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Despite the fact that access to clean and disease-free drinking water is a basic human right enshrined in South Africa’s constitution, utilities often find it difficult to produce safe drinking water as they have to deal with highly contaminated water...

PROBLEM

Despite the fact that access to clean and disease-free drinking water is a basic human right enshrined in South Africa’s constitution, utilities often find it difficult to produce safe drinking water as they have to deal with highly contaminated water sources. Poor sanitation and sewage contamination often leads to polluted surface water, which in turn is a major challenge for water utilities.

In 2015, less than half of South African citizens (45.8%) had access to piped water in their houses. Less than two thirds (62%) of citizens rated their water service as good, down from 76% approval in 2005. Nearly 13% of citizens rated the service as poor, citing reasons such as murky water, bad smell and taste of water, or water that is unsafe to drink. Mpumalanga and Limpopo have the most disrupted water supply, with 60% of citizens in those provinces reporting disruptions of more than two days.

Water utilities like Rand Water are expected to provide clean water for drinking, cleaning and agriculture. But they must manage a convoluted system of rivers and pipes – inputs and outputs at every stage – as well as pollution risks and changes in water use due to drought. Local authorities are ultimately responsible for delivering clean and disease-free water to their populations, but this challenge is compounded by poor governance and lack of capacity as well as the problems mentioned above.

Water quality is negatively affected by agricultural runoff, human and animal waste, and a wide range of pollutant chemicals that may be introduced into water systems at various points along the way. The resulting biological contaminants (protozoa, bacteria, fungi and viruses) and chemical contaminants (including industrial, agricultural and pharmaceutical chemicals) pose a massive health risk.

Of particular concern are endocrine-disrupting chemicals (EDCs), which influence the hormone balance in humans and animals, and lead to cancer and problems with sexual reproduction. South African legislation does not currently require the screening of chemicals for endocrine disruptive effects before usage in food, cosmetics, household, industrial, agricultural, pharmaceutical products and packaging materials. These chemicals inevitably end up in South Africa’s water supply along with industrial effluents, sewage works and landfill sites all contributing to the pollution of our water sources and environment.

Source:

Statistics SA (2015)

SOLUTION

By testing and understanding different aspects of water quality within the Rand Water catchment area, researchers can help Rand Water address potential health problems not yet covered by legal standards for clean and safe drinking water. The University of Pretoria hosts four research chairs, funded by Rand Water, to carry out water testing and studies that span engineering, microbiology and public health. Their different yet overlapping research streams provide data, new testing methods and early potential health risk warning systems that help Rand Water and other utilities to look beyond minimum legal requirements for water quality and better manage future health risks.

Chair in Public Health Professor Maureen Taylor’s group regularly tests bodies of water for viruses, focusing in particular on gastroenteric viruses such as hepatitis A virus, norovirus and rotavirus. Detecting specific viruses in water sources allows the researchers to ensure that water treatment processes are stringent, and warn water utilities such as Rand Water of potential breaches in the process so they can take appropriate prevention measures. They work with many water utilities in Gauteng, the Free State and the Northern Cape, as well as with the Outbreak Response Unit of the National Institute for Communicable Diseases (NICD). In addition, Prof Taylor’s research focuses on the potential risks to public health posed by biological and chemical water contaminants.

Professor Fanus Venter (Chair in Microbiology) is overseeing a long-running project to understand the bacterial ecosystem present within a water distribution network that stretches more than 160kms, from Vereeneging to Secunda. This project will, for the first time, show what bacterial species are present in this water system and their relative abundance, and how this changes over time and space in response to different factors such as water treatment, temperature and seasonality.

Finally, Professor Riana Bornman (Senior Research Professor in the School of Health Systems and Public Health) and her group are looking at the presence and effects of EDCs in the environment. To do this, they monitor ‘sentinel species’ – fish or amphibians that would be most exposed to waterborne EDCs. This data provides an idea of the dangers posed by some of the more common contaminants in South African water, such as 7-nonylphenol, polychlorinated biphenyls (PCBs) and dichlorodiphenyltrichloroethane (DDT).

