After taking stock of heightened air pollution across the country and its considerable impact on health of residents, the Ministry of Health and Family Welfare has decided to act against chronic obstructive pulmonary disease, which is characterised by poor airflow in the respiratory system.

On October 7, the department for Prevention and Control of Noncommunicable Diseases issued letters to state governments stating that the disease will be included under the non-communicable programme, said Dr Damodar Bachani, the deputy commissioner for non-communicable diseases. The non-communicable programme now works towards reducing the burden of cancer, cardiovascular diseases, diabetes and strokes. Chronic obstructive pulmonary disease, commonly known as COPD, and asthma, will now be part of the programme.

COPD is a chronic lung disease like asthma and with similiar symtoms. The progressive chest disease that causes coughing, wheezing, shortness of breath, chest tightness and other symptoms. While smoking is the biggest risk factor for COPD, another risk factor is long-term exposure to lung irritants such as air pollution, dust and chemical fumes.

“We have to try reduce both the source of pollution and the exposure to pollution," said Bachani. "But, from our end, we as the health sector have to take responsibility of people who are affected by air pollution.”

Documenting evidence

In 2010, the Global Burden of Disease study ranked air pollution as as the leading cause of death and disability in India. In India, around 1.6 million premature deaths and 59 million disability-adjusted life years are attributable to PM2.5 – that is fine particulate matter less than 2.5 microns in diameter – and other pollutants found in household and ambient air pollution.

Last year, the Ministry of Health and Family Welfare had formed a 16-member steering committee “to frame an action plan for mitigating the adverse health impacts of indoor and outdoor air pollution”. The committee, the report claims, “broke new ground” as it was the first in the world reviewing health impacts on pollution explicitly, and examining the issue of air pollution primarily from a health policy perspective.

The steering group studied various evidences of air pollution, both ambient and household, and its effects on health. The group examined evidence from around the world and the evidence from within the country.

Taken together, both household and ambient pollution account for 9% of the national disease burden. The effects of household and ambient air pollution exceed every other risk factor including poor nutrition, smoking, alcohol, high blood pressure and obesity.

Children who are exposed to household emissions, and causes acute respiratory infection and pneumonia. “Air pollution affects their respiratory system, which is still developing,” said Bachani. “The vaccine preventable diseases such as diarrhoea and pneumonia are the main causes of mortality in children. But what do you do with pneumonia that is caused by air pollution?”

A 100-district pilot programme

With this evidence in hand, the steering group felt something needed to be done about chest diseases caused by air pollution, particularly COPD.

“While we have programmes that take care of pneumonia, cancer, and heart disease, we are not doing anything for COPD," said Bachani. "An immediate decision was taken at the highest level – at the health minister’s level – to include COPD in the NCD programme.”

The department is preparing technical and operational guidelines to bring COPD into the ambit of the non-communicable diseases programme. Training modules for doctors and health workers are being developed by doctors at All India Institute of Medical Sciences, Delhi.

The department has written to the state health departments to identify 100 districts across the country that have a acute air pollution problems. “In the next project implementation plans, we have asked the states to identify 100 districts which they think have this problem, possibly based on air pollution data,” Bachani said. The department also plans to link villages health administrations to district hospitals to can diagnose and treat air pollution-related diseases.

Gearing up technologically

The union government has earmarked Rs 15 lakh to buy equipment and Rs 25 lakh to buy drugs that will be required to treat COPD. The department will provide portable spirometers that measure lung capacity and lung volume, which can be used at district hospitals, and even at screening camps at different localities.

“We want to identify changes in the lung early, which is possible with spirometer,” said Bachani. “Currently, only medical colleges have this equipment. But not even all of them. In Lady Hardinge where I teach, it is not available.” The only other equipment which was available at district level hospitals are X-rays, which Bachani said, identify changes in the lung too late. Doctors and technicians at the district hospital level will be trained in using spirometer and treating patients.

The health department also plans to provide inhalers, oxygen cylinders to contend with severe asthmatic attacks, bronchodilator that dilate the airway passages, among other therapies.

“There is very little on non-communicable diseases in our curriculum,” said Bachani. “These (COPD and asthma) are common ailments. Most doctors would just give cough syrup and antibiotics. Doctors should know how to manage an asthma attack. We are looking at not just theoretical training, but also interactive skill based training.”

The department also wants the COPD programme to be linked with the tuberculosis control programme. “People with a chronic cough come to TB clinics," Bachani pointed out. "If TB is ruled out, then these patients should be referred to our clinics, and not sent back. Similarly, our clinics can also send patients not tested for TB to TB centres.”

Reducing household emission

What is key to reducing these health hazards, however, is reducing emissions and exposure to household and ambient pollution. In rural India and in urban slums, many people still use biofuels, a considerable source of both household and ambient air pollution.

The health department wants the Swacch Bharat Abhiyaan to focus not only on garbage disposal but also at ways to cut air and water pollution. The department, in the new programme, seeks to rope in village health and sanitation committees to attempt bringing about behavioral change among residents who use biofuels for cooking. Such a committee normally includes accredited social health activists or ASHAs, auxiliary nurse midwives and social health workers.

The need for such widespread uptake of clean cooking energy – and therefore a movement away from traditional energy sources and cooking practices – will require drawing on behavioural and social sciences, the steering committee report noted.

But studies indicate that the air pollution exposure reductions need to be substantial, and sustained over long periods to significantly reduce the burden of disease. A few households in a village switching over to cleaner sources of energy will not help. This change cannot be brought over with just communication, but more needs to be done at the policy level, especially with the Ministry of Petroleum and Natural Gas.

“If we want to change rural health, we cannot just convert 10 households from biofuels to LPG, it won’t help,” said Bachani. “All the households have to shift to a cleaner fuel for the disease burden to come down. The action has to be taken by other ministries.”

Multi-sectoral plan to reduce air pollution

  • Ministry of Agriculture: Policy in place to promote multiple uses of crop residues and prevent their on-farm burning
  • Ministry of Human Resource Development: Awareness about pollution among school children, and their regular health screening
  • Ministry of Women and Child Development: Awareness among self help groups for protection of women and children from significant exposure to smoke from biomass inside the house
  • Ministry of New & Renewable Energy: Develop policies relating to clean chulhas (cookstoves) 
  • Ministry of Communications & Information Technology: Use of mobile phones to encourage healthy choices and warn people about air pollution