The Impact of Household Energy and Indoor Air Pollution on the Health of the Poor: Implications
for Policy Action and Intervention by Charles Kirubi
Abstract
More than 2 billion of the world s poorest people
still rely on biomass and coal burning for household
energy needs. Use of these fuels leads to levels of
indoor air pollution many times higher than
accepteble ambient air quality standards. This
exposes women and children to a major public
health hazard. Including the risk of acute
respiratory infections (ARI), (pneumonia, chronic
respiratory disease and lung cancer), and is
estimated to account for a substantial proportion
of the global burden of disease in developing
countries. Other important direct health impacts
from household energy use among the poor include
burns to children and injuries to women from
carrying wood.
A wide range of interventions can reduce the impact
of indoor air pollution. These include changes to
the Source (improved stoves, cleaner fuels), living
environment (better ventilation) and user behaviour
(keeping children away from smoke during peak
cooking times). These can be delivered through
policies operating at national level and local level.
Experience to date shows that successful
implementation requires participation by local
people (particularly women), collaboration
between 'sectors' with responsibility for health,
energy, environment, housing, planning etc., and
with an emphasis on market sustainability.
Introduction
Exposure to indoor air pollution from the combustion
of traditional biomass fuels (wood, charcoal, animal
dung, and crop wastes) and coal is a significant public
health hazard predominantly affecting poor rural and
urban communities in developing countries. Large
numbers of people are exposed on a daily basis to
harmful emissions and other health risks from biomass
and coal-burning, which typically takes place in open
fires or low-efficiency stoves with inadequate venting.
It is estimated that globally 2 billion people -one third
of the world's population - rely completely on
traditional (solid) fuels for everyday household energy
needs (UNDP, 2000, Reddy, et al, 1997).
Biomass energy plays a vital role in meeting local
energy demand in many regions of the developing
world. Biomass is a primary source of energy for close
to 2.4 billionpeople indeveloping countries (lEA, 1998).
It is easily available to many of the world's poor and
provides vital and affordable energy for cooking and
Status of Environmental Health Education in
The Eastern Africa Region
space heating. The majority of those exposed are
women, who are normally responsible for food
preparation and cooking, and infants/young children
who are usually with their mothers near the cooking
area. According to the International Energy Agency
(lEA, 2002), approximately 50% of the population in
developing countries relies on biomass energy, with
some regions recording higher proportions (73% in
Africa). Biomass is the energy source for the poor.
This is especially true for traditional biomass energy,
which is often collected as a 'free' fuel (Reddy et al,
1997; Karekezi and Kithyoma, 2002). There appears
to be a correlation between poverty levels and
traditional biomass use in many developing countries.
Health effects of biomass energy use in
households
The use of poorly ventilated, inefficient stoves 'can
have the same adverse health impacts as smoking two
packs of cigarettes a day' according to UNOP (ITOG,
2001). However, the initial emphasis of research on
household energy in developing countries was on
environmental impacts of biomass use, such as impacts
on deforestation and desertification, resulting in a level
of zeal for increased efficiency. The public health
benefits from reduction in exposure to indoor smoke
as well as the reduction in carbon emissions became
the subject of attention there after. This "double
dividend"-improving public health while reducing
adverse environmental impacts-focused a great deal
of effort on the design and dissemination of improved
stoves. From the public health perspective, biomass
smoke contains a large number of pollutants that, at
varying concentration levels, pose substantial risks to
human health. Among hundreds of harmful pollutants
and irritant gases, some of the most important include
particulate matter, carbon monoxide, nitrogen dioxide,
sulphur dioxide (mainly from coal), formaldehyde, and
carcinogens such as benzo[a]pyrene and benzene.
Studies from Asia, Africa and the Americas have
shown that indoor air pollution levels from combustion
ofbiofuels are extremely high - often many times the
standards in industrialized countries such as those set
by the U.S. Environmental Protection Agency (US-
EPA) for ambient levels of these pollutants (Schirnding,
et aI2001).
