Water, sanitation, and hygiene inequities in high-income countries: an introduction and agenda

Problems in water, sanitation, and hygiene (WASH) services in high-income countries are far more common than we may often assume. For instance, 1.1 million people in the United States lack running water in their homes – with access levels deteriorating in prominent US cities since the global financial crisis (Meehan et al. 2024) – and 20% of households in England are living in water poverty (Sylvester et al. 2023). Signature cases such as the lead poisoning of drinking water in Flint, Michigan, USA (Radonic & Jacob 2021), water contamination by forever chemicals in Trissino, Italy (Mastrantonio et al. 2018), and dry season sewage discharges in UK waterways (Usher 2023) speak to an uneven record of providing clean, safe, affordable, and acceptable water and sanitation services, even in high-income countries. Yet, as this Special Issue demonstrates, failures in WASH provision extend beyond such signature cases to include places and populations with less or no recognition. In a future where the climate crisis is expected to intensify and exacerbate existing inequities (Menzies et al. 2022; Anthonj et al. 2024), safe, secure, and equitable WASH services are more important than ever.

The timing of this Special Issue is no accident. In recent years, several research communities have turned their focus to the matter of WASH in high-income countries, a geographic shift from previous research in low- and middle-income countries. This shift was driven by a coalescence of factors, which we discuss in the following section. Transdisciplinary WASH researchers are bringing together compelling insights from work focused on high-income countries, consolidating a foundation for future research in this area (Balasooriya et al. 2023; Brown et al. 2023; Lee et al. 2023). The aim of this Special Issue, therefore, is to catalyse a conversation at the confluence of multiple communities of research and practice, all of which are focused on deepening understanding and actively transforming WASH failures in high-resource settings.

In this introduction, we put forward an agenda towards more equitable WASH services, by identifying research synergies and suggesting productive pathways to move forward together. We aim to do this not only by bringing empirical focus to less recognised situations or marginalised populations in high-income countries, but also by challenging the mindset of ‘development’ research, both globally and locally. First, we set out key terminology and trace the newfound interest in WASH in high-income countries, positioning its emergence at the confluence of multiple fields. Second, we identify key themes that cut across the 11 diverse contributions of the Special Issue, namely, areas of (in)visibility, (mis)trust, power and control, and re-imagining practice.

Finally, we conclude by suggesting future directions, signposting a future research agenda, and raising critical questions for the next steps. We propose this collection as a contribution to the necessary task of re-imagining the provision of services that extend to all people. Looking ahead, we also take this opportunity to offer a threefold agenda for future research in this area: (1) emphasising the importance of WASH in high-income countries in its own right given the increasing inequities in many of these countries; (2) situating it as a focal point of a wider ‘reckoning’ of purpose – including challenging the development mindset – currently taking place within global WASH; and (3) reflecting on the crucial need to confront politics in all WASH research and practice.

As a recent field of study, WASH inequities in high-income countries sit at the confluence of several strands of transdisciplinary inquiry and praxis. This ‘jostling’ of approaches stokes creativity and difference yet also contributes to a dizzying array of distinct terms, frameworks, and approaches. In this section, we trace the diverse intellectual roots of the field through an exploration of three key terms.

First, the acronym ‘WASH’ is well-critiqued from within its own field for binding together three distinct topics and reinforcing an enduring hierarchy, in chronological order. The move to compress water, sanitation, and hygiene into WASH has gone hand-in-hand with the evolution of a global health and development sector (de Wit et al. 2024). This global sector attributes its origins to Victorian era ideals of hygiene and public health in mid-1900s Britain, citing a key intellectual root as John Snow's discovery that cholera was waterborne by tracing an outbreak in London to a public handpump (Cairncross 1992). Equally, scholars and practitioners recognise that public health became a cornerstone of colonial and imperial control in the late 19th and early 20th centuries, before it evolved into a central component of international development (de Wit et al. 2024). Leading voices in the sector have stressed that efforts to strengthen WASH systems will never be successful without addressing wider global structures of injustice (Carter 2021). Others highlight the need to integrate human rights principles into new systems strengthening approaches to ensure that equitable services remain the goal (SWA 2024).

These roots deeply permeate, but they were not widely acknowledged in the sector until approximately 5 years ago. At that time, a wider cultural shift was inspired by pre-existing movements, particularly Black Lives Matter, which led to a period of critical conversation on the origins of WASH and the legacies of inequity in the global sector, including in leadership (Worsham et al. 2020), knowledge creation (Luseka 2020a), financing structures and global targets (Luseka 2020b), research practice (Lue et al. 2023), and power dynamics (Nagpal 2024).

