Public Health
At least 25 public health professionals from leading institutes have written to the Environment Ministry.

As the last date for submitting comments on the draft National Clean Air Program (NCAP) by Ministry of Environment, Forests & Climate Change (MoEF&CC) draws near, at least 25 public health professionals from leading institutes have written to the Environment Ministry urging more attention to public health in the policy than there is, in the draft. They belong to institutions such as: Indian Public Health Association; Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry; Postgraduate Institute of Medical Education and Research, Chandigarh; Chittaranjan National Cancer Institute; Center for Public Health; Punjab University; School of Public Health, SRM Chennai; Huma Lung Foundation, Chennai.

While congratulating the Ministry for releasing a much-needed draft policy on National Clean Air Program, the letter of the public health professionals urges the Ministry to not limit health implications of air pollution to mere research and data gathering exercise, as it is, in the current form.

The letter quotes an Indian Council of Medical Research (ICMR) led study of 2017 on the disease burden in India. According to the study, "The contribution of air pollution to disease burden remained high in India between 1990 and 2016, with levels of exposure among the highest in the world. It causes burden through a mix of non-communicable (NCD) and infectious diseases, mainly cardiovascular diseases, chronic respiratory diseases and lower respiratory infections. The burden of household air pollution decreased during this period due to decreasing use of solid fuels for cooking, and that of outdoor air pollution increased due to a variety of pollutants from power production, industry, vehicles, construction, and waste burning.”

The letter urges the MoEF&CC to collaborate with Ministry of Health and leading health sector participants to outline, in the final NCAP document, the protective measures that will mitigate the adverse health impacts of air pollution, such as provisions with respect to health infrastructure (medicines, allotment of hospital beds, equipment and trained personnel) that it aims to add to the existing network to look into the incidences of increasing NCDs as a result of air pollution. The letter also urges that final document on NCAP should detail provisions that it aims to introduce to check air pollution from various sources. NCAP should also specify time-bound emission reduction targets and outline its plan to implement stricter sector-specific emissions norms in more detail. 

Here is the full text:

Sir,

Congratulations on bringing out the first draft policy note on the National Clean Air Program (NCAP) for India. In a country with one fifth of global population at risk due to air pollution, it is a much-needed step in the direction of regulating the sources and mitigating the impacts. 

We appreciate the fact that your ministry has constituted a high-level apex committee and a working group under the joint chairmanship of Indian Council of Medical Research (ICMR) and MoEF&CC to “identify thrust areas in environment health and to evaluate the related projects”. We are also encouraged by the note that in line with the recommendation of the working group, your Ministry in coordination with Ministry of Health and ICMR, has already initiated action towards study on National Environmental Health Profile, with emphasis on impact of air pollution on health. We note that the need for more indigenous health data is highlighted in the NCAP note and that provision for two studies over the next one year with a budget of 5 crores has been allocated.

We however, feel that the overall weightage and attention given to health in the NCAP document falls short of the expectation of the public health community. 

We would like to draw your attention to an ICMR led report of 2017 titled “India: Health of the Nation’s States”, which highlights the disease burden and risk factors trends in every state of the country from 1990 to 2016. There are two important observations in the report of relevance and can further inform the NCAP policy draft. 

First being the high contribution of air pollution to disease burden in India. On this the report notes “household air pollution was responsible for 5% of the total disease burden in India in 2016, and outdoor air pollution for 6%.” It further goes on to state “the contribution of air pollution to disease burden remained high in India between 1990 and 2016, with levels of exposure among the highest in the world. It causes burden through a mix of non-communicable and infectious diseases, mainly cardiovascular diseases, chronic respiratory diseases, and lower respiratory infections. The burden of household air pollution decreased during this period due to decreasing use of solid fuels for cooking, and that of outdoor air pollution increased due to a variety of pollutants from power production, industry, vehicles, construction, and waste burning.”

On the aspect of Non-Communicable Diseases (NCDs) the report notes that the NCDs are on a rise in all the states. It observes, “the contribution of most of the major non-communicable disease groups to the total disease burden has increased all over India since 1990, including cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, cancers, musculoskeletal disorders, and chronic kidney disease. Among the leading non-communicable diseases, the largest disease burden or DALY rate increase from 1990 to 2016 was observed for diabetes, at 80%, and ischaemic heart disease, at 34%. In 2016, three of the five leading individual causes of disease burden in India were non-communicable, with ischaemic heart disease and chronic obstructive pulmonary disease as the top two causes and stroke as the fifth leading cause. The range of disease burden or DALY rate among the states in 2016 was 9-fold for ischaemic heart disease, 4-fold for chronic obstructive pulmonary disease, and 6 fold for stroke, and 4 fold for diabetes across India.”

