ENERGY AND 40699 POVERTY Special Report June 2007 CHINA Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Enis Bari and Majid Ezzati (Eds.) Energy Sector Management Assistance Program Copyright © 2007 The International Bank for Reconstruction and Development/WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Printed in India First printing June 2007 ESMAP Reports are published to communicate the results of ESMAP's work to the development community with the least possible delay. The typescript of the paper therefore has not been prepared in accordance with the procedures appropriate to formal documents. Some sources cited in this paper may be informal documents that are not readily available. 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ESMAP encourages dissemination of its work and will normally give permission promptly and, when the reproduction is for non-commercial purposes, without asking a fee. ENERGY AND POVERTY Special Report 002/07 June 2007 Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Enis Bari and Majid Ezzati (Eds.) Energy Sector Management Assistance Program (ESMAP) Contents Preface vii Acknowledgments ix Acronyms and Abbreviations xi Executive Summary xiii 1. Introduction 1 Rural Household Energy and IAP 1 Environmental Dimension 11 IAP Interventions: What are the Knowledge Gaps? 13 Project Context 19 Structure of this Report 19 2. Project Overview 21 Project Description 21 Project Design 25 3. Foundations for Intervention Design 31 General Design Considerations 31 BaselineData 37 IAP Interventions 48 4. Intervention Results 61 Changes in Stove Use 61 Energy Efficiency under Controlled Conditions 64 Changes in IAP Levels 64 Changes in IAP-related Knowledge and Behavior 67 IAP-related Health Indicators 69 Findings and Implications 71 5. Alternative Energy and Technology Options 75 Overview 75 Alternative Energy Options for China 77 Advantages of Changing or Processing Fuels 81 Alternative Cookers and New Stove Design 85 Scaling Up Issues 86 6. Summary and Recommendations 91 Policy and Program Recommendations 97 Suggestions for Future Work in Research and Development 101 iii Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Tables 1.1: Rural Household Consumption by Energy Source, for Selected Years (percent) 4 1.2: Annual Mortality Caused by IAP Exposure from Solid Fuels 8 1.3: Life Expectancy in Project Provinces 17 2.1: Categorization of Selected Townships 27 3.1: Geographic and Environmental Features of the Study Areas 32 3.2: Housing Characteristics of Study Participants (percent households) 36 3.3: Household Energy Use Behavior and Time-activity Patterns as Determinants of Exposure 36 3.4: Stove Characteristics of Study Households (percent households) 41 3.5: Fuel Characteristics of Study Households (percent households) 42 3.6: Stove Use Hours in Middle and Late Heating Season 42 3.7: Quantity of Fuel Consumption (kg/month) 43 3.8: Knowledge of the Health Effects of Respirable Pollutants (percent respondents) 44 3.9: Knowledge of IAP Sources by Province (percent respondents) 45 3.10: Knowledge of Methods to Reduce Smoke from Energy Use by Province (percentage respondents) 45 3.11: Baseline IAP-related Health Data (percent of respondents/tested persons) 49 3.12: Types and Number of Stoves Tested 50 3.13: Improved Stoves and Ventilation Systems Installed in Study Areas 51 3.14: Stove Intervention Costs by Province 56 3.15: Number of Households and Persons Involved in Health Education and Behavioral Activities 58 4.1: Baseline Fuel Use Among Study Participants (percent households) 62 4.2: Summary of Pre- and Post-intervention Stove Use 63 4.3: Comparing Fuel and Heat Efficiency of Old and New Stoves 64 4.4: Change in Pollutant Concentrations under Controlled Conditions 65 4.5: Summary of IAP Concentration Changes 72 5.1: China's Increasing Renewable Energy Capacity 77 5.2: Comparison of Indoor Air Concentrations of Fluoride after Fluoride-fixing Treatment 84 5.3: Comparison of Indoor Air Concentrations of Sulfur Dioxide after Fluoride-fixing Treatment 84 5.4: Comparison of Indoor Air Concentrations of Respirable Particulate Matter after Fluoride-fixing Treatment 84 5.5: Household Fuel Choices and Barriers to Adoption 86 6.1: Change in Selected Knowledge and Behavior Indicators 93 6.2: Summary of Changes in Selected Health Indicators in Comparison with Control Group 95 iv Contents Figures 1.1: Estimated Household Reliance on Solid Fuels by Country, 2000 2 1.2: Household-level Emissions by Fuel-type (per meal) 2 1.3: Relationship between Income and Solid Fuel Use 3 1.4: China's Rural Household Transition in Energy Consumption, 1979-98 5 1.5(a): Rural Household Energy Expenditure by Fuel-type 6 (deciles of per capita income) 1.5(b): Rural Household Energy Expenditure by Fuel-type (deciles of per capita income) 7 1.5(c): Rural Household Energy Expenditure by Fuel-type 7 (deciles of per capita total expenditure) 1.5(d): Rural Household Energy Expenditure by Fuel-type 7 (deciles of per capita total expenditure) 1.6: Rural Residential Energy Consumption by Study Province (per capita) in Selected Years 9 1.7: Leading 20 Global Risk Factors for Mortality 10 1.8: Leading 20 Global Risk Factors for Loss of Healthy Life (Measured in DALYs) 10 1.9: Map of China, Showing the Four Study Provinces 19 2.1: Organizational Structure of IAP Project 24 2.2: Intervention Model and Hypotheses 25 2.3: Overview of Project Methodology 27 2.4: Location of Selected Counties in Project Provinces 28 2.5: Location of Selected Townships in Project Counties 28 3.1a: Original Biomass Range (left), Bed-heating Device (center) and Chimney (right), Gansu 52 3.1b: Improved Biomass Range (left), Bed-heating Device (center) and Chimney (right), Gansu 52 3.2a: Coal Iron Stove (left) and Chimney (right), Guizhou 53 3.2b: Air-circular Stove (left) and Ventilation System (right), Guizhou 53 3.3a: Original Biomass Stove-bed Device, Inner Mongolia 54 3.3b: Improved Biomass Stove-bed Device, Inner Mongolia 54 3.4a: Original Coal Range (left) and Underground Stove (right), Shaanxi 55 3.4b: Improved Coal Range (left) and Underground Stove (right), Shaanxi 55 3.5: Illustrative Health Education and Behavioral Materials 57 5.1: Residential sector Electricity Consumption by Country Group (per capita) 77 5.2: Biomass Gasified Stoves 85 Annexes Project Overview Annex 1: Project Implementation Schedule 103 Annex 2: Project Partner Organizations 105 Foundations for Intervention Design Annex 3.1: Provincial Statistical Overview 109 Annex 3.2: County Statistical Overview 113 Annex 3.3: Demographic and Socioeconomic Characteristics of Study 115 Households and Respondents v Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Annex 3.4: Technical Design for Measuring IAP Concentrations 117 Annex 3.5: IAP Baseline Data 119 Annex 3.6: Baseline Questionnaires 123 Section A: Household Characteristics 124 Section B: House and Kitchen Characteristics 124 Section C: Fuel Use 125 Section D: Stove Characteristics 126 Section E: Food Processing and Cooking 130 Section F: Health Awareness (Cognition) 132 Annex 3.6.1: Health Survey Questionnaire: Adult Health Survey Individual Questionnaire 133 Section A: General Information 133 Section B: Dietary Habits 134 Section C: General Health Condition and Disease Burden 135 Section D: Diseases and Symptoms 135 Section E: Hypertension 137 Section F: Tuberculosis 138 Section G: Asthma 139 Section H: Emphysema and Other Obstructive Pulmonary Diseases 139 Section I: Pregnancy and Delivery 140 Section J: Health Measures 141 Intervention Results Annex 4.1: Pre- and Post-intervention IAP Concentrations and Changes by Province 143 Annex 4.2: Provincial Tables for IAP-related Knowledge and Behavioral Changes 155 Annex 4.3: Health Survey and Examination Results for Selected IAP-related Health 163 Symptoms, by Province References 167 vi Preface Decades of research have shown that Indoor Air Pollution (IAP), resulting from household cooking and heating, using low quality fuels and poorly ventilated stoves, is responsible for an array of respiratory- related and other diseases. In 2002, the World Health Organization (WHO) reported that, in developing countries, IAP is the fourth leading cause of death and burden of disease, surpassed only by malnutrition, unsafe sex and lack of safe water and appropriate sanitation. Families in poor rural areas are disproportionately affected as they typically lack the resources and opportunity to access cleaner, more efficient fuels and appliances. While household energy use behavior varies around the world, one common feature remains: In most societies, women are responsible for cooking. Because they usually have primary responsibility for child care as well, children and infants also may spend several hours a day inhaling harmful pollutants and are at risk of burns from hot stoves. In colder climates, such as northern China ­ where heating is essential throughout a significant portion of the year ­ the picture of energy use and IAP exposure is more complex. IAP and energy use patterns relate broadly to many of the UN Millennium Development Goals (MDGs). Reduced exposure to IAP contributes to improving women's and children's health (Goals 4 and 5). It can reduce poverty (Goal 1) by enabling healthier populations to participate in economic activities. In addition, transitioning to more efficient household cooking and heating practices can empower women, by freeing up their time (now spent collecting fuel) for human development activities (Goal 3); it can also allow more children, especially girls, to attend school (Goal 2). Moreover, switching to cleaner fuels and alternative cooking and heating patterns can reduce pressure on forests and allow crop residues (commonly burned for heating) to be used more efficiently as fertilizer (Goal 7). Despite global recognition of IAP's enormous relevance to international development and global health, identifying the most effective ways to tackle the problem has proved daunting. Recent advances in intervention science ­ spanning a wide range of disciplines, from engineering to epidemiology and the social sciences ­ can help to fill the gap between advocacy and action. Yet, no intervention program can be sustained if it fails to take into account the social and physical complexities of household energy use and fuel combustion. We believe a comprehensive approach which brings together the concerns of multiple sectors is eventually needed for successful mitigation. To this end, World Bank, in cooperation with China's Ministry of Health and the Chinese Center for Disease Control and Prevention (China CDC) initiated in 2002 the project Sustainable and Efficient Energy Use to Alleviate Indoor Air Pollution in Poor Rural Areas of China. This multisectoral project drew on international IAP research and experience of the past two decades, taking stock of programs implemented in China and elsewhere. vii Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China The study aimed to test the viability of behavioral (health education) and technological (improved stoves and better ventilation) solutions to mitigate IAP in poor rural areas of China under real life implementation conditions. The central tenet was a multisectoral approach, incorporating concerns from the fields of health, energy, environment, education and poverty reduction. We hope that the lessons from this project will motivate research, policy and program responses in China and elsewhere toward large-scale, sustainable improvement in environmental, health and socioeconomic outcomes of household energy use. Enis Bari Majid Ezzati Senior Public Health Specialist Associate Professor World Bank Harvard School of Public Health viii Acknowledgments This study was undertaken by a multidisciplinary team of Chinese and international scientists, with financial and technical support from ESMAP. We also gratefully acknowledge significant financial assistance of the Department for International Development, U.K. (DFID) and the Swedish International Development Agency (SIDA). The authors wish to thank the households which participated in the study for their help and hospitality. Staff of the China CDC in the four study provinces (Gansu, Guizhou, Inner Mongolia and Shaanxi) provided critical assistance in field study design and data collection. The authors extend their thanks to the many scientists and staff members of the China CDC's National Institute for Environmental Health and Related Product Safety, Beijing, and the Ministry of Health's Foreign Loan Office (FLO), who contributed to project design and implementation. China CDC's National Institute for Environmental Health and Related Product Safety also authored a report, titled "Sustainable and Efficient Energy Use to Alleviate Indoor Air Pollution in Poor Rural Areas in China," which describes the implementation of this project and provides numerous technical details complementary to this study. It can be accessed in English and in Chinese at http://61.49.18.66/iap/eg/index.asp. The comments of peer reviewers Mr. Grant Ballard- Tremeer (Eco Ltd.) and Mr. Brendon Barnes (Environment and Health Research Unit, Medical Research Council of South Africa) are gratefully acknowledged. The authors extend their appreciation to Ms. Kalpana Balakrishnan (Sri Ramachandra Medical College and Research Institute, Chennai, India), who contributed to project design and initiation. The authors also thank Ms. Kseniya Lvovsky (Lead Environmental Economist), Ms. Fadia Saadah (Sector Manager, Human Development Department, South Asia Region) and Ms. Dominique Lallement (former ESMAP manager) for their support throughout the project. The authors would like to acknowledge the assistance of Mr. Douglas Barnes, Ms. Marjorie K. Araya and Ms. Ananda Swaroop in the editing and production of this report. Special thanks goes to Mr. Lansong Zhang (Senior Program Assistant, Beijing Office) for liaising so effectively between World Bank team and the Chinese research partners. ix Acronyms and Abbreviations ADB Asian Development Bank ARI Acute Respiratory Infection Al2O3 AluminumOxide As Arsenic B Behavioral Intervention C Control Ca (OH)2 Calcium Hydroxide CaF2 Calcium Fluoride CaO CalciumOxide CBOs Community-BasedOrganizations Celsius C CH4 Methane C6H6 Benzene ChinaCDC China Center for Disease Control and Prevention CI Confidence Interval CO CarbonMonoxide CO2 CarbonDioxide DALYs Disability Adjusted Life Years DFID Department for International Development, U.K. DME Dimethyl Ether ESCOs Energy Service Companies ESMAP Energy Sector Management Assistance Program ETS Environmental Tobacco Smoke F Fluorine FLO Foreign Loan Office GAVI Global Alliance for Vaccines and Immunization GDP Gross Domestic Product GHG Greenhouse Gas GW Giga Watt (s) g/MJ-d Grams Per Megajoule of Energy Delivered to the Cooking Pot H Hydrogen HDI Human Development Index xi Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China IAP Indoor Air Pollution IEA International Energy Agency Kg Kilogram Kgce Kilogram Coal Equivalent (Standard Coal Equivalent) Kg/h Kilogram (s) Per Hour Km Kilometer KW Kilo Watt (s) KWh/m2 Kilowatt-Hour Per Day Per Square Meter LPG Liquefied Petroleum Gas MBTUs Million British Thermal Units MDGs United Nations Millennium Development Goals µg Micrograms µg/m3 Micrograms Per Cubic Meter Mg Milligram Mg/m3 Milligrams Per Cubic Meter MM Millimeter Million sq m Million Square Meter MW MegaWatt (s) NGOs Non Governmental Organizations NIOSH National Institute for Occupational Safety and Health NO2 NitrogenDioxide PM Particulate Matter PPP Purchasing Power Parity PPM Part(s) Per Million PV Photovoltaic PVC Poly Vinyl Chloride R&D Research and Development RE Renewable Energy RETs Renewable Energy Technologies RPM Respirable Particulate Matter S Sulfur S + B Stove Plus Behavioral Intervention SIDA Swedish International Development Agency SiO2 Silicon Dioxide SO2 Sulfur Dioxide TAG Technical Advisory Group UNDP United Nations Development Programme WHO World Health Organization xii Executive Summary For more than half of the world's population, The country's energy transition to cleaner fuels solid fuels (coal and biomass) provide the is slow. Today, biomass accounts for 55 percent primary source of domestic energy. Their of rural energy use, while coal represents a incomplete combustion, using poorly ventilated growing share of 34 percent (14 percent heating and cooking stoves, emits hundreds of higher than in 1990). In rural areas, energy health- damaging pollutants. IAP from cooking consumption is accelerating sharply because of and heating is a serious health hazard increased use of solid fuels, notably coal. throughout the developing world, especially in Since electricity accounts for only 6 percent of poor rural areas; IAP has been identified as a the total rural energy consumption, these data cause of a range of respiratory and other suggest that most of the increased consumption is diseases. In 2000, IAP from household burning for heating and cooking. If so, exposure to IAP of coal and biomass resulted in more than 1.6 may be worsening, despite new technologies and million deaths, nearly 3 percent of the global government-supported stove interventions. burden of disease. Dataregardinginterventionsaroundtheworldand Inefficient fuel use exacerbates energy wastage inChinaaregenerallyinadequatefordesigning and environmental problems; moreover, effective and sustainable reductions in IAP.Mostpast fuel-gathering, traditionally borne by women, is a interventions were designed to conserve energy; time consuming and laborious task. Substantial reducingexposuretoairbornepollutantsand welfare gains at all levels (nationally, regionally improved health were not the primary concerns. and globally) can result from helping developing Where they focused more on health effects, the nations to improve appropriate use of solid fuels interventions were often implemented in artificial while reducing, at the same time, IAP and its settings divorced from rural realities. Thus, health-related costs. epidemiological,toxicological,and,mostimportantly, interventionresearchonthehealth effects of IAP from Rural China Context solid fuels is at a relatively early stage. A stronger China's large rural population ­ more than 900 foundation of knowledge is needed to design million residents ­ suffers extensively from the ill appropriateinterventionswhichsimultaneouslyaddress health effects of exposure to IAP,1 exacerbated by energy conservation, health and environmental the growing use of contaminated coal. concerns, both affordably and sustainably. 1In 2004, based on the 2000 census, China's National Bureau of Statistics cited 69 percent of the population, or about 900.6 million, as rural. xiii Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Concentration of pollutants at locations inside the should be accounted for while designing and house depends on energy technology (stove-fuel implementing IAP interventions. combination), house design (for example, house size and construction materials, room The project was implemented in four provinces: arrangement and number of windows) and stove Gansu, Guizhou, Inner Mongolia and Shaanxi. use behavior (for example, whether fuel is dried In at least two of these provinces, winter conditions before combustion). In addition to pollution levels, are harsh. Household characteristics in the study exposure depends on time activity budgets of areas portray rural populations living in household members (for example, time spent considerable poverty, as reflected by low family inside or near the stove and direct participation incomes, illiteracy and other disadvantages. in cooking tasks) and alternative food drying Despite rapid economic growth in the provinces, techniques. In short, IAP exposure can be reduced rudimentary household energy methods and using a wide array of technological, housing and practices in rural areas are a legacy of China's behavioral interventions. poverty and lack of capacity to handle such problems as IAP, even if informed of the health Project Summary risks. Lack, or perceived lack, of affordable alternatives necessitates use of low combustion The World Bank, in cooperation with China's solid fuels and inefficient heating and Ministry of Health and the China CDC in 2002, cooking stoves. initiated the project "Sustainable and Efficient Energy Use to Alleviate Indoor Air Pollution in The study measurements focused on documenting Poor Rural Areas of China." The project tested reductions in three indoor air pollutants: respirable affordable household energy interventions particles, carbon monoxide (CO) and Sulfur designed to reduce IAP exposure. To the best of Dioxide (SO2). Baseline data were collected to our knowledge, this study represents the first provide an understanding of the day to day, community-based intervention trial to have tested seasonal and spatial variations in pollution. The the combined effect of technological and technological, housing and behavioral behavioral IAP interventions, and their determinants of exposure were also documented. implementation in rural settings. Study design This information was used to design the IAP features and measurement instruments were interventions and provide the basis for evaluating selected or developed so that project results would their effectiveness. In addition, surveys were be useful to energy and IAP health specialists and conducted on IAP-related knowledge and behavior encourage policy makers and other stakeholders and selected health indicators for women and to be more proactive in proposing polices or children in the study households. The household implementing large-scale programs to effectively energy use interventions were of two types: address IAP and its health effects. 1) alternative stove technology (including improved ventilation systems; and 2) health It was anticipated that success in reducing IAP in education and behavioral activities. In each these provinces would lead to significant case, the interventions were tailored to fit improvements in the health of their rural location-specific conditions. populations, especially women and children, who typically are most exposed to the indoor Approximately, 500 households were household environment. The principal expected selected from each of the 11 townships on a outcome was better understanding of how quasi-experimental community trial basis, for a location-specific factors and considerations total of 5,500 households. These households were xiv ExecutiveSummary then divided into three groups: stove plus when heating was the main energy use. behavioral intervention (S + B), behavioral The evidence for cooking stove interventions was intervention (B) and control (C). In the case of less consistent. Fuel consumption for heating Inner Mongolia, only two groups were formed (versus cooking) is generally more stable and less (B and C). Baseline data for all three sets of intense when compared with cooking stoves. groups, collected through surveys and testing, Therefore, the indoor air quality benefits of provided the background against which to evaluate heating stoves are less susceptible to compromise the energy, IAP and health-related effects resulting from stove-handling behavior if the combustion is from the project interventions. Comparison of well separated from the living and sleeping areas results for S + B and B against changes in the and/or smoke is ventilated outdoors. The results same indicators for C, where no interventions of cooking stove interventions were more mixed were conducted, provided estimates of the relative because users tend to modify combustion effectiveness of the various interventions, patterns more regularly when cooking. To better abstracting from exogenous trends (for example, succeed, cooking stove interventions require temperature changes and energy prices) affecting greater modification of user behavior or stoves household energy use in rural China. which are robust to these behaviors. The interventions took into account the energy Introduction of alternative stove-handling needs for cooking and heating, housing behaviors, as part of the health education characteristics, fuel use and such sociocultural program, led to increased IAP-related knowledge factors as food types and storage methods. and changes in specific behavioral indicators Between March and October 2004, alternative based on self-reported data. With regard to indoor stoves were designed and tested for efficiency air quality, however, no measurable IAP benefits under both controlled conditions and actual resulted from health education and behavioral household use to assess the role of user behavior interventions alone, that is, without alternative in stove performance. Health education and stoves. These findings may reflect that behavioral interventions, including dissemination of people's behavior with regard to cooking and educational materials through village discussion heating ­ activities central to daily life ­ may be groups and visits to model homes, were also little affected by their knowledge and concerns implemented in the project areas. about long-term health outcomes, especially where infrastructure and household economic Post-interventiondatawerecollectedapproximately status limit opportunities for switching fuels and one year after the stove technology and behavioral stoves. They may also reveal the need to improve interventions were completed. Between December the design of behavioral interventions. In more 2004 and April 2005, indoor levels of Particulate comprehensiveinterventions,healtheducationcan Matter (PM4), CO, and SO2 were again measured play a key role in encouraging the uptake and use usingmethodsidenticaltothoseemployedtocollect of new technologies (for example, cleaner fuels and the baseline data. Follow-up surveys were also stoves) and reducing IAP exposure through specific conducted on the efficiency of household energy routes (for example, bioaccumulation of Fluorine (F) use, knowledge of the IAP health risk, behavioral in food dried over fire). changesandIAP-relatedhealthindicators. What Interventions are Needed? Analysis of the baseline and post-intervention data demonstrates relatively consistent evidence that China's early stove interventions of the 80s and stove interventions had IAP reduction benefits early 90s were motivated largely by energy xv Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China conservation to reduce biomass use and its effects A clear area in the need of investment is research on land degradation and deforestation. There was on and development of new technological options, also a shift toward greater consumption of coal for assisting producers and distributors in moving heating. It is only relatively recently that the health along the "experience curve" for such dimensions of household energy use interventions technologies. Such options as cleaner coal (with have been documented and used as input in lower Arsenic (As) and F concentrations) and designing and marketing new technologies. improved stoves will be difficult to sustain without a marketing and delivery system which facilitates There have been some advances in energy household access. As the poorest communities will generation in China, supported in recent years by continue to have the least ability to pay, most global warming concerns and the sharp rise in oil alternative household energy technologies prices. In the last two decades, China has mitigating IAP will not be marketable, and will demonstrated some commitment to Renewable therefore continue to require donor or Energy (RE) sources, as well as cleaner energies government interventions. Even so, government- (including the conversion of solid fuels to clean supported interventions may not be sustainable in liquid and gaseous fuels suitable for cooking and the long run. Also critical are appropriately heating). But the need for interventions in poor designed market interventions (involving the rural areas is immediate; it requires using all participation of the commercial fuel and stove available options, including cleaner fuels, more sector), which have a chance of uptake after efficient combustion technologies and fuel public interventions come to an end. alterations. As biomass energy technologies continue to advance, it may be advisable for China The options for promoting sustainable introduction to encourage rural areas to rely more heavily on of clean energy technologies are closely tied to renewable biomass energy rather than coal. The developing countries' capacity for energy encouragement may need little prompting if the research, development, demonstration and price of biomass gasified stoves falls sharply, which deployment.2 Paucity of training venues, movement along the "experience curve" would technology and information exchange, and likely allow. But increased biomass use would need technology standards exacerbate the perennial to be accompanied by careful land management challenge of funding. In addition, microcredit to and land tenure initiatives. foster locally-designed and implemented commercialization efforts is systematically lacking. Developing and Scaling up Interventions Moreover, research is lacking on the relationship International experience offers useful lessons. between renewable energy projects and the Market-based mechanisms are likely to be socioeconomic contexts in which they are important for long-term sustainability and embedded. Overcoming market failures cannot efficiency of interventions; yet, there are clear be resolved by private enterprises alone. Scaling areas for public sector investment both to create up and improving the sustainability of interventions and promote better technologies, and to deliver require better assessment of the supply and these technologies to the poorest households. demand for alternative energy technologies, and 2For more details, see Kammen, D.M., R. Bailis and A. Herzog. 2002. Clean Energy for Development and Economic Growth: Biomass and Other Renewable Energy Options to Meet Energy and Development Needs in Poor Nations. Policy Discussion Paper, ESDG. New York: United Nations Development Programme (UNDP), and Ezzati, M., R. Bailis, D.M. Kammen, T. Holloway, L. Price, L.A. Cifuentes, B. Barnes, A. Chaurey and K.N. Dhanapala. 2004. "Energy Management and Global Health." Annual Review of Environment and Resources 29: 383-419. xvi ExecutiveSummary evaluation of the policies and programs that can ventilation systems, despite the pervasiveness of optimally increase intervention coverage with a IAP and greater household awareness of its high degree of community effectiveness. health risks, calls for microcredit and other incentives to induce demand for new household To this end, the public sector plays an important energy technologies. These are all important role in supporting Research and Development considerations for high quality and (R&D) of household energy use alternatives; comprehensive (and almost certainly introducing infrastructure and financial incentives intersectoral) programs on IAP interventions which support the dissemination of new energy which go beyond raising concern and aim to technologies; and education, training and alleviate a major cause of mortality and awareness-raising activities. Rural residents' morbidity in poor rural areas of China and continued reliance on rudimentary stove and other developing countries. xvii 1. Introduction Fei Yu, Zuzana Boehmova, Enis Bari and Majid Ezzati Indoor Air Pollution (IAP), resulting from the use the complex environmental, technological and of solid fuels in poorly ventilated heating and behavioral issues which must be factored into cooking stoves, is a serious health hazard in while designing sustainable solutions. developing countries, increasing the occurrence of a range of respiratory and other diseases. Rural Household Energy and IAP Inefficient fuel use exacerbates the energy wastage and environmental problems; Globally, nearly 3 billion people rely on solid moreover, fuel-gathering is a time-consuming fuels (biomass and coal) as their primary and laborious task traditionally borne by source of domestic energy. In many developing women. Substantial welfare gains at all levels countries, biomass (wood, charcoal, crop (nationally, regionally and globally) can result residues and dung) accounts for more than from helping developing nations to reduce IAP 50 percent of energy consumption and as much and its health-related costs. as 90 percent in some lower-income ones. Evidence from certain countries indicates that In this spirit, World Bank, in 2002, initiated a the declining trend of household dependence project in China to test affordable household on biomass has slowed, or even reversed, energy interventions (improved stoves with especially among poorer households (Ezzati et better ventilation, health education and al., 2004). Estimated household reliance on behavioral changes) designed to substantially solid fuels is heaviest in Africa, South reduce IAP and exposure to it.3 The project and South-East Asia and the Western was implemented in four provinces (Gansu, Pacific (Figure 1.1). Guizhou, Inner Mongolia and Shaanxi) where rural poverty is still widespread. This Chapter Heavy reliance by rural households on explains why addressing IAP in rural China is of inefficient solid fuels for heating and cooking urgent importance. It introduces the nexus of results in high emission levels of Carbon household energy use and health, along with Monoxide (CO)4 and Particulate Matter (PM)5 3The project builds on World Bank-supported Comprehensive Maternal and Child Health VI Project, which succeeded in significantly reducing infant, child and maternal mortality rates in the project provinces. It also led to the observation that Indoor Air Pollution (IAP) was a major source of ill health among the rural poor. 4CO is an odorless, colorless toxic gas. At lower levels of exposure, CO causes symptoms which include headache, dizziness, disorientation, nausea and fatigue. At higher concentrations, CO poisoning is fatal. 5PM is the sum of all solid and liquid particles suspended in air when fuel is burned, many of which are hazardous. High concentrations and specific types of particles have been found to present a serious risk to human health. Of greatest concern are particles small enough to be inhaled into the deepest parts of the lung; these include PM10 (aerodynamic diameter less than 10 microns) and even finer ones, known as PM2.5 (aerodynamic diameter less than 2.5 microns). 1 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Figure1.1:EstimatedHouseholdRelianceonSolidFuelsbyCountry,2000 Note: Solid patterns represent countries for which estimates are based on model predictions. Source: Smith et al. 2004. (Figure 1.2). The main explanations for such can buy specific fuels if they choose to do so. heavy reliance are affordability (of fuel and/or Liquid fuels, notably Liquefied Petroleum Gas start-up cost for stove) as well as energy (LPG) and kerosene, are usually more infrastructure which determines whether people expensive than solid fuels, require more costly Figure1.2:Household-levelEmissionsbyFuel-type(permeal) 100.0 Eleventh Eleventh 10.0 1.0 0.1 Biogas LPG Kerosene Wood Roots Crop Dung CO Residues Hydrocarbons 0.1 1 3 19 22 60 64 PM 0.3 1 4.2 17 18 32 115 2.5 1 1.3 26 30 124 63 Note: Health-damaging pollutants per unit energy delivered: ratio of emissions to Liquefied Petroleum Gas(LPG) (data from K. Smith et al. 2000). Values are shown as Grams Per Megajoule of Energy Delivered to the Cooking Pot (g/MJ-d). Source: Smith, Rogers and Cowlin 2005. 2 Introduction stoves and harder to obtain for people in rural Rural China Context areas or urban slums. Indeed, many forms of biomass are traditionally collected on an Across China, residential energy individual, noncommercial basis. As Figure 1.3 consumption varies widely, reflecting demonstrates, the relationship between income differing access to energy sources, prices, and reliance on solid fuels is strongly climate, income and urbanization levels dependent on region. (Jiang and O'Neill 2004). Rural household consumption accounts for about 25 percent But the transition to cleaner fuels with increasing of the total national energy use (Wang and incomes should not be interpreted as deterministic. Feng 2001). From 1980 to 2004, rural Other factors, including alternative consumer household energy use per capita increased desires, may be equally or more important than about 60 percent. Over this period, the cleaner fuels. Further the energy options with increasing wealth and income vary: for example, composition of energy sources changed a household may decide to consume more energy, dramatically. The share from biomass fell switch to another form of energy or source of nearly 30 percent (from 84 percent to access, or use a mix of energy sources. slightly more than 55 percent), while The choice may be influenced by cultural context, that from coal increased 20 percent energy infrastructure and policy considerations (from only 14 percent to 34 percent) (Ezzati et al. 2004). (Table 1.1).6 Figure1.3:RelationshipbetweenIncomeandSolidFuelUse 120 fuels US$2 per day 80 Using 60 Households 40 of 20 Percentage 0 AFR-D AFR-E AMR-B AMR-D EMR-D SEAR-D WPR-B Global Burden of Disease (Mortality) Subregions Note: Abbreviations indicate WHO subregions: AFR = Africa, AMR = Americas, EMR = Eastern Mediterranean, SEAR = South-East Asia and WPR = Western Pacific. Corresponding letters (after each subregion) indicate mortality strata: B = low child mortality and low adult mortality, D = high child mortality and high adult mortality, E = high child mortality and very high adult mortality (WHO 2002). Source: Blakely et al. 2003. 6The annual National Rural Household Survey, which included information on biomass energy use, was discontinued in 2000; data on biomass use provided by the Ministry of Agriculture provide rough estimates of magnitudes and trends. 3 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Over the past 25 years, rural Chinese households 1998 level, accounting for 25 percent of the have transitioned toward commercial fuels (Figure rural energy supply in 2004; straw accounted 1.4). During the 80s, use of both biomass and for 30 percent. In total, biomass accounted for commercial energy increased (the latter more 55 percent of the rural energy supply, compared to rapidly than the former). During the 90s, rural use 34 percent for coal (Table 1.1). of biomass was relatively stable; only the highest household income group reduced use significantly That the burning of solid fuels represented (Jiang and O'Neill 2004). Use of agricultural more than 90 percent of increased consumption residues (straw and stalk) remained constant, while over the period suggests that most of the fuelwood use declined because of restricted access increase was for heating and cooking.7 A sharp to mountains and other reforestation measures. increase in electricity consumption would have suggested increased use of consumer durables Over the 1998-2004 period, rural energy (for example, refrigerators or television sets); consumption increased sharply. Data for 2004 show but, as Figure 1.4 illustrates, electricity absolute and per capita increases of 31 and 28 contributed only marginally to meeting the percent respectively; straw, fuelwood and coal surge in rural energy demand. The nature of accounted for more than 90 percent of increased increased demand thus indicates the likelihood use. Fuelwood use increased 43 percent over the of substantially greater exposure to IAP.8 Table 1.1: Rural Household Consumption by Energy Source, for SelectedYears (percent) Energy Share (%) Energy Source 1980 1990 1998 2004 TotalBiomass 84.3 77.4 56.7 55.5 Fuelwood 39.6 36.3 23.0 25.1 Straw and Crop Residues 44.7 41.1 33.7 30.4 TotalCommercial 15.7 22.6 43.3 44.5 Coal 14.2 20.1 32.0 34.0 Electricity 1.0 2.2 8.1 6.0 LPG + 0.5 0.3 3.2 4.5 RuralHouseholdConsumption per capita (Kgce)* 329.0 380.8 414.0 529.3 *Kilogram Coal Equivalent (Standard Coal Equivalent). Sources: Transportation and Energy Department, National Planning Committee of China; China Department of Agriculture, Technology and Education Office. 7An additional reason could have been better reporting of data. 8It should be noted that this data is limited to rural household-energy use (rural industry is not included); thus, further research is needed. Preparations are under way to implement the China Residential Energy Consumption Survey II (C-RECS II). The aim is to use data from this fuel-scale survey to improve China's energy consumption statistics and provide input to the standards-setting process for household appliances to create reference year data on which future China Residential Energy Consumption Survey (C-RECS) surveys can be built. Survey content would be adapted and expanded from the smaller C-RECS-I survey conducted in 1999, which was limited to urban households. The survey has been jointly planned and conducted by China's National Bureau of Statistics; Lawrence Berkeley National Laboratory; Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences; and Technical Economic and Energy System Analysis Group, Tsinghua University. 4 Introduction Figure 1.4: China`s Rural Household Transition in Energy Consumption, 1979-98 4.5 Electricity 4 Fuel Oil 3.5 Coal 3 Fuelwood tce 2.5 Straw and Stalk 2 million 1.5 1 0.5 0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Years (Mortality) Subregions Note: Data are from the 1999 National Rural Household Survey conducted by the China Rural Socioeconomic Survey Division, State Statistical Bureau. Source: Jiang and O`Neill 2004. Regional differences in rural household energy households use a combination of energy sources, consumption reflect resource availability and the most common being biomass, coal and climatic conditions. Reliance on biomass ranges electricity. In higher income households, from a high of 83 percent in North-East China to preference has shifted toward more sophisticated a low of 57 percent in North China. Provinces sources, such as electricity or LPG (Jiang and with extensive coal deposits (Guizhou, Hebei, O`Neill 2004). Ningxia, Shanxi, Xingjiang and Yunnan) rely heavily on coal (Jiang and O`Neill 2004). The In 1999, per capita expenditure on rural recent increase in the number of coal mines and household energy was approximately 56 yuan the low price of coal, together with restrictions on (US$6.8) (Jiang and O`Neill 2004), representing wood gathering, have encouraged households to 3.4 percent of the total expenditures and 2.3 switch from biomass to coal. Households percent of the total income. Energy expenditure proximate to urban areas (Beijing, Shanghai and increased with household expenditure: the share Tianjin) rely more heavily on electricity. spent on coal declined, that spent on LPG Northern provinces use more energy than increased and that spent on electricity remained southern ones, reflecting colder weather constant. While coal consumption increased with conditions. (Air conditioning is not yet prevalent in income, biomass and electricity consumption were rural areas.) It is noteworthy that 98 percent of income inelastic ­ at least at this stage of households have electricity;9 yet, in rural areas, development (Wang and Feng 2001). The reason electricity accounts for only 6 percent of total may have been a government ban on harvesting energy use (primarily for lighting). Nearly all fuelwood in certain forests. 9According to the 2001 Rural Household Survey (State Statistical Bureau), 98.3 percent of townships, 97.8 percent of villages and 97.4 percent of rural households have access to the power grid (see also China Energy Statistical Yearbook 2000-02, China Statistics Press). 5 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Thus, rural China appears to be in the early account for 55 percent of the rural energy, and stages of energy transition; the process of coal for another 34 percent. In sum, the IAP substituting modern fuels for biomass is slow.10 occasioned by the continued burning of solid Concurrent with this transition, China is fuels for heating and cooking remains a serious experiencing rapid growth in energy problem in China. consumption, which is closely correlated with net income growth and improved access to Profiles of Project Provinces electricity, coal and other fuels (Figure 1.5). Inthefourprojectprovincesreportedhere,rural Over the past two decades, per capita net income household energy use varied from 1998 to 2004. of rural households increased fourfold in real EnergyuseincreasedsubstantiallyinGuizhouand terms. While rising net income has been InnerMongolia,grewmoderatelyinGansuand accompanied by greater reliance on commercial declinedslightlyinShaanxi(Figure1.6).InGuizhou, energy to meet additional energy demand, the use substantialincreasesinruralresidentialenergyuse of biomass continues. Nevertheless, the effect of couldhavebeenfueledbyatriplingintheuseof China`s policy interventions (as distinct from the firewoodandadoublingintheuseofcoal.InInner general tendency of developing countries to switch Mongolia,thesmallincreasewaslikelytohavebeen to commercial fuels as incomes increase) is fueledprimarilybygreateruseofstalk.11 Noneofthe unclear. Whatever the trends and interventions, fourprovincesshowedacleartrendtowardincreased the fact remains that biomass continues to relianceoncoalrelativetootherenergysources. Figure1.5(a):RuralHouseholdEnergyExpenditurebyFuel-type(decilesofpercapitaincome) 140 Fuelwood, Straw andGrass 120 Charcoal year) 100 Coal (yuan/ 80 CoalProduct Electricity 60 Other Fuels 40 Expenditure 20 Energy 0 642 1,043 1,316 1,564 1,820 2,105 2,440 2,894 3,628 6,206 Per Capita Income (yuan/year) 10 Education is a primary variable which bears on biomass use: As education levels rise, biomass use declines. Other variables include household size, occupation and geographic conditions (Jiang and O`Neill 2004). 11 The figures show a surprising increase. One possible explanation is differences in reporting mechanisms; another is that it is a phenomenon deserving further exploration. 6 Introduction Figure 1.5(b): Rural Household Energy Expenditure by Fuel-type (deciles of per capita income) 100% Fuelwood, Straw 90% andGrass 80% Charcoal 70% Coal 60% 50% CoalProduct 40% Electricity Expenditure 30% Other Fuels 20% Energy 10% 0% 642 1,043 1,316 1,564 1,820 2,105 2,440 2,894 3,628 6,206 Per Capita Income (yuan/year) Figure 1.5(c): Rural Household Energy Expenditure by Fuel-type (deciles of per capita total expenditure) 140 Fuelwood, Straw andGrass 120 Charcoal 100 Coal (yuan/year) 80 CoalProduct 60 Electricity Other Fuels 40 Expenditure 20 Energy 0 536 899 1,200 1,600 2,486 4,862 Per CapitaTotal Expenditure (yuan/year) Figure 1.5(d): Rural Household Energy Expenditure by Fuel-type (deciles of per capita total expenditure) 100% Fuelwood, Straw andGrass 90% 80% Charcoal 70% Coal 60% CoatProduct 50% Electricity 40% Expenditure Other Fuels 30% Energy 20% 10% 0% 536 899 1,200 1,600 2,486 4,862 Per CapitaTotal Expenditure (yuan/year) Source : Jiang and O'Neill (2004). Reprinted with permission of Inderscience. 