Bengaluru: It’s common knowledge that air pollution is an invisible killer in India. Now, in a first, a virtual dashboard shows how India’s women and children stand to reap huge health benefits if the nation achieves at least part of its clean air targets.

As per the Health Benefit Assessment Dashboard released on Tuesday (September 30), the prevalence of some major diseases – including anaemia – among women and children could decrease by at least a third if India meets at least 30% of its targets set up under the National Clean Air Programme (NCAP).

The dashboard (accessible here) links health data provided by the National Health Survey (NHS) 2019-21 to the health benefits that women and children across different states would accrue if NCAP targets are met.

At the release of the dashboard in Delhi on September 30, medical doctors, officials and researchers on health and air pollution also listed ways forward on how policy interventions, as well as political will, would be crucial to tackle air pollution across the country.

An invisible killer

It may be imperceptible to the naked eye, but air pollution is a big killer. According to a study in 2023, air pollution is responsible for more than two million deaths every year.

The NCAP launched in 2019 by the Indian government aimed to reduce levels of particulate matter (both PM10, particles less than ten micrometres in diameter, and PM2.5, particles less than 2.5 micrometres in diameter, that are released by human activities such as the burning of fossil fuels and construction) by 20% to 30% by 2024 or when compared to levels in 2017 across around 130 cities.

This also involves conducting source apportionment studies (obtaining information about pollution sources and the amount they contribute to ambient air pollution levels) and establishing emission baselines. However, as of February 2023, only 39 cities had completed the apportionment studies, a study has found.

Similarly, most cities are behind on NCAP targets, another study has found – despite Rs 2,216.23 crore being pumped into the programme till date.

The Indian government then changed the targets: in 2022, it announced that NCAP's aim would be to reduce PM2.5 and PM10 concentrations by 40% by 2026.

Not attaining targets is a problem because air pollution is known to cause numerous diseases. Among them are diabetes, hypertension, anaemia, chronic obstructive pulmonary disease (COPD, a progressive lung disease) and heart disease.

One way to measure the extent of these diseases is ‘disease prevalence’, which is the total number of existing cases of a disease in a specific population at a particular point in time or over a given period.

Linking the disease prevalence of these five diseases to health data from the fifth NHS of 2019-21, Climate Trends, a research-based consulting and capacity-building initiative and the Indian Institute of Technology, Delhi, developed the Health Benefit Assessment Dashboard.

The dashboard shows what the direct health benefits to women (of reproductive age between 15 and 49) and children (under the age of five) across the country would be if NCAP targets are met.

Benefits of achieving clean air targets

According to results from the dashboard, the prevalence of diabetes among women across the country is currently 1.7%, and this could drop to 1.4% if targets are met.

Overall, reductions in diabetes prevalence are projected to range between 8% and 25%, with the greatest benefits in Delhi, Uttar Pradesh, Bihar, Assam and Haryana, while more moderate gains are seen in states such as Jharkhand, Odisha, Punjab, Rajasthan, West Bengal and Gujarat.

Hypertension in women is also expected to decline if NCAP targets are met, by 2% to 8%. The biggest improvements are likely to occur in Punjab, Haryana, Delhi, Assam, Bihar and Uttar Pradesh.

For COPD, the projected reductions range from 3% to 12%. Delhi, Uttar Pradesh, Bihar, Haryana, Odisha and Punjab are expected to show the strongest improvements.

Similarly, heart disease among women is projected to decline by 3% to 10%; and anaemia, by 3% to 8%.

State-wise findings are also pertinent. Take the case of women in Uttar Pradesh, for instance. The current disease prevalence of anaemia is a staggeringly high 53.96% in women in the state, as per the NHS. This will reduce to 49.55% if NCAP targets are met.

The disease prevalence of diabetes among women here is 1.21%. This will reduce to 0.95% if NCAP targets are met.

When it comes to hypertension, the disease prevalence among women in Uttar Pradesh is currently 4.54% as per NHS data. This will reduce to 4.26% if NCAP targets are met.

