Global Environmental Health: Research Gaps and Barriers for Providing Sustainable Water, Sanitation, and Hygiene Services: Workshop Summary (2009)

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2 Global Water Services: Short- and Long-Range Views In many regions of the world, water services policies are fragmented. Many different agencies regulate the various aspects of water services, from those that protect the watersheds to those that regulate the water from the tap. The situa- tion may also differ if one lives in a community with a small water technology or a large urban one with a community water services system. Currently, there is a movement toward sustainable water services that incorporate technologi- cal, economic, and social aspects in a holistic manner. This holistic approach moves beyond simple access to water to also consider sanitation and hygiene. This chapter looks at the short- and long-term views for water needs both in the United States and abroad. The Native American Approach to Sustainable Water: The Seventh Generation Concept Cathy Abramson, Member Tribal Board of Sault Tribe of Chippewa Indians The preservation of the Great Lakes is a matter of great personal responsibil- ity; the lakes have raised countless generations, with the hope that its safe and natural environment will continue to do the same for future generations. A tribe known as the Anishinaabe lived in the Great Lakes region for centuries, and, as recently as a few decades ago, fished and drank water directly from the lakes. Now, industrial contamination from steel and paper mills has caused long-term damage; however, it was the solid waste and trash washing up on the shore of Sugar Island that led the community to create a coalition of local tribes and First Nation groups to fight for their environment and way of life. The way of the tribes has always been to treat the earth in terms of sustainability for seven future generations. Participants are urged to use many modalities, from traditional heal-  

 GLOBAL ENVIRONMENTAL HEALTH ing, to education, to science, to collaboration with others to push for a successful future for the seventh generation. Sustaining Progress for Clean and Safe Water Benjamin Grumbles, Assistant Administrator U.S. Environmental Protection Agency When it comes to water, Benjamin Franklin said it best, “we know the worth of water when the well runs dry.” As issues of water quality and security coalesce with issues of water quantity, changing landscapes, and weather patterns, the value of water comes into question. Although there are many reasons to believe the current patterns of unlimited, high-quality water are impossible to maintain for the future, water prices remain artificially low, with most of the costs and risks remaining invisible to consumers. Adjusting water pricing to reflect the true costs involved is a major need. This will promote water conservation and improvements and at the same time prevent future costs from escalating in such a way that the well runs so dry or dirty. Prior approaches by U.S. Environmental Protection Agency (EPA) focused primarily on water quality, without considering the limita- tions or implications of water quantity. This approach is changing, with the EPA hoping to educate stakeholders and the public about the symbiotic relationship between quantity and quality. Challenges to be addressed and potential solutions to ensure the future availability of quality water have been outlined. The Legacy of Clean Water: Gains in Health and the Environment The 35th anniversary of the Clean Water Act in 2007 pointed to significant public health advances. For example, of the 230 million people served by waste- water treatment facilities in the United States, more than 98.5 percent are served by systems that provide secondary treatment. Furthermore, an estimated 31 mil- lion pounds of pollutants have been kept from waterways in the past 35 years as a direct result of the Clean Water Act and its amendments; the EPA is expanding its efforts to include the impacts of nonpoint sources (water pollution from diffuse sources) as the next step in removing toxic contaminants from water sources. The Safe Water Drinking Act of 1974 has led to nearly universal access to high-quality drinking water. Regulatory standards have been almost entirely achieved through scientific investigation into adverse environmental health impacts, emerging con- taminants, and safe levels. In the past century, access to clean water has resulted in a three-quarters reduction in child mortality nearly half the total mortality reduc- tion in major cities (Cutler and Miller, 2005), and a water delivery system admired throughout the world. Despite these gains, many challenges remain that threaten past accomplishments, with the potential to make future threats for adequate and safe water insurmountable. 

