This paper synthesizes results from a side session convened at the 2020 University of North Carolina, Chapel Hill, Water and Health conference focused on knowledge gaps, challenges, and approaches to achieve SDG 6 among marginalized communities in high-income countries. We provide approaches and next steps to advance sustainable WASH services in communities that have often been overlooked.
The era of the Sustainable Development Goals (SDGs) has seen continued progress toward global targets for access to safe water, sanitation, and hygiene (WASH). SDG 6 aims to ‘Ensure availability and sustainable management of water and sanitation for all.’ Worldwide WASH coverage has climbed at a rate of approximately 0.5% per year for basic or safely managed drinking water and 1% per year for at least basic sanitation between 2000 and 2017 (Joint Monitoring Program 2020). As of 2017, 89.6% of the global population is estimated to have access to at least basic drinking water and 73.5% is estimated to have access to at least basic sanitation (Joint Monitoring Program 2020). These trends reflect coordinated efforts by governmental, international, and aid-based organizations that have contributed to 1.8 billion people gaining access to drinking water and 2.1 billion gaining access to sanitation since the year 2000 (Joint Monitoring Program 2019).
Despite this progress, significant inequalities still exist in WASH access (Anthonj et al. 2019), including in high-income countries where 6.2 million people were estimated to still rely on untreated surface water or unimproved drinking water sources and at least 9 million more lacked piped water in 2017 (Joint Monitoring Program 2020). Similarly, 8.4 million people were estimated to lack access to even basic sanitation in high-income countries in 2017 (Joint Monitoring Program 2020). These inequalities persist despite high-income countries' commitments to achieving universal water access by signing on to the SDGs (Kumar et al. 2016; Publications Office of the European Union 2018). In the United States (U.S.), these gaps in access have been associated with race. American Indian, Alaskan Native, Black, and Hispanic households are more likely to lack indoor plumbing (Deitz & Meehan 2019; Meehan & Jurjevich 2020). Even where piped water supplies and basic sanitation do exist, problems of poor water quality, inadequate quantity, and unsafe waste management are often found among low-income, historically marginalized, and minority populations, as documented among Indigenous Canadians living on reserves (Anthonj et al. 2019); remote Indigenous communities in Australia (Hall 2019; Hall et al. 2020); Tribal Nations (Eggers et al. 2018) and Alaska Native communities in the U.S. (Mattos et al. 2021); itinerant and sedentary Roma communities across Europe belonging to diverse groups including Sinti, Travellers, Kalé, and Gens du voyage (Van Hout & Staniewicz 2012; Davis & Ryan 2016; Anthonj et al. 2020); displaced persons (Araya et al. 2019), migrant communities (Semenza et al. 2016), and refugee camps (Dhesi et al. 2018; Tsesmelis et al. 2020) in Europe; rural and peri-urban Black communities in the southern U.S. (Stillo & Gibson 2016; Flowers et al. 2019); Hispanic communities along the U.S.-Mexico border (Rowles et al. 2020) and in California's San Joaquin Valley (Balazs et al. 2011); and people experiencing homelessness (Capone et al. 2018; Frye et al. 2019).
Despite the growing awareness of this reality in high-income countries, the populations that remain without safe water and sanitation services are often ‘invisible’ to, and thus underserved by, local and national governments. With the estimated water and sanitation coverage in high-income countries exceeding 98% in 2017 (Joint Monitoring Program 2020), the remaining 2% can easily be forgotten or ignored. In addition, current Joint Monitoring Program (JMP) metrics for characterizing WASH access fail to capture disparities in the reliability, quality, and affordability of water and sanitation services. They overlook problems associated with private water supplies such as private wells, which are vulnerable to contamination and may provide only intermittent service (Lockhart et al. 2020; Rowles et al. 2020; Hunter et al. 2021); failing onsite wastewater systems, which may contaminate local surface water and groundwater supplies (Kohler et al. 2016; Schaider et al. 2016; Yang et al. 2016); and lack of affordability, which can lead to water shutoffs (Ifill & Montag 2019). As a result, the true magnitude of WASH inequities in high-income countries is unknown. Nonetheless, there are many case studies that document the health impacts of these under-recognized inequities in high-income countries. Examples from recent literature in the U.S. include reliance on private well water in Wake County, North Carolina, leading to a 25% increased odds of elevated blood lead levels in children (Gibson et al. 2020), poor sanitation in Alabama linked to an increased burden of disease from intestinal parasites (McKenna et al. 2017), and lack of handwashing access contributing to increased rates of COVID-19 among the Navajo Nation (Schmidt 2020; Kakol et al. 2021). Concerted efforts are needed to cover the ‘last mile’ and overcome the structural barriers to safe WASH access in these contexts. In addition, efforts are needed to characterize the magnitude of inequities not adequately measured by the JMP.
Recognizing the need to respond to WASH challenges in high-income nations, organizers from the University of California Merced, the University of Colorado Boulder, the University of North Carolina at Chapel Hill (UNC), Loma Linda University, Indiana University–Bloomington, the University of Twente, Swiftwater Solutions, Dig Deep, and the International Association of Plumbing and Mechanical Officials (IAPMO) convened a session at the annual UNC Water and Health Conference on October 27, 2020 entitled ‘Getting left behind: Ensuring high-income countries achieve water and sanitation for all by 2030 (SDG6).’ The goal of the session was to convene a network of researchers, practitioners, community representatives, and policymakers focused on WASH in high-income country contexts to identify areas of shared experience, challenges, and need. The results below summarize the major themes and priorities as outlined by participants of the session. Citations are provided to refer the reader to additional scholarship on each topic that emerged during the session but are not intended to indicate that the findings are the result of a systematic literature review by the authors. The subsequent discussion section synthesizes the session results into recommendations and action steps for future research, policy, and practice. Thus, this practical paper aims to inform high-income country governments, academics, water and wastewater professionals, and the broader WASH community on future priorities and collaborations needed to achieve universal, equitable WASH coverage in high-income countries.