Whereas cities in industrialised countries infrequently
exceed the US-EPA 24-hour standard for PMl 0 (small
particles of diameter less than 10 microns) in rural
homes in developing countries, the standard may be
exceeded on a regular basis by a factor of 10, 20, and
153
sometimes up to 50, exceeding even the high levels
found outdoors in such cities as in coal-burning northern
China (Schirnding, et al200 I). Typical 24-hour mean
levels of PM lOin homes using biofuels may range
from 300 to 3,000+ mg/m 3 depending on the type of
fuel, stove, and housing. Concentration levels measured
depend on where and when monitoring takes place,
given that significant temporal and spatial variations
(within a house, including from room to room), may
occur. Ezzati et al, 2000, for example, have recorded
concentrations of 50,000 ug/m 3 or more in the
immediate vicinity of the fire, with concentration levels
falling significantly with increasing distance from the
fire. These small particles are able to penetrate deep
into the lungs and appear to have the greatest potential
to damage health. Levels of carbon monoxide and
other health-damaging pollutants also often exceed
international guidelines.
Health effects from biomass is therefore one of the
major global health and energy problems. The largest
direct impacts would seem to be respiratory infections
in children (the most significant class of disease in the
world) and chronic lung disease in non-smoking women.
There are also a range of other health problems
associated with biomass fuel cycle such as the impacts
on women and children of gathering heavy loads of
biomass in distant and sometimes dangerous areas and
appear to have the greatest potential to damage health.
Levels of carbon monoxide and other health-damaging
pollutants also often exceed international guidelines.
A review of recent studies on indoor air pollution
in Kenya Reducing indoor air pollution in rural
households: Western & Kajiado, Kenya
This ITDG Smoke and Health project was carried out
in Western and Kajiado areas of Kenya between 1998-
2001 (lTDG, 2001). Working with 50 households in
rural Kenyan communities, the main objectives of the
project were twofold: to improve the quality of life,
through reduction in indoor air pollution, for households
in these study areas; and to develop a participatory
methodology for further research into appropriate ways
to alleviate indoor air pollution. The two areas are totally
different climatically and geographically as well as
culturally (lifestyles, cooking habits and house types).
Baseline monitoring in the kitchens in these areas
showed that smoke levels were unacceptably high: in
Kajiado, the 24-hour average of respirable particulates
(PMIO) was 55261lglm3 and in West Kenya, the levels
were I713llglm3 . If one compares these values to the
EPA standards for acceptable annual levels of
respirable particulates of 50llg/m3 (Table 1), it can be
seen that the daily rates (which are comparable, in
Status of Environmental Health Education in
TL_l":' __ .•.__ .4..c...!__ n __ ! __
these societies, to the annual rates) are over one
hundred times greater in Kajiado and twenty times
greater in West Kenya than the accepted values. Table
2 shows typical values for .particulate levels in the
kitchen of a rural home, compared to current standards
advised by the US Environmental Protection Agency
(EPA)
154
....,cn::r •..•
<> g
tTl",ill 0...• ....,
<> tTl3 ::s> ~.
~~~8~.e.g ::I:
~j
Er
-VI
VI
More fuelwood harvestingIncrease in gathering Increase in human caloric needs to do Less food preparationtime ••• the harvesting Less frequent preparation•...
Increase risk of assault & injury (e.g., Inadequately cooked foodSubstitute inferior fuels reported in refugees camps in Kenya Preference for fast-cooking, (but(eg. Dung, residues) & Marsabit) often less nutritious) foods
Substitute commercial Increased risk from natural Less preparation of special foods forhazards children, pregnant, lactatingfuels mothers, the ill, elderly, etc•...
Economize on fuelwood
Inferior biomass fuels
Cookstoves More air pollution
More tending time
Less consumption---.. More cooking time Poor time allocation....
Less income
Less rest
Less space & water heating•.. Less hygiene•...
