Disconnections and Disease: Water Supply and Health

Dr Gareth Rees, Head Designate, Centre for Public & Environmental Health Research

University of Surrey

Water and health

"All peoples, whatever their stage of development and social and economic condition, have the right to have access to drinking water in quantities and of a quality equal to their basic needs", United Nations Conference; Mar Del Platta, 1977.

During the 19th century irrefutable proof was gathered for the transmission of disease by contaminated drinking water supplies. The seminal work of John Snow, Edwin Chadwick and other Victorian pioneers of public health and sanitation established, beyond dispute, the need for adequate supplies of clean water and appropriate sanitation to protect public health. The results of their work remain central to the supply of water services today.

Approximately eighty percent of disease and sickness incidents worldwide can be related, in some way, to water (Agarwal et al, 1981). Water and disease interact in many ways and at many levels. The association can be apparent, for example the direct transmission of cholera and typhoid by water contaminated with human excrement, or less apparent if the transmission of the disease requires an intermediate vector whose life cycle involves water; for example, the transmission of the malaria parasite by mosquitoes. Extensive studies into the role of water in the transmission and control of disease has generated a classification system that may be used to select appropriate remediation. Four main classes have been identified:

Waterborne disease: Most of the diseases in this class are transmitted by the faecal oral route. The disease is contracted by ingestion of water that is contaminated with the pathogen. Cholera, typhoid, hepatitis A, cryptosporidium and giardia are examples of waterborne diseases. The transmission of the disease is controlled by improving the quality of the water supply.

Water washed diseases: Diseases in this class are prevalent where the quantity of water available is inadequate for hygiene. Bacterial dysentry and several skin and eye infections belong to this class. The transmission of water washed diseases is controlled by improved personal hygiene and by increased water quantity.

Water related insect vectors: Includes diseases that are transmitted by insect vectors that require water to complete their life cycle.

Water based diseases: Diseases in which part of the life cycle of the parasite takes place in an aquatic host.

In this classification system there are no strict divisions between the classes; some pathogens may fit in more than one class. This is particularly true for waterborne and water washed diseases.

Water and health in the UK

Waterborne and water washed diseases are of foremost concern to public health in the UK. Elaborate methods are used to treat source waters to maintain a quality that is considered wholesome within the specification of the England and Wales, Water Quality Regulations (1989). Separate and isolated systems for the supply of drinking water and the removal of wastewater are used to avoid contamination of domestic supplies. Although contamination incidents occur from time to time, it may be assumed that reasonable steps are being taken nationally to control and monitor the quality of the water supply and, therefore, the emerging public health issues will relate to water quantity. This paper takes, as its central theme, the view that the provision of adequate supplies of water for health is a fundamental right of all UK citizens.

International attitudes to water supply

The national reserve of freshwater is not unlimited and it is important that appropriate, integrated water management programmes are instituted to protect this vital resource. But water management and water supply carry a high cost that must be recovered to sustain these activities. The paraphernalia of economics, therefore, is an integral part of water management. Until recently, the World Bank upheld the opinion that the supply of water was an economic issue; intentionally treating it as a commodity. Similar stands were taken by other international agencies. Slowly, however, opinions have changed and at the 1992 UN Conference on Environment and Development (UNCED) in Rio de Janeiro, member countries endorsed policies that stressed integrated water resources management "based on the perception of water as an integral part of the ecosystem, a natural resource and a social and economic good". Subsequently the UN and the World Bank have changed their focus from being supply driven to one that is demand driven (Le Moigne). The social consequences of water supply must be inherent within a demand driven focus.

The World Health Organisation, in its series of declared "Targets for Health for All" for the year 2000 states that all people should have access to adequate supplies of safe drinking water. As a signatory to the declaration, the government of the United Kingdom is bound by this principle. Indeed, the government published a consultation paper entitled Using Water Wisely in which it states that "A plentiful supply of water is fundamental to the quality of human life in the modern world" (cited in Price, 1993).

Although water management has both a social and economic good, it is considered here that the supply of clean, wholesome water for health is of such wide consequence that the social good must prevail over any economic argument.

