Environmental Science and Pollution Research

, Volume 25, Issue 33, pp 33038–33055 | Cite as

Water infrastructure and well-being among First Nations, Métis and Inuit individuals in Canada: what does the data tell us?

  • Melanie O’GormanEmail author
  • Stephen Penner
Water, sanitation, pollution and health in the Arctic


This paper documents the association between water and sanitation infrastructure and health indicators in Canada for First Nations, Métis and Inuit individuals living on and off-reserve in Canada. We use two data sources: the Aboriginal Peoples Survey and a survey conducted in a First Nations community in northern Manitoba—St. Theresa Point First Nation. We find statistically significant relationships between water infrastructure and health status in both sources of data. In particular, among individuals living off-reserve, contaminated water is associated with a 5–7% lower likelihood of reporting good self-rated health and a 4% higher probability of reporting a health condition or stomach problem. Those in St. Theresa Point First Nation without running water are four times more likely to report an illness relative to those with running water. Off-reserve, this likely suggests a need for improved public education on the management of private water supplies and more frequent water testing. Our case study suggests that further investment in water/sanitation infrastructure and housing is needed in the community.


Water and sanitation infrastructure Health First Nations, Métis and Inuit people 


The safety of drinking water and sanitation in Canada is now an issue that makes headlines and is not taken for granted. Boil water advisories persist across the country in First Nations communities.1 Private water supplies (wells and cisterns) are susceptible to contamination from many sources, including industrial waste, improper sanitation practices, oil and gas development and hydroelectric generation.2 As a result, many Canadians report not trusting their water supply and relying on bottled water for their drinking water.3

This paper investigates the correlation between health and water supply for First Nations, Métis and Inuit individuals living off-reserve and in one First Nations community. Water supply and sanitation systems differ substantially on and off-reserve. Individuals living off-reserve rely primarily on municipal water supply, with only approximately 10% of Canadians using private drinking water supplies (wells and cisterns) (Statistics Canada 2011). Regarding sanitation off-reserve, in 2009, 82% of Canadian households were connected to municipal sewer systems, 13% had private septic systems and 1% used communal septic systems (Statistics Canada 2011). Water quality off-reserve became a topical issue in the year 2000 when seven individuals passed away and thousands became ill in Walkerton, Ontario due to Escherichia coli contamination of the public water supply (CBC News 2010). A number of lessons were learned for Canadian policy makers and water treatment plant operators from this crisis, for example that pathogenic microorganisms still pose a great risk to public drinking water, that sudden changes in rainfall or runoff should be expected and trigger defensive measures by treatment plant operators and that system operators must respond quickly to adverse water quality indicators (Hrudey et al. 2002).

On-reserve water and sanitation is funded by Band Councils and the Federal government through Indigenous and Northern Affairs Canada (INAC). Approximately 19% (152 water systems) of First Nations however obtain water through a Municipal-Type Agreement (MTA)—accessing potable water via a neighbouring municipality (Neegan Burnside Ltd 2011). Whereas the vast majority of homes off-reserve have water piped into their homes, in on-reserve only, 69% of homes have a piped water supply while 15% had water trucked in (delivered to a cistern) and 13% obtained water from a well and the remaining individuals collected water from a neighbour’s house, lake or river (FNIGC 2011). Sanitation systems on-reserve consist of a mixed system of sewage treatment facilities and septic tanks, similar to the system off-reserve. However, 8% of adults living on-reserve in 2008–2010 lacked any type of sanitation system (FNIGC 2011).

Off-reserve water quality is monitored, and boil water advisories (BWAs) are issued by provincial authorities. In 2015, 10% of households in Canada reported that they had been notified of a boil water advisory. The province with the highest proportion of households served with a BWA was Manitoba at 36% (Statistics Canada 2011). First Nations communities receive funding from Health Canada for water quality monitoring, and Band Councils are responsible for issuing BWAs (Woods 2014).

We find statistically significant associations between water/sanitation infrastructure and health/well-being both on and off-reserve. In the next section, we discuss the academic literature this paper contributes to. The “National study: an analysis of the 2006 Aboriginal Peoples Survey (APS)” section describes our methodology for the off-reserve analysis and presents our findings. The “Understanding the implications of inadequate water infrastructure in a Northern Manitoba First Nation” section presents our findings for the case study. The “Conclusion” section concludes.

Literature review

Policy makers and academics alike assume that there is a strong connection between access to water and health/well-being; however, there is very little data-driven analysis on this issue in the Canadian context and for indigenous populations. We investigate this issue empirically both off-reserve and on-reserve.