Second, the term ‘inequity’ calls into question conditions that reach far beyond a technological fix. Indeed, the argument that inequities in WASH services – like any environmental or social injustice – are produced through relations of power is a core tenet of scholarship in political ecology, environmental justice, and critical water governance (Swyngedouw 2004; Loftus 2009; McFarlane 2011; Budds 2013; Meehan 2014; Sultana 2018; Meehan et al. 2023b). Over the past three decades, these scholars have developed theoretical resources and amassed a substantial body of evidence that helps explain why inequities persist; who and where experiences them; and how people survive and transform unjust conditions (Meehan et al. 2023b). Key differences exist in theory and method, however. While a focus on water and sanitation problems, particularly in the Global South, is shared with the WASH community, critical scholars tend to view dysfunctional or deficient services as the result of power asymmetries – for example, the political, economic, and racialised conditions that prompted the Flint water crisis (Radonic & Jacob 2021).

Related to inequity are the terms ‘household water insecurity’, ‘water poverty’, and ‘water justice’. Household water insecurity is defined as ‘a lack of safe, reliable, sufficient, and affordable water for a thriving life’ (Meehan et al. 2020: 2; see also Jepson et al. 2017a). The centrality of ‘a thriving life’ as the benchmark of this definition is unmissable, premised on Sen's capability approach as discussed in Jepson et al. (2017a, b). In high-income countries, water poverty literature is primarily concerned with the economic dimensions of water access for households (Yoon et al. 2021; Anderson et al. 2023). This falls under the broader concept of water insecurity, as the affordability dimension of securing water access.

Although the term ‘water insecurity’ originated in geopolitics to characterise transboundary water conflicts (Staddon & James 2014), we use it to recognise the insecurity of WASH beyond ‘home’ or living spaces, to include workplaces, schools, and healthcare facilities, as well as unconventional homes including vans, boats, shelters, and prisons. We use WASH insecurity as an extension of this term to clearly include all matters of sanitation and hygiene, as well as water.

Third, critical development studies recognises that the term ‘high-income countries' itself is contested. Arguably, alternative terms such as Minority and Majority World serve better to clarify hidden global power dynamics (Alam 2008). There is also longstanding debate concerning whether the use of dichotomous language (including Global North and South), and the associated drawing of boundaries, helps or hinders our perspective on the world (Khan et al. 2022). We have chosen to use the terminology ‘high-income countries’ in this collection to emphasise the economic contexts in which decisions around water and sanitation are taken, and which produce conditions of inequity. In high-income countries, the lack of access faced by certain populations cannot easily be attributed to a lack of resources (Roaf & Winkler 2024). For this reason, these discussions are unavoidably political.¹

Across the papers collected here, and key to our summary and ‘call to action’ is a recognition that approaching deeper understandings of diverse lived experiences requires a different set of theoretical and methodological tools. We recognise existing work by Anthropologists² (particularly, the Anthropology of Development), Environmental Sociology, and Human Geography and the increasing use of ethnographic methods for studying water worlds (for instance, Anand (2017) on hydraulic citizenship; Strang (2009) on water in human–environmental relationships; Wutich (2011) on reciprocity, subsistence, and survival). These methods provide holistic and nuanced understandings of systemic discrimination, (in)visibility, and the experiences of those who are overlooked, disavowed, or ignored.

Overall, water, sanitation, and hygiene are simultaneously issues of technology, engineering, anthropology, politics, governance, planning, economics, ecology, and many more. WASH acknowledges that it is on the precipice of a new era (Luseka 2020a; Carter 2021; de Wit et al. 2024; Nagpal 2024), and research emerging from high-income countries has great potential to shape this new era by drawing from anthropological and critical water governance theory and growing anti-colonial sentiments. Given the combination of disciplinary traditions, rather than continuing to struggle for consensus, our agenda with this Special Issue is to find language that supports collaboration between these fields.

The papers collected here represent an array of approaches to uncovering and tackling WASH inequities. In this section, we identify and discuss four common threads that tie the papers together: issues of (1) (in)visibility, (2) (mis)trust, (3) power and control, and (4) the re-imagination of WASH practice.

