Editorial
The notion of air pollution can conjure up the murky haze that clings to urban skylines, but air pollution is often a much more intimate threat, emanating from hearth and home. WHO estimates have placed a global tally of more than 7 million deaths caused annually by air pollution; of this number, 4·3 million deaths are attributed to household air pollution created by stoves that use biomass, such as crop waste and animal dung, or coal as fuel. To address the threat of indoor air pollution in low-income and middle-income countries, WHO released new guidelines for indoor air quality and household fuel combustion on Nov 12. The adoption of large-scale transitions to other forms of fuel or new technology is a pervasive challenge. However, on the basis of the quality of evidence and using interim goals, the WHO guidelines specify four major recommendations. First, emission rates from household fuel combustion should not surpass the emission rate targets of carbon dioxide for annual and 24-h averages. Second, governments and partners must prioritise transitional fuels and technologies that are beneficial to health, such as clean fuel stoves that use natural gas or solar electricity. The third and fourth recommendations are to reduce reliance on the household use of coal and kerosene, respectively. These are difficult goals to meet in resource-limited settings where the levels of household air pollution are the highest. Pneumonia and household air pollution make an intimate and insidious pair. Although rates of child pneumonia have fallen by 58% between 1990–2013, pneumonia continues to be a leading killer of children. More than 50% of pneumonia deaths in children younger than 5 years are associated with exposure to household air pollution and occur in only six countries—China, Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan. Fittingly, Nov 12, the date that WHO released its guidelines, was World Pneumonia Day, which aims to raise awareness, promote interventions for prevention and treatment, and spur global action to combat pneumonia. For several reasons—including the difficulty of measuring the use of traditional forms of fuel, the fact that women and children are disproportionately affected by pollution from household fuel combustion, and the often fragmented deployment of intervention efforts—the problem has not previously received as www.thelancet.com Vol 384 November 22, 2014
much attention as it deserves. 2014, however, has done much to change that through independent reports by WHO, the Institute for Health Metrics and Evaluation (IHME), and The Lancet Respiratory Medicine Commission, which have mapped out the scope of the issue, identified the risks of household air pollution in pneumonia and other respiratory tract infections, and introduced riskreduction strategies. Because of the strong evidence linking household air pollution and respiratory tract infections in infants and children and negative developmental health outcomes, early intervention is crucial. A collaborative report from the Millennium Development Goals Health Alliance and IHME underscored the importance of increasing availability of rapid detection methods and low-cost treatments of respiratory infections. Providing a complementary suggestion, The Lancet Respiratory Medicine Commission identified the need to scale up pneumococcal conjugate vaccination, but cautions that vaccination will only be partly successful since exposure to household air pollution can hamper its efficacy. The risk for pneumonia and child mortality, however, can be substantially reduced where household air pollution is better managed. Considerable overlap exists between the Commission’s recommendations and those in the WHO guidelines. Specifically, both reports suggest the need to offset reliance on traditional fuels, such as coal and kerosene, with clean fuels such as gas. But affordability is paramount. In the most impoverished settings, without subsidising these shifts, it is unlikely that there will be traction. Furthermore, women, who are affected the most by household air pollution, are valuable stakeholders and essential to the success of interventions. Finally, monitoring progress is a crucial joint recommendation. Although neighbourhood and household levels of pollution must be assessed, individual-level monitoring is the only way to account for varying roles within the household and an important way to measure success. Prescriptive steps are easier outlined than implemented. With the enormity of the predicament, stakeholders must be both inside the home as well as outside. It is a daunting prospect to consider how to make clean energy available to all, but it is fundamental. Providing safer fuel alternatives and technology will save lives and literally change how the world cooks—one household at a time. The Lancet
Blend Images/John Lund/Stephanie Roeser/ Getty Images
Improving air quality starts at home
For WHO’s new indoor air pollution guidelines see http://who.int/mediacentre/ news/releases/2014/indoor-airpollution/en/ For the IHME report on indoor pollution and pneumonia deaths see http:// www.healthdata.org/sites/ default/files/files/policy_ report/2014/PolicyReport_ IHME_PushingthePace_2014.pdf For the Commission on household air pollution see Commission Lancet Respir Med 2014; 2: 823–60
