The drinking water disparities framework: on the origins and persistence of inequities in exposure

Public drinking water contaminant estimates for birth cohorts in the Environmental Influences on Child Health Outcomes (ECHO) Cohort

BACKGROUND

The United States Environmental Protection Agency (USEPA) regulates over 80 contaminants in community water systems (CWS), including those relevant to infant health outcomes. Multi-cohort analyses of the association between measured prenatal public water contaminant concentrations and infant health outcomes are sparse in the US.

OBJECTIVE

Our objectives were to (1) develop Zip Code Tabulation Area (ZCTA)-level CWS contaminant concentrations for participants in the Environmental Influences on Child Health Outcomes (ECHO) Cohort and (2) evaluate regional, seasonal, and sociodemographic inequities in contaminant concentrations at the ZCTA-level. The ECHO Cohort harmonizes data from over 69 extant pregnancy and pediatric cohorts across the US.

METHODS

We used CWS estimates derived from the USEPA's Six-Year Review 3 (2006-2011) to develop population-weighted, average concentrations for 10 contaminants across 7640 ZCTAs relevant to the ECHO Cohort. We evaluated contaminant distributions, exceedances of regulatory thresholds, and geometric mean ratios (with corresponding percent changes) associated with ZCTA sociodemographic characteristics via spatial lag linear regression models.

RESULTS

We observed significant regional variability in contaminant concentrations across the US. ZCTAs were most likely to exceed the maximum contaminant level for arsenic (n = 100, 1.4%) and the health-protective threshold for total trihalomethanes (n = 3584, 64.0%). A 10% higher proportion of residents who were American Indian/Alaskan Native and Hispanic/Latino was associated with higher arsenic (11%, 95% CI: 7%, 15%; and 2%, 95% CI: 0%, 3%, respectively) and uranium (15%, 95% CI: 10%, 21%; and 9%, 95% CI: 6%, 12%, respectively) concentrations.

IMPACT

Nationwide epidemiologic analyses evaluating the association between US community water system contaminant concentration estimates and associated adverse birth outcomes in cohort studies are sparse because public water contaminant concentration estimates that can be readily linked to participant addresses are not available. We developed Zip Code Tabulation Area (ZCTA)-level CWS contaminant concentrations that can be linked to participants in the Environmental Influences on Child Health Outcomes (ECHO) Cohort and evaluated regional, seasonal, and sociodemographic inequities in contaminant concentrations for these ZCTAs. Future epidemiologic studies can leverage these CWS exposure estimates in the ECHO Cohort to evaluate associations with relevant infant outcomes.

Decomposition analysis to assess intervention strategies for reducing health-related exposure disparities in Michigan public drinking water systems

OBJECTIVE

Contamination in U.S. public drinking water systems (PWS) is estimated to cause millions of illnesses and billions of dollars in medical expenditures annually. Few prior studies have explored intervention strategies, including environmental enforcement, to reduce estimated health-related exposure disparities (exposure disparity) in PWS, which are driven partially by socioeconomic status (SES), racism, and PWS characteristics.

METHOD

This study used a longitudinal measurement method to estimate the annual health-related exposure level (health level) of each PWS in Michigan, based on data from the Enforcement and Compliance Online (ECHO) and U.S. Census Bureau databases. Using a decomposition model with four strategies, we analyzed how eliminating disparities in SES, proportion minority, environmental enforcement, and PWS characteristics across communities would affect adjusted exposure disparities.

RESULTS

This study found that adjusted race- and poverty-based exposure disparities have existed since the 1980s but might have decreased in the last one or two decades. PWS characteristics strongly impacted the crude and adjusted exposure disparity. Environmental enforcement, although less effective in minority-concentrated communities, reduced the adjusted race-based exposure disparity by 10%-20% in the 1980s, 8% in the 1990s, and 0.012% in the 2010s. Equalizing the poverty rate distribution reduced the adjusted race-based exposure disparity by 0.72% in the 1980s and 6.8% in the 2010s. However, equalizing racial and ethnic composition distribution increased the adjusted poverty-based exposure disparity in the 2000s.

CONCLUSION

These findings indicate that economically disadvantaged or minority-concentrated communities in Michigan disproportionately suffer from poorer PWS quality. Enhanced environmental enforcement, increased household income, PWS investment, and other actions are needed to address these exposure disparities effectively.

Examining inequality in aquatic ecosystem services: Evidence from large-scale monitoring programs

We hypothesize that aquatic ecosystem services are likely to be inequitably accessible and addressing this hypothesis requires systematic assessment at regional and national scales. We used existing data from large-scale aquatic monitoring programs (National Coastal Condition Assessment, National Lakes Assessment) to examine relationships between ecosystem condition, approximating a subset of cultural and provisioning services, and inequality (population below poverty level, minority population). We also assessed whether monitoring sites equitably represented the gradient of socioeconomic backgrounds. Several water quality indicators were associated with significantly different minority and low-income percentages; however, the effect size was generally small, with the exception of nitrogen condition status. Minority communities were somewhat under-represented when comparing the distribution of all census blocks to those in proximity to monitoring sites. Analyses were sensitive to the skewed distribution of monitoring sites with a low frequency of observations at the more socially vulnerable part of the gradient. We discuss implications of these findings for improving the representation of vulnerable communities in large-scale monitoring programs.

Drinking water source and exposure to regulated water contaminants in the California Teachers Study cohort

BACKGROUND

Pollutants including metals/metalloids, nitrate, disinfection byproducts, and volatile organic compounds contaminate federally regulated community water systems (CWS) and unregulated domestic wells across the United States. Exposures and associated health effects, particularly at levels below regulatory limits, are understudied.

OBJECTIVE

We described drinking water sources and exposures for the California Teachers Study (CTS), a prospective cohort of female California teachers and administrators.

METHODS

Participants' geocoded addresses at enrollment (1995-1996) were linked to CWS service area boundaries and monitoring data (N = 115,206, 92%); we computed average (1990-2015) concentrations of arsenic, uranium, nitrate, gross alpha (GA), five haloacetic acids (HAA5), total trihalomethanes (TTHM), trichloroethylene (TCE), and tetrachloroethylene (PCE). We used generalized linear regression to estimate geometric mean ratios of CWS exposures across demographic subgroups and neighborhood characteristics. Self-reported drinking water source and consumption at follow-up (2017-2019) were also described.

RESULTS

Medians (interquartile ranges) of average concentrations of all contaminants were below regulatory limits: arsenic: 1.03 (0.54,1.71) µg/L, uranium: 3.48 (1.01,6.18) µg/L, GA: 2.21 (1.32,3.67) pCi/L, nitrate: 0.54 (0.20,1.97) mg/L, HAA5: 8.67 (2.98,14.70) µg/L, and TTHM: 12.86 (4.58,21.95) µg/L. Among those who lived within a CWS boundary and self-reported drinking water information (2017-2019), approximately 74% self-reported their water source as municipal, 15% bottled, 2% private well, 4% other, and 5% did not know/missing. Spatially linked water source was largely consistent with self-reported source at follow-up (2017-2019). Relative to non-Hispanic white participants, average arsenic, uranium, GA, and nitrate concentrations were higher for Black, Hispanic and Native American participants. Relative to participants living in census block groups in the lowest socioeconomic status (SES) quartile, participants in higher SES quartiles had lower arsenic/uranium/GA/nitrate, and higher HAA5/TTHM. Non-metropolitan participants had higher arsenic/uranium/nitrate, and metropolitan participants had higher HAA5/TTHM.

IMPACT

Though average water contaminant levels were mostly below regulatory limits in this large cohort of California women, we observed heterogeneity in exposures across sociodemographic subgroups and neighborhood characteristics. These data will be used to support future assessments of drinking water exposures and disease risk.

PFAS-Contaminated Pesticides Applied near Public Supply Wells Disproportionately Impact Communities of Color in California

Contaminated drinking water from widespread environmental pollutants such as perfluoroalkyl and polyfluoroalkyl substances (PFAS) poses a rising threat to public health. PFAS monitoring in groundwater is limited and fails to consider pesticides found to contain PFAS as a potential contamination source. Given previous findings on the disproportionate exposure of communities of Color to both pesticides and PFAS, we investigated disparities in PFAS-contaminated pesticide applications in California based on community-level sociodemographic characteristics. We utilized statewide pesticide application data from the California Department of Pesticide Regulation and recently reported concentrations of PFAS chemicals detected in eight pesticide products to calculate the areal density of PFAS applied within 1 km of individual community water systems' (CWSs) supply wells. Spatial regression analyses suggest that statewide, CWSs that serve a greater proportion of Latinx and non-Latinx People of Color residents experience a greater areal density of PFAS applied and greater likelihood of PFAS application near their public supply wells. These results highlight agroecosystems as potentially important sources of PFAS in drinking water and identify areas that may be at risk of PFAS contamination and warrant additional PFAS monitoring and remediation.

