India Leads the Way: A Health-Centered Strategy for Air Pollution

India Leads the Way: A Health-Centered Strategy for Air Pollution

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Perspectives | Editorial

A Section 508–conformant HTML version of this article is available at

India Leads the Way: A H ­ ealth-­Centered Strategy for Air Pollution

The Government of India has recently initiated unprecedented efforts to address the substantial national health burden attribu­ table to ambient and household air pollution. The key first step wa s t he constitution by t he Ministry of Health and Family Welfare (MHFW) of an expert c om m it tee on a ir pol lut ion a nd hea lth. This committee put together a landmark report (MHFW 2015) released earlier this year that outlined targeted actions aimed at providing the largest exposure reductions (and conse­ quent health benefits), instead of traditional approaches to air quality management. India’s health ministry is perhaps the first among low- and ­middle-­income countries to initiate steps that directly address air pollution as a national health concern. Discussions initiated through this process have led to a number of concrete policy actions consistent with these recommendations, the most recent of which is highlighted within the 2016–2017 budget just released by the government: a commitment of at least US$1.5 billion to address household air pollution by providing clean cooking gas to 50 million poor households in the next 3 years (MF 2016). This is an enor­ mous step forward in addressing household air pollution caused by polluting cookfuels. The impetus for the MHFW report came from recent assessments on the burden of disease that highlight the scale of air pollution– related health impacts (Lim et al. 2012, Forouzanfar et al. 2015) and the need to address dual burdens from ambient and household air pollution in the nation (Balakrishnan et al. 2014). Around 1.5 million premature deaths in India—deaths due to a range of acute and chronic health conditions—are attributable annually to the indoor and outdoor exposures of the population to air pollution (IHME 2015). This places air pollution near or at the top of the list of all known risk factors for ill health in the country, above high blood pressure, smoking, child and maternal malnutrition, and risk factors for diabetes (IHME 2015). Although management of the latter risks has long been part of national health programs managed by the MHFW, the report makes a compelling case for a major national ­cross-­ministerial effort directed at air pollution, to be spearheaded by the ministry. We describe here the salient ­recommendations of the report. The health burden from air pollution comes from outdoor ­exposures in both urban and rural areas as well as from within house­ holds. In fact, approximately 170 million households, primarily in rural areas, are exposed indoors and near the household to ­pollution resulting from poor combustion of solid fuels such as wood, crop residues, and dung in traditional cookstoves (Bonjour et al. 2013). The result is more premature deaths from this cause (> 0.9 million annually) than in any other country (IHME 2015). Unfortunately, in spite of significant economic development and consequent growth in the use of clean fuels in some populations, the number of people

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using solid fuels in India does not seem to have cha nged significantly in the past 30 years (Bonjour et al. 2013), although it now constitutes a smaller frac­ tion of the overall population. Vehicles and power plants—key contributors to urban ambient air pollution—historically have been the only sources to be addressed in national ambient air quality management efforts. The report addresses both household (indoor) and outdoor air pollution in an integrative fashion instead of treating them as separate issues— the first time by a government agency, to our knowledge. This is especially relevant given that household cookstoves also contribute an estimated 25% of ambient air pollution in India (Chafe et al. 2014). Notably and importantly, the report invokes a new paradigm of exposure manage­ ment instead of concentration management as a national air pollution control strategy, and prioritizes policies and actions accordingly to achieve substantially enhanced cost effectiveness and speed in achieving health benefits. From a health perspective, what matters is not just the absolute volume of emissions but how much of the pollution is breathed in by indi­ viduals, defined sometimes as the “intake fraction” (Bennett et al. 2002). With advances in understanding and capabilities that have come from new monitoring technologies, digital data management, remote sensing, and associated modeling, it is now possible to undertake such exposure apportionment in India. Several potential approaches can be used to rank sources that are most proximate to the population (such as stoves, vehicles, and neighborhood trash burning) as highest priority, since these produce the highest exposures per unit emissions. It implies somewhat different strategies for monitoring than have been used in other countries—for example, placing more ambient monitors in rural as well as urban areas to better follow population exposures (Balakrishnan et al. 2014). The report provides a ­health-­based argument for intensifying efforts to control household air pollution and to expand access to truly clean sources of household energy, shifting the focus away from just promoting s­o-­c alled “improved” technologies that have not proven to be health protective (MNRE 2016). It also promotes a new research agenda to apply the range of modeling, networking, and sensing tools now becoming available to assess in specific places the impact of specific source types on exposure rather than just on concentrations (NRC 2012). The report also highlights that reducing air pollution to achieve health goals will require actions across a range of government agencies, but that it can—and should—be led by health ministries (as has been the case for smoking and sanitation, for example). A clearer recogni­ tion of the problem and articulation of possible pollution control strategies can cause other ministries to start taking steps on their own, as has been the case with the Ministry of Petroleum and Natural Gas, which has taken a number of innovative steps to expand access to


