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Congestion of the streets and lungs in India
Country in Focus
www.thelancet.com/respiratory Vol 5 April 2017
Dr Raja Dhar, a consultant respiratory physician at Fortis Hospital, Kolkata. “Good [critical care treatment] is available only in private tertiary care hospitals in India. However, these centres are very expensive and out of reach for most middle-class families. Quality critical care treatment in India has to percolate down to smaller nursing homes and healthcare units for it to make a difference to the common man in India”, he said. “Even more importantly, government hospitals have to build up state-of-the-art critical care units which the common man can access. This is currently nonexistent.” The nation’s capital, New Delhi, which was ranked the world’s most polluted city in the 2014 WHO report, no longer has that distinction, though it still remains the world’s most polluted megacity. Some 25 million people live in Delhi, and it’s growing fast; the UN projects the city’s population to reach 36 million by 2030. Some 1200 vehicles are added each day to the city’s current total, which now exceeds 7·4 million, according to the website delhiair.org. Vehicular pollution is a “huge factor” in India’s respiratory prob lems, says Dhar, who adds that, “With an increasingly strong middle class with good buying power, the number of private cars has increased enormously. The private and state buses are old and derelict with faulty exhaust systems, which add to the burden of pollution.” In 2000, only 4% of the nation’s new cars used diesel. That number has risen to 50%, according to a February, 2014, report from India’s Environment Pollution (Prevention and Control) Authority. The report adds that in Delhi—where vehicle numbers overall have nearly doubled between 2002 and 2012— road conditions are such that “it is too dangerous to walk and cycle safely in the city”. One might say the
same about the air conditions; diesel emissions are classified as a class 1 carcinogen by WHO, which contends that such exhaust can cause lung cancer. A “typical diesel car emits around ten times more nitrogen oxides than an equivalent gasoline car”, according to the European Federation for Transport and Environment. In recent years, India has seen a sharp rise in the incidence of lung cancer among non-smokers. “The direct association between lung cancer and outdoor air pollution still remains mainly conjectural”, says Dhar. “However, pulmonologists agree that about 20% of the lung cancer cases we see are in nonsmokers and are largely related to air pollution.” He adds that, “Trends in lung cancer show a significant rise in Delhi, Chennai, and Bengaluru [Bangalore] in both sexes”, pointing out that “smoking rates in these metropolitan cities have plateaued, at least in men. Hence pollution seems to be an important factor.” With the nation’s pollution an ongoing crisis, organisations such as We Mean To Clean (WMTC) are striving to combat the issue.
For more on the world’s most polluted cities see http://timesofindia.indiatimes. com/life-style/health-fitness/ health-news/10-of-worlds-20most-polluted-cities-in-India-Listinside/articleshow/52249911.cms For more on the report from Greenpeace India see https://secured-static.greenpeace. org/india/Global/india/ Airpoclypse--Not-just-Delhi--Airin-most-Indian-cities-hazardous-Greenpeace-report.pdf For more on the study on under-five mortality see http://www.jnsbm.org/article. asp?issn=0976-9668;year=2015 ;volume=6;issue=1;spage=3;epa ge=6;aulast=Kumar For more on the report on diesel cars in India see http://cseindia. org/userfiles/EPCA_report.pdf
Unsplash
With a population of more than 1·3 billion, India is home to ten of the world’s 20 most polluted cities, according to a 2016 report by WHO. On the face of it, this number might be considered an improvement, considering that a WHO report from 2014 said India had 13 of the 20 mostpolluted cities. However, the 2016 report included 3000 cities worldwide —nearly double the number of the 2014 report. A study published in the May, 2016, issue of Geophysical Research Letters suggests that India’s air pollution kills about 500 000 people per year. However, a recent Greenpeace India report puts the annual death toll at up to 1·2 million. Whichever figure is more accurate, hazards abound. WHO says that India has the world’s highest mortality due to chronic respiratory disease. Almost 3·5 million cases of acute respiratory infection were reported in 1 year according to India’s National Health Profile 2015. A study published in 2015 reported that acute respiratory infections were the most frequent cause of mortality for children under five. India also accounts for some 2·2 million of the world’s 8·6 million new cases of tuberculosis each year. Even though India has twice as many new cases as any other nation, WHO believes that as many as 40% of India’s tuberculosis cases go unreported. Although air pollution might not directly cause tuberculosis, it can weaken the respiratory system, increasing the probability that latent tuberculosis infections will proceed to active disease. For Indian people with serious health conditions, there is usually scant available treatment. Even though intensive care costs less in India than in most high-income nations, the cost of critical care is not affordable to most people. India’s overall critical care situation “leaves much to be desired”, admits
iStockphoto/BDphoto
