March 21, 2023

An article published online March 14 by The Lancet Global Health explores what one researcher calls “the unfinished business of water and sanitation in rich countries.”

Dr. Joe Brown

Dr. Joe Brown

The review was led by Joe Brown, PhD, PE, associate professor of environmental sciences and engineering at the UNC Gillings School of Global Public Health. Brown worked with an international team of co-authors to collect evidence and examples of current trends in safe water and sanitation access.

The researchers conclude that while it’s common knowledge that clean drinking water and quality sanitation services confer widespread health benefits, gaps in this essential public health infrastructure persist — even in high-income countries (HICs).

Most attention around basic infrastructure and health is focused on low- and middle-income countries, where the public health burden of poor-quality services is greatest. But in some HICs, existing gaps are actually growing, driven by structural inequalities, racism, housing instability, poverty, migration, climate change, and insufficient investment and planning.

“We’re hoping this piece will raise awareness,” Brown says. “By placing this paper in a global health journal, we are trying to break down the artificial separation between ‘local’ and ‘global’ on this topic, which focuses primarily on low-and middle-income countries. People often assume that high-income countries, including the United States, provide reliable water and sanitation services for all. The reality is that the infrastructure is highly variable across settings within these countries. As services have expanded over the past two centuries, marginalized groups have been excluded and this legacy continues to the present. Still, these disparities can be undone if governments are proactive in changing course.”

Brown and his co-authors note that in high-income settings, it’s uncommon to find studies quantifying how much disease is linked to a lack of water and sanitation services. However, case studies from underserved communities and data from targeted studies of microbial and chemical contaminants point to ongoing disparities in access.

Highly visible cases like the lead crisis in Flint, Michigan, and the ongoing lack of adequate water and sanitation in refugee camps in Greece are reminders that service gaps can deeply affect the health and quality of life of affected populations, even in countries with ample resources.

Ultimately, the researchers conclude that non-discrimination — the bedrock principle of human rights law — is of particular relevance in HICs, where only a small percentage of the population is denied access to reliable water and sanitation services.

In the U.S., for example, Native American households are 19 times more likely — and Black or Latin American households nearly twice as likely — to be without functional water and sanitation access than households that identify as white.

“My collaborators on this paper come from Australia, Canada, the Netherlands, Slovakia, Austria and the United Kingdom, as well as locations across as the U.S.,” says Brown. “We represent a variety of disciplines, and this review brings in concepts from human rights, environmental justice and systems thinking together with public health engineering. We want to shed a light on the fact that persistent disparities in water and sanitation access in wealthy countries cannot be adequately explained by an absence of resources or capacity. Instead, we highlight the roles that discrimination and systemic racism play in reinforcing inequality and limiting the reach of infrastructure. It is not a coincidence that the most visible gaps in access to safe water and sanitation are among ethnic and racial minorities. They have been excluded from essential services through explicit policy choices, including inaction and a failure to redress historical wrongs.”

The researchers contend that truly satisfying the human right to clean water and adequate sanitation services in HICs will require meaningful change from the status quo. They recommend that governments apply a systems approach to the problem; collect publicly accessible, disaggregated data on infrastructure access; center underserved groups in all new approaches; and create actionable policies that recognize safe water and sanitation provision as something a government is obligated to provide to all people within its borders.

“This is an important paper,” says Barbara Turpin, PhD, chair of the Department of Environmental Sciences and Engineering at the Gillings School. “Dr. Brown has been looking to see whether the U.S. is honestly meeting the World Health Organization’s sustainable development goals for water and sanitation services. In this piece, he and his co-authors point out the data gaps that allow us to think we are — but really, we are not. This is clearly a health equity issue.”

Contact the UNC Gillings School of Global Public Health communications team at

Visit our communications and marketing team page.
Contact with any media inquiries or general questions.

Communications and Marketing Office
125 Rosenau Hall
CB #7400
135 Dauer Drive
Chapel Hill, NC 27599-7400