Deepak Palakshapa became a pediatrician to give poor children access to good medical care. During his residency, however, the now associate professor at Wake Forest University School of Medicine in Winston-Salem was shocked to discover that the patient, who was taking care of two grandchildren, had no food. “Our clinic had set up one of these food drive boxes, and at the end of the visit she asked if she could take one of the boxes because she had no food for the holidays,” he recalls.
Thirteen years later, the team at the Palakshappa clinic asks each patient two simple questions to determine whether they will run out of food in a given month. But there are some important questions they don’t ask: Do you drink tap water? Is it drinkable and enough? Can you cook with it and use it to mix baby formula with cereal? Such questions could reveal some of the millions of Americans who experience water scarcity, a condition directly related to food scarcity.
No health care water insecurity test. The problem isn’t even on the radar of most public health professionals, although recent water disasters in Flint, Michigan and Jackson, Mississippi are beginning to change that. Clinicians who are Being aware of water insecurity “thinks, ‘If I test it, what am I going to do with it?'” Palakshapa says, noting the lack of resources to mitigate it.
Researchers know that water security is not limited to one region or population. But “we don’t know how big of a problem it is,” says Sera Yang, an associate professor of anthropology and health at Northwestern University. “And it’s going to continue to bite us in the ass because we don’t measure these things right.” Public health researchers talk about food and nutrition, while water researchers are relegated to infrastructure circles, and rarely do the two worlds overlap. Young says, “We need to build a bridge between these two disciplines.”
Most estimates put 2.2 million people in the US at risk of water shortages. Asher Rosinger, director of the Water, Health and Nutrition Laboratory at Pennsylvania State University, says this is likely a “huge” undercount, and the actual number could be closer to 60 million. There are no official estimates of combined food and water insecurity, making it difficult to understand the scale of the problem, let alone propose solutions.
“We measure water by the number of cubic meters and distribute it over the land,” says Northwestern’s Young. “Or we measure infrastructure, like, ‘Where do you get your drinking water from?’ Is it from the faucet? Or from a well? Is it from a borehole? But you can think of 99 scenarios where you have a faucet, but you can’t pay for the water to flow, or you don’t trust the water that comes out of it, or the infrastructure upstream of the faucet has collapsed. There are many reasons why measuring physical accessibility or infrastructure provides little insight into what the real problem is.
Young says the only way to truly understand water insecurity is to consider the human experience, which doctors have learned to do with food availability.
Accurate data is essential to prevent the water gap because lack of food increases the probability water insecurity. In a study published last July Journal of the Academy of Nutrition and Dietetics, Young, Rosinger, and a third coauthor tracked the tap water avoidance of more than 31,000 US residents over 13 years. They found that people who didn’t drink tap water were 21 percent more likely to be malnourished than those who didn’t. The researchers concluded that “efforts to reduce food insecurity must simultaneously address water security issues, including the availability and quality of tap water.
As with hunger, there are myriad reasons why a person may experience water scarcity—some financial, some structural, and others related to quality and access. Still others are short-term complications caused by disaster or local government failure.
You might think that access to plenty of drinking water is a basic human right. Legally, this is not the case in the US (although California has tried to make it so). However, many Americans spend more than 12 percent of their income on water and sewer services. Others have lead pipes that contaminate tap water (Newark); whether bacteria seeps into wells (Iowa); or sewage entering pipes during a storm (Milwaukee); or nitrates running off agricultural fields (Las Vegas). A storm can knock out the electricity that pumps the water (Puerto Rico) or the pump itself (Jackson). The people of the Navajo Nation lack basic water infrastructure. Then there are regions where aquifers are drying up, such as California’s Central Valley.
Water poverty has a lot to do with health beyond the primary need to drink a couple of liters a day. Perhaps most conclusively, research shows that children exposed to lead can suffer developmental delays and brain damage. Rosinger also found that people who avoid tap water are more likely to drink sugar-sweetened beverages (SSBs, in public health parlance). This alternative increases their risk of obesity, diabetes and other diet-related diseases, which have the most lasting consequences for children.
SSB is one of the few problems that public health researchers track that combines both food and water scarcity. Christina Hecht, senior policy advisor at the University of California’s Nutrition Policy Institute, helped found the National Drinking Water Alliance in 2015, whose mission is to improve access to drinking water and educate people about the importance of drinking water instead of sugary drinks. “We debated whether we should prioritize tap water safety, but in 2015 we really didn’t think it was a big issue,” she says. “Then Flint happened.”
Flint is just one of many poor communities now recognized as having catastrophically unsafe water infrastructure. The city has a 29 percent food insecurity rate among black residents. In McDowell County, West Virginia, which will receive federal aid to pilot wastewater infrastructure improvements, nearly 32 percent of its residents (mostly white) live below the federal poverty line. Centuries-old pipes, in some cases made of wood, bring water so dirty that residents capture stream water and store it in tanks. Most requested item at your local food bank? Bottled water.
Consequences flow from here. A person who lacks water cannot cook food. Rosinger says, “If your faucet is dry, your water is turned off, or you’re just avoiding it because you think it’s dangerous, you’re more likely to go out to eat. And studies show that you consume more calories and lack variety in your diet. So it’s also food insecurity.
Spending money on bottled water, which Rosinger says is “many times more expensive than tap water,” can eat $100 out of a monthly grocery budget. For context, the maximum monthly SNAP benefits are $835 for a family of four. A mother insecure about water may pay for bottled water to mix infant formula or cereal; women who tend to breastfeed can skimp on their hydration.
Palakshappa’s colleague, Dr. Kimberly Montez, recently met with a malnourished mother from Latin America whose baby was failing to gain weight. She didn’t trust tap water enough to drink it, so she was under-hydrated, which made breastfeeding difficult. Instead, she turned to formula milk, but that too presented problems because she thought she had to buy expensive bottled water to make it, Montez says.
If researchers can understand why people avoid faucets, they may be better able to address fear and educate about the need for water, not soda.
Young says the water trust and SSB questions are a great start. “But don’t forget about cooking. People are afraid to boil pasta, so we should ask: do you drink your water? Do you cook with your own water? Do you bathe with your own water? And are you angry about the state of your water? There is some legislative interest in adding questions about water insecurity to the National Health and Nutrition Examination Survey, which collects data on things like diabetes prevalence and fruit and vegetable consumption. “If we want people to be healthy, we have to understand that it’s the result of many things, and water is usually not on that list,” she says.
Regarding how clinicians can help people who are identified as water insecure, some initiatives are being developed. SNAP recipients can already use benefits to buy bottled water, even though it comes from their broader food allotment. Nourish California, an anti-hunger nonprofit, conducted a pilot this year to see what happens when households without water receive additional SNAP dollars to cover half of their monthly water expenses. The results are still being analyzed. “We know we have to fix the welds and fix the pipes, but in the meantime, let’s not let people go hungry,” says Jared Kahl, the organization’s senior attorney.
The Environmental Protection Agency offers grants to help disadvantaged communities fund drinking water projects, test for lead and remediate schools. Some states, like New York, offer help with paying past-due water bills.
Meanwhile, Young and her colleagues developed the Water Insecurity Experiences (WISE) scales, which prompt researchers to ask questions about water availability, access, and reliability for home use. It is similar to the Food Insecurity Experience Scale, which asks about access to nutritious food. Young says WISE provides a common language for food and water security camps because they are based on common measures and indicators.
“The evidence is growing—and it makes sense—that water security is fundamental to food security, so ‘fixing’ water addresses the root cause of food insecurity,” Young says. “The great thing is that giving people a language to speak across the aisle can be a win-win.”
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