.e. water that meets regulated quality standards). At a community level, the literature has broadly claimed that a major barrier to safe drinking water access is low technical, managerial, and financial (TMF) capacity. At a broader structural level, the environmental justice literature has shown that historical neglect of low-income communities of color has resulted in numerous water systems without the financial and political resources to meet water quality standards. This study investigates the contemporary processes by which distributive injustices persist in California’s Central Valley. The study uses key informant interviews with a range of stakeholders, including employees at the state, county and community, non-profit organizations, and engineers, to understand why sustainable water quality solutions for small low-income communities remain such a challenge. The interviews are structured around a decision chain, which builds out the specific steps needed to go from a maximum contaminant level violation to remediation. The resulting decision chain makes visible the multiple steps at multiple stages with multiple actors that are needed to arrive at a solution to substandard water quality. It shows the numerous nodes at which progress can be stalled, and thus functions as a behind-the-scenes look at the (re)production of persistent inequalities. The complexity of the process shows why having the TMF capacity needed to get to a safe water system is not a reasonable expectation for most small community water systems. Inequalities are continually being produced and cemented, often by the very steps aimed towards remediation, thus making persistent disparities in safe drinking water access a de facto state-sanctioned process that compounds a discriminatory historical legacy.
Public service access in low- and middle- income countries is shaped by how much governments spend on services and where they choose to prioritize delivery. Accordingly, the local public goods and distributive politics literatures are largely focused on government spending and patterns of access. We argue that, even after access is granted, service quality can vary dramatically, and may vary with socioeconomic and political characteristics. We provide one of the first analyses of a key dimension of service quality: intermittency, which affects vital services such as water and electricity for hundreds of millions of people. We illustrate how to study it by highlighting the specific facets of intermittency that must be managed within the network; we show that these dimensions may be manipulated separately, and that infrastructure network structure shapes the allocation of intermittency. The literature from urban India shows that access to water connections (like access to many other local public goods) is typically associated with higher socio-economic status. In contrast, we find that in our study sites in Bangalore, water
flows through pipes more frequently and predictably in low-income areas—thereby underscoring the importance of studying intermittency, and service quality more generally, as phenomena distinct from access.
Bottled water is a rapidly growing yet relatively understudied source of drinking water globally. In addition to concerns about the safety of bottled water, the adverse environmental health and social impacts associated with bottled water production, distribution, consumption, and reliance are considerable. Our objective was to comprehensively review, analyze, and synthesize ∼20 years of publicly available data on bottled water quality and associated health outcomes in China. We conducted a systematic review and meta-analysis of publicly available studies of bottled water quality and associated health outcomes in China published between 1995 and early 2016 (in Chinese and English). We pre-specified and registered our study protocol, independently replicated
key analyses, and followed standardized reporting guidelines. Our search identified 7059 potentially eligible records. Following screening, after full-text review of 476 publications, 216 (reporting results from 625 studies) met our eligibility criteria. Among many findings, 93.7% (SD = 10.1) of 24 585 samples tested for total coliforms (n = 241 studies), and 92.6% (SD = 12.7) of 7261 samples tested for nitrites (n = 85 studies), were in compliance with China’s relevant bottled water standards. Of the studies reporting concentration data for lead (n = 8), arsenic (n = 5), cadmium (n = 3), and mercury (n = 3), median concentrations were within China’s standards for all but one study of cadmium. Only nine publications reported health outcome data, eight of which were outbreak investigations. Overall, we observed evidence of stable or increasing trends in the proportions of samples in compliance over the ∼20 year period; after controlling for other variables via meta-regression, the association was significant for microbiological but not chemical outcomes (p = 0.017 and p = 0.115, respectively). Bottled water is typically marketed as being safe, yet in most countries it is less well-regulated than utility-supplied drinking water. Given the trend of increasing bottled water use in China and globally—and the associated environmental health impacts—we hope this work will help to inform policies and regulations for improving bottled water safety, while further highlighting the need for substantially expanding the provision of safe and affordable utility-supplied drinking water globally.
Water affordability is central to water access but remains a challenge to measure. California enshrined the human right to safe and affordable water in 2012 but the question remains: how should water affordability be measured across the state? This paper contributes to this question in three steps. First, we identify key dimensions of water affordability measures (including scale, volume of water needed to meet ‘basic’ needs, and affordability criteria) and a cross-cutting theme (social equity). Second, using these dimensions, we develop three affordability ratios measured at the water system scale for households with median, poverty level, and deep poverty (i.e., half the poverty level) incomes and estimate the corresponding percentage of households at these income levels. Using multiple measures conveys a fuller picture of affordability given the known limitations of specific affordability measures. Third, we analyze our results disaggregated by a key characteristic of water system vulnerability–water system size. We find that water is relatively affordable for median income households. However, we identify high unaffordability for households in poverty in a large fraction of water systems. We identify several scenarios with different policy implications for the human right to water, such as very small systems with high water bills and low-income households within large water systems. We also characterize how data gaps complicate theoretical ideals and present barriers in human right to water monitoring efforts. This paper presents a systematic approach to measuring affordability and represents the first statewide assessment of water affordability within California’s community water systems.
