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Energy and Health in the 2019 BJP Manifesto

The BJP’s Manifesto was released in the last few days. A little hard to hunt down, initially, though a PDF is hosted at documentcloud.

In a section that is partly a list of achievements and partly a description of next steps:

We have evolved technologically better strategies and devices to map the level of pollution in cities and rivers and have taken effective steps to reduce the level of pollution in major cities, including the national capital. We will convert the National Clean Air Plan into a Mission and we will focus on 102 most polluted cities in the country. Through concerted action, we will reduce the level of pollution in each of the mission cities by at least 35% over the next five years.

Another part of he Manifesto is framed around 75 milestones for India’s 75th anniversary, including some focusing on health, energy, air pollution, and water & sanitation.

Under Infrastructure:

Ensure a pucca house to every family. Ensure the LPG gas cylinder connection to all poor rural households. Ensure 100% electrification of all households. Ensure a toilet in every household. Ensure access to safe and potable drinking water for all households. Bharat Mission to achieve ODF+ (Open Defecation Free) and ODF++ in cities and villages. Ensure ODF status for all villages and cities.

Under good governance:

Work towards substantially reducing the current levels of air pollution. Work towards completely eliminating crop residue burning to reduce air pollution.

Air Pollution and Impact Analysis of a Pilot Stove Intervention: Report to the Ministry of Health and Inter-Ministerial Clean Stove Initiative of the Lao People's Democratic Republic

Hill LD, Pillarisetti A, Delapena S, Garland C, Jagoe K, Koetting P, Pelletreau A, Boatman MR, Pennise D, Smith KR. 2015. Air Pollution and Impact Analysis of a Pilot Stove Intervention: Report to the Ministry of Health and Inter-Ministerial Clean Stove Initiative of the Lao People’s Democratic Republic.

Quantification of a saleable health product (aDALYs) from household cooking interventions

Smith KR, Pillarisetti A, Hill LD, Charron D, Delapena S, Garland C, Pennise D. 2015. Quantification of a saleable health product (aDALYs) from household cooking interventions. World Bank.

Household Air Pollution and Noncommunicable Disease

HEI Household Air Pollution Working Group. 2018. Household Air Pollution and Noncommunicable Disease. Communication 18. Boston, MA: Health Effects Institute. peer reviewed.

Household Air Pollution Intervention Tool (HAPIT)

HAPIT screenshot

Access HAPIT. HAPIT estimates health changes due to interventions designed to lower exposures to household air pollution (HAP) of household members currently using unclean fuels (wood, dung, coal, kerosene, and others). These interventions could be due to cleaner burning stoves, cleaner fuels, other ventilation changes, motivating changes in behavior, etc. HAPIT currently uses background disease rates and relationships between exposure to PM2.5 and health outcomes described as part of the Institute for Health Metrics and Evaluation’s 2013 Global Burden of Disease and Comparative Risk Assessment efforts.

Household fuel use and pulmonary tuberculosis in Nepal: A case-control study

Bates MN, Pope K, Sijali TR, Pokhrel A, Pillarisetti A, Lam N, Verma S. 2019. Household fuel use and pulmonary tuberculosis in Nepal: A case-control study. Environmental Research 168: 193-205. doi.org/10.1016/j.envres.2018.09.036

Using personal exposure measurements of particulate matter to estimate health impacts associated with cooking in peri-urban Accra, Ghana

Delapena S, Piedrahita R, Pillarisetti A, Garland C, Rossanese M, Pennise D. 2018. Using personal exposure measurements of particulate matter to estimate health impacts associated with cooking in peri-urban Accra, Ghana. Energy for Sustainable Development 45: 190:197. doi.org/10.1016/j.esd.2018.05.013

Unacceptable: U.S. Opposition to Breast-Feeding Resolution Stuns World Health Officials

Shame, shame, shame:

A resolution to encourage breast-feeding was expected to be approved quickly and easily by the hundreds of government delegates who gathered this spring in Geneva for the United Nations-affiliated World Health Assembly.

Based on decades of research, the resolution says that mother’s milk is healthiest for children and countries should strive to limit the inaccurate or misleading marketing of breast milk substitutes.

Then the United States delegation, embracing the interests of infant formula manufacturers, upended the deliberations.

American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children.

Yet another example of prioritizing corporate avarice over concerns of health and the environment. See here, here, here, and here for brief overviews of the benefits of breast-feeding.

