World Report
Burning issues: tackling indoor air pollution
Indoor air pollution is gradually gaining more global attention as an important public health
issue. Talha Khan Burki reports on new initiatives to stem people’s exposure to household smoke.
“The best vaccine for pneumonia is
ensuring kids don’t breathe dirty air
at home”, asserts Maria Neira, director
of WHO’s Public Health and the
Environment Department, referring to
just one of the many health problems
arising from indoor air pollution.
According to WHO, 2 million people
die as a result of the smoke generated
by open fires or crude stoves within
their homes every year. Indoor air
pollution has been definitively linked
to lung cancer, chronic obstructive
pulmonary disease, and pneumonia,
the risk of which is doubled by
exposure to indoor smoke. More
than 900 000 people die from pneu-
monia caused by indoor air pollution
every year. 500 million house-
holds worldwide—roughly 3 billion
people—rely on solid fuels, such
as wood, animal dung, or coal, for
cooking and heating. These fuels are
usually burned in a rudimentary stove,
or in a traditional open fire. It need
not be a problem, at least in terms of
health. But only assuming the fuel is
completely combusted—wood must
be dry, and the stove must work
efficiently—and there is plenty of
ventilation, a spacious chimney, or a
sizeable window. In those places where
the use of solid fuels prevails, however,
these conditions rarely apply, and the
consequences can be severe.
Moreover, research into the subject
began fairly recently, and is far from
comprehensive. The pollutants
carried by indoor smoke can fill
households to levels well in excess
of WHO guidelines for indoor air
quality. Emerging evidence implicates
indoor smoke in the development
of tuberculosis, low birthweight and
perinatal mortality, asthma, cataracts,
and cardiovascular disease. Some of
this might well be taken into account
when WHO updates its global burden
www.thelancet.com Vol 377 May 7, 2011
of disease data later this year. Even
the numbers for lung cancer might be
underestimated: the percentage refers
only to those cases attributable to
the burning of coal—predominantly
in China—which doubles the risk of
lung cancer, but when biomass fuels
(wood, for instance) burn, they also
emit carcinogens.
“‘...despite the magnitude of this
growing problem...the health
impacts of exposure to indoor
air pollution have yet to
become a central focus of
research, development aid, and
policy making.’”
Additionally, when family mem-
bers—usually women—are despatched
to gather fuel, they risk snakebite,
broken bones, and backache. It can
take several hours to accumulate
adequate material for a household’s
needs, especially if the stove does not
work very well, time which cannot be
devoted to, say, education.
Those unable to forage enough
fuel from the local area can find
themselves spending up to a third of
their income on purchasing supplies
of charcoal. Even worse is the plight
of those in war-torn countries such as
the Democratic Republic of the Congo.
In these places, women gathering
bits of wood and agricultural residue
are in danger of sexual violence and
physical assault. Then there are the
stoves themselves, the more rickety
of these are prone to toppling over,
setting fire to the home or imparting
serious burns to those who dwell
therein. Those using open fires face
similar risks.
The smoke itself contains an array
of unpleasant chemicals—carbon
monoxide, methane, nitrous oxides,
benzene, sulphur and arsenic (from
coal), and formaldehyde, to name
a few. Cooks—commonly women,
perhaps with a youngster strapped
to their back—can be exposed to this
smoke for 3–7 h a day. Small particles—
diameters less than 2·5 μm—seem to
be particularly damaging; although
the exact mechanism by which they
prompt disease is not yet known.
All of which means that for high
mortality regions—places such as
Afghanistan, where 95% of the
population burn solid fuels; India,
which has about 400 000 deaths every
year as a result of such pollution, and
Africa, where pneumonia attributable
to cooking smoke kills 0·5 million
children younger than 5 years every
year—indoor air pollution is the fourth
most lethal killer.
Yet, “despite the magnitude of this
growing problem” notes WHO “the
health impacts of exposure to indoor
air pollution have yet to become a
central focus of research, development
aid, and policy making”. Some of this
is down to a lack of awareness—death
certificates simply cite “pneumonia”
or “bronchitis”, for example, with no
mention of what caused the sickness—
and the fact that this is a problem of
poverty. Then there is the lack of a
Corbis
About 500 million households worldwide burn solid fuels indoors every year
1559
 World Report
AFP/Getty Images
In war-torn countries, women who gather indoor firewood can be at risk of attack
substantial body of research outlining
the effect of indoor air pollution, and
the results yielded by interventions.
