Living in a Gas Chamber

Living in a Gas Chamber

Pollution has come knocking as a systemic disaster. Do the Centre and the State Governments have any action plan to combat the deteriorating air quality?

By Amresh Kumar Tiwary

The air quality in the National Capital Region is deteriorating day by day due to increasing pollution with the result that the incidence of respiratory and other chest ailments are on the rise. The situation has reached such an alarming dimension that many people are installing oxygen cylinders at home for emergency purposes, especially as a precautionary measure where elderly people are staying. Medical practitioners feel that the problem needs the attention of not just some individuals, but of an entire system, to make the Capital city’s air breathable again.

Delhi is not alone, almost every busy city around the world is slipping into this inescapable state of ghettos of traffic fumes and industrial effluents. For example, Beijing’s case has been scary in recent times, caught in a manufacturing race over time. Visibility was nil this time, leading to emergency cleanup and an industrial shutdown yet with a permanent solution eluding all. No doubt, the economic inevitabilities, an unplanned development and a socio-economic life propelled by hysterically aspirational marketing are taking life around the world to a point of no return.

A recent study by WHO showed that New Delhi’s air is the world’s worst polluted, and 13 of the 20 most polluted cities in the world are in India. A month ago, nothing was visible in Beijing with a thick haze of dust and fumes covering the city, and even other regions in China. But data showed that New Delhi’s air was worse in terms of quality. Between August 2014 and August 2015, Delhi’s levels of air pollution by the more harmful PM2.5 (‘fine’ Particulate Matter in the air with an aerodynamic diametre of less than 2.5 µm), was far above the levels in Beijing.

 

What is Particulate Matter (PM)

Particulate matter (PM) is the term for particles found in the air like dust, dirt, soot, smoke and liquid droplets. They are mostly created by automobiles and coal-fired power plants. Some are large or dark and can be seen as smoke. Others are so small and can be seen only by an electron microscope. Particles smaller than 10 micrometres in diametre (PM10) pose a health hazard. During inhalation they get deposited in the lungs. Particles smaller than 2.5 micrometres in diametre (PM2.5) are called “fine” particles. Approximately 1/30th the width of a human hair, these particles pose the greatest health risks. They get deeply lodged in the lungs.  The ‘fine’ particles come mostly from combustion activities of motor vehicles, power plants, wood burning, industries and the like. Particles with diametres between 2.5 and 10 micrometres called “coarse” come from crushing or grinding operations and dust from the roads.

There are agencies worldwide that establish ambient air quality standards for each of the criteria pollutants. The most harmful pollutants closely associated with excessive premature mortality are these ‘fine’ PM2.5 particles.

Although air quality in developed countries has been generally improved over the last decades, the adverse health effects of particulate air pollution, even at relatively low levels, remains a global public health concern.

Not only the Chinese Government but also civil society organizations are now saying that Beijing’s air quality is improving steadily due to aggressive anti-pollution policies. Average annual PM2.5 levels fell by about 25% from November 2014 to November 2015, after more modest reductions since 2012. But India’s Capital is still too far from achieving its goal to minimize pollution levels.

Data collated by the Central Pollution Control Board shows Anand Vihar located in East Delhi has the worst air quality in the Capital, 30-40 per cent more polluted than localities such as Dwaraka and Punjabi Bagh. The WHO and other global bodies monitoring the air quality in Delhi go a step further and define the area as among the most polluted in Asia. Add to that  hundreds of trucks carrying animals and processed meat to and from adjoining Ghazipur, which has Asia’s largest livestock market and slaughter house, and you can imagine why Anand Vihar is the most alarming name in the pollution story.

Anand Vihar’s Air Quality Index (AQI), a parameter measuring the chief pollutants, was as high as 455, 473 and 495, respectively, during the peak hours against a safe level of 50. At this `severe’ level, even healthy people can be affected, while those with existing respiratory ailments face serious threats. PM10, or respirable particulate matter with a size equal to or less than 10 micron, is the lead pollutant in the area. Prolonged exposure to PM10 in high concentrations can cause coughing, wheezing, asthma attacks and bronchitis. The level of the even more dangerous PM2.5 (tinier and more easily inhaled particulate matter) too was four or five times the safe standard of 60 micrograms per cubic metre.

