For Millions Without Clean Water, COVID Prevention Guidelines are Out of Hand

Dirty waterMore than 2 million Americans lack consistent access to clean water. In some communities, like Flint, MI, the municipal water supplies are so contaminated as to be unusable. Without clean water, the most basic COVID mitigation strategy--frequent handwashing--is out of reach. Frequent handwashing is essential for mitigating the COVID epidemic. But for millions who lack consistent access to clean water, this basic public health measure isn't as simple as it sounds.

For a majority of Americans, clean water is available at the flip of a tap in our homes, schools, and workplaces. We tend to take our public water systems for granted. Yet for many in the United States, finding water that's fit to drink, cook with, and bathe in is an everyday challenge.

A 2019 study conducted by the US Water Alliance showed that at least two million Americans live without access to running water, indoor plumbing, and safe sanitation. In partnership with researchers at Michigan State University and the nonprofit DigDeep, the group analyzed national census data on "complete plumbing," defined by the US Census as "hot and cold piped water, a bathtub or shower, and a flush toilet" in a home, to determine water accessibility.

A Hidden Crisis

The authors argued that gaps in federal data collection mean the actual number of Americans who lack regular access to clean water is likely far higher. That's because in some communities, people have full plumbing, but it delivers dirty, contaminated, largely unusable water.

In a coronavirus-stricken world, these findings beg an important question: How do people without running water and indoor plumbing follow those all-important hand-washing guidelines?

In all likelihood, they don't.

It should not come as a surprise that there is a big overlap between the populations most vulnerable to COVID and those hardest hit by our nation's hidden water crisis.

The US Water Alliance report found that communities of color are more likely to lack water access than white communities. This disparity is particularly extreme for Native Americans. Poverty is a common factor across the board. Lack of access to clean water is a problem in poor urban communities--with Flint, Michigan, being the most glaring example--and in low-income rural communities.

"These challenges are the result of historical and geographical factors that have left entire communities without adequate services," wrote US Water Alliance CEO Radhika Fox in a press release.

With regard to COVID, the CDC reported in April that racial and ethnic minority groups bear a disproportionately high burden of illness and deaths related to COVID-19. A studyRadhika FoxRadhika Fox, CEO, US Water Alliance in New York City identified that death rates among Black/African American individuals (92.3 deaths per 100,000 population) and Hispanic/Latino individuals (74.3 per 100,000) were substantially higher than in white (45.2) or Asian (34.5) groups.

The pandemic also poses unique challenges to indigenous Americans, who also show a disproportionately high number of COVID cases and deaths. Many tribal communities, like many Black and Latino communities, already suffer from high rates of chronic health conditions like diabetes, asthma, and heart disease, which are now known to worsen the virus's toll.

This is not to say that lack of access to clean water is a causal factor in COVID. But it is likely to raise risk on both the personal and community levels. The harsh reality is that people without access to clean water are less able to take even the most basic measures to protect themselves and mitigate transmission.

Dirty Water

COVID has exposed and exacerbated many longstanding health inequalities in American society. Among them is the dire state of basic infrastructure in many communities.

In 2014, the predominantly African American city of Flint, Michigan––one of the poorest cities in the country with a population of nearly 426,000––made national headlines when dangerously high levels of lead to were found circulating through the local municipal water system. This happened after the town's administrators opted to begin sourcing Flint's water supply from the Flint River, rather than from Lake Huron, but failed to implement proper anticorrosive measures.

Thousands of residents were exposed to lead in their drinking water for several years, putting an entire community––and particularly its children––at risk of severe long-term cognitive and behavioral health effects associated with lead poisoning.

Lead and rust are not the only contaminant found in Flint's water. Low chlorine levels in the water system were linked to the proliferation of Legionella pneumophila, a disease-causing pathogen that thrives in aqueous environments. An outbreak of Legionnaires' disease––a form pneumonia that Legionella bacteria cause––killed at least 12 and sickened another 87 people in Flint in 2014 and 2015.

Six years later, the problems have still not been rectified, and many Flint residents are without clean water in their homes.

Michaganders impacted by Flint's dirty water have what technically counts as "full plumbing" in their homes--so they would not count as "lacking access" in official tallies. But when a town's tap water is so contaminated that it runs brown from the faucet, do its residents truly have "complete" clean water access?

Toxic water problems aren't unique to Flint, nor to the state of Michigan.

