Water and Disease: It's Not What You Think

He asked the seminar a second time, “What is the most significant problem that Alaskan communities without piped water face? I’ll give you a hint – it does not have anything to do with diarrheal disease.”


I was stumped. To me, water quality issues always had the same outcome – more trips to the bathroom. Sure, I realized that collecting water in many communities resulted in long trips that affected education, childcare, etc., but I always thought the result of drinking poor quality water always related to some variant of diarrheal disease. After a few meager attempts from the crowd, with no one in the room guessing the answer, the room was silent. No eager hand to be found, I assumed everyone had the same confusion as me.


An uneasy pause followed. Exasperated, the lecturer exclaimed “respiratory illness!” Provided with the answer, my puzzlement didn’t abate. What in the world did water have to do with getting a cold? After an explanation from the lecture and further investigation, I found the issue to be quite complicated. As always, the story with water quality is often far more complex and nuanced than it originally appears.


According to the literature, regions in Alaska with a lower proportion of home water services have higher hospitalization rates for influenza and pneumonia (1).  The question is: Why? It turns out the answer is not in the water itself, but what people do with the water. In communities without piped water, people do not have as many opportunities for hand washing and other hygiene-related practices. Studies suggest that the lack of hand washing leads to an increase in respiratory illness (2-5). Therefore, in communities without piped water there was a reduced ability for sanitary practices to be used and consequently, a proliferation of respiratory illness.


As it turns out, simply having potable water near a population center is not a panacea – myriad factors influence the impact of water on the health of a community. Providing clean water to many Alaskan Natives’ has undoubtedly saved lives, but the task of providing clean, convenient water in many communities is not finished. Studying and implementing water quality initiatives requires appreciating the diverse ways that we use water. It is evident that water has an immense impact on our and others’ lives across the world and thus, we must continually, creatively, and competently work towards providing convenient access to pure water for all.




1.     Hennessy TW, Ritter T, Holman RC, et al. The Relationship Between In-Home Water Service and the Risk of Respiratory Tract, Skin, and Gastrointestinal Tract Infections Among Rural Alaska Natives. American Journal of Public Health. 2008;98(11):2072-2078. doi:10.2105/ajph.2007.115618.

2.     Cairncross S, Valdmanis V. Water supply, sanitation and hygiene promotion. In: Jamison DT, Breman JG, Measham AR, et al., editors. , eds. Disease Control Priorities in Developing Countries 2nd ed.New York, NY: Oxford University Press; 2006:771–79

3.     Luby SP, Agboatwalla M, Feikin DR, et al. Effect of handwashing on child health: a                        randomised controlled trial. Lancet 2005;366:225–233 [PubMed]

4.     Ryan MA, Christian RS, Wohlrabe J. Handwashing and respiratory illness among young adults in military training. Am J Prev Med 2001;21:79–83 [PubMed]

5.     Fung IC, Cairncross S. Effectiveness of handwashing in preventing SARS: a review. Trop   Med Int Health 2006;11:1749–1758 [PubMed]



Together for Water, Together for More

“When I applied to the Pure Water Access Project Fellowship as a second semester freshman I truly had no idea what I was getting myself into. I had no idea about a lot of things at that point actually—how to do laundry, how to put sheets onto a small lofted bed successfully, or how to use a public bus. I had grown up in a small rural town in southwestern Ohio and The Ohio State University felt large, ominous and a hugely terrifying. So when I applied to the fellowship I was still searching for something. A few weeks later I nervously interviewed and days later received an acceptance email. I remember sitting at PWAP orientation on a Sunday morning, surrounded by the other new fellows and feeling incredibly out of my league and more clueless than ever before. I kept thinking how did I get in, I don’t know how to fix anything, I don’t even know the first thing about water interventions let alone data driven approaches, also where is Sri Lanka again?


I was astounded by the accomplishments of the other fellows and felt the imposter effect coming on strong. I was terrified that I would not be able to keep up, that I would fail. But this past year in PWAP has changed my perspective in many folds. I’ve gained insight into one of the most pressing issues facing our planet today, assisted in planning a benefit banquet, met incredible entrepreneurs and advocates, updated our website, helped to jumpstart the non-profit blog, improved my scientific writing and so much more.

