Air pollution caused one in every eight deaths and a total of 1.24 million deaths in India in 2017. More than half these victims were less than 70 years old, according to the air pollution mortality and morbidity estimates by India State-Level Disease Burden Initiative published in The Lancet Planetary Health on December 6, 2018.

India’s annual average level of fine inhalable particles in the air, commonly referred to as PM 2.5, was 90 μg/m3–the fourth highest in the world and more than twice the limit of 40 μg/m³ recommended by the National Ambient Air Quality Standards in India and nine times the World Health Organization annual limit of 10 μg/m3.  

India has a disproportionately high share of premature deaths due to air pollution–despite being home to 18% of global population, it accounts for 26% premature deaths and disease burden due to air pollution.

About 77% of India’s population was found to be exposed to ambient air pollution levels above the national safe limit. Worst-hit northern states include less-developed ones–Rajasthan, Uttar Pradesh, Bihar–and affluent ones such as Delhi, Punjab, Haryana and Uttarakhand.
“There was skepticism in India regarding the estimates of ill health due to air pollution but this study proves that air pollution–including both ambient and household pollution–is one of the biggest risk factors for death and disability in India, more than tobacco use, salt intake, high blood pressure and any other risk factor,” Kalpana Balakrishnan, professor, Sri Ramachandra Institute of Higher Education and Research, Chennai and lead author of the study, told IndiaSpend.

“This study conclusively proves that air pollution leads to a decrease of 1.7 years of life expectancy and not four years as believed before,” said Balrama Bhargav, Director General, Indian Council of Medical Research (ICMR).

The study was the first ever comprehensive estimate of impact of air pollution in each state of India and was jointly conducted by the ICMR, the Public Health Foundation of India (PHFI), and the Institute for Health Metrics and Evaluation (IHME). The initiative works in collaboration with the ministry of health and family welfare and over 40 experts across India.

Poor, less developed states have earlier deaths
As pointed out earlier, 77% of the country was exposed to annual mean PM 2.5 levels higher than the national limit and there was significant variation between pollution levels in different states. The state with the highest ambient air pollution was 12 times worse than the state that suffered the least. This difference was 43 times in the case of household pollution.

The minimum exposure level of PM 2.5 is between 2.5 and 5.9 μg/m3, said the report.

Northern states with lower social development index (SDI)–calculated using per capita income, education levels and total fertility rate–Bihar, Uttar Pradesh, Rajasthan and Jharkhand had the highest levels of both ambient and household pollution. These states would benefit the most if air pollution was lesser: For example, inhabitants of Rajasthan and Uttar Pradesh will add two more years to their life if air pollution was below the national limit.

Badly affected middle and high SDI states such as Delhi, Punjab and Haryana could also add to the life expectancy of their residents from the reduction of ambient air pollution but by fewer years–1.6, 1.8 and 2.1 years respectively.

Source: The Lancet Planetary Health

Solid fuels lead to high deaths and disability
Even though more than half (55.5%) of the country is still using solid fuels–dung, coal, wood and agricultural residue–for burning, it was greater than 72.1% in the low-SDI states of Bihar, Jharkhand, Odisha, Chhattisgarh, Assam, Madhya Pradesh and Rajasthan. These states together suffered half the deaths caused by household pollution.

Source: The Lancet Planetary Health

All states had deaths attributed to household pollution. For example, Kerala has almost equal number of deaths due to ambient and household pollution. “It is a myth that most states have shifted from solid fuel to cleaner fuels,” said Balakrishnan.

There has been a 30% decrease in household pollution in the last five years (2012-2017) but it is too early to say if it is due to Pradhan Mantri Ujjwala Yojana (PMUY) that aims to distribute LPG cylinders to low income households, said Balakrishnan.

While it has the potential to cause single highest decrease in household pollution, evidence will be available two years from now. “While the problem of access and availability of clean fuel has been solved, the focus should now be to make it affordable,” she said.

Household air pollution led to 482,000 deaths and 21.3 million disability adjusted life years (DALYs)–years lost due to ill-health, disability or early death–in 2017.

Ambient air pollution affected 38.3% more men than women while household pollution killed 17.6% more women than men.

More respiratory issues due to the air than smoking
Air pollution is commonly associated with lung disease but contributed to 38% of India’s cardiovascular disease and diabetes burden in 2017.

In 2015, 2.5 million of 10.3 million deaths in India due to non-communicable diseases (NCDs) are linked to pollution. This makes India the country with the highest number number of pollution-related deaths, followed by China, IndiaSpend reported on January 3, 2018.

Chronic Obstructive Pulmonary Disease (COPD) led to 13% of all deaths and 7.5 million were at risk of the disease in 2016, IndiaSpend reported in January 2018.

Since PM 2.5 crosses the blood-air barrier affecting all organs of the body, the government is taking serious cognisance of its health impact and has included COPD in its screening programme for non-communicable diseases as part of Ayushman Bharat, said Bhargava of the ICMR.
The disease burden for lower respiratory infections due to air pollution was higher than the rate attributable to tobacco use.

For non-communicable diseases, including COPD, ischaemic heart disease, stroke, diabetes, lung cancer, and cataract, disease burden due to air pollution was same as that of tobacco use, said the report.

