The Impact of Household Energy and Indoor Air Pollution on the Health of the Poor: Implications for Policy Action and Intervention by Charles Kirubi

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2 The Impact of Household Energy and Indoor Air Pollution on the Health of the Poor: Implications for Policy Action and Intervention by Charles Kirubi Abstract More than 2 billion of the world s poorest people still rely on biomass and coal burning for household energy needs. Use of these fuels leads to levels of indoor air pollution many times higher than accepteble ambient air quality standards. This exposes women and children to a major public health hazard. Including the risk of acute respiratory infections (ARI), (pneumonia, chronic respiratory disease and lung cancer), and is estimated to account for a substantial proportion of the global burden of disease in developing countries. Other important direct health impacts from household energy use among the poor include burns to children and injuries to women from carrying wood. space heating. The majority of those exposed are women, who are normally responsible for food preparation and cooking, and infants/young children who are usually with their mothers near the cooking area. According to the International Energy Agency (lea, 2002), approximately 50% of the population in developing countries relies on biomass energy, with some regions recording higher proportions (73% in Africa). Biomass is the energy source for the poor. This is especially true for traditional biomass energy, which is often collected as a 'free' fuel (Reddy et al, 1997; Karekezi and Kithyoma, 2002). There appears to be a correlation between poverty levels and traditional biomass use in many developing countries. A wide range of interventions can reduce the impact of indoor air pollution. These include changes to the Source (improved s, cleaner fuels), living environment (better ventilation) and user behaviour (keeping children away from smoke during peak cooking times). These can be delivered through policies operating at national level and local level. Experience to date shows that successful implementation requires participation by local people (particularly women), collaboration between 'sectors' with responsibility for health, energy, environment, housing, planning etc., and with an emphasis on market sustainability. The use of poorly ventilated, inefficient s 'can have the same adverse health impacts as smoking two packs of cigarettes a day' according to UNOP (ITOG, 2001). However, the initial emphasis of research on household energy in developing countries was on environmental impacts of biomass use, such as impacts on deforestation and desertification, resulting in a level of zeal for increased efficiency. The public health benefits from reduction in exposure to indoor smoke as well as the reduction in carbon emissions became the subject of attention there after. This "double dividend"-improving public health while reducing adverse environmental impacts-focused a great deal of effort on the design and dissemination of improved s. From the public health perspective, biomass smoke contains a large number of pollutants that, at varying concentration levels, pose substantial risks to human health. Among hundreds of harmful pollutants and irritant gases, some of the most important include particulate matter, carbon monoxide, nitrogen dioxide, sulphur dioxide (mainly from coal), formaldehyde, and carcinogens such as benzo[a]pyrene and benzene. Studies from Asia, Africa and the Americas have shown that indoor air pollution levels from combustion ofbiofuels are extremely high - often many times the standards in industrialized countries such as those set by the U.S. Environmental Protection Agency (USEPA) for ambient levels of these pollutants (Schirnding, et ai2001). Health effects households Introduction Exposure to indoor air pollution from the combustion of traditional biomass fuels (wood, charcoal, animal dung, and crop wastes) and coal is a significant public health hazard predominantly affecting poor rural and urban communities in developing countries. Large numbers of people are exposed on a daily basis to harmful emissions and other health risks from biomass and coal-burning, which typically takes place in open fires or low-efficiency s with inadequate venting. It is estimated that globally 2 billion people -one third of the world's population - rely completely on traditional (solid) fuels for everyday household energy needs (UNDP, 2000, Reddy, et al, 1997). Biomass energy plays a vital role in meeting local energy demand in many regions of the developing world. Biomass is a primary source of energy for close to 2.4 billion people in developing countries (lea, 1998). It is easily available to many of the world's poor and provides vital and affordable energy for cooking and of biomass energy use in Whereas cities in industrialised countries infrequently exceed the US-EPA 24-hour standard for PMl 0 (small particles of diameter less than 10 microns) in rural homes in developing countries, the standard may be exceeded on a regular basis by a factor of 10, 20, and 153