The most paramount contribution however, is that this fellowship has given me confidence. In PWAP we are given problems, often very ambiguous and told to try to solve them to the best of our ability. This daunting task in my first year is now a welcomed challenge. And I’ve learned that we are capable. I think that’s one of the greatest things about this fellowship-- giving undergraduate students the opportunity to truly make a dent in the planet, proving to themselves that this is possible. It’s often difficult and yes, often I have to watch a YouTube tutorial or two but I’ve come to realize that I am capable of learning and contributing to making a difference.  


Confidence can be found in the success and failure. Through the feeling of failure and the glow of success I have begun to trust my own ability and to run towards uncertainty rather than away.”


Fellow Olivia Adkins


Water and Women: An Intersection of Water Accessibility and Feminism

With the rise of New Wave Feminism in the modern era, pictures of Betty Friedman or Beyoncé may flash through the minds of many when asked about gender equality. But for the thousands of women and girls in South Africa collectively, the journey to equality is even farther than most of us realize—the distance of walking to the moon and back 13 times. (1)


In most parts of the United States, water access is turning the faucet to the left. But to girls and children in Africa and Asia accessibility to water is on average a 3.7 mile walk away. (2)

Families need this water for cooking, cleaning, drinking and washing every single day. Women are disproportionally affected by the lack of water access in most rural communities because the duty of water collection typically fall to their shoulders as care givers. A basic life necessity for all members of a family is an immensely heavy burden to bear. 


On average daily, women and children globally spend 200 million hours collecting water. (3)

This is time not spent on income generating activities, attending school, caring for family member or pursuing their own goals and aspirations. And time is our most valuable resource as humanity.


World wide less than 1 in 3 people have proper access to a toilet. (4) And in many countries, women are not allowed to relieve themselves during the day due to cultural expectations and restrictions. They must wait for the darkness of night to maintain their privacy and dignity, a precedent resulting in infection and limitation. With merely 45% of schools in developing countries offering adequate sanitation facilities (5) going to a latrine or toilet facility at school is either impossible or indecent for young women. This factor often leads to many girls quitting school early when they reach puberty and require increased privacy. Statistically, one in every four girls does not complete primary school in comparison with one in seven boys (6). But when provided with clean water and a toilet facility, school enrollment rates for girls improve by over 15%-- especially if they no longer are forced to walk miles every day to fetch water (7). The availability of proper waste facilities allows girls the freedom to use restrooms with privacy and dignity. Without reasonable access to clean water and sanitations at home, in schools or workplaces women are sentenced to an eternal of lack of time and opportunity resulting in disease and dishonor. Without education or opportunity, the poor will continuously remain poor, the poorest of these are often women and children.


These statistics have an even larger economic consequence. For every dollar spent on sanitation and water in the US, there is a four dollar USD economic return8.. Research has proven that for every 10% increase in women’s literacy, a country’s economy can grow by 0.3% (9). The lack of women’s education and sanitation ripples out into a country’s GDP, affecting their international trade efficiency and strength and slowing economic growth in these developing nations from the inside out.

Women represent 40% of the global labor force, however in Sub-Saharan Africa 40 billion working hours (roughly a year’s worth of labor equating the entire workforce in the country of France) are given up every single year to water collection (10). While the correltion between water access and betterment of humanity come in no shortage, the international urgency on this important issue is lacking.


If it was an easy or quick problem to solve, we probably already would have. The lack of funding, engineering complications, remote location, global prioritization and political red tape is overwhelming. But there is truly hope for change. Thousands of organizations, NGOs and social enterprise companies are making waves-- no pun intended, in the WaSH community. One of them being, the Pure Water Access Project. With a mindset of sustainability and equal access, issues such as these are our lifeblood. Change does not have to be large to be important. Pledge today as a woman, a mother, a daughter, a husband, a wife, a father, a believer in world in which the simple classification of gender is not so heavy a burden to bear.


1. Water For Women, UN Water.org http://www.unwater.org/fileadmin/user_upload/worldwaterday2015/docs/Water%20For%20Women.pdf

2. A. Roberts, 2008 http://bit.ly/194ysCr

3. UN Water Water for Women http://www.unwater.org/fileadmin/user_upload/worldwaterday2015/docs/Water%20For%20Women.pdf

4. Facts About Water and Sanitation, Water.org (http://water.org/water-crisis/water-sanitation-facts/ )

5. Raising even more clean hands: Advancing health, learning and equity through WASH in schools. UNICEF 2012

6. World Bank, 2012/UNDP, 2009. http://bit.ly/1zSc2wW

7.  UN: http://bit.ly/1DWAQET Global costs and benefits of drinking-water supply and sanitation interventions to reach the MDG target and universal coverage.

