Background: More than 80% of sewage generated by human activities is

discharged into rivers and oceans without any treatment, which results in
environmental pollution and more than 50 diseases. 80% of diseases and 50% of
child deaths worldwide are related to poor water quality.
Methods: This paper selected 85 relevant papers finally based on the keywords
of water pollution, water quality, health, cancer, and so on.
Results: The impact of water pollution on human health is significant, although
there may be regional, age, gender, and other differences in degree. The most
common disease caused by water pollution is diarrhea, which is mainly
transmitted by enteroviruses in the aquatic environment.
Discussion: Governments should strengthen water intervention management
and carry out intervention measures to improve water quality and reduce water
pollution’s impact on human health.
Introduction
Water is an essential resource for human survival. According to the 2021 World
Water Development Report released by UNESCO, the global use of freshwater
has increased six-fold in the past 100 years and has been growing by about 1%
per year since the 1980s. With the increase of water consumption, water quality
is facing severe challenges. Industrialization, agricultural production, and urban
life have resulted in the degradation and pollution of the environment, adversely
affecting the water bodies (rivers and oceans) necessary for life, ultimately
affecting human health and sustainable social development (Xu et al., 2022a).
Globally, an estimated 80% of industrial and municipal wastewater is discharged
into the environment without any prior treatment, with adverse effects on human
health and ecosystems. This proportion is higher in the least developed
countries, where sanitation and wastewater treatment facilities are severely
lacking.
Sources of Water Pollution
Water pollution are mainly concentrated in industrialization, agricultural
activities, natural factors, and insufficient water supply and sewage treatment
facilities. First, industry is the main cause of water pollution, these industries
include distillery industry, tannery industry, pulp and paper industry, textile
industry, food industry, iron and steel industry, nuclear industry and so on.
Various toxic chemicals, organic and inorganic substances, toxic solvents and
volatile organic chemicals may be released in industrial production. If these
wastes are released into aquatic ecosystems without adequate treatment, they
will cause water pollution (Chowdhary et al., 2020). Arsenic, cadmium, and
chromium are vital pollutants discharged in wastewater, and the industrial sector
is a significant contributor to harmful pollutants (Chen et al., 2019). With the
acceleration of urbanization, wastewater from industrial production has gradually
increased. (Wu et al., 2020). In addition, water pollution caused by
industrialization is also greatly affected by foreign direct investment. Industrial
water pollution in less developed countries is positively correlated with foreign
direct investment (Jorgenson, 2009). Second, water pollution is closely related to
agriculture. Pesticides, nitrogen fertilizers and organic farm wastes from
agriculture are significant causes of water pollution (RCEP, 1979). Agricultural
activities will contaminate the water with nitrates, phosphorus, pesticides, soil
sediments, salts and pathogens (Parris, 2011). Furthermore, agriculture has
severely damaged all freshwater systems in their pristine state (Moss, 2008).
Untreated or partially treated wastewater is widely used for irrigation in water-
scarce regions of developing countries, including China and India, and the
presence of pollutants in sewage poses risks to the environment and health.
Taking China as an example, the imbalance in the quantity and quality of surface
water resources has led to the long-term use of wastewater irrigation in some
areas in developing countries to meet the water demand of agricultural
production, resulting in serious agricultural land and food pollution, pesticide
residues and heavy metal pollution threatening food safety and Human Health
(Lu et al., 2015). Pesticides have an adverse impact on health through drinking
water. Comparing pesticide use with health life Expectancy Longitudinal Survey
data, it was found that a 10% increase in pesticide use resulted in a 1% increase
in the medical disability index over 65 years of age (Lai, 2017). The case of the
Musi River in India shows a higher incidence of morbidity in wastewater-irrigated
villages than normal-water households. Third, water pollution is related to natural
factors. Taking Child Loess Plateau as an example, the concentration of trace
elements in water quality is higher than the average world level, and trace
elements come from natural weathering and manufacture causes. Poor river
water quality is associated with high sodium and salinity hazards (Xiao et al.,
2019). The most typical water pollution in the middle part of the loess Plateau is
hexavalent chromium pollution, which is caused by the natural environment and
human activities. Loess and mudstone are the main sources, and groundwater
with high concentrations of hexavalent chromium is also an important factor in
surface water pollution (He et al., 2020). Finally, water supply and sewage
treatment facilities are also important factors affecting drinking water quality,
especially in developing countries. In parallel with China rapid economic growth,
industrialization and urbanization, underinvestment in basic water supply and
treatment facilities has led to water pollution, increased incidence of infectious
and parasitic diseases, and increased exposure to industrial chemicals, heavy
metals and algal toxins (Wu et al., 1999). An econometric model predicts the
impact of water purification equipment on water quality and therefore human
health. When the proportion of household water treated with water purification
equipment is reduced from 100% to 90%, the expected health benefits are
reduced by up to 96%.. When the risk of pretreatment water quality is high, the
decline is even more significant (Brown and Clasen, 2012).
