Regional Health Forum WHO South-East Asia Region(Volume 7,Number 1)

Exposure to Indoor Air Pollution: Evidence from Andhra Pradesh, India

Kalpana Balakrishnan¹, Sumi Mehta² , Satish Kumar³  and Priti Kumar⁴  

     Background

According to the World Health Organization, indoor air pollution from solid fuels ranks fourth amongst risks to human health in developing countries and ranks higher still in India (third), just below malnutrition and lack of safe sanitation and drinking water [1]. There is a growing body of literature on the health impacts of indoor air pollution, especially in women and children [2-6]. Studies yield an estimated range of 400 000-2 million premature deaths annually attributable to IAP in India with a majority of deaths occurring in children under five due to acute respiratory infections (pneumonia). There is also strong evidence of impact on women, up to 34 000 deaths resulting from chronic obstructive disorders [7].

A study was piloted in three districts of Andhra Pradesh, a state in southern India to have better information on the exposure levels for population subgroups and assess the effectiveness of some interventions. The study involved

      a household-level survey of house and fuel characteristics and behavioural factors (e.g., time to cook, infant protection measures);

       monitoring of indoor concentrations of respirable suspended particulate matter (RSM P; mean aerodynamic diameter of 4μm) and 24-hour time-activity patterns of the household members and

      statistical analysis to explore linkages between the RSPM concentrations and determinants of exposure [8].

Out of 412 sampled households, 270 households relied on wood as the primary cooking fuel and 97 used dung. Clean fuels such as kerosene and LPG, were used by 11 and 34 households respectively. Small farmers with low education levels inhabited 50 per cent of households. Smoking, mostly by male members, was prevalent in up to 45 per cent of the households. Use of improved stoves was negligible, with heavy reliance on traditional stoves without chimneys.

      Study Findings

In households using solid fuel, average 24-hour exposures to RSPM were the highest amongst women cooks (442±37 μg/m3) compared to all the other household members. Amongst non-cooks, older women (61-80 years) experienced the highest exposures (337±57 μg/m3), followed by children under five (262±55 μg/m3). This is presumably because older women remain indoors for larger periods of time. Exposures of female and male children were similar. Men of 16-60 years experienced the least exposures owing to greater likelihood of working outdoors (148±5 μg/m3)

In households using solid fuels, kitchen configuration played an important role in affecting exposures of all household members, including children under five. Average living area RSPM concentrations were the highest in households having indoor kitchens without partitions (280 ± 17 μg/m3) followed by households with indoor kitchens with partitions (264 ± 17 μg/m3). Enclosed outdoor kitchens or simply outdoor cooking resulted in even lower levels of indoor exposure (178 ± 11 μg/m3 and 175 ± 10 μg/m3, respectively) but still exceeded health guidelines for outdoor air pollution (24-hour Indian standard for particulate matter less than 10 μm is 100 μg/m3 for rural areas). Thus, dispersion considerably affected indoor levels even during outdoor cooking.

In households using LPG, children were exposed to three to four times lesser RSPM levels (76 ±6 μg/m3) compared to solid fuel using households and these levels were similar to all the other population subgroups.

     Conclusions and Policy Implications

All members of the family were exposed on a daily basis to high levels of air pollution due to traditional use of biomass fuels. Even when cooking was done outside the house –in a separate kitchen or in the open air, a common practice of poor rural households–the resulting indoor levels of RSPM and exposure of all family members greatly exceeded health guidelines for ambient air.

The study highlights the important gender and age dimensions of the IAP problem. Women, in their traditional capacity as cooks, suffer from much greater average daily exposures than other family members. Among non-cooks, young children are most vulnerable to the health risks because IAP is likely to have the greatest detrimental impact during the early developmental phase. This finding lends support to the results of other studies in India linking household fuel use to child mortality rates[9]. Therefore, IAP punishes young children twice – by making them ill and making their mothers ill, thus reducing the mother’s ability to take care of the children.

Biomass will remain the principal cooking fuel for a large majority of rural households for many years ahead. Hence, more attention should be paid to effective IAP mitigation strategies that employ a variety of options, from improvements in fuels and cooking technologies (e.g. improved stoves) to housing improvements (e.g. kitchen configuration, chimneys and ventilation improvements) to facilitating behavioural changes among women, children and other household members (e.g. keeping children away from smoke).