8. WHO http://www.who.int/water_sanitation_health/publications/2012/globalcosts.pdf

9. UNICEF. "Water, Sanitation and Hygiene" http://www.unicef.org/media/media_45481.html

10. World Bank, 2012/UNDP, 2009.

Fellow Olivia Adkins

Aging Water Infrastructure and Waterborne Disease Outbreaks in the US

The evidence is unequivocal – infrastructure in the United States is aging faster than it is being replaced [1]. The deteriorating infrastructure includes water distribution systems, which provide the country with a constant supply of potable water. Water main breaks – particularly, the low-pressure events that are associated with them – have been associated with an increase in contamination in water systems and incidences of acute gastrointestinal disease [2-4]. This news is troubling, given that there are approximately 240,000 water main breaks in the US every year [5].

So how do these crises occur? Upon reaching the end of their useful life, the water distribution systems is more susceptible to losses of physical integrity, which leads to an increase in the number of breaks [6]. In their 2006 report on risk assessment and reduction for distribution systems, the Committee on Public Water Supply Distribution Systems of the National Research Council defined a loss of physical integrity as when the system no longer acts as a barrier that prevents external contamination from deteriorating the internal drinking water supply [7]. To contextualize the scope of the situation, it is important to note the current trends and state of water infrastructure in the United States. Due to a variance in construction styles, many pipes in the US are due for replacement in the upcoming years. In fact, the American Water Works Association estimates that the investments needed for buried drinking water total more than $1 trillion over the next 25 years [8]. More than just a looming economic burden, there has been already been a marked increase in water main breaks in certain regions of the US [6]. Clearly, aging water infrastructure in the US is a significant problem in economic terms – the rest of this report argues that the deterioration of our water systems also affects population health.

During 1971 to 2006, a total of 780 outbreaks associated with drinking water resulted in 577,094 cases of illness and 93 deaths [9]. Although the annual number of reported drinking water outbreaks decreased considerably after 1980, outbreaks continued to occur, with an increasing proportion of them attributable to our distribution systems. Although ample evidence of an aging water distribution system in the US and the prevalence of WBDO via distribution systems exists, it is important to elaborate how these two phenomena are related.  Water distribution is not a completely closed system; more than 10% of water is lost in many systems in the US, which may be attributable to breaks and leaks [10]. To scale the amount of water lost in water distribution systems in the US, the United States Geological Survey (USGS) estimated that 1.7 trillion gallons of water are lost yearly in these systems [6]. Part of the water loss is due to unpaid use, but much of the problem stems from the previously mentioned leaks and breaks, which are being exacerbated by the aging state of our nation’s infrastructure.

Central to the relationship between AWI and WBDO is that the deficiencies the physical integrity of the distribution system opens the possibility of microbiological contamination of the water from the external environment. If positive pressure is maintained, the possibility of contamination is low, but if a transient or low-pressure event occurs, the system is vulnerable to contamination [2-4]. Contamination via microbes surrounding distribution systems is a highly plausible scenario – Karim, Abbaszadegan, and Lechevallier found indicator microorganisms and enteric viruses in over 50% of their samples taken near water distribution systems [11]. Related to the prevalence of deficiencies in the water distribution system, Tinker et al. have found that in Atlanta, GA, water that spends more time in the distribution system is more likely to cause an AGI [12].

Often, in the US, we take the potability of our water for granted, without thinking of the considerable distances the water must travel to reach our homes safely. It is of utmost importance that future policymakers acknowledge the gravity of the situation, and that the proper investments are made to mitigate the effects of aging water infrastructure. In the end, the problems delineated in this post offer a larger lesson in water sustainability -- constant maintenance, community awareness, and sound political decisions are key factors in the provision of safe drinking water.  It is essential that we work towards providing this invaluable resource for not just the current population, but also for future generations as well.



1.        Engineers, A.S.o.C., Failure to Act: The Economic Impact of Current Investment Trends in Water and Wastewater Treatment Infrastructure. 2011: Boston, MA.



2.          Nygård, K., et al., Breaks and maintenance work in the water distribution systems and gastrointestinal illness: a cohort study. International Journal of Epidemiology, 2007. 36(4): p. 873-880.