Quantifying Disparities in Per- and Polyfluoroalkyl Substances (PFAS) Levels in Drinking Water from Overburdened Communities in New Jersey, 2019-2021

BACKGROUND

Policymakers have become increasingly concerned regarding the widespread exposure and toxicity of per- and polyfluoroalkyl substances (PFAS). While concerns exist about unequal distribution of PFAS contamination in drinking water, research is lacking.

OBJECTIVES

We assess the scope of PFAS contamination in drinking water in New Jersey (NJ), the first US state to develop regulatory levels for PFAS in drinking water. We test for inequities in PFAS concentrations by community sociodemographic characteristics.

METHODS

We use PFAS testing data for community water systems (CWS) (n = 491 ) from the NJ Department of Environmental Protection (NJDEP) from 2019 to 2021 and demographic data at the block group level from the US Census to estimate the demographics of the NJ population served by CWS. We use difference in means tests to determine whether CWSs serving "overburdened communities" (OBCs) have a statistically significant difference in likelihood of PFAS detections. OBCs are defined by the NJDEP to be census block groups in which: a) at least 35% of the households qualify as low-income, b) at least 40% of the residents identify as people of color, or c) at least 40% of the households have limited English proficiency. We calculate statewide summary statistics to approximate the relative proportions of sociodemographic groups that are served by CWSs with PFAS detections.

RESULTS

We find that 63% of all CWSs tested by NJDEP from 2019 to 2021 had PFAS detections in public drinking water, collectively serving 84% of NJ's population receiving water from CWSs. Additionally, CWSs serving OBCs had a statistically significant higher likelihood of PFAS detection and a higher likelihood of exposure above state MCLs. We also find that a larger proportion of people of color lived in CWS service areas with PFAS detections compared to the non-Hispanic white population.

DISCUSSION

These findings quantitatively identify disparities in PFAS contamination of drinking water by CWS service area and highlight the extent of PFAS drinking water contamination and the importance of PFAS remediation efforts for protecting environmental health and justice. https://doi.org/10.1289/EHP12787.

An economic evaluation of strategies to ensure safer drinking water in the homes of families with young children in select United States locations

Introduction

In the United States, safe, accessible drinking water is not equitable due to source water contamination, unreliable water treatment, or hazardous plumbing infrastructure. Drinking water free of lead, nitrates, and arsenic is vital for infant and young children's health.

Methods

Researchers conducted a study combining single-case study review methods and economic evaluation for 6 US policies or programs. Researchers used case-study findings, activity-based costing, publicly available US population data, and existing literature to create 5-year cost projections (2020-2024) for strategies to address lead, nitrates, or arsenic in drinking water from private wells or community water systems for families with low incomes and young children aged 0-5y. Researchers estimated the number of households reached and the costs by activity and payer of implementing each policy or program using case-specific geographic location and eligibility criteria.

Results

The total number of households reached varied from 295 to 135,000 depending on water source, population of focus, and geographic location. Focused strategies reached higher proportions of families with low incomes and young children. Community water system and state-wide strategies had the broadest reach. The total annual program cost per household that received information about their water quality ranged from $75 to $2,780. Of this cost, the portion paid by the household varied from $0.12 to $1,590, not including mitigation.

Conclusions

These findings can inform local decisions about policies and programs in communities seeking to increase awareness and access to safer drinking water, particularly in homes of families with low incomes and young children.

Contribution of arsenic and uranium in private wells and community water systems to urinary biomarkers in US adults: The Strong Heart Study and the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Chronic exposure to inorganic arsenic (As) and uranium (U) in the United States (US) occurs from unregulated private wells and federally regulated community water systems (CWSs). The contribution of water to total exposure is assumed to be low when water As and U concentrations are low.

OBJECTIVE

We examined the contribution of water As and U to urinary biomarkers in the Strong Heart Family Study (SHFS), a prospective study of American Indian communities, and the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective study of racially/ethnically diverse urban U.S. communities.

METHODS

We assigned residential zip code-level estimates in CWSs (µg/L) and private wells (90th percentile probability of As >10 µg/L) to up to 1485 and 6722 participants with dietary information and urinary biomarkers in the SHFS (2001-2003) and MESA (2000-2002; 2010-2011), respectively. Urine As was estimated as the sum of inorganic and methylated species, and urine U was total uranium. We used linear mixed-effects models to account for participant clustering and removed the effect of dietary sources via regression adjustment.

RESULTS

The median (interquartile range) urine As was 5.32 (3.29, 8.53) and 6.32 (3.34, 12.48) µg/L for SHFS and MESA, respectively, and urine U was 0.037 (0.014, 0.071) and 0.007 (0.003, 0.018) µg/L. In a meta-analysis across both studies, urine As was 11% (95% CI: 3, 20%) higher and urine U was 35% (5, 73%) higher per twofold higher CWS As and U, respectively. In the SHFS, zip-code level factors such as private well and CWS As contributed 46% of variation in urine As, while in MESA, zip-code level factors, e.g., CWS As and U, contribute 30 and 49% of variation in urine As and U, respectively.

IMPACT STATEMENT

We found that water from unregulated private wells and regulated CWSs is a major contributor to urinary As and U (an estimated measure of internal dose) in both rural, American Indian populations and urban, racially/ethnically diverse populations nationwide, even at levels below the current regulatory standard. Our findings indicate that additional drinking water interventions, regulations, and policies can have a major impact on reducing total exposures to As and U, which are linked to adverse health effects even at low levels.

Regional and racial/ethnic inequalities in public drinking water fluoride concentrations across the US

BACKGROUND

Although the US Centers for Disease Control and Prevention (CDC) considers fluoridation of community water systems (CWSs) to be a major public health achievement responsible for reducing dental disease, recent epidemiologic evidence suggests that chronic exposure to population-relevant levels of fluoride may also be associated with adverse child neurodevelopmental outcomes. To our knowledge, a nationally representative database of CWS fluoride concentration estimates that can be readily linked to US epidemiologic cohorts for further study is not publicly available. Our objectives were to evaluate broad regional and sociodemographic inequalities in CWS fluoride concentrations across the US, and to determine if county-level racial/ethnic composition was associated with county-level CWS fluoride.

METHODS

We generated CWS-level (N = 32,495) and population weighted county-level (N = 2152) fluoride concentration estimates using over 250,000 routine compliance monitoring records collected from the US Environmental Protection Agency's (EPA) Third Six Year Review (2006-2011). We compared CWS-level fluoride distributions across subgroups including region, population size served, and county sociodemographic characteristics. In county-level spatial error models, we also evaluated geometric mean ratios (GMRs) of CWS fluoride per 10% higher proportion of residents belonging to a given racial/ethnic subgroup.

RESULTS

4.5% of CWSs (serving >2.9 million residents) reported mean 2006-2011 fluoride concentrations ≥1500 µg/L (the World Health Organization's guideline for drinking water quality). Arithmetic mean, 90th, and 95th percentile contaminant concentrations were greatest in CWSs reliant on groundwater, located in the Southwest and Eastern Midwest, and serving Semi-Urban, Hispanic communities. In fully adjusted spatial error models, the GMR (95% CI) of CWS fluoride per a 10% higher proportion of county residents that were Hispanic/Latino was 1.16 (1.10, 1.23).

IMPACT STATEMENT

We find that over 2.9 million US residents are served by public water systems with average fluoride concentrations exceeding the World Health Organization's guidance limit. We also find significant inequalities in community water system fluoride concentration estimates (2006-2011) across the US, especially for Hispanic/Latino communities who also experience elevated arsenic and uranium in regulated public drinking water systems. Our fluoride estimates can be leveraged in future epidemiologic studies to assess the potential association between chronic fluoride exposure and related adverse outcomes.

US drinking water quality: exposure risk profiles for seven legacy and emerging contaminants

BACKGROUND

Advances in drinking water infrastructure and treatment throughout the 20th and early 21st century dramatically improved water reliability and quality in the United States (US) and other parts of the world. However, numerous chemical contaminants from a range of anthropogenic and natural sources continue to pose chronic health concerns, even in countries with established drinking water regulations, such as the US.

OBJECTIVE/METHODS

In this review, we summarize exposure risk profiles and health effects for seven legacy and emerging drinking water contaminants or contaminant groups: arsenic, disinfection by-products, fracking-related substances, lead, nitrate, per- and polyfluorinated alkyl substances (PFAS) and uranium. We begin with an overview of US public water systems, and US and global drinking water regulation. We end with a summary of cross-cutting challenges that burden US drinking water systems: aging and deteriorated water infrastructure, vulnerabilities for children in school and childcare facilities, climate change, disparities in access to safe and reliable drinking water, uneven enforcement of drinking water standards, inadequate health assessments, large numbers of chemicals within a class, a preponderance of small water systems, and issues facing US Indigenous communities.

