Household Air Pollution Risks in India Kirk R

Household Air Pollution Risks in India Kirk R. Smith, MPH, Ph. D Professor of Global Environmental Health University of California, Berkeley Fulbright-Nehru Distinguished Chair IIT-Delhi

The Environmental Health Pathway

1. 8 million years ago, the cooking became a regular feature in human society Catching Fire: How Cooking Made Us Human, R Wrangham Basic Books, 2009

The three major solid fuels

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

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

The Environmental Health Pathway

Woodsmoke is natural – how can it hurt you? Or, since wood is mainly just carbon, hydrogen, and oxygen, doesn’t it just change to CO 2 and H 2 O when it is combined with oxygen (burned)? Reason: the combustion efficiency is far less than 100%

Energy flows in a well-operating traditional wood-fired cookstove A Toxic Waste Factory!! Typical biomass cookstoves convert 6 -20% of the 15% moisture fuel carbon to toxic substances PIC = products of incomplete combustion = CO, HC, C, etc. Source: Smith, et al. , 2000

Toxic Pollutants in Biomass Fuel Smoke from Simple (poor) Combustion • Small particles, CO, NO 2 • 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( )pyrene • Oxygenated organics – 20+ aldehydes including formaldehyde & acrolein – 25+ alcohols and acids such as methanol – 33+ phenols such as catechol & cresol Source: Naeher et al, – Many quinones such as hydroquinone J Inhal Tox, 2007 – Semi-quinone-type and other radicals • Chlorinated organics such as methylene chloride and dioxin Typical chullah releases 400 cigarettes per hour worth of smoke

The Environmental Health Pathway

Health-Damaging Air Pollutants From Typical Wood-fired Cookstove. Typical Health-based Standards Best single indicator Typical Indoor Concentrations IARC Group 1 Carcinogens

The Environmental Health Pathway

First person in human history to have her exposure measured doing the oldest task in human history ~5000 ug/m 3 during cooking >500 ug/m 3 24 hour Emissions and concentrations, yes, but what about exposures? Kheda District, Gujarat, 1981

The Environmental Health Pathway

How much PM 2. 5 is unhealthy? • WHO Air Quality Guidelines – 10 ug/m 3 annual average – No public microenvironment, indoor or outdoor, should be more than 35 ug/m 3 • National standards – annual outdoors – USA: 12 ug/m 3 – China: 35 ug/m 3 – India: 40 ug/m 3

CRA published along with the other GBD papers on Dec 14, 2012 in The Lancet

Annual Review of Public Health, vol 35, 2014, out this month

Comparative Risk Assessment Method Exposure Levels: Past actual and past counterfactual Exposure-response Relationships (risk) Disease Burden by age, sex, and region Attributable Burden by age, sex, and region

State-wise estimates of 24 -h kitchen concentrations of PM 2. 5 in India Solid-fuel using households Balakrishnan et al. 2013 (SRU group)

Study design N* OR 95% CI Intervention 2 1. 28 1. 06, 1. 54 Cohort 7 2. 12 1. 06, 4. 25 Case-control 15 1. 97 1. 47, 2. 64 Crosssectional 3 1. 49 1. 21, 1. 85 All 26 1. 78 1. 45, 2. 18 Dherani et al Bull WHO

ALRI/ Pneumonia Diseases for which we have epidemiological studies COPD Lung cancer (coal) Lung cancer (biomass) Cataracts Ischemic heart disease Stroke These diseases are included in the 2010 Comparative Risk Assessment (released in 2012)

New Category of Evidence for CVD • No direct studies of CVD and HAP, yet – But studies showing effects on blood pressure and ST-segment, important disease signs • Epidemiologic evidence shows clear, consistent evidence of increasing risk across exposures to combustion particles – at higher exposures – Active smoking – and lower exposures – Outdoor air pollution and secondhand tobacco smoke

Heart Disease and Combustion Particle Doses HAP Zone From “Mind the Gap, ” Smith/Peel, 2010 and Pope et al. , 2009

Integrated Exposure-Response: Outdoor Air, SHS, and Smoking and Heart Disease Smokers HAP Zone Secondhand Tobacco Smoke Outdoor Air Pollution CRA, 2011

EHP, 2007 EHP, 2011

Integrated Exposure-Response: Outdoor Air, SHS, and HAP Solid Fuel Zone Secondhand Tobacco Smoke Outdoor Air Pollution CRA, 2010

