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Exploring how projects of global health intersect with processes of urbanization

Exploring how projects of global health intersect with processes of urbanization

Hillary Birch

by Hillary Birch

Drinking water quality is paramount for public health but progress towards access to good quality drinking water for all remains a critical issue around the world. According to the United Nations, 26% of the world’s population does not have access to safe drinking water, 46% lack access to basic sanitation, and water-related diseases remain a leading cause of illness and death in many countries (United Nations World Water Development Report 2023). The challenge of water, sanitation, and hygiene (WASH) is felt acutely in informal settlements in the Global South where inadequate water and sanitation contributes to a range of physical and social inequities, from stunted growth to chronic diarrhea, to increased rates of sexual violence faced by girls and women.

Handwashing infrastructure during the COVID-19 pandemic. Photo credit: Kerton Victory / CDC (flickr)

As Livingston (2019: 14) posits, “water technology [is] public health over the longue durée,” but the development of water infrastructure for the explicit purpose of public health is not guaranteed as structures and systems of coloniality continue to shape Southern cities today. Global health interventions that aim to improve WASH in informal settlements are typically directed towards proximal causes of infection transmission, addressed through water chlorination in the household and a focus on WASH behaviour change. These interventions have not been met with sufficient investment in the construction and maintenance of essential infrastructures and eliciting behaviour change can rely on stigma and shame (Galvin 2014). Ultimately, the focus on proximal causes of disease transmission means that the distribution of drinking water is not significantly changed, service disruptions remain frequent, and chemical or microbial contamination of drinking water at its source are not dealt with (Cumming et al. 2019).

Through my PhD research I study how global health projects in WASH are implicated in challenges of urban water management. In my project water quality is conceptualized as more than just a straightforward biophysical measurement, instead as something contested by a range of actors who are drawn into water’s flows in urban space, either in their daily life, or through projects implemented to change the flows of water and waste in a city. I am working to better understand how urban water quality is contested and negotiated across scales by WASH interventions that seek to improve access to water for the purposes of hygiene and health promotion, including the institutional and infrastructural effects of these contestations for urban water management.

Heterogenous water infrastructures shape access to good quality drinking water. Photo credit: Arne Hoel / The World Bank (flickr)

I am investigating the governance of urban water quality through a case study of Lusaka, the capital of Zambia. Lusaka is one of the fastest growing cities in Southern Africa with a population of approximately 3.3 million, where more than half the city’s residents live in informal communities. The aquifer that provides Lusaka with most of its drinking water is vulnerable to infiltration as recharge areas are located in fast growing sectors of the city where residents rely on both boreholes and septic tanks, making groundwater vulnerable to faecal contamination (Reaver et al. 2021). Lusaka experiences increasing climate variability in the form of water shortages, power outages, and flooding and long-term rainfall trends suggest drier rainfall seasons and more frequent and intense localised rainfall events. Flash floods coupled with inadequate stormwater infrastructure are predicted to result in serious health consequences associated with the poor sanitary conditions in the city (Ndebele-Murisa et al. 2020). Global health actors have now begun to pitch WASH as a ‘missing link’ to climate adaptation in Lusaka through design improvements to toilets, improved waste collection for non-sewered services, and upgrades to piped water connections to reduce leakages (Gerlach et al. 2020).

By placing global health activities in the context of urban water management in Lusaka, I aim to demonstrate how global health intersects with processes of urbanization today and is generative of new ways of governing cities as water supplies become less stable due to climate change. By examining the production of water quality across domains of hygiene, water, and sanitation I seek to connect fragmented silos of practice in WASH to better address interlinkages between equity, the environment, and health to contribute towards true urban resilience for all.


Hillary Birch is a PhD student in Environmental Studies in the Faculty of Environmental and Urban Change at York University, supervised by Professor Roger Keil. She holds a master’s degree in urban governance from Sciences Po in Paris, France, where she studied the urban governance of Ebola in Monrovia, Liberia. She also holds a master’s degree in political science from McGill University. Hillary has worked in various roles in global health related to sexual and reproductive health and early child development. Her PhD explores how projects of global health intersect with processes of urbanization that shape flows of water in a city and change its quality. Hillary is a Dahdaleh Global Health Graduate Scholar in Planetary Health, and her research is supported by a SSHRC Doctoral Fellowship.