Biomass Reduction and Environmental Air Towards Health Effects in Africa - BREATHE partnership

Biomass fuel smoke exposure presents a direct threat to health affecting more than a billion people world- wide. Further, biomass fuel use is ecologically destructive and an indirect threat to all by the effect on climate change. This Partnership of international experts, African investigators and other stakeholders will initiate and manage shared projects that make the best use of field sites and teams provided by £8m of recent grant investment directed at reducing the health effects of household air pollution.

Background

Half the world's population including 700 million people in Africa use biomass fuel (animal or plant material) to provide energy for cooking, heating and lighting. People (mainly women) using biomass fuel and young children - particularly babies carried on the backs of their mothers while cooking - experience substantial smoke exposure, due to both partial combustion of fuel and poor ventilation methods. This household air pollution (HAP) is an established threat to health in several ways including adverse pregnancy and neonatal outcomes, acute lower respiratory tract infections (WHO estimates 870,000 deaths among the under 5s in 2004), chronic obstructive pulmonary disease and lung cancer.

There are three current intervention trials designed to test the health impact of improved household air quality - two in Africa and one in Nepal. All of these investigators are involved in this Partnership. It is of critical importance to maximise the opportunities presented by these trials, both for measured health impact in all ages, capacity development in health related research and policy change in most affected countries.

The Global Alliance for Clean Cookstoves (www.cleancookstoves.org) formed in 2010 and is committed to " foster the adoption of clean cook stoves and fuels in 100 million households by 2020" in order to "save lives, improve livelihoods, empower women, and combat climate change". The GACC, together with WHO (which is is a founding partner of GACC), have identified the need for a Partnership between studies and support this application, with WHO also actively contributing to the partnership. We will fill important knowledge gaps and offer research capacity building opportunities to African researchers within the Partnership by linking with a highly successful research capacity initiative that has been running in Africa for 6 years (Pan African Thoracic Society Methods in Clinical Epidemiologic and Operations Research).

Objectives of the Partnership

1. Draw together experts and investigators in major indoor air pollution trials in order to share current findings, plans and data.
2. Harmonise trial design to ensure that exposure monitoring and health effect evaluation are comparable among active trials and that new studies benefit from past experience.
3. Ensure intervention fuels/technologies used for trials (and subsequent scaling-up) meet household needs and deliver substantially reduced exposure levels.
4. Optimise the opportunity to discover measures of smoke exposure that can be used to show exposure reduction in human subjects, using resource made accessible by current trials but not yet funded by those studies.
5. Engage African trainees in new studies by a bottom-up approach offering mentored research training and new projects in the context of large, regionally relevant research projects.
6. Ensure that these objectives are achieved with active management including an Annual Meeting for a week and interim theme work such as trainee projects and trial site collaborations.

The BREATHE Partnership conference will include thematic sessions where data are presented but also
a) Workshops to harmonise case definitions, intervention implementation, sample and data collection and other aspects of household air pollution intervention trial practice that will benefit from collegiate working and
b) Working Groups to plan future activity.

The BREATHE Africa Partnership will bring together experts in indoor air pollution in order to achieve maximum benefit from several large currently funded interventions in Africa by sharing data and plans and by learning from the study teams of previous studies which reduced indoor smoke exposure elsewhere. We will initiate, develop, link and manage themed projects which share major well-resourced study sites and research teams focused on improving health by reducing biomass fuel smoke exposure.

We have identified knowledge gaps and translational opportunities in this field themed as (1) Exposure and Biomarkers, (2) Health Effects, (3) Mechanisms and (4) Interventions. Each Theme has an expert Lead, a team of Partners with PhD students and opportunity to engage more research trainees at an Annual Meeting including a substantial Research Capacity Development cross-cutting programme. The specific objectives, which are common to each Theme, are to (a) harmonise trial design to ensure that exposure monitoring and health effect evaluation are comparable among active trials and that new studies benefit from past experience, (b) undertake mechanistic work, including testing of new biomarkers, using resource made accessible by current trials but not yet funded by those studies, (c) engage African trainees in new studies by a bottom-up approach offering mentored research training and new projects in the context of large, regionally relevant research projects. The BREATHE Africa Partnership is a platform to allow new, collaborative grants to be submitted by international teams with close engagement at important African field sites.

The Partnership includes members from the African trials, previous trials published outside of the region, the Global Alliance for Clean Cookstoves and experts from the World Health Organisation, American Thoracic Society and Pan African Thoracic Society. It is set to be a "game changer" in the field of household air pollution.

The BREATHE Partnership is committed to improving health and reducing poverty in sub Saharan Africa. The Partnership objectives will deliver new high quality evidence regarding health, societal and economic effects seen when households adopt advanced cook stove technologies. Direct impacts beyond the scientific themes and research capacity development (both covered in Academic Beneficiaries) will occur (a) in the locale of the studies, ( b) in the sub Saharan Africa region and (c) internationally:

IMPACT IN THE LOCALE OF THE STUDIES

In the locale of the studies, we will achieve economic, societal and environmental impact by engagement with research participants and staff.

Economic Impact
The Partnership studies will engage very impoverished households. Participating households' benefits include efficient-burning cook stoves, less time spent gathering wood and carbon credits for trial villages.

Societal Impact
Cook stove studies will be high profile in participant communities. Discussion around pollution, burns risk , long-term health and diet offer benefit beyond the direct health effects of cooking smoke.

Environmental Impact
The studies will directly reduce the amount of wood burned and will therefore immediately reduce environmental destruction.

Local staff: Local people employed on the projects will gain training and experience relevant to future employment, particularly in the NGO sector.

SUB SAHARAN AFRICA REGIONAL IMPACT

At regional level we will achieve health policy and commercial impact during the life of the grant by planned engagement with the public sector including Ministries of Health, with business and industry, with NGO partners and with Higher Educational Institutions including universities and medical schools.

Public Sector
We have engaged through the MECOR programme with regional conferences including the Kenya Lung Conference. This gives professional, government and NGO engagement with household air pollution. Further, we have Ministry of Health representation from Malawi, Kenya and Ghana in our Partnership, with other countries including Nigeria represented in the GACC.

Business/Industry
Some stove production has already been sponsored in the sub Saharan Africa region (Phillips, sponsoring production of a factory in Lesotho for the Malawi study) in anticipation of a sustainable production and sales pipeline.

Third Sector
NGOs implementing cook stove programmes require exposure-response in order to choose stoves that will have health effects by biomass smoke reduction. These data are not available but will be generated by the Partnership. We have worked with Concern Universal in published pilot studies to develop the Malawi CAPS study.

Higher Educational Institutions (HEI)
MECOR trainees will become the academic leaders of their parent HEIs as seen in the 14 year experience of MECOR-style training in Latin America. Our Partner, the American Thoracic Society, has seen international impact from the Latin America programme and will engage with our trainees in career development.

IMPACT ON INTERNATIONAL POLICY

At international level, we will inform international policy through WHO links with national governments and the Health Working Group of the Global Alliance for Clean Cookstoves.

WHO Indoor Air Quality Standards Panel
Bruce (Interventions Theme Lead) is the Chair of this advisory panel and will ensure that our data impact on future revisions of the standards.

Global Alliance for Clean Cookstoves
The GACC Health Working Group has been charged by the GACC with advising Wellcome Trust, Gates, MRC, DFID, NIH and other major donors on important changes in the field. The co-chairs of this Health Working Group have advised this Partnership proposal.

Carbon Finance Initiatives
Carbon credits offer a sustainable method of delivery for future cook stove initiatives and we have established partnerships to develop this benefit.