(A Research Project of International Institute for Environment and Development (IIED), the London School of Hygiene and Tropical Medicine (LSHTM), in collaboration with research partners in Kenya, Tanzania, and Uganda.)

On a global scale, 25,000 people die each day as a result of a combination of poor water quality. Water-related diseases associated with poor environmental health conditions, such as cholera, diarrhoeal diseases, malaria, schistosomiasis and typhoid, represent the single largest cause of human morbidity and mortality. Some 1.7 billion people, more than one third of the world's population, are without safe water supply. By 2025, an estimated quarter of the world will suffer from chronic water shortages, many of whom will reside in Africa.

To combat the growing problems of degraded and depleted water supplies and poor environmental health, a number of new international water programmes have been launched, including the Freshwater Initiative of the United Nations Commission on Sustainable Development, the Global Water Partnership and the World Water Council. Despite these efforts, designing and implementing effective and equitable water and health policies and programmes remains extremely problematic. In part, this is because there are so few empirically-rich, historically-informed lessons on which to base current thinking and future practice. By using the Drawers of Water data as its baseline and carrying out detailed historical analyses across a spectrum of rural and urban communities in East Africa, this new study is charting the major trends and changes that have occurred in the domestic water and environmental health sectors over the past three decades. Few studies offer as rich an array of insights into the complex issues surrounding domestic water use and environmental health as that classic text, and no study provides a better foundation on which to base a new, interdisciplinary, multi-country research project to explore the links between water, health, policy and poverty.

The biblical "hewers of wood and drawers of water" were slaves and lowly servants (Joshua 9:21). In modern Africa drawers of water are frequently poor women and children who are widely subject to heavy costs and threats to their health. Over the past three decades, changes in public policies and investments in services and supplies in Kenya, Tanzania and Uganda have sometimes exacerbated rather than ameliorated water and health problems as population pressures and competition for scarce resources have increased.

In considering how best to meet these increasingly critical domestic needs for water, two sets of problems arise. One relates to how much and what kind of improvement in supplies is desirable. What are the effects on family and community life of different quantities and qualities of water? Since each improvement involves cost, what are the offsetting gains from making it? What combination of water supply, treatment, and delivery can best serve the individual and society? In the present state of economic development and political change in Africa, it is whimsical to suggest that every household should have a filtered, piped supply. But if that ideal cannot be achieved for most of the population, what are the desirable intermediate goals?

The second set of problems relates to the practical organisation and means to be used to obtain improved supplies. Since Drawers of Water was published in 1972, the countries of Kenya, Tanzania and Uganda have each followed very different political and economic trajectories. Each has approached the problem of creating 'safe water environments' for its citizens in different ways, formulating different policies, creating different institutions, implementing different programmes and employing different technologies. Which of these policies, institutions, programmes and technologies has worked, which has not and why? What kinds of improvements have stood the test of time? Which ones have increased people's (particularly poor people's) access to and use of water? In what cases have people been willing to pay for and carry out needed operation and maintenance of systems? Against considerations of what is socially desirable must be set what is practically feasible, given current - and future - environmental, financial, human, institutional and technical constraints.

Given this background, the project aims to:

1. replicate the original Drawers of Water methodology as closely as possible in order to carry out a comprehensive, repeat, cross-sectional analysis of domestic water use and environmental health trends and changes across a wide spectrum of rural and urban communities in Kenya, Tanzania and Uganda over the past three decades;
2. reconstruct the history of domestic water supply and environmental health changes and impacts in selected research sites so as to enable a detailed assessment of the extent to which investments in domestic water and environmental health systems and services have contributed to improvements in physical well-being;
3. assess the intra-community and inter-community variations in domestic water use related to investments in water supply and environmental health systems and services;
4. examine the roles that local and external factors, policies and programmes have played in improving people's access to reliable water supplies and adequate sanitation systems;
5. inform and influence national and international debates on water and health policy issues by presenting the research results at a series of national and international workshops and in a set of formal and informal publications targeted at policy makers, development practitioners, donors, private sector actors and the general public.
6. outline a strategy for selecting several representative rural and urban communities from among the Drawers of Water field sites for long-term monitoring, so as to enable the longitudinal analysis of changing water supply and environmental health conditions under different physical and socio-economic conditions in future.