3.          Ercumen, A., J.S. Gruber, and J.M. Colford, Jr., Water distribution system deficiencies and gastrointestinal illness: a systematic review and meta-analysis. Environmental Health Perspectives, 2014. 122(7): p. 651-60.



4.          Hunter, P.R., et al., Self-reported diarrhea in a control group: a strong association with reporting of low-pressure events in tap water. Clinical Infectious Diseases, 2005. 40(4): p. E32-4.



5.          Agency, U.E.P., Addressing the challenge through innovation. 2007.



6.          USEPA, Aging Infrastructure research Program: Addressing the Challenge through Innovation. 2007.



7.         (Council), N.N.R., Drinking Water Distribution Systems: Assessing and Reducing Risks. 2006, The National Academies Press: Washington, D.C.



8.        (AWWA), A.W.W.A., Buried No Longer: Confronting America's Water Infrastructure Challenge. 2011.



9.       Craun, G.F., et al., Causes of outbreaks associated with drinking water in the United States from 1971 to 2006. Clinical Microbiology Reviews, 2010. 23(3): p. 507-28.



10.        Kirmeyer, F., Martel, & Howie, Pathogen Intrusion Into the Distribution System. 2001, AWWA Research Foundation and the American Water Works Association: Bellevue, WA.



11.       Karim, M.R., M. Abbaszadegan, and M. Lechevallier, Potential for pathogen intrusion during pressure transients. Journal / American Water Works Association, 2003. 95(5): p. 134-146.



12.       Tinker, S.C., et al., Drinking water residence time in distribution networks and emergency department visits for gastrointestinal illness in Metro Atlanta, Georgia. Journal of Water & Health, 2009. 7(2): p. 332-43.

Fellow Alex Northrop

Flint MI

January of 2016, Flint, Michigan shocked the world. For 60 years, the U.S. had been known as a nation devoid of struggles with access to common resources like clean water, but within weeks Flint proved that to be false. The emphasis of the Clean Water Crisis has often centered upon the struggles that developing nations have had in promoting this resource to their citizens. Yet all the while, circumstances like those of Flint have gone unnoticed because the Clean Water Crisis has often emphasized looking beyond America for issues with water access. Identifying these shortcomings isn’t intended to serve as a slight to the work done to promote water access abroad, but instead is a way to highlight the areas for continued improvement and innovation within this industry. The signs indicating a clean water crisis were abundant in Flint, but people refused to look at them, because the dominant narrative regarding the Global Clean Water Crisis directed their attention elsewhere.


The circumstances leading to Flint’s clean water crisis mirror the story described in the film and novel, The Big Short. The story describes that in the time leading to the global economic recession of 2008, a few wall street executives and hedge fund managers began to look beyond the dominant narrative spread about the American economy’s strength. In accomplishing this, they identified what they thought to be obvious flaws in the structure of our economy, which then resulted in a major recession. In much the same way, Flint and communities in similarly depressed economic states across the U.S., have shown distinct signs of decline that would precipitate the circumstances leading to Clean Water Crises.


Flint was once a thriving city in the 1970s’, built on the back of GM’s presence in the area, with GM employing nearly 40% of the city’s population, and supporting almost half of the region’s economy. However, in the 1980s’, GM began to consolidate its business near its competitors in Detroit, resulting in divestments from its factories in Flint that crippled the area’s economy with thousands of jobs being cut. With few similar opportunities for employment available, many were left unemployed and impoverished. Flint has since steadily deteriorated into its current depressed state, with 41.5% of residents living under the poverty line, and 25% living on salaries of less than $15,000 a year.1 These circumstances have left Flint desperate to save money wherever it could. So when Flint’s city council discovered it could save $200 million over 25 years if it switched its primary water source from the Detroit Water and Sewage Department, to the Karegnondi Water Authority, they took the opportunity to overhaul the city’s water infrastructure. Until a new pipeline was built, Flint relied on using pipes from the 1960s’ to the Flint river to access water. No tests were conducted on whether the water of the Flint river would cause corrosion within outdated pipes, instead officials thought it better to “wait and see” what impact the water would have.2 The results of this have been well documented in the last year. The water from the Flint river indeed caused corrosion in the outdated water pipes the city chose to use, and a significant portion of the city was left with contaminated water coming from their pipes. Had these facts been better known beforehand, many would certainly be concerned that Flint was exposing itself to potentially crippling harm. However the question remains, why weren’t the circumstances that precipitated Flint’s water crisis better known?


