Public Health and Household Energy - the International Context

1.0 Introduction

In first health briefing paper, a wide range of health impacts associated with household energy were described. These included the direct effects of indoor air pollution (IAP) on acute lower respiratory infections (ALRI), chronic obstructive lung disease (COLD), lung cancer and a number of other conditions, other direct consequences of energy use such as burns and poisoning, as well as less direct impacts resulting from time spent and risk associated with collecting fuel, restricted opportunities for economic activity, and so on. The links with environment and gender were explored, and the close inter-relationship between energy use, health and poverty emphasised.

It was noted that, of all the impacts of household energy on the well-being of poor people, it is the health effects of IAP that are best understood and quantified. However, the fact that many other impacts of household energy use on health and development have been inconsistently studied and poorly quantified does not mean that these are not also important. Estimates of the global burden of disease associated with solid fuel use were reported. The most recent information on GBD, published in the 2002 World Health Report - and discussed further below - found that IAP is responsible for around nearly 3% of "Disability Adjusted Life Years" (DALYs) [WHO 2002].

In this second paper we will look in some more detail at the new WHO information on GBD, and then go on see how emerging knowledge about the links between household energy and health relate to key issues on the international health and development agenda, and some of the implications these issues have for research and policy.

Global burden of disease from indoor air pollution

Drawing on the most consistent studies of ALRI, COPD and lung cancer, the World Health Organisation has recently estimated that IAP is responsible for around 1.6 million deaths per year, and 2.7% of the global burden of disease, expressed as Disability Adjusted Life Years lost [WHO 2002]. This placed IAP eighth in the global ranking of key risk factors for disease.

A more information picture can be gained from a focus on the poorest countries - those with the highest levels of mortality and the greatest dependence on solid fuel (Figure 1). Among these countries, the use of solid fuels was ranked fourth among key risk factors for health, behind malnutrition, unsafe sex (AIDS/HIV) and water/sanitation (Figure 1), responsible for around 1 million deaths and 4% of DALYs. The majority of these DALYs arise from ALRI in young children, and it is estimated that approximately 40% of all child deaths from this condition in the high mortality developing countries are the result of exposure to indoor air pollution.

Figure 1: Estimated burden of disease (DALYs) for key risk factors in high mortality developing countries. [Source WHO 2002].

These estimates are based solely on those health impacts for which the evidence is most robust - epidemiological studies of increased risk of ARI, COLD and lung cancer due to IAP. These GBD figures may therefore be an under-estimate of the true situation, and a priority for research is to extend our knowledge of the other health impacts of household energy use in developing countries

Links between energy, health and sustainable development

Among the most significant recent developments in this field have been the growing recognition of a set of inter-related issues which address links between energy, health and sustainable development, including:

• The importance of environment and health, particularly for children
• The restrictions that current patterns of energy use in developing countries place on economic and social development
• The impacts of energy use in developing countries on health, particularly in respect of air pollution
• The fundamental role of sustainable development in addressing all these issues

The importance now being accorded to these issues is reflected in the attention given by international organisations, governments, and in the forums, policies and other activities that signify this awareness and - crucially - provide opportunities for action. A number of the most relevant of these activities are now described leading up to the 2002 WSSD in Johannesburg, with a particular focus on the recognition of health links and impacts, and how health related action can contribute to positive change.

• The World Health Organisation (WHO) has in recent years developed a broad portfolio of work in this field. This has included a focus on children"s environmental health through the work of the Children"s Environmental Health task force (and post-WSSD the Healthy Environments for Children Alliance), research on the prevention of ALRI through reduced IAP, technical work on air pollution monitoring, risk and quality standards [WHO-PEH], estimates of the GBD associated with IAP (see above), and a range of broader work on household energy and health [WHO 1992; Washington 2000], indicators, and a joint lead role in WSSD preparation [WSSD 2002(a) - Health]. In March 2002, a Consultation was held in Bangkok on Children"s Environmental Health, one product of which was the "Bangkok Statement" [Bangkok Statement 2002]. This acknowledged the importance of the environment to public health and the vulnerability of children, noting that "more than one quarter of the GBD can be attributed to environmental risk factors. Over 40% of the environmental disease burden falls on children under 5 years of age, yet these constitute only 10% of the world population". The consultation examined a wide range of environmental risk factors, and concluded that "in developing countries the main environmental health problems affecting children are exacerbated by poverty, illiteracy and malnutrition, and include: indoor and outdoor air pollution, lack of access to safe water and sanitation, exposure to hazardous chemicals, accidents and injuries". Some additional information on WHO activity in respect of WSSD and child health research is given below.