RESULTS

Research and data on US drinking water contamination show that exposure profiles, health risks, and water quality reliability issues vary widely across populations, geographically and by contaminant. Factors include water source, local and regional features, aging water infrastructure, industrial or commercial activities, and social determinants. Understanding the risk profiles of different drinking water contaminants is necessary for anticipating local and general problems, ascertaining the state of drinking water resources, and developing mitigation strategies.

IMPACT STATEMENT

Drinking water contamination is widespread, even in the US. Exposure risk profiles vary by contaminant. Understanding the risk profiles of different drinking water contaminants is necessary for anticipating local and general public health problems, ascertaining the state of drinking water resources, and developing mitigation strategies.

Race, Racism, and Drinking Water Contamination Risk From Oil and Gas Wells in Los Angeles County, 2020

Objectives. To evaluate the potential for drinking water contamination in Los Angeles (LA) County, California, based on the proximity of supply wells to oil and gas wells, and characterize risk with respect to race/ethnicity and measures of structural racism. Methods. We identified at-risk community water systems (CWSs) as those with supply wells within 1 kilometer of an oil or gas well. We characterized sociodemographics of the populations served by each CWS by using the 2013-2017 American Community Survey. We estimated the degree of redlining in each CWS service area by using 1930s Home Owners' Loan Corporation security maps, and characterized segregation by using the Index of Concentration at the Extremes. Multivariable regression models estimated associations between these variables and CWS contamination risk. Results. A quarter of LA County CWSs serving more than 7 million residents have supply wells within 1 kilometer of an oil or gas well. Higher percentages of Hispanic, Black, and Asian/Pacific Islander residents and a greater degree of redlining and residential segregation were associated with higher contamination risk. Conclusions. Redlining and segregation predict drinking water contamination risks from oil development in LA County, with people of color at greater risk. (Am J Public Health. 2023;113(11):1191-1200. https://doi.org/10.2105/AJPH.2023.307374).

The effects of contemporary redlining on the mental health of Black residents

Understanding how structural racism, including institutionalized practices such as redlining, influence persistent inequities in health and neighborhood conditions is still emerging in urban health research. Such research often focuses on historical practices, giving the impression that such practices are a thing of the past. However, mortgage lending bias can be readily detected in contemporary datasets and is an active form of structural racism with implications for health and wellbeing. The objective of the current study was to test for associations among multiple measures of mental health and a measure of contemporary redlining. We linked a redlining index constructed using Home Mortgage Disclosure Act data (2007-2013) to 2021 health data for Black/African American participants in the Study of Active Neighborhoods in Detroit (n = 220 with address data). We used multilevel regression models to examine the relationship between redlining and a suite of mental health outcomes (perceived stress, anxiety, depressive symptoms, and satisfaction with life), accounting for covariates including racial composition of the neighborhood. We considered three mediating factors: perceived neighborhood cohesion, aesthetics, and discrimination. Although all participants lived in redlined neighborhoods compared to the complete Detroit Metropolitan area, participants with very low income, low levels of experienced discrimination, and lower perceptions of neighborhood aesthetics resided in highly redlined neighborhoods (score ≥5). We observed that higher resident-reported neighborhood aesthetics were found in neighborhoods with lower redlining scores and were associated with higher levels of satisfaction with life. We found that lower levels of redlining were significantly associated with higher levels of perceived discrimination, which was significantly, positively associated with anxiety, depressive symptoms, and perceived stress scores. Our findings highlight that contemporary redlining practices may influence the aesthetics of the built environment because these neighborhoods experience less investment, with implications for residents' satisfaction with life. However, areas with lower redlining may be areas where Black/African American people experience increased perceived discrimination.

School Nutrition Environment and Services: Policies and Practices That Promote Healthy Eating Among K-12 Students

BACKGROUND

Changes to policies at the federal, state, and local levels over the last decade have influenced the school nutrition environment and services.

METHODS

This systematic review includes an analysis of individual research articles and government reports published from 2010 to 2021 that examine interventions to improve the school nutrition environment and services and increase the availability, selection, and consumption of healthier foods and beverages in K-12 schools in the United States.

RESULTS

Nutrition standards for school meals and food outside of meals improved access to healthier options in school. Providing school nutrition professionals with professional development, improving the palatability of school meals, offering taste tests, pre-slicing fruit, providing recess before lunch, offering incentives for trying healthier options, and providing access to drinking water resulted in increased selection and consumption of healthier items. There were inconclusive or mixed findings for some intervention strategies including adequate seat time for meals.

CONCLUSIONS

Despite demonstrated improvements to school meal programs and competitive foods, more work is needed to change the selection and consumption of healthier options among K-12 students. Schools can use multiple interventions to improve the school nutrition environment and services and help students adopt food and beverage choices that support health.

Burden of disease from contaminated drinking water in countries with high access to safely managed water: A systematic review

The vast majority of residents of high-income countries (≥90%) reportedly have high access to safely managed drinking water. Owing perhaps to the widely held perception of near universal access to high-quality water services in these countries, the burden of waterborne disease in these contexts is understudied. This systematic review aimed to: identify population-scale estimates of waterborne disease in countries with high access to safely managed drinking water, compare methods to quantify disease burden, and identify gaps in available burden estimates. We conducted a systematic review of population-scale disease burden estimates attributed to drinking water in countries where ≥90% of the population has access to safely managed drinking water per official United Nations monitoring. We identified 24 studies reporting estimates for disease burden attributable to microbial contaminants. Across these studies, the median burden of gastrointestinal illness risks attributed to drinking water was ∼2,720 annual cases per 100,000 population. Beyond exposure to infectious agents, we identified 10 studies reporting disease burden-predominantly, cancer risks-associated with chemical contaminants. Across these studies, the median excess cancer cases attributable to drinking water was 1.2 annual cancer cases per 100,000 population. These median estimates slightly exceed WHO-recommended normative targets for disease burden attributable to drinking water and these results highlight that there remains important preventable disease burden in these contexts, particularly among marginalized populations. However, the available literature was scant and limited in geographic scope, disease outcomes, range of microbial and chemical contaminants, and inclusion of subpopulations (rural, low-income communities; Indigenous or Aboriginal peoples; and populations marginalized due to discrimination by race, ethnicity, or socioeconomic status) that could most benefit from water infrastructure investments. Studies quantifying drinking water-associated disease burden in countries with reportedly high access to safe drinking water, focusing on specific subpopulations lacking access to safe water supplies and promoting environmental justice, are needed.

Small Community Water Systems Have the Highest Prevalence of Mn in Drinking Water in California, USA

Manganese (Mn) is currently regulated as a secondary contaminant in California, USA; however, recent revisions of the World Health Organization drinking water guidelines have increased regulatory attention of Mn in drinking water due to increasing reports of neurotoxic effects in infants and children. In this study, Mn concentrations reported to California's Safe Drinking Water Information System were used to estimate the potentially exposed population within California based on system size. We estimate that between 2011 and 2021, over 525,000 users in areas with reported Mn data are potentially exposed to Mn concentrations exceeding the WHO health-based guideline (80 μg L-1), and over 34,000 users are potentially exposed to Mn concentrations exceeding the U.S. Environmental Protection Agency health-advisory limit (300 μg L-1). Water treatment significantly decreased Mn concentrations compared to intake concentrations for all system sizes. However, smaller water systems have a wider range and a higher skew of Mn concentrations in finished water than larger systems. Additionally, higher Mn concentrations were found in systems above the maximum contaminant levels for chromium and arsenic. The treatment of these primary contaminants appears to also remove Mn. Lastly, data missingness remains a barrier to accurately assess public exposure to Mn in very small, small, and medium community water system-delivered water.

Geospatial Assessment of Racial/Ethnic Composition, Social Vulnerability, and Lead Water Service Lines in New York City

BACKGROUND

The state of New York expects to receive $ 115  million in 2022 alone from the U.S. Infrastructure Investment and Jobs Act to support the replacement of lead water service lines.

OBJECTIVES

Our objective was to determine the number and proportion of potential lead water service lines across New York City (NYC) and to evaluate the association between census tract-level racial/ethnic composition, housing vulnerability, and child lead exposure vulnerability with service line type (Potential Lead, Unknown) for n = 2,083 NYC tracts.

METHODS

We conducted a descriptive analysis assessing water service line material recorded in the NYC Department of Environmental Protection's Lead Service Line Location Coordinates database. We used conditional autoregressive Bayesian Poisson models to assess the relative risk [RR; median posterior estimates, and 95% credible interval (CrI)] of service line type per 20% higher proportion of residents in a given racial/ethnic group and per higher housing vulnerability and child lead exposure vulnerability index scores corresponding to the interquartile range. We also evaluated the associations in flexible natural cubic spline models.