Health interventions must be guided by both emission and exposure estimates. A policy that addresses multiple sources of pollution will be critical for prevention and dealing with existing health impacts of air pollution, which requires the representation and coordination of various ministries.

Alarmed at the current air pollution levels in the city, the Delhi High Court  described the situation as similar to living “in a gas chamber“ and demanded an immediate action plan from the Centre and the State Government to combat the deteriorating air quality. Identifying emissions by vehicles and construction related particulates as key pollutants in the Capital, the court recently ordered a clampdown on both, asking the Government agencies to take necessary steps thereby dismissing the plans filed by the Environment Ministry and the Delhi Government as non-comprehensive.

The High Court also took a serious view of the extreme air pollution being caused by unrestrained burning of trash and leaves in the city and the adjoining areas. It ordered the Delhi Government to ask all Sub-Divisional Magistrates to get cracking against the offenders.

Health consequences

Exposure to high levels of air pollution can cause a variety of adverse health outcomes. It increases the risk of respiratory diseases like bronchitis, emphysema, childhood pneumonia and asthma, heart diseases, stroke and lung cancer. Children, the elderly, the poor and the sick are the most susceptible.

According to Dr Anup Mohta, Director, Chacha Nehru Bal Chikitsalaya, East Delhi, it is not simply those who spend a lot of time outdoors who are affected, even month-old babies are unable to breathe normally and suffer from blockage of the nostrils due to air pollutants.  All that can be done in such cases is to open up the upper airway by administering saline drops.

Worldwide, 3.7 million premature deaths were attributed to ambient air pollution in 2012.  About 88% of these deaths occurred in low and middle income countries.

The WHO maintains a worldwide, public database on urban outdoor air pollution in its Global Health Observatory. The database contains measured outdoor air pollution levels of PM2.5 and PM10 from 1100 cities in 92 countries for the years 2003-2010. These are used for estimating mean annual exposures of the urban population to fine particulate matter. In 2013, WHO began collaborating with major institutions and agencies worldwide in the development of a global air pollution platform that includes data on air pollution concentrations based on satellite monitoring, chemical transport models and ground measurements, inventories of pollution emissions from key sources, and models of air pollution drift – permitting estimates of air pollution exposures even in areas where there are no ground level monitoring stations.

WHO’s main function is to identify and monitor air pollutants with the greatest impact on people’s health. This helps the WHO member-States to focus their actions on the most effective way to prevent or reduce health risks. WHO also reviews and analyzes the accumulated scientific evidence, and uses expert advice to draw conclusions on how different types of air pollutants affect health as well as identify effective measures to reduce the air pollution burden.

The Governments can identify the main sources of ambient air pollution, and implement policies known to improve air quality, such as promotion of public transport, walking, and cycling, streamlining of power plants etc.

Essential accompanying steps must include increasing awareness about the high disease burden from ambient air pollution and its main sources, as well as highlighting the importance of taking action to implement country-specific interventions. In addition, the use of effective monitoring to evaluate and communicate the impact of interventions is also an important tool in raising awareness. It can help drive policy action that brings benefits for health, climate and the environment.

WHO estimates that 12.7% of deaths could be averted by improving air quality worldwide. Lower levels of air pollution will reduce the burden of respiratory and cardiovascular disease-related illnesses, health-care costs, and lost worker productivity due to illness, as well as increasing life expectancy among local populations. In addition, actions that reduce ambient air pollution will also cut emissions of short-lived climate pollutants, particularly black carbon which is a major component of soot emissions from diesel vehicles, and other sources, as well as greenhouse gases (eg. CO2) contributing to long-term climate change impacts.

Climate change produces a number of adverse effects on health. This includes those from drought and extreme weather events (eg. windstorms, floods), such as water-borne and food-borne diseases. It also increases the prevalence of vector-borne diseases like dengue or malaria.

Leading role for health sector

Public health recognizes air pollution as an important determinant of health. Today this is especially the case in developing countries where exposure to air pollution is now higher than in developed countries, where mitigation measures led to reductions in exposure.  Air pollution combines with other aspects of the social and physical environment to create a disproportional disease burden in less affluent parts of society.