GLOBAL WATER SERVICES  Challenges in Future Water Quality and Quantity Major challenges exist to preserve future water security and quality. These include maintenance of current infrastructure, levels of water “nutrients,” such as nitrogen and phosphorous, climate change impacts, such as sea level rise and storm intensity, and preservation of wetlands and coastal ecosystems. Many of these changes are compatible with the future needs and consequent actions of other sectors, such as energy, security, and urban planning. Whether these chal- lenges will be surmounted with an uninterrupted water supply depends on current implementation of changes in policy and regulation. Science has advanced to develop risk-based health standards under the Safe Drinking Water Act for 90 contaminants. The EPA has established a program to identify emerging and unregulated contaminants for future action. Furthermore, to achieve these goals, the EPA has implemented a multiple barrier approach to protect water from the source to the tap. In an ideal world, carrying out the multiple barrier approach would be easy, but the reality is that contaminations can come from a wide variety of sources. Technology is critical to the process of supplying safe drinking water. The same technology that allows for removal of contaminants also allows for detection of the remaining contaminants at lower concentrations. The challenge for those in the field is that there is considerable uncertainty about the potential effects of low-level contamination on public health. For the EPA, this is an area for further research. Water Infrastructure: Asset or Emerging Threat The United States has an approximately 1.6 million miles of water pipe- line, which allows approximately the entire nation to have direct access to high-quality and regulated drinking water. Yet many of these pipes are over 100 years old or far past their intended period of use; thus there is an increas- ing possibility of the presence of pathogens in the pipes that pose risks for vulnerable populations, such as elderly or immunocompromised people. The EPA is currently very concerned about the viability, maintenance, and replace- ment of the existing pipes, and it estimates the cost to address these problems over the next 20 years at $224 billion. Further strategic planning is needed to increase the capacity of or consolidate the 53,000 water systems in use, of which approximately half serve 500 or fewer people. The public is generally unaware of these risks, a situation that poses an obstacle in terms of funding and widespread support for needed renovations. The EPA is trying to be proactive with other federal, state, and local agencies, tribal governments, and nongovernmental organizations to help everyone under- stand the growing need for maintaining, sustaining, and increasing the capacity of these systems, both in the United States and abroad. At the same time, however, people are recognizing that a one-size-fits-all approach is not the right strategy. A 2002 EPA report focused on a strategy for achieving sustainability for water 

10 GLOBAL ENVIRONMENTAL HEALTH and wastewater infrastructure. As part of the improved management of these assets, the report embraced water efficiency, a watershed approach, and full-cost pricing—that is, spreading the cost over all users, with the heaviest users paying a greater share. Building in the cost will allow for maintenance of the system, pre- vent its reliance on federal taxpayer dollars, and encourage water conservation. Agricultural Impacts: Nitrogen, Phosphorous, and Sediment Large-scale impacts of nonpoint source pollution are also a source of concern. Agricultural impacts on water owing to nitrogen are analogous to carbon impacts on energy. Inadequate focus has been given to understanding the complete cycles of nitrogen and phosphorous throughout the environment. Globally, no doubt exists that significant effects on ecosystems and health will result. Recent reports on algae blooms, dead zones, and fish kills have raised concern that little is being done to regulate these nonpoint sources. Furthermore, sediment is associated with large-scale farming operations and loss of vegetation, which threatens to choke off much of the Mississippi River ecosystem. The National Research Council report (NRC, 2008) recommended the need for a more integrated and collabora- tive approach to focus on the nutrients and sediments in this watershed. It is a daunting task to remedy, as 31 states are part of the watershed and contribute to the nutrient loading. Although the focus of nitrification has been on point sources, recent efforts have concentrated on the nonpoint sources. To begin to address these issues, more regulatory, financial, scientific, and technological solutions are needed to address this problem as its short-term effects expand into larger impacts on biodiversity, water quality, and soil erosion. Climate Change: Not Just an Energy Problem As the impacts of climate change become well recognized, areas in addi- tion to energy production and transportation are being investigated to reduce the impact of greenhouse gases. The EPA and the National Water Program, the Clean Air Act, the Safe Drinking Water Act, the Ocean Dumping Act, and programs for the protection of coastlines and wetlands are being reviewed for modifica- tions to mitigate climate change. Particular areas of concern include sea level rise, increasing storm intensity, ocean chemistry, and invasive species. Increased efforts to protect coastal sites are needed as storms become more intense, result- ing in coastal erosion and sea level rise; wetlands preservation is an important step in protecting coastal areas. The incursion of storms and the loss of coast may cause drinking water supplies to be contaminated with salt water. The impact of changing weather on water will undoubtedly be considerable—the recent drought in Atlanta is one example of the potential for regional or national conflicts about water rights and access. 

