Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697640377116.pdf (Australia)
Unsafe drinking water quality in remote Western Australian Aboriginal communities Semone Rainer-Smith,1 Graeme J. Millar,1 Peter Grace,1 Allison Hutton,2 Jay Rajapakse,1* Wendy Hoy,3 Christine Jeffries-Stokes,4 and Brian Hudson1 1Science and Engineering Faculty, Queensland University of Technology, Brisbane, Queensland, Australia 2University of Central Queensland, Gladstone, Queensland, Australia 3The University of Queensland, Royal Brisbane & Women’s Hospital, Herston, Queensland, Australia 4The Rural Clinical School of Western Australia, Kalgoorlie, Western Australia, Australia *Corresponding author.
Email: jay.rajapakse@qut.edu.au Received 23 April 2018 Revised 22 July 2018 Accepted 31 July 2018 Abstract Chronic kidney disease (CKD) is important in the ﬁelds of public health and health geography because of its heavy burden on the health system and high cost of treat- ment in its advanced stages.

The causes of CKD are associated with diabetes and hy- pertension, but in some parts of the world, the disease occurs in the absence of these factors.
Researchers identify this condition as CKD of “unknown” causes (CKDu).

CKDu is a multi-factored health problem and one suspected causal factor is contam- inated drinking water.

The disease occurs globally but is found in particularly high concentrations among people of certain ethnic and disadvantaged social groups living in very different locations around the world.
CKD has become endemic in Western Australia where hospital admissions for Aboriginal people requiring renal dialysis or treatment for diabetes are much higher than for the general population.

The possible proportions of CKDu cases among the CKD patients are unknown.

This study examines the drinking water quality among communities such as these.

Water chemistry analysis in these areas indicates that the nitrate and uranium content greatly exceed ofﬁcially recommended levels.
Most of these communities rely on raw groundwater to supply their domestic needs, and it is very likely that the people are unwittingly ingesting high levels of nitrates and uranium, probably including uranyl nitrates.

Very few such remote communities have access to treated drinking water, and cost-effective water treatment systems are required to provide potable water at the local scale.
Keywords health geography; chronic kidney disease; remote Aboriginal communi- ties; drinking water quality; heavy metals; Western Australia Introduction Chronic kidney disease (CKD) is a global problem that is of particular importance because of the suffering it causes, and also because of the heavy ﬁnancial burden it imposes on public health sys- tems, which arises from the high cost of treatment in the advanced stages of the disease.
In Australia, an estimated 10 per cent of the adult population have biomedical signs of CKD, the disease being particularly prevalent among Aboriginal people (AIWH, 2017).
CKD has long been linked with diabetes and hypertension, but in some parts of the world, notably Sri Lanka, El Salvador, Nicaragua, Costa Rica, and other Central American countries, the disease has been found Geographical Research May 2019 57(2), 178–188 doi:10.1111/1745-5871.12308 178 Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 J. Rajapakse et al., Chronic kidney disease and water quality 179 in the absence of these factors.
to occur Researchers studying this problem use the term CKD of unknown aetiology (CKDu) to identify the condition.

Several hypotheses have been offered to explain the occurrence of CKDu, among them dehydration associated with heat stress, strenuous labour, exposure to agrochemicals that are nephrotoxic (harmful to kidneys), and contam- inated drinking water (PAHO, 2017; WHO Country Ofﬁce Sri Lanka, 2016).
The proportion of CKDu cases among Australian Aboriginal CKD sufferers is unknown, but it may be signiﬁ- cant at least in some environments.

Contaminated drinking water is a problem in remote Western Australian Aboriginal communities where the incidence of CKD is high.

It is likely that the cause of CKDu is multifactorial.
In this paper, we apply a geographical perspec- tive to research undertaken as part of a collabora- tive project involving medical, public health, environmental engineering, and geographical pro- fessionals.

The geographical component relates to spatial patterns of distribution, both geological in a speciﬁc region of and anthropological, Western Australia.
The paper includes discussions relating to geological topics such as the mineral content of rocks and to matters of particular interest to human geographers, notably dispersed patterns of human settlement and the provision of services to remote communities.

We also speculate about the possible relationship of a serious health problem and to the environment of the people who inhabit it.
For health geographers, this study provides a practical example of the application of their disci- pline to the search for solutions to problems that require detailed research in many other ﬁelds.

The subject under discussion is one that should concern geographers and others because it ad- dresses a question of social disadvantage in a country that enjoys one of the highest standards of living in the world.
In the following discussion, we investigate water contaminants present mostly in ground- water in remote communities and consider their possible role as nephrotoxic agents contributing to CKD.
Our study focuses on nitrate and ura- nium compounds because it is well known that many of the towns and communities in the study area are at risk from water contamination with naturally occurring nitrates, and there is a considerable overlap between the region’s con- siderable uranium deposits and the aquifers from which bore water is drawn (Jeffries- Stokes, 2017).
© 2018 Institute of Australian Geographers Method and data sources In what follows, we examine the hypothesis that contaminated drinking water may be one of the factors that causes CKDu, focusing particularly on the possible role of groundwater containing uranium and nitrates.

Both of these compounds are believed to be nephrotoxic (Jayatilake et al., 2013; Jeffries-Stokes, 2017; Nolan & Weber, 2015; Soderland et al., 2010).
Additionally, the re- action between dissolved uranium species in solu- tion with nitrate can form a compound called uranyl nitrate, which is highly nephrotoxic (Blantz et al., 1985).

