70100 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 I ND ON E S IA 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 more than half of the world’s population, solid fuels, such as wood, agricultural residues, dung, and coal, are the primary source of household cooking and heating fuel. Indoor combustion of solid fuels using traditional stoves releases a large amount of particulate matter (PM) and gaseous pollutants, causing seri- ous health consequences for exposed populations. IAP emission levels generated by Key Messages 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 • Approximately 40 percent of Indonesian recommended levels suggested by the World Health Organization (WHO) guide- households continue to rely on traditional lines and national standards (WHO/UNDP 2009). biomass (mostly wood) for cooking. Most Smoke from cooking fuels accounts for an estimated 2 million worldwide pre- of these households are in rural areas and are mature deaths annually—more than the deaths from malaria and tuberculosis com- likely to continue using traditional biomass in bined (WHO/UNDP 2009). It is the ninth leading risk factor attributed to burden the near future. of disease and the tenth leading cause of global mortality. • Household burning of traditional biomass Women and children in developing countries are particularly affected by is a major health risk factor in Indonesia. the negative health outcomes associated with IAP from solid fuel use. Women The indoor air pollution caused by the use and girls are disproportionally affected because of the amount of time spent cook- of traditional biomass is responsible for an ing. Young children are especially vulnerable since they spend much of their time estimated 45,000 premature deaths annu- indoors to be close to their mothers, including while they are cooking. ally, with women and children particularly A meta-analysis of the global studies on the risk of pneumonia in children under affected. 5 indicates that children who are exposed to smoke from solid fuels are more than 1.8 times more likely to contract pneumonia than those who are not (Smith et al. • In order to decrease indoor air pollution, 2010). The analysis also shows that the increase in the risk for contracting the ill- Indonesia needs to build on its earlier nesses of acute lower respiratory infection (ALRI), chronic obstructive pulmonary experiences and scale up access to modern disease (COPD), cataracts, lung cancer, and cardiovascular disease ranges widely— and cleaner methods of cooking. The World from less than 10 percent to more than double. On average, the chance of contract- Bank is launching the Indonesia Clean Stove ing previous mentioned illnesses ranges from 78 percent for ALRI in children under Initiative to help increase the access to clean 5 to more than 150 percent for COPD in women over 15 (World Bank 2011a). and efficient stoves through capacity build- ing, policy development, and the support of Table 1. Household Emission Levels by Type of Fuel (per Meal) selected government action plans. Wood JUNE 2012 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 Three Provinces with Largest Number of What is the Household Energy Use Households Using Wood for Cooking (millions) Situation in Indonesia? Province 2007 2008 2009 2010 Approximately 40 percent of Indonesian households still East Java 5.3 5.5 5.1 4.8 rely on traditional biomass (mainly wood) for cooking. Central Java 5.2 5.3 4.4 4.0 Although the share of households using wood has declined West Java 3.6 3.6 3.1 2.9 slightly in recent years—from 49 percent in 2007 to 40 percent Source: National Socio-Economic Survey, BPS 2008–11. in 2010—as of 2010, approximately 24.5 million households still relied on wood as their primary cooking fuel (figure 1). the national total. By 2010, the number was reduced to 11.7 Wood continues to be the dominant cooking fuel in 18 of 33 million but these three provinces still represent almost half of provinces. This wide use of wood can be attributed mostly to the country’s wood users (table 2). the lack of access to and affordability of more advanced fuels The number of LPG users increased fivefold as a result and stoves (figure 2). of the government kerosene-to-LPG conversion program The largest number of households that depend on wood begun in 2007. LPG replaced a large portion of the kerosene for cooking fuel are in East Java, Central Java, and West Java. market, which has led to the increase of LPG users from 5.6 In 2007, the three provinces combined had more than 14 mil- million in 2007 to 27.6 million in 2010. Consequently, LPG lion users of wood for cooking, accounting for 53 percent of became the dominant cooking fuel in 10 Indonesian provinces, and kerosene users declined to a total of 7 million country- wide. Households that rely on LPG are concentrated on Java Figure 1. Number of Households Relying on Island (figure 3). Cooking Fuels, by Type, 2007–10 60 What are the Health Impacts Caused Others by IAP in Indonesia? Firewood Kerosene Indonesia ranks second among East Asia and Pacific coun- 40 Gas/LPG tries in mortality attributed to IAP from solid fuel combus- Millions tion. IAP caused by the use of solid cooking fuels has resulted in over 45,000 premature deaths in Indonesia annually. In par- 20 ticular, chronic obstructive lung disease is a major contributor to the total number of premature deaths (table 3). 