7 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Health Risks and IAP smoke), asthma, nasopharyngeal and laryngeal cancers, tuberculosis, low birth weight and eye The burning of biomass or coal in open or poorly disease (for example, cataracts). A comprehensive ventilated stoves results in the emission of survey conducted by the World Health hundreds of chemical substances, in the form of Organization (WHO) in 2000 found that each gases, liquids (suspended droplets) and solids year the first three of these diseases cause the (suspended particulates). These pollutants include death of more than 900,000 children under age CO, Nitrogen Dioxide (NO2), particles in the five and more than 700,000 adults (WHO 2002). inhalable range (below 10 µm in aerodynamic Globally, acute lower respiratory infection is the diameter) and other organic matter (for example, most common cause of mortality among children benzo[a]pyrene, Benzene (C6H6) and under age five. As Table 1.2 indicates, 98.5 and formaldehyde). In addition to the above pollutants, 98.7 percent of the respective deaths of children combustion of coal may release oxides of Sulfur and adults from IAP exposure, caused by solid fuel (S) and heavy metal contaminants, including use, occur in developing countries. Annually, IAP Arsenic (As) and F. Concentrations of inhalable results in a loss of healthy life years equivalent to particles, CO and Sulfur Dioxide (SO2) in some 40.9 million Disability Adjusted Life Years households reliant on solid fuels for heating and (DALYs)12 (WHO 2002). cooking, may be multiples of standards for For developing world regions, Ezzati et al. (2002) ambient air pollution. found that indoor smoke from solid fuels is a leading health risk factor. Globally, of the 20 leading health Detailed epidemiological and toxicological risk factors causing death, IAP ranks 11th (Figure research on the health effects of IAP from solid 1.7); in terms of DALYs, IAP ranks eighth (Figure fuels has only recently begun. Nonetheless, the 1.8). For high mortality developing regions (that is, growing consensus is that IAP is a causal agent of those with very low income), IAP ranks fourth in acute respiratory infection, chronic obstructive importance as a health risk factor. For low mortality pulmonary disease, lung cancer (from coal developingregions,includingChina,IAPranks eighthinimportanceasahealthriskfactor. Table1.2:AnnualMortalityCausedbyIAPExposurefromSolidFuels CountryGrouping %ofGlobal Children Adults Population Under Five Years High Mortality Developing Countries 38 808,000 232,000 Low Mortality Developing Countries 40 89,000 468,000 Demographically and Economically 22 13,000 9,000 Developed Countries Source: WHO 2002. 12DALYs lost to mortality are the total discounted value of years lost to premature death across all causes and age groups. DALYs lost to disability are based on the incidence and duration of various types of disability multiplied by a weight which accounts for the severity of the disability compared to loss of life. Total DALYs result from the sum of DALYs lost to mortality and disability, adjusted by a discount rate so that future years of healthy life are valued at progressively lower levels and by age group weightings, so that years of life lost at different ages are given different relative values. 8 Introduction Figure1.6:RuralResidentialEnergyConsumptionbyStudyProvince(percapita)inSelectedYears 1.20% Coal Gas 2004 1.00% Natural Gas 2004 LPG 0.80% Biogas tce0.60% 1996 Processed Oil 1998 1996 1998 1998 2004 1996 Electricity 0.40% 1998 2004 1996 Coal 0.20% Firewood Stalk 0.00 Inner Guizhou Shaanxi Gansu Mongolia Source: China Department of Agriculture, Technology and Education Office. Women and children are at greatest risk since The Comparative Risk Assessment analysis they spend more hours per day indoors in the estimated that, in 2000, IAP was the fourth vicinity of the cooking stove. Worldwide, the risk leading health risk factor contributing to to women from IAP is nearly 50 percent higher mortality in China, causing more than 500,000 than for men (Ezzati 2002). Risk is highest in deaths (WHO 2002). Indoor smoke from solid South-East Asia, Western Pacific (including fuels was the fifth most important risk factor in China) and Sub-Saharan Africa. Across the terms of DALYs, accounting for 2.5 percent of developing world, IAP is a serious health the total lost healthy life years. hazard, especially in rural areas where reliance on biomass and coal for heating and cooking, Virtually all of China's rural households ­ under poor combustion and ventilation representing some 900 million of the country's conditions, is virtually universal.13 total population of 1.3 billion,16 rely on |biomass Challenge of Rural China and coal to meet their daily heating and cooking needs. Extensive use of coal for heating and The global health risks from IAP noted in the cooking emits high SO2 concentrations, which are previous section apply equally in China.14,15 associated with adverse health effects. 13Reduction of IAP is reflected in the United Nations Millennium Development Goals (MDGs); solid fuel use is an indicator of environmental sustainability (Goal 7), while reduced IAP is related to many other goals, including the goals of reducing child mortality and promoting gender equality. 14The WHO comparative risk assessment, conducted over a two-year period in 14 world regions, including the Western Pacific (of which China accounts for 85 percent of the population), provides an authoritative assessment of the health consequences of IAP in China (WHO 2002). 15 According to the Asian Development Bank (ADB), 17 percent of China's population still lives on less than US$1 per day (Key Indicators 2005). In 2004, China's per capita income was US$1,290 (World Development Indicators database, August 2005); based on Purchasing Power Parity (PPP), this translates into US$5,530. Rural income is about one-third of the national average. 16Based on the 2000 census, the National Bureau of Statistics of China in 2004 cited 69 percent (900.6 million) of the country's population as rural. 9 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Monitoring the health effects of improved stoves in In Xuanwei, incidence of chronic obstructive Xuanwei County, Yunnan Province, before and pulmonary disease decreased noticeably after after the intervention provides the most detailed household coal stoves were improved (Chapman evidence of the ill effects of coal smoke. et al. 2005). Following the introduction of Figure 1.7: Leading 20 Global Risk Factors for Mortality High Blood Pressure Tobacco High Cholesterol Underweight Unsafe Sex Low Fruit and Vegetable Intake HighBMI PhysicalInactivity Alcohol Unsafe Water, Sanitation and Hygiene Indoor Smoke from Solid Fuels High Mortality Developing Iron Deficiency Low Mortality Developing Urban Air Polluticn Developed Zinc Deficiency Vitamin A Deficiency Unsafe Health Care Injections Particulate Occupational Risk Factors for Injury Lead Exposure IllicitDrugs 0 1000 2000 3000 4000 5000 6000 7000 8000 Attributable Mortality in Thousands (Total 55,861) Source: Ezzati et al. 2002. Figure 1.8: Leading 20 Global Risk Factors for Loss of Healthy Life (Measured in DALYs) Underweight Unsafe Sex High Blood Pressure Tobacco Alcohol Unsafe Water, Sanitation and Hygiene High Cholesterol Indoor Smoke from Solid Fuels Iron Deficiency HighBMI Zinc Deficiency Low Fruit and Vegetable Intake High Mortality Developing Vitamin A Deficiency Low Mortality Developing PhysicalInactivity Developed Occupational Risk Factors for Injury Lead Exposure IllicitDrugs Unsafe Health Care Injections Lack of Contraception Childhood Sexual Abuse 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% Attributable DALY (% of Global DALY ­ Total 1.46 billion) Source: Ezzati et al. 2002. 10 Introduction improved stoves in the early 1980s, levels of use of biomass for heating and cooking. household particles were reduced by a factor of But foraging for biomass (for example, three. Reduction in lung cancer, a decade later, branches or young trees) in new growth areas was about 40 percent for men and 45 percent for following clearing (for example, for logging women (Lan et al. 2000). or agriculture) can hamper reforestation. Encouraging a shift to charcoal, which offers The health risks from coal use increase in those some health benefits compared to wood,17 regions of China where coal is contaminated by F could lead to more severe environmental or As (or both). According to the Institute for degradation because (given current charcoal Endemic Fluorosis Control, China CDC, F content production methods) more fuelwood is needed of coal is high in 201 counties, affecting 35,000 per meal when cooking with charcoal versus villages and nearly 34 million residents. Some wood; even the most efficiently produced 17 million people are subject to dental fluorosis; charcoal translates into net loss of energy.18 incidence in children eight to 12 years old is high. Crop residues used for fuel rather than Endemic Arsenic (As) poisoning from toxic coal livestock fodder or soil nutrient can lower occurs in eight counties (representing 42 townships agricultural output.19 and 142 villages or 333,905 residents). In Guizhou and Shaanxi provinces, exposure to As Household biomass use for fuel is potentially poisoning from burning toxic coal is high. Greenhouse Gas (GHG) neutral (Smith, Uma In Guizhou, four counties (32 villages) are heavily and Kishore 2000; Bailis, Ezzati and Kammen exposed. Drying of corn and red peppers in 2003). If harvested sustainably and burned households or sheds warmed by coal stoves results under ideal conditions, biomass fuel results in high levels of contamination as pollutants are almost entirely in the emission of water vapor transmitted to food. In many areas, the fluorosis and Carbon Dioxide (CO2); water vapor is content of corn and red peppers exceeds the quickly incorporated into the hydrologic cycle national standard (1.5 Milligram Per Kilogram with no measurable warming effect, while CO2, [Mg/Kg]) (hundreds of times so for red peppers in the most common GHG, is absorbed by new Guizhou, Yunnan and Sichuan) (Yu 2005 and plant growth through photosynthesis. At issue, Finkelman, Belkin and Zheng 1999). however, is the degree of incomplete combustion typical of most household stoves in developing Environmental Dimension countries. In addition to water vapor and CO2, hundreds of gaseous and aerosolized compounds Beyond the risk to human health, rural household are emitted, including CO, Methane (CH4) and use of solid fuels, particularly biomass, can nonmethane hydrocarbons. Non CO2 Greenhouse indirectly lead to potentially irreversible Gases (GHGs) are not absorbed by photosynthesis environmental damage. For example, and remain in the atmosphere until they are deforestation seldom occurs because of household broken down by complex natural processes. 17While charcoal is worse than other fuels with respect to Greenhouse Gas (GHG) emissions, it can lead to reduced concentrations of pollutants like PM (Bailis et al. 2004). 18 Since most of the fuelwood energy is lost in the production process, charcoal users utilize more fuelwood than direct users (Kammen and Lew 2005). 19 Soil degradation and erosion, along with disruption of water systems and soil nutrient cycles, can result in reduced agricultural productivity, damaged ecological systems and altered wind movements. Energy generated from biomass combustion using traditional technology releases many pollutants known as potential hazards to ecological systems. Energy harvesting, the process by which energy is captured and stored, and combustion add to the net flow and stock of Greenhouse Gases (GHGs), which contribute to climate change. 11 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China DependingontimehorizonsandtheGHGs considered. While biomass-burning stoves rank measured, estimates of emissions for various stove- well in terms of gases included within the Kyoto fuelcombinationsindevelopingcountriesindicate Protocol, they rank at best on a par with kerosene that both LPG and kerosene have a GHG effect or LPG if the full range of gases emitted are comparable to, if not lower than, renewable considered. Biomass-burning stoves rank biomass fuels. Further, the effect is far less decidedly behind kerosene or LPG stoves if the comparedtobiomassfuelsnotusedrenewably. biomass consumed is not renewed. Because stoves fueled by liquid and gas (fossil fuels) Furthermore, the stove-type demonstrates a are generally more efficient than those fueled by wide range of emission factors.21 solid biomass, emissions per unit of energy delivered favors LPG and kerosene over most China is a non-Annex 1 country under the United biomassfuels.Givencurrentcombustiontechnology Nations Framework Convention on Climate and behavior, a shift to kerosene and LPG can Change, which means it has not agreed to binding reduce exposure to IAP and GHG emissions. targets for reduction of CO2 and other GHG emissions under the Kyoto Protocol. As China is Nevertheless, the environmental implications of the world's second largest emitter of GHGs, its household use of solid sulfate fuels should not be pledge to cut emissions is important.22If no understated. The burning of coal creates ambient measures are taken, the country is projected to air pollution (for example, aerosols) with local, experience the largest absolute growth in CO2 regional and even global implications. Increased emissions between now and 2025. China's household energy use efficiency from echnological five-year national development plan sets the improvements benefits both households and the objective of raising energy efficiency by 20 global community through reduced CO2 and other percent by 2010. The country's long-term goal is emissions.20 But the dual health and environment to reduce its overall coal dependency from 65 to benefit should not occur at the expense of other 35 percent of energy generation by 2050. priorities in developing countries, where many China's primary concern, however, is with local factors bear on the cycle of poverty. problems, such as PM and SO2 emissions. Acid China's Environmental Policies rain, caused largely by the consumption of high-Sulfur coal, falls on some 30 percent of land. In the 90s, China's policies to reverse In an effort to encourage switching to cleaner deforestation and reduce soil degradation burning fuels, the government introduced a tax on discouraged reliance on biomass and contributed high-Sulfur coals. A system of emissions trading likely to rural households' switching to coal. for SO2, similar to that in the United States, is A comprehensive evaluation of 28 stove/fuel being pilot-tested. The government is applying technologies commonly used in China found that stricter pollution controls on power plants, as the relative benefits of biomass and fossil fuels and well as policies designed to increase the policies promoting various fuel-types depend on share of natural gas in the country's fuel whether all products of incomplete combustion are mix (EIA 2005). 20Ozone is not emitted directly, but is produced by the reactions of nitrogen oxides and hydrocarbons (known as volatile organic compounds) or CO. Elevated surface-level ozone concentrations are correlated with plant damage, as well as respiratory disease and premature mortality. 21"It is possible to implement policies with the best of intentions for alleviating the burden of collecting fuel, which may actually result in increased exposure of populations to health damaging pollutants and increased global warming contributions." (Edwards et al. 2004). 22This pledge was repeated at the Montreal meeting held in late 2005 to finalize the "rule book" for the Kyoto Protocol. 12 Introduction The polluter-pays principle is being applied more · What factors determine human exposure and rigorously. Initiatives under consideration include what are their relative contribution to tax incentives for environmental protection, as well personal exposure? as preferential loans and subsidies for · What is the exposure response relationship environmental-friendly products. The government between IAP and disease? has begun setting energy efficiency standards for · Which determinants of human exposure can be household appliances. China's medium- and long- influenced through any given intervention term energy development program for the strategy, and to what extent? 2004-20 period (recently approved by the State · What are the effects of any intervention on Council) includes building strategic reserves, human exposure and health outcomes, energy conservation, fuel diversification, energy and how would they persist or change security, further exploration and over time? environmental preservation. · What are the broader environmental effects of any intervention, its costs and the social and IAP Interventions: What are the economic institutions and infrastructure Knowledge Gaps? required for its success? While IAP has received increasing attention as a Rural household exposure to IAP can be health risk to rural households, less is known about reduced through interventions in emissions the design and dissemination of appropriate source and energy technology, housing and interventions.23 Drawing lessons from international ventilation and behavior and time activity experience is hampered by lack of systematic budget (Von Schirnding et al. 2001). To this studies on household energy interventions. end, it is critical that further research be While benefits of the interventions adopted may be conducted on the complex interactions among known, the motivation for adoption, as well as the technological, behavioral, economic and long-term effects and sustainability, are generally infrastructural factors which determine the not. Also, broader environmental and success of environmental health interventions, socioeconomic implications have not been especially with such nonhealth dimensions as sufficiently researched. To date, research has household energy (Jin et al. 2006). focused on improved stoves and fuels. Initial interventions in the early 80s were often marked These issues are especially important for female by lack of detailed data on stove performance. household members. Unless the details of the Efficiencies and emissions, for example, were users' needs and behavior are considered during often measured in controlled environments design, making energy cleaner may have (Krugmann 1987; Manibog 1984). More recently, contradictory results for women in certain aspects. research has shifted to monitoring stove For example, improved ceramic woodstoves with performance under "actual use" conditions increased combustion efficiency may require that (Ezzati et al. 2004). fuelwood be cut into smaller pieces and added more frequently, increasing women's workload To design and disseminate appropriate and possibly exposing them to high-risk emissions interventions, researchers must ask: during refueling. 23This section draws extensively on Ezzati et al. (2004) and Ezzati and Kammen (2002a, 2002b). 13 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Review of China's Stove Programs Other agencies soon introduced their own stove programs. In the mid-90s, the Ministry of Health The Chinese National Improved Stoves Program, a started a program to promote improved kitchens publicly-financed initiative of the Ministry of in poorer regions. It also initiated a program in Agriculture initiated in the early 80s, aimed to areas where fluorosis from burning high-fluoride provide rural households more efficient biomass coals was endemic. In 1998, the National stoves and, later, improved coal stoves for Development and Reform Commission (formerly cooking and heating (Smith et al. 1993; Sinton the State Development Planning Commission) et al. 2004). The primary motivation was to initiated the Yangtze River Valley Environmental conserve energy and reduce time and labor Protection Project, which aimed to reduce soil needed to collect biomass, thereby affording erosion through reforestation; the project included household members more time to pursue provincial and county stove programs patterned human development activities.24 Health after the Chinese National Improved considerations were not of primary concern. Stoves Program. The program extended to 860 counties (about In 2002, an independent review by a 40 percent of all counties). Aided by independent multidisciplinary team of U.S. and Chinese provincialandcountyprograms,commercialactivity researchers found that China's improved andwordofmouth,improvedstovesspread household stove programs had succeeded in throughoutChina.Theaveragesubsidiesfor providing better stoves to most households in the improved biomass and coal stoves were 26 percent targeted counties. The success reflected strong and 10 percent, respectively. By the early 90s, 130 administrative, technical and outreach millionimprovedstoveshadbeeninstalled,anduse competence and local resources, supported by of biomass eased in most regions. As the program extensive national-level attention. Most biomass wound down, the Ministry of Agriculture shifted its stoves were found to have flues and other support to stove manufacturers and Energy Service technical improvements, although field efficiencies Companies (ESCOs). From the mid-90s on, support were less than expected at the design stage. for the stove industry was replaced by extension By contrast, most coal stoves, even those using services and certification systems to standardize improved fuel (briquettes), lacked flues and thus stoves.Developmentanddisseminationofimproved could not be considered improved. In nearly all stoves was now left mainly to market suppliers, with cases, PM levels after stove introduction were some local government oversight. The Ministry substantially higher than the national standard for claimed that, by 1998, 185 million of China's 236 indoor air. Thus, the benefits of improved biomass millionruralhouseholdshadimprovedbiomassor stoves were outweighed by the use of portable coal stoves. But degree of coverage varied widely coal stoves without flues (Sinton et al. 2004). by region (reaching only 22 percent of households in western provinces, compared with nearly In 2004, the Household Monitoring Project in China 100 percent in eastern provinces and evaluatedtheNationalImprovedStovesProgram 70 percent in the central region). (Sinton et al. 2004).25 A survey of 3,476 24Beginning with the Sixth Five-Year Plan (1981-85), the State listed development of fuelwood forests as part of the national reforestation program and rural energy development. Increasing fuelwood supply and fuel efficiency was considered a strategic necessity in rural development. 25Collaborating institutions were University of California (Berkeley and San Francisco), Tsinghua University, Renmin University and Chinese Center for Disease Control and Prevention (China CDC)(funding was provided by the Household Energy and Health Programme, Shell Foundation, London). 14 Introduction householdswasconductedwhichincludedmeasures chimneys are urgently needed in areas using of health, stove performance, socioeconomic factors poisonouscoals. and(inasubsampleofhouseholds)indoorair quality. Three provinces (Zhejiang, Hubei and Other studies indicate that improved stove Shaanxi) were chosen to represent, respectively, programs introduced by local health agencies high,mediumandlowadoptionrates. have produced promising results. For example, a study conducted in Shaanxi (Ankang County) In January 2005, a widely attended workshop was showed that improved stoves and installation of held in Beijing to disseminate results of the underground ventilation ducts reduced fluoride National Improved Stoves Program review concentration of indoor air from 150 milligram(s) (China Energy Group and Smith 2005). (mg)/m3 to 3 mg/m3, well below the The review concluded that: internationally accepted standard of 20 mg/m3. Fluoride contamination of food dried indoor, · Despite extensive improved stove above the stoves, was also greatly reduced (from distribution, IAP caused by the incomplete 1,342.2 mg/Kilogram(s) kg to 52.2 mg/kg in the burning of biomass and coal remains a case of chili peppers). Studies in Xuanwei and critical factor threatening the health of rural North-East Sichuan hold further testimony to the fact residents; average particle levels in that improved stoves can significantly decrease IAP. households often exceed the national IAP Lessons from these studies, together with models standardMicrogramsPerCubicMeter(150µg/m3) and designs for improved stoves, ventilation by a factor of two or greater (Smith 2005);26 systems and pilot activities, have been · Since solid fuels will continue to dominate incorporated into the project reported here. rural household energy supplies in the A major lesson is that improved stoves must be foreseeable future, improving the ways in subject to more scientifically-based design criteria. which solid fuels are used, combined with Insufficient scientific analysis of the implications of widening access to and use of higher quality fuel-saving cooking stoves may have resulted in forms of energy, must be a key part of increased exposure to health-damaging China's rural energy strategy; pollutants and increased release of GHGs · New technologies (developed mainly by the (Edwards et al. 2004).27 private sector) which offer potential for using biomass fuels in cleaner, more efficient ways Use of coal-heating stoves in winter months and should be encouraged on a large scale; greater substitution of coal for biomass in cooking direct government intervention should be may have undermined the indoor air benefits of limited to quality control, Research and improved biomass stoves. Although the thermal Development (R&D) and assistance to the efficiency of commercial energy is generally poorest areas; and higher than that of noncommercial energy, coal · Use of coal with toxic elements (F and As) must stoves used in rural areas are usually inefficient be discontinued; improved stoves with and more polluting than improved biomass stoves. 26For the households surveyed, a significant reduction (120 µg/m3) in 24-hr, particle levels were recorded by switching from older to improved biomass stoves; winter measurements were invalidated by common use of multiple stoves and fuels, particularly unvented coal heating stoves. 27The focus on more efficient cooking stoves meant supplementary stoves for heating and attendant pollution. Improved flues and chimneys resulted in neighborhood and area pollution, which penetrated back into the indoor environment (see Edwards et al. 2004, p. 405). 15 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China A new government program to reduce F and As overall poverty rate would be 1.5 instead poisoning from coal use includes an improved of 8 percent; stove program which targets areas where disease · Most poverty reduction has occurred in rural from these toxins is serious. By 2010, areas, resulting from growth in primary 75-95 percent of households in high-disease agriculture; but growth has lagged in provinces areas (compared to 20 percent today) will have where the greatest effect on poverty reduction improved stoves. would have been realized; and · Increasingly, aggregate growth is derived from Poverty in Rural China sources which bring limited gains to the poorest; thus, to maintain its past progress in Despite impressive economic growth over the past combating poverty, China must effectively two decades, more than 100 million Chinese address the problem of rising inequality. continue to live in acute poverty. More than two-third of China's rural poor live in the western Analysis of the four provinces studied in this provinces. Poverty is most severe in the project reveals that, during the 80s and 90s, north-western provinces (World Bank 2001). mean per capita income in rural areas increased by an average annual percentage Trends in Poverty Reduction of 3.9 (Inner Mongolia), 3.5 (Ganzu), An econometric analysis of poverty trends in China 2.4 (Shaanxi) and 2.1 (Guizhou). Given the included the following findings (Ravallion and national rural rate of 3.4 percent, Shaanxi and Chen 2004):28 Guizhou lagged by comparison. With the exception of Inner Mongolia, whose national · In the 20-year period after 1981, the per capita income ranking rose to 15, the proportion of the population living below project provinces remained low on the income China's new poverty lines fell from 53 percent scale. Over the same 20-year period, national to 8 percent;29 in 2001, incidence of poverty incidence of rural poverty declined 6 percent was 12 percent; annually. In Inner Mongolia, Ganzu and · Poverty reduction has progressed by fits and Guizhou, the rural reduction rate was equal to starts. Half occurred in the early 80s; after or higher than the national rate, while that of stalling in the late 80s and early 90s, reduction Shaanxi was lower (only 3 percent). resumed in the mid-90s, only to stall again in the late 90s; In 2005, the United Nations Development · Absolute inequality has increased, and relative Programme (UNDP) reported that a large inequality is higher in rural areas (Zhou and percentage of the Chinese population lives close Wan 2004); to the poverty line (UNDP and China · Had inequality not increased and had the Development Research Foundation 2005). same economic growth rates prevailed, the Each year, some 30 percent of rural 28See also Rural Survey Organization, National Bureau of Statistics, China (Poverty Statistics in China, September 2004). 29The long-standing official poverty line for rural areas is 300 yuan (Y) per capita per year at 1990 prices (US$0.66 per day in constant 1985 PPP dollars). The new poverty lines developed for the study were based on region-specific food bundles, valued at median unit values by province. These bundles were then scaled to reach 2,100 calories per capita per day. Allowance for nonfood consumption was based on the nonfood spending of households in neighborhoods, where total spending equaled the food poverty line in each province (separately for rural and urban areas). The national poverty line was derived from the means of the regional lines, yielding Y 850 per year for rural areas and Y 1,200 for urban areas, in 2002 prices. 16 Introduction households fall back into absolute poverty.30 Per capita disposable income in urban According to a 2003 survey, 27 percent of areas was 3.2 times that of rural areas. Life poor households in the 11 western provinces expectancy in urban areas was more than 75 are impoverished due to illness or injury.31 In years, compared to less than 70 in rural areas officially designated poor counties, more (eight years in the western provinces). than 4 percent of residents are ill or weak, and access to medical care is limited.32 In the four project provinces, large Substandard health care services,33 combined urban-rural disparities were revealed with lack of medical insurance and social for female life expectancy (10 years in security, frequent natural disasters and Guizhou) (Table 1.3). Nearly 10 percent increased incidence of disease, are key of rural residents had no formal causes of rural poverty. education. In the western provinces, school enrollment was low and dropout Urban-rural Disparities rates high, in part, because of unaffordable China's Human Development Index (HDI) school fees. In China's poorest villages, improved significantly over the past three up to 50 percent of school-aged boys decades (from 0.52 in 1975 to 0.75 in dropped out before completing primary 2003),34 but the disparity between urban school, particularly in minority ethnic and rural improvement is significant. In 2003, areas where language is a barrier; nearly all the index for urban areas was 0.816, school-aged girls in these areas did not compared to only 0.685 for rural areas. attend school (World Bank 2001). Table1.3:LifeExpectancyinProjectProvinces Urban Rural Province All Female All Female Gansu 75.5 77.2 67.2 67.8 Guizhou 73.9 76.7 64.7 66.2 InnerMongolia 74.1 76.5 69.3 70.4 Shaanxi 75.9 77.2 69.3 70.6 China 75.2 77.5 69.5 71.3 Source: UNDP and China Development Research Foundation 2005. 30National Bureau of Statistics, 2003. 31Statistics and Information Center, Ministry of Health, 2004. 32The third National Public Health Service Survey (2003) indicated that, for rural residents, 62 percent of two-week patients in western provinces did not see doctors because of economic hardship. 33Government per capita outlay for health care is more than five times higher in urban versus rural areas (Institution of Health Care Economy, Ministry of Public Health, 2003). 34The UN Human Development Index (HDI) is a comparative quality of life measure based on three basic dimensions of human development: Life Expectancy at Birth (LEB); knowledge as measured by the adult literacy rate and combined primary, secondary and tertiary Gross Enrollment Ratio (GER); and Gross Domestic Product (GDP) per capita at PPP in U.S. dollars; 177 countries were ranked in 2003. 17 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Health/Household Energy Nexus energy efficiency (for example, cars or buildings) and a mandatory labeling system for energy-using That China's poverty is concentrated in rural areas appliances. To date, no efficiency standards have bears on the health/household energy use nexus. been set for rural buildings.40 During the 90s, household energy spending increased some 200 percent to more than Projections for 2030 indicate that coal will RMB ¥300 by the end of the decade.35 While continue to dominate as a primary energy source middle- and upper-income quintiles spent more in China (Kato 2003). Currently, coal accounts for than the poor on energy in absolute terms, the nearly 70 percent of China's primary energy, but poor faced immense difficulty absorbing increased increased use of oil, gas and hydropower, together costs for household energy.36 Over a two-year with introduction of nuclear energy, is expected to period (2003-05), the price of ituminous coal reduce coal dependence to 60 percent. Over the increased nearly 50 percent; over the same next 25 years, China is projected to account for period, the price of gasoline and diesel increased 20 percent of world incremental demand for 34 and 20 percent, respectively.37 Rural ousehold energy and 50 percent of incremental demand for fuel prices, especially for biomass and low-grade coal. Energy demand will pressure supply, coal, lagged fuel prices in urban areas and for meaning that prices will remain high or even rise, industry, but national energy supply-and-demand with the possibility that the poor may not have pressures meant a significant increase in the cost economic or physical access to cleaner fuels; thus, of commercial fuel for heating and cooking. they would continue to depend on biomass and low-quality coal. Absence of countermeasures, In response to the energy crisis, the government emission of CO2 and other GHGs would increase, has targeted cutting energy use per unit of Gross compounding the climate changes already Domestic Product (GDP) by 20 percent by afflicting many parts of the world, including China. 2010.38 Market pricing of fuel, thereby liminating Addressing the poverty aspects of the health/ the 20-30 percent or higher subsidies now household energy nexus requires a system of enjoyed by consumers, offers one way to achieve township-based targeting; the bulk of funding for this goal.39 But the government hopes to exempt IAP interventions must be directed to poor some 700 million farmers from price rise. Other ownships within and outside nationally designated measures include setting stricter standards for poor counties (World Bank 2001).41 35Government of China, Compilation of Typical Survey Data of China's Rural Economy (1986-99), Office of Fixed Point Surveillance, Ministry of Agriculture. 36National Bureau of Statistics of China, Rural Household Survey in China, 2004. The Industry and Transportation Statistics Department, National Bureau of Statistics of China, is responsible for collecting and compiling China's energy statistics. The Bureau is endeavoring to improve the quality of its energy statistics, including data on residential energy use. Preparations are under way to conduct the second C-RECS II in collaboration with the Lawrence Berkeley National Laboratory. 37Beijing Energy Efficiency Center (www.beconchina.org). 38Statement by Chinese Premier Wen Jiabao at the Summit Meeting of East Asian Leaders in Malaysia, December 2005. 39In February 2005, the price of natural gas (US$ per Million British Thermal Units MBTUs) was US$4.55 in China, compared to more than US$7 in the United States. The gap was partially closed during 2005, as the government of China increased domestic energy prices five times. The China Daily (January 20, 2006) quoted Zhao Xaioping, Director, Pricing Department, National Reform and Development Commission (NRDC), as saying that the prices of oil, gas, coal and electricity would soon be liberalized by subjecting them to market forces. 40Labeling for energy efficiency was first introduced in 1999 for refrigerators; more information is available at World Energy Council (www.worldenergy.org). 41Since 1986, the government's county-based, poverty targeting system, has resulted in near-complete omission, even under the 8-7 Poverty Reduction Plan, introduced in 1994, to fund "the other half of the poor" residing outside designated counties. World Bank (2001) concluded: "The central and provincial governments should increase their assistance to the poor areas in support of a limited set of health services directed at the principal causes of morbidity and mortality. At a minimum, this should include increased public funding for the control of infectious diseases, overall disease surveillance and reporting, health information and education and the strengthening of the basic infrastructure of the health system in the poorest areas." 18 Introduction Project Context the health of the rural population notably omen and children, who typically are the most As noted previously, World Bank initiated a exposed to the indoor household environment project in China, in 2002, to test affordable (Ezzati et al. 2004). household energy interventions ­ improved stoves, better ventilation, health education and The project is empirically based in order to behavioral changes ­ designed to substantially build understanding and compile data and reduce IAP and exposure to it. Known as the results potentially applicable to other areas of Sustainable and Efficient Energy Use to Alleviate China and other developing countries. Indoor Air Pollution in Poor Rural Areas of A multidisciplinary team participated in the China, the project was designed to add to the project. This report endeavors to capture the foundation of knowledge which will enable the development of sustainable interventions insights of each component, as well as the customized to local conditions. collective findings and conclusions. The project was implemented in four provinces Structure of this Report characterized by widespread rural poverty This report is structured as follows. Chapter 2 and (in at least two of the test areas) harsh describes the project goals and objectives and winter conditions: Gansu, Guizhou, Inner general methods used. Chapter 3 provides Mongolia and Shaanxi (Figure 1.9). It is socioeconomic profiles for each of the four anticipated that success in reducing IAP in these provinces studied, together with references to the provinces will lead to significant improvement in countiesandtownshipswhichservedasthestudy Figure 1.9: Map of China, Showing the Four Study Provinces Source: Jin et al. 2006. Reprinted with permission of Elsevier. 19 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China sites; it also provides baseline data on levels of IAP, with regard to household energy use, IAP levels, household energy use, behavior affecting knowledge and behavioral changes and health exposure and health indicators related to indicators. Chapter 5 considers alternative respiratory disease. Chapter 3 also describes the technological options for reducing IAP. Finally, stove and health education/behavioral Chapter 6 summarizes the project lessons and interventions conducted as a part of the project. offers policy and program recommendations for Chapter 4 discusses results of the interventions future R&D studies. 20 2. Project Overview Zuzana Boehmova, Fei Yu, Enis Bari and Majid Ezzati This Chapter is divided into two sections: project access and the interaction between technology description and project design. The first section and householdbehavior. considers the basis of the project in terms of its goals and objectives, expected outcomes and Objectives beneficiaries, components and implementation Project objectives were to: and management and partner organizations. The second presents the project's underlying · Determine the scope and severity of IAP in the rationale, its intervention model and hypotheses test sites of four Chinese provinces where rural and site selection process. populations are exposed to high levels of IAP because of climatic, topographic and Project Description socioeconomic reasons; · Understand the technological and behavioral The purpose of this project was to evaluate the determinants of exposure; community effectiveness of relatively simple and · Determine the knowledge about health risks affordable household energy interventions associated with IAP and potential interventions (alternative stoves, better ventilation, health to reduce the level and degree of exposure; education and behavioral changes) to lower · Test a variety of potential household energy exposure to IAP in rural China.42 Further, the project interventions to reduce IAP and assess their aimed to facilitate implementation of these health, energy, environmental, educational and interventions and build local capacity for their poverty reduction benefits; and supply and maintenance. The anticipated · Evaluate the technical, sociocultural, outcomes in project intervention areas were organizational and economic feasibility of substantially lower levels of IAP and exposure to broader application of the interventions and it, thereby helping to lower associated health their sustainability. risks. More generally, the expected outcome was advancing knowledge about location- To gain broad support and interest, the specific factors and considerations in designing interventions were designed to yield significant and implementing IAP interventions. Project benefits at an affordable cost and be possible to results demonstrate the need for further implement within local institutions using local research, notably in technology design and infrastructure. An important indicator of success 42Project funding and technical assistance were provided by World Bank through financial support from the Energy Sector Management Assistance Program (ESMAP), Department for International Development, U.K. (DFID) and the Swedish International Development Agency (SIDA). 21 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China was the degree of end use. Major factors in this changes in their energy use behavior and regard were economical, applicable and effective technology, resulting in reduced risk of burns. interventions; main fuel-types currently in use; Throughout the project, communities, residents more efficient fuel combustion; and local capacity would benefit from high quality ambient air. for supplying and maintaining improved stoves. With greater knowledge, local stakeholders, including Community-Based Organizations Throughout its implementation, the project sought (CBOs), Non Governmental Organizations to demonstrate how household energy use and (NGOs), health personnel and microenterprises, environment are linked to the ecology of rural would be empowered to improve local communities; promote more efficient, governance's handling of IAP-related health issues. environmental-friendly household cooking and Damage to local forest ecosystems would be heating devices (thereby easing the energy mitigated, while revenue from a healthier, and burden in rural areas); and demonstrate thus more productive, labor force would increase. alternative household energy technologies and mainstream their use in World Bank projects in At national and international levels, the project was China and elsewhere. expected to improve evidence-based policy-making. Project results would contribute to The project was designed to contribute to better formulating or revising IAP standards and technical understanding of social and gender issues (through specifications for cooking and heating devices. In its focus on women and children); intersectoral addition to strengthening national research and linkages (notably health, energy use and development capacity, the country's burden of environment); community involvement (by respiratory illness and related health care costs encouraging locally designed improved stoves and would ease. Finally, the project would ventilation systems); and national and local demonstrate the benefits of combining health, capacity-building (through partnerships with the energy and environment to address IAP and Institute for Environmental Health and Related contribute to the international body of IAP Product Safety; China CDC; Foreign Loan Office literature and knowledge management. (FLO), Ministry of Health; and local county governments and health offices). Components and Implementation Expected Outcomes and Beneficiaries The project focused mainly on stove and behavioral interventions in townships of the By introducing and making available new stove targeted provinces and, to a lesser extent, small and ventilation designs, it was expected that the grants and awareness-building.43 Specific project would substantially improve fuel efficiency interventions included distribution and installation and reduce IAP in the participating households. of improved stoves and ventilation systems to test Higher quality of indoor air would improve the the effectiveness of new designs in reducing IAP health of household members, especially those and associated health risks. Behavioral who spend more time in the cooking vicinity. interventions included health education, attitudes Through greater awareness of IAP health risks, and practices to improve household energy use. household members would make risk-reducing The small grants component focused on building 43Detailed information on this logframe approach is available at http://wbln1023/OCS/Quality.nsf/Main/MELFHandBook/$File/LFhandbook.pdf 22 ProjectOverview capacity in four areas: 1) introducing household followed by monitoring and evaluation, which energy technologies and training local technicians focused on selected health indicator effects of the in their use; 2) seeking ways to lower toxic interventions; activities included baseline surveys substances from coal use; 3) encouraging and post-intervention measurements development of low-emission, biomass-burning of indoor air pollutants. Other scheduled activities stoves for rural application; and 4) facilitating included:1) strengthening of local institutional and sustainable local responses to the IAP health technical capacities and development of IAP risk. The awareness-building component intervention strategies and policies; and 2) developed training materials and trained health knowledge management through dissemination of education and other local personnel in raising project findings and publications in peer-reviewed awareness about the health-related risks of IAP journals (Annex 1). and methods to reduce them.44 Management and Participants The project was implemented in four phases. The first phase pilot-tested alternative stove The project team, led by the FLO, Ministry of designs and monitored multiple pollutants in Health, consisted of staff from the Institute for homes that used coal or biomass for heating Environmental Health and Related Product and cooking (implemented in Guizhou and Safety, China CDC; Huaxi School of Public Shaanxi). The second phase collected baseline Health, Sichuan University; CDC provincial and data (from household, health and other surveys county offices; and local hospitals in project and tests on energy use, IAP and health) with townships. The team also included international which to design and evaluate IAP interventions experts from Sri Ramachandra Medical College (implemented in selected counties, townships and Research Institute (India), Harvard and villages in Gansu, Guizhou, Inner Mongolia University and World Bank (Figure 2.1) (Annex and Shaanxi). The third phase focused on the 2). Provincial-level project teams were interventions (both technological and ehavioral). responsible for project programming and The fourth phase consisted of post-intervention organization, monitoring, analysis and data collection and evaluation of the assessment of project outcome and community intervention program's effect. commitment. County- and township-level technical teams (experts, technicians and Prior to intervention, a feasibility study was engineers from health care departments and conducted on:1) market analysis and adoption of local hospitals) were in charge of project planning stove and ventilation designs based on existing and organization, training, development of health knowledge and local conditions; and 2) field- and education materials and advising communities. market-testing of stoves and ventilation devices. Townships established teams to manage planning The main intervention study included supply and and implementation of project activities. Each distribution of alternative stoves, market project province and county set up a special development, health education and training project account and provided counterpart funds as activities and policy considerations. This was an expression of commitment. 