RESULTS

Out of 854,672 residential service line records, 136,891 (16.0%) were Potential Lead, and 227,443 (26.6%) were Unknown. In fully adjusted models, higher proportions of Hispanic/Latino residents and higher child lead exposure vulnerability were associated with Potential Lead service lines in flexible spline models and linear models [RR = 1.15 (95% CrI: 1.11, 1.21) and RR = 1.11 (95% CrI: 1.02, 1.20), respectively]. Associations were modified by borough; Potential Lead service lines were associated with higher proportions of non-Hispanic White and non-Hispanic Asian residents in the Bronx and Manhattan, and with higher proportions of non-Hispanic Black residents in Queens.

DISCUSSION

NYC has a high number of Potential Lead and Unknown water service lines. Communities with a high proportion of Hispanic/Latino residents and those with children who are already highly vulnerable to lead exposures from numerous sources are disproportionately impacted by Potential Lead service lines. These findings can inform equitable service line replacement across New York state and NYC. https://doi.org/10.1289/EHP12276.

Determinants of tap water mistrust among Phoenix, Arizona Latinx adults

The purpose of this investigation was to characterize factors that predict tap water mistrust among Phoenix, Arizona Latinx adults. Participants (n = 492, 28 ± 7 years, 37.4% female) completed water security experience-based scales and an Adapted Survey of Water Issues in Arizona. Binary logistic regression determined odds ratios (OR) with 95% confidence intervals (95% CI) for the odds of perceiving tap water to be unsafe. Of all participants, 51.2% perceived their tap water to be unsafe. The odds of mistrusting tap water were significantly greater for each additional favorable perception of bottled compared to tap water (e.g., tastes/smells better; OR = 1.94, 95% CI = 1.50, 2.50), negative home tap water experience (e.g., hard water mineral deposits and rusty color; OR = 1.32, 95% CI = 1.12, 1.56), use of alternatives to home tap water (OR = 1.25, 95% CI = 1.04, 1.51), and with decreased water quality and acceptability (OR = 1.21, 95% CI = 1.01, 1.45; P < 0.05). The odds of mistrusting tap water were significantly lower for those whose primary source of drinking water is the public supply (municipal) (OR = 0.07, 95% CI = 0.01, 0.63) and with decreased water access (OR = 0.56, 95% CI = 0.48, 0.66; P < 0.05). Latinx mistrust of tap water appears to be associated with organoleptic perceptions and reliance on alternatives to the home drinking water system.

Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California

BACKGROUND

Access to water and sanitation is a basic human right; however, in many parts of the world, communities experience water, sanitation, and hygiene (WaSH) insecurity. While WaSH insecurity is prevalent in many low and middle-income countries, it is also a problem in high-income countries, like the United States, as is evident in vulnerable populations, including people experiencing homelessness. Limited knowledge exists about the coping strategies unhoused people use to access WaSH services. This study, therefore, examines WaSH access among unhoused communities in Los Angeles, California, a city with the second-highest count of unhoused people across the nation.

METHODS

We conducted a cross-sectional study using a snowball sampling technique with 263 unhoused people living in Skid Row, Los Angeles. We calculated frequencies and used multivariable models to describe (1) how unhoused communities cope and gain access to WaSH services in different places, and (2) what individual-level factors contribute to unhoused people's ability to access WaSH services.

RESULTS

Our findings reveal that access to WaSH services for unhoused communities in Los Angeles is most difficult at night. Reduced access to overnight sanitation resulted in 19% of the sample population using buckets inside their tents and 28% openly defecating in public spaces. Bottled water and public taps are the primary drinking water source, but 6% of the sample reported obtaining water from fire hydrants, and 50% of the population stores water for night use. Unhoused people also had limited access to water and soap for hand hygiene throughout the day, with 17% of the sample relying on hand sanitizer to clean their hands. Shower and laundry access were among the most limited services available, and reduced people's ability to maintain body hygiene practices and limited employment opportunities. Our regression models suggest that WaSH access is not homogenous among the unhoused. Community differences exist; the odds of having difficulty accessing sanitation services is two times greater for those living outside of Skid Row (Adj OR: 2.52; 95% CI: 1.08-6.37) and three times greater for people who have been unhoused for more than six years compared to people who have been unhoused for less than a year (Adj OR: 3.26; 95% CI: 1.36-8.07).

CONCLUSION

Overall, this study suggests a need for more permanent, 24-h access to WaSH services for unhoused communities living in Skid Row, including toilets, drinking water, water and soap for hand hygiene, showers, and laundry services.

Sociodemographic Factors Are Associated with the Abundance of PFAS Sources and Detection in U.S. Community Water Systems

Drinking water contaminated by per- and polyfluoroalkyl substances (PFAS) is a widespread public health concern, and exposure-response relationships are known to vary across sociodemographic groups. However, research on disparities in drinking water PFAS exposures and the siting of PFAS sources in marginalized communities is limited. Here, we use monitoring data from 7873 U.S. community water systems (CWS) in 18 states to show that PFAS detection is positively associated with the number of PFAS sources and proportions of people of color who are served by these water systems. Each additional industrial facility, military fire training area, and airport in a CWS watershed was associated with a 10-108% increase in perfluorooctanoic acid and a 20-34% increase in perfluorooctane sulfonic acid in drinking water. Waste sector sources were also significantly associated with drinking water PFAS concentrations. CWS watersheds with PFAS sources served higher proportions of Hispanic/Latino and non-Hispanic Black residents compared to those without PFAS sources. CWS serving higher proportions of Hispanic/Latino and non-Hispanic Black residents had significantly increased odds of detecting several PFAS. This likely reflects disparities in the siting of PFAS contamination sources. Results of this work suggest that addressing environmental justice concerns should be a component of risk mitigation planning for areas affected by drinking water PFAS contamination.

Water struggles and contested use: A capabilities assessment of household water security in marginalized communities

In this study, we apply a capabilities approach to analyze a water consolidation project and water security outcomes following a severe drought in East Porterville, California. By combining hydro-social theory with the capabilities approach, we provide a holistic approach to household water security that is historically situated, considers residents' needs, and accounts for areas of life beyond hydration and domestic use. In addition, we offer a critical analysis of water system consolidation, a process of combining water systems physically and/or managerially as a solution to water insecurity in small towns. Drawing on interviews with residents, local experts, and government officials as well as archival research and participant observation, we find that the water consolidation project has mixed results for the East Porterville community, with beneficial, limiting, and contested effects on residents' social, cultural, and economic life. Although residents now have a consistent source of water in their homes, they find themselves limited in their ability to use water for drinking and cultural and economic purposes. Water negotiations and contestations also affected property values, independence, and livability. Through this empirical application of the capabilities approach, we demonstrate the need to expand the concept of water security and consolidation outcomes through needs-based perspectives. Furthermore, we show how the coupling of capabilities approach with a hydro-social framework provides descriptive, analytical, and explanatory tools for understanding and addressing household water security.

Engaging in Health Activism through Neighbor-to-Neighbor Communication

Given the importance of local organizing to environmental health advocacy and activism, we need more understanding of how neighbors communicate about health risks. Individual residents in a neighborhood can be agents of social change, communicating about common health concerns and ways to cope with them, potentially leading to health activism. In this study, we used a grounded theory approach to analyze Pennsylvania residents' (N = 407) responses to open-ended questions that asked their thoughts on engaging in conversations with neighbors about the risk of lead exposure. Our findings describe (a) what respondents would want to share with neighbors about health risks and how they would communicate with their neighbors, (b) what actions they would like to promote to neighbors, and (c) what additional factors would facilitate conversations with neighbors. Based on the critical examination of the findings, we discuss communication strategies that can motivate health activism to bring about social structural changes.

Disparities in Drinking Water Manganese Concentrations in Domestic Wells and Community Water Systems in the Central Valley, CA, USA

Over 1.3 million Californians rely on unmonitored domestic wells. Existing probability estimates of groundwater Mn concentrations, population estimates, and sociodemographic data were integrated with spatial data delineating domestic well communities (DWCs) to predict the probability of high Mn concentrations in extracted groundwater within DWCs in California's Central Valley. Additional Mn concentration data of water delivered by community water systems (CWSs) were used to estimate Mn in public water supply. We estimate that 0.4% of the DWC population (2342 users) rely on groundwater with predicted Mn > 300 μg L^-1. In CWSs, 2.4% of the population (904 users) served by small CWSs and 0.4% of the population (3072 users) served by medium CWS relied on drinking water with mean point-of-entry Mn concentration >300 μg L^-1. Small CWSs were less likely to report Mn concentrations relative to large CWSs, yet a higher percentage of small CWSs exceed regulatory standards relative to larger systems. Modeled calculations do not reveal differences in estimated Mn concentration between groundwater from current regional domestic well depth and 33 m deeper. These analyses demonstrate the need for additional well-monitoring programs that evaluate Mn and increased access to point-of-use treatment for domestic well users disproportionately burdened by associated costs of water treatment.

