If you had a magic wand, where would you wave it first? Okay, let’s be specific. If your magic wand could help to alleviate the woes of the world – rather than your own bank balance and other imperfections – what would you wave it at? Would the cooking fires of the poorest people in the world spring immediately to your mind?
Probably not. But take a closer look at something as basic as what makes us ill or kills us. You’ll find the facts in The World Health Report 2003, which is published by the World Health Organization (WHO) and makes for a disturbing read. Not much of what it tells us is surprising. There are plenty of things to wave your magic wand at: a redistribution of weight around the world, for example, would certainly not come amiss, since the number of overweight people roughly matches the number of people who are starving.
As you go down the lists – and there are many, many lists – your attention might well be drawn to the suffering of the poorest. Here the causes of death and illness are all too preventable – and at the heart of them is one, pervasive source of misery: poverty. However, even the most potent magic wand will not be able to eliminate poverty or alleviate all that suffering with a single wave. So we must prioritize. Start with the most serious and work down the list until we have made such an impact that we feel able to try to wring something more self-indulgent from the glorified twig.
In the WHO report there is a helpful table, a list that rates, in order of impact, the various risk factors affecting the poorest people in the world. The measurement used is DALYs (Disability Adjusted Life Years), which incorporates morbidity as well as mortality, so something that does not kill, just incapacitates, or does not kill quickly, is recorded as part of the impact.
Top of the list – well, no surprise here – is malnutrition: the consequences of too little, as opposed to too much, food. Then there is the relatively recent scourge of HIV/AIDS. Third on the list is another well-known problem – dirty water and poor sanitation.
But would you rest your wand after tackling just the top three? Would you do what the development community seems to have done – just skip over number four and head straight on down to zinc, iron and vitamin A deficiencies at number five?
Missed out, at number four, is a ‘silent killer’ that is responsible for the deaths of more children under the age of five than AIDS, malaria or measles. The killer is ubiquitous and mundane – the smoke from cooking fires.
Worldwide, 2.4 billion people rely on ‘biomass’ for the bulk of their energy requirements. The cooking and heating fires of over a third of humanity are fuelled by animal dung, crop residues and wood. Frequently burned on traditional three-stone stoves, these fuels are producing, as they have for millennia, a toxic cocktail of smoke that is responsible for the deaths of at least 1.6 million people every year.
The problem is widespread but it is far from indiscriminate. It is the poor who rely on the lower grades of fuel and have least access to cleaner technologies. More specifically, indoor air pollution affects women and small children far more than anybody else. Adults tend to suffer most from chronic obstructive pulmonary disease, such as bronchitis. Children are more prone to acute lower respiratory infections such as pneumonia.
A recent report from the British-based Intermediate Technology Development Group (ITDG), Smoke – the Killer in the Kitchen, has dubbed this the ‘silent killer’ for more reason than the stealthy way it permeates the lives and lungs of billions of people. No-one is talking about it – which is, in itself, nothing short of an international scandal.
That may sound a little hysterical. But take a closer look at that WHO report. Of the 10 biggest killers, 9 are highlighted, referring the reader to further information about what’s being done to lessen their impact. The only subject not to receive this treatment is smoke.
Until very recently there was insufficient evidence to link indoor air pollution to ill-health or death. However, a growing number of health studies clearly demonstrate this link, now quantified for the first time by the WHO. An increasing number of international health professionals is recognizing that indoor air pollution is indeed a problem.
Even so, far more is known about the levels of air pollution in the cities of Europe than in the kitchens of the developing world. A great deal of time and effort is put into measures that will reduce exposure across cities in the North. Very small changes in levels are able to generate substantial changes in mortality.
One European study estimated that the deaths of well over 5,000 inhabitants in 19 European cities could be prevented annually with a reduction in particulate levels of just five micrograms per cubic metre. The European Commission has legislated for a reduction in exposure to particulates so that the level of 50 micrograms per cubic metre should not be exceeded more than seven times a year. Compare this with a Kenyan study that found women exposed to an average of 1,250 micrograms per cubic metre, peaking at over 50,000 micrograms. The exposure is continual – day in, day out. The United Nations Development Programme has suggested that this ‘can have the same adverse health impacts as smoking two packets of cigarettes a day’.