The public health community has tried for decades to show, through evidence-based research, that safe water, sanitation, and hygiene (WASH) and clean cooking fuels that reduce household air pollution are essential to safeguard health and save lives in low-income and middle-income countries. In the past 40 decades, there have been many innovations in the development of low-cost and efficacious technologies for WASH and household air pollution, but many of these technologies have been associated with disappointing health outcomes, often because low-income
households have either not adopted, or inconsistently adopted, these technologies. In this Viewpoint, we argue that public health researchers (ourselves included) have had an oversimplified understanding of poverty; our work has not focused on insights into the lived experience of poverty, with its uncertainties, stresses from constant scarcity, and attendant fears. Such insights are central to understanding why technologies for safe water or clean cooking are unused by so many households that could benefit from them. We argue that, rather than improved versions of
household-scale delivery models, transformative investments in safe water and clean cooking for all require utility-scale service models. Until then, research should focus on interim safe water and clean cooking options that are directed towards the utility-scale service model.
The human right to water (HRTW) and sustainable development goals (SDG) emphasize that human well-being depends not just on the quality and physical accessibility of drinking water, but also on its economic accessibility. Despite this recognition, governments and academics alike have been hard-pressed to define and measure water affordability. In the US, affordability is no longer solely focused on utility cost-recovery models but equitable water access for individuals and households. How should water affordability be measured to represent this
new focus? This question motivates the critical review presented here. We propose that household-centered affordability measures reflect the normative aims of internationally established frameworks such as the HRTW and the SDGs. Linking measurement to aims is essential to improve transparency and comparability across studies, and ultimately, to align measures with water access objectives. First, we characterize normative positions outlined in the HRTW and SDGs and identify defining features of water affordability. Second, we identify dominant definitions and measures of affordability, including novel approaches. Bringing the defining features of affordability to bear on existing measures enables us to identify several emergent debates in the literature where affordability measures could better incorporate the aspirations of the HRTW and SDGs. We conclude with recommendations on how to improve water affordability measurements, while recognizing the trade-offs between ideal measures and practical implementation.
COVID-19 is a disease with no proven pharmaceutical intervention and no proven vaccine. In such circumstances, prevention is all we have. The role of handwashing in the prevention of communicable diseases has been known for over a century, yet it remains severely neglected as a public health investment, to be periodically re-discovered during pandemic-scale infections. Over 26% of the global population has no access to a handwashing station in the home; for many low-income countries this proportion rises to over 50%. In other instances, the water is unaffordable or the supply has been shut off on account of unpaid bills. But when there is no water in the home or yard, or no mechanism for delivering enough water, good hand-washing is extremely difficult. Well before COVID-19, global cost-benefit analyses of water and sanitation investments, with benefits measured in time-savings as well as health, showed significant net benefits in all sub-regions of the developing world. This Viewpoint paper argues that, in the current crisis and its aftermath, it is imperative for governments and donors to prioritize and generously fund affordable, reliable, and accessible water services in underserved regions of the world. More than ever before, this is a foundational investment for health, dignity and development.
Most urban residents in high-income countries obtain piped and treated water for drinking and domestic use from centralized utility-run water systems. In low- and middle-income countries (LMICs), however, utilities work alongside myriad other service providers that deliver water to hundreds of millions of city-dwellers. Hybrid modes of water delivery in urban areas in low- and middle-income countries are systems in which a variety of state and nonstate actors contribute to the delivery of water to households, schools, healthcare facilities, businesses, and government offices. Historically, the field has evolved to include within-utility networks and outside-the-utility provision mechanisms. Utilities service the urban core through network connections, while nonstate, smaller-scale providers supplement utility services both inside and outside the piped network. The main reform waves since the 1990s—privatization and corporatization—have done little to alter the hybrid nature of provision. Numerous case studies of nonutility water providers suggest that they are imperfect substitutes for utilities. They reach millions of households with no access to piped water, but the water they deliver tends to be of uncertain quality and is typically far more expensive than utility water. Newer work on utility-provided water and utility reforms has highlighted the political challenges of private sector participation in urban water; debates have also focused on the importance of contractual details such as tariff structures and investor incentives. New research has produced numerous studies on LMICs on the ways in which utilities extend their service areas and service types through explicit and implicit relationships with front-line water workers and with supplemental nonstate water suppliers. From the nonutility perspective, debates animated by questions of price and quality, the desirability or possibility of regulation, and the compatibility (or lack thereof) between reliance on small-scale water providers and the human right to safe water, are key areas of research. While understanding the hybrid nature of water delivery is essential for responsible policy formulation and for understanding inequalities in the urban sphere, there is no substitute for the convenience and affordability of universal utility provision, and no question that research on the conditions under which particular types of reforms can improve utility provision is sorely needed.
BACKGROUND: Inadequate access to safe drinking water remains a global health problem, particularly in rural areas. Boiling is the most commonly used form of point-of-use household water treatment (HWT) globally, although the use of bottled water in low- and middle-income countries (LMICs) is increasing rapidly.
OBJECTIVES: We assessed the regional and seasonal prevalence of HWT practices (including bottled water use) in low-income rural areas in two Chinese provinces, evaluated the microbiological safety of drinking water and associated health outcomes, and estimated the air pollution burden associated with the use of solid fuels for boiling.