Exposure to air pollutants is largely beyond the control of individuals and requires action by public authorities at the national and regional levels. The health sector can play a central role in leading a multi-sectoral approach to prevent exposure to air pollution. It can engage and support other relevant sectors (transport, housing, energy production and industry) in the development and implementation of long-term policies to reduce the risks of air pollution to health.

Reducing the public health impacts of ambient air pollution requires addressing the main sources of air pollution, including inefficient fossil fuel combustion by motor vehicles and in power generation and improving energy efficiency in homes, buildings and manufacturing. Action by public authorities at the national, regional and even international levels is called for. Individuals can also contribute to improving air quality by choosing cleaner options for transport or energy production.

 

 

Box:

What the doctors say

Diesel emissions are a carcinogen

“Diesel emissions have also been defined by WHO’s International Agency for Research on Cancer as a carcinogen. Building cities around rapid public transport systems, complemented by dedicated walking and cycling networks, will reduce pollution.  Transport is directly responsible for anywhere from 15 to 70% of urban ambient air pollution in urban areas. A holistic approach involving energy, industry, and building sectors, together with the transport sector, is required to reduce the disease burden from ambient air pollution.”

Dr A K Agarwal, Professor of Excellance and former Dean, Maulana Azad Medical College, New Delhi

 

Disproportional disease burden

“Improving ambient air pollution is an inter-sectoral challenge. There is significant inequality in the exposure to air pollution and the related health risk: air pollution combines with other aspects of the social and physical environment, creating disproportional disease burden in populations with limited incomes and with minimal local resources to take action.”

Dr K K Aggarwal, Heart Specialist and Secretary General, Indian Medical Association, New Delhi

 

 Lack of awareness

“In parts of Europe where stricter standards and regulations for vehicles have been enforced, ambient air pollution levels are stable. There is often a lack of awareness about the health burden of ambient air pollution.”

Dr Vinay Aggarwal, Founder-Chairman, Max Superpeciality Hospital, Vaishali, and former president, Indian Medical Association, New Delhi

 

Dr Manisha Yadav, Medical Practitioner

 “Around 50 percent of people, almost all in developing countries, rely on coal and biomass in the form of wood, dung and crop residues for domestic energy. These materials are typically burnt in simple stoves with incomplete combustion. Consequently, women and young children are exposed to high levels of indoor air pollution every day. There is consistent evidence that indoor air pollution increases the risk of chronic obstructive pulmonary disease and of acute respiratory infections in children and it is the biggest cause of death among children under 5 years of age in developing countries. Exposure to indoor air pollution may be responsible for nearly two million excess deaths in developing countries. Indoor air pollution is a major global public health threat requiring greatly increased efforts in the areas of research and policy-making.”

 

Asthma care – Some tips

There are a number of reasons for developing asthma, but increasing air pollution is being considered as one of the major causes. Asthma is characterized by an abnormal behaviour of the bronchial pipes triggered by an allergic reaction that makes breathing difficult.  The problem increases in the winter.

 

Here are some tips to alleviate your suffering

If you are experiencing severe symptoms of wheezing while breathing both in and out, coughing that won’t stop, very rapid breathing, chest tightness or pressure, tightened neck and chest muscles called retractions, difficulty in talking, feeling of anxiety or panic, pale, sweaty face and blue lips or fingernails or worsening of symptoms despite taking medication, you might be having an attack of asthma.

Sometimes asthma symptoms include sighing, fatigue, and rapid breathing, not coughing or wheezing. You must take certain precautions like never forget your inhaler, stay calm, beware of indoor allergens, never breathe from your mouth.

For being extra safe this winter, pull a neck gaiter, scarf or turtleneck up over your mouth and nose to warm the air you are inhaling. Avoid exercising outdoors when it’s very cold outside. It is also advised to change the filters of your heating system every year before winter season starts.

Asthma is a persistent disease of the bronchial pipes (air shaft) that makes breathing difficult.  It is usually connected to allergic reaction or other forms of hypersensitivity.

According to Dr Pankaj Sayal, Senior Consultant, Pulmonology, PSRI Hospital, New Delhi, asthma problems gradually increase in winter. Cold weather can cause asthma to flare up more than usual, not to mention the extra threat of colds and flu, which can badly affect the respiratory system.  The attacks happen more often in the winters because of mainly two reasons: the patients usually spend more time indoors in the winters and there is cold outside. Hence the challenges in the winters increase for the asthma people.