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clean cooking gas to the poor (see, for example, Tripathi et al. 2015). Health ministries can also deploy their own assets to mitigate the impacts of air pollution through appropriate training, treatment, and information dissemination. In India, the MHFW has a million local health workers, tens of thousands of hospitals and clinics, and thou­ sands of institutions that train health professionals, as well as extensive infrastructure through the Rural Health Mission and state govern­ ments. Health ministries and medical doctors also retain unique status in most countries as credible sources of information to influence the public, media, and policy makers. All in all, the integrative exposure management–driven approach taken by the MHFW report will not only help address this major problem in an efficient and effective manner, but also serve as a model for other developing countries that likewise need to manage health impacts from a combination of household and outdoor air pollution. The report is pioneering particularly by virtue of its coming from a ministry of health. Ever since the widespread r­ecognition of the hazards of environmental pollution in the 1950s, actions on air pollution have been nearly universally managed by envi­ ronment agencies. Although health is commonly considered as a criterion for setting regulatory standards, air pollution has been considered neither in the same landscape as all the other impor­ tant risk factors that affect national health (most of which lie in completely different sectors), nor in the context of the special assets of the health sector that can be brought to bear on air pollution control. Even though air pollution is a major threat, of course, a ­resource-­c onstrained country such as India has many other health challenges to address as well, and needs to carefully weigh the relative benefits of actions across sectors. With 10 of the dirtiest 20 cities in the world (WHO 2016) and 700 million people caught in the “chulha trap,” i.e., still lacking access to clean fuels for cooking (Smith and Sagar 2014), India is in the throes of a silent health crisis due to air pollution that has become the greatest of any major country in the world both in total and per capita (twice that of China) (IHME 2015). The extreme nature of the situation requires major initiatives and innovative ­cross-­sectoral approaches to organize the monitoring and evalua­ tion of targeted controls. India’s MHFW has set the ball in motion by providing a pioneering framework for addressing air pollution impacts for both rural and urban populations.

References Balakrishnan K, Cohen A, Smith KR. 2014. Addressing the burden of disease attributable to air pollution in India: the need to integrate across household and ambient air pollution exposures. Environ Health Perspect 122(1):A6–A7, doi:10.1289/ehp.1307822. Bennett DH, McKone TE, Evans JS, Nazaroff WW, Margni MD, Jolliet O, et al. 2002. Defining intake fraction. Environ Sci Technol 36(9):207A–211A, doi:10.1021/es0222770. Bonjour S, Adair-Rohani H, Wolf J, Bruce NG, Mehta S, Prüss-Ustün A, et al. 2013. Solid fuel use for household cooking: country and regional estimates for 1980–2010. Environ Health Perspect 121(7):784–790, doi:10.1289/ehp.1205987. Chafe ZA, Brauer M, Klimont Z, Van Dingenen R, Mehta S, Rao S, et al. 2014. Household cooking with solid fuels contributes to ambient PM 2.5 air pollution and the burden of ­disease. Environ Health Perspect 122(12):1314–1320, doi:10.1289/ehp.1206340. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. 2015. Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386(10010):2287–2323, doi:10.1016/S0140-6736(15)00128-2. IHME (Institute for Health Metrics and Evaluation). 2015. GBD Compare [website]. Seattle, WA:Institute for Health Metrics and Evaluation, University of Washington. Available: [accessed 29 April 2016]. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. 2012. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859):2224–2260, doi:10.1016/S0140-6736(12)61766-8. MF (Ministry of Finance). Union Budget 2016–2017. New Delhi, India:Ministry of Finance, Government of India (29 February 2016). MHFW (Ministry of Health and Family Welfare). 2015. Report of the Steering Committee on Air Pollution and Health-Related Issues. New Delhi, India:Ministry of Health and Family Welfare, Government of India (August 2015). Available: php?lid=3650 [accessed 29 April 2016]. MNRE (Ministry of New and Renewable Energy). 2016. National Biomass Cookstoves Programme [website]. New Delhi, India:Ministry of New and Renewable Energy, Government of India. Available: national-biomass-cookstoves-initiative/ [accessed 29 April 2016]. NRC (National Research Council). 2012. Exposure Science in the 21st Century: A Vision and a Strategy. Washington, DC:National Research Council, National Academy of Sciences. Available: [accessed 29 April 2016]. Smith KR, Sagar A. 2014. Making the clean available: escaping India’s chulha trap. Energy Policy 75:410–414, doi:10.1016/j.enpol.2014.09.024. Tripathi A, Sagar AD, Smith KR. 2015. Promoting clean and affordable cooking—smarter subsidies for LPG. Econ Polit Wkly 5 0(4 8):81– 8 4. Available:  ht tp: //w w journal/2015 /4 8 /notes/promoting-clean-and-af fordable-cooking.html  [accessed 29 April 2016]. WHO (World Health Organization). 2016. Burden of Disease from Ambient and Household Air Pollution [website]. Geneva, Switzerland:World Health Organization. Available: http:// [accessed 29 April 2016].

A.S. was cochair, K.B. and A.R. were members, and S.G. and K.R.S. were special advisors to the steering committee that wrote the report described here. All the authors had equal roles in the preparation of this editorial. The authors declare they have no actual or potential competing financial interests and acknowledge the efforts of all the other committee members.

Ambuj Sagar,1 Kalpana Balakrishnan, 2 Sarath Guttikunda,1 Anumita Roychowdhury, 3 and Kirk R. Smith4 1Indian Institute of Technology Delhi, New Delhi, India; 2Sri Ramachandra University, Chennai, Tamil Nadu, India; 3Centre for Science and Environment, New Delhi, India; 4University of California, Berkeley, Berkeley, California, United States

Address correspondence to K.R. Smith, 747 University Hall, School of Public Health, University of California, Berkeley, CA 94720-7360 USA. E­ -­mail: [email protected]

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