In India, Breathing Kills

In ten years, one in eight of us will be in sick bed, gasping for air even as overburdened hospitals begin to buckle under and medical bills spiral

Firstpost print Edition

For the last 35 years, asthma had been Suman Sharma’s constant companion: painful, sometimes crippling, but manageable, none the less. Then, five years ago, something began to change. Her lungs began to rebel against her body, setting off terrifying paroxysms that seized her airways. From 2016 on, the hospital admissions began, twice or thrice a year. She’s changed doctors, treatments and made permanent fixes to her lifestyle, like dropping the morning walks she enjoyed—but there’s no permanent cure in sight.

 In India, Breathing Kills

Representational image. AP

Every ten minutes or so, when things are bad, Sharma has to use a nebuliser, that injects a mist of drugs directly into her lungs.

The toxic grey smog that blankets New Delhi, and other cities across northern India, has now receded. The face-masks used by growing numbers of children and health-conscious adults have come off, and the screaming newspaper headlines about air pollution have disappeared.

But each breath we’ll be taking will be killing us, just as surely as it was then.

The sunlight showering down on us reacts with vehicular pollution and toxic industrial emissions to form a lethal cocktail that spreads wide, at ground level, making its way into our lungs. “We don’t see it,” says SK Chhabra, head of pulmonary and critical care medicine at New Delhi’s élite Primus Super Speciality Hospital, “but that doesn’t mean it’s not there”.

Every eighth Indian, studies show, will die because they breathed. Air pollution is now a greater risk factor than even tobacco for a range of diseases, starting with lower respiratory infections and spanning the spectrum to chronic obstructive pulmonary diseases, ischemic heart disease, stroke, diabetes, lung cancer and even cataract.

Heart disease and diabetes alone make up a staggering 38 per cent of India’s disease burden due to air pollution.

EXPANDING CRISIS

SHARMA won’t be stepping out of her home in the peak heat of the summer: dust and smoke set off her condition. There are times, though, when she just can’t help it. The mother of two school-going children, there are responsibilities that can’t be avoided. That means an expenditure of ₹3,000 a month on medicines and doctors’ fees, spiking to upwards of ₹100,000 each time she has to be admitted to hospital with severe breathing problems, usually for between four and seven days.

Perhaps most painful for her is the toll her terrifying symptoms take on her children. “It disturbs the family so much, I can’t even explain,” says Sharma.

In the next few weeks, Chhabra is expecting hospitals to see a surge of patients, as the growing levels of ultraviolet light cause oxygen to break down into the inorganic molecule O3, a potent respiratory hazard, adding to the existing toxic load of vehicle and industrial pollution.

For most people, air that doesn’t appear smoggy is clean—but that just isn’t a case. Even if the optical quality of the air is good, particulate matter levels are almost always way above the safe limits.

Indian standards mandate that air which has less than 40 micrograms (μg) of particles with a diameter of 2.5 micrometres (μm), or PM2.5, per cubic metre, is safe. The World Health Organisation’s safe limit safe is 10μg per cubic metre. The air in Delhi and other cities across India only meets those standards when it’s raining 24x7.

“Last year, Delhi had three such days,” says Arvind Kumar, chairman of the chest medicine centre at Sir Ganga Ram hospital.

In 2013, a study involving 312,944 people in nine European countries revealed that for every increase of 10μg per cubic metre of PM10 particles, the lung cancer rate rose 22 per cent. The smaller PM2.5 were even more deadly, with a 36 per cent increase in lung cancer per 10μg/m3.

Fifteen of the 20 most polluted cities are in India, a study by non-profit Greenpeace and Swiss-based company IQAir AirVisual determined this year. Even more hard-hitting evidence came from the medical journal, The Lancet, in December, in a study with multiple partners, including the Government of India. It found that one in every eight deaths in India in 2017 was a consequence of air pollution.

“Earlier, policy-makers questioned the strength of evidence of harmful effects of air pollution on health”, says Lalit Dandona, distinguished research professor at the Public Health Foundation of India and a lead author of the paper. “There’s no doubt now”.

HOSPITAL WARRIORS

NOT long after he moved to Sir Ganga Ram Hospital from the All India Institute of Medical Sciences, Kumar started noticing black spots on the lungs of his patients. The patients were mostly from Delhi, unlike his patient profile at AIIMS. “It was a subtle but hard-hitting change,” Kumar recalls. “I felt that this information is serious with huge public health implications,” he says. In 2018, he conducted an analysis 150 lung cancer patients who had undergone surgery at the hospital between 2012 and 2017 and compared them with his AIIMS patients of 1988.