There are many studies that examine the connection between water and health for a developing country context. For example, Jalana and Ravallion (2003) examine the impact of investments in water infrastructure on child health in rural India using propensity score matching methods. The authors find that diarrhoea among children decreases for families with piped water relative to households without it. Impacts are however largely non-existent however for poorer families and when the mother is poorly educated. Gamper-Rabindran et al. (2010) similarly find that health impacts from piped water provision in Brazil differ by quantile of the under one infant mortality rate (IMR) distribution. The latter two papers thus suggest that piped water provision can significantly improve health when complemented by other public health investments. Using 172 household surveys, Günther and Fink (2010) find that increasing access to water and sanitation infrastructure lowers the odds of children suffering from diarrhoea by 7–17% and reduces the mortality risk for children under the age of five by about 5–20%. Zhang (2012) finds that introducing village-level water plants in China is associated with reductions in the incidence of illness and an increase in weight-for-height for both adults and children. Günther and Schipper (2013) use a randomized controlled trial which assesses the role of improved water transport and storage containers on the water quality and health of households in Benin. Estimates suggest that such containers were effective at reducing E. coli contamination.

In the Canadian context, there are quite a few studies analyzing the connection between illness and water supply for a non-indigenous population. For example, Edwards et al. (2012) uses data collected by the Interior Health Authority in British Columbia (BC) to understand water system risk. The author finds that poorly constructed, deteriorating and shallow wells are most susceptible to contamination, especially those in proximity to sources of contamination such as agricultural and human waste. Murphy et al. (2016) set out to identify the source of roughly 21 million acute gastrointestinal illnesses (AGIs) that occur annually in Canada. The authors estimate that roughly 314,000 illnesses stem from contaminated water from systems serving more than 1000 people.

However, case studies or econometric analyses focusing on an indigenous population in Canada are rare. Exceptions include Polaris Institute (2008), Daley et al. (2014), Greenwood et al. (2015) and Lipka and Deaton (2015). The Polaris Institute produced a report called ‘Boiling Point!’, which highlights the water conditions present in six First Nations communities in Canada and some of the socio-economic impacts resulting from a lack of clean water and sanitation. Daley et al. (2014) explore water shortages due to a trucked water system and the connection with human health and well-being in Coral Harbour, Nunavut. Greenwood et al. (2015) contains a survey of indigenous health in Canada and discusses the cost of defending oneself against poor water infrastructure due to on-reserve resource extraction. Lipka and Deaton (2015) explore the association between a First Nations community having a boil water advisory if they have a MTA for drinking water with a nearby municipality compared to those communities without one. The authors find that having a MTA is associated with a 40% reduction in the system having a high risk ranking and an 18 (38)% reduction in the community failing health (aesthetic) guidelines.

Our contribution in this paper is first, a cross-Canada analysis of the association between health conditions and water conditions off-reserve, which allows us to calculate the increased likelihood of a health condition for those with inadequate water systems compared to those with adequate water systems. Second, we present the results of a case study highlighting the broad impacts of a lack of adequate water and sanitation infrastructure in one First Nation community in northern Manitoba—St. Theresa Point First Nation.

National study: an analysis of the 2006 Aboriginal Peoples Survey (APS)

Waterborne illness in Canada is generally associated with lost time due to symptoms such as vomiting and diarrhoea. In rare cases, such as the outbreak of Escherichia coli (E. coli) in the municipal water supply system in Walkerton, ON in 2000, such illnesses can be fatal.4 However, the municipal water systems in Canada are generally thought to provide safe, aesthetically pleasing water to Canadians. Such off-reserve water supply systems operate according to the Guidelines for Canadian Drinking Water Quality established by the Federal–Provincial–Territorial Committee on Drinking Water. However, it is believed that the majority of waterborne illnesses are associated with private water systems.5 Owners of such systems are responsible for monitoring and maintaining their water quality.

Below we use the 2006 Aboriginal Peoples Survey (APS) to link self-reported health conditions with water access and quality. The APS is a post-censal survey of First Nations, Métis and Inuit individuals on socio-economic conditions such as educational attainment, language and income. This is the largest available data for a First Nations, Métis and Inuit sample with both health and water information. A large sample generates confidence that the results can be reasonably generalized to the First Nations, Métis and Inuit population. However, respondents of the 2006 APS were largely living off-reserve. This is problematic given that inadequate water and sanitation is largely an issue on-reserve; hence, in the next section, we discuss the connection between water and health using on-reserve data—a sample of individuals from St. Theresa Point First Nation.


We ask the research question: is poor self-reported health associated with one’s water/wastewater system, and if so, to what extent? We model the probability of individual I reporting good health, Hi, as a function of explanatory variables Xi and the water conditions they face, W:

$$ P\left({H}_i=1\right)=f\left(\ \alpha +\beta {X}_i+\delta W+{\varepsilon}_i\right) $$
where f denotes the standard normal cumulative distribution function. We consider four different measures of good health or well-being:
  • An individual’s self-rated health status (the variables ‘health_stat’ and ‘health_stat2’)

  • An indicator of whether an individual has any of the following chronic health conditions: diabetes, asthma, cancer, a stomach problem including an ulcer, hepatitis or an issue with their kidneys (the variable ‘health_condition’).

  • An indicator of whether the individual reports suffering from stomach/gastrointestinal issues (the variable ‘stomachp’).

  • An indicator of whether the individual has ever been unemployed due to a health issue (the variable ‘Unempl’).

