2010 is the Year of the Lung with October 14 marked for the first time ever as World Spirometry Day, a day to check your lung function. This day is just a reminder that while chronic obstructive pulmonary disease (asthma, chronic bronchitis, etc) or COPD is currently the fourth leading cause of death worldwide, it is predicted to move up to third place in another two decades, overtaking TB and HIV. What is important to note is that each country has to seek its own solutions as there is significant difference in the factors behind COPD across countries. In high-income countries, smoking is the largest risk factor, accounting for 73% of COPD mortality, while in low and middle income countries smoking is related to 40% of COPD mortality and another 35% is due to indoor smoke from cooking with biomass fuels.
Led by the western world, the negative impact of smoking has been accepted and there has been significant, though still not sufficient, government intervention, even in India?through taxes, rules on smoking in public places, etc. But there is another larger, much more vulnerable set of population at risk in developing countries. Half the world, about 3 billion people, is exposed to smoke from biomass fuel, three times more than the number of smokers. Within these households, it is the women and infants who bear the highest burden of smoke, as they hover around the stoves.
How widespread is the problem in India? More than 60% of rural households use firewood for cooking, 14 % use dung cakes, and 13 % use straw, shrubs, grass, etc. Even in urban India, where LPG is the preferred fuel for cooking, almost a quarter of households use wood as cooking fuel. LPG, which is the safest fuel, has the lowest use in rural households and in states like Bihar, Orissa, Jharkhand, Meghalaya and Chhattisgarh, less than 10% of all the households use LPG.
Despite an already bloated subsidy bill, there is a proposal by the oil ministry to subsidise gas connections to the rural poor, by waiving the security deposit of Rs 1,400 per connection. The aim is to cover 10 million new gas connections in villages every year till 2015, and the subsidy is to be shared by the Centre and the oil PSUs? CSR funds. But it is unclear whether the gas cylinder will thereafter be subsidised enough to make it affordable to the poor. Given the large number of households that need to be covered, the financial viability of such a programme has to be well understood at both the macro and the micro level before implementation.
If LPG is not a financially viable option, what is the solution then for indoor smoke? It is important to understand the local context in which households use solid fuels, to see where change can be affected easily and effectively. The problem is worst for those poor households that cook in the same room they live in, that make up a third of India?s rural households. In both urban and rural areas, 9 in10 households that use biomass fuels cook on an open fire, without diverting the smoke through a chimney. NFHS 2005-06 showed a higher prevalence of TB in households that do not have a special room for cooking and also found much lower levels among households that have a chimney compared to those that did not. The survey, however, did not find a correlation between overcrowding and TB levels, pointing to the presence of the chimney as the biggest influencer on lower TB prevalence.
The fact that indoor smoke is a health hazard has been on the government radar for many decades now, and a smokeless chulha with chimney has been included in the houses provided under the Indira Awas Yojana. But despite numerous programmes and NGO intervention, smokeless chulhas have not been adopted in large numbers.
Researchers who have cared enough to investigate put down a number of reasons for this. Adoption of smokeless chulhas is higher in households where women make the decision to change and where women have higher schooling levels. In many households, there is resistance to change, concerns about maintenance, non-compatibility with the fuel of choice, etc. Experience at ARTI (Appropriate Rural Technology Institute) shows that a successful stove is one that works with different biomass fuels, adapts to people?s needs when cooking different kinds of food and accepts different, non-standard cooking vessels. The design of the chimney is also important; it should be easy to transport, assemble, clean and repair. Above all, the entire cooking mechanism has to fit in with the lifestyle and location of the household. As SEWA has discovered in Gujarat, what is most important is not just training women to use the new chulha properly, but also interacting with them over time to ensure that there is correct use and maintenance.
It is vital that the government recognises that a top-down, one-size-fits-all approach will not yield results. Thankfully, there is a ray of light here. As part of its National Biomass Cookstove Initiative, the new and renewable energy ministry has recently tied up with IIT Delhi and the X Prize Foundation to launch a global cook-stove competition. Greater collaboration between the government and NGOs working in this area will go a long way in innovating to reduce the burden of COPD and improve life for women and infants in the poorest of Indian households.
The author is chief economist at Indicus Analytics Pvt Ltd