1 World Health Organization16 December 2017 Health Impacts of Household Energy Use

2 Overview Household air pollution (HAP) – what is it?Health Impacts of Household Energy Use Other Impacts of Household Energy Use WHO Guidelines on Indoor Air Quality Clean Household Energy Solutions Toolkit

3 Overview: Household Air PollutionHousehold air pollution (HAP) is a mixture of pollutants released during the incomplete combustion of carbon-based fuels (wood, coal, dung) used in and around the home (not just indoors!) Released during use of inefficient technologies for activities including cooking, heating, lighting Outdoor Air Pollution PAH CH4 NOx CO2 CO NMVOCs SOx CH2O Cooking, eating and lighting Emissions include PM, like methane, polycyclic aromatic hydrocarbons, carbon monoxide, etc. We breathe in and out CO2 all the time. The health effects from exposure to carbon dioxide are only seen at very high concentrations, way more than one would see in the environment. Rather it is other air pollutants that are often the result of incomplete combustion that are damaging to health in the shorter and longer term. PM

4 Health Impacts: Household Air Pollution Particulate Matter (PM)Most important pollutant commonly associated with adverse health effects is particulate matter (PM) Many factors affect the toxicity of PM Complex mixture of chemical components Size, particle core chemistry, metals, biogenic origin etc. Exposure to PM is associated with bronchial irritation, inflammation, reduced mucociliary clearance, reduced macrophage response and carcinogenic events. Outdoor Air Pollution The most important air pollutant commonly associated with health effects is particulate matter. The complex nature of PM makes is difficult to identify the true component(s) that effect health, however in a number of toxicological and observational studies (including dose-response studies) have shown direct relations between exposure and adverse health outcomes such as inflammation, oxidative stress, etc.

5 Health Impacts: Household Air Pollution Particulate Matter (PM)STRONG Evidence Ischaemic Heart Disease Stroke Chronic obstructive pulmonary disease Childhood pneumonia Lung cancer Cataract CO NMVOCS PAH SOx NOx TENTATIVE Evidence Adverse Pregnancy Outcomes Cognitive development Tuberculosis Diabetes Dark blue –strongest evidence, used to derive disease burden…. Others have tentative evidence

6 Cooking: Global primary use of polluting fuels and technologiesAccordingly WHO has been monitoring household energy use and its impacts on health for over a decade. Every year, WHO estimates exposure to household air pollution based on nationally representative survey data on the fuels and technologies being used in the home for cooking. In 2014, over 3 billion people primarily used polluting fuels and technologies for cooking (WHO 2014)

7 Cooking: Deaths due to use of polluting fuels and technologiesThe air pollution resulting from the inefficient of household energy (aka household air pollution) is the leading environmental risk factor for ill health. It is the leading environmental risk of noncommunicable diseases in women living in LMIC, leading cause of childhood pneumonia, globally. Accordingly WHO has been monitoring household energy use and its impacts on health for over a decade. Every year, WHO estimates exposure to household air pollution based on nationally representative survey data on the fuels and technologies being used in the home for cooking. ~4 million deaths a year from household air pollution— including over 3 million deaths to noncommunicable diseases (WHO 2014)

8 Cooking: Deaths due to use of polluting fuels and technologiesAccounts for over half of childhood pneumonia deaths (the largest cause of death in children under 5 years) 2nd largest environmental risk for noncommunicable disease in women in developing countries The air pollution resulting from the inefficient of household energy (aka household air pollution) is the leading environmental risk factor for ill health. It is the leading environmental risk of noncommunicable diseases in women living in LMIC, leading cause of childhood pneumonia, globally. Accordingly WHO has been monitoring household energy use and its impacts on health for over a decade. Every year, WHO estimates exposure to household air pollution based on nationally representative survey data on the fuels and technologies being used in the home for cooking. ~4 million deaths a year from household air pollution—including over 3 million deaths to noncommunicable diseases