Community Perceptions of Arsenic Contaminated Drinking Water and Preferences for Risk Communication in California's San Joaquin Valley

Due to chronic exposure to elevated levels of arsenic in drinking water, thousands of Californians have increased risk for internal cancers and other adverse health effects. The mortality risk of cancer is 1 in 400 people exposed to above 10 μg/L of arsenic in their drinking water. The purpose of this community assessment was to understand the perceptions and awareness of the residents and public water representatives in rural, unincorporated farming communities of color in San Joaquin Valley, California. In our research, we asked 27 community informants about their (1) available water sources, (2) knowledge about the health impacts of arsenic, and (3) preferences for risk communication and education regarding the health impacts of arsenic-contaminated drinking water. Through our qualitative coding and analysis, we found that most community informants indicated that there was limited community awareness about the health effects of drinking water with elevated arsenic levels. Preferences for risk communication included using in-language, culturally relevant, and health literate health promotion strategies and teaching these topics through the local K-8 schools' science curriculum with a language brokerage approach to transfer student knowledge to family members. Key recommendations include implementing these communication preferences to increase community-wide knowledge about safe drinking water.

Nationwide geospatial analysis of county racial and ethnic composition and public drinking water arsenic and uranium

There is no safe level of exposure to inorganic arsenic or uranium, yet recent studies identified sociodemographic and regional inequalities in concentrations of these frequently detected contaminants in public water systems across the US. We analyze the county-level association between racial/ethnic composition and public water arsenic and uranium concentrations from 2000-2011 using geospatial models. We find that higher proportions of Hispanic/Latino and American Indian/Alaskan Native residents are associated with significantly higher arsenic and uranium concentrations. These associations differ in magnitude and direction across regions; higher proportions of non-Hispanic Black residents are associated with higher arsenic and uranium in regions where concentrations of these contaminants are high. The findings from this nationwide geospatial analysis identifying racial/ethnic inequalities in arsenic and uranium concentrations in public drinking water across the US can advance environmental justice initiatives by informing regulatory action and financial and technical support to protect communities of color.

Socioeconomic vulnerability and public water arsenic concentrations across the US

Inorganic arsenic is a known human carcinogen and is routinely detected in US community water systems (CWSs). Inequalities in CWS arsenic exist across broad sociodemographic subgroups. Our objective was to evaluate the county-level association between socioeconomic vulnerability and CWS arsenic concentrations across the US. We evaluated previously developed, population-weighted CWS arsenic concentrations (2006-2011) and three socioeconomic domains (the proportion of adults with a high school diploma, median household income, and the Centers for Disease Control and Prevention's overall socioeconomic vulnerability score) for 2,604 conterminous US counties. We used spatial lag models and evaluated the adjusted geometric mean ratio (GMR) of CWS arsenic concentrations per higher socioeconomic domain score corresponding to the interquartile range, and also evaluated flexible quadratic spline models. We also stratified by region and by United States Department of Agriculture Rural-Urban Continuum Codes to assess potential effect measure modification by region and rurality. Associations between socioeconomic vulnerability and CWS arsenic were modified by region and rurality and specific to socioeconomic domain. The fully adjusted GMR (95% CIs) of CWS arsenic per interquartile range higher proportion of adults with a high school education was 0.83 (0.71, 0.98) in the Southwest (corresponding to 17% lower arsenic with higher education), 0.82 (0.71, 0.94) in the Eastern Midwest (18% lower), and 0.65 (0.31, 1.36) in New England (35% lower). Associations between median household income and CWS arsenic were largely null. Higher overall socioeconomic vulnerability was significantly associated with lower CWS arsenic, but only in counties in the Central Midwest and those with total populations less than 20,000. Findings may reflect regional/local differences in both socioeconomic/socio-cultural context and public drinking water regulatory efforts. Across the US, individual domains of socioeconomic vulnerability (especially educational attainment) are more strongly associated with inequalities in CWS arsenic than the complex overall socioeconomic vulnerability index.

Recent advances and remaining barriers to the development of electrospun nanofiber and nanofiber composites for point-of-use and point-of-entry water treatment systems

In this review, we focus on electrospun nanofibers as a promising material alternative for the niche application of decentralized, point-of-use (POU) and point-of-entry (POE) water treatment systems. We focus our review on prior work with various formulations of electrospun materials, including nanofibers of carbon, pure metal oxides, functionalized polymers, and polymer-metal oxide composites, that exhibit analogous performance to media (e.g., activated carbon, ion exchange resins) commonly used in commercially available, certified POU/POE devices for contaminants including organic pollutants, metals (e.g., lead) and persistent oxyanions (e.g., nitrate). We then analyze the relevant strengths and remaining research and development opportunities of the relevant literature based on an evaluation framework that considers (i) performance comparison to commercial analogs; (ii) appropriate pollutant targets for POU/POE applications; (iii) testing in flow-through systems consistent with POU/POE applications; (iv) consideration of water quality effects; and (v) evaluation of material strength and longevity. We also identify several emerging issues in decentralized water treatment where nanofiber-based POU/POE devices could help meet existing needs including their use for treatment of uranium, disinfection, and in electrochemical treatment systems. To date, research has demonstrated promising material performance toward relevant targets for POU/POE applications, using appropriate aquatic matrices and considering material stability. To fully realize their promise as an emerging treatment technology, our analysis of the available literature reveals the need for more work that benchmarks nanofiber performance against established commercial analogs, as well as fabrication and performance validation at scales and under conditions simulating POU/POE water treatment.

Tapwater Exposures, Effects Potential, and Residential Risk Management in Northern Plains Nations

In the United States (US), private-supply tapwater (TW) is rarely monitored. This data gap undermines individual/community risk-management decision-making, leading to an increased probability of unrecognized contaminant exposures in rural and remote locations that rely on private wells. We assessed point-of-use (POU) TW in three northern plains Tribal Nations, where ongoing TW arsenic (As) interventions include expansion of small community water systems and POU adsorptive-media treatment for Strong Heart Water Study participants. Samples from 34 private-well and 22 public-supply sites were analyzed for 476 organics, 34 inorganics, and 3 in vitro bioactivities. 63 organics and 30 inorganics were detected. Arsenic, uranium (U), and lead (Pb) were detected in 54%, 43%, and 20% of samples, respectively. Concentrations equivalent to public-supply maximum contaminant level(s) (MCL) were exceeded only in untreated private-well samples (As 47%, U 3%). Precautionary health-based screening levels were exceeded frequently, due to inorganics in private supplies and chlorine-based disinfection byproducts in public supplies. The results indicate that simultaneous exposures to co-occurring TW contaminants are common, warranting consideration of expanded source, point-of-entry, or POU treatment(s). This study illustrates the importance of increased monitoring of private-well TW, employing a broad, environmentally informative analytical scope, to reduce the risks of unrecognized contaminant exposures.

Drivers of Spatiotemporal Variability in Drinking Water Quality in the United States

Approximately 10% of community water systems in the United States experience a health-based violation of drinking water quality; however, recently allocated funds for improving United States water infrastructure ($50 billion) provide an opportunity to address these issues. The objective of this study was to examine environmental, operational, and sociodemographic drivers of spatiotemporal variability in drinking water quality violations using geospatial analysis and data analytics. Random forest modeling was used to evaluate drivers of these violations, including environmental (e.g., landcover, climate, geology), operational (e.g., water source, system size), and sociodemographic (social vulnerability, rurality) drivers. Results of random forest modeling show that drivers of violations vary by violation type. For example, arsenic and radionuclide violations are found mostly in the Southwest and Southcentral United States related to semiarid climate, whereas disinfection byproduct rule violations are found primarily in Southcentral United States related to system operations. Health-based violations are found primarily in small systems in rural and suburban settings. Understanding the drivers of water quality violations can help develop optimal approaches for addressing these issues to increase compliance in community water systems, particularly small systems in rural areas across the United States.

Improved Decision-Making: A Sociotechnical Utility-Based Framework for Drinking Water Investment

To achieve the goals of the Safe Drinking Water Act, state and local water authorities need to make decisions about where to direct limited funding for infrastructure improvements and currently do so in the absence of adequate evaluative metrics. We developed a framework grounded in utility theory that compares trade-offs explicitly and broadens the factors considered in prioritizing resource allocations. Relevant existing indices were reviewed to identify data applicable to drinking water decision-making. A utility-theory-based decision analysis framework was developed and applied to evaluate how different objectives affect funding decisions for lead service line replacement (LSLR) programs in Pennsylvania and Michigan, United States. The decision framework incorporates drinking water quality characteristics with community and environmental quality attributes. We compare additive and multiplicative model structures, different weights, and spatial scales. Our decision framework showed that the inclusion of additional data beyond what is usually considered in LSLR decisions could change the top 10 counties or public water systems prioritized. Further, the counties or water systems in the top 10 were influenced by the model structure and weights. Prioritization changed based on which data were included, and has implications for the use of evaluative metrics beyond traditional water system data.