GLOBAL WATER SERVICES 11 Paradoxically, climate change prevention through carbon sequestration may also risk contaminating drinking water; agencies are therefore creating guide- lines to protect drinking water from injected carbon. Changes in acidity or the composition of global oceans are also affecting the ecosystem and the diversity of life. In addition, the introduction of invasive species leads to destruction of natural habitat and disruptions or die-offs throughout the food chain; currently, over 180 invasive species exist from the Gulf of Mexico to the Great Lakes to San Francisco Bay—from protozoa to large fish. Although guidelines exist to regulate ballast water dumping, the EPA is currently considering adding further restrictions on the dumping of ballast water into U.S. waters. These additions to the Clean Water Act would unify and strengthen the U.S. policy that reduces the introduction of aquatic invasive species. Future Directions for U.S. Water Regulation Much progress has been made in the area of water and environmental pro- tection over the past few decades. The public has accepted the inseparable links between health, water, and regulatory and scientific environmental protection. Potential future threats still exist, such as problems in the water supply from per- sonal care products, pesticides, and pharmaceutical products. New projects will examine the endocrine-disrupting chemicals and biosolids present in the influent waste stream traveling into wastewater treatment. Several government agencies plan to combine their efforts at multiple stages, from introduction into the waste stream to exposure to health impacts, in addition to creating new guidelines on disposal and water treatment for products disrupting endocrine function. To reach a sustainable water infrastructure, implementation of full-cost pric- ing, such as charging users a fee based on water usage, would cover the cost of the water and its infrastructure construction and maintenance. Improvements in the sustainability of infrastructure and increased motivation by organizations and individuals to implement cost-saving efficiency measures would result. Cities should learn from prior mistakes and build on previous successes. For example, Pittsburgh’s sewer overflow problems stem from having 50 local authorities managing sewer projects in the EPA’s previous clean water efforts. Greening the watershed is key to efficiency and sustainability simultaneously and is an obvious priority in greening the water system. It protects the water supply and increases green space while protecting infrastructure. The future of water regulation and conservation is a collaborative, science-based approach that uses long-term out- comes with environmental health benefits. 

12 GLOBAL ENVIRONMENTAL HEALTH Creating the Sanitary City: Water, Wastewater, and Health in American Cities Martin Melosi, Director Center for Public History While Fredrick Law Olmsted, one of the builders of New York’s Central Park, called trees “the lung of the city,” sanitation services can be thought of as the circulatory system of the city. Sanitation services are important vehicles for revealing contemporary environmental thought as it relates to urban life and city development. A look at the history of Western civilization’s modern water and sewage systems from the 19th and 20th centuries provides insight into the policy issues facing water services today. Water services are linked inextricably to prevailing public health and ecological theories and practices of the time. These factors, in turn, determine the form and function of the implementation of water systems, and along with technology they can have far-reaching effects. In 1842, British reformer Edwin Chadwick called it time to bring “the serpent’s tail into the serpent’s mouth.” In essence, it was time for the water distri- bution systems that had been developing for decades to unite with sewer systems, which were virtually unheard of at that point. Although his ideas were blocked by plumbing interests, there is now a consensus that the distribution of water and the treatment and disposal of wastewater are inextricably linked. A growing push to more strongly link the engineering of these systems with environmental and health professional participation would benefit all three disciplines. A review of history shows how the sanitation system came to be, and how it closely correlates with cultural ideas and trends in health and medicine. Miasmas and Mechanics: Early 19th-Century Water Management The concept of sanitation was not recognized until several decades after the development of systems that transported water for local and domestic use. In 1800, 17 waterworks were operating in the United States, but no real city- wide sewer or wastewater facilities yet existed. The concept of sewage systems emerged in the 1830s with the development of the “sanitary idea” by Edwin Chadwick: filth, dirty conditions, and bad smells (miasmas), along with poverty, could lead to disease and health problems. This notion contrasted with previous ideas that health was determined by divine intervention. The miasmatic theory strongly influenced what became the first sanitary awakening in the United States between 1830 and 1880. In the United States prior to this time, residents of cities suffered from a range of diseases and a series of problems that could not be corrected by pub- lic action because the prevailing attitudes of the time were that private citizens were ultimately responsible for their water and waste. And in that environment, it became increasingly difficult for communities that were experiencing popula- 

