Towards safe drinking water and clean cooking for all

The public health community has tried for decades to show, through evidence-based research, that safe water, sanitation, and hygiene (WASH) clean cooking fuels reduce household air pollution are essential safeguard save lives in low-income middle-income countries. In the past 40 decades, there have been many innovations development of low-cost efficacious technologies WASH pollution, but these associated with disappointing outcomes, often because households either not adopted, or inconsistently technologies. this Viewpoint, we argue researchers (ourselves included) had an oversimplified understanding poverty; our work focused on insights into lived experience poverty, its uncertainties, stresses from constant scarcity, attendant fears. Such central why water unused by so could benefit them. We that, rather than improved versions household-scale delivery models, transformative investments all require utility-scale service models. Until then, research should focus interim options directed towards model. IntroductionUniversal access remains elusive goal sustainable development. Global is strewn examples devices unused, cookstoves forgotten about. Active debates exist countries (LMICs) do use simple, measures improve their quality life. Even when adopt measures, correct consistent frequently practised; filters replaced, chlorine replenished, traditional, solid-fuel stove continues alongside cleaner-burning, more efficient stoves.1Amrose S Burt Z Ray I Safe drinking regions.Annu Rev Environ Resour. 2015; 40: 203-231Crossref Scopus (49) Google Scholar, 2Ruiz-Mercado Masera O Zamora H Smith KR Adoption sustained cookstoves.Energy Policy. 2011; 39: 7557-7566Crossref (273) 3Clasen T Let “A” stand air: integrating interventions (HAP) sanitation (WaSH) settings.Environ Health Perspect. 2019; 12725001Crossref PubMed (24) Scholar Epidemiological models suggest high adherence needed reach measurable benefits.4Brown J Clasen High necessary realize gains interventions.PLoS One. 2012; 7e36735Crossref (145) 5Enger KS Nelson KL Rose JB Eisenberg JNS joint effects efficacy compliance: a study treatment effectiveness against childhood diarrhea.Water Res. 2013; 47: 1181-1190Crossref (89) However, meticulously designed studies concerning domestic energy unable enough levels habitual LMICs.6Smith Sagar A Making available: escaping India's chulha trap.Energy 2014; 75: 410-414Crossref (95) 7Reygadas F Gruber JS Dreizler L Measuring user compliance cost-effectiveness programs: cluster-randomized ultraviolet disinfection rural Mexico.Am Trop Med Hyg. 2018; 98: 824-834Crossref (4) 8Parvez SM Azad R Rahman M et al.Achieving optimal technology behavioral uptake single combined nutrition, trial (WASH benefits) Bangladesh.Trials. 19: 358Crossref (33) Furthermore, several treatments cookstoves, even correctly used, meet minimum WHO standards human health.9Champion WM Grieshop AP Pellet-fed gasifier stoves approach gas-stove like performance during in-home Rwanda.Environ Sci Technol. 53: 6570-6579Crossref (37) 10Roden CA Bond TC Conway Pinel AB MacCarty N Still D Laboratory field investigations particulate carbon monoxide emissions traditional cookstoves.Atmos Environ. 2009; 43: 1170-1181Crossref (240) ScholarThe collective cost unsuccessful attempts enormous: globally, 0·8–1·8 million deaths annually attributed unsafe (WASH),11Landrigan PJ Fuller Acosta NJR al.The Lancet Commission health.Lancet. 391: 462-512Summary Full Text PDF (1821) solid leads 1·6–3·8 annually.11Landrigan Children younger 5 years most vulnerable group respect microbial contamination inadequate WASH, which common form low-resource settings. Household affects women men they primary cooks households. Women also affected usually expected collect be responsible management. Therefore, investing cleaner gender equality.A considerable body exists possible reasons low cheap LMIC households.12Figueroa ME Kincaid DL Social, cultural correlates storage. Johns Hopkins Bloomberg School Public USAID, Baltimore, MD2010Google For shown (null) results regarding devices.6Smith 13Schmidt W-P Cairncross poor populations: evidence scaling up now?.Environ 986-992Crossref (204) 14Pickering AJ Null C Winch Benefits SHINE trials: interpretation intervention linear growth diarrhoea.Lancet Glob Health. 