Children of migrant workers in New Delhi wearing protective face masks wait to cross the border to Uttar Pradesh, 2020. Photo: Reuters/Adnan Abidi.
On December 16, a second inquest into the death of nine-year-old Ella Kissi-Debrah, in the UK, concluded that dangerous levels of air pollution caused her death in 2013 from a fatal asthma attack. This decision came on the back of several years of campaigning by Ella’s mother Rosamund and others, who argued that high levels of air pollution, due to the presence of a busy motorway near their home, contributed to her respiratory condition. This first of its kind direct attribution of air pollution on a death certificate sets a legal precedent that will hopefully put to rest denials heard around the world, and especially in India, questioning the links between air pollution and premature death.
Ella’s story highlights two important aspects of this crisis for us in India. One, air pollution exposure is a serious risk factor for children with lifelong consequences, and which requires prioritising policies targeting children and pregnant women. Two, policymakers, researchers and advocates need to give special attention to pollution hotspots in parallel with air quality at aggregate levels. In doing so, we must also acknowledge how social inequities dictate who lives and works in these hotspots, resulting in exposure disparities.
Early childhood exposure
There is now an established body of evidence showcasing the epidemiological and causal mechanisms behind how air pollution affects the wellbeing of both the vulnerable and healthy in society. Last week, this evidence base was strengthened in India when the Indian Council for Medical Research, the Public Health Foundation of India and the Institute for Health Metrics and Evaluation released a report on the burden of disease estimates attributable to air pollution. These estimates revealed that close to 1.7 million premature deaths each year could be due to air pollution exposure. Children under 5 years of age accounted for over 150,000 of these deaths, with air pollution being the second most important risk factor (behind malnutrition) for death and disease in this age group.
Barring genetic predispositions or vulnerabilities due to poverty and malnutrition, children of Ella’s age are not supposed to have serious illnesses – let alone meet untimely deaths. Children in India have levels of exposure often 5-20 times what Ella experienced in London. Exposure to air pollution at a vital developmental phase of life can have lifelong impacts, with early childhood exposure associated with neurocognitive impairments and respiratory and cardiometabolic illnesses. Air pollution exposure during the third trimester of pregnancy has also been associated with adverse birth outcomes and early childhood health impairments. Reducing exposure rapidly and to levels far below what we consider safe under the National Ambient Air Quality Standards is essential if India’s demographic dividend is to bear fruit.
Tackling household sources of pollution is especially important given neonates and young children spend a large proportion of their time indoors and in proximity to their mothers, who often cook over traditional chulhas. While the Pradhan Mantri Ujjwala Yojana made a promising start in tackling the issue of access to cleaner burning sources of household fuel, meeting sustained and exclusive use of these clean fuels in rural households requires much more investment as well as a more thoughtful approach. Recent evidence from the fifth National Family Health Survey reinforces this point. While clean fuel use in rural households has increased between 2014 and 2019, they remain well below 50% in states like Bihar, West Bengal and Assam, and where the impacts will be felt hardest.
Environmental justice is social justice
Socio-economic disparities influence our experience of air pollution. Evidence from around the world shows us that policies, especially those concerning housing and urban planning, leave marginalised communities, based on income, caste and race as applicable, living near pollution hotspots like industries, transport hubs and landfills. As a result, they are often exposed to more air pollution than their more privileged counterparts and more often suffer from inclement health. The residents of Mahul in Mumbai, Manali in Chennai and Ghazipur in Delhi could provide ready testimony in this regard. Policymakers and researchers must not lose sight of neighbourhoods and communities that are especially vulnerable within and near cities.
Blinkered attention on big cities – but often just on Delhi – has led to pollution hotspots getting exported elsewhere in India. When old, polluting vehicles get banned from the big cities, they ply in smaller towns. Polluting industries get banished from cities to set up shop elsewhere, where they are under even less pressure to comply with regulatory norms. Although pollution control boards are designed to tackle industrial pollution, they are often not equipped with adequate staff, technical expertise and financial resources for the task.
This lack of attention from India’s urban elites, the media and the government is already bearing ominous fruit. Ambient air pollution continues to be severe in the Indo-Gangetic plain, and it has risen rapidly in both rural and urban areas in Central and South India. Trends in Chhattisgarh and Jharkhand are particularly alarming, and could be due to the proliferation of new coal power plants.
While air pollution is often billed as a “great equaliser” for its ability to affect the rich and the poor equally, the proliferation of purifiers and expensive N95 masks is an indication that urban elites are able to find private solutions. While some of us may be able to buy our way to a more breathable environment, brown skies and perennially high exposure form an inescapable reality for the vast majority of Indians.
More people will die prematurely in India this year from air pollution exposure than due to the country’s COVID-19 pandemic. Axiomatically, air pollution needs to be tackled with the same urgency as the pandemic – if not more urgently. Our approach in research, advocacy and policymaking also needs to recognise the inherent disparities in how vulnerable and marginalised populations suffer, often silently, and amplify those voices calling for action on all major pollution sources.
This in turn means we must eschew the piecemeal approach we have taken till date, and aim instead for ambitious and coordinated action across rural and urban India to improve air quality. Ultimately, we must do better by the memories of the thousands of children like Ella, whose lives are cut short by this malevolent threat.
Santosh Harish is a fellow at the Centre for Policy Research, New Delhi. Bhargav Krishna is a Doctor of Public Health candidate at the Harvard TH Chan School of Public Health, and co-founder of Care for Air. The views expressed here are the author’s own.