Keystone, W.Va. — Donna Dickerson’s heart would sink every time she’d wake up, turn on the faucet in her mobile home and hear the pipes gurgling.

Sometimes it would happen on a day when her mother, who is 86 and has dementia, had a doctor’s appointment and needed to bathe. Sometimes it would be on Thanksgiving or Christmas when family had come to stay.

“It was sickening, literally a headache and it disrupted everything,” she said. “Out of nowhere, the water would be gone, and we’d have no idea when it’d be back.”

While failures of big city water systems attract the attention, it’s small communities like Keystone, West Virginia that more often are left unprotected by destitute and unmaintained water providers. Small providers rack up roughly twice as many health violations as big cities on average, an analysis of thousands of records over the last three years by the Associated Press shows. In that time, small water providers violated the Safe Drinking Water Act’s health standards nearly 9,000 times. They were also frequently the worst performers. Federal law allows authorities to force changes on water utilities, but they rarely do, even for the worst offenders.

“We’re talking about things that we’ve known in drinking water for a century, that we have an expectation in this country that everybody should be afforded,” said Chad Seidel, president of a water consulting company.

The worst water providers can have such severe problems that residents are told they can’t drink the water. For ten solid years Dickerson and 175 neighbors in the tiny, majority Black community had to boil all their water. That length of time is nearly unheard of — such warnings usually last only for days.

The Safe Drinking Water Act was signed into law in 1974 and initially protected Americans against 22 contaminants, including arsenic. Nearly half a century later, evolving science has broadened the coverage to more than 90 substances, and strengthened standards.

The miracle is that most water systems keep up – 94% of them comply with health standards.

After years of problems, Keystone finally got hooked up to a new water system last December, McDowell Public Service District, which focuses on upgrading systems in coal communities. Deteriorating water mains were replaced. A non-proft called DigDeep helped pay to connect homes to the new infrastructure.

When a water utility doesn’t treat water properly or has high levels of a contaminant, states are supposed to enforce the law. They usually give communities time to fix problems, and often they do. If there is intransigence or delay, a state authority can escalate action and impose fines. Yet in many towns, that doesn’t go well; there is no money to pay the fines. Some places struggle year after year.

The EPA stresses the vast majority of systems do provide safe water. For those having trouble, the agency has increased technical assistance, inspections and enforcement. Those efforts have decreased the number of systems consistently committing health violations, according to Carol King, an attorney in the EPA Office of Enforcement and Compliance Assurance.

The top concern of the water industry itself is funding for infrastructure, according to a survey.

Recruitment of professionals to run small water systems is one main issue. The largely white, male workforce is aging.

Earlier in his career, Tim Wilson, a water manager, spent time running the treatment plant in Wahpeton, Iowa, a community of just over 400 that expands when vacationers rush in during the summertime.

Small, rural communities have a “ridiculously hard” time recruiting certified operators, he said. Once they are trained, they can be lured away by better pay and benefits elsewhere.

The job demands can be heavy: in Wahpeton, Wilson not only ran the treatment plant, he plowed snow and testified as a zoning expert at local government meetings.

People in Ferriday, Louisiana had to get their water from the National Guard for four months back in 1999. The town’s water treatment plant, which had struggled to keep the water from turning brown, had completely failed. Those four months left a mark.

“I haven’t drunk the water since,” said Jameel Green, 42, who has lived in Ferriday most of his life. He now makes sure his two girls, ages 16 and eight, don’t drink the water either.

A new water treatment plant was supposed to fix Ferriday’s issues. But staff at the new plant struggled to find the right mix of chemicals, according to Rev. James Smith Sr., who was brought in to help with the issue. The state fined the town $455,265. No payment has been made. Rev. Smith said the water has improved significantly with increased testing and pilot studies.

Without a lot more money and more aggressive intervention in the worst places, experts say many Americans will continue to endure an expensive search for drinkable water, or else they’ll drink water that is potentially unsafe.

“In my view, this is a desperate problem,” said Manny Teodoro, a professor at the University of Wisconsin who focuses on public policy and water.