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Smoke – the Killer in the KitchenIndoor Air Pollution in Developing Countries

Hugh Warwick and Alison Doig

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Published by ITDG Publishing 103-105 Southampton Row, London WC1B 4HL, UKwww.itdgpublishing.org.uk

© ITDG Publishing 2004

First published in 2004

ISBN 1 85339 588 9

All rights reserved. No part of this publication may be reprinted or reproduced orutilized in any form or by any electronic, mechanical, or other means, now known orhereafter invented, including photocopying and recording, or in any informationstorage or retrieval system, without the written permission of the publishers.

A catalogue record for this book is available from the British Library.

ITDG Publishing is the publishing arm of the Intermediate Technology DevelopmentGroup. Our mission is to build the skills and capacity of people in developingcountries through the dissemination of information in all forms, enabling them toimprove the quality of their lives and that of future generations.

Typeset by FiSH Books, London Printed in Great Britain by Latimer Trend, Plymouth

Front cover: Children stoking a traditional fireplace, NepalCredit: ITDG

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Acknowledgements iv

Acronyms v

Executive summary vi

Smoke – the killer in the kitchen 1A crisis affecting mainly poor women and children 2Smoke and the Millennium Development Goals 3

Smoke’s increasing cloud across the globe 5Why has so little been done? 6How smoke kills and injures 8Exposure in poor homes far exceeds accepted safety levels 8Researching how smoke affects health 10Health effects of indoor air pollution 10

Reducing exposure to indoor air pollution 13Cooking on a cleaner fuel 13Getting smoke out of the house 16Cutting smoke volumes 18Reducing the need for fire 18Changing patterns of behaviour 19Heating the home 19Identifying appropriate solutions 20

Weighing up the cost of smoke alleviation 21Lessons from stoves programmes 21Smoke reduction efforts and health spending 22

A Global Action Plan 25 High level international conference 25Millennium Development Goals 25 A global partnership 25Sustainable finance 26National task forces 27

Appendix 1: Lessons to be learnt from improved stoves programmes 29

Appendix 2: Getting the market right for wide-scale dissemination 33

Appendix 3: Action by key stakeholders on indoor air pollution 35World Health Organization 35Energy Sector Management Assistance Programme 35Partnership for Clean Indoor Air 36United Nations Development Programme 36National governments 36Global Village Energy Partnership 36Shell Foundation 37Research community 37Development community 37

Notes and references 39

Contents

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ITDG would like to thank Hugh Warwick for his tremendous research and for hispatience in producing this report. Our great appreciation goes to Liz Bates, NigelBruce and Eva Rehfuess for their continued support and invaluable advice given tothe report team. Thanks also go to Majid Ezzati, Grant Ballard-Tremeer, JyotiParikh, Kirk Smith, Karen Westley, Kurt Hoffman, Sarah Kline and John Magrathfor their comments, contributions and general assistance in compiling this work.Special thanks go to the ITDG country project teams in Kenya, Nepal and Sudanfor their inspiring work with communities to reduce smoke pollution in manyhomes and passing their experience on to many more.

iv

Acknowledgements

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ALRI Acute lower respiratory infectionCOPD Chronic obstructive pulmonary diseaseDALYs Disability-adjusted life yearsDFID Department for International Development ESMAP Energy Sector Management Assistance ProgrammeHECA Healthy Environments for Children AllianceHEDON Household Energy NetworkLDC Less developed countriesLPG Liquid petroleum gasMDG Millennium Development GoalsPRSP Poverty Reduction Strategy PaperUNDP United Nations Development ProgrammeUNICEF United Nations Children’s FundUSAID United States Aid USEPA United States Environmental Protection AgencyWHO World Health OrganizationWSSD World Summit on Sustainable Development

Acronyms

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‘The burden of biomassfuel use is a majoraspect of most poorwomen’s lives. It absorbs largeamounts of time inheavy work, it can havenegative effects onhealth, and, althoughthis problem has beenrecognised for 30years, very little hasbeen done about it.’17

The use of poorlyventilated, inefficientstoves ‘can have thesame adverse healthimpacts as smokingtwo packs of cigarettesa day’.

United NationsDevelopment

Programme

Of the four greatest risks of death anddisease in the world’s poorest countries1 –being underweight; unsafe sex; unsafewater, sanitation and hygiene; and smokefrom solid fuel – the internationalcommunity has mobilized resources tocombat the first three. It is nothing shortof an international scandal that the fourthhas been largely ignored. This report callsfor global action to fight the killer in thekitchen – smoke from cook stoves.

The killer in the kitchen

More than a third of humanity, 2.4billion people, burn biomass (wood, cropresidues, charcoal and dung) for cookingand heating. When coal is included atotal of 3 billion people – half the world’spopulation – cook with solid fuel.

The smoke from burning these fuelsturns kitchens in the world’s poorestcountries into death traps. Indoor airpollution from the burning of solid fuelskills over 1.6 million people, predominatelywomen and children, each year. This ismore than three people per minute. It is adeath toll almost as great as that caused byunsafe water and sanitation, and greaterthan that caused by malaria. Smoke in thehome is one of the world’s leading childkillers, claiming nearly one millionchildren’s lives each year.

Women and children hit hardest

Indoor air pollution is not anindiscriminate killer. It is the poor whorely on the lower grades of fuel and haveleast access to cleaner technologies.Specifically, indoor air pollution affectswomen and small children far more thanany other sector of society. Womentypically spend three to seven hours perday by the fire, exposed to smoke, oftenwith young children nearby.

Over half of all people cooking onbiomass live in India and China. Howeverthe proportion of the population cookingon biomass is highest in sub-SaharanAfrica, rising to over 90% of thepopulation in many countries. This is achronic problem for people living in rural

areas of developing countries, but notexclusively – there is a growing problemin the cities as well.

A problem set to get worse

On current trends an extra 200 millionpeople worldwide will rely on biomass fortheir cooking and heating needs by 2030,according to the International EnergyAgency. In parts of Central Asia where gasand electricity used to be available peopleare reverting back to using biomass astheir main fuel source. In Tajikistan since1991 the incidence of acute respiratoryinfection, the world’s greatest child killer,has risen by 35% largely as a result ofburning wood indoors.

The effects of smoke on health

In the cities of the industrialized world airpollution has long been recognized as amajor health hazard. A great deal of timeand effort is put into measures that willreduce exposure to air pollution. Yet inpoor people’s homes throughout thedeveloping world levels of exposure topollutants are often 100 times greaterthan recommended maximums.

Illnesses caused by indoor air pollutioninclude acute lower respiratory infection.A child is two to three times more likelyto contract acute lower respiratoryinfection if exposed to indoor airpollution. Women who cook on biomassare up to four times more likely to sufferfrom chronic obstructive pulmonarydisease, such as chronic bronchitis. Lungcancer in women in China has beendirectly linked to use of coal burningstoves. In addition there is evidence tolink indoor air pollution to asthma,tuberculosis, low birth weight and infantmortality and cataracts.

Reducing lethal levels of smoke

Billions of people would lead a healthierlife if their exposure to lethal levels ofsmoke were reduced. Public awareness ofthe health risks of smoke is a crucial firststep. The most effective way to reduce

Executive summary

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smoke in the home is to switch to acleaner fuel, such as liquid petroleum gas(LPG), kerosene or biogas.

However, the vast majority of people atrisk are too poor to change to a cleanerfuel, or have no access to modern fuels. Inthese homes, the answer will be to reduceexposure, for example by using welldesigned chimney stoves, or smoke hoodswhich can reduce indoor air pollution byup to 80%.

Though simple, low-cost solutions areavailable, a technical fix alone is not theanswer. Cooking is a deeply cultural anddomestic task and communitiesthemselves, particularly the women, mustbe directly involved in developingsolutions that suit their circumstances.

Realizing the need for action

The international community is slowlygearing up to tackle indoor air pollution,with new initiatives from the WorldHealth Organization and the launch ofthe United States EnvironmentalProtection Agency-led Partnership onIndoor Air Pollution and the UnitedNations Development Programme’s LPGChallenge. Organizations such as the ShellFoundation and a number of non-governmental organizations, includingITDG, are working directly with poorcommunities to find solutions and scaleup their efforts. However, compared withaction on the other main risks of death,there has been extremely limited fundingand insufficient high-level internationalpolitical backing for such initiatives.

How to stop this killer

Reducing the exposure of approximatelyhalf the world’s population to smoke willtake concerted political will, internationalco-ordination, government action andtargeted funding. It will require energy,environment, health, shelter anddevelopment sectors to work together inpartnership.

For relatively little outlay, massivehealth benefits and savings in life could beachieved. Solutions are already available.

The total cost of providing three billionpeople with access to healthy indoor airwould be in the region of US$2.5 billionannually over the next 12 years. To kick-start an effective market in distributinglow-cost smoke solutions, it is estimatedthat government spending andinternational development aid would be inthe region of 20% of this total, around$500 million a year – less than one percent of total western aid spending.

What is urgently required is a globalcampaign that matches the level of thischronic problem, in line with theinternational community’s response tohunger, HIV/AIDS, dirty water, poorsanitation and malaria.

A Global Action Plan

ITDG calls on the United Nations toinstigate a Global Action Plan to addressthis neglected killer. The first step wouldbe for the UN Secretary General toconvene urgently a high level internationalconference to set in motion action planswith the necessary resources.

The conference should agree thefollowing four-part strategy:• Millennium Development Goals – a

specific reference to and action onpreventing and reducing childmortality through reducing risk fromindoor air pollution.

• A global partnership – which puts theglobal political weight and resourcesinto the existing Partnership for CleanIndoor Air, bringing together theleading international players from thehealth, development, energy, shelterand environment sectors to worktowards a global solution and toprepare strategic plans to tackle indoorair pollution.

• Sustainable finance – that establishesthe extra and sustainable resourcesfrom traditional and non-traditionaldonors needed to bring clean air tomillions of homes.

• National task forces – that bringtogether the key national and local levelstakeholders to enable them to addressthe problem with international support.

vii

Around two-thirds of women with lung cancer in China and India are non-smokers.15

Executive summary

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Contact details:For further information contact:Intermediate Technology DevelopmentGroup Schumacher Centre for TechnologyDevelopment Bourton Hall Bourton-on-Dunsmore Warwickshire CV23 9QZ UKe-mail: [email protected]: +44 – 01926 634400 Fax: +44 – 01926 634401 www.itdg.org

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More than a third of humanity, 2.4 billionpeople, use biomass (wood, crop residues,charcoal and dung) for cooking andheating.3 Of these, approximately 800million depend solely on crop residuesand dung.4 It is a technology that haschanged little since the Stone Age. Whencoal is included a total of 3 billion people– approximately half the world’spopulation – cook with solid fuel.5

The smoke from burning these fuels inthe home is one of the four leading causesof death and disease in the world’spoorest countries.7 The indoor airpollution from the burning of solid fuelsis linked to the deaths of over 1.6 millionpeople, predominately women andchildren, each year. This is more thanthree people per minute.6 It is a death tollalmost as great as that caused by dirtywater and poor sanitation, and greaterthan malaria.

Smoke in the home is one of theworld’s leading child killers, claimingnearly one million children’s lives eachyear. Illness caused by smoke kills morechildren annually than malaria orHIV/AIDS.

The most recent figures from the WorldHealth Organization (WHO) show that indeveloping countries where mortality ishigh, the four greatest risks leading todeath, disease and injury are beingunderweight, unsafe sex, unsafe water,sanitation and hygiene and smoke fromsolid fuel.

Three of these risks are the subject ofwide-ranging campaigns and programmes,albeit massively under funded. Being

underweight, unsafe sex, and unsafe waterand sanitation are well known as theprincipal causes of death and disease.7 It isan international scandal that relativelylittle is known and done about theimpacts of indoor air pollution.

The World Health Report 2002 carriesa breakdown of the causes of death anddisease around the world. Figure 1indicates the total number of deaths in theworld attributable to these leading healthrisks, and also shows the impact of illhealth and disability (measured in DALYs)in the world’s poorest countries wheremortality is highest.

Smoke – the killer in the kitchen

1

Disability-adjusted lifeyears (DALYs)

The WHO and WorldBank measure healthrisks according to adisability-adjusted lifeyears (DALYs) formula.DALYs estimate life yearslost from disease andinjuries and thesubsequent disabilityover the remaining years.It is a measure thatallows comparison ofhealth interventionsacross various lifethreatening diseases.

Poverty condemns half of humanity to cook with solid fuels oninefficient stoves. Smoke in homes from these cook stoves is the fourthgreatest risk factor for death and disease in the world’s poorestcountries, and is linked to 1.6 million deaths per year. Yet theinternational community has largely neglected it. Women and childrenare most at risk from the killer in the kitchen, as they spendconsiderable time around the cooking fire. Reducing indoor airpollution across the developing world would contribute significantly toachieving the internationally agreed Millennium Development Goals, inparticular the aim to reduce child mortality by two-thirds by 2015.

A woman cooking on anopen fire in Sudan.

ITDG/D

r Nig

el B

ruce

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The main victims of death fromexposure to indoor air pollution arewomen and children. Children aged underfive account for 56 per cent of totaldeaths from indoor air pollution. Themain cause of children’s death fromindoor air pollution is acute lowerrespiratory infections (ALRI). At 2.1million deaths a year, ALRI is the world’sleading killer of children under five. Morethan 50 per cent of these deaths arecaused by indoor air pollution, lack ofadequate heating and other precariousliving conditions.4

Recently the UN General Assemblyrestated their aim to control malaria. It isinteresting to parallel the scale of theproblems presented by malaria and indoorair pollution. Twenty per cent of theworld’s population are at risk frommalaria; almost 50% are at risk from

indoor air pollution. Malaria kills aboutone million people per year; indoor airpollution kills over 1.6 million.6,11,7 Quiterightly there is a major internationalcampaign to fight malaria. This reportargues for a similar worldwide campaignfor healthy indoor air.