METHODS: We conducted cross-sectional surveys and collected drinking water samples from 1,033 rural households in Guangxi and Henan provinces. Temperature sensors affixed to pots and electric kettles were used to corroborate self-reported boiling frequencies and durations, which were used to model household air pollution (HAP) in terms of estimated particulate matter ≤2:5 lm in aerodynamic diameter (PM2:5) concentrations.
RESULTS: Based on summer data collection in both provinces, after controlling for covariates, boiling with electric kettles was associated with the largest log reduction in thermotolerant coliforms (TTCs) (−0:66 log10 TTC most probable number=100 mL), followed by boiling with pots (−0:58), and bottled water use (−0:39); all were statistically significant (p< 0:001). Boiling with electric kettles was associated with a reduced risk of TTC contamination [risk ratio ðRRÞ= 0:25, p< 0:001] and reported diarrhea (RR = 0:80, p= 0:672). TTCs were detected in 51% (n= 136) of bottled water samples. For households boiling with biomass, modeled PM2:5 concentrations averaged 79 lg=m3 (standard deviation = 21).
DISCUSSION: Our findings suggest that where boiling is already common and electricity access is widespread, the promotion of electricity-based boiling may represent a pragmatic stop-gap means of expanding safe water access until centralized, or decentralized, treated drinking water is available; displacing biomass use for water boiling could also reduce HAP concentrations and exposures. Our results also highlight the risks of increasing bottled water use in rural areas, and its potential to displace other sources of safe drinking water, which could in turn hamper efforts in China and other LMICs toward universal and affordable safe water access
Although access to piped drinking water continues to increase globally, information on the prevalence and
clonal composition of coliforms found in piped water systems in low-resource settings remains limited. From June to July 2016, we examined Escherichia coli isolates in domestic water from the distribution system in Alibag, a small town in India. We analyzed the isolates for drug resistance and genotyped them by multilocus sequence typing. Of 147 water samples, 51 contained coliforms, and 19 (37%) of the 51 were biochemically confirmed to contain E. coli. These samples contained 104 E. coli isolates—all resistant to ampicillin. Resistance to ceftazidime was observed in 52 (50%) isolates, cefotaxime in 59 (57%), sulfamethoxazole–trimethoprim in 46 (44%), ciprofloxacin in 30 (29%), and gentamicin in two (2%). Thirty-eight (36%) belonged to sequence types recognized as extraintestinal pathogenic E. coli (ExPEC); 19 (50%) of these 38 ExPEC belonged to known uropathogenic E. coli lineages. This exploratory field research shows the extent to which “improved” drinking water is a potential source of E. coli strains capable of causing extraintestinal infections
The rapid growth of bottled water use in low- and middle-income countries, and its normalization as a daily
source of drinking water, does not provide a pathway to universal access. Generous and sustained investment in
centralized and community utilities remains the most viable means for achieving safe water access for all.
Low adoption and compliance levels for household water treatment and safe storage (HWTS) technologies have made it challenging for these systems to achieve measurable health benefits in the developing world. User compliance remains an inconsistently defined and poorly understood feature of HWTS programs. In this article, we develop a comprehensive approach to understanding HWTS compliance. First, our Safe Drinking Water Compliance Framework disaggregates and measures the components of compliance from initial adoption of the HWTS to exclusive consumption of treated water. We apply this framework to an ultraviolet (UV)–based safe water system in a cluster-randomized controlled trial in rural Mexico. Second, we evaluate a no-frills (or “Basic”) variant of the program as well as an improved (or “Enhanced”) variant, to test if subtle changes in the user interface of HWTS programs could improve compliance. Finally, we perform a full-cost analysis of both variants to assess their cost effectiveness (CE) in achieving compliance. We define “compliance” strictly as the habit of consuming safe water. We find that compliance was significantly higher in the groups where the UV program variants were rolled out than in the control groups. The Enhanced variant performed better immediately postintervention than the Basic, but compliance (and thus CE) degraded with time such that no effective difference remained between the two versions of the program.
Employing a matched cohort research design, eight wards with intermittent water supply are compared to eight wards upgraded to continuous (24 x 7) supply in a demonstration project in Hubli–Dharwad, Karnataka,
with respect to tap water quality, child health, water storage practices, and coping costs across socio-economic strata. Water consumption and waste in the intermittent zones, and the potential for scale-up of continuous supply to the entire city, are estimated. It was found that the 24 x 7 project improved water quality, did not improve overall child health, but did reduce serious waterborne illnesses in the lowest-income strata, reduced the costs of waiting, increased monthly water bills, and potentially reduced water security for some of the poorest households.