Less time & human energy
for other productive/learning•.. Less food supply activities•... Less food produced
Less food purchased
Less food stored
Figure 1: Household coping strategies for fuelwood shortages (Source: Adapted from UNDP, 2000 & Kirubi 1998)
Table 2: Pollution level (PM10) in micrograms per cubic
metre of air( Ul!!m3)
i------:--c--- -------- _Source of During use 24 bour Annual
_._~!p~!.urt:._~_. __ . ~.!.c:!~~__ave~~~ _
Biofuel Typically from Typically 24 hour
(wood, 1000 up to 500 to average levels
dung, etc) 20000 or more 1000 or are
more experienced
..__..__.. . .__._._..._. . ~_~!Y...~a.:L. ..
US- EPA Only 1%
standard of 24
hour 50
periods
to exceed
150
The study tested the effectiveness of four interventions
to mitigate and reduce the indoor air pollution namely
smoke hoods, eaves spaces, windows and stoves.
Results show that there were substantial reductions in
the particulate matter and carbon monoxide levels in
the sample households after the interventions were
installed. The pre-intervention levels of PMresp in
Kajiado were over 5000llgim3 and in West Kenya
were over 17001lg!m3.Kitchen CO levels were 74ppm
in Kajiado and over 10ppm in West Kenya. Overall
changes in 24-hour averages following the
interventions in Kajiado showed a 36 % reduction in
PMresp, and in West Kenya there was an overall
reduction of 63%. Significant substantial reductions
were observed in both Kajiado and West Kenya for
particulates and room CO. The findings also show
that smoke hoods were by far the most effective in
this particular study. Overall fmdings are summarized
in Table 3.
Improved cookstove technology and indoor air
pollution: Kiambu District, Kenya
A study by Wafula, et al (2000) from the Department
of Pediatrics and Child Health, College of Health
Sciences, University of Nairobi, demonstrated
statistically significantly reductions in the prevalence
of ARI and conjunctivitis among women and children
under five in Kiambu District who used stoves versus
those who did not (Table 4). Therefore, as the health
risks associated with biomass cooking become
increasingly clear, the case for continued and expanded
improved stove projects is strengthened. Kammen
(1995) notes that successful improved cookstove
pragrammes and outreach, education, demonstration
and construction efforts can contribute to reducing
harmful woodsmoke exposure in a number of ways:
a) by improving venting of combustion gases through
use of a flue or chimney, b) by improving combustion
efficiency through better stove designs, and c) by
Status of Environmental Health Education in
The Eastern Africa Region
encouraging use of cleaner burning fuels and more
advanced stove designs - process called moving up
the "energy ladder."
Further, by reducing the time needed to collect (or
purchase) cooking fuels and combining health gains
with improvements in household fuel, cookstove
programmes can simultaneously meet economic
efficiency, environmental conservation and quality of
life objectives. This finding is further supported by a
study on poverty reduction aspects of successful
improved household stove pragrammes undertaken in
Nairobi (Kenya), Kampala (Uganda) and Addis Ababa
(Ethiopia) (ESD, 2000). Transition to more advanced
stove designs and cleaner fuels can significantly reduce
indoor air pollution (Table 5).