Inequities are often made to be invisible. Consequently, a major contribution of emerging research in this space is to make WASH inequities visible by evidencing their prevalence, spatial distribution, political and socio-economic production, and lived experiences. Starting with prevalence, our first paper focuses on the issue of ‘big data’, emphasising the underrepresentation of marginalised groups.

In the European Union, the 2020 Drinking Water Directive requires EU member states to advance equitable water services. Huber et al. (2024) examine the evidence for this in different member states, by reviewing reports and interviewing water regulators to characterise disparities in drinking water access among social groups. They find that insufficient data is a major barrier in identifying marginalised or otherwise vulnerable groups, such as Roma and Traveller groups and people experiencing homelessness, as well as other shared concerns across states including service affordability and rural investment. This paper reminds us that overcoming ‘silo-thinking’ is vital, both in terms of bridging disciplines, bringing together types of data and expertise, and in terms of the scales at which we act, looking at holistic local–regional–national coordination.

Big data is a critical lens for making inequities in high-income countries visible, and yet, this data alone will not give us the full picture. Some people may actively resist being captured in such datasets, and others by the nature of their off-grid lifestyles will likely never be fully included in state-level data (Sylvester & Underhill 2024). The importance of addressing gaps in data while ensuring more systematic data collection is the starting point of a committed process of devising and, crucially, implementing just solutions. The data gaps that we need to fill include not just more detailed information about the service levels available to marginalised groups, but also contextual data that allows us to understand the underlying causes of their lack of access (Huber et al. 2024).

Another route towards making inequities visible is through mobilising a human rights lens – as seen in recent scholarship on the right to water (Sultana & Loftus 2012, 2020). In our next paper, Roaf & Winkler (2024) point out that decision-makers in high-income countries cannot use the reasoning of a lack of resources to justify or excuse unequitable access. The authors argue for the application of a human rights lens to research and advocacy on water and sanitation in European countries, motivated by cases of exclusion such as those faced by Roma communities in Sweden, refugees in France, and those experiencing homelessness in Germany. The paper concludes that European actors – including researchers – can learn from actions taken elsewhere in the world to promote universal rights to water and sanitation in high-income countries. Roaf & Winkler (2024) argue persuasively for human rights principles as keys to unlocking more equitable policymaking. More pointedly, these principles make it starkly visible that people have rights to water and sanitation regardless of their legal or financial status, undermining narratives of deservingness or ‘good’ versus ‘bad’ choices leading to different outcomes for individuals or communities. As such, they provide a lens for advocacy and awareness-raising.

Concepts of safety and (mis)trust in services also emerged as a prominent theme in the Special Issue. Trust in institutions is declining in many high-income countries³ (not only regarding water and sanitation) due to a myriad of factors (Citrin & Stoker 2018; Wilson et al. 2023). Yet, water provision is a key institution relying on public trust to function effectively.

In the United States, Pierce et al. (2024) reflect on levels of public trust in water institutions as seen in tap and tap-alternative drinking water consumption and purchasing among predominantly low-income and minoritised individuals in Detroit, Michigan. Using household-level survey data, they analyse how gender, race, and household income correlate with tap distrust and drinking water source choice. This combines to form a nuanced picture of consumer choices and preferences, challenging assumptions of binary choices and querying the relationship between tap water consumption levels, ‘tap trust’, and bottled water consumption. This study considers the local nuances of their research context, citing the lack of transparency around lead and secondary contaminants in water systems, as well as histories of water shut-offs, particularly in low-income and minoritised areas.

Anderson et al. (2024) use creative methods to investigate definitions of ‘safe drinking water’ from technical and lived perspectives, asking how different evidence is valued when making decisions around water supply. Their context is the town of Aviemore, Scotland, where conflict has arisen between residents and the utility after the local drinking water source was changed from surface water (from the nearby loch) to groundwater. Ultimately, the paper argues that current definitions of ‘safety’ in Sustainable Development Goal (SDG) 6 are inadequate as they fail to account for subjective perceptions of what is safe. They argue that non-scientific, alternative ways of understanding safety are crucial to improving public participation in the governance and management of water supplies.

The third thread we draw focuses on questions of power and control. Imbalances of power have historical roots in colonial practices of deliberately choosing to provide services to certain areas and not others in order to maintain control (Mathur & Mulwafu 2018; Kithiia & Majambo 2020; Venis 2023).