A crisis affecting mainly poorwomen and children

Indoor air pollution is nothing new. Asthe smoke-stained walls and ceilings ofcaves occupied by prehistoric man attest,smoke has been a fact of life formillennia. Living without smoke isinconceivable for many people indeveloping countries. The vast majorityof staple foods, 95%, need cookingbefore they can be eaten.11 Cooking needsenergy.

This is not an indiscriminate killer.Indoor air pollution is strongly related topoverty. It is the poor who rely on thelower grades of fuel and have least accessto cleaner technologies.

Indoor air pollution affects women andsmall children far more than it affects anyother sector of society. In developingcountries cooking is the preserve ofwomen. This means that of all familymembers they have the greatest exposureto indoor air pollution.13 Women typicallyspend between three and seven hours perday by the fire, longer when fires are alsoused for heating the home.

Children under the age of five are alsoparticularly at risk because they spendmost of their time with their mothers;often very young ones are strapped totheir mother’s body. The impact thislength of exposure has on small childrenis exacerbated by a number of factors.Children’s airways are smaller, thereforemore susceptible to inflammation. Theirlungs are not fully developed until theyare teenagers, so they breathe faster. Also,their immune systems are not fullydeveloped – a process that may be furtherdelayed by malnutrition. These facts meanthat children absorb pollutants morereadily than adults and also retain them intheir system for longer.14

2

Figure 1: World HealthReport’s estimates of deathand ill-health (DALYs) fromleading risk factors in theyear 2000.7

4 000 000

3 500 000

3 000 000

2 500 000

2 000 000

1 500 000

1 000 000

500 000

0

Dea

ths

140 000 000

120 000 000

100 000 000

80 000 000

60 000 000

40 000 000

20 000 000

0Underweight Unsafe sex Unsafe water Indoor air pollution

DA

LYs

Deaths worldwide

DALYs in high mortality countries

Acute lowerRespiratory

Infection

Disease linkedto indoor air

pollution(primarily ALRI)

2 500 000

2 000 000

1 500 000

1 000 000

500 000

0

4

Diarrhoea Malaria Measles HIV/AIDS4 98 9

Figure 2: Deaths in theunder-fives by variouscauses.10


Cultural practices may promote theexposure of the elderly and the sick tohigh levels of indoor air pollution if theyend up spending extended periods of timeclose to the fire.15

Women carry a double burdenThe impact on women is more than justfrom the smoke. In most societies it is alsothe women’s responsibility to provide thebiomass fuel. The time cost alone, in ruralareas, can be extreme. Estimates rangefrom two to twenty hours per week spentcollecting fuel, and the distances coveredover difficult terrain can be considerable.In Nepal, for example, women can walkover 20 km per journey in search ofwood. This level of work not only reducesthe amount of time women can spend onother activities, such as earning money orresting, but it contributes to a range ofadditional threats to health and well-being. Women are vulnerable to backproblems from carrying heavy loads,frequently in the order of 20 kg, and theyare more at risk of violence – rape,beating, injury and snakebites. Girls areoften removed from school to assist inwood collection.16

A DFID-sponsored study concludes:‘The burden of biomass fuel use is amajor aspect of most poor women’s lives.It absorbs large amounts of time in heavywork, it can have negative effects onhealth, and, although this problem hasbeen recognized for 30 years, very littlehas been done about it.’17

But it is also clear that women are notpassive victims of biomass use. Womenhave developed strategies to cope withshortages of fuel, including shorteningcooking times, changing food processingtechniques, cooking fewer meals andchanging the types of food eaten. Theyare essentially managers of the naturalresource of biomass.17

As biomass in rural areas is collected atno financial cost, mainly by women andchildren, it falls outside national energyaccounts. It is therefore essentiallyinvisible as an issue. Decision makersneed to be aware of the extent of women’seffort. But women’s input of their own

time and energy is, like biomass, invisiblein energy statistics and therefore remainslow on the agenda.18

A great deal can be learnt from thedecisions women make regardingbiomass, and these lessons should beincorporated into any proposed effort toreduce indoor air pollution.

Smoke and the MillenniumDevelopment Goals

The international community has pledgedto reduce poverty by 2015 through whathave been called the MillenniumDevelopment Goals (MDGs). The MDGshave set targets for a reduction in poverty,improvements in health and education,and protection of the environment, andare commonly accepted as a frameworkfor measuring progress towards povertyalleviation.

The MDGs concentrate the efforts ofthe world community on achievingsignificant, measurable improvements inpeople’s lives. They establish yardsticksfor measuring progress towards povertyreduction in developing countries, andhave become the focus of much of theoverseas aid funding of rich countries andmultilateral institutions.

Reducing the level of indoor airpollution is included in MDG7, ensuringenvironmental sustainability, as anindicator to monitor the proportion ofpeople using solid fuels.

3

Smoke affects the lowerstatus members of thecommunity – women andchildren.

‘If people do not havefuel for lighting, theymust sit in the dark; ifthey do not have fuelfor cooking, quitesimply, they starve.’12

Killer in the Kitchen


Measuring the proportion of peoplerelying on solid fuel may turn out to be avery blunt instrument for monitoringindoor air pollution. Though cookingwith a cleaner fuel is by far the leastpolluting option, switching to higherquality fuel is out of reach for the vastmajority of people at risk. Poverty willcontinue to condemn many households tocook on traditional fuel. In the short tomedium term, the most feasible option forthese homes is to get smoke safely out ofthe house.

What is required within theMillennium Development Goals is a morerealistic method of measuring progresstowards reducing indoor air pollution thattakes into account the realities of poorpeople’s economic choices and ways ofreducing levels of smoke in their homes.

Nevertheless reducing levels of indoorair pollution could contribute to theachievement of most of the MDGs. Mostsignificantly, MDG 4 has a target toreduce by two-thirds the under-fivemortality rate between 1990 and 2015.

Millennium Development GoalsIn September 2000 the member states of the United Nations unanimously adopted the Millennium Declaration that set inplace the Millennium Development Goals of reducing poverty by 2015. The goals are:

MDG 1: Eradicate extreme poverty and hunger

MDG 2: Achieve universal primary education

MDG 3: Promote gender equality and empower women

MDG 4: Reduce child mortality

MDG 5: Improve maternal health

MDG 6: Combat HIV/AIDS, malaria and other diseases

MDG 7: Ensure environmental sustainability

MDG 8: Develop a global partnership for development

The UK’s Department for International Development (DFID) acknowledges that energy plays a crucial role in underpinningefforts to achieve the MDG. ‘Lack of access to adequate, affordable, reliable, safe and environmentally benign energy is asevere constraint on development.’11

At the World Summit on Sustainable Development (WSSD) in Johannesburg in 2002 there was acknowledgement that thevicious cycle of energy poverty needs to be broken in order to achieve the Millennium Development Goals for reducing worldpoverty. A lack of access to clean and affordable energy can, and should, be considered a core dimension of poverty.19

Reducing exposure to indoor air pollution will help meet seven of the goalsMMDDGG 11 –– Healthier families mean a healthier workforce, and therefore a greater potential for undertaking income-generatingactivities from farming to small industry.

MMDDGG 22 – Girls often have to spend considerable time collecting fuel for cooking – time that could be better spent in school.

MMDDGG 33 - Women are the primary targets of intervention. Any improvement in the conditions in which women live and workpromotes gender equality and empowerment. Interventions that have reduced indoor air pollution have been shown toincrease women’s social capital and provide opportunities to develop new skills and increase income levels.

MMDDGGss 44 aanndd 55 –– The two groups of people most affected by indoor smoke are women and children under the age of five.Interventions that reduce exposure will improve the health of mothers and children.

MMDDGG 66 – The improved conditions within the home provided by interventions to reduce indoor air pollution would help tomitigate the effects of HIV/AIDS and other illness. More efficient use of fuel means that less needs to be collected, reducingthe work burden. Also, the reduction of exposure to smoke will reduce the more vulnerable person’s risk of illness.

MMDDGG 77 – Some of the interventions to reduce indoor air pollution can result in the more efficient use of wood fuel andtherefore contribute to a lessening in greenhouse gas emissions and the conservation of forest areas – thereby contributingto environmental sustainability.20 Surprisingly, even switching from inefficient use of biomass to fossil fuel (kerosene or LPG)can reduce climate impact, as it can conserve forestry and emit less greenhouse gas than inefficiently burned biofuels.21

‘We will spare no effortto free our fellow men,women and childrenfrom the abject anddehumanisingconditions of extremepoverty, to which morethan one billion ofthem are currentlysubjected.’

United NationsMillennium Declaration22

4


Smoke is a chronic problem in rural areasof developing countries. Most people whodepend on biomass fuels live in thecountryside where wood and agriculturalresidues are readily available.

However, there is a growing problemin cities as well, as many people movingfrom rural areas to urban settlementscontinue to use traditional fuels. There isa complex relationship between indoorand outdoor pollution in urban areas. Incities, indoor air pollution can be duepartly to external pollution sources suchas vehicle emissions. In turn, the outdoorair pollution in parts of cities can consistlargely of the emissions from fires inpeople’s homes.

On current trends, the number ofpeople relying on biomass for cookingand heating is set to rise by 200 million,to 2.6 billion, by 2030. The majority ofthe rise will be in South Asia and sub-Saharan Africa. The actual percentage ofthe world’s population relying on biomassis projected to decline, but the rate ofdecline will not keep up with populationgrowth.31

It is not just countries that have neverhad access to more modern forms ofenergy that are suffering. Countrieswhose economies are in transition, forexample Tajikistan and the KyrgyzRepublic, have, in rural areas, conditionsthat are rapidly becoming similar to thosein developing countries.

Political change and economicdownturn have resulted in the collapse ofmuch of the infrastructure. People havelost access to the power grid and cleanerhousehold fuels such as liquid petroleumgas (LPG). Rural populations are

Latin America96 million (4.0%)

Sub-Saharan

Africa575 million (24%)

North Africa

and the

Middle East8 million (0.3%)

South Asia(incl. India and Pakistan)

713 million(29.8%)

Rest of Asia292 million (12.2%)

China706 million (29.5%)

TOTAL 2390 million

Latin America96 million (4.0%)

Sub-Saharan

Africa575 million (24%)

North Africa

and the

Middle East8 million (0.3%)

South Asia(incl. India and Pakistan)

713 million(29.8%)

Rest of Asia292 million (12.2%)

China706 million (29.5%)

Figure 4: Map showingdistribution of peopledepending on biomassfuels (2000). Source: IEA,World Energy Outlook, 2002

TOTAL 1 619 000

Latin America26 000 (1.6%)Latin America26 000 (1.6%)

Western Pacific 503 000 (31.1%)

South East Asia559 000 (34.5%)

Eastern Mediterranean 118 000 (7.3%)

Eastern Europe21 000 (1.3%)

Western Pacific 503 000 (31.1%)

South East Asia559 000 (34.5%)

Eastern Mediterranean 118 000 (7.3%)

Eastern Europe21 000 (1.3%)

Sub-Saharan

Africa 392 000(24.2%)

Sub-Saharan

Africa 392 000(24.2%)

5

Smoke’s increasing cloud across the globeIt is in the world’s poorest regions that smoke is a major threat,including China, India and sub-Saharan Africa. On current trends, 200 million more people will rely on these polluting fuels by 2030.Women and children are exposed for up to seven hours a day topollution concentrations 100 times and more above accepted safetylevels. There is ample medical evidence that smoke from burningbiomass fuels leads to killer diseases, such as penumonia, chronicbronchitis and lung cancer.

Figure 3: Map showingdistribution of deaths fromindoor smoke from solidfuels (2000). Source: TheWorld Health Report 2002


reverting to the use of wood, dung, cropresidues and low-quality coal for fuel.There are concerns that, as the traditionof using such energy sources has beeninterrupted for several decades ofsubsidized access to cleaner fuels, therewill be a deterioration in health due toindoor air pollution.23

The most striking example of this is inTajikistan where the coverage of gas andelectricity has reduced. People are nowreverting back to using biomass. Theimpact of this is all too familiar – between1991 and 2000 there has been a dramatic35% increase in cases of acute respiratoryinfection, ‘largely as a result of burningwood indoors’.24

Why has so little been done?

Given that half of humanity is at riskfrom burning solid fuels and that in theworld’s poorest countries indoor airpollution is the fourth greatest risk factorfor death and disease, it would beexpected that there would have beensignificant action to address this crisis.But this is not the case.

Indoor air pollution persists as aproblem because of many interactingfactors; not least are:

• Largely not understood or ignoredUntil very recently there was insufficientevidence to link indoor air pollution andill health or death. However, there arenow a growing number of health studiesclearly demonstrating this link, which hasrecently been quantified for the first timeby the WHO. An increasing number ofinternational health professionals arerecognizing that indoor air pollution is aproblem.

• Cure not preventionResponses to childhood acute lowerrespiratory infection (ALRI) so far havefocused on treatment rather than onremoving one of the major causes of theillness – smoke in the home. Over the pastdecade, the United Nation’s Children’sFund (UNICEF) has been monitoring theprogress of the aims of the World Summitfor Children (1990 to 2000). One aimwas to reduce by one-third deaths due toALRI in children under five. This targethas not been hit. The main method usedto prevent ALRI deaths was treatment bythe selective use of antibiotics, but thefindings showed that in half the 80countries reviewed, fewer than 50% ofthe children with ALRI were taken to thehealth care provider.25

6

Demonstrating the link between indoor air pollution and ill healthin Tamil Nadu, India39

The Indira Gandhi Institute of Development has carried out a detailed survey of thehousehold energy use and health of 5028 households in 30 villages in Tamil Nadu. In aboutten per cent of these households the research team monitored the direct exposure to smokeof the family members.