9 Cooking: Health Impact from Household Air Pollution  OutdoorsWorld Health Organization 16 December 2017 12% of ambient air pollution originates from residential solid fuel combustion for cooking on average globally in 2010 (Chafe et al., 2014) Jessica Lewis, India Ambient PM2.5 from residential cookstoves is estimated to cause 370,000 to 500,000 global premature deaths annually (Anenberg et al., 2013; Chafe et al., 2014; Forouzanfar et al., 2015; Lacey et al., 2017)

10 Household Energy Use: Limitation of Estimates & Data GapsOnly for cooking: do not incorporate health risks from use of polluting fuels and technologies for other end uses (e.g., heating and lighting) Only primary fuel/technology: do not consider use of multiple fuels and devices Estimates are derived for health impacts of PM Jessica Lewis, North India Ashden Awards, Pakistan Shutterstock/Tudor Spinu

11 Important to Consider Full PictureWorld Health Organization Important to Consider Full Picture 16 December 2017 Talk about energy use for cooking, heating light And others Use of mutliple fuels and technologies

12 Heating: Primary Use of Polluting Fuels and TechnologiesWorld Health Organization Heating: Primary Use of Polluting Fuels and Technologies 16 December 2017 Limited nationally representative data on heating WHO Household energy database contains: 42 surveys Covering 23 countries Compared to over 950 surveys for cooking

14 Other Health Impacts Burns, scalds, poisonings & injuryTraditional stoves can pose major safety risks in the home. The use of traditional stoves are estimated to cause 95% or more of burns in low and middle income countries Outdoor Air Poution Other direct links, in relation to household fuel combustion have been seen in relation to safety, such as burns and injury from fuel collection. Time savings from reduced fuel collection and cooking time could allow for more income generation, education and can improve the quality of life for billions. Others effects from all air pollution in general, have been seen as a result from climate change such as increased risk for vector borne diseases like malaria

15 Other Health Impacts Burns, scalds, poisonings & injuryMany households still rely on kerosene for cooking, heating and lighting. Kerosene is a leading cause of childhood poisonings in low and middle income countries Fuel collection and preparation can lead to musculo-skeletal injuries

16 Other Impacts Beyond Disease: Livelihood & Enviro. DegredationFuel collection, preparation, cooking are major sources of time loss, particularly for women and children. Use of biomass fuel for cooking and heating leads to unsustainable wood harvesting, forest ecosystem damage (Bensch & Peters 2011; Bailis et al )

17 Overview Household air pollution (HAP) – what is it?Health Impacts of Household Energy Use Other Impacts of Household Energy Use WHO Guidelines on Indoor Air Quality Clean Household Energy Solutions Toolkit

18 Previous WHO Air Quality GuidelinesEvidence reviews of: Fuel use: Global; for cooking, heating & lighting Emissions: range of technology & fuel options, how relate to AQG Levels: HAP and exposure Health impacts of HAP: risk for pneumonia, COPD, lung cancer, etc., including exposure-response. Burns and poisoning: risks, burden and interventions Intervention impacts: HAP/exposure in routine use Adoption at scale: barriers and enablers, costs/benefits, finance “The guidelines presented here are recommended to apply to all environments where population exposure occurs and therefore protect all population groups”. (WHO Air quality guidelines, global update 2005, p 179)

19 WHO Guidelines on indoor air quality: household fuel combustionNormative guidance found in the WHO Guidelines for indoor air quality: household fuel combustion : Provides emission rate targets for PM2.5, and CO that determine whether fuel and technology combinations are “clean” for health Recommendation discouraging kerosene use Emphasizes importance of addressing all main household energy end uses for health benefits In response to the urgent need to address the global health crisis from household fuel combustion, in November 2014, WHO released its first-ever normative guidance on household fuel combustion. These guidelines provide practical evidence based guidance on what fuels and technologies used in the home can be considered clean including: Recommendations on what fuels can be ‘dirty’ for health including kerosene and unprocessed coal. Recommendations on the needed performance of clean fuels and technologies in the home in the form of emission rate targets Recommends about the importance of addressing all household energy uses, partiuclary cooking, heating and lighting to ensure benefits for health and the environment.