3 sometimes up to 50, exceeding even the high levels found outdoors in such cities as in coal-burning northern China (Schirnding, et al200 I). Typical 24-hour mean levels of PM loin homes using biofuels may range from 300 to 3,000+ mg/m 3 depending on the type of fuel,, and housing. Concentration levels measured depend on where and when monitoring takes place, given that significant temporal and spatial variations (within a house, including from room to room), may occur. Ezzati et al, 2000, for example, have recorded concentrations of 50,000 ug/m 3 or more in the immediate vicinity of the fire, with concentration levels falling significantly with increasing distance from the fire. These small particles are able to penetrate deep into the lungs and appear to have the greatest potential to damage health. Levels of carbon monoxide and other health-damaging pollutants also often exceed international guidelines. these societies, to the annual rates) are over one hundred times greater in Kajiado and twenty times greater in West Kenya than the accepted values. Table 2 shows typical values for.particulate levels in the kitchen of a rural home, compared to current standards advised by the US Environmental Protection Agency (EPA) Health effects from biomass is therefore one of the major global health and energy problems. The largest direct impacts would seem to be respiratory infections in children (the most significant class of disease in the world) and chronic lung disease in non-smoking women. There are also a range of other health problems associated with biomass fuel cycle such as the impacts on women and children of gathering heavy loads of biomass in distant and sometimes dangerous areas and appear to have the greatest potential to damage health. Levels of carbon monoxide and other health-damaging pollutants also often exceed international guidelines. A review of recent studies on indoor air pollution in Kenya Reducing indoor air pollution in rural households: Western & Kajiado, Kenya This ITDG Smoke and Health project was carried out in Western and Kajiado areas of Kenya between (ltdg, 2001). Working with 50 households in rural Kenyan communities, the main objectives of the project were twofold: to improve the quality of life, through reduction in indoor air pollution, for households in these study areas; and to develop a participatory methodology for further research into appropriate ways to alleviate indoor air pollution. The two areas are totally different climatically and geographically as well as culturally (lifestyles, cooking habits and house types). Baseline monitoring in the kitchens in these areas showed that smoke levels were unacceptably high: in Kajiado, the 24-hour average of respirable particulates (PMIO) was 55261lglm3 and in West Kenya, the levels were I713llglm3. If one compares these values to the EPA standards for acceptable annual levels of respirable particulates of 50llg/m3 (Table 1), it can be seen that the daily rates (which are comparable, in TL_l":'...4..c...! n! 154

4 ...,cn ::r.. <> g ttl", ill , <> ttl 3 ::s > ~. ~~ ~8 ~.e. g ::I: ~ j Er -VI VI More fuelwood harvesting Increase in gathering Increase in human caloric needs to do Less food preparation time... the harvesting Less frequent preparation Increase risk of assault & injury (e.g., Inadequately cooked food Substitute inferior fuels reported in refugees camps in Kenya Preference for fast-cooking, (but (eg. Dung, residues) & Marsabit) often less nutritious) foods Increased risk from natural Less preparation of special foods for Substitute commercial hazards children, pregnant, lactating fuels... mothers, the ill, elderly, etc Economize on fuelwood Cooks Inferior biomass fuels More air pollution More tending time Less consumption More cooking time Poor time allocation Less income Less rest Less space & water heating..... Less hygiene Less time & human energy for other productive/learning.. Less food supply... activities Less food produced Less food purchased Less food stored Figure 1: Household coping strategies for fuelwood shortages (Source: Adapted from UNDP, 2000 & Kirubi 1998)

