many residents make do with polluted groundwater, distant standpipes, or expensive water sold by local vendors at prices far higher than the official water tariff. For sanitation, open defecation remains common, particularly for children. Some of the alternatives can be just as unhealthy, not only for the users but for their local communities. In overcrowded settlements such sanitary hazards are particularly unhealthy. Other local deficiencies, such as solid waste collection problems, inadequate drainage, crowding, tenure disputes and income poverty amplify the effects of inadequate water and sanitation. Sanitation workers often lack the most minimal protection and working conditions. In some neighbourhoods, this can contribute to what some have called syndemics, with multiple diseases, hazards and social conditions reinforcing each other and leading to sudden increases in morbidity and mortality. In others it creates endemic health problems, which contribute to long-term urban health inequalities.
An important aspect of the link between urban governance and water and sanitation provision lies in the collective nature of the challenge. By using sanitary toilets households protect their neighbours as much as themselves. Everyone is put at risk in a neighbourhood with open defecation, poorly constructed or maintained pit latrines, flies breeding in human faeces, and other unhygienic conditions. Clean water protects the user more directly, and securing it involves a somewhat different governance challenge as a result. Yet even if a household secures sufficient clean water for its own use, in many cultures children regularly drink water in other people’s homes and from public sources. Moreover, piped water networks have an inherently collective character, which in private hands can create monopolies, with individual providers having excessive powers to reduce supplies and raise prices. In any case, most water and sanitation related diseases can be transmitted person-to-person, and simply being in close contact with infected individuals is a risk. As such, within a community where people interact closely, preventing the outbreak of these infectious diseases is inevitably a collective challenge.
In economic terms, water and sanitation improvement are quasi-public goods and create the sort of collective action problems conventionally used to justify government intervention. Indeed, the public health benefits of water and sanitation utilities were used to help justify the creation of public utilities. These utilities, while in some cases very successful, performed disappointingly over the course of the 20th century, especially in low-income settings, particularly where economic, social and political divisions have been rife. With the rise of