• In April 2002, the G8 Environment Ministers met in Banff, Canada, and delivered a statement as part of their work to "advance preparations for the upcoming World Summit on Sustainable Development" [G8 Banff 2002]. Their statement considered environment and development, environment and health, and the national and international governance issues required. The G8 recognised that "The connection between health and the quality of our environment has become a key driver of environmental protection in both developed and developing countries", and that "there is also a growing appreciation of the linkages between environment, health and poverty". In line with theme of the March 2002 WHO Bangkok meeting (above), concern was expressed by the G8 Ministers in particular for children and other vulnerable populations.

• The 2002 World Summit on Sustainable Development (WSSD) was an important focus for bringing these issues together and providing and impetus for action. The meeting was only part of an ongoing process, the impact of which will need to be assessed over time. The preparation for this meeting nevertheless provides some clear insight into the extent to which the issues discussed here are gaining attention, and in particular how awareness of health impacts and linkages might be/is being translated into more effective action by health "systems" as well as though collaboration with other "sectors" at various internationally, nationally and at the local level. The "Framework for Action" documents produced by the WEHAB (Water, Energy, Health, Agriculture and Biodiversity) working groups are a useful guide to the approach. Two of these working group reports, Health and Environment led by WHO and UNICEF [WSSD/WEHAB Health 2002] and Energy led by UNDESA, UNDP and UNIDO [WSSD/WEHAB Energy 2002] are the most pertinent for this review. In identifying the challenges, both reports emphasised the linkages between energy, health and development with the problems of household energy, IAP and poverty (especially in sub-Saharan Africa) receiving attention. In terms of addressing the problems, the health group considered the role of the health systems with the need for action outside the health sector and collaborative action having particular emphasis: "A shared health, environment and development agenda is needed to address both the direct threats to health associated with poor living conditions and the indirect threats associated with global change and development itself (p14)." The reports should be referred to for the detailed proposals on implementation, but some key themes from the Health and Environment group are the incorporation of health in development planning through (for example) environmental action plans, ensuring opportunities are taken for maximising health promotion and protection in the policies of all sectors, strengthening information on health and environment linkages, and building capacity to act on greater awareness of such links. The Energy group report noted that "providing access to energy services in rural areas is a daunting challenge that is not receiving adequate attention or resources". Five key areas are considered by this group for action: access to energy and modern energy services; energy efficiency; renewable energy; advanced fossil-fuel technologies; and energy and transport. It is interesting and encouraging to see how many of the targets and activities directly or indirectly impact on health - from reducing indoor air pollution, through the contribution of cleaner and more modern energy for health services, vaccination, education and provision of safe drinking water, increasing opportunities for income generation, and many other examples.

There have been mixed reactions to the outcomes and achievements of WSSD, many rather negative in terms of missed opportunities for concrete action.

Among the more clearly identified actions resulting from WSSD in respect of this topic are (a) the Partnership for Clean Indoor Air, a US funded initiative led by the Environmental Protection Agency, and (b) the Healthy Environments for Children Alliance, led by WHO.

The Partnership for Clean Indoor Air has indicated that it will initially focus on four core aspects of the problem:

• Social and behavioural barriers: develop locally targeted training modules for community and public health leaders to identify strategies to understand and modify behaviour patterns to overcome the cultural barriers regarding use of traditional fuels and stoves.
• Market development: support development of local business models and markets for improved cooking mechanisms, including development of micro-finance and other financial assistance options to develop local businesses and spur investments.
• Technology design: develop a certification organisation (to be self-sustaining over time) to identify, and develop design guidelines or standards for, efficient and needs-responsive cooking and heating technologies and ventilation systems.
• Health effects research: identify and pursue priority research needs to expand and refine knowledge of health effects of indoor cooking and heating practices in a variety of settings (e.g. fuel type, stove type, ventilation system).

This work is currently getting underway, and experience from the partnership will be reported in due course, in particular where this is relevant to the work of Sparknet.

The Healthy Environments for Children Alliance ( www.who.int/heca ) is described as "a world-wide alliance to intensify global action on environmental risks to children"s health that arise from the settings where they live, learn, play and earn, by providing knowledge, increasing political will, mobilising resources and catalysing action". Among the activities of HECA since WSSD are a stakeholder meeting held in Geneva in December 2002 (report available on web site), and a focus on children"s environment for World Health Day (April 7^th 2003). Key topics for action, identified in the December 2003 meetings, are:

• Household water security
• Hygiene and sanitation
• Air pollution, indoor and outdoor
• Disease vectors
• Chemical hazards
• Unintentional injuries or "accidents"

The reader is referred to the web site (see above) for more information on the work of HECA, and for resource materials.