Bornman’s Environmental Chemical Pollution and Health (ECPH) Research Unit conducts a battery of bioassays for estrogenic, thyroid and androgenic activity. Screening the aquatic environment with selected in vitro tests can be used to assess the endocrine-disrupting activity of the mixtures present. The research team also uses these findings to compile risk assessments for South Africans exposed to harmful chemicals, which can inform policies for addressing the problem at municipal or provincial level.

Context, stats & background
What is wrong with SA’s water?

South Africa receives half the global average rainfall: every year, 492mm of rain falls in the country, as opposed to the 985mm that the rest of the world receives. This classifies SA as a water-stressed country. In addition, that rain is unevenly distributed across SA, adding to the water stress in some parts of the country.

Distribution of average annual rainfall in South Africa.

The ANC government inherited a fragmented and unequal water supply system from the apartheid government, resulting in massive service backlogs. In 1990, 15 million people were without a safe water supply, and some 20 million did not have acceptable sanitation.

Since then, the government has made significant inroads into this problem. Urban communities have universal access to clean, safe water, and rural communities have gone from 66% access in 1990 to 79% access in 2010. However, deteriorating infrastructure, poor governance and drought threaten to undo much of this progress.

nother major challenge in supplying South Africans with clean water is the state of wastewater treatment services in the country. In an attempt to improve the dismal performance ofthe more than 1200 wastewater treatment plants, the Department of Water Affairs introduced the Green Drop system for wastewater treatment plants to evaluate their own performance.

Of the 824 systems that reported their Green Drop status in 2013, 60 received Green Drop Status (a score of >90%). While this is an improvement on the 40 facilities that were certified in 2011, it still represents a paltry 7% of all facilities that participated in the programme.

Further, the vast majority of publicly-owned treatment plants were in ‘critical state’ (<30% compliance and in need of drastic intervention in all aspects of sanitation), and overall 55% were not within acceptable standards of operation. The 2009 Green Drop report also found that some wastewater treatment plants are not measuring effluent quality at all.

A comparable Blue Drop system is in place for Water Services Authorities (WSA’s), which has shown an improvement in South Africa’s overall Blue Drop score from 51.4% in 2009 to 79.6% in 2014.

However, much like the Green Drop rating, only 44 of 1036 systems received a Blue Drop certification (4%). Overall, the Blue Drop scores have dropped across the country from 2012, where the national score was 87.6% and nearly 100 WSA’s achieved Blue Drop certification.

Contrary to much of the rest of the country, Rand Water has been an industry leader in ensuring safe, clean water for the citizens living in their catchment area. Five of Rand Water’s 17 WSA’s received a Blue Drop certification in 2014, more than any other water utility in the country.

Source: (WHO, | http://www.wssinfo.org/, | WaterWise, | Jackson and Busari, | Green Drop, | Blue Drop)

How is UP’s partnership with Rand Water helping?

Rand Water is one of the largest water utilities in South Africa, responsible for supplying 14 million South Africans with drinking water. Rand Water is considered by the Department of Water Affairs as a flagship water utility. Thus, innovations and technical expertise developed by Rand Water and the Rand Water Chairs at the University of Pretoria are passed down to other, smaller utilities.

The University of Pretoria is one of two local universities to which Rand Water committed more than R6 million towards research. On top of outsourcing regular water quality testing to UP (e.g. testing for viruses), Rand Water relies on this research to ensure that they stay one step ahead of the minimum legal requirements for drinking water in South Africa.

What are the common contaminants?

An important part of this research is geared towards understanding exactly what is in the water that runs through our pipes. These can be chemicals, viruses, and pathogenic (disease-causing) or environmental bacteria and protozoa.

Prof Taylor’s group recently found sapoviruses in 80% of wastewater treatment plants (WWTPs) and water sources affected by effluent from these WWTPs in Limpopo, and they have identified several new norovirus strains and a novel hepatitis A strain in untreated surface water sources. Although these were present in very low concentrations, for many intestinal viruses, just 10-100 virions are enough to cause infection.

Until the advent of metagenomics, the only way to study the microorganisms in a water system was to culture the microbes directly on agar plates, and count the bacteria that grew there. However, this is an extremely limited method, for many bacteria will not grow under these conditions.