The survey showed that in 96% of the households in the survey, biomass fuels were themain cooking source. Direct exposure to smoke of the cook in each household was veryhigh, with exposure to particulate matter ranging from 500 to 2000 �g/m3 during cookingperiods (noting that typical standards for maximum exposure to particulates are about 50to 100 �g/m3). In addition, concentrations of particulates in areas adjacent to the cookingarea were also extremely high, which is important considering that children and older peopleare likely to be in the home during these periods.

Incidence of respiratory illness was measured, showing that prevalence of obstructivedisorders amongst women cooks using biofuels was around 22%. Incidence of cough,phlegm, breathlessness, wheezing and eye irritation are also significantly higher inhouseholds using biomass fuels compared to those using LPG.


• Low status of womenSmoke mainly affects those perceived to be the lower status members of acommunity – women and children. Their work and contribution to societyand the economy is rarely calculated innational economic planning. Therefore,the poverty alleviation benefits ofimproved, clean cooking have not beenfully recognized.

• Focus on environment not healthThere has been a great deal of work doneon improving stove design, with the goalsof energy efficiency and fuel saving, liftingthe burden of women’s time and effort,and with the environmental motive of

saving forests. It is only in the last fewyears that attention has turned to theissue of indoor air pollution.

• Other pressing problemsPolicy makers are slowly beginning torecognize smoke as a problem, but it hasthe disadvantage of being viewed as lesssignificant than more acute issues, such asfood, HIV/AIDS, water and sanitationand malaria. However, the impact ofindoor air pollution can be as acute anddramatic as malaria. A young childgetting pneumonia, for example, andhaving no access to hospital, will be asacutely in need of help to prevent death asif they had malaria.

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Cloud across the globe

Guatemalan studyProfessor Kirk Smith from the University of California is leading a team embarking on themost thorough analysis of the impacts of biomass generated indoor air pollution yetconducted. The four-year, US$2 million Guatemalan programme started in 2002 and hopesto learn whether reducing indoor air pollution will decrease the incidence of pneumoniaamong young children.

Working in the highlands of Guatemala the international team are conducting a randomizedintervention trial that will increase confidence in indoor air pollution risk estimates.

There are 500 households taking part in the trial. Each is randomly assigned to receive eitheran improved stove (a plancha) or to continue to use a three-stone fire and receive nointervention (these households receive a stove at the end of the experiment). The planchais a relatively expensive wood-burning stove constructed from brick and concrete blocks,with a three pot-holed steel top plate and a metal chimney. It was developed locally and iswell accepted.

Each week, trained field workers visit all the households taking part in the study and askquestions about the health of the children. Sick children are referred to the study physiciansfor clinical assessment. While the principal focus is on the incidence of ALRI/pneumonia, theyare also recording other important health outcomes, including diarrhoea, nutritional status,scalds/burns along with child growth and development.

Time-activity patterns of the householders are monitored, as well as quality of life indicators,to establish whether the new stoves affect cooking practices and other household routines.Asthma, the incidence of low birth weight as well as women’s respiratory and cardiac healthare also monitored.

Levels of exposure to indoor air pollution are assessed periodically. While monitoring smallparticles is the best indicator, the measuring devices are cumbersome and noisy, so carbonmonoxide is measured as a proxy using a small tube attached to the child’s clothing for 48-hour intervals. Particulates are measured directly in a sub sample with state of the artmachinery. Additionally, outdoor pollution levels are measured to quantify any relationshipswith indoor pollution.34,35


How smoke kills and injuresSmoke is the result of the incompletecombustion of fuel. The composition ofsmoke produced by cooking stoves varieswith factors such as fuel quality or stovedesign. One of the most detailed reviewsof indoor air pollution was led byProfessor Kirk Smith from the Universityof California:

‘Biomass fuel smoke contains significantquantities of several pollutants for whichmany countries have set outdoor air qualitystandards – for example, carbon monoxide,particles, hydrocarbons, and nitrogenoxides. In addition, the aerosol containsmany organic compounds considered to betoxic or carcinogenic, such as formaldehyde,benzene, and polyaromatic hydrocarbons.’29

It is instructive to see what a kilogramof wood will generate. On a typical three-stone wood-fired stove about 18% of theenergy goes into the pot, 8% into thesmoke and 74% is waste heat.26 But it isthe pollutants that are of more concern. Akilogram of burning wood can producesignificantly harmful levels of gases,particles and dangerous compounds.

Significant information about howmuch smoke people are exposed to can begained from measuring the pattern ofemissions from cooking fires in the home. This is shown clearly in the work of environmental health researcherMajid Ezatti in rural Kenya. Figure 6indicates the high intensity emissions that commonly occur when using

biomass fuels. The mean PM10

measurement near the fire was 1250 µg/m3 – yet levels actually peaked atover 50 000 µg/m3.27

Emissions in the kitchen can vary fromday to day and from season to season,due to the moisture content and density ofthe fuel, the amount of airflow, the typeof food being cooked and any changes inthe stove or fuel used. 27

Exposure in poor homes farexceeds accepted safety levels

It is not as if the world is unaware of theimpact of smoke-based pollution. Ampleevidence has been collected of the impactof relatively low levels of particulatepollution on health in the industrializedworld. There is now evidence showingthat levels of pollution previouslyconsidered to be safe are having adverseeffects.29 This is why the EuropeanCommission is introducing new targets tofurther lower levels of particulatepollution. Council Directive 1999/30/ECstates that a PM10 24-hour limit value of50 µg/m3 should not be exceeded morethan 35 times per year by 1 January 2005and no more than seven times per year by1 January 2010 in the member states.Also, a PM10 annual limit value shouldnot exceed 40µg/m3 by 1 January 2005and 20 µg/m3 by 1 January 2010.30

Again, it should be borne in mind thatthe levels experienced by women andsmall children in developing countries forup to seven hours every day are frequently

8

TTaabbllee 11:: Pollutantsgenerated from burning onekilogram of wood.26

Pollutant Typical Typical Number ofconcentrations* standards set to times in excess

protect health of guidelines

Carbon monoxide (ppm†) 129 8.6 15Particles (µg/m3) 3300 100 33Benzene (µg/m3) 800 2 4001-3 Butadiene (µg/m3) 150 3 50Formaldehyde (µg/m3) 700 100 7

* From burning 1 kg of wood in a traditional stove in a 40 m3 kitchen with 15 air changes per hour.

† parts per million.


in excess of one hundred times theselevels.

There are sophisticated devices placedon streets in many of Europe’s citiesmonitoring levels of pollution, includingthe levels of particulates. There is a greatdeal of certainty about the levelsexperienced by people living in therelatively particle-free environments ofNorth American and European cities, yetthere is a dearth of information about

levels experienced in the kitchens ofdeveloping countries.31

It is valuable to compare these figureswith the latest results from a Europeanwide investigation of outdoor airpollution. The APHEIS (Air Pollution andHealth: a European Information System)study surveyed the levels of air pollutionof 19 cities and also monitored the healthof the 32 million inhabitants of thesecities. The conclusions of this health

9

Figure 6: Day-longmonitoring of pollution andcooking activities showingPM10 concentration (at adistance and height of0.5m) in a household thatused a three-stone stoveinside. The lower horizontalline indicates the meanpollution for the day. Ugaliis the staple maize orsorghum flour meal. Itrequires active stirring fromthe cook during preparation,therefore keeping her closeto the fire.27

0

20 000

µg/m

3

40 000

60 000

80 000

06:00 09:00 12:00 15:00 18:00 21:00Time

7:04 9:5011:30 13:00

16:40 20:11

Mean pollutionfor the day

(1250 µg/m3)

Stoves burning or in use

Fuel added or moved

warmth; tea; water ugali warmth; tea; water ugali


Figure 5: Measuringparticulates PM10 and PM2.5.

The measures used for particulates are PM10 and PM2.5. Theserefer to particle sizes of less than 10micrometres (�m) diameterand less than 2.5�m respectively. The small size of theseparticles enables them to be carried deep into the lungs, withPM2.5 the most penetrating and appearing to have the greatestpotential for damaging health.

The photograph shows a fly’s eye at 100 times normal size.Below is a line representing 100 µm at the same scale, comparedwith a PM10 particle (which is just one tenth of its width), and aPM2.5 particle which is one quarter smaller again).

100 µm magnified � 100

Particle PM10

Particle PM2.5

Imag

es o

f Nat

ure,

Arizo

na S

tate

Uni

vers

ity


impact assessment were that 5547 deaths(with a range of 3368 to 7744) could beprevented annually if long-term exposureto outdoor concentrations of PM10 werereduced by 5 mg/m3.30

Researching how smoke affectshealth

The health impacts of ambient particulatepollution in industrialized countries havebeen researched thoroughly and havegiven rise to the guidelines in Figure 7.But these results are only applicable to therelatively small range of exposuresexamined, mostly less than 200 µg/m3.The exposure-response relationship atconcentrations of thousands of µg/m3 isrelatively unknown. Yet these are thelevels experienced indoors in developingcountries where around 80% of globalexposure to particulate pollution occurs.32

An on-going study in Guatemala is themost likely to give a clear answer to thelinks between exposure and disease, aswell as the impact that interventions canhave (see page 7). It is a collaborationbetween the University of California inBerkeley, the University of Liverpool anddel Valle University in Guatemala, and isthe largest study of its kind.

In addition, the Shell Foundation aresponsoring a substantial project, called‘Standard Monitoring Packages forHousehold Energy and Health Field

Projects’, to develop a package ofstandardized monitoring methods forindoor air pollution. This package willallow those working in the field tomonitor both exposure levels and healthimpacts effectively, and to compare resultsinternationally.33

Health effects of indoor airpollution

There is a substantial body of evidenceclearly showing that exposure to smoke inthe home is a huge health hazard. As withmost medical knowledge there aredifficulties in drawing exact conclusionsas to what levels of exposure to smokewill cause what levels of disease, as thereare so many other factors whichcontribute to ill health. However theevidence is clear that smoke in the homeis a major risk.

Acute lower respiratory infection(ALRI)The WHO estimates that, in terms ofDALYs, 35.7% of all acute lowerrespiratory infections are caused byexposure to solid fuel smoke.7

Acute lower respiratory infection, suchas pneumonia, is the world’s greatestkiller of children under the age of five. Itaccounts for around 2.1 million deathsannually in this age group. More than50% of deaths due to ALRI are caused by

10

Figure 7: Comparison oftypical levels of PM10 indeveloping country homeswith WHO guidelines.15

Lower300�g/m

Exposure during stove use(typical range)

Smoke exposure,average over a day

(typical range)

3 3

Upper3 000�g/m

3

Upper20 000�g/m

3

WHOguidelines

10�g/m associatedwith excess risk

3

Lower300�g/m


indoor air pollution, lack of adequateheating and other precarious livingconditions.4

Evidence from a series of studies indeveloping countries indicates that youngchildren living in homes using solid fuelhave two to three times more risk ofsuffering from ALRI than unexposedchildren. This figure is reached afterother factors, such as socio-economicstatus, have been taken intoconsideration.36

Indoor air pollution can increase theincidence of ALRI by affecting the body’sdefence systems. For example, the abilityto filter and remove particles in the upperairways and the immune system can becompromised.29

In the early part of the twentiethcentury ALRI, in the form of pneumonia,was a major cause of death inindustrialized countries. Its decline as amajor killer began with improvements inhousing and nutrition before the adventof vaccines and antibiotics.29

Chronic obstructive pulmonarydisease (COPD)In industrialized countries, tobaccosmoking accounts for over 80% ofchronic obstructive pulmonary disease –the progressive and incompletelyreversible obstruction of the airflow, suchas chronic bronchitis.

However in the developing world thisdisease also occurs in areas where tobaccosmoking is rare.15 A woman who cooksover a biomass fire has between two andfour times more chance of suffering fromCOPD than a woman who remainsunexposed.36 The WHO estimates that22% of all COPD is caused by exposureto indoor smoke from biomass fires.7

Lung cancerThe most important cause of lung canceris tobacco smoke. But in developingcountries, women who do not smokeform an unexpectedly high proportion oflung cancer patients. For example, aroundtwo-thirds of women with lung cancer inChina and India are non-smokers.13 It isnow clearly demonstrated that cooking

with open coal stoves in China causeslung cancer in the women who use them.36

So far a clear link between lung cancerand wood smoke exposure has yet to bedemonstrated. And while the rates of lungcancer in rural areas where there is a lotof exposure to wood smoke are low, thiscould be due to a variety of factors. Asbiomass smoke contains knowncarcinogens, such as benzoapyrene, 1,2butadiene and benzene, it would not bepossible to dismiss the lung cancer risks ofexposure.37,15

If exposure to all carcinogens in woodsmoke parallels exposure to particulates,then cooking with traditional biomassstoves is equivalent to smoking severalcigarettes per day. And it has beenestimated that in some homes womenwho cook for three hours per day areexposed to similar amounts ofbenzoapyrene as if they had smoked twopacks of cigarettes.38

Pulmonary tuberculosisThere have been three studies publishedthat suggest that people in homes usingwood for cooking are at 2.5 times morerisk of active tuberculosis.37 This increasein risk may result from a reducedresistance to infection as exposure tosmoke interferes with the properfunctioning of the lungs.15 Studies onanimals have shown declining immunefunction with exposure to wood smoke.36

Low birth weight and infant mortalityLow birth weight is a key factor in infantmortality and morbidity. Exposure totobacco smoke is known to be asignificant contributor to decreased birthweight. Active smoking is associated witha mean reduction in birth weight of up to200 grams and passive smoking has asmaller effect, estimated at between 20and 120 grams.40 Can any parallels bedrawn with the impact of indoor airpollution?