7: e1139-e1146Summary (153) Researchers provided free encourage devised educational social marketing campaigns increase awareness value indoor air, little avail.15Luoto Najnin Mahmud al.What point-of-use products consumers use? Evidence randomized controlled among urban Bangladesh.PLoS 6e26132Crossref (55) 16Burt Njee RM Mbatia Y al.User preferences willingness pay water: experimental Tanzania.Soc Med. 2017; 173: 63-71Crossref (25) 17Kirby MA Nagel CL Rosa G al.Effects large-scale distribution natural draft rocket-style diarrhea acute respiratory infection: western province, Rwanda.PLoS 16e1002812Crossref non-governmental organisations developed strategies promote behavioural change applied peer-pressure tactics nudges products, mixed effects.18Thaler RH Sunstein CR Nudge: improving decisions about health, wealth happiness. Penguin Group, New York, NY2009Google 19Mosler H-J systematic behavior sector developing countries: conceptual model, review, guideline.Int 22: 431-449Crossref (220) 20Guiteras RP Levine DI Luby SP Polley TH Khatun-e-Jannat K Unicomb Disgust, shame, soapy tests novel hygiene.J Assoc Resour Econ. 2016; 3: 321-359Google 21Kar Zerriffi From cookstove acquisition transition: framing aspects interventions.Energy Res Soc Sci. 42: 23-33Crossref (42) ScholarIn researchers, ourselves included, internalised everyday complexity poverty. Viewpoint based own economics, cognitive science, anthropology, deeper First, available Second, show providing universal model Third, behaviour individuals, although necessary, might alleviate financial stressors keep adoption low. Finally, imply provision services just best practice—the policy already accepted idea22WSUPThe supply guide: communities.https://www.wsup.com/insights/the-urban-water-supply-guide-service-delivery-options-for-low-income-communitiesDate: 2014Date accessed: December 2, 2020Google Scholar—but method possibly only energy, as called Sustainable Development Goals.Affordability US$2 per person dayMany provide burn labelled particularly affordable literature, upfront costs durable systems, such ceramic stoves, calculated, operation, refills, education, unpaid family labour always accounted for.23Smith What's cooking? brief update.Energy Sustain Dev. 2010; 14: 251-252Crossref 24Fonseca Franceys Batchelor al.Life-cycle approach: WASHCost Briefing Note 1.https://www.ircwash.org/sites/default/files/Fonseca-2010-Life.pdfDate: 2011Date role income (or who controls it) neglected calculation affordability, other suggestions generic thresholds;25Hutton benefits reaching coverage drinking-water supply.J Water 11: 1-12Crossref (68) 26Nussbaumer P Bazilian Modi V poverty: focusing what matters.Renew Energy Rev. 16: 231-243Crossref (323) meaning cost, consideration need non-discretionary expenses (eg, food), defined. literature rarely extended beyond economic indicators understand feels affordable. Perhaps importantly, money management looks members live off $2 day.Financial stress people povertyPeople simply less money; engaged meagre cash flows. Collins colleagues27Collins Morduch Rutherford Ruthven Portfolios Poor: how world's day. Princeton University Press, Princeton, NJ2009Crossref showed earns day does steady income: can days earn $1 $3. Thus, will continually make tradeoffs basic needs. example, daily budgets food potentially small debts neighbours local storekeepers, given loans out help helped them past. trying some emergencies somewhere theft temptation. Banerjee Duflo28Banerjee AV Duflo E Poor Economics. Affairs, NY2011Google suggested “they [people poor] sophisticated economists survive”. juggling takes substantial time effort, one has, forced juggle.28Banerjee circumstances, it seem unnecessary purchase product at certain uncertain immediate; everyone drinks untreated becomes sick. liquefied petroleum gas cylinders, using, prohibitive.16Burt 29Gould CF Urpelainen LPG fuel: adoption, use, impact India.Energy 122: 395-408Crossref (122) Buying generous loan feel risky. Yet days, perhaps brought $3, hard resist toy grandchild, nail varnish daughter, if bottle liquid chlorine. efforts cannot alter realities.Cognitive povertyPoverty imposes Mullainathan Shafir30Mullainathan Shafir Scarcity: having too means much. Picador, NY2013Google call bandwidth tax; poverty uses capacity worries manage flows, earned multiple jobs. Ethnographic mental Bangladesh named chinta r?g, worry disease.31Selim Cultural dimensions depression Bangladesh: qualitative two villages Matlab.J Popul Nutr. 28: 95-106Crossref (29) People report children, onset emergency, permanent states exhaustion. They tenuous sanitation. When consumed immediate future needs, long-term stability, lose salience.30Mullainathan Saving expense, cylinder refill gas-fuelled stove, fall outside bandwidth. Understanding living scarcity foundational way circumstances. To knowledge, no barriers of, non-compliance with, approaches factored tax Behaviour hard, say, after set null results. But especially families whom everything hard.Safe energy: service?The become scaled habitual, made easy use. nudge-theory terms, default option health-promoting option.18Thaler fuel needs mimic utility service. chlorinated piped premises, long bills affordable.32Burt Ercümen Billava intermittent continuous service: costs, benefits, equity sustainability system reforms Hubli-Dharwad, India.World 109: 121-133Crossref (20) Additionally, cylinders subsidised refills delivered home, charges affordable.6Smith 33Lewis JL Bhojvaid Brooks al.Piloting India.J Commun. 