Breathing kills, even indoors

A middle-aged mother kneels to arrange the firewood in her smoky mud stove, unaware that the air she is breathing is shortening her life. He children play in a fume-filled hut, their eyes burning and throats congested.

Most of the discourse around air pollution involves diesel emissions and urban smog, but dirty air within the household is a silent emergency that is killing people prematurely – mostly mothers and their children who spend the most time around the kitchen hearth, especially in winter. 

The pollution is the result of incomplete burning of biomass including firewood, crop residue or animal dung, in inefficient stoves that do not allow adequate oxygen for combustion located in a confined space inside homes.

The smoke has high levels of suspended particulate matter at concentrations worse than in most urban smogs of South Asian cities. The result is acute respiratory infections (ARI), chronic obstructive pulmonary disease (COPD) as well as cardiovascular complications.

Over two-thirds of Nepali households still use biomass as fuel, and the proportion is 90-95% in rural areas removed from the electricity grid or LPG suppliers' networks. As mud stoves belch out smoke, poorly ventilated kitchens trap them indoors, prolonging exposure.

“This triggers inflammation of the airways, causing smoke particles to penetrate deep into the lungs and enter the bloodstream,” explains Sudhir Lohani, a Nepali respiratory physician. “Over time, this causes a reduction of the blood's oxygen-carrying capacity and compromises immune response. With time, it can cause stroke, ischaemic heart disease, COPD and lung cancer.” 

In young children, the same pollutants increase the risk of ARIs which can easily turn fatal since they have not yet built up a strong immune system. The Nepal Demographic and Health Survey of 2016 revealed that 31% of neonatal deaths in Nepal were from respiratory and cardiovascular disorders.

The survey also showed a glaring disparity: infant mortality rate is higher in rural Nepal with 55 per 1,000 live births, while it is 38 in cities. Likewise, 64 out of 1,000 children in rural Nepal do not survive till their fifth birthday. “Without doubt, a major factor causing this urban-rural inconsistency is indoor air pollution,” adds Lohani.

Nepal’s child survival rate has improved dramatically in the last 30 years. In 1990, the under-5 mortality rate was 150 per 1,000 live births. However, the national average also masks a vast geographical discrepancy with the mortality rates in Karnali and Madhes Province much higher than the national average. 

In rural homes, women and children disproportionately bear this burden. Patriarchal structures and limited decision making power limit women’s access to cleaner fuels, forcing them to make do with cheaply available firewood and dung cakes.

Says Lohani, “While men typically work outdoors, women shoulder the responsibility of household cooking, exposing themselves and their children to pollutants and carcinogens in smoke. Moreover, as primary breadwinners, men often have better access to nutritious food, leaving women and children undernourished and vulnerable to respiratory illness.”

In fact, the World Health Organization has long recognised indoor pollution as a gendered issue. In 2012 alone, over 60% of premature deaths from household air pollution globally occurred among women and children.

Limited availability and affordability of cleaner energy sources, such as LPG and electricity, continue to trouble remote Nepali inhabitants. Although government commitments aim for clean cooking by 2030, progress is sluggish.

In cities, Nepali families are moving to electric or gas stoves in modern kitchens. But access to gas and electricity as well as poor purchasing power deprives rural families of cleaner fuels.

Economic data reveals LPG costs over 10 times more than firewood with equivalent thermal energy in Nepal. While electricity and LPG provide cleaner options, they are bulky, entail high installation costs, and face limited accessibility due to unreliable distribution networks in remote areas. 

Moreover, high initial costs of electric appliances and low awareness impede wider electricity usage in villages. In contrast, firewood, crop residue, and dung remain accessible and affordable without such infrastructural barriers. Hence, they continue to dominate rural energy consumption.

Energy experts say that as Nepal’s power grid will have an electricity surplus in the coming years, the government’s strategy should be to make electricity cheaper for household use within the country instead of exporting it. This can be a win-win: reducing Nepal’s import bill for LPG which is growing exponentially, while improving people’s health by reducing vehicular emissions and indoor pollution.

Environmentalist Anil Chitrakar says the priority should actually be more on providing cheap energy to households than to subsidise electric cars.

He told us: “Yes, battery-powered cars are needed, but very few Nepalis have cars. Since all Nepalis have to cook, rebates for electric stoves and rice cookers would reduce LPG use and clean up indoor pollution.” 

Although indoor pollution is of concern mostly in rural homes, Nepal is rapidly urbanising and 66% of the country’s 30 million people live in cities – most of them in Kathmandu and the Tarai towns.

In cities, indoor air pollution takes new forms like toxic chemicals and volatile organic compounds, fire retardants used in carpets and upholstery, and smoking family members.

Addressing indoor pollution must start with awareness among policy makers as well as the public, experts say. Awareness will lead to behaviour change only if alternatives are affordable and accessible. For example, a mother in Mugu will only switch to an electric stove if it is cheaper than firewood, and if there is cheap power supply. 

Says Lohani, “As long as individuals remain oblivious to the poor quality of air they are breathing in their homes every day, things may not get better.”