Retrofitting to reduce health effects of heat for urban poor

India is experiencing a rising frequency of heat waves and extreme temperatures. Increasing temperatures, heatwaves and increasing urbanization lead to heat stress and heat-related illnesses. Estimates suggest that heat stress can be attributed to ~740,000 excess deaths annually in India (1)(2). Soon India could experience heat waves that may break the human survivability limit (3). Rising heat across India can jeopardize economic productivity, quality of life along with health status. With rising temperatures, demand for indoor cooling devices/measures is also rising fast. Only 8% of Indian households own air-conditioning units and fans alone are inefficient to maintain thermal comfort during summer (4). Association of heat stress with several diseases across age groups and adverse pregnancy outcomes have been reported (5)(6). The poor and marginalized populations (~1/3rd Indian population) living in inadequately ventilated, hot and crowded homes without good indoor cooling options are more vulnerable to extreme heat. Heat stress affects differentially vulnerable populations, worst for the urban poor.

Heat-related morbidity/mortality risk is higher in urban areas due to the urban heat island effect. Odisha (India) has a harsh climate with a double burden of heat (35-470C) & humidity (60-90%) during the summer season, which lasts for about 4 months. The urban flagship Government program (Urban-PMAY, Pradhan Mantri Awas Yojana) supports housing for economically weaker section (EWS) families, with floor areas 30-60 sq. mtr., built of concrete/RCC roofs, & precast cement block walls with limited ventilation (7). These EWS households have limited/inadequate/inappropriate ventilation facilities. These EWS houses are not climate-sensitive, especially for the summer season. Additionally, the houses of the poorer families are of small size, with unplanned architecture and built-up, inadequate ventilation facilities and accommodate crowded families. The family members living in these EWS and poor households are exposed to the heat stress, both indoors (for all, while living indoors) and outdoors (for those, who go outside for any reason). Thus, no one is spared from the heat stress in these households. Heat stress manifests in different forms for different family/household members, according to age, occupation, health status and associated risk factors. To minimize heat-stress morbidities, mortalities and also productivity losses and improve the quality of life, especially for children, elderly people and women spending most of their time at home.

The Odisha (State) Heat Action Plan focuses on public awareness, early warning advisory for prevention of heat exposure, health system preparedness for managing heat strokes and heat stress-related illnesses, & inter-agency collaboration for response (8). But, there is no mention or plan for heat-stress mitigation strategies, which is inevitable for EWS households. The extreme heat/climate coupled with high indoor humidity and crowding act as counterintuitive leading to heat stress, even staying indoors (9)(10)(11). For minimizing the adverse health impacts of heat/humidity, household (indoor/neighborhood) level interventions are needed, targeting the vulnerable populations/members in these housings. While new heat-mitigating measures are easier for new constructions, the adoption of appropriate strategies/interventions for the already-built houses is challenging and needs contextualization and customization according to the structure and architecture. 

Odisha State Health Action Plan primarily focuses on outdoor heat exposure reduction for individuals and doesn't mention any definite/specific measures to reduce indoor heat-stress. Both heat and humidity contribute to indoor heat-stress effects. We propose feasibility-linked, contextualized, sociocultural appropriate, need-based retrofitting interventions in the urban EWS & poor houses in slum areas (in addition to standard communication as per State Heat Action Plan) to reduce indoor heat-stress exposure-related health effects through a combination of interventions: (1) reducing heat absorption through the (1.1) sun-exposed walls (locally made agro-waste and lime-based bio-bricks and/or sheets) and (1.2) roof (for flat RCC roofs using bio-brick false ceiling, lime wash, shading with local materials, vegetation; and for sloping roofs using terracotta tiles & vegetation); (2) improve indoor passive ventilation through reorganization of window/door/other openings/partitions & mechanical air draft exhausts.

These interventions target urban EWS and poor households using indigenous materials & culturally appropriate context-specific interventions, developed, customized and retrofitted with households and community participation, which shall make these acceptable and potentially sustainable. The use of agro-waste, terracotta and lime-based materials, locally sourced and manufactured shall make them cheap and the effort economically sustainable. These efforts shall have a minimal carbon footprint and reduce the agro-waste burning-related carbon footprint.