44A fourth component on policy and regulatory framework development was to review and revise environmental, energy and health guidelines in the light of the field studies on energy use, IAP diffusion and household behavior. Given the intervention nature of the project, this component was not developed extensively; but follow-up activity in response to this report's recommendations is expected. 23 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Implementation Consultation and and Administration Cooperation of Hospital for FLO Bureau CDC Community Government Community chnicianseT Mongolia Households Helingeer Health Helingeer County Dahongcheng Hospital Xindianzi Stove 500 Intervention Bank Workshop Inner World Public Professional of Sichuan School Huaxi Health, University for of Hospital Hospital FLO Bureau CDC Government Community Community Health chnicianseT Households Office of Shaanxi Hanbin Health Hanbin District Bank Hongshan Shizhuan Stove 1,000 Intervention Loan World Ministry Foreign (FLO), Related Disease and for CDC) CDC of for Health Hospital Hospital Hospital Center (China Bureau CDC Guizhou Government Community Community Community Manufacturers Households Chinese, Guiding Health Guiding County Prevention Xinpu Dexin Xinba Stove 1,000 Intervention Environmental Alleviation for Safety and Project Poverty Institute Product Control of IAP of Protection Prevention. Office Association Bureau for Academy and Hospital Hospital Hospital Group CDC Energy County CDC Structure Environment Agriculture Government Control of of University Scientific Council Rural Gansu Health Community Households Community Community echniciansT Development Huixian of Guiding County Disease State and Bureau Ministry singhuaT Chinese China Mayan Jialing Yinxing Stove 1,000 Intervention for Center Organizational 2.1: Chinese Figure Source: 24 ProjectOverview Project Design technologies, health education is vital to encouraging behavioral changes (for example, This project draws on international lessons in food-drying practices). Detailed documentation of household energy intervention, including programs the effect of program interventions is needed to in China, Mongolia, Kenya, Ethiopia and Tanzania build local, national and international support to (Ezzati and Kammen 2002a; Smith, Mehta and continue and expand on IAP-related initiatives. Maeusezahl-Feuz 2004). Such studies have emphasized exposure assessment, estimation of Underlying Principles the health burden and effectiveness and technical feasibility of specific interventions. One important Drawing on these lessons, this project adopted a lesson is the need to field-test interventions in holistic approach which combined technological various socioeconomic, cultural, climatic and interventions (stove and ventilation technologies) topographical settings and jointly assess the health, with behavioral ones (community-based health energy and environmental implications throughout education, behavioral changes, market the project cycle (design, implementation, development and capacity-building) (Figure 2.2). monitoring and evaluation). Another lesson is the To ensure effective and sustainable results, many need to take account of the living environment and organizations cooperated to provide training, customary practices of low-income rural families. outreach services, market promotion and logistical Low-cost, low-maintenance technologies are support for a wide range of provincial and local critical to facilitate affordability and sustainability. health officials, education specialists, engineers, Access to technology and energy infrastructure administrators, stove producers and suppliers and must also be considered. To ensure uptake, others interested in reducing IAP. Finally, cultural, maintenance and long-term use, direct subsidies to economic, environmental, and socioorganizational acquire improved stoves should be complemented dimensions of the project were thoroughly by health education, market development and appraised, and health education and technical capacity-building activities. In addition to training programs were adapted to local needs generating interest in new stove and ventilation andconditions. Figure2.2:InterventionModelandHypotheses · Fuel Efficiency Household Economy · Use of Harmful Sources of Fuels Multipronged Intervention · Heating/Cooking Technologies Health · Living Environment · Behavioral Change Indoor Air Pollution Ecology Note: Dotted lines indicate a secondary effect, which takes time to materialize. 25 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Approach baselineandpost-interventioncomparisonsfor eachtownshipsubjecttostoveandbehavioral The basic design approach was to test the activitiesorbehavioralactivitiesalonecouldbe post-intervention outcomes of household energy matchedagainstbaselineandpost-intervention use interventions: IAP, energy, health and comparisonsforthecontroltownships,providing environment. From the four project provinces, the basis for difference-in-difference analysis.45 5,550 households (500 households from each of This provided the empirical evidence on 11 townships) were selected to test the the relative effectiveness of the interventions. The 11 site townships were divided interventions (Figure 2.3). into three intervention groups: The project design included extensive data · Stove plus behavioral intervention (S + B). This collection through household and health group included one township site from each surveys, on-site measurement of multiple project province (with the exception of Inner pollutants in the air and other media Mongolia) (1,500 households). These three (for example, F in food dried over fire) and sites were subject to the full range of stove and health examinations (especially for childhood ventilation technology and behavioral respiratory diseases). Households were selected (community education and behavioral changes) on a cluster randomized basis, subject to interventions, accompanied by institutional including women and children members. capacity-building at provincial, county and township levels. New alternative stoves Site selection Process were provided at approximately one-third market cost; The project was carried out in low-income, rural · Behavioral intervention (B). This group included counties of the four project provinces: Huixian one township site from each project province (Gansu), Guiding (Guizhou), Helingeer (Inner (2,000 households). These four sites were Mongolia) and Ankang (Shaanxi) (Figure 2.4). In all subject to a more limited range of four counties, the need for space heating was interventions. They were not offered new extensive, households relied heavily on solid fuels stoves at subsidized rates, and the interventions (coalandbiomass)forheatingandcooking focused on health education and behavioral andIAPwasaseriousproblem.Additionalsite changes;and selection considerations were community interest in · Control (C). This group included one township and local government support for the project. site from each project province (2,000 households). These four sites were not subject The 11 townships sites were chosen based on their to any interventions; rather, they served to similar economic circumstances and household indicate exogenous trends (for example, environments, including housing structure and secular interannual fluctuations caused by food habits. Additional site selection considerations varying winter temperatures or other factors were degree of concentration of residents, status which may have affected energy use) between of transportation access and residents' willingness project initiation and completion. In this way, to participate (Table 2.1 and Figure 2.5). 45 The mean difference between after and before values of the outcome indicators for each of the intervention groups was calculated; from this was subtracted the mean difference between after and before values for the control. The second difference (that is, the difference-in-difference) is the estimated project effect. 26 Project Overview Figure2.3:OverviewofProjectMethodology S + B B Guizhou Inner Shaanxi B Mongolia Gansu C C IAP monitoring; health questionnaires and examinations; behavioral activities Baseline monitoring; market and policy investigation; stove and energy monitoring S + B: Improving stoves; health education; market development; encouraging policy changes Intervention B: Health education; market development; encouraging policy changes C: No intervention measures Post-intervention IAP monitoring; health questionnaires and examinations; behavioral Evaluation activities monitoring Evaluation of Evaluation of indoor quality; health and behavioral activities monitoring; market the Project development and policy changes evaluation; project management evaluation Note: S + B = stove plus behavioral intervention, B = behavioral intervention, C = control. Table2.1:CategorizationofSelectedTownships Intervention Group1 Province County C B S + B Gansu Huixian Yinxing Jialing Mayan Guizhou Guiding Xinba Dexin Xinpu Inner Mongolia Helingeer Xindianzi Dahongcheng -- Shaanxi Ankang Shizhuan2 Shizhuan2 Hongshan 1C = control (no intervention), B = behavioral intervention, S + B = stove plus behavioral intervention. 2Shizhuan is effectively divided by a mountain, enabling the township to serve as a control (C) and behavioral intervention (B) group. 27 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Figure2.4:LocationofSelectedCountiesinProjectProvinces Location of Hui County in Gansu Province Location of Guiding County in Guizhou Province HuiCounty Guiding County Location of Ankang City Location of Helingeer County in Inner Mongolia in Shaanxi Province Helingeer County AnkangCity Source: Chinese Center for Disease Control and Prevention. Figure2.5:LocationofSelectedTownshipsinProjectCounties HuixianCounty(Gansu) Mayan Yinxing Hui County Full Intervention Group Jialing Partial Intervention Group Control Group 28 ProjectOverview GuidingCounty(Guizhou) IAP Project Groups in Guiding County Xinba Xinpu Dexin Guiding Full Intervention Group Partial Intervention Group Control Group Helingeer(InnerMongolia) Helingeer Xindianzi Dahongcheng Partial Intervention Group Control Group 29 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China AnkangCounty(Shaanxi) IAP Project Groups in Ankang City Shiquan Hanyin Shizhuan Hongshan Ankang Ziyang Full Intervention Group Partial Intervention Group Control Group Mountains Source: Chinese Center for Disease Control and Prevention. A total of 5,500 households were chosen from The project areas had been included in the 11 townships (500 from each township). earlier World Bank-funded Health VI Household selection was based on initiatives; thus, many trained and several considerations: experienced health, engineering and other experts were available to · Inclusion of women (older than 18 years of participate in the project. Furthermore, age) and children (14 years of age or earlier or current environmental pollution younger) in the household and at home; investigations, epidemiological surveys, · Length of time women had lived in the health examinations and health education township (more than one year); and programs provided information relevant · Voluntary participation of households. to the project. 30 3. Foundations for Intervention Design* Zuzana Boehmova, Fei Yu, Zheng Zhou, Enis Bari and Majid Ezzati As discussed in Chapter 2, the household energy four study provinces, highlighting the array of use interventions undertaken in this project were of factors ­ from poverty and literacy to rural-urban two types: 1) alternative stove technology, disparities, economic trends and energy including improved ventilation systems; and 2) resources ­ which contribute to affordability and health education and behavioral activities. Each behavioral responses. Other relevant design was accompanied by capacity-building activities for considerations, also discussed in this section, are local health, energy and related agencies and housing characteristics and household energy use institutions. Both interventions were tailored to fit behavior and time-activity patterns. the location-specific conditions and general circumstances of the four project provinces and Provincial Profiles their respective counties and townships. A shared characteristic of the four provinces ­ and an important criterion for selection in this study ­ is To provide a foundation for evaluating the economic status. Among China's 31 provinces, interventions undertaken, baseline data were autonomous regions and municipalities, Guizhou collected on IAP levels, household energy use, ranks 31 (last) in terms of GDP per capita, knowledge and behavioral characteristics and followed immediately by Gansu at 30 and Shaanxi IAP-related health conditions. These data, and Inner Mongolia at 25 and 15, respectively.47,48 summarized in this Chapter, contributed to the design of IAP interventions.46 Despite the presence of more efficient fuels (for example, petroleum or hydropower), most rural General Design Considerations households rely on inefficient energy sources and stove technologies (Guizhou and Shaanxi depend Many factors bear on the design of IAP primarily on coal, while Gansu and Inner interventions. This section offers brief Mongolia rely more on biomass). For all study socioeconomic and demographic profiles of the areas, the heating season lasts from November to 46Portions of this Chapter draw from Jin et al. (2006). 47Profiles are based primarily on data from the China and provincial statistical yearbooks. Provincial GDP numbers are for 2004, while most other data are for 2003. Township data are based on household surveys conducted by provincial and county-level staff of the Health Bureau and China Center for Disease Control and Prevention (China CDC). Because women have primary responsibility for cooking and child care, most respondents were female household members. 48China Statistical Yearbook (2005). * Portions of this text is from the article by project team members Yinlong Jin et al., "Exposure to indoor air pollution from household energy use in rural China : the interactions of technology, behavior and knowledge in health risk management," Social Science and Medicine, 2006 June; 62(12):3161-76. Permission for reproduction of material was granted by Elsevier. 31 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China late March, and IAP from household energy use offer potential opportunities for implementing (heating and cooking) is a health risk.49 Other health education activities. shared characteristics of these provinces and their counties and townships include high illiteracy In 2004, per capita GDP was nearly Y 6,000 rates (especially among females), a high (US$730), the second lowest provincial average in percentage of ethnic minorities (including China. Rural net household incomes were a linguistic differences) and large rural third or less of this amount, reflecting the populations heavily reliant on farming for their low productivity, agricultural basis of farming livelihoods (Table 3.1).50 communities. Provincial revenues per capita were Table3.1:GeographicandEnvironmentalFeaturesoftheStudyAreas Province (County) Gansu Guizhou InnerMongolia Shaanxi Feature (Huixian) (Guiding) (Helingeer) (Ankang) Altitude(m) 800-1,500 1,100-1,400 1,400-1,600 350-1,000 Summer Temp. (avg. C°), 28 27 21 28 (daily min.-max.) (19-35) (19-33) (20-22) (23-41) Winter Temp. (avg. C°), 9 8 ­10 5.5 (daily min.-max.) (­5-16) (­1-15) (­13- ­8) (­8-11) Average Rainfall (mm) 240-320 1,100-1,400 420 1,120 Average Number of 2,500 1,100 2,700 1,500 Sunny Hours per Year PopulationDensity 57 220 180 20 (persons per Km2) Source: Chinese Center for Disease Control and Prevention. Gansu also low, weakening the government's ability to support public services. However, the revenue Gansu has a population of approximately 26 position is improving as a result of strong GDP million, some 76 percent of which live in rural growth rates over the past few years. Gansu's areas. While the predominant ethnicity is Han, accelerating industrial output reflects rapid growth nearly 2 million people are of ethnic minority and of exports (including textiles, chemicals, minerals are among Gansu's poorest residents. Education and nonferrous metals). levels are low; illiteracy, at about 20 percent, is twice the national rate. The age structure of the In terms of energy resources, petroleum and coal population is relatively young. The province's five offer limited opportunities, but hydropower's million primary and secondary school students potential is extensive (installed generating capacity 49Final project report, China CDC (2006). 50Annexes 3.1 and 3.2 provide statistical overviews of the study provinces and counties, respectively, while Annex 3.3 provides data on socioeconomic and demographic characteristics of the study households. 32 Foundations for Intervention Design is currently 30 million Kilo Watt (s) (KW). With regions. Like Gansu, Guizhou has a weak fiscal regard to Renewable Energy (RE), Gansu's climate position, which undermines support for public is suitable for the development of wind and solar services; thus central government transfers are power. Environmental improvement measures important. Despite fiscal constraints, poverty include meeting national air- and water-quality reduction projects over the last five years have standards. In addition, 43 smog-control zones and included rural electrification and other 47 natural reserves have been established, the infrastructure investments. latter covering nearly 20 percent of the province. Forest protection is a priority. Guizhou's high illiteracy rate, especially in rural areas, reflects the unaffordable cost of sending The three townships selected for the study ­ children to school, compounded by the language Jialing, Mayan and Yinxing ­ are located in difficulty of ethnic minorities. Some 40 percent of Huixian County. Of the four project counties, the province's labor force has only an elementary Huixian has the lowest GDP per capita (90 percent school education (most have not completed five of its population is rural). Household survey years of schooling). The population's low education respondents for this study indicated that nearly half and literacy status hampers public of the households had family income of less than healtheducation. Y 1,000 (US$120) in the year prior to the survey. They also reported large family sizes (86 percent The province has a subtropical humid climate and of families had four to seven household experiences ample precipitation, especially in members). The respondents, 96 percent of whom mountainous areas. Agriculture, the main source were women, indicated illiteracy rates which of employment, accounts for only 20 percent of approximated the provincial average for women. GDP, which largely explains rural poverty. Industrial output is increasing rapidly, supported by Guizhou a sharp jump in energy production in recent years; the province has ample coal resources and With a population of 39 million, Guizhou is the hydropower potential. most densely populated of the study provinces. Ethnic minorities (including Yao, Miao, Buyi, The three townships selected for the Dong and Tujia) account for 56 percent of the study ­ Xinpu, Xinba and Dexin ­ are located in population, and the province is designated as an Guiding County. Compared to Huixian (Gansu), autonomous region. About 76 percent of residents Guiding has a higher GDP per capita, yet, net live in rural areas. rural household incomes are lower, reflecting During the 90s, Guizhou's economic growth larger families in the former. Of the four lagged; more recently, it has matched or counties studied, Guiding has the highest exceeded the national average. In 2004, the percentage of population under 15 years of growth rate was 11.4 percent and GDP per capita age. Household survey respondents, 70 percent reached Y 4,082 (US$495); yet this was the of whom were women, reported a 35 percent lowest provincial average in China. Furthermore, illiteracy rate and a high percentage of rural residents' net disposable income per capita residents with only a primary education. Some was less than half the provincial average. 75 percent of families in the three townships Nonetheless, provincial data indicate a substantial reported four to seven household members, drop in the level of poverty over the past decade, and nearly 70 percent had family incomes of although it is still widespread in mountainous less than Y 1,000. 33 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China InnerMongolia greenhouse effect and unscientific exploitation have aggravated drought, desertification and soil Among China's provinces, municipalities and erosion. In an effort to revert cultivated land to autonomous regions, Inner Mongolia (designated grasslands and forests, the central government an autonomous region) is the third largest, yet, it recently launched the Ecological Construction has one of the lowest population densities (only Project, one of the 10 projects in its western 23.8 million residents in 2004). About 43 percent developmentcampaign. of residents live in urban areas, by far the highest ratio among the four project provinces. The Han The two townships selected for this study ­ ethnicity accounts for nearly 80 percent of Dahongcheng and Xindianzi ­ are located in residents, while Mongolians and other ethnic Helingeer County, with a 90 percent rural groups account for more than 20 percent. population. Net rural household incomes and literacy rates are the highest of the four By 2004, GDP per capita had risen to Y 11,387 counties studied. Still, Helingeer has high rates (US$1,390); the region ranked 15 among the of infant and child mortality. Household survey country's 31 provinces, autonomous regions and respondents, 64 percent of whom were women, municipalities. However, rural households' indicated a higher degree of education disposable income per capita was less than 25 compared to the other study areas but a higher percent of this amount, and an estimated 800,000 illiteracy rate compared to the provincial people remained severely poor. The local average. Compared to respondents in townships government's fiscal position has strengthened of the other study provinces, Helingeer rapidly, enabling support for critical public respondents reported higher family incomes services. In 2004, local expenditure per capita and smaller average family sizes. was well above the national average. Published data show high enrollment ratios, including Shaanxi secondary schools. Illiteracy is estimated at about 12 percent. Shaanxi's population of 37 million is almost entirely of the Han ethnicity. Some 68 percent of Farming and animal husbandry engage more than residents live in rural areas. Like the other three 50 percent of the labor force, yet, account for study provinces, Shaanxi experienced rapid only about 20 percent of the GDP. By contrast, the economic growth in 2004; that year, per capita secondary industry engages less than 20 percent income reached Y 7,790 (US$950). Rural of the labor force yet accounts for more than household incomes were about 25 percent below 40 percent of the GDP. Transport and the provincial average. Shaanxi's fiscal position elecommunications services are well developed. reflects its low income ranking; on a per capita In terms of energy resources, the region has the basis, local revenues were 40 percent less than second largest coal reserves in China, as well as the national average, with the result that local extensive hydropower and petroleum resources; expenditures were significantly below the the region is a net exporter of energy. nationalaverage. Inner Mongolia features a temperate continental Rural poverty is widespread, education levels are climate with long, cold winters. Of the four study low and illiteracy is high. Some 40 percent of provinces, it has the coldest temperatures (only females receive little education, and female 80-150 frost-free days); thus, home heating illiteracy is prevalent in rural areas. But the requirements are intensive. In recent decades, the situation is changing rapidly; primary education is 34 Foundations for Intervention Design nearly universal, and a reasonable percentage townships, relatively low family incomes and large continues on to junior and senior high schools. familysizes. As in the other study provinces, the agricultural Housing Characteristics sector is the main source of employment, but accounts for only about 20 percent of the Jin et al. (2005) provide basic information on GDP. Secondary industry accounts for nearly housing characteristics of the households studied 50 percent of the GDP and total output of (Table 3.2). In Gansu, nearly 90 percent of major industries (electronics, machinery, houses have a wall separating the kitchen from the pharmaceuticals, chemicals, energy and bedroom and living room areas, with separate food) is increasing at nearly 20 percent annually. entrances. In Guizhou, the most common housing As part of the central government's western design consists of cooking/living, sleeping and development strategy, transportation infrastructure entrance/storage rooms connected by doors. Most is being extended; currently under construction is houses have a separate cooking area reserved for a new railway designed to resolve north-south special occasions. Cooking is usually done in one bottlenecks. Shaanxi's extensive coal and gas of the main rooms (cooking/living room), reserves and hydropower potential are especially during the winter (heating season). increasingly accessible. In Inner Mongolia, older homes are constructed within a cave-like structure; a single room is used Shaanxi's low winter temperatures require many for cooking, living and sleeping (the cooking heating hours per day, resulting in limited air stove is connected to the bed for heating). exchange due to closing of windows and doors. Newer homes in the study area have a wall with For rural residents heavily dependent on coal for windows and a door that connects the cooking heating, IAP poses a serious health risk. As part and sleeping/living areas. In Shaanxi, most of its effort to improve environmental conditions, houses have a cooking area connected to the provincial authorities have intensified efforts to main house by a door, a living room with a protect and expand forest coverage (currently, ground stove (fire pit) used for heating and nearly 29 percent). In 2003 and 2005, many boiling water and one bedroom (sometimes thousands of rural households suffered a series equipped with a ground stove). Most houses of natural disasters (drought, floods and have a small attic used only for storage. hailstorms), which caused extensive damage and economic hardship. Household Energy use Behavior and Time-activity Patterns The selected study townships ­ Hongshan and Shizhuan ­ are located in Ankang County.51 With IAP exposure is affected by a variety of behavioral 2.6 million people (more than 80 percent of factors related to household energy, including whom live in rural areas), Ankang is the most ventilation practices and the time-activity patterns populated of the four counties studied. Although of household members. Table 3.3 summarizes key infant mortality rates are low, household survey exposure-related behaviors in the four study respondents reported the highest illiteracy rates provinces. The implications of these data for IAP (especially among females) of the four sets of interventions are discussed in the next section. 51As indicated in Table 2.1, Shizhuan serves as both a control (C) and behavioral intervention (B) group. 35 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Table3.2:HousingCharacteristicsofStudyParticipants(percenthouseholds) Inner Gansu Guizhou Mongolia Shaanxi Characteristic (n=1,518) (n=1,508) (n=1,035) (n=1,580) Construction Material Mud, Wood and Tile 71.5 40.1 38.2 76.3 Brick, Wood and Tile 25.9 42.9 36.6 8.0 Other 2.6 17.0 12.7 15.7 Usual Cooking Location Specialized Kitchen 88.5 25.4 36.2 93.5 Bedroom 3.3 4.7 46.6 1.7 LivingRoom 7.9 67.6 16.3 4.6 OtherRooms 0.3 2.2 0.9 0.2 Other Characteristics Houses with Gaps between NoGap 22.4 NoGap NoGap WallandRoof Kitchens with Window 90.3 73.8 72.8 60.3 Kitchens with Ventilation Fans 0.9 0.9 10.2 2.3 Note: n = number of households in the sample. Source: Zhou et al. (2006). Table3.3:HouseholdEnergyUseBehaviorandTime-activityPatternsasDeterminantsofExposure EnergyUse Gansu Guizhou InnerMongolia Shaanxi Cooking · Affects primarily · Affects primarily · Affects all · Affects primarily womenwho womenwho household women who spend spend >2 hours spend 2.5-3 members since 2.5-3 hours per per day cooking hours per day allcooking daycooking human/animal cookinghuman takes place in humanand food andanimal the same room animalfood · Somecooking/ food aslivingand · Somecooking tea-makingtakes · Cookingthe sleeping andheating place on fire pan mainmeal · Womenwho watertakes in the living and takes place in spend >2 hours place on the sleeping area in the living area, perday groundstovein morningand affecting other cookinghuman the living area, nighttime, household andanimal affecting other affecting all members foodare household household particularly members members affected Heating* · Affects all · Affects all · Affects all · Affects all household household household household memberswho memberswho memberswho memberswho spendtime spendtime spend time on spend time around aroundthe aroundthe the heated bed, the ground stove fire pan or on heatingstove especially children in the living the heated bed, in the living and the elderly, area especially area andwomenwho · Withno 36 Foundations for Intervention Design Energy use Gansu Guizhou InnerMongolia Shaanxi childrenand · Chimneyin use the same chimney, smoke the elderly mosthouses stove for cooking disperses in the · Seasonalpattern onlygoesto · Seasonalpattern house (approximately theatticand (approximately · Seasonal four to six smokedisperses six to seven pattern months) in the house months) (approximately throughthe fivetosixmonths) porous · Groundstoves separation inbedroomsno of main floor longerused andattic becauseof · Seasonal concerns pattern aboutCO (approximately six to seven months) Food NA · Food NA · In the past, food Drying (chili and corn) was stored over and isdried the stove. Public Storage directly above healthprograms the stove or havepromoted in the attic alternative abovethe behaviorsto chimney outlet. store food in Most rice is bagsand/or storedinbags away from the duringdrying stove · 54 and 81% ofhouseholds donotwash corn/chili before eating * Although the provinces have relatively similar heating seasons, the intensity of home heating is higher in the colder provinces, particularly in Inner Mongolia. In Guizhou, for example, increased humidity and cloudiness are the main feature of the heating season. Therefore, the stove is used for shorter daily durations and with less intensity than in Inner Mongolia. Similarly, windows may be left open in Guizhou during the heating season, but are closed and sealed in Inner Mongolia. Note: NA = Not applicable. Source: Jin et al. (2006). Reprinted with permission from Elsevier. Baseline Data IAPLevels To build the technical foundation for designing IAP Based on a pilot study conducted in January interventions and the basis for evaluating their 2003 (Jin et al. 2005), which examined the effectiveness, the study included extensive surveys, relationship between pollutants and interviews and testing to collect baseline data on measurement points in four households in each IAP levels, household energy use, knowledge and of the study counties in Guizhou and Shaanxi, behavior and IAP-related health symptoms.52 and a survey on household energy use 52This section draws on Jin et al. (2005). 37 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China behaviors and time-activity budgets, an optimal particulate matter with a median aerodynamic combination of pollutants and measurement diameter of less than 4 micrometers (µm)(and 10, locations was selected to best characterize µm respectively), CO and SO2. Tests involving exposure conditions in each province. Pollutants fluoride and As were also conducted (Annex 3.4). were measured at two to three points in the ResultingData cooking, living and sleeping areas (the main exposure microenvironments). In a few homes In all provinces, concentrations of Respirable and for selected pollutants, measurements were Particulate Matter (RPM) exceeded current made at additional points for comparison. health-based standards and guidelines for PM in an outdoor environment.53 Gansu and Inner Measurement Design and Monitoring Mongolia ­ the two provinces where biomass is the Twodesignswereusedtomeasureindoorairquality: primary fuel ­ had the highest concentrations; high concentrations in Inner Mongolia reflect colder · Small sample of households and multiple temperatures, longer heating hours and a housing measurement days: six households were arrangement which combines heating and selected from each province (four in Inner cooking (Annex 3.5). Mongolia) and monitored continuously over a four-day period, which enabled measurement Except for a few observations in Gansu, Inner of day-to-day variations; and Mongolia and Shaanxi, 24-hour mean CO · Large sample of households and a single concentrations were consistently below measurement day: 72-76 households were health-based standards and guidelines.54 Not selected from each province and monitored observable from the data was the possibility that over a 24-hour period. CO concentrations may have been higher during cooking and when bedroom doors and Both designs conducted monitoring twice a year, windows were closed at night. Guizhou had the corresponding to the middle (March) and late lowest CO concentrations due to the type of (December) heating season. Households coal and stove used and the configuration of monitored in March over a four-day period were chimney/attic ventilation. also observed in December; for the larger set of households monitored over a one-day period in Cost considerations limited SO2 measurements March, a subset was selected for one-day to Guizhou and Shaanxi ­ the two provinces monitoring in December. Both designs selected where coal is the primary fuel. SO2 households based on family income, energy use concentrations were higher than the WHO and housing characteristics. Measurements were guideline value of 0.04 Part(s) Per Million taken by teams of investigators from the national (PPM) at all locations in both provinces; China CDC, assisted by the Center's provincial concentrations in Shaanxi were substantially and county staff and health workers. higher than the corresponding points in Guizhou. Higher concentrations in Shaanxi Three key indoor air pollutants were monitored: were likely due to the type of coal used and respirable particles (PM4 and PM10; that is, lack of chimneys (in contrast to Guizhou). 53For example, for RPM, the U.S. Environmental Protection Agency requires that the 24-hr mean concentration of PM2.5 be below 65 Micrograms per Cubic Meter (íg/m3) and annual mean concentration below 15 íg/m3. 54For eight-hr exposure of CO, WHO guideline value is 10 Part(s) Per Million (PPM), while that of the American Conference of Governmental Industrial Hygienists is 25 PPM. 38 Foundations for Intervention Design Pollutant concentrations at various living room reflecting the use of coal stoves. measurement points. Room concentration of Pollutant levels in the bedroom were pollutants were generally determined by whether determined by a combination of direct emission the stove in that room was used for cooking or and dispersion from other locations. High heating and the housing characteristics which concentrations in both the heated living room affect dispersion. and bedroom illustrate the important role of heating as a source of exposure in winter. The pollutant microenvironments for each province were as follows: Pollutant concentrations in middle and late heatingseason. Pollutantconcentrationsaccording · Gansu. The cooking room had RPM levels to the heating season (December or March) cannot 50-60 percent higher than the bedroom. be generalized across the four provinces. In Gansu CO concentrations were more even between and Shaanxi, average concentration of all measured the two rooms (about 5 PPM in March and pollutants were higher in December than in March 8.75 PPM in December, with concentration in at all measurement points. In Guizhou, average the cooking room slightly higher in each RPM concentration in the cooking/living room were period). Biomass use during short periods of nearly equal in December and March (about 300 intense combustion results in high levels of RPM µg/m3); in the bedroom, however, average in the cooking room, whereas slow-burning concentration in December were approximately coal stoves for the heated bed yield low RPM one-third lower than those in March. By contrast, levels but relatively high CO levels; average concentration of CO and SO2 were · Guizhou. The highest concentration of indoor higher in December than in March in both the air pollutants was the attic area, where the cooking/livingroomandbedroom.Highhumidityin chimney ends. Concentrations in the bedroom Guizhou and the need to keep stored food dry were similar to or even slightly higher than in explain, at least in part, interprovincial differences. the cooking/living room. The bedroom is an InInnerMongolia,wheredatacollectionbeganonly important exposure microenvironment even in December 2003, baseline interseasonal though it has no stove and is connected by a comparisonswerenotpossible. door to the cooking/living room. Dispersion via the attic through the porous separation with the Pollutant concentrations across multiple ground floor results in concentrations in the measurement days. Daily variations in IAP levels bedroom being similar to those in the cooking/ are reflected in household data subject to living room; measurements over continuous days (Jin et al. · Inner Mongolia. Cooking and heating occur 2005). Pollutant concentrations across multiple in the same room, making it the main measurement days varied by a factor of 2-10.55 exposure microenvironment; and Standard deviation of multiple measurements for · Shaanxi. The cooking room, heated living the same household varied between 10 and 100 room and bedroom all had relatively similar percent of their mean. With the exception of SO2 RPM concentrations. But concentrations of in Shaanxi, variation was consistently less in CO and SO2 were highest in the heated December than in March. 55Minimum and maximum concentrations were calculated separately for each household and then averaged over all such households. The coefficient of variation (defined as the standard deviation divided by the mean) was also calculated for each household and then averaged over all households. 39 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Variability of pollution across households to or exceed those caused by cooking. (interhousehold variation) was compared to Thus, stove improvements should be variability across measurement days (interday accompanied by changes in housing variation) for the same household. In all cases, arrangements which separate the main stove except CO in the cooking/living room in Guizhou from the living area; and during March, variation across households was · In households with a separate cooking area greater than within households. This finding used only on special occasions (that is, most suggests that factors which determine pollution households in Guizhou), most cooking concentrations (for example, duration of stove use, occurs in the living area, combined with quantity and quality of fuel and ventilation and winter heating. While reducing exposure stove use behaviors) are likely to vary more across does not call for changes in housing households than day-to-day within households. arrangements, it requires stove improvements which increase the chimney Data Implications for Household Energy length to limit dispersion of pollutants inside Use Interventions the house (including those from the attic). The IAP baseline data reveals the main exposure In summary, the baseline data indicate that IAP routes in the four provinces. These findings were was a serious problem in all four provinces. used to design household energy use interventions, On average, PM4levels exceeded the national asfollows: standard by nearly 100 percent in Inner Mongolia and by about 70 percent in Gansu, Guizhou and · In households with separate cooking and Shaanxi.56 SO2 levels exceeded the national living/sleeping areas and distinct cooking and standard by 60 percent or more in Guizhou, Inner heating stoves (that is, most households in Mongolia and Shaanxi. CO levels exceeded the Gansu and Shaanxi), the cooking stove is a national standard by nearly 50 percent in Inner year-round source of exposure for women Mongolia and by 45 and 33 percent in Shaanxi and young children; thus, improvement in and Gansu, respectively.57 cooking stoves can reduce exposure. Heating during winter is possibly a greater source of Household Energy Use exposure for all household members than cooking. Therefore, reducing exposure Household energy use surveys, including requires more extensive improvement in general household and kitchen/fuel use heating stoves than those used for cooking; characteristics, were conducted for all study · In households with the same cooking and households. While coal is the near-universal living areas and no physical distinction fuel for heating in Guizhou and Shaanxi, between cooking and heating stoves (that is, 18 and 52 percent of study households in the most households in Inner Mongolia), cooking two provinces, respectively, use biomass as is a year-round source of exposure for all their main cooking fuel. Such multifuel and household members. Heating during winter multistove use means that successful results in exposure periods which are equal intervention programs must consider 56Chinese National Standard for Indoor Air Quality, China State Environment Protection Agency. 57Ministry of Public Health and National Institute for Environmental Health and Related Product Safety, China CDC; Sustainable and Efficient Energy Use to Alleviate Indoor Air Pollution in Poor Rural Areas in China: Final Report, Beijing, 2006. 40 Foundations for Intervention Design the various energy uses, combustion (stove) F; the stone coal used in Shaanxi has high technologies and fuel sources (Tables 3.4 and S concentrations and possibly traces of 3.5). With regard to coal, for example, the type toxic trace elements (Finkelman, Belkin and used in Guizhou may contain traces of As and Zheng 1999). Table3.4:StoveCharacteristicsofStudyHouseholds(percenthouseholds) Inner Gansu Guizhou Mongolia Shaanxi C B S + B C B S + B C B C B S + B StoveUse/ Pre- Pre- Pre- Pre- Pre- Pre- Pre- Pre- Pre- Pre- Pre- Type n= n= n= n= n= n= n= n= n= n= n= 509 509 500 523 501 484 527 508 508 491 581 Cooking Coal 44.7 23.0 27.8 ­ ­ ­ ­ ­ 100.0 100.0 100.0 Biomass 100.0 100.0 100.0 33.1 20.8 67.4 ­ ­ 64 65.2 72.1 Range Stove-bed ­ ­ ­ ­ ­ ­ 87.1 96.7 ­ ­ ­ Device Heating Coal ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ Biomass Range ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ Underground ­ ­ ­ ­ ­ ­ ­ ­ 97.8 96.1 95.7 Stove Kang 100.0 100.0 100.0 ­ ­ ­ ­ ­ ­ ­ ­ Stove-bed ­ ­ ­ ­ ­ ­ 87.1 96.7 ­ ­ ­ Device Cooking and Heating Coal ­ ­ ­ 100.0 100.0 100.0 75.5 51.6 ­ ­ ­ Fire Pan 72.1 85.4 33.4 ­ ­ ­ ­ ­ ­ ­ ­ Note: C = control, B = behavioral intervention, S + B = stove plus behavioral intervention; blank (­) cells indicate that household members did not claim this stove type as their main stove. Source: Jin et al. (2005). 