The variables we use to denote one’s water conditions, W, are as follows:
  • An indicator of whether the individual reports that their water has been contaminated or not (the variable ‘water_contaminated’)

  • An indicator of whether an individual has running water in their home or not (the variable ‘running_water’)

  • An indicator of whether an individual has a working flush toilet and a sanitation system or not (the variable ‘sanitation’)

In order to control for other health determinants, we include the following explanatory variables Xi: the respondent’s age, gender, income, province, education level, whether they smoke, their household income level, their perception of their health care access, whether they attended a residential school and whether they have left the community recently. As the dependent variables are all binary variables, we use a probit model to investigate whether there are statistically significant relationships between the health indicators and the water variable after controlling for other explanatory variables.

Variable definitions

We now describe our variables of interest. First, we begin with our health/well-being variables, Hi, which serve as our dependent variables (those whose variance we are trying to explain). The variable health_stat is a dummy variable taking the value of 1 if a respondent indicates that their health is ‘excellent’, ‘very good’ or ‘good’, and zero otherwise (they could have referred to their health as ‘fair’ or ‘poor’). Health_stat2 is a dummy variable taking the value of 1 if a respondent indicates that their health is excellent or very good and zero otherwise. These two variables provide us with an indication of self-rated health status.

The variable health_condition is a dummy variable that takes on the value of 1 if the individual reports that they have had any of the following health conditions: diabetes, asthma, cancer, stomach problems, intestinal ulcers, hepatitis or kidney disease. These conditions were chosen out of a longer list either because they could be directly caused by contaminated water (e.g. stomach problems due to bacterial contamination or cancer due to industrial waste dumped into the water) or indirectly caused by contaminated water or a lack of water (e.g. a lack of running water in one’s home may lead to poorer food choices which could lead to diabetes, or a lack of sufficient water may prevent an individual from cleaning their home sufficiently which could lead to mould growth and induce asthma).

Unempl is a dummy variable that takes on the value of 1 if the individual answered ‘health problems’ to the question ‘What are the reasons that have kept you from working at a full-time job?’ and zero otherwise. ‘Stomach_prob’ is a dummy variable taking the value of 1 if the respondent answered ‘yes’ to the question: ‘Have you been told by a doctor, nurse or other health professional that you have stomach problems or intestinal ulcers?’ and zero otherwise.

Next, we describe the variables that proxy for a respondent’s water access/quality, Wi. The respondent is taken to have running water if they answered that they have both cold and hot running water in their home. The variable water_contaminated takes on the value of 1 if the individuals answered yes to the question ‘Are there times of the year when your water is contaminated?’. It could be taken as a proxy for an individual being notified by a boil water advisory or an individual who is simply aware of the risks associated with their water supply. ‘Toilet’ is a dummy variable taking the value of 1 if the individual reported having a flush toilet in their home and zero otherwise. Sanitation is a dummy variable that takes the value of 1 if the respondent has a toilet and a septic tank or sewage system and zero if they only have one of these or neither.

Our independent or explanatory variables, Xi, are variables typically associated with health status. We add them sequentially so as to examine the marginal contributions of these variables. The two variables that are included initially are ‘age’ and ‘gender’. Age is a continuous variable that indicates the respondent’s age. The variable gender takes on the value of 1 if the respondents indicate that they are male and zero if they are female.

The variable ‘mobility’ takes on the value of 1 if an individual has lived outside their community for at least 1 month at some point over the last year, and zero otherwise. ‘Grad’ denotes whether the individual in question has graduated from high school (but not a high school equivalency program (GED)) or not. ‘Smoke’ is a dummy variable taking on the value of 1 if the respondent answered ‘occasionally’ or ‘daily’ to the question: ‘At the present time do you smoke cigarettes daily, occasionally or not at all?’. ‘Health access’ denotes the availability of health services or the response to the question ‘Overall, how would you rate the availability of doctor’s or physician care services in your community?’, with the answers excellent, very good, good, fair or poor as responses. The variable ‘resid’ denotes that the respondent attended a federal residential school. ‘Income’ is a continuous variable and denotes total family income for the household of the respondent over the last year. Table 1 presents the means of our dependent variables and our independent variables.
Table 1

Means of variables from Aboriginal Peoples Survey

Dependent variables









 Stomach problem


Independent variables





















Source: Statistics Canada (2005)

Tables 2 and 3 present the means of our dependent variables by water/sanitation access and water quality, respectively. In general, water/sanitation access is associated with better self-reported health with a few exceptions. Surprisingly, those without running water are less likely to have a health condition and less likely to be unemployed due to a health condition, and those without sanitation are less likely to have a stomach problem. However, those reporting that their water has been contaminated are more likely to indicate that they are in good health, less likely to report a stomach condition or more general health condition and are less likely to be unemployed due to a health condition.
Table 2

Conditional means of dependent variables by water access/quality


By running water

By toilet

No running water

Running water

No toilet



























Source: Statistics Canada (2005)

Table 3

Conditional means of dependent variables by water access/quality (continued)


By septic tank/sewage system ownership

By Water Contamination

No septic or sewage system

Septic tank or sewage system

No contaminated water

Contaminated water


























Source: Statistics Canada (2005)


We first summarize our main results and then explain them in detail. After controlling for other health determinants, we find that:
  • Running water is not associated with superior health.

