health and biomass cookfuels

Health and Biomass Cookfuels

Kirk R. Smith, MPH, PhD

Professor of Global Environmental Health

University of California, Berkeley

Fulbright-Nehru Distinguished Chair

IIT-Delhi – 2013/14

WHO SEAR Meeting

Sri Lanka, March 20, 2014

Important Paper Published!

Conclusions

• A high incidence of cor pulmonale was noted in Delhi in

an entirely nonindustrial population. [Even though

smoking much more] (m)en were only slightly more

affected than women and there was a preponderance of

rural over urban cases.

• The patients were comparatively young ,…. And presented

with very florid signs of congestive heart failure on their

first visit to hospital.

Etiology Speculation

• In the rural and semirural areas, the houses were mostly 1-

or 2-roomed mud huts in which several members of the

family lived together. There was no outlet for smoke with

the result that the house was filled with smoke when the

family meal was cooked.

• The fuel used almost universally is cow dung which is

dried into flat cakes for this purpose. Probably from

inadequate combustion, it emits a lot of smoke.

Did you notice this paper when it

came out?

• Probably not, since it was 54 years ago!

• Circulation. 1959; 20:343-352

• Pioneering study, excellently done, and

published a major journal, but

• Little notice and no serious work initiated

except a few sporadic case accounts for the

next 20+ years

• Next serious health publications by Dr.

M,R, Pandey in Nepal in the early 1980s

Road Map

• Brief summary of health evidence for the

region using the environmental health

pathway

• And history of biomass use in the region

• What has been done to deal with the issue,

which is mainly improved biomass stoves

• And what is possible outside the

mainstream approach: clean fuels

The Environmental Health Pathway

The three major solid fuels

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

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

South East Asia

Africa

Western Pacific

World

Eastern Mediterranean

Americas

Europe

83

82

48

66

53

27

22

77

61

46

41

35

14

7

62

87

82

95

60

42

38

02

04

06

08

01

00

Pe

rcen

tage

of po

pu

lation

usin

g s

olid

fue

ls (

%)

1980 1990 2000 2010year

Percent of households cooking with solid fuels by region

Bonjour et al., GBD-2010

0500

1,0

00

1,5

00

2,0

00

Popula

tion (

mill

ions)

AfricaAmericas

Eastern MediterraneanEurope

South East Asia Western Pacific

1980

1990

2000

2010

1980

1990

2000

2010

1980

1990

2000

2010

1980

1990

2000

2010

1980

1990

2000

2010

1980

1990

2000

2010

Primarily using solid fuels Primarily using non-solid fuels

02,0

00

4,0

00

6,0

00

8,0

00

World

1980

1990

2000

2010

Total Population Cooking with Solid FuelsBonjour et al., CRA-2010

SEAR Households Cooking with Solid Fuel

1990 2010

Timor-Leste 96% (82, 100) 92% (79, 100)

Myanmar 98 (89, 100) 92 (79, 100)

DPR of Korea 98 (85, 100) 91 (78, 100)

Bangladesh 91 (78, 100) 91 (78, 100)

Nepal 74 (61, 88) 82 (69, 95)

Sri Lanka 89 (76, 100) 75 (62, 88)

India 87 (73, 99) 58 (45, 71)

Indonesia 67 (53, 81) 55 (42, 68)

Bhutan 78 (65, 93) 40 (27, 53)

Thailand 63 (50, 77) 26 (13, 39)

Maldives 64 (15, 78) 8 (0, 22)

The Environmental Health Pathway

Or, since wood is mainly just carbon, hydrogen, and oxygen,

doesn’t it just change to CO2 and H2O when it is combined

with oxygen (burned)?

Reason: the combustion efficiency is far less than 100%

Woodsmoke is natural – how can it hurt you?

Toxic Pollutants in Biomass Fuel 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

The Environmental Health Pathway

Health-Damaging Air Pollutants From

Typical Wood-fired Cookstove.