1821
The notion of air pollution can conjure up the murky haze that clings to urban skylines, but air pollution is often a much more intimate threat, emanating from hearth and home. WHO estimates have placed a global tally of more than 7 million deaths caused annually by air pollution; of this number, 4·3 million deaths are attributed to household air pollution created by stoves that use biomass, such as crop waste and animal dung, or coal as fuel. To address the threat of indoor air pollution in low-income and middle-income countries, WHO released new guidelines for indoor air quality and household fuel combustion on Nov 12. The adoption of large-scale transitions to other forms of fuel or new technology is a pervasive challenge. However, on the basis of the quality of evidence and using interim goals, the WHO guidelines specify four major recommendations. First, emission rates from household fuel combustion should not surpass the emission rate targets of carbon dioxide for annual and 24-h averages. Second, governments and partners must prioritise transitional fuels and technologies that are beneficial to health, such as clean fuel stoves that use natural gas or solar electricity. The third and fourth recommendations are to reduce reliance on the household use of coal and kerosene, respectively. These are difficult goals to meet in resource-limited settings where the levels of household air pollution are the highest. Pneumonia and household air pollution make an intimate and insidious pair. Although rates of child pneumonia have fallen by 58% between 1990–2013, pneumonia continues to be a leading killer of children. More than 50% of pneumonia deaths in children younger than 5 years are associated with exposure to household air pollution and occur in only six countries—China, Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan. Fittingly, Nov 12, the date that WHO released its guidelines, was World Pneumonia Day, which aims to raise awareness, promote interventions for prevention and treatment, and spur global action to combat pneumonia. For several reasons—including the difficulty of measuring the use of traditional forms of fuel, the fact that women and children are disproportionately affected by pollution from household fuel combustion, and the often fragmented deployment of intervention efforts—the problem has not previously received as www.thelancet.com Vol 384 November 22, 2014
much attention as it deserves. 2014, however, has done much to change that through independent reports by WHO, the Institute for Health Metrics and Evaluation (IHME), and The Lancet Respiratory Medicine Commission, which have mapped out the scope of the issue, identified the risks of household air pollution in pneumonia and other respiratory tract infections, and introduced riskreduction strategies. Because of the strong evidence linking household air pollution and respiratory tract infections in infants and children and negative developmental health outcomes, early intervention is crucial. A collaborative report from the Millennium Development Goals Health Alliance and IHME underscored the importance of increasing availability of rapid detection methods and low-cost treatments of respiratory infections. Providing a complementary suggestion, The Lancet Respiratory Medicine Commission identified the need to scale up pneumococcal conjugate vaccination, but cautions that vaccination will only be partly successful since exposure to household air pollution can hamper its efficacy. The risk for pneumonia and child mortality, however, can be substantially reduced where household air pollution is better managed. Considerable overlap exists between the Commission’s recommendations and those in the WHO guidelines. Specifically, both reports suggest the need to offset reliance on traditional fuels, such as coal and kerosene, with clean fuels such as gas. But affordability is paramount. In the most impoverished settings, without subsidising these shifts, it is unlikely that there will be traction. Furthermore, women, who are affected the most by household air pollution, are valuable stakeholders and essential to the success of interventions. Finally, monitoring progress is a crucial joint recommendation. Although neighbourhood and household levels of pollution must be assessed, individual-level monitoring is the only way to account for varying roles within the household and an important way to measure success. Prescriptive steps are easier outlined than implemented. With the enormity of the predicament, stakeholders must be both inside the home as well as outside. It is a daunting prospect to consider how to make clean energy available to all, but it is fundamental. Providing safer fuel alternatives and technology will save lives and literally change how the world cooks—one household at a time. The Lancet
Blend Images/John Lund/Stephanie Roeser/ Getty Images
Improving air quality starts at home
For WHO’s new indoor air pollution guidelines see http://who.int/mediacentre/ news/releases/2014/indoor-airpollution/en/ For the IHME report on indoor pollution and pneumonia deaths see http:// www.healthdata.org/sites/ default/files/files/policy_ report/2014/PolicyReport_ IHME_PushingthePace_2014.pdf For the Commission on household air pollution see Commission Lancet Respir Med 2014; 2: 823–60
1821
