Deepak Palakshappa became a pediatrician to give poor children access to good medical care. Still, back in his residency days, the now associate professor at Wake Forest University School of Medicine in Winston-Salem was shocked to find that a patient who was looking after two young grandchildren was food insecure. “Our clinic had set up one of those food drive boxes, and near the end of a visit, she asked if she could have any of the cans because she had no food for the holidays,” she recalls.
Thirteen years later, Palakshappa’s clinic team now asks each patient two simple questions to determine whether they will run out of food in a given month. But there are some crucial questions they don’t ask: Do you drink your tap water? Does he drink enough? Can you cook food with it, and use it to mix formula milk and baby cereal? Such questions could reveal some of the millions of Americans who are water insecure – a circumstance directly related to food insecurity.
There is no health care screener for water insecurity. The issue 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 aware of water insecurity “thinking, ‘If I screen for this, what am I going to do about it?'” Palakshappa said, noting the paucity of resources available to mitigate it.
Researchers know that water insecurity is not limited to one region or population. But “we don’t know how big a problem it is,” said Sera Young, an associate professor of anthropology and health at Northwestern University. “And it’s going to keep biting us in the ass, because we’re not measuring these things correctly.” Public health researchers talk about food and nutrition, while water researchers are siled in infrastructure circles, and it’s rare for the two worlds to overlap. Young said, “We need to build a bridge between those two disciplines.”
Most estimates put US water insecurity at 2.2 million residents. 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 scope of the problem, let alone propose solutions.
“We measure water by how many cubic meters there are and divide it across the land,” says Northwestern’s Young. “Or we measure infrastructure, which is like, ‘Where do you get your drinking water from? Is it from a tap? Is it from a well? Is it from a borehole?’ But you can imagine 99 scenarios where you have a tap but you can’t pay for water to flow through it, or you don’t trust the water that comes out of it, or the infrastructure upstream from the tap is gone is shit. There are many reasons why measuring physical or infrastructure availability gives you insight into the real problem.”
The only way to truly understand water insecurity, says Young, is to consider people’s lived experiences as clinicians have learned how to do with food access.
Accurate data is essential to closing the water gap because food insecurity increases the likelihood of water insecurity. In a study published last July in the Journal of the Academy of Nutrition and Dietetics, Young, Rosinger and a third co-author tracked 13 years’ worth of tap water avoidance among more than 31,000 US residents. They found that people who did not drink their tap water were also 21 per cent more likely to be food insecure than those who did. “Efforts to mitigate food insecurity should simultaneously address issues of water insecurity, including the availability and quality of tap water,” the researchers concluded.
As with hunger, there are many reasons a person might be water insecure – some financial, some structural, and others related to quality and access. Still others are short-term situations caused by disaster or local government failure.
You might think that access to plenty of drinking water is a basic human right. Legally, in the US, it is not (although California has taken a stab at doing so). Still, many Americans spend more than 12 percent of their income for water and sewer service. Others have lead pipes that contaminate tap water (Newark); or bacteria seeping into wells (Iowa); or sewage backup to pipes during storms (Milwaukee); or nitrates running off farm fields (Las Vegas). A storm can knock out the electricity that pumps water (Puerto Rico), or knock out the pump itself (Jackson). Residents of the Navajo Nation lack basic water infrastructure. Then there are regions where aquifers run dry, such as in California’s Central Valley.
Water poverty has a lot to do with health beyond the basic need to drink a couple of liters a day. Perhaps most consequentially, 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 terms). This alternative increases their risk for obesity, diabetes and other diet-related diseases, with the most long-term implications for children.
SSBs are one of the few issues that public health researchers track that combine food and water insecurity. Christina Hecht, senior policy advisor at the University of California’s Nutrition Policy Institute, helped found the National Drinking Water Alliance in 2015, with a mission to improve access to drinking water and educate people about the importance of drinking water instead of sugary drinks. “We discussed whether we needed to prioritize making sure tap water was safe, but in 2015, we didn’t really think that was a big problem,” he said. “Then Flint happened.”
Flint is one in a long line of high poverty communities now recognized for catastrophically unsafe water infrastructure. The city has a food insecurity rate of 29 percent among its majority-Black population. In rural McDowell County, West Virginia, which will receive federal aid to pilot wastewater infrastructure improvements, nearly 32 percent of its residents (majority white) live below the federal poverty line. Century-old pipes, which in some cases are made of wood, bring water so dirty that residents capture creek water and store it in tanks. The most requested item at a local food bank? Bottled water.
The results ripple from here. Someone who is insecure about water cannot prepare food. Rosinger says, “If your tap is dry, your water is shut off, or you’re avoiding it because you think it’s dangerous, you’re more likely to go out to eat And research shows that you eat more calories and lack dietary variety. So, it’s nutritional insecurity too.”
Spending money on bottled water, which Rosinger says is “orders of magnitude more expensive than tap water,” could eat up to $100 from a monthly grocery budget. For context, the maximum monthly SNAP benefits are $835 for a family of four. A mother who is insecure about water could pay for bottled water to mix formula milk or baby cereal; women who tend to breastfeed may neglect their own hydration.
Recently a colleague of Palakshappa’s, Dr. Kimberly Montez, with a food insecure Latin American mother whose baby was not gaining weight. She didn’t trust the tap water enough to drink, so she wasn’t hydrated enough, which made breastfeeding difficult. Instead, she turned to formula, but that also caused problems, because she thought she had to buy expensive bottled water to make it, Montez said.
If researchers can understand why people avoid their taps, they may better address fears and educate about the need for water over soda.
Young says questions about the water trust and SSBs are a great start. “But don’t forget about cooking food. People are afraid to boil pasta so we should be asking, Are you drinking your water? Do you cook with your water? Do you bathe with your water? And are you fed up with your water situation?” There is some legislative interest in requiring the National Health and Nutrition Examination Survey, which collects data on things like diabetes prevalence and fruit and vegetable consumption, to add questions about water insecurity. “If we want people to be healthy, we need to realize that is a product of many things and generally water is not on that list,” he said.
Regarding the question of how clinicians can assist people identified as water insecure, there are some initiatives in the works. SNAP recipients can already use benefits to buy bottled water, even though it comes out of their broader food allotment. Nourish California, an anti-hunger nonprofit, conducted a pilot this year to see what happens when water-insecure households receive additional SNAP money to cover half of their monthly water expenditures. The results are still being analyzed. “We know we have to fix the welds and we had to fix the pipes, but in the meantime, let’s not have people go hungry,” said Jared Call, senior advocate at the organization.
The Environmental Protection Agency offers grants to help disadvantaged communities fund drinking water projects, lead testing and school remediation. Some states, such as New York, offer assistance in paying late water bills.
Meanwhile, Young and her colleagues devised the Water Insecurity Experiences Scales (WISE), which encourage researchers to ask questions about water availability, access and reliability for domestic 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 the food and water insecurity camps, as they rely on common measures and indicators.
“Evidence is mounting – and it also makes sense – that water security underpins food security, so when you ‘fix’ water, one of the main drivers of food insecurity is addressed,” said Young. “By giving people the language to speak across the aisle, the beautiful thing is, this can be a win-win situation for everyone.”
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