An asthma attack is characterized by an unexpected corroding symptom caused by the tightening of the muscles around your airways (bronchospasm). During an attack, the lining of the airways also becomes swollen or provoked and mucus more than normal is produced. All these factors create bronchospasm, inflammation, and mucus production.

Says, Dr Swapnil Shikha, Director, Amrapali Healthcare, Noida,”There are many more reasons why winter is a problem for asthmatics. The cold air itself is a common trigger of breathlessness and the attacks, plus winter brings with it an increase in colds and respiratory infections like Swine flu etc. Being indoors can cause problems too as the air is often of poor quality during the winter because we prevent fresh air circulation by closing the doors and windows to keep out the chill.”

Smog is another factor which can aggravate asthma for people living in and around Delhi. Much of this is unavoidable so it’s important that you and those around you know about your asthma in case you do have an attack.

Dr Pankaj Sayal, says,  To avoid getting infections or catching cold one should always wash one’s hands properly with soap and water because infections aggravate the asthmatic condition. Alcohol-based sanitizers work best for this.

One should not sit by a fire place as the smoke of the burning woods is like burning tobacco and it triggers asthma. Exercise indoors. On days when it’s bitterly cold outside and the wind chill makes it feel like it’s below zero, go to the gym instead of exercising outside. The temperatures and the humidity in the gym are less likely to cause a problem. If you still want to exercise in the fresh (albeit cold) air, choose a time of the day when it might be warmer, such as the mid-afternoon.

Says, Dr Swapnil Shikha, Your home heating system may blow dust throughout your house, especially when you first start it up for the winter. It’s important to clean and replace the filters before turning on your system so as not to release the debris and trigger an asthma attack. Clean and check the filters periodically throughout the heating season to avoid issues with winter asthma. Also, try to keep the temperature and humidity levels in your home consistent.

The Centre for Disease Control and Prevention (CDC) recommends that most people aged 6 months and older get an annual flu shot to help protection against the flu virus. Having asthma won’t make you more susceptible, but if you do get the flu, the results could be more serious, even if you keep your asthma symptoms under control. It’s important that people with asthma get the injectable form of the flu vaccine made with inactivated killed flu virus.  People with asthma shouldn’t get the nasal spray (FluMist) vaccine because it contains live virus.

 

 

Alarming Disclosure

Studies conducted in low income countries have found that exposure to indoor air pollution resulting from the use of biomass fuel for cooking and second-hand tobacco smoke has adverse effects on maternal health and foetal growth resulting in preterm birth and Low Birth Weight (LBW).

Low Birth Weight (LBW) is defined as weight less than 2500g at birth. Further categories include Very Low Birth Weight (VLBW) which is less than 1500g and Extremely Low Birth Weight (ELBW) which is less than 1000g. Normal birth weight after completion of nine months of gestation is 2500–4200g. Birth weight is governed by two major processes: duration of gestation and intrauterine growth rate.

The LBW is thus caused by either a short gestation period (Prematurity) or due to intrauterine growth retardation (IUGR) or a combination of both. Prematurity is usually defined as a gestational age of less than 37 weeks. LBW babies are at high risk because, 20% of neonatal mortality is due to LBW alone. LBW and prematurity are together associated with 35% neonatal mortality. The birth weight of babies is directly influenced by the health status of the mother during pregnancy.

According to Dr Suneela Garg, Director-Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, the proportion of babies with a LBW is an indicator of a multifaceted public health problem that includes long-term maternal malnutrition, ill health, hard work and poor health care in pregnancy. On an individual basis, LBW is an important predictor of new-born health and survival and is associated with higher risk of infant and childhood mortality.

LBW prevalence of a country is a good measure reflecting its public health problems and has been used as a very sensitive public health indicator for all the developing countries, including India. Globally the incidence of LBW is 15% or approximately 1 in every 7 child births and in India it is 28%. In developing countries, LBW is mostly attributed to IUGR; while in developed countries it is mainly due to prematurity.