There are thousands of substancesemitted in both tobacco smoke and woodsmoke. However, analysis of cigarettesmoke isolates just a few dozen asparticularly important to health. The

11


The United NationsDevelopmentProgramme (UNDP)states that the use ofpoorly ventilated,inefficient stoves ‘canhave the same adversehealth impacts assmoking two packs ofcigarettes a day’.2


chemical most responsible for retardingintrauterine growth is believed to becarbon monoxide (CO). Carbonmonoxide results from the incompletecombustion of biomass and fossil fuels.When inhaled it combines with thehaemoglobin in the blood to formcarboxyhaemoglobin (COHb) – amolecule that does not readily releaseoxygen to the body, or the foetus. 40 Thisis the main reason for the warningspublished on cigarette packets in the UKlinking smoking with harm to the unbornchild.

The combustion of wood and otherbiomass is qualitatively similar to burningtobacco. Studies have shown thatexposure to biofuels can result in COHblevels ranging from those seen in passivesmoking up to those experienced in heavyactive smoking. However, there is verylimited data published on the effects ofburning biomass on foetal growth.

The most rigorous study comes fromGuatemala. It concluded that, when anumber of other factors, such as socio-economic status are taken intoconsideration, women who use wood fuelhave babies weighing an average of 63 gless than those who use cleaner fuels. Thisplaces the level of impact at least on a parwith passive smoking. This is the firststudy of its kind, and more research isneeded to support these findings.40

CataractsOne of the most frequently reportedcomplaints about exposure to smoke isthat it affects the eyes of the cooks.46

While the majority of complaints areabout red, watering eyes and other

relatively superficial irritations, there isgrowing evidence that indoor air pollutioncauses cataracts. Hospital-based studies inIndia have shown an increased incidenceof cortical, nuclear and mixed cataracts.Studies on the eyes of rats have shownthat wood smoke, like cigarette smoke,causes damage to the lens.15

AsthmaAsthma in poor rural communities indeveloping countries has not been studiedin much detail. In industrialized countries,the influence of air pollution remainscomplex – and sometimes inconsistent.However there is evidence that woodsmoke pollution may be a trigger forasthma or exacerbate it when combinedwith tobacco smoke and other ambientpollutants.37

Risks to women from fuel collectionThroughout the developing world it iswomen who provide fuel for the homeand actually carry out most tasks thatrequire energy at home. The averageamount of time spent each day collectingfuel is between one half and two hours.Where it is scarce fuel wood collectioncan take much longer. Other than theopportunity costs associated with thistime burden, there are significant riskslinked with this activity.

Transporting large loads of woodexposes women to injuries such asfractures and miscarriages from falls andcarrying weight when pregnant. In areasof war and civil unrest women will beexposed to violence and injury fromlandmines and other unexplodedordnance as they collect fuel.

12

‘Many older women go blind or have badeyesight . . . it has a lot to do with all thesmoke from fires, whichthey cook over.’

Umana Tesfasellasie,Oxfam project officer,

Eritrea41

The Great Smog Indoor concentrations of particulate pollution in developing countries are typically in the region of 300–3000mg/m3 andmay reach 30 000mg/m3 or more during periods of cooking.4 When the smoke-laden fog – the Great Smog – envelopedLondon in December 1952 it exacted a death toll of an estimated 4000. Mortality from bronchitis and pneumonia increasedsevenfold due to the smog. For six days, from 5–10 December, the people of London were exposed to levels of particulatepollution comparable to that experienced by women and children in developing countries for up to seven hours a day, everyday. This smog event was a key factor in the creation of the UK’s Clean Air Act in 1956 that for the first time controlleddomestic smoke emissions.28

The UK’s Clean Air Act shows that when faced with a dire public health crisis government can act quickly and decisively.Similar swift and purposeful action is required on a global scale if indoor air pollution is be tackled.


As poor people’s incomes increase theytend to switch to cleaner fuels for cookingand heating. In time, as poverty levels arereduced, lethal levels of indoor airpollution will fall. But poor people cannotafford to wait for a rising tide ofprosperity to clean up the air in theirhomes, and the international communityhas an obligation to ensure life is mademore tolerable for today’s generation.There are actions that can be taken in theshort term, that will ensure long termbenefit for those at risk.

In a review of ways of reducing smokelevels, undertaken for the WHO and theUnited States Aid (USAID), alternativeswere considered according to three areas.These comprise: interventions at thesource of smoke; interventions directedtowards the living environment; andinterventions aimed at the user.

Cooking on a cleaner fuel

The most effective means of reducingindoor air pollution is to switch to cleanerfuel that produces significantly loweremissions. While this may not currentlybe an option for many people due to highcosts, lack of access to the fuel and otherbarriers, for those who are able the switchfuels, the benefits are great.

In many urban areas cleaner fuels, suchas kerosene and LPG, cost less per unit offuel than biomass. However, there is oftena larger cash investment needed topurchase the fuels and the stoves. Forexample LPG must be bought each weekor month by the bottle, but poor peopleusually purchase fuel daily in smallquantities. Making fuel available insmaller quantities would benefit poorercustomers. Mechanisms such as micro-

Reducing exposure to indoor air pollutionThe solution to indoor air pollution is relatively simple: either stopsmoke getting into the home or remove it from the home. Thehealthiest option is to cook with a cleaner fuel. However, for theforeseeable future, many poor people will have little option but to cookon low-grade fuels. The best option for them is to safely remove thesmoke from the kitchen. Experience shows that there is no ‘one size fitsall’ technical fix. A lasting solution depends upon the activeparticipation of those at risk, poor women.

Source of smoke

IImmpprroovveedd ccooookkiinngg ddeevviicceessChimneyless improved biomass stovesImproved stoves with chimneys

AAlltteerrnnaattiivvee ffuueell––ccooookkeerr ccoommbbiinnaattiioonnssBriquettes and pelletsCharcoalKeroseneLPGBiogasProducer gasSolar cookers (thermal)Other low smoke fuelsElectricity

RReedduucceedd nneeeedd ffoorr ffiirreeEfficient housingSolar water heating

Living environment

IImmpprroovveedd vveennttiillaattiioonnHoods/fireplacesWindows/ventilation holes

KKiittcchheenn ddeessiiggnn aanndd ppllaacceemmeenntt ooffssttoovveeShelters/cooking hutsStove at waist height

User

RReedduucceedd eexxppoossuurree tthhrroouugghh ooppeerraattiioonnooff ssoouurrcceeFuel dryingUse of pot lidsGood maintenanceSound operation

RReedduuccttiioonnss bbyy aavvooiiddiinngg ssmmookkeeKeeping children out of smoke

Table 2: Potential interventions for the reduction of exposure to indoor air pollution.53

13


credit loans or subsidies may also help toreduce the cost of fuel switching.42

In rural areas there is less incentive toswitch fuels, as biomass is gathered at nofinancial cost to the user. Cost issuesaside, there are other concerns about fuelswitching. Many of the poorest membersof society in developing countries maketheir living from collecting and sellingbiomass fuel. The result of a wholesaleshift from biomass fuel could be theremoval of a vital source of income forsome of the most vulnerable people insociety.43

The United Nations DevelopmentProgramme’s LPG Challenge aims atovercoming the barriers for ruralcommunities to access LPG in countrieswhere it is readily available in urbanareas.

Cleaner fuel and climate changeThere may be concerns about the climatechange impact of switching to a non-renewable, petroleum-based fuel.Professor Kirk Smith, from the Universityof California, tackled this argument in a

paper entitled ‘In Praise of Petroleum’,45

published in Science in December 2002.He argues that if the two billion or sopeople currently reliant on biomass wereto shift to LPG, emissions of greenhousegases would increase by less than 2%.Professor Smith goes on to illustrate howthe smallest of increases in efficiency inthe world car fleet could counter this rise.If an improvement of just 0.5% per year(5.1% over 10 years, not much more thanone mile per gallon) were made, thiswould free up annually sufficient fuelenergy for the cooking needs of all thetwo billion currently burning biomass.

Over-consumption of fossil fuels isprimarily a problem for the industrializedworld. As Professor Smith puts it:

‘Rather than excluding petroleum, some ofthis one-time gift from nature oughtactually to be reserved to help fulfill ourobligation to bring the health and welfareof all people to a reasonable level: anessential goal of sustainable development,no matter how defined.’45

14

Figure 8: Emissions alongthe energy ladder.29 TThhee eenneerrggyy llaaddddeerr

The energy ladder is a scale which rates the quality of household fuels. At the lower end ofthe ladder are the traditional biomass fuels: dried animal dung; scavenged twigs and grass;through to crop residues, wood and charcoal. Moving up the ladder, coal is next, followed bykerosene, bottled and piped gas, biogas (from digesting animal dung) and electricity. Gaseousfuels are the cleanest burning household fuel. In general, as households climb the ladderthere is an associated increase in the sophistication of the cooking technology, its cleanliness,efficiency and its cost.29 Cooking with electricity is too costly for poor households.

CO (g

/mea

l)

1.8

Dung

PM (g/m

eal)

CO

PM

40

35

30

25

20

15

10

5

0

1.6

1.4

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0.8

0.6

0.4

0.2

0

10

10

Cropresidues

Wood Kerosene Gas Electricity

‘Kerosene and LPGactually produce fewergreenhouse emissionsper unit of energyservice than biomassfuels used in traditionalways.’

UNDP World EnergyAssessment21


Using solid biomass fuel can, in fact,produce higher greenhouse gas emissionsper meal than fossil fuels, kerosene andLPG,26 even where the biomass fuel isharvested sustainably. This is due toinefficient combustion of the biomass fuel,which releases products of incompletecombustion, including methane, whichhave a greater greenhouse potential thancarbon dioxide. In some situations,therefore, fuel switching to fossil fuelsmay be recommended to reducegreenhouse gas emissions.

Biogas from dung and other waste

Biogas is extremely effective, as it convertsa renewable material (dung and otherorganic waste materials) into a gaseous,clean fuel. While biogas is being introducedin parts of Asia very successfully – thereare over 120 000 bio-gasifiers in Nepalalone – the culture in much of Africamakes it harder to introduce there. Furtherresearch and development of renewable,clean cooking fuels will be essential forlonger term cooking options.

15

GGhhaannaa LLPPGG44

Promotion of LPG started in Ghana in 1990 to reduce the wastage caused by flaring constituent gases at the refinery, andto reduce dependence on charcoal and fuel wood. The Ministry of Energy took the lead in promotion and price control ofLPG use for cooking. The programme involved: public awareness raising to increase demand for LPG; door-to-door delivery;reduced cost cylinders; encouragement of LPG use in schools and hospitals; promotion of LPG with commercial foodvendors.

Elements of the traditional cook stove were used in the design of the locally promoted LPG stove. Between 1989 and 1997cylinder sales increased from 80 000 to 600 000 per year, with 22.7% of households in the capital city, Accra, using LPG.Promotion of LPG to lower income households and in rural areas has not been so successful, however.

The UNDP LPG Challenge is now planning to work with local stakeholders in Ghana to overcome the barriers for LPGpromotion in rural areas, and to encourage private companies to sell to rural customers.69

A household biogas plant inNepal.

Reducing exposure

ITDG/S

imon

Dun

net


Getting smoke out of the house

The biomass trapWhile switching to a cleaner fuel is themost effective means of reducing indoorair pollution, abject poverty will meanmany hundreds of millions of peopleworldwide will have no access to fossilfuels for a very long time to come. Theywill be trapped into using biomass as theirprimary fuel. The barriers to accessingclean fuels are many, for example:

• For extremely low-income householdsthe up-front costs of purchasing newcooking technologies, as well as theon-going cost of fuel, are beyond theirmeans.

• Where biomass is collected free ofcharge, even though it takes aconsiderable amount of time to collect,using limited cash income to purchasecooking fuel is not given priority inmany very low-income households.

• In extremely remote areas it is verydifficult to provide a reliable supply offuel, and transport costs will increasethe price of fuel supply.

• Many developing countries do not yethave sufficient infrastructure todistribute LPG or kerosene on a widescale.

Where biomass fuels will remain thedominant domestic fuel, it is essential tomaintain a reliable and sustainable supplyof fuel wood. Fuel wood collection for usein rural areas is not a significant cause ofdeforestation as women generally collectdead wood and twigs and rarely chopdown trees.26 However, in environmentallystressed areas, fuel wood collection has asignificant impact. Where deforestationhas occurred, often due to eithercommercial logging or land clearance foragriculture, there is a need to providesustainable fuel wood sources for ruralpopulations.

In many countries trees are often felledunsustainably to provide fuel wood andcharcoal to supply urban demand. Urgentpolicies and measures are required here tocurtail the loss of forestry. Many people

make a living, legally and illegally, in thesupply of fuel to cities in the developingworld. It will be essential to maintainthese livelihoods, while restoring forestresources.

For those trapped into using biomassas their main domestic fuel, options forreducing exposure to indoor air pollutionwill entail safe ways of getting smoke outof the home.

Smoke hoods, eaves and windowsFor the foreseeable future billions ofpeople will continue to use biomass astheir main fuel. Therefore it is essentialthat efforts to reduce exposure to indoorair pollution be directed at the realitypeople face now. Smoke will continue tobe produced, so it needs to be removedfrom the house.

Substantial reductions to smokeexposure have been obtained withrelatively simple methods. For example,an ITDG project in Kenya reducedparticulate and carbon monoxidepollution in homes by nearly 80%through the use of smoke hoods andimproved ventilation in the home.

Smoke hoods work on the sameprinciple as flues and chimneys, but havethe advantage of being freestanding andindependent of the stove.47 Smoke hoodshave been shown to achieve substantialreductions (80% in some homes) inrespirable particulates and carbonmonoxide.

By enlarging the eaves spaces in atraditional house, substantial benefitscan be achieved. For example, in theKenya project respirable particulateswere reduced by 60%. The number ofhouses showing very high levels ofsmoke pollution was also reducedsignificantly.46

However, the enlargement of windowsin the same project seemed to have littleimpact on indoor air pollution, althoughwindows are required in houses withsmoke hoods to allow an air flow throughthe house.46 The enlarged windows didhave benefits, such as improving lightingin the houses, but did not addsignificantly to the reduction of smoke.