Crosson et al. (2024) emphasise the continued use of sanitation as a political decision and tool, particularly in places with substantial power asymmetries. Their research looks at WASH in prisons in the United States, using the first author's autoethnography and key informant interviews with formerly incarcerated people and a prison officer. They emphasise that restricted access to WASH should not be part of sentences – this equates to cruel and unreasonable punishment in international law, violating human rights and UN minimum standards for prisons. Yet, prison power dynamics often directly involve WASH, such as neglecting to repair facilities, undignified designs, and deliberate withholding of access by prison officers. This paper mirrors points made by Roaf & Winkler (2024) concerning ‘inherent dignity’ and the need to promote human rights led solutions within high-income countries, not just as levers for international political negotiations and posturing.

While prisons are settings most starkly characterised by power and control, the issue of public toilets is also connected to this thread. Public facilities are a central tenet of WASH service provision, enabling people to participate in public life, and acting as essential lifelines for people without access to personal facilities in a stable and fixed home environment (Meehan et al. 2023a). Calzo et al.’s (2024) study outcomes associated with restricted access to restrooms for people experiencing homelessness in San Diego, California (USA), asking what facilities people use, whether their choices are restricted, and whether they have issues with skin-related health conditions. They find that the presence of gatekeepers and poor restroom hygiene can lead to restroom avoidance, correlating with increased open defecation and worse health outcomes.

Also concerned with toilet access, but from a different angle, Phiri et al. (2024) approach the case of public toilets in the city centre of Leeds, England, in the context of the nationwide decline in access to public toilets since the 1980s, which has accelerated during a recent period of central government-imposed austerity that has seen cuts to Local Authority budgets. This paper deploys innovative methods, using the Institutional Grammar Tool to analyse the 1936 Public Health Act to determine that the policy undermines infrastructural citizenship. They find that a lack of ‘rules’ means that Local Authorities can escape the obligation to provide and maintain toilet facilities. The authors connect this understanding of governance, policy, economics, and pressure on local authorities to the Right to the City, and the exclusion of some groups of citizens (such as the unwell, the pregnant, the unhoused, and children) from public spaces. This ‘public toilet citizenship’ is positioned as fundamental for participation in civic life, and the authors make compelling connections between health, well-being, and dignity.

Methodology focusing in-depth on legislation is unusual in the WASH space, but powerfully reveals the legacies of state-sanctioned exclusion of certain groups of people from society at large, not just from WASH access. Eminson (2024) explores legislative discrimination against Romany and Traveller communities in the United Kingdom following the UK's Policing, Crime, Sentencing and Courts (PCSC) Act 2022, taking a particular focus on its implications for water and sanitation access. The act is considered as a cumulative addition to over five centuries of persecution via legislation, in addition to sociocultural discrimination against Romany and Traveller people. This study finds that, in further limiting their movements and proscribing historical stopping places, the PCSC Act in 2022 is perceived to restrict culturally appropriate WASH access for Romany and Traveller communities. Eminson explores the impact on survey respondents in light of surrounding debates on human rights and environmental racism.

The centrality of water and sanitation for people's health, wellbeing, participation in society, and lifestyle of choice makes them a means through which to enact power and control. These papers show how this occurs both actively and passively. This circles back to the thread of visibility and the different ways of making inequities visible. While quantitative data on WASH access in prisons is extremely limited, Crosson et al.’s (2024) work centres lived experiences which unquestionably show intense inequities in this setting. Further, while data on Romany and Traveller peoples is very limited, public legislation spanning centuries has consistently, actively discriminated against this group, and the same sentiment is reflected openly in many parts of UK society (Eminson 2024).

Romero-Gomez et al. (2024) carry out similar reflection in the metropolitan area of Barcelona, Spain. They engage theories of accumulation by dispossession and ecological modernisation to expand existing theory on water poverty, arguing that it is much more than just an affordability threshold. Rather, for low-income households, water poverty is a holistic condition that speaks to their lived vulnerability exacerbated by wider state processes of neoliberal governance. The paper emphasises ‘the insufficient consideration of the multidimensionality of the problem’ of water poverty in high-income countries, in which too great a focus on efficiency and affordability impedes wider understandings of the material conditions and challenges facing households. The authors argue for an expanded understanding of water poverty that would encompass experiences of water comfort, or the ‘anxiety, [and] lack of mental and physical comfort [that] may force unsatisfactory consumption habits'. Moreover, future efficiency-led studies need to recognise ‘unjust ecological modernisation processes’ that stem from free market environmentalism policies and systematically disadvantage already vulnerable populations (Romero-Gomez et al. 2024).