We consider this question as it relates to remote Western Australian Aboriginal commu- nities.

Our discussion is based on data obtained from publications listed in the PubMed, Medline, Scopus, Science Direct, SciFinder, and Western Australian Government databases for the years 1962 to 2017.
Water quality test results were ob- tained from projects assessed and declared by the Western Australian Government Department of the ofﬁce of the Environmental Protection Author- ity and the Ofﬁce of the Auditor General Western Australia.

The groundwater quality data at Wiluna were collected from January 2010 to August 2014 by the consultants, RPS Group, on behalf of Toro Energy Limited for an environmental impact as- sessment by the Environmental Protection Author- ity (EPA).
A public environmental review (PER) of the ‘Extension to the Wiluna uranium project’ was completed in February 2016 and approval for the project was granted to Toro Energy Limited in July 2017 by the Australian Government’s De- partment of the Environment and Energy.

The RPS Group report is available through a link at the Western Australian Government website.

Other information was obtained from Western Australian Government publications as listed un- der references.
This study uses the Australian Drinking Water Guidelines (ADWG) as the pri- the mary reference base.

Where appropriate, World Health Organization (WHO) and United States Drinking Water Guidelines (USEPA) are consulted (Commonwealth of Australia, 2016; WHO, 2011, 2012); these are listed in Table 1.

While drinking water guidelines are being applied, it is not yet known if they are relevant to the forma- tion and nephrotoxic effects of uranyl nitrate.
Starting with a brief consideration of CKD in Western Australia, we examine the possible role of uranium and nitrate compounds as contributory factors in the occurrence of CKDu before discussing the ﬁndings as they relate to Western Australia.
We follow this work with brief case Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 180 Geographical Research May 2019 57(2), 178–188 Table 1 Combined Drinking Water Guidelines WA Govt (Water Corporation, 2013) (mg L 1) 11.3 Element Nitrate Nitrate-N Nitrite Uranium ADWG (Commonwealth of Australia, 2016) (mg L 1) 50 (as NO3) child 100 (as NO3) adult 3 0.017 WHO (WHO, 2011) (mg L 1) US EPA (USEPA, 2009) (mg L 1) 50 (as NO3) 11 3 0.02 45 10 1 0.03 studies of some remote Aboriginal communities.
Based on our conclusions from this study, we make recommendations intended to contribute to better health in Aboriginal Australian communities and reduce the ﬁnancial burden of public health care in that state.

Chronic kidney disease in Western Australia Chronic kidney disease is endemic in Australia.

In 2014 alone, 2,610 people commenced kidney replacement therapy and 22,234 people remain on dialysis or are living with a transplant (The Australian Kidney Foundation – Kidney Health Australia, 2016).
In 2014, the number of people who died from CKD was estimated at 22,218; that is, one person every 25 minutes (The Australian Kidney Foundation – Kidney Health Australia, 2016).

Most of these people will not know they have CKD as there are no symptoms in the early stages of the disease.

It is estimated that one in 10 Austra- lian adults is currently living with biomedical markers of CKD, expressed as reduced glomerular ﬁltration rates or presence of protein in the urine.
Unfortunately, one in ﬁve Indigenous Australians has these markers (The Australian Kidney Founda- tion – Kidney Health Australia, 2016).

Chronic kidney disease in Western Australia’s Indigenous population Indigenous adults living in remote areas are more than twice as likely to have markers of CKD (The Australian Kidney Foundation – Kidney Health Australia, 2016).

In Western Australia, 10.1 per cent of the population or 176,900 people live with markers of CKD.
This number increases for Indigenous Western Australians at 22.8 per cent of the population or 10,200 people.

This bias is reﬂected in higher hospital admission rates for Indigenous people when compared with that of the general population.

In 2007, admissions for In- digenous people was 12 times higher for renal di- alysis and eight for diabetes (Government of Western Australia, 2013a).
times higher For at least the past two decades, excessive rates of kidney disease have been recognised among Aboriginal people living in remote areas of Australia.

The age-standardised incidence rate of renal replacement therapy (RPT) for Aboriginal people in the Kalgoorlie region from 1993 to 1998 was about 27 times that of the general Aus- tralian population, which was, along with Tennant Creek in the Northern Territory, the highest in the nation (Cass et al., 2001).
Similar patterns were found by other researchers with expanded num- bers of Indigenous people starting renal replace- ment the period from 1993 to 2001(Preston-Thomas et al., 2007).

Kidney Health Australia’s regionalising data from the Indigenous component of the Australian Health Survey, con- ducted in 2012, showed a high frequency of markers of kidney disease in WA’s Indigenous people (The Australian Kidney Foundation – Kidney Health Australia, 2016).
therapy over Can uranium and nitrate compounds act as facilitators of CKD?

Environmental toxins implicated in kidney dam- age include heavy metals, such as uranium, cad- mium, lead, aluminium, and arsenic.

Other implicated toxins include nitrate, ﬂuoride in con- junction with water hardness, pesticides, herbal medicines, and air pollutants, such as tobacco smoke.
Although these factors are known to play a role in the causation of kidney disease, deﬁning their exact role in the aetiology is a challenge (Jayatilake et al., 2013; Jeffries-Stokes, 2017).