Urban service provision falls somewhere on the continuum of lower-cost, lower-quality, unreliable and intermittent to higher-cost, higher-quality, reliable and continuous. Piped water services in India are generally in the former category, but efforts are underway in some cities to shift to continuous supply. We use a matched-cohort research design to evaluate one such effort: an upgrade to continuous water service in a pilot zone of Hubli-Dharwad, India, while the rest of the city remained on intermittent services. We conducted a survey of ∼4000 households with four rounds of data collection over 15 months. We evaluated the household-level net benefits, the equity of their distribution, and the affordability of water access under continuous supply. We also evaluated the project at the system-level (household and utility), estimating the net present value of the upgrade and the feasibility of scale-up to the entire city. We found positive net benefits for households overall, but uneven distribution of these benefits across socio-economic strata. We also found that the costs of supply augmentation, a necessary step for scale-up, significantly reduced the project net present value. The potential for scale-up is thus unclear.
Many policies and programs based on informational interventions hinge upon the assumption that providing citizens with information can help improve the quality of public services, or help citizens cope with poor services. We present a causal framework that can be used to identify leaks and blockages in the information production and dissemination process in such programs. We conceptualize the “information pipeline” as a series of connected nodes, each of which constitutes a possible point of blockage. We apply the framework to a field-experimental evaluation of a program that provided households in Bangalore, India, with advance notification of intermittently provided piped water. Our study detected no impacts on household wait times for water or on how citizens viewed the state, but found that notifications reduced stress. Our framework reveals that, in our case, noncompliance among human intermediaries and asymmetric gender relations contributed in large part to these null-to-modest results. Diagnostic frameworks like this should be used more extensively in development research to better understand the mechanisms responsible for program success and failure, to identify subgroups that actually received the intended treatment, and to identify potential leaks and blockages when replicating existing programs in new settings.
Almost half of all deaths from drinking microbiologically unsafe water occur in Sub-Saharan Africa. Household water treatment and safe storage (HWTS) systems, when consistently used, can provide safer drinking water and improve health. Social marketing to increase adoption and use of HWTS depends both on the prices of and preferences for these systems. This study included 556 households from rural Tanzania across two low-income districts with low-quality water sources. Over 9 months in 2012 and 2013, we experimentally evaluated consumer preferences for six “low-cost” HWTS options, including boiling, through an ordinal ranking protocol. We estimated consumers’ willingness to pay (WTP) for these options, using a modified auction. We allowed respondents to pay for the durable HWTS systems with cash, chickens or mobile money; a significant minority chose chickens as payment. Overall, our participants favored boiling, the ceramic pot filter and, where water was turbid, PuR™ (a combined flocculant-disinfectant). The revealed WTP for all products was far below retail prices, indicating that significant scale-up may need significant subsidies. Our work will inform programs and policies aimed at scaling up HWTS to improve the health of resource-constrained communities that must rely on poor-quality, and sometimes turbid, drinking water sources.
Approximately two billion people drink unsafe water. Boiling is the most commonly used household water treatment (HWT) method globally and in China. HWT can make water safer, but sustained adoption is rare and bottled water consumption is growing. To successfully promote HWT, an understanding of associated socioeconomic factors is critical. We collected survey data and water samples from 450 rural households in Guangxi Province, China. Covariates were grouped into blocks to hierarchically construct modified Poisson models and estimate risk ratios (RR) associated with boiling methods, bottled water, and untreated water. Female-headed households were most likely to boil (RR = 1.36, p < 0.01), and among boilers those using electric kettles rather than pots had higher income proxies (e.g., per capita TV ownership RR = 1.42, p < 0.01). Higher-income households with younger, literate, and male heads were more likely to purchase (frequently contaminated) bottled water, or use electric kettles if they boiled. Our findings show that boiling is not an undifferentiated practice, but one with different methods of varying effectiveness, environmental impact, and adoption across socioeconomic strata. Our results can inform programs to promote safer and more efficient boiling using electric kettles, and suggest that if rural China’s economy continues to grow then bottled water use will increase.
Measurements of household water consumption are extremely difficult in intermittent water supply (IWS) regimes in low‐ and middle‐income countries, where water is delivered for short durations, taps are shared, metering is limited, and household storage infrastructure varies widely. Nonetheless, consumption estimates are necessary for utilities to improve water delivery. We estimated household water use in Hubli‐Dharwad, India, with a mixed‐methods approach combining (limited) metered data, storage container inventories, and structured observations. We developed a typology of household water access according to infrastructure conditions based on the presence of an overhead storage tank and a shared tap. For households with overhead tanks, container measurements and metered data produced statistically similar consumption volumes; for households without overhead tanks, stored volumes underestimated consumption because of significant water use directly from the tap during delivery periods. Households that shared taps consumed much less water than those that did not. We used our water use calculations to estimate waste at the household level and in the distribution system. Very few households used 135 L/person/d, the Government of India design standard for urban systems. Most wasted little water even when unmetered, however, unaccounted‐for water in the neighborhood distribution systems was around 50%. Thus, conservation efforts should target loss reduction in the network rather than at households.
Significant development funding flows to informational interventions intended to improve public services. Such “transparency fixes” often depend on the cooperation of frontline workers who produce or disseminate information for citizens. This article examines frontline worker compliance with a transparency intervention in Bangalore’s water sector. Why did compliance vary across neighborhoods, and why did workers exhibit modest rates of compliance overall? Drawing on ethnographic observation and an original data set, this article finds that variation in workers’ family responsibilities and financial circumstances largely explains variation in compliance with the intervention. Furthermore, workers often prioritize long‐standing responsibilities over new tasks seen as add‐ons, leading to modest rates of compliance overall. Perceptions of “core” jobs can be sticky—especially when reaffirmed through interactions with citizens. This article represents one of the first multimethod companions to a field experiment, and illustrates how the analysis of qualitative and observational data can contribute to impact evaluation.