Health consequences of low water use and disconnection from supplies

Following the privatisation of the water industry there was an unprecedented rise in the number of households disconnected from water supplies. Between 1989 and 1992, the number of domestic disconnections rose from around 8,000 to over 21,000 (OFWAT, 1993). At the same time the number of notified cases of dysentry, due to Shigella sonnei, and hepatitis A increased substantially to the highest levels since 1969 (Anon, 1994). The possible correlation between these two events prompted epidemiological investigations into the health impacts of water disconnection (Fewtrell et al, 1994; Middleton et al, 1994) and a considered review of the potential health consequences of water disconnection by the British Medical Association (1994). Concurrent with these studies was a series of analyses of the social and health impact of low water use resulting from "water poverty" and "water debt" (Herbert and Kempson, 1995; Lister, 1995; McNeish, 1993).

Many studies have shown that there is a correlation between the use of water for personal hygiene and the control of transmission of gastrointestinal infections (for example, Black et al, 1981). However, there have been few investigations of the social and health impacts of water disconnection or of inappropriate low water use due to cost saving. Middleton and co-workers (1994) cite several cases in the Birmingham area of extreme hardship caused by disconnection of water supplies: people unable to take prescribed tablets without water; one family with two children with sickle cell anaemia who were disconnected twice within six months; one household infested with rats in which the family was unable to wash themselves clean of rat poison. Furthermore, Fewtrell and colleagues (1994) observed a significant correlation between the numbers of disconnected households and the incidence of hepatitis A and shigellosis in the Hull and Beverley area. From further analysis of the data, Fewtrell concluded that there was a stronger statistical association with economic depravation and then proceeded to dismiss the impact of disconnection. However, these observations would be anticipated if the points of disconnection form a focus for the development of disease which is rapidly transmitted to contacts who may be using inadequate quantities of water due to economic deprivation. Households that are disconnected from water supplies might not seek medical advice whilst trying to overcome more compelling problems (Middleton et al, 1994) thereby reducing their impact on the medical statistics upon which retrospective studies rely. Furthermore, disconnected households are resourceful in obtaining alternative supplies from neighbours and friends. These supplies may be sustainable for a short period only, after which the household may be compelled to use untreated sources of water of unknown composition. Therefore, it is premature to dismiss the role of water disconnections in the development and transmission of disease.

For households and individuals on low income, water has become an increasingly expensive commodity. Where water meters have been introduced there is substantial evidence to show that low income groups restrict water use (McNeish, 1993) to the potential detriment of their own health. Fifty four percent of hardship households reported reductions in the use of the toilet and seventy three percent reported reductions in the use of the bath or shower (Lister, 1995).

The issue of water quantity is not simply one of water disconnection. Enforced reductions in water use due to economic deprivation may be of greater public health concern and should be considered as an integral part of the water quantity debate.

Paying for water services

The production and provision of clean water to consumers is expensive both in terms of initial capital outlay and in ongoing operation, maintenance, management and extension of services. However, the payment of charges and levies for water supplies is frequently an emotive issue (Howard, 1995). It is essential for the long-term sustainability of the water sector that costs are recovered. Where cost recovery has been ignored, the effect has been a deterioration of infrastructure which eventually leads to the complete breakdown of systems, absence of adequate water supply and an increased public health risk. In addition, the cost of treatment and disposal of return flows of wastewater must also be recovered. The principles and mechanisms of cost recovery have been considered by the WHO and published as a handbook (WHO, 1990).

After the year 2000 water companies in the UK will not be permitted to use rateable values as the basis for charging for water and sewerage although the Water Services Association, on behalf of the water companies, maintains that it is an appropriate mechanism for cost recovery. Conversely, OFWAT supports the introduction of water meters to link directly cost with use. It is proposed that water meters would assist water companies to identify high users and that by directly linking cost to volume, water meters would have an overall environmental benefit from reduced water usage without compromising public health.

Public attitude to the introduction of water meters has been mixed. A study carried out by WS Atkins, on behalf of the Department of the Environment and OFWAT, concluded that most households had not experienced any difficulties as a consequence of metering and thought that it was reasonable to meter water. Of those in the study who experienced hardship, only 32% thought it reasonable to meter water.