In this paper, we will discuss two environmental toxins, namely, uranium and nitrate present in very high concentrations in water sources in remote Western Australia.
© 2018 Institute of Australian Geographers Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 J. Rajapakse et al., Chronic kidney disease and water quality 181 Uranium Uranium is found in minute quantities in most rocks, soils, and water bodies.
However, it accumulates in the environment due to leaching from soils, rocks, and natural deposits, release of mill tailings, and combustion of coal and other fuels, including the use of phosphate and other fertilisers containing uranium.

Western Australia has approximately 211,000 tonnes of known uranium deposits (Government of Western Australia, 2013) with uranium levels recorded in remote parts of the state as generally naturally occurring (Commonwealth of Australia, 2016).
The term “naturally occurring uranium (U)” refers to U compounds with a series of radioisotopes: 234U, 235U, and 238U with 238U providing the majority of the isotopes (Government of Western Australia, 2013).

Uranium is responsible for both radiological and chemical toxicity; nevertheless, the low level of radioactivity of natural uranium poses no danger of cancer risk.

However, researchers consider that the chemical toxicity is responsible for kidney injury (Závodská et al., 2008).
Contamination of aquifers with uranium is known to impair kidney function and damage bones (Nolan & Weber, 2015).

Nephrotoxicity of uranium in mammals has been extensively reported, but limited data are available for humans (Agency for Toxic Substances and Disease Registry (ATSDR), 2013; Vicente-Vicente et al., 2010; WHO, 2012).

Uranium enters drinking water when groundwa- ter dissolves minerals containing uranium in sur- rounding bedrocks.
Numerous factors regulate mobility of U in water, most importantly pH, for- mation of complexes with coexisting dissolved ions and oxidation–reduction reactions.

Oxidised uranium is relatively soluble and leaches from rocks to migrate in the environment.

Most com- monly, inorganic soluble uranium salts are uranyl nitrate, uranyl ﬂuoride, uranium tetrachloride, ura- nyl acetate, and sulphate.

Uranium dissolves read- ily in hydrochloric acid and nitric acid but slowly in sulphuric acid (Katz, 2014).
Combustion of fos- sil fuels may result in formation of NOx and SOx gases, which dissolve in rain drops and form nitric and sulphuric acid.

Ammonia evaporation from the farming industry may also lead to the forma- tion of nitric acid.
Uranium needs to be in its hexavalent (VI) state to become mobile in solution; this occurs via the process of nitrate reduction to the oxidation of or- ganic matter, alkalinity, mobilising uranium in its hexavalent state— and can generate © 2018 Institute of Australian Geographers are present.

U (VI), activating its solubility.

The generation of alkalinity alone cannot produce soluble uranium if the uranium originated in its tetravalent state— U (IV), which is insoluble and immobile.
In strong reducing environments, precipitation of soluble uranium will occur.

Generally, in aqueous solu- tions, this change only occurs in the oxidised hexavalent form U (VI), at low pH due to the sol- uble UO22+ uranyl cations.
The uranyl ion is very pH dependent due to hydrolysis and the formation of carbonate species where atmospheric CO2 or carbonate minerals Under reducing/anoxic conditions, U is reduced to its tet- ravalent U (IV) state and its concentration in water decreases due to poor solubility of uraninite (UO2).

The uranium oxidation–reduction reac- tions that occur in the environment and in micro- bial reactions may also result in the formation of complexes with organic matter.
Uranium (VI) forms stable complexes with dissolved organic carbon.

Therefore, uranium mobility can be signif- icantly enhanced in organic-rich waters (Smedley et al., 2006).
Recent studies indicate that oxidation of uranium (IV) minerals (uraninite) by dissolved oxygen (aerobically) or nitrates (anoxically) from agricultural run-off into uranium (VI) may form chemical complexes with carbonate and calcium ions in groundwater, mobilising the uranium through the soil column and contaminating the groundwater (Burow et al., 2017; Nolan & Weber, 2015).
In the presence of iron, certain bacteria (Thiobacillus and Ferrobacillus) can oxidise any dissolved iron from the ferrous to the ferric state.

Consequently, ferric iron can convert insoluble uranium dioxide, UO2 (U4+) to soluble UO2+2 ions (U6+) thus mobilising the uranium (Scharer & Ibbotson, 1982).

Evidently, the groundwater biogeochemistry of uranium is quite complex, making the treatment of contaminated groundwa- ter difﬁcult (Stewart et al., 2006).
Uranium toxicity depends on absorption, which solubility.

Once increasing increases with ingested, uranium initially appears in the blood- stream where it forms a bond with the membrane of the red blood cells.

Clearance from the blood- stream is rapid as uranium accumulates in the kid- neys and the skeleton with less depositing in the liver (WHO, 2012).
Uranium exposure is “weakly associated” with altered proximal tubular functions, suggesting that ingestion cause renal damage low levels of (Chandrajith et al., 2010; Kurttio et al., 2002).

Consumption primarily leads to nephritis (inﬂam- mation of the kidneys) in people (WHO, 2012).
The ADWG list the safe upper limit of uranium Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 182 Geographical Research May 2019 57(2), 178–188 ingestion in drinking water as 0.017 mg/L1 (Commonwealth of Australia, 2016).

Nitrate In a simple nitrogen cycle, the nitrogen (N2) trans- fers to ammonium (NH4) and then via nitriﬁcation converts to nitrite (NO2) and nitrate (NO3), where it moves into the groundwater (Powlson, 1993).
At higher levels (Table 1), nitrogen becomes a listed contaminant in drinking water (Commonwealth of Australia, 2016; Flamenbaum et al., 1974; Ofﬁce of the Auditor General Western Australia, 2015; WHO, 2011).