16


17

Kenyan study46

The ITDG Smoke Project was launched in1998. Working with 50 households in ruralKenyan communities, the project aimed toreduce exposure to indoor air pollution.The participatory approach adopted forthis work meant that the project workersarrived willing to listen to the needs of thehouseholds rather than to impose specificinterventions.

The interventions chosen were: smokehoods; increased ventilation throughwindows and eaves; and more efficientcombustion through improved stoves.

• Smoke extraction through smokehoods was selected in favour ofchimney stoves, based in part on thesuccessful operation of smoke hoods ina previous project and on the failure ofthe chimney stoves installed during agovernment scheme.

• Increasing the amount of ventilationinvolved installing a window or cuttingeaves spaces into the wall at roofheight.

• The Upesi stove has been shown toreduce fuel use by about 40%compared with traditional three-stonefires. Households that have used themstate that the kitchens are cleaner,children are safer from accidents andthere is a considerable saving in theuse of fuel wood.

An important component of this programme was the exchange visits that allowed localdissemination of ideas. Initial reluctance on the part of many cooks turned to enthusiasmonce they had seen the interventions in place in other people’s kitchens.

The results showed substantial reductions in particulate matter and carbon monoxide levelsin the households after the installation of interventions. The most effective intervention wasthe use of smoke hoods, which reduced particulate pollution by an average of 75% andcarbon monoxide in the room by 78%. The personal exposure experienced by the women inthe study was reduced to about one third.

Additionally there were some very positive impacts on poverty. Community membersobserved that they felt healthier; there was more time to engage in economic activities whenthe stoves were used; and local artisans increased their income from the manufacture ofinterventions. There were significant improvements for women, above and beyond theirhealth. Participating women were found to have increased confidence and improved statusin the community.

These changes are not without their problems, with some reports that houses were nowcooler, concerns about privacy and security which were overcome by using wire mesh overopenings, and some financial problems for households who were contributing to the costsof the programme.

This was the first stage of a programme of work with the target communities. The on-goingwork is now aimed at achieving wider use of the interventions through public awareness,developing local markets for the interventions and establishing local financing mechanismsto help households afford the necessary changes in their homes.

A West Kenya kitchen with smoke hood, largeeaves space and windows.

Reducing exposure

ITDG/D

r Nig

el B

ruve

Responses tointerventions in theKenya study

‘I can now do mystudies in the kitchen,’one boy, Sironga Masur,told the team. ‘I neverused to study with thefire on due to choking

smoke.’

‘Now I can have abreath of fresh air. Nomore tearing, no morered eyes, bye-bye to

headaches.’

‘You no longersuffocate while in the

kitchen cooking.’


Cutting smoke volumes

Improved biomass stovesImproved stoves were primarily designedto increase energy efficiency. The Upesistove, for example, has been promotedthroughout Kenya and can reduce fuel useby about 40%.46 These stoves weredeveloped with good reason. Reducingfuel requirements will ease demand onforestry, lessen the burden on womencollecting fuel, and in urban areas cutexpenditure on fuel.

Some improved stoves can also helpreduce emissions of smoke. Studies haveshown a small decrease from certainimproved stoves, although many stoves infact increase emissions if air flow to thefuel is restricted.53

If an improved stove incorporates aflue or chimney, one would anticipatesmoke would be reduced. There are somevery effective chimney stoves, which havebeen designed to remove smoke from thehouse, and tested in the home to show asignificant reduction in smoke. Goodexamples are the rocket stove48 andEcostove,49 which are increasingly beingused in Central America.

However, there are also potential

problems with many chimney stoves. Fluesmay not perform well if they are notinstalled properly, they can be poorlydesigned and can be fragile. Chimneys areexpensive and may be ineffective if thesmoke returns through doors andwindows.47 They can also block up quicklywith soot and require regular cleaning.

These points indicate that improvedstove must be more rigorously designedand monitored to demonstrate asignificant impact on IAP in the home.

Reducing the need for fire

Hay boxesA very simple technology can reduce theneed for fuel for cooking – this is thefireless cooker, or a ‘hay box’. This actslike a slow cooker, and is good formaking soups, rice or stews. The food isheated to boiling, then placed in a boxfilled with insulating material, such as hayor crumpled newspaper.50 The foodcontinues to cook slowly. Thedevelopment organization Winrock foundthat the hay box was very popular withthe women’s groups they worked with inNairobi, where hay boxes are proving aspopular as improved stoves.51

TThhee ssuucccceessss ooff tthhee EEccoossttoovvee iinn NNiiccaarraagguuaa49

After diarrhoea, acute respiratory illness isthe greatest cause of death in young childrenin Nicaragua. In both rural and urban parts ofthe country, three-stone fires are stillcommonly used. In urban Managua andsmaller towns, a new stove is making inroadsto replace the traditional stove. This is theenergy efficient Ecostove, developed by theNGO Proleña, with technical support fromAprovecho.48 The Ecostove is an innovativewoodstove which is insulated, with hotemissions (smoke) vented through a chimney.The stove is sealed, preventing nearly allindoor air pollution, and reduces consum-ption and expenditure on wood fuel by 50%.It is common for women to increase theirincome by creating a small business to cooktortillas and soup to sell at their back door orfrom small stalls. This requires long periodsby the stove. The Ecostove has beenparticularly beneficial to these households.

18

Woman cooking on an Ecostove in Nicaragua.

Roge

rio

Carn

eiro

de

Miran

da


Solar water heaters and cookersSolar water heaters, which absorb theheat of the sun, can fairly consistentlyprovide water at 60oC. This has beenestimated to result in a 30% reduction inthe amount of fire use and therefore,potentially, a 30% reduction in exposureto air pollution. They need not be costlyas effective systems can be constructedfrom black piping and plastic drums.53

As much of the need for improvedcooking comes from countries withabundant sunshine, it would seem alogical step to move towards solar power,and there are some very strong advocatesfor this technology. However, there arealso some serious concerns.

Solar cookers, which concentratesunlight directly to cook food, have beenseen as a clean alternative way ofcooking. Unfortunately there has beenlimited success in practice. The use ofsolar energy means preparing a meal atmidday, which does not coincide with themain family mealtime in many cultures. Italso requires the cook to work out ofdoors, which reduces privacy whilecooking and makes cleanliness difficult.16

For solar cookers to be used more widely,they must be developed along with theusers to ensure greater acceptance fromthe target community.

Photovoltaic solar home systems,which produce electrical power, are notcapable of delivering the levels of powersufficient to cook a family meal. They arealso, currently, very expensive for mostpoor people.

Changing patterns of behaviour

Simple changes in the way the cook behavescan reduce exposure to smoke. Forexample, making sure that fuel wood is drycuts emissions. The use of a pot lid canreduce the fuel consumed during simmeringby a factor of three and overall emissionlevels by almost a half. Keeping childrenaway from the fire is also an obvious wayof reducing their exposure – but if they arehabitually carried on their mother’s back,or the mother is the only childminder fortoddlers, this can be very difficult.53

Cooking outdoors would, in manyinstances, reduce exposure to indoor airpollution, and in some parts of the world,for example the aborigines in Australia,this is the norm. However, for mostcultures cooking indoors is normalpractice.

There are some practical objections tocooking outdoors. There is a need to keepcool (when the sun is hot outside); there isthe need to keep warm (when the fire isrequired for heating); there is a need tokeep the fire sheltered from the wind asthe heat is directed away from the pot;there is a need to keep the food cleanfrom wind-blown dirt; and there is theneed to keep safe (a closed kitchen keepsfood safe from thieving people anddogs).52

There may also be cultural objectionsin some societies – people do not like tohave others see what they are eating – andthe fire is sacred, a source of life, andtherefore needs to be at the heart of thehousehold.

Heating the home

Most of the interest in the impact ofindoor air pollution has concentrated onthe use of stoves primarily as devices forcooking in the tropics. However, in eventhe hottest countries, there may be aneed to heat the home, especially atnight. And in a number of regions, forexample the Himalayas and the Andes,space heating is essential. In northernPakistan, for example, summertemperatures can reach 45oC yet fall to–40oC in the winter. Exposure to smokeis exacerbated enormously whenmembers of the family spend longer bythe fire during the winter. The increasedneed for fuel creates another burden forwomen. Unfortunately, stoves that arewell insulated, though more efficient atcooking, will release a smaller amountof energy into the room. And theaddition of chimneys will conduct heataway from the space where it is needed.These needs have not been well cateredfor in the development of stovetechnology.16

19

Some reasons whywomen do not cookoutside

• Climate – need tokeep cool (when it isblazing hot outside),need to keep warm(when heating isrequired) and theneed to keep dry(during the rainyseason). There isoften switchingbetween inside andout depending on theweather conditions.

• Gender – the kitchenis a woman’s domain,where she keeps herutensils and foodordered and clean,implying the need fora private space.

• Cultural – people donot like other peopleseeing what they areeating. People regardthe fire as sacred –and so it has to be atthe heart of thehousehold.

• Energy – cookingoutdoors burns muchmore fuel due to thewind. The wind alsoblows dirt and duston to the food.

• Safety – the need tokeep safe and to stopfood being stolen byother people oranimals.

Reducing exposure


Where there is a need to heat thehome, thermally-efficient housing canreduce, or even eliminate the need forheating, reducing the family’s exposure topollution. There are some measures, suchas correct solar orientation, that costnothing at the time of construction.Where insulation is installed, smoke mustbe vented from the house.53

Identifying appropriate solutions

Cooking is a deeply cultural and privateaffair, as it occurs in the home. Experiencehas indicated that there is no point tryingto dictate a solution to a community. Thisis a view supported by a WHO andUSAID-supported consultation on indoorair pollution and health: ‘A single issue,technology-driven approach to indoor airquality is doomed to failure … Such anapproach would limit the choices

available to the local community andfrequently demands of them changes thataffect numerous aspects of their lives.’The authors argue that ‘the key to successis to adopt project approaches thatbroaden the range of secure andsustainable choices available to the localactors and thus to enable them to devisetheir own solutions’.53

Any programme must be based onwhat is acceptable to the community.There is no point investing massiveresources into something that will not beused. For example in Sri Lanka, earlystove projects were aimed at what the‘experts’ assumed was the key issue. Butthe emphasis on fuel-efficiency at the costof users’ priorities often resulted in lowacceptance amongst households.54 This is acommon factor in the failure of manyunsuccessful stoves programmes aroundthe world.

20

Selecting appropriate technologies – comparing experience in Sudan, Kenya and NepalITDG is working in three very different locations to develop locally appropriate solutions to indoor air pollution.55

Participatory approaches have enabled the community to select solutions that suit their own needs. Their choice oftechnology, in each location, was influenced by cultural aspects, cost of both the technology and the fuel, geographicallocation, access to fuels and climate.

In the refugee settlement in Kassala, Sudan, the community identified LPG as an appropriate solution once microfinancewas made available to cover the initial cost of the stove. The scheme is popular, and already others outside the projectare using the credit system to buy stoves. Fuel costs are much lower for LPG than for charcoal and wood in Kassala, sorepayments can be offset by reduced fuel costs.

In the communities around Kisumu town in Kenya, wood fuel is much cheaper than LPG or collected ‘for free’, so mosthouseholds have elected to continue using biomass. Smoke hoods and eaves spaces are proving effective. A fewhouseholds could afford to choose LPG.

In the remote, cold mountain village of Gatlang in Nepal, solutions have been more difficult to identify as energy is neededto heat the house as well as to cook the food. It is remote, making LPG or kerosene unavailable, so biomass is the onlysolution. Home insulation has been identified as a possible means of retaining room heat whilst reducing the need to burnfuel wood for space heating. Ways of venting the smoke are currently being developed, along with metal stoves to reducefuel use.

Table 3: Solutions chosen by three different communities.

CCoouunnttrryy LLooccaattiioonn SSoolluuttiioonnss cchhoosseenn bbyy ccoommmmuunniittiieess56

Kenya Kisumu, town Upesi improved stove, smoke hoods, eaves space, hay boxes, LPG

Sudan Kassala, refugee settlement Mostly LPG

Nepal Gatlang, remote mountain village (cold area) Venting smoke, improving home insulation


Lessons from stoves programmes

Many lessons have been learned frompromoting improved stoves (see Appendix1). While these programmes were notfocused on reducing indoor air pollution,experience was gained on how tointroduce appropriate technologies withinpoor communities.

The most successful stoves programmehas been in China, where more than 175million improved stoves have beenintroduced.21 It has been reported to bethe most cost-effective measure in ruralenergy conservation undertaken in thecountry.57

The success of the China programme isattributed to stove designs suited to users’needs, targeted national promotionschemes and effective localimplementation, including setting upcommercial rural energy companies.Direct subsidy from the government perstove was relatively low, and variedbetween counties, with higher subsidies incounties where need was greatest.

An interim study of this work showedthat the Chinese government spentUS$200 million (including the cost ofadministration, research and development,promotion and direct subsidies) overseven years for more than 100 millionstoves.58 Follow-up studies show that over70% of these stoves were in frequent use.If the direct cost to the householders ofinstalling stoves was $1 billion (100million stoves costing on average $10each), then, overall government spendingon improved stoves was about 20% of thedirect cost of installation. Theseprogrammes were not designed for smoke

removal, they were aimed at fuelefficiency. However, the Chineseexperience shows that this type ofprogramme can target millions of peoplewith limited subsidy.59

Other successes with fuel-efficientstoves have included programmes in SriLanka, which have reached over 25% ofthe population – over 800 000 homes –and established a self-sustaining stovesindustry (see box, over page). Kenya hasled the way in sub-Saharan Africa withover 780 000 stoves distributed, largely inurban areas.21

Appropriate stove design andimplementation at a local level leading tocommercial markets for stoves were keyfactors in each of these programmes.Experience has shown that a level ofsubsidy is also required to target the most poor and vulnerable sectors ofsociety.