Health agencies have an important role to play in integrating indoor air pollution into existing maternal and child health programmes as well as to address IAP in other home-related health programmes (e.g. hygiene, water and sanitation). Further, agencies can raise awareness amongst rural families about the health impacts of household energy and provide specific information on the range and effectiveness of mitigation options. Various methods – from including IAP issues in basic hygiene education by primary schools and health centres to mass media – should be utilized. Improving knowledge of the IAP problem and possible solutions among major stakeholders, including the medical community, is as important.

While research gaps and uncertainties in exposure and specific health outcomes should not be used as an excuse to delay actions, there are some critical areas where better knowledge is needed to help design effective interventions. Exposure assessment studies can help to identify the most affected populations and household level determinants of exposure (e.g., kitchen ventilation) that can be modified to improve health impacts. Based on these studies, large-scale survey instruments, such as the Census, can be modified to include additional household parameters that influence exposure. So far, two parameters – type of fuel used and ventilation – emerged as the key determinants of exposure in the study.

Finally, IAP is “cross-sectoral” in nature and requires increased collaboration and commitment between the agencies responsible for health, energy, environment, housing and rural development.

     Acknowledgement

The study was conducted as part of the World Bank programme, Household Energy, Indoor Air Pollution and Health in India, supported by the joint UNDP/World Bank Energy Sector Management Assistance Programme (ESMAP). We would like to thank the Ministry of Environment and Forests, Government to India and the Indian Council of Medical Research for supporting this exposure assessment exercise.

     References

     World Health Organization. 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life, WHO. Geneva.

      Bruce N, Perez-Padilla R, Albalak R. 2000. Indoor Air Pollution in Developing Countries: A Major Environmental and Public Health Challenge. Bulletin of the World Health Organization. Vol. 78 (9): 1078-1092.

      Awasthi, S, Glick H, and Fletcher, R 1996. Effect of Cooking Fuels on Respiratory Diseases in Preschool Children in Lucknow, India. American Journal of Tropical Medicine and Hygiene 55(1): 48–51.

      Ezzati, M, and Kammen, DM 2001. Indoor Air Pollution from Biomass Combustion as a Risk Factor for Acute Respiratory Infections in Kenya: An Exposure –Response Study, Lancet, 358 (9282), 619-624 (erratum 358(9287)),

      Mishra, V, and Rutherford, R 1997. Cooking Smoke Increases the Risk of Acute Respiratory Infections in Children. National Family Heath Survey Bulletin, No. 8, IIPS Mumbai and East-WestCenter, Honolulu.

      Balakrishnan K, Sankar S, Parikh J, Padmavathi R, Srividya K, Venugopal V, Prasad S, and Pandey V, 2002. Daily Average Exposure to Respirable Particulate Matter from Combustion of Biomass Fuels in Rural Households of Southern India, Environmental Health Perspectives, 110 (11): 1069-1075.

      Smith, KR. 2000. National Burden of Disease in India from Indoor Air Pollution. Proceedings of the NationalAcademy of Sciences 97:13286–13293.

      World Bank. 2002. India: Household Energy, Air Pollution, and Health, Joint UNDP/World Bank Energy Sector Management Assistance Programme.

      World Bank. 2000. Environmental Health in India: Priorities in Andhra Pradesh. South Asia Environment and Social Development Unit, Washington, DC.

1 Head, Environmental Health Eng. Cell, SriRamachandraMedicalCollege and Research Institute, Chennai. Other team members from this institute included S Sambandam, P Ramaswamy, J Arnold, R Ayyappan, D Venkatesan, D Bhuvaneswari and A Anand.
2 Environmental Health Sciences, School of Public Health, University of California, BerkeleyUSA (Current address: Global Programme on Evidence for Health Policy, World Health Organization, Geneva, Switzerland). Other team members from this institute included Kirk R Smith, Professor and Associate Director for International Programmes Centre for Occupational and Environmental Health.
3 Faculty, Environmental Health, Institute of Health Systems, Hyderabad. Other team members from this institute included P Mahapatra, PV Chalapati Rao and N Sreenivasa Reddy.
4 Environment Specialist (Consultant), South Asia Environment and Social Development Unit, World Bank, New Delhi, India. The study was managed by Kseniya Lvovsky, Lead Environmental Economist and Task Leader, and Sameer Akbar, Environment.