To sum up, water pollution results from both human and natural factors. Various
human activities will directly affect water quality, including urbanization,
population growth, industrial production, climate change, and other factors
(Halder and Islam, 2015) and religious activities (Dwivedi et al., 2018). Improper
disposal of solid waste, sand, and gravel is also one reason for decreasing water
quality (Ustaoğlua et al., 2020).
Impact of Water Pollution on Human Health
Unsafe water has severe implications for human health. According to
UNESCO 2021 World Water Development Report, about 829,000 people die each
year from diarrhea caused by unsafe drinking water, sanitation, and hand
hygiene, including nearly 300,000 children under the age of five, representing
5.3 percent of all deaths in this age group. Data from Palestine suggest that
people who drink municipal water directly are more likely to suffer from diseases
such as diarrhea than those who use desalinated and household-filtered drinking
water (Yassin et al., 2006). In a comparative study of tap water, purified water,
and bottled water, tap water was an essential source of gastrointestinal disease
(Payment et al., 1997). Lack of water and sanitation services also increases the
incidence of diseases such as cholera, trachoma, schistosomiasis, and
helminthiasis. Data from studies in developing countries show a clear
relationship between cholera and contaminated water, and household water
treatment and storage can reduce cholera (Gundry et al., 2004). In addition to
disease, unsafe drinking water, and poor environmental hygiene can lead to
gastrointestinal illness, inhibiting nutrient absorption and malnutrition. These
effects are especially pronounced for children.
Purpose of This Paper
More than two million people worldwide die each year from diarrhoeal diseases,
with poor sanitation and unsafe drinking water being the leading cause of nearly
90% of deaths and affecting children the most (United Nations, 2016). More than
50 kinds of diseases are caused by poor drinking water quality, and 80% of
diseases and 50% of child deaths are related to poor drinking water quality in the
world. However, water pollution causes diarrhea, skin diseases, malnutrition, and
even cancer and other diseases related to water pollution. Therefore, it is
necessary to study the impact of water pollution on human health, especially
disease heterogeneity, and clarify the importance of clean drinking water, which
has important theoretical and practical significance for realizing sustainable
development goals. Unfortunately, although many kinds of literature focus on
water pollution and a particular disease, there is still a lack of research results
that systematically analyze the impact of water pollution on human health and
the heterogeneity of diseases. Based on the above background and discussion,
this paper focuses on the effect of water pollution on human health and its
disease heterogeneity.
Materials and Methods
Search Process
This article uses keywords such as “water,” “water pollution,” “water quality,”
“health,” “diarrhea,” “skin disease,” “cancer” and “children” to search Web of
Science and Google Scholar include SCI and SSCI indexed papers, research
reports, and works from 1990 to 2021.
Inclusion-Exclusion Criteria and Data Extraction Process
The existing literature shows that water pollution and human health are
important research topics in health economics, and scholars have conducted in-
depth research. As of 30 December 2021, 104 related literatures were searched,
including research papers, reviews and conference papers. Then, according to
the content relevancy, 19 papers were eliminated, and 85 papers remained. The
purpose of this review is to summarize the impact of water pollution on human
health and its disease heterogeneity and to explore how to improve human
health by improving water pollution control measures.
Information extracted from all included papers included: author, publication date,
sample country, study methodology, study purpose, and key findings. All analysis
results will be analyzed according to the process in Figure 1.
FIGURE 1
FIGURE 1. Data extraction process (PRISMA).
