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Tribal Lands in the U.S. Benefit from Wastewater Monitoring

It was an eclectic gathering: Tribal leaders, an academic, a wastewater facility operator and a healthcare official, all joining forces in the fight against Covid-19.

The spark behind this meeting? A partnership between Tribal communities and Arizona State University, with support from the Pandemic Prevention Institute and The Rockefeller Foundation. Together, the goal is to equip the population with the tools and skills needed to identify harmful pathogens in wastewater, mitigating the impact of Covid-19 and future disease outbreaks.

The partnership includes seven Tribal communities in Arizona, with plans to add another six soon. This is one of the Institute’s ten initial wastewater monitoring projects, supported by a $3.5 million investment, in the U.S., India, Ghana, and Bangladesh.

Over the next nine months, ASU and its partners plan to support the collection of 900 samples from three general locations: Tribal lands’ wastewater access points such as pumping stations that move waste from one elevation to another, wastewater treatment infrastructure such as sewage systems serving community centers and schools on Tribal land, and wastewater treatment plants in towns bordering reservations. These samples will be analyzed for SARS-CoV-2 virus prevalence and concentration, and where permissible, sequenced to identify variants.

At the same time, ASU is committed to training people from Tribal communities in skills related to wastewater monitoring, including sampling methods and data translation, to increase internal capacity to run wastewater programming.

“Wastewater monitoring is an efficient way to empower historically underserved communities with health insights. With these data in hand, Tribal leaders, affiliated health systems and community members can better advocate for the resources needed to respond to existing and future disease threats,” said Megan Diamond, a Health Initiative Manager and wastewater surveillance lead at The Rockefeller Foundation. “The Indigenous American population led the way in vaccine uptake, and are already trailblazers with wastewater monitoring.”

The Path of Wastewater Monitoring

A Vulnerable Community Battered by Covid-19

Indigenous Americans suffered a disproportionately high number of Covid-19 deaths, according to the CDC and numerous other studies, which put the mortality rate for Indigenous Americans living both on Tribal lands and elsewhere in the U.S. at more than two times higher than white Americans.

Indigenous Americans, who make up two percent of the total U.S. population, were particularly vulnerable to poor outcomes from Covid-19, in part due to the high burden of chronic disease in the community.

For instance, 23.5 percent of the Indigenous population have diabetes compared to 8 percent of white, non-Hispanic people. They are also at a much higher risk for coronary heart disease, being 50 percent more likely to be diagnosed with this condition. While access to health care has improved, it remains inadequate, plagued by underfunding and healthcare worker shortages.

This is compounded by decades of systemic racism that has led to persistent health disparities and unmet need, resulting in a life expectancy that is 5.5 years lower than the combined U.S. population.

The high incidence of Covid-19 cases among Indigenous Americans is not news to Dr. Otakuye Conroy-Ben, Assistant Professor in ASU’s School of Sustainable Engineering and the Built Environment, who is helping oversee the PPI-supported along with Dr. Rolf Halden, Director of the Biodesign Center for Environmental Health Engineering and an ASU professor.

“Everyone in my family has gotten sick from Covid—some of them twice,” says Conroy-Ben, who grew up in Porcupine, S.D. on the Pine Ridge Indian Reservation. The same is true of her husband’s family, from the Navajo Tribe, and she lost her mother-in-law to the virus.

Map of Tribal Land collection sites

Expanding Wastewater Tracking to Prevent Future Pandemics

Why wastewater?

No single method of detecting and tracking pathogens is a silver bullet, and any effort to prevent future pandemics must include a combination of approaches, including both traditional and non-traditional data. Wastewater is an important part of the equation, showing promise to enable early detection of emerging pathogens in community sampling before they appear in clinical specimens, allowing for a more proactive response.

It can also be less expensive than clinical testing – you can gain insights into hundreds to thousands of people with a single specimen – and non-invasive. Because of this, wastewater monitoring can be a more equitable pathogen surveillance approach, overcoming barriers within communities that are traditionally underserved or more difficult to access while offering insight to strategically deploy limited healthcare resources.

