In 2015, the air pollution conversation took a different turn in the national capital. Dr. Arvind Kumar, a surgeon in New Delhi, showed surgical images of lungs turned black from their healthy pink to the media and panels he was on. He attributed air pollution as one of the causes of this damage. Later, in November of 2018, the outdoor premises of Dr. Kumar’s then workplace sported a signboard fitted with a large pair of artificial lungs equipped with high-powered particle-trapping filters to mimic the human lung’s function. Available for the public to see, the idea was to demonstrate the effects of the city’s toxic smog on its resident’s lungs. In just 10 days, the oversized lungs had turned to a nasty dark brown from their original white.

“Doctors have always highlighted the health impacts of air pollution through their research. But most of this information was limited to medical journals and articles. However, Dr. Kumar’s voice along with images of the diseased lung from his OR provided a pictorial representation to the problem,”  says Matrushri Shetty, the Director of Programs and Strategy at the New Delhi-based Lung Care Foundation, co-founded by Dr. Kumar in 2015. “Over the years Lung Care Foundation through its advocacy campaigns has brought out this medical information in a format understandable to the common people.”

In December of 2018, supported by the Lung Care Foundation and the NGO Healthcare Without Harm, ‘Doctors for Clean Air’—later adding ‘Climate Action’ to the organization’s name—was founded, which is today a network of over 600 doctors across Indian cities, endorsed by 20 of the country’s leading medical associations. 

Three years later, the air continues to be toxic. As of 23 November, the Air Quality Index has been above 200—considered ‘very unhealthy’—across Delhi and various other cities in the northern states of the country, including Hisar in Haryana, Bhatinda in Punjab, and Bhadohi in Uttar Pradesh. 

Doctors that The Bastion spoke to agreed that during this time of the year, they observe an increase in otherwise healthy patients complaining of shortness of breath or running noses, and an exacerbation of underlying conditions of lung diseases or asthma. As the first points of contact with patients, what roles can doctors play in communicating the ill effects of air pollution to them, and can their role go beyond hospitals?

Respiratory Problems and Other Ailments Have Set the Stage

“Generally speaking, when doctors are treating at least 60 patients a day, they do not have the time to tell them about the negative impacts of air pollution,” says Dr. Shiva K Misra, a Kanpur-based Chief Consultant Surgeon also associated with Doctors for Clean Air. “This is why Doctors for Clean Air and Climate Action makes a conscious effort to sensitise citizens, including healthcare workers, to the health impacts of air pollution. We do this through training healthcare workers, awareness building, and advocacy with the government,” he says, adding that doctors occupy a unique position to have this conversation because of how much faith patients have in them.

Launch of Doctors for Clean Air in 2018; courtesy of Matrushri Shetty.

In early November of 2021, a Canadian doctor grabbed media eyeballs by doing exactly that. He made a strange diagnosis. While treating a patient who was struggling to breathe after wildfires in the region worsened her asthma, he diagnosed her as suffering from “climate change”, making this possibly the first such recorded case.  “If we are not looking at the underlying cause, we are just treating the symptoms,” he told a Canadian newspaper

“More than anything else, this type of diagnosis helps increase the focus and awareness on the larger environmental problems at hand that are impacting people directly,” Dr. Uma Kumar, Head of Department of Rheumatology at All India Institute of Medical Sciences told The Bastion“That Canadian doctor initiated a conversation, which is why we are talking about it right now.”

In 2020, Dr. Uma Kumar led a study that showed that air pollution not only impacted respiratory health, but was also connected with autoimmune diseases (conditions where the immune system mistakenly attacks the body). Upon testing 500 healthy volunteers from Delhi who had been residing in the city for more than ten years, the team tested them for autoantibodies—which are markers of autoimmune diseases. They found 18% of the patients carried these autoantibodies, predisposing them to various autoimmune diseases like Rheumatoid Arthritis and Lupus. “More importantly, we found that those who were residing within 200 metres of the main road had a higher prevalence of autoimmune disease markers than the subjects that resided at 250 metres or more from the main road,” Dr. Uma Kumar adds.

“We [the AIIMS Rheumatology Department] started noticing that post-Diwali every year, there was an influx of patients whose arthritis and joint problems would suddenly flare-up. We were curious to see if environmental factors impacted this, apart from their genetics. But, there was not much data available,” Dr. Uma Kumar says. “Initially, when we took the study’s proposal to the funding agency, we had a tough time convincing them that this is an important topic; everyone was surprised to hear that there could be connections between air pollution and autoimmune diseases! Even today, not enough is being spoken of the impacts of polluted air on diseases other than respiratory ones, like hypertension or diabetes.”

When Dr. Uma Kumar treats patients who show symptoms possibly triggered by air pollution in her clinic, she makes sure to include air pollution as a risk factor to their patient’s conditions, just like smoking. But this is easier said than done.

Roadblocks in Walking the Pollution Talk

“Just like we talk to our patients about the impacts of tobacco chewing on lung cancer, we have now started including air pollution in conversations too,” says Dr. Misra. “While patients understand this, it’s not always viable for them to reduce their exposure to sources of pollution.” In Uttar Pradesh’s Kanpur, where Dr. Misra’s practice is based, construction sites and traffic congestion are common. “Now, in a traffic jam, can you imagine how much toxic vehicular emissions are inhaled by a cart-puller, or autorickshaw or two-wheeler drivers? And yet, even if we tell them how bad the air is for them to inhale, they cannot simply leave their jobs,” Dr. Misra says. “The same is the case for patients from rural areas around Kanpur who come in with complaints of breathlessness. Through conversations, we come to know that they cook on a chulha [or wood and coal-fired stove], which as literature shows is now a large contributor to indoor air pollution. But, it’s not easy for them to move away from these practices until cheaper, cleaner alternatives are easily accessible.” Schemes like the Pradhan Mantri Ujjwala Yojna have been a positive step in this direction.