Native and Indigenous Populations and Gastric Cancer: A Worldwide Review

Gastric cancer is a worldwide concern, particularly for Indigenous populations who face greater disparities in healthcare. With decreased access to screening and critical treatment delays, this group is experiencing adverse health effects. To determine what factors drive these disparities, a systematic review was performed in PubMed. This revealed a lack of research on gastric cancer specific to this population. The literature primarily focused on subset analyses and biological aspects with sparse focus on determinants of health. The results informed this presentation on factors related to Indigenous gastric cancer, which are influenced by colonialism. Indigenous populations encounter high rates of food shortage, exposure to harmful environmental agents, structural racism in the built environment, H. pylori, and compromised healthcare quality as an effect of colonialism, which all contribute to the gastric cancer burden. Putting gastric cancer into a cultural context is a potential means to respond to colonial perspectives and their negative impact on Indigenous patients. The objective of this manuscript is to examine the current state of gastric cancer literature from a global perspective, describe what is currently known based on this literature review, supplemented with additional resources due to lack of published works in PubMed, and to present a model of gastric cancer through the lens of a modified medicine wheel as a potential tool to counter colonial healthcare perspectives and to honor Indigenous culture.

Sociodemographic inequalities in uranium and other metals in community water systems across the USA, 2006-11: a cross-sectional study

BACKGROUND

The US Environmental Protection Agency (EPA) currently sets maximum contaminant levels (MCLs) for ten metals or metalloids in public drinking water systems. Our objective was to estimate metal concentrations in community water systems (CWSs) across the USA, to establish if sociodemographic or regional inequalities in the metal concentrations exist, and to identify patterns of concentrations for these metals as a mixture.

METHODS

We evaluated routine compliance monitoring records for antimony, arsenic, barium, beryllium, cadmium, chromium, mercury, selenium, thallium, and uranium, collected from 2006-11 (2000-11 for uranium; timeframe based on compliance monitoring requirements) by the US EPA in support of their second and third Six-Year Reviews for CWSs. Arsenic, barium, chromium, selenium, and uranium (detectable in >10% records) were included in the main analyses (subgroup and metal mixture analyses; arsenic data reported previously). We compared the mean, 75th percentile, and 95th percentile contaminant concentrations and the percentage of CWSs with concentrations exceeding the MCL across subgroups (region, sociodemographic county-cluster, size of population served, source water type, and CWSs exclusively serving correctional facilities). We evaluated patterns in CWS metal concentration estimate profiles via hierarchical cluster analysis. We created an online interactive map and dashboard of estimated CWS metal concentrations for use in future analyses.

FINDINGS

Average metal concentrations were available for a total of 37 915 CWSs across the USA. The total number of monitoring records available was approximately 297 000 for arsenic, 165 000 for barium, 167 000 for chromium, 165 000 for selenium, and 128 000 for uranium. The percentage of analysed CWSs with average concentrations exceeding the MCL was 2·6% for arsenic (MCL=10 μg/L; nationwide mean 1·77 μg/L; n=36 798 CWSs), 2·1% for uranium (MCL=30 μg/L; nationwide mean 4·37 μg/L; n=14 503 CWSs), and less than 0·1% for the other metals. The number of records with detections was highest for uranium (63·1%). 75th and 95th percentile concentrations for uranium, chromium, barium, and selenium were highest for CWSs serving Semi-Urban, Hispanic communities, CWSs reliant on groundwater, and CWSs in the Central Midwest. Hierarchical cluster analysis revealed two distinct clusters: an arsenic-uranium-selenium cluster and a barium-chromium cluster.

INTERPRETATIONS

Uranium is an under-recognised contaminant in CWSs. Metal concentrations (including uranium) are elevated in CWSs serving Semi-Urban, Hispanic communities independent of location or region, highlighting environmental justice concerns.

FUNDING

US National Institutes of Health Office of the Director, US National Institutes for Environmental Health Sciences, and US National Institute of Dental and Craniofacial Research.

Climate Change, Environmental Disasters, and Health Inequities: The Underlying Role of Structural Inequalities

PURPOSE OF REVIEW

We review and analyze recent literature in public health, urban planning, and disaster management to better understand the relationships between climate change, natural disasters, and root causes of health disparities in the USA.

RECENT FINDINGS

Existing scholarship establishes clear linkages between climate change and increasing occurrences and severity of natural disasters across the USA. The frequency and types of disasters vary by region and impact both short and long-term health outcomes. Current research highlights health inequities affecting lower income and minoritized communities disproportionately, but data-driven studies critically examining the role of structural inequalities in climate-induced health disparities are sparse. Adding to the body of knowledge, our conceptual framework maps how long-standing structural inequalities in policy, practice, and funding shape vulnerability of lower-income, racially and ethnically marginalized individuals. Vulnerability follows three common pathways: disparities in "exposure", "sensitivity", and "resiliency" before, during, and after a climate disaster. We recommend that future research, policy, and practice shift towards solutions that unearth and address the structural biases that cause environmental disaster and health inequities.

User experience of point-of-use water treatment for private wells in North Carolina: Implications for outreach and well stewardship

Private well users are potentially exposed to a range of chemical contaminants through their drinking water. Point-of-use (POU) water treatment represents one potential solution to reduce harmful exposures through well water, but well users frequently do not adopt household treatment even if they learn their water is contaminated. This study elucidates the experiences, perceptions, and beliefs of 17 households on private wells in North Carolina that participated in a pilot-scale POU water treatment intervention to better understand the drivers and barriers of POU treatment adoption among well users. The intervention consisted of an under-sink activated carbon block POU filter designed to remove lead and two long-chain perfluoroalkyl acids. Filter effluents and influents were tested monthly for eight months. Questionnaires administered before and after the intervention showed a significant decrease in participants' perceived vulnerability to well water contamination, with 77% feeling vulnerable to poor well water quality before, compared to 23% after the filter was installed. However, the POU filters did not fully eliminate feelings of water insecurity (for example, concerns about exposure to contaminants when bathing remained). Lack of knowledge and skills associated with installing and maintaining POU treatment were important barriers to adoption for some well users. Perceptions of POU treatment were also significantly correlated with the intent to implement other well stewardship behaviors such as well water testing. The results highlight the need for strengthened outreach and support programs that provide technical assistance, education, and financial support for households relying on private wells.

Using Water Intake Dietary Recall Data to Provide a Window into US Water Insecurity

BACKGROUND

In the United States, problems with the provision of safe, affordable water have resulted in an increasing number of adults who avoid their tap water, which could indicate underlying water insecurity. Dietary recalls provide critical nutritional surveillance data, yet have been underexplored as a water insecurity monitoring tool.

OBJECTIVES

This article aims to demonstrate how water intake variables from dietary recall data relate to and predict a key water insecurity proxy, that is, tap water avoidance.

METHODS

Using 2005-2018 NHANES data from 32,329 adults, I examine distributions and trends of mean intakes of total, plain (sum of tap and bottled water), tap, and bottled water, and percentage consuming no tap and exclusive bottled water. Second, I use multiple linear and logistic regressions to test how tap water avoidance relates to plain water intake and sugar-sweetened beverage (SSB) consumption. Next, I use receiver operating characteristics (ROC) curves to test the predictive accuracy of no plain water, no tap, and exclusive bottled water intake, and varying percentages of plain water consumed from tap water compared with tap water avoidance.

RESULTS

Trends indicate increasing plain water intake between 2005 and 2018, driven by increasing bottled water intake. In 2017-18, 51.4% of adults did not drink tap water on a given day, whereas 35.8% exclusively consumed bottled water. Adults who avoided their tap water consumed less tap and plain water, and significantly more bottled water and SSBs on a given day. No tap intake and categories of tap water intake produced 77% and 78% areas under the ROC curve in predicting tap water avoidance.

CONCLUSIONS

This study demonstrates that water intake variables from dietary recalls can be used to accurately predict tap water avoidance and provide a window into water insecurity. Growing reliance on bottled water could indicate increasing concerns about tap water.

The Drinking Water Tool: A Community-Driven Data Visualization Tool for Policy Implementation

The Drinking Water Tool (DWT) is a community-driven online tool that provides diverse users with information about drinking water sources and threats to drinking water quality and access due to drought. Development of the DWT was guided by the Community Water Center (CWC) as part of the Water Equity Science Shop (WESS), a research partnership integrating elements of community-based participatory research and the European Science Shop model. The WESS engages in scientific projects that inform policy change, advance water justice, and reduce cumulative exposure and disproportionate health burdens among impacted communities in California. WESS researchers conducted qualitative analysis of 15 stakeholder interviews regarding the DWT, including iterative feedback and the stakeholder consultation process as well as stakeholder perceptions of the tool's impact on California water policy, organizing, and research. Results indicate that the DWT and the stakeholder engagement process which developed it were effective in influencing policy priorities and in promoting interagency coordination at multiple levels to address water equity challenges and their disproportionate burdens, particularly among rural and low socioeconomic status areas and communities of color.