  • Contaminated water is associated with a 5–7% reduction in self-reported health status and a 4% increase in illness incidence generally and in stomach problems in particular.

  • Sanitation is associated with a small likelihood (a 4% lower chance) of reporting being in good health.

The results of our regression analysis are presented in Appendix 1. We first present in Table 9 the results of the estimation of a probit model using running_water as our key water variable and age, resid and gender as explanatory variables. We find statistically significant associations between the self-rated health variables and running water. Those with running water are 8% more likely to report being in excellent, very good or good health, and those with running water are 10% more likely to report being in excellent or very good health. We also find that men are more likely to have higher self-rated health and are less likely to report a health condition. Age is associated with lower self-rated health status, an increased likelihood of reporting a health condition and a higher chance of being unemployed due to a health condition. Attendance at a residential school is associated with lower health status and an increased likelihood of reporting health conditions, as has been found in other studies on this issue (for example, Milloy 1999).

We are aware however that there are many other determinants of health besides age, gender and running_water. Therefore, in the remaining tables, we add additional variables into our model to allow us to control for their influence and to gain further insight into the marginal effect of running_water on our dependent variables. In Table 10, we include provincial dummy variables (but omit the marginal effects for these variables to save space). We include these dummy variables because it could be the case that the main determinant of our dependent variables is geography due to varying policies across provinces, different health care systems, varying source water quality, etc., and so including these dummy variables allows for such variation. We find very little impact on the marginal effect of running water on our dependent variables from this addition.

In Table 11, we present the model estimates resulting from the addition of the variable mobility (described above). It is important to control for this variable because if an individual is not in the community or at home for much of the year, we would not expect their health/employment situation to be as affected by the water situation in their community or home. We find statistically significant associations with all of our dependent variables except health_stat2 and Unempl. For example, an individual who has moved away from the community is 3% more likely to report a health condition. In general, those who are more mobile appear to have lower health status. The addition of this variable as well has little impact on the marginal effect of running water on our dependent variables.

In Table 12, we present the model estimates arising from the addition of the remaining explanatory variables to our model. This includes income, educational attainment, health access and whether an individual is a smoker. Perception of health access has a negative association with health status and a positive association with health conditions and unemployment. This entails that those who feel their health access is inferior to other Canadians are less likely to feel healthy and more likely to report health conditions or have a health-related unemployment spell. Those who smoke are approximately 10% less likely to report excellent or very good health, are 4% more likely to report a stomach condition and are 5% more likely to be unemployed due to poor health. Income and educational attainment are associated with higher self-rated health and less incidence of illness as might be expected. Once we include these variables in our regression, the running_water variable loses its statistical significance. This suggests that the additional factors we control for are correlated with the running_water variable and can independently explain much of the variation in the dependent variables.

In Tables 13, 14, 15, 16 and 17, we follow the same procedure as above—first using only age, gender and resid as explanatory variables and then sequentially adding other health determinants into the model—but now use the water variable water_contaminated as our key water variable. With only age, resid and gender included in model, we find that contaminated water is associated with a 7% (10%) reduction in health_stat (health_stat2). Contaminated water is associated with a 4.3% higher likelihood of reporting a health condition and a 3.6% higher likelihood of reporting a stomach problem. Contaminated water is also associated with a 3.3% higher probability of being unemployed due to a health condition.

These marginal effects are stable across the regressions that add mobility and the provincial dummies as explanatory variables. However, once we add the other health determinants, there is no longer a statistically significant association between water_contaminated and Unempl. The other marginal effects are reduced; however, statistically significant associations remain. Hence, we find that after accounting for other health determinants, contaminated water is associated with a 5 or 7% reduction in self-reported health status (depending on the definition of health status) and a roughly 4% increase in illness incidence generally and in stomach problems in particular.

Last, in Tables 17, 18, 19 and 20, we proceed in the same manner as above and investigate the correlations between our dependent variables and the variable sanitation alongside other hypothesized health determinants. Once we add all hypothesized health determinants, we find (counterintuitively) that those with a sanitation system and a flush toilet are 4% less likely to report good self-rated health status. There is no statistically significant relationship between the other dependent variables and sanitation. This and our first set of results suggest that those without indoor plumbing off-reserve are not suffering health consequences as a result of their inadequate plumbing. However, so few individuals are in the category of lacking sanitation services or running water among the indigenous, off-reserve population that self-reported health status, illness and unemployment spells seem to be explained by idiosyncratic factors once standard health determinants are controlled for.

Understanding the implications of inadequate water infrastructure in a northern Manitoba First Nation

The situation in First Nation communities differs dramatically from that off-reserve in terms of water/sanitation infrastructure and indoor plumbing. In northern Manitoba, many homes still lack indoor plumbing. Families living in overcrowded housing use buckets to collect water from a community tap and haul this water back to their home for drinking, bathing, cooking and cleaning. Such households often resort to rationing water given the drudgery associated with hauling water, especially in frigid temperatures (Fallding 2010a).

