Household Solid Fuel Pollution and Health: An Update December 15, 2006 Yogyakarta

1. Household Solid Fuel Pollution and Health: An UpdateDecember 15, 2006 Yogyakarta Kirk R. SmithUniversity of California, Berkeley

2. Toxic Tsunami threatening planet’s health By OUR CORRESPONDENT New evidence indicates that a massive wave of toxic material may soon be affecting populations all over the world because of faulty technology.

3. It will wash across the countryside exposing the poorest half of humanity to a toxic soup containing • Dozens of poisonous organic chemicals known to be mutagens, immune system suppressants, severe irritants, blood poisons, inflammation agents, central nervous system depressants, cilia toxins, endocrine disrupters, or neurotoxins. • Several other chemicals firmly established as human carcinogens. • Other toxic inorganic chemicals known to cause asphyxiation, stillbirth, infant death, heart disease, and severe acute and chronic lung disease.

4. Other aspects of this Toxic Tsunami • It will be the result of a process that pours this toxic soup directly into 100s of millions homes every day; all year; every year. • It will expose families to toxic levels much higher those of people living on top of toxic waste dumps, working in most heavy industries, or residing in the dirtiest cities • These toxic levels will be tens or hundreds of times the levels set by international and national organizations to protect health • Insidiously, it will target women and young children in the poorest households

5. What might be the health consequences if this happens? • A vast epidemic of a respiratory illness that kills faster than SARS or Avian Flu – initiation to death in 2 days in some cases. • So fast, that trying to apply medical care is often hopeless. • Estimates are that soon it would be killing at the rate of at least one thousand a day, perhaps as many as a million a year • This would be equivalent to some 1000 SARS epidemics per year, and would occur year in and year out, with no end in sight.

6. Will there bea massive emergency meeting in Geneva of international agencies and donors with unlimited authority and funds to take action? The answer is no – indeed nothing will be done.

7. Toxic Tsunami threatening planet’s health By OUR CORRESPONDENT New evidence indicates that a massive wave of toxic material may soon be affecting populations all over the world because of faulty technology.

8. Household Solid Fuel Burning • Toxic, yes, but no tsunami because it is already here • Summary of current risk estimates • Recent research results from Guatemala • Ongoing research in South Asia

9. World Energy – 2001 World Energy Assessment, 2004

10. Woodsmoke is natural – how can it hurt you? 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%

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

12. Toxic Pollutants in Biomass Fuel Smokefrom 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()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

13. First person in human history to have her exposure measured doing one of the oldest tasks in human history Exposures seem to be high in a large vulnerable population. But what are the health effects? Kheda District, Gujarat, India 1981

14. How Much Global Ill-Health can be Attributed to Household Indoor Air Pollution? • What do we mean by “ill-health?” • What do we mean by “attributed?” • What do we mean by “indoor air pollution”

15. What do we mean by ill-health? • Lost life-years, which accounts for age of premature death and duration of illness • DALYs = Disability adjusted life years lost

16. What do we mean by “indoor air pollution” • Too few measurements worldwide to determine exposures by measurements • Can use solid fuel use as a proxy as widespread surveys available • Makes physical sense because of larger pollutant emissions • There is a growing epidemiologic literature showing health effects

17. “Clean” “Dirty” Smith, et al., 2005

18. National Household Use of Biomass and Coal in 2000

19. Attributable Risk? • The amount of ill-health that would not exist today if the exposure to the risk factor had not occurred in the past. • Assumes all other risk factors remain constant • Need to compare to some feasible alternative such as clean fuels (no cooking is not feasible) • Calculated as if all other risk factors remain the same and thus addition of attributable risks must be done with care

20. Attributable Fractions do not add to 100% Underweight 40% Poor Housing? 40%? Lack of breastfeeding 10% Household solid-fuel burning? 2-3 million ALRI Deaths In Children Under 5 Diarrhea 20% Measles 10% Outdoor pollution? Zn Deficiency 15% Poor case-management 50%? No vaccines 25-50% Genetic Susceptibility ? Rough estimates only

21. Published in late 2004, 2 vols, ~2500 pp Available on World Health Organization website http://www.who.int/publications/cra/en/

22. Only two qualified with sufficient evidence to be included in the WHO CRA Chronic obstructive lung disease Interstitial lung disease Diseases for which we have some epidemiological studies ALRI/ Pneumonia (meningitis) Cancer (lung, NP, cervical, aero-digestive) Asthma Low birth weight Blindness (cataracts, trachoma) Tuberculosis Early infant death Heart disease? Cognitive Impairment?