Stroke ALRI Lung Cancer COPD Ischemic Heart Disease ug/m 3 annual average PM 2. 5

Metrics • Mortality – important, but can be misleading as it does not take age into account or years of illness/injury – Death at 88 years counts same as at 18, which is not appropriate • Disability-adjusted Life Years (DALYs) lost do account for age and illness. • GBD 2010 compares deaths against best life expectancy in world – 86 years

Global DALYs 2010: Top 20 Risk Factors Premature Deaths HBP -9. 3 million Alcohol – 7. 7 Tobacco – 5. 7 SHS-T – 0. 6 House AP – 3. 5 SHS-C – 0. 5 High BMI – 3. 4 Phys Inactive – 3. 2 Outdoor AP – 3. 3 High Sodium – 3. 1

Global Burden of Environmental Risks

Top 15 causes of ill-health in India (GBD/CRA 2010) HAP Total: ~1, 000 premature deaths annually Women and Girls Men and Boys:

Framing • Not called “indoor” because stove smoke enters atmosphere to become part of general outdoor air pollution (OAP) • HAP contributes about 12% to OAP globally, but much more in some countries • ~25% in India • Thus, part of the burden of disease due to OAP is attributable to cooking fuels in households

%PM 2. 5 from “Residential” Emissions from INTEX_B 25 -30% of primary particle pollution in India is from household fuels Source: Asian Emission Inventory for NASA INTEX_B 2006 (accessed 2010) 36 Chafe, 2010

Satellite-based ambient PM 2. 5 37 van Donkelaar et al, EHP 2010

Delhi Jan 14, 2013 24 h mean PM 2. 5: 316. 5 µg/m 3

Rural India 24 h mean PM 2. 5: 194. 7 µg/m 3

HAP mortality in India in 2010 ~10 lakh annual premature deaths -About one-quarter of global total -Secondhand cooksmoke ~1, 5 lakh more -About 10% of national mortality -About the same as tobacco -About 50% more than outdoor air pollution, which is about 600 k n. b. these estimtes can be compared but not added as there are overlaps

Summary • One of the top risk factors in the world for ill-health. • Biggest impact in adults --3 million premature deaths (two-thirds the DALYs) • Still important for children ~500, 000 deaths (onethird the DALYs) • One million total premature deaths in India • Biggest single risk factor of any kind for Indian women and girls • Important source of outdoor air pollution • Impact going down slowly because background health conditions improving • Actual number of people affected is not going down

What can be done?

Conceptual Indian Energy Ladder Very Low Income 200 million Low Income 400 million Middle Income 400 million High Income 200 million Electricity Decreasing Household Air Pollution Natural Gas Liquefied Petroleum Gas Biogas Kerosene Non-solid fuels Coal Wood Crop Waste Dung Solid Fuels Increasing Prosperity and Development

“Clean” “Dirty” Smith, et al. , 2005

Conceptual Indian Energy Ladder Very Low Income 200 million Low Income 400 million Middle Income 400 million High Income 200 million Decreasing Household Air Pollution Electricity Natural Gas Liquefied Petroleum Gas ? Biogas ? Kerosene Non-solid fuels Coal Wood Crop Waste Dung Solid Fuels Increasing Prosperity and Development

Integrated Exposure-response relationship Child pneumonia Risk Starting here Going here 3 WHO air quality annual guideline: 10µg/m 3 IT 1 : 35 µg/m 3 Leaves ~80% of burden untouched 2 Can we get here? PM 2. 5 Exposure 1 LPG 46 | Fan Rocket Public health and environment 25 125 ‘Chimney 200 O/Fire 300 µg/m 3

How close to clean enough? • New WHO Indoor Air Quality Guidelines will be about 0. 9 mg/min PM 2. 5 to protect ~80% of households at AQG-IT 1, 35 ug/m 3 • Cleanest biomass blower stove tested by the USEPA is about 8 times more polluting in lab. • But does not achieve this over time in the field • Need to push harder to find ways to make biomass burn cleanly in inexpensive devices

48 | Public health and environment

Secretary Vivek Rae • Doubled number of distributors for next year --20 million new people • Brought together heads of marketing for the 3 major oil companies to hear the lecture • Had his staff do the homework in advance • By adjusting requirements for distributors and a massive push • They are developing a plan to double LPG access in rural India in next five years • ~250 million people