In these communities, winter roads are often only open for a few weeks per year which makes the cost of transporting construction material for retrofitting homes extremely expensive. Pete Sarsfield, a retired medical officer, refers to situations such as those described above as Canada’s ‘refugee camps’ (Fallding 2010b). Individuals subsist on such little water per day that the conditions for poor health—especially rashes, chronic diarrhoea and distress—are ripe.

While the health benefits of improved drinking water and sanitation services seem obvious, there are numerous other economic benefits of improved water infrastructure. These health benefits are associated with averted healthcare costs—for example, fewer hospitalizations and less need for medication. There are also fewer absences from work and increased labour earnings due to reduced incidence of illness. Children’s attendance at and performance in school is likely to improve if they are ill less due to improved water quality and sanitation. There are environmental benefits of proper sanitation infrastructure, including reduced groundwater contamination, improved soil quality and improved health of aquatic life. Finally, many individuals and communities place a high inherent value on access to safe drinking water.

In this section, we discuss these wider-ranging benefits of improved water and sanitation services, with the focus now on-reserve. In March 2016, we conducted a survey in St. Theresa Point First Nation in northern Manitoba to document the daily implications of a lack of funding for water infrastructure. With this survey, we asked:
  • What are the day-to-day impacts of improper water infrastructure?

  • Are there health implications?

  • Is a lack of proper water infrastructure affecting schooling?

  • Are there still homes that need to be retrofitted?

  • How much are people spending on bottled water/filtration systems?

  • Are there any concerns with cisterns?

We conducted four focus groups—with elders, nursing station staff, teachers and council. The purpose of these focus groups was to obtain participants’ views on interventions that would improve the safety and reliability of drinking water in the community and to talk generally about the impacts of a lack of running water/improper sanitation on the community. We then surveyed 142 people. We first went door-to-door—stopping in at peoples’ homes and interviewing them there—to ensure that we spoke to people facing very different water conditions—some with running water, some without, some who use a cistern, some on the main water line, etc. We also had a booth at the Northern Store where we recruited survey respondents more randomly, in order to increase our sample size. The survey consisted of open-ended questions and quantitative questions, and we summarize the findings below.

Demographics of the sample

Our sample of 142 respondents contains roughly equal numbers of men and women and an age distribution resembling that in the population.6 The most common language reported is Oji-Cree (60% of respondents reported that as their primary language) while another 31% reported speaking mostly Oji-Cree and English.

As noted in Table 4, the majority of the population lives on very little income per month—less than $1500 per month. This accords with the average monthly income of approximately $1000 per person reported in the 2011 Census for St. Theresa Point First Nation (Statistics Canada 2013). This is concerning given the high cost of basic necessities in the community as it is relatively isolated.7
Table 4

Average monthly income per individual in case study community

Less than $1500












Above $9000


Source: Authors’ calculations using survey data

The education distribution of our sample is similar to that in the population as reported in the 2011 Census (Table 5). While 81% of our sample has less than a high school diploma, a similar proportion had less than a high school diploma in 2011 (Statistics Canada 2013).
Table 5

Highest level of education completed

Grade 8 or less


Grade 9


Grade 10


Grade 11


Grade 12


GED or another adult education program




Bachelor’s degree


Master’s degree




Source: Authors’ calculations using survey data

Water access

‘People can’t afford water—[that entails] $25 out of their childrens’ mouths’ (Survey respondent)

Thirty-five percent of our sample accesses water using a water tank. These households have a water tank that is filled by a truck with water from the water treatment plant. This water tank connects to taps inside the house. The other 54% have water from the water treatment plant coming into their house via a pipe. The remaining 11% have no running water in their home—they have no indoor plumbing, so one must bring water into the home using a bucket.

Only 4.5% of water tanks are located inside the home. The remaining tanks are located either under or outside the house. Water can freeze in tanks located outside the house given the long winter experienced in the community. Two thirds of water tanks are not secured with a lock so that tanks can be exposed to contamination due to people throwing things in them or animals entering them. Eighty-seven percent of individuals reported having a shower in their home, while 85% of individuals have a washing machine for their clothes.

In terms of sanitation, 89% of individuals reporting having a flush toilet in their home. Three percent reported using an outhouse, while 8% reported using a slop pail.8 Only 74% of respondents report having their sewage removed by a pipe to the lagoon. The remaining 26% either do not have indoor plumbing or their waste goes from their toilet into a tank outdoors that gets picked up by a community truck. These figures indicate that indeed some households are living in ‘developing country’ conditions, without basic water and sanitation facilities in their homes.

For those with water tanks, there are a limited number of water trucks in the community to refill water tanks when needed. Filling your water tank also costs $25 so many households report not being able to afford a refill, so conserving on water instead. Another common complaint was that water tanks are not refilled often enough. Given household sizes, a water tank only lasts so long until it needs to be re-filled, and there are not enough water trucks to deal with the demand for refilled tanks. Table 6 presents the proportion of time individuals that have access to water.
Table 6

How often do you have access to water?