These examples of recent activity (and there are many others, including for example key agreements which are set out in the WSSD WEHAB reports) clearly illustrate that awareness of energy, health and development linkages is starting to drive policy and planning at all levels.

Improving evidence for policy

If household energy and indoor air pollution are to become priority areas for international health and development action, there will need to be more robust and compelling evidence of the direct links with health, and - most important of all - evidence of the impact on key health outcomes of actual interventions. Research evidence is of course not the only factor that drives (or inhibits) policy, but it is becoming increasingly important, not least as a basis for economic analyses that are becoming more and more influential in resource planning.

One of the most important gaps in our knowledge about health risks is the relationship between the level of exposure and the most important health outcomes - for example ALRI. Figure 2 presents four possible relationships between exposure and health effects and illustrates why this issue is so important for interventions and policy.

Of particular importance to this discussion is the fact that very large numbers of poor people are, and (as things stand) are likely to remain for the foreseeable future, primarily users of biomass and other solid fuels. We know that, burned indoors in open fires, these fuels result in very high levels of IAP - typically with 24 hour average small particle (PM₁₀) levels in excess of 1000 mg/m³ [Health-brief 1; Bruce 2000]. This is indicated by the "open fire" category in Figure 1. Biomass stoves, whether of the ceramic chimney-less type or with chimneys, in practice rarely bring about reductions greater than 50-60% in these ambient levels of pollution, shown by the wood stove category in Figure 1. Where the impact on women and children"s personal exposures (as opposed to kitchen pollution levels) have been studied, the reductions are proportionately less - around 30% to 40% - probably because of a combination of factors [Bruce IA 2002], including:

• People may spend longer in less polluted homes
• Exposure to peak emissions during cooking tasks may not change in the same way as average exposure
• Even in rural areas there are exposure source outside the home due to smoke from other homes encountered either in the outdoor environment or when visiting neighbours.

This experience shows that in practice it is hard to achieve large reductions in IAP exposure among poor rural people using solid fuels, at least not to the low levels associated with clean fuels (Figure 2). At present, it is only at these low levels - up to 150 mg/m³ PM₁₀, that we have reasonably good evidence of the relationship between pollution levels and risk of various health outcomes [Air quality guidelines/WHO PEH], although it should be emphasised that all of this knowledge is drawn from urban developed country populations. In contrast, for developing country populations, we know very little about how much a move from the very high levels associated with open fires to the moderate levels seen with effective improved stoves will do to reduce the risk of serious conditions such as ALRI.

Figure 2: Schematic illustration of the possible relationships (A-D) between PM₁₀ level and the incidence of ALRI - see text and box for full explanation

Clearly, these various scenarios will have very different implications for estimates of the cost-effectiveness of interventions. The ability to carry out such economic analysis is another reason why investigation of this relationship is a priority issue for health research.

Our lack of knowledge about this relationship results - at least in part - from the fact that most studies on biomass use and ALRI risk to date have not measured pollution or exposure. However, the most recently published study on this topic does do so, and has started to provide some insight into what the relationship may look like [Ezzati 2001a; Ezzati 2001b]. This study describes a group of 345 rural Kenyan people (of which 93 were aged less than 5 years), living in 55 homes on a rural cattle ranch. Households used mainly wood or charcoal, in open fires and improved (chimney-less) stoves. Detailed personal exposure assessment was combined with weekly (initially bi-weekly) health outcomes assessment for adults and children using WHO criteria for the assessment of ALRI. The exposure-response relationships for particulates and incidence of ALRI, in children (less than 5 years) and adults are reported and presented in diagrams. The trend of increasing risk with higher levels of exposure was highly significant, and the authors report that the curve tends to flatten off with higher exposures.

If comparison is drawn with the schematic example used in Figure 2, the findings of Ezzati are in effect most like line D (though not as marked, as line D is present as an extreme case for emphasis), but readers are referred to the original papers for further interpretation. Socio-economic status and birth weight were not adjusted for in these analyses, but the authors reported that income, housing and nutrition varied little due to the social organisation of this ranch community. Other issues that should be considered in the interpretation of this study are the relatively small numbers, and the fact that the reported incidence of ALRI in young children was considerably higher than previously reported in similar populations.

Further work on describing the risk of ALRI associated with different levels of IAP exposure is currently starting in a randomised controlled trial, now underway in a sample of 500 homes in rural Guatemala which traditionally use open fires and wood fuel A locally produced chimney stove, the plancha (right) which in good condition is known to meet household needs and markedly reduce IAP levels, has so far been introduced to 250 of the houses (the intervention group) and will be offered to the remaining homes on completion of the study (the control group). Weekly home visits backed up by physician assessment and chest X-rays is being used to determine the incidence of ALRI, diarrhoea and other health outcomes in children up to 18 months of age. Combined with careful assessment of levels and changes in pollution and personal exposure, this randomised trial design should allow a far more robust assessment of the health impact of a popular intervention and measured reductions in IAP exposure, and contribute further to our knowledge of the relationship between exposure level and risk. For more information on the trial visit [ http://ehs.sph.Berkeley.edu/guat ].

