Racial Disparities in Urban Drinking Water Access in North Carolina: A Study on City Water Service

1. Jackie MacDonald Gibson, Associate Professor Environmental Sciences and Engineering Gillings School of Global Public Health University of North Carolina at Chapel Hill Drinking Water Access in Urban Areas of North CarolinaRacial Disparities

2. The U.S. Safe Drinking Water Act Protects Municipal Water Quality • “An act . . . to assure that the public is provided with safe drinking water . . . which dependably complies with . . . maximum contaminant levels . . . at which . . . no known or anticipated adverse effects on the health of persons occur ”

3. . . . But Excludes Private Wells • “The term ‘public water system’ means . . . a system has at least 15 service connections or regularly serves at least 25 individuals”

4. One-Third of North Carolinians Rely on Private Wells for Their Water

5. Private Well Reliance Is Higher in NC Than in Almost All Other States

6. Research Focus: Disparities in Access to City Water Service in Urban Areas • Motivation for studying disparities • Relationships between race and access to city water • Water quality in private wells in underserved urban areas • Microbes • Lead • 4. Factors influencing decisions to extend water and sewer service

7. Project Motivation Jeff Engel, MD, MPH State Epidemiologist, 2002-2009 Director of Public Health, 2009-2012

8. Project Motivation Jeff Engel, MD, MPH State Epidemiologist, 2002-2009 Director of Public Health, 2009-2012

9. Moore County (circa 2000) Map courtesy of Hannah Leker

10. Map courtesy of Hannah Leker

11. Map courtesy of Hannah Leker

12. Engel: How Many Communities Are Excluded from Nearby Water Service? • Surveyed all 100 county health directors. • Only 39 responded. • Provided qualitative rather than quantitative descriptions.

13. Example Survey Responses • “Homes with privies, straight-pipes, failing drain fields, or incomplete plumbing. • Severely limited soils with high water table.” Pitt County • “Clusters of homes with insufficient or failing septic systems. • Residences with cistern, spring, or no piped water to home. • Clusters of homes with no available space remaining to install a replacement septic system or replacement well.” Stokes County

14. Research Focus: Disparities in Access to City Water Service in Urban Areas • Motivation for studying disparities • Relationships between race and access to city water • Water quality in private wells in underserved urban areas • Microbes • Lead • 4. Factors influencing decisions to extend water and sewer service

15. Focus on “Extraterritorial Jurisdictions” (ETJs) Example ETJs of Southern Pines, Pinehurst, and nearby towns Dark colors = towns Light colors = ETJs

16. Wake County as Starting Point • Where are underserved communities in Wake County ETJs? • Is race a significant factor in predicting water and sewer access in Wake County ETJs?

17. Data Sources • County-level tax parcel data • Municipal service connections • U.S. Census • Demographics

18. Analysis Method: Logistic Regression • What factors predict “odds” of water service in a random census block in an extraterritorial jurisdiction? • Analyze significance of explanatory factors with “logistic regression:”

19. Results: Tax Data Reveal Unserved Wake County Areas

20. Descriptive Data Suggest Race Is Associated with Water Access

21. Logistic Regression Shows Race Is Significantly Associated with Water Access Income is NOT a significant predictor of water service access. Interpretation: Every 10% increase in Black population increases odds of being without water service by exp(0.1*0.36)=1.037 (3.7% increase). MacDonald Gibson, J. et al. “Racial Disparities in Access to Community Water Supply Service in Wake County, North Carolina.” Frontiers in Public Health Services and Systems Research 3.3 (2014): Article 6.

22. Research Focus: Disparities in Access to City Water Service in Urban Areas • Motivation for studying disparities • Relationships between race and access to city water • Water quality in private wells in underserved urban areas • Microbes • Lead • 4. Factors influencing decisions to extend water and sewer service

23. Household Water Samples Collected in Randomly Selected Homes • 57 tested for bacteria • 30 tested for lead, other metals

24. Results: High Prevalence of Bacterial Contaminants

25. Microbial Contaminants Increase Acute Gastrointestinal Illness Risks • Stillo, F., and J. MacDonald Gibson. In press. Exposure to contaminated drinking water and health disparities in North Carolina. American Journal of Public Health.

