70101 Health Impacts of Indoor Air Pollution At-a-Glance E A P C L E A N S T O V E I N I T I AT I V E K N O W L E D G E E X C H A N G E S E R I E S CH INA Why is Indoor Air Pollution a Health Issue? Indoor air pollution (IAP) caused by the burning of solid fuels in traditional stoves is one of the leading risk factors attributed to mortality and burden of disease. For about half of world’s population, solid fuels such as wood, agricultural residues, dung, and coal are the primary sources for household cooking and heat- ing needs. Indoor combustion of solid fuels using traditional stoves releases a large amount of particulate matter (PM) and gaseous pollutants, causing serious health consequences for exposed populations. IAP emission levels generated by solid fuels are often 20–100 times those of clean fuels like liquefied petroleum gases (LPG), as is shown in table 1, and often up to 20 times higher than the maximum recommended Key Messages levels suggested by the World Health Organization (WHO) guidelines and national standards (WHO/UNDP 2009). • More than half of China’s population still Smoke from cooking fuels accounts for an estimated 2 million worldwide pre- relies on solid fuels (coal and biomass) for mature deaths annually—more than the deaths from malaria and tuberculosis com- cooking and heating. Most of these house- bined. (WHO/UNDP 2009). It is the ninth leading risk factor attributed to burden holds are in rural areas and are likely to con- of disease and the tenth leading cause of global mortality. tinue using solid fuels in the near future. Women and children in developing countries are particularly affected by the negative health outcomes associated with IAP from solid fuel use. Women and • Household burning of solid fuels is a major girls are disproportionally affected because of the amount of time spent cooking. health risk factor in China, estimated to lead Young children are especially vulnerable since they spend much time indoors to be to more than half million premature deaths close to their mothers who are often at cooking stoves. annually with women and children particu- A meta-analysis of global studies on the risk of pneumonia in children under 5 larly affected. indicates that children who are exposed to smoke from solid fuels are more than 1.8 • China needs to build on its earlier suc- times more likely to contract pneumonia than those who are not (Smith et al. 2010). cessful stove programs and undertake The analysis also shows that the increase in the risk for contracting the illnesses of more active interventions. The World Bank acute lower respiratory infection (ALRI), chronic obstructive pulmonary disease is launching the China Clean Stove Initiative (COPD), cataracts, lung cancer, and cardiovascular disease ranges widely—from less to help increase access to clean and effi- than 10 percent to more than double. On average, the chance of contracting one of cient stoves through capacity building, policy these illnesses ranges from 78 percent for ALRI in children under 5 to more than development, and the support of selected 150 percent for COPD in women over 15 (WHO/UNDP 2009; WB 2011a). government action plans. Table 1. Household Emission Levels by Type of Fuel (per Meal) Wood Biogas LPG Kerosene Residues Crop Dung CO 0.1 1 3 19 60 64 PM 2.5 1 1.3 26 124 64 Note: Health-damaging pollutants per unit energy delivered: ratio of emissions to LPG. Data from K. Smith et al. 2000. Source: Smith, Rogers, and Cowlin 2005. This publication is a product of the collaboration between the staff of the Infrastructure (EASIN) and Health (EASHH) units of the East Asia and Pacific region of the World Bank. Table 2. Top Five Provinces with the Largest Number of What is the Household Energy Use Rural Households Using Solid Cooking Fuels (millions) Situation in China? Province Biomass Coal Total More than half of China’s population still relies on solid Henan 10 10 20 fuels for cooking and heating. Despite China’s impressive Sichuan 15 4 19 economic growth and accomplishments in poverty reduction, Shandong 14 5 19 households have been slow to climb the energy ladder and tran- Hunan 7 8 15 sition from the use of coal and traditional fuels for cooking and Hebei 7 7 14 heating to modern alternatives. Most of these households are Source: National Agriculture Census 2006. in rural areas and it is likely that the use of solid fuels will con- tinue even past 2030. Of the 263.8 million rural households in Rural households in western and northern China pre- China, approximately 133.2 million rely primarily on wood dominately depend on solid fuels (figure 1). Except for a few and agricultural residues (60.2 percent) and an additional 57.6 million households use coal for their cooking fuel. southeastern provinces, almost all rural households in China use solid fuels for cooking. The most concentrated areas of households solid fuel use for cooking are in central and eastern Figure 1. Percentage of Rural Households Relying Primarily China because of the large populations and the access to these on Solid Fuels for Cooking (percentage) energy sources (figure 2). The provinces of Henan, Sichuan, Shandong, Hunan, and Hebei have the most rural households using solid fuels for cooking. As table 2 illustrates, Henan Province has the largest number of rural households using solid fuel for cooking (20 million) and Sichuan Province has the largest number of rural household using biomass fuels (15 million). What are the Health Impacts Caused by IAP in China? The households burning of solid fuels represents a major health risk factor in China. It ranks sixth among all risk fac- tors of ill health, only exceeded by alcohol abuse, high blood Source: National Agriculture Census 2006. pressure, tobacco use, underweight, and occupational hazards (Smith et al. 2007). WHO/UNDP estimates that IAP from solid fuel use leads to over a half million premature deaths Figure 2. Number of Rural Households Relying Primarily annually in China (table 3). It triples the COPD incidence on Solid Fuels for Cooking (millions) and constitutes a major risk factor for acute lower respiratory tract infections (ALRI), causing deaths in young children in particular. The combustion of locally-produced coal with high fluo- ride and arsenic content is a major cause of endemic fluoro- sis and arseniasis. According to data from 2000, 201 counties with total populations of approximately 33.678 million were affected by coal burning endemic fluorosis, and 8 counties with total populations of approximately .33 million were affected by coal-burning endemic arseniasis. The most affected areas of endemic fluorosis are in Guizhou and Shaanxi provinces (Jia, 2011). Source: National Agriculture Census 2006. 