Inclusion of health impacts in monitoring and evaluation

Recent years have seen growing pressure to include health impacts in the monitoring and evaluation of household energy interventions and policy. This is a very positive development, but there are quite a number of practical issues that will require development and testing work over the next few years.

The nature of health outcome assessment, and the practical issues associated with collecting that information, depends very much on the level of activity (e.g. national, district, local project, etc.) and sophistication of the information required. At national level, for example, the type of fuel and type of stove used give some indication of broad level of exposure. Questions such as these can be built into national household surveys, censuses, etc. At a more local, project level, there may be a requirement for much more detailed assessment of exposure and actual health outcomes (such as respiratory symptoms and disease). Pollution and exposure can serve as a proxy for health impacts (although issues discussed above on exposure-response relationship remain important to the interpretation of changes in exposure levels), but even these are technically quite demanding to measure and can be difficult in a routine setting. Measurement of actual health outcomes are even more challenging outside of a well- controlled research design, especially for child health (e.g. incidence of ALRI).

Another very important issue is to ensure consistency in the methods used, so that experience gained with different types of intervention in various parts of world can be compared. Work on the development of evaluation methods, including harmonisation, is currently underway and will be reported further over the coming year.

Strengthening collaborative action

As noted throughout this paper, if the problems associated with household energy use in developing countries are to be addressed successfully, there is a clear need for collaborative action from a wide range of "sectors". The health sector, and in particular health care services, are relatively clear about their role in respect of those who become ill. However, they are very much more uncertain about the part they can play in "multi-sectoral" efforts to develop and implement interventions that, although capable of delivering substantial health benefits, are implemented primarily by other agencies. The reduction of indoor air pollution is a good example of this, as responsibility for the interventions falls mainly within sectors such as energy, housing, health and finance.

Collaborative working is rarely straightforward, and often requires active development and support. This raises a number of issues that will need to be addressed:

• The role of each sector needs to be more clearly defined in order to avoid duplication and confusion about responsibilities.
• As part of the definition and agreement of roles, there is a need to identify the agency that can lead collaborative work in a given country or setting
• Multisectoral action requires good coordination, a function that will need to be put in place
• Collaborative action is often difficult in practice: typically this requires an institutional or programme focus, experienced leadership which often needs to be "facilitative" in nature, and adequate time for partners to learn how best to work together.

Although requiring more definition - mostly usefully through an assessment of practical experience - a preliminary proposal for the roles that might be adopted by the various sectors and agencies involved is set out in Table 1. These should be seen as indicative only, as specific roles will vary between countries, settings, and different levels of action (national, district, community, etc.). It has been emphasised that communities and their representatives have an important role in this work, and it is therefore important that, together, these agencies develop effective partnerships with communities. Lessons from inter-sectoral working in related environment and health programmes (for example, water and sanitation) can help (see below).

Table 1.Possible roles for various sectors and agencies involved in work on household energy, health and development

As has been mentioned, development of these roles may take time, but much can be learned from other programmes. The Healthy Cities and communities initiatives offer one source of experience. Specific programmes (for example, water and sanitation) provide an example of how these have evolved as health interventions - primarily for the prevention of childhood diarrhoeal disease.

Until recently, water and sanitation were not considered suitable for a health intervention because the infrastructure was too expensive for the results achieved. It has become clear, however, that the health sector does have a role, but because there are benefits across sectors, several sectors must work together to share the costs.

As a result, the health sector now tends to focus on programmes to maximize the benefit of the inputs, e.g. behaviour change (making best use of water and sanitation when provided), while other sectors facilitate the provision of infrastructure.

Conclusions

With the publication of the 2002 World Health Report, the importance of environmental risk factors - specifically including indoor air pollution - has been emphasised to a wide global audience. At the same time, the linkages between household energy and health, environment and development have been increasingly acknowledged in recent years. The 2002 WSSD, whatever its limitations, together with other international policy activities over recent years, show this to be the case. Subsequent initiatives such as the Partnership for Clean Indoor Air and the WHO-led Healthy Environments for Children Alliance also indicate a will to translate this knowledge into action. Yet, this action remains at a relatively early stage - at least in terms of global co-ordinated action. As a vehicle for information and policy development, Sparknet stands to benefit from the growing influence of health perspectives in household energy research and policy, so links with these and other initiatives will be maintained and strengthened.

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