26. New Results Show Elevated Levels of Lead in 8 of 30 Households EPA lead action level

27. Research Focus: Disparities in Access to City Water Service in Urban Areas • Motivation for studying disparities • Relationships between race and access to city water • Water quality in private wells in underserved urban areas • Microbes • Lead • 4. Factors influencing decisions to extend water and sewer service

28. Method: Qualitative Analysis • Key informant interviews in three communities • Transcribe interviews, and code using Atlas.ti • Identify common themes

29. Variety of Perspectives Sought

30. Results: Cost Concerns Drive Decisions

31. Awareness of Health Risks Is Low

32. Public Health Community Can Play a Key Role • “I think the health director saying this is a community • health hazard . . . that means you’ve got • to take care of it. . . . That ended the argument.” • New Hanover county official Naman, Julia Marie, and Jacqueline MacDonald Gibson. “Disparities in Water and Sewer Services in North Carolina: An Analysis of the Decision-Making Process.” American Journal of Public Health July 2010 (2015): e1–e7.

33. Summary • Mapping reveals racial disparities in water service in Wake County ETJs. • Increasing black population decreases odds of water service. • Water sampling suggests poor water quality in some domestic wells in ETJs. • Microbes • Lead • What else? • Key informants suggest poor awareness of health risks among decision-makers.

34. Your Ideas Strategies for eliminating racial disparities in access to regulated drinking water? Strategies for ensuring households with private wells receive safe drinking water?

35. Acknowledgements • This research was supported by grants from the Robert Wood Johnson Foundation under the Mentored Research Scientist Development Program in Public Health Systems and Services Research and by the IBM Junior Faculty Development Award at the University of North Carolina at Chapel Hill.

36. Thanks to my (current and former) students! • Nick DeFelice • Jill Johnston • Julia Naman • Frank Stillo • Hannah Leker • Daniel Sebastian • David Gorelick • Daisy Wang • Yuyun Liang • Brenda Benevides • Yang Du • Anna Ballesiotes • Jamie Sabo • Joe Strasser

37. MacDonald Gibson Group Relevant Publications • DeFelice, Nicholas B., Jill E. Johnston, and Jacqueline MacDonald Gibson. “Reducing Emergency Department Visits for Acute Gastrointestinal Illnesses in North Carolina (USA) by Extending Community Water Service.” Environmental Health Perspectives 24.10 (2016): 1583–1591. • MacDonald Gibson, J. et al. “Racial Disparities in Access to Community Water Supply Service in Wake County, North Carolina.” Frontiers in Public Health Services and Systems Research 3.3 (2014): Article 6. • Naman, Julia Marie, and Jacqueline MacDonald Gibson. “Disparities in Water and Sewer Services in North Carolina: An Analysis of the Decision-Making Process.” American Journal of Public Health July 2010 (2015): e1–e7. Web. • Stillo, F., and Jacqueline MacDonald Gibson. “Exposure to Contaminated Drinking Water and Health Disparities in North Carolina.” American Journal of Public Health(in press, expected November 2016).

38. Selected Additional References • Aiken, CS. “Race as a Factor in Municipal Underbounding.” Annals of the Association of American Geographers July 2013 (1987): 37–41. • Gilbert, Peter. “The State of Exclusion: An Empirical Analysis of the Legacy of Segregated Communities in North Carolina.” UNC Center for Civil Rights. 2013. • Heaney, Christopher et al. “Use of Community-Owned and -Managed Research to Assess the Vulnerability of Water and Sewer Services in Marginalized and Underserved Environmental Justice Communities.” Journal of environmental health 74.1 (2011): 8–17. • Heaney, Christopher D et al. “Public Infrastructure Disparities and the Microbiological and Chemical Safety of Drinking and Surface Water Supplies in a Community Bordering a Landfill.” Journal of Environmental Health 75.10 (2013): 24–36. • Johnson, James H. et al. “Racial Apartheid in a Small North Carolina Town.” The Review of Black Political Economy 31.4 (2004): 89–107. • Joyner, Ann Moss, and Carolyn J Christman. Segregation in the Modern South : A Case Study of Southern Moore County. Cedar Grove Institute for Sustainable Communities. 2005. • Lichter, Daniel T. et al. “Municipal Underbounding: Annexation and Racial Exclusion in Small Southern Towns.” Rural Sociology 72.1 (2007): 47–68. • Marsh, Ben, Allan M. Parnell, and Ann Moss Joyner. “Institutionalization of Racial Inequality in Local Political Geographies.” Urban Geography 31.5 (2013): 691–709. • Wilson, Sacoby M. et al. “Built Environment Issues in Unserved and Underserved African-American Neighborhoods in North Carolina.” Environmental Justice 1.2 (2008): 63–72.