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India takes steps to curb air pollution India’s air pollution problem needs to be tackled systematically, taking an all-of-government approach, to reduce the huge burden of associated ill-health. Patralekha Chatterjee reports.

Nine-year-old Neil suffers from asthma. In India, an estimated 1.5 million kerosene and diesel – industrial plants When he is sick – with wheezing, breath- people died from the effects of air pol- that burn fossil fuels and open burning ing problems or sleeplessness – he lution in 2012, according to WHO data. of waste. misses many of his favourite activities. Globally, air pollution – both indoor “We see the acute effects of air pol- “He’d like to be out playing more, and outdoor – caused nearly 7 million lution, especially in young children and doing the things children love,” says his deaths, or 11.6% of deaths in 2012, mak- the elderly, and in people suffering from mother, lawyer Leena Menghaney, who ing it the world’s largest single environ- chronic obstructive pulmonary disease also has asthma. “Some months he misses mental health risk, according to World and heart disease,” says Dr Randeep as much as seven or eight days of school.” health statistics 2016. Guleria, head of the Department of The Menghaney family lives in the About 98% of cities in low- and Pulmonology and Sleep Disorders at the middle-class neighbourhood of Indira- middle-income countries with more All India Institute of Medical Sciences puram in Ghaziabad, a city of 2.3 million than 100 000 inhabitants do not meet in Delhi. inhabitants that flanks the Indian capital norms set out in the World Health Orga- Chronic obstructive pulmonary of Delhi. nization’s (WHO) air quality guidelines, disease is a set of lung diseases that Air pollution is a major risk factor for according to WHO’s global urban air prevent normal breathing and can, heart disease, stroke, chronic obstructive quality database. eventually, be fatal. pulmonary disease (umbrella term for An increasing number of Indian “Exposure to high levels of pollut- several progressive lung diseases includ- cities are now measuring and reporting ants affects lung capacity and predis- ing emphysema) and lung cancer, and their air pollution levels to WHO and poses children to respiratory problems increases the risks for acute respiratory the number of such cities, globally, has in later life,” Guleria says, adding: infections and exacerbates asthma. nearly doubled to 3000 in 103 countries “When the air pollution levels go up, With the economy booming in since 2014. the patients’ underlying disease worsens, many of India’s cities since the turn of Reducing the deaths and ill-health and emergency visits to hospital and this century the number of road vehicles from air pollution is one of the targets the need for medication go up dramati- and dusty construction sites have mul- of sustainable development goal three cally too.” tiplied, and outdoor air pollution has and, last year at the United Nations Last year, the Steering Committee become a major health hazard and a climate change conference in Paris, gov- on Air Pollution and Health-Related major killer. ernments recognized the need to curb Issues, set up by India’s federal Ministry This adds to the already large burden emissions to reduce global warming. of Health and Family Welfare, submitted of ill-health caused by household air pol- The sources of India’s air pollu- a report to the federal government on lution from the use of solid fuels for cook- tion are many: indoor cook stoves, the devastating effects of air pollution ing in the world’s second most populous road traffic – including the ubiquitous on people’s health in India. country of some 1.3 billion people. auto-rickshaws that use a toxic mix of It proposed measures that com- mittee members argued would provide the largest reduction in exposure to air pollution and, as a result, improvements in people’s health. For K Srinath Reddy, who co- chaired the committee, the report is important because it highlights the contribution of air pollution to the rise in cardiovascular diseases in his country. “It was the first time that an official report in India examined air pollution as a health rather than an environmental issue,” says Reddy, who is also the presi- dent of the Public Health Foundation of India. Since the sources of air pollution were so diverse, the committee pro- posed “a concerted and coordinated effort across the government” with the Courtesy of Dinesh Mohan involvement of a dozen other ministries, including finance, agriculture, rural de- Traffic congestion in Delhi, India. velopment, power and transport.