The improved stoves programme inIndia, where the government subsidizedover half the cost of the stove, hasresulted in mixed success. While 30million stoves have been installed inhomes, follow-up surveys have shownthat only one-third of these improvedstoves are still in use. Reasons for thelimited success have related to centralizedcontrol of the programme and poor stovedesign. In some cases, users’ perceptionwere of low energy savings, no removal ofsmoke and high breakdown rates (seeAppendix 1).21

Appendix 2 gives an outline of themodel ITDG is developing from its manyyears working in household energy todisseminate technologies for reducingindoor air pollution at a community level.

Weighing up the cost of smokealleviationPoor people are willing to invest in improved cooking if they see thebenefit, as has been demonstrated by programmes to introduce fuel-efficient stoves. China has successfully introduced nearly 200 millionfuel-efficient stoves at minimal cost. In both Sri Lanka and Kenyanearly one million improved stoves have been introduced. For minimaloutlay, significant health gains can be achieved. The total cost ofreaching those in need will be US$500 million a year for 12 years – lessthan 1% of the West’s aid budget.

21


Smoke reduction efforts and healthspending

It is useful to compare the spending so faron reducing indoor air pollution with thaton other major health concerns.

Currently indoor air pollution receivesa few million US dollars each year in directfunds (for example, from the ShellFoundation, DFID and the World Bank),mostly to support individual pilot projects.

Though not sufficient to meet needs,overseas development assistance providedto water and sanitation was US$1.4billion in 2001, with total spending fromall sources (developing countries, aid,private and community investment)totalling $14 billion.60 The Global Fund toFight AIDS, Tuberculosis and Malaria hadabout $1 billion per year in pledges frominternational donors61 and US PresidentGeorge Bush recently announced $15billion from the USA over the next fiveyears in the fight against AIDS.

In comparison the cost of reducingindoor air pollution would be in theregion of $2.5 billion annually over thenext 12 years based on an average cost of$50 per home. If the Chinese experience isfollowed, where the government spendingwas equivalent to 20% of the amountspent by households on the improvedtechnology, then government spendingand international development aid wouldbe in the region of $500m a year.

All these pressing issues – clean waterand sanitation, AIDS, TB, malaria – haveto be tackled at one time. Saving a child’slife from smoke only to have him or herdie of diarrhoea is not an option.

If ill health and death from hunger,HIV/AIDS, poor water and sanitation,malaria and indoor air pollution can allbe fought together in a cost-effective way,then the benefit to health in thedeveloping world will be tremendous.

Comparing costs of health gainsIn order to compare the impact ofdifferent health programmes the termdisability-adjusted life year (DALY) hasbecome widely used. The World BankEnvironment Strategy has compiled theknown studies on the cost per DALYsaved as due to interventions, as follows:62

• Hygiene and behavioural change: $20 per DALY

• Water connections in rural areas: $5 per DALY

• Malaria control: $35-75 per DALY • Improved biomass stoves: $50-100 per

DALY • Use of kerosene and LPG stoves in

rural areas: $150-200 per DALY • Improved quality of urban air: large

variations, from negative costs to $70 000 per DALY, and more for somepollution control measures. Mostmeasures cost over $1000 per DALY.

22

Successful uptake of stoves in Sri Lanka: lessons to be learnedDespite persistent political instability, and thedifficulties of introducing a new product to both usersand producers, stove programmes in Sri Lanka havemanaged to reach over 25% of the households in thecountry. This success was due to combined initiativesof NGOs and the government. A new self-sustainingstove industry has been established within 20 years,benefiting around 250 producers and 800 000 cooksand their households. While not much more thanUS$1.5 million has been spent on stoves by develop-ment agencies and households since 1977, the financialbenefits (mainly fuel wood savings) are valued at over$37.5 million. That does not take account of theunquantifiable but impressive quality of life, health andenvironmental benefits.54

A Sri Lankan stove designed to suit local conditions.

ITDG/Je

an L

ong


The World Bank has proposed thathealth sector interventions of up to $150per DALY saved should be consideredcost-effective.63

The data would suggest thatinterventions to reduce exposure toindoor air pollution are cost-effective inreducing the burden of disease – especiallywhen compared with the expense ofmeasures to control urban air pollution.37

Estimated costs and benefits for thehouseholderMuch of the cost for implementingsolutions to indoor air pollution will beborne by the households themselves.

Therefore, it is important to assess thecost to the user, (see Table 4). Some of theinterventions are relatively low cost;others are a significant outlay for a poorhousehold.

The use of subsidies and governmentsupport would have to be considered toincrease access to these solutions for manyvery poor people. However, given thesocial, gender, economic (see box above)and environmental benefits of some of thesolutions, in addition to the health gains,many of the solutions become anextremely attractive options forgovernments aiming to achieve theMillennium Development Goals.

23

Economic gains from reducing indoor air pollution – evidence from IndiaIn one of the largest studies ever undertaken of the costs incurred by poor families, the Indira Ghandi Institute ofDevelopment Research looked at the rural energy and health impacts on poor rural communities in three of India’s northernprovinces of Rajasthan, Himachal Pradesh and Utter Pradesh.

The research looked at the health of adults, but not children. Forty five per cent of families had an income of less than10 000 rupees a year, which is less than US 60 cents a day. The costs to poor families due to days lost collecting fuelwood, lost earnings and cost of medical treatment of adults came to 85 billion rupees ($1.84bn) per year. Days lost dueto collecting fuel and illness came to 1 billion days. These figures are for a population of 226 million.39

In another India study, Green India 2047 by Tata Energy and Resources Institute, it was estimated that a change to cleanerfuel would increase slum dwellers’ income by between 2000 and 7400 rupees ($43–161) per annum.

‘Several studies to value the economic benefits of controlling air pollution have demonstrated not only its significant healthbenefits but also its economic feasibility: the cost of implementing policy decisions no longer appears prohibitive once itis weighed against the economic benefits of a healthy citizenry. Benefits of controlling air pollution indoors – pollutionmainly due to burning firewood, dung-cakes, etc. for cooking – are even higher, and the groups that would benefit mostare women and children, especially those living in slums, and those in rural areas in general.’64

Solution Approximate cost Possible reduction in indoor air pollution

Chimney stove $10–150 0–80% depending on type, cost, condition, etc

LPG stove Burner $30–120 Up to 90%Cylinder deposit $50–60Weekly cost for fuel $1–2

Smoke hood $10–60 Up to 80%

Biogas $300 Very clean (no data currently available)

Solar cooker $5–50 No emissions, but may not replace all biomass cooking

Behavioural changes, e.g. use of pot lids, drying fuel, keeping children way from smoke Less than $5 Variable (no data available)

Table 4: Typical costs for solutions to indoor air pollution5 (derived from specific studies and therefore illustrative, notnecessarily accurate for all cases).

Cost of smoke alleviation



There is an urgent need to reduce indoorair pollution in millions of homes in Asia,Africa and Latin America. This paper callsfor the United Nations Secretary Generalto instigate a Global Action Plan tomobilize the political will and resources tomake clean air a reality in the homes ofmillions.

The Global Action Plan will build onand expand existing efforts and providethe strategic leadership in driving and co-ordinating national and internationalaction. It will also be the focus formobilizing the necessary resources fromtraditional and new forms of funding.

The Global Action Plan would entailthe following:

High level international conference

The first step would be for the UNSecretary General’s office to conveneurgently a high level internationalconference of the major stakeholders –governments, UN agencies, bilateral andmultilateral donors, private sector,research institutions and non-governmental organizations – to agree ashared vision, common approaches andset in motion strategic plans to tackle thescourge of indoor air pollution.

The conference should agree thefollowing four-part strategy:

• Millennium Development Goals – a specific reference and action onpreventing and reducing childmortality through reducing risk fromindoor air pollution.

• A global partnership – which puts theglobal political weight and resourcesinto the existing Partnership for CleanIndoor Air, bringing together theleading international players from thehealth, development, energy, shelterand environment sectors to worktowards a global solution and to

prepare strategic plans to tackle indoorair pollution.

• Sustainable finance – that establishesthe extra and sustainable resourcesfrom traditional and non-traditionaldonors needed to bring clean air tomillions of homes.

• National task forces – that bringtogether the key national and locallevel stakeholders to enable them toaddress the problem with internationalsupport.

Millennium Development Goals

Indoor air pollution is inextricable linkedto poverty. Reducing indoor air pollutioncan contribute to many of the MDGs. Butgiven that smoke is such a major childkiller, and that efforts to tackle childhoodacute lower respiratory infection arefalling short of targets, there needs to be aspecific reference and action onpreventing deaths from indoor airpollution under MDG 4 Reducing ChildMortality.

A global partnership

Indoor air pollution is a global problemrequiring a global solution. The UnitedStates Environmental Protection Agencyled Partnership for Clean Indoor Air hasattracted a number of key players since itwas launched in Johannesburg inSeptember 2002. The internationalcommunity needs to rally round thepartnership and transform it into a trulyglobal partnership.

The international community is slowlybeginning to take indoor air pollutionseriously. Key organizations already activein the fight against indoor air pollutioninclude (see Appendix 3): the WHO; theWorld Bank; the United NationsDevelopment Programme (UNDP); theGlobal Village Energy Partnership; the

A Global Action Plan

25

The United Nations should instigate a Global Action Plan to addressthis neglected killer. The first step would be for the UN to conveneurgently a high level international conference to set in motion actionplans with the necessary resources.


Shell Foundation; and many NGOs andcommunity groups.

Increasing co-operation between all thekey players in the energy, environment,health, shelter and development sectors isthe first step towards achieving the globalreach needed. This partnership ofgovernments, UN agencies, bilateral andmultilateral donors, private sector,research institutions and non-governmental organizations will need to:

• build consensus on priorities andprepare strategic plans to tackle indoorair pollution

• facilitate partner co-ordination toexpand the availability of, and accessto, cleaner fuels and safe methods ofextracting smoke from the home

• offer technical support and share bestpractice across a range of sectors

• assist the development of furtherimproved ways of reducing the risk ofindoor air pollution

• support further necessary research intounderstanding the best way to reducerisk

• communicate and advocate the needfor a greater response to indoor airpollution.

International working groupIn the early stages of co-operation there

needs to be a multi-stakeholder workinggroup with the remit to developrecommendations for policy and practiceon ways in which levels of indoor airpollution can be alleviated at national andlocal level. Working within a given timeframe, the working group should:

• collate information on previousexperience and identify factors whichhave led to success and to failure inthe past

• based on this knowledge, developpolicy recommendations for alleviatingsmoke on a wide scale at national andlocal level

• provide indicators of the cost ofintroducing these policy measures, andof the expected levels of povertyreduction and health benefit resulting

from the introduction of thosemeasures

• recommend further actions, atinternational, national and local level,which are needed to fill the knowledgegaps on successfully alleviating indoorair pollution.

This information will be essential forguiding national task forces and assistingthem to adapt the international experienceto suit local conditions.

Continuing researchAn essential part of the international co-operation will be concerted efforts bythe health research community, whocontinue to provide evidence on the risksinvolved in exposure to household smokeand the health benefits of householdinterventions to reduce exposure. Thisresearch will be needed in the drive topersuade national governments of theurgency of tackling indoor air pollution.The fact that there is ongoing researchshould not raise questions as to theseriousness of indoor air pollution. Thisresearch is aimed at gaining anunderstanding of the best ways toeradicate a very real problem.

Any global strategy to tackle indoor airpollution will need to ensure there is aglobal understanding of what variablesare measured, and where and when.Standards need to be set to allow progressto be monitored and programme results tobe compared. The Partnership for CleanIndoor Air is developing a harmonizedmethodology to evaluate initiatives whichaim to reduce the impact of indoor airpollution.33

Sustainable finance

Bilateral and multilateral donors(governments, World Bank, IMF andregional development banks) and non-traditional donors need to commit thenecessary level of funding without cuttingtheir financial commitments to otheressential poverty-reduction strategies.

It is estimated the funding should be inthe order of US$500 million per year over

26


the next 12 years. This money will berequired for implementing programmes inindividual countries, and for research,development and co-ordination at theinternational level. The aim of the fundingis to enable all people to reduce the healthrisks associated with indoor air pollution.This will include subsidies forcommunities most in need.

National task forcesIn the first phase of the action plan therewill be a need to focus on a set number ofcountries that will champion efforts toreduce indoor air pollution. Thesecountries will act as pioneering centres ofexcellence setting up national indoor airpollution plans that are linked to nationalpoverty reduction, health, energy, shelterand environmental plans.

Above all, there has to be action on theground, at a national and local level, topromote healthy indoor air for all, and toremove the barriers that prevent peoplefrom living in a clean indoorenvironment. Operating at a nationallevel, the task forces will bring togetherstakeholders (government, private sector,NGOs and communities) to take actionon smoke. Each task force should beguided by the findings of the internationalworking group, and carry out a similarscoping, costing and policy review at anational level.

Working across various governmentsectors, task force responsibilities willinclude:

• raising public awareness of the effectsof indoor air pollution and solutionsto it

• reforming national technical andenergy markets in order to expandavailability of cleaner fuels

• developing locally acceptable ways ofextracting smoke from the home

• social marketing of appropriatesolutions introducing the necessaryfinancial support for poor familiessuch as microcredit and subsidies.

National government responseSpecifically, national policies, and inparticular the Poverty Reduction StrategyPapers (PRSPs), should include action onindoor air pollution. This would be in linewith achieving MDG 4 on reducing infantmortality and MDG 7 on environmentalsustainability. National environmentstrategy and national energy plans shouldthen be amended in line with achievingthis PRSP target.

Private sector responseThe private sector is already becominginvolved in some countries through theUNDP LPG Challenge. This programmeaims to reduce the commercial risks forprivate sector involvement in developingcountries, particularly in rural markets. Itis also looking to develop best practice forproviding a rural service. Private energycompanies should support the UNDP inthis effort, and contribute resourcestowards its goals.

