RECENTLY, we shared data on stunting. This week, we turn to the second highest risk factor underlying Pakistan’s health burden — air pollution. According to the Global Burden of Disease 2019 report, after malnutrition, exposure to air pollution increases the risk of diseases that cause both premature death and illness in the country — this is a sobering fact, one we can no longer afford to overlook or dismiss.

Pakistanis are exposed to hazardous levels of both indoor air pollution and outdoor air pollution, raising the incidence of ischemic heart disease, stroke, lung cancer, neonatal morbidity, lower respiratory infections, diabetes, and chronic obstructive pulmonary disease. Experts refer to these diseases as non-communicable diseases (NCDs), which we can prevent only by eliminating risk factors that cause them. Otherwise they need to be managed over a lifetime, incurring substantial costs.

A recent paper from Aga Khan University Hospital notes that about 1,000 people in Pakistan suffer a stroke every day. Out of these, about 400 people die within 30 days. The authors suggest that limiting air pollution exposure alone can prevent 30 per cent of strokes in Pakistan. Yet, the Punjab government’s NCD Unit does not even list air pollution as a risk factor for NCDs. This suggests that we require significant efforts to raise awareness of air pollution’s health impacts.

Besides health, air pollution also directly and indirectly affects cognitive ability — that is, our IQ, logical thinking, and our ability to reason, form ideas, and retain information. Air pollution directly affects the brain’s neurological function, leading to cognitive degeneration. On the other hand, the inability to breathe properly affects one’s focus. We all know that when we cannot breathe properly, focusing on basic tasks becomes difficult, let alone physical chores and schoolwork.

Ensuring clean air is a public service. Yet improving air quality does not involve quick fixes.

Air pollution thus increases school and job absences and performance. Researchers have found strong evidence demonstrating that an increase in pollution levels leads to higher school absences. Similarly, improvements in air quality improves school attendance. Even if students make it to school, studies from California and Israel show that exposure to air pollution in the classroom can noticeably decrease students’ test scores — keep in mind, these settings have vastly superior air quality compared to Pakistan.

Pollution exposure even before birth can lead to permanent, lasting consequences. Research from various countries suggests that exposure to air pollution during pregnancy results in the child in later life having lower scores on language and math tests in school; depressed earnings later in life; high unemployment; lower probability of college attendance; reduced high school completion; and higher chances of incarceration.

Since pollution exposure affects the brain, it leads to poor decision-making and fosters aggressive behaviour. Evidence from China shows that air pollution reduces investors’ performance. More disturbing evidence from the UK suggests that air pollution exposure leads to more traffic accidents. Studies from the US reveal that air pollution leads to a considerable increase in violent crime. Shockingly, the rise in violent crime due to air pollution occurs at levels well below stipulated air quality standards.

Given the above research, we shouldn’t be surprised that governments in many countries take air pollution seriously and voters demand this from their elected officials. In Pakistan, however, the same urgency is not evident.

An important area of concern — which often goes neglected in Pakistan — is indoor air pollution (IAP), which results from cooking and heating with solid fuels on open fires and traditional cookstoves. Since women mostly carry the burden of cooking, and their children often spend time with them, IAP disproportionately affects women and children. Almost all women and children exposed to IAP belong to low-income households, which overwhelmingly rely on cheap solid fuel to meet their energy demands. Many other countries have investigated and addressed IAP since the 1980s. However, Pakistan remains conspicuous by its lack of research in this area.

In most developed countries, a shift away from biomass fuel burning to natural gas and electric options has reduced the IAP risk factor. However, according to the Pakistan Social and Living Standards Measurement Survey 2019-2020, only 37pc of Pakistani households have access to clean fuel technology for cooking and lighting.

Ensuring clean air is a public service. Yet improving air quality does not involve quick fixes. Pakistanis already have a constitutional right to a clean and healthy environment. Under the 18th Amendment, air quality management is a provincial government responsibility. To improve air quality, we need to devise an overarching national-level clean air plan — after all, air does not respect provincial boundaries. The federal government must ensure that provincial governments keep their end of the bargain. We also need stakeholders across the board — including citizens, the private sector, and local governments — to band together to fix this problem. In short, we must prioritise air pollution.

Tackling air pollution is not impossible. A national clean air plan could include the following measures: 1) devising and implementing a household energy strategy to facilitate the transition to cleaner fuels, a priority for the poorest households; 2) monitoring and reporting on air pollution and raising citizens’ awareness of its impacts; 3) putting in place air quality standards linked to health effects; 4) requiring companies to use new monitoring technologies — such as those adopted by pollution regulators in several Indian state governments — that transmit real-time pollution data to create public pressure and increase compliance; 5) addressing transport-related emissions, often the major source of emissions in cities; and 6) developing pollution tax instruments.

Poor air quality affects all Pakistani households, regardless of income. However, it disproportionately affects poor households, deteriorating their health, raising their health expenditures, and thus dragging them back into poverty. Given that more than half of Pakistan’s population is vulnerable to falling back into poverty, and that much of the country’s population is already exposed to dirty outdoor and indoor air, this makes for an explosive mix.

Kulsum Ahmed is the director of Integrated Learning Means and an honorary fellow at the Consortium for Development Policy Research. Sanval Nasim is an assistant professor of economics at Colby College. This article draws from research funded by the International Growth Centre.

Published in Dawn, July 30th, 2022