How water infrastructure can advance health equity

A cholera epidemic struck Chicago in 1854, killing one in every 18 residents. The devastating waterborne disease, which could kill in under 24 hours, threatened the small midwestern town that was quickly growing into a burgeoning metropolis. A year later, the city embarked on an ambitious engineering project to design and build America's first comprehensive sewer system.

When we consider the greatest public health achievements of the last 150 years, we typically think about the development and widespread use of vaccines or the discovery of antimicrobial drugs. Sewer systems don’t usually top the list. But they should. Sewer systems dramatically reduced waterborne diseases, like cholera and typhoid. Both were significant causes of illness and death in the early 20th century.

Today, we’re in the midst of a huge generational investment in our nation’s public health, even though we don’t typically think about it that way. The Bipartisan Infrastructure Law, enacted by President Biden in 2021, made a $50 billion investment in water. Just as building a comprehensive sewer system in Chicago addressed the cholera epidemic, investments in water infrastructure today can drive transformative public health achievements. On the flip side, underinvestment in water has compromised the health of an entire generation of children in communities that have traditionally been underserved.

We’re only at the tip of the spear in spending the $50 billion in water investments. Modernizing our water systems and improving operational efficiency is critical, but we cannot squander this opportunity to ALSO advance health equity. The way we do this is by centering people: prioritizing communities that have experienced a lack of investment, such as communities with low incomes or communities of color; helping those communities unlock federal dollars; and ensuring they have the power to shape the policies and systems impacting their lives.

Prioritizing communities

Investment in water infrastructure isn’t just about the dollars; it’s about the communities and the people, the equity in access and results. The Jackson, Mississippi, water crisis shone a light on what happens when we let our water management system become inequitable and highlighted why we have to make decisions about investment and implementation with an eye toward rectifying historical disparities. That requires prioritizing communities like Jackson.

Just two years ago, a deep freeze hit the majority Black capital of Mississippi, leaving nearly 150,000 residents without safe drinking water. As head of the Environmental Protection Agency’s (EPA) Office of Water, I met with grandmothers caring for their grandchildren, who had to boil water just to give them baths. And I visited with Jackson State University students to learn how the water crisis was disrupting their education. Imagine what it would have been like to have to leave your dorm room to use a port-a-potty and a portable shower before heading to class every morning? Young people working hard to get a degree should not have to worry about whether drinking water in their faucets is safe.

A history of disinvestment in water infrastructure led to this crisis, and it's on track to become a common occurrence as the U.S. experiences more extreme climate events. This legacy of structural racism results in early health disparities that later become significant inequities in health. For example, lead exposure is more likely to affect communities of color, and it results from underinvestment in water infrastructure. Studies have shown that Black children consistently have higher blood lead levels than white children, which can have significant consequences for their long-term health. Among other serious health effects, lead can affect children’s brain development, resulting in behavioral changes and lower education attainment.

That’s why ensuring communities like Jackson benefit from historic investment in water infrastructure is so critical — we must get funding into the hands of the people who need it most. Every single state has communities that have long experienced a lack of investment in both rural and urban areas. We must commit to bringing those communities to the table and giving them their fair share of funding.

Helping communities unlock federal dollars

But it will take more than prioritizing these communities. Many communities that would benefit most from federal funding for water infrastructure lack the staffing capacity, technical expertise, or financial capability to apply. These communities won’t be able to unlock federal dollars and financial opportunity without intentionality.

We must do more to help communities build the necessary human and financial capacity to secure and deploy funding. For example, a Robert Wood Johnson Foundation loan to Communities Unlimited, a nonprofit community development financial institution, is enabling the organization to provide loans to water utilities in seven Southern states to pay for the design and engineering plans, environmental studies, and legal expenses needed to apply for federal water funds to upgrade infrastructure for drinking water, wastewater, and stormwater. Communities Unlimited projects that this investment will secure at least $75 million in public funding for 100 communities in the U.S. South and lay the groundwork for replication in other regions.

The reality is that very few of the communities that would benefit from federal funding the most have successfully accessed it. In fact, only 10% of water systems in the U.S. have ever successfully accessed State Revolving Fund (SRF) programs, the largest funding source for water infrastructure administered by the EPA.

In addition to the kinds of assistance RWJF provides, the EPA is collaborating with state SRF programs to share models and examples to help build the capacity needed to target resources to communities that have historically experienced a lack of investment. The EPA also launched a $500 million technical assistance program to help communities at every step of the process, from identifying projects to applying and managing them. All these efforts are working. Communities across the country are in the pipeline to get funding when they never have before.

Ensuring communities are empowered to shape policies and systems affecting their lives

Finally, we have to ensure communities have the power to shape the policies and systems that affect their lives. From the outside looking in, all the ways communities encounter structural racism aren’t always apparent. However, community members understand how current water infrastructure and public health systems often fail them and how challenging living in a community without access to safe drinking water and vital clean water infrastructure can be.

And yet, people and communities most affected by poor quality and unsafe water are often excluded from water policy, planning, funding, and project decisions. Organizations and agencies that hold power in water decision-making are rarely diverse and lack representation of communities most affected by water inequities. We have to change that. In other words, we must approach this work so that we aren’t imposing policies on people but building capacity for communities to steer their own work.

Consider the outcome when the community impacted has a seat at the table. For example, organizations like the Community Water Center in California help communities organize and advocate for water solutions driven by their residents.

When large agriculture companies wanted to drill deep wells to tap into groundwater following a drought — a practice that has historically dewatered local wells for communities who rely on this precious resource — residents in the San Joaquin Valley came together to voice their concerns. That community input led to the rejection of six groundwater management plans that, if passed, would have put 127,000 people at high risk of losing their water supply entirely by 2040.

A path forward for water

Water is essential to everything we do. It sustains us, keeps us clean, fuels the farms and ranches that feed us, and maintains our health. But, the systems safeguarding and managing our precious water resources across the country are aging and outdated. In many communities, essential parts of the drinking water and wastewater systems were built more than a century ago.

The situation is even more challenging for communities where infrastructure investment was uneven or never came, leaving millions across America lacking essential water services. Aging, overstretched, and inadequate water infrastructure puts our communities at risk, compromising the health of a generation of children.

But by fully embedding equity into federal funding, accessing that funding, and bringing communities to the table to chart their own future, we can ensure that the largest-ever investment in our nation’s public health system — water infrastructure — will create healthier, thriving communities.