Shallow groundwater containing toxic concentrations of arsenic is the primary source of drinking water for millions of households in rural West Bengal, India. Often, this water also contains unpleasant levels of iron and non-negligible fecal contamination. Alternatives to shallow groundwater are increasingly available, including government-built deep tubewells, water purchased from independent providers, municipal piped water, and household filters. We conducted a survey of 501 households in Murshidabad district in 2014 to explore what influenced the use of available alternatives. Socioeconomic status and the perceived likelihood of gastrointestinal (GI) illness (which was associated with dissatisfaction with iron in groundwater) were the primary determinants of the use of alternatives. Arsenic knowledge was limited. The choice amongst alternatives was influenced by economic, social, and aesthetic factors, but not by health risk perceptions. The use of purchased water was rarely exclusive and was strongly associated with socioeconomic status, suggesting that this form of market-based water provision does not ensure universal access. Demand for purchased water appeared to decrease significantly shortly after free piped water became available at public taps. Our results suggest that arsenic mitigation interventions that also address co-occurring water problems (iron, GI illness) could be more effective than a focus on arsenic alone.
Intermittent delivery of piped water can lead to waterborne illness through contamination in the pipelines or during household storage, use of unsafe water sources during intermittencies, and limited water availability for hygiene. We assessed the association between continuous versus intermittent water supply and waterborne diseases, child mortality, and weight for age in Hubli-Dharwad, India.
We conducted a matched cohort study with multivariate matching to identify intermittent and continuous supply areas with comparable characteristics in Hubli-Dharwad. We followed 3,922 households in 16 neighborhoods with children <5 y old, with four longitudinal visits over 15 mo (Nov 2010–Feb 2012) to record caregiver-reported health outcomes (diarrhea, highly credible gastrointestinal illness, bloody diarrhea, typhoid fever, cholera, hepatitis, and deaths of children <2 y old) and, at the final visit, to measure weight for age for children <5 y old. We also collected caregiver-reported data on negative control outcomes (cough/cold and scrapes/bruises) to assess potential bias from residual confounding or differential measurement error.
Continuous supply had no significant overall association with diarrhea (prevalence ratio [PR] = 0.93, 95% confidence interval [CI]: 0.83–1.04, p = 0.19), bloody diarrhea (PR = 0.78, 95% CI: 0.60–1.01, p = 0.06), or weight-for-age z-scores (Δz = 0.01, 95% CI: −0.07–0.09, p = 0.79) in children <5 y old. In prespecified subgroup analyses by socioeconomic status, children <5 y old in lower-income continuous supply households had 37% lower prevalence of bloody diarrhea (PR = 0.63, 95% CI: 0.46–0.87, p-value for interaction = 0.03) than lower-income intermittent supply households; in higher-income households, there was no significant association between continuous versus intermittent supply and child diarrheal illnesses. Continuous supply areas also had 42% fewer households with ≥1 reported case of typhoid fever (cumulative incidence ratio [CIR] = 0.58, 95% CI: 0.41–0.78, p = 0.001) than intermittent supply areas. There was no significant association with hepatitis, cholera, or mortality of children <2 y old; however, our results were indicative of lower mortality of children <2 y old (CIR = 0.51, 95% CI: 0.22–1.07, p = 0.10) in continuous supply areas. The major limitations of our study were the potential for unmeasured confounding given the observational design and measurement bias from differential reporting of health symptoms given the nonblinded treatment. However, there was no significant difference in the prevalence of the negative control outcomes between study groups that would suggest undetected confounding or measurement bias.
Continuous water supply had no significant overall association with diarrheal disease or ponderal growth in children <5 y old in Hubli-Dharwad; this might be due to point-of-use water contamination from continuing household storage and exposure to diarrheagenic pathogens through nonwaterborne routes. Continuous supply was associated with lower prevalence of dysentery in children in low-income households and lower typhoid fever incidence, suggesting that intermittently operated piped water systems are a significant transmission mechanism for Salmonella typhi and dysentery-causing pathogens in this urban population, despite centralized water treatment. Continuous supply was associated with reduced transmission, especially in the poorer higher-risk segments of the population.
Well into the 21st century, safe and affordable drinking water remains an unmet human need. At least 1.8 billion people are potentially exposed to microbial contamination, and close to 140 million people are potentially exposed to unsafe levels of arsenic. Many new technologies, water quality assessments, health impact assessments, cost studies, and user preference studies have emerged in the past 20 years to further the laudable goal of safe drinking water for all. This article reviews (a) the current literature on safe water approaches with respect to their effectiveness in improving water quality and protectiveness in improving human health, (b) new work on the uptake and use of safe water systems among low-income consumers, (c) new research on the cash and labor costs of safe water systems, and (d) research on user preferences and valuations for safe water. Our main recommendation is that safe water from “source to sip” should be seen as a system; this entire system, rather than a discrete intervention, should be the object of analysis for technical, economic, and health assessments.