Identifying schools at high-risk for elevated lead in drinking water using only publicly available data

Estimating the risk of lead contamination of schools' drinking water at the State level is a complex, important, and unexplored challenge. Variable water quality among water systems and changes in water chemistry during distribution affect lead dissolution rates from pipes and fittings. In addition, the locations of lead-bearing plumbing materials are uncertain. We tested the capability of six machine learning models to predict the likelihood of lead contamination of drinking water at the schools' taps using only publicly available datasets. The predictive features used in the models correspond to those with a proven correlation to the dominant, but commonly unavailable, factors that govern lead leaching: the presence of lead-bearing plumbing materials and water quality conducive to lead corrosion. By combining water chemistry data from public reports, socioeconomic information from the US census, and spatial features using Geographic Information Systems, we trained and tested models to estimate the likelihood of lead contaminated tap water in over 8,000 schools across California and Massachusetts. Our best-performing model was a Random Forest, with a 10-fold cross validation score of 0.88 for Massachusetts and 0.78 for California using the average Area Under the Receiver Operating Characteristic Curve (ROC AUC) metric. The model was then used to assign a lead leaching risk category to half of the schools across California (the other half was used for training). There was good agreement between the modeled risk categories and the actual lead leaching outcomes for every school; however, the model overestimated the lead leaching risk in up to 17% of the schools. This model is the first of its kind to offer a tool to predict the risk of lead leaching in schools at the State level. Further use of this model can help deploy limited resources more effectively to prevent childhood lead exposure from school drinking water.

Inequities in Drinking Water Quality Among Domestic Well Communities and Community Water Systems, California, 2011‒2019

Objectives. To evaluate universal access to clean drinking water by characterizing relationships between community sociodemographics and water contaminants in California domestic well areas (DWAs) and community water systems (CWSs). Methods. We integrated domestic well locations, CWS service boundaries, residential parcels, building footprints, and 2013-2017 American Community Survey data to estimate sociodemographic characteristics for DWAs and CWSs statewide. We derived mean drinking and groundwater contaminant concentrations of arsenic, nitrate, and hexavalent chromium (Cr[VI]) between 2011 and 2019 and used multivariate models to estimate relationships between sociodemographic variables and contaminant concentrations. Results. We estimated that more than 1.3 million Californians (3.4%) use domestic wells and more than 370 000 Californians rely on drinking water with average contaminant concentrations at or above regulatory standards for 1 or more of the contaminants considered. Higher proportions of people of color were associated with greater drinking water contamination. Conclusions. Poor water quality disproportionately impacts communities of color in California, with the highest estimated arsenic, nitrate, and Cr(VI) concentrations in areas of domestic well use. Domestic well communities must be included in efforts to achieve California's Human Right to Water. (Am J Public Health. 2022;112(1):88-97. https://doi.org/10.2105/AJPH.2021.306561).

Residential proximity to hydraulically fractured oil and gas wells and adverse birth outcomes in urban and rural communities in California (2006-2015)

Supplemental Digital Content is available in the text.

Background:

Prenatal exposure to hydraulic fracturing (HF), a chemically intensive oil and gas extraction method, may be associated with adverse birth outcomes, but no health studies have been conducted in California.

Methods:

We conducted a retrospective cohort study of 979,961 births to mothers in eight California counties with HF between 2006 and 2015. Exposed individuals had at least 1 well hydraulically fractured within 1 km of their residence during pregnancy; the reference population had no wells within 1 km, but at least one oil/gas well within 10 km. We examined associations between HF and low birth weight (LBW), preterm birth (PTB), small for gestational age birth (SGA), and term birth weight (tBW) using generalized estimating equations and assessing urban-rural effect modification in stratified models.

Results:

Fewer than 1% of mothers (N = 1,192) were exposed to HF during pregnancy. Among rural mothers, HF exposure was associated with increased odds of LBW (odds ratio [OR] = 1.74; 95% confidence interval [CI] = 1.10, 2.75), SGA (OR = 1.68; 95% CI = 1.42, 2.27) and PTB (OR = 1.17; 95% CI = 0.64, 2.12), and lower tBW (mean difference: –73 g; 95% CI = –131, –15). Among urban mothers, HF exposure was positively associated with SGA (OR = 1.23; 95% CI = 0.98, 1.55), inversely associated with LBW (OR = 0.83; 95% CI = 0.63, 1.07) and PTB (OR = 0.65; 95% CI = 0.48, 0.87), and not associated with tBW (mean difference: –2 g; 95% CI = –35, 31).

Conclusion:

HF proximity was associated with adverse birth outcomes, particularly among rural Californians.

A pilot study on the feasibility of testing residential tap water in North Carolina: implications for environmental justice and health

BACKGROUND

In 2015 alone, community water systems serving about 21 million Americans violated the United States Environmental Protection Agency's (US-EPA) water quality standards. While water at community treatment and distribution centers is regularly monitored and tested, little is known about pollutants in the water systems at the household level.

AIMS

This pilot study assessed the feasibility of (1) testing for the presence and concentration of 14 contaminants and physicochemical parameters in household tap water in a low-income neighborhood and (2) using community engagement for recruitment and citizen science approaches to data collection.

METHODS

We used a multistage approach that included geo-mapping to delineate testing sites, community engagement for recruitment and citizen science approaches to increase the response rate. We used a 14-in-one dipstick test designed to measure trace amounts of heavy metals, non-metallic elements, and physicochemical water properties in drinking water in a sample of 70 homes.

RESULTS

In 50%, 25%, and 7% of water samples tested, the concentration of mercury, lead, and chromium, respectively, were higher than US-EPA drinking water standards. Citizen science approaches were effective for increasing response rates and low-income household participation in water quality testing.

SIGNIFICANCE

The overlap between poverty, older homes, and high concentrations of potentially toxic metals in drinking water presents concerns for community health. Our pilot community engagement and citizen science approaches are likely scalable and would be of benefit to both the scientific community and to municipalities with constrained budgets. Future studies may examine the role of the principles of environmental justice in the distribution and prevalence of toxic elements in drinking water.

Tap Water Consumption and Perceptions in United States Latinx Adults

Insufficient water intake is associated with adverse health outcomes, including chronic disease prevalence and mortality. Adherence to Institute of Medicine total water intake (TWI) recommendations has been low in recent decades, and TWI has been consistently lower in Latinx adults compared with non-Hispanic (NH) white adults. While overall plain water intake is similar between Latinx and NH white adults, Latinx adults consistently consume significantly more bottled water and less tap water. The purpose of this review is to identify factors that may contribute to low water intake and low tap water intake, particularly in Latinx adults. The decision to drink water is complex and is influenced by a myriad of factors including context, environment, eating behaviors, geography, and beverage attributes. Plain water preferences appear to be related, in part, to perceptions of tap water safety as Latinx adults are significantly more likely to perceive their tap water as unsafe compared to NH white adults. Although recent investigations have not consistently or comprehensively evaluated the same factors, we have compiled their findings to describe the complex, interrelated determinants of tap water safety perceptions in Latinx adults. The present review proposes that perceptions are influenced by water insecurity, demographics, prior experiences, organoleptic (sensory) perceptions and availability and sources of information. Existing interventions designed to improve TWI primarily focus on improving access to water and/or educating individuals on the importance of hydration. However, this may not be sufficient in Latinx populations where water is not trusted. Future work should comprehensively assess these factors in Latinx samples and include validated plain water intake, TWI, and hydration status measures. A greater understanding of these relationships could inform interventions to improve TWI and hydration status in Latinx adults.

Using a Community-Based Participatory Mixed Methods Research Approach to Develop, Evaluate, and Refine a Nutrition Intervention to Replace Sugary Drinks with Filtered Tap Water among Predominantly Central-American Immigrant Families with Infants and Toddlers: The Water Up @Home Pilot Evaluation Study

Descriptions of the implementation of community-based participatory mixed-methods research (CBPMMR) in all phases of the engagement approach are limited. This manuscript describes the explicit integration of mixed-methods in four stages of CBPR: (1) connecting and diagnosing, (2) prescribing-implementing, (3) evaluating, and (4) disseminating and refining an intervention that aimed to motivate Latino parents (predominantly Central American in the US) of infants and toddlers to replace sugary drinks with filtered tap water. CBPMMR allowed for co-learning that led to the identification of preliminary behavioral outcomes, insights into potential mechanisms of behavior change, and revisions to the intervention design, implementation and evaluation.

Drinking water contaminants in California and hypertensive disorders in pregnancy

Environmental pollutants have been associated with hypertensive disorders in pregnancy including gestational hypertension, preeclampsia, and eclampsia, though few have focused on drinking water contamination. Water pollution can be an important source of exposures that may contribute to adverse pregnancy outcomes.

METHODS

We linked water quality data on 13 contaminants and two violations from the California Communities Environmental Health Screening Tool to birth records from vital statistics and hospital discharge records (2007-2012) to examine the relationship between drinking water contamination and hypertensive disorders in pregnancy. We examined contaminants in single- and multipollutant models. Additionally, we examined if the relationship between water contamination and hypertensive disorders in pregnancy differed by neighborhood poverty, individual socioeconomic status, and race/ethnicity.