Responses to acute lower respiratory infection (ALRI) in children have so far focused on treatment rather than removing the major cause. Over the past decade UNICEF has been monitoring the progress of the World Summit for Children. One of its aims is to reduce by a third deaths due to ALRI in children under five. This target has not been met. Why? Because the main method used has been the treatment of symptoms with antibiotics, rather than dealing with smoke in the home.
Smoke affects most of those who are perceived to be lower-status members of a community – generally women and children. Their work and contribution is rarely calculated in national economic planning, so the benefits of clean cooking environments have not been fully recognized.
In fact women carry a double burden. In most societies it is also women’s responsibility to provide fuel. The cost in time alone can be extreme. Estimates range from 2 to 20 hours per week spent collecting it. In Nepal, for example, women were found to be walking over 20 kilometres per journey in search of wood. Women are also vulnerable to back problems that result from carrying loads that can be in the order of 20 kilograms. Young girls are often removed from school to help with this task. Women’s input of time and energy is, like the biomass itself, invisible in energy statistics and therefore remains low on the agenda.
Over the last 30 years or so there have been many development projects focused on providing people with improved stoves. However, the goals have been energy efficiency and fuel saving, to lift the burden of women’s time and effort, as well as to save forests. Only in the last few years has attention turned to the issue of indoor air pollution.
Obviously, there are other very pressing problems to be dealt with, such as food, HIV/AIDS, sanitation and malaria. However, the impact of indoor air pollution can be as acute and dramatic as malaria.
It’s not as if there are no relatively easy solutions available. But one of the most significant obstacles to making use of them – and this is where the magic-wand waver has to take good care – is the development industry’s tendency to present readymade solutions to a community. It is essential that the affected community is involved in the design of proposed solutions. Without this, previous innovations have sometimes been ineffectual. For example, one new design for a stove required women to spend many hours chopping fuel to a small size. In the end the women just altered the stove, allowing larger pieces of fuel to be added but undermining its efficiency.
ITDG are currently involved in rural Kenya, where they are putting ‘participatory democracy’ into practice. Workers listen to the needs of households rather than impose specific interventions. One particularly important component is exchange visits to disseminate ideas locally. Initial reluctance on the part of many cooks turned to enthusiasm once they had seen other people’s kitchens. Every intervention needs this sort of care. Cooking is a deeply cultural activity.
Frequently burned on traditional three-stone stoves, these fuels are producing, as they have for millennia, a toxic cocktail of smoke that is responsible for the deaths of at least 1.6 million people every year
The results have shown substantial reductions in particulate matter and carbon monoxide levels in households. Most effective is the use of a hood that extracts smoke, which reduces particulate pollution by an average of 75 per cent and carbon monoxide by 78 per cent.
This is still just a small project working to resolve one of the world’s most significant health problems. There needs to be co-ordinated international action. And while there are some moves in this direction, more needs to be done – just in case no magic wand appears.
ITDG is calling on the United Nations to instigate a Global Action Plan. The total cost of providing nearly half of the world with access to healthy indoor air would be in the region of $2.5 billion annually over the next 12 years. To kick-start an effective market to distribute low-cost smoke solutions would require less than one per cent of the total Western aid budget.
So perhaps there is no real need for that magic wand after all. For the quality of life of over a third of humanity to be improved, all that is required is a little bit of political will. The world can no longer claim ignorance of this ‘silent killer’. We need a global campaign that matches the international response to hunger, HIV/AIDS, dirty water and malaria.
Smoke – the Killer in the Kitchen, by Hugh Warwick and Alison Doig, is published by the ITDG (http://www.itdg.org). It can also be downloaded for free from: http://www.itdg.org/html/smoke/smoke_index.htm