Co-ordinating at a local levelNon-governmental organizations areideally placed to bridge the gap betweenmultilateral action and community action.It will be essential to bring together localstakeholders – community-basedorganizations, local government, healthservice, finance and the private sector – todevelop strategies for scaling up theimpact of local interventions.

Importantly, the impact of theinterventions at a household level must bemonitored for exposure, health and socio-economic impact. The Shell Foundation,USEPA, WHO, ITDG, ESMAP and othersare all supporting work to this end – butit will need much greater effort to benefitmillions of households.

Communities at the heart ofdevelopmentThe communities should be fully integratedinto the development process. Poverty itselfis the heart of the problem, and povertyeradication must be the main goal.

27

Global Action Plan



In 1994 the World Bank recognized thevalue of improving stoves: ‘the best stoveprograms yield economic as well asenvironmental and social benefits. Forexample, in urban areas, where mostpeople purchase wood fuels, the paybacktime of an improved stove in fuel savingsfor consumers is sometimes only a fewmonths; because the stoves lastconsiderably longer, cash flow is improvedfor people even if they cannot yet makethe transition to modern fuels. Likewise,in rural areas, more efficient stoves canreduce the time spent collecting fuel forcooking, freeing time for child care andincome-producing activities.’42

But the World Bank was not naive tothe reality. ‘No matter how efficient orcheap the stove, individual householdshave proved reluctant to adopt it if it isdifficult to install and maintain or lessconvenient and less adaptable to localpreferences than its traditionalcounterpart. On the other hand,households have been most receptivewhen the dissemination process takes fullaccount of the capacities and needs oflocal stove producers and consumers . . .technical improvements in efficiency mustbe complemented by appropriate projectdesign and implementation, perceptiblysuperior services, and proper institutionalsupport, if they are truly to take root.’42

For an intervention to be consideredsuccessful, it also needs to be sustainable –economically as well as environmentally.For example, work in Sri Lanka resulted inmore than just a reduction of fuel woodconsumption.54 The project managed to:

• provide employment opportunities forstove producers and builders

• generate income for stove producers,builders, distributors and sellers

• enhance the technology developmentcapacity of local artisans/researchorganizations/agencies

If interventions can work on thiseconomic level, then they can becomesustainable, running without the furtherinterventions of external agencies.

Other results to emerge from Sri Lankaare that a successful programme can:

• raise awareness about environmental,ecological and energy concerns

• educate at national and householdlevels about health, safety and hygiene

• act as a springboard to othercommunity and gender developmentinitiatives.54

In his 1994 review on the uptake ofimproved stoves for the World Bank,Douglas Barnes assessed the key reasonsfor success and failure (see table 5).

It is interesting to compare theimproved stove programme in China,which has had a high level of success,with that in India, which has producedmixed results (see table 6). The Chinesescheme was a national programme witheffective and targeted localimplementation. The Indian schemeattempted national implementation of acentrally controlled programme.

Appendix 1: Lessons to be learntfrom improved stoves programmes

29

Many lessons have been learnt from the dissemination of stoves. Whilethese programmes were not focused on reducing indoor air pollution,knowledge was gained about how to introduce technologies withinpoor communities.


30

RReeaassoonnss ffoorr ssuucccceessss RReeaassoonnss ffoorr ffaaiilluurree

Programme targets regions where traditional fuel and Programme targets regions where fuel or stoves are not stoves are purchased or fuel is hard to collect purchased or fuel is easy to collect

People cook in environments where smoke causes health People cook in the open and smoke is not really a problems and is annoying problem

Markets surveys are undertaken to assess potential Outside ‘experts’ determine that improved stoves are market for improved stoves required

Stoves are designed according to consumer preferences Stoves are designed as a technical package in the including testing under actual use laboratory ignoring customers’ preferences

Stoves are designed with assistance from local artisans Local artisans are told or even contracted to build stovesaccording to specifications

Local or scrap materials are used in production of the Imported materials are used in the production of the stove, stove, making it relatively inexpensive making it expensive

The production of the stove by artisans or manufacturers The production of the stove by artisans or manufacturers is is not subsidized subsidized

Stoves or critical component are mass produced Critical stove components are custom built

Similar to traditional stove Dissimilar to traditional stove

The stove is easy to light and accepts different The stove is difficult to light and requires the use of small sized wood pieces of wood

Power output of stove can be adjusted Power output cannot be easily controlled

The government assists only in dissemination, The government is involved in productiontechnical advice and quality control

The stove saves fuel, time and effort The stove does not live up to promised economy orconvenience under real cooking conditions

Donor or government support extended over at least Major achievements expected in less that three years; all five years and designed to build local institutions analysis, planning and management done by outsidersand develop local expertise

Monitoring and evaluation criteria and responsibilities Monitoring and evaluation needs are not planned and chosen during planning stages according to specific budgeted, or criteria are taken uncritically from other goals of project projects or not explicitly addressed

Consumer payback of one to three months Consumer payback of more than one year

Table 5: Possible reasons for success or failure of stove programmes.42


31

CChhiinnaa IInnddiiaa

The programme focused on areas with the greatest need The programme was implemented countrywide, resulting in and selected pilot counties with biomass fuel deficits dispersion of effort and dilution of financial resources

Direct contracts between the central government and the The programme administration was cumbersome, moving county bypassed much bureaucracy. This arrangement from the centre to the state level, then to the district, and generated self-sustaining rural energy companies that finally to the taluka, where the stove programme is just manufacture, install and service stoves and other one of many national efforts being implemented locally by energy technologies. the same people

Local rural energy offices run by provincial Lack of a strong monitoring plan was a severe weakness in governments are in charge of technical training, early programmes. Some improvement has occurred service, implementation and monitoring for the through assignment of the task to university-based programmes. These efforts are separately funded technical backup units. Coverage is still incomplete, and relatively independent however

Stoves are not only suitable for fuel savings and India has made a wide variety of attempts to integrate reduction of household smoke, but also are designed efficiency and convenience, which have suffered from the for convenience and attractiveness, highlighting the top-down structure of the programmelessons learned from problems in early programmes that stressed only fuel savings

Stove adopters pay the full cost of materials and Stove adopters pay about half the cost of stoves; the labour. The government helps producers through government pays the rest. As a result the producer’s stove construction training, administration and incentive to construct stoves is oriented towards the promotion support government

Emphasis has been on long-lived stoves made of Many of the stoves have been made from local materials ceramic or metal and otherwise designed to be a and by villagers without artisanal skills, resulting in short significant household asset for a number of years lifetimes in day-to-day household use

Table 6: Comparison of stoves programmes in India and China.21

Appendix 1



• Market surveys are used to identifywomen’s and men’s opinions on howthey prioritize smoke alleviation andtheir preferences for smoke removalproducts, before and after asmoke/health campaign. Consideringconsumer willingness and ability topay, as well as identifying appropriatetechnologies, will be key factors in thissurvey.

• Intermediaries, such as non-government organizations, communitygroups, local government and theprivate sector play a key role inmaintaining the sustainability of themarket through support andencouragement of women to promoteimproved cooking technologies.

• Public awareness raising for bothwomen and men on the risks causedby smoke, and the greater comfortlevels experienced with its removal, isrequired to increase the demand forsmoke alleviation and make it apriority.

• Effective marketing and promotionstrategies should be tested to see whatis effective and appropriate to get thepublic awareness message across to thetarget audience. Working with targetcommunities and other stakeholders,successful promotion methods (e.g.radio, video, street plays) can beidentified.

• Microcredit schemes and revolvingfunds for both suppliers andconsumers, which will allow men andwomen to access credit, can encouragetake-up by ensuring that there isenough ‘up-front’ capital to provideand pay for products. It is importantto create links with credit institutions,with the aim of establishingmicrofinance facilities to encouragehouseholds to purchase smokealleviating products.

• To ensure a supply of good-qualityproducts, entrepreneurs should be

trained in both technical and businessskills.

• Providing a sustainable and affordableproduct supply to the consumer isparamount in determining whichbusiness models should be adopted.Factors include: quality andaffordability; expected product life;locally produced versus locallyassembled or distributed products;added value within the community;cost and reliability of supply – ifmanufactured outside the community;supply chains for products requiringconsumables; maintenance and after-sales service.

• An analysis of how appropriate creditfacilities should be structured tostimulate demand and facilitatemanufacture and distribution ofquality products will complement thebusiness plans.

It will be important to monitor theimpact of the dissemination of thetechnologies on the target area. This willnot just be in terms of how many hoodsor stoves have been disseminated, but willinvolve monitoring smoke levels and somequantitative measure of the expectedhealth improvements in selected homes,and socio-economic assessment of theimpact of the interventions on thehousehold. It is also important tomaintain quality control of the products,to ensure they are reliable, and thereforemaintain a good reputation.

Appendix 2: Getting the marketright for wide-scale dissemination

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ITDG are using the following strategy for scaling-up dissemination ofinterventions to reducing indoor air pollution. This strategy is based onmany years of experience of implementing technology transfer.



World Health Organization

WHO is building a programme to reducethe burden of disease attributable to indoorair pollution. Ths programme includes:

• encouraging research into healtheffects of indoor air pollution

• developing a harmonized methodologyto facilitate comparative evaluation ofintervention studies

• supporting on-going research oninterventions

• building capacity at a regional andnational level to assess health impacts

• providing evidence to policy makerson the need to reduce indoor airpollution.

At the World Summit for SustainableDevelopment (WSSD) in Johannesburg,WHO launched the HealthyEnvironments for Children Alliance(HECA), which aims to create:

‘A world-wide alliance to intensify globalaction on environmental risks to children’shealth that arise from the settings wherethey live, learn, play and earn, by providingknowledge, increasing political will,mobilizing resources, and catalysingaction.’10

HECA was launched by WHO as animportant follow-up contribution toWSSD and realization of the health andenvironment components of theMillennium Development Goals. One ofits main targets is to reduce indoor airpollution in homes. This alliance is in itsearly stages, but it aims to bring togethera large range of stakeholders to worktowards healthier environments forchildren, with interventions to reduceindoor air pollution high on their agenda.

Energy Sector ManagementAssistance Programme

In recent years, the joint WorldBank/UNDP Energy Sector ManagementProgramme (ESMAP) has been sponsoringa group of studies and programmes onindoor air pollution.66 Projects are beingimplemented in India, China, Guatemala,Mongolia and Nicaragua, and includeawareness raising on indoor air pollution,studies of health impacts, developmentand dissemination of interventions toreduce indoor air pollution, andassessment of policy for reducing indoorair pollution in homes. In addition,ESMAP is undertaking work on capacitybuilding and policy assessment in indoorair pollution. This study aims to increasethe capabilities and knowledge needed toreduce the human health and associatedsocial, economic and environmentalimpacts of household solid fuel use in thepoorest households in key developingcountries.

The ESMAP-sponsored study of indoorair pollution in India is being carried outby the World Bank South Asia andEnvironment Unit.67 This study entitledHousehold Energy Air Pollution andHealth, aims to:

• facilitate political commitment tomitigating health impacts fromhousehold energy use

• assist in formulating and implementingaction programmes in India at local,state and national level

• enhance knowledge and create greaterawareness amongst stakeholders inIndia

• contribute to developing practical toolsfor measuring and predicting levels ofindoor air pollution and healthimpacts.

Appendix 3: Action by keystakeholders on indoor air pollution

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A number of groups – intergovernmental and non-governmentalorganization – are active in research and development on indoor airpollution.

The WHO Director-General, Gro HarlemBrundtland, highlightedthe urgency of thisissue on World HealthDay 2003. She stated:“The biggest threats tochildren’s health lurk inthe very places thatshould be safest –home, school andcommunity.’ The maindangers were from airpollution caused bydirty household fuel,lack of safe drinkingwater and poorsanitation.65


Partnership for Clean Indoor Air

A new positive initiative has come from theUnited States Environmental ProtectionAgency (USEPA) in developing thePartnership for Clean Indoor Air. The aimis to halve mortality related to indoor airpollution in targeted areas. Thispartnership is in its early stages, but itsaims are for the partners to contribute theirresources and expertise to implement thegoals of the initiative and work together to:

• obtain formal commitments from, anddevelop action plans with, key sectors(e.g., health, environmental, energy) inpartnering countries before beginningefforts in a given country

• develop culturally appropriate trainingand other public outreach materials,educational programmes, andawareness campaigns, and adapteconomic and planning tools to localsettings

• identify in-country industry – includinglocal entrepreneurs – and other non-governmental partners to participate inplanning and implementation activities

• identify lessons learned from pastefforts and develop performancemeasures to evaluate past and currentactivities, and identify successful locallybased implementation strategies.

In the longer term, the Partnership forClean Indoor Air will focus on broadexpansion of efforts throughoutpartnering countries.68

United Nations DevelopmentProgramme

The United Nations DevelopmentProgramme (UNDP) is championing onesolution to indoor air pollution through itsLPG Challenge. The aim of this initiativeis to reduce the risks for private sectorcompanies to supply rural markets indeveloping countries. The LPG Challengeplans to bring liquefied petroleum gas(LPG) to the rural population by linkingUNDP’s knowledge and experience ofdevelopment and community consultationwith industrial suppliers of LPG and their

gas appliances. The key issue is to addressmarket and technical barriers to expandthe use of LPG in rural areas.69 The firststage of action will be pilot schemes inselected countries.

National governments

The macro-energy policies of mostdeveloping countries frequently include nomention of their most important fuelsource – biomass. The three notableexceptions are India, South Africa andChina. These countries have carried outsignificant improved stove programmes toreduce fuel consumption in the pastdecade, with varied degree of success.