Studying the diversity of bacteria using metagenomics revealed more than 3000 bacterial species in the water during treatment at Zuikerbosch near Vereeniging, and more than 10 000 across the length of the pipeline. These fell into more than 200 bacterial families, which included genera such as Acinetobacter, Clostridium, Flavobacterium, Legionella, Paenibacillus, Prevotella and Sphingomonas. Some of these genera are known to contain potential opportunistic pathogens: common bacteria that will not cause disease except in immune-compromised individuals (i.e. the young, the old, and those with AIDS or other immune deficiencies).

The most abundant species is Nitrosomonas oligotropha, an ammonium-oxidising bacterium. This bacterium is present because Rand Water (and many other water utilities around the world) treat the water with chloramine to limit bacterial populations to acceptable levels. While this is effective, it releases large amounts of ammonia into the water and drives up the population of N.oligotropha.

Another common group of bacteria in this distribution network is members of the genus Mycobacterium. Some species of this genus are known to cause skin and respiratory problems in immunocompromised individuals. Bacteria from the Proteobacteria, Acidobacteria, Actinobacteria and Planctomycete families are also common.

It is likely that this type of microbial biodiversity would be found in almost any artificial water system in the world. It is only because researchers have looked at Zuikerbosch that they have been able to show this diversity here for the first time.

Identifying the various bacteria and other microorganisms present in the water supply is an important step forward for water quality research. The vast majority of these organisms are harmless or even beneficial, and there is no need to remove them from the system. Rather, this research allows water utilities to understand the ecology within the water system, which will help them to develop better management and control strategies and keep on top of emerging pathogens when they do appear.

Professor Bornman’s work has identified a large number of EDCs and endocrine-disrupting metals (EDMs) in Gauteng rivers and other untreated water sources. These included PCBs, octylphenol (OcP) and p-nonylphenol (p-NP), lindane, DDT, endrin, heptachlor epoxide, methoxychlor, and phthalates.

Her research suggested that if left untreated, domestic or agricultural use of this water could have both toxic and carcinogenic effects as well as causing endocrine disruption. Researchers found that levels were 30-450 times higher than acceptable lifetime exposure levels.

What is novel about this approach?

While regular testing for harmful biological and chemical substances should be done for all water utilities in South Africa, this is not the case in reality due to difficulties with finance and governance. The Rand Water testing regime is the best of any water utility in South Africa, and serves as a demonstration of what effective testing and research can achieve in maintaining water quality.

The national water testing standard is known as SANS 241, which defines a number of determinands that need to be met in order for drinking water to be safe. This standard covers microbiological risks such as coliform bacteria and certain protozoan parasites, as well as physical determinands like levels of chlorine and other chemicals, and colour.

This ongoing research collaboration between Rand Water and UP means that Rand Water tests for a great number of other potential risks to human health on a voluntarybasis. These include testing for a number of viruses, type and quantity of algae, and chemical parameters like corrosiveness and radioactivity.

In particular, the ecosystem approach to understanding the bacteria and fungi present in a water system is entirely novel in South Africa, and is in fact not commonplace anywhere in the world. Most water utilities still test for microbial activity using cell culture plates – adding water samples to selective media and testing the bacteria that grow there. Thus, Prof Venter’s approach represents the cutting edge of water quality research.

How is this research helping Rand Water?

Rand Water is dedicated to supplying drinking water that is not harmful to human health. That means adhering to legal requirements and industry standards, but also identifying potential threats not covered by those standards.

The research conducted by the Rand Water chairs will help Rand Water to stay on top of emerging potential health risks in South Africa’s water supply. This is above and beyond the usual testing for common contaminants that Rand Water conducts in conjunction with UP to ensure compliance with all legal requirements for a water utility.

At the University of Pretoria, the solutions to change the world can be found in the research we do today; like our work alongside Rand Water, protecting South Africa’s water supply by testing and monitoring changes in water quality, ensuring that we stay ahead of emerging health risks.

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Additional media:

The history of Tshwane’s water supply:

South Africa faces four epidemics - Infectious diseases (especially HIV/AIDS and TB), non-communicable diseases (especially diabetes and cardiovascular diseases), high levels of violence and injury, and mother and child illness and death...