Unfortunately, Flint isn’t alone in seeing its struggles be unnoticed by most. Other communities in America including areas outside Baton Rouge, Louisiana, Huntsville, Alabama, Fresno, California, and many more have dealt with unique issues in accessing clean water. The lack of attention these regions receive has been attributed to the racial dynamics of the areas. Flint, for example, is one of the few cities in the country with a majority African-American population, and the other regions noted above are areas with significant portions of their population from multiethnic backgrounds. Rep. Dan Kildee (D-Mich.) put it best when discussing with the Huffington Post, “‘There’s a philosophy of government that has been writing these places off — places like Flint get written off...And, to me, even though those people making those decisions might not see it this way, it’s hard for me to accept the fact that race is not the most significant factor.’” Kildee isn’t alone in promoting this sentiment, as many other legislators, including the likes of Hillary Clinton have expressed similar concerns.3  


The reality of injustice towards racial minorities has taken so long to come to light, and it’s exposing a broad system of injustice that has gone unnoticed for so long. When the “Black Lives Matter” movement gained momentum and raised awareness for the realities of police brutality in America, they weren’t highlighting a new epidemic, but were promoting awareness of a tragic reality that has gone unnoticed by media for so long. Similarly, Flint’s clean water crisis isn’t a new reality, as communities of color have historically been displaced to areas with poor environmental conditions and regulations, and have had their struggles with clean water access be forgotten and undocumented.3 The systems of injustice in the U.S. take on many forms, there may be other conditions we are still unaware of that plague communities of color, and it requires that we bring attention to them in order to work towards discovering their solutions.


As more is revealed about the poor circumstances of water access in communities like Flint, we will begin to unearth more information about the reality that other communities in similar economic positions are experiencing. However, there is a trend of disparities in attention and circumstance that has made this issue one that stretches beyond Flint. There is a pattern of abuse and neglect historically, a system of injustice that identifies how and why communities like Flint are written off by politicians. Exploring this system could provide the necessary context for realizing the reality of the Clean water crisis in America. Flint’s water crisis was one that could’ve been easily prevented, and it’s possible that other communities in the U.S. with similar economic and racial dynamics could find themselves in similarly preventable situations that could result in unfortunate crises. Exploring the cases of communities like Flint is a large part of what PWAP hopes to be a greater collective effort to work towards alleviating issues with pure water access domestically, while we continue to expand our work abroad.

  1. http://www.msnbc.com/interactives/geography-of-poverty/ne.html

  2. http://www.npr.org/sections/thetwo-way/2016/04/20/465545378/lead-laced-water-in-flint-a-step-by-step-look-at-the-makings-of-a-crisis

  3. http://www.huffingtonpost.com/entry/racist-roots-of-flints-water-crisis_us_56b12953e4b04f9b57d7b118


Fellow Ridhwan Sediqe


Water. We drink it. Shower in it. Flavor it. Swim in it. Spray our lawns with it. To many of us, H2O is a readily accessible utility, often taken for granted. For 738 million people worldwide, that is not the case. They do not have the luxury to drink it, to shower in it, to flavor it, to swim in it, let alone spray their lawn with it. 783 million. That's the number that a group a four undergraduates at The Ohio State University wanted to change.

As people say, change rarely comes easy. But what people won’t tell you is that you don’t have to be a multi-million dollar 50-year-old organization to do it. You can be an undergrad student who just moved into your freshman dorm to make waves in the world. The Pure Water Access Project founders were just that. Our beginnings are humble but our impact is anything but. Since 2010, we have participated in various sustainable clean water projects worldwide, changing hundreds of lives.

To us, water is not a guarantee, summoned like an item at a restaurant. Water means a young girl gets to go to school instead of traveling miles to the nearest well. Water means thousands of young children’s lives will not tragically end due to water borne illnesses and improper sanitation. Water means a village has more time to devote to growing food or earning an income, fighting the obscene poverty they were born into. Water means a woman can jumpstart her own business, taking control of her future. Water means hope. This simple mix of hydrogen and oxygen shapes our world, it lies at the foundation of all that we do as humans. Yet we still underestimate its power.

In a constantly adapting, ever-changing world, sustainability is the key to ensuring that our efforts are not fruitless. In a rapidly evolving world that may sometimes look bleak, we are optimistic. We have succeeded before and we will do it again. With the help of donors, partners, and global communities, Pure Water Access is more than an idea. It’s our Project.


Fellow Olivia Adkins