The main determinants of LBW brought out by various studies include – maternal pre-pregnancy weight, maternal weight gain during pregnancy, maternal height < 145cm, inadequate antenatal check-up (< 3 visits), maternal age < 20 years, anaemia (haemoglobin level < 11 g%), inadequate dietary intake during pregnancy, birth spacing, birth order, maternal education, economic status, heavy work during pregnancy, rest, smoking and alcohol consumption during pregnancy and other maternal health problems.

Indoor air pollution (IAP) is an important risk factor for morbidity and mortality; it accounts for about 4% of the global burden of disease. Nearly two million people die each year from causes related to IAP. More than 90% of these deaths occur in low and middle income countries, often in rural or semi-urban areas. IAP levels in these countries are typically many times higher than developed world standards for ambient air quality. Since women and young children often spend considerable time indoors, mostly associated with food preparation and cooking, they are at greatest risk for exposures to IAP.

Globally, three billion people, about half the world’s population, rely on solid fuel including wood, charcoal, crop residues, dung and coal as the main source of household energy. In many low and middle income countries, solid fuel used for household activities such as cooking and heating is a major source of IAP. 4.8% of deaths in low income countries are attributed to IAP, whereas in high income countries outdoor air pollution is the major problem. Solid fuels are often burned over an open fire or in an inefficient stove. The incomplete combustion of solid fuels in simple stoves releases a complex mixture of toxic chemicals.

It has been observed in the studies conducted in low income developing countries that indoor air pollution was associated with a significant increased risk of LBW when compared to mothers who used LPG fuel for cooking during pregnancy. Indoor air pollution due to incomplete combustion of biomass fuel in open stoves without chimneys can produce carbon monoxide (CO), carbon dioxide (CO2), nitrogen dioxide (NO2), sulphur dioxide (SO2), volatile organic compounds and particulate matter concentrations many times higher than those found in the worst outdoor settings. These are associated with significant adverse health effects on the pregnant mother as well as directly on the foetus leading to poor intrauterine growth.

Says Dr Naveen Prabhu J, Department of Community Medicine, Maulana Azad Medical College, New Delhi, “Not only consumption of tobacco during pregnancy but even exposure to second-hand tobacco smoke (SHTS) also increases the risk of prematurity and IUGR. The most likely mediators in tobacco smoke are carbon monoxide and nicotine. Carbon monoxide can interfere with oxygen delivery to the foetus and nicotine is believed to result in rapid increases in maternal catecholamines and consequent uterine vasoconstriction, both leading to uteroplacental insufficiency and IUGR.”

Unfortunately, the households that use the poorest quality cooking fuels are often the most likely to allow indoor smoking, thus increasing the exposure to poor quality indoor air. The condition is worsened by the fact that most of these households in the low income developing countries have poor ventilation and overcrowding, leading to trapping of noxious air indoors with more number of people breathing themselves to ill health. So, exposure to IAP has adverse effects on maternal health and foetal growth resulting in preterm birth and low birth weight. The detrimental effects of IAP further continue into infancy and childhood leading to significant childhood morbidity and mortality.

Emphasis should be on creating awareness among the rural and urban poor about the hazards of indoor air pollution and adoption of healthy lifestyle practices like avoiding use of solid biomass fuels and avoiding smoking indoors especially in proximity to children and women. Subsidies for construction of separate well ventilated kitchens with chimneys or exhaust for smoke and free provision of LPG fuel for the underprivileged people need to be taken up by the Government. Legislations on source reduction of harmful solid fuels should be implemented.

Also, at the community level, planting of trees and greeneries in the houses would help in purifying the polluted air. Further research are needed to determine how indoor air quality can be improved and monitored and the effect that such measures would have on improving maternal and child health outcomes.

 

Sharp rise in lung cancer cases in India

Lung cancer, one of the most deadly cancers, has reached almost epidemic proportions in India owing to the increased prevalence of air pollution. Increased vehicular traffic and industrial pollution seems to be adversely affecting the environment and causing serious concerns.

Lung cancer is one of the most deadly cancers of the present times. It is a tumour in the lungs characterized by uncontrolled growth of abnormal cells in the tissues of the lung that start off in one or both lungs, usually in the cells that line the air passages.

These tumours are of two types, benign tumours – the ones that remain in one place and do not spread – and malignant tumours – the ones that keep spreading into other parts of the body. With the increase in the number of tumours they keep on becoming larger in size, impeding the lung’s ability to provide the blood stream with oxygen.