5 Table 2: Pollution level (PM 10 ) in micrograms per cubic metre of air( Ul!!m 3 ) i------:--c _ Source of During use 24 bour Annual _._~!p~!.urt:._~_.. ~.!.c:!~~ ave~~~ _ Biofuel Typically from Typically 24 hour (wood, 1000 up to 500 to average levels dung, etc) or more 1000 or are more experienced _...._.. ~_~!Y...~a.:L... US- EPA Only 1% standard of 24 hour 50 periods to exceed 150 The study tested the effectiveness of four interventions to mitigate and reduce the indoor air pollution namely smoke hoods, eaves spaces, windows and s. Results show that there were substantial reductions in the particulate matter and carbon monoxide levels in the sample households after the interventions were installed. The pre-intervention levels of PMresp in Kajiado were over 5000llgim3 and in West Kenya were over 17001lg!m3. Kitchen CO levels were 74ppm in Kajiado and over 10ppm in West Kenya. Overall changes in 24-hour averages following the interventions in Kajiado showed a 36 % reduction in PMresp, and in West Kenya there was an overall reduction of 63%. Significant substantial reductions were observed in both Kajiado and West Kenya for particulates and room CO. The findings also show that smoke hoods were by far the most effective in this particular study. Overall fmdings are summarized in Table 3. encouraging use of cleaner burning fuels and more advanced designs - process called moving up the "energy ladder." Further, by reducing the time needed to collect (or purchase) cooking fuels and combining health gains with improvements in household fuel, cook programmes can simultaneously meet economic efficiency, environmental conservation and quality of life objectives. This finding is further supported by a study on poverty reduction aspects of successful improved household pragrammes undertaken in Nairobi (Kenya), Kampala (Uganda) and Addis Ababa (Ethiopia) (ESD, 2000). Transition to more advanced designs and cleaner fuels can significantly reduce indoor air pollution (Table 5). Improved cook technology and indoor air pollution: Kiambu District, Kenya A study by Wafula, et al (2000) from the Department of Pediatrics and Child Health, College of Health Sciences, University of Nairobi, demonstrated statistically significantly reductions in the prevalence of ARI and conjunctivitis among women and children under five in Kiambu District who used s versus those who did not (Table 4). Therefore, as the health risks associated with biomass cooking become increasingly clear, the case for continued and expanded improved projects is strengthened. Kammen (1995) notes that successful improved cook pragrammes and outreach, education, demonstration and construction efforts can contribute to reducing harmful woodsmoke exposure in a number of ways: a) by improving venting of combustion gases through use of a flue or chimney, b) by improving combustion efficiency through better designs, and c) by 156

6 Table 3: Overview of reductions in particulates and carbon monoxide resulting from installation of interventions Source: ITDG, 2001 Table 4: Prevalence of ARI and conjunctivis as a function of cooking devices used in households ARI prevalence Conjunctivitis prevalence traditional improved Prevalence traditional improved Prevalence 3-stone fire reduction 3-stone fire reduction Women 38% 13.5% 64% 12% 4% 67% (15-20 yrs) Children 59% % 40.9% 12.4% 70% «5 yrs) (Source: ESD, 2000) Table5: Concentration of carbon monoxide (CO) from indoorbiofuel combustion, various fuel & combinations,kenya Fuel and No. of CO (parts per combination measurements million by volume)' Dung/traditional Wood/traditional Charcoal/traditional Charcoal/improved Kerosene fuel & WHO l-hour exposure standard 46 (Source: Karnmen, 1995) The "energy ladder" concept is fundamental to efforts tounderstand household energy decision-making. It is the household or micro-economic corollary to what Statusof Environmental Health Education in TheEastern Africa Region 157 happens at the macro-economic level as countries industrialize and move from traditional biomass to commercial fossil-fuel-based economies (Kammen, 1995). Under this hypothesis, as households become more affluent, they move from simple s and inexpensive fuels to more sophisticated, convenient, and costly fuels and s. The ladder climbs from dung or crop residues combusted in three-stone fires, to wood or charcoal use in metal or improved s, to kerosene wick or pressure systems and finally propane, liquid petroleum and electric appliances. The health and energy impact of climbing up this ladder can be dramatic. Simple biomass s may use six to seven times as much fuel as modem improved, and release 50 times more pollutants than a gas used to prepare the same quantity of food (Karnmen, 1995). The poorest segments of society, thus not only are exposed to higher levels of pollution, but must also spend greater share of household income and resources