20: 28-42Crossref (31) easier choices today's market continue conventional practices, practices habits free. Adding bucket agitating waiting before compared water. instead switching fuels, stacking wood older unimproved makes easier. likely rewards—eg, mainly fast convenient.33Lewis By contrast, biomass-burning despite aggressive promotion, unused.In favour whether systems centralised, small-grid, hybrid,34Hoffmann Feldmann U Bach PM al.A agenda management: exploring potential nongrid, small-grid hybrid systems.Environ 2020; 54: 5312-5322Crossref (45) treated services. piped-in safe, well practice regularly left household.14Pickering 35Cumming Arnold BF Ban implications three major new trials effect stunting: consensus statement.BMC 17: 173Crossref (100) need. This unwilling take personal responsibility “people's ability shaped circumstances.”36Marmot gap: challenge unequal world. Bloomsbury, London2015Google expect education creative methods scale current access, limited circumstances Rather, exercising requires effort thought. delivering is, all, high-income and, increasingly, better countries.We making ethical point stuck choices.3Clasen pragmatic argument, drawing intentioned get adopted used scale. reduce, add to, contend daily, science. Research behaviours implicitly attributes take-up inconsistent households.The stateHow implement deliveries utility-based otherwise regulated model? expensive, centralised decentralised, conventionally considered expensive communities. reason, point-of-collection scale, conveyed short-term discussion implemented. perspective cost–benefit analysis, questioned: waterborne diseases high, disproportionately borne those least afford pay.3Clasen rational reliable convenient spend (and engineering talent) few from. debate here pays pay. Do recovered (which case devices) state (ie, taxpayer) subsidise communities?State-subsidised programmes established at-scale LMICs. An example includes China's project (the National Improved Stoves Programme); programme enabled 100 households, coordinated ministries, county village officials, companies.37Sinton Peabody JW Liu Gan Q assessment programs China.Energy 2004; 8: 33-52Crossref (176) Ujjwala replace 50 biomass-fuelled worked government channels home below line. unaffordability barrier.38Kar Pachauri Bailis Using sales data assess Karnataka.Nat Energy. 4: 806-814Crossref (61) Regarding China invested heavily village-based utilities, 400 gained (but treated) between 2000 2017.39Li Cohen Li Zhang impacts socioeconomic safety China: provincial-level comparative analysis.Sustainability. 85Crossref (10) utilities LMICs accused inefficiencies, corruption, benefiting incomes. During early 2000s, however, supported governments Kampala (Uganda) Hubli-Dharwad (India) increased reliability thousands each city,40Berg SV Mugisha Pro-poor promoting justice Uganda's project.Water 12: 589-601Crossref 41Kumpel Comparing supply.Water 5176-5188Crossref (130) case, availability was increased.33Lewis Low lifeline rates expansion both cases, done populations elsewhere. Low-income countries, competing resources, necessitating tradeoffs. invest generously, international assistance needed, aim. important. States incompetent, venal, citizens incomes concern. country history without implementation regulation, necessarily direct provision. If, instead, see rolling back support communities, run risk “sharply regressive” outcomes cooking, equality, health.42Marmot Society slow inequality.Lancet. 395: 1413-1414Summary (40) ScholarA modelExtending community-scale municipal-scale where lowest Interim steps therefore necessary. solutions pathway opposed crowd Productive directions include designing evaluating cost-efficient mechanisms gas,43Kimemia Annegarn Domestic South Africa: challenges lessons.Energy 93: 150-156Crossref (32) electricity mini-grids, fitted automatic chlorinators,44Crider Sainju Shrestha al.System-level chlorination community-managed systems.https://www.eawag.ch/fileadmin/Domain1/Abteilungen/sandec/schwerpunkte/WST/REACH/automatic_chlorination.pdfDate: 2019Date staffed kiosks dispensing homes via flexible pipes.22WSUPThe communities