We believe that there is enough research and evidence (including the ones cited above) on the fact that air pollution is causing havoc to the health and well-being of the people in India. We also believe that good health of the public is the foundation of the economic and social development of the country. 

Hence, it is important that for NCAP to be successful and relevant its outline on health has to be bold, future looking and not restricted to mere research and data gathering exercise. 

We suggest that NCAP’s vision on health should broadly consist of the following measures – 

a)   To mitigate the adverse health impacts of air pollution and 

b)   Make provisions for the betterment of affected population; 

On the mitigation and repair side, NCAP, in consultation with the Ministry of Health, should detail the provisions with respect to health infrastructure (medicines, allotment of hospital beds, equipment and trained personnel) that it aims to add to the existing network to look into the incidences of increasing NCDs as a result of air pollution. Such outline should be state wise in consultation with the respective state governments as we have seen some of the states worst affected by air pollution, do not have any medical facility for communities to access. The NCAP draft should also outline the health insurance schemes or other benefits that it aims to provide to assist affected persons in accessing medical help. A separate budgetary allocation for these aspects is also important in this context.

On the preventive aspect to ensure no future impacts to health due to air pollution, NCAP should detail provisions that it aims to introduce to check air pollution from various sources. It should specify time bound emission reduction targets and outline its plan to implement stricter sector-specific emissions norms in more detail in the document. Like the apex committee and the working group, NCAP needs to collaborate with Ministry of Health and leading health sector participants to conduct Health Impact Assessments in addition to Environmental Impacts Assessment and formulate Health Management Plans to ensure the effective implementation of the air pollution action. 

We hope that our suggestions are taken in immediately to build a robust National Clean Air Program in order to deliver its benefits to the citizens of India.

Sincerely,

Dr Sree Karuna Murthy Kolli, 

National Vice President South Indian Public Health Association (IPHA) & 

President, Andhra Pradesh State IPHA

Dr. Smarjit Jana, 

Medical Doctor and Public Health Specialists, 

Former National Advisor to India’s Ministry of Health and Family Welfare’s National AIDS Control program

Dr Ravindra Khaiwal, MRSC, FHEA

Additional Professor of Environment Health,

School of Public Health

PGIMER, Chandigarh

Dr. Suman Mor, M.Tech, Ph.D (IITD)

Coordinator, Centre for Public Health & Assistant Professor, 

Dept. of Environment Studies 

Panjab University, Chandigarh

Dr. Manas Ranjan Ray

Professor

Department of Experimental Hematology 

Chittaranjan National Cancer Institute, India

Dr. Hisamuddin Papa 

Senior Pulmonologist & Founder of HUMA Lung Foundation, Chennai

Dr Adithya Pradyumna, 

Public Health Professional, India

Dr. Amitranjan Basu

Shaheed Hospital

Dalli Rajhara, Chhattisgarh 

Dr. Shanthosh Priyan. S

Senior resident,

Preventive and Social Medicine,

JIPMER, Pondicherry

Dr. Imrana Qadeer

Former Head of Department of Social Medicine and Community Health 

Jawaharlal Nehru University

New Delhi

Dr. Vikneshan. M

Associate professor

Indira Gandhi Institute of Dental Sciences

Pondicherry

Dr. Palanivel C

Associate Professor

Preventive and Social Medicine

JIPMER, Pondicherry

Dr. Karthick Balaji

Assistant Professor

Preventive and Social Medicine

JIPMER, Pondicherry

Dr. Nidhin Cyril 

Public Health Professional, 

Indian Research Station Bharati, 

Antartica

Dr. Sejal 

Public Health Professional, 

Indian Research Station Bharati, 

Antartica

Dr. Rajan R Patil

Epidemiologist

School of Public Health

SRM Deemed University

Chennai

Dr. Manisha Khemani

Master of Public Health

JIPMER, Pondicherry

Dr. Surbhi Tripathi

Master of Public Health

JIPMER, Pondicherry

Dr. Ranjana Ravindranath

Master of Public Health

JIPMER, Pondicherry

Mrs. Margrette Elsy

Master of Public Health

JIPMER, Pondicherry

Mrs. Saraswathi

Master of Public Health

JIPMER, Pondicherry

Mr. Arul Prakash

Master of Public Health

JIPMER, Pondicherry

Mr. Britzer Paul

Master of Public Health

JIPMER, Pondicherry

Mrs. Vishnupriya Iyer

PhD Scholar, Community Medicine

JIPMER, Pondicherry