We see that WASH inequities are highly contextual, and tied to legacies of social and spatial exclusion, underfunding, marginalisation, and mistrust. In the United States, research shows the interplay of race, class, income, and geography in producing inequity in water services (Baijius & Patrick 2019; Deitz & Meehan 2019). As such, taking meaningful action requires a deep understanding of context, as seen in our fourth thread of ‘re-imagining practice’.

Ripkey et al. (2024) offer an overview of a Centers for Disease Control Foundation partnership with six community-based organisations (CBOs) to test contextualised solutions to WASH inequities in the United States. The authors observe that the data landscape is currently inadequate for accurately measuring WASH access challenges but assert that these are known to impact communities and individuals at intersections of race and class, particularly those who have historically been marginalised and disenfranchised. The authors propose addressing service provision gaps through strategic partnerships with CBOs, which are well placed to conduct impactful interventions due to strong lived experience, contextual understanding, and community trust. The paper goes on to interrogate the features of effective partnership with CBOs, asking how impact can be measured at both programme and local levels.

Nagpal et al. (2024), also working in the United States, argue that current structural and financial support is insufficient (particularly given limits on eligibility criteria and the complexity of application processes) to assist under-resourced and historically underinvested communities. They note that communities require greater assistance to apply for capital expenditure and operating expense financing. As well as infrastructure funding, communities also need water and sewer rates to be adjusted to account for household income, and service providers who serve large under-resourced areas ought to receive long-term assistance for operation and maintenance of these valuable assets.

Both papers make visible certain excluded communities and propose considerate, relational action that can be taken to make impact. Working to rectify inequities is presented jointly with reflection on the state processes of marginalisation.

Achieving just and equitable WASH services for all people is a necessary and momentous task. As reflected in this Special Issue, the efforts must span theory and practice, across a range of sectors and disciplines. The present moment, as we hurtle towards SDG 6, is a critical juncture where normative concepts of ‘universal’ or ‘safely managed’ services are being questioned. If we seek to truly leave no one behind, then we must re-imagine and re-build WASH services in a way based firmly in ideals and practices of equity and justice.

The insights of this essay and Special Issue will help inform global WASH for the 21st century. Our intervention proceeds from a recognition that WASH research and practice is driven by a desire to improve services, conditions, and a ‘thriving life’ for all people. The provocations raised here are targeted at decision-makers, policy-makers, as well as at fellow researchers, and to the WASH field more generally. Ultimately, these provocations are concerned with how we might do better for service users: how we can use transdisciplinary approaches to make hidden inequities visible, how we can integrate technocratic and experiential knowledges, and how our research can contribute to challenging ways in which power is expressed in societies to restrict or deny access to services. Additionally, ways to re-imagine practice-based interventions, demonstrating the merits and challenges of bridging the gap between state-level resourcing and marginal communities. Questions that emerge from this collection include:

• How might we reposition WASH provision as central to civic life and inclusion in society for all?

• Who or what do we make visible through our work? Can we be more intentional in exposing or explaining structural challenges facing communities and service users?

• How do we go about addressing gaps in data? What data do we consider necessary, and for what ultimate purpose do we need to collect it?

• What and whose data do we trust? Whose knowledge do we value? How can we involve citizens alongside ‘experts’ in water management, overcoming mutual mistrust?

• What are the limitations of survey methodologies in investigating complex social phenomena and practises? How can we acknowledge experiential knowledge while retaining a high-level overview and practicing rigorous data collection that is relevant beyond the local context?

• What types of change can we, as researchers, advocate for? How can WASH research help to challenge discrimination and societal exclusion?

• What role can WASH research play in considerations of financing, funding, and affordability for service provision in disadvantaged or under-resourced communities?

• How can we make our research more inclusive, more human?⁴

• Reflexivity: How do we frame our actions as researchers, and the scope of our research? What type of research – and outcomes – do disadvantaged or under-resourced communities want to see?

These challenges present opportunities for further transformation of the WASH field. Therefore, we conclude by gesturing at a future research agenda that asks big questions of the core of WASH theory and practice. This collection demonstrates that sustained attention to WASH in high-income countries is beneficial and necessary in its own right. Additionally, our geographic focus has the potential to challenge the fundamentals of WASH research rooted in development narratives that are now being rewritten. The papers gathered here exemplify different approaches to navigating the power and politics inherent to WASH. Navigating this confrontation with reflexivity can help us to approach complex challenges, by keeping at the fore the wider injustice and structural inequity in their roots.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.