PROBLEM

South Africa faces four epidemics - Infectious diseases (especially HIV/AIDS and TB), non-communicable diseases (especially diabetes and cardiovascular diseases), high levels of violence and injury, and mother and child illness and death - linked to one another by persistent social inequality. Together, they account for the top ten causes of preventable death and avoidable ill-health in South Africa.

The National Department of Health (DoH) has recognised that the healthcare system is unable to meet this challenge due to the scale and complexity of the disease burden and the current structure of the healthcare system. Services and capacity development in SA’s healthcare system are skewed away from general primary healthcare, and towards specialist care.

While intensifying its efforts to tame the devastating effects of HIV/AIDS and TB, in 2010 the National Department of Health introduced policies designed to make primary healthcare more effective. Most importantly, these policies included National Health Insurance and an overhaul of primary healthcare to achieve universal health coverage. To achieve the second objective, the DoH introduced the concept of ward-based health teams, where community health workers (CHWs) take primary care to communities rather than keeping primary care in clinics and hospitals.

Source: StatsSA (2015);A Practical guide to Doing COPC, Marcus 2015

SOLUTION

The Department of Family Medicine at the University of Pretoria (UP) took this opportunity to integrate service, learning and research into a community health platform in a way that had not previously been possible. Professors Jannie Hugo and Tessa Marcus built their intervention on the principles of community-oriented primary care (COPC), a model of healthcare developed by Drs Sydney and Emily Kark in rural Kwa-Zulu Natal in the 1940’s. COPC is a geographically-based collaborative approach to health that starts with individuals and families in their homes. UP’s Department of Family Medicine worked to establish a version of COPC that would work in South Africa in the 21st century. Supported by the Gauteng Provincial Department of Health (GPDoH), the University of Limpopo, and the Sefako Makgatho Health Science University, the process was started in 2011 in Tshwane District as a pilot. Teams were set up in nine communities in partnership with local NGOs. In 2014 the City of Tshwane Municipality entered into an agreement with the Department of Family Medicine to use a COPC approach to health in the municipality. Through this collaboration, the model has expanded and matured. Presently, there are 43 professional nurse led ward-based health teams with 370 CHWs deployed in defined geographical areas across the city from Mamelodi through the inner city to Atteridgeville, Soshanguve and Olievenhoutbosch. To date, community health workers have registered 230 000 individuals in 77 000 households, with community health workers providing immediate and follow up support to individuals and families in need. The number of households serviced by the programme is growing every day. To support the COPC approach, Hugo and the Family Medicine team have collaborated with private sector partners to create AitaHealth™, a purpose-built data collection, support and management system. Using web and mobile phone technology, team leaders and CHWs assisted by doctors and other specialists work with real-time information to make decisions and provide care. Parallel to this, Marcus, Hugo and the team are developing a formal system of learning that is integrated into delivering services. The idea is to empower healthcare workers at all levels to deal with the complex demands of their work, - in this model, constant learning is an integral part of the service. The COPC curriculum addresses service providers working at all levels of the system. It engages CHWs, medical professionals and health system managers from the workplace through the classroom to post-graduate studies. The School of Medicine’s existing undergraduate medical student community placement programme has been extended from clinics into people’s homes and places of work. Through it, medical students and community health workers learn from each other. The Department of Family Medicine links education, training and research to service through collaborations within the Faculty of Health Science and with the Institute for Food Nutrition and Wellbeing (IFNuW), the DST-NRF Food Security Centre of Excellence and the Department of Social Development, as well as with the National Department of Higher Education’s Technical Vocational Education and Training (TVET) programme. To date the Department of Family Medicine team has directly and indirectly contributed to the training of some 1000 learners in community oriented primary care. This education covers such diverse topics as the theory and practice of community-based healthcare, diseases and disorders common to South Africa, community health, and monitoring and evaluation. The power of COPC rests in comprehensive care that integrates the home, the clinic, the doctor’s practice and the hospital; and that consistently improves an individual’s ability to manage their own health. It will take time and persistence to realise the full impact of the approach; however, by combining service, research and education through technology-enabled data collection COPC is set to revolutionise health in South Africa.