In rural China ~607 million people drink boiled water, yet little is known about prevailing household water treatment (HWT) methods or their effectiveness. Boiling, the most common HWT method globally, is microbiologically effective, but household air pollution (HAP) from burning solid fuels causes cardiovascular and respiratory disease, and black carbon emissions exacerbate climate change. Boiled water is also easily re-contaminated. Our study was designed to identify the HWT methods used in rural China and to evaluate their effectiveness.
We used a geographically stratified cross-sectional design in rural Guangxi Province to collect survey data from 450 households in the summer of 2013. Household drinking water samples were collected and assayed for Thermotolerant Coliforms (TTC), and physicochemical analyses were conducted for village drinking water sources. In the winter of 2013–2104, we surveyed 120 additional households and used remote sensors to corroborate self-reported boiling data.
Our HWT prevalence estimates were: 27.1% boiling with electric kettles, 20.3% boiling with pots, 34.4% purchasing bottled water, and 18.2% drinking untreated water (for these analyses we treated bottled water as a HWT method). Households using electric kettles had the lowest concentrations of TTC (73% lower than households drinking untreated water). Multilevel mixed-effects regression analyses showed that electric kettles were associated with the largest Log10TTC reduction (-0.60, p<0.001), followed by bottled water (-0.45, p<0.001) and pots (-0.44, p<0.01). Compared to households drinking untreated water, electric kettle users also had the lowest risk of having TTC detected in their drinking water (risk ratio, RR = 0.49, 0.34–0.70, p<0.001), followed by bottled water users (RR = 0.70, 0.53–0.93, p<0.05) and households boiling with pots (RR = 0.74, 0.54–1.02, p = 0.06).
As far as we are aware, this is the first HWT-focused study in China, and the first to quantify the comparative advantage of boiling with electric kettles over pots. Our results suggest that electric kettles could be used to rapidly expand safe drinking water access and reduce HAP exposure in rural China.
Inconsistent use of household water treatment and safe storage (HWTS) systems reduces their potential health benefits. Ultraviolet (UV) disinfection is more convenient than some existing HWTS systems, but it does not provide post-treatment residual disinfectant, which could leave drinking water vulnerable to recontamination. In this paper, using as-treated analyses, we report on the field efficacy of a UV disinfection system at improving household drinking water quality in rural Mexico. We further assess the risk of post-treatment contamination from the UV system, and develop a process-based model to better understand household risk factors for recontamination. This study was part of a larger cluster-randomized stepped wedge trial, and the results complement previously published population-level results of the intervention on diarrheal prevalence and water quality. Based on the presence of Escherichia coli(proportion of households with ≥1 E. coli/100 mL), we estimated a risk difference of −28.0% (95% confidence interval (CI): −33.9%, −22.1%) when comparing intervention to control households; −38.6% (CI: −48.9%, −28.2%) when comparing post- and pre-intervention results; and −37.1% (CI: −45.2%, −28.9%) when comparing UV disinfected water to alternatives within the household. We found substantial increases in post-treatment E. coli contamination when comparing samples from the UV system effluent (5.0%) to samples taken from the storage container (21.1%) and drinking glasses (26.0%). We found that improved household infrastructure, additional extractions from the storage container, additional time from when the storage container was filled, and increased experience of the UV system operator were associated with reductions in post-treatment contamination. Our results suggest that the UV system is efficacious at improving household water quality when used as intended. Promoting safe storage habits is essential for an effective UV system dissemination. The drinking glass appears to represent a small but significant source of recontamination that is likely to impact all HWTS systems.
With this article, we develop the Drinking Water Disparities Framework to explain environmental injustice in the context of drinking water in the United States. The framework builds on the social epidemiology and environmental justice literatures, and is populated with 5 years of field data (2005–2010) from California’s San Joaquin Valley. We trace the mechanisms through which natural, built, and sociopolitical factors work through state, county, community, and household actors to constrain access to safe water and to financial resources for communities. These constraints and regulatory failures produce social disparities in exposure to drinking water contaminants. Water system and household coping capacities lead, at best, to partial protection against exposure. This composite burden explains the origins and persistence of social disparities in exposure to drinking water contaminants.
Urban water systems in Asia and Africa mostly provide intermittent rather than continuous water supplies; such systems compromise water quality and inconvenience the user. Starting in 2008, an upgrade to continuous (24/7) water services was provided for 10% of the twin cities of Hubli-Dharwad, India, through a process of privatisation and formalisation. The goals were to improve water quality, free consumers from collecting and storing water, and reduce non-revenue (i.e. unpaid for) water. Drawing on household surveys (n = 1986) conducted in 2010-2011 in the 24/7 zones, as well as on a range of interviews, we find that, even with ‘formal’ 24/7 water service, most consumers continue the supposedly ‘informal’ practices of in-home storage and water use without payment of bills. We argue that multiple unaccounted-for factors – including a history of distrust between the consumer and the utility, seemingly small infrastructural details, resistance to higher tariffs, and valuing convenience above water quality – have kept these informal practices embedded within the formalised delivery system. Our research contributes to understanding why formalisation may only partially supplant informal practices even when the formal system is functional and reliable.