7 to cook the same meal. For instance, Cecelski (2003) highlights that higher-income people generally use more efficient and more convenient sources of energy, such as gas and electricity, whereas poor people use less efficient and less convenient sources, such as fuelwood and human energy. In actuality, multiple fuel use is common at all income levels and the "fuel ladder" is perhaps more accurately replaced by a "fuel pyramid" of multiple fuels for different purposes and at different times. What is important to note is that poor people have fewer energy options than do the nonpoor people, and they often pay more for them both absolutely (paying higher unit prices) and relatively (as a percentage of their income) than do the nonpoor. Poor women nonetheless highly value and need multiple Table 5: Potential interventions Source Improved cooking devices Chimneyless improved biomass s Improved s with flues attached Alternative fuel-cooker combinations Briquettes & pellets Charcoal, kerosene Liquefied petroleum gas (LPG) Biogas, producer gas Solar cookers (thermal) Other low smoke fuels Electricity energy options to help manage their daily work and time. In Java (Indonesia) families using electricity have lower lighting expenditures and receive on average six times as much light as households using kerosene (World Bank, 2000). For cooking, the urban poor often pay more for wood and charcoal than they would for LPG once the end-use efficiencies of the fuels are taken into account. Recommendations for reducing lap exposure in developing countries Intervention measures to reduce the impact of lap include changes to the source, living environment and user behaviour, (Table 4) and can be delivered through policies operating at national and local level. for reducing lap exposure in developing countries Living environment Improved ventilation Hoods/frreplaces& chimneys into structure of house Windows/ventilation holes built Kitchen design & placement the Shelters/cooking huts Stove at waist height of User behavior Reduced exposure operation of source Fuel drying Use of pot lids Good maintenance Sound operation through Reductions by avoiding smoke Keeping children off smoke Food preparation Partially pre-cooked food Reduced need for the future Efficient housing Solar water heating Source: Scbirnding, et al, 2001 documentation of data on traditional biomass supply and consumption, which is regularly updated and validated, need to be instituted. Implications for energy policy and recommendations a) Data and information gaps and needs Data and information on biomass energy use in many developing countries is outdated and often unreliable, which makes it difficult to plan. In comparison to the conventional energy sector, which has comprehensive 5-10 year plans, planning for biomass energy is often incoherent, sporadic, and starved of the necessary budgetary allocation (Karekezi, et al 2004). The mobilization of additional financial and technical resources to support data collection and associated biomass energy planning is of priority importance (Kituyi, 2002). Initiatives pertaining to inefficient and environmentally unsound traditional energy options should primarily be aimed at research and analysis as well as data collection to provide the basis for developing effective strategies for reducing reliance on traditional energy options. It is noted that many poor developing countries do not have reliable databases on traditional biomass energy use. This makes it difficult to formulate appropriate policy and field-oriented interventions. Mechanisms for collection and b) Removing the barriers to accelerated adoption and use of improved biomass technologies Many policy analysts stress the need for aggressive dissemination of improved biomass technologies (Ils'Is) in developing regions, to mitigate the negative effects of traditional biomass energy use particularly indoor air pollution that is linked to respiratory diseases, one the main causes of death for children under the age of five. Governments should put in place policies that support the development and dissemination of mts. Private sector, NGOs, CBOs and donor organisations should implement projects aimed at ensuring the rapid dissemination of mts. Efforts to reduce the cost of widely used Ils'Is such as improved cooks should be accelerated, so that they are within the reach of even the poorest of the poor in Africa. Barriers to the uptake of improved biomass technologies should be addressed, and lessons from successful programmes documented for widespread dissemination and replication. \58

8 c) Regulation/promotion of sustainable charcoal production and use Given the harmful environmental impacts of charcoal production in the region, there is need to regulate the production of charcoal (EAA,2003). Afforestation and reforestation projects should be established as part of all charcoal production programes. The widespread use of improved and efficient charcoal kilns should be promoted. Africa, Kenya's consumption of LPG at l.lkg/capita compares dismally to other countries such as Egypt (36.2kg/capita), Senegal (10.3 kg/capita), Cote de voire (2.7kg/capita) and it is far below the African average consumption of8.3kg/capita (Nyoike, 2004). References Cecelski, E., 2003, 'Energy, Poverty & Gender: Enabling equitable Access to rural electrification:current thinking on energy, poverty & gender', World Bank, Washington, DC d) Addressing