Clean Cooking and the SDGs: integrated analytical approaches to guide energy interventions for health and environment goals

Rosenthal J, Quinn A, Grieshop AP, Pillarisetti A, Glass R. 2018. Clean Cooking and the SDGs: integrated analytical approaches to guide energy interventions for health and environment goals. Submitted to Energy for Sustainable Development. 42: 152-159. doi.org/10.1016/j.esd.2017.11.003

The potential health benefits of lower household air pollution after a liquefied petroleum gas (LPG) cookstove intervention

Steenland K, Pillarisetti A, Kirby M, Peel J, Clark M, Checkley W, Chang H, Clasen T. 2018. The potential health benefits of lower household air pollution after a liquefied petroleum gas (LPG) cookstove intervention. Environment International 111:71-79. doi.org/10.1016/j.envint.2017.11.018

The Impact of Household Energy Interventions on Health and Finances in Haryana, India: An Extended Cost-Effectiveness Analysis

Pillarisetti A*, Jamison D, Smith KR. 2017. The Impact of Household Energy Interventions on Health and Finances in Haryana, India: An Extended Cost-Effectiveness Analysis. In C. Mock, O. Kobusingye, R. Nugent, K. R. Smith (Eds.), Injury Prevention & Environmental Health, Disease Control Priorities, third edition, volume 7. Washington, DC: World Bank.

ousehold Air Pollution from Solid Cookfuels and Health

Smith KR, Pillarisetti A. 2017. Household Air Pollution from Solid Cookfuels and Health. In C. Mock, O. Kobusingye, R. Nugent, K. R. Smith (Eds.), Injury Prevention & Environmental Health, Disease Control Priorities, third edition, volume 7. Washington, DC: World Bank.

Air pollution-related health and climate benefits of clean cookstove programs in Mozambique

Anenberg SC, Henze DK, Lacey F, Irfan A, Kinney P, Kleiman G, Pillarisetti A. 2016. Air pollution-related health and climate benefits of clean cookstove programs in Mozambique. Environmental Research Letters. doi: 10.1088/1748-9326/aa5557

The Return of London's Fog

London’s fogs may be about to make a comeback. Christine Corton, in the NYT:

In January, researchers at King’s College London announced that pollution levels on Oxford Street, in central London, had exceeded limits set for the entire year in just the first four days of 2015. Similarly alarming numbers have been recorded for other streets in the city — and yet the mayor, Boris Johnson, has delayed implementation of stricter air-quality measures until 2020.

What’s happening in London is being played out in cities worldwide, as efforts to curtail the onslaught of air pollution are stymied by short-term vested interests, with potentially disastrous results.

I just experienced a particular, particulate version of this hell first-hand in Delhi. For the last few days of my trip, a dense, thick haze - clearly not an innocuous fog - permeated the city and surrounding environs. On one trip back to our flat, all of my fellow taxi passengers complained of burning eyes and sore throats.

The closest PM monitor during that drive back — actually quite far from us — read over 250 µg/m3. That’s around 10x higher than a ‘bad’ day in the US. Moreover, we guessed that the levels we were experiencing were closer to 350 µg/m3. As a point of reference, the maximum mean hourly PM2.5 concentration in London since 2008 was approximately 30 µg/m3.

Corton points to a behavioral component to the historic London Fog episodes — a parallel I find particularly interesting:

There was a cultural component, too. The British were wedded to their open fires. Closed stoves, popular throughout much of Europe, especially in Germany, were shunned by Londoners. During World War I, Britons were exhorted, in the words of the famous song, to “keep the home fires burning.” Politicians were simply not willing to risk unpopularity by forcing Londoners to stop using coal and go over to gas or electric heating instead. In Britain today, in an echo of these earlier concerns, the government is cutting subsidies for onshore wind and solar farms, anxious not to offend voters in rural areas where such facilities would be built.

It took a disaster to force London to change direction. In 1952, a “great killer fog” lasted five days and killed an estimated 4,000 people. In a Britain trying to turn a corner after the death and destruction of the Blitz, this was unacceptable. A Clean Air Act was passed in 1956, forcing Londoners to burn smokeless fuel or switch to gas or electricity, power sources that had become much cheaper as these industries expanded.

Let’s hope that policy levers and momentum — not a disaster — can help transition away from solid fuels in India and beyond.

Conditional cash transfers for energy poverty... and murder reduction

Conditional cash transfers — paying people to change behavior, usually to spur positive ‘social’ outcomes — continue to be in the news. Much of the focus is on their use as poverty reduction tools (Bolsa Familia in Brazil, JSY in India) through encouraging behaviors like antenatal care visits and sending children to school.

Two recent article — one in the NYT, one in Mother Jones — highlighted the use of CCTs and other targeted cash transfer tools for dramatically different outcomes.