The toxicity of nitrate to humans is due to the re- duction of ingested nitrite which then transforms into nitrosamines, which are carcinogenic (Tiso & Schechter, 2015).
A major health effect of ni- trates in humans is the oxidation of normal haemoglobin to methaemoglobin, which inhibits the transport of oxygen to tissues.

This condition is called methaemoglobinaemia (blue baby syn- drome), with infants under the age of six months at the greatest risk (Commonwealth of Australia, 2016).

High levels of nitrates in adults have been linked to stomach, colon, bladder, and prostate cancer (Morales-Suarez-Varela et al., 1995).
A 2011 study conducted in Taiwan found childhood brain tumours associated with high levels of ni- trates in the drinking water (Weng et al., 2011).

In- gestion of nitrates actions of nitrosamines in the gut could lead to increased risk of diabetes, hypertension, and cardiovascular dis- ease, which could contribute to the risk of renal disease (Jeffries-Stokes, 2017).
through the A study led by Australia’s CSIRO (1992) re- corded high nitrate concentrations in groundwater in arid zones of Australia (Barnes et al., 1992).

The researchers found that high levels of nitrate originated near the surface, caused by biological ﬁxation from the cyanobacteria present in the soil crust combining with bacteria in termite mounds.

Nitrate-NO3 samples taken from the groundwater recorded levels in exceedance, up to 80 mg/L1 (Barnes et al., 1992).
A groundwater chemical analysis by the WA Rivers and Water Commission (completed in 1999) sampled 35 bores and wells, with the highest nitrate-NO3 level (130 mg/L1) sampled in allu- vium (Johnson et al., 1999).

Uranyl nitrate It has been suggested that for uranyl nitrate to form in solution, nitrates bind to uranyl ions in solution (Ye et al., 2010).

There is evidence that uranium oxide, when exposed to excess nitric acid, dis- solved to form uranyl nitrate (Gelatar et al., 2015).
Furthermore, uranyl nitrate depends on acid concentration, and the production of uranyl nitrate increases with nitric acid concentration (Ye et al., 2010).

Uranyl nitrate in solution is a weak acid due to the hydrolysis of uranyl ions (Tomazic et al., 1962).

Uranyl nitrate is the most widely used uranyl salt of commerce.
Because of high solubility in water, uranyl nitrate is absorbed by the gastroin- testinal tract to a much greater degree than low soluble uranium compounds, therefore, associ- ated with high toxicity of the soluble forms of uranium.

Uranyl nitrate received much attention from investigators of animal toxicological re- search, although all soluble uranium compounds toxicity (Agency for Toxic Sub- have renal stances and Disease Registry (ATSDR), 2013).
World Health Organization Guidelines for drinking water quality on uranium have detailed studies of uranium nephrotoxicity on humans and animals, and the effect of uranyl nitrate on animals has been extensively discussed (WHO, 2012).

Uranium and nitrates in drinking water sources in Western Australia Most residents in remote Western Australia use groundwater as their primary drinking water source.
Water quality data from these remote areas have been reviewed and compared with ADWG (Commonwealth of Australia, 2016) to determine the presence of soluble uranium and nitrates; known nephrotoxic agents (Flamenbaum et al., 1974; WHO, 2012).

Uranium ingestion causes nephritis, or inﬂam- mation of the kidneys (WHO, 2012).

Uranyl nitrate is another known nephrotoxic agent (Flamenbaum et al., 1974).
Water quality data (pH, CaCO3, nitrates, and uranium) have been analysed for three remote regions in Western Australia, with a focus on the groundwater at towns of Leonora and Wiluna.

The desert Laverton (South) to Wiluna (North), including lies within the region the town of Leinster, (Figure 1).

Groundwater is used throughout Leonora, Laverton, and Wiluna for town water supplies, pastoral purposes, for irrigated horticul- ture, and citrus cultivation at Wiluna (Johnson et al., 1999).
The Northern and Eastern Goldﬁelds are major nickel and gold producing regions.
There are over © 2018 Institute of Australian Geographers Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 J. Rajapakse et al., Chronic kidney disease and water quality 183 Figure 1 Location map for study settlements Source: Johnson et al., 1999 20 operating mines and numerous prospects for uranium, rare earths, and base metals, all depen- dent on groundwater for ore processing (Johnson et al., 1999).
A review of regional groundwater re- the Leinster’s groundwater sources shows that source contains salinity ranging from 1,000 up to 200,000 mg/L1, where the average rainfall is about 250 mm per year for the region (Rajapakse et al., 2013).

The water supply for Laverton is obtained from the Beasley Creek bore and the Wedge Pit bore ﬁeld, which are located about 12 kilometres north-west of the town.
Nitrate in all the town wa- ter supplies exceeds the 50 mg/L1 (nitrate as © 2018 Institute of Australian Geographers Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 184 Geographical Research May 2019 57(2), 178–188 NO3) standard for drinking water and is generally greater than 30 mg/L1, with a maximum concen- tration of 130 mg/L1.
Most of the remote communities rely on un- treated groundwater systems to provide domestic water, although many different water treatment systems are available (USEPA, 2009; WHO, 2012).

Their suitability for remote community ap- plications at affordable cost needs further research.
According to the Water Corporation (2013) in 1996, the Western Australian Department of Heath exempted the following remote towns from meet- ing the water quality guidelines regarding exces- sive nitrate levels in drinking water: Cue, Meekatharra, Mount Magnet, Nabawa, New Norcia, Sandstone, Wiluna, Yalgoo, Laverton, Leonora, and Menzies.