Conceptual Indian Energy Ladder Very Low Income 200 million Low Income 400 million Middle Income 400 million High Income 200 million Electricity Decreasing Household Air Pollution Natural Gas ? Liquefied Petroleum Gas Biogas Kerosene Non-solid fuels Coal Wood Crop Waste Dung Solid Fuels Increasing Prosperity and Development

Story of Two States Gujarat: 1981 -2013 Kerala: 2005 -2013

In the 1980 s, the first link to air pollution science

First person in human history to have her exposure measured doing the oldest task in human history Kheda District, Gujarat, 1981

Field Team, Gujarat, 1981

Diwaliben, October 2013

Gujarati Villages since 1981 • • Reliable electricity Piped water Cell phones Satellite TV Pucca schools More pucca houses and roads In spite of 3 -5 “improved” biomass stove programs since the 1970 s – none now in existence • Chulhas in every house

Assessment of “Improved Stoves” Smith, et al. , 1983

Neighborhood Pollution in an Indian Village

Measurement of Neighborhood Pollution Smith, et al. , 1983

Kerala story • Like most of India, Kerala has had an electric peak in early evenings • Starting after mid decade, however, Kerala started experiencing a fast-growing morning peak as well • Reason: massive sales of induction cookstoves (ICs) were shifting demand • Experience is that once a woman is used to an IC, she does not want to go back.

Kerala Energy Management Centre, 2011

What is an induction cookstove? • Electric, yes, but • Entirely different technology from traditional electric stoves – high frequency magnetic field induces heat in pot alone • More efficient ~90% instead of ~60% • Faster cooking >1. 5 x • Finer and more responsive control of heat • Safer – surface is warm but does not burn or cause fires • Long-lived, easy to clean, sophisticated controls if desired

Induction Cooktop Market in India 2012 -2016 Published: March 2013 Infiniti Research Limited 35. 4% per year growth predicted: 2012 -2016 Factor of nearly five increase! - - Bajaj Electrical Ltd. - Compton Greaves Ltd. - Eurolux - Glen Appliances Pvt. Ltd. - Inalsa - Jaipan Industries Ltd. - Kenwood Ltd. - Khaitan Electrical Ltd - Morphy Richards - Panasonic Corp. - Phillips - Preethi Kitchen Appliances, Ltd. -Sunflame -TTK Prestige Ltd. -Usha International Ltd. -Westinghouse

Biggest share of Indian market Dozens of models Commercial sector growing rapidly also Not yet aimed to rural areas

Flying off the shelves in China

Considerations • Power reliable in major cities and 2 -3 full states and on the march nationally. • Cooking would add serious additional demand, but at great benefit, and not large compared to need in general – E. g. , for 100 M households, 20 GWe more during addition of needed 200+ in next decades • PV microgrids are proliferating in India to supply villages without power – Technically doable to provide sufficient power for induction cooking, but economics uncertain

Conceptual Indian Energy Ladder Decreasing Household Air Pollution Very Low Income 200 million Low Income 400 million ? Middle Income 400 million High Income 200 million Electricity Natural Gas Liquefied Petroleum Gas Biogas Non-solid fuels Wood Crop Waste Dung Solid Fuels Increasing Prosperity and Development

Questions for consideration Key Word! • What are the full benefits of reliable electricity? • Is there a leapfrog cooking technology that would – Be clean, efficient, and safe? – Sufficiently transformational to “sell itself” and rapidly take over the market? • How else to fill in the “empty quarter” of the energy ladder?

Conceptual Indian Energy Ladder Very Low Income 200 million Low Income 400 million Middle Income 400 million High Income 200 million Electricity Decreasing Household Air Pollution How do we help people move into this realm? Natural Gas Liquefied Petroleum Gas Biogas Kerosene Non-solid fuels Coal Wood Crop Waste Dung Solid Fuels Increasing Prosperity and Development

Millions India: What If? A Chulha Trap or a Clean Fuel Gap? 9% instead of 5. 5%/yr for 20 years

Bottom line: HAP – In addition to continuing to try to Make the available clean – Shouldn’t we also try harder to Make the clean available?

Bottom Line: OAP • Need to consider household combustion as one of the important sources • Need to measure in rural areas where there are many sources and people • Need to develop OAP management regions that are organized by air basin, not political boundaries such as cities

Many thanks Publications and presentations on website – easiest to just “google” Kirk R. Smith