As part of its work to prevent or mitigate another pandemic through globally collaborating to turn data into action from nations to neighborhoods, the Pandemic Prevention Institute is a leading voice in highlighting wastewater monitoring as a vital resource for early pathogen detection.

The Institute launched the Wastewater Action Group, a national initiative that seeks to transform wastewater data into public health action through partnerships with universities, the private sector, federal and state public health agencies and city health departments. This group is refining protocols for wastewater sampling, testing, and sequencing. They are also developing metrics to inform wastewater-based risk thresholds, and expanding wastewater testing and information to underserved populations.

The Institute’s focus includes increasing the generation and usability of wastewater data for multiple pathogens in low- and middle-income countries and other high traffic settings, such as transportations hubs.

Wastewater Tracking: An Old Concept Gains Renewed Attention

The concept of pathogen tracking through monitoring wastewater is not new.

In the 1940s, epidemiologists used wastewater surveillance to track diseases such as polio. Sewage surveillance provided early warning of hepatitis A virus and norovirus outbreaks in Sweden in 2013, and it was credited that same year with thwarting a looming outbreak of paralytic polio in Israel. As missed vaccinations and vaccine hesitancy increase during the Covid-19 pandemic, the threat of previously contained disease – such as polio – will only increase, as seen recently in Malawi and Israel.

Collection sites on Tribal Land

Wastewater monitoring gained renewed attention with the arrival of Covid-19, in part because it provided quick insights into communities as testing declined and vaccination plateaued. In the U.S., the Centers for Disease Control and Prevention launched a National Wastewater Surveillance Program and hundreds of wastewater programs have sprung up globally.

Halden’s own interest in the field shows its broad potential. He began studying wastewater surveillance after a grad student of his lost two friends to prescription drug addiction. He became convinced that wastewater could provide insights into a community’s health and potential risks, including when those most at risk were unlikely or unable to seek medical help. He began working with the city of Tempe in 2018.



Collection sites on Tribal Land

Trust: A Challenge on Tribal Lands and to Pandemic Prevention Globally

Despite its promise, trust was a key factor to integrating wastewater sampling in Tribal communities—as it is in efforts to establish a global pandemic early warning system.

In 1989, an ASU professor approached the Havasupai Tribe, a community of around 750 people who have been based in the Grand Canyon for at least 800 years. He was seeking blood samples to help understand why diabetes cases within their community were rising. The Tribe gave permission, but then researchers used the samples to study and publish papers on other medical disorders without receiving consent from the Tribe.

After years of litigation, the Tribe settled in April 2010 for a payment of $700,000, the return of blood samples, and additional assistance including scholarships and help obtaining federal funding for a health clinic.

The new ASU team is working hard to establish trust, including a commitment not to publish the results of their work, as academics often do, until they have the tribes’ permission. “Under current agreements, they own the data and any presentation has to go through them,” noted Conroy-Ben.

Rich Data Sources and Trust: The Future in Fighting Outbreaks

Building trust—locally or globally—is a process. The Pandemic Prevention Institute and others on the frontlines of efforts to create an early warning system against future pandemics believe that as data from traditional and non-traditional sources results in action that helps save lives, decisionmakers everywhere from nations to neighborhoods will welcome passive, always-on monitoring.

The neighboring city of Tempe is an example. “We embraced wastewater surveillance when we realized we could combat opioid addictions with compassion, services and science,” said Rosa Inchausti, Deputy City Manager who has worked with the city for 29 years.

With the start of the Covid-19 outbreak, the city shifted its wastewater efforts to detect the virus, and recently expanded their geographic reach into Guadalupe, an underserved community of 6,700 sandwiched between Tempe and Phoenix, half of whose residents identify as members of the Yaqui tribe.

“Our work there exemplified and amplified our commitment to equity and inclusion,” Inchausti said. “We overlaid everything with our equity map, identified the most vulnerable, and set up wastewater testing at no cost to them. It allowed our larger community to understand where to put resources, where to send educational material.

“Rich data and trust,” she says. “That’s the power of local governments. That’s the future, period.”