These exemptions are still current.

Community health nurses are instructed to provide bottled water free to nursing mothers, at no cost.
Yalgoo recently reported that no bottled water has been supplied, nor were they aware of the re- quirement.

The Shire Council of Yalgoo suspects this to be the case in four other communities (ABC News, 2016).

The 2015 Western Australian Auditor General’s report reviewed the Remote Area Essential Ser- vices Program, which delivers power, water, wastewater repair, and maintenance services to a few remote communities.

This program is man- aged by the Western Australian Department of Housing.
Figure 2 identiﬁes the 14 communities where nitrate-NO3 exceeds the ADWG for chil- dren (50 mg/L1), two communities who exceed the ADWG for adults (100 mg/L1), and another Figure 2 Nitrate-NO3 levels in remote WA drinking water.

Source: Ofﬁce of the Auditor General Western Australia, 2015 community where the nitrate level is in the upper limits of exceedance (Ofﬁce of the Auditor Gen- eral Western Australia, 2015).
These levels have been recorded for 84 communities in 2014 (Ofﬁce of the Auditor General Western Australia, 2015).

The Auditor General’s report notes that there are three communities where safe drinking water levels were exceeded for uranium (0.017 mg/L1) (Ofﬁce of the Auditor General Western Australia, 2015).

Of particular concern is the remote commu- nity of Tjuntjuntjarra, where drinking water failed safe levels for both nitrates and uranium.
Tjuntjuntjarra, one of ﬁve communities being monitored, has failed 18 out of 22 water quality tests for uranium.

These levels are reported to be up to double the safe guideline values.

The other four communities have not been named (Ofﬁce of the Auditor General Western Australia, 2015).

The following four examples illustrate the na- ture of the problem.

The remote community of Cosmo Newberry exceeded nitrate levels in drink- ing water, recording 140 mg/L1.
The Auditor General’s report found nitrates in the community of Mt Margret in exceedance of the ADGW at 25–95 mg/L1 in 2013–14 (Ofﬁce of the Auditor General Western Australia, 2015).

In the Northern Goldﬁelds, the community of Kutkabubba recorded nitrate exceedances in water up to 75 mg/L1 (Ofﬁce of the Auditor General Western Australia, 2015).

The uranium in this re- gion is generally found at surface level to a depth of ﬁve metres underground (Scott, 2015).
Drink- ing water in Kutkabubba is sourced directly from two bores and is delivered via a gravity system, as raw untreated water (Western Australian Plan- ning Commission, 2012).

Most groundwater in Wiluna (30 kilometres south of Kutkabubba) can be found at an approxi- mate depth of two to 10 metres, and uranium is found in contact with the groundwater (Scott, 2015).

Groundwater chemical analysis at Wiluna was undertaken from January 2010 to August 2014 (RPS Group, 2015).
According to that report, more than 200 samples for all major and minor ions were recorded over a period of four years.

Re- sults for nitrate-N and uranium are shown in Figure 3.

Of these, nitrate-N was sampled only 48 times, ranging from 6.2 to 107 mg/L1 (RPS Group, 2015).

Nitrate-N levels exceeded WA guidelines of 11.3 mg/L1, 83 per cent of the time (RPS Group, 2015).
Uranium levels in the groundwater were tested 212 times ranging from 0.0001 to 1.46 mg/L1, exceeding guidelines 79 per cent of the time (RPS Group, 2015).
© 2018 Institute of Australian Geographers Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 J. Rajapakse et al., Chronic kidney disease and water quality 185 Figure 3 Nitrate-N and Uranium levels in WA Wiluna groundwater 2010–14 Uranium contamination in aquifers could be linked to nitrates Figures 4a and 4b show uranium and nitrate levels respectively in 13 groundwater wells sampled dur- ing March 2014 at South Wiluna in Western Australia.
Both graphs clearly indicate that uranium and nitrate levels exceed the guideline values in most of the samples.

It has been suggested that ura- nium contamination in aquifers could be directly linked with nitrates because nitrates can mobilise uranium (Nolan & Weber, 2015; Pasquale, 2016).

Figure 4c clearly demonstrates this relationship where the nitrate-N levels follow a similar trend to uranium levels.
The United States study found that, although nitrate was the primary agent in the mobilisation of uranium, it did so in conjunction with alkalinity and carbonates (Nolan & Weber, © 2018 Institute of Australian Geographers 2015).

The actual amount of nitrate required in solution to mobilise the U is still unknown.

The relationship between mobilising uranium (IV) in the presence of high alkalinities, expressed as CaCO3, has been historically established (Parkhurst et al., 1996).
Where high levels of ura- nium in solution are detected in conjunction with the carbonate–ion pH ranges seven to eight, activity enhances uranium mobilisation (Nolan & Weber, 2015).

As can be seen in Figure 4d, the pH range of the groundwater is within this range and alkalinity was present between 50 and 300 mg/L1 as favourable the CaCO3, conditions for uranium mobilisation.
Although the pH range in the March 2014 samples varied be- tween 6.9 and 9.0, the 2010 and 2014 samples show that there are wells with pH as low as 5.9, supporting earlier Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 186 Geographical Research May 2019 57(2), 178–188 Figure 4 South Wiluna (WA) Groundwater quality, March 2014 suggesting favourable conditions for uranyl nitrate formation.
The area of Yeelirrie has tested positive for ura- nium in both surface and groundwater.