Flint Pipes MinTang Kelsey Pieper SithsonianCross section of municipal water pipes from Flint, MI (Image by Min Tan & Kelsey Pieper, originally published in Smithsonian)Aging infrastructure, source water contamination, and the high financial cost of water system upgrades have all thwarted safe water delivery in many parts of the US. Significant water contamination problems have been identified in 43 of the 50 states. Among the cities with serious public water problems are Pittsburgh, PA, Brady, TX, and Milwaukee, WI.

In August 2019, the Environmental Protection Agency (EPA) acknowledged ongoing lead contamination in Newark, NJ's drinking water system. The EPA concluded that water filtration devices––which the City of Newark provided to residents after initially detecting lead in the water––were likely not "reliably effective" in reducing lead concentrations to safe levels. The Agency encouraged city officials to distribute "bottled water as soon as possible" to the people of Newark. "Residents should be advised...to use bottled water for drinking and cooking, until we can be assured of the reliable efficacy of filtration devices." 

A similar strategy was employedin Flint, where the state handed out millions of free water bottles to residents over a two-plus year period between 2016 and 2018. Many communities without reliable public water systems depend on bottled or imported water for all of their personal consumption, food preparation, and sanitizing needs.

But using bottled water to plug holes in a faulty public works system just causes other leaks downstream. Not only is packaged water far costlier than tap water, it's also a major contributor to plastic pollution. Bottled beverages generate a huge amount of plastic waste worldwide. Regions where clean water is unavailable are some of the biggest culprits. 

Plastics--and the compounds used to make them--can themselves be water contaminants.

A new survey from the Environmental Working Group (EWG) shows the wide prevalence of chemicals related to plastic production in the US drinking water supply. The EWG confirmed the presence of per- and polyfluoroalkyl substances (PFAS)––a broad group of potentially toxic fluorinated compounds––in the tap water or groundwater of nearly 1,500 US communities.

PFAS are found in a host of common household products including nonstick cookware, furniture, and clothing. They are also used in the manufaturing of plastics, insulation, rubber, and other materials.

According to EWG, PFAS––also called "forever chemicals" because they persist in the environment and in the human body indefinitely––are associated with several forms of cancer, thyroid disease, and weakened childhood immunity. As of March 2020, researchers had identified PFAS contamination in 1,477 locations spanning 49 US states. "The extent of American communities' confirmed contamination with...PFAS continues to grow at an alarming rate," the group cautioned. 

In the Southwest, old abandoned uranium mines on the Navajo Nation continue to contaminate local water sources. The Navajo Nation estimates that up to 30% of its population––approximately 54,000 people––do not have piped water in their homes and must instead haul it either from safe watering holes or unregulated sources like livestock wells or springs. Those without in-home plumbing facilities risk using or consuming uranium-contaminated water. Exposure to high levels of uranium or the radiation it emits can lead to serious health problems.

In an attempt to protect their health, some in the Navajo community avoid local water altogether. "People don't feel safe drinking their water, so they're drinking sugary beverages instead," said Zoe Roller, senior program manager at the US Water Alliance. On the Navajo Nation, high diabetes prevalence is linked in part to the fact that "in some places, it's easier to get a soda than it is to get clean water. It's also a food desert problem," she added. "Healthy food isn't available." 

An International Issue

Outside the US, water cleanliness and accessibility are huge public health concerns. According to the United Nations (UN), safe drinking water and hygienic sanitation facilities are "precondition[s] for health and for success in the fight against poverty, hunger, child deaths and gender inequality." But in many areas, even those baseline services don't yet exist. The UN reports that "billions of people still lack safe water, sanitation and handwashing facilities."

Young children are highly susceptible to illness and death from waterborne and sanitation-related illnesses like diarrheal diseases and malaria. The UN Children's Fund (UNICEF) reports that, 6,000 children die of water-related diseases every day.

One of the UN's 17 Sustainable Development Goals is to ensure the "availability and sustainable management of water and sanitation for all." In 2015, UN member nations adopted the 2030 Agenda for Sustainable Development, which included a pledge to reduce by 50% the number of people living without clean drinking water and basic sanitation. Despite some notable achievements over the last two decades, that remains a distant goal.

"Achieving universal access to even basic sanitation service by 2030 would require doubling the current annual rate of progress," the group predicts. "More efficient use and management of water are critical to addressing the growing demand for water, threats to water security and the increasing frequency and severity of droughts and floods resulting from climate change."

With billions of people washing their hands and cleaning their belongings more frequently since the COVID outbreak, the demand on the world's water supplies is increasing.

Climate Change Adds Pressure

Climate scientists have long warned that the world's existing water problems are likely to worsen as global temperatures continue to rise.