The relevant information of the paper is exported to the Excel database through
Endnote, and the duplicates are deleted. The results were initially extracted by
one researcher and then cross-checked by another researcher to ensure that all
data had been filtered and reviewed. If two researchers have different opinions,
the two researchers will review together until a final agreement is reached.
Quality Assessment of the Literature
The JBI Critical Appraisal Checklist was used to evaluate the quality of each
paper. The JBI (Joanna Briggs Institute) key assessment tool was developed by
the JBI Scientific Committee after extensive peer review and is designed for
system review. All features of the study that meet the following eight criteria are
included in the final summary:1) clear purpose; 2) Complete information of
sample variables; 3) Data basis; 4) the validity of data sorting; 5) ethical norms;
(6); 7) Effective results; 8) Apply appropriate quantitative methods and state the
results clearly. Method quality is evaluated by the Yes/No questions listed in the
JBI Key Assessment List. Each analysis paper received 6 out of 8.
Results
The quality of drinking water is an essential factor affecting human health. Poor
drinking water quality has led to the occurrence of water-borne diseases.
According to the World Health Organization (WHO) survey, 80% of the world’s
diseases and 50% of the world’s child deaths are related to poor drinking water
quality, and there are more than 50 diseases caused by poor drinking water
quality. The quality of drinking water in developing countries is worrying. The
negative health effects of water pollution remain the leading cause of morbidity
and mortality in developing countries. Different from the existing literature
review, this paper mainly studies the impact of water pollution on human health
according to the heterogeneity of diseases. We focuses on diarrhea, skin
diseases, cancer, child health, etc., and sorts out the main effects of water
pollution on human health (Table 1).
TABLE 1
TABLE 1. Major studies on the relationship between water pollution and health.
Water Pollution and Diarrhea
Diarrhea is a common symptom of gastrointestinal diseases and the most
common disease caused by water pollution. Diarrhea is a leading cause of illness
and death in young children in low-income countries. Diarrhoeal diseases
account for 21% of annual deaths among children under 5 years of age in
developing countries (Waddington et al., 2009). Many infectious agents
associated with diarrhea are directly related to contaminated water (Ahmed and
Ismail, 2018). Parasitic worms present in non-purifying drinking water when is
consumed by human beings causes diseases (Ansari and Akhmatov., 2020) . It
was found that treated water from water treatment facilities was associated with
a lower risk of diarrhea than untreated water for all ages (Clasen et al., 2015).
For example, in the southern region of Brazil, a study found that factors
significantly associated with an increased risk of mortality from diarrhoea
included lack of plumbed water, lack of flush toilets, poor housing conditions, and
overcrowded households. Households without access to piped water had a 4.8
times higher risk of infant death from diarrhea than households with access to
piped water (Victora et al., 1988)
Enteroviruses exist in the aquatic environment. More than 100 pathogenic
viruses are excreted in human and animal excreta and spread in the environment
through groundwater, estuarine water, seawater, rivers, sewage treatment
plants, insufficiently treated water, drinking water, and private wells (Fong and
Lipp., 2005). A study in Pakistan showed that coliform contamination was found
in some water sources. Improper disposal of sewage and solid waste, excessive
use of pesticides and fertilizers, and deteriorating pipeline networks are the main
causes of drinking water pollution. The main source of water-borne diseases such
as gastroenteritis, dysentery, diarrhea, and viral hepatitis in this area is the
water pollution of coliform bacteria (Khan et al., 2013). Therefore, the most
important role of water and sanitation health interventions is to hinder the
transmission of diarrheal pathogens from the environment to humans
(Waddington et al., 2009).
Meta-analyses are the most commonly used method for water quality and
diarrhea studies. It was found that improving water supply and sanitation
reduced the overall incidence of diarrhea by 26%. Among Malaysian infants,
having clean water and sanitation was associated with an 82% reduction in
infant mortality, especially among infants who were not breastfed (Esrey et al.,
1991). All water quality and sanitation interventions significantly reduced the risk
of diarrhoeal disease, and water quality interventions were found to be more
effective than previously thought. Multiple interventions (including water,
sanitation, and sanitation measures) were not more effective than single-focus
interventions (Fewtrell and Colford., 2005). Water quality interventions reduced
the risk of diarrhoea in children and reduced the risk of E. coli contamination of
stored water (Arnold and Colford., 2007). Interventions to improve water quality
are generally effective in preventing diarrhoea in children of all ages and under
5. However, some trials showed significant heterogeneity, which may be due to
the research methods and their conditions (Clasen et al., 2007).