41 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Table3.5:FuelCharacteristicsofStudyHouseholds(percenthouseholds) Inner Gansu Guizhou Mongolia Shaanxi Fuel C B S + B C B S + B C B C B S + B Use/ n= n= n= n= n= n= n= n= n= n= n= Type 509 509 500 523 501 484 527 508 508 491 581 Cooking Coal 1.6 0.4 1.6 95.6 97.6 70.0 5.3 3.9 60.6 55.6 59.0 Biomass 98.4 99.6 98.4 4.4 2.4 30 94.7 96.1 39.4 44.4 61.0 Heating Coal 34.6 16.3 30.2 100.0 100.0 100.0 96.2 80.2 98.6 96.7 96.2 Biomass 65.4 83.7 69.8 ­ ­ ­ 3.8 19.8 1.4 3.3 3.8 Note: C = control, B = behaviorial intervention, S + B = stove plus behavioral intervention; blank (­) cells indicate that household members did not claim this fuel-type as their main fuel. Source: Jin et al. (2005). Table3.6:StoveUseHoursinMiddleandLateHeatingSeason Mean Hours Stove Used (95% CI) LivingArea March December Gansu Cooking 3.0 (2.7-3.3) (n = 96) 2.7 (2.1-3.4) (n = 33) LivingRoom/Bedroom 2.3 (1.2-3.5) (n = 96) 4.1 (1.5-6.8) (n = 33) Guizhou Cooking/LivingRoom 16.5 (15.8-17.2) (n = 96) 15.3 (14.0-16.5) (n = 32) Inner Mongolia Cooking/LivingRoom/Bedroom 7.3 (6.1-8.4) (n = 65) Shaanxi Cooking 8.4 (6.6-10.3) (n = 100) 9.6 (6.5-12.6) (n = 36) LivingRoom 16.8 (13.7-19.9) (n = 25) 18.2 (16.1-20.3) (n = 30) Bedroom 8.7 (6.7-10.7) (n = 98) 6.8 (2.8-10.8) (n = 24) Note: CI = Confidence Interval; n = number of household days of observation. Source: Household survey (self-reported figures). Other relevant household energy use data includes thelongestdailycookingandheatingperiods hours of stove use and amounts of fuel consumed. (Table 3.6). In Guizhou, where winter months are Of the households studied, those in Shaanxi have characterized by high humidity, keeping stored food 42 Foundations for Intervention Design dry is a priority. For this reason, warmer March questionnaire on energy technology and IAP temperatures may have systematically resulted knowledge and behavior, which was linked to the in lower energy use (and lower pollution levels) health survey questionnaire (Annex 3.6).58 In in the living rooms in Shaanxi and Gansu, but addition, data on energy use behavior were not those in Guizhou. (It should be noted that collected through field observation by key informants the differences are not statistically significant.) (villagehealthworkers,andvillagecommitteesand Inner Mongolia has the highest quantity of fuel leaders). Because cooking and child care are consumption (Table 3.7). primarily done by women, the questionnaire focused mainlyonfemalehouseholdmembers. Knowledge and Behavior Across all provinces and sociodemographic In each township, approximately 150 households groups, the majority of respondents were aware were selected to complete a household that smoke from cooking and heating is a health Table 3.7: Quantity of Fuel Consumption (kg/month) Coal Biomass Intervention Group HeatingSeason OtherSeasons HeatingSeason OtherSeasons Gansu C 47 ± 78 7 ± 29 241 ± 162 201 ± 119 B 38 ± 81 3 ± 21 371 ± 136 258 ± 98 S + B 78 ± 148 3 ± 49 320 ± 178 256 ± 124 Guizhou C 366 ± 195 214 ± 138 65 ± 184 129 ± 238 B 326 ± 244 194 ± 183 25 ± 107 42 ± 142 S + B 282 ± 163 158 ± 142 162 ± 262 322 ± 332 Inner Mongolia C 232 ± 115 19 ± 80 257 ± 130 184 ± 104 B 247 ± 255 19 ± 86 369 ± 255 282 ± 230 Shaanxi C 256 ± 134 185 ± 106 104 ± 226 124 ± 177 B 243 ± 106 161 ± 102 116 ± 241 150 ± 188 S + B 229 ± 106 173 ± 109 103 ± 204 135 ± 280 Note: C = control, B = behavioral intervention, S + B = stove plus behavioral intervention. Source: Household survey (self-reported figures). 58The household questionnaire was conducted by provincial and county staff of the Health Bureau and China CDC. 43 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China hazard (Table 3.8). Respondents from Guizhou ­ a source. In terms of age groups, respondents below poorprovincewhosepopulationincludesahigh the age of 40 had the greatest knowledge of health proportionofethnicminoritiesandlimitedhealth hazards. There was a slight gradient by education education ­ had the least knowledge of the health andincome,withthoseofhighersocioeconomic risksassociatedwithrespirablepollutantsfromany status generally having greater knowledge of risk. Table3.8:KnowledgeoftheHealthEffectsofRespirablePollutants(percentrespondents) Province Inner Gansu Guizhou Mongolia Shaanxi Questionnaire Statement1 (n=463) (n=476) (n=323) (n=479) Smoking is a health hazard 93.3 60.1 90.4 80.1 ETS is a health hazard 76.0 47.7 83.3 74.9 Smoke from burning fuel or from cooking is a health hazard 74.5 53.8 77.3 59.7 AgeGroup(years) <40 40-59 >60 (n = 1,226) (n = 455) (n = 60) Smoking is a health hazard 82.2 76.9 60.3 ETS is a health hazard 71.7 65.0 52.5 Smokefromfuelusedforcooking or heating is a health hazard 67.5 60.3 58.3 Educational Level Illiterate Elementary JuniorHigh Senior (n = 472) (n = 760) (n = 387) Highand Higher (n = 63) Smoking is a health hazard 71.5 82.2 85.4 92.1 ETS is a health hazard 60.2 70.0 76.9 82.3 Smoke from fuel use for cooking or heating is a healthhazard 53.6 68.6 70.8 85.5 IncomeGroup2 <1,500 1,500-2,999 3,000-4,499 >4,500 (n=137) (n=442) (n=452) (n=684) Smoking is a health hazard 62.2 75.6 79.2 86.8 ETS is a health hazard 50.4 63.1 67.6 77.8 Smoke from fuel use for cooking or heating is a health hazard 55.6 65.0 61.9 62.2 1ETS = Environmental Tobacco Smoke. 2Combined value of cash income and subsistence food. Source: Jin et al. (2006). 44 Foundations for Intervention Design Regarding knowledge of the causes of IAP, only that awareness about interventions for reducing 16 percent (Guizhou), 12 percent (Shaanxi) and indoor smoke was relatively low, except for 5 percent (Gansu) of those interviewed knew that ``improving stove and chimney'' in Shaanxi, smoke from fuel combustion contains harmful where an improved stove program has been in components, including dust, CO, SO2, fluoride, place, and in Inner Mongolia, where efforts are As and "other chemicals." The link to indoor air under way to improve the design of the bed-stove quality was only clear for respondents in Inner configuration in newly constructed homes. In all Mongolia, where recent efforts have encouraged four provinces, few respondents thought that the installation of ventilation fans (Table 3.9). improving stove-handling skill would reduce indoor smoke from energy use. Most respondents could Even where knowledge of health risks exists, it not identify alternative fuels. must be coupled with knowledge about effective interventions (or solutions) from which individuals Chapter 4 (Annex 4.2) presents the energy/IAP and households may choose. Table 3.10 illustrates knowledge and behavior survey data, combining Table 3.9: Knowledge of IAP Sources by Province (percent respondents) Inner Gansu Guizhou Mongolia Shaanxi IAPSource (n=463) (n=476) (n = 323 ) (n=479) Cooking 36.7 51.6 77.7 63.1 Heating 16.8 38.3 57.6 54.1 Smoking 16.0 42.4 71.5 55.7 Poor or Limited Ventilation 23.3 49.0 63.8 42.3 Note: In the questionnaire, IAP was defined as the contaminated/polluted/bad air inside the house. Source: Jin et al. (2006). Reprinted with permission from Elsevier. Table 3.10: Knowledge of Methods to Reduce Smoke from Energy Use by Province (percentage respondents) Inner Gansu Guizhou Mongolia Shaanxi Method (n=463) (n=476) (n = 323 ) (n=479) Improving Stove 29.2 32.4 61.9 71.6 ImprovingChimney 21.4 29.7 26.0 68.4 Improving the Skills of 12.5 19.4 19.8 13.9 Stove Handlinga Improving Ventilationb 57.7 34.8 65.9 46.6 NoSmokingIndoors 4.5 22.4 44.3 15.7 SpendingLess Time Using Stove 6.9 17.6 10.8 8.3 aExamples given to respondents included splitting wood into small pieces and cleaning ash regularly to allow better burning. bExamples given to respondents included opening windows and doors. Note: n = number of households. Source: Jin et al. (2006). Reprinted with permission from Elsevier. 45 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China pre- and post-intervention measurements for control methods; nearly 40 percent were often all study groups. in the kitchen. Gansu Guizhou In Gansu, women's IAP-related knowledge In Guizhou, 50-60 percent of women in the before the health education and behavioral three household groups understood during the interventions was similarly low among all three baseline period that IAP could affect health. study groups. Only about 33 percent Less than 20 percent understood the source of understood that cooking is a source of IAP, and dental fluorosis, and almost none were aware less than 20 percent understood that heating is that coal and unwashed food could be a source. another source. By contrast, 70 percent or Age of women was not a significant factor more understood that IAP is a health hazard. influencing understanding, but education was; Consistent with the poor understanding of IAP the illiterate showed considerably less sources, only about 30 percent and 20 percent, awareness of the IAP health effect than those respectively, understood that improved stoves with primary or higher education. Those with and improved chimneys could reduce IAP. Age, higher incomes also tended to be more aware education and income differences did not yield of the risks. Most households dried corn and consistent differences in understanding of chili with coal smoke, and most (with the IAP-related knowledge. Indoor use of fire pans exception of S + B households) did not wash was extensive, ranging from 70-85 percent of food before cooking. Age, education and households in the control (C) and behavioral income were not significant factors influencing intervention (B) groups; only 33 percent of the method of food treatment. households in the stove plus behavioral intervention (S + B) group reported this With regard to stove use and maintenance practice. Age, education and income habits, 70 percent or more recognized that the differences were not influential factors in stove mouth should be covered after adding explaining fire pan use. fuel. However, only 25 percent or less understood the advisability of watering coal ash Women's stove use and maintenance practices when removing. As in the case of food varied; they were poor regarding closing the treatment, age, education and income were stove door when in use, yet strong with regard not significant factors influencing stove use to use of shorter wood and moderately good and maintenance habits. Most households with regard to watering ash before removing. (70 percent or more) often open windows while Some 80 percent or more women often open cooking. Age and educational differences do windows while cooking. Women younger than not appear to strongly influence this behavior, 30 years of age displayed similar practices as but a greater percent of households with higher women over 30. The practices of women with a incomes open windows while cooking. Less than junior-high school education and above were 10 percent of children exhibited knowledge of moderately better than those with only primary the source of IAP. But the health education schooling or less. Income differences did not group exhibited relatively strong knowledge appear to influence stove use behavior. Before about IAP pollutants, their effect and control the health education and behavioral methods; this knowledge was three times or interventions, children in Gansu had little more the percentage for the C group, perhaps knowledge of IAP sources, health effects and indicating survey inconsistency. 46 Foundations for Intervention Design InnerMongolia while more than 66 percent in the S + B group understoodthatthestovemouthshouldbeclosed InInnerMongolia,understandingthesourcesofIAP after adding fuel, less than 40 percent in the B washigh(60-80percent).Cookingwasidentifiedas group did. Age, education and income did not bear theprimarysourceofIAP,followedbyheatingandbed significantlyonstoveusehabitsandmaintenance. aeration.Mostwomen(50-75percent)understoodthat Amongstudents,only6percentunderstoodthe improvedstoveswouldleadtoreducingIAP,butfewer source of IAP, but 40-50 percent understood the (25percentorless)understoodthatimprovedstoveuse reference to pollutants and health effects. About wouldalsoreduceIAP.Age,educationandincome 33 percent of students had heard of dental fluorosis, differencesarenotreflectedinconsistentdifferencesin and about 25 percent were aware of prevention IAP-relatedknowledge.Some90percentofhouseholds methods. Most students (70 percent or more) stayed haveastove-bedheatingdevice,andmost(atleastin outofthekitchentoavoidsmokeinhalation. theBgroup)havenoseparationbetweenthestoveand bed.Again,age,educationandincomedifferencesdo IAP-related Health Symptoms notappeartoinfluencehouseholdstructures.Children hadarelativelyhighunderstandingofIAPsources,and Baseline data on the health conditions and status of arelativelygoodunderstandingofthehealtheffectof the project target populations were drawn from a notseparatingthestove-bedareas. comprehensive health survey questionnaire of all women and children aged eight to 12 in the target Shaanxi households (intervention and control groups) (Annex 3.6). Also, extensive health examinations In Shaanxi, more than 60 percent of women were conducted for all women (above 18 years of exhibited understanding during the baseline period age) and children (eight to 12 years old) in the that improving stoves is a method for IAP control. study households. Furthermore, extensive testing However, less than 40 percent and 20 percent, was conducted of children under five for acute respectively, understood that greater ventilation respiratory infection. The technical survey methods and improved fire-handling skills could reduce IAP. used and health examinations are outlined below. There was no consistent pattern with regard to age, education, or income. Only about 15 percent Technical Designs of households dry corn and chili in coal smoke, and an even smaller percentage store these foods Health examinations were conducted regarding near the stove. As in the case of IAP control, age, lung conditions, eye and nose infections, education and income do not appear to influence evidence of fluoric and As toxins and acute food treatment methods. respiratory infection in children. Regarding lung conditions, a sample of 150 women and During cooking, some 50-70 percent of women ­ 150 children (eight to 12 years of age) was especially those below 40 years of age and those randomly drawn from the S + B and C groups. better educated and with higher incomes ­ often Experienced clinicians selected to conduct the open windows. More than 90 percent understood lung examinations were trained and tested on that use of shorter wood contributes to reducing IAP; the use of specialized equipment.59 59The health survey was designed according to the general questionnaire of the International Atmosphere Standard Consultant Committee (ATS-DLD-78) and modified to account for Chinese conditions. Surveyors (113 in total) were trained, based on the "Investigation Training Manual for Health Surveys" and "Investigator Manual for Knowledge Attitude Positive (KAP) Surveys." 47 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China To test for fluoric and As toxins in household children under five had symptoms of acute members, urine samples were taken from women respiratory infection. In Guizhou, fluoride urine and children (eight to 12 years of age). In both concentrations in women and children were 1.35 Gansu and Shaanxi, 100 persons were selected and .90 mg/L, respectively; 27 percent of children from each of the S + B and C groups. In Guizhou, in that province were exposed to foods fluoric presence was tested on a similar basis, but contaminated with fluorides from coal smoke. including the B group. In Inner Mongolia, urine testing applied to the B and C groups. Experienced Annex 4.3 presents in full the detailed baseline clinicians selected to conduct the examinations data for IAP-related health symptoms, were trained according to the "Diagnostic Criteria combining pre- and post-intervention findings of Endemic Arseniasis" and "Clinical Diagnostic for all study groups. Criteria of Dental Fluorosis." IAP Interventions Acute respiratory infections among children (under The baseline data on IAP-related health five years old) were monitored extensively for all symptoms underscored the seriousness of the projecthouseholdgroups.Townshipclinicians, IAP problem in the study areas, as illustrated by trainedaccordingtoWHOstandardsfordiagnosing the finding that some 15 percent of children acute respiratory infection,60 conductedbimonthly under age five suffer symptoms of acute examinationsoverathree-monthperiod. respiratory illness. Baseline data on IAP All questionnaire surveys and medical concentrations illustrated the need for examinations were conducted after the subject alternative stove technologies, including (or his or her guardian) signed a consent form. improved ventilation systems, while information on household energy use provided the ResultingData fuel-specific, local design features for adapting these technologies. Baseline data on IAP-related The baseline, IAP-related health symptoms of knowledge and household behavior the target households in the four provinces were demonstrated the need for health education and serious (Table 3.11). During the three months behavioral interventions tailored to both local prior to the baseline health survey, some conditions and the general circumstances of the 15 percent of women in the target households project provinces, counties and townships. experienced IAP-related respiratory symptoms The next sections describe the resulting stove (for example, running nose and coughing with and ventilation improvements and health phlegm), 13 percent had IAP-related eye education and behavioral activities implemented symptoms (for example, irritation) and 27 percent in the four study areas. had IAP-related neurological-mental symptoms (for example, headache and dizziness). During the Selecting Alternative Stove Technologies two-week period prior to the baseline health survey, some 20 percent of children aged eight In response to the core IAP-related site to 12 experienced IAP-related nasal symptoms, problems, stove improvements were designed to 7 percent had pharyngeal symptoms and increase combustion efficiency and reduce 4 percent had eye symptoms. Fifteen percent of emissions. Combustion efficiency and emission 60"Management and Instruction Manual for Acute Respiratory Infection (ARI) in Infants." 48 Foundations for Intervention Design 499 773 1,109 = C n 12.2 2.9 = 34.9 n 3.2 28.5 1.3 = n 14.9 2.8 0.0 13.0 0.1 0.0 engorgement eyes, 494 748 1,104 = = Shaanxi B n 11.9 13.0 28.3 n 6.3 32.2 7.6 = n 15.4 7.7 1.0 14.7 8.0 0.0 watery eyes, B 578 855 1,022 both +S = = = of n 25.1 21.1 42.4 n 11.4 40.9 14.7 n 23.1 14.4 3.0 19.1 0.4 0.6 irritation) (not 572 645 883 = C n 7.7 2.3 6.6 = n 8.2 11.5 7.4 = n 21.0 5.8 9.0 14.3 2.2 0.0 itching dizziness. week, Mongolia phlegm. a and 545 623 1,084 of in = Inner B n 13.0 5.7 = 17.8 n 3.2 14.6 3.5 = n 30.2 20.0 1.0 18.7 1.3 week 0.0 days a in productive five than aches 562 813 670 ghing head = = C n 22.7 21.2 44.3 n 7.5 = 18.8 10.6 n 39.3 22.6 9.0 28.1 7.5 cou more morning. 0.3 and for the five in eyes than 550 739 792 coughing both more = = together Guizhou B n 14.5 13.5 32.2 n 8.3 23.2 7.4 = n 43.7 11.4 8.0 39.5 8.7 of 0.0 stick hours, observations. to of irritation four B 548 711 785 continuously, +S = n 10.8 5.9 = 15.4 n 3.1 11.1 5.3 = eyelids n 24.3 0.8 8.0 19.9 8.4 than number 0.0 hours, = more n sneezing four causing for than eyes control; 653 770 885 = = = C n 27.3 23.3 34.5 n 2.4 22 = 10.5 n 53.8 26.4 1.1 more both C 39.1 31.0 0.6 obstruction, headache or nasal lasting one 620 741 569 = Gansu B n 0.5 6.7 = 15.3 n 5.1 5.6 6.2 = n 51.5 16.2 9.1 nose, eyes from continuous intervention, 23.9 41.1 1.2 both of running include a discharge B 593 730 600 behavioral = Dat +S = = n 11.1 14.0 28.2 n 5.4 14.3 0.6 = n 42.3 32.0 2.5 32.2 36.7 0.3 include irritation eyes, months B 1 both three Health persons) months include or figures). past edt 2 one intervention, months) laer weeks) three the months in 3 past three two Infection, IAP- months) Infection the three affecting behavioral (self-reported omen weeks) Children in past W months) past past symptoms weeks) for plus (in three children two (in the allergies survey Baseline respondents/tested for Phlegm in three for two years-old of stove of Symptoms past years-old past (in Respiratory 5 symptoms = Respiratory Mucus B 3.11: (in past 12 (in Hemoptysis history + Household to bleaT Health Selected Respiratory Eye Neurological-mental (in Selected 8 Eye Nasal Pharyngeal Acute Surveillance Under Acute Coughing, and Dyspnea Nasal Pharyngeal eyE symptoms S eyes, (percent Respiratory Eye Neurological-mental 1 2 of 3 Note: Source: 49 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China tests of original and improved stoves were performance, respectively. Pollutant emissions conducted in five to eight representative (PM10, S02 and CO) were measured at given households for the S + B groups in Gansu, heights and distances from the stoves; each Guizhou and Shaanxi and the B group in Inner pollutant was continuously tested relative to the Mongolia (Table 3.12). amount of fuel consumed. The analysis method and instruments used were the same as those In total, 27 improved stoves, involving five described for IAP monitoring. stove-types, were pilot-tested. All were checked in the study households by scientists and Stove and Ventilation Interventions engineers from the Institute for Environmental Some 2,500 alternative stoves were provided to Health and Related Product Safety of the households on a subsidized basis (S + B groups China CDC. Once selection was narrowed, in Gansu, Guizhou and Shaanxi and B group the improved models were installed in 30-50 in Inner Mongolia). In addition, some 200 households in each province before households from the B groups chose to install large-scale installation. new stoves at full cost. Improved ventilation Indexes for pyrology efficiency were systems complemented the introduction of new determined based on the national standard stoves (Table 3.13). (Testing Method for Household Use of Coal and Pre- and Post-intervention Comparisons Biomass Stoves [GB6412-86]). The amount of fuel needed to heat and vaporize a given Taking into account local fuel use, household amount of water was measured; tests were conditions, housing structure and other factors, conducted under both controlled and local stove improvements were adopted in the study home conditions to measure ideal and actual counties/provinces, as follows:61 Table 3.12:Types and Number of StovesTested Before Intervention After Intervention Province Fuel-type Stove-type Number Stove-type Number Gansu Biomass Brick or clay 8 Coal/biomass 8 stove two-fuel stove Guizhou Coal Simple metal 6 Air-circular stove 6 stove (Beijing stove) Inner Biomass Brick or clay 8 Improved 8 Mongolia stove-bed device stove-bed Shaanxi Coal Separate coal 3;2 Twocombustion 2;3 andbiomass chambers for both ranges,basic biomassandcoal, underground combustionchambers chambers stove with improved insulation 61The detailed structures and technical parameters of the stoves are provided in the final project report of the China CDC. 50 Foundations for Intervention Design Table3.13:ImprovedStovesandVentilationSystemsInstalledinStudyAreas InterventionGroup S+B B Study Area Intervention-type Numberof Intervention-type Numberof (county, Finished Devices Finished Devices province) Installed Installed Guiding, Air-circular coal 500 Chimney extends 430 Guizhou stove, chimney outdoors extendsoutdoors Hui, Coal/biomasstwo-fuel 500 Coal/wood-using 71 Gansu stove, stove, air-sucking heating-bed 500 Heating-bedused 29 usedwithwood withwood Helingeer, NA NA Separate stove-bed 62 Inner device Mongolia Ankang, Coal-usingstove, 469 Undergroundstove/ 91 Shaanxi underground stove 469 range using coal with chimney Note: S + B = stove plus behavioral intervention, B = behavioral intervention. NA = Not applicable. Hui, Gansu. Cooking stove (Figures 3.1a, b). inside the room, resulting in smoke. They had Most of the original brick or clay (biomass) range either no chimney or one whose diameter or stoves had limited insulation with either no height resulted in inappropriate ventilation. chimney or one whose diameter or height resulted The new stoves are constructed of stronger in inappropriate ventilation. The new stoves are material and are insulated. The fuel opening constructedofstrongermaterialandareinsulated.The is outside the room with an airflow system to sizeofthecombustionchamberandchimneydiameter transfer heat through the bed-stove andheightaredesignedforappropriateventilation. combination. The chimney diameter and height are designed for appropriate Heating stove (Figures 3.1a, b). Most of the ventilation. A fire pan is sometimes used for original brick or clay (biomass) heated beds heating, making tea and cooking had limited insulation and an opening for fuel small meals. 51 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Guiding, Guizhou: Cooking and heating stove The new air-circular stoves have an internal (Figures 3.2a, b). Original coal iron stoves metal combustion chamber and outer metal were simple, enclosed metal containers body, separated by air. They are insulated with limited insulation and no door. and have a multilayered upper door to fit Chimneys, equipped on some stoves, variously sized cooking pots. The chimney seldom extended outside the house. extends outdoors. Figure3.1a:OriginalBiomassRange(left),Bed-heatingDevice(center)andChimney(right),Gansu Key Disadvantages: · Poorly structured biomass range · No smoke tract for bed-heating device · Incomplete combustion and heavy IAP · Poorly structured chimney and restricted exhaust Figure3.1b:ImprovedBiomassRange(left),Bed-heatingDevice(center)andChimney(right),Gansu KeyAdvantages: · Increased height of chimney with better · Improved structure of biomass ventilation range · Smoke tract for bed-heating device with · Clean combustion and efficient safer and more efficient heating energy use 52 Foundations for Intervention Design Figure 3.2a: Coal Iron Stove (left) and Chimney (right), Guizhou Key Disadvantages: · Chimney extends only into the attic · Incompletecombustion · Released smoke used to dry food · Heavy IAP emission · Stoves in serious disrepair Figure 3.2b: Air-circular Stove (left) andVentilation System (right), Guizhou KeyAdvantages: · Highacceptance · Completecombustion · Chimney extends outdoors · Lower IAP emission · Chimney wind cap exhausts smoke · Adaptedlocalcustoms 53 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Helingeer, Inner Mongolia. Cooking and heating house design and construction to separate the stove (Figures 3.3a, b). The original brick or cooking component from the heated bed. In clay (biomass) cooking stove was connected to a some cases, stoves have been moved out of the bed to create a bed-stove. Stove improvements bedroom, and ventilation fans have been are limited because they require changes in installed in the kitchen. Figure3.3a:OriginalBiomassStove-bedDevice,InnerMongolia Key Disadvantages: · No barrier between stove and bed · Restricted ventilation resulting in heavy IAP · Safety hazard, especially for children · Poorly structured with inefficient heat Figure3.3b:ImprovedBiomassStove-bedDevice,InnerMongolia KeyAdvantages: · Exhaust fan placed in kitchen · Stove moved out of bedroom (if two or · Chimney extended outdoors more rooms) · Addedsmoketractformoreefficientheating;and · Stove and bed separated by a barrier · Burns reduced for children (if one room) 54 Foundations for Intervention Design Ankang, Shaanxi. Cooking stove (Figures 3.4a, without chimneys. Stove improvements include b). Construction similar to that of Gansu (see better-insulated combustion chambers, with Figures 3.1a,b). Heating stove (Figures 3.4a, b). chimneys that extend outside the house Coal stoves for heating were built underground, above the eave. Figure 3.4a: Original Coal Range (left) and Underground Stove (right), Shaanxi Key Disadvantages: · No bed ventilation · Incomplete combustion with heavy IAP · Stove with no mouth ring or chimney Figure 3.4b: Improved Coal Range (left) and Underground Stove (right), Shaanxi KeyAdvantages: · Hot water supply · Energy-saving · Chimney extended outdoors · More efficient heating 55 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Table 3.14 summarizes the costs of the new stoves symptoms familiar to the population and ventilation devices for each study province. (for example, respiratory diseases, eye and vision problems, dizziness, headache and CO Developing Health Education and poisoning). In provinces where coal contains Behavioral Activities specific trace pollutants In all provinces, the following health education and (for example, F), the associated health behavioral activities were undertaken: outcomes (for example, dental and skeletal fluorosis) and routes of exposure · Sources of IAP. Fuel, stove and behavioral (for example, deposition on food dried over sources of IAP exposure were emphasized. fire) were also emphasized; These included coal-types (for example, those · Benefits of stove improvement. Fuel change with higher S or F content); stove characteristics and stove improvement to (for example, lack of chimney or one not reduce IAP exposure were promoted. Local extending outside the house, bed-stove or fuels and stoves were emphasized, as were heated bed without physical separation stove quality and maintenance. between fuel and living areas and poorly In Guizhou, where it was possible to ventilated stoves and cooking ranges); and extend the chimney of existing stoves, stove use behaviors (for example, not closing/ use of a longer chimney was covering the stove door or using too large emphasized; and pieces of fuel to allow for proper combustion); · Alternative stove use and ventilation · Health hazards of IAP exposure. Emphasis behaviors. Specific stove maintenance and was on both the role of chronic exposure to IAP stove use behaviors were presented as as a health hazard and specific diseases and alternatives to the behavioral determinants Table3.14:StoveInterventionCostsbyProvince Stove or Total Household Intervention Province Device Adopted Cost (RMB ¥) Portion Group Gansu CookingStove, 320-350, 120-150 S + B Heating-bed 370-420 (includingpartial Device materials and labor), Guizhou Air-circular Stove 300 100 (including S + B transportand fittings, for example, chimney) InnerMongolia Stove-bed Device 400 100-400 (including B partialmaterials andlabor) Shaanxi Underground Stove 585 185 (including S + B andOven transport,partial materials and labor) Note: S + B = stove plus behavioral intervention, B = behavioral intervention. Source: Chinese Center for Disease Control and Prevention. 56 Foundations for Intervention Design Figure3.5:IllustrativeHealthEducationandBehavioralMaterials School blackboard explaining how stove improvement Poster explaining how to prevent fluorosis. helps health. Village cadre distributing materials. Villagers` group discussion. Leaflet explaining stove use and behavioral habits which reduce exposure. 57 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China of exposure. These included fuel-handling, and IAP exposure. Following is a summary account closing or covering stove doors and of the key messages conveyed and methods used better ventilation of the cooking and for each province. living areas (subject to constraints of winter temperatures). Gansu. Key message: "IAP is caused by the improper ventilation of the old stove and use of Health education and behavioral activities were fire beds and fire pans." Health education training extensive (Table 3.15). In addition to the 3,500 was provided to 50 and 30 persons in households households and 5,000 students directly in the S + B and B groups, respectively. Village engaged, many more township residents (in the meetings were held, led by township hospital S + B and B groups) were reached through officials, village cadres and doctors. IAP broad distribution of some 27,000 information information (including the costs of not addressing leaflets. Some 5,850 students participated in a the problem and the relative inexpensive options composition contest on IAP, its health hazards for reducing IAP exposure) was publicized. and ways to reduce the problem. An array of Women played a prominent role, holding family materials (bulletin boards, films, visits to model meetings to exchange skills and to discuss ways to homes, manuals and village meetings) decrease indoor smoke and the advantages of contributed to building awareness. new stoves. Where possible, VCDs were played to Table3.15:NumberofHouseholdsandPersonsInvolvedinHealthEducationandBehavioralActivities Group S + B B Study Area Community School Community School (County, Province) (Households) (Persons) (Households) (Persons) Hui,Gansu 500 1,000 500 450 Guiding, Guizhou 500 800 500 1,400 Helingeer, Inner NA NA 450 460 Mongolia Ankang,Shaanxi 500 530 500 330 Total 1,500 2,330 1,950 2,640 Note: S + B = stove plus behavioral intervention, B = behavioral intervention; NA = Not applicable. Matching Key Messages to Local Realities demonstrate IAP health risks and methods to avoid them. Visits were made to model households, Health education materials were prepared notably to Mayan township where women in separately for each province so that specific model households demonstrated the use and messages could be matched to local geography maintenance of improved stoves. VCDs were also and climate, fuel and stove and sociocultural played in the local schools to educate students. factors. Preparation and dissemination of the materials also took into account the roles of men Guizhou. Key message: "Coal used in heating and women in household energy choice, stove use and cooking contains fluoride, which harms health 58 Foundations for Intervention Design and leads to fluorosis." The slogan "Prevent received health education training. Bulletins and Fluorosis, Chimney Outdoors" was painted on the other IAP-related materials were distributed widely. chimneys of more than 1,000 households. Health Visits to model homes and women's small-group education activities were conducted mainly in discussions contributed to better understanding of community centers and primary and middle the IAP problem and options for reducing schools. More than 450 persons, mainly from exposure. The county government reinforced the households in the B group, were trained in health campaign by requiring new house construction to education. Village rules and pacts were made to separate the bedroom and kitchen. reduce IAP, control fluorosis and change villagers' habits and behavior. Bulletins, films and Shaanxi. Key message: "People suffer from addresses by specialists and country and township fluorosis by using local bone coal with high leaders outlined how to prevent and control IAP fluoride content in underground stoves without andfluorosis. flues." Only 35 persons received health education training. Village working groups Inner Mongolia. Key message: "Use of a stove organized meetings of five to eight women at a connected to the bed in one room leads to time to discuss IAP health risks and ways to scalding of children and IAP, so stove and bed decrease indoor smoke. The advantages and should be in separate rooms." Village meetings proper use and maintenance of new stoves were held, led by township hospital officials, were described. VCDs and other educational village cadres and doctors. Twenty-seven persons materials were used. 59 4. Intervention Results* Zheng Zhou, Fei Yu, Zuzana Boehmova, Enis Bari and Majid Ezzati The changes which resulted from the stove and knowledge and behavioral indicators and behavioral interventions discussed in Chapter 3 IAP-related health symptoms. demonstrate the effectiveness of the project's heating-stove interventions in reducing IAP from Changes in Stove Use coal and biomass fuels. Cooking stove In the project provinces and China generally, interventions, whereby users modified combustion multifuel and stove use are common features of patterns more regularly (which included large household energy because of fuel availability and fluctuations in combustion intensity), exhibited multiple energy uses (for example, cooking and more mixed performance. When energy was used heating). Still the relative importance of fuels for heating, the fuel combustion pattern was more varies by project province. In Guizhou and stable and less intense. The improved heating Shaanxi, for example, use of coal for heating is stoves (including the heated bed in Gansu and the nearly universal (a small proportion of households underground stove in Shaanxi), which separated in Shaanxi use biomass). In Gansu and Inner the combustion chamber from the indoor Mongolia, biomass is the main cooking fuel, and environment and/or ventilated smoke outdoors, coal plays a major role in heating (Table 4.1). were effective in reducing IAP and were not sensitive to user behaviors. Thus, well-designed Because of the project's short time span, fuel use and -constructed stove improvements can composition was assumed to remain largely significantly reduce IAP exposure and its associated unchanged throughout the project period. Stove disease burden in China, where heating is a basic and stove-ventilation data show improvements in energy use for much of the population. technical characteristics (for example, whether a stove had a chimney or whether it extended The following sections describe the outcomes outside the house) in the S + B group, as the which resulted from the project's alternative intervention design intended. stove technology (including improved ventilation systems) and health education and behavioral Improvement in stove ventilation also occurred interventions. Results are reported according to in the B group (for example, improved chimney the four major outcomes: stove use and in Guizhou and Shaanxi and reduced reliance potential stove efficiency, IAP, IAP-related on stove-bed device in Inner Mongolia). * Portions of this text is from the article by project team members Yinlong Jin et al., "Exposure to indoor air pollution from household energy use in rural China: the interactions of technology, behavior and knowledge in health risk management," Social Science and Medicine, 2006 June; 62(12):3161-76. Permission for reproduction of material was granted by Elsevier. 61 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Table4.1:BaselineFuelUseAmongStudyParticipants(percenthouseholds)* Inner Gansu Guizhou Mongolia Shaanxi C B S+B C B S+B C B C B S+B n= n= n= n= n= n= n= n= n= n= n= Fuel 509 509 500 523 501 484 527 508 508 491 581 Cooking Coal 1.6 0.4 1.6 94.3 97.5 69.2 5.3 3.9 60.6 55.6 59.0 Biomass 98.4 99.6 98.4 5.7 2.5 30.8 94.7 96.1 39.4 44.4 61.0 Heating Coal 34.6 16.3 30.2 100 100 100 96.2 80.2 98.6 96.7 96.2 Biomass 65.4 83.7 69.8 0 0 0 3.8 19.8 1.4 3.3 3.8 *Figures are based on a survey question which asked household respondents about main fuel for cooking and heating. Note: C = control, B = behavioral intervention and S + B = stove plus behavioral intervention; n = number of observations. Provincial Results extending outdoors (reflecting a dramatic increase of 88 percentage points compared to Intervention results by province were as the baseline). The percentage of biomass follows (Table 4.2): range use declined in all groups; · Inner Mongolia. Households in both groups · Gansu. In the S + B group, stove and stove (B and C) exhibited increased use of biomass ventilation data showed improvement in stove ranges following the interventions. Reliance on technical characteristics (that is, presence or the stove-bed heating device decreased for length of chimney), as a result of the households in the B group, while it increased intervention design. Among the B group, for those in the C group. In terms of separation improvement in stove ventilation were noted between stove and bed, after installation of (that is, chimneys extended higher above exhaust fans, B group households showed little the ground). For all three groups, the change, while separation increased for C percentage of households using coal grouphouseholds;and stoves increased (although S + B and B · Shaanxi. S + B groups reported a sharp showed larger increases than C); increase in the use of chimneys. In · Guizhou. The S + B and B groups showed particular, all households in the S + B group significant improvement in stove technical had chimneys for coal and underground characteristics. In the S + B group, stoves, while most B group households did post-intervention, all households had chimneys not have chimneys. 62 Intervention Results Post =n 414 100 16.7 001 B +S Pre =n 581 100 72.1 95.7 coal. burn Post =n 458 100 68.4 001 to B range coal Shaanxi Pre =n 491 100 65.2 96.1 the heating. the control, use of = and C Post =n 437 100 63.4 001 also use C cooking percent; Pre =n range, 508 100 64.0 97.8 Increased 100 coal primary than Post =n the slowly. 454 73.4 both B under for more more Pre =n 508 86.6 86.6 51.6 used total burns reported are can Mongolia Post =n coal 490 96.7 96.7 92.9 olds, stoves Inner C numbers Pre =n 527 93.9 93.9 75.5 househ Coal because of feed. Post =n 377 23.6 87.1 87.1 001 heating, heating or subset B a animal +S Pre =n 484 67.4 001 nighttime cooking while for for preparing fuel Post =n 456 16.9 001 for survey. biomass, stove) and and with coal B Guizhou Pre =n 501 20.8 001 baseline stove range festival) the season. one in the additional Post =n 458 27.9 001 than use spring an stove heating es use more C U evotS Pre =n 523 33.1 001 (or example, heating 2004-05 uses households in (for device All intervention. Post =n 469 75.3 001 001 33.3 winter tionnevret B coal. events household a +S (underground) stove-bed if Pre =n 500 27.8 001 001 and large no colder behavioral 33.4 for their the Thus, had in plus st-inoP biomass used Post =n 473 47.4 001 001 coal reflects stove 85.2 both counted. use = B B and- use primarily households likely are Gansu Pre =n 509 23.0 001 001 + is of S 85.4 can Pre survey and of households purpose y Post =n 504 57.0 001 001 range 71.7 range percent a 5 C many for Pre =n 509 44.7 001 001 72.1 biomass than cooking used intervention, Summar the less 1 the post-intervention Device 4 Mongolia, 4.2: Range Device stoves 2 Bed the 1, Use Stove in All 3 Heating Stove Pan Gansu, Guizhou, Shaanxi, Inner behavioral ableT In In In In = Stove/ Fuel Cooking Coal Stove/Range Biomass Range Stove-bed Heating Coal Biomass Underground Stove Heated Stove-bed Cooking and Coal Fire 1 2 3 4 stove Note: B 63 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Energy Efficiency under Controlled Conditions Changes in IAP Levels Under controlled conditions, fuel and heat Air quality monitoring following the efficiency of the new stoves increased stove/ventilation interventions mirrored the significantly over that of the old ones (no data techniques for collecting baseline data. With on actual user conditions were collected). few exceptions, the same households were In these tests, the fuel that new stoves consumed selected for post-intervention testing of RPM, to vaporize a given amount of water under CO and SO2 levels. Two testing methods were household conditions decreased 30-50 percent. used: 1) approximately 75 households (some With the exception of the new stove used in 27 from each of the S + B, B and C groups) Shaanxi (where increased ventilation of the from each province were tested for one heating stove may have led to higher fuel complete day in December 2004 and March consumption), heat efficiency increased 2005; and 2) smaller sets of households 25 percent on an average. Table4.3:ComparingFuelandHeatEfficiencyofOldandNewStoves Fuel Consumption (Kg/h) Heat Efficiency (%) Province Stove-type Fuel Old New % Old New % Stove Stove Change Stove Stove Change Guizhou Air-circular Coal 0.84 0.58 30 12 15 25 Gansu Biomass Biomass 3.84 1.88 51 13 17 31 Shaanxi Underground Coal 1.02 0.60 41 26 21 ­19 Inner Stove-bed Biomass NA NA NA 9 13 19 Mongolia Device Note: Heat efficiency equals weight of fuel needed to bring a fixed volume of water to boil. Increased heat efficiency (%) equals heat efficiency of new stove minus heat efficiency of old stove divided by heat efficiency of old stove. NA = Not applicable. While both efficiency and pollutant emissions are (some six from each province) were tested related to the combustion process, they are continuously over four-day periods in separate characteristics; reducing pollutant December 2004 and March 2005. emissions was the main goal of this project. The measurement points used were the Measurements under household conditions same as during the baseline phase. indicated that the new stove/ventilation In addition to the above household technologies not only had higher fuel and heat measurements, pollutant levels from a efficiency, but considerably lower emissions (per small number of old and new stoves unit of heat). With regard to environmental were measured under controlled stove implications, the results were too mixed or limited use conditions equivalent to ideal stove to draw conclusions. use behavior. For these controlled 64 Intervention Results measurements, local fuel was used and Changes under Controlled Conditions scientists and engineers from the Institute for Environment Health, China CDC, Undercontrolledconditions,reductionsinRPM operated the stoves. Concentrations of indoor concentrationswereconsistentandsubstantial;most air pollutants were measured at given werestatisticallysignificant,despitethesmallnumberof distances from the stoves for the duration tests.ForSO2,thereductioninShaanxiwassubstantial, of combustion of an approximate fixed reflectinghighpreinterventionconcentrationsresulting amount of fuel. fromthetypeofcoalused(Table4.4). Table 4.4: Change in Pollutant Concentrations under Controlled Conditions Stove Fuel RPM(µg/m3) CO(PPM) SO2 (PPM) Gansu Preintervention Wood 3,400 (n = 7) 64.8 (n = 7) NA CookingRange Post-intervention Wood 60 (n = 7) 7.5 (n = 8) NA CookingRange -3,340 (-98%) -57.3 (-88%) (p = 0.04) (p = 0.04) Guizhou Preintervention Raw 3,520 (n = 5) 14.5 (n = 5) 1.25 (n = 6) (Beijing Stove) Coal Post-intervention Raw 420 (n = 5) 5.0 (n = 4) 1.14 (n = 6) (Air-circular Stove) Coal -3,100 (-88%) -9.5 (-66%) -0.11 (-9%) (p = 0.006) (p = 0.08) (p = 0.62) Shaanxi Preintervention Stone 1,240 (n = 6) 23.0 (n = 6) 7.96 (n = 5) CookingRange Coal andUnderground Stove Post-intervention Stone 90 (n = 4) 5.8 (n = 4) 0.92 (n = 4) CookingRange Coal andUnderground Stove -1,150 (-93%) -17.2 (-75%) -7.05 (-89%) (p = 0.18) (p = 0.01) (p = 0.21) Note: n = number of observations; = absolute reduction in pollutant concentrations Source: Chinese Center for Disease Control and Prevention. 