In 2018, NASA's Jet Propulsion Laboratory reported that of the 37 largest aquifers on Earth, 21 had already exceeded sustainability tipping points and showed signs of depletion. Of those, 13 were "considered significantly distressed, threatening regional water security and resilience." 

Crucial water reservoirs all over the world are now at risk. A 2019 National Geographic feature explored numerous water dilemmas currently confronting Australia. It's already one of the driest parts of the world––and it's getting hotter and drier. Several major Australian cities, including Perth, Adelaide, Sydney, and Brisbane, all experienced alarming water shortages during a recent drought. At one point, Melbourne's municipal water storage levels plummeted to a staggering 33%. In parts of Australia's arid interior, groundwater sources are being depleted more quickly than they can naturally replenish. Municipalities are actively refilling them with treated wastewater.

Similar techniques are in practice elsewhere in the world, including the US. In Florida, the city of Clearwater piloted an innovative groundwater replenishment project in 2014 through which reclaimed, purified wastewater was injected back into a local aquifer. The system's designers hope it will support the "increased sustainability of existing water resources through protecting them from saltwater intrusion from the Gulf of Mexico and Tampa Bay."

As some of our most important freshwater resources are drying up, the human population continues to grow, further increasing our demand for clean, drinkable water.

In major agricultural regions, water scarcity endangers the land's capacity for food production.

California––one of the top food-growing states and producer of more than a third of the country's vegetables and two-thirds of its fruits and nuts––has seen average temperature jumps and multiple severe droughts over the last decade.

Urban areas have their own climate-related water crises. Some of America's largest cities, like Los Angeles and Phoenix, were built in environments that do not contain natural water systems large enough to support their current populations. They rely heavily on water imported or diverted from other areas. Las Vegas derives nearly 90 percent of its water from the Colorado River.

Creative Solutions

As the coronavirus pandemic brings much of modern human life to a screeching halt, it has also provided an extraordinary opportuity for environmental healing. Air pollution Moses West AWGMoses West, a retired Army Special Forces Captain, stands beside his Atmospheric Water Generator--an energy-efficient device that draws clean, drinkable water out of the atmosphere. levels are dropping, ozone holes are healing, and cities usually cloaked in smog are suddenly offering views of clear blue skies and long-obscured distant mountain ranges.In some regions of the world, polluted rivers are running clean for the first time in decades.

But to sustain these improvements will require a massive collective global effort. 

In its water access report, the US Water Alliance outlined an ambitious plan to close the country's water gap. "Everyone has a role to play in making this plan a reality: water and wastewater utilities, policymakers, regulators, funders, the private sector, nonprofits, residents of communities who lack water access, and you," the group urged.

Around the world, individuals and organizations are rising to the challenge, developing creative solutions in their own communities.

In Texas, Moses West, a retired US Army Captain and founder of the Water Rescue Foundation, invented a homemade atmospheric water generator (AWG) that pulls in air from the environment to produce clean, drinkable water. He has since built several low-energy, low-cost AWG machines and deployed them to Flint, as well as hurrican-ravaged communities in Puerto Rico and other areas where residents cannot easily access clean water. 

Elsewhere in the world, inexpensive solar disinfection (SODIS) techniques are widely used to purify water. The simple process uses solar UV radiation to decontaminate water by inactivaing light-sensitive viruses, bacteria, and protozoa that cause common diarrheal diseases. SODIS users can purify water using transparent bottles placed in areas of direct sunlight, such as outdoor racks or on the roof of a building.

Health care professionals are well poised to help patients and communities dealing with water scarcity. It was a pediatrician, Dr. Mona Hanna-Attisha, who first exposed the water crisis in Flint. She began reviewing her patients' medical records after the city switched to its new water source in 2014 and noticed an alarming increase in the percentage of children with elevated lead levels.

A 2017 editor's letter in the AMA Journal of Ethics highlighted the need for clinicians to actively work towards ensuring patient access to clean water. The author, Maseray Kamara, called for "community-based research initiatives, expanding the medical school curriculum to prepare environmentally and water-quality conscious physicians, and seeking interdisciplinary collaborations among basic scientists, engineers, and public health experts" (AMA J Ethics. 2017; 19(10): 966-969).

Since most of us do have easy access to a seemingly unlimited supply of clean water, it is natural that medical professionals and public health officials assume that everyone can always drink, shower, or wash their hands whenever they want or need to do so. That assumption may sometimes be wrong. But out of fear of judgment or shame, some patients who have difficulty obtaining safe water may choose not to reveal the problem to their clinicians.

In a time when personal hygiene has potentially massive public ripple effects, that's an important thing to keep in mind.

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