Environmental exposure to active pharmaceutical ingredients (APIs) can have negative effects on the health of ecosystems and humans. While numerous studies have monitored APIs in rivers, these employ different analytical methods, measure different APIs, and have ignored many of the countries of the world. This makes it difficult to quantify the scale of the problem from a global perspective. Furthermore, comparison of the existing data, generated for different studies/regions/continents, is challenging due to the vast differences between the analytical methodologies employed. Here, we present a global-scale study of API pollution in 258 of the world’s rivers, representing the environmental influence of 471.4 million people across 137 geographic regions. Samples were obtained from 1,052 locations in 104 countries (representing all continents and 36 countries not previously studied for API contamination) and analyzed for 61 APIs. Highest cumulative API concentrations were observed in sub-Saharan Africa, south Asia, and South America. The most contaminated sites were in low- to middle-income countries and were associated with areas with poor wastewater and waste management infrastructure and pharmaceutical manufacturing. The most frequently detected APIs were carbamazepine, metformin, and caffeine (a compound also arising from lifestyle use), which were detected at over half of the sites monitored. Concentrations of at least one API at 25.7% of the sampling sites were greater than concentrations considered safe for aquatic organisms, or which are of concern in terms of selection for antimicrobial resistance. Therefore, pharmaceutical pollution poses a global threat to environmental and human health, as well as to delivery of the United Nations Sustainable Development Goals.

This paper explores the daily risks of households with respect to dimensions of inadequate water access and supply (quality, quantity, continuity and affordability). We describe how perceptions of risk are shaped and how households seek to reduce possible health impacts and potential economic losses through aversion behaviours. To this end, households' activities relating to water storage, treatment and usage, together with water source preference, were analysed using a qualitative approach. We developed a framework that describes actual risk, risk perceptions and aversion behaviours. Risk perceptions and the adoption of aversion behaviours of varying frequency and intensity are based on a complex interaction between personal and shared experiences that relate to water supply dimensions, socioeconomic characteristics, and social networking. Moreover, we discuss household risk management strategies and provide some recommendations aimed at improving future approaches to the study of aversion behaviours.

In countries that have established and have been maintaining a robust piped water system, bottled water has been perceived to be of better quality than piped water. We argue that piped water and bottled water cannot be easily compared in the Indonesian context. Drinking from tap water has never been accepted as the norm as piped water has no guarantee of purity and safety. The substantial marketing efforts of the bottled water industry highlight the appeal of bottled water in regard to, not only good water quality and physical health, but also taste, convenience, mental health, and social and environmental values. Despite many negative social and environmental issues associated with bottled water, this enigmatic commodity is becoming 'the' drinking water in Indonesia and is inseparable from modern life.

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