Water Pollution and Skin Diseases
Contrary to common sense that swimming is good for health, studies as early as
the 1950s found that the overall disease incidence in the swimming group was
significantly higher than that in the non-swimming group. The survey shows that
the incidence of the disease in people under the age of 10 is about 100% higher
than that of people over 10 years old. Skin diseases account for a certain
proportion (Stevenson, 1953). A prospective epidemiological study of beach
water pollution was conducted in Hong Kong in the summer of 1986–1987. The
study found that swimmers on Hong Kong’s coastal beaches were more likely
than non-swimmers to complain of systemic ailments such as skin and eyes. And
swimming in more polluted beach waters has a much higher risk of contracting
skin diseases and other diseases. Swimming-related disease symptom rates
correlated with beach cleanliness (Cheung et al., 1990).
A study of arsenic-affected villages in the southern Sindh province of Pakistan
emphasized that skin diseases were caused by excessive water quality. By
studying the relationship between excessive arsenic in drinking water caused by
water pollution and skin diseases (mainly melanosis and keratosis), it was found
that compared with people who consumed urban low-arsenic drinking water, the
hair of people who consumed high-arsenic drinking water arsenic concentration
increased significantly. The level of arsenic in drinking water directly affects the
health of local residents, and skin disease is the most common clinical
complication of arsenic poisoning. There is a correlation between arsenic
concentrations in biological samples (hair and blood) from patients with skin
diseases and intake of arsenic-contaminated drinking water (Kazi et al., 2009).
Another Bangladesh study showed that many people suffer from scabies due to
river pollution (Hanif et al., 2020). Not only that, but water pollution from
industry can also cause skin cancer (Arif et al., 2020).
Studies using meta-analysis have shown that exposure to polluted Marine
recreational waters can have adverse consequences, including frequent skin
discomfort (such as rash or itching). Skin diseases in swimmers may be caused
by a variety of pathogenic microorganisms (Yau et al., 2009). People (swimmers
and non-swimmers) exposed to waters above threshold levels of bacteria had a
higher relative risk of developing skin disease, and levels of bacteria in seawater
were highly correlated with skin symptoms.
Studies have also suggested that swimmers are 3.5 times more likely to report
skin diseases than non-swimmers. This difference may be a “risk perception
bias” at work on swimmers, who are generally aware that such exposure may
lead to health effects and are more likely to detect and report skin disorders. It is
also possible that swimmers exaggerated their symptoms, reporting conditions
that others would not classify as true skin disorders (Fleisher and Kay. 2006).
Water Pollution and Cancer
According to WHO statistics, the number of cancer patients diagnosed in 2020
reached 19.3 million, while the number of deaths from cancer increased to
10 million. Currently, one-fifth of all global fevers will develop cancer during their
lifetime. The types and amounts of carcinogens present in drinking water will
vary depending on where they enter: contamination of the water source, water
treatment processes, or when the water is delivered to users (Morris, 1995).
From the perspective of water sources, arsenic, nitrate, chromium, etc. are highly
associated with cancer. Ingestion of arsenic from drinking water can cause skin
cancer and kidney and bladder cancer (Marmot et al., 2007). The risk of cancer
in the population from arsenic in the United States water supply may be
comparable to the risk from tobacco smoke and radon in the home environment.
However, individual susceptibility to the carcinogenic effects of arsenic varies
(Smith et al., 1992). A high association of arsenic in drinking water with lung
cancer was demonstrated in a northern Chilean controlled study involving
patients diagnosed with lung cancer and a frequency-matched hospital between
1994 and 1996. Studies have also shown a synergistic effect of smoking and
arsenic intake in drinking water in causing lung cancer (Ferreccio et al., 2000).
Exposure to high arsenic levels in drinking water was also associated with the
development of liver cancer, but this effect was not significant at exposure levels
below 0.64 mg/L (Lin et al., 2013).