The lack of robust data linked to the impact of heat-mitigating interventions limits the largescale adoption and within the government program. Also, there is a need to generate the data on economic aspects of the interventions. To make it scientific and acceptable for the wider population and government, there is a need for documenting these on the field for the health effects and household/community responses. As health and quality of life effects are the primary outcomes of the heat-mitigating strategies, we propose to document the effects on the household members in the intervention group compared to the non-intervention group. For the health effects, we especially target vulnerable household members (elderly, under-five children and women, who mostly stay indoors) to document the heat stress-linked bio-physiological parameters/markers, along with the quality of life and generic health status of other household members. The longitudinal documentation of health parameters for the household members and association with the environmental (indoor and outdoor/ambient) parameters including temperature and humidity during the pre-, summer & post-summer periods shall assist in identifying the most appropriate isolated/combination of interventions for these poor urban houses, their acceptance & implementation challenges for refinement and scaling.

We propose to document the effects of these heat-mitigation interventions in combination on the health (biological markers using wearable sensors, periodic assessments & tests) and quality of life, sleep, and work productivity for the household members (n=75, 25 households/groupx3groups) compared to the non-intervention households (n=25) (12)(13)(14)(15). The change in indoor and outdoor/ambient temperature and humidity shall be regularly documented using TRH monitors. The household and community acceptance, perceived health and quality of life changes, cost and willingness to pay for these interventions shall inform the suitable adaptations and strategies to increase the community demand and potential induction into the government action plan. 

The proposed interventions shall target urban EWS and poor households in slum areas, which constitute the disadvantaged and vulnerable group, who are at risk for the heat-stress adverse effects. The EWS and poor slum households are vulnerable to heat-stress-related effects. In these poor households, the elderly, under-five children and women members, who mostly stay indoors are relatively more vulnerable to indoor heat and humidity adverse effects. The State Heat Action Plans or other government-supported efforts have no program for household-level interventions. Those who can afford to invest using their own money, which is a big limitation for these poor and EWS households. Also, the currently available heat-mitigation measures are relatively costly and short-lasting for these households to afford.  

The interventions/solution shall impact the lives of the household members from multiple facets, health, quality of life, and work productivity. The intervention/solution shall have an impact on the heat stress-linked health effects along with the quality of life and generic health status of other household members.

The systematic and longitudinal documentation (pre-, summer & post-summer periods) of these impacts using targeted measures/indicators for health, quality of life, sleep, and work productivity along with the environmental parameters (indoor and outdoor/ambient temperature and humidity) shall inform the impact and generate evidence base for policy, program advocacy, user/community advocacy for demand generation. The documentation shall also enable business adoption and scaling up of the intervention/solution.

We propose to implement the interventions in 200 households (50 each from EWS and slum areas with different types of house built/architecture; and 50 comparison households without intervention).

We propose to document the impact through the collection of data at various levels:

• Households: sociodemography, construction/architecture, heat adaptation/cooling measures, intervention adherence/modifications, geospatial location and neighborhood
• Household members: The data shall capture the index members and other members-
  • Index individuals in the intervention and comparison households- elderly (>60 years), under-five children, women and outdoor workers (both gender, 1 member per category from each household, from 3 intervention areas & 1 comparison area) during the pre-summer (Jan-Feb), summer (Mar-Jun) and post-summer (Jul-Aug), total eight months of the observation period. Periodic bio-physiological markers (temperature, HR, BP, activity, sleep, every 2 weekly), blood markers (haemogram, HSP-70, once each during pre-summer and summer periods and three times during summer- 2 weeks, 4 weeks and 12 weeks after ambient heat ≥350C), urine (specific gravity, coterminous with the blood tests)
  • All family members: health status (illness/hospitalization/death), work status, occupational/school absenteeism   
• Environment (outdoor & indoor): heat & humidity monitoring (using TRH monitors), ambient data from the met station, neighborhood greenness cover (Normalized Difference Vegetation Index).
• Community acceptance, adoption of intervention and willingness to pay (interviews, n=20-30; focus group discussions, FGD, 2/area)

The application of interventions and documentation of the effect shall assist in pushing the heat-mitigation intervention agenda for these poor households forward and the potential inclusion of options under the government, non-government, community-led and individual-led efforts. Also, the local business generation and entrepreneurship promotion shall further scale up, making it further cost-effective. 

The project consortium includes INCLEN-Delhi, School of Architecture & Planning, KIIT-Bhubaneswar (SAP-KIIT); Kalinga Institute of Medical Sciences, Bhubaneswar (KIMS); Indian Institute of Technology, Delhi (IIT-D).