23. 4.9 million deaths/y 1.6 million deaths/y Other Environmental Risk Factors World Health Reports – 2002, 2001

24. 420,000 deaths/y 743,000 deaths/y

25. ALRI associated with use of solid fuels: analysis of ~10 observational studies Smith et al in WHO, Comparative quantification of health risks, 2004

26. History of a Research Project • ~1980: early studies of health effects in Nepal and elsewhere • 1981: first measurements of pollution levels in India • 1984: international meeting to decide on needed research • Chose randomized control trial (RCT) of ALRI • 1986-89: unfunded proposals to do RCT in Nepal • 1990: WHO establishes committee to find best sites • 1992: Guatemala chosen • 1991-1999: Pilot studies to establish data needed for proposal • 1996-1999: unfunded proposals • 2001: NIH funds first randomized control trial for air pollution in highland Guatemala • 2002-2005: fieldwork completed • 2006: first results being published • 22 years from deciding to conduct RCT to results!

27. ‘Plancha’ chimney wood stove First Randomized Control Trial inAir Pollution History Highland Guatemala Traditional 3-stone open fire

28. Randomize Keep open fire Plancha • Follow up till aged 18 months • Surveillance for ALRI, diarrhoea, &c • Detailed exposure monitoring Years 1-3 Compare incidence and exposure in 2 groups Plancha offered to ‘controls’ Years 3-4 Overview of study design • 530 eligible households: open fire, woman pregnant or child less than 4 months • Baseline survey and exposure assessment Year 1 5500 Households total

29. Results (in brief) No significant effect for all pneumonia But an important effect for serious pneumonia MD-diagnosed severe pneumonia – bacterial, hypoxic Interpretation: Young children in households cooking with open woodfires have about two-thirds (1/0.59) more serious pneumonia than those with well-operating improved woodstoves with chimneys

30. 90% de reducción 48-h ug/m3 PM2.5 PM1.0

31. Tubito Tubito

32. ~ 50% reduction in child exposures

33. Household Pollution

34. Lack of clean fuel 30%? Household solid-fuel burning? Lack of chimneys 20%? Attributable Fractions do not add to 100% Underweight 40% Poor Housing? 40%? Lack of breastfeeding 10% 2-3 million ALRI Deaths In Children Under 5 Diarrhea 20% Measles 10% Outdoor air pollution? Zn Deficiency 15% Poor case-management 50%? No vaccines 25-50% Genetic Susceptibility ? Rough estimates only

35. Chronic obstructive lung disease Interstitial lung disease Diseases for which we have some epidemiological studies ALRI/ Pneumonia (meningitis) Cancer (lung, NP, cervical, aero-digestive) Asthma Low birth weight Blindness (cataracts, trachoma) Tuberculosis Early infant death Heart disease? Cognitive Impairment?

36. Guatemala Study of Blood Pressure in Women (mean age of 52) Effect of the improved stove on systolic BP Randomized: -3.7 mm Before and After: -3.1 mm Source: McCracken et al., 2006

37. TB: A Global Problem • Disease incidence: 8 million new cases of each year • 1.8 million in India • 300 thousand in Bangladesh • 50 thousand in Nepal • Mortality: about 2 million per year • 600 thousand in South Asia • 15 thousand in Nepal • Chief outcome of HIV in the world • Treatment is problematic, particularly as multi-drug resistant strains that are appearing

38. Association between current solid fuel use relative to cleaner burning fuel or electricity and risk of tuberculosis

39. Multi-center South Asian TB/IAP case-control studiesFunded by Fogarty International Center • Hypothesis: Exposure to indoor smoke from solid cooking fuel increases the risk of clinically confirmed active TB • Simultaneous studies in Chandigarh, Chennai, Lucknow, and Pokhara • Care is being taken by the teams to use common protocols so it will be possible to combine data for increased statistical power • All groups finished data collection by early 2007

40. Thank you