At its most basic level, this research will answer five fundamental questions:

1. How has people's use of water changed over this period?;
2. How have their sources of water and service levels changed?;
3. What effect have these changes had on people's water use and well-being?;
4. What internal and external factors contributed to these changes?; and
5. What implications does an understanding of these trends and changes raise for future policies and programmes in the water and health sectors?

The first three questions examine the volume used and the social costs of different uses and sources of water, particularly their health costs. The last two questions explore the determinants of domestic water use and environmental health and how public policies and external support agencies can build upon achievements while avoiding the mistakes of the past. Some aspects of each of these questions are the subject of this study of domestic water use and environmental health in East Africa. With their great variety of economic, environmental and social change, the landscapes and peoples of Kenya, Tanzania and Uganda illustrate issues which are found in somewhat similar form throughout Africa and the rest of the developing world. Essentially these are issues of reconciling public (and increasingly private) investment and development policy with the decisions and actions of individual water users and local and external institutions with imperfect scientific understanding of the effects of water quality and quantity on human life.

The benefits and costs of providing safe, convenient and reliable water supply to households in the developing world has been the subject of a vast and wide-ranging research effort for at last four decades. Most of this research has focused on the relationship of water and disease (e.g., Noda, et al. 1997; Okun, 1987; Bradley 1977), the efficacy of water supply projects in improving health (e.g., Esrey 1996; Esrey, et al. 1991; Cairncross, et al. 1988; Feachem, et al. 1977), the causes and consequences of differential access and control of water resources (particularly with regard to gender) (e.g., Makule, 1997; WHO 1995; Sangodoyin, 1993; Defaut, 1988; Elmendorf and Isley, 1982; McSweeney, 1979; White, 1977) and the financing of water supply infrastructure (e.g., Sharma, et al., 1996; Nakagawa, 1994; Postel, 1993; Therkildsen, 1988; Saunders and Warford, 1976).

Despite the quantity of studies completed, relatively little is known about a number of key aspects of domestic water use. In particular, knowledge is scarce about the long-term trends and changes household water use in any part of the world, as most studies have been limited to one season or one year. Because of the lack of good baseline information, there are few longitudinal or repeat studies to be found. Moreover, where studies have attempted to examine changes over time, they have tended to be limited in their geographic scope; frequently concentrating on a single community or district. There is also a lack of quality information about water use in rural areas, as most research has focused on the developing world's expanding urban centres and ‘mega-cities' (Thompson, 1996; Hardoy, et al., 1992; Hardoy and Satterthwaite, 1989). Among the regions of the world, both of these research gaps are most acute for Sub-Saharan Africa - the region whose population is the most rural and has the least access to improved water supply (Rosen and Vincent, 1998; Sharma, et al. 1996; WASH, 1990).

This review focuses on the contribution that the study Drawers of Water has made to the literature on domestic water use and environmental health and its continuing influence on water policy and practice. It begins with a brief summary of the original study itself, then describes how the proposed project will build upon and expand the key themes addressed in that pioneering effort.

In 1972, Gilbert F. White, David J. Bradley and Anne U. White produced an authoritative and informative book entitled, Drawers of Water: Domestic Water Use in East Africa. The study was the first large-scale assessment of domestic water use in Africa and is widely regarded as a major contribution to the study of community water supply and environmental health issues in the Third World.

A recent and wide-ranging review of the literature on household water resources and rural productivity in Sub-Saharan Africa carried out by Harvard University, USA, (Rosen and Vincent 1998: 3) describes the continuing relevance and broad influence of Drawers of Water:

Knowledge of household water supply and productivity in ... Africa is limited to a handful of original studies, which continue to be cited and recycled in the literature. Foremost among them is Drawers of Water ... [It] remains the most comprehensive and compelling account available of ... water use in Africa (emphasis added).