20 Recommendation: Household use of coalUnprocessed coal should not be used as a household fuel Rationale: It is very difficult to burn coal cleanly in home IARC Monograph: emissions from household use of coal are a Group 1 carcinogen Coal often contains toxins (fluorine, arsenic, mercury, etc.) which are not destroyed on combustion. There should be further assessment of so-called ‘clean’ and ‘smokeless’ coal Strength of recommendation: STRONG Unprocessed coal: coal that has not been treated by chemical, physical or thermal means to reduce contaminants Common contaminants include: fluorine, arsenic, lead, selenium and mercury. These contaminants are not destroyed by combustion. The IARC monograph on coal provides a very strong evidence base for this recommendation.

21 Recommendation: Policy during transition Urban and peri-urban Rural better-off To ensure ‘best possible’ Testing Standards Certification Rural poor Traditional biomass Low emission biomass Clean fuels

22 Clean Household Energy Solutions Toolkit (CHEST)

23 Clean Household Energy:Unlocking Progress for Health, Climate, Development The Energy Nexus is a big focus of SE4All. The slide above highlights some of the benefits extending beyond direct health outcomes resulting from addressing access to clean and modern energy services. Similar nexus benefits exist between health and the other energy goals.

24 Questions or Comments? Jessica Lewis [email protected]Thank You Questions or Comments? Jessica Lewis

25 Extra Slides

26 Drudgery & Time Loss Top 10 countries for average hrs. boys and girls spent collecting wood or water in the past week (WHO 2016)

27 WHO Guidelines on indoor air quality: household fuel combustionThe guidelines are designed to provide countries and implementing partners with practical information on the performance and characteristics of domestic combustion technologies and fuels needed to prevent negative health effects attributed to air pollution caused by household fuel combustion.

28 WHO Guidelines for Indoor Air Quality: Household Fuel Combustion (IAQG)Questions addressed: What device and fuel emission rates are required to meet WHO air quality guideline for PM2.5 (annual) and for CO (24 hours)? In light of the acknowledged challenges in securing rapid adoption and sustained use of very low emission household energy devices and fuels, what approach should be taken during this transition? Should coal be used as a household fuel? Should kerosene be used as a household fuel? IAQG were developed to provide countries and other stakeholders with practical recommendations on the performance and characteristics of household combustion technologies (e.g. cookstoves, lamps, space heaters) and fuels needed to acheive the WHO guidelines values and prevent negative health effects currently attributable to household fuel combustion Evidence reviews of: Fuel use: Global; for cooking, heating & lighting Emissions: range of technology & fuel options, how relate to AQG Levels: HAP and exposure Health impacts of HAP: risk for pneumonia, COPD, lung cancer, etc., including exposure-response. Burns and poisoning: risks, burden and interventions Intervention impacts: HAP/exposure in routine use Adoption at scale: barriers and enablers, costs/benefits, finance

29 WHO IAQG define “clean” for health?Normative guidance found in the WHO Guidelines for indoor air quality: household fuel combustion provide: Provides emission rate targets for PM2.5, and CO that determine whether fuel and technology combinations are “clean” for health Provides guidance on the policy in transition to the sustained adoption of clean fuels (e.g. LPG) and technologies Recommendations made against kerosene and unprocessed coal use Emphasizes importance of addressing all main household energy end uses for health benefits In response to the urgent need to address the global health crisis from household fuel combustion, in November 2014, WHO released its first-ever normative guidance on household fuel combustion. These guidelines provide practical evidence based guidance on what fuels and technologies used in the home can be considered clean including: Recommendations on what fuels can be ‘dirty’ for health including kerosene and unprocessed coal. Recommendations on the needed performance of clean fuels and technologies in the home in the form of emission rate targets Recommends about the importance of addressing all household energy uses, partiuclary cooking, heating and lighting to ensure benefits for health and the environment.