Uranium recording has been detected in exceedance, 0.439 mg/L1 in surface water (URS Australia Pty Ltd, 2015) where the health based limit is 0.017 mg/L1; that is, 25 times higher, whereas in the groundwater levels as high as 2.4 mg/L1 (140 times higher) were reported (URS Australia Pty Ltd, 2011).

Nitrates were present but levels were within guideline values.
The surface water sources reported here were ephemeral and not con- sidered suitable for drinking water supply, stock watering, or irrigation.

Many of the groundwater bores in the Yeelirrie catchment are pastoral wells, monitoring wells, and production wells.

Most pas- toral wells have fallen into disuse in recent times, but at least one well in the area continued to be used as a water supply source.
These observations are at least compatible with the hypothesis that high levels of uranium and ni- trate contamination in drinking water can cause re- nal injury.

We have also demonstrated that, in all the communities examined as case studies, ura- nium and nitrate concentrations greatly exceed of- ﬁcially recommended levels.
Thus, uranium and nitrate levels above health guideline values in drinking water supplies may be additional causal factors in the occurrence of CKD in remote West- ern Australian Aboriginal communities.

Conclusion Western Australia is one of many areas around the globe where CKD has become a serious public health problem.

Considering the alarming CKDu cases reported in different geographic areas globally, the likelihood of a high proportion of CKDu cases among these CKD patients is a cause for concern.
The multifactorial nature of CKDu warrants novel risk factors to be investigated.

Focusing on remote Aboriginal communities, this study examined a possible causal relationship between the occurrence of the disease and the pres- ence of contaminants in drinking water, particu- larly uranium and nitrates found in the local groundwater.

Both uranium and nitrates can cause renal in- jury; they are nephrotoxic agents in their own right.
Chemical analysis of groundwater used for drinking has shown that both uranium and nitrates are present in remote Western Australia.

The recorded data are in exceedance of in solution, © 2018 Institute of Australian Geographers Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 J. Rajapakse et al., Chronic kidney disease and water quality 187 the safe drinking water guidelines.
While the role of CaCO3 (as expressed as alkalinity) has been historically documented in its ability to mobilise uranium, recent research indicates that the role of nitrates as critical in mobilising uranium in solu- tion.

Most remote communities rely on raw groundwater to supply domestic water, often with- out treatment.

In these cases, it is extremely likely that the communities are unwittingly ingesting high levels of nitrates and uranium including a probability of the presence of uranyl nitrates.
Very few remote communities in Western Australia have access to treated drinking water, and cost- effective water treatment systems are required to provide potable water at the local scale.

Uranium is generally not analysed routinely in groundwater monitoring and should be included in water-quality investigations.

The relationship between soluble uranium and nitrates creating ura- nyl nitrate in drinking water, as an additional envi- ronmental water contaminant, remains to be investigated.
The implementation of measures to supply safe drinking water to Western Australia’s is urgently remote Aboriginal needed, and further research is required on the public health implications of chemically contami- nated water supplies.

Sound public health policies to ensure access to safe drinking water to remote communities are a priority.
communities Research is needed to determine what propor- tion of Aboriginal CKD patients also suffer from the normal causal conditions, and how many do not, thus indicating possible signs of CKDu.

More broadly, the research should be expanded to exam- ine aspects of water supply that relate to alternative sources available and the means of distribution to highly dispersed remote settlements.

Qualitative research is needed to ascertain the special require- ments of Aboriginal communities.
It is important to ensure that the improvement of the health and wellbeing of Australia’s Indigenous population is achieved in a manner that meets the needs and as- pirations of the country’s Aboriginal people.

As researchers and policymakers, we need to listen to their voice.

Only by undertaking studies that draw on a wide range of knowledge and expertise can health policies for spatial and social planning be successfully prepared and applied.

References ABC News, 2016.


Bottled water not supplied to infants despite poor tap water quality.

Western Australia: ABC News.

Available at: http://www.abc.net.au/news/2016-09-23/ not-all-mid-west-communities-receiving-bottled-water/7870204 [Accessed 22/06/2018].

© 2018 Institute of Australian Geographers Agency for Toxic Substances and Disease Registry (ATSDR), 2013.

Toxicological Proﬁle for Uranium.

Atlanta: Division of Toxicology and Human Health Sciences.

AIWH.

2017.
AIWH.

2017.

Chronic kidney disease compendium [Online].

Available at: https://www.aihw.gov.au/reports/chronic-kid- ney-disease/chronic-kidney-disease-compendium/contents/ how-many-australians-have-chronic-kidney-disease.

[Accessed 06/01/2018].

Barnes, C.J., Jacobson, G. and Smith, G.D., 1992.

The origin of high-nitrate ground waters in the Australian arid zone.

Journal of Hydrology, 137(1–4), pp.181–97.

Blantz, R.C., Pelayo, J.C., Gushwa, L.C., Myers, R.R.

and Evan, A.P., 1985.


Functional basis for the glomerular alterations in uranyl nitrate acute renal failure.

Kidney International, 28(5), pp.733–43.

Burow, K.R., Belitz, K., Dubrovsky, N.M. and Jurgens, B.C., 2017.

Large decadal-scale changes in uranium and bicarbon- ate in groundwater of the irrigated western US.

Science of the Total Environment, 586, pp.87–95.

Cass, A., Cunningham, J., Wang, Z. and Hoy, W., 2001.
Regional variation in the incidence of end-stage renal disease in Indigenous Australians.