Disease prevalence of heart disease among women in the state will drop from 0.47 to 0.44%, and COPD will reduce from 0.73 to 0.66% – all if NCAP targets are met.

In the case of children, achieving NCAP targets could lead to “measurable declines in the prevalence of lower respiratory infections (LRI), low birth weight and anaemia among children across India”.

Per NHS data, Bihar and Delhi record the highest LRI prevalence at 9.89% and 10.45%: this will drop to 9.37% and 9.73% respectively if NCAP targets are met.

The numbers are “shocking” but “abstract”, said Dr Virinder Sharma, technical member at the Commission for Air Quality Management in Delhi NCR, who was at the workshop for the release of the dashboard.

“They are not connected with people directly. The impacts feel distant, like climate change – something in the future, gradual, especially in terms of morbidity. People do not see the impacts immediately. There’s no “death certificate” for air pollution. Losses are happening – whether in Delhi NCR hospitals, workplaces or through shortened lifespans – but the crisis is silent, invisible and diffuse. It is easy to underestimate unless it is connected to people’s lived reality.”

Role of policy, political will, decentralisation

It is also important to target point sources and other large emitters, said Dr Kalpana Balakrishnan, dean, research, Sri Ramachandra Institute of Higher Education and Research, Chennai.

“We have ignored the role of industrial emissions,” she said. “Money, as in air pollution being seen as an indicator of development – a good thing to have when you have power plants bellowing out smoke, when you have large fleets on the road. Air pollution may smell like money for the rich, but for the poor, it smells like the lack of money to be able to do anything about it.”

Dr Soumya Swaminathan, chairperson of the M.S. Swaminathan Research Foundation, listed several actions that the Indian government needs to take to ensure that NCAP targets are met to tackle air pollution.

The health and environment ministers should jointly chair an environmental health commission or a high-level task force, she said. If state health and environment ministers are also brought on board, then discussions can go beyond just air pollution to include other environmental health risks as well. At the moment, we have nothing like that, she noted.

“Political will and setting up structures at a high level will change everything,” Swaminathan said. “The second issue is institutional reforms, governance and legal frameworks. We need better legislative action, which would then translate into policies, and finally into implementation.”

Swaminathan recommends creating an “Environmental Health Regulatory Agency” for the country that looks at both health and air pollution data, and other environmental health risks, makes science-based recommendations and policies, with the authority to implement and enforce them.

“That is very, very critical,” she said. “We need to look at air pollution as a national problem, not just as a problem of Delhi and its surrounding areas. We really need a national-level body that makes policy and uses data from all parts of India.”

For such a national problem, there must be a “nationally concerted effort”, according to Dr Anand Krishnan, professor at the Centre for Community Medicine in the All India Institute of Medical Sciences, Delhi.

“Whether it is the ICMR [Indian Council of Medical Research] or another body, some agency has to take this up as a national issue, identify priority areas for research, fund them and get them done. This way, policies also link better to research. If it is a concerted, nationally recognised effort, then it will certainly have more traction with policymakers …The way forward is national prioritisation, but also breaking down air pollution into smaller, manageable parts.”

Similarly, expanding finance to tackle air pollution is extremely important, as is revamping NCAP targets, Swaminathan added.

“We need to revisit NCAP and revamp the target … India should take the leadership role to address air quality at global forums because we are very well-equipped and have cross-border collaboration with neighbouring countries. Technology transfer could give us some solutions at a faster pace. Urban local bodies have a big role to play. At present, inter-state coordination is weak and needs to be strengthened.”

Decentralisation is also key because empowering local bodies will go a long way in ensuring that policies are implemented, the experts said. India’s local bodies are grappling with air pollution and there is a need for people and resources at this level, said Dr Sharma.

“We need to start at the local level and work upward,” agreed Dr Krishnan. “One of the simplest local priorities India should tackle is solid waste management. These are issues municipalities can address, without needing central intervention.”

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