GLOBAL WATER SERVICES 13 tion growth to address their health problems, because their ideas from a scientific point of view were absolutely incorrect. As a result, there was a growing need to move beyond individual responsibility for collecting water and disposing of wastewater toward an integrated system, since access to water was not only necessary for fire protection, but also a vital step in promoting public health in the community. The first example of this shift was seen in 1801 with the completion of Philadelphia’s public Fairmount Water Works, eventually drawing attention from all over the world as the first major water distribution system in the United States (Figure 2-1). The public became more accepting of the idea that disease could be combated through the import of clean water into the household. Owing to the availability of clean water, the use of unfiltered but fresh water for household purposes had a significant impact. This, however, was only a mechanistic or water transportation system, rather than an integrated drinking water delivery system with treatment technology. The design considered only the ease of transport and not the health and environmental issues of storage, filtration, and potential contamination. Thus the major problem was concerns of contamination at the water source and an inability to use much more than sensory means to test water quality. This was the method of design of the modern water and sanitary system—a design with virtually no understanding of bacteriology, filtration, water testing, environmental protection, or disease. In addition, no interventions or systems were developed to deal with sewage and waste because, unlike the intrinsic value and revenue source of water supplies, the same could not be said of sewer services. FIGURE 2‑1  The Centre Square Pumping Station in Philadelphia in 1801 (early stage of the Fairmount Water Works). Figure 2-1.eps SOURCE: Melosi, 2000. The Sanitary City: Urban Infrastructure in America from Colo- nial Times to the Present. Baltimore: bitmap image Johns Hopkins University Press. 

14 GLOBAL ENVIRONMENTAL HEALTH With no financial incentive, underground sewer systems did not begin until the late 19th century. As a result, most modern water and sanitation systems were developed independently in the United States and in much of the world, which put limitations on the creation of a unified water treatment system. One benefit of the shift to the miasmic view, however, was the concept of filtration; if filth could be removed from water, then it should be healthier to drink than unfiltered water. Filtration became available at the end of the 19th century and led to a rapid reduction in water-borne communicable disease and mortality. Even in their earliest iterations, water systems had consequences, which were at times economical, political, and environmental. Rural and less populated areas were exploited in order to divert water toward and waste away from large urban areas. For example, the aqueduct that fed Los Angeles destroyed much of the economy of Owens Valley, from where the water had been diverted early in the 20th century. Battles continue to this day between jurisdictions over resources and where to divert waste. Bacteriology: The Discovery of Germs and New Treatment Technology As the miasmatic theory lost its vitality and science advanced, the bacterio- logical age commenced by the turn of the century. For the first time, there was a definitive and physical cause of disease that was plausibly linked to water. Since the causes were controllable on a large scale, public health exploded as a field, while a regard for public welfare increased immensely. Public health measures and large-scale public works were seen as appropriate responses. The develop- ments of pharmaceuticals, immunization, and isolation for communicable dis- eases coincided with the bacteriological period, with health continuing to improve at an unparalleled pace. However, the work of engineers did not correlate with the work of public health or prevention medicine personnel, insofar as medicine increasingly focused on the individual and not the public at large. As a conse- quence, the sanitation and water systems became engineering issues, with public health officials assuming less of a role in the protection and treatment of water. Although there was some public health oversight in the planning of systems, a new institutional split developed that persists to this day. The bacteriological period saw the construction of major public works proj- ects for both water distribution and sanitation. They were supported financially by public agencies and were intended to be permanent; the permanent nature of theses projects led to future limitations and diminished adaptability. At the same time, filtration systems became more sophisticated, and treatment, such as chlorination, became more widespread. More attention was given to the problem of what to do with large volumes of water pumped into homes—what should its fate be? Septic tanks came into use at this time, along with other commu- nity-wide underground wastewater systems. There was also a strategic decision to move from a combined, single-pipe system to remove both wastewater and 

