Deepak Palakshappa became a pediatrician to provide good medical care to poor children. While still in residency, the now associate professor at Wake Forest University School of Medicine in Winston-Salem was shocked to discover: that the patient caring for two young grandchildren was food insecure. “Our clinic had put out one of those food boxes, and at the end of the visit, he asked if he could have any of the canned food because he didn’t have any food for the holidays,” she recalled.
Thirteen years later, the team at Palakshappa’s clinic now asks each patient two simple questions to determine whether they will run out of food in a given month. But there are some critical questions they don’t ask. do you drink your tap water? Is it drinkable and plentiful? Can you cook food with it and use it to mix baby formula and cereal? Such questions may reveal some of the millions of Americans who are water insecure, a circumstance that is directly related to food insecurity.
No healthcare water insecurity checker. 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. Doctors who People who are aware of water insecurity “think. “If I check it, what am I going to do about it?” says Palakshappa, noting the lack 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 of a problem it is,” says Sera Young, an associate professor of anthropology and health at Northwestern University. “And it’s going to continue to bite us in the ass because we’re not measuring these things right.” Public health researchers talk about food and nutrition, while water researchers are locked into infrastructure, and rarely do the two worlds overlap. Yang says: “We need to build a bridge between those two disciplines.”
By most estimates, 2.2 million US residents are water insecure. Asher Rosinger, director of the Water, Health and Nutrition Laboratory at Pennsylvania State University, says this is likely a “huge” shortfall, and the true number may 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 the water in cubic meters and distribute it over the land,” says Northwestern’s Young. “Or we’re measuring infrastructure, which is like, where do you get your drinking water from? Is it from the faucet? Is it from a well? Is it a well? But you can imagine 99 scenarios where you have a faucet, but you can’t pay for the water to flow through it, or you don’t trust the water coming out of the faucet, or the infrastructure upstream of the faucet has broken down. There are many reasons why measuring physical access or infrastructure only allows you to see what the real problem is.”
The only way to truly understand water insecurity, Young says, is to consider people’s lived experiences, as doctors have learned to do with food access.
Accurate data is needed to close the water gap because food insecurity increases the likelihood water insecurity. In a study published last July Journal of the Academy of Nutrition and Dietetics, Young, Rosinger, and a third coauthor followed tap water avoidance among more than 31,000 US residents over a 13-year period. They found that people who didn’t drink their tap water were 21 percent more likely to be food insecure than those who did. “Efforts to alleviate food insecurity must simultaneously address issues of water insecurity, including access and quality of tap water,” the researchers concluded.
As with hunger, there are many reasons a person may be water insecure, some financial, some structural, and others related to quality and access. Still others are short-term problems caused by disaster or local government failure.
You might think that having plenty of drinking water is a basic human right. Legally, this is not the case in the US (though California took a stab at making it so). However, many Americans spend more than 12 percent of their income on water and sewer service. Others have lead pipes that contaminate tap water (Newark); or bacteria entering wells (Iowa); or sewage in pipes during storms (Milwaukee); or nitrates running off farm 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 do not have 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 few liters a day. Perhaps most consistently, research shows that children exposed to lead can have 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 the risk of obesity, diabetes and other diet-related diseases, which are the most long-term consequences for children.
SSBs are one of the few problems that public health researchers are tracking that combine both 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 the tap water was safe, but in 2015 we really didn’t think it was a big deal,” he says. “Then Flint happened.”
Flint is just one of a long line of high-poverty communities now known to have catastrophically unsafe water infrastructure. The city has a 29 percent food insecurity rate among its majority black population. In rural McDowell County, West Virginia, which will receive federal aid for pilot wastewater infrastructure improvements, nearly 32 percent of its (majority white) residents 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. The most requested item at the local food bank. Bottled water.
The implications follow from here. A person without water cannot prepare food. Rosinger says: “If your tap is dry, your water is shut off, or you’re just avoiding it because you think it’s dangerous, you’re more likely to go out to eat. And research shows you’re consuming more calories and lacking in dietary variety. So that’s food insecurity too.”
Spending money on bottled water, which Rosinger says is “significantly more expensive than tap water,” can eat $100 out of a monthly food budget. For context, maximum monthly SNAP benefits are $835 for a family of four. A water-insecure mother may pay for bottled water to mix baby formula or cereal; women who tend to breastfeed can save on their own hydration.
Palakshappa’s colleague, Dr. Kimberly Montes, recently met with a food-insecure mother from Latin America whose child was unable to gain weight. She didn’t really trust tap water to drink it, so she was underfed, which made breastfeeding difficult. She turned to formula instead, but that also caused problems because she thought she’d have to buy expensive bottled water to make it, Montes says.
If researchers can understand why people avoid their faucets, they can better address fears and inform the need for water instead of soda.
Young says the issues surrounding water trust and SSBs are a great start. “But don’t forget to cook. People are afraid to boil pasta, so we have to ask, are you drinking your water? Do you cook with your water? Do you bathe in your water? And you are angry because of your water condition? There is some legislative interest in requiring the National Health and Nutrition Examination Survey, which collects data on diabetes prevalence and fruit and vegetable consumption, to add questions on water insecurity. “If we want people to be healthy, we have to understand that it’s the result of many things, and water is generally not on that list,” he says.
As for how health workers can help people identified as water insecure, there are several initiatives. SNAP recipients can already use benefits to buy bottled water, though it comes from their broader food distribution. Nourish California, a hunger-fighting nonprofit, ran a pilot this year to see what happens when water-insecure households receive additional SNAP dollars to cover half of their monthly water costs. The results are still being analyzed. “We know we have to fix the welds and we have to fix the pipes, but at the same time, let’s not starve people,” said Jared Cole, the organization’s senior attorney.
The Environmental Protection Agency offers grants to help disadvantaged communities fund drinking water programs, test for lead and remediate schools. Some states, like New York, offer help to pay past-due water bills.
Meanwhile, Yang and colleagues created the Water Insecurity Experiences (WISE) scales, which prompt researchers to ask questions about the availability, accessibility, and reliability of water for household use. It is similar to the Food Insecurity Experience Scale, which asks about access to nutritious food. Yang says WISE provides a common language for food and water insecurity camps because they rely on common measures and indicators.
“The evidence is mounting, and it just makes sense that water security underpins food security, so when you ‘fix’ water, the main driver of food insecurity is addressed,” Young says. “Giving people a language to talk in the hallways, the beautiful thing is that this can win.”
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