<< Return to Table of Contents By Ted Alcorn Clean drinking water and effective sanitation are so ubiquitous in America that it is hard to grasp the magnitude of their impact on the public’s health. But in their absence, water-related disease causes more death and illness than any single cause. The advent of municipal water treatment in the early 20th century is probably responsible for greater gains in life expectancy than any other advance in Western medicine. In lower-income countries that still lack such services, waterborne parasites, diarrhea and resultant malnutrition account for much of the burden of disease, particularly in children under 5 years. As a joint-degree student at The Johns Hopkins University Bloomberg School of Public Health, I can’t remember taking a class that didn’t at some point acknowledge the importance and intractability of water-related problems. Improving the accessibility of clean water, I was instructed, was a preeminent task of public health. In the summer of 2008, I landed a research fellowship to go to Ghana with the Johns Hopkins Center for Water and Health. Typical of low-income countries in West Africa, Ghana’s water sector is burdened by rapid urbanization and frail infrastructure, and nearly half of the capital city, Accra, can’t rely on regular drinking water. The rural population is, for reasons of geography and politics, even less likely to be reached. Supplying them with drinking water was the objective of our work. The project was being implemented by the private corporation WaterHealth International. WHI describes itself as a firm of “social entrepreneurs.” The company partners with rural communities lacking access to clean water and subsisting on untreated river water. They install a small water-filtration and purification facility to produce clean water, and sell it by the bucketful at a low cost. The “WaterHealth Center” is managed over an eight-year period, until the initial investment is recovered, then ownership of the facility is transferred to the community. Thereafter, WHI earns revenues by maintaining this network of kiosks, but all additional profits on water sales accrue to the village. During my stay, I divided my time between tracking down policymakers in the capital and living in the villages that would pilot the project. But the more I learned, the more my attention drifted from the water itself to the systems that ought to have been providing it. Local people knew the health risks the river was exposing them to and were willing to pay for clean water. Why couldn’t the government deliver it—or why didn’t an adequate private market for water exist? I had come expecting to find a public health problem; instead, I seemed to be facing a problem of economics. Government officials I spoke with had a simple explanation for why the public sector wasn’t providing water in rural areas: It is unaffordable. Extending pipelines and upgrading treatment facilities in urban areas consume much of the government’s resources and attention. The private sector doesn’t allow this vacuum to go completely unfilled, however; a scattered industry of small-scale providers has sprung up to serve those who can pay. Tanker trucks rumble down the streets ferrying thousands of gallons of water from public taps to wealthier homes that lie off the piped network, and vendors hawk bagged water from the median to passing motorists. But performance of these providers illustrates the weaknesses of private sector distribution. The providers don’t enjoy the economies of scale of a centralized public system, so the water they sell is more costly than piped water. And because these services are thinly regulated, there are valid fears about water quality. Furthermore, private sector providers turn a profit by cherry-picking customers, supplying water in areas connected by good roads and to people who can afford their exorbitant rates. The poor and the remote are not served at all. Social entrepreneurship charts a middle course, attempting to harness the strengths of a planned network with the decentralization of the private sector. But achieving broad coverage of the population remains a challenge. For every person I met purchasing water at the kiosk, two others would pass down the path to the old collection point on the river, where the water was filthy but free. From WHI’s perspective, achieving a sustainable level of business spells success, but will the community’s health be significantly improved as a result, when even a single lapse from using clean water can result in disease? And how can a private company be made accountable for health outcomes, equality of service and coverage of the population? Faced with the sheer difficulties of providing clean water, I tire of the moralists’ poetic but empty slogan that “water is life” and therefore shouldn’t bear a price. But a true solution for rural water supply can’t, in solving the economics of the project, forget the original public health objectives that it set out to achieve. On my last day in Accra, I accompanied a tanker driver on his rounds. After the final delivery, some water remained in the truck, and he offered it to the neighborhood. As families poured from their homes with buckets and plastic basins, racing to collect those final few gallons, I thought about all of the intangible benefits of dependable, clean, plentiful water: The ability to drink and bathe without fear of disease, the hours liberated from the regular toil of collection, and the simple confidence that water will continue to run clean and pure in the days that follow—a confidence most of us have grown so accustomed to that we hardly recognize it. The world may not yet be able to provide water to all of its residents, but we have an obligation, I think, to invent a new world where that can be achieved. Ted Alcorn is an International Policy concentrator in the SAIS/Bloomberg School of Public Health joint-degree program.
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