Environmental Health in India: What are the issues and what is India

doing about it?

Kirk R. Smith, MPH, PhD Professor of Global Environmental Health

University of California, Berkeley

Visiting Distinguished Professor Sri Ramachandra University, Chennai

PROFESSOR TK PARTHA SARATHY

ENDOWMENT ORATION Sri Ramachandra University, Chennai

October 6, 2016

Developed country mean

Disability-adjusted life years - DALYs

Data from GBD-13

Metabolic Risks

Behavioral Risks

Environmental Risks

The Environmental Risk Transition

• How do environmental and other health risks trend during economic development?

• Not uniform in every country at every period,

• But broadly the case both historically and in cross section.

Risk

Development

Traditional Risks

The Environmental Risk Transition

Risk

Development

Traditional Risk Modern Risks

The Environmental Risk Transition - USA

Risk

Development

Traditional Risk

Modern Risks

The Environmental Risk Transition - India

Very large risk overlap period

The three major solid fuels

Leading cause of disease burden in 2010 by country Population Cooking with Solid Fuels in 2010 (%)

Toxic Pollutants in Wood Smoke from Simple (poor) Combustion

• Small particles, CO, NO2 • Hydrocarbons

– 25+ saturated hydrocarbons such as n-hexane – 40+ unsaturated hydrocarbons such as 1,3 butadiene – 28+ mono-aromatics such as benzene & styrene – 20+ polycyclic aromatics such as benzo(α)pyrene

• Oxygenated organics – 20+ aldehydes including formaldehyde & acrolein – 25+ alcohols and acids such as methanol – 33+ phenols such as catechol & cresol – Many quinones such as hydroquinone – Semi-quinone-type and other radicals

• Chlorinated organics such as methylene chloride and dioxin

Source: Naeher et al, J Inhal Tox, 2007

Typical chulha releases

400 cigarettes per hour worth of smoke

First person in human history to have her exposure measured doing the oldest task in human history

Kheda District, Gujarat, 1981

Emissions and concentrations, yes, but what about exposures? ~5000 ug/m3

during cooking >500 ug/m3 24-hour Indian standard 40 ug/m3

Balakrishnan et al. 2013

First national household air pollution exposure assessment

Burnett et al., EHP. 2014, Integrated Exposure-Response Functions

Secondhand Tobacco Smoke

Outdoor Air Pollution

RESPIRE

Stroke

Ischemic Heart Disease

ALRI

ug/m3 annual average PM2.5

COPD Lung Cancer

Relative disability-adjusted life years DALYs

LPG is benchmark

DALYs

About 9 lakh premature deaths per year in India

What has been done-#1

Wait for development to work.

Low- and Middle-Income Countries

More than any time in

human history

1990: 85%: 700 million people using solid fuels 2010: 60%: 700 million people ~1980 700 million people in entire country

700 million people in the Chulha Trap

What has been done-#1

Wait for development to work. • Percent using solid fuel slowly declines

with development alone (no special policies)

• But in India, the number of people exposed has never declined

What has been done #2: Make the available clean

• Many hundreds of “improved” biomass stove programs over ~60 years

• Including major national programs in China and India in the 1980/90s covering ~200 million households in all

• And in India, Peru, Mexico, Nepal, Honduras, and other countries today

• Hundreds of NGOs, big and small, promoting stoves around the world over the decades

Unfortunately • The cleanest “improved” biomass stoves have

been disseminated to only a few tens of thousands of households in the world

• And, in spite of much progress, as yet, no “improved” biomass stove in the world comes close to the boundary between solid and non-solid fuels

• Thus, none seem clean enough to be reliably truly health protective in household use

• But more effort is still warranted.

Increasing Prosperity and Development

Dec

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Hou

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Very Low Income

200 million

Low Income 400 million

Middle Income 400 million

High Income 200 million

Crop Waste Dung

Coal

Kerosene

Natural Gas

Electricity

Non-solid fuels

Solid Fuels

Liquefied Petroleum Gas

Biogas/Solar

Wood

Conceptual Indian Energy Ladder

?

New Paradigm

Making the clean available

Public health and environment 31 |

Blaming the Oil/Gas Industry

• “Fracking” • Tanker spills • Off-shore platform failures • Pipeline explosions • Refinery fires • Air pollution • And, of course • Climate change

The industry needs to push back

• It produces the fuel that could save millions of lives every year.

• By definition! • All among the poorest and most vulnerable

populations in the world • But to make this case, it needs to do much

better to make LPG available to poor populations

Public health and environment 34 |

Indian LPG program • Stage I: began Jan 1, 2015: PAHAL

– Direct Bank Transfer: largest in human history – All LPG now sold at market rate. – LPG sales rose 40% in commercial sector

• Stage II: began April 1, 2015 – “Give it up” campaign: 30k per day – ~11 million households have done so (June), – Connection fee from CSR funds of oil

companies ~1800 INR – Focused only on poor families (BPL)

Give It Up campaign • Extensive social marketing

– Modi and other celebrities in speeches, media ads, bill boards, etc

– SMS messages – Fairs, athletic events, posters, skits, etc – Delivery boys – Website linking those giving up to those

receiving: middle class to poor – Key chains, plaques, awards, etc.

• Health is the message – “make a poor man’s kitchen clean”

Times of India Oct 2, 2015 Gandhi’s Birthday

MyLPG website: Feb 24, 2016

LPG expansion, cont. • Phase III: Jan 1, 2016

– Income limit – USD 15,000– to be extended downwards

• Phase IV: April 1, 2016 – Ujjwala Scheme – Extend past GIU – And add additional incentives – To reach a total of 50 million below poverty

line households in 3 years – 8000 crore from gov – 1600 Rs x 5 crore

Public health and environment 44 |

LPG expansion, cont.