All of the time


Most of the time


Hardly ever




Source: Authors’ calculations using survey data

Those that lack water have a number of options for obtaining it. Individuals (30.3%) reported obtaining water from a neighbour’s house. Individuals (39.2%) report hauling water from the community taps or the lake, and on average, individuals spend approximately 2 h per day hauling water. Some individuals report hauling water from these sources either because they lack running water or because they do not trust the water that comes from their water tank.

Water quality

Only 64.8% of survey respondents said that they trust their water to be clean. Not surprisingly, 32.2% of respondents boil their water before drinking it and 68.2% purchase bottled water.

It is essential that water in the household/water tank is tested to ensure that it is not contaminated. According to Health Canada, water in tanks should be tested daily and tanks cleaned weekly (Baird et al. 2013). However, only 42% of individuals in our survey report that their water has been tested, and approximately 62% of individuals indicate that their water is not tested annually. Those using water tanks reported many concerns regarding their tank and the water trucks used to deliver their water. Table 7 illustrates that water tanks are not cleaned regularly. On average, it costs $85 to clean a tank which suggests that some households may not be able to afford the cleaning supplies or time/labour to clean their tank. A recent study also in a northern Manitoba First Nation revealed high levels of E. coli in water from cisterns (Farenhorst et al. 2017).
Table 7

How often is your water tank cleaned? (proportion indicating response)

More than once a year


Once a year


Less than once a year


Source: Authors’ calculations using survey data

Well-being by water access

In Appendix 2, we present means of dependent variables by water access. In this data, our dependent variables are self-rated health status, illness prevalence and work/school attendance.

Average health status by water access

‘Babies with rashes—but so many babies look like that. Then racism happens—because such issues are blamed on parents’ mistreatment’ (Survey respondent)

‘People are desensitized—because it happens all the time here’ (Survey respondent)

Below we investigate whether there is a statistically significant correlation between well-being and water access/quality in St. Theresa Point First Nation. As demonstrated in Table 8, the majority of individuals in our sample describe their health as either good, very good or excellent.
Table 8

Self-rated health status



Very Good








Source: Authors’ calculations using survey data

Survey respondents and health officials reported many health conditions resulting from contaminated water or a lack of indoor plumbing. They noted that children tend to get rashes after bathing. Many have chronic diarrhoea. For those who need dialysis, the unreliable water pressure wreaks havoc on their treatment. Others reported impetigo and methicillin-resistant Staphylococcus aureus (MRSA).

Tables 21, 22, 23, 24, 25, 26 and 27 present mean differences in self-rated health by access to water. For each water variable, we run a Student’s t test (in cases of two groups) and analysis of variance (ANOVA) (in cases of more than two groups) in order to identify statistically significant differences between groups of sample respondents by water variable. Results are regarded as statistically significant at p < 0.10.

These tables suggest that average health status is more favourable for those with running water relative to those without running water and that average health status is more favourable for those with piped water and sewage service compared to those without such services. However, surprisingly, having a flush toilet is associated with inferior health status compared to having an outhouse or no toilet, and hauling water and infrequent water tank cleaning are associated with superior health. Regardless, these differences are not statistically significant; hence, we must conclude that self-rated health status does not differ by water access/quality in this sample. There are a number of possible interpretations for this result. First, as ‘health status’ is self-rated, it could be that individuals simply do not perceive a reduction in their health status as a result of say hauling water or being without indoor plumbing. They feel healthy or are managing to maintain their health despite these challenges. Second, it could be that the subjective nature of the variable makes it incomparable across individuals. For example, one person who has ideal access to water may rank their health as good, which to them is a strong rating, while another person with poor access to water may rate their health to be very good because they are generally an optimistic/positive person. These idiosyncratic differences between individuals can mask a positive correlation between water access and physical health.

Water illnesses by water access/quality

Next, we investigate whether there are large differences in illness prevalence by access to water (in Tables 28, 29, 30, 31, 32, 33 and 34). We find that indeed those without running water in their home are approximately four times more likely to acquire a waterborne illness. Those without a flush toilet at home are two times more likely than those with an outhouse of getting sick, while those without a flush toilet are four times more likely to get sick compared to those with one.

Table 32 indicates that as a person’s frequency of water access increases (moving from never having water access to having it all the time), their illness prevalence decreases monotonically. This association likely stems from the use of a cistern by large households. When a household has many residents, the water tank often runs dry and household members then start to ration water. This water rationing may lead to less cleaning of the home which may lead to illness.