But the past year has had some
encouraging advances.
In September, 2010, the UN
Foundation launched the Global
Alliance for Clean Cook Stoves. “It’s
a very important development”,
explains Nigel Bruce from the
University of Liverpool, UK. “It’s a
recognition that this issue needed
global coordination.” The Alliance—a
public–private initiative—brings to-
gether partners from the range of
specialties across which the issue of
indoor air pollution sprawls. There
is public health, of course, but also
energy, international development,
female empowerment, climate
change, technology, and business.
“This is potentially one of the most
affordable public health issues”, Neira
told The Lancet, “because we can link
it to the energy and climate change
agenda—there’s an exciting mix
of benefits”.
“We’re focusing on key areas for
engagement to enable the scaling up
of clean cook stoves”, Leslie Cordes—
interim executive director of the
Global Alliance—told The Lancet.
The Alliance has set up nine working
groups to examine various aspects of
the problem—one tackles technology
and fuels, another climate research,
and another focuses on carbon
finance. The health group—led by
1560
Nigel Bruce—will identify those areas
of research necessary to provide a
clearer idea of the damage wrought
by indoor pollution. The groups will
report back later in the year, outlining
priorities and items for early action.
The Alliance has set a target of
100 million clean and efficient stoves
to be in use by 2020, covering 20%
of the affected population. The
long-term aim is universal access to
such stoves.
Needless to say, a crucial component
is raising awareness. In this regard,
the Alliance seems to have made
a good start, with Hillary Clinton
providing high-profile support, the
US Government offering US$50 million
over the next 5 years and partners such
as Shell and Morgan Stanley pledging
their support.
There are all kinds of issues at
play. In some countries, half of fuel
is used to boil water for purification
purposes; hence, improvements to
water infrastructure would alleviate
the problem. Consumers can be
encouraged to make small changes—
placing lids on pans and drying
fuel before use. Building chimneys,
cooking outside, and keeping children
away from fires would ease the
health burden on individual families,
although this will not ameliorate the
climate effect or harmful emissions to
the local community.
The real benefits will be seen by
switching to cleaner fuels and cleaner
stoves. Improved stoves—those fitted
with fans, for example—combust fuel
more efficiently, have lower emissions,
and require shorter cooking times.
Electricity, solar power, or liquid
petroleum gas issue none of the
noxious pollutants associated with
coal and wood. Cordes points out that
countries like Senegal have developed
the infrastructure for rolling out the
use of clean fuels like propane but in
most places solid fuels are the only
viable option for the population. In
which case, encouraging innovative
designs to ensure that stoves combust
these fuels effectively is likely to form
the cornerstone of the Alliance’s
strategy. “There’s emerging evidence
to suggest that when stoves are
working well, they are almost as
efficient as burning clean fuels”, says
Bruce. Indeed, laboratory studies of
some advanced stoves found that the
harmful emissions associated with
solid fuels were reduced by 98%.
Once the fuels and technology
necessary to reduce emissions have
been identified, and the potential
health benefits proven—and this
requires randomised trials and
plenty of high-quality evidence—
questions of accessibility arise. The
Alliance has stated its intention to
“develop a thriving global clean cook
stove industry”, and is examining
financing options that will ensure
that those who need the stoves can
acquire them.
Finally, there is the issue of donors.
The Alliance thinks it will require
$250 million, although the picture
will become clearer once the working
groups return their findings. Cordes
draws comparisons with the fight
against malaria. “We’re off to the
same bold kind of start, and we need
the same kind of comprehensive
framework and solid foundation.”
Neira is optimistic this can be done.
She points out that the direct health
benefits of clean stoves are a strong
incentive for people to change their
behaviour. “We agree that we are
missing some positive arguments on
the climate change agenda”, she says.
“The health argument is very powerful
and we are not using it enough”.
If pilot projects for clean stoves, such
as the national one that is underway in
Peru, can be shown to pay dividends,
this would be a powerful draw for
donors from all sectors. After all, this
is a topic that cuts across several of
the Millennium Development Goals.
“This is real public health—primary
prevention”, concludes Neira. “And it
could be the public health legacy of
the 21st century.”
Talha Khan Burki
www.thelancet.com Vol 377 May 7, 2011