Context, stats & figures

What is wrong with modern healthcare?

In the last 150 years, healthcare has become increasingly hospital-centred, diseased focused and specialised. While this has led to major medical advances, has improved access to healthcare and has proven to be highly profitable, it also excludes large parts of the population and cannot provide universal access to healthcare. The system as it stands tries to categorise every patient very narrowly and find a narrow cure, effectively simplifying health issues by removing all context for a person’s health. Unfortunately, this ignores the very obvious truth that specific health issues cannot be dissociated from the overall health of a person. This has the consequence of resolving health problems on the scale of disease, rather than on the scale of the individual.

What is community oriented primary care?

Sydney and Emily Kark were physicians working in Pholela, an impoverished, segregated reserve in what is now KwaZulu-Natal. For 15 years in the 1940’s, they together with a small team, were the de facto healthcare system for an entire population that had been denied access to Western medicine. They pioneered a brand new approach to primary care, which entailed surveying the health of the local population, establishing relationships with the tribal leaders in the area, and training local people as health workers. They took this model to the Hebrew University, where they taught the COPC approach to clinicians, public health workers and epidemiologists from around the world. After being forced to leave the country by the Apartheid government, they continued to build international capacity in COPC.

Community-oriented primary care (COPC) challenges the industrialised healthcare model by addressing health problems at the community level. It is defined as follows:

“COPC is primary care where professionals from different disciplines and approaches work together with organisations and people in defined communities to identify and respond systematically to health and health-related needs in order to improve health.” - Tessa S. Marcus Community Oriented Primary Care, 2013.

The five principles of COPC

Local health and institutional analysis: The people and organisations in a geographically defined area are the starting point for any COPC programme. In this case, each CHW is assigned 200-250 households in a ward. CHWs take an inventory of all visible organisations and facilities (including clinics, GPs, traditional healers and specialists) and build local working service partnerships from there.

Next, they register households, conduct a household assessment and categorise individuals and families according to national health priorities. These include detecting and responding to any emergency, pregnancy, risk of TB, request for HIV testing, and households with children under five or those in need of home-based care.

Comprehensive care: This means that community health teams are involved in and support every aspect of family and individual health. CHWs promote health and support disease prevention, treatment, rehabilitation and palliation.

Equity: In a society as unequal as South Africa’s, this ensures that people with greater needs are given greater attention while everyone with the same need gets the same attention. This means that access to care and health resources is determined by healthcare needs rather than money, power or privilege.

Practice with science: There are two aspects to this principle. First, it means that healthcare practices should be based on systematically collected evidence. Secondly, it means that science must be put into practice and tested. Because healthcare knowledge and practice changes all the time, effective healthcare requires the expertise of people from different professions and backgrounds.

Service integration around users: Finally, this principle is about continuous, partnership-driven and person-centred healthcare. It highlights the importance of treating a health problem by looking at the whole person, the people they live with and their environment.

“We’re not doing research for research’s sake, or publication’s sake; we’re doing it so that healthcare can be based on the best available evidence. We’re making sure that the person at the coal face has the best tools available, and that the research is linked to a delivery system.” – Tessa S. Marcus

Source: Mullan and Epstein, 2002; A Practical guide to Doing COPC, Marcus 2015

How does technology enable COPC?

Without a technological platform, COPC is difficult to achieve in a complex health system. This is why the UP Department of Family Medicine worked with private sector specialists to build the smartphone-enabled, web-linked AitaHealth™ platform.

AitaHealth™ is a smartphone app used by CHWs to do community oriented primary care. The CHWs use modules on the app to collect information and guide their responses, including scheduling follow up visits. The information collected by CHWs is available to team leaders via a centralised database. This enables them to support CHWs in real time. It also supports planning and management of individual CHWs and teams.

AitaHealth™ was designed and built by UP Department of Family Medicine in partnership with Mezzanineware, a mobile software company owned by Vodacom. All content was created by the UP Family Medicine team and the app has been rigorously tested both at the university and in the field to ensure that it achieve its purpose.