In our sample, hauling water is also associated with an increased illness rate—those that haul water are 66% more likely to report a waterborne illness. There is quite a large literature linking water hauling and various measures of well-being but generally for a developing country context. For example, Meeks (2012) finds that labour-saving technology related to water fetching was associated with fewer acute intestinal infections and more time for home farm production in Kyrgyzstan. Using Demographic and Health Surveys carried out in 26 African countries, Pickering and Davis (2012) estimate the effect of decreased water fetching time on health using geographic variation in freshwater availability as an instrumental variable for walk time to a water source. They find that a 15-min decrease in walk time to a water source is associated with a 41% reduction in diarrhoea prevalence and an 11% reduction in under-five child mortality. Similarly, Koolwal and Van de Walle (2010) use rural household-level data from surveys spanning sub-Saharan Africa (Madagascar, Malawi, Rwanda, and Uganda), South Asia (India, Nepal, and Pakistan), North Africa (Morocco), and the Middle East (Yemen) and find that a reduction in the time to water is positively correlated with child schooling.

Work/school attendance by water quality/access

We asked each respondent if their or their child’s work or school attendance was ever affected by an illness due to water contamination. Thirty percent of individuals that participated in the survey say that they have missed work or school because they or a family member was sick from a waterborne illness. Eighteen percent say that they have missed school or work for another water-related reason (e.g. the school is closed because of a lack of running water or not being able to shower before work). In Tables 35, 36, 37, 38, 39, 40 and 41, we find only one statistically significant difference in school or work attendance by water access. Those who haul water are 63% more likely to report missing work or school due to a waterborne illness. Hauling water is a time-consuming activity, with some individuals spending up to 6 h a day doing it (Fallding 2010c). Individuals who haul water are also less likely to have access to water given the arduous nature of the activity—often in temperatures as low as − 30 °C. This can lead to illness which in turn can lead to work and school absenteeism.

We asked individuals that haul water ‘What would you do with the extra time if you weren’t hauling water?’. Some responses are below.

‘I would focus on my family, spending time with them’

‘I would clean my home and yard during the summer’

‘I would relax’

‘I would exercise’

‘I would play video games’

‘I would watch TV or visit friends’

The most prominent response was: ‘I would work’ (27% of respondents indicated this reason)

Impacts on schooling

‘The water situation does make a difference when you’re talking about the quality of life of the students’ (Survey respondent)

Many focus group participants and interviewees noted impacts of improper water infrastructure on education. A key reason for this is that the water pressure at the school is very unpredictable. On days when the water pressure is extremely low, the school must close. Even if the water is off for many hours, the school shuts down for the day, and this happens often. Intermittent water access is thus a reason for reduced contact hours with teachers and other educators.

There is not enough water to flood the skating rink so it does not function. Because the eye wash stations do not work, science teachers cannot perform experiments. Some students go to the washroom every hour—they have diarrhoea—but they still manage to come to class. Other students do not attend class because they cannot do laundry at home and are embarrassed of their clothes being dirty.

These issues are in addition to a more general lack of funding for school facilities. For example, the only school in the community has no library—the library had to be converted into two classrooms due to the high rate of population growth in the community. Focus group participants note that having regular, reliable access to water at the school would improve the school climate for both teachers and students and thus improve the quality of education.

Survey participants’ main water priority

‘If everyone got water from the main line—how would things change?’ (Survey respondent)

Our final question on the survey was ‘What, in your view, is most important for improving the water/sanitation situation in your community?’ The most prominent answer was ‘for all to be directly connected to main water line’—38% of respondents indicated this. Twenty-nine percent of individuals indicated a general desire for clean water. Ten percent of individuals demanded more water trucks. Other responses are below:

‘I would like water to run in pipelines in each home for convenience like washing clothes or daily shower’

‘Water filtration systems’

‘Need more trained workers to work at the plant’

‘Clean cisterns’

‘Better water delivery’

‘Workers need to check levels of chlorine in the water we drink’

‘More water trucks - people left waiting for weeks’

‘Need bigger water treatment plant’

‘Better water pressure’

‘Better roads’

‘More septic tanks’

‘Improved water pressure’

‘Water that I could trust so I don’t need to boil it’

‘More retrofitting of homes’

‘Hooked to main water line instead of worrying about saving every last drop of water’

‘More frequent testing of water’


‘How can there be any reconciliation in a country where this kind of inequality is acceptable?’ Shoal Lake 40 Chief Erwin Redsky (Council of Canadians 2015)

This study has found that there is a statistically significant association between self-rated health and water contamination for First Nations, Métis and Inuit individuals off-reserve. There also appears to be a close connection between waterborne illness and water access/quality in St. Theresa Point First Nation. These findings are inherently concerning—that, similar to the situation in many developing countries, many individuals in Canada are concerned about becoming ill from drinking water that comes from their tap, and some simply lack running water in their home.

We find that off-reserve water contamination is associated with a 5–7% reduction in the likelihood of reporting good self-rated health and a 4% higher incidence of stomach infections. In on-reserve, we find that those without running water or without a flush toilet are four times more likely to report an illness and that those hauling water are 63% more likely to report missing school or work due to a waterborne illness. Hence, while there are statistically significant associations between health and water/sanitation conditions in both samples, the magnitudes of such associations are higher on-reserve.