RESULTS

Arsenic, nitrate, trihalomethane, hexavalent chromium, and uranium were detected in a majority of water systems. Increased risk of hypertensive disorders in pregnancy was modestly associated with exposure to cadmium, lead, trihalomethane, and hexavalent chromium in drinking water after adjusting for covariates in single pollutant models with odds ratios ranging from 1.01 to 1.08. In multipollutant models, cadmium was consistent, lead and trihalomethane were stronger, and additional contaminants were associated with hypertensive disorders in pregnancy including trichloroethylene, 1,2-Dibromo-3-chloropropane, nitrate, and tetrachloroethylene. Other contaminants either showed null results or modest inverse associations. The relationship between water contaminants and hypertensive disorders in pregnancy did not differ by neighborhood poverty.

CONCLUSIONS

We found increased risk of hypertensive disorders in pregnancy associated with exposure to several contaminants in drinking water in California. Results for cadmium, lead, trihalomethane, and hexavalent chromium were robust in multipollutant models.

Environmental Health Threats to Latino Migrant Farmworkers

Approximately 75% of farmworkers in the United States are Latino migrants, and about 50% of hired farmworkers do not have authorization to work in the United States. Farmworkers face numerous chemical, physical, and biological threats to their health. The adverse effects of these hazards may be amplified among Latino migrant farmworkers, who are concurrently exposed to various psychosocial stressors. Factors such as documentation status, potential lack of authorization to work in the United States, and language and cultural barriers may also prevent Latino migrants from accessing federal aid, legal assistance, and health programs. These environmental, occupational, and social hazards may further exacerbate existing health disparities among US Latinos. This population is also likely to be disproportionately impacted by emerging threats, including climate change and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Latino migrant farmworkers are essential to agriculture in the United States, and actions are needed to protect this vulnerable population.

Validity of a Four-Item Household Water Insecurity Experiences Scale for Assessing Water Issues Related to Health and Well-Being

We sought to determine whether a shortened version of the 12-item Household Water Insecurity Experiences (HWISE) Scale, which measures water insecurity equivalently in low- and middle-income countries (LMICs), is valid for broad use. Using data from 9,261 households in 25 LMICs, subsets of candidate items were evaluated on their predictive accuracy, criterion validity, and sensitivity–specificity. A subset with items assessing “worry,” “changing plans,” “limited drinking water,” and “inability to wash hands” because of problems with water (range: 0–12) were highly correlated with full HWISE Scale scores (correlation coefficient: 0.949–0.980) and introduced minimal additional error (root mean square error: 2.13–2.68). Criterion validity was demonstrated, and a cut point of ≥ 4 correctly classified more than 91% of households as water secure or insecure. The brief HWISE-4 can be used in LMICs to inform decisions about how to most effectively target resources and evaluate public health interventions.

Water affordability and human right to water implications in California

Water affordability is central to water access but remains a challenge to measure. California enshrined the human right to safe and affordable water in 2012 but the question remains: how should water affordability be measured across the state? This paper contributes to this question in three steps. First, we identify key dimensions of water affordability measures (including scale, volume of water needed to meet 'basic' needs, and affordability criteria) and a cross-cutting theme (social equity). Second, using these dimensions, we develop three affordability ratios measured at the water system scale for households with median, poverty level, and deep poverty (i.e., half the poverty level) incomes and estimate the corresponding percentage of households at these income levels. Using multiple measures conveys a fuller picture of affordability given the known limitations of specific affordability measures. Third, we analyze our results disaggregated by a key characteristic of water system vulnerability-water system size. We find that water is relatively affordable for median income households. However, we identify high unaffordability for households in poverty in a large fraction of water systems. We identify several scenarios with different policy implications for the human right to water, such as very small systems with high water bills and low-income households within large water systems. We also characterize how data gaps complicate theoretical ideals and present barriers in human right to water monitoring efforts. This paper presents a systematic approach to measuring affordability and represents the first statewide assessment of water affordability within California's community water systems.

Our Relationship to Water and Experience of Water Insecurity among Apsáalooke (Crow Indian) People, Montana

Affordable access to safe drinking water is essential to community health, yet there is limited understanding of water insecurity among Native Americans. Therefore, the focus of this paper is to describe Apsáalooke (Crow Indian) tribal members' experiences with water insecurity. For Apsáalooke people, local rivers and springs are still vitally important for traditional cultural activities. We interviewed 30 Native American adults living on the Crow Reservation in Southeastern Montana. Participants answered six open-ended interview questions about their water access, costs of obtaining water and changes in their domestic and traditional water uses. Participants emphasized how the use of water has changed over time and described the complex challenges associated with addressing water insecurity in their community, including the importance of considering the spiritual and cultural impacts of water insecurity on health. Water insecurity is a growing global problem and more attention and efforts are needed to find appropriate and affordable solutions.

A case study in participatory science with mutual capacity building between university and tribal researchers to investigate drinking water quality in rural Maine

BACKGROUND

Participatory science or citizen science is increasingly being recognized for providing benefits to scientists and community members alike. However, most participatory science projects include community researchers only in the sample collection phase of the research project. Here we describe how a rural tribal community and urban university utilized participatory science methods to engage community researchers across an entire research study, creating numerous opportunities for mutual capacity building.

OBJECTIVES

Researchers from MIT and the Sipayik Environmental Department, a tribal government department, partnered to co-launch a participatory science project to analyze municipal and private well drinking water quality in households in three Maine communities. The objective was to provide households with information about metals, primarily lead and arsenic, in their drinking water, and to improve public education, community partnerships, and local scientific capacity.

METHODS

MIT and Sipayik researchers engaged local communities through public community meetings, mailed flyers sent to residents, and meetings with local stakeholders. MIT and community researchers worked together to design and implement the study to quantify metals in community drinking water samples, as well as hold capacity-building trainings. Individual drinking water results were communicated to households, and generalized results were discussed at community meetings in the report-back phase.

RESULTS

The study attained a 29% household participation rate in the region. The researchers completed the analysis and report-back on 652 water samples. Isolated incidences of lead and geologically-attributable arsenic exceeding EPA standards were found. Individual report-backs of the results enabled local participatory scientists to make their own informed public health decisions. The study produced methodologies for navigating potential ethical issues, working with diverse communities, and collaborating over challenging geographical distances.

DISCUSSION

This project developed methodologies to build long-term relationships with local scientists and to engage community members and enhance the environmental literacy of rural communities. Both MIT and Sipayik researchers learned from each other throughout the project; Sipayik researchers built technical capacity while MIT researchers gained local and cultural understanding. Community outreach methods were most effective when sent directly to residents as mailed flyers or through Sipayik researchers' outreach.

Under-Sink Activated Carbon Water Filters Effectively Remove Lead from Private Well Water for over Six Months

Children who rely on private well water in the United States have been shown to be at greater risk of having elevated blood lead levels. Evidence-based solutions are needed to prevent drinking water lead exposure among private well users, but minimal data are available regarding the real-world effectiveness of available interventions like point-of-use water treatment for well water. In this study, under-sink activated carbon block water filters were tested for lead and other heavy metals removal in an eight-month longitudinal study in 17 homes relying on private wells. The device removed 98% of all influent lead for the entirety of the study, with all effluent lead levels less than 1 µg/L. Profile sampling in a subset of homes showed that the faucet fixture is a significant source of lead leaching where well water is corrosive. Flushing alone was not capable of reducing first-draw lead to levels below 1 µg/L, but the under-sink filter was found to increase the safety and effectiveness of faucet flushing. The results of this study can be used by individual well users and policymakers alike to improve decision-making around the use of under-sink point-of-use devices to prevent disproportionate lead exposures among private well users.

Geographies of insecure water access and the housing-water nexus in US cities

Safe, reliable, and equitable water access is critical to human health and livelihoods. In the United States, an estimated 471,000 households or 1.1 million individuals lack a piped water connection and 73% of households are located in cities, close to networked supply. In this study, we undertake a nationwide analysis of urban water access in the United States, with the aim of explaining the drivers of infrastructural inequality in the 50 largest metropolitan areas. Drawing on statistical analysis and regression modeling of census microdata at the household scale, our analysis reveals spatial and sociodemographic patterns of racialized, class-based, and housing disparities that characterize plumbing poverty. Among unplumbed households, we show that households headed by people of color are almost 35% more likely to lack piped water as compared to white, non-Hispanic households. Precarious housing conditions are an equally strong predictor: Renter-occupied households in the 50 largest US metros were 1.61 times more likely than owner-occupied households to lack piped water. We argue that insecure domestic water access in the United States should be understood as a housing issue that reflects structural inequalities of race and class, particularly in cities with widening wealth gaps. The article concludes with a call for research and action at the intersection of water provision, housing, and social inequality-a paradigm we call the housing-water nexus.