Nitrates are a broader contaminant that is more closely associated with human
cancers, especially colorectal cancer. A study in East Azerbaijan confirmed a
significant association between colorectal cancer and nitrate in men, but not in
women (Maleki et al., 2021). The carcinogenic risk of nitrates is concentration-
dependent. The risk increases significantly when drinking water levels exceed
3.87 mg/L, well below the current drinking water standard of 50 mg/L. Drinking
water with nitrate concentrations lower than current drinking water standards
also increases the risk of colorectal cancer (Schullehner et al., 2018).
Drinking water with high chromium content will bring high carcinogenicity caused
by hexavalent chromium to residents. Drinking water intake of hexavalent
chromium experiments showed that hexavalent chromium has the potential to
cause human respiratory cancer. (Zhitkovich, 2011). A case from Changhua
County, Taiwan also showed that high levels of chromium pollution were
associated with gastric cancer incidence (Tseng et al., 2018).
There is a correlation between trihalomethane (THM) levels in drinking water and
cancer mortality. Bladder and brain cancers in both men and women and non-
Hodgkin’s lymphoma and kidney cancer in men were positively correlated with
THM levels, and bladder cancer mortality had the strongest and most consistent
association with THM exposure index (Cantor et al., 1978).
From the perspective of water treatment process, carcinogens may be introduced
during chlorine treatment, and drinking water is associated with all cancers,
urinary cancers and gastrointestinal cancers (Page et al., 1976). Chlorinated
byproducts from the use of chlorine in water treatment are associated with an
increased risk of bladder and rectal cancer, with perhaps 5,000 cases of bladder
and 8,000 cases of rectal cancer occurring each year in the United States (Morris,
1995).
The impact of drinking water pollutants on cancer is complex. Epidemiological
studies have shown that drinking water contaminants, such as chlorinated by-
products, nitrates, arsenic, and radionuclides, are associated with cancer in
humans (Cantor, 1997). Pb, U, F- and no3- are the main groundwater pollutants
and one of the potential causes of cancer (Kaur et al., 2021). In addition, many
other water pollutants are also considered carcinogenic, including herbicides and
pesticides, and fertilizers that contain and release nitrates (Marmot et al., 2007).
A case from Hebei, China showed that the contamination of nitrogen compounds
in well water was closely related to the use of nitrogen fertilizers in agriculture,
and the levels of three nitrogen compounds in well water were significantly
positively correlated with esophageal cancer mortality (Zhang et al., 2003).
In addition, due to the time-lag effect, the impact of watershed water pollution
on cancer is spatially heterogeneous. The mortality rate of esophageal cancer
caused by water pollution is significantly higher downstream than in other
regions due to the impact of historical water pollution (Xu et al., 2019). A study
based on changes in water quality in the watershed showed that a grade 6
deterioration in water quality resulted in a 9.3% increase in deaths from
digestive cancer. (Ebenstein, 2012).
Water Pollution and Child Health
Diarrhea is a common disease in children. Diarrhoeal diseases (including cholera)
kill 1.8 million people each year, 90 per cent of them children under the age of
five, mostly in developing countries. 88% of diarrhoeal diseases are caused by
inadequate water supply, sanitation and hygiene (Team, 2004). A large
proportion of these are caused by exposure to microbially infected water and
food, and diarrhea in infants and young children can lead to malnutrition and
reduced immune resistance, thereby increasing the likelihood of prolonged and
recurrent diarrhea (Marino, 2007). Pollution exposure experienced by children
during critical periods of development is associated with height loss in adulthood
(Zaveri et al., 2020). Diseases directly related to water and sanitation, combined
with malnutrition, also lead to other causes of death, such as measles and
pneumonia. Child malnutrition and stunting due to inadequate water and
sanitation will continue to affect more than one-third of children in the world
(Bartlett, 2003). A study from rural India showed that children living in
households with tap water had significantly lower disease prevalence and
duration (Jalan and Ravallion, 2003).