In collaboration with a local non-profit organization, this study evaluated the expansion of a program that promoted and installed Mesita Azul, an ultraviolet-disinfection system designed to treat household drinking water in rural Mexico. We conducted a 15-month, cluster-randomized stepped wedge trial by randomizing the order in which 24 communities (444 households) received the intervention. We measured primary outcomes (water contamination and diarrhea) during seven household visits. The intervention increased the percentage of households with access to treated and safely stored drinking water (23–62%), and reduced the percentage of households with Escherichia coli contaminated drinking water (risk difference (RD): −19% [95% CI: −27%, −14%]). No significant reduction in diarrhea was observed (RD: −0.1% [95% CI: −1.1%, 0.9%]). We conclude that household water quality improvements measured in this study justify future promotion of the Mesita Azul, and that future studies to measure its health impact would be valuable if conducted in populations with higher diarrhea prevalence.
Few studies of environmental justice examine inequities in drinking water contamination. Those studies that have done so usually analyze either disparities in exposure/harm or inequitable implementation of environmental policies. The US EPA’s 2001 Revised Arsenic Rule, which tightened the drinking water standard for arsenic from 50 μg/L to 10 μg/L, offers an opportunity to analyze both aspects of environmental justice.
We hypothesized that Community Water Systems (CWSs) serving a higher proportion of minority residents or residents of lower socioeconomic status (SES) have higher drinking water arsenic levels and higher odds of non-compliance with the revised standard. Using water quality sampling data for arsenic and maximum contaminant level (MCL) violation data for 464 CWSs actively operating from 2005–2007 in California’s San Joaquin Valley we ran bivariate tests and linear regression models.
Higher home ownership rate was associated with lower arsenic levels (ß-coefficient= −0.27 μg As/L, 95% (CI), -0.5, -0.05). This relationship was stronger in smaller systems (ß-coefficient= −0.43, CI, -0.84, -0.03). CWSs with higher rates of homeownership had lower odds of receiving an MCL violation (OR, 0.33; 95% CI, 0.16, 0.67); those serving higher percentages of minorities had higher odds (OR, 2.6; 95% CI, 1.2, 5.4) of an MCL violation.
We found that higher arsenic levels and higher odds of receiving an MCL violation were most common in CWSs serving predominantly socio-economically disadvantaged communities. Our findings suggest that communities with greater proportions of low SES residents not only face disproportionate arsenic exposures, but unequal MCL compliance challenges.
Background: Research on drinking water in the United States has rarely examined disproportionate exposures to contaminants faced by low-income and minority communities. This study analyzes the relationship between nitrate concentrations in community water systems (CWSs) and the racial/ethnic and socioeconomic characteristics of customers.
Objectives: We hypothesized that CWSs in California’s San Joaquin Valley that serve a higher proportion of minority or residents of lower socioeconomic status have higher nitrate levels and that these disparities are greater among smaller drinking water systems.
Methods: We used water quality monitoring data sets (1999–2001) to estimate nitrate levels in CWSs, and source location and census block group data to estimate customer demographics. Our linear regression model included 327 CWSs and reported robust standard errors clustered at the CWS level. Our adjusted model controlled for demographics and water system characteristics and stratified by CWS size.
Results: Percent Latino was associated with a 0.04-mg nitrate-ion (NO3)/L increase in a CWS’s estimated NO3 concentration [95% confidence interval (CI), –0.08 to 0.16], and rate of home ownership was associated with a 0.16-mg NO3/L decrease (95% CI, –0.32 to 0.002). Among smaller systems, the percentage of Latinos and of homeownership was associated with an estimated increase of 0.44 mg NO3/L (95% CI, 0.03–0.84) and a decrease of 0.15 mg NO3/L (95% CI, –0.64 to 0.33), respectively.
Conclusions: Our findings suggest that in smaller water systems, CWSs serving larger percentages of Latinos and renters receive drinking water with higher nitrate levels. This suggests an environmental inequity in drinking water quality.
This paper shows how uncertainty undermines collaborative transboundary groundwater management. Focusing on the Santa Cruz Aquifer, spanning the United States–Mexico border between Arizona and Sonora, the authors describe the uncertainties within the aquifer using interviews and hydrologic studies. We discuss how data requirements and ambiguous interpretations exacerbate these uncertainties, and explain how each country’s water-management culture combines with this uncertainty to create contrasting views on groundwater availability and abstraction impacts. As a result, water managers in both countries predict different impacts from pumping and recharge, and each uses that information discursively to support unilateral policies rather than to promote collaborative management.
