The Planetary Health Alliance
Fiji is the center of the South Pacific, an island vulnerable to many natural disasters and one that recently, in 2016, witnessed a Category 5 tropical cyclone Winston which left many challenges and opened new opportunities at re-looking at how environmental health services are delivered.
The RISE (Revitalising Informal Settlements and their Environment) study is a collaborative research led by Monash University in collaboration with Standford University and Emory University, with local university at implementation sites, Fiji National University and Hassanudin University in Indonesia. Urbanisation is a major demographic trend globally with Informal settlements accounting for much urban growth, exacerbating the inextricably linked challenges of sanitation, water provision, and public health. The team have pioneered an alternative, water-sensitive approach that integrates sustainable design with the management of the water-cycle, benefiting human health and urban ecosystems.
The project has five specific objectives:
-To develop novel urban design, architecture, and infrastructure models in partnership with local communities to implement water-sensitive revitalisations. These models will incorporate ongoing feedback between communities, team members, and other stakeholders.
-To measure, analyse, and interpret the impact of the interventions on environmental contamination and ecology.
-To assess the impacts on human health.
-To determine the broader impacts on residents’ wellbeing.
-To enable priority setting for the sustainable revitalisation of informal settlements and drive policy and investment decisions.
RISE will use a parallel-cluster RCT design with stratified randomisation by tidal/non-tidal sites (i.e. settlements). 6 settlements in each of Suva and Makassar will be randomly assigned to the intervention group, and 6 to controls. Monitoring and assessment will be conducted for all settlements during years 2–5. In year 6, the ADB will implement the intervention in all control settings following the conclusion of the study. In Fiji, the (12) selected communities have formed a Community Engagement Councils and have also agreed to participate in the study. These communities have past problems of water inundation following heavy rain, flooding or coastal events.
This decentralised, climate-change sensitive approach provides financial flexibility for multistage developments and adaptability to future technologies. It promises a solution to the water services challenges of informal settlements, yet has only been demonstrated in developed world settings. It is anticipated that this project will deliver the first public health and environmental data on the benefits and risks of water-sensitive approaches. Our scientific, economic and implementation findings will provide the basis for profound changes to infrastructure policies, investments, loan strategies, and their sustainability across the Asia-Pacific and the developing world.
Background: Drinking brackish water has been associated with high blood pressure among communities in southwest coastal Bangladesh. The objective of this study was to evaluate the impacts of managed aquifer recharge (MAR), a hydro-logical intervention to lower drinking water salinity by pumping rainwater and pond water to dilute brackish aquifers, on blood pressure and urine protein in southwest coastal Bangladesh.
Methods: We conducted a stepped-wedge cluster randomized trial (NCT02746003) with 5 monthly visits among 1,191 participants from 542 households in 16 communities. At each visit subsequent to baseline, 4 additional communities were randomized to receive MAR water access. We measured salinity of the households’ drinking and cooking water and measured participants blood pressure, weight and 24-hour urinary total protein, sodium, potassium, calcium, magnesium and creatinine all visits. Participants’ socio-demographic data, height and confounder information was collected during the baseline visit. We used multilevel regression models to estimate effects of MAR water on participants’ systolic blood pressure and urine protein using participant-, households- and community-level random intercepts and reported cluster robust standard error. We performed intention-to-treat and per-protocol analyses.
Findings: Participants randomized to have access to MAR water had 1.89 (95% CI: 0.51, 3.27; p=0.007) mmHg higher mean systolic blood pressure, and 1.39 (95% CI: 0.23, 2.55; p=0.018) mmHg higher mean diastolic blood pressure than communities with no access to MAR when adjusted for age, sex, body mass index, physical activity, religion, smoking and socio-economic status. The ratio of median 24-hour urine protein among participants with and without access to MAR water was 1.10 (95% CI: 0.96, 1.25; p= 0.159) in the fully adjusted model. When access to MAR water was provided, 40% of households in 2nd , 21% in 3rd, 20% in 4th and 40% in last visit reported that they did not consume MAR water for drinking and cooking. Households reported exclusive use of pond water for drinking (51 — 79%) and cooking (89 — 95%) prior to MAR access. Per-protocol analyses estimated that participants consuming MAR water for both drinking and cooking purposes had 1.13 (95% CI: -0.43, 2.70; p=0.157) mmHg higher systolic blood pressure.
Interpretation: Our findings show no evidence that MAR systems reduced blood pressure and urine protein of the population. Although the intention-to-treat analyses suggest MAR interventions increase population blood pressure, poor adherence to the MAR intervention due to availability of pond water limits the intention-to-treat findings.
At the planetary scale the occurrence and severity of cyanobacteria blooms appear to be increasing, likely due to warming temperatures and changes in nutrient availability in freshwater habitats. These harmful algae blooms represent a public health threat when people are exposed to cyanotoxins through contact with contaminated water or from eating contaminated food. Consistent with this trend, we have documented recurring seasonal blooms of freshwater cyanobacteria throughout the Lower Columbia River Basin, USA. We have also monitored for the presence of the compound beta-Methylamino-L-alanine (BMAA). BMAA is a non-proteinogenic amino acid produced by cyanobacteria and has been linked to human neurological diseases resembling Amyotrophic Lateral Sclerosis. To date BMAA is not monitored by regional government agencies and thus represents an unknown threat to public health in the states of Oregon and Washington.
Field sites were visited monthly between April and September over three consecutive years to collect samples and to deploy and service in situ sensors to observe variability in water quality over time. Cyanobacteria blooms were identified by microscopy and by the presence of the algal pigment phycocyanin via in situ sensors. BMAA measurements were made using existing protocols to allow for low level detection via Liquid Chromatography coupled to tandem Mass Spectrometry.
Between 2014-2017 we have consistently documented blooms of several cyanobacteria species throughout a greater than 220 km stretch of the lower Columbia River and its tributaries. The blooms are typically found in the intertidal habitats and sloughs, however seasonal blooms of Microcystis spp. have occurred every year in the main channel of the Willamette River tributary that have triggered public health warnings by the Oregon Health Authority. Measurements of BMAA throughout the region indicate that when cyanobacteria are present BMAA can be detected at concentrations ranging from 0.05 – 1.2 ng/mg-cells.
Cyanobacteria blooms in the Columbia River Basin represent a little understood threat to public health, however, their emergence in recent years is cause for concern. We detected BMAA in conjunction with blooms of Microcystis spp. and other cyanobacteria, suggesting that human exposure to this compound is possible. BMAA is not currently monitored by regulatory agencies and thus uncertainty exists related to its distribution and association with cyanobacteria blooms. Our results indicate that BMAA is widespread in the Lower Columbia Basin and future research efforts should include BMAA analysis to better understand its potential threat to human health.