In the NYT, poverty and energy issues were at the fore:

The Indian government subsidizes households’ purchases of cooking gas; these subsidies amounted to about $8 billion last year. Until recently, subsidies were provided by selling cylinders to beneficiaries at below-market prices. Now, prices have been deregulated, and the subsidy is delivered by depositing cash directly into beneficiaries’ bank accounts, which are linked to cellphones, so that only eligible beneficiaries — not “ghost” intermediaries — receive transfers.

Under the previous arrangement, the large gap between subsidized and unsubsidized prices created a thriving black market, where distributors diverted subsidized gas away from households to businesses for a premium. In new research with Prabhat Barnwal, an economist at Columbia University, we find that cash transfers reduced these “leakages,” resulting in estimated fiscal savings of about $2 billion.

There’s even more “smart” targeting coming soon. My advisor and colleagues in India have been working to “[describe] how the LPG subsidy could be even more completely targeted to the poor without any actual ‘taking away’ of the subsidy from the rich and middle class, which would likely trigger heavy political push back. As a result, several hundred million additional poor Indians could have affordable access in the next decade without increasing subsidy costs to the government (indeed probably reducing them) or LPG imports — both not likely to be popular.”

In Mother Jones, CCTs were being used to reduce murders:

Richmond hired consultants to come up with ideas, and in turn, the consultants approached [Devone] Boggan. It was obvious that heavy-handed tactics like police sweeps weren’t the solution. More than anything, Boggan, who’d been working to keep teen offenders out of prison, was struck by the pettiness of it all. The things that could get someone shot in Richmond were as trivial as stepping out to buy a bag of chips at the wrong time or in the wrong place. Boggan wondered: What if we identified the most likely perpetrators and paid them to stay out of trouble?

It seems to be working.

It was a crazy idea. But since ONS was established, the city’s murder rate has plunged steadily. In 2013, it dropped to 15 homicides per 100,000 residents—a 33 year low. In 2014, it dropped again. Boggan and his staff maintained that their program was responsible for a lot of that drop-off by keeping the highest-risk young men alive—and out of prison. Now they have a study to back them up.

On Monday, researchers from the National Council on Crime and Delinquency, a non-profit, published a process evaluation of ONS, studying its impact seven years in. The conclusion was positive: “While a number of factors including policy changes, policing efforts, an improving economic climate, and an overall decline in crime may have helped to facilitate this shift, many individuals interviewed for this evaluation cite the work of the ONS, which began in late 2007, as a strong contributing factor in a collaborative effort to decrease violence in Richmond.”

Susanna Hertrich's Risk Perception Art

Susanna Hertrich:

A reflection on common fears in societies where anxieties have become a lifestyle choice (2010 - ongoing).

Regarding the piece above:

Public dread and actual deaths caused by most common sources of energy. Based on a longterm study by the International Atomic Energy Agency (IAEA).

via @darbyjack

HAPIT, the Household Air Pollution Intervention Tool, to evaluate the health benefits and cost-effectiveness of clean cooking interventions

Pillarisetti A*, Mehta S, Smith KR. 2015. HAPIT, the Household Air Pollution Intervention Tool, to evaluate the health benefits and cost-effectiveness of clean cooking interventions. In E. A. Thomas (Ed.), Broken Pumps and Promises - Incentivizing Impact in Environmental Health. Switzerland: Springer,.

Introducing HAPIT

I’ve lead recent efforts to create a web-based tool to estimate the impacts of household air pollution interventions (like stoves, gas dissemination, etc) using methods based on what’s known about household air pollution and its contribution to the Global Burden of Disease. The project began as an Excel-based spreadsheet before moving to the web leveraging Shiny, R, and a fair amount of javascript. From the site:

HAPIT estimates and compares health benefits attributable to stove and/or fuel programs that reduce exposure to household air pollution (HAP) resulting from solid fuel use in traditional stoves in developing countries. HAPIT allows users to customize two scenarios based on locally gathered information relevant to their intervention, which is the recommended approach. This will normally require preliminary field work at the dissemination site to demonstrate pollution exposures before and after the intervention in a representative sample of households. If no local information is available, however, HAPIT contains conservative default values for four broad classes of household energy interventions based on the available literature — liquid fuels, chimney stoves, rocket stoves, and advanced combustion stoves. As each country’s health and HAP situation is different, HAPIT currently contains the background data necessary to conduct the analysis in 55 countries — those with more than 50% of households using solid fuels for cooking and China, which has a lower percentage of households using solid fuels for cooking, but a high number in absolute terms. See the drop down list on the left and the Info tab for more details.

