Access to safe water a growing concern around the globe: APHA Annual Meeting focuses on water.

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For Richard Rheingans, the world is divided into two groups: those who worry about water and those who don't. For people who do, access to water shapes daily routines and leads to health and safety risks for those who travel far for the most basic of human needs.

"Water is the single most important environmental cause of poor health at the global level, but its impact goes beyond the health impacts we usually talk about," said Rheingans, PhD, MA, who works within the Center for Global Safe Water at Emory University's Rollins School of Public Health. "For people without access (to safe water), it becomes the defining element of what their days are about ... the cost of attention, stress, distraction, safety in collecting water. It can define what your reality is."

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According to the World Health Organization, about 1.1 billion people lack access to a safe water source, more than 2.5 billion people go without adequate sanitation, and four out of every 10 people globally are already being affected by water scarcity--and WHO predicts the situation will probably worsen due to population growth, urban development, growing industrial water use and climate change. In fact, the United Nations predicts that by 2025, about two-thirds of the world population, or 5.5 billion people, will live in areas experiencing severe to moderate water stress, with communities in North Africa and Western and South Asia expected to bear the disproportionate burden. Such a water situation is tied to a host of deadly, but sadly preventable, diseases, especially for children, with diarrheal disease the second leading cause of death globally for children younger than 5.

Progress on the global Millennium Development Goals on water and sanitation, which call for halving the proportion of people without access to safe drinking water and sanitation by 2015, are mixed. According to WHO, progress toward the safe drinking water goal is "on track," but the "trend appears to be deteriorating." On sanitation, however, if current trends continue, the goal will be missed by more than half a billion people. Rheingans noted, though, that because the goal does not target universal access to safe water and taking into consideration population growth, even if the safe drinking water goal is met, the world will still be home to three-quarters of a billion people without access to an improved water source.

The water problem seems--and indeed has been--perfectly suited for typical public health interventions, particularly considering the field's foundations are rooted in the work of 1850s British physician John Snow, who famously traced a cholera epidemic to a public water pump. However, one of the "challenges of water and sanitation is precisely that the solution seems relatively simple, but the devil's in the details, there's no silver bullet," Rheingans, an APHA member, told The Nation's Health. Often the barrier is a nation's or community's lack of technical capacity to improve water access and quality, including building proper infrastructures, as well as a lack of acknowledgement that safe water is a public good, he said. For many people, though, getting clean, piped water remains a far-off reality, and so public health workers continue to work on creative ways to put the gift of safe water into individual hands.

Point-of-use water treatment--in other words, teaching people to treat water inside the household rather than waiting for expensive water treatment infrastructures to reach all those in need--is reaping positive outcomes and offering useful lessons in health marketing. APHA member Eric Mintz, MD, MPH, team leader for the Centers for Disease Control and Prevention's Diarrheal Diseases Epidemiology Team, experienced such a lesson first-hand in the early 1990s when he was working in Peru to help curb a cholera epidemic that was sweeping across Latin America. While residents were being advised to boil their water, the solution was not a sustainable fix--"people just weren't boiling all the water they needed," Mintz said. Mintz and colleagues began advising that residents use a few drops of common bleach, which contains the sanitizing component sodium hypochlorite, to clean their water, but it was a hard sell--bleach bottles are usually marked with a menacing skull-and-crossbones poison logo and expressly warn users not to ingest their contents.

Undeterred, Mintz, his team and partners developed a more diluted substance, packaged it in little bottles with friendly labels and marketed it under different names. The effort, first launched in Bolivia, was a success, and Mintz later helped bring the idea to communities in Africa as well. In a 2001 commentary published in APHA's American Journal of Public Health, Mintz and co-authors wrote that using sodium hypochlorite as a point-o-fuse treatment can reduce diarrheal illness by up to 85 percent, noting that "approaches that rely solely on time- and resource-intensive centralized solutions will leave hundreds of millions of people without access to safe water far into the foreseeable future."

"Having water that's safe, having clean hands and safe food, and a system to dispose of waste ... that trumps pretty much all of the pathogens that cause diarrheal disease," Mintz told The Nation's Health. "It's a rising tide that lifts all boats. But water scarcity is scary for me. I don't have something in a little bottle that can create more water."

While developing nations bear the unfortunate brunt of unsafe and scarce drinking water sources, the United States is certainly not immune to such problems. In 2003, water managers from 36 states told the Government Accountability Office that they expected shortages in the next 10 years, with drought conditions predicted to worsen the situation even more. Such a situation is particularly severe across the U.S. Southwest, according to the United States Global Change Research Program, which reported "water supplies (in the region) will become increasingly scarce, calling for trade-offs among competing uses and potentially leading to conflict." One state where situations of supply and quality are coming to a head is California, where earlier this year, in the midst of the state's third year of drought, Gov. Arnold Schwarzenegger called for increased water conservation activities and heightened water management techniques--also known as rationing.

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Beyond supply, the quality of California's drinking water, particularly its groundwater, is complicating the state's water alternatives, with some groundwater supplies so polluted that health department notices advising residents not to drink tap water have become commonplace, said Debbie Davis, legislative analyst with the California-based Environmental Justice Coalition for Water. The water issue is especially bad in rural, lower-income communities, where groundwater is often contaminated with agricultural chemicals, and residents lack the economic means to shift to bottled water. Even families who can afford bottled drinking water cannot afford enough for all of their needs, such as for washing their dishes or clothes, she said.

"There are communities here that literally don't have safe water for years at a time," Davis told The Nation's Health.

Such issues could soon worsen, as continuing drought and other climate change-driven weather events affecting surface water supplies mean more California residents may soon rely on groundwater, said Kathryn Phillips, MA, MPP, who works on California water issues for the Environmental Defense Fund. Just this July, the U.S. Geological Survey found that with continuing drought, California "groundwater supplies are under increasing pressure ... landowners are drilling more and deeper wells, and underground water levels are starting to drop once again." And, unfortunately, California currently has no statewide, comprehensive regulations for monitoring groundwater usage. Among the solutions, Phillips said, is promoting incentives and tools that support water conservation--"we have to have water laws that are appropriate to the 21st century and that emphasize efficiency," she said.

"We've got to start being sensitive to what the water reality is," Phillips said. "There's plenty of water to serve our needs right now, but only if we use it efficiently."

For more on water and public health, visit www. cdc.gov/healthy water or www.who.int/water_sanitation_health/en.

"Water and Public Health: The 21st Century Challenge" is the theme of APHA's 137th Annual Meeting, which runs Nov. 7-11 in Philadelphia.