The World Bank, IMF and donorgovernments provide assistance tonational governments and citizensthrough their Poverty Reduction StrategyPapers (PRSPs), which have become themain route for overseas developmentfunding. The PRSPs are action plans forthe implementation of the MDGs on anational level, and funded throughMedium Term Expenditure Frameworks.Very few PRSPs currently include energyplanning in any form, and those that dofocus on electricity supply. While acutelower respiratory infections may beincluded in public health plans, there is nofocus on indoor air pollution. Thepercentage of the population using solidfuel is being monitored under MDG 7 asan indicator of sustainable development,so should be introduced to the PRSPs.

Global Village Energy Partnership

Global Village Energy Partnership waslaunched at WSSD in Johannesburg in2002 by ESMAP. The partnership aims toconnect 400 million people to electricityand cleaner fuels over the next decade –virtually doubling the number of poorvillagers who each year gain access tolighting, heating, and power – andproviding 50 000 communities withenergy services for schools, hospitals, andclinics.70 With very strong partners fromthe energy sector across the developingworld, GVEP could be a strong agent for

36


introducing clean cooking practices andpolicies at a national level, and forimplementation of projects on the ground.

Shell Foundation

The Shell Foundation, through itsSustainable Energy Programme, is fundinga substantial body of work on householdenergy and health, contributing US$10million over five years.71 The programmeis supporting a number of pilot projects inIndia, Africa and Latin America. Thesepilot projects focus on developingappropriate technologies, which will thenbe disseminated widely through localcommercial markets. Shell Foundation hassponsored studies on the lessons learnedfrom previous stoves programmes,including the huge dissemination schemein China. In addition it has commissioneda substantial programme entitledStandard Monitoring Packages forHousehold Energy and Health FieldProjects, which aims to develop astandardized and manageable package ofmonitoring tools for this purpose.

Research community

There are a limited number of researchcentres that have been leading the way inassessing the health impact of indoor airpollution, and working in the field toestablish the health benefits ofinterventions to reduce exposure toindoor air pollution. Leading researchcentres include:

• School of Public Health,Environmental Health SciencesDivision, University of CaliforniaBerkeley, research headed by ProfessorKirk Smith

• Department of Public Health,University of Liverpool, researchheaded by Dr Nigel Bruce

• Renewable and Appropriate EnergyLaboratory (RAEL), research headedby Professor Dan Kammen

• Indira Gandhi Institute ofDevelopment Research, researchheaded by Professor Jyoti Parikh.

Though there is little doubt thatexposure to indoor air pollution indeveloping countries presents a majorthreat to health, there is still a need formore research investigating the specificlinks between disease and exposure. Andwhile there is a great deal of observationalevidence, the case will be strengthened bymore rigorous studies, quantifyingexposure and ensuring that confoundingfactors, such as socio-economic status, areadequately addressed. However, the needfor further research should not hinder thedevelopment and implementation ofinterventions to reduce exposure.

Development community

ITDG has on-going projects in Kenya,Nepal and Sudan, working withcommunities, local businesses and policymakers to develop and scale-up locallyappropriate interventions to reduceindoor air pollution in homes. A handfulof other NGOs are carrying out similarprojects at a country level, for exampleAprovechio and HELPS International inGuatemala, the Appropriate RuralTechnology Institute in India, WinrockInternational in Kenya, and the ChildWelfare Scheme in Nepal. These projectsare being sponsored mainly by the UKDepartment for InternationalDevelopment, the World Bank EnergySector Management AssistanceProgramme and the Shell Foundation.

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Appendix 3


1 High mortality developing countries: Algeria,Angola, Benin, Botswana, Burkina Faso,Burundi, Cameroon, Cape Verde, CentralAfrican Republic, Chad, Comoros, Congo, Côted’Ivoire, Democratic Republic of the Congo,Equatorial Guinea, Eritrea, Ethiopia, Gabon,Gambia, Ghana, Guinea, Guinea-Bissau, Kenya,Lesotho, Liberia, Madagascar, Malawi, Mali,Mauritania, Mauritius, Mozambique, Namibia,Niger, Nigeria, Rwanda, Sao Tome andPrincipe, Senegal, Seychelles, Sierra Leone,South Africa, Swaziland, Togo, Uganda, UnitedRepublic of Tanzania, Zambia, Zimbabwe,Bolivia, Ecuador, Guatemala, Haiti, Nicaragua,Peru, Afghanistan, Djibouti, Egypt, Iraq,Morocco, Pakistan, Somalia, Sudan, Yemen,Bangladesh, Bhutan, Democratic People’sRepublic of Korea, India, Maldives, Myanmar,Nepal

2 ‘UNDP pushes for expanded energy services tomeet the poor’s basic needs’, press release (8April 2002)www.undp.org/dpa/pressrelease/releases/2002/april/08apr02.html

3 The World Energy Outlook 2002, InternationalEnergy Agency, www.iea.org

4 ‘Initiating an alliance for action: healthyenvironments for children’, WHO (2002)www.cgil.it/org.politicasalute/adessostomeglio/200250/OMS.pdf

5 Addressing the Impact of Household Energyand Indoor Air Pollution on the Health of thePoor: Implications for policy action andintervention measures, paper prepared for theCommission on Macroeconomics and Health,WHO (2002)

6 Bruce, N. et al. ‘Indoor air pollution indeveloping countries: a major environmentaland public health challenge’, Bulletin of theWorld Health Organization (2000) 78 (9)

7 The World Health Report: 2002: Reducingrisks, promoting healthy life, WHO (2002)

8 ‘Roll Back Malaria’, WHO (2001 to 2010),www.rbm.who.int

9 www.developmentgoals.org10 ‘Healthy environments for children: an alliance

to shape the future of life’, WHO (2002)www.who.int

11 Energy for the Poor: Underpinning theMillennium Development Goals, DFID (August2002)

12 http://ecoharmony.com/hedon/ quote from DrE. Bates

13 Addressing the Links between Indoor AirPollution, Household Energy and HumanHealth, WHO (2002)

14 Budds, J. et al. What’s Cooking: A review of thehealth impacts of indoor air pollution andtechnical interventions for its reduction, WELL(2001) www.lboro.ac.uk/WELL

15 Bruce, N. et al. The Health Effects of IndoorAir Pollution Exposure in DevelopingCountries, WHO (2002)www.who.int/peh/air/Indoor/OEH02.5.pdf

16 Clancy, J. ‘Blowing the smoke out of thekitchen: core issues in household energy andgender’,www.sparknet.info/goto.php/view/2/theme.htm

17 Clancy J. et al. ‘The gender – energy – povertynexus: finding the energy to address genderconcerns in development’, DFID Project No.CNTR998521

18 Cecelski, E. The Role of Women in SustainableEnergy Development, report to the NationalRenewable Energy Laboratory, BoulderColorado, USA (1999). Referred to in 15

19 Branco, A. et al. ‘The WSSD and its resultsregarding gender and energy’, ENERGIA NewsVol.5 (4 December 2002)

20 ‘Scaling-up of sustainable biomass energymanagement systems in sub-Saharan Africa’,proposal by ITDG and GTZ-ProBEC inresponse to WSSD (2002)www.earthsummit2002.org/ic/energy/biomass.pdf

21 ‘Rural energy in developing countries’, WorldEnergy Assessment: Energy and the challenge ofsustainability, UNDP (2000) chapter 10,www.undp.org/seed/eap/activities/wea/

22 United Nations Millennium Declaration(September 2000) www.un.org/millennium

23 Litvak, V. ‘Household energy and health:summaries of on-line forum’, weeks 1–5, ShellFoundation Sustainable Energy Dialogue (20July 2001)

24 Tapping the Potential: Improving watermanagement in Tajikistan, National HumanDevelopment Report (2003)

25 Progress since the World Summit forChildren:A statistical review (2003),www.childinfo.org

26 ‘Energy, the environment, and health’, WorldEnergy Assessment: Energy and the challenge ofsustainability (2000) Chapter 3,www.undp.org/seed/eap/activities/wea/

27 Ezzati, M. et al. ‘The health impacts ofexposure to indoor air pollution from solidfuels in developing countries: knowledge, gaps,and data needs’, Environmental HealthPerspectives, Vol.110, No.11, (November 2002)

28 www.met-office.gov.uk/health/features/200302/pea_soup.html

29 Smith, K. et al. ‘Indoor air pollution indeveloping countries and acute lowerrespiratory infections in children’, Thorax(2000), Vol.55, pp.518–532

30 APHEIS Health Impact Assessment of AirPollution in 26 European Cities, second-yearreport (2000–2001), Institut de Veille Sanitaire,Saint-Maurice

31 Smith, K. and Jantunen, M. ‘Why Particles?’Chemosphere, 49 (2002) pp.867–871

32 Ezzati, M. et al. ‘Indoor air pollution frombiomass combustion and acute respiratoryinfections in Kenya: an exposure-responsestudy’, The Lancet, 358 (25 August 2001)

33 www.shellfoundation.org/breatheeasy34 ‘Will less exposure to indoor air pollution

Notes and references

39


prevent childhood pneumonia?’ Bridges, COEHnewsletter (September 2001)

35 Smith, K. ‘The Guatemala stove interventiontrial’ (January 2003)http://ehs.sph.berkeley.edu/guat/

36 Smith, K. ‘Indoor air pollution in developingcountries: recommendations for research’,Indoor Air (2002) Vol.12, pp.198–207

37 von Schirnding, Y. et al. Addressing the Impactof Household Energy and Indoor Air Pollutionon the Health of the Poor: Implications forpolicy action and intervention measures,Commission on Macroeconomics and Health,WHO (2002)

38 Smith, K. and Liu,Y. ‘Indoor air pollution indeveloping countries’, Epidemiology of LungCancer, Marcel Dekker, New York. Referred toin 13

39 Parikh, J. Rural Energy and Health Impacts,report for the Ministry for Environment andForest, Indira Gandhi Institute of Development,Mumbai (2000) www.igidr.ac.in/~jp/rural.htm

40 Boy, E. et al. ‘Birth weight and exposure tokitchen wood smoke during pregnancy in ruralGuatemala’, Environmental Health Perspectives(January 2002) 110 (1)

41 Beesley, J. Making Bread Eritrea Style, OxfamEritrea Emergency Response (August 2003)

42 Barnes, D.F. et al. What Makes People Cookwith Improved Biomass Stoves? A comparativeinternational review of stove programs, WorldBank technical paper, No.242 Energy Series(1994)

43 Fuel Substitution: Poverty impacts on biomassfuel suppliers DFID, (February 2003)

44 Quaye-Foli, E.A. ‘Liquefied Petroleum Gas(LPG) promotion: the Ghana experience’,presentation from the UNDP/World BankEnergy and Poverty Workshop, Addis Ababa,Ethiopia (October 2002)

45 Smith, K. ‘In Praise of Petroleum?’ Science,Vol.298 (6 December 2002)

46 Reducing Indoor Air Pollution in Rural Homesin Kenya: Working with communities to findsolutions, The ITDG Smoke and Health Project(1998–2001), ITDG (January 2002)

47 Budds, J. et al. ‘What’s cooking: a review of thehealth impacts of indoor air pollution andtechnical interventions for its reduction’, WELL(2001) www.lboro.ac.uk/WELL

48 Stills, D. et al. ‘Increasing efficiency andreducing harmful emissions in traditionalcooking stoves’, Boiling Point No.47, ITDG(Autumn 2001)

49 Miranda, R. ‘The modernization of smallbusiness through the Ecostove in Nicaragua’,Boiling Point No.47, ITDG (2001)

50 ‘Haybox Cookery’, Centre for AlternativeTechnology, Tip Sheet 5, CAT Publications,Machynlleth (1997)

51 Gore, J., presentation at meeting of thePartnership for Indoor Air Pollution, New York(9 May 2003)

52 Bates, E., personal comment, ITDG (May 2003)

53 Ballard-Tremeer, G. et al. Review ofInterventions to Reduce the Exposure ofWomen and Young Children to Indoor AirPollution in Developing Countries,WHO/USAID Consultation on Indoor AirPollution and Health (3/4 May 2000)www.ecoharmony.com

54 Crewe, E. et al. Sri Lankan Stove Programmes:A sustainable success story, ITDG (June 2002)

55 ‘Smoke, health and household energy’, ITDGDFID project No.R802 (September 2002 toMarch 2003)

56 Bruce, N. ‘Household energy, smoke andhealth: developing sustainable interventions’,Global Health Council Conference, WashingtonDC (28 May 2003)

57 Lu, Y., Fueling One Billion: An insider’s storyof Chinese energy policy development,Washington Institute Press, Washington DC(1993)

58 Smith, K. ‘One Hundred Million ImprovedCookstoves in China: How Was It Done?’World Development (1993) Vol.21 No.6,pp.941–961.

59 Misra, et al. ‘We can do something aboutdeadly smoke’, International Herald Tribune(14 February 2003)

60 ‘Hitting the targets’, recommendations to theG8 for delivery of the Millennium DevelopmentGoals on water and sanitation, Action Aid(2003)

61 www.globalfundatm.org62 Lvovski, K. Environment and Health,

Environmental Strategy Paper No.1, WorldBank (October 2001)

63 ‘World Bank. Investing in health’, WorldDevelopment Report, Oxford University Press,New York (1993), referred to in 36

64 Tata Energy and Research Institute, GreenIndia 2047 (1997)

65 ‘WHO calls for urgent and concertedinternational action to prevent 5 millionchildren’s deaths annually from environmentalhazards’, WHO press release (7 April 2003)www.who.int/mediacentre/releases/2003/pr28/en/

66 http://wbln0018.worldbank.org/esmap/site.nsf67 http://wbln1018.worldbank.org/sar/sa.nsf68 Partnership for Clean Indoor Air, part of the US

Government initiative Powering SustainableDevelopment, US Environmental ProtectionAgency (2002)

69 ‘The LPG Challenge’, Partnership InitiativeInformation Sheet, WSSD, Johannesburg (2002)

70 Lallement, D. et al. ‘International programmes:focus on global village energy partnership’,ENERGIA News (2002) Vol.5 No.4

71 www.shellfoundation.org

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