HAPIT also estimates program cost-effectiveness in US dollars per averted DALY (disability-adjusted life year) based on the World Health Organization’s CHOICE methodology (see Info tab for more detail). It takes a financial accounting approach in that it 1) does not take into account the household costs such as fuel and health expenses or time spent cooking or acquiring fuel and 2) assumes that programs are covering the cost of fuel-based interventions (such as annual LPG costs per household). For custom scenarios, users can adjust the per-household maintenance or fuel cost based on the characteristics of their programs. All program costs should be entered in current US dollars.

There are a number of nice features of HAPIT, but one I’m particularly fond of is the customized, session-based pdf generated by clicking “Download Report.” HAPIT’s a work in progress and will continue to evolve in the coming months.

Water, Salt, and Sugar

Nice, brief origin story of Oral Rehydration Salts and their deployment in Bangladesh. In particular, I enjoyed the parts describing the challenges of translating the science into practice in the field. Many of the lessons are relevant to our work in household energy and health.

  1. Use competent, well-trained field workers — and figure out clever ways to incentivize good, thorough work.

So how did BRAC tackle this daunting challenge? A three-month field trial in 1979 tested whether mothers recalled BRAC field workers’ instructions on how to prepare O.R.S. This was no easy task considering that poor, illiterate households did not have measuring spoons or cups.

BRAC’s verbal guidelines included the dangerous symptoms of diarrhea, when to administer O.R.S. and how to make it with a three-finger pinch of salt, a handful of sugar and a half liter of water. In another critical step, monitors returned to villages days or weeks after the initial instruction to quiz the mothers. Health workers were paid according to how many questions their subjects answered correctly, thus incentivizing quality instruction and not just the number of lessons. The trial found that verbally trained illiterate and semi-literate rural mothers could make properly formulated O.R.S. that passed laboratory tests.

  1. Ensure that field workers believe in and, when appropriate, use the items and practices they are promoting.

[Mr. Fazle Abed, BRAC’s founder and chairperson] identified other early hurdles that slowed the adoption of O.R.S. by mothers. After inquiring about slow adoption in some villages, he found that only a fraction of health workers believed in O.R.S. themselves; they didn’t even use it to treat their own diarrhea. To dispel doubts among trainers, BRAC brought them from the field to research labs in Dhaka to scientifically show how O.R.S. worked. Health workers were then advised to convince distrustful villagers by sipping O.R.S. during household training sessions.

  1. Don’t ignore the men, who have disproportionate sway over household decisions in many parts of the world.

After this breakthrough, adoption of ORS increased but then plateaued. Again, Mr. Abed tried to find the root of the problem. He enlisted anthropology students in Dhaka to interview people about why they weren’t using O.R.S. They found that men were alienated from the discussions between female health workers and mothers and so withheld support for O.R.S. In villages, “we had to take men into confidences so we told them exactly how O.R.S. worked,” Mr. Abed recalled. When men were included in discussions, adoption of O.R.S. increased significantly.

Obviously not a perfect analogy. ORS is curative — a response to ill-health — and requires a change in treatment behavior. Arguably the need for ORS decreases in a world with adequate access to clean water and sanitation — but absent that panacea, removing barriers to affordable, easy treatment is essential. The shift we seek to encourage, towards clean cooking, is meatier — it requires big changes to routine behavior. The lessons above still hold, though. We need field workers who believe in the interventions (and, conversely, interventions worthy of their belief), we need to compensate them well, and we need buy-in from whole communities.

Gates Notes: Two Videos That Illuminate Energy Poverty

Bill Gates, at his blog:

Many developing countries are turning to coal and other low-cost fossil fuels to generate the electricity they need for powering homes, industry, and agriculture. Some people in rich countries are telling them to cut back on fossil fuels. I understand the concern: After all, human beings are causing our climate to change, and our use of fossil fuels is a huge reason.

But even as we push to get serious about confronting climate change, we should not try to solve the problem on the backs of the poor. For one thing, poor countries represent a small part of the carbon-emissions problem. And they desperately need cheap sources of energy now to fuel the economic growth that lifts families out of poverty. They can’t afford today’s expensive clean energy solutions, and we can’t expect them wait for the technology to get cheaper.

Gates links to two videos from political scientist Bjorn Lomborg. They’re interesting and decent encapsulations of issues we grapple with regularly. We know what works, and indeed most of us in the developed world use either gas or electricity — or both — to cook everyday. Offering solutions that only partially protect health seems morally dubious, a point Lomborg and Gates make. Lomborg’s videos are embedded below. Grist for the mill.