The Medical Journal of Australia, 175(1), pp.24–7.

Chandrajith, R., Seneviratna, S., Wickramaarachchi, K., Attanayake, T., Aturaliya, T.N.C.

and Dissanayake, C.B., 2010.

Natural radionuclides and trace elements in rice ﬁeld soils in relation to fertilizer application: study of a chronic kidney disease area in Sri Lanka.

Environmental Earth Sciences, 60(1), pp.193–201.

Commonwealth of Australia, C. 2016.


Australian Drinking Water Guidelines paper 6.

Version 3.2 Updated February 2016 and Medical Research Council.

ed.

: National Health Flamenbaum, W., Huddleston, M.L., McNeil, J.S.

and Hamburger, R.J., 1974.

Uranyl nitrate-induced acute renal failure in the rat: micropuncture and renal hemodynamic studies.

Kidney International, 6(6), pp.408–18.

Gelatar, J.K., Kumar, B., Sampath, M., Kumar, S., Mudali, U.K. intact UO2 and Natarajan, R., 2015.
Dissolution of in batch and rotary dissolver conditions.

Journal pellet of Radioanalytical and Nuclear Chemistry, 303(1), pp.1029–35.

Government of Western Australia, 2013.

Guide to Uranium in Western Australia.

Australia: Department of Mines and Petrolium.

Government of Western Australia, 2013a.

Pilbara—Population and Health Status.

Rural Health West: Outreach in the out- back, WA County Health Service.

Available at: http://www.


ruralhealthwest.com.au/docs/outreach-in-the-outback-docs/ pilbara-regional-needs-analysis-ﬁnal-060513.pdf?sfvrsn=2 [Accessed: 22/06/2018].

Jayatilake, N., Mendis, S., Maheepala, P. and Mehta, F.R., 2013.

Chronic kidney disease of uncertain aetiology: prevalence and causative factors in a developing country.

BMC Nephrology, 14, p.180.

Jeffries-Stokes, C., 2017.

The Western Desert Kidney Health Project.

PhD Thesis.

The University of Western Australia.


Johnson, S., Commander, D. and O’Boy, C., 1999.

Groundwa- ter resources of the northern Goldﬁelds [Online].

Water and Rivers Commission.

Available at: https://www.water.wa.

gov.au/__data/assets/pdf_ﬁle/0010/4330/10480.PDF.

[Accessed 06/01/2018].

Katz, S.A., 2014.

The chemistry and toxicology of depleted uranium.

Toxics, 2(1), pp.50–78.


Kurttio, P., Auvinen, A., Salonen, L., Saha, H., Pekkanen, J., Makelainen, and I., Vaisanen, S.B., Penttila, Komulainen, H., 2002.

Renal effects of uranium in I.M.

Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3 188 Geographical Research May 2019 57(2), 178–188 drinking water.

Environmental Health Perspectives, 110(4), pp.337–42.

Morales-Suarez-Varela, M.M., Llopis-Gonzalez, A. and Tejerizo-Perez, M.L., 1995.
Impact of nitrates in drinking water on cancer mortality in Valencia, Spain.

European Journal of Epidemiology, 11(1), pp.15–21.

Nolan, J. and Weber, K.A., 2015.

Natural uranium contamina- tion in major US aquifers linked to nitrate.

Environmental Science & Technology Letters, 2(8), pp.215–20.

Ofﬁce of the Auditor General Western Australia, 2015.

Delivering Essential Services to Remote Aboriginal Commu- nities.

Perth: Ofﬁce of the Auditor General Western Australia.

PAHO, 2017.
PAHO, 2017.

Epidemic of chronic kidney disease in agricul- tural communities in Central America.

Case deﬁnitions, methodological basis and approaches for public health sur- veillance.

Washington DC: PAHO.

Parkhurst, D.L., Christenson, S.C. and Breit, G.N., 1996.

Ground-water-quality assessment of the central Oklahoma Aquifer, Oklahoma: geochemical and geohydrologic investi- gations.

Washington, DC: US Government Printing Ofﬁce.

Pasquale, A., 2016.
Pasquale, A., 2016.

Uranium Contamination in Aquifers Could be Linked to Nitrate.

Earth – The Science Behind the Headlines.

Alexandra, VA: The American Geoscience Institute.

Available at: https://www.earthmagazine.org/arti- cle/uranium-contamination-aquifers-could-be-linked-nitrate [Accessed 25/06/2018].

Powlson, D.S., 1993.

Understanding the soil-nitrogen cycle.

Soil Use and Management, 9(3), pp.86–94.

Preston-Thomas, A., Cass, A. and O’Rourke, P., 2007.
Trends in the incidence of treated end-stage kidney disease among Indigenous Australians and access to treatment.

Australian and New Zealand Journal of Public Health, 31(5), pp.419–21.

Rajapakse, J., Liyanage, R., Tindale, N. and Waterman, P., 2013.

Secure and safe water supplies in remote Australian and rural Sri Lankan regions: common issues and emerging responses.

In: K. Charters, ed.


Sustainable Economic Growth for Regional Australia (SEGRA) Conference, 16–18 October 2013, Paciﬁc Bay Resort, Coffs Harbour, NSW, Australia: SEGRA.

RPS Group, 2015.

Centipede-millipede groundwater impact assessment.

Available at: https://consultation.epa.wa.gov.au/ open-for-submissions/per-wiluna-extension/ [Accessed 06/ 01/2018].

Scharer, J.M.

and Ibbotson, B., 1982.