The data reported in Drawers of Water were acquired between 1965 and 1968 by interviews and observations at 34 study sites in Kenya, Tanzania, and Uganda. Thirteen field workers (students from East African universities) assisted in collecting the water-use information in 741 households. Twelve of the sites are in rural areas; the other 22 are in and around urban centres. Fifteen of the sites, all in urban places, had water piped to the houses at the time of the study. Water was carried to the houses in all twelve of the rural sites and in seven of the urban.

The study examined in detail the quantity and social cost of water used in the households, the relationship of domestic water to health, and the factors that determine the selection of the source of water used by the family. In the households with piped connections, three factors are of general significance in the quantity used per capita: (1) the unit cost of water; (2) the size of the family; and (3) the family's material wealth. At the sites where households carry water, patterns of use range widely. Multiple regression analysis, tried for combinations of factors, did not explain the variance, although the number of people in the household and the size of the container used to carry water are somewhat more significant than other factors are.

‘Cost' was not only cash expenditure for water that is sold but also a measure of the time and energy used to procure the water: the 'social cost' of obtaining water. In the unpiped sites, two and a half to three round trips were made each day to a source usually less than half a kilometre from the house. The estimate for calories expended daily in drawing water ranged from nearly zero where water is collected from roof runoff to 1930 where the source was distant. Two concise, well-organised chapters consider the extent and nature of water-related diseases and their social and economic effects. Estimates are made for the costs of these diseases in East Africa, including economic losses from lower productivity, illness, and death. Much of the material here is striking. For example, a reader unfamiliar with economic valuation for human life will learn how "the cost of a child death" in East Africa is calculated to between $16.80 and $21.00 (in 1972 dollars).

How a household makes a decision in selecting its source of water is shown to be extremely sophisticated. From the explanations given in the interviews, the choice seems to be made by rejecting possible alternative sources that are less acceptable for various reasons, especially energy cost and quantity. The quality of water is a combination of colour, taste, turbidity, odour, and perceived risk to health - a matter of local judgement and personal choice, not easily defined.

The final chapter address the problem of public policy for water development in tropical countries. Comparative costs are estimated for six types of improved water supply on a national scale and for an urban area, with alternatives based on the number of people served and on different amounts of annual investment over a ten-year period. A hypothetical African country, eight percent urban, with a total population of nine million, would require an annual investment of US$1.6 million (in 1972 dollars) over a ten-year period to eliminate unimproved water sources in urban areas and to reduce to less than 10 the percentage of the rural population drawing water from unimproved sources.

The crux of the document may well be epitomised, in the words of the authors, as follows: "The way people respond to present and improved supplies and the effect this has on community health and welfare should be examined for the whole range of theoretically possible improvements. Increased volume of use does not necessarily bring proportionate gains in health. Neither does the construction of additional safe supplies necessarily result in increased use by those people who most need them."

Great care has been taking in the editing of this volume. More than a hundred tables and figures are so well integrated with the text that the reader is seldom aware of discontinuity in the narrative. The pen-and-ink sketches that supplement the photographs are not only instructive but pleasing to the eye. The bibliography of some two hundred references is diverse both in subject matter and in geographical area.

The insights drawn by the authors from their assessment of domestic water use in East Africa provide valuable lessons for academics and practitioners alike and make Drawers of Water compulsory reading for anyone concerned about community water supply in Africa. The axiom remains that people's understanding, participation and responsibility are indispensable ingredients for successful projects and programs. The challenge remains how to weave these attributes into the provision of potable, reliable water supplies to over one billion individuals in the coming decades.

The chief limitation of Drawers of Water appears to be the relatively short period of time over which domestic water use was examined in the region. It is difficult to discern any long-term patterns or trends in the behaviour of the water users or to accurately assess the impacts of water policies and investments on the well-being of the sample communities from the study as it now stands. This shortcoming is not unique to Drawers of Water, however. As noted above, a review of the domestic water and environmental health literature reveals that few major repeat cross-sectional studies of domestic water use have been conducted in any part of the Third World (Rosen and Vincent, 1998; Clarke, 1993; Evans, 1992; Postel, 1992; WASH, 1990).

