Access to clean water and sanitation is a human right enshrined in international law. Although there has been progress in recent years, contaminated water and waterborne diseases remain major threats to public health — not only in low income countries, but also in wealthier nations such as the United States.

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On August 3, 2010, the General Assembly of the United Nations (UN) recognized access to clean water and sanitation as a human right alongside other fundamental rights, such as life and liberty, freedom of expression, and education.

According to the UN:

“Lack of access to safe, sufficient, and affordable water, sanitation, and hygiene facilities has a devastating effect on the health, dignity, and prosperity of billions of people and has significant consequences for the realization of other human rights.”

Untreated water contains pathogens such as the bacteria that cause diarrhea and the parasitic worms that cause schistosomiasis (snail fever).

These pathogens spread far and wide when untreated human waste contaminates groundwater and open water that people use for drinking, irrigation, bathing, and washing utensils.

In recent decades, there has been progress toward realizing the universal right to clean water and sanitation.

The World Health Organization (WHO) estimates that between 2000 and 2017, the proportion of the global population with access to safely managed drinking water increased from 61% to 71%.

During the same period, the proportion of the global population with access to safely managed sanitation services increased from 28% to 45%.

Despite this progress, however, dirty drinking water and contaminated soil continue to pose a threat to the health of huge numbers of people worldwide.

For example, the Centers for Disease Control and Prevention (CDC) report that among children under 5 years of age, there are 1.7 billion cases of diarrhea and 446,000 deaths from the condition every year globally.

The CDC also says that there are around 3 million cases of cholera, a waterborne infection, and 95,000 deaths from it annually.

As a result of poor sanitation, parasitic worms in contaminated soil infect hundreds of millions of people worldwide every year.

Around 785 million people, which equates to around 1 in 10 people worldwide, still lack access to drinking water facilities.

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A surprisingly large number of these people live in rich nations. In fact, one study found that between 2013 and 2017, around 1.1 million people in the U.S. had insecure water access.

Almost a half of these people lived in the 50 largest metropolitan areas of the U.S. This included 65,000 people in New York who did not have access to piped water.

Researchers at the University of Arizona in Tucson and King’s College London in the United Kingdom conducted this study. It appeared in the journal Proceedings of the National Academy of Sciences in 2020.

In the paper, the study authors say:

“Without tap water, how do you wash your hands? In a global health pandemic such as COVID-19, the difference between secure and insecure water access — starting with those 65,000 unplumbed New Yorkers — is a matter of life and death.”

The study revealed that households without running water were more likely to include people of color, to live in mobile homes or rented accommodation, and to spend a higher proportion of their income on housing costs.

“We offer clear evidence that gaps in urban water access are neither random nor accidental but underpinned by precarious housing conditions and systemic social and racialized inequality,” the study authors conclude.

They suggest that their numbers almost certainly underestimate the scale of the problem, as the U.S. Census Bureau tends to undercount people in rented accommodation, people without homes, and people of color.

They point out, for example, that people without homes often face great difficulty accessing clean water and toilet facilities and that their numbers are currently growing in U.S. cities.

Another study confirmed that, although access to water and sanitation is supposedly universal in towns and cities across the U.S., official figures do not account for people without homes or those in substandard housing.

When the researchers took these factors into account, they found that at least 630,000 people did not have access to a flush toilet and that a further 300,000 relied on shared sanitation.

Scientists at the Georgia Institute of Technology in Atlanta conducted this study. It appeared in the American Journal of Public Health in 2020.

Although the percentage of people without basic sanitation services is low in the U.S., the study authors write, the absolute number is large for “a high income country where resources exist to address the issue.”

They note that people living in rented accommodation may have running water and a flush toilet, but when these facilities break, landlords might take weeks or months to organize repairs.

Both the above studies conclude that introducing measures to ensure affordable and adequate housing is the most effective way to improve access to water and sanitation in U.S. towns and cities.

In 2019, a major report by two nonprofit organizations — the US Water Alliance and Dig Deep — proposed a plan of action to tackle what it called “America’s hidden water crisis.”

The report, Closing the Water Gap in the United States, estimates that more than 2 million people in the U.S. do not have access to safe drinking water and sanitation.

However, it reiterates that the U.S. does not collect comprehensive data on water poverty. This has made it particularly difficult to assess the scale of the problem for those who are worst affected: low income communities and communities of color.

The report cites evidence that Native American households, for instance, are 19 times more likely than white households to have inadequate plumbing.

Also, African American and Latinx households appear to be nearly twice as likely to face this challenge as white households.

The report’s authors assert that the problem is not isolated dwellings living “off the grid” but entire communities that lack access to clean water and safe sanitation.

They provide examples from six communities, from California to Puerto Rico, to highlight how widespread and deep rooted the problems are.

In the report, they write:

“On the Navajo Nation in the Southwest, families drive for hours to haul barrels of water to meet their basic needs. In West Virginia, they drink from polluted streams. In Alabama, parents warn their children not to play outside because their yards are flooded with sewage. Families living in Texas border towns worry because there is no running water to fight fires.”

The report concludes that in rural communities, in contrast with towns and cities, the root cause of water poverty is isolation from municipal water services.

In urban areas, utility providers tend to cover the installation and maintenance costs of water and sewer lines. However, for communities that are too far from these municipal systems, individual households may be responsible for installing a private well and septic system, often with minimal technical and financial support.

Among their proposed solutions, the report’s authors argue that community-led initiatives that involve the meaningful participation of residents are more likely to succeed because they foster collaboration among neighbors and a sense of ownership.

However, they also call for additional government grants, as well as operational and technical assistance where required.

On March 31, 2021, President Joe Biden published a program of infrastructure investment — the “American Jobs Plan” — which includes $111 billion of investments in water infrastructure.

Among its ambitions is the modernization of aging drinking water and wastewater systems by scaling up existing successful programs.

In addition, the plan includes calls for $56 billion in grants and loans to “states, tribes, territories, and disadvantaged communities.”

Medical News Today asked George McGraw, the chief executive officer of Dig Deep, how optimistic he was that the new investments would address the concerns raised in the Dig Deep and US Water Alliance report.

“Given the scope of the problem with more than 2,200,000 Americans living without basic access to safe drinking water and sanitation,” he said, “it is impossible that the problem will be solved overnight.”

However, he also said that he was encouraged by the investments that Congress and the Biden Administration were making to tackle the problems.

He added that the “number one thing” that Congress and the Administration can do to help marginalized communities such as Native Americans is significantly increase the level of annual federal funding targeted at tribes and other impacted communities.

However, he emphasized that the funds should be made available as grants rather than loans.

Furthermore, local government, utilities, nonprofits, and community groups should be allowed to use the money as they see fit, he said, “for things like decentralized systems or operations and maintenance costs in places that systems cannot financially support themselves.”

Looking to the future, many U.S. individuals are going to have to dig deeper — quite literally.

A study led by the U.S. Forest Service predicts that by the end of the 21st century, climate change and population growth will present serious challenges to water supply in some regions of the U.S.

Declines in rainfall, say the authors, will rule out any hope of increasing reservoir storage capacity.

Among the few remaining options to cope with severe shortages will be to increase groundwater extraction — in other words, dig deeper wells — and pump more water out of rivers, with all the environmental costs that this will entail.

Of course, much of the rest of the world will be facing similar challenges from a warming climate and increasing populations.

It is hard to escape the conclusion that, in the coming decades, the human right to water and sanitation may seem an increasingly distant dream for some of the world’s most socially and economically deprived communities.