Investigators: Lead- INCLEN (Manoja Das- Public health, Environmental health, Implementation science, Health impact assessment; Shikha Dixit- Geospatial epidemiology; Ramesh Poluru- Biostatistics, Data management).

Co-Applicants: School of Architecture and Planning-KIIT (Sudha Panda, Avik Roy, Priyabrata Routray- architecture, planning, urban management & sustainability); KIMS (Alpana Mishra, Smrutiranjan Nayak- Public health, Environmental health; Basanti Pathi- Laboratory science, microbiology, immunology); IIT-D (Sagnik Dey, Rohit Chaudhary- environment, climate change, climate-health nexus).

PI/Team lead (Das-INCLEN), leads several research on community & facility-based maternal & child health. He studied the effects of heat-stress on intussusception & acute encephalopathy in children. He co-leads research on heat-stress-induced mitochondrial & metabolic changes in children. He has led innovations in child health, immunization & technology development.

INCLEN team- lead project coordination, documentation, analysis & interpretation.

SAP-KIIT team- lead the intervention prototype development, testing & installation. The team has been working in the area and on agro-material-based bio-brick prototyping and its testing over the last five years.

KIMS team- lead health assessments & sample testing.

IIT-D team- lead environmental data collation, management & analysis.

The team shall partner with the Bhubaneswar City Municipality for implementation. The team members are working with the state and national government on several health programs. We shall engage with the local community, where the INCLEN, KIIT and KIMS team have been working on several research studies. The team has long-standing experience in community-level research on several issues. INCLEN team has been working on developing community-partnered co-creation of solutions using Nexus Planning approaches. 

The team has been working for four years on the production and refinement of compressed bio-bricks and bio-sheets made of agro-waste and lime. The team has also been working on building the structures using these bio-bricks/bio-sheets and methods of retrofitting in the existing households. 

The prototype has been used in the limited experiment phase for one house completely made of bio-bricks and a few households for testing. 

We request support from Solve for addressing the financial barrier and guiding the business plan development. Apart from seed financial support, we are keen to benefit from the strategic planning and business mentoring guidance along with networking with the other Solvers.

We are specifically looking for support in the following areas:

• Bio-brick technology refinement: We seek MIT technical expertise in material science and architecture to refine the product.
• Networking and advocacy: For generating advocacy, and awareness at various levels and networking with suitable partners for technical and business collaborations.
• Documentation: refine the documentation and undertake independent evaluations of the model and applications.
• Financial: For start-up and research and development activities for further refinement in the product and quality control.

The heat-mitigating options are easier to integrate and implement for the houses during the construction than applying them in already-built houses. The alterations become difficult for the EWS and poorer families, who are at the maximum risk.  

The proposed interventions focus on adaptation and induction of appropriate single/combination of heat-mitigating strategies to reduce indoor heat and humidity status via a reduction in heat absorption from the sun-exposed walls and ceilings using locally prepared compressed bio-bricks/sheets out of agro waste and lime with zero/reduced carbon emission, roof shading/covering and improving indoor ventilation through reorganization of window/door/other openings/partitions & mechanical air draft exhausts. These proposed interventions are low in cost & socioculturally appropriate, acceptable and durable. The pilot phase experience indicates that the materials survive rain and fire, remain insect-free & are easy to clean/maintain.

The retrofitting of such items is easy and doable with the local labour workforce without the need for skilled manpower. The raw materials are locally sourced, and the bio-brick/sheets are locally produced, and thus, are cheap. We shall engage with the local manufacturers for technology transfer, technical support & marketing to make them available for self-financed use and select the suitable option based on the context. The partner agency(ies) for production, marketing & engagement with the government, non-government & philanthropic stakeholders with appropriate need-based adaptation with cost stratification shall enable scaling up and sustainability. 

We anticipate that if the initial experience becomes successful, partnership with the local manufacturers and entrepreneurs shall expand the application from the proposed one city to about five cities in the state and five cities outside the state covering about 10,000 households.

For achieving them, we shall actively pursue partnerships with start-up agencies and small-scale manufacturing houses in several cities for local manufacturing through technology transfer and support. The business arrangement and models for the partnership shall be explored, for which we seek guidance from the Solve technical experts. 