65 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Changes under Household Conditions significance, in late (March-April) versus peak (December-January) heating seasons. This was not The levels and changes in concentrations of the case for the separate kitchens in Gansu and pollutants under household use condition Shaanxi, where reductions in RPM concentrations show substantially more heterogeneous were similar during peak and late heating seasons. stove performance than in controlled tests This result may be related to the seasonal nature (Annex 4.1).62 It should be noted that the of heating (living room and bedroom) versus a proportional reduction in 24-hour household more stable pattern of energy use for cooking concentrations after the stove intervention may be (separate kitchen). The pattern for the gaseous lower than those in controlled tests for two possible pollutants (CO and SO2) was less consistent; reasons: 1) user skills and behaviors may lower concentrations declined in a smaller number of the pollution-reducing effectiveness of a stove; and measurement points, and the proportional 2) twenty four-hour measurements consist of reductions were smaller. periods when the stove is burning intermittent with those when the stove is off. Therefore, Full Intervention and Control Comparisons proportional reduction in 24-hour concentrations may be less than those In Gansu, S + B consistently had a larger decline observed during burning periods. than C. This result was observed for both RPM and CO in cooking and living/bedrooms. The IAP With few exceptions, post-intervention RPM reduction benefits of S + B were larger, with concentrations declined for S + B and B, as well better statistical significance in the living/bedroom as C (for example, B group in Guizhou during the measurements than in the cooking room in December-January measurement period). Given December-January; the benefits of S + B were the physical separation of the three clusters, it is larger in the cooking room in March-April. unlikely that the decline in C was a consequence Benefits during peak heating months of contamination effects. Rather, it may represent (December-January) in the living/bedroom in all determinants of indoor air pollutants external to likelihood resulted from major design changes of the interventions. However, temperature appears the heated bed (Panel 1); cooking room reduction not to have been the cause; data from the China benefits resulted from new stove construction, with National Meteorological Information Center stable cooking patterns over time. indicate that average monthly temperatures were slightly higher during the post-intervention periods In Guizhou, S + B (with few exceptions) had in Gansu, Guizhou and Inner Mongolia, and larger reductions than C for all three measured slightly lower in Shaanxi, compared with the same pollutants in December-January, but smaller months during the baseline measurements, but not reductions in March-April, especially for RPM. enough to explain the RPM reduction in C. None of the results in March-April were statistically significant. The March-April finding results largely For rooms where heating is important (living room from unusually high concentrations in the baseline and bedroom), reduction in RPM concentrations measurements for C (621 µg/m3 in the cooking/ were generally less, and with lower statistical living room and 552 µg/m3 in the bedroom), 62Annex 4.1 shows the levels and post-intervention changes in concentrations of indoor air pollutants under household use conditions. It provides the basis for difference-in-difference analysis by showing, for each province, the changes in IAP concentration levels for the intervention groups compared to the control groups. 66 Intervention Results which leads to large observed post-intervention With regard to comparing results of S + B and B, reductions in this group. Of the 33 measurements S + B groups clearly outperformed B groups. In leading to these baseline estimates, nine were Gansu and Guizhou, S + B groups reported above 1,000 µg/m3; six of these were measured in consistently larger reductions in concentrations of the same village within a two-day period. These all pollutants than did B groups during the peak outliers have a relatively large effect on the results. heating season; the differences were mostly statistically significant. In Shaanxi, the S + B In Shaanxi, the effects of S + B on various groups reported larger reductions in all pollutants pollutants in different months were the least during the late heating period; one-third of the consistent among the three provinces; the only differences were significant. noticeable benefits compared to C were for RPM and SO2 concentrations in the bedroom. This Changes in IAP-related Knowledge finding may reflect the improved combustion/ and Behavior ventilation of new stoves in the bedrooms, with low Like changes in IAP concentration levels, changes in concentrations of RPM and SO2, but not of CO, IAP-related knowledge and household behavior for S which is a crude indicator of total combustion. + B and B were the combined effect of stove and Reduction benefits in the bedroom were larger in behavioral activities. With regard to B, the outcome December-January than in March-April, reflecting understandablyreflectsbehavioralactivitiesonly. the seasonal nature of bedroom heating. In this Annex 4.2 provides pre- and post-intervention province, C outperformed S + B in terms of survey results for women and children in the study change in concentrations of all three pollutants in households. Because the survey questions varied by the living room in December-January, although province, one should exercise caution in making sample sizes were smaller because fewer interprovincialcomparisons. households used their living room stove. Cooking room results had no consistent patterns or IAP-related Knowledge statistical significance.63 Questions common to all provinces included the Other Relevant Comparisons main sources of IAP, their health effects and control methods. Knowledge about fluorosis is In addition to comparing results between S + B relevant only for Guizhou and Shaanxi (Table and C, comparing B and C, as well as S + B and 6.1, Annex 4.2). B relative to changes in C are also relevant. In Inner Mongolia, where only B was undertaken, With few exceptions, all groups showed reductions in RPM and CO concentrations for the B post-intervention improvement in IAP-related group were greater than that of the C group, knowledge. The process of completing the although none of the differences were statistically health survey likely raised respondents' significant. With few exceptions, the B groups in awareness of the IAP problem. In some cases, the other three provinces showed no significantly S + B groups had larger improvements than did different reductions in pollutant concentrations B groups, suggesting that the process of from those of the C groups. Of the five significant participating in stove improvements could results, four indicated that B had smaller have contributed to raising awareness of reductions than C, and one showed the opposite. IAP-related knowledge. 63It should be noted that sample sizes were smaller for living room measurements because fewer households used their living room stove, which reduced the power of testing. 67 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China In Gansu, women in the S + B group reported Behavioral Indicators greater improvement in knowledge of health hazards and risk perceptions than those in the C Questions common to all provinces mainly group; most of these improvements were included stove use habits (for example, closing statistically significant. Differences between B and stove lid, using shorter wood, watering ash and C groups exhibited no consistent patterns. With few opening windows). For children, the behaviors exceptions, women in the S + B group included avoiding smoke and staying out of the demonstrated greater statistically significant kitchen while cooking. Fluorosis prevention improvement than those in the B group. Among behavior was relevant only for Guizhou and children (with one exception), the B group Shaanxi (Table 6.1, Annex 4.2). demonstrated less improvement than the C group, In Gansu, women in the S + B groups showed and all results were statistically significant. greater improvement than C groups in all cases; In Guizhou, women in both S + B and B groups most differences were statistically significant. reported greater statistically significant B group had greater improvement than C group in improvement than those in the C group. With few three out of four cases, but none of the differences exceptions, the S + B group reported greater were statistically significant. S + B groups improvement than the B group; half of the demonstrated greater improvement than differences were statistically significant. For B group, and the differences were mostly children (except for the IAP health impact), the B significant. These results are consistent with group reported greater improvement than the C increased awareness of IAP-related knowledge in group, and the differences were mostly significant. Gansu province. For children, the differences These results suggest that both S + B and B groups between B and C groups were neither consistent benefited from behavioral interventions, with norsignificant. S + B groups benefiting more than B groups. In Guizhou, with the exception of "washing corn In Inner Mongolia, with few exceptions, women before cooking," women in both S + B and B in B group demonstrated greater improvement groups had greater statistically significant in IAP-related knowledge (except with respect improvement in food treatment behavior than to heating as a source of IAP) than those in those in C group. Differences between S + B and C group, but the differences were mostly B groups showed no consistent patterns. In this insignificant. With regard to children, B group case, participation in stove improvement appears demonstrated statistically significant greater not to have had any effect on food treatment improvement than C group, except with respect behavior. In terms of stove use and maintenance to the IAP health impact. habits, both groups reported greater statistically significant improvement than the C group. S + B In Shaanxi, women in the S + B groups reported and B groups showed no significant differences. greater improvement than the C group, although No consistent patterns were shown for children. half of the differences were insignificant. There was no consistent pattern in the differences In Inner Mongolia, women in B group between B and C groups or between S + B and C demonstrated statistically greater improvement groups. For children, B group demonstrated than C groups in all aspects, indicating that the greater improvement than C group, and the interventions were effective in changing behavior. differences were mostly statistically significant. With regard to children, B group demonstrated 68 Intervention Results greater statistically significant improvement than The interventions were generally less effective for didCgroups. B group than for S + B groups. This finding suggests that behavioral intervention alone is In Shaanxi, in terms of food treatment behavior, insufficient to change behavior or even awareness. women in the S + B group demonstrated greater This finding is consistent with others regarding IAP improvement than those in the C group, and the concentrations, which found no IAP benefits from differences were mostly significant. Differences behavioral interventions alone. This may reflect between B and C groups showed no consistent that people's cooking and heating behaviors, pattern. The S + B group exhibited greater which are central to daily life, may be little improvement than the B group, and differences affected by their knowledge and concerns about were mostly statistically significant. In terms of long-term health outcomes, especially where stove use and maintenance behavior, the S + B infrastructure and household economic status limit group demonstrated greater improvement than the changes in fuels and stoves (Jin et al. 2005). C group, although the differences were mostly Another possibility may be that behavioral change insignificant. The S + B group also reported effects may not have been large enough to lead to greater improvement than the B group, but observable improvement in pollution levels, differences were mostly insignificant. Differences whereas stove improvement resulted in larger, between B and C groups showed no consistent more measurable effects. As noted previously, the patterns. For children, B groups showed greater sample sizes for pollution measurements were statistically significant improvement than C groups small (20-30 per group), which limited the power in behavior changes to reduce IAP exposure. of testing. If behavioral changes caused any changes in pollution levels, they may have been Health education and behavioral activities may too small to be detected. have led to incremental IAP knowledge, but it was insufficient to convince households in B group to In terms of improving understanding of incur the full cost of a new stove. It may be that IAP-related knowledge among women, the more intensive health education and behavioral interventions were effective in all S + B groups, activities continued over a longer period, or but mostly ineffective in B groups, with the alternatively, if the cost of stove improvement exception of Guizhou. As noted above, were to fall, one might observe more benefits participation in stove interventions may have from such activities. It should be noted that the improved awareness of IAP-related knowledge. cost of the stoves for the B group was In the case of school children, the interventions approximately one-quarter of per capita annual were mostly effective, except for Gansu. net income in rural areas. IAP-related Health Indicators Overall, the interventions had some effects in changing stove use habits, but the results were Many of the health effects of IAP exposure in rural more consistent and had more statistical China involve chronic conditions with significance for S + B groups than for B group. heterogeneous definitions (Lan et al. 2002); Again, stove and ventilation improvement however, this study was not designed to detect interventions may have facilitated IAP-related health benefits, which require substantially longer behavioral changes. One exception is Inner follow-up and more accurate diagnostic criteria. Mongolia, where the interventions were effective Because of the project's short time frame, rigorous in improving IAP-related behavior in the B group. collection of results and subsequent analysis were 69 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China not feasible. But given the frequent health reductions in symptoms than the C group. Lung complaints by women in the study provinces (for function showed no consistent pattern. In terms of example, headaches and lacrimation), we decided IAP-related eye, nasal and pharyngeal symptoms to include a set of symptoms to gauge any among children, the B group had statistically improvement in this area (Table 6.2, Annex 4.3). greater reductions for all symptoms than the Thissectionbrieflyevaluatestheeffectivenessof C group. With regard to symptoms of acute interventionsbycomparingsymptomschangein respiratory infection, children under age five interventionandcontrolgroupsforeachstudyprovince. showed no consistent pattern. In Gansu, the differences in IAP-related health In Shaanxi, with regard to IAP-related respiratory, symptoms(forexample,dyspnea,nasalmucusand eyeandheadache/dizzinesssymptomsamong eye irritation) between women in S + B and C women, both S + B and B groups reported greater groupsweremixedandmostlyinsignificant. reductions than C group; however, only the For children, S + B groups reported worsening differences between the S + B and C groups were symptomscomparedwithCgroups,althoughthe statistically significant. In terms of urine fluoride, the differences were insignificant. S + B groups S + B group reported greater significant reductions reported less increase in symptoms than B groups, than did the C group. Differences between the B and the differences were mostly significant. andCgroupsshowednoconsistentpattern.Interms For children under age five, changes in the of IAP-related eye, nasal and pharyngeal symptoms incidence of symptoms of acute respiratory infection among children, S + B groups reported greater showed no consistent patterns for S + B or C groups. reduction than C groups, which were mostly Bgroupsreportedmostlysignificantreductionsinthe significant.TheBgroupshowednoconsistent incidenceofallsymptomsofacuterespiratoryinfection. pattern. For children under age five, with few Heterogeneityoftheprojectgroupsmayhave exceptions, both S + B and B groups reported accountedforthiscontradictoryresult. reduction in symptoms of acute respiratory infection post-intervention, and the increases were greater In Guizhou, with regard to IAP-related respiratory, than those reported by the C group. eyeandheadache/dizzinesssymptoms,the differences between women in S + B and C groups Summing up, the health effects of the interventions showednoconsistentpattern,whilethe varied by province. Among women and children Bgroupreportedgreaterstatisticallysignificant (eight to 12), they appear to have been more reductions than the C group for all symptoms. Urine effective in Guizhou, Inner Mongolia and Shaanxi, fluorideresultsshowednoconsistentpattern.With and less effective in Gansu. In terms of symptoms of regard to eye and nasal symptoms among children, acute respiratory infection among children under both S + B and B groups not only reported less age five, the interventions were more effective in increases than the C group, but also less reduction Gansu and Guizhou, and less effective in Inner in pharyngeal symptoms; most of the results were MongoliaandShaanxi.Self-reportingofhealthdata statistically significant. For children under age five, may have resulted in measurement error, as well as both S + B and B groups reported mostly greater systematic bias (for example, those in the statisticallysignificantreductionsinallsymptomsof intervention group may have changed their acute respiratory infection than C groups. reportingbehaviorafterthehealtheducation program). Symptoms of acute respiratory infection In Inner Mongolia, with regard to respiratory, eye among children under age five were obtained andheadache/dizzinesssymptomsamongwomen, throughevaluationsbyhealthprofessionals;but theBgrouphadgreaterstatisticallysignificant because of the short duration of monitoring, it is 70 Intervention Results likely that only a small number of diagnosed cases reduce exposure to Fluorine (F) deposited onto food were acute lower respiratory infection. dried or stored over the attic chimney. Thus, the interventions may have put less emphasis on the The short follow-up period for all health outcomes ambientconcentrationsofthethreeindicator may have limited changes in symptoms which occur pollutantsusedinthisanalysis.Asmallnumberof graduallyorlag.Inaddition,heterogeneityamong atticmeasurementsdemonstratedthatreductionin study groups may have been a serious problem in concentrations of all three pollutants in S + B were assessing health effects. In some cases, S + B about10timesthatinC. groups reported significant increase in certain symptoms, while the C group showed either no No IAP reduction benefits resulted from health significantchangeorreducedsymptoms.Itis educationandbehavioralinterventionsalone, doubtful that the interventions resulted in increased despite the relative extensiveness of the program. symptoms. Group-specific factors unrelated to the Introducingalternativestovehandlingbehaviors(as interventions may have affected the health of the part of the health education program) led to respondents.Alternatively,theinterventionprogram changes in specific behavioral indicators (for may have affected the reporting behavior of S + B example, covering stove door or top after fuel is and B groups differently from the C group. added),basedonself-reporteddata;butthese changes had no measurable benefits for indoor air Findings and Implications quality.Tworeasonsaccountforthisfinding. First, awareness of health risks and interventions Resultsdemonstratedthatheatingstoveinterventions cannot lead to changes in fuel and stove choices were effective in reducing IAP from the burning of withoutsufficientphysicalandfinancialaccessto coal and biomass fuels (Table 4.5). When energy alternative fuels and stoves. Second, the specific was used for heating, fuel combustion occurred in a behavioralchangesreportedbyparticipantsmaynot more stable pattern and with less intensity. have been sufficient to lead to reduced emissions, Therefore, the new heating stoves, which separated given the central role of cooking and heating in daily thecombustionchamberfromtheindoor life. Nonetheless, health education can play a key environmentand/orventilatedsmokeoutdoors, part in more comprehensive intervention programs were effective in reducing IAP and were not by encouraging the uptake and use of new sensitive to user behaviors (for example, new heated technologies (for example, cleaner fuels and stoves) bedinGansuandundergroundheatingstovein and reducing IAP exposure through specific routes Shaanxi). Because heating is the main energy use (for example, bioaccumulation of F in food dried throughoutmuchofruralChina,well-designedand over fire). -constructedstoveimprovementscansignificantly reduce IAP exposure and associated disease burden. One should also note the study's limitations. First, the relatively small sample size for Results of cooking stove interventions were more pollutant measurements (owing to measurement mixedbecausecookersmodifycombustionpatterns costs) limited the statistical power of our actively and regularly, leading to relatively large analysis. However, one feature of the findings fluctuationsincombustionintensity.Theinconsistent was consistency of reductions for different findingsonpollutionreductioninGuizhoumayhave pollutants, seasons and locations for some been related to this factor because the same coal provinces (for example, S + B in Gansu) versus stovewasusedforcookingandheating(cooking inconsistent and opposite evidence on benefits in was the primary use in March). Furthermore, a other cases (for example, B); sample size is less major aim of the interventions in Guizhou was to likely to have affected consistency of results. 71 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Table4.5:SummaryofIAPConcentrationChanges PM4 CO SO2 p-value >0.05 >0.05 >0.05 < and > < and > < and 0.05 <0.1 0.1 0.05 <0.1 0.1 0.05 <0.1 >0.1 December-January Measurement Period S + B Gansu CookingRoom Living/Bedroom Guizhou Cooking/LivingRoom Bedroom Shaanxi CookingRoom Bedroom LivingRoom B Gansu CookingRoom Living/Bedroom Guizhou Cooking/LivingRoom Bedroom Inner Mongolia Cooking/Living/Bedroom Shaanxi CookingRoom Bedroom LivingRoom 72 Intervention Results PM4 CO SO2 p-value >0.05 >0.05 >0.05 < and > < and > < and 0.05 <0.1 0.1 0.05 <0.1 0.1 0.05 <0.1 >0.1 March Measurement Period S + B Gansu CookingRoom Living/Bedroom Guizhou Cooking/LivingRoom Bedroom Shaanxi CookingRoom Bedroom LivingRoom B Gansu Cookingroom Living/bedroom Guizhou Cooking/LivingRoom Bedroom Shaanxi CookingRoom Bedroom LivingRoom Note: p < 0.05 is statistically significant at 5 percent level, p > 0.05 and < 0.1 is statistically significant at 10 percent level, p > 0.1 is statistically nonsignificant; = larger reduction or smaller increase, = smaller reduction or larger increase; S + B = stove plus behavioral intervention, B = behavioral intervention. 73 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Second, with regard to the community Finally, the study did not include long-term randomization design used (to avoid or limit follow-up on the benefits of the interventions. contamination of the C group by the health Over time, it is possible that user behavior would education intervention), differences in improve, leading to better performance for both environmental and socioeconomic factors (even interventions; at the same time, stove deterioration between townships in the same county) may could lead to a reduction in the observed have occurred, despite efforts to select similar performance of the new stoves. villages and households. Such differences would mean that the study design is only This study's findings are consistent with partially randomized and that there may have observational studies in China and Kenya.64 been differential secular trends in pollution The emerging evidence has two implications for before and after interventions in various scaling up intervention programs. First, stove townships. For example, substantially higher programs must emphasize design and biomass use for cooking in the S + B group in construction to ensure that solid fuel combustion is Guizhou may have influenced the IAP effects of isolated from the living and working environment stove interventions. (to the extent possible) and is robust to user behavior. This, in turn, requires facilitated multiple Third, day-to-day fluctuations in temperature or purposes of energy use, including cooking and other factors which determine household energy heating, and how they may affect stove use behavior may have resulted in variability in the performance and human exposure. Evidence on number of stove use hours and, hence, pollution alternative stove limitations also means that across measurement days. This variation would be sustained and robust reduction in IAP exposure equivalent to measurement error in "usual requires strategies to initiate and disseminate pollution" for each household and reduce the alternative fuels. Since macroeconomic and statistical significance of the findings. Converting infrastructure factors are likely to limit large-scale pollutant concentrations to per hour stove use, switching to petroleum-based fuels, an important based on the self-reported number of stove use area for future research is preprocessing of hours each measurement day, did not change solid fuels into cleaner ones. The next Chapter thefindings. discusses available options. 64Alternative cooking stoves have more variable performance than cleaner fuels; the stoves are affected by design, construction and maintenance; and ventilated heating stoves (China) have observed health benefits. 74 5. Alternative Energy and Technology Options Fei Yu, Zuzana Boehmova, Enis Bari and Majid Ezzati The previous Chapter discussed the various Although advanced (high-tech) energy technological IAP interventions which were tested innovation in developing nations is certainly as part of this project. Additional household energy needed, energy transformation in poor areas use options have other environmental and will take years to achieve and require economic implications. This Chapter discusses substantial investment in technology R&D. selected options, with emphasis on RE sources, as Therefore, we also address simpler alternative well as current trends in alternative energy energy options applicable to existing cooking generation, both worldwide and in China. and heating equipment in rural areas. Overview Global Energy Mix Energy is essential to meeting the most basic In the near future, oil, gas and coal will continue to household needs, whether cooking, heating, dominate the aggregate global energy markets; lighting, or boiling water. Growing environmental notwithstanding hydroelectric power, and the share concerns in both the industrial and developing of RE sources will remain relatively small. At the world, combined with the sharp price rise in fossil same time, there are outliers; for example, 77 fuels ­ particularly oil and natural gas ­ over the percent of France's electricity is generated by past few years, have increased interest in nuclear energy, while 20 percent of Denmark's is alternative energies for electricity generation and derived from wind power (Parfit 2005). Around transport. Although alternative fuel sources still the world, coal (which remains abundant relative meet only a small percentage of global energy to oil and gas reserves) continues to dominate demand, the more commercially viable ones are electricity generation; however, natural gas is growing rapidly. In addition, developing countries making inroads. Moreover, solar power is being now emphasize the development of distributed discussed as a potential solution to bring electricity power ­ localized power generation ­ driven by to rural communities in the developing world the necessity to provide relatively cheap and which lack power and generators. reliable power in the absence of developed electricity grids, which are expensive to build If oil and gas prices remain high, there will be and maintain. This trend could have a additional incentive to diversify away from these significant effect on alleviating poverty and fuels as primary energy sources. This, in turn, improving public health, as one chief obstacle could spur technology breakthroughs that make to rural energy supply is the distance from alternative energy more attractive in terms of power centers and insufficient energy cost. In the meantime, both government infrastructure in these areas. legislation and market forces will determine the 75 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China extent to which the energy mix changes over China is now beginning to utilize the country's time. Currently, the three most commercially massive flow of RE sources, from biofuels to viable sources of alternative energy whose costs wind and solar power. Exploitable onshore wind compare favorably with coal and natural gas resources alone could provide 253 Giga Watt are nuclear, hydropower and wind power. (s) (GW) of electric capacity, while offshore Other promising sources include solar, resources could provide three times that geothermal renewable biomass-based systems amount.67 China is already the largest producer and modified coal. of solar thermal energy for hot water, boasting 60 percent of the world's installed capacity. And Energy Technology Context in China with the Renewable Energy Promotion Law, the government has committed to producing 15 China's continuing economic growth, increasing percent of the country's power from clean energy needs and strained resources will affect energy sources by 2020.68 Still, reaching that its domestic and global energy markets alike, goal will require an ambitious level of public including worldwide fuel availability and pricing. and private investment ­ up to Y 1.5 trillion The country's rapid growth in energy use will (US$184 billion) by some estimates. contribute to climate change and exacerbate environmental problems. At the same time, Although China is second worldwide in total China's energy concerns are accelerating the energy consumption, electricity consumption per development of alternative energy technologies, capita remains low (Figure 5.1); since 2002, especially renewable or clean energy.65 Under the country has experienced annual electricity the 2005 Renewable Energy Law enacted last shortages, mainly in coastal cities. China's year, the government "encourages economic Eleventh Five-Year Plan (2006-10) sets the entities of all ownerships to participate in the expansion of electricity generation capacity at development and utilization of renewable about 8 percent per year. energy, and protects legal rights and interests of the developers and users of renewable energy With soaring oil prices, alternative energy on the basis of law." This law creates the becomes financially viable, although renewable regulatory framework for RE development, sources currently represent only 6 percent of provides economic incentives and financial China's total energy consumption. By 2020, support for R&D and promotes construction of China's government plans to generate 18 percent RE facilities through discounted lending of the country's energy consumption from and tax preferences.66 renewable sources (Table 5.1). 65In a November 7, 2005 speech, President Hu Jintao noted: "Prioritizing the exploitation and use of renewable energy is the only way for the world to deal with its growing energy... China attaches great importance to the development and utilization of renewable resources, making them a key driver of economic and social development"; see Yinglin Liu, "China's Top Leaders Stress Importance of Renewable Energy" (available at www.worldwatch.org). 66Cong, Hu, "Legislature Passes Renewable Energy Bill." China Daily, March 1, 2005. 67"China's Wind Energy Potential Appears Vast," November 2005 (available at www.worldwatch.org). 68"China: World Bank to Help Scale up Use of Renewable Energy," June 17, 2005 (available at www.worldbank.org). 76 Alternative Energy and Technology Options Figure5.1:ResidentialSectorElectricityConsumptionbyCountryGroup(percapita) Canada UnitedStates Australia/New Zealand Japan Western Europe Eastern Europe 2025 Former Soviet Union 2002 Middle East SouthKorea Central and South America Mexico Other Emerging Asia China Africa India 0 1000 2000 3000 4000 5000 6000 Source: EIA (2005). Table5.1:China'sIncreasingRenewableEnergyCapacity Renewable Technology 2004 2020(Projected) Hydroelectric Power 108 GW 290 GW Wind 760 MW 30 GW Solar Thermal 65 million sq m 300 million sq m SolarPhotovoltaic 65MW 2GW Biomass Development of 20 GW capacity Source: National Development and Reform Commission (Mid- and Long-term Development Plan for Rural Energy). Alternative Energy Options for China Hydropower Over the next two decades, a range of Water-generated power, primarily from advanced, alternative energy options large-scale dams, accounts for about 20 percent relevant to China may become applicable of global energy production; of all the world's RE to household energy use. These are described sources, hydropower is by far the greatest below. contributor. In 2004, global hydroelectric 77 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China production grew 5 percent, with Asia representing industries. Over the past decade, wind technology half of that growth.69 has improved significantly; its importance has grown rapidly, especially in Europe, where political Hydropower enjoys a number of advantages. incentives to develop RE have been strong. In addition to sustainability, it can handle both seasonal and daily peak loads. At times of peak Wind power has many advantages. First, it is a demand, water releases from the reservoir clean and truly RE source. Second, it is scalable in through a turbine, generating hydroelectricity; that it can not only be used to generate power in a during periods of lower demand, excess electrical local area or even at an individual level; but it can capacity can be used to pump water into a higher also generate large amounts of power which can reservoir, storing electricity for later use. be added to an electricity grid system. Third, it is becoming more cost-competitive; wind farm The disadvantages of hydropower generated by construction cost is lower than that of many types large-scale dam projects are its potentially of traditional power plants. Finally, in land-based damaging effects on wildlife and downstream wind farms, once the wind towers are built, the agriculture, possible displacement of local surrounding land area can be used for agriculture population and high GHG emissions compared to or other purposes. other renewable sources. Another drawback is the large amount of infrastructure required for The most significant disadvantage is that the wind householddistribution. required to drive the turbines can be intermittent and does not always blow when electricity is Current hydropower growth is mainly in needed. However, rapid expansion of the wind developing countries, including China, India energy industry is likely to continue as new and and Iran. In addition to its enormous and improved turbine technologies begin to generate controversial Three Gorges Dam project on the more electricity, thereby resolving past problems Yangtze River, China is developing other large which limited power generation. Newer hydroelectric projects. China's hydroelectric technologies which reduce noise and reserves stand at 700 million KW, 40 percent of environmental pollution can lessen the negative its total conventional energy sources. Although effect on bird populations71Perhaps, more China's hydropower exploitation potential ranks importantly, wind power can accelerate the move first in the world, its utilization ratio remains low toward distributed energy ­ energy supplied on a (24 percent). Over the next 20 years, the local scale rather than a national grid ­ which may country plans to utilize hydropower more greatly benefit remote rural communities, especially rapidly; at the same time, the adverse in developing countries. A key question is how many environmental effects of large projects must be turbines are necessary to provide sufficient energy taken into account.70 for a household's energy needs, depending on their WindPower cooking,heatingandotherrequirements. After hydropower, wind power is far more In China, wind power currently accounts for developed than most other alternative energy only 0.17 percent of the total installed energy 69"BP Statistical Review of World Energy," 2005 (available at www.bp.com). 70"Priority Given to Efficient Hydropower." China Daily, October 29, 2004. 71RPS Energy News (available at www.rpsplc.co.uk). 78 Alternative Energy and Technology Options capacity, but its potential is immense. According developments have greatly reduced costs. In to some estimates, China's electricity generated recent years, global PV production has grown at by wind energy could reach 14 percent of roughly 20 percent annually; some studies global wind energy output by 2020.72 While forecast that, within the next decade, costs could off-grid wind power can produce clean, decline to about US$1.50 watt (W), reportedly the relatively cheap power for villagers, the effect borderline cost at which this energy source would of these units on China's energy sector is small be competitive with other technologies (Kammen compared to what grid-connected wind farms 2004). Broader-scale adoption will likely depend could achieve. Several regions, including Inner on technological breakthroughs which can reduce Mongolia, already have rural wind energy the cost of PV and that of other fuels. Adoption programs which play an important role. But lack may also be contingent on increased government of developer incentives has kept the wind power support. Beyond cost, the greatest barriers to market far from achieving its potential.73 increasing large-scale solar power generation are the amount of land required for massive electricity Solar Energy production, and the intermittent nature of the energy source (solar systems cannot work at night Solar power, available in many part of the or in bad weather). developing world, is a renewable natural resource whose energy conversion process is PV power generation could play an effective role emission-free. Solar energy is of two types: in serving many remote rural areas of China. The Photovoltaic (PV) and solar thermal. Solar cost of producing PV power in rural China would energy technology is scalable, meaning that it be far less than that of developed countries. can be used for domestic heating purposes or large-scale commercial electricity generation. SolarThermal Yet, mainstreaming of solar power is still a long way off; currently, solar power accounts for less In the developing world, solar thermal energy than 1 percent of the global energy. has been used in many small cities and rural Unlike wind power, broad scale use of solar households to heat water for washing, crop drying, energy is more expensive than fossil fuels. space heating and solar cooking. In the developed China is well endowed with solar energy world, it is used in millions of domestic hot water resources. Nearly 67 percent of the territory systems. It is most applicable in areas which receives more than 4.6 Kilowatt-Hour Per Day Per feature high solar insolation ­ the total energy per Square Meter (KWh/m2) solar radiation per day.74 unit area received from the sun ­ such as the Mediterranean Region or Australia. Photovoltaic On a small scale, solar ovens are relevant for Solar PV cells, which involve converting solar rural cooking needs. The cookers include an power into electricity, have become more insulated box made of wood, metal, plastic, or widespread in powering houses and businesses in cardboard, whose open top is covered with one or some regions; as with wind power, technology two glass plates. Light enters through the glass and 72"Wind Energy Has Huge Potential." Xinhua News Agency, May 15, 2004 (available at www.china.org). 73Debra Lew and Jeffrey Logan, "Incentives Needed to Energize China's Wind Power Sector" (available at www.pnl.gov). 74World Energy Council (available at www.worldenergy.org). 79 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China is absorbed and reflected by foil-covered walls as consisting of steam or hot water, natural steam or infrared radiation (heat). The glass top blocks the hydrothermal resources are easiest to exploit. infrared rays, capturing the heat in the box. As Some 16 countries including China, the United long as the sun shines, food can be steadily States and Israel ­ now use geothermal cooked in pots on a bottom metal plate, and the energy for aquaculture. The main challenges oven can heat several liters of water or food to to widespread geothermal use include high more than 300°C within an hour (Kammen cost and technological issues: Drilling for 1995). The drawback of this technology is the new resources typically accounts for half issue of adaptability. Since the cooking process is the costs.77 significantly slower than the one using traditional fuels, preparing meals requires changes in LPG and Gaseous Fuels planning and behavior. In addition, villagers have reported that the cooking process causes food to Gaseous fuels, including natural gas, are among taste different than what they are accustomed to. the cleanest household energy sources. Worldwide production of LPG (a derivative of natural gas and Currently, China, India and Japan control oil processing and crude oil refining) continues to 75 percent of the market for solar thermal grow at an annual rate of 2.6 percent, driven by collectors and supplementary equipment.75 increasing use in China, India and the United To date, this emergent industry has concentrated States.78 In developing countries, LPG is a primary principally on small-scale use. household cooking fuel. Together with kerosene, LPG is more energy-efficient than traditional Geothermal Energy biomass; but unlike kerosene, LPG produces significantly less air pollution and poses no risk of Derived from the earth's natural heat, geothermal poisoning or fire. Therefore, substitution of energy is used to generate electricity and as a traditional biomass fuels by LPG presents several source of heat for direct use, such as space advantages: 1) less air pollution when burned; 2) heating for greenhouses, aquaculture and with lower emissions of GHG pollutants when used in heat pumps. For heat production, hydrothermal traditional stoves; and 3) reduced dependence on (hot water and steam) resources are commonly gathering of biomass fuels and, thus, less used for district heating. Electricity generation from deforestation. Despite these significant potential geothermal sources can occur at various advantages, the relative costliness of LPG temperatures (from below 100 °C to high makes it inaccessible to most of the world's temperature steam plants at steam temperatures poor (Smith, Rogers and Cowlin 2005). above 300 °C).76 For commercial use, a Similarly, in China, supplies of domestic natural geothermal reservoir capable of providing gas (and oil) are limited. Since imported LPG hydrothermal resources is necessary. Usually prices track international oil prices, importing located at depths of 1,000-4,000 meters and LPG is likely to continue to be costly in China; 75STP 2005: Solar Thermal Power, CST Concentrated Solar Thermal Energy (edition 1), 2005 (www.the-infoshop.com/study/abs32125-solar-t-power.html). 76U.S. Department of Energy (www1.eere.energy.gov). 77World Energy Council (www.worldenergy.org). 78World LP Gas Association, Annual Report 2005 (www.worldlpgas.com). 80 Alternative Energy and Technology Options therefore, it is not a viable alternative for poor continueusingtraditionalstovesbutmaybeableto rural areas.79 replacetraditionalsolidfuelswithonesthatemit fewer indoor air pollutants. Among alternative fuel- Modern Biomass cookercombinationsarebriquettesorpellets, Modern biomass typically substitutes for kerosene, LPG, biogas, or ethanol. Some of these conventional fossil-fuel energy sources. It includes technologies have already had a significant effect on forest wood and agricultural residues and biogas local patterns of energy use, economic activity and and biofuels from energy crops, including plant the environment. With respect to rural household oils and plants containing starch and sugar. With use, several developing countries are conducting regard to household energy, electricity generated biofuel stove tests. The advantage is that biofuel is via advanced conversion methods, such as produced locally, often at competitive prices. production in biomass gasifiers, is especially Biomass Preprocessing promising. Worldwide, including the developing country context, biomass gasifiers are being used While biomass fuels are likely to remain the chief extensively. Other modern biomass-derived fuels energy source for most poor people, improved include Hydrogen (H), ethanol from ligno- stoves and cleaner technology can reduce fuel cellulosic biomass and methanol (wood alcohol), requirements and lessen adverse health and discussed in the next section. The competitiveness environmental effects. Because biomass and of these concepts depends, in large part, on the bioenergy rely on locally available resources, they development of oil prices (Faaij 2006). hold advantages for alleviating poverty and mitigating climate change. Furthermore, the Advantages of Changing or Processing Fuels energy production stages of more sophisticated In rural areas of many developing countries, biomass-based products provide potential local access to technologically advanced or expensive employment opportunities. Regarding land alternative energy options remains limited. Given degradation, if bioenergy stocks are planted on the severity of IAP in China and other developing degraded soil, they have the prospect of bringing countries, low-tech options affordable to poor rural long-term improvements to land quality and communities are needed now. Under such fertility. Growing biomass can also provide various conditions, the following become the best available ecosystem services, including the halting of soil alternatives: 1) improved combustion by altering erosion and preservation of the hydrological cycle or replacing cooking and heating devices; 2) (Kammen, Bailis and Herzog 2002). change in fuel; and 3) preprocessing fuel (for Another possible improvement in biomass example, biogas, coal gasification, briquettes, or technology can be attained by compacting loose cleaner coal). These options are discussed both fibrous or granular material into briquettes or generally and with special reference to China in pellets. Standardizing size and moisture content, the sections that follow. and radically amplifying energy density, can Substituting polluting fuels with cleaner ones to meet greatly enhance fuel efficiency. Although examples cookingandheatingneedsshouldhavean of competing successfully against charcoal or especially high priority (Zhang and Smith 2005). fuelwood are rare, in Kenya, one private company Thisisapplicabletopoorhouseholds,whichwill has succeeded in briquetting charcoal dust 79In 2001, LPG imports accounted for nearly 33 percent of consumption. 