 

The most common symptoms of lung cancer are:

• Cough: It stays and gets worse eventually and is accompanied by blood, sometimes
• Chest pain: Increases when laughing or coughing
• Breathing problems: Shortness of breath
• Weakness: Getting tired easily and becoming weak, resulting in weight loss and drop in appetite
• Frequent bronchitis & pneumonia: Either it doesn’t go, or is recurring.

Non-small cell lung cancer can be treated with surgery, chemotherapy, radiotherapy or a combination of all, depending upon the stage of the cancer. However, small-cell lung cancer is mostly treated with chemotherapy, radiotherapy and other medications as surgery is not suitable for this as it would have already spread by the time it was diagnosed.

Recent study by the Indian Council of Medical Research (ICMR) under its National Cancer Registry Programme claims deaths due to cancer saw a rise of 6 percentage points between 2012 and 2014. On an average, around 1300 people die due to cancer daily.

According to Dr Amit Aggarwal, Sr. Consultant in Medical Oncology Department, BLK Super Speciality Hospital, “When we blame smoking to be the cause of lung cancer, an astonishing fact comes across us. There has been a great rise in the number of lung cancer cases among women over the past 20 years. This might prove air pollution to be a bigger threat to the disease.”

Dr. Rajesh Jain, Sr. Onco Surgeon, Action Cancer Hospital, New Delhi, says, “With a million new cases being reported every year, cancer seems to be tightening its grip on India. Ageing population, unhealthy lifestyle, use of tobacco and related products are few major reasons identified as precursors to the rise in mortality due to cancer.”

Almost 90 percent of all lung cancer cases globally are associated with smoking, irrespective of the fact that the person is an active smoker or a passive one, as both are dangerous. Heavy exposure to metals like asbestos, radon, uranium or arsenic is another reason causing lung cancer. However, the disease may also run in family genes. A study reveals that people with the rare inherited T790M mutation of the epidermal growth factor receptor (EGFR) gene have higher chances of getting lung cancer. But environmental pollution has led to a steep rise in lung cancer among Indians in the 45 to 55 age group.

Air pollution kills about 7 million people worldwide every year, according to a research conducted by the World Health Organization (WHO). It occurs due to the interference of harmful gases, dust and smoke into the atmosphere deteriorating the quality of the air in the atmosphere, making it unsuitable for breathing. In fact, out of the 20 most polluted cities in the world, 13 are in India, with Delhi topping the chart.

While in 1990, one woman was diagnosed with the disease for every three men, the figure has doubled to two for every three male cases.  According to research, lung cancer in women increased up to 94.1% in 2013 compared to 1990. In case of men the increase in percentage was 62 in 2013 compared to 1990. However, it is quite difficult to identify the early symptoms of lung cancer.

Consequences of Air Pollution

Trigger for asthma

Asthma is a chronic, occasionally debilitating inflammatory disease of the airways that may be caused by air pollution from vehicles, factories or power plants. The experts state that the following air pollutants are common triggers of asthma: ground level ozone, sulfur dioxide, fine particulate matter and nitrogen oxide. The Center for Disease Control and Prevention or CDC states that another important trigger for asthma attacks is environmental or secondhand tobacco smoke. The CDC suggests that parents, friends and relatives of children with asthma should attempt to quit smoking and should never smoke in proximity to a child or a person with asthma, as this could cause an asthma attack.

Chronic Obstructive Airway Disease

Chronic obstructive pulmonary disorder is also a disease that can be caused by air pollution. Chronic Obstructive Pulmonary Disease (COPD) is also known as Chronic Obstructive Lung Disease (COLD) and Chronic Obstructive Airway Disease (COAD). It is characterized by chronically poor airflow. Chronic bronchitis and emphysema are common chronic obstructive pulmonary disorders. With this, a person’s airways and air sacs lose their shape and become distended or floppy and over-inflation of the alveoli causes shortness of breath.

Risk of lung cancer

Urban air pollution boosts lung cancer risk, and motor vehicle emissions may be particularly problematic. Lung cancer is characterized by the uncontrolled growth of abnormal cells in one or both lungs. Over time, the abnormal cells can develop into tumors and impair the lung function.