GLOBAL WATER SERVICES 15 TABLE 2-1  Public Versus Private Ownership of Waterworks, 1830–1924 Year # Works Public Private % Public % Private 1830 45 9 36 20 80 1840 65 23 42 35.4 64.6 1850 84 33 51 39.3 60.7 1860 137 57 80 41.7 58.3 1870 244 116 128 47.5 52.5 1880 599 293 306 48.9 51.1 1890 1879 806 1073 42.9 57.1 1896 3197a 1690 1490 52.9 46.6 1924 9850 6900 2950 70 30 aIncludes 17 undocumented systems. SOURCE: Melosi, 2000. The Sanitary City: Urban Infrastructure in America from Colonial Times to the Present. Baltimore: Johns Hopkins University Press. storm water toward a separate pipe for sanitary waste that came from homes and commercial establishments and another separate pipe for storm water. This was first implemented in Memphis, Tennessee, in 1880 after a series of infectious disease outbreaks. However, the system did not have an elaborated storm water apparatus, and the city still experienced flooding problems. Today, little debate exists in technical communities about the advantages of separate systems over combined systems. The problem of pollution in waterways was still largely unrecognized at the turn of the 20th century, with a number of wastewater plants dumping directly into streams and lakes regardless of water treatment. Many engineers argued that, when phenol or other chemicals were released into the water, they acted as a disinfection agent and therefore helped to eliminate disease-carrying bacteria. Furthermore, if there was a proper dilution formula, then the industrial pollution problem was remedied by dumping the chemical into a large and fast-moving watercourse. However, this merely displaced the problems from inside the city to the natural environment and more rural areas. Battles between upstream and downstream cities intensified. The concept of pollution was changing, however, as the dangers of chemical and industrial contamination were recognized and pol- lution was no longer considered a biological problem. Water treatment continued to improve, and large public systems dominated the field (Table 2-1). The New Ecology: Responding to New Technologies and Cultural Shifts When the United States moved into the modern era after World War I, large- scale challenges from industrialization and other sources of pollution occurred. Ultimately, however, a more ecological approach to sanitary service delivery led to greater attention to incorporating environmental concerns into new projects 

16 GLOBAL ENVIRONMENTAL HEALTH and approaches to water. As the population spread into larger and more suburban areas, the costs associated with water treatment increased and the benefits were less apparent than in initial projects. Financial pressures also limited resources for new projects. By the 1930s, there was an increasing role of the federal govern- ment, not in the development of local water systems, but rather in the testing of particular problems and providing support. The federal government stepped in to create standards for systems, impacting health standards and delivery technolo- gies. For the most part, however, water and wastewater systems in place today remain similar to their early incarnations. At the time, attitudes about medicine and health again shifted, as new medications and patient treatments became better understood. The strong focus on preventive medicine of the medical com- munity was rapidly replaced by an interest in medical treatment of the diseased individual, a trend that is only beginning to be reversed today. Again the role of public health in water and sanitation diminished and remains relatively low in industrialized nations. One of the disadvantages of a permanent, highly capitalized set of systems, such as in the United States and elsewhere, is their lack of resilience—the inabil- ity to address emerging problems. Following the postwar years, water pollution became complicated by nonpoint sources and groundwater contamination. These problems could not be addressed easily by means of large treatment plants located near a river. Such structures have proven to be essential in dealing with point pol- lution, but they could not necessarily address other forms of pollution. In summary, the water and sanitation systems developed in the 19th and 20th centuries were strongly influenced by social norms and prevailing scientific theory. Little was known about the etiology of disease, the presence of pathogens in water, filtration or treatment, or environmental protection—and those aspects were not incorporated into early systems. Later advances still failed to amend the limitations of future systems, becoming larger and less adaptable. Public health played a decreasing role over time, whereas maintenance and replacement of water systems became the bigger issue as original infrastructure passed the century mark. The future of water and sanitation requires a sustainable and adaptable system. The original design never regarded the need to address environmental contamination that was not from a point source. Historic trends are critical to the current situation, as the infrastructure and limitations owing to public health and cultural ideas of sanitation have shaped the current path, making it difficult to change direction. Nevertheless, optimism prevails as public opinion shifts back toward the value of preventive medicine and public health, the preservation of the environment, and investments in public infrastructure.