State-specific strategies suggested
“Control of ambient particulate matter pollution requires action in several sectors and the linkage of these actions for greatest impact,” said the report.

The report suggested state-specific policies–in Delhi, the use of compressed natural gas by vehicles; in Punjab, subsidies for alternative technologies to compost agricultural waste so it does not have to be burnt; and in Maharashtra, the mandatory use of fly ash in the construction industry within 100 km of coal or lignite thermal plants. But these measures can also be expanded to other states with particulate matter emission issues, it said.

The Clean Air for Delhi Campaign, launched in early 2018 by ministry of environment, forest and climate change, that led to the launch of the National Clean Air Programme got a special mention in the report. The programme aims to sensitise the public on issues relating to air pollution and enhance coordination between the implementing agencies across the country.

The report was also optimistic about the impact of efforts like India’s Intended Nationally Determined Contribution target–that countries take themselves to reduce national emissions and adapt to the impacts of climate change. India’s target aimed at the reduction of particulate matter by 33-35% by 2030.

The promotion of electricity-driven public transport and upgradation of vehicles to the emissions-friendly Bharat Stage VI standards will also help reduce pollution levels, the study said.

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend
 

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Apart from adivasis, if you feature on the bottom of the social ladder in India, or are dalit (schedule caste or SC) or Muslim, you are more likely to die younger, suffer poor health and have low access to healthcare compared to those belonging to the non-Muslim upper class, found the analysis “Caste, Religion, and Health Outcomes in India, 2004-14” by economist Vani Kant Borooah, published in the Economic & Political Weekly on March 10, 2018.
 
Over the decade to 2014, all social groups, except adivasis, were living longer than in 2004–the mean age of death for STs had reduced since 2004 when it was 45 years.
 
Dalits, whose average lifespan was 42 in 2004, were likely to live six years longer by 2014, the analysis found.
 
Non-Muslim households of the upper classes appear to live the longest among the six groups with a mean age of death of 60 years in 2014–up from 55 years in 2004.
 
“The point about group membership is that while it may not be the primary factor behind health inequality, it is the main cause of health inequity,” Barooah wrote, adding that the inequity refers to the inequality an individual suffers because of factors beyond their control.
 
To evaluate the relative role a person’s economic and social status plays in determining his/her health status in India, Barooah used National Sample Survey Office (NSSO) datasets from 2004 and 2014. Combining the NSSO “social group” and “religion” categories, households were split into six groups: adivasis of which 56% were Hindu and 33% were Christian; dalits of which 93% were Hindu; non-Muslim other backward classes; Muslim other backward classes; and non-Muslim upper classes.

 
In non-social group variables–categories unrelated to caste and religion–the average life of a labourer (45.2 years) was more than three years shorter than that of a non-labourer (48.4 years), the analysis found. Similarly, living in a “backward” or less-developed state reduced the average age of death (44.4 years) by over seven years compared to living in a “forward” or more developed state (51.7 years).
 
Adivasis least likely to report being in poor health; Muslims most likely
Despite adivasis dying younger than other social groups, least among them felt they were in ill-health (24%), though the numbers reporting sick had risen from 19% since 2004, according to the study, which also analysed NSSO data on the perception of current health status among senior citizens (aged 60 years and above) across social groups. This was the same among persons of the non-Muslim upper class group, which had minimally changed since 2004 (23%).
 
The status showed whether these persons reported to be in excellent, very good, fair, or poor health, allowing the study to calculate a predicted probability of poor health (PPPH).
 
Most to report being in poor health, or 35%, were Muslims–both OBC and upper class–the data showed.
 
More women (28%) than men (24%) reported to be in poor health, the study found.

 
Among non-social groups, the predicted PPH was significantly higher for persons in “wage labour” households (29%) than for those self-employed or earning regular salaries (26%), the study found.
 
In 2014, people in urban areas were more likely to report being in poor health (28.7%) than their rural counterparts (25.3%) though this was not the case a decade ago when rural (24.3%) and urban (24.5%) residents shared similar views.
 
Also, fewer persons in “forward states” were likely to report being in poor health (24.2%) than those in “backward” states (29.2%), the analysis showed.
 

Poor, single persons more likely to report being in poor health
The economic circumstances of a person’s household also played a role in determining the predicted PPH, the study found. Persons in households belonging to the lowest two wealth categories were significantly more likely (over 27% for both) to report being in poor health than persons in the highest wealth category (25.4%), NSSO data show.
 
Access to flush or septic tank latrine in the house reduced the predicted PPH (24.6%) compared to the perception of persons with access to latrines of other types or no latrine altogether (27.9%), the study found.
 
Similarly, cooking with gas or electricity (24.4%) compared to other fuel types (27.8%) significantly reduced the predicted PPH.
 
Personal attributes too played an important role in determining a person’s predicted PPH.
 
For example, married persons had a lower predicted PPH than those who were single, widowed or divorced, according to the study, which also found the predicted PPH of illiterate persons (27.9%) was significantly higher than that of graduates (18.3%).
 
(Saldanha is an assistant editor with IndiaSpend.)

Courtesy: India Spend
 

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