To describe what he found, Kumar says, ‘disturbing’ is too mild a word. “It was shocking”, he says. “I knew that these black spots on lungs will ultimately lead to disaster”.

Kumar found that while the smokers to non-smokers ratio was 90:10 in his earlier cases, in the new cases it had changed to 50:50—a five-fold jump in lung cancer in non-smokers. These new patients were younger; eight per cent were below 40 years old, while in the old cases no patient was below the age of 60. Forty per cent of the new cases were women.

From the out-patient-departments and emergency rooms of the hospitals the doctors are issuing a warning—failure to improving air quality will impose horrific costs on Indians. “In the next 10 years, we are going to see an explosion in the number of new lung cancer cases in India,” says Kumar.

AIIMS found, in 2017, that the smokers to non-smokers ratio for lung cancer is now 60:40. The Tata Memorial hospital in Mumbai stated in 2016 that they are seeing lung cancer increasingly in non-smokers.

In AIIMS, the doctors say there is a jump across all cancers. Besides lungs, kidneys, bladder and blood cancers also have a strong correlation to air pollution. Even though studies to establish the links will take years, the cost in human lives for failing to act now will be staggering.

For years now, doctors have been warning of the building storm—but policy-makers haven’t been listening. In 1998, JN Pande, then working at AIIMS’ medicine department, found that whenever pollution went up, emergency room visits for asthma and other respiratory illnesses went up by 21 to 25 per cent.

Pande’s study formed the foundation of the Supreme Court order which changed Delhi’s bus fleet to CNG, a cleaner fuel, from diesel. The impact was drastic. From 1997 to 2002, Suphur dioxide dropped by 39 per cent and carbon monoxide fell by 32 per cent. Levels of lead and benzene also dropped significantly.

But over time, pollution levels crept up again—unchecked.

Karan Madan, assistant professor of pulmonary medicine and sleep disorders at AIIMS, has been studying admissions in emergency wards of five government hospitals in Delhi. “On high air pollution days we see patients who have never had any respiratory illness in the past come in with symptoms like asthma”, he says. “

In another first-of-its-kind study, he is enrolling asthmatic children and pregnant women for continuously monitoring their exposure to air through a sensor. The sensors are stationed at homes and schools and also worn as a belt which record air pollution exposure at that time at that place.

“We will see how asthmatic children’s symptoms are changed according to change in pollution,” says Madan. For the pregnant women, the study, which will take two years to complete, will show if pollution affects the birth weight of their babies.

Last summer, doctors at the AIIMS cancer centre organised India’s first-ever conference on the links between the environment and cancer. “You cannot imagine how bad I felt writing on conference documents that this was the first discussion we’d had on the issue,” says Abhishek Shankar, assistant professor, department of preventive oncology, AIIMS.

“This is a one-way journey”, says Shankar. “Once you have lung cancer, you will die. There is no cure.”

The economic case to act for clean air now is beyond contest. In 2013, a World Bank report said that India’s labour loss due to air pollution was $55.39 billion and welfare losses were $505 billion, which is collectively more than 8.4 per cent of the country’s GDP. As air pollution brings more people into hospitals, they lose productive days at work. Families lose income and incur out-of-pocket expenses.

Air pollution is also imposing massive strains on an already-creaking healthcare system, say doctors. As the demand for services grows, the load will shift from government to private doctors; the costs on patients will be enormous.

At the AIIMS cancer centre, says GK Rath, the load on doctors is increasing sharply. AIIMS has had to create a new cancer centre at Jhajjar, but most experts concur that the demands on the medical system will overwhelm the available resources in coming years.

But the way to cease this inflow of patients due to totally preventable risk factors is by targeting individual polluting sectors. “We should move on to talk about solutions,” says Madan.

Even though the union government has moved to address some parts of the pollution crisis—notably by seeking to tamp down seasonal crop-burning—the initiatives aren’t nearly enough. There are a number of long-term plans in place to address vehicular pollution, but these will take years—even decades—to have an impact. Industrial pollution, meanwhile, is growing.

Elections to choose India’s next Parliament should have had the air pollution crisis confronting our cities as a key issue. But not a single party has said exactly what it intends to do, and how this action will be funded. The silence shows how little our leaders care about our lives—but that won’t change until we start to value those of our loved ones, and our own.

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