Irrespective of the method of charging water, it is low income families who pay the greatest proportion of income in water bills. As the cost of water continues to increase in excess of inflation, and water companies such as Yorkshire Water return record profits despite a year of poor service and controversy, the financial burden upon low income families will grow. This has been acknowledged by the chairman of OFWAT in his introduction to the 1994/95 OFWAT report where he states "...what is apparent is that increasingly some family units will continue to have difficulty in paying bills and that there will be continued pressure for a change in the law to enable companies to show preference to such customers in their tariffs". Many of these family units are being driven into water debt (Herbert and Kempson, 1995) and ultimately to disconnection.

In England and Wales the water companies are legally entitled to disconnect from water supplies for non-payment of bills. They argue that to remove this entitlement would encourage non-payment of bills. In Scotland and Northern Ireland, disconnection is illegal and there is no evidence to suggest that there is a higher incidence of non-payment. By continuing with a policy of disconnection, the water companies are ignoring the social importance of water. Disconnection should never be an issue and it is proposed here that a system of charges is introduced that would eliminate the need for disconnection. For this proposal to operate it is accepted that water meters will be installed at all households to measure water use.

Proposal

The proposal is simple; water services to all households should be delivered free of charge to a volume of water that is required for health and hygiene. The use of additional volumes of water will be charged on an incremental scale.

The aim of the proposal is to control overuse of water without compromising public health.

There is significant preliminary work required before this proposal can be implemented:

·Water companies must accept the principle that water is a social issue and not an economic issue. The incentive for water companies should be the protection of public health and not the financial interests of their shareholders. During the implementation of the proposal, the profits of water companies and the dividends paid to their shareholders shall be reinvested to supply water meters free of charge to all households and to reimburse households who have paid for the installation of a meter.

·A national study shall be developed to determine an acceptable volume of water for the UK that is require for health and hygiene. Special consideration shall be given where there is a particular medical need for water. This volume of water will be supplied to all households free of charge.

·A structured scale of charges for additional volumes of water shall be developed to ensure the long-term sustainability of the water companies. Dividends to company shareholders and profit beyond that required for reinvestment will be excluded from the calculations.

·The government must fund a programme of public education to ensure general understanding of the reason behind the installation of water meters and to allay fears that it will incur additional cost to the household.

·At the same time the methods must be developed to educate the public in appropriate methods of reducing water use that do not compromise health.

It is proposed that the work should be completed and the policy introduced by the year 2000.

References

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G. and Tinker. J (1981)

Anon. (1994) No need to run dry. Lancet, 344 , 1-2.

Black, R.E., Dykes, A.C., Anderson, K.E.,Handwashing to prevent diarrhoea in day-care centres. American

Wells, J.G., Sinclair, S.P., Gary, W.G.,Journal of Epidemiology, 113, 445-451.

Hatch, M.H., and Gangarosa,E.J. (1981)

BMA (1994) Water- A vital resource. British Medical Association, London.
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Herbert,A and Kempson, E. (1995) Water debt and disconnection. Policy Studies Institute, London.

Howard, G. (1995) Cost recovery in drinking water supplies; background paper for the Black Sea Regional Workshop on drinking water quality. Istanbul.

Le Moigne, G.Change of emphasis in World Bank. New World Water 17-21

Lister, R (1995) Water poverty. Journal of the Royal Society of Health , 80-83.

McNeish, D (1993) Liquid Gold. The cost of water in the '90s. Ilford: Barnardos.

Middleton, J.D., Saunders, P. and Water disconnection and disease. Lancet, 344, 62.

Corson, J. (1994).

Office of Water Services. (1993) Annual Report 1992. HMSO, London.

Price, H. (1993) Disconnections of domestic water supplies. Environmental Health, June, 173-175.

WHO (1990), Handbook of Financial Principles and Methods. World Health Organisation Working Group on Cost Recovery. WHO/CWS/90.10.

Dr Gareth Rees is the Head Designate of the Centre for Public and Environmental Health Research of the University of Surrey, and Head of the Department of Environmental Management at Farnborough College of Technology. He has achieved international recognition for his work in the field of water quality and health. He is advisor to the EC on water quality and to the House of Lords Select Committee on European Affairs on recreational water issues. He has worked extensively in conjunction with the Environment Agency, the Department of the Environment and various non-governmental organisations. In June 1995 he gave an expert presentation on Water Resource Management to the European Parliament hearing on water policy.