Congestion of the streets and lungs in India
253
Pixabay/Pucho
Country in Focus
For more on foreigners leaving the cities see https://www. nytimes.com/2015/05/31/ opinion/sunday/holding-yourbreath-in-india.html
254
Established in October, 2014, WMTC is a Delhi-based volunteer group that holds labour-intensive cleaning events and seeks to promote the concept of cleanliness as a civic responsibility. Cofounder Manish Khurana (New Delhi, India) does not know of any region in India that is tackling the problem on a substantial level. “Air pollution is at alarming levels in all major metropolises and
even in some smaller Indian cities. And there haven’t been any concrete steps taken to curtail this issue anywhere.” Far from viewing this situation as the inevitable result of a huge, rapidly developing nation, Khurana believes there is plenty of blame to go around: “It’s a collective failure as a society… In many cases political tussles take precedence over critical issues such as this”, he says. “There is also a laidback attitude among citizens. ‘Not my job’. People want cleaner air but no one is willing to adopt even minor changes in their lifestyle to reduce their carbon footprint. People don’t realise it’s a collective effort.” Khurana explains that there are a lot of new middle-class families in India for whom “visiting a grocery store on their motorbike or scooter even 100 m away from home is a fashion. Then there’s a lot of people for whom riding in big cars gives a sense of prestige. That leads to congestion on roads, on which people don’t even care to switch off their car engines
[when idling]. And that leads to unnecessary emissions.” He points out that there are plenty of anti-pollution laws and penalties, but “there’s no compliance. Law enforcement is weak, rendering all such regulations and bans meaningless.” In his view, “The government needs to address this issue with the highest sense of urgency. It needs to chart out a strict law enforcement plan with heavy and strict penalties with no exceptions whatsoever to the violators.” Whether related to air pollution or otherwise, respiratory illness is more pervasive in India’s slums, where there is overcrowding combined with inferior nutrition and diminished health-care access. But everyone is in considerable danger, and foreigners have been leaving India’s cities because of pollution. The need for air can be a great equaliser, and in India it has become apparent that everyone, regardless of income bracket and social status, has to breathe.
Ray Cavanaugh
www.thelancet.com/respiratory Vol 5 April 2017
www.thelancet.com/respiratory Vol 5 April 2017
Dr Raja Dhar, a consultant respiratory physician at Fortis Hospital, Kolkata. “Good [critical care treatment] is available only in private tertiary care hospitals in India. However, these centres are very expensive and out of reach for most middle-class families. Quality critical care treatment in India has to percolate down to smaller nursing homes and healthcare units for it to make a difference to the common man in India”, he said. “Even more importantly, government hospitals have to build up state-of-the-art critical care units which the common man can access. This is currently nonexistent.” The nation’s capital, New Delhi, which was ranked the world’s most polluted city in the 2014 WHO report, no longer has that distinction, though it still remains the world’s most polluted megacity. Some 25 million people live in Delhi, and it’s growing fast; the UN projects the city’s population to reach 36 million by 2030. Some 1200 vehicles are added each day to the city’s current total, which now exceeds 7·4 million, according to the website delhiair.org. Vehicular pollution is a “huge factor” in India’s respiratory prob lems, says Dhar, who adds that, “With an increasingly strong middle class with good buying power, the number of private cars has increased enormously. The private and state buses are old and derelict with faulty exhaust systems, which add to the burden of pollution.” In 2000, only 4% of the nation’s new cars used diesel. That number has risen to 50%, according to a February, 2014, report from India’s Environment Pollution (Prevention and Control) Authority. The report adds that in Delhi—where vehicle numbers overall have nearly doubled between 2002 and 2012— road conditions are such that “it is too dangerous to walk and cycle safely in the city”. One might say the
same about the air conditions; diesel emissions are classified as a class 1 carcinogen by WHO, which contends that such exhaust can cause lung cancer. A “typical diesel car emits around ten times more nitrogen oxides than an equivalent gasoline car”, according to the European Federation for Transport and Environment. In recent years, India has seen a sharp rise in the incidence of lung cancer among non-smokers. “The direct association between lung cancer and outdoor air pollution still remains mainly conjectural”, says Dhar. “However, pulmonologists agree that about 20% of the lung cancer cases we see are in nonsmokers and are largely related to air pollution.” He adds that, “Trends in lung cancer show a significant rise in Delhi, Chennai, and Bengaluru [Bangalore] in both sexes”, pointing out that “smoking rates in these metropolitan cities have plateaued, at least in men. Hence pollution seems to be an important factor.” With the nation’s pollution an ongoing crisis, organisations such as We Mean To Clean (WMTC) are striving to combat the issue.