• Phase V: Fall, 2016 – Ujjwala+ campaign – Target biomass using households – That do not qualify as BPL – Funding from donations of individuals, NGOs,

businesses, foundations, gram panchayats, schools, and some matching GOI funds

• Now there are ways to address all biomass-using households in the country

Increasing Prosperity and Development

Dec

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Hou

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Very Low Income

200 million

Low Income 400 million

Middle Income 400 million

High Income 200 million

Crop Waste Dung

Coal

Kerosene

Natural Gas

Electricity

Non-solid fuels

Solid Fuels

Liquefied Petroleum Gas

Biogas

Wood

Conceptual Indian Energy Ladder

?

India: What happened? Millions

India: What happened? Millions

In 35 years, “improved” biomass stoves had almost no impact on health. At the same time more than 400 million Indians took up clean fuels, mainly LPG

India: What If? Millions

9% instead of 5.5%/yr for 20 years

A Chulha Trap or a

Clean Fuel Gap?

By 2020 • 50 million more connections in BPL

households • On top of perhaps 50 million growth in

middle class • Doubling previous growth rate • By 2025 with Ujjwala+

– Perhaps another 50 million biomass households from Ujjwala+

• Maybe reach UN goals for 2030 >95% with clean cooking fuels?

Typical Indian LPG cylinder and stove Needs work to make it truly aspirational

Of course • Just providing affordable access to LPG or

other clean fuel does not mean people instantly switch 100%

• However, since 60% of world uses gas and/or electricity it argues strongly that the others will eventually follow.

• Is clearly what is needed in long term – why not sooner rather than later?

Subsidy or ? • Health sector does not refer to programs to

vaccinate or provide maternal care to the poor as “subsidies” but rather

• Social investments • In order for public support of clean fuels to be

termed social investments, they need to be far better targeted than in the past.

• Modern IT technology provides ways to do so • JAM – bank accounts, Adhaar, mobile phone

New Directions

• Work to help target subsidies – Embrace modern IT to do so

• Work with others to explore entirely different distribution modes

• Develop marketing for enhancing use after adoption

Unique historical opportunity • More than a billion dollars (8000 crore)

being spent in three years solely on providing clean fuels to India’s poor.

• Facilitated by India’s middle class giving up their subsidies– voluntarily! >1500 Cr/y

• New internal “foreign aid” planned • Massive commitment by government • What will be the result? • Research community needs to step up

What we need to learn • How to increase usage to the point health

benefits are large • Not a new task in the health sector –

– Just giving people latrines does not meant they are used

– Or condoms or bednets – Or many other interventions

• We have an intervention research challenge but we have good experience to apply

Environmental Risks

The Tamil Nadu Air Pollution and Health Effects (TAPHE) Study

1200 pregnant women and 1200 adults were enrolled from across 110 villages in Thiruvallur District and 10 municipal zones of Chennai City

World Health Organization Collaborating Centre for

Occupational & Environmental Health

Department of Environmental Health Engineering

Sri Ramachandra University

Indian Council of Medical Research Centre for Advanced Research

On Environmental Health: Air Pollution

Among pregnant women, a 10µg/m3 change in household PM2.5 concentrations was associated with a 4 gm (95% CI: 1.38 gm,7.18gm) decrease in birth weight or a 2% increase in low birth weight (OR =1.02; 95% CI, 1.003-1.037).

– Models were adjusted for cohort location (rural vs. urban), type of house construction (a SES indicator), SES, family size, primary cookfuel, location of kitchen, maternal education, occupation, age and BMI, sex of the child, maturity (term vs. pre-term), birth order (gravida) and previous history of a low birth weight child. Restricting the analyses to term births reduced the effects estimates slightly.

Among children< 2 years, a 10 µg/m3 change in household PM2.5 concentrations was associated with a 0.3% (95%CI: 0.02%-0.69%) increase in the longitudinal prevalence of ARI and a 0.9% (OR=1.009; 95%CI: 1.001-1.016) increase in the number of episodes of ARI (in linear and Poisson regression models), respectively.

– Models were adjusted for malnutrition (weight-for-age z-score < -2), low birth weight, lack of exclusive breastfeeding during first 4 months, lack of measles immunization, solid fuel use, crowding, parental smoking, maternal illiteracy, season and birth order.

TAPHE Study Outputs (Birthweight and ARI)

World Health Organization Collaborating Centre for

Occupational & Environmental Health

Department of Environmental Health Engineering, SRU, Chennai

Sri Ramachandra University

Indian Council of Medical Research Centre for Advanced Research

On Environmental Health: Air Pollution

Provides some of the first quantitative exposure-response functions for birthweight , ARI, respiratory symptoms and lung function in relation to household and ambient air pollution

Provides some of the first integrated rural urban E-R estimates in India

Provides inputs for on-going and future cohort studies Informs intervention programs and affords abilities to piggy

back on natural experiments or planned air quality actions in rural and urban settings

Provides a framework for creating India specific exposure models

TAPHE Study Outputs

India

• Has very big environmental health problems • But has taken completely Indian and

innovative steps to solving one of them – household air pollution

• And has been developing the research expertise to evaluate these and to do even better while contributing to global science

• At SRU, and elsewhere

Many thanks

For publications & presentations: Just “Google” Kirk R. Smith