However, such illnesses also impose a monetary cost for the Canadian taxpayer as the healthcare system deals with an increased number of patients and employees are absent from work. We can estimate roughly how much taxpayers would save if water quality could be improved. We find that contaminated water off-reserve is associated with a 3.5% higher incidence of stomach/intestinal problems. The economic cost of infectious and parasitic diseases in Canada (including the costs of hospitalization and physician care, drug costs and the cost of lost production due to illness, injury and premature death) in 2008 was estimated at $2.92 billion (Economic Burden of Illness in Canada 2014). Taking 3.5% of this value gives $102.2 million that would be saved if water quality could be improved off-reserve. Naturally, this figure must be viewed with caution given that all infectious and parasitic diseases are not water-borne (which means that the figure is very likely an overestimate) and that water quality is known to be inferior on-reserve (which means that the figure is very likely an underestimate).

Our off-reserve results suggest that indeed contaminated water is affecting health off-reserve for First Nations, Métis and Inuit individuals. Given the more stringent regulations and testing of water for municipally supplied drinking water, we interpret these results as stemming from contamination of private water systems. As noted above, waterborne illnesses have been reported to be more prevalent for private drinking water systems. Yet a recent study found that well owners are very unlikely to have their well water tested—over a 5-year period, only 0.31% of Ontario well owners submitted samples for testing annually. Of those submissions, 23% of wells were found to have bacterial contamination (Maier et al. 2014). This suggests that more effort must be made to educate private water system owners on the importance of regular water testing, and more training was provided to those with cisterns on how to maintain them.

The water infrastructure conditions in St. Theresa Point First Nation—widespread cistern use, water rationing, and a lack of indoor plumbing in some homes—are unfortunately present in many First Nations communities across Canada. This will require increased capital funding for water infrastructure, increased funds for operation and maintenance of water systems, increased funding for housing and retrofitting of existing housing. The government of Canada promised $1.8 billion for this purpose (Government of Canada 2016) in its 2016 budget. However, in 2011, it was estimated that $4.7 billion would be required to bring water systems in line with INAC protocols (Neegan Burnside Ltd 2011), so increased funding is needed.

However, more than increased funding is needed to ensure water conditions’ on-reserve improvement. The current system of providing capital funding to First Nations for water infrastructure is slow and cumbersome—communities with ‘high risk’ water systems are prioritized while communities with ‘medium risk’ wait.9 A recent story in the national newspaper the Globe and Mail revealed that it typically takes 3 years for construction on a water infrastructure project to begin once funding is approved (McClearn 2016). There is also a need for increased training of water treatment plant operators. Cash-strapped communities often do not have the funds necessary for proper operation and maintenance of water systems and proper maintenance of cisterns. This suggests that reforms are needed to the system of water and sanitation provision in Canada.


  1. 1.

    There were 133 Drinking Water Advisories present in 90 First Nations communities in Canada as of 31 October 2016 (Health Canada 2016).

  2. 2.

    Jones et al. (2006) reports that an estimated 45% of all waterborne outbreaks in Canada involve non-municipal systems.

  3. 3.

    In 2011, 22% of Canadians drank primarily bottled water instead of tap water. This proportion is however higher—at 27% for households with a non-municipal water supply (Statistics Canada 2013). In a sample of individuals on reserve, 71% of respondents reported drinking bottled water (Regional Health Survey 2008).

  4. 4.

    Charrois (2010) notes that 3–5% of cases of acute gastrointestinal illness in vulnerable populations (infants and the elderly) are fatal.

  5. 5.

    Schuster et al. 2005 found that of 288 outbreaks of water-borne illness over a 27-year period; two thirds were from semi-private or private systems.

  6. 6.

    The proportion of our sample that is below 30 years old is 45.4% while a similar proportion of the population is below 20 years old in the case study community as reported in the 2011 Census (INAC 2016).

  7. 7.

    Only one third of our sample reporting having sufficient food to eat all of the time.

  8. 8.

    Some individuals have more than one of these options (e.g. they use a slop pail but also have an outhouse); therefore, the sum off the percentages is higher than 100%.

  9. 9.

    Indigenous and Northern Affairs Canada (INAC) assigns water systems a risk rating between 1 and 10 based on the following factors: quality and quantity of source water (10% weighting the risk rating), the system’s design (30% weighting), how well the system is operated and maintained (30% weighting), record keeping and reporting (10%), and operators’ training and certification (20%). A system with a risk rating above 7 is deemed ‘high risk’ and a system with a rating between 4 and 7 is ‘medium risk’. McClearn explains that medium risk systems still ‘between 4 and 7. These feature major deficiencies in one or two components and minor deficiencies in others’ (McClearn 2016).



We are very grateful for the time and knowledge shared with us by participants of this study. The survey that forms the basis for this paper could not have been conducted without the assistance of Raymond Harper, for which we are very thankful. We appreciated the support with logistics for this study provided by Morgan Vespa and Shianne McKay of the Centre for Indigenous Environmental Resources (CIER). Finally, we thank Helen Fallding for her guidance since the beginning of this project and Karen Busby for the academic leadership which led to the funding of this project.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of WinnipegWinnipegCanada

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