For more on the world’s most polluted cities see http://timesofindia.indiatimes. com/life-style/health-fitness/ health-news/10-of-worlds-20most-polluted-cities-in-India-Listinside/articleshow/52249911.cms For more on the report from Greenpeace India see https://secured-static.greenpeace. org/india/Global/india/ Airpoclypse--Not-just-Delhi--Airin-most-Indian-cities-hazardous-Greenpeace-report.pdf For more on the study on under-five mortality see http://www.jnsbm.org/article. asp?issn=0976-9668;year=2015 ;volume=6;issue=1;spage=3;epa ge=6;aulast=Kumar For more on the report on diesel cars in India see http://cseindia. org/userfiles/EPCA_report.pdf
Unsplash
With a population of more than 1·3 billion, India is home to ten of the world’s 20 most polluted cities, according to a 2016 report by WHO. On the face of it, this number might be considered an improvement, considering that a WHO report from 2014 said India had 13 of the 20 mostpolluted cities. However, the 2016 report included 3000 cities worldwide —nearly double the number of the 2014 report. A study published in the May, 2016, issue of Geophysical Research Letters suggests that India’s air pollution kills about 500 000 people per year. However, a recent Greenpeace India report puts the annual death toll at up to 1·2 million. Whichever figure is more accurate, hazards abound. WHO says that India has the world’s highest mortality due to chronic respiratory disease. Almost 3·5 million cases of acute respiratory infection were reported in 1 year according to India’s National Health Profile 2015. A study published in 2015 reported that acute respiratory infections were the most frequent cause of mortality for children under five. India also accounts for some 2·2 million of the world’s 8·6 million new cases of tuberculosis each year. Even though India has twice as many new cases as any other nation, WHO believes that as many as 40% of India’s tuberculosis cases go unreported. Although air pollution might not directly cause tuberculosis, it can weaken the respiratory system, increasing the probability that latent tuberculosis infections will proceed to active disease. For Indian people with serious health conditions, there is usually scant available treatment. Even though intensive care costs less in India than in most high-income nations, the cost of critical care is not affordable to most people. India’s overall critical care situation “leaves much to be desired”, admits
iStockphoto/BDphoto
Congestion of the streets and lungs in India
253
Pixabay/Pucho
Country in Focus
For more on foreigners leaving the cities see https://www. nytimes.com/2015/05/31/ opinion/sunday/holding-yourbreath-in-india.html
254
Established in October, 2014, WMTC is a Delhi-based volunteer group that holds labour-intensive cleaning events and seeks to promote the concept of cleanliness as a civic responsibility. Cofounder Manish Khurana (New Delhi, India) does not know of any region in India that is tackling the problem on a substantial level. “Air pollution is at alarming levels in all major metropolises and
even in some smaller Indian cities. And there haven’t been any concrete steps taken to curtail this issue anywhere.” Far from viewing this situation as the inevitable result of a huge, rapidly developing nation, Khurana believes there is plenty of blame to go around: “It’s a collective failure as a society… In many cases political tussles take precedence over critical issues such as this”, he says. “There is also a laidback attitude among citizens. ‘Not my job’. People want cleaner air but no one is willing to adopt even minor changes in their lifestyle to reduce their carbon footprint. People don’t realise it’s a collective effort.” Khurana explains that there are a lot of new middle-class families in India for whom “visiting a grocery store on their motorbike or scooter even 100 m away from home is a fashion. Then there’s a lot of people for whom riding in big cars gives a sense of prestige. That leads to congestion on roads, on which people don’t even care to switch off their car engines
[when idling]. And that leads to unnecessary emissions.” He points out that there are plenty of anti-pollution laws and penalties, but “there’s no compliance. Law enforcement is weak, rendering all such regulations and bans meaningless.” In his view, “The government needs to address this issue with the highest sense of urgency. It needs to chart out a strict law enforcement plan with heavy and strict penalties with no exceptions whatsoever to the violators.” Whether related to air pollution or otherwise, respiratory illness is more pervasive in India’s slums, where there is overcrowding combined with inferior nutrition and diminished health-care access. But everyone is in considerable danger, and foreigners have been leaving India’s cities because of pollution. The need for air can be a great equaliser, and in India it has become apparent that everyone, regardless of income bracket and social status, has to breathe.
Ray Cavanaugh
www.thelancet.com/respiratory Vol 5 April 2017