2 Health Impacts of Indoor Air Pollution | CHINA Table 3. Annual Number of Premature Deaths Attributed to Air Pollution Caused by Cooking with Solid Fuels, 2007 Pneumonia— Chronic Obstructive Lung Total Premature Deaths Children <5 Disease—Adults >30 Cancer—Adults >30 Total Premature Deaths per 1,000 People 9,100 505,900 33,900 548,900 0.42 Source: WHO and UNDP 2009. What Can Be Done to Alleviate IAP? A Way Forward IAP exposure can be reduced using a wide array of China needs to build on its earlier stove programs and technological, housing, and behavioral interventions. undertake more active and effective interventions that Concentrations of indoor pollutants depend on a number of simultaneously address energy conservation, health, pov- factors, including the stove-fuel combination (advanced clean erty, and environmental concerns. During the 1980s and stoves can reduce IAP levels by more than 50 percent); house 1990s, China instituted a very successful national improved design (e.g., size of structure, materials used in construction, stove program (NISP), implemented by the Ministry of arrangement of rooms, and quality of ventilation); and behavior Agriculture, which distributed 180 million improved stoves regarding the use of stoves (for example, whether or not fuel countrywide. The NISP was largely motivated by concerns is dried before it is combusted). In addition to pollution levels, about energy conservation, including the reduction of biomass exposure rates are affected by a number of factors, including use and its effects on land degradation and deforestation. The amounts of time spent indoors, closeness to a cookstove, and health dimensions of household energy use have only recently cooking practices. been identified as a driver for designing and marketing new The most effective way to reduce IAP is by switching to stoves. The Ministry of Health (MOH) pioneered a program clean fuels (electricity, natural gas, LPG, and biogas). This in the mid-1990s to promote “improved kitchens� in poorer should be encouraged, but most rural households are regions of the country, providing improved stoves to house- still likely to continue using solid fuels in the near future. holds in targeted areas where fluorosis caused by burning high Modern clean fuels are usually more costly than solid fuels fluoride coal is endemic. and they require more expensive stoves and a delivery infra- When the NISP program ended in late 1990s, the govern- structure that is difficult for people in rural areas to obtain. By ment expected the private sector to intensify stove commer- contrast, many forms of biomass are collected traditionally on cialization and, to some degree, it has. The private sec- a noncommercial basis in rural areas. Given these factors, large- tor currently produces more than 2 million efficient coal scale fuel switching will not occur in rural areas until rural stoves and more than 600,000 high-efficiency low-emission economies become substantially more developed. biomass stoves. But the development and production of ad- In households where the use of solid fuels is likely to vanced biomass stoves has not kept pace with the challenge of persist, the most effective remedy for IAP is the promo- promoting clean stoves in all households. At the current pace, tion of improved or advanced stoves that use solid fuels in it will take decades to reach this goal. a cleaner and more efficient way along with an awareness In addition to the positive health implications, scaling up campaign. There is a pressing need to develop, promote, and access to clean and efficient stoves would be an important deploy the new generation of more advanced and efficient step toward reducing poverty, improving gender equality, and stoves now commercially available that can significantly reduce improving local and global environments. It is consistent with fuel usage and emissions and thereby improve health outcomes. China’s strategy on promoting energy conservation and reduc- A key part of the promotion should be a campaign to raise ing carbon emissions as well as promoting green energy in awareness about the negative health and environmental impacts villages. China should, therefore, build on its earlier successful of traditional stoves, providing motivation for the behavioral stove programs and undertake more active interventions in a changes needed for local people to adopt the new products coordinated manner. In addition to existing programs that pro- (World Bank 2011a). mote cleaner burning fuels (e.g., biogas), other options should be explored, including the creation of a new generation of innovative, cleaner-burning biomass stoves, the development of better marketing techniques to promote them, and the encour- agement of private sector efforts to market and sell this new generation of more advanced biomass stoves. Health Impacts of Indoor Air Pollution | CHINA 3 EAP Clean Stove Initiative China CSI is part of the East Asia and Pacific (EAP) Clean Stove Initiative, a follow-up to the Energy Flagship Report, One Goal, Two Paths: Achieving Universal Access to Modern Energy in East Asia and Pacific (1G2P). EAP CSI focuses on achieving access to modern cooking and heating solutions in East Asia and the Pacific, especially the scaling-up of access to advanced cooking and heating stoves for poor, primarily rural households that are likely to continue using solid fuels for cooking and heating even after 2030. EAP CSI is a multi-country, multi-phase program with funding support from Australian Agency for International Development (AusAID). It includes four country-specific programs (China, Indonesia, Mongolia, and Laos) and a Regional Energy Access Forum to promote regional collaboration, learning, and knowledge-sharing about access to modern energy at the household level. EAP CSI takes a three-pronged approach focusing on (1) strengthening institutional capacity and creating an enabling policy and regulatory environment for scaling-up access to clean and efficient stoves; (2) supporting supply-side market and business development; and (3) stimulating demand for clean and efficient stoves. 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Agency for International Development. June 2012