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Table 3: Overview of reductions in particulates and carbon monoxide resulting from
installation of interventions
Source: ITDG, 2001
Table 4: Prevalence of ARI and conjunctivis as a function of cooking devices used in households
ARI prevalence Conjunctivitis prevalence
traditional improved Prevalence traditional improved Prevalence
3-stone fire stove reduction 3-stone fire stove reduction
Women 38% 13.5% 64% 12% 4% 67%
(15-20 yrs)
Children 59% 23.1 61% 40.9% 12.4% 70%
«5 yrs)
(Source: ESD, 2000)
Table5: Concentration of carbon monoxide (CO) from
indoorbiofuel combustion, various fuel & stove
combinations,Kenya
Fuel and stove No. of CO (parts per
combination measurements million by
volume)'
Dung/traditional 25 220-760
stove
Wood/traditional 38 140-550
stove
Charcoal/traditional 14 230-650
stove
Charcoal/improved 22 80-200
stove
Kerosene fuel & 8 20-65
stove
WHO l-hour exposure standard 46
(Source: Karnmen, 1995)
The "energy ladder" concept is fundamental to efforts
tounderstand household energy decision-making. It is
the household or micro-economic corollary to what
Statusof Environmental Health Education in
TheEastern Africa Region
happens at the macro-economic level as countries
industrialize and move from traditional biomass to
commercial fossil-fuel-based economies (Kammen,
1995). Under this hypothesis, as households become
more affluent, they move from simple stoves and
inexpensive fuels to more sophisticated, convenient,
and costly fuels and stoves. The ladder climbs from
dung or crop residues combusted in three-stone fires,
to wood or charcoal use in metal or improved stoves,
to kerosene wick or pressure systems and finally
propane, liquid petroleum and electric appliances.
The health and energy impact of climbing up this ladder
can be dramatic. Simple biomass stoves may use six
to seven times as much fuel as modem improved stove,
and release 50 times more pollutants than a gas stove
used to prepare the same quantity of food (Karnmen,
1995). The poorest segments of society, thus not only
are exposed to higher levels of pollution, but must also
spend greater share of household income and resources
157
to cook the same meal. For instance, Cecelski (2003)
highlights that higher-income people generally use more
efficient and more convenient sources of energy, such
as gas and electricity, whereas poor people use less
efficient and less convenient sources, such as fuelwood
and human energy. In actuality, multiple fuel use is
common at all income levels and the "fuel ladder" is
perhaps more accurately replaced by a "fuel pyramid"
of multiple fuels for different purposes and at different
times. What is important to note is that poor people
have fewer energy options than do the nonpoor people,
and they often pay more for them both absolutely
(paying higher unit prices) and relatively (as a
percentage of their income) than do the nonpoor. Poor
women nonetheless highly value and need multiple
energy options to help manage their daily work and
time. In Java (Indonesia) families using electricity have
lower lighting expenditures and receive on average six
times as much light as households using kerosene
(World Bank, 2000). For cooking, the urban poor often
pay more for wood and charcoal than they would for
LPG once the end-use efficiencies of the fuels are
taken into account.
Recommendations for reducing lAP exposure in
developing countries
Intervention measures to reduce the impact of lAP
include changes to the source, living environment and
user behaviour, (Table 4) and can be delivered through
policies operating at national and local level.
Table 5: Potential interventions for reducing lAP exposure in developing countries
Source Living environment User behavior
Improved cooking devices Improved ventilation Reduced exposure through
Chimneyless improved biomass stoves Hoods/frreplaces& chimneys built operation of source
Improved stoves with flues attached into structure of house Fuel drying
Windows/ventilation holes Use of pot lids
Alternative fuel-cooker combinations Good maintenance
Briquettes & pellets Kitchen design & placement of Sound operation
Charcoal, kerosene the stove
Liquefied petroleum gas (LPG) Shelters/cooking huts Reductions by avoiding smoke
Biogas, producer gas Stove at waist height Keeping children off smoke
Solar cookers (thermal)
Other low smoke fuels Food preparationElectricity Partially pre-cooked food
Reduced need for the future
Efficient housing
Solar water heating
Source: Scbirnding,et al, 2001
Implications for energy policy and
recommendations
a) Data and information gaps and needs
Data and information on biomass energy use in many
developing countries is outdated and often unreliable,
which makes it difficult to plan. In comparison to the
conventional energy sector, which has comprehensive
5-10 year plans, planning for biomass energy is often
incoherent, sporadic, and starved of the necessary
budgetary allocation (Karekezi, et al 2004). The
mobilization of additional financial and technical
resources to support data collection and associated
biomass energy planning is of priority importance
(Kituyi, 2002). Initiatives pertaining to inefficient and
environmentally unsound traditional energy options
should primarily be aimed at research and analysis as
well as data collection to provide the basis for
developing effective strategies for reducing reliance
on traditional energy options. It is noted that many poor
developing countries do not have reliable databases
on traditional biomass energy use. This makes it difficult
to formulate appropriate policy and field-oriented
interventions. Mechanisms for collection and
Status of Environmental Health Education in
The Eastern Africa Region
documentation of data on traditional biomass supply
and consumption, which is regularly updated and
validated, need to be instituted.