81 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China on a commercial scale (Kammen, Bailis and Another option is tri-generation technology, which Herzog 2002). combines clean cooking fuel, hot water for heating and electricity from corn stalks and uses Role of Charcoal microturbines in a bioenergy experiment. Although more polluting than clean fossil fuels, Unfortunately, its disadvantage is low market charcoal burns cleaner and produces less IAP than viability and risk of acute CO poisoning. Specific wood and raw biomass (Bailis, Ezzati and Kammen environmental policies encouraging technological 2003). Compared to fossil fuels, charcoal is easier strategies, such as crop residue-based to transport and distribute on a large scale since tri-generation, would be necessary (Henderick and expensive infrastructure, including refineries and Williams 2000). processing, is not required. However, current A technology which converts coal into a clean fuel, inefficient production methods, which use minimal known as Dimethyl Ether (DME), provides an technical inputs, are harmful to the global opportunity for coal-rich areas. Produced from environment and destructive to forests. Thus, any carbonaceous feedstock, including natural without land management policies which promote gas, coal, or biomass, DME's characteristics as a sustainable production, the public health benefits household fuel resemble those of LPG (Larson and from household charcoal use would come at a Yang 2004); it can be used for various sectors, large environmental cost. Technological and policy including household cooking and heating. But tools for switching to sustainable harvesting, as using DME as a fuel requires that it be produced at successfully demonstrated in Brazil and Thailand, low cost in large quantities. Other technologies are necessary to reduce potential adverse effects, involving the preprocessing of coal, a procedure including GHG emissions (Ezzati et al. 2004). In applicable mainly to coal-abundant China, are this way, charcoal can become a more suitable discussed in the next section. option for households for which clean burning cooking fuels, such as ethanol and natural gas, are Applications in Rural China inaccessible or unaffordable. Fuel Conversion Technologies Advanced biomass and coal technologies are particularly relevant to this project as these two A variety of procedures can convert solid fuels account for nearly 100 percent of the biomass into cleaner energy forms (for household energy used for cooking and heating in example, gases, liquids and electricity); these rural China. In this context, converting solid fuels include methods to generate bioethanol and to clean liquid and gaseous fuels offers biodiesel, which are highly relevant in significantly greater potential than certain types of developing countries. Another pertinent improved stoves to reduce harmful emissions. technology relies on synthesized hydrocarbons Even when successful, improved stoves still emit (Fischer-Tropsch liquids), produced from a concentrations of indoor air pollutants well above gaseous feedstock, including gasified biomass. standards set for outdoor air in developed This mixture of CO and H is called a synthesis countries (Ezzati and Kammen 2001). gas (syngas), and the resulting hydrocarbon products are refined to produce the desired In recent years, China has encouraged greater synthetic fuel. Two cooking fuels which can be use of coal and discouraged biomass (with the produced from biomass via the exception of dung), on the basis that biomass use Fischer-Tropsch synthesis are synthetic LPG and degrades the soil and contributes to deforestation. kerosene (Larson and Jin 1999). However, advances in clean, Renewable Energy 82 Alternative Energy and Technology Options Technologies (RETs) could call this policy into technologies can be successfully implemented, question. If used efficiently and sustainably (that is, they are not competitive at the present cost. But through rotational planting), biomass is less this technology might become moreinteresting harmful to the environment than coal. financially should the prices of other fuels continue Furthermore, if biomass technologies continue to to rise (Larson and Yang 2004). advance to the point where clean fuels are produced at a cost competitive with traditional Bioenergy Options fuels, the energy/health/environment equation Rural China offers numerous opportunities to would change in favor of more, not less, biomass better utilize bioenergy resources. According to use (Larson and Jin 1999). some estimates, about half of the total crop Improving Stove Fuel Quality residues could be available for energy use after serving as fertilizer, animal fodder and industrial To improve fuel quality and reduce dangerous feed. The current role of crop residues in emissions resulting from cooking and heating, household energy use is mostly in inefficient, high so-called "honeycomb" coals have been used in emission equipment (Zhang and Smith 2005). urban and rural Chinese households for decades. With regard to synthesized hydrocarbons (Fischer- The shape of the coal enables a more effective Tropsch liquids), China has sufficient agricultural and balanced air supply, leading to increased residues to produce enough liquid fuels to meet combustion efficiency (Zhang and Smith 2005). the needs of a significant fraction of its rural Another means by which high efficiency and low population; but this process is capital-intensive emissions can be achieved is fuel pelleting. These (Fischer 2001). In short, biomass technologies technologies improve portability and increase leading to clean fuels for rural household cooking efficiency at low emission levels (Zhang and and heating, have not advanced to the point of Smith 2005). mass commercialization. In addition, given China's extensive coal reserves, Fluoride-Sulfur Neutralization use of coal-derived DME could present a promising option for producing clean synthetic As discussed in Chapter 1, 201 counties in China fuels from coal. A production technology, known have coal deposits with high fluorine content, as oxygen-blown gasification, generates synthesis affecting 35,000 villages and nearly 34 million gas from coal; though not yet used in China's people. Furthermore, coal containing As is high in energy sector, it is already well established in some provinces, including Guizhou and Shaanxi. the country's chemical processing industry Throughout China, low-quality coal deposits have (Williams 2001). high SO2 content. Fluoride-sulfur elements can be reduced by washing coal or adding fixing agents. For coal-derived gases to become a commercially The washing procedure is expensive, ineffective in viable fuel in China's poor rural households, removing organic Fluoride, requires considerable technology testing would be needed. China's first amounts of water and may result in secondary commercial DME fuel production plant was contamination through wastewater. The preferred constructed in mid-1990s. A recent study suggests technology is to add fixing agents to the coal to that national policies which ensure that capture Fluoride and S during combustion, Independent Power Producers can sell electricity to capturing the elements' residue in the coal ash the grid, would facilitate growth of a coal-DME instead of releasing it into the atmosphere. industry in China. While coal gasification Fluoride-Sulfur fixing additives include CaF2 83 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China (Calcium Fluoride), CaF2-CaO-Al2O3 (Calcium- shell-calcium, has been conducted to improve Fluoride-Calcium Oxide-Aluminum Oxide), SO2 results. Ca(OH)2 (Calcium Hydroxide), and CaF2-CaO- In Guizhou and Shaanxi, where coal is the SiO2 (Calcium Fluoride-Calcium Oxide-Silicon primary household fuel, the Institute of Dioxide), which decompose at a higher heat Geographic Sciences and Natural Resources than normal coal fire temperatures. Research, Chinese Academy of Sciences, has Laboratory and industrial-scale tests in China conducted Fluoride-Sulfur fixing tests. One such indicate that addition of the equivalent of 5 percent test involved coating bone coal with Calcium- Lime (CaO) to coal significantly reduces Fluoride radical, Fluoride-fixing absorbent (dolomite or emissions and SO2 emissions to a lesser extent. limestone). In another test, the same fixing Experimentation with various additives, including agent was added to powdered coal, which was Table 5.2: Comparison of Indoor Air Concentrations of Fluoride after Fluoride-fixing Treatment Group F Content Student (mg/m3) t Test Briquette Added with Absorbents (a) 0.086 ± 0.041 a:b Control Briquette (b) 0.184 ± 0.091 P < 0.05 Bone Coal Coated with Absorbents (c) 0.046 ± 0.029 c:d Control Bone Coal (d) 0.324 ± 0.259 P < 0.01 Table 5.3: Comparison of Indoor Air Concentrations of Sulfur Dioxide after Fluoride-fixingTreatment Group SO2 Content Student (mg/m3) t Test Briquette Added with Absorbents (a) 0.16 ± 0.07 a:b Control Briquette (b) 1.17 ± 1.09 P < 0.05 Bone Coal Coated with Absorbents (c) 0.28 ± 0.19 c:d Control Bone Coal (d) 1.13 ± 0.49 P < 0.01 Table5.4:ComparisonofIndoorAirConcentrationsofRespirableParticulateMatterafterFluoride-fixingTreatment Group PM10 Content Student (mg/m3) t Test Briquette Added with Absorbents (a) 0.310 ± 0.235 a:b Control Briquette (b) 0.588 ± 0.867 P>0.05 Bone Coal Coated with Absorbents (c) 0.139 ± 0.035 c:d Control Bone Coal (d) 0.311 ± 0.185 P< 0.05 Source: Tables 5.2, 5.3 and 5.4 Chinese Center for Disease Control and Prevention. 84 Alternative Energy and Technology Options subsequently formed into coal briquettes. model (6m3) costs US$300, one-third of which Preliminary results showed that coating bone is subsidized. coal with the fixing agent reduced indoor Fluoride concentrations by 86 percent. Adding Unlike fuel preprocessing, which occurs outside the the fixing agent to coal briquettes reduced household,anothersolutionistochangethenature Fluoride emissions by 74 percent. Levels of SO2 of the fuel directly in the cooking and heating area. and RPM were also reduced, although less This method utilizes gasifier stoves, which are significantly (Tables 5.2-5.4). designedtopromotesecondarycombustion, achieve high combustion efficiency and, therefore, More widespread applications of the use biomass more efficiently. While increased Fluoride-Sulfur fixing agents in Ziyang County combustionefficiencyiseasilyaccomplishedusing (Shaanxi) and Longli County (Guizhou) yielded small electric blowers, certain models are designed similar results. The low costs of the fixing agent tospurcombustionviaanaturaldraft. and process offered a cost-effective way to reduce the health risk from indoor air In China, biomass gasifier stoves commonly have concentrations of Fluoride and Sulfur Further two levels. The biomass is consumed in two tests are required to verify this conclusion. stages: 1) it is ignited in the lower part of the stove, where it produces gas under anaerobic Alternative Cookers and New Stove Design combustion at a certain temperature; and 2) the gas is conveyed to the second level, where an In some developing countries, simple cookers open flame is used for heating and cooking (in addition to the solar cookers described (Figure 5.2). These stoves exhibit higher heat above) and electricity-powered equipment play efficiency and lower pollutant emissions. Crop an important role. In China, small-scale residues, branches and other biomass may be digesters, using animal and human waste as used as fuel. Still in the early stages of market feed material, are widely used. In Nepal, more development, biomass gasified stoves may provide than 80,000 households use CH4 from an important advance over traditional heating and biogas digesters for cooking; the most popular cookingstoves. Figure5.2:BiomassGasifiedStoves Gasified stoves for cooking. Gasified stoves for heating and cooking. Source: Chinese Center for Disease Control and Prevention. 85 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China China is also developing coal gasified institutional) all bear on the likelihood that stoves, which are now available. As in the alternate household fuels and improved case of biomass gasified stoves, heat technologies will be adopted at the local level. efficiency is higher than traditional biomass Table 5.5 summarizes the barriers to adopting stoves or air-circular coal stoves. However, their selected technology options. cost (RMB ¥450-600) is more than Although the health, welfare and environmental twice that of traditional stoves. With benefits of cleaner fuels are substantial, the long increased units and movement along the path from R&D to market transformation requires experience curve, the cost should become support (Chapter 6). In the 80s and early 90s, for more competitive and affordable in poor example, China's National Improvement Stove rural areas. Program was supported extensively by district- Scaling Up Issues level research, training and education/promotion programs; major subsidies were extended to Behavior, economic resources, community and counties, households and technical institutions regional infrastructure (both physical and (Sinton et al. 2004). In Inner Mongolia, Table 5.5: Household Fuel Choices and Barriers toAdoption Energy Source Selected Electricity Bottled Kerosene Charcoal Coal Fuelwood Crop Determinant Gas1 Residues, of Adoption Animal Dung Equipment Very High Medium Low Low-medium Lowor Lowor Costs high zero zero Nature of Lumpy Lumpy Small Small Small, Small, Small, Payments zero if zero if zero if gathered gathered gathered Nature of Restricted Often Often Good, Good, Good, Variable; Access2 restricted, restricted dispersed dispersed dispersed depends bulky to in low-income markets markets markets on local transport areas and reliable and and crops supplies, reliable reliable and though supplies supplies, livestock prices and though holding. supplies prices High can vary and opportunity seasonally supplies where can vary residues seasonally are used as fodder and/or dung is used as fertilizer 1Includes LPG, butane and natural gas. 2Nature of access refers to the ease with which households can choose the fuel if they are willing to pay for it, determined by physical and institutional infrastructure (Ezzati et al. 2004). Sources: Kammen, Bailis and Herzog (2002) and Ezzati et al. (2004). 86 Alternative Energy and Technology Options introduction of some 130,000 small-scale wind What Factors Undermine Adoption? energy systems was achieved through careful planning and creation of an effective regional The chain from R&D of alternative household and local infrastructure for manufacturing, sale, energy technologies to market transformation is maintenance and training. Limited government long, and many factors thwart progress along the subsidies helped to support individually way. R&D tends to be underfunded, in part, purchased household systems. because industrial countries have largely resolved the problems of household IAP and domestic In Kenya, by contrast, local and international cooking and heating requirements. In addition, agencies promoted introduction of the alternative household energy technologies have improved-efficiency ceramic stove, known as the characteristics of a public good; thus, it is the Kenya Ceramic Jiko, largely by supporting difficult to appropriate costs to end users or narrow research and refinement rather than through the benefits to those who buy the results. As such, direct subsidies for commercial stove production private returns are less than social ones, and dissemination. Expanded numbers and resulting in suboptimal investment in basic R&D. types of manufacturers and vendors led to The consequences of this market failure are that increased competition, spurring innovations in significant social benefits (including health and materials used and production methods, thereby environment) remain unrealized. The problem overcoming initial design flaws and high costs. is especially acute in developing countries, Today, there is a widespread wholesale and where other pressing priorities (for example, retail network for the Kenya Ceramic Jiko, and infrastructure, education and primary health prices have fallen to a third or less of their services) often take priority. original price. The chain is further weakened by persistent Kenya has been at the forefront of PV systems poverty. In rural areas of many developing without significant aid, subsidy, or other support countries, per capita income is one-third (or less (Kammen 2002). More typically, however, R&D than) already low national averages. Fuel support in developing countries is low and gathering in poor rural areas, largely done by unreliable, reflecting tight fiscal realities. women and children, is undervalued. Thus, Moreover, training venues, technology and affordability is an important constraint to adoption information exchange and technology standards of new alternatives. are usually lacking. Entrenched use of traditional technologies also China has achieved widespread rural blocks adoption of alternatives; continued reliance dissemination of RETs (and fuel efficiency on traditional energy options is common in areas technologies more generally) through a mix of with low population densities and deficient national standards, R&D support and infrastructure (for example, roads, electricity and encouragement of local innovation and communications). Community and regional energy entrepreneurship (Kammen et al. 2002; infrastructure (both physical and institutional) are Lu 1993). Still, that IAP persists as a serious important, but often overlooked, components of health risk and that rural households continue successful intervention programs (Ezzati et al. to rely on cooking and heating stoves lacking 2004). New energy technologies, including the most rudimentary fuel efficiency measures cleaner coal, are difficult to sustain without (for example, flues) indicate the gap marketing and delivery systems which facilitate yet to be closed. household access. Accessibility (and quality) of 87 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China energy resources is a key determinant of energy · The involvement of local institutions; use (Jiang and O'Neill 2004). Trained workers to rationalization of taxes and tariffs; construct, install and maintain new energy incorporation of quality control and standards technologies are also essential (Jin et al. 2006). mechanisms; and facilitation of financing, warranties, training and other mechanisms In industrial countries, small-scale decentralized are needed to protect and encourage end energy systems are typically outside the purview of users;and academic or research institutes. Such initiatives as · The focus should not be limited exclusively to the Renewable Energy Policy Project and poor rural populations, who are least able to Renewables for Sustainable Village Power pay for new energy technologies; these Program are helping to fill the information gap.80 technologies achieve greatest market Still, sustained investigations of the technical, penetration in areas where fuels are socioeconomic, health, environmental and policy purchased rather than collected issues surrounding household energy technology (for example, straw and fuelwood), as fuel alternatives are scarce. In developing countries, savings are realized in direct monetary the capacity for such investigations is limited (von terms rather than time saved. Schirnding et al. 2001; Ezzati and Kammen 2002a, 2002b). Regarding the last point, poor rural communities may not attract viable ESCOs International Lessons whereby private companies or government Despite differing circumstances and utilities enter into contractual agreements with determinants, common lessons can be drawn community members to provide them hardware from international experience in advancing and or services. Thus, the hardware or services promoting technologies for household energy offered must be affordable, match local use (Kammen 2002): preferences and be capable of being operated and maintained by households and local · Technologies should be researched and tested technicians. Establishment of revolving funds or under local conditions; other mechanisms may be needed to assist · Mechanisms are needed to overcome households in meeting the upfront costs of the initial cost barrier (for new technical hardware. Fee-for-service energy technologies, cost is invariably high for the companies are another option; but to reiterate, first units installed); the incentive to include poor rural communities · Decisions must be made on the role of as clients may be limited. market-based mechanisms and where to direct grants and subsidies (that is, to research, Research Direction infrastructure, training, interdisciplinary capacity-building and local sustainability versus China's National Improvement Stove Program directly to users); and follow-up activities have provided extensive 80Information on the Renewable Energy Policy Project and Renewables for Sustainable Village Power Program is available at www.repp.org and www.rsvp.nrel.gov, respectively. 88 Alternative Energy and Technology Options information on dissemination approaches, types of institutions, market policies and training institutional arrangements and local technology opportunities needed to develop community or development strategies (Lu 1993). However, household-scale energy services are largely further research is needed on the technical, absent. International development assistance, economic, political and commercial factors combined with supportive policy, regulatory and which bear on energy R&D and market institutional measures at all levels of government, transformation. The obstacles facing rural is necessary to create the conditions conducive to households and potential ESCOs, in particular, energy innovation and implementation. must be better understood. Finally, since household demand for energy use It should be noted that China's National interventions appears relatively weak (Larson Improvement Stove Program was not designed as and Rosen 2002), further research and a pro-poor program (Sinton et al. 2004). It was information are needed on IAP health risks and cofunded with the counties; since participation the potential benefits of interventions. depended on local officials' willingness to devote Long-term studies are required to determine limited resources, the program was implemented sustainability, as well as energy, health and mainly in better-off counties. In rural China, the environmental effects. 89 6. Summary and Recommendations Fei Yu, Zuzana Boehmova, Enis Bari and Majid Ezzati The issue of IAP provides an important Study Summary opportunity to design and field-test As discussed in Chapter 5, review of earlier community-based solutions to mitigat its health, household energy projects in China and social, environmental and economic effects. elsewhere revealed that most efforts were directed The study presented in this report was designed primarily at energy efficiency and reduced use of to add to the foundation of knowledge which will biomass fuels, not reducing IAP or exposure. enable the development of sustainable IAP For example, the Chinese National Improved interventions customized to local conditions. Stoves Program of the 80s, prompted by Because IAP exposure is a major health risk environmental conservation objectives, focused requiring public and community involvement, on achieving greater fuel efficiency to meet effective interventions must encompass both cooking requirements. technological and behavioral elements. To the best of our knowledge, this study Since 1980, rural China's residential energy use represents the first community-based trial has increased significantly; over the past six to designed to test the combined effect of eight years, solid fuel consumption has increased technological (improved stoves and better about 30 percent. As indicated in Chapter 1, ventilation) and behavioral (health education biomass now accounts for 55 percent of rural and behavioral changes) interventions in household energy use, while coal ­ whose rural settings under actual conditions of importance as an energy source is accelerating ­ program implementation. The study's accounts for 34 percent. These trends, together empirical evidence of the relative effectiveness with rural households' continued reliance on of these interventions will contribute to traditional, poorly ventilated cooking and heating a better understanding of how household stoves; low-quality coal; and inappropriate customs energy technology, health education and (for example, smoke-drying of corn and other behavioral interventions interact in produce) have meant that IAP continues as a reducing exposure. major health risk. This is especially true for the severely poor, who can least afford stove This Chapter briefly summarizes the study, alternatives, better quality fuels and medical offers implications of the main findings and attention when afflicted by respiratory and other highlights design limitations. It then draws IAP-related illnesses. Thus, reducing household together lessons which can be applied to exposure requires practical, carefully designed future projects and suggests recommendations stove technology alternatives and health and areas requiring further research and testing. education and behavioral interventions. 91 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Approach health risk, behavioral changes and IAP-related health indicators. As discussed in Chapter 3, the study in four Chinese provinces focused on reducing IAP as Implications of Findings characterized primarily by three indoor air pollutants: respirable particles, CO and SO2 (the Analysis of baseline and post-intervention data role of fluoride in dried food was also considered). demonstrates relatively consistent evidence that Baseline data were collected to provide an stove interventions had IAP benefits when understanding of day-to-day, seasonal and spatial heating was the main energy use. The evidence variations in pollution. The technological, housing for cooking stove interventions was less and behavioral determinants of exposure were consistent (Gansu was the only province also documented. This information was used to indicating benefits in the cooking room). Fuel design stove and behavioral (health education) consumption for heating (versus cooking) is interventions tailored to local conditions in the four generally more stable and less intense, study provinces (Gansu, Guizhou, Inner Mongolia compared to cooking stoves. Therefore, the and Shaanxi). In addition, surveys were conducted indoor air quality benefits of heating stoves are on IAP-related knowledge and behavior and less susceptible to compromise from selected IAP-related health indicators for women stove-handling behavior if the combustion is and children in the study households. well separated from the living and sleeping areas and/or smoke is ventilated outdoors The interventions took into account the energy (for example, new heated beds in Gansu or needs for cooking and heating, housing underground heating stoves in Shaanxi) were characteristics, fuel use and sociocultural factors effective in reducing IAP. The results of cooking (for example, food-types and storage methods). stove interventions were more mixed because Between March and October 2004, alternative users modified combustion patterns more stoves were designed and tested for efficiency regularly (including large fluctuations in under both controlled conditions and actual combustion intensity). To better succeed, household use to assess the role of user behavior cooking stove interventions require greater in stove performance. Health education and modification of user behaviors (for example, behavioral interventions, including dissemination of proper use of flues, wood size and dryness, and educational materials through village discussion frequency of stoking) and/or stoves which are groups and visits to model homes, were also robust to these behaviors. implemented in the project areas. Introduction of alternative stove-handling Post-intervention data were collected behaviors, as part of the health education approximately one year after the stove technology program, led to increased IAP-related and behavioral interventions were completed. In knowledge and changes in specific behavioral December 2004 and March 2005, indoor levels indicators based on self-reported data. With of respirable particles, CO and SO2 were again regard to indoor air quality, however, no measured using methods identical to those measurable IAP benefits resulted from health employed to collect the baseline data. Follow-up education and behavioral interventions surveys were also conducted on the efficiency alone, despite the extensive nature of the of household energy use, knowledge of the IAP program (Table 6.1). 92 Summary and Recommendations Table6.1:ChangeinSelectedKnowledgeandBehaviorIndicators Gansu Guizhou InnerMongolia Shaanxi Indicator S + B B S + B B B S + B B Significant at 5% Level Y N Y N Y N Y N Y N Y N Y N Knowledge Women Sources of IAP Cooking Heating Smoking Health Impact of IAP IAP Control Methods Improving Stove ImprovingVentilation NoSmokingIndoor Understanding Rate of DentalFluorosis Children Source of IAP Pollutants HealthImpact IAP Control Methods EtiologyofDentalFluorosis CoalSmoke FoodContaminated with Fluorides Measures for Dental Fluorosis Prevention Behavior Women Close Stove Door WhenUsing Using Shorter Wood Watering Ash Before Removing OpeningWindowsin Cooking(often) Children Every Day or Often in the Kitchen Get Out and Avoid Smoke Note: S + B = stove plus behavioral intervention, B = behavioral intervention; Y = yes, N = no. 93 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China These findings may reflect that people's A second design limitation concerned selection of behavior with regard to cooking and heating ­ the study groups. Factors and practical activities central to daily life ­ may be little affected considerations such as political will, location and by their knowledge and concerns about long-term population size, which affect program health outcomes, especially where infrastructure implementation, were used to select the study and household economic status limit opportunities groups, with intervention and control groups for switching fuels and stoves (Jin et al. 2006). selected at the community versus individual The findings may also reveal the need to improve household level. Community randomization also the design of behavioral interventions. avoided or limited the contamination of control Provincewide characteristics may not sufficiently group by health education intervention. Despite reflect local conditions, including differing efforts to select similar villages and households, fuel-types, cooking and heating combinations, there may have been differences in environmental housing structures and household behavioral and socioeconomic factors, even between patterns. Interventions tailored to household needs townships in the same county. These differences must consider the diverse characteristics of would mean that the study design is only partially household energy use and the time and economic randomized and that there may have been constraints faced by low-income rural households. differential secular trends in pollution before and after interventions in different townships, or Study Limitations differential potential response to interventions. An alternative analysis of the same data could use With regard to study design, one must distinguish matching techniques, with households matched on between inherent limitations, based on intrinsic sociodemographic and other factors, to reduce the properties of the design, and limitations caused by exogenous effects on the results. incomplete or variant field application and data collection practices. Other practical considerations were caused by incomplete or variant field application of the study In this study, one design limitation involved the design and data collection properties, including small number of households subject to detailed use of scientific measuring equipment within a post-intervention measurements of indoor air compressed period of time and, hence, the need pollutants (about 30 for each province). for concentrating tests within selected townships This constraint, necessitated by the need to (the baseline phase was further affected by the conserve costs and minimize household SARS outbreak which limited travel by the project disruption, affected the statistical power of the team). For example, day-to-day fluctuations in analysis. One feature of the findings, however, temperature would have affected the results by was consistency of reductions across pollutants, increasing random variation in stove use.81 seasons and locations for some provinces (for example, S + B in Gansu) versus A third limitation of the study design involved the inconsistent and opposite evidence on benefits time span between baseline and post-intervention in other cases (for example, B); the consistency data. It is possible that over time user behavior of results is less likely to have been affected by improves leading to better performance for both sample size. interventions; on the other hand, stove 81Converting pollutant concentrations to per hour stove use, based on the self-reported number of stove use hours each measurement day, did not alter the study results. 94 Summary and Recommendations deterioration may lead to a reduction in the (eight to 12 years of age) were self-reported, observed performance of new stoves. Further, which has a number of shortcomings. within this one-year period, the health effects could not be adequately assessed; thus, the Finally, the study was not designed to evaluate the analysis focused instead on health symptoms, local environmental effects of the stove and proxy indicators of reduced exposure and lung behavioral interventions. In China, rural energy function tests. Information on changes in use accounts for 12.7 percent of the total energy selected health indicators was made available to consumption, and solid fuels account for provide background for future studies 90 percent of the rural household energy use, (Table 6.2). In addition, much of the health with important implications for ambient air indicators among women and older children pollution and climate change. Harvested Table6.2:SummaryofChangesinSelectedHealthIndicatorsinComparisonwithControlGroup Gansu Guizhou Inner Shaanxi Indicator Mongolia S + B B S + B B B S + B B Significant at 5 % Y N Y N Y N Y N Y N Y N Y N Level Women Respiratory Eye Headache/Dizziness Children8-12 Eye Nose Pharynx ARIforChildren underFive ARISymptoms Cough,Phlegm, Hemoptysis Dyspnea NasalDischarge Pharynx Eye Note: S + B = stove plus behavioral intervention, B = behavioral intervention, and C = control. Y = yes, N = no; ARI = acute respiratory infection. 95 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China sustainably and burned under ideal conditions, programs (for example, transport access to fuel biomass as a fuel is largely neutral in terms of sources free of toxins and availability of skilled GHG emissions (Smith, Uma and Kishore 2000; workerstodesignandinstallimprovedstoves). Bailis, Ezzati and Kammen 2003). In many The study included extensive training programs developing countries, however, biomass stoves are for stove workers to ensure successful typically inefficient, resulting in incomplete stoveinterventions; combustion. When the products of incomplete · For much of China's population, heating is an combustion are considered, biomass cooking important source of IAP exposure, and is likely stoves often have considerably worse GHG effects to respond to stove interventions. The main than such fossil fuels as kerosene and LPG, even if reason is that heating can be separated from biomass is 100 percent renewably harvested the living space, and does not require constant (Edwards et al. 2004). user adjustment (unlike cooking); · Behavioral interventions alone appear While the alternative biomass stoves introduced in ineffective in lowering IAP exposure, as this study improved combustion and overall changes in stove use, ventilation and other efficiency under controlled conditions (less fuel habits affecting IAP levels and exposure are was needed to boil and vaporize a given quantity insufficient. Furthermore, knowledge of IAP of water), IAP measurements focused on pollutants health risks alone is insufficient to change fuel harmful to health. Rural households' increased or stove purchasing decisions, especially if reliance on coal, combined with their sharp alternative stove technologies are costly, not increase in energy use (30 percent since 1998), readily available, or are perceived as such; has meant increased sulfate aerosols and other · Although the study found that the IAP forms of ambient air pollution with wide local, benefits from health education and regional and even global implications. The behavioral interventions were insignificant, environmental advantages of biomass over coal two potential benefits from health education were not a subject of this study. justify their continued use as part of more comprehensive intervention programs. First, LessonsLearned health education may have long-term The following lessons may be drawn from this study: benefits in the form of encouraging the uptake of other interventions ­ such as · Interventions designed to reduce IAP must also cleaner fuels and less expensive alternative fulfill the purposes of energy use, itself affected stoves which may become available in the by climatic, ecological and sociocultural factors. future ­ or affect how these technologies are Even the small study subset of China's rural used. Second, health education may help population exhibited much diversity in housing reduce IAP exposure through specific routes, characteristics, stove designs, ventilation even if ambient concentrations remain systems, fuel use, levels of indoor air pollutants unchanged. For example, the study indicated and household behavioral patterns. that children subject to health education Interventions must be tailored to meet local interventions in Guizhou and Shaanxi became needs and conditions. They must also be more aware of the risk of bioaccumulation of affordable and sustainable; fluorine from smoke-dried corn, peppers and · Provincial- and community-level energy other foods. Detailed data on household time infrastructure,bothphysicalandinstitutional,is activity budgets could help identify behavior animportantconsiderationforIAPintervention which may lead to larger IAP reductions; 96 Summary and Recommendations · Fuelalternativesfortraditionalbiomasscooking interdisciplinary expertise and multisectoral/ stoves and coal heating stoves need further R&D. cooperation, reflecting the complex Cleanerfuels,includinggasifiedbiomass(Larson interrelationships between household energy and Jin 1999), could substantially reduce IAP use, IAP levels, household exposure, health and related health risks. The Chinese Ministry of and environmental effects, and other factors. Agriculture has established an effective A comprehensive approach to household nationwide network to develop rural RE sources, energy use and IAP exposure is needed. includinggasifiedbiomass,solarenergyand The Chinese Ministries of health, agriculture microhydropower.Gasificationofbiomasshas and environment have become more aware of been the key element of the Ministry's rural the health effects of IAP. However, the issue Renewable Energy Development Program. must be further mainstreamed into the Since 2000, it has invested 3.4 billion RMB in policy making process of the ministries the program, which has involved 26,344 concerned, and interventions should be villages and 3.74 million rural households. packaged to reduce multiple risk factors. To date, 18 million rural households have methane-generatingpits,andtheMinistryplans Policy and Program Recommendations to increase the number of households to The options for promoting the sustainable 39 million (15.82 percent of the total rural introduction of clean energy technologies are households)by2010; closely tied to developing countries' capacity for · Whilecontinuedrelianceonlocallyavailable energy research, development, demonstration fuels is important for rural households, reflecting and deployment. Beyond the critical lack of concerns of affordability and infrastructure funding is the paucity of training venues, limitations,advancesincleantechnologies technology and information exchange and applied to these fuels are increasingly relevant technology standards. In addition, microcredit (Kammen, Bailis and Herzog 2002). to foster locally designed and implemented Clean energy alternatives for cooking stoves are commercialization efforts are systematically animportantconsiderationinreducingIAP. lacking. Moreover, research is lacking on the Electricity, available in most rural areas, accounts relationship between RE projects and the for only a small percentage of energy use socioeconomic contexts in which they are (mainly for lighting). Oil and natural gas are also embedded. All too often, projects are alternatives,buttheircostandlimitedavailability planned, implemented and evaluated based in most rural areas, combined with demand for on unexamined assumptions about local industrialandurbanuse,meanthatbiomassand conditions and the projects' socioeconomic coal will remain the dominant energy sources in consequences. rural China for the foreseeable future. In this context, conversion of solid fuels to clean liquid Meeting these challenges entails overcoming and gaseous fuels for cooking stoves offers the market failures, which cannot be resolved by potentialforsignificantreductioninharmful private enterprises alone. Scaling up and emissions. Public sector support is required for improving the sustainability of interventions require conductingR&Donthesenewtechnologies better assessment of the supply and demand for and reaching the economies of scale necessary alternative energy technologies and evaluation of tomakethemaffordabletolow-income the policies and programs which can optimally households;and increase intervention coverage with a high degree · IAP studies and interventions require of community effectiveness. 97 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Need for Public Intervention these risks, in terms of illness and lost income, may be poorly understood. As a follow-up step, A public good is such that consumption of it by one setting and enforcing standards for fuel and heat individual does not preclude its use by other efficiency are necessary, as are setting guidelines individuals. Its two main features are nonrivalrous for indoor air quality. consumption and nonexcludability. This concept contrasts with that of a private good, whose Research and Development Support consumption precludes consumption by others (Mas-Colell, Whinston and Green 1995). While The public sector also plays an important role in access to clean water and sanitation is widely supporting R&D of household energy use recognized as a set of environmental alternatives. Basic and early stages of applied health-exposure indicators, and these are research also have characteristics of a public commonly cited as measures of indicators of good, and require public sector support to ensure poverty and measures of ill health, the levels of the socially desired level of investment. This is water-related hygiene could also be parallel to especially the case concerning energy use for indicators of household air quality-related rural households in developing countries. hygiene. These potential indicators could be Their governments lack the resources to pursue correspondingly defined as access to clean fuel such R&D, while industrial countries have made and access to ventilated combustion technology the transition to clean fuels and are no longer (World Bank 2002). Therefore, it is necessary to concerned with IAP (Ezzati et al. 2004). Resolving apply lessons from water supply and sanitation the IAP problem in developing countries has experience to community-based approaches to parallels with the Global Alliance for Vaccines and stoves programs. We conclude that parallels Immunization (GAVI), which addresses poorer between IAP and sanitation interventions are strong countries' inability to provide child vaccines. and assume that indoor air quality is a local A public/private alliance, GAVI accelerates the (intrahousehold) public good, with substantial development of new vaccines and technologies welfare gains. However, one must distinguish through its support of R&D. The alliance includes between direct and active public interventions vaccine manufacturers and research institutes. For (for example, stove distribution) and indirect only US$30 per immunized child, many lives are interventions (for example, tax subsidies to being saved. Without this global effort, some 2-3 manufacturers or tax cuts to consumers who million children would die each year from purchase better quality stoves). vaccine-preventable diseases. Such institutional approaches are needed to bring technology to the In particular, due to nonrivalrous consumption, poor (Sachs 2002). it is difficult to price use of the information in a way which reflects marginal cost. Because of Role of Subsidies nonexcludability, it is difficult to exclude use of the information by households unwilling to pay for it. The potential role of RETS and clean fuels in Information related to IAP health risks, therefore, transforming rural residential energy use in has characteristics of a public good. Without public developing countries is enormous. However, the sector intervention, too little information would be transition will only be realized if energy projects made available to households. While the study and policies are evaluated and implemented indicated that baseline awareness of IAP-related based on their overall social, economic, health risks was high, at least among younger and environmental and public health merits. The better educated women, the opportunity costs of lock-in effect of established energy services and 98 Summary and Recommendations infrastructure weighs against introduction of new household energy use are usually in short supply. technologies. Subsidies for existing systems or fuels Training may be relatively costly for private exacerbate the problem. enterprises, and the returns low, especially if the training is lost to competitors through labor On the other hand, subsidies which support transfers. Provision for systematic training, possibly introduction of new energy technologies may be through some form of public/private sector needed to spur progression along the learning partnership, is required. The Chinese Ministry of curve and help offset initial production and Personnel could be the relevant authority to set distribution costs before economies of scale qualification standards and help provide training. become operational. Furthermore, the tendency of poor households to progressively discount future Fuel and Stove Standards benefits and heavily weight present costs (hyperbolic discounting) suggests public National and local area technology (for intervention, particularly if significant externalities example, fuel and stove) standards are yet (for example, public health costs) are associated another requirement in addressing the IAP with this tendency (Cutler, Glaeser, and Shapiro problem. The government of China has begun 2003); otherwise, households and communities at setting energy efficiency standards for large would tend to underinvest in measures to household appliances, and a mandatory reduce IAP exposure. In turn, this would labeling system for energy using appliances has discourage the development and introduction of been introduced. China's medium- and long- new energy technologies, warranting some form term energy development program (to 2020) of government intervention to better approximate includes energy conservation and fuel the socially optimal level of investment. diversification measures. Stricter standards for energy efficiency of buildings are being Support for Skill Development and Training enforced in urban areas; to date, these standards do not apply to rural buildings. Beyond technology, the public sector needs to support development of human capital related to Standards are necessary to reduce information household energy use. This applies to education asymmetry between producers and consumers. generally, including sensitizing students to the IAP In a developing country context, where problem, as well as to the more specialized fields competition may be limited and regulatory of engineering, economics, public health, provisions minimal, absence of standards could environmental science and other subjects critical to result in producers providing misleading research on IAP and household energy use information. Requiring producers to meet alternatives. At a practical level, training is needed verifiable standards of fuel efficiency and to create a pool of skilled technicians capable of emissions helps consumers determine value for properly installing and maintaining stove and expenditure. In this way, the government can ventilation systems and adapting stoves to new fuel help reduce information asymmetry and provide alternatives. One would expect the private sector a means for market signaling. However, to function effectively in providing such services standards for cooking and heating stoves must once the technology and infrastructure hurdles had be carefully designed. The relationship between been surmounted; however, market flaws, such as cooking and heating functions must be reflected the free rider problem, might again require in the standards, which should not act as government intervention or encouragement. barriers to entry for new stove manufacturers In developing countries, technicians skilled in and distributors. 