Bull World Health Organ 2016;94:487–488 | doi: http://dx.doi.org/10.2471/BLT.16.020716 487 News

Proposals included switching to natural gas vehicles helped temporar- structural solutions such as having clean energy sources for cook stoves, ily in the 1990s, but Delhi still ranks proper regulatory bodies and proper public transport and industry, as well among the world’s most polluted cit- monitoring,” Ramanathan says. as measures to reduce road traffic by ies, just like Los Angeles in the 1960s,” Perhaps India’s capital city has the raising fuel taxes and parking fees, levy- Ramanathan says. advantage of having many nongovern- ing congestion charges, and creating For Ramanathan, three systematic mental organizations (NGO) campaign- vehicle-free zones and cycle paths. solutions are required for maximum im- ing for better health, a vocal media “The tragedy is that there are per- pact. One, replace existing cook stoves which reports extensively on health fectly feasible solutions to the air pollu- with clean cook stoves, two, reduce pol- problems caused by air pollution, and tion problem, but these are surrounded lution from diesel transport and, three, a supreme court that recently banned by myths,” says Veerabhadran Ram- restrict open burning of biomass and the registration of diesel vehicles in the anathan, professor of Atmospheric and fossil fuels. capital. Climate Sciences at the Scripps Institu- Meanwhile, liquid petroleum gas More has been done in Delhi than tion of Oceanography at the University and electricity, along with biogas and elsewhere in India to tackle the problem. of California, San Diego. ethanol are some of the clean energy The auto-rickshaws run on compressed For example the myth that tackling alternatives. natural gas and, earlier this year, the air pollution is expensive. “In California “India could cut its total air pollu- state government piloted a congestion we found that if you clean up the air, tion by one third overnight by giving scheme to reduce the volume of traffic, each dollar invested in air pollution clean cooking stoves to all its villagers,” in which vehicles with odd and even returned nearly US$ 30 to [the state of] Ramanathan says. “When California number plates could enter the city on California. wanted to pass its air pollution laws, alternate days. “There were huge health benefits there was tremendous resistance from Other recent measures in the capital along with a large increase in new jobs industry. include tighter vehicle emissions’ norms, and thus in people’s well-being,” Ram- “They said ‘it will destroy our higher penalties for burning rubbish and anathan says. economy, no one will come to Califor- better control of road dust. In 2013, Ramanathan teamed up nia’, and the then president of the United But while Delhi’s air quality has im- with the Air Resources Board, the States [of America] Lyndon B Johnson proved slightly, according to the WHO clean air agency in California, and the had to give California special permis- air quality database, air quality levels in Energy and Resources Institute, an sion to enact stricter laws than the rest smaller cities, such as Ghaziabad, where Indian research agency, to initiate the of the country through congressional the Menghaney family live, have severely India–California Air Pollution Mitiga- approval,” he says. deteriorated in recent years, according tion Program. “When trucks from outside Califor- to Indian NGO, the Centre for Science They compiled a report and issued nia came to California, they had to abide and Environment. 12 recommendations on how to reduce by California’s laws. Everything I see in Public health advocates and clean air pollution from the transportation Delhi today happened in California in air campaigners are keen to see action sector in India. The findings called for a the 1960s. beyond Delhi. systematic approach across the country. “That is why we – in the India–Cali- Recently the Indian government “You can’t tackle air pollution by fornia Air Pollution Mitigation Program took some steps in this direction com- just cleaning up locally. Delhi is a per- – looked at both the technical solutions, mitting to a 50% reduction in house- fect example: switching to compressed such as cleaning up your cars, and also holds using solid fuel for cooking and, last December, removing subsidies for polluting cooking gas to improve access to clean fuel for household cooking. India recently included an addi- tional target on reducing air pollution to the nine targets set out in WHO’s Global action plan for the prevention and control of NCDs 2013–2020 in its national NCDs strategy. For Dr Kalpana Balakrishnan who heads the WHO Collaborating Centre for Occupational and Environmental Health at the Center for Advanced Research on Environmental Health in Chennai, such moves are thanks to a growing recognition of the double burden of outdoor and household air pollution for urban and rural popula- tions. WHO /Diego Rodriguez “Recent efforts are an important first step in this direction,” says Bal- Open burning in a street in Mumbai, India. akrishnan. ■

488 Bull World Health Organ 2016;94:487–488| doi: http://dx.doi.org/10.2471/BLT.16.020716