This article asks three connected questions: First, does the public view private and public utilities differently, and if so, does this affect attitudes to conservation? Second, do public and private utilities differ in their approaches to conservation? Finally, do differences in the approaches of the utilities, if any, relate to differences in public attitudes? We survey public attitudes in California toward (hypothetical but plausible) voluntary and mandated water conservation, as well as to price increases, during a recent period of shortage. We do this by interviewing households in three pairs of adjacent public and private utilities. We also survey managers of public and private urban water utilities to see if they differ in their approaches to conservation and to their customers. On the user side we do not find pronounced differences, though a minority of customers in all private companies would be more willing to conserve or pay higher prices under a public operator. No respondent in public utility said the reverse. Negative attitudes toward private operators were most pronounced in the pair marked by a controversial recent privatization and a price hike. Nonetheless, we find that California’s history of recurrent droughts and the visible role of the state in water supply and drought management undermine the distinction between public and private. Private utilities themselves work to underplay the distinction by stressing the collective ownership of the water source and the collective value of conservation. Overall, California’s public utilities appear more proactive and target-oriented in asking their customers to conserve than their private counterparts and the state continues to be important in legitimating and guiding conservation behavior, whether the utility is in public hands or private.
Large numbers of households in cities around the developing world do not have access to one of the most basic of human needs–a safe and reliable supply of drinking water. This paper uses the experience of India as a lens through which to view the problems of access to water in urban areas and the various options available for reform. Using two sets of data from the National Family Health Survey, as well as published and unpublished secondary sources, the paper presents the status of access to drinking water in urban India, the performance of India’s urban water sector compared to other Asian metropolitan regions and the reform efforts that are under way in several Indian cities. A review of these ongoing reforms illustrates some of the political economy challenges involved in reforming the water sector. Based on this analysis, we draw out directions for more effective research, data collection and policy reform. While each country faces unique challenges and opportunities, the scope and range of the Indian experience provides insights and caveats for many low-income nations.
Equity is central to community-based development efforts, but community perspectives on equity are seldom examined in the development literature. This study investigates how equity in a rainwater harvesting program is understood, and practiced in two Rajasthani communities. Drawing on Bourdieu’s concept of symbolic capital, we find that the symbolic capital accrued from contributing to the project is as central to community understandings of equity as the distribution of benefits from the project. We find that a continuing sense of community despite heterogeneity is itself a form of symbolic capital. Community-based valuations of equity thus enable a more catholic approach to costs, and benefits that broadens our knowledge both of equity, and of development.
The Contested Commons explores the theme of common environmental resources from the dual perspectives of economics and anthropology, with a focus on developing countries
That women play a central role in the provision, management, and safeguarding of water is one of the four internationally accepted principles of water management. This principle is especially important for the developing world where millions of women lack access to water for their basic needs. The objectives of this chapter are to summarize what is known about women with respect to water and about water with respect to women as well as to provide a sense of the current debates around these themes. A review of the literature suggests that the lack of gender-disaggregated data on the impacts of water policies, and underlying disagreements on how gender and development should be theorized, makes it difficult to reach robust conclusions on which policies can best assure poor women reliable access to water for their lives and livelihoods.
Economists are right when they point out that irrigation water prices are absurdly low compared with their scarcity value, and that at such low prices there is no incentive to conserve. However, it does not follow that raising water prices is the natural next step for developing countries such as India. There are two broad reasons for this conclusion: first, in the near to medium term, canal water prices probably cannot be raised to the point where they significantly affect water demand. The negative impact on farm revenues would be too drastic and the policy would not find broad public support. Second, low water prices are often not the main reason behind the farmers’ water-inefficient crop choices. Moreover, farm-level inefficiencies appear not to be the most significant ones on existing canals, nor are water prices the most significant prices driving irrigation demand. A better first step would be to enforce simple allocation rules – such as per-hectare rations – that would make the scarcity value of water immediately obvious. The analysis in this article is based on a study of one canal system in Maharashtra.
Illegal water diversions and lax rule-enforcement are common on irrigation canals. We present a mathematical programming model of a watercourse, calibrated to a canal in Maharashtra on which farmers voted to cooperate to control water theft. The model solution computes the crop choices and profits of individually optimizing farmers who differ in their location. It reveals the spatial distribution of gains and losses from cooperation. It illuminates why voluntary bargaining will rarely achieve an efficient water allocation. It also shows that landless laborers might well be against local cooperation, if the expropriated water nurtures labor-intensive crops.
In much of the world, fresh water is scarce and getting scarcer. Growing populations, increasing industrialization, and environmental concerns have all put pressure on the water consumed by agriculture. This paper addresses the economic consequences of a permanent reduction in canal water for irrigation. Using detailed cost-of-cultivation data from the Gediz Basin, Turkey, the key questions are: How can farmers best respond to reduced surface water supplies? How can the canal management authorities best distribute this limited water? And,can the demand for water be reduced through input and output price policy? These questions are answered with scenario comparisons under several water availability,crop pattern, price and investment assumptions, for the short and medium time horizons.
Keeping productivity high and water use low requirescoordination between farmers and the water managementauthorities. The analysis shows that, in this region,farmers should keep all their land irrigated at loweryield levels, rather than reduce their cropped areas.The canal managers should opt for a short irrigationseason, rather than an extended season with long dryintervals. Sensitivity analysis on a range of pricesindicates that crop, rather than water prices, affectthe efficiency of water use. The scenarios areevaluated using AGWAT, a spreadsheet-based farm-budgetprogram which is simple and widely applicable. Therange of policy choices considered establishes aframework of analysis for other, potentiallywater-short basins, beyond the Gediz or Turkey.