b) Removing the barriers to accelerated
adoption and use of improved biomass
technologies
Many policy analysts stress the need for aggressive
dissemination of improved biomass technologies (Ils'Is)
in developing regions, to mitigate the negative effects
of traditional biomass energy use particularly indoor
air pollution that is linked to respiratory diseases, one
the main causes of death for children under the age of
five. Governments should put in place policies that
support the development and dissemination of mTs.
Private sector, NGOs, CBOs and donor organisations
should implement projects aimed at ensuring the rapid
dissemination of mTs. Efforts to reduce the cost of
widely used Ils'Is such as improved cookstoves should
be accelerated, so that they are within the reach of even
the poorest of the poor in Africa. Barriers to the uptake
of improved biomass technologies should be addressed,
and lessons from successful programmes documented
for widespread dissemination and replication.
\58
c) Regulation/promotion of sustainable charcoal
production and use
Given the harmful environmental impacts of charcoal
production in the region, there is need to regulate the
production of charcoal (EAA,2003). Afforestation and
reforestation projects should be established as part of
all charcoal production programes. The widespread
useof improved and efficient charcoal kilns should be
promoted.
d) Addressing gender-energy concerns
It is important for improved biomass energy system
development and dissemination programmes to
recognize the gender- and income-differentiated
impactsof biomass energy use. In particular, improved
biomass energy technologies that alleviate the burden
and negative health effects of traditional biomass
energy on the rural poor (comprising primarily of
women and children) should be promoted and given
prominence in government policies
e) Fuel substitution
It is critical to for national energy policies to work
towards progressive to clean and efficient energy
services that would substitute traditional biomass,
particularLPG and kerosene through removal of tariffs.
As a cooking fuel, LPG is 10 times more energy
efficient than wood fuel and several thousand times
lesspolluting.' In 1995, Kenya had fewer than 50,000
household LPG cylinders in use, almost entirely in the
fourlargest urban areas. Yet LPG remains inaccessible
tomost of the population due to high upfront costs as
well as high tariffs and duties (18% VAT, and import
dutyon LPG) in Kenya for instance. If the latter were
removed, one industry group estimates sales of
cylinders would increase by 20% and sales of gas by
18%.2 Price volatility of LPG is another critical
concern for domestic consumers. Credit schemes
through various channels would also accelerate the
ratesoffuel switching from biomass to LPG particularly
forthe urban-poor and rural households - resulting in
a win-win situation for the health of poor people, the
economy and environment. The lessons from Brazil
with respect to promoting LPG for cooking in
households are very relevant to other developing
countries. By 1999, Brazil had managed to achieve
99.4%adoption and use of LPG stoves by households,
thanks to subsidies which catalysed and bolstered the
demand and the market", This almost completely
eliminatedthe use offuelwood for cooking and created
300,000jobs. It is estimated that this shift in fuels has
avoided the deforestation of one million hectares of
forest per year. Among developing countries, Brazil
ranks seventh in per capita consumption of LPG at
approximately 40 kg/capita/year. In sub-Saharan
Statusof Environmental Health Education in
TheEastern Africa Region
Africa, Kenya's consumption of LPG at l.lkg/capita
compares dismally to other countries such as Egypt
(36.2kg/capita), Senegal (10.3 kg/capita), Cote de voire
(2.7kg/capita) and it is far below the African average
consumption of8.3kg/capita (Nyoike, 2004).
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