30 Recommendations

31 Rec. 1(a): Emission rate targets (PM2.5)Recommendation For 90% of homes to meet the WHO AQGs for PM2.5, emission rates should not exceed the emission rate targets (ERTs) set out below. Emissions rate targets (ERT) Emission rate (mg/min) Percentage of kitchens meeting AQG (10 µg/m3) Percentage of kitchens meeting AQG IT-1 (35 µg/m3) Unvented Intermediate 1.75 9% 60% Final 0.23 90% 100% Vented 7.15 4% 0.80

32 Rec. 1(b): Emission rate targets (CO)Recommendation For 90% of homes to meet the WHO AQG for CO, emission rates should not exceed the emission rate targets (ERTs) set out below. Emissions rate targets (ERT) Emission rate (g/min) Percentage of kitchens meeting AQG (7 mg/m3) Unvented Intermediate 0.35 60% Final 0.16 90% Vented 1.45 0.59

33 Focus on emissions reductions – why?Outdoor  indoor Evidence base stronger than for other approaches Implementation practicality – via design, production, standards, etc Some options (clean fuels), are relatively independent of user behaviour.

34 Model linking emissions to air qualityInputs: Emission rates: PM2.5 CO Kitchen volume Air exchange rate Duration of use (hours per day) Outputs: Predicted average concentrations of: PM2.5 CO There a number of different emissions models out there, this particular model assumes devices are used for 4 hours a day, in room that is 30 cubic meters with an air exchange rate of 15 times per hour. Please not that kitchen can actually be any room where the combustion practice is taking place. Kitchen is used here as cookstoves is where we had all the evidence to base our model on but is applicable elswhere. Assumes uniform mixing of pollutants and air in kitchen

35 Recommendation: Policy during transitionFor many, it will take time to meet AQGs (especially PM2.5), so intermediate steps (solid fuel stoves) may be required Policy should promote clean fuel where and when possible Solid fuels: test emissions (ref Recommendation #1), use best possible options Monitor use and air pollution (not just laboratory) Rationale: Health evidence: need low levels for major health benefits (ALRI) In practice, solid fuel stoves not achieving low levels Even clean fuel users well above IT-1 (from other sources) Based on evidence, requires (near) exclusive use of clean fuels to achieve AQG (PM2.5).

36 Rec. 4: Use of kerosene Recommendation:Household combustion of kerosene is discouraged while further research into its health impacts is conducted  Rationale: High levels of emissions of PM and other health-damaging emissions. Epidemiologic studies suggest links to tuberculosis, cancer, respiratory disease, adverse birth outcomes, etc., but are not of adequate consistency/quality. Kerosene use carries substantial risks of burns and poisoning. Strength of recommendation: CONDITIONAL Simple technologies like wick kerosene lamps have shown to be some of the most polluting and present more safety risks than more sophisticated lamps. Kerosene is responsible for a large majority of burns and fires in developing countries and is one of the leading causes of poisonings in children.

37 Good Practice Recommendation: Securing health and climate co-benefitsConsidering the opportunities for synergies between climate policies and health, including financing– governments and agencies who develop & implement policy on climate change mitigation should consider action on household energy and carry out relevant assessments to maximize health and climate gains. Household biomass use is one of the largest contributor to global black carbon emissions—recent studies suggest 25% of BC emissions are derived from HH biomass use.

38 Residential Coal Combustion for Cooking & Heating Improving health through cleaner household energyProblem: The incomplete combustion of coal in households for cooking and heating releases high levels of mercury, sulfates, high levels of carbon monoxide and other health damaging pollutants indoors. Interim solutions for health: Coal stoves with flues (e.g. chimneys) Improved coal stoves Coal processing (e.g. briquetting) Ultimate solutions for health: Clean fuels (e.g. Liquefied Petroleum Gas, biogas) Advanced biomass stoves (e.g. fan-assisted gasifier stoves) where appropriate

39 Global Alliance for Clean Cookstoves (GACC) How WHO is working on domestic energy needs? Clean Home Energy Solutions Connecting WHO’s AP work to other global work on home energy, sustainable development & climate Global Alliance for Clean Cookstoves (GACC) UN Secretary General’s Sustainable Energy for All initiative (SE4All) Climate & Clean Air Coalition on Short-Lived Pollutants (CCAC) WHO’s Global Platform for Air Quality & Health WHO is working with various partners to ensure that efforts to improve domestic energy use across all settings in met in a healthy way. Also WHO is working to bridge outdoor air pollution and indoor air pollution to synergize efforts across agencies, and initiatives.