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

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 ”
Today, water quality in U.S. cities is protected by the Safe Drinking Water Act. Congress enacted this legislation in 1974 to ensure that all cities across the United States were providing their citizens with water of high quality, free of contaminants known to cause adverse health effects.

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”
However, those relying on private wells for their drinking water do not receive the protections of the Safe Drinking Water Act. This legislation covers only water supplies that serve at least 25 people or 15 households year-round.

4. One-Third of North Carolinians Rely on Private Wells for Their Water
In North Carolina, more than one-third of the population—3.3 million residents--relies on private wells for drinking water, according to the U.S. Geological Survey. These 3.3 million North Carolinians therefore do not have the same guarantee of high-quality drinking water as the 6.2 million state residents who obtain their water from community water systems that provide water treatment and disinfection.
DATA SOURCE: Maupin et al., 2014

5. Private Well Reliance Is Higher in NC Than in Almost All Other States
Among U.S. states, North Carolina has the third-highest reliance on private wells for drinking water. Only Maine and Alaska have higher proportions of residents relying on private wells. This chart shows how North Carolina compares to the other 49 states and the District of Columbia in reliance on private wells for drinking water. The horizontal axis shows the percentage of the population relying on wells. North Carolina is highlighted in red.
DATA SOURCE: Maupin et al., 2014

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,

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

9. Moore County (circa 2000) Map courtesy of Hannah Leker
To illustrate the phenomenon of underbounding in North Carolina, I will briefly illustrate the situation that was faced by several minority communities in Moore County. The details of these communities are documented in a report by the Cedar Grove Institute for Sustainable Communities. One of my former students, Hannah Leker, prepared these maps.
To begin, consider this map of town boundaries around Pinehurst, Southern Pines, and Aberdeen. You an see that the town boundaries are jagged and include “donut holes”—communities in the center of town that are excluded from town boundaries.
SOURCE: Joyner and Christman, 2005
Map courtesy of Hannah Leker

10. Map courtesy of Hannah Leker
On this map, we can overlay racial composition. The dark brown areas are African American. You can see how several of these communities are excluded from town boundaries. As an example, let’s examine closely the community in the center of Aberdeen.
Map courtesy of Hannah Leker

11. Map courtesy of Hannah Leker
This map shows water pipes around the African American community encircled by Aberdeen as of about You can see that water pipes surround but do not serve the African American community. It appears that this community was excluded from municipal water service—it was underbounded.
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 U.S. Census
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
Variable
Coefficient
p Value
Intercept
-0.57
0.0001
%Black
0.36
0.05
Income
6.1 x 10-7
0.72
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
Households with at least on positive sample: Total coliforms,49%; E. coli, 14%; Enterococcus, 28%; Any organism, 65%

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 (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 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 (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 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.