99 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Standards must also reflect diversity of consumer dispersed over wide areas ­ economies of scale demand, which reflect differing circumstances of shouldbequicklyrealizable.Supply-side household incomes, fuel availability behavioral impediments, however, may include the risk of characteristics and customs, housing structures and failure to capture the expected Rate of Return from other location-specific factors. Whether households investmentinexperimentation(oradaptationof adopt and use alternative fuels and stoves will foreign technology), caused by copying by others depend on the ease of accessing these alternatives (Hausmann and Rodrik 2002). Research is needed and their cost. It will also depend on household onwhymarketmechanismsappearunresponsiveto perceptions and valuation of the IAP health risk the IAP problem. As this study shows, health and benefits to be gained from reducing it. education alone is insufficient to lower IAP exposure; Household demand for technology will further be it is a necessary complement to strengthening the affected by intrahousehold variation in risk/benefit demandfornewhouseholdenergytechnologies. perception and access to resources. Market dysfunctionalities may warrant tax or other incentiveswhichraiseinvestmentinhousehold Facilitation of Private Sector Responses energy technologies to a more socially optimal level. Since alternative stoves and cleaner fuels are Welfare, Preventive Health Care and private goods, it could be expected that the Poverty Reduction marketplace could fairly determine their prices through competition among suppliers and The case for greater public sector action in distributors. Consumer choice is exercised simply addressingIAP-relatedhealthrisksindeveloping by deciding whether to buy the alternative stove countrieshasabroaderlogic.Healthisfundamental technologies. Of concern are the impediments or to enh4ancing the lives of people and the freedom possible barriers to their provision and purchase. they enjoy. A sick person may cripple a household Severe poverty in rural areas is perhaps the main and greatly limit its range of real opportunities, barrier, explaining continued reliance on underminingsubstantialorpositivefreedom(Sen rudimentary stove and ventilation systems despite 1999). Thus, it is often more effective, in the the pervasiveness of IAP. As the China IAP study promotionofsubstantialfreedom,toinvestinpublic demonstrates, in certain cases, the cost of programs which provide access to inexpensive heath nonsubsidized alternative stoves may equal to a assistance (preventive health care) than to divide the high percentage of net household income, which allocatedfundsamongthosewhohappentobesick. typically is subsistence level. Rural households Furthermore, empirical studies show that health have limited or no access to credit; even if they improvementsprovideasignificantboostto decide that the net benefits of the alternative stoves economicgrowthindevelopingcountries(Bloom would be positive, they may simply lack the and Canning 2000). Health, like education, is a necessary funds. Microcredit facilities are needed fundamentalcomponentofhumancapital.IAP,asa in such circumstances. major cause of mortality and morbidity in rural areasofChinaandotherdevelopingcountries, Despitepovertyandlackoffinancialmeans,China's should become a more serious priority than has rural population is large, and evidence of been the case to date. consumer-basedexperimentationwithalternative stoves and fuels would be the expected market The goal of poverty reduction underscores this response, especially given the improvement in rural priority. Despite rapid economic growth in China, incomes over the past three decades. Furthermore, more than 100 million people continue to suffer given the market's large size ­ even though from severe poverty. Nearly 30 percent of these 100 Summary and Recommendations severely poor are impoverished due to illness or imperfections and government weakness in injury.82 Furthermore, a high percentage of rural developing countries; households lives close to the poverty line, is · Review of training, standards and other highly susceptible to illness and lacks access to specific elements needed for effective health care services.83 Again, IAP should be a intervention programs; priority concern. · Analysisofthepracticalityoffocusingpublic interventionsonsupportingpoorruralhouseholds, Suggestions for Future Work in Research inlightoftheneedtomovealongthelearning and Development curveandgaineconomiesofscalebeforenew Further research and testing are required in the technologiesreachaffordabilitybythepoor; followingareas: · Cost-effectiveness analysis of intervention options, including microcredit and commercial, · Better understanding of the seasonal patterns of private sector led initiatives (Easterly 2006);85 IAP exposure and how stove and behavioral · Cost-benefit analysis of intervention program; interventions may affect exposure; coupled with welfare benefits and costs of IAP interventions this, a clearer distinction is needed between IAP should be evaluated;86 and emissions from heating versus cooking, stoves · Analysis of how gender issues and andpurposes; intrahousehold gender disparities influence · Monitoring of stove performance and user household technology choices, and how these behavior over time; particularly needed is are affected by education and literacy levels. testing the degree to which proper stove and ventilation maintenance can contribute to In conclusion, IAP should be a priority concern reduced IAP exposure and improved in poor rural areas of China, where a high IAP-related health indicators (Sinton et percentage of households is susceptible to al. 2004);84 respiratory and other IAP-related health risks and · Effects of alternative stoves on the amount of lacks access to adequate health care. This study fuel used and their local/global has documented the effects of household stove environmental effects; and behavioral interventions for reducing IAP · Review of the supply-and-demand factors concentration levels in rural China, with health critical to achieving high quality technological indicators as the outcome of interest. It did not advances in household energy use, recognizing document the energy savings or reduction in GHG the affordability limitations of rural households; emissions from these interventions; but potential · Review of the respective roles of the gains in these areas suggest that benefits from the private and public sectors in addressing the government's involvement in reducing IAP could IAP problem, recognizing market extend well beyond health. 82Government of China, Ministry of Health, Statistics and Information Center, 2004. 83United Nations Development Programme, China Human Development Report, 2005. 84Sinton et al. (2004) found that, good stove maintenance were negatively correlated with childhood asthma and adult respiratory diseases. 85The Shell Foundation is experimenting with a market-based approach to the problem of indoor smoke. Microenterprises are being encouraged to produce and distribute improved stoves, adapting them to consumer wants and relying on cash sales to consumers, including payments in goods. 86Health benefits could be addressed by determining the level of benefits necessary to just the cost of the interventions, then assessing their degree of reasonableness. Welfare benefits should include energy conservation and associated savings in time and labor for gathering fuel and the improved productivity of the rural labor force and hence potential for higher household incomes. Environmental benefits should also be evaluated. Costs include the international assistance and budgetary funds used to support IAP projects, as well as the private costs incurred (for example, alternative food-drying techniques). The Economic Internal Rate of Return (EIRR) for IAP projects should be greater than the social opportunity cost of capital (approximately 12 percent in real terms). Sensitivity analysis would likely indicate that EIRR estimates for IAP projects are heavily influenced by IAP measurement levels, which are difficult to gain free of econometric "noise." 101 Annex 1 Project Implementation Schedule Project Initiation (December 2002-February 2003): · Health examinations (lung function, eyes, nose and throat, fluorosis and arseniasis and urine · Project launch conference; technical workshop, testing of women and children); training of trainers and explanation and · Pyrological tests of heat efficiency and IAP promotion for project partners; emissions for alternative household stoves to improve design; and · Pilot field visits to determine project county and · Preparation of health education materials township sites and household groups according aimed at IAP control and stove improvement in to agreed-on selection criteria; pilot surveys accordance with local culture, tradition and with small samples of households; economic circumstances. · Establishment of local lead and working groups Implementation of Interventions (May 2004- for project implementation; December 2004): · Pilot sampling of IAP for design of evaluation · Proposed stove improvement devices for technique;and various areas; conducted large-scale stove/ventilation intervention; conducted · Assessment of local stove market and post-intervention inspection; design of initial stove improvement and · Implementation of public health education at market development interventions. project sites using multiple approaches and focused on behavioral changes; BaselineSurveys/Initiatives(March2003-April2004): · Pyrological tests, comparing improved and originalstoves; · IAP monitoring (indexes included RPM, CO, · Stovemarketdevelopment(includingknowledge SO2 in indoor air and fluorine and arsenic disseminationandtechnicaltrainingoflocalstove traces in air, coal, food, drinking entrepreneurs, measures to lower production water and soil); costsandincreasequalityandmobilizinglocal · Baseline data on energy use/fuel consumption enterprises to participate in the project); and andstove-types; · Local capacity-building in controlling IAP · Health questionnaire survey (data collection on through workshops, training of local personnel general household situation and health status of in IAP monitoring and stove technologies and family members); knowledgedissemination. 103 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Postevaluation and Reporting (January 2005- in December 2004 in Inner Mongolia. November 2005): Health Education/Behavioral Activities Surveys · IAP monitoring, postmonitoring as the same households in baseline study; Health Education/Behavioral Activities Surveys and · Evaluation of health education; general health surveys were carried out in April · Evaluation of women and children's 2003 (baseline) and April 2005 (evaluation). healthstatus; · Status of stove market development; Household Energy Interventions · Status of local capacity-building; and · Evaluation of project management. Stove (2004) Gansu May-November Fieldwork: Shaanxi May-December Guizhou June-October IAPMonitoring InnerMongolia June-October IAP baseline studies were conducted in March and December 2003 in Gansu, Guizhou Health Education (2004 or 2004-05) and Shaanxi provinces and in December 2003 Shaanxi May-December in Inner Mongolia. Evaluation studies were InnerMongolia June-October conducted in December 2004 and March 2005 Gansu May-January in Gansu, Guizhou and Shaanxi provinces and Guizhou June-February 104 Annex 2 Project Partner Organizations Central level soften World Bank/International Bank for Reconstruction and Development(IBRD) loans. Foreign Loan Office, Ministry of Health In addition, the central government increases (Contract Holder) investment in priority health problems; provincial-, district-, and county-level governments may also The FLO (formerly World Bank Loan Office) was allocate counterpart funding. established in 1983 under supervision of the Bureau of Foreign Affairs and Department of Institute for Environmental Health and Planning and Finance. As part of the institutional Related Product Safety, Chinese Center for reform of 1989, the Office was renamed and its Disease Control and Prevention responsibilities were expanded. Since 1992, the Office has been categorized as an enterprise, The Institute for Environmental Health and Related rather than a government department. Its 39 Product Safety, Chinese Center for Disease staff members manage health loan projects. Control and Prevention, established in May 2002, Major responsibilities include coordinating health is based on the former Institute of Environmental projects supported by loans from international Health and Engineering and Institute of financial institutions; health loans from bilateral Environmental Health Monitoring, Chinese governments and nongovernmental agencies; Academy of Preventive Medicine. The Institute has grants which finance and supplement loan seven administrative and 12 technical projects; interaction with international fund-raising departments, with more than 260 faculty and staff, and project-implementing institutions and including more than 60 senior researchers. organizations in support of health sector development in ethnic minority, marginalized and The Institute's research focus includes indoor air impoverished areas; management of project quality, drinking water quality, environmental supported by foreign capital; project-management chemical pollutants, environmental services, including finance, procurement, technical microorganisms and health effects of assistance and operational research; domestic and electromagnetic radiation. Major responsibilities overseas training services; and business and are providing scientific evidence of and enterprise development through project technical support for formulating laws and cofinancing or joint ventures. hygiene standards on environmental health and product safety and advising government The Office uses a three-pronged approach in decision makers on environmental health issues. foreign capital utilization. It borrows from World The Institute also monitors environmental health Bank, while seeking grants from various sources to factors (for example, air, water, soil and solid 105 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China waste) and assesses construction projects from a operational implementation. hygiene perspective. In addition, it conducts premarket, environmental safety evaluations of Provincial Centers and Offices: new techniques and products; collects Center for Disease Control and Prevention environmental health information and (Gansu) preventive care statistics; and participates in Center for Disease Control and Prevention community-based,environmentalhealthPromotion (Guizhou) Office of Project Administration (Inner Mongolia) Huaxi School of Public Health, Office of Project Administration (Shaanxi) Sichuan University Huaxi School of Public Health is one of China's County level most respected academic institutions in the Public Health Bureau in Districts, public health field. The school consists of Townships and Counties 15 departments with 284 staff members (25 professors, 51 associate professors and 98 At the county level, public health bureaus (part lecturers). University departments include health of the county government) are in charge of statistics, epidemiology, environmental health health-related issues. The number of staff and health economy. Doctoral and masters members ranges from 30 to 60. Bureaus programs focus on toxicology, child/adolescent include multiple departments (for example, and maternal/child health, public health and health policy, disease control, legal supervision, public administration. The total number of finance and foreign loans). Main responsibilities full-time students exceeds 1,400. The school is are preparing and implementing health a member of the Health Economy Research guidelines and regulations, supervising and Training Network, established by the implementation of health development plans, Ministry of Health, Ministry of Finance and undertaking surveillance of infectious and World Bank. endemic diseases, establishing certified public Provincial level standards for medical workers, organizing assistance for emergency situations and Foreign Loan Office, Provincial Public implementing health education and Health Bureaus technology development. The Foreign Loan Office, Provincial Public Center for Disease Control and Prevention Health Bureaus undertakes activities in Districts, Townships, and Counties using health-related World Bank loans and foreign government loans and grants. Local branch offices of the central Center The Office's main responsibilities are to for Disease Control are staffed by 20-60 prepare program proposals and final personnel. Departments include offices of summaries of projects and their endemic disease and tuberculosis control. implementation, coordinate counterpart Major responsibilities are establishing and fund-raising, compile annual project plans and implementing health education plans and an provincial work plans in accordance with project expanded county immunization program, objectives, prepare supervisory visits, and managing responses to epidemics and public negotiate with partner organizations to confirm heath issues (for example, iodine deficiency, technical schemes and resource allocation for fluorosis, Kaschin-Beck disease and intestinal 106 Annex 2: Project Partner Organizations parasite control) and conducting surveillance of Township level environmental health. The centers Community Hospitals, Townships implement regulations under the Statute for and Counties Infectious Disease Control on treatment of sexually transmitted diseases, including HIV/AIDS. Centers Thecommunityhospitals'responsibilitiesinclude are equipped with X-ray machines, vapor phase childimmunization,maternalandchildhealth color spectrometers, atomic absorption activities, endemic control in precincts and spectrophotometers and atom fluorometry and implementationofvarioustasksdeterminedbythe enzyme-linked apparatuses. healthadministrationdepartmentandtownship government. Hospitals have 10-20 staff members Country Bureaus and Centers: andbothoutpatientandinpatientdepartments(about Public Health Bureau and Center for Disease 10 beds). Medical equipment is usually limited. Control (Huixian County, Gansu) Public Health Bureau and Center for Disease CommunityHospitals: Control (Guiding County, Guizhou) Yinxing, Jialing and Mayan (Huixian County,Gansu) Public Health Bureau and Center for Disease Xinpu, Xinba and Dexin (Guiding County, Control and Health Care Station (Helingeer Guizhou) County, Inner Mongolia) Xindianzi and Dahongcheng (Helingeer County, Public Health Bureau and Center for InnerMongolia) Disease Control (Hanbin District, Ankang Hongshan and Shizhuan (Hanbin district, City, Shaanxi) Ankang City, Shaanxi) 107 Annex 3.1 Provincial Statistical Overview Inner Statistic Gansu Guizhou Mongolia Shaanxi Economic Performance GDP (billions of yuan), 20031 130.5 135.6 215 239.9 GDP Growth Rate (%), 1996-20001 9.2 10.1* 10.0 9.3* GDP per capita (yuan), 20031 5,022 3,603 8,975 6,480 Urban1 11,651 8,573 14,658 13,233 Rural1 2,928 2,042 4,740 3,258 Per capita, Net Rural-household 1,673.0 1,564.7 2,267.6 1,675.7 Income (yuan), 20031 Consumption Per capita Expenditure, Urban (yuan)2 5,299 4,949 5,419 5,667 Per capita Expenditure, Rural (yuan)2 1,337 1,185 1,771 1,455 Food (% of total)2 43.8 57.0 41.3 39.4 Medicare (% of total)2 7.2 4.0 7.0 7.4 Housing: Average Number of Rooms 3.89 2.21 1.9 3.02 by Household, 20003 Energy Total Energy Production (10,000 tons of sce)1 2,854.5 5,829.5 8,428.6 5,848.5 Coal (% of total)1 83.0 96.0 97.2 71.6 Total Energy Consumption (sce)1 3,068.4 3,725.7 5,190.1 3,447.9 Coal (% of total)1 92 63 93.47 68.9 Demographic Trends Total Population (millions), 20031 26.03 38.7 23.8 36.9 109 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Inner Statistic Gansu Guizhou Mongolia Shaanxi Annual Population Growth Rate (%),1990-20001 1.3 0.8 1.0 .9 Rural Population (% of total), 20004 76.0 76.1 57.3 67.7 Population Under Age 15 (% of total), 20003 26.9 30.2 21.2 24.9 Human Development Index 20032 0.675 0.639 0.738 0.729 Health Services Health Agencies (no.)1 1,1201 6,499 6,859 11,831 Hospitals (no.)1 382 390 450 813 Beds (no.) per 1,000 People, 20035 2.2 1.5 2.6 2.6 Practicing Physicians (no.) per 1,000 People, 20035 1.4 1.0 2.1 1.7 Basic Medical Insurance Coverage (% of population)2 5.6 3.5 10.6 8.2 Hospitalized Delivery Rates (%), 20022 59 31 83 80 Health Indicators Urban Life Expectancy at Birth (years), 20002 75.5 73.9 74.1 75.9 Male2 74.0 71.4 71.9 74.7 Female2 77.2 76.7 76.5 77.2 Rural Life Expectancy at Birth (years), 20002 67.2 64.7 68.8 69.3 Male2 66.5 63.5 67.5 68.1 Female2 67.8 66.2 70.4 70.6 Infant Mortality Rate (%), 20003 50.9 67.9 31.0 31.7 County Infant Mortality Rate (%), 20003 60.1 78.9 38.7 35.9 Male3 50.6 68.5 34.9 29.9 Female3 71.3 90.6 43.0 43.7 Under-five Mortality Rate (%), 20003 9.7 15.6 6.0 6.1 County Under-five Mortality Rate (%), 20003 11.1 17.8 7.3 6.7 Male3 9.4 15.5 6.7 5.7 Female3 13.0 20.5 8.02 7.9 Literacy and Enrollment Adult Illiteracy Rate (% age 15 and above), 20003 19.7 19.8 11.6 9.8 110 Annex 3.1: Provincial Statistical Overview Inner Statistic Gansu Guizhou Mongolia Shaanxi CountyAdultIlliteracyRate(%age15andabove),20003 24.2 23.8 15.5 12.5 Male3 15.2 12.1 9.7 7.5 Female3 33.6 36.6 22.0 17.7 Primary School Attendance Rate (%)2 97.3 97 99 98.9 Junior High School Attendance Rate (%)2 91.6 87.8 90.1 94.2 Public Sector Finances Local per capita Income (yuan)2 342 328 590 488 Local per capita Expenditure (yuan)2 1,171 876 1,902 1,152 Public Expenditure on Education (% of total)2 17 19 20 15 * 2003data. Sources: 1Provincial Statistical Yearbook 2003. 2UNDP, China Human Development Report 2005. 3Population Census 2000 (Province). 4China Population Statistical Yearbook 2001. 5China Health Statistical Yearbook 2003. 111 Annex 3.2 County Statistical Overview Helingeer Huixian Guiding (Inner Ankang County (province) (Gansu) (Guizhou) Mongolia) (Shaanxi) Economic Performance GDP (10,000 yuan), 20031 32,757 149,055 293,203 1,036,000 GDP per capita (yuan), 20031 1,492 5,193 15,505 3,963 Net Rural Household income (yuan)1 1,697 1,568 2,672 Housing Average Number of Rooms, By Household2 3.6 2.0 2.6 2.8 Demographic Trends Total Number of Households1 54,500 45,674* 51,688 750,126* Total Population (millions), 20031 0.219 0.258 0.189 2.613 Rural Population (% of total), 20032 0.89 0.84 0.88 0.83 Population Under Age 15 (%), 20002 24.3 29.3 20.8 26.8 Total Fertility Rate, 2000-052 1.5 1.8 1.6 1.6 Health Services Sickbeds (no.) per 1,000 people1 1.2 1.9 Medical Technical Personnel (no.) per 1,000 people 0.1 2.8 Health Indicators County Infant Mortality Rate (%), 20002 24.9 60.9 102.3 20.23 Male 27.3 53.7 52.5 Female 22.4 68.9 163.6 County Under-five Mortality Rate (%), 20002 5.6 13.9 19.6 24.63 113 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Helingeer Huixian Guiding (Inner Ankang County (province) (Gansu) (Guizhou) Mongolia) (Shaanxi) Male 6.5 12.8 9.9 Female 4.7 15.0 31.3 Literacy and Enrollment Adult Illiteracy Rate (ages 15 and above), 20032 15.7 13.3 21.2 19.0 Female2 21.1 21.3 30.7 25.1 Male2 11.0 6.1 12.8 13.6 Public-sector Finances Local per capita Revenue (yuan)1 697 155 Local per capita Expenditure (yuan)1 627 1,715 563 * Census data, 2000. Sources: 1Statistical Yearbook 2003 (County). 2Population Census 2000 (Province). 3Ankang City Women and Children's Development Status Report (www.akstats.gov.cn/news/ShowArticle.asp?ArticleID=459). 114 Annex 3.3 Demographic and Socioeconomic Characteristics of Study Households and Respondents Gansu Guizhou Inner Shaanxi Mongolia Characteristic (n=463) (n = 476) (n = 323) (n = 479) Gender of Respondent Male 4.3 30.9 35.9 35.9 Female 95.7 69.1 64.1 64.1 Age of Respondent Below40 89.2 64.1 78.6 67.2 40-59 9.7 30.9 21.1 28.8 60 or Above 1.1 5.0 0.3 4.0 Education Level of Respondent Illiterate 19.0 34.5 25.7 36.3 Elementary 52.7 45.8 39.6 38.6 JuniorHigh 25.7 17.4 26.9 21.7 SeniorHigh 2.6 2.3 5.9 1.9 Junior College and Over 0.0 0.0 1.9 1.5 Number of Household Members Fewer than Four 13.0 19.2 84.8 17.7 Four to Seven 86.2 76.8 13.9 80.8 Eight or More 0.8 4.0 1.2 1.5 Family Annual Income in the Previous Year (yuan)1 Less than 1,000 47.4 14.3 12.4 39.6 1,000-1,999 18.1 6.5 6.8 9.4 115 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Gansu Guizhou Inner Shaanxi Mongolia Characteristic (n=463) (n = 476) (n = 323) (n = 479) 2,000-2,999 19.1 28.3 13.6 26.3 3,000-3,999 8.5 18.4 10.2 9.6 4,000 or More 6.8 32.6 57.0 15.1 Family Annual Storage Income in the Previous Year (yuan)2 Less than 1,000 45.6 68.1 10.8 40.7 1,000-1,999 26.2 10.4 17.6 19.6 2,000-2,999 18.3 10.0 18.0 22.4 3,000-3,999 5.5 3.8 18.6 9.9 4,000 or More 4.3 7.7 35.0 7.5 Rank Order Correlation of Family 0.310 0.472 0.301 0.260 Income and Storage 1 Exchange rate (2003-04) of 8-8.5 yuan = US$1. 2Respondents' estimated value of foods and other agricultural products families produced and consumed at home or stored in the previous year. Note: Numbers in Table represent % households or respondents; n = number of observations. Source: Jin et al. (2006). 116 Annex 3.4 Technical Design for Measuring IAP Concentrations Respirable particles were measured according to All filters (field blanks and samples) were the protocol of the National Institute for conditioned for 24 hours before weighing. Occupational Safety and Health (NIOSH protocol Sampling for Respirable Particle Matter (PM10) 0600), which was designed to capture particles were continually determined using the LD-3C dust with a median aerodynamic diameter of 4 mm sampler (China). Respirable dust concentrations (PM4). Samples were collected using a 10 mm were calculated by dividing the blank-corrected nylon cyclone equipped with a 37mm diameter increase in filter mass by the total air volume poly-vinyl-chloride (PVC) filter (pore size 5µm sampled(mg/m³). supplied by SKC Inc., U.S.) at a flow rate of 2.5 l/min. Air was drawn through the cyclone CO and SO2 were measured using long-term preselectors using battery-operated constant flow diffusion tubes (manufactured by GASTEC, U.S.), pumps (Model PCXR8 supplied by SKC Inc., U.S.). with detection ranges of 10-200 or 50-1000 ppm All pumps were calibrated before and after each for CO and 2-100 ppm for SO2. The average sampling day, using a field mini-meter, itself concentrations were calculated on a time-weighted calibrated by a soap bubble meter in a laboratory. basis and expressed as mg/m³. Due to cost Pumps were also calibrated in a laboratory after considerations, SO2 levels were measured only in each field exercise, using the same mini-meter. the two coal-burning provinces of Guizhou and In order to maintain battery power throughout the Shaanxi. Samples of fluoride and As were sampling period, pumps were programed to cover collected using a relative filter-flow rate of the 24-hour interval through intermittent sampling 2.0 l/min., operated with programmable constant (one minute out of every four to six minutes). flow pumps (PCXR8 supplied by SWKC Inc., U.S.). One field blank was taken on each sampling day. They were tested according to NIOSH protocols 7300 and 7902, respectively. Gravimetric analyses were conducted at the laboratory of the National Institute for PM10, S02 and CO concentrations were evaluated Environmental Health and Related Products Safety, according to the Standard for Indoor Air Quality of China CDC, using an analytic microbalance China (GB/T 18883-2002). PM4 concentrations (1/100,000, Sartorius 2004 MP, Germany) were evaluated according to the Japanese Indoor calibrated against standards provided by the Standard Enforced in Office Buildings (< 3.5 µm, Bureau of National Technological Control. 0.15mg/m³). 117 Annex 3.5 IAP Baseline Data Figure A3.5.1: Baseline RPM Data Average 24-hour concentration of RPM (PM4) at difference points and measurement periods (March and December 2003) in the four project provinces. Gansu Guizhou 5,000 5,000 n=96 n=33 n=96 n=33 4,000 n=96 µ=351 µ=457 4,000 µ=352 n=32 µ=518 µ=661 (202-500) (280-634) (224-480) µ=301 n=96 ) (467-855) ) 3 (364-671) 3 µ=315 3,000 3,000 (178-425) g/mµ( g/mµ( (185-443) 4 4 PM 2,000 PM 2,000 n=32 µ=202 (159-245) 1,000 1,000 0 0 Mar Dec Mar Dec Mar Dec Mar Dec CookingRoom Living/Bedroom Cooking/Living Room Bedroom InnerMongolia Shaanxi 5,000 5,000 4,000 n=98 µ=188 (132-241) 4,000 n=61 ) ) n=81 3 3,000n=100 3 µ=718 µ=719 (638-898) µ=187 g/mµ( 3,000 (480-958) g/mµ( (143-230) n=29 4 µ=329 n=24 4 2,000 PM n=38 n=25 (261-397) µ=381 PM 2,000 µ=223 µ=215 (266-355) (164-282) (136-293) 1,000 1,000 0 0 Mar Dec Mar Dec Mar Dec Point1 Point2 CookingRoom LivingRoom Bedroom Cooking/Living/Bedroom (Dec) Note: n = number of observations; µ = mean (numbers in parentheses give the 95 percent Confidence Interval [CI] for the mean). Source: Jin et al. (2005). Reprinted with permission from the American Chemical Society. 119 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Figure A3.5.2: Baseline CO Data Average 24-hour concentration of CO at different measurement points and measurement periods (March and December 2003) in the four project provinces. Gansu Guizhou 50 50 n=96 40 µ=5.5 40 (4.7-6.3) 30 n=33 n=96 µ=8.4 µ=4.8 n=33 30 (ppm) (5.5-11.3) (4.1-5.5) µ=11.3 (6.9-15.7) (ppm) n=32 CO 20 n=25 CO 20 n=32 µ=1.3 n=25 µ=1.3 µ=1.8 µ=1.2 (1.0-1.6) (1.4-2.1) (1.6-2.0) (1.0-1.5) 10 10 0 0 Mar Dec Mar Dec Mar Dec Mar Dec CookingRoom Living/Bedroom Cooking/Living Room Bedroom InnerMongolia Shaanxi 50 n=30 50 n=36 µ=13.3 µ=6.8 (9.1-17.6) 40 40 (4.7-8.9) n=24 n=24 µ=10.8 µ=5.3 30 30 (6.3-15.3) n=24 (3.4-7.2) (ppm) n=65 n=65 (ppm) µ=2.3 µ=7.4 n=24 µ=7.3 (1.7-2.9) CO 20 20 (6.7-8.1) CO µ=2.0 (6.6-7.9) (1.1-3.0) 10 10 0 0 Mar Dec Mar Dec Mar Dec Point1 Point2 CookingRoom LivingRoom Bedroom Cooking/Living/Bedroom (Dec) Note: n = number of observations; µ = mean (numbers in parentheses give the 95 percent CI for the mean). Source: Jin et al. (2005). Reprinted with permission from the American Chemical Society. 120 Annex 3.5: IAP Baseline Data Figure A3.5.3: Baseline SO Data 2 Average 24-hour concentration of SO2 at different measurement points and measurement periods (March and December 2003) in the four project provinces. Gansu Guizhou 5 5 4 4 3 n=25 3 µ=0.16 n=32 (ppm) (0.02-0.30) n=25 (ppm) 2 µ=0.18 2 n=25 µ=0.13 2 SO 2 (0.12-0.25) SO µ=0.20 (0.06-0.21) n=9 n=4 (0.15-0.24) µ=0.0827 µ=0.0824 1 1 (0.0820-0.835) (0.0806-0.0841) 0 0 Mar Dec Mar Dec Cooking Room (Mar) Living/Bedroom (Mar) Cooking/Living Room Bedroom InnerMongolia Shaanxi n=24 5 5 n=97 µ=1.39 µ=0.48 (0.81-1.97) (0.33-0.62) 4 4 n=99 µ=0.44 n=36 n=25 µ=0.97 n=30 (0.33-0.56)µ=0.69 µ=1.44 3 3 (0.40-0.97)(0.62-1.33) (0.93-1.96) (ppm) (ppm) 2 2 n=7 n=7 SO SO 2 µ=0.25 µ=0.31 2 (0.08-0.41) (0.01-0.61) 1 1 0 0 Point1 Point2 Mar Dec Mar Dec Mar Dec Cooking/Living/Bedroom (Dec) CookingRoom Living Room Bedroom Note: If the concentration of CO and SO2 were outside the detection range of the testing tubes, the following assumptions were made: (i) those measurements only slightly higher than the measurement range were set to the maximum value; (ii) those measurements substantially higher than the measurement range were set to 150 percent of the maximum value; (iii) those measurements lower than the measurement range were set to the minimum value. The overall results and conclusions of the analysis were not sensitive to these assumptions. n = number of observations; µ = mean (numbers in parentheses give the 95 percent CI for the mean). Source: Jin et al. (2005). Reprinted with permission from the American Chemical Society. 121 Annex 3.6 Baseline Questionnaires Household Questionnaire ID: HouseholdAddress: Group: _________ Village: ___________Town: ___________ City/County: ___________ Householder Women1 Women2 Women3 Child1 Child2 Child3 Name Sex F F F Age Name of surveyor: ________________ Date (day/month/year): ___________ Name of responder: ________________ Sex:________ Age: ________ (years old) Education degree: 1. illiterate 2. elementary school 3. primary school 4. senior high school/vocational high school/ technical secondary school/junior college and higher Information and agreement: To inform the responder, the following items ask for his/her agreement and signature: 1. The objective of this survey is to discover the relationship between IAP and your and your family's health. Samples may be required, including water, food, urine, etc. 2. We undertake to hold confidential all information from this survey. 3. You may collaborate with us on your free will, Thank you. Signature: (By responder or guardian) 123 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Section A: Household Characteristics A1. How many persons are in your family? (They must be the family members who live together) ______________________________________ A2. Where do you get the water that you use for drinking? 1. Tapwater 2. From well in village 3. From well in the yard 4. From river, lake, cistern, pool 5. Naturalspring 6. Water stored in vault 7. Other (specify):____________ A3. Your do you get drinking water? From: 1. water tap 2. vat 3.pool 4. other (specify): ____________ A4. Your cash part of annual income of your family last year: ____________ RMB yuan A5. Please estimate as precisely as you can the value of food and other agricultural products which your family produced and consumed or stored last year. ____________ RMB yuan A6. Do you raise the following animals or plants? A6a. poultry (chicken, duck, goose, etc.) 1. Yes 2. No A6b. livestock (pig, horse, cattle, sheep, etc.) 1. Yes 2. No A6c. cat, dog, or bird 1. Yes 2. No A6d. flowers and plants 1. Yes 2. No A7. The main source of light for your family: 1 = electricity 2 = kerosene 3 = biogas 4 = candle 5 = other (specify):__________ Section B: House and Kitchen Characteristics B1. How large is your indoor area? __________________m2 B2. When was your house built? ______________ (for example, 1999) B3. Main material composing of your house: 1 = earth, wood, grass 2 = earth, wood, tile 3 = brick, wood, tile 4 = brick, concrete 5 = metal, concrete 6 = other (specify): __________ B4. Is there a gap between the wall and roof? 1. Yes 2. No (if no, go to B5) B4a. Record the typical size of the gap in centimeters. cm 124 Annex 3.6: Baseline Questionnaires B5. How often do you open windows in winter while heating? 1. once or more every day 2. once every 2-3 days 3. once every 4-5 days 4. once a week 5. once every 2-3 weeks 6. onceamonth 7. never in winter 8. other (specify): ___________ B6. Where do you usually do cooking? 1. in specialized kitchen 2. inbedroom 3. in living room 4. other (specify):______________ B7. Characteristics of cooking place B7a. Indoor kitchen with separation wall to ceiling .........................1. Yes 2. No B7b. Indoor kitchen with partial separation wall .............................1. Yes 2. No B7c. Indoor kitchen without separation wall ...................................1. Yes 2. No B7d. Separated indoor kitchen outside the house ..........................1. Yes 2. No B7e. Open air kitchen outside the house ......................................1. Yes 2. No B8. Is there a fan for ventilation (vented to outside) in the kitchen? 1. Yes 2. No B9. Are there windows in the kitchen which open to the outside air? 1. Yes 2. No Section C: Fuel Use C1. What types of fuels does your household mainly use for cooking and heating? Cooking Heating C1a1 winter: _____________ C1a2 winter: _____________ C1b1spring: _____________ C1b2spring: _____________ C1c1 summer: _____________ C1c2 summer: _____________ C1d1autumn: _____________ C1d2autumn: _____________ 1 = wood (logs), 2 = wood (twigs/branches), 3 = crop residue, 4 = dung, 5 = coal/coke/bone coal, 6 = charcoal, 7 = kerosene, 8 = Liquefied Petroleum Gas (LPG), 9 = biogas, 10 = other (specify):___________ C2. If you use coal stove, how much coal do you use monthly? C2a. Not during heating days: ______Jin (0.5kg) C2b. During heating days: ______Jin 125 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China C3. If you use traditional biomass stove, how much do you use per month? C3a. Not during heating days: ______Jin C3b.During heating days: ______Jin C4. Has your household changed the main fuel in the past 10 years? 1) Yes 2) No C5. Briefly describe changes: time, extent and reasons for change. C6. For you, what's the price of fuel you are using? 1) Expensive 2) Moderate 3) Cheap C7. Do you know other fuel? 1) Yes (note: ) 2) No C8. Are you willing to use other fuel? 1) Yes 2) No C9. A new type of fuel can reduce indoor smoke, but it's more expensive than what you are using. Are you willing to change? 1) Yes 2) No 3) Don't care 4) Don't know C10. How much are you willing to pay if you change to using a new type of fuel? 1) No more than 110 percent compared to current price 2) 110-120 percent compared to current price 3) 120-150 percent compared to current price 4) 150-200 percent compared to current price Section D: Stove Characteristics D1. The type of stove(s) you own and its main purpose (each type is just for one main purpose) Mainly for Cooking Mainly for Heating Number Location* Number Location* Unimproved Biomass Stove Improved Biomass Stove Traditional Coal Stove Improved LPG Stove Biogas Firedamp Fire Pan Open fire with no Hearth Other (specify):_________ *Location:1 = specialized kitchen, 2 = bedroom, 3 = living room, 4 = other(specify):_________ D2. Does your household have the following: D2a. Heated bed ("kang," a bed-heating configuration) 1) Yes 2) No D2b. Ground stove 1) Yes 2) No 126 Annex 3.6: Baseline Questionnaires D3. Does the heated bed have a chimney extending outside? 1) Yes 2) No 3) Other (note) D4. Do you know about other stoves? 1) Yes (note) 2) No D5. Are you satisfied with the stove you are using? 1) Yes (go to D3) 2) No 3) Indifferent D6. Are you willing to improve the stove you are using if possible? 1) Yes 2) No 3) Indifferent 4)Don'tknow D7. If you want to improve the stove, how much are you willing to pay for it? 1) Less than 100 2) 100-199 3) 200-299 Interviewer: If household has one or more biomass stoves, fill out the following questions: D8. What purpose is the stove used for? D8a.Cookingmeals 1 Yes 2 No D8b. Heating/boiling water 1 Yes 2 No D8c. Heating on rainy days 1 Yes 2 No D8d. Heating in winter 1 Yes 2 No D8e. During shortage of other fuels 1 Yes 2 No D8f. Cooking animal feed 1 Yes 2 No D8g. Other (specify): __________ D9. Does the stove have an air-blower (fan)? 1. No 2. air-blowing box (traditional) 3. manual fan 4. electric fan D10. Does this stove have a chimney? 1. Yes 2. No D10a. If so, does the chimney go outside your house 1. Yes 2. No D11. How often is the chimney cleaned? _______month D12. Distance from top of chimney to the eaves in centimeters? ______cm D12a. Does the chimney go past the eaves? 1. Yes 2. No D13. Height of chimney in centimeters (from ground to top of chimney) ______cm D14. Does the stove have a hood? 1. Yes 2. No D15. Does the stove have a door that is for adding fuel and that can be closed? 1. Yes 2. No D16. Does the stove have a grate? 1. Yes 2. No D17. If used for heating, is this stove connected to a "kang" (heated bed)? 1. Yes 2. No D17a. In the past year, has any family member suffered burns from the kang? 1. Yes 2. No D17b. Name of the injured person and frequency of scalding (burns): Name: ________ frequency: _________ Name: ________ frequency: _________ Name: ________ frequency: _________ D18. When was the stove installed?_______(for example, 1999) D19. How did you acquire this stove? 127 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China D19a. Decided to purchase on own 1. Yes 2. No D19b. Relative or friend recommended 1. Yes 2. No D19c.Governmentrequiredpurchaseorinstall 1. Yes 2. No D19d. Government provided a subsidy 1. Yes 2. No D19e. Already existed in the house when moved in 1. Yes 2. No D19f. Other (specify): __________________ D20. How much did it cost, including materials and labor for installation?______Yuan D21. Did other persons pay for the stove? 1. Yes 2. No (go to D19) D22. Who paid for the stove? 1. Government 2. Nongovernmental Organization 3. Enterprise 4.Other (specify):_____ D23. How much did the other person pay for the stove? ________yuan D24. How long ago was stove last repaired or refurbished? _____year Interviewer: If household has one or more coal stoves, fill out the following questions: D25. Interviewer: Describe the Type of Stove: D25a. Portable stove 1.Yes 2.No D25b. Fixed stove 1.Yes 2.No D25c. Other (specify):__________ D26. For what purposes is the stove used? D26a.Cookingmeals 1.Yes 2.No D26b. Boiling water 1.Yes 2.No D26c. Heating on rainy days 1.Yes 2.No D26d. Heating in winter 1.Yes 2.No D26e. During shortage of other fuels 1.Yes 2.No D26f. Cooking animal feed 1.Yes 2.No D26g. Other (specify): __________ D27. Does the stove have a chimney? 1.Yes 2.No D27a. If yes, does the chimney go outside the house? 1.Yes 2.No D28. If the stove has a chimney, how often is the chimney cleaned? _____ times per month D29. Height of the stove in centimeters (from top of chimney to eaves): _____ cm D30. Height of chimney in meters (from the floor ground): _____ m D31. Does the stove have a hood? 1.Yes 2.No D32. Does the stove have a fire door? 1.Yes 2.No D33. Do you close the fire door while cooking? 1.Yes 2.No 128 Annex 3.6: Baseline Questionnaires D34. Does the stove have a grate? 1.Yes 2.No D35. If used for heating, does the stove have a water heating system or other apparatus for heating water? 1. Yes 2. No D36. When was the stove installed?______(for example, 1999) D37. How did you acquire this stove? D37a. Decided to purchase on own 1. Yes 2. No D37b. Relative or friend recommended 1. Yes 2. No D37c. Government required purchase 1. Yes 2. No D37d. Government gave or subsidized 1. Yes 2. No D37e. Already existed in house when moved in 1. Yes 2. No D37f. Other (specify): __________________ D38. How much did it cost, including materials and labor for installation?____ yuan D39. Did others pay any of the cost? 1. Yes 2. No D40. Bywhom? 1. Government 2. Nongovernmental Organization 3. Enterprise 4.Other (specify): ______ D41. How much _____ yuan D42. How much does the kind of coal you use most cost? _____ yuan / 50kg or _____ yuan/piece D43. When was stove last repaired or maintained? ________ year (for example, 1999) Biogas Stoves Interviewer: If household has a biogas stove, fill out the following questions: D44. For what purposes is the stove used? D44a. For cooking meals 1. Yes 2. No D44b. For boiling water 1. Yes 2. No D44c. During shortage of other fuels 1. Yes 2. No D44d. Cooking animal feed 1. Yes 2. No D44e. Other (specify):_______________ D45. Is this the stove mainly used for cooking? 1. Yes 2. No D46. Where do you acquire the biogas? 1. Household biogas digester 2. Village biogas digester 3. Other (specify): __________ D47. When was the stove installed? _____(for example, 1999) D48. How did you acquire this stove? D48a. Decided to purchase on own 1. Yes 2. No D48b. Relative or friend recommended 1. Yes 2. No D48c. Government required purchase 1. Yes 2. No 129 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China D48d. Government gave or subsidized 1. Yes 2. No D48e. Already existed in house when moved in 1. Yes 2. No D48f. Other (specify): __________________ D49. How much did it cost, including materials and labor for installation? _______ yuan D50. Did others pay any of the cost for? 1. Yes 2. No D51. Bywhom? 1. Government 2.Nongovernmental Organization 3. Enterprise 4.Other (specify): _________ D52. How much? _______ yuan Section E: Food Processing and Cooking E1. What is the main food you consume daily? E1a. Corn 1)Yes 2)No E1b.Wheat 1)Yes 2)No E1c. Rice 1)Yes 2)No E1d.Oat 1)Yes 2)No E1e.Potato 1)Yes 2)No E1f. Other (note: ______) 1)Yes 2)No E2. What are the main means for drying food? E2a.Corn 1) Dry in the sun 2) Dry in the shade 3)Roast 4) Other (note: ) E2b. Wheat 1) Dry in the sun 2) Dry in the shade 3)Roast 4) Other (note: ) E2c. Rice 1) Dry in the sun 2) Dry in the shade 3)Roast 4) Other (note: ) E2d.Oat 1) Dry in the sun 2) Dry in the shade 3)Roast 4) Other (note: ) E2e. Capsicum 1) Dry in the sun 2) Dry in the shade 3)Roast 4) Other (note: ) E2f. Other (note: ) E3. What are the main means for storing food? 1) Storage in poke 2) Pile up without cover 3) Pile up and covered with plastic pellicle 4) Storage in container without cover 5) Storage in covered container 6) Other (note: ) E4. Do you wash capsicum before eating it? 1) Always 2) Sometimes 3) Never (go to E7) E5. How do you wash it? 1)Soaking 2) Scouring 3) Rinsing 4) Other (note: ) E6. What water do you use to wash? 1) River or dyke water 2) Well water 3) Tap water E7. Do you wash corn before grinding or eating it? 1) Always 2) Sometimes 3) Never (go to E10) E8. How do you wash it? 1)Soaking 2) Scouring 3) Rinsing 4) Other (note: ) 130 Annex 3.6 :Baseline Questionnaires E9. Which water do you use to wash? 1) River or dyke water 2) Well water 3) Tap water E10. Which water do you use to cook with? 1) River or dyke water 2) Well water 3) Tap water E11. Doyoucook? 1) Always 2) Sometimes 3) Never E12. How often do you feel choking or burning eyes when your family is cooking? 1) Always 2) Sometimes 3) Never 4) Don't know (go to E14) E13. What is the reason? 1) Fuel smoke 2) Grease mist 3) Other (note: ) E14. Do you usually burn the grease until mist appears while cooking? 