0 The use of fuel wood for cooking is also linked with an 2007 2008 2009 2010 increased risk for asthma, lung tuberculosis, and ARI among children under 5 in Indonesia. A number of studies show that Source: National Socio-Economic Survey, BPS 2008–2011. the use of solid fuels in Indonesia, especially by populations in Figure 2. Number of Households Relying Primarily Figure 3. Number of Households Relying Primarily on Wood for Cooking, 2010 on LPG for Cooking, 2010 Source: National Socio-Economic Survey, BPS 2011. Source: National Socio-Economic Survey, BPS 2011. 2 Health Impacts of IndoorAir Pollution | INDONESIA 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 8,700 36,600 NA 45,300 0.19 Source: WHO and UNDP 2009. rural areas, is closely related to the high incidence of respiratory develop, promote, and deploy this new generation of advanced diseases. For example, the use of wood compared to the use stoves that can significantly reduce fuel usage and emissions and of LPG or kerosene for cooking increases the risk of asthma thereby improve health. A key part of the promotion should be by 5.8 times and tuberculosis by 6 times (Aron 2004). Several a campaign to raise awareness about the negative health and other studies showed that the practice of mothers bringing environmental impacts of traditional stoves, providing moti- children into the kitchen during cooking increases the risk of vation for the behavioral changes needed for local people to infants contracting ARI and pneumonia by 2–6 times. A lack adopt the new products (World Bank 2011a). of ventilation in the kitchen is likely to increase the incidence of asthma by 6 times and is also linked with a higher incidence A Way Forward of ARI. Indonesia needs to build on its earlier experiences with stove programs and undertake more effective interven- What Can Be Done to Alleviate IAP? tions that simultaneously address energy conservation, IAP exposure can be reduced by using a wide array of health, poverty, and environmental concerns. Indonesia technological, housing, and behavioral interventions. A began implementing improved cookstove programs (ICSPs) by concentration of indoor pollutants depends on a stove-fuel a handful of NGOs as early as the 1980s.While there have been combination (e.g., advanced clean stoves can reduce IAP lev- some achievements, most of the programs are still in their pilot els by more than 50 percent), house design (e.g., house size phases and the total number of cookstoves that have been dis- and construction materials, room arrangement, and ventilation seminated remains relatively limited and sporadic. condition), and stove-use behavior (e.g., whether or not fuel is The Government Kerosene to LPG Conversion Program dried before it is combusted). In addition to pollution levels, (2007–12) is making real progress in providing incentives for exposure depends on the amount of time spent inside or near households to switch from kerosene to LPG. The program has a stove, direct participation in cooking tasks, and alternative helped to reduce the budgetary cost related to kerosene subsi- cooking practices. dies. However, the switching program mainly targets kerosene users and has had minimal penetration among biomass users. It Switching to clean fuels (e.g., electricity, natural gas, LPG, is estimated that in the next decade the use of biomass as cook- and biogas) is the most effective way of reducing IAP and ing fuel will continue to be high—and may even increase in should be encouraged, but most rural households are likely some areas if there is no significant policy interventions. to continue using solid fuels in the near future. Modern In addition to the positive health implications, scaling up clean fuels (e.g., natural gas, LPG, and electricity) are usually access to clean and efficient stoves would also be an important more expensive than solid fuels, requiring more costly stoves step toward reducing poverty, improving gender equality, and and delivery infrastructure, particularly more difficult for rural improving the local and global environment. It is, therefore, populations to obtain. By contrast, many types of biomass are the time for Indonesia to build on its previous experiences traditionally and noncommercially collected in rural areas. and accelerate the scale-up of programs that aim to improve Therefore, fuel switching will not occur in rural areas on a the livelihood of people by addressing the above-mentioned large scale until rural economies become substantially more concerns in a coordinated manner. Along with the existing developed. programs that promote cleaner burning fuels (such as LPG and Where the use of solid fuels persists, the most effective biogas), other options should be explored, including the cre- remedy is the promotion of improved or advanced stoves ation of a new generation of innovative, cleaner-burning bio- that use solid fuels in a cleaner and more efficient way— mass stoves, the development of better marketing techniques to along with an awareness campaign. A new generation of promote them, and the encouragement of private sector efforts advanced and more efficient improved stoves are now com- to market and sell this new generation of more advanced bio- mercially