A few years back, while working in Benin, environmental health specialist Jay Graham saw an elderly woman in line at a pump to get water. She looked far too old to carry the water home herself, so he was relieved to see other people helping her — until he realized they were just making sure she had successfully balanced the 40-pound can on her head.

In parts of the world without running water, people must rely on an alternative: walking [to] water.

It's a physically demanding, time-consuming responsibility and one that almost always falls to females, according to Graham. He and his colleagues from the Milken Institute School of Public Health at the George Washington University have published a new study in PLOS ONE looking at data from 24 sub-Saharan African countries. They found that in all of the countries, in households where a family member had to spend more than 30 minutes to collect water, the primary collectors were women, ranging from 46 percent in Liberia to 90 percent in Cote d'Ivoire. When the chore is a kid's job, there's still a major gender gap: 62 percent for girls versus 38 percent for boys.

The research uncovered that in these countries, there are an estimated 13.54 million women (and 3.36 million children) who are responsible for water collection trips that take 30 minutes or longer.

That so many people, particularly children, shoulder this burden is what distresses Graham. "The scale of the problem really sinks in," he says.

And it highlights the fact that it's not just the quality of water that's at issue. The Millennium Development Goal to boost the population with access to safe drinking water was met in 2012. But focusing on safety wasn't enough, Graham says. "You also can't be spending crazy amounts of time collecting this water," he says.

It all starts with who is doing the job. "That's typically an adult woman, above 15," Graham says. Because of widespread gender inequality, he explains, females are saddled with most of the unpaid chores.

To collect the water, she likely carries a jerry can, a bright yellow plastic container that was originally filled with cooking oil. It's been cleaned out and then repurposed for water storage. If it's full, it holds 5 gallons and weighs about 40 pounds, Graham explains. In many places in sub-Saharan Africa, the woman is probably just holding the can and not using a wheelbarrow or a barrel that could be rolled home.

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People ask Graham why more women collecting water don't simply pick one of these less taxing methods. It's because they can't, he explains. "It's usually uneven terrain" with obstacles along the way, he notes.

The path to the water source may change frequently, adds Ben Crow, a sociology professor at the University of California Santa Cruz, who has researched the intricacies of water collection in Kenya. For one study, he placed GPS units on jerry cans to learn where and how far from home women traveled.

Before setting off, a woman must figure out which pump she can visit to actually acquire water on that particular day, Crow says. There are seasonal shortages and rations that may complicate this decision — and lengthen the trip. "In times of scarcity, the journey time can be quite long. They may spend half an hour coming there and another half hour back," he says.

Once a woman gets to a water source, she can expect to spend even more time waiting in line. When there's just a single hand pump, progress is slow. It's common to leave a jerry can to hold your spot, says Graham, who has seen rows of them stretching out for many feet. If the woman lives close enough, she may return home to do domestic chores. If not, she may just hang out.

Then comes the hard part: taking the water home.

Crow picked up a full jerry can once. "I could just about get it on my head," he says. "Could I walk with it? No."

As for Graham, he has lifted a few cans to feel the weight, but that's it. "It's hard work," he says. "If I go backpacking, I can't go very far with 40 pounds." And, he adds, he's a full-grown man who has never gone hungry. Many of the women and girls who regularly carry water are living in poverty.

Long walks with such a heavy load take their toll, notes Jo-Anne Geere, a lecturer at the Norwich Medical School at the University of East Anglia. She has also never hauled a jerry can. As a physiotherapist, she treats neck and back problems, "so I don't fancy creating my own," she says.

In her work examining the health implications of water collection in South Africa, Geere has found that carrying these heavy loads on one's head is associated with a particular pain pattern, with discomfort in the upper back and hands and an increased risk of headaches. (She's still studying why, although she suspects it's because of the compression of discs in the neck.) In one survey she collected data from six villages; 69 percent of participants reported spinal pain, and 38 percent complained of back pain.

It's not necessarily a single trip for water each day that's causing these consequences. Depending on the size of the family and the household's needs — like laundry, for instance — women may make this trip multiple times on the same day. If water is available only during a certain window, "they rush, and can't pace," Geere says.

Even if a woman finishes her water collection duties without aches and pains, there's a good chance she's exhausted, Crow adds. And there are still plenty of other domestic tasks on her to-do list. There usually isn't enough time to finish it all by bedtime, he says, which is why women often sleep less than men. "There is evidence that women may sleep fewer hours than men in response to the time demands of their various tasks," he says.

He notes that reducing the time required for water collection has been found to boost women's economic activity. (One told him that after she had a tap in her home, she was freed up to go to job interviews.)

What Graham hopes people take away from his analysis is that these lengthy water collection times have real impacts on individual lives — typically, the lives of women and girls — and it's important that they're considered when measuring progress in access to safe water.

Geere often thinks about one woman she encountered during her research in South Africa. They met at a spring, and Geere asked if she could accompany her — and three kids, ages 9, 8 and 4 — home. The 20-minute walk "was very steep and slippery," recalls Geere, who was surprised when they were greeted by the woman's husband and a 3-month-old baby. As the woman explained that she was nursing, another two babies appeared.

"This woman had triplets and was trying to fetch water for her whole family," Geere says. "She was managing it, but she said, 'I get incredibly tired.' I said, 'Of course you do.'"

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