1)Yes 2)No E15. Do you open the door and windows to ventilate when your family is cooking? 1) Always 2) Sometimes 3) Never E16. Do you think smoking can do harm to you and your family's health? 1)Yes 2)No 3) Don't care 4) Don't know E17. Do you know which means can reduce smoke? E17a. Improvedstove 1)Yes 2)No E17b. Improved chimney: 1)Yes 2)No E17c. Improve the skills of making a fire 1)Yes 2)No E17d. Improvedventilation 1)Yes 2)No E17e. No smoking in the house 1)Yes 2)No E17f. Spending less time cooking 1)Yes 2)No E17g. Other (note: ) 1)Yes 2)No E18. Do you know which components of smoke can do harm to health? (choose all that apply) 1)Dust 2)CO 3) SO2 4)F 5)As 6) Other (note: ) 7)Don'tknow E19. Smoke is denser when cooking. How do you deal with it? 1) Open the windows to ventilate 2) Leave the kitchen provisionally 3) Don't care 4)Don'tknow E20. Do you ever want to reduce the time spent in kitchen? 1)Yes 2) Don't care 3) No E21. During the past year, has your family wanted to construct new house? 1)Yes 2)No 3)Don'tknow 131 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China Section F: Health Awareness (Cognition) F1. How often do you feel choking or burning of eyes when you are cooking? 1) Always 2) Sometimes 3) Never 4) Don't care F2. Do you know whether the ventilation is good or bad in your home? 1)Good 2)Bad 3) Don't care F3. Do you think you need to improve the ventilation in your home? 1)Yes 2)No 3) Don't care F4. Are you willing to improve ventilation in your family? 1)Yes 2)No 3) Don't care F5. Do you know what is the cause of indoor air pollution? F5a.Cooking 1)Yes 2)No F5b.Heating 1)Yes 2)No F5c.Smoking 1)Yes 2)No F5d. Bad ventilation 1)Yes 2)No F5e. Other (note: ) 1)Yes 2)No F6. Are there smokers in your family? 1) Yes (how many: ) 2) No (go to F8) F7. How often do they smoke in your house? 1) Always 2) Sometimes 3) Never F8. Do you think smoking can do harm to health? 1)Yes 2)No 3)Don'tknow F9. When somebody smokes near you, do you think whether it will do harm to your health or not? 1)Yes 2)No 3)Don'tknow F10. Have you ever heard of dental fluorosis (apply in Guizhou and Shaanxi)? 1)Yes 2) No (go to F12) F11. Do you know what causes dental fluorosis? 1)Water 2)Coal 3)Food 4) Smoking 5) Other (note: ) F12. Do you want to acquire more information on the relationship between health and smoke? 1)Yes 2)No 3) Don't care 4)Don't know F13. Which means of information do you like? 1) TV, broadcast 2) Slogan written on the wall 3) Field consultation to doctor 4) Field symposium with expert 5) Other (note:______) The survey is over, thanks! Surveyor check: signature__________________ Date ___________ 132 Annex 3.6.1 Health Survey Questionnaire: Adult Health Survey Individual Questionnaire (To Be Completed by Household Members over 18 Years Old) ID: HouseholdAddress: Group: ___________ Village: ___________ Town: ______________ City/County: ___________ Name of householder: _________________ Name of responder: _____________________ Name of surveyor: _________________ Date (day/month/year): _____________________ Section A: General Information I would like to ask you some general questions about yourself. Like the other questions I've asked, your responses are voluntary; if you don't want to answer any question, tell me and we'll go on to the nextquestion. A1. In which month and year were you born? (in lunar calendar) A2. How old were you at your last birthday? A3. Your ethnic background: 1. Han 2. Hui 3. Mongolia 4. Weiwuer 5. Man 6. Miao 7. Zhuang 8. Buyi 9. Yi 10. Dai 11. Yao 12. Other (specify:_______) 13. I don't know A4. What is the highest grade or year of schooling you've completed? 1 = No schooling 2 = Primary school 3 = Middle school 4 = High school/technical secondary school/vocational high school 5 = Junior college or above A5. How long have you lived in this place? _______years A6. Do you smoke? 1. Yes 2. No A7. Did you used to smoke? 1. Yes 2. No (If both A6 and A7 answered "no," then go to A11) A8. How old were you when you first started smoking? Enterage 133 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China A9. What kind of cigarette/tobacco do you smoke? 1. Nonfiltered cigarette 2. Filtered cigarette 3. Tobacco pipe/tobacco 4. Other (specify_______________) A10. How many cigarettes/cigars/pipes or how much tobacco do you typically consume in one day? A10a. Nonfiltered cigarette: _________ A10b. Filtered cigarette: _________ A10c. Tobacco pipe/tobacco: _________Liang (50 gram) A11. Is there anyone else in your household smoking? 1. Yes 2. No A11a. If yes, how much tobacco do they consume per day? A11a1. Nonfiltered cigarette: _________ A11a2. Filtered cigarette: _________ A11a3. Tobacco pipe/tobacco: _________ Liang (50 gram) A11b. Does he/she smoke at home? 1.= Often 2 = Sometimes 3 = Never A12. Do you cook at home? 1 = Yes 2 = No A12a. When did you start cooking? _________ years of age A13. How long does your family cook every day? ___________ minutes A14. How long do you take in cooking every day? __________ minutes A15. Your job/career: 1 = Aquatics breeding/animal culturing/planting, 2 = Village cadre/teacher/ village doctor, 3 = Carpenter/handcrafter, 4 = Individual operator, 5 = Cook, 6 = Employee of enterprise in village/town, 7 = Student, 8 = Housewife, 9 = Other (specify):______ A16. How long have you been engaged in this work? ____________ years A17. In the past 12 months, how long have you worked outside your town?______months A18. Here are some questions about the place and time of your daily activities (converted into minutes by investigator): Locus Duration A18a. In kitchen, by the stove A18b. In kitchen, not by the stove A18c. At home, but not in kitchen A18d. Indoor, but not at home A18e. Outdoor Section B: Dietary Habits Attention! The following questions refer to your own appetite, not your whole family. B1. On an average, how much vegetables do you eat every day? _________Jin (500gram) B2. On an average, how much meat do you eat every day? _________Liang (50 gram) 134 Annex 3.6.1: Health Survey Questionnaire: Adult Health Survey Individual Questionnaire B3. Have you eaten the following foods for a long time? (If you have, please fill in the blanks with your amount and frequency; if you don't, fill in with "0.") B3a. Smoky dried chili ________ Jin ________ Liang (every month) B3b. Smoky dried corn ________Jin ________ Liang (every month) B3c. Baked ________ Jin ________ Liang (every month) B3d. Fumed bean curd ________ Jin ________ Liang (every month) B3e. Other (specify________) ________ Jin ________ Liang (every month Section C: General Health Condition and Disease Burden C1. In general, do you feel your health is:1 = Excellent 2 = Fair 3 = Poor C2. Compared with most people of the same age around you, would you feel your health is: 1 = Better than others 2 = The same as others 3 = Worse than others C3. In general, can you deal with the following activities? C3a. Planting 1 = Yes (without difficulty) 2 = Yes (with difficulty) 3 = No C3b. Cooking, washing 1 = Yes (without difficulty) 2 = Yes (with difficulty) 3 = No C3c. Climbing steps 1 = Yes (without difficulty) 2 = Yes (with difficulty) 3 = No C3d. Walking around by yourself 1 = Yes (without difficulty) 2 = Yes (with difficulty) 3 = No C3e. Eating, drinking and dressing by yourself 1 = Yes (without difficulty) 2 = Yes (with difficulty) 3 = No C4. In the past one year, were you diagnosed with the following diseases? (you can select more than oneoption) a. Eye diseases b. Respiratory diseases (including flu) c. Digestive diseases d. Gynecological diseases e. Arsenic poisoning f. Fluorosis/fluorosis of bone g. Cardiovascular diseases h. Accident/injury i. Others (specify:_________) C5. In the past one year, how much money did you spend on seeing a doctor? _________Yuan Section D: Diseases and Symptoms D1. Do you often cough when you have a cold? 1. Yes 2. No D2. Do you often cough even if you don't have a cold? 1. Yes 2. No D3. If both D1 and D2 are answered "Yes," D3a. How many months does cough last each year? 1. < 1 month 2. 1-2 months 3. >3 months D3b. How many years has the condition above lasted? ___________years D4. Is cough always with phlegm when you have a cold? 1. Yes 2. No D5. Do you often cough with phlegm even if you don't have a cold? 1. Yes 2. No 135 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China D6. If both G4 and G5 are answered "Yes," D6a. How many months does cough with phlegm last each year? 1. < 1 month 2. 1-2 months 3. > 3 months D6b. How many years has the condition above lasted? ___________years D7. Do you have the syndrome of breathing heavily? D7a. When you have a cold: 1. Yes 2. No D7b. When you don't have a cold 1. Yes 2. No D7c. In most of the daytime/at night 1. Yes 2. No D8. D8a. Do you have difficulty in breathing when you walk fast or climb on a slope? 1. Yes 2. No D8b. Do you walk more slowly than persons as old as you for difficulty in breathing? 1. Yes 2. No D8c. Do you have to stop to catch your breath when you walk at moderate speed? 1. Yes 2. No D8d. Do you have to stop and catch your breath when you have walked 100m or for a few minutes? 1. Yes 2. No D8e. Do you feel that you are unable to go outside for difficulty in breathing or do you feel difficulty in breathing even while taking off/on your cloths? 1. Yes 2. No D9. In the past three months, have you had: D9a. Headache lasting more than 4 hours 1. Yes 2. No D9b. More than five times of headache in a week 1. Yes 2. No D9c. Dizziness, where you felt like you were spinning 1. Yes 2. No D9d. Nausea with vomiting 1. Yes 2. No D9e. Nausea lasting more than eight hours 1. Yes 2. No D9f. Nasal discharge 1. Yes 2. No D9g. Nasal obstruction 1. Yes 2. No D9h. Continuously sneezing 1. Yes 2. No D9i. Cough 1. Yes 2. No D9j. Cough with phlegm 1. Yes 2. No D9j1. What was the color of phlegm? 1 = white 2 = yellow 3 = yellow/green 4 = green 5 = brown D9k. Fever 1. Yes 2. No D9l. Irritation of both eyes lasting more than four hours 1. Yes 2. No D9m. Irritation of both eyes more than five times in a week 1. Yes 2. No D9n. Itching (not irritation) of both eyes 1. Yes 2. No D9o. Hyperaemia of eyes 1. Yes 2. No D9p. Watery often 1. Yes 2. No D9q. Discharge of one or both eyes making your eyelids stick together in the morning 1. Yes 2. No D9r. History of allergies affecting one or both eyes 1. Yes 2. No D9s. Other symptoms (specify): _________________ D10. Have you ever been diagnosed with any of the following diseases? 136 Annex 3.6.1: Health Survey Questionnaire: Adult Health Survey Individual Questionnaire Were you diagnosed with the Were you diagnosed with following diseases by doctor? the following diseases in the past12months? Diseases Yes No Years Yes No Rhinitis Flu Bronchitis Pneumonia (bronchialpneumonia) Tuberculosis Asthma Emphysema ChronicBronchitis Hypertension HeartDisease Mite-related Allergy Allergy induced by food, medicine, pollen, chemicals or others Skeletal Fluorosis DentalFluorosis D11. During the last 12 months, did illness cause you to miss work or school? 1. Yes 2. No (Go to Section C) D12. During the last 12 months, how many days or months have you missed of the following due to illnesses? D12a. Work/agriculture ________days D12b. Work indoor (employed) ________days D12c. Homework ________days D12d. Going to school or learning ________days Section E: Hypertension E1. Interviewer Checks Section D: Does Respondent have History of Hypertension? 1 =Yes (Continue) 2 =No (Go to Section F) E2. Do you have hypertension now? 1. Yes 2. No 3. I don't know E3. How many years have you had hypertension? Enter years: 137 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China E4. Do you currently take medication for your hypertension? 1 =Yes 2 =No E5. How many different types of medication do you take? ENTER #: E6. Have you ever been told that you have had any of the following conditions which have been affected by your hypertension? E6a. Myocardial infarction 1 =Yes 2 =No E6b. Stroke 1 =Yes 2 =No E6c. Nephropathy 1 =Yes 2 =No E7. Have you lost weight or changed your diet for the treatment and control of hypertension? 1. Yes 2. No E8. In the past 12 months, how many times did you seek medical care for your hypertension? E8a. As an inpatient (in a hospital) Enter #: E8b. As an outpatient (in a hospital) Enter #: E9. Have you ever had your cholesterol checked? 1 = Yes 2 = No 3 = Don't know E10. In the past one year, how much money did you spend seeing a doctor for your hypertension? Yuan/RMB Section F: Tuberculosis F1. Interviewer Checks Section D: Does respondent have history of tuberculosis? 1 = Yes (Continue) 2 = No (Go to Section G) F2. When were you first diagnosed with tuberculosis?_______years old _______ don't know F3. In the past one year, has anyone else in your house been diagnosed with tuberculosis? 1 = Yes 2 = No F4. Has any of your household members been tested for tuberculosis in the past one year? 1 = Yes 2 = No F5. Do you currently take medication for this problem? 1 = Yes 2 = No (go to F8) F6. How many medications do you take? Enter #: F7. For how many months have you been taking the medications? ENTER # of months: F8. Do you still have the cough now? 1 = Yes 2 = No F9. How many weeks did you have your cough? ENTER # of weeks: F10. In the past 12 months, how many times have you sought medical care for this problem? F10a. As an inpatient (in a hospital) Enter #: F10b. As an outpatient (in a hospital) Enter #: 138 Annex 3.6.1: Health Survey Questionnaire: Adult Health Survey Individual Questionnaire F11. In the past one year, how much money did you spend seeing a doctor for your tuberculosis? Yuan/RMB Section G: Asthma G1. Interviewer checks Section G: Does respondent have a history of asthma? 1 =Yes (Continue) 2 =No (Go to Section H) G2. How long have you been diagnosed with asthma? Years G3. How many different types of oral medicines do you take now? Enter #: G4. How many different types of inhaled medicines do you take now? Enter #: G5. How many times of asthma attack have you had in the past year? Enter #: G6. In the past 12 months, how many times have you sought medical care for this problem? G6a. As an inpatient (in a hospital) Enter #: G6b. As an outpatient (in a hospital) Enter #: G7. Have you ever had a test of your breathing? 1 = Yes 2 = No 3 = Don't know G8. How much money did you spend on seeing a doctor in the past year? Yuan/RMB Section H: Emphysema and Other Obstructive Pulmonary Diseases H1. Interviewer Checks Section D: Does Respondent Have a History of Emphysema, Chronic Bronchitis, or COPD Disease? 1 = Yes (Continue) 2 = No (Go to Section I) H2. Which of the following have you been diagnosed with? H2a. Emphysema 1 = Yes 2 = No H2b. Chronic bronchitis 1 = Yes 2 = No H2c. Chronic obstructive pulmonary disease 1 = Yes 2 = No H2d. Other lung disease (specify):__________ 1 = Yes 2 = No H3. Which of the following have you been diagnosed with in the past year? H3a. Emphysema 1 = Yes 2 = No H3b. Chronic bronchitis 1 = Yes 2 = No H3c. Chronic obstructive pulmonary disease 1 = Yes 2 = No H3d. Other lung disease (specify):__________ 1 = Yes 2 = No H4. How many oral medicines do you take now? Enter #: H5. How many inhaled medicines do you take now? Enter #: 139 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China H6. In the past 12 months, how many times have you sought medical care for this problem? H6a. As an inpatient (in a hospital) Enter #: H6b. As an outpatient (in a hospital) Enter #: H7. Have you ever had a test of your breathing? 1 = Yes 2 = No 3 = Don't know H8. In the past year, how much money did you spend on seeing a doctor for this disease? Yuan/RMB Section I: Pregnancy and Delivery I1. Is Respondent a Woman Who Reports Being Pregnant in the Past Five Years? 1 = Yes (Continue) 2 =No (Go to Section J) I2. How many times have you been pregnant in the last five years? Enter #: I3. How many times have you given birth? Enter #: I would like to ask you some questions about your most recent delivery. (By delivery we mean the last time you gave birth to a child). I4. Did you weigh this most recent baby at birth? 1 = Yes 2 = No 3 = Dead (go to I7) I5. What was the birth weight of this most recent baby? Enter # of Grams_____________ I6. How old is that child now? Enter either years or months and circle code. If less than one month enter "00" in months. I7. Where did the delivery take place? 1 = Home 2 = Hospital 3 = Clinic 4 = Other (specify):______ I8. How much money did you spend for the delivery of the most recent baby? __________Yuan I9. How old were you when the baby was born? Enter Age: I10. Were there any complications around the time of delivery? a. Bleeding b. Infection c. Asphyxia d. High blood pressure e. Other (specify):__________ I11. Did you have prenatal care for this pregnancy? 1 = Yes 2 = No (Go to I14) I12. How many prenatal care visits did you take for this pregnancy? Enter #: I13. At how many months of pregnancy did you obtain the first prenatal care? Month #: I14. Did you have an ultrasound examination during this pregnancy? 1 = Yes 2 = No I15. How many times did you have an ultrasound examination for this pregnancy? Enter # of Times: 140 Annex 3.6.1: Health Survey Questionnaire: Adult Health Survey Individual Questionnaire I16. How many weeks was the pregnancy before you delivered this last baby? Enter # of Weeks: I17. Was this most recent baby breastfed? 1 = Yes 2 = No I18. Did you have hypertension during this most recent pregnancy? 1 = Yes 2 = No 3 = Don't know I19. Did you smoke during this most recent pregnancy? 1 = Yes 2 = No I20. Did you drink alcohol during this most recent pregnancy? 1 = Yes 2 = No I21. Were you diagnosed with tuberculosis during this most recent pregnancy? 1 = Yes 2 = No Section J: Health Measures J1. Eyes J1a. Hyperaemia of conjunctiva 1.Yes 2.No J1b. Lachrymation 1. Yes 2.No J1c. Secretion 1.Yes 2.No J2. Nose J2a. Nasal obstruction 1. Yes 2.No J2b. Nasal discharge 1.Yes 2.No J3. ArsenicPoisoning J3Dermatosis 1.Yes 2.No Classification: Keratosis at palm and sole 1 = Normal 2 = Degree 3 = 4 = III Pigmentation: 1 = Normal 2 = Degree 3 = 4 = III Depigmentation: 1 = Normal 2 = Degree 3 = 4 = III Bowen's Disease or Skin Carcinoma 1 = Yes 2 = No Clinic classification: 1 = Normal 2 = Dubious 3 = Low-grade 4 = Mid-grade 5 = High-grade 6 = Bowen's Disease or Skin Carcinoma 141 12 12 21.8 16.3 199 6.4 2005 262) 5.9), ) Mar-Apr (137, 0.01) 0.54) 0.39) (3.3 0.02 -501 (-72%) -230 = -307 = -1.9 (-29%) = (p1= (p2 (p3 rovinceP (p1 Intervention 32 32 2003 17.1 14.4 700 5.6 7.6) Mar-Apr 1,073) (5.4, by 326,( Behavioral Jan and 2.1 28 30 2004 13.4 184 3.4 218) 5.2) Dec- 0.03) 0.15) 0.00) (3.4, 0.03) Stove (150, -678 (-79%) = -298 = -594 = -8.2 (-66%) = Jan 9.8 9 (p1 (p2 (p3 9 (p1 2003 13.0 862 12.5 Dec- 19.4) Changes 1,435) (5.5, (290, 10 10 3.3 2005 14.5 14.1 203 and 356) 4.7) Mar-Apr (49, 0.09) 0.77) (1.8, 0.76) -194 (-49%) = 77 = -0.2 (-6%) = (p1 (p2 (p1 32 32 2003 15.5 13.0 397 5.3 4.1) Intervention Mar-Apr 574) ) 3 (2.9, (219, Room Jan Gansu Behavioral 6.2 (µg/m (ppm) 28 30 2004 12.4 307 4.6 356) Dec- CO 8.1) RPM Cooking (259, 48- 0.29) 0.07) (4.8, 0.01) (-21%) = 692 = 6.2 )%86( = Concentrations (p1 (p2 (p1 Jan 12 12 2003 -0.9 4.7 391 8.3 548) 4.5) Dec- (3.0, IAP (233, 10 12 2005 18.8 16.8 186 7.5 250) 9.7) Mar-Apr 0.02) (1.8, 0.74) (122, -271 (-59%) -0.7 (-11%) = (p1= (p1 32 2003 23.2 17.8 754 32 4.6 Mar-Apr 683) 8.2) (4.6, (231, -intervention Control Jan 2004 8.0 28 30 11.5 400 7.7 Dec- 547) 8.9) ostP 0.04) (6.6, 0.47) (252, -380 (-49%) = -2.2 (-22%) = 4.1 Jan (p1 (p1 2003 8.2 2.8 12 12 780 9.9 Dec- 16.1) 1,116) Annex and-erP (3.6, (444, 1 2 3 1 T1(°C) T2(°C) n Level n Level 143 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China 12 12 171 8.7 change 193) in 14.1) 0, concentration 0.53) 0.14) (15 0.08) 0.60) 0.43) (1.4, 0.69) 0.47) 0.21) -1.2 = -1.7 = -121 (-41%) = 07- = 892 = 3.1 (20%) = 7.1 = 0.3 = mean difference (p2 (p3 (p1 (p2 (p3 = Intervention 32 32 292 5.6 428) )0.8 (p1 (p2 (p3 = 3 level (5.1, (156, group; Behavioral C 28 30 and 177 2.8 measurement; and 227) 9.6) of 0.03) Stove -6.0 = 8.01- 0.00) 0.06) 0.02) 0.01) 0.01) 0.00) 0.00) days groups = (128, (6.8, -575 (-76%) = -367 = -402 = 9.81- (-70%) = 1.22- = -19.2 = (p2 (p3 9 (p1 (p2 (p3 9 (p1 (p2 (p3 752 household 27.1 38.5) of intervention 1,363) two (142, (15.7, the number of 10 10 158 9.2 = n 234) 3.5) each s). 5.0 0.82) (83, 0.06) 0.34) (2.2, 0.01) hr 0.23) days;t = -419 (-73%) = -368 = -1.7 = (-37%) -1.3 = (16 between ]). (p2 (p1 (p2 (p1 (p2 min. 32 32 577 6.4 5.7) 960 measuremen change positive Intervention in ) 1,002) < all as 3 (3.6, was over (153, (µg/m increase * (ppm) Gansu Behavioral ) 72 30 165 CO 6.5 difference = RPM 182) 6.6) averaged 2 and 8.4 0.05 Living/Bedroom 0.09) 0.65) (4.7, 0.75) 0.06) measurement = (147, -173 (-51%) = 53 = 3.0 (6%) = -2.9 = of negative (p2 (p1 (p2 (p1 (p2 group; as 12 12 338 3.5 539) 7.3) duration measurement, same the shown the is (3.4, (138, in pollution because 10 12 134 9.2 with [reduction 180) 3.6) (87, 15- 0.23) (2.2, 0.47) dropped measurements month (-28%) = -0.4 (-12%) = was households (p1 (p1 same 32 32 185 3.3 day inside the 259) 4.1) one to and for pre-intervention (110, (2.5, data and relative outside Control are 28 30 146 6.8 post- 160) 9.9) measured 0.02) changes (132, (7.2, 0.00) between -208 (-59%) = 2.3 (59%) = measurement, (all of (p1 (p1 12 12 354 4.5 days change 7.0) temperatures = groups 524) = 1 B (184, (3.9, T2 and B household CI); and + S 2 3 1 2 3 1 2 3 28 T1 the n Level n Level percent Of * Note: (95 between 144 Annex 4.1: Pre- and Post-intervention IAP Concentrations and Changes by Province 12 12 204 2005 19.2 17.3 271) 1.98 2.70) Mar-Apr 0.97) a (136, 2 0.20) 0.33) 0.16) 0.73) 0.52 3( = )%6 (-1%) = 484 0.12)= 38 = (1.26, 0.79 = -0.44 = -(p1 (p2 (p3 (p1 (p2 (p3 Intervention AN 8 32 2003 19.0 206 260) 1.46 Mar-Apr 2.41) (152, (0.51, Behavioral Jan and 2004 0.1 5.6 29 30 199 257) 2.25 86) Dec- 2. 0.13) 0.12) 0.02) 0.52) 0.61) 0.56) Stove (141, 0.25 1( = )%3 -245 (-55%) = -227 = -261 = (1.64, -0.46 = 0.34 = (p1 (p2 (p3 (p1 (p2 (p3 Jan 12 12 2003 10.0 13.0 444 771) 2.00 Dec- 2.50) (117, (1.51, 12 12 2005 25.8 22.2 133 223) 2.20 4.32) Mar-Apr (44, 58- 0.08) a 0.20) 0.34) 0.31) -39%)( = 401 = (0.09, )%7 0.96 7( = 1.23 = (p1 (p2 (p1 (p2 2003 AN 8 31 218 Intervention Mar-Apr 18.0 260) 1.24 1.58) Room ) 3 Gaizhou (175, (0.91, Jan Behavioral 3.1 (µg/m (ppm) 30 32 2004 12.8 192 CO 1.55 Dec- RPM 240) 1.93) (144, 61 0.64) 0.73) 0.67) 0.31) Cooking/Living (9%) = 43 = (1.17, -0.09 (-5%) = -0.80 = (p1 (p2 (p1 (p2 Jan 7.4 3.9 12 12 2003 176 230) 1.64 Dec- 1.92) (122, (1.37, 11 11 2005 20.6 21.8 135 204) 0.98 Mar-Apr 1.40) a (66, 0.01) -486 (-78%) = (0.56, 72.0- 0.20) (-22%) = (p1 (p1 2003 AN a 9 33 20.4 Mar-Apr 126 982) 1.25 1.45) (260, (1.05, Control Jan 2004 0.0 3.6 30 32 258 Dec- 353) 2.35 3.13) (163, 81- 0.81) 0.09) (-7%) = (1.57, 0.71 (43%) = Jan (p1 (p1 2003 6.3 6.9 8 8 276 Dec- 410) 1.64 1.95) (141, (1.33, 1 2 3 1 2 3 T1(°C) T2(°C) n Level n Level 145 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China 12 12 0.32 224 0.49) 348) (0.15, 20.0- 0.94) (101, 0.61) b 0.11) (-6%) = 21.0- 0.54) = 32.0- 0.37) = 23 17%)( = 515 = 421 0.05)= 8 (p1 (p2 (p3 (p1 (p2 (p3 Intervention 32 0.34 192 0.81) 243) (142, (0.00, Behavioral 30 and 0.29 40) 26 192 0. 253) 0.39) Stove (0.18, 0.06 (26%) = 84.0- 0.24) 0.99) 0.04) 0.30) 0.02) = 0.00 = (131, -96 (-33%) = -142 = -133 = (p1 (p2 (p3 (p1 (p2 (p3 12 12 0.23 288 0.33) 362) (214, (0.13, 12 12 69 0.30 0.58) 150) 0.14) 0.53) (41, 0.01) b 0.23) (0.01, 0.21 = (233%) 0.11 = -92 (-49%) = 391 = (p1 (p2 (p1 (p2 8 31 0.09 188 Intervention 0.16) 227) ) 3 (149, (0.01, (ppm) (µg/m 2 32 29 Behavioral Gaizhou SO 0.20 0.26) Bedroom 152 RPM 186) 0.12) 0.13) (118, 9- 0.94) (0.15, 0.06 (43%) = 84.0- 0.22) = 73 (32%) = = (p1 (p2 (p1 (p2 12 12 0.14 115 0.20) 152) (78, (0.08, 11 10 96 0.17 90) 0.26) 0.04) (47, b 0.01) (0.09, 0.10 = (143%) -483 (-88%) = (p1 9 (p1 33 b 0.07 0.12) 255 919) (185, (0.03, Control 32 28 0.77 250 1.20) 397) 0.02) 0.56) (0.34, 0.54 = (104, 64 (235%) (23%) = 8 (p1 8 (p1 0.23 204 0.32) 287) (122, (0.14, 1 2 3 1 2 3 n Level n Level 146 Annex 4.1: Pre- and Post-intervention IAP Concentrations and Changes by Province 12 12 1.56 2.26) 0.31 relative relative 0.55) between 0.77) 0.38) 0.64) 0.44) 0.61) 0.82) more more positive]). (0.85, 0.16 (11%) = 0.49 = 0.35 = (0.07, 0.12 (63%) = 0.09 = 0.05 = change in as 8 (p1 (p2 (p3 8 (p1 (p2 (p3 Intervention showing, showing, 3 3 1.40 2.38) 0.19 0.43) increase µg/m µg/m difference = and (0.42, (0.00, 146 167 2 e Behavioral by by 30 30 7) negativ and 1.73 .16)2 0.26 0.3 change change group; as 0.30) 0.13) 0.44) 0.68) 0.19) 0.15) Stove (1.29, -0.47 = (-21%) -1.01 = -0.35 = (0.14, -0.03 -( 10%) = -0.32 = -0.15 = also also same shown is (p1 (p2 (p3 (p1 (p2 (p3 the 12 12 in 2.20 3.08) 0.29 0.44) differences differences [reduction All. All. 3 3 (1.33, (0.15, month µg/m µg/m measurements 12 12 1.05 1.89) 0.17 0.31) 475 385 same to to (0.22, 91.0- 0.65) 0.77) 0.38) 0.68) days; the to = (-15%) 0.14 = (0.03, 0.07 (70%) = 0.04 = (p1 (p2 (p1 (p2 reduced reduced pre-intervention 8 7 relative are are and 1.24 are Intervention 1.48) 0.10 0.23) measurement all post- (0.99, (0.00, over changes (ppm) (ppm) measurements measurements between 32 (all 2 32 Behavioral Gaizhou CO 1.51 1.76) SO 0.20 0.25) averaged (1.26, 21.0- 0.51) (-7%) = 66.0- 0.23) 0.01) = (0.15, 0.12 = (150%) 71.0- 0.46) change groups = = B 1 (p1 (p2 (p1 (p2 preintervention preintervention and B 12 12 the the measurement, CI); + 1.63 1.90) 0.08 0.15) in in S percent (1.36, (0.00, pollution between (95 11 11 with 0.77 1.02) 0.14 concentrations concentrations 0.21) change in (0.52, 33.0- 0.06) 0.36) = (-30%) (0.08, 0.03 (27%) = average average households concentration (p1 9 9 (p1 the the inside mean difference 1.10 1.37) 0.11 0.15) = = 3 and dropped, dropped, level (0.83, (0.07, is) is) 3 3 outside Control group; 23 23 µg/m µg/m C 1.92 2.45) 0.47 0.70) and 0.07) 0.03) (5,900 (5,292 measured measurement; of (1.39, 0.54 (39%) = (0.23, 0.29 (62%) = groups point groups. point groups. 8 (p1 8 (p1 days 1.38 1.70) 0.18 data data 0.29) temperatures = intervention largest intervention largest intervention household T2 (1.06, (0.08, of the the two single in single in and the 1 2 3 1 2 3 T1 of n Level n Level the the number If If = a benefits b benefits Note: n each 147 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China 2005 Mar-Apr Intervention 2003 Mar-Apr Behavioral Jan and 2004 Dec- Stove Jan 2003 Dec- 2005 Mar-Apr 1 2003 Point Intervention Mar-Apr ) 3 Mongolia Jan (µg/m b (ppm) Behavioral 2004 -4.9 13.1 51 6.62) 251 17 CO 5.32 Dec- RPM (76,426) Inner 0.00) 0.11) (4.01, -611 (-71%) = -405 = 03.2- 0.01) (-30%) = (p1 (p2 (p1 Jan 0.2 33 8.66) 2003 14.7 Cooking/Living/Bedroom 862 35 7.62 Dec- 1,184) (6.59, (541, 2005 Mar-Apr 2003 Mar-Apr Control Jan 2004 Dec- 3.11- a 11.4 02 343 7.07) 25 5.87 (4.67, (220,466) 0.01) 0.11) -206 (-38%) = -1.25) (-18% = Jan (p1 (p1 2003 0.4 82 14.7 549 30 7.12 Dec- (6.09,8.15) (446,651) 1 2 1 T1(°C) T2(°C) n Level n Level 148 Annex 4.1: Pre- and Post-intervention IAP Concentrations and Changes by Province change in concentration mean difference = = 3 Intervention level group; C Behavioral measurement; and and of days groups Stove household intervention of two the number of = n each days; between 2 ]). Point change hrs.). hrs.). measurement positive in Intervention as ) (16 hrs.). hrs.). (16 all 3 min. (16 (16 min. over Mongolia (µg/m d (ppm) difference increase Behavioral 41 16 960 min. min. 960 = 174 260) CO 5.46 < 6.79) < 2 and RPM 960 960 averaged Inner 0.36) (88, 0.00) 0.33) 0.00) 0.17) was < < was -1.05 = -687 (-80%) = -310 = (4.13, -2.46 (-31%) = -1.43 = was was negative group; (p2 (p1 (P2 (p1 (P2 as 33 35 duration duration Cooking/Living/Bedroom 861 7.92 measurement, same 8.85) their duration duration their shown its its the is in (425,1,298) (6.98, pollution because because because because with [reduction dropped dropped dropped measurements dropped month were was were was households same inside the to and pre-intervention measurements measurement measurement measurements 3 1 1 2 and relative outside Control are c 22 post- 25 174 218) 5.50 0.00) 0.12) measured changes (130, measurement, measurement, measurement, measurement, between -377 (-68%) = (4.50,6.51) -1.03 (-16%) = of of of of (all (p1 (p1 82 30 days days days days change 551 groups 661) 6.53 = 7.40) temperatures 1 B = and (440, T2 (5.67, household household household household B CI); + 23 16 23 16 and S 2 1 2 1 2 the the the the T1 n Level n Level percent Of Of Of Of a b c d Note: (95 between 149 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China 11 11 9.2 4.5) 3, 16.9 16.7 119 2005 177) (1. Mar-Apr 0.07) 0.85 0.55) (62, = = = 9.0 0.28) 0.40) 0.07) -81 (-41%) (p1 -14) (p2 -69 (p3 (45%) = -1.6 = -6.9 = 8 0.2 3.0) (p1 (p2 (p3 Intervention 33 2003 18.6 200 273) (1.0, Mar-Apr (128, 6 Behavioral 8.8 15.3) Jan 29 and 2004 -0.2 0.4 132 0.26) 0.63) 0.58) 190) = = = (2.2, Dec- (74, -53 (-29%) (p1 64 (p2 33 (p3 0.89) 0.50) 0.98) Stove 21 3.9 -0.5 (-5%) = -2.6 = -0.1 = 14.8) (p1 (p2 (p3 Jan 0.5 7.3 12 2003 185 (3.8, 265) Dec- (105, 21 16.4) 10.2 11 0.83) 0.59) (4.0, 2005 23.4 21.0 178 242) = = Mar-Apr -12 (-6%) (p1 55 (p2 (113, 8 4.2 3.8) 8.7 0.02) = 3.5 0.17)= (325%) (0.9, (p1 (p2 34 2003 190 Intervention Mar-Apr 15.3 298) ) 3 (83, 8 Room 7.5 7.7) Jan (µg/m (ppm) 29 (3.7, Behavioral 8.3 0.7 Shaanxi 2004 128 156) 0.06) 0.88) CO Dec- Cooking RPM = = (100, -86 (-40%) (p1 31 0.83) 0.30) (p2 21 1.6 -0.4 9.4) (-7%) = -2.5 = (p1 (p2 Jan 7.4 7.5 12 (2.7, 2003 214 299) Dec- (129, 21 0.5 7.5) 11 2005 22.2 20.5 102 (2.4, 149) Mar-Apr 0.02) (55, = 5.2 0.08) = -67 (-40%) (p1 (100%) 8 33 5.2 3.8) (p1 2003 15.9 169 Mar-Apr 206) (1.2, (132, Control Jan 2004 -1.4 8.3 32 8 9.7) 170 Dec- 257) 3.7 (5.0, (84, 0.24) 1.2 0.12) = (40%) = Jan (p1 2003 0.3 3.4 -99 (-37%) (p1 12 7.0) 269 Dec- 424) 21 2.5 (3.3, (115, 1 2 3 1 2 3 T1(°C) T2(°C) n Level n Level 150 Annex 4.1: Pre- and Post-intervention IAP Concentrations and Changes by Province 6 11 0.60) 69 0.39 193),0( (0.18, 0.30) 0.12 (44%) = 81.0- 0.56) 0.12) 0.01) 0.23) 0.12) = -0.38 = -231 (-71%) = -152 = -167 = 33 0.38) 9 (p1 (p2 (p3 (p1 (p2 (p3 Intervention 0.27 327 471) (0.16, (183, 85) Behavioral 30 0. 8 0.55 200 311) and (0.26, (89, 0.54) 0.63) 0.11) Stove 0 1.00) -0.14 = 0.20 = -0.78 = 8 (0%) = 952 0.01) = 682 0.01) 12 1.07) (-20%) = 0.69 (p1 (p2 (p3 200 252) (p1 (p2 (p3 (0.31, (148, 12 1.38) 5 75 0.93 (9,105) (0.49, 0.04) 0.58) 0.88) 33 0.65) 0.50 = 0.20 = 8 46- 0.19) (-53%) = 51 = 0.43 (116%) 121 219) (p1 (p2 (p1 (p2 (0.21, (23, Intervention ) 3 32 1.43) 7 (ppm) 0.93 Room 100 146) (µg/m 2 Shaanxi Behavioral (0.43, (54, SO Living RPM 0.02) 0.07) 0.00) 0.64 = 0.98 = 9 -286 = 72- 0.79) 12 0.48) = (221%) (-74%) 0.29 (p1 (p2 386 544) (p1 (p2 (0.10, (228, 12 1.74) 6 0.93 103 189) (0.12, (17, 0.30 )%84( 0.45) = 97- 0.34) (-43%) = 33 0.86) (p1 8 (p1 0.63 182 353) (0.40, (11, Control 33 1.06) 8 0.74 113 166) (0.42, 43.0- 0.39) (59, 0.00) (-31%) = -259 (-70%) = (p1 (p1 12 1.86) 21 1.08 372 485) (0.31, (258, 1 2 3 1 2 3 n Level n Level 151 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China 6 4.3 8.3) 6 11 7 0 (0.0, 0.19 0.33) 107) 0.09) 0.50) 0.25) 0.00) 0.02) 0.00) (33, 0.05) -5.2 (0.04, = = = -157 = 8 6.8 .4) (-60%) = -2.2 = -3.5 = -1.61 (-89%) -1.04 -1.40 (-69%) 13 (p1 (p2 (p3 9 (p1 (p2 (p3 (p1 Intervention 32 (3.8, 1.80 227 2.34) 384) (71, 8 (1.25, Behavioral 41.4) 30.7 9 4 and 2.34 48) 30 7 (20.0, 3. 100) 0.00) Stove 8 19.4 = 5.6 0.23)= 6.9 0.34)= 0.00) 0.14) 0.04) (48, 0.00) 1.90 = 1.34 = 1.66 = = 17.9) (172%) (1.21, (432%) -432 (-85%) 11.3 (p1 (p2 (p3 8 (p1 (p2 (p3 (p1 (4.7, 10 0.44 506 0.70) 666) 6 2.1 2.0) (346, (0.17, (0.3, 6 12 9 0 0.10 0.16) 126) 8 0.01) 0.00) 9.2 3.9) -1.7 (-59%) = 3.1 0.41)= (0.05, 12.0- 0.05) 0.24) (53, (-68%) < 0.36 = 49- (-51%) = (1.9, (p1 (p2 (p1 (p2 (p1 8 33 0.31 184 Intervention 0.51) 235) ) 3 8 46.4) (0.11, (133, 31.0 (ppm) (ppm) 8 (µg/m 8 2 28 9 Shaanxi Behavioral CO (15.6, SO 1.69 2.59) Bedroom 123) RPM 8.9 0.25) 0.70) 0.67) 01 (46%) = -3.1 = (0.79, 0.24 (17%) = 23.0- 0.73) (73, 0.07) = -152 (-61%) = 32.7) 21.2 (p1 (p2 (p1 (p2 (p1 (9.7, 01 8 1.45 250 2.36) 419) (81, 6 (0.55, 3.1 2.5) 6 (0.1, 11 9 5 0.14 0.28) 135) 0.04) 0.07) -3.0 (-70%) = (0.00, 75.0- 0.05) (56, (-80%) = 55- (-37%) = 8 3.4 7.0) (p1 8 (p1 (p1 33 (1.6, 0.71 150 1.28) 198) (102, (0.14, Control 8 8 29 27.5) 21.1 2.66 121 3.85) 148) (14.6, 0.00) 0.42) (94, 0.02) 12.9 = (157%) (1.46, 0.56 (27%) = -146 (-55%) = (p1 (p1 (p1 21 2.8 8.5) 21 6 2.10 267 3.09) 373) (7.8, (160, (1.12, 1 2 3 1 2 3 1 n Level n Level n Level 152 Annex 4.1: Pre- and Post-intervention IAP Concentrations and Changes by Province 11 8.0 change 11 1.0) 0.14 in 0.21) concentration 0.46) -102 = 36- 0.64)= (0.5, 0.18) -1.4 (-64%) = 4.0 0.72)= 0.13) 0.00) 0.15) 0.04) -1.9 = (0.07, -0.66 (-83%) = -0.46 = -0.71 = mean difference (p2 (p3 8 ) (p1 (p2 (p3 (p1 (p2 (p3 = = Intervention 2.2 3 32 4.4 0.80 level 1.13) (0.0, group; (0.47, C Behavioral 8 ) 31 measurement; and and 16.7 27.7) 0.31 0.44 of 0.00) 0.00) Stove -286 = -280 = (5.6, 7.1 0.78) (11%) = 1.2 0.77)= 6.6 0.39)= 0.00) 0.01) 0.02) groups days (0.18, -1.69 -( 85%) = -1.50 = -1.26 = p2( (p3 (p1 (p2 (p3 ) (p1 (p2 (p3 10 10 15.0 household intervention 22.6) 2.00 2.82 of two (7.4, (1.19, the number of 12 0.2 12 = 3.4) 0.34 n each 0.72) 93- 0.51)= (0.5, days; 5.0 0.56) (33%) = 3.2 0.06)= 0.79) 0.33) (0.00, 0.05 (17%) = 0.25 = between ]). (p2 (p1 (p2 (p1 (p2 8 5.1 32 change 2.6) 0.29 measurement positive Intervention 0.49) in all as (0.4, (0.08, over (ppm) 8 6.4 (ppm) difference increase Behavioral 2 32 = Shaanxi CO 7.8) SO 0.63 2 and 1.01) averaged 6- 0.91) (1.4, 0.34) 0.47) = -4.9 (-52%) = -4.5 = (0.25, 34.0- 0.52) (-41%) = 42.0- 0.74) = negative group; (p2 8 (p1 (p2 as 5.9 8 (p1 (p2 20.6) 1.06 measurement, same 2.51) the shown is in (0.0, (0.00, pollution 21 7.0 12 with [reduction 1.0) 0.15 0.29) (0.4, 0.09) -1.8 (-72%) = (0.01, 02.0- measurements 0.09) month (-57%) = households same 8 (p1 (p1 5.2 33 inside the 4.6) 0.35 0.55) to and pre-intervention (0.3, (0.15, and relative outside Control 8 1.5 post- are 33 11.8) 0.62 1.04) 0.90) (0.0, -0.4 (-7%) = (0.20, 91.0- 0.64) measured between changes (-23%) = (all 6 (p1 5.5 6 (p1 change 8.0) = groups 0.81 1.66) temperatures 1 B = (3.0, and T2 B (0.00, CI); + and S 2 3 1 2 3 1 2 3 T1 n Level n Level percent Note: (95 between 153 =n 159 C Changes =n 951 B Shaanxi =n 161 B +S Behavioral =n 951 3.1 C 73.0 46.5 -0.8 and Inner * Mongolia =n 8.4* 7.1 164 B 82.3 68.3 -2.9 -2.1 =n 168 C Knowledge =n 154 B Guizhou B =n 154 +S -related * IAP Knowledge =n 155 C 43.2 53.8* 16.8 48.0* 19.4 26.1 ted * * for IAP-relas'ne =n 156 B 36.5 41.5 -6.6 Gansu -12.3 19.9 41.4* 17.9 29.5* mo W B * * * * * * * ablesT for =n 152 +S 30.3 66.9 13.1 25.4 13.8 64.3 16.3 22.9 10.5 31.4 Results 4.2 yev IAP Sur of (baseline) 1 2 3 1 2 3 1 A4.2.1: Annex rovincialP Factor Sources Cooking Heating Smoking bleaT 155 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China 79.2 -5.1 0.5 43.4 * * * Shaanxi 74.1 -9.3 -4.2 34.8 17.2 16.7 * * * 3.7 8.6 61.4 28.9 34.0 29.8 37.9 -9.9 * 49.7 -3.2 45.9 10.6 Inner Mongolia 2.2 4.5 73.8 42.7 21.2* 10.6 7.0 60.7 * 6.4* 5.7 48.1 Guizhou * * 52.0 44.3 43.6 37.9 * * 96 28.4 32.9 58.0 38.7 -2.5 5.6 0.1 * * * * * * 3.4 2.7 2.3 8.9 Gansu 79.5 12.3 -16.1 26.3 65.2 30.1 20.0* 22.5 10.8 * * * * * 5.3 1.9 57 5.7 0.3 6.5 1.8 9.3 7.4 6.4 24.6 12.3 28.4 28.3 65.5 31.6 -14.4 IAP of Methods Indoors Stove entilationV Impact 2 3 1 2 3 Control 1 2 3 1 2 3 Smoking 1 2 Health IAP Improving Improving No 156 Annex 4.2: Provincial Tables for IAP-related Knowledge and Behavioral Changes changes. for group B Shaanxi with compared group B + S = 3 Inner Mongolia changes; for group C * 0.6 with 19.1 compared * * groups B 19.1 71.3 52.2 and Guizhou B + * * S 6.4 * = 2 89.1 70 17.8 group; study same the in Gansu level. post-intervention percent 5 and at -3.4 pre- Rate significant changes Fluorosis statistically is percentage = 3 Dental 1 2 3 1 Understanding of *Difference Note: 157 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China * * * * C 151 2.6 4.2 1.3 73.9 49.4 43.9 44.8 50.1 37.3 33.3 = n Shaanxi * * * * * * * * * B 714 2.6 4.1 8.4 7.8 1.3 78.0 49.4 36.2 32.0 43.9 53.2 50.1 45.1 69.3 36.0 = n * * C 981 2.5 43.8 11.2 44.3 50.9 51.9 = n Mongolia * * * * * * B Inner 031 68.3 29.4 18.2 87.5 12.5 -38.4 67.2 25.9 20.7 = n * * C 851 8.7 1.4 78.3 16.2 31.9 20.7 55.9* 14.9 60.9 11.7 = n Guizhou * * * * * * * * B 882 8.7 7.8 87.0 53.8 43.4 11.5 47 17.7 -38.2 66.5 29.3 31.1 11.7 68.2 64.1 wledge = Kno n tedaler- * * * C IAPs'ne 681 9.4 12.7 74.9 27.4 23.7 55.9 34.4 50.6 = n Childrrof Gansu B 763 * * * * * * * * = 12.7 61.1 n -13.8 26.7 33.5 28.6 45.2 28.6 -27.3 41.1 35.2 -15.4 Results yev Fluorosis Sur Methods IAP Dental of of Impact A4.2.2: Smoke 1 2 1 2 1 2 Control 1 2 1 2 ableT Factor Source ollutantsP Health IAP Etiology Coal 158 Annex 4.2: Provincial Tables for IAP-related Knowledge and Behavioral Changes 33.7 23.3 C 151 33.7 13.3* 23.3 -10.7* = n changes. for * * group B 714 48.8* 35.5 53.2* 63.9 (C) = n control with C 981 compared = n group (B) B Shaanxi 031 7.1* 27.0 11.9 education) = (health n intervention C 851 27.0 -5.5 56.6 33.7* = Mongolia n behavioral = 2 Inner B 882 9.0* 58.4* 63.9* 42.7* group; = study n same the in C 681 = n level. post-intervention Guizhou B 763 Prevention percent 5 and at = Fluorides pre- n with Fluorosis significant changes Dental for statistically is percentage = Contaminated 1 Gansu 1 2 1 2 Factor Food Measures Difference * Note: 159 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China C =n 734 2.5 2.8 54.2 93.9 B =n 458 1 38.8 -4.2 0.5 91.3 -2.3 Shaanxi S+B =n 414 66 5 2.9 *9.5 1.3 5.4 10.2* 93.2 C =n 490 58.8 24.7* B =n 454 22 64.8* 40.1* Inner Mongolia C =n 458 5.1 87.6 B =n 456 71.5 24.3* 22.8* Guizhou S+B =n 9.4* 377 86.7 10.9* -13.4* Changes vioralaheB C =n 8.3 0.4 505 25.7 90.7 latede IAP-rs'ne B =n 5.5 7.1 2.3 9.1 473 30.9 91.1 mo * W Gansu orf S+B =n 074 7.3 6.9* 5 39.4 37.4* 33.6* 31.9* 85.7 Results yev Mouth Fuel doo Door W Sur Stove Adding Stove Using 1 2 3 1 2 3 Shorter 1 2 3 A4.2.3: Factor Cover After Close When Use ableT 160 Annex 4.2: Provincial Tables for IAP-related Knowledge and Behavioral Changes =n 85 4.3 72.8 24.7 -1.4 5.2 2- changes. for group B =n 651 71.2 -2.4 -5.8 6.7 9 1.7 21.8 -5.3 -3.3 with compared Shaanxi =n 751 6.7 54.8 32.2 28.8* 34.6* 37.6 -5.1 -3.1 2.0 -27.1 -25.7 -34.7 group B + S = 3 2.1 1.9* 0 2.0 33.8 36.1 66.2 -37.3 changes; for 7.3 3.2 74.5* 72.6* 12.8 73.9 37.8* 84.9 -2.1 -2.3 -71.8 -34.5 group control Inner Mongolia with 3.1 16.8 =n 861 75.6 -9.2 13.3 13.8 11.1 -4.6 compared 4.9 4.9* 6.3 groups =n 451 B 69.2 15.2* 24.4 15.9 -1.0* -14.8 14.9 -9.6 -14.2* and B + S = 9.5* 5.9 2 Guizhou 25.5 10.8* =n 451 1.6* 8.5 1.5* 5.2 4.1* 75.7 16.8* 26.0* -12.3* 18.5 -18.3* -13.7* group; study 37.2 -0.2 89.9 -2.7 4.4 2.6 7.5 -3.5 same the in 2.3 4.3 43.1 89.1 -7.6 9.1 7.7 9 0 -10.3 13.9 -3.5 level. post-intervention Gansu percent 8.5* 7.8 5 5.3 and 53.4 82.2 21 2.7 14.7* 22.3* 2- -8.2 -15.9 10.5 -9.9 -6.4 -6.4 at pre- significant changes Ash Removing statistically Windows Cooking is percentage = 1 2 3 1 2 3 1 2 3 1 2 3 ater 1 W Before Open While Often Rarely Never Difference* Note: 161 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China C 151 20.9 -4.9 8.0 3.3 71.4 -0.5 9.6* 88.3 = n Shaanxi B 714 6.2 2.0 36.5 -20.8 -15.9* 60.9 21.2 20.4 -0.3 71.5 22.5* 12.9* = n C 851 33.3 -0.4 65 -5.7 1.6 10.7 64.6 22.1* = n Guizhou B 882 36.3 -2.1 -1.7 05 8.1 5.7 3.0 13.7 -5.8 8.0* 84.4 = -14.1* n post-intervention and Changes C 681 8.7 pre- 42.2 51.7 -7.2 1.6 -0.6 vioralaheB = changes n changes. d Gansu for percentage relate- = 1 group IAPs'ne B 763 6.0 C 35.6 -7.2 6.9 49.7 16.4 14.7 -9.6 -10.2 with level. = n Mongolia; Childr percent compared 5 for Kitchen Inner at for group the Smoke B in = results 2 Results significant yev Often Avoid survey Sur or and no group; statistically Day is were study 1 2 1 2 1 2 Out 1 2 A4.2.4: Factor Every Rarely Never Get There same ableT Difference the * Note: in 162 C =n 994 9.8* 2.9 8.6* 12.2 23.8* 34.9 -related B =n 494 8.1* 11.9 -1.7 31 18.1* -5.7 4.1 28.3 10.0* Shaanxi IAP B =n 875 +S 25.1 1- -9.1* 5.2 -10.8* 21.1 -21.3* -15.7* 42.4 -30.3* -38.9* -40.3* C =n 275 7.7 2.3 8.5* 6.6 12.8* -1.5 Selected Mongolia Inner B =n 545 31 -5.5* 5.7 for -2.7 -18.3* -11.2* 17.8 -14.2* -12.7* C =n 265 9.5 22.7 15.8* 21.2 14.4* 44.3 esultsR B =n 055 Guizhou 14.5 -1.9 -17.7* 13.5 -3.1 -17.5* 32.2 -8.0* -13.9* B +S =n 845 10.8 12.5* -3.3 5.9 5.0 9.7* 14.4* 14.9* 18.0* 15.4 15.6* 23.6* Province Examination by C =n 356 27.3 -9.7* 23.3 -2.2 34.5 -5.4* and B Gansu =n 620 5 6.7 14.6* 24.3* 18.7* 20.9* 15.3 12.7* 18.1* B 4.3 Survey Symptoms, +S =n 395 11.1 -2.1 7.6* -16.7* 41 -3.4 -1.2 1 4.6 -22.1* 28.2 -11.7* 1 2 3 1 2 3 1 2 3 omen Annex Health Health Selected Health Symptom W Respiratory eyE Headache/ Dizziness 163 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China C =n 377 3.2 8.0 1.3 7.8* =n 14.9 14.1 28.5 -3.9* 1,109 B =n 847 6.3 15.4 Shaanxi 10.1 4- 32.2 -4.4 -5.2 7.6 1.1 -6.7* =n 1,104 15.3* B =n 558 23.1 +S 11.4 -5.5 =n -19.6* -15.6* 40.9 -20.9* -21.7* -16.5* 14.7 -5.7* -6.8* -13.5* 1,022 29.0* C =n 546 8.2 4.2* 7.4 11.5 10.8* -1.3 =n 388 12 -2.4 Mongolia Inner B =n 326 3.2 30.2 -0.4 -4.6* 14.6 -6.1* 3.5 -2.5* -1.2* =n -3.6* -16.9* 1,084 C =n 318 7.5 5.3* 6.0 =n 076 39.3 18.8 14.7* 10.6 31.1* B =n 937 8.3 43.7 Guizhou -2.5* -7.8* 7.4 2.1 0.6* =n 297 23.2 -12.6* -27.3* -14.8* B +S =n 117 3.1 24.3 4.6* -0.7 7.1* 6.0* 11.1 -8.7* 5.3 2.2 1.6* 1 =n 587 18.6* -14.1* C =n 077 2.4 -0.7 22 -0.2 6.0 =n 588 53.8 4.3 10.5 B Gansu =n 147 5.1 3.7* 4.4* 5.6 6.2 8.6* 8.0* =n 965 51.5 12.5* 12.7* -41.2* B = 42.3 +S =n 037 5.4 9.0 6.1 -2.8 6.2 8.2 n 006 14.3 -9.9* 6 8.2 2.2 -5.8* 9.0 Respiratory 1 2 3 1 Selected Health Symptom Children 8-12 eyE esoN 1 2 3 1 2 3 Symptoms 5) Pharynx Acute Infection(children < 164 Annex 4.3: Health Survey and Examination Results for Selected IAP-related Health Symptoms, by Province C 2.8 -2.7* 0 1.0 31 -3.4* 1 6.3* B 7.7 6.7* 9.4* 1.0 Shaanxi 19.2* -0.1 -0.2 8.0 4.4* 14.7 13.3* 16.7* B 6.1* 8.8* +S 32.9* 13.7* 14.4 -0.6 3.0 5.9* 4 18.2* 18.1* 18.3* 19.1 19.2* 22.6* 11.3* C 5.8 1.0 9.0 -0.5 14.3 -0.2 2.2 2.1 Mongolia Inner B -1.2 02 -7.2* -7.3* 1.0 0.5* 1.0* 4.2 6.2 1.3 3.7* 18.7 C 9.0 8.0 22.6 15.8* 28.1 *02 7.5 10.4* B 0 8.0 8.7 Guizhou -45.9* 11.4 -0.3 -1.1 -15.8* 39.5 -4.9* -3.7* -24.9* B +S 7.0 8 -3.5* -3.5 8.0 -0.4 -1.2 -0.1 8.4 -45.2* -19.3* 19.9 -6.6 -3.7* -11.5* -31.5* C 26.4 2- 1.1 -0.4 39.1 11.5* 13 5.0 Gansu B 16.2 -8.4* 9.1 -0.6 -0.2 B -44.6* -10.4* 23.9 -18.9* -30.4* 41.1 -34.2* +S -2.5 42.1* 23 8.1 8.3 2.5 12.2* -1.5 -1.1 -0.9 32.2 -1.9 -13.4* 17.0* 36.7 -0.4 Mucus 2 3 1 2 3 1 2 3 1 2 3 1 Selected Health Symptom Cough, Phlegm, Hemoptysis Dyspnea Nasal Pharynx 165 Special Report Household Energy, Indoor Air Pollution and Health: A Multisectoral Intervention Program in Rural China compared 0 0 group C B + S Shaanxi = 3 B 9.1 0 0 0 changes; for 5.0* 3.1* 0.6 B -0.3 -0.3 -0.3 group +S C with 0 0 C compared Mongolia Inner 5.2 0 2.0 2.0 groups B B and B + S = 2 0.3 8.0 C group; study 0 0 same B -0.8 -14.1* the in Guizhou B *0 0 0 -0.8 0 +S -14.1* post-intervention and pre- 0.6 C -0.2 changes Gansu level. percent percentage B 1.2 -1.2* 1- 5 = -34.7* at 1 B -0.9 0.3 1.8* 2 3 significant +S 33.8* observations; of statistically changes. is for number 2 3 1 2 3 = Selected Health Symptom eyE n group B Difference* Note: with 166 References Bailis, R., M. 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Environmental Research Letters 1: 01401 170 Special Reports Series Region/Country Activity/Report Title Date Number ENERGY AND POVERTY THEMATIC AREA East Asia and Pacific (EAP) Sustainable and Efficient Energy Use to Alleviate Indoor Air Pollution in Poor Rural Areas in China 06/07 (002/07) RENEWABLE ENERGY THEMATIC AREA GLOBAL (GLB) Risk Assessment Methods for Power Utility Planning 03/07 (001/07) 171 Energy Sector Management Assistance Program Purpose The Energy Sector Management Assistance Program (ESMAP) is a global technical assistance partnership administered by the World Bank and sponsored by bi-lateral official donors, since 1983. ESMAP's mission is to promote the role of energy in poverty reduction and economic growth in an environmentally responsible manner. Its work applies to low-income, emerging, and transition economies and contributes to the achievement of internationally agreed development goals. ESMAP interventions are knowledge products including free technical assistance, specific studies, advisory services, pilot projects, knowledge generation and dissemination, trainings, workshops and seminars, conferences and round-tables, and publications. ESMAP work is focused on four key thematic programs: energy security, renewable energy, energy-poverty and market efficiency and governance. Governance and Operations ESMAP is governed by a Consultative Group (the ESMAP CG) composed of representatives of the World Bank, other donors, and development experts from regions which benefit from ESMAP's assistance. The ESMAP CG is chaired by a World Bank Vice-President, and advised by a Technical Advisory Group (TAG) of independent energy experts that reviews the Program's strategic agenda, its work plan, and its achievements. ESMAP relies on a cadre of engineers, energy planners, and economists from the World Bank, and from the energy and development community at large, to conduct its activities. Funding ESMAP is a knowledge partnership supported by the World Bank and official donors from Belgium, Canada, Denmark, Finland, France, Germany, Iceland, the Netherlands, Norway, Sweden, Switzerland, United Kingdom, United Nations Foundation and the United States Department of State. ESMAP has also enjoyed the support of private donors as well as in-kind support from a number of partners in the energy and development community. FurtherInformation For further information on a copy of the ESMAP Annual Report or copies of project reports, please visit the ESMAP Website: www.esmap.org. ESMAP can also be reached by E-mail at esmap@worldbank.org or by mailat: ESMAP c/o Energy, Transport and Water Department The World Bank Group 1818 H Street, NW Washington, D.C. 20433, U.S.A. Tel.: 202.458.2321 Fax: 202.522.3018 ENERGY AND POVERTY Just less that one-half of the people in developing countries have no access to electricity and a similar number are reliant on biomass energy for cooking and heating. As a consequence, they are deprived of the means of moving out of poverty. Greater access to modern energy services can improve poor people's income through enhancement of productive use of energy and it can also increase their quality of life by providing quality lighting, communication, and other important services. Energy Sector Management Assistance Program (ESMAP) ESMAP has the goal of substantially 1818 H Street, NW improving energy use by poor people Washington, DC 20433 USA through addressing the widespread Tel: 1.202.458.2321 Fax: 1.202.522.3018 problems of the household energy. This is Internet: www.esmap.org done through high quality analytical work Email: esmap@worldbank.org on energy access, promoting an increase in the quality and number of projects dealing with energy and poverty issues by international donors, and by disseminating successful approaches to the international development community.