10 mg/m3

Carbon Monoxide:150 mg/m3

0.1 mg/m3

Particles3.3 mg/m3

0.002 mg/m3

Benzene0.8 mg/m3

0.0003 mg/m3

1,3-Butadiene0.15 mg/m3

0.1 mg/m3

Formaldehyde0.7 mg/m3

Wood: 1.0 kgPer Hour

in 15 ACH40 m3 kitchen

Typical Health-based

Standards Typical Indoor

Concentrations

Best single indicator 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

Kheda District,

Gujarat, 1981

Emissions and

concentrations,

yes, but

what about

exposures?~5000 ug/m3

during cooking

>500 ug/m3 24-

hour

How much PM2.5 is unhealthy?

• WHO Air Quality Guidelines

– 10 ug/m3 annual average

– No public microenvironment, indoor or

outdoor, should be more than 35 ug/m3

• National standards – annual outdoors

– USA: 12 ug/m3

– China: 35 ug/m3

– India: 40 ug/m3

CRA published along with the other

GBD papers on Dec 14, 2012

in The Lancet

Annual Review of Public Health,

vol 35, 2014, to be published in March

Definitions

• Global Burden of

Disease (GBD)

• Envelope of death,

illness, and injury by

age, sex, and region.

• Coherent – no overlap

– one death has one

cause

• Comparative Risk

Assessment (CRA)

• The amount of the

GBD due to a

particular risk

factor, e.g. smoking

• Not coherent –

deaths can be

prevented by

several means

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

GBD: Lost Life Years for India

1990 2010

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 PM2.5

in India

Solid-fuel using

households

Balakrishnan et al.

2013

Diseases for which we have

epidemiological studies ALRI/

Pneumonia

COPD

Lung cancer(coal)

Cataracts

Lung cancer(biomass)

These diseases are included in the

2010 Comparative Risk Assessment (released in 2012)

Ischemic

heart disease

Stroke

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

Cross-

sectional

3 1.49 1.21, 1.85

All 26 1.78 1.45, 2.18

Dherani et al Bull WHO (2008)

Top 15 causes of ill-health in India (GBD/CRA 2010)

HAP Total: ~1,000,000 premature deaths annually

Women and Girls Men and Boys:

CRA results from

GBD 2010:

Ranking Household Air

Pollution

(HAP) across regions

In country ranking for HAP • Highest attributable disease burdens from

HAP are in South Asia and Africa

• HAP also among the highest ranking

risk factors* in many countries

*among those examined

Lim et al, Lancet 2012

GBD-2010

Framing.

• Not called “indoor” because stove smoke

enters atmosphere to become part of general

outdoor air pollution (OAP)

• HAP contributes about 13% 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

Satellite-based ambient PM2.5

van Donkelaar et al, EHP 201045

%PM2.5 from “Residential” Emissions from INTEX_B

46Source: Asian Emission Inventory for NASA INTEX_B 2006 (accessed 2010) Chafe, 2010

25-30% of

primary

particle

pollution in

India is from

household

fuels

C. Child

ALRI

17,139,800

DALYs

B. Female

IHD

9,092,910

DALYs

A. Male IHD:

17,102,900

DALYs

India:

IHD and

child ALRI

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 (one-

third the DALYs)

• Biggest single risk factor of any kind for South

Asian 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?

Indian Population in 2010

??

Heart Disease and Combustion Particle Doses

HAP

Zone

From “Mind the Gap,”

Smith/Peel, 2010 and Pope

et al., 2009

Integrated Exposure-Response:

Ischaemic Heart Disease

HAP

Zone

CRA,

2011Outdoor Air

Pollution

Secondhand

Tobacco Smoke

Smokers

Stroke

Ischaemic Heart Disease

ALRI

ug/m3 annual average PM2.5

COPDLung Cancer

Public health and environment 55555555|

Exposure-response relationship

Risk

PM2.5 Exposure

O/Fire‘ChimneyRocketLPG

3

1

125 200 300 µg/m325

Fan

2

WHO air quality

annual

guideline:

10µg/m3

IT1 : 35 µg/m3

Child pneumonia

Leaves ~80% of

burden

untouched

Can we get

here?