gender-energy concerns It is important for improved biomass energy system development and dissemination programmes to recognize the gender- and income-differentiated impactsof biomass energy use. In particular, improved biomass energy technologies that alleviate the burden and negative health effects of traditional biomass energy on the rural poor (comprising primarily of women and children) should be promoted and given prominence in government policies Energy Alternatives Africa (EAA) Ltd, 2003, 'Sustainable energy in Kenya series, Policy Briefing No.2, Sustaining woodjuel supply', Nairobi Energy for Sustainable Development (ESD), 2000, 'Poverty Reduction Aspects of Successful Improved Households Stove Programmes', DFID KaR R7368, e) Fuel substitution It is critical to for national energy policies to work towards progressive to clean and efficient energy services that would substitute traditional biomass, particularlpg and kerosene through removal of tariffs. As a cooking fuel, LPG is 10 times more energy efficient than wood fuel and several thousand times lesspolluting.' In 1995, Kenya had fewer than 50,000 household LPG cylinders in use, almost entirely in the fourlargest urban areas. Yet LPG remains inaccessible to most of the population due to high upfront costs as well as high tariffs and duties (18% VAT, and import duty on LPG) in Kenya for instance. If the latter were removed, one industry group estimates sales of cylinders would increase by 20% and sales of gas by 18%.2 Price volatility of LPG is another critical concern for domestic consumers. Credit schemes through various channels would also accelerate the ratesoffuel switching from biomass to LPG particularly forthe urban-poor and rural households - resulting in a win-win situation for the health of poor people, the economy and environment. The lessons from Brazil with respect to promoting LPG for cooking in households are very relevant to other developing countries. By 1999, Brazil had managed to achieve 99.4%adoption and use of LPG s by households, thanks to subsidies which catalysed and bolstered the demand and the market", This almost completely eliminatedthe use offuelwood for cooking and created 300,000jobs. It is estimated that this shift in fuels has avoided the deforestation of one million hectares of forest per year. Among developing countries, Brazil ranks seventh in per capita consumption of LPG at approximately 40 kg/capita/year. In sub-saharan Ezzati & Kammen, 2001, 'Quantifying the Effects of Exposure to Indoor Air Pollution from BiomassCombustion on Acute Respiratory Infections in Developing Countries', Environmental Health Perspectives Volume 109, Number 5, May 2001; pp: International Energy Agency 'World Energy Outlook', lea, Paris.lEA 2002 Intermediate Technology Development Group, 2001, 'Reducing indoor air pollution in rural households in Kenya:working with communities to find solution, The ITDG Smoke and Health project ,' ITDG Kammen, 1995, 'From energy efficiency to social utility: lessons from cook design, dissemination& use', In: Goldemberg, J., & Johanson, T.B., (eds), 1995, Energy as an instrument for socialeconomic development, UNDP, NY. Karekezi, S., & Kithyoma, W., 2002, 'Renewable rural Africa: is a PV-led renewable energy strategy the right approach for providing modern energy to the rural poor of sub-saharan Africa?' In: Energy Policy 30 (2002): , Elsevier Science Ltd. Karekezi, S., Lata, K, Coelho, S.T., 2004, 'Traditional Biomass Energy: Improving its Use and Moving to Modern Energy Use', Thematic Background Paper, Renewables 2004, 159

9 Kirubi, c., 1998, Impact of woodfuel demand on Marsabit Forest, M.Sc. Thesis, Environmental Science Department Kenyatta University Kituyi, 2002 Nyoike, P., 2004, Overview of draft national energy policy, proceedings of workshop for the Draft National Energy Policy, School of Monetary Studies, 12th-13 th February 2004, Ministry of Energy, Nairobi Reddy, A.K.N., Williams, R.H., & Johansson, T., 1997, 'Energy After Rio: Prospects & Challenges', UNDP, New York. Schimding, Y., Bruce, N., Smith, K., Ballard- Tremeer, G., Ezzati, M., & Lvovsky, K., 2001, 'Addressing the impacts of household energy & indoor air pollution on health of the poor - implications for policy action & intervention measures', WHO Commission on Macroeconomic & Health (CMH working paper series, Paper No. WG5:12), Washington DC. UNDP UN Department of Economic and Social Affairs & World Energy Council, (UNDP& WEC) 2000,' World Energy Assessment: the challenge of sustainability', UNDP, New York Wafula, E.M., Kinyanjui, M., Nyabola, L., & Tenambergen, E.D., 2000, In: Energy for Sustainable Development (ESD), 2000, 'Poverty Reduction Aspects of Successful Improved Households Stove Programmes', DFID KaR R7368, World Bank, Energy Sector Management Assistance Programme (ESMASP), 2000, 'Energy Services for the Worlds Poor' World Bank, Washington, DC. 160