available worldwide, but they have yet to be intro- mass stoves. duced in large numbers in Indonesia.There is a pressing need to Health Impacts of Indoor Air Pollution | INDONESIA 3 EAP Clean Stove Initiative Indonesia Clean Stove Initiative (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 the Pacific (1G2P). EAP CSI focuses on achieving access to modern cooking and heating solutions in East Asia and the Pacific, specifically on scaling-up access to advanced cooking and heating stoves for poor, primarily rural households, which are likely to continue using solid fuels for their cooking and heating needs beyond 2030. EAP CSI is a multicountry, multiphase 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. The 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 advanced stoves; (2) supporting supply-side market and business development; and (3) stimulating demand for clean and efficient stoves. Achieving universal access to modern energy services by Badan Pusat Statistik (BPS)., 2008-2011. National Socio-Economic Survey. http://dds.bps.go.id/eng/ 2030 is the goal set by the United Nations, which declared Mudehir, M. 2002. Hubungan faktor-faktor lingkungan rumah dengan 2012 as the Year of Sustainable Energy for All. Indonesia, with kejadian penyakit ISPA pada anak balita di kecamatan Jambi Selatan. a large population lacking access to modern energy services, M.Ph. University of Indonesia. will have an important role to play in achieving this global goal. Mulyana, N, 2001, Pola memasak sebagai faktor resiko terjadinya infeksi saluran pernapasan akut (ISPA) pada anak balita di wilayah To this end, the World Bank is working with the Bioenergy kerja PUSKESMAS Garuda, Kec. Andir, Bandung tahun 2001. M.Ph. Department of Ministry of Energy and Mineral Resources to University of Indonesia. launch the Indonesia Clean Stove Initiative (CSI), which aims Badan Pusat Statistik (BPS). 2011. National Socio-Economic Survey, to help scale up access to clean and efficient cooking solutions 2008–2011. Smith, K. R. 2000. National burden of disease in India from indoor air pol- in Indonesia through capacity building, policy development, lution. Proc Natl Acad Sci USA 97(24): 13286–13293. and the support of selected government action plans. Smith, K. R., J. Rogers, and S.C. Cowlin. 2005. Household fuels and ill- health in developing countries: what improvements can be brought by Selected Sources for More Information LP gas (LPG)? Paris, France, World LP Gas Association & Intermediate One Goal Two Paths: Achieving Universal Access to Technology Development Group. Modern Energy in East Asia and Pacific: Smith, et al. 2007. Monitoring and Evaluation of Improved Biomass http://elibrary.worldbank.org/content/book/9780821388372 Cookstove Programs for Indoor Air Quality and Stove Performance: Conclusion from the Household Energy and Health Project. Energy for World Health Organization: Sustainable Development 11(2): 5–18. http://www.who.int/indoorair/en/ Sukar, et al. 1994. Pengaruh kualitas lingkungan dalam ruangan terha- dap penyakit ISPA–pneumonia di Indramayu–Jawa Barat, 1993–1994, Global Alliance for Clean Cookstoves: Laporan Akhir, Pusat Penelitian Ekologi Kesehatan Badan Penelitian http://cleancookstoves.org/ dan Pengembangan Kesehatan, Dep. Kes. R.I. Indonesia Indonesian Stove Network: Sutrisna, B. 1993. Risk factors for pneumonia in children under 5 years JKTI http://www.tungku.or.id/ of age and a model for its control. Ph.D. (Summary of dissertation). University of Indonesia. Photo Credit Wattimena, S.C. 2004. Faktor lingkungan rumah yang mempegaruhi Courtesy of GERES, 2011. hubungan kadar PM 10 dengan kejadian ISPA pada balita di wilayah PUSKESMAS Curug, Kabupaten Tanggerang. M.Ph. University of Indonesia. References WHO (World Health Organization). 2005. WHO Air Quality Guidelines Anon. 2004. Uji petik indoor perumahan di 5 wilayah (Cilegon, Kebumen, Global Update 2005. Copenhagen: World Health Organization. Gresik, Pangkep, Banjarmasin), Dir. Penyehatan Lingkungan, Dir. ———. 2006. Fuel for Life: Household Energy and Health. Geneva: World Pemberantasan Penyakit Menular and Penyehatan Lingkungan. Health Organization. Asia Regional Cookstove Program (ARECOP) and Department of Adolescent ———. 2007. Indoor Air Pollution: National Burden of Disease Estimates. and Child Health and Development, World Health Organization., Geneva: World Health Organization. 2008. Situation analysis of indoor air pollution and household energy WHO and UNDP. 2009. The Energy Access Situation in Developing use in Indonesia. Countries. New York: United Nations Development Programme. World Bank. 2011a. Household Cookstoves, Environment, Health, and Climate Change. Washington, DC: World Bank. ———. 2011b. One Goal, Two Paths: Achieving Universal Access to This note is prepared by Yabei Zhang and Yun Wu, with review Modern Energy in East Asia and Pacific. Washington, DC. inputs from Dejan Ostojic, Eva Jarawan, and Doug Barnes. The Zhang, Yabei. 2010. Finding out the Killer in the Kitchen: An Analysis of findings, interpretations, and conclusions do not necessarily Household Energy Use, Indoor Air Pollution, and Health Impacts in India. Lambert Academic Publishing. reflect the views of the Executive Directors of the World Bank or those of the Australian Agency for International Development. June 2012