How close to clean enough?

• New WHO Indoor Air Quality Guidelines

will be about 0.9 mg/min PM2.5 to protect

~80% of households at AQG-IT1, 35 ug/m3

• 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

The Energy Ladder: Relative Pollutant

Emissions Per Meal

0.1

1.0

10.0

100.0

CO Hydrocarbons PM

CO 0.1 1.0 3 19 22 60 64

Hydrocarbons 0.3 1.0 4.2 17 18 32 115

PM 2.5 1.0 1.3 26 30 124 63

Biogas LPG Kerosene Wood RootsCrop

ResiduesDung

Smith, et al., 2005

“Clean” “Dirty”

?

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?

In the 1980s, the first link to air

pollution science

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 1970s – none now in

existence

• Chulhas in every house

Smith, et al., 1983

Assessment of “Improved Stoves”

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 >1.5x

• Safer – surface is warm but does not burn or

cause fires

• Long-lived, easy to clean, sophisticated

controls if desired

- - 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

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!

Flying off the shelves in China

?

Increasing Prosperity and Development

De

cre

asi

ng

Ho

use

ho

ld A

ir P

oll

uti

on

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

?

Bottom line

–In addition to continuing to try to

Make the available clean–Shouldn’t the health community

also try harder to help

Make the clean available?

India: What If?Millions

9% instead

of 5.5%/yr

for 20 years

A Chulha Trap

or a

Clean Fuel Gap?

Costs are Large

• 100 million households

• @ 12,000 INR/year LPG cost

• Including stove amortization

• Is 120k crore

• A big number!

• But far smaller than the benefits

Benefits

• Indian per capita income per DALY

saved—reduced by 50% due to lags

• One work day (10 hours) a week saved

labor at rural employment scheme wage

(100 INR/day)

• Outdoor particle air pollution reduction at 1

lakh per ton

• Carbon market at 600 INR/ton carbon

Economics: Benefits

Benefits:

$50 billion

for 100

million

households

Costs:

20 billion US

for 100

million

households

Challenge

• How to balance the costs with the benefits?

• Which accrue to different groups?

• And do so in a politically and economically

sustainable model?

• Lessons to learn from other health

interventions?

• Approaches to link energy sector to health

sector?

How do we help

people move into

this realm?

HAP Interventions

• Move aggressively to ban coal and kerosene

in household use

• Aggressively expand access to LPG and

other clean fuels

• Expand and stabilize household electricity

access – pick off cooking tasks with electric

appliances

• Develop and deploy very clean biomass

stoves – none yet available at scale,

however

SEAR Target

• 50% reduction in the proportion of

households using solid fuels by 2025

• Achievable?

http://www.indiaenergy.gov.in/

Energy Scenarios Website Launched

By Planning Commission (March 2014)

2012 2027-base 2027-aspirational

LPG 32% 33% 41%

Electricity

0.10% 1% 7%

PNG 0.3% 6% 16%

Biomass 64% 55% 32%

Coal 1.4% 1% 1%

Kerosene 2.5% 2% 3%

Biogas 0.3% 1% 1%

Total 100% 100% 100%

India’s Planning Commission Trajectory 4

(aspirational) for Household Cooking

Meets SEAR Target!!

Bottom line for SEAR• HAP target is probably achievable in India.

• But will take much effort to do so

• WHO should push the agencies – focus on

potential for major health improvement

• But this will still leave ~50% of rural

households with dirty fuels in 2025

• Perhaps something even more ambitious

might be considered?