Bacterial oxidation of inorganic-compounds in mining wastes.

Conservation & Recycling, 5(1), pp.47–53.


Scott, P., 2015.

Toro energy limited groundwater reinjection study, Lake Maitland Uranium Project.

Perth, Western Aus- tralia.

Available at: https://s3-ap-southeast-2.amazonaws.

com/toroﬁles/Appendices/Appendix+10.30+Lake+Maitland+ Groundwater+Reinjection+Study+(Pennington+Scott,+2015b).pdf [Accessed: 22/06/2018].

Smedley, P. L., Smith, B., Abesser, C. and Lapworth, D., 2006.

Uranium Occurrence and Behaviour in British Groundwater.
Commissioned Report, CR/06/050N, Keyworth, Nottingham, UK: British Geological Survey.

Available at: http://dwi.

defra.gov.uk/research/completed-research/reports/0847.pdf [Accessed 22/06/2018].

Soderland, P., Lovekar, S., Weiner, D.E., Brooks, D.R.

and Kaufman, J.S., 2010.

Chronic kidney disease associated with environmental toxins and exposures.

ACKD, Advances in Chronic Kidney Disease, National Kidney Foundation, 17(3), pp.254–64.
Stewart, D.I., Csovari, M., Barton, C.S., Morris, K. and Bryant, D.E., 2006.

Performance of a functionalised polymer-coated silica at treating uranium contaminated groundwater from a Hungarian mine site.

Engineering Geology, 85(1–2), pp.174–83.

The Australian Kidney Foundation – Kidney Health Australia, 2016.

State of the Nation, 2016 Kidney Health Week, Chronic Kidney Disease Hot Spots.

Kidney Health Australia.


Available at: https://kidney.org.au/cms_uploads/ docs/state-of-the-nation--kidney-health-week-2016--chronic- kidney-disease-hot-spots.pdf [Accessed 22/06/2018].

Tiso, M. and Schechter, A.N., 2015.

Nitrate reduction to nitrite, nitric oxide and ammonia by gut bacteria under physiological conditions.

PLoS One, 10(3), e0119712.

Tomazic, B., Branica, M. and Tezak, B., 1962.


Precipitation and hydrolysis of uranium (vi) in aqueous solutions: uranyl nitrate-potasium hydroxide-neutral electrolyte.

Croatica Chemica Acta, 34 (4).

41–50.

URS Australia Pty Ltd, 2011.

Groundwater study, Yeelirrie Uranium Project.

Draft Report prepared for BHP Billiton Yeelirrie Development Company Pty Ltd. East Perth, Western Austrlaia, 195 pp.

URS Australia Pty Ltd 2015.


Surface water study: proposed Yeelirrie development, Available at: https://www.

camecoaustralia.com/uploads/downloads/per_documents/ Appendix_H1_-_Surface_Water_Study.pdf [Accessed 28/ 06/2018].

USEPA, 2009.

National Primary Drinking Water Regulations, United States Environmental Protection Agency.

Ofﬁcial website of the United States Government.


Available at: https://www.epa.gov/ground-water-and-drinking-water/na- tional-primary-drinking-water-regulation-table [Accessed 22/06/2018].

Vicente-Vicente, L., Quiros, Y., Perez-Barriocanal, F., Lopez- Novoa, J.M., Lopez-Hernandez, F.J. and Morales, A.I., 2010.

Nephrotoxicity of uranium: pathophysiological, and therapeutic perspectives.

Toxicological diagnostic Sciences, 118(2), pp.324–47.

Water Corporation, 2013.


Drinking Water Quality Report 2012/ 2013 Western Australia.

Weng, H.H., Tsai, S.S., Wu, T.N., Sung, F.C.

and Yang, C.Y., 2011.

Nitrates in drinking water and the risk of death from childhood brain tumors in Taiwan.

Journal of Toxicology and Environmental Health.

Part A, 74(12), pp.769–78.

Western Australian Planning Commission, 2012.

Kutkabubba Layout Plan No.1.

Background Report.

Department of Plan- ning, Government of Western Australia.
Available at: http:// www.planning.wa.gov.au/dop_pub_pdf/Kutkububba_LP1_ Report.pdf [Accessed 22/06/2018].

WHO, 2011.

Guidelines for Drinking Water Quality.

Geneva: WHO.

WHO, 2012.

Uranium in Drinking Water.

Background document for development of WHO Guidelines for drink- ing-water Quality.

Geneva, Switzerland: World Health Orga- nisation.

WHO Press.

Available at: http://www.who.int/ water_sanitation_health/publications/2012/background_ura- nium.pdf [Accessed 22/06/2018].
WHO Country Ofﬁce Sri Lanka, 2016.

Report of the WHO- International Expert Consultation on Chronic Kidney Dis- ease of Unknown Etiology.

Colombo, Sri Lanka: World Health Organization.

Ye, X.G., Smith, R.B., Cui, S.T., de Almeida, V. and Khomami, B., 2010.

Inﬂuence of nitric acid on uranyl nitrate association in aqueous solutions: a molecular dynamics simulation study.

Solvent Extraction and Ion Exchange, 28(1), pp.1–18.

Závodská, L., Kosorinova, E., Scerbakova, L. and Lesny, J., 2008.
Environmental chemistry of uranium.

Hungarian Electronic Journal of Sciences, pp.1–19.

© 2018 Institute of Australian Geographers Inquiry into the prerequisites for nuclear energy in AustraliaSubmission 219 - Attachment 3