Water infrastructure and health in U.S. cities☆
Introduction
Poor water quality remains a major threat to human health. As of 2019, 2.2 billion individuals lack access to safely managed drinking water, leaving them vulnerable to typhoid fever, cholera, and other water-related diseases.1 Each year 11–21 million persons contract typhoid fever after consuming contaminated water and about 200,000 of those individuals die as a result. Additionally, 485,000 of the 1.6 million diarrheal deaths that occur each year are thought to be a direct result of contaminated water. These figures are despite a 2010 United Nations resolution recognizing clean drinking water and sanitation as human rights.2
Today residents in developed countries are largely insulated from these threats, but that was not always the case. The network of mains many rely on to safely transport water and waste were developed en masse during the 19th century. Before then, a typical urban resident obtained water from wells and pumps and disposed of human and household wastes in privy vaults and cesspools.3 This arrangement frequently led to the contamination of local water supplies, leaving city dwellers susceptible to the same illnesses that continue to plague today's developing countries.
What lessons might developing countries take from the historical urban experience? The answer to this question is complicated, as the path that cities took to eliminate the threat of waterborne disease is not a perfect analog for the challenges associated with providing safe water and sanitation today. One of the more universal features is the reliance on large infrastructure investments. Thus, policymakers often turn to history in order to gain an understanding of the short and long-run social returns to improving water and sanitation.
This article examines how cities in the United States came to eliminate waterborne illness and the extent to which the costs associated with improving the sanitary environment were offset by health and productivity gains. The article highlights both the forces that shaped sanitary investment and how the implementation of these investments informs the set of methodological approaches one can use to quantify these returns. This provides a useful framework for researchers interested in understanding the impact of sanitary infrastructure on health and urban development.
The decision to focus on the U.S. experience is driven by space considerations. The technological, political, and economic innovations discussed in this paper are not uniquely American. It is also not the case that U.S. cities were uniquely susceptible to waterborne illness. However, a theme of this article is that historical features inform methodological choices and so it is necessary to provide an overview of the history. While many settings could be considered, a useful feature of the United States experience is that investments were heavily decentralized, occurring mostly at the local-level. A byproduct of decentralized investment is a substantial amount of variation in both the timing and types of investments that were made across U.S. cities, which is useful for generating well-identified evidence for a range of potential infrastructure solutions.
Section snippets
Causes and consequences of typhoid fever
For most of the 19th century Americans suffered from waterborne diseases in large numbers. We lack precise estimates of the scale of the problem because of incomplete and inaccurate vital statistics. Typhoid fever mortality offers the closest approximation since, at least until the early 20th century, typhoid fever deaths were due almost exclusively to contaminated water. We also know that the case fatality rate of typhoid fever during this time was between 5 and 10%. Thus, for every observed
Evolution of infrastructure investment
Urban waterworks construction occurred in several phases. To fix ideas, Fig. 1 plots trends in waterworks construction among U.S. cities. The sample includes any incorporated place with a population of 2500 or more as of 1900. Each bar represents the number of waterworks constructed in a given year, with data on waterworks construction coming from Baker (1897). The solid black line represents the cumulative share of the 1900 urban population residing in cities that have a waterworks. The first
Eliminating typhoid fever in American cities
Typhoid fever death rates are a key metric for assessing the efficacy of clean water interventions during this period. As Whipple (1908, p.228) stated: The relation between [water quality and typhoid death rates] is so close that the typhoid death-rate has been often used as an index of the quality of the water. Generally speaking, it is safe to do this; a very low death-rate indicates a pure water, and a very high rate, a contaminated water. Typhoid fever mortality is an imperfect proxy
Quantifying the health benefits of sanitation
A skeptical reader might discard the idea that water purification generated large benefits on the basis that waterborne diseases, like typhoid fever, were not a major killer. The most comprehensive source on mortality during this period is the US Census Bureau's “Mortality Statistics” publications, which start in 1900.19
Aggregating costs and benefits
The previous section indicates that infrastructure investments were influential in eliminating waterborne disease but the effect of any one intervention depends on other external factors. In general, it seems that for each typhoid fever death that was prevented there were 2–5 deaths from other causes that were also prevented. This suggests that water improvements could explain anywhere from 20 to 40% of the mortality decline between 1900 and 1940.
What did the gains look like in a typical city?
Conclusion
Between 1880 and 1930 American cities eliminated the threat of waterborne disease by investing in water and sewer infrastructure. This article reviewed the forces that guided those investments and the various tools used to improve the sanitary environment. The article assessed the impact of these investments on health. The evidence suggests that the economic value of eliminating waterborne disease far exceeded the cost of investment.
The arrival of safe water and sanitation in U.S. cities
Author statement
All work was completed by Brian Beach and there are no financial sources to disclose.
Declaration of competing interest
I, Brian Beach, have no conflicts of interest to disclose.
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This article indirectly benefited from many conversations that I had with Werner Troesken. Werner's enthusiasm for sanitation and health was infectious, and I am grateful to have had the opportunity to work with him. I am also thankful for feedback from Walker Hanlon, Dan Rees, Martin Saavedra, the editor (Laurent Gobillon) and two anonymous referees.