A similar problem is underway in Punjab’s Ludhiana, where seasonal stubble burning leads to periodic respiratory problems for the farmers. “Till about five years ago, I used to hold medical camps at the farms to identify the various health problems that farmers were facing due to the stubble they burnt,” says Dr. Akashdeep, a Ludhiana-based doctor, also associated with Doctors for Clean Air and Climate Action. “Farmers agreed  that the burning worsened their cough. So, if we want to tackle this problem at the source, farmers need alternatives.” For Dr. Akashdeep, this would require a slightly different—and medically-inspired—approach to agricultural policy.

When treating a chain smoker who may be suffering from lung cancer, Dr. Akashdeep and his team explain nicotine addiction to them and how to deal with withdrawal symptoms. “Through it all, our idea is not to accuse them of being a smoker, but to constantly remind them that we are there to support them through this physiologically and psychologically. The same sensitivity, without being accusatory to the farmers or penalising them, will have to be the approach while dealing with stubble burning,” adds Dr. Akashdeep.

Around the Diwali season between October to November, which also coincides with stubble burning and changing weather, Dr. Akashdeep’s hospital witnesses an increase in patients facing some impacts of air pollution by 15% to 20%. “At the same time, I would still be wary of making a causal link between air pollution and diseases like Asthma and chronic inflammatory lung disease. Vehicular and industrial emissions and other sources of pollution definitely worsen already existing lung diseases like asthma, but so do other factors. These months around Diwali are also characterised by changing weather [in north India] making people more susceptible to viral infections too, which present some of  the same symptoms [as polluted air],” says Dr. Akashdeep.

The absence of information on air pollution’s ill effects for patients and their families—from doctors or other sources—can have dire consequences. An unfortunate case in point is that of nine-year-old Ella Adoo-Kissi-Debrah, a resident of London, who died in 2013. In 2020, Ella became the first person in the United Kingdom to have air pollution as a cause of death on their death certificate—the result of a long legal battle fought by her mother to sue the city’s Mayor for letting pollution proliferate over the prescribed limits. The verdict agreed that air pollution beyond legal limits contributed to Ella’s asthma, while also pointing towards another contributing factor to her death—the failure to provide Ella’s mother with information about air pollution exacerbating asthma. While the role of doctors in highlighting this relationship is significant, the work of healthcare workers also goes beyond that—it sits at the intersection of health, policy, and law.

Bringing Law, Policy, and Health Together

In the same spirit of intersectional healthcare, doctors’ research and literature is also supporting legal cases around air pollution. This is evident in one of the National Green Tribunal’s (NGT) rulings in September of this year. NGT’s southern bench asked Central Pollution Control Boards and states across India’s non-attainment cities—or cities that do not meet National Air Quality standards over a five year period—to submit the status of State Action Plans to combat air pollution, under the centre’s National Clean Air Program. This came after a plea that cited a report by Lung Care Foundation which claimed that air pollution led to lung diseases, obesity, asthma, and other diseases, especially in adolescents.

“In courts, many judgments extend the ‘right to life’ while dealing with cases of air pollution, connecting health impacts directly to air pollution,” says Aditya Prasad, a Delhi-based lawyer. This includes the recent ban on all crackers except green ones by the Supreme Court in October. Hearing a plea by firecracker manufacturers to not consider a blanket ban for the sake of employment, the Supreme Court said, “under the guise of employment of few, we cannot permit others to infringe the right to life of other citizens.”

“These are important judgments for people’s health, but unfortunately authorities only implement them like knee-jerk reactions during particular months of the year, while the pollution problem persists throughout the year,” Prasad adds. “Throughout the year, we need to ensure proper implementation of the many positive court orders [on cases of air pollution] and directions, which are currently facing an implementation gap. Why should we come to the point of fighting a legal case after a child’s death, like Ella’s [Adoo-Kissi-Debrah] when we already know what harm breathing polluted air does? We need to solve the problem before it reaches that stage of death, through efficient implementation of various court orders.”

Prasad also adds that while the landmark ruling in the case of Ella’s death might not be binding in Indian law and practice, it can surely have a persuasive value if similar cases are fought in the country. “So far, there have not been cases in India where the individuals have come forward to sue the administration for not complying with the pollution limits,” he adds.

But this situation might change soon. “Such legal cases might become our future advocacy strategies in the coming years,” says Bhavreen Kandhari, a member of Warrior Moms, a mothers-led movement operating across states in India demanding clean air. “It is through such cases that we can move the conversations beyond discussing the problem of air pollution over social media during Diwali; such legal cases will reinforce the question of accountability to the administration and ensure compliance with  air quality standards.” 

Doctors have also taken the health and pollution conversation to the recently held COP26, the global conference where countries discussed climate change and the environment. In a video titled, Our Handwriting May Be Bad, But Our Message is Clear, 25 healthcare workers across the world provided testimonies of witnessing the impacts of climate change in their patients. Following this screening at COP26, over 600 organisations—representing 46 million nurses, doctors, and health professionals worldwide—signed an open letter to national leaders calling on them to deliver on climate action. 

Doctors and healthcare professionals play an important role in generating awareness among their patients about the possible impacts of air pollution on their health. But, gauging how the patients perceive this information, and how much they can do to limit their exposure to polluting elements, requires stepping into the fields of policy and law, too. Many doctors are now working with this multidisciplinary approach in mind, which has galvanised air pollution conversations outside of hospital spaces, and into courts, movements, and international negotiations.

Featured image: early morning fog in New Delhi; courtesy of Ninara (CC BY 2.0).


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