Two key points about how AitaHealth™ works are worth highlighting. Firstly, the app guides CHWs through a process and information entered into the app prompts the CHW towards action. If a person reports TB-associated symptoms and he or she is not on treatment, AitaHealth™ prompts the community health worker to advise the patient to go to the clinic for testing.

Second, AitaHealth™ is backed up by a sophisticated, web-enabled infrastructure. All information and interventions are available to managers to help with service planning and delivery. AitaHealth™ information is linked to a patient record system through Synaxon, another partner in the programme. This infrastructure provides continuity of information and care by linking people in their homes to professionals in clinics and hospitals.

The platform also provides robust data on the real health situation and services in defined geographical communities. This means that ward-based healthcare teams can tailor healthcare to individuals and defined places, while at the same time the data can be used for basic and applied research. In time, AitaHealth™ will provide some of the most robust clinical and epidemiological data ever recorded.

Is there precedent for this type of approach?

Community oriented primary care has been around for about 75 years. While it has had sporadic appeal in different parts of the world at different times, everywhere it has been difficult to shift well-entrenched, traditional healthcare systems. Inspired by Brazil’s primary healthcare system, the Department of Health’s primary care reengineering provided UP’s DFM with a chance to test the concept in South Africa. In its current iteration, however, the system at work here has no precedent anywhere in the world. The combination of academic rigour, public health focus, clinical care and technological innovation has yielded a novel and transformative platform for improving society-wide health outcomes.

What role does education play?

As much as the technological platform helps healthcare providers deliver services, it does not substitute for individual capability that comes from learning, doing and experiencing. Education therefore plays a critical part in all healthcare, and in COPC in particular. It is there to equip healthcare workers and professionals with the knowledge and skills required to carry out the complex tasks of COPC. To this end, the Department of Family Medicine and the City of Tshwane have built continuous work integrated learning into the COPC implementation plan. This learning is supported by curricula, face to face training and specially developed learning materials. These are designed to support learning in the workplace and to help CHWs transition into further qualifications. In addition, through the UP COPC Research Unit Marcus is driving a major community health education research initiative. With NRF funding, some 14 masters and 12 doctoral students are working on various aspects of learning in community health in order to improve the model, quality of care and the general level of capability in health, including in health research.

What projects are involved in the COPC initiative?

The AitaHealth™ platform is designed to allow research projects to ‘slot in’ to the system, provided that they can help develop the community based healthcare platform. Research in the COPC initiative includes using Umbiflow (developed by the CSIR) to detect growth delays in pregnancy, under the leadership of Prof Robert Pattinson (Department of Obstetrics and Gynaecology and MRC’s Maternal and Infant Health Care Strategies Unit); Hearscreen™ - an on-site hearing test developed by Prof De Wet Swanepoel (Department of Speech-Language Pathology and Audiology); screening for substance abuse and addiction (with City of Tshwane Department of Social Development) as well as health education research through the Community Health Education Research Initiative (CHERI). In addition, individual health status assessment modules on the AitaHealth™ app are collecting information on reproductive health, general health and lifestyle, non-communicable diseases and infant and child development.

Who benefits?

The project has begun to support healthcare in the communities around Tshwane where it has been rolled out. The approach is replicable and scalable, which means that it can be extended to all parts of the city as well as across districts and provinces throughout the country in time. Through research and education, the benefits of this initiative extend well beyond the communities where COPC is being implemented. Taken as a whole, the COPC initiative will result in a sustainable and affordable community-based health system that is integrated across multiple sectors of society and puts community health to the fore, benefitting millions of South Africans.

What’s next?

Technology-enabled COPC has proven to be a successful approach to improving health in the City of Tshwane. Based on this success, a version of the AitaHealth™ app called StudentAita, is being made available to medical students across the country. The Department of Family Medicine hopes that it will be possible to roll out COPC with AitaHealth™ nationally and that UP and other medical schools and students will be an integral part of this process.

Lastly, a thorough assessment of the impact that COPC is having on community health will be key to ensuring this initative’s long-term success.

At the University of Pretoria, the solutions to change the world can be found in the research we do today; much like COPC, which empowers communities to be able to care for themselves. A necessary contribution in making healthcare accessible to those who need it most.

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