Journal of Energy in Southern Africa 20(1): 4–13 DOI: http://dx.doi.org/10.17159/2413-3051/2009/v20i1a3296 Household energy, indoor air pollution and child respiratory health in South Africa Brendon Barnes School of Human and Community Development, University of the Witwatersrand; and Environment and Health Research Unit, Medical Research Council of South Africa Angela Mathee Environment and Health Research Unit, Medical Research Council of South Africa Elizabeth Thomas Centre for Health Policy, School of Public Health, University of the Witwatersrand; and Medical Research Council of South Africa Nigel Bruce Department of Public Health, University of Liverpool, England Abstract Introduction Indoor air pollution due to the indoor burning of Over half the global population (3 billion people) polluting fuels has been associated with Acute are reliant on solid biomass fuels such as wood, Lower Respiratory Infections (ALRI) amongst chil- coal, crop residues and animal dung for their dren less than five years old. This paper reviews evi- domestic energy requirements (The World Rsources dence of the association between household energy, Institute, 1998; Ezzati et al., 2004). When burned indoor air pollution and child ALRI in South Africa. indoors in open fires or rudimentary appliances, the Studies show evidence consistent with the interna- incomplete combustion of solid biomass fuels tional literature with the likelihood of ALRI between release high concentrations of toxic pollutants such 2 and 4 amongst children living in households using as particulate matter (PM), carbon monoxide (CO), polluting fuels compared to households using elec- oxides of nitrogen, sulphur dioxide (SO2) and tricity. Indoor air pollution is responsible for the volatile organic compounds into the living environ- deaths of up to 1 400 children annually. Interven- ment (Smith, 1987; Bruce et al., 2000). In addition tions have demonstrated 46 – 97% lower pollution to environmental concerns such as deforestation concentrations compared to open fires. However, and greenhouse emissions, the high household the sustainability of selected interventions has been reliance on solid biomass fuels has been associated questioned in certain contexts. The paper discusses with a number of health outcomes. the strengths and weaknesses of the evidence and Exposure to indoor air pollution has been asso- highlights opportunities for further research. ciated with chronic obstructive pulmonary disease, Keywords: household energy, indoor air pollution, lung cancer, nasopharyngeal cancer, tuberculosis child ARI, interventions and diseases of the eye in adults; low birth weight and, of particular concern, acute lower respiratory infections (ALRI) such as pneumonia amongst chil- dren less than five (Bruce et al., 2000; Smith et al., 2000). ALRIs are the single leading cause of death amongst children less than 5 years old worldwide 4 Journal of Energy in Southern Africa • Vol 20 No 1 • February 2009 (Murray and Lopez, 1997) and amongst the top 4 dissertations were prioritised for review, which killers of South African children less than five years means that (important) topics such as renewable old (von Schirnding et al., 1991b; Bradshaw et al., energy and housing efficiency that are under repre- 2003). sented from an indoor air pollution perspective in Young children are more susceptible to ALRI the published peer-reviewed literature receive limit- through indoor air pollution exposure for a number ed attention. Before proceeding, it is important to of reasons. The epithelial linings of children’s lungs understand the spatial and temporal patterns of are not fully developed resulting in greater perme- household energy in South Africa. ability of pollutants (Pande, 2000), their immune systems are not fully developed thereby limiting the Household energy patterns body’s defence against infection (Smith et al., The ‘energy ladder’ model has been used to cate- 2000), they have higher respiration rates and they gorise energy sources along a hierarchy according have a larger lung surface area per kilogram of to their cost, ease of use, technological advance- body weight thus breathing in approximately 50% ment and, importantly for this work, the concentra- more (polluted) air under normal breathing condi- tions of air pollution they produce (Smith et al., tions compared to adults (Moya et al., 2004). In 1994). At the bottom of the ladder are solid bio- addition, from an exposure perspective, children mass fuels such as cow dung, crop residues and tend to follow their caregivers’ around, for example, wood. Biomass fuels are followed by coal, charcoal through carriage on their caregivers’ backs (Mtango and paraffin (often referred to as transition fuels). et al., 1992). ‘Modern fuels’ such as liquid petroleum gas (LPG), Indoor air pollution exposure is a function of the natural gas and electricity occupy the higher rungs complex interplay between household fuel patterns of the ladder. Electricity is situated at the top of the (Smith, 1987), appliances (Ezzati et al., 2000), ladder and is considered to be the safest fuel in housing design (Bruce et al., 2002) and human terms of indoor air quality. As fuels become more behaviour (Barnes, 2005). In addition, risk factors advanced and safer, however, they also increase in such as nutrition, crowding, family history of infec- both direct (to use them) and indirect (to purchase tion, poor vaccination history and exposure to envi- appliances to use them) cost at the household level ronmental tobacco smoke (Kirkwood et al., 1995; (Smith, 1987). Victora et al., 1994) may influence child susceptibil- The South African government’s household ity to ALRI. Even more challenging is the fact that energy strategy has had a strong focus on house- indoor air pollution unravels against the backdrop hold electrification (http://www.dme.gov.za/ener- of poverty that influence each of these factors. gy/elect_inep/stm). The INEP electrified over 2.5 In terms of global relevance, South Africa is par- million households between 1994 and 2000 at a ticularly interesting for two reasons. Firstly, there rate of approximately 1 000 households per day. As have been a number of scientific studies (summa- a result, between 1994 and 1999, the proportion of rized in this paper) to understand the problem of households with access to electricity increased from indoor air pollution and child ALRI in South Africa. a 36% to 63% (Department of Minerals and Secondly, there have been a number of post- Energy, 2001). By the end of 2006, 73% of South apartheid policy developments – including the African households had access to electricity Clean Air Act (NEM 2004) and the Integrated (Department of Minerals and Energy, 2006). National Electrification Programme (INEP) – that Table 1 summarizes the main energy used for have been designed to address, amongst others, cooking and space heating derived from Statistics indoor air pollution. The problem, however, is that South Africa’s 1996 and 2001 census as well as except for one review of the methodological quality 2007 community survey data sets. Electricity was of epidemiological studies (Wichmann & Voyi, the main fuel used for cooking and heating followed 2005), the scientific evidence has yet to be integrat- by either paraffin or wood at each interception. It is ed into a single review document. encouraging to note that there was a marked The aim of this paper, therefore, is to review the increase in the proportion of households using elec- scientific evidence of the association between tricity for cooking (+20%) and heating (+14%) household energy, indoor air pollution and child between 1996 and 2007; gas remained relatively ALRI in South Africa. In terms of methodology, static; while there were decreases in paraffin (-7% studies were sourced using the PubMed, Google for cooking and -1% for heating), wood (-7% for Scholar and Electronic Theses and Dissertation cooking and -8% for heating) and coal (-3% for (ETD) databases. Search terms included the follow- cooking and -4% for heating) (Statistics South ing: South Africa, household energy, indoor air pol- Africa, 1998, 2003 and 2007). lution, child ALRI, epidemiology, wood smoke, Movement up the energy ladder was particular- interventions and poverty. Overall, 68 works were ly noticeable amongst the Black African1 population sourced based on their relevance to the topic. Peer- group, which due to apartheid legislation was, and reviewed journal articles, peer reviewed reports and continues to be, the most underserved social group Journal of Energy in Southern Africa • Vol 20 No 1 • February 2009 5 Table 1: South African fuel use 1996-2007 Source: Statistics South Africa (1998, 2003 & 2007) Main fuel used for cooking Main fuel used for heating Year 1996 2001 2007 1996 2001 2007 Electricity 47 51 67 45 49 59 Gas 3 3 2 1 1 1 Paraffin 21 21 15 14 15 13 Wood 23 21 15 27 25 20 Coal 4 3 1 8 7 4 Animal dung 1 1 <1 <1 <1 <1 * Unspecified fuels not included in terms of energy access. Electricity as the main that electricity for their domestic energy needs. In fuel used increased by 8.9% for cooking and 9.3% rural contexts, however, not only is electricity access (between 1996 and 2001) for heating amongst this poorer but fuel switching is more commonplace, group – possibly a function of improved access to that is, the combined use of electricity with other electricity the INEP together with an improvement (usually) biomass fuels. in household income to be able to afford that elec- Multiple fuel use has been highlighted by a num- tricity. ber of localised studies that have focused on house- While the Statistics South Africa datasets pro- hold energy patterns. A study in the rural North vide a useful overview of household energy pat- West Province (Mathee et al., 2000), for example, terns, the figures tend to mask the use of multiple found that after electrification, all households used fuels for cooking and heating purposes. The census electricity immediately for lighting (the cheapest data is derived from a question that focused on the function).