1. Target-1: Prototype refinement- Month 4

1.1. Refine the bio-brick/bio-sheet prototypes and the ventilation interventions customised for different types of houses

1.2. Population acceptance and feedback on the designs and interventions   

2. Implementation of the intervention in first phase – Month 8

2.1. Implementation of the interventions in the target and comparison houses

2.2. Baseline documentation of the data from the households collected

3. Documentation of the data from the households through the summer and post-summer cycles- Month 16

3.1. Completion of the data collection from the households

3.2. Expansion of the intervention households beyond the supported and targeted numbers through additional support and self-funding or shared funding

4. Scaling up of the interventions beyond the supported households- Month 24 

We propose a three-channel theory of change for this proposal and intervention success.

1. Demonstration project: We think that the dictum of ‘Seeing is believing’ is important for such an effort. Demonstration of the intervention installation and its effect on the households with scientific documentation of the impact shall be able to push the translation. The community-level observations and spread of mouth along with the media dissemination, scientific discussions and publication shall assist in furthering the adoption of the intervention and customization. The documented impact on the temperature, humidity and health bio-markers shall provide robust evidence for furthering the effort of heat mitigation strategies in low-resource and traditional societies/households.

2. Advocacy with community, technical partners and government: The evidence documented along with the multichannel advocacy targeting the community, technical community and government stakeholders shall push for the adoption of the interventions locally, in India and possibly in other countries with similar contexts.

3. Business collaborations: The demonstration project and experience from customization with scientific documentation shall be able to attract business collaborations for technology transfer and franchising options in different areas/states in India. We shall also explore possible collaborations outside India.

We believe that all these theories of change for successful translation depend on a good demonstration effort and documentation. We are requesting the MIT SOLVE for the support in the demonstration project. 

These cement and RCC-based constructions are not environment-friendly and climate-sensitive, for India. The core technology for the proposed solution is driven by the traditional, ancestral knowledge and practice of bio-material-based building construction in India with modern manufacturing adaptation. While with rapid urbanization and revolution in house construction modalities, it is challenging to go back to the traditional system of architecture. But, traditional knowledge and practices can be suitably adapted to benefit the current challenges. This is also using agro-waste and environment-friendly materials, which can be customized with colour and texture to make these retrofitting attractive coupled with modernization. 

The solution targets EWS and poorer households, who stay in less organized localities. We focus on documenting the impact of the interventions on the vulnerable population in these households. The team involves a gender mix. The organizations in the consortium welcome gender, social class, religion and cultural diversity.       

Our business model aims for a mix of technology transfer and franchise models. The various possibilities are:

1. The team shall explore collaboration and business agreements with the local and domestic manufacturers for the larger volume production of the bio-bricks/bio-sheets and the ventilation-improving options through technology transfer. It shall explore options for financial arrangements. 2. The team shall engage with the manufacturers and agencies on a franchise model.  

We shall seek appropriate guidance from the MITS SOLVE team on this to make it most appropriate  

The intervention’s sustainability depends on the documentation and demonstration of the environmental, economic, social & perceived health benefits/impacts. We target the PMAY-U EWS houses, the Government of India’s flagship program, supported by the State Governments. Considering the recognition of climate change as an important agenda in the recent global and national political environment, we hope that the evidence generation on the health impacts of these interventions shall be considered under the PMAY-U EWS program for appropriate adaptation. Society, community & households also recognize the rising temperature as a significant concern experienced by all the sections. For this project, we shall partner with the state government, municipality, and architects/builders for these houses along with the other community influencers. The documented effect/impact shall allow future translation, adoption & scaling up in the existing houses and future constructions. The engagement of the professional associations/groups from health, architecture, civil engineers, disaster management, climate/environment & civil society activists shall enable wider dissemination and interest generation for further sustenance. We shall also engage with suitable agencies for corporate social responsibility, philanthropic support & charitable activities for adoption/support. The documentation of impact shall pave the way for suitable inclusion of such interventions/adaptations under the City/District/State/National Heat Action Plans & Climate Change Action Plans.

The interest from various stakeholders and users shall encourage the local entrepreneurs/business for manufacturing these bio-bricks/adaptations for scale-up and sustainability. Once the interest/demand from the community and users is there, the business sustainability and further adaptations/improvisations shall be feasible.

We hope that the demonstration effort shall attract attention and encourage the adoption in the affluent and middle-class population.   

We have been sustaining on the grants for projects and we have been successful over the last several years. We have limited experience in business models and ventures but would like to expand our efforts with support from MIT SOLVE.