UN SE4All

• The UN’s Sustainable Energy for All

Initiative is even more ambitious

• Which is 95% of households using modern

cooking fuels by 2030

EHP, 2007

EHP, 2011

EHP, 2011

Many thanks

Publications and

presentations on website

– easiest to just

“google” Kirk R. Smith

Questions for consideration

• 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

New Partners in India

• Ministry of Health and Family Welfare

– First MOH in world to take on reducing HAP

as a major goal. First meeting of steering

committee next week to design program

• Ministry of Petroleum/Natural Gas

– MOP/NG considering expansion of LPG as a

health priority, potentially in conjunction with

MOH. First meeting next week

• Ministry of Power:

– working to bring them on board through the

Bureau of Energy Efficiency

Not all diseases included

• Many with evidence not included yet

– Low birth weight

– TB

– Other cancers – cervical, upper respiratory, etc

– Cognitive effects

– Pneumonia in adults

• Can expect that HAP effects, over time, will

be found for nearly all the many dozen

diseases found for smoking.

• But at lower risk levels

Biggest impacts from smoking

• Lung cancer

• Heart disease of various kinds

• Chronic obstructive lung disease

• Stroke

• Same adult impacts as HAP

What other cancers from smoking?

• “Traditional” smoking cancers: oral cavity,

pharynx, larynx, oesophagus, pancreas,

urinary bladder, and renal pelvis

• Newly confirmed cancers: nasal, sinus,

nasopharynx, stomach, liver, kidney, uterine

cervix, oesophagus, and leukaemia

Review of Epi Evidence: Lung Cancer, 2004

Birth defects due to smoking in

pregnancy include

• cleft lips and cleft palates,

• neural tube defects

• shortened or missing arms and legs,

• gastrointestinal abnormalities,

• being born with their intestines hanging outside the body

• heart defects

• baby boys born with undescended testes.

Human Reproduction Update, 2009

Infectious disease and smoking

• pneumonia

• TB

• meningococcal disease

• otitis media

• influenza

Archives of Internal Medicine, 2004

Other impacts of smoking

• preterm delivery,

• stillbirth,

• low birth weight, and

• sudden infant death syndrome (SIDS)

• lower bone density in older women.

• cataracts

• IQ and cognitive impacts (SHS)

CDC, 2012

Bottom Lines

• We understand the risks of combustion particles not only from a large number of studies in households, but also from studies of outdoor air pollution, secondhand smoke, and active smoking.

• Over time, we can expect that nearly every effect found in smokers will be found from household smoke, but a lower risk levels.

• We no longer refer to it as “indoor” air pollution because the exposures occur not only inside, but around the house, down the street, and indeed regionally – “secondhand cook smoke”

• Cannot solve outdoor air pollution problems in South Asia and other regions without reducing substantially household pollution.

Just because we know it’s a risk,

does not mean we know how to fix it

• 1964: Surgeon General’s Report but Framework

Convention on Tobacco Control was 2005 and not

all countries yet signed up and impacts growing

• ~1900: Mosquito-born disease cause established,

but still 1.4 million die of malaria today

• ~1890: causation of health risk from human waste

in drinking water firmly established: still today

one-third of world population without adequate

sanitation/water

Why is it so hard?

• What we know works, gas and electricity, is not “affordable” by the poor.

• Other technologies difficult and less effective and no drug companies to pay for their advancement

• Particularly difficult because of the high component of behavioral change required

• Yet, the fact that 60% of the world is now protected, gives us reason to think we can protect the other 40%

• Will take a new type of research and development, however, both sophisticated and rigorous, to develop and test the interventions in ways to convince the health community

• And completely different levels of funding, for example the kinds of large intervention trials done for vaccines, water/sanitation, bednets, etc. – $10s of millions each

If it doesn’t take fifty years,

it isn’t worth doing.*

• Let us hope, however, that in 2030 we are

not like poor water/sanitation today, i.e.,

120 years from when causation was

accepted by most people, but still killing

millions annually.

*Attributed to Albert Einstein

New WHO AQGs Will Play an

Important Role in this Future

• By indicating in an authoritative way what is clean enough to protect health.

• For example, it will help the new Indian National Cookstove Initiative to operationalize its far-sighted vision for all Indian households:

• “Our aim is to achieve the quality of energy services from cookstoves comparable to that from other clean energy sources such as LPG.”

– Ministry of New and Renewable Energy, 2009