Snuffing us out

AS someone who smoked for more than 20 years but has not for the past five I have begun to develop the insufferable evangelism of the "born-again" non-smoker. But I am opposed to the evangelists in the new Indian initiative against tobacco products. The reason why an anti-smoking campaign should not be the top priority is simple. If we have to order India's health concerns and organise our energies accordingly there are more important, but less glamorous, campaigns waiting to be taken up. The best example is the serious damage caused by smoke of a different kind - in kitchens. Dung cake, twigs, grass, crop residues and wood continue to be cooking fuels in millions of homes in the country. Every day the burning of these fuels in poorly designed stoves in ill-ventilated kitchens is causing serious injury to hundreds of millions of women and children. The death and morbidity that such "kitchen" pollution causes is far greater than that from tobacco use. But the women in India who have to make do with polluting fuels belong to the invisible society which those who pontificate about tobacco (or vehicle pollution) cannot be bothered about.

We all know about the injuries caused by tobacco, but the magnitude of ill health from pollution in Indian kitchens is staggering. One researcher in the United States, Kirk R. Smith, has been tracking this issue for years. Stripped of the ifs and buts here are his recent findings. In the early 1990s, less than half of the 152 million households in India used solid fuels (kerosene or liquid pertroleum gas), had improved chulas or cooked in the open air. That left an estimated 82 million homes (462 million people) open to risk from indoor pollution caused by smoke from the bio-mass fuels. Based on a variety of field studies, Smith argues that the women over 15 and the children under five years who spend time in these 82 million kitchens are vulnerable to lung cancer, acute respiratory infections, chronic obstructive pulmonary disease (strong evidence), tuberculosis, asthma and blindness (moderate evidence) and heart diseases (suggestive evidence). The estimate is that every year as many as 4,00,000 to 5,00,000 women and children die prematurely in India from illnesses caused by pollution in the kitchen. The real figure is likely to be even higher. The disability-adjusted life years (DALY), which measures the loss of life expectancy caused by both sickness and death, is much as 12-17 million every year.

Where do the health effects of indoor air pollution stand in comparison to other risk factors and diseases? The figures here are even more revealing. The ill health caused by kitchen pollution accounts for between four to six per cent of the total national burden of disease in India. Among the risk factors of ill health, the most important (naturally) is that caused by malnutrition and second is our pathetic water and sanitation systems. Next comes indoor air pollution. This is far, far more than the risk factors that arise from unsafe sex, occupational health, alcohol and tobacco. The last mentioned is at the bottom of the hierarchy and accounts for less than two per cent of the national burden of disease..

It is not that tobacco use in India is unimportant. It is and its incidence is increasing at an uncomfortably high pace. But there is always money and support available to fight big business in tobacco because it is fashionable and there is none for the mundane issue of kitchen pollution. (The World Health Organisation has been quick to latch on to the publicity it can get from its anti-tobacco initiative. But do not bother to search on the WHO web site for any initiatives to end kitchen pollution in South Asia, China, south-east Asia and Africa. There are none.) If one is looking for a campaign that will yield immediate success, how about an end to wringing our hands about the subsidies involved in LPG and the leakages from Public Distribution System supplies of kerosene? A major expansion in the use of these fuels in our kitchens will make a dramatic improvement in the health of millions of women and children.

Chapter 3 of The World Energy Assessment (United Nations Development Programme) has a discussion of indoor pollution in India. "National burden of disease in India from indoor air pollution" by Kirk R. Smith can be found at www.pnas.org

C. RAMMANOHAR REDDY

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