Water is an essential building block of the Earth system and a nonsubstitutable resource upon which humankind must depend. But a growing body of evidence shows that freshwater faces a pandemic array of challenges. Today we can observe a globally significant but collectively unorganized approach to addressing them. Under modern water management schemes, impairment accumulates with increasing wealth but is then remedied by costly, after-the-fact technological investments. This strategy of treating symptoms rather than underlying causes is practiced widely across rich countries but leaves poor nations and many of the world's freshwater life-forms at risk. The seeds of this modern “impair-then-repair” mentality for water management were planted long ago, yet the wisdom of our “water traditions” may be ill-suited to an increasingly crowded planet. Focusing on rivers, which collectively satisfy the bulk of the world's freshwater needs, this essay explores the past, present, and possible future of human-water interactions. We conclude by presenting the impair-then-repair paradigm as a testable, global-scale hypothesis with the aim of stimulating not only systematic study of the impairment process but also the search for innovative solutions. Such an endeavor must unite and cobalance perspectives from the natural sciences and the humanities.