This lack of detailed information and knowledge about the long-term impacts of domestic water and environmental health initiatives and interventions on local people's hygiene behaviour and physical well-being makes designing and developing new water and health policies and strategies extremely difficult, since there are so few empirically-rich, historically-informed lessons on which to base current thinking and future practice (Manun'Ebo, et al. 1997; Makule, 1997; Cairncross and Kochar, 1994; Boot and Cairncross, 1993). It is for this reason that the International Institute for Environment and Development (IIED) and the London School of Hygiene and Tropical Medicine (LSHTM), in collaboration with research partners in Kenya, Tanzania and Uganda, decided to undertake a comprehensive follow-up to Drawers of Water. Following the close of the United Nation's Water Decade, and the rapid growth of demand on an already scarce resource, a re-examination of domestic water use and environmental health in East Africa, three decades after that landmark study, appears both relevant and timely.

While the design phase includes specification of the topics, the research will address most of the original themes as well as current issues in domestic water and environmental health planning. Drawers of Water made three principal contributions to our understanding of water-health relationships, which continue to be central themes in the literature. The first is the analysis of the choice and use of domestic water supplies, including assessment of the range of available water sources, perceptions of water quality and needs for improved water sources (Churchill, 1987; Elmendorf and Isley, 1982). The second is the empirical investigation of the health impacts of water use and water quality (Cairncross, 1996, 1989; Esrey, 1996; Drangert 1993; Kolsky, 1993; Esrey et al., 1991; Linkskog, et al. 1987; Briscoe, et al. 1986; Feachem 1977; Feachem, et al. 1977). These themes will be continued. In particular, the water quality issues may be expanded, given the current expertise and available facilities in East Africa.

The third contribution of the original study is the analysis of national and community investment in domestic water supplies, and calculations of benefits and costs. The research will review changes in national priorities and investment, but will focus on new trends, such as the reduction of state involvement in the sector, the changes in donor disbursements to the sector, the privatisation of public systems and the emergence of community-managed water and sanitation systems. Case histories will be compiled for selected sites, documenting the development and utilisation of water and sanitation systems and services since the late 1960s.

One other important issue that has emerged in the last 30 years will be included in the study. Community management, including the operation and maintenance of water supply and sanitation systems, is now recognised as a critical but often neglected aspect of water development (IRC, 1995; Evans, 1992; WHO, 1992; Hardoy, et al, 1992; Hardoy and Satterthwaite, 1989; Therkildsen, 1988). The research agenda will include an assessment of the collective action of local groups in each community and their effectiveness in developing, operating and maintaining domestic water and sanitation systems (Thompson, 1997, 1996; Narayan, 1994, 1993; Finsterbusch, 1990; Feuerstein, 1986). This analysis will involve intra- as well as inter-community comparisons, since the range and diversity of service levels and systems, and thus the ability for local groups to operate and maintain them, varies considerably within, as well as between rural and urban communities (Cairncross 1996; Drangert, 1993).

Linked to this local-level analysis will be an examination of higher-level institutional arrangements and relations related to the provision of water and health services. Over the past three decades, decentralised planning and power-sharing between national and local government authorities has had a profound effect on the nature, capacity and performance of public agencies involved in domestic water supply and environmental health (Khroda 1998; Mujwahuzi and Maganga 1998; Muzaale 1998; Nakagawa, et al. 1994; Environment and Urbanization, 1993; 1991). Furthermore, the number, size and influence of NGOs and CBOs in the water and health sectors over the past decade has been equally dramatic and warrants special consideration, especially with regard to their roles in the development and implementation of more participatory approaches to water supply and sanitation (Edwards and Hulme, 1992; Environment and Urbanization, 1995; 1990).