In conclusion, water pollution is a significant cause of childhood diseases. Air,
water, and soil pollution together killed 940,000 children worldwide in 2016, two-
thirds of whom were under the age of 5, and the vast majority occurred in low-
and middle-income countries (Landrigan et al., 2018). The intensity of industrial
organic water pollution is positively correlated with infant mortality and child
mortality in less developed countries, and industrial water pollution is an
important cause of infant and child mortality in less developed countries
(Jorgenson, 2009). In addition, arsenic in drinking water is a potential
carcinogenic risk in children (García-Rico et al., 2018). Nitrate contamination in
drinking water may cause goiter in children (Vladeva et al.., 2000).
Discussions
This paper reviews the environmental science, health, and medical literature,
with a particular focus on epidemiological studies linking water quality, water
pollution, and human disease, as well as studies on water-related disease
morbidity and mortality. At the same time, special attention is paid to
publications from the United Nations and the World Health Organization on water
and sanitation health research. The purpose of this paper is to clarify the
relationship between water pollution and human health, including: The
relationship between water pollution and diarrhea, the mechanism of action, and
the research situation of meta-analysis; The relationship between water pollution
and skin diseases, pathogenic factors, and meta-analysis research; The
relationship between water pollution and cancer, carcinogenic factors, and types
of cancer; The relationship between water pollution and Child health, and the
major childhood diseases caused.
A study of more than 100 literatures found that although factors such as country,
region, age, and gender may have different influences, in general, water
pollution has a huge impact on human health. Water pollution is the cause of
many human diseases, mainly diarrhoea, skin diseases, cancer and various
childhood diseases. The impact of water pollution on different diseases is mainly
reflected in the following aspects. Firstly, diarrhea is the most easily caused
disease by water pollution, mainly transmitted by enterovirus existing in the
aquatic environment. The transmission environment of enterovirus depends on
includes groundwater, river, seawater, sewage, drinking water, etc. Therefore, it
is necessary to prevent the transmission of enterovirus from the environment to
people through drinking water intervention. Secondly, exposure to or use of
heavily polluted water is associated with a risk of skin diseases. Excessive
bacteria in seawater and heavy metals in drinking water are the main pathogenic
factors of skin diseases. Thirdly, water pollution can pose health risks to humans
through any of the three links: the source of water, the treatment of water, and
the delivery of water. Arsenic, nitrate, chromium, and trihalomethane are major
carcinogens in water sources. Carcinogens may be introduced during chlorine
treatment from water treatment. The effects of drinking water pollution on
cancer are complex, including chlorinated by-products, heavy metals,
radionuclides, herbicides and pesticides left in water, etc., Finally, water pollution
is an important cause of children’s diseases. Contact with microbiologically
infected water can cause diarrhoeal disease in children. Malnutrition and
weakened immunity from diarrhoeal diseases can lead to other diseases.
This study systematically analyzed the impact of water pollution on human
health and the heterogeneity of diseases from the perspective of different
diseases, focusing on a detailed review of the relationship, mechanism and
influencing factors of water pollution and diseases. From the point of view of
limitations, this paper mainly focuses on the research of environmental science
and environmental management, and the research on pathology is less involved.
Based on this, future research can strengthen research at medical and
pathological levels.
In response to the above research conclusions, countries, especially developing
countries, need to adopt corresponding water management policies to reduce
the harm caused by water pollution to human health. Firstly, there is a focus on
water quality at the point of use, with interventions to improve water quality,
including chlorination and safe storage (Gundry et al., 2004), and provision of
treated and clean water (Khan et al., 2013). Secondly, in order to reduce the
impact of water pollution on skin diseases, countries should conduct
epidemiological studies on their own in order to formulate health-friendly bathing
water quality standards suitable for their specific conditions (Cheung et al.,
1990). Thirdly, in order to reduce the cancer caused by water pollution, the
whole-process supervision of water quality should be strengthened, that is, the
purity of water sources, the scientific nature of water treatment and the
effectiveness of drinking water monitoring. Fourthly, each society should prevent
and control source pollution from production, consumption, and transportation
(Landrigan et al., 2018). Fifthly, health education is widely carried out. Introduce
environmental education, educate residents on sanitary water through
newspapers, magazines, television, Internet and other media, and enhance
public health awareness. Train farmers to avoid overuse of agricultural chemicals
that contaminate drinking water.