Stunting in Nepal: kitchen smoke adding fuel to the fire

New research links smoke from cook stoves to high levels of stunted growth among children in Nepal
<p>A traditional Nepali wood-fired stove [image by: Abhaya Raj Joshi]</p>

A traditional Nepali wood-fired stove [image by: Abhaya Raj Joshi]

Niramala Dahal recalled the days when her first daughter coughed incessantly. Dahal, now in her 40s, lives with her two children in Bakhreldihi, Kavre, around 50 kilometres east of Kathmandu.

She and her husband had rushed the one-year-old to the doctor, who had diagnosed a chest infection.

“The doctor prescribed some antibiotics and within a few days, she was back to normal. She now studies in high school in Kathmandu,” Dahal said. “In hindsight, we believe that the smoke from our kitchen caused the infection.”

Their daughter was lucky. She survived the infection, and never contracted it again. However, other Nepali children are not so lucky. 66% of households in the country use biomass fuels (wood, crop residues, and dung) for cooking. According to the recently published Yale Environment Quality Index 2018, Nepal ranks 145th in the world when it comes to using clean sources of energy in the kitchen.

“Although LPG was available, we would cook indoors burning fuel wood,” explained Dahal. “Food cooks fast on a gas stove, but in a rural household like ours where fuel wood is abundant, it does not make financial sense.” She added that, “the older generation believed that food prepared using fuelwood is tastier, and in winter the fire keeps us warm.”

Nirmala Dahal in front of her gas cooker, used on the occasions when the wood-fired stove won’t do [image by: Abhaya Raj Joshi]
Electricity was just too expensive an option for them. She had many reasons to want to use wood. But the list of harmful effects of the gases emitted by biofuels – considered the least clean and efficient of all available sources of energy – is even longer, and mothers like Dahal are not fully aware of them.

According to the World Health Organization (WHO) in poorly ventilated households, indoor smoke can have fine particle concentrations up to 100 times higher than acceptable levels. The smoke from the fireplace, rich in carbon monoxide, nitrogen oxide, formaldehyde, benzene and many other toxic organic compounds, does not have anywhere to go in Nepali kitchens where chimneys are a rarity.

The World Health Organization has already declared that pollutants in the air are the leading environmental cause of cancer. But for mothers like Dahal, and her daughter, there are additional risks. They are exposed to smoke for a longer period than men, since children in their early years spend most of their time with their mothers, who carry out their daily chores in the kitchen.

Over the years a great deal of research has gone into the effects of household air pollution, especially among Nepali children. A number of studies have suggested that biofuel smoke increases the risks of breathing-related ailments such as acute lower respiratory infections, as well as having adverse effects on birth weight.

Stunted growth – new revelations

A study published recently now suggests, probably for the first time in the case of Nepal, that kitchen smoke might also be associated with stunting, one of Nepal’s perennial child health issues.  Stunting refers to impaired development and growth from conception to the age of two.

According to the latest National Demographic Health Survey, more than one-third of children under five in Nepal are too short for their age. The chronic condition not only hinders the physical development of children, but also restricts their cognitive abilities. The problem is more severe in rural areas (40%), compared to urban (32%).

The lack of chimneys in most Nepali houses adds to the pollution problem [image by: Abhaya Raj Joshi]
During the late 1970s, it was believed that more than 70% of Nepali children were too short for their age. Studies commissioned by the government, along with global experience, suggested that the root cause of stunting among Nepali children was food insecurity. They were eating too little food and irregularly. Limited access to clean drinking water and poor sanitary conditions added to the problems.

To address the problem, Nepal’s government set up a number of initiatives, with ministries from agriculture to sanitation cooperating. By 2016 only around 36% of Nepali children were reported to be short for their age. Researchers believe that this was achieved through improved prenatal and neonatal care and improved nutrition.

“Most of what we have achieved in terms of reduction in stunting can be attributed to improved access to water, sanitation and hygiene,” said researcher and nutritionist Atul Upadhyay. “Improvement in the food safety situation has also helped reduce stunting,” he added.

The relationship between stunting and kitchen smoke

A limited number of studies have been conducted in South Asia  to examine the association between stunting and kitchen smoke. A pioneering study from India showed a positive association between biofuel smoke and stunting in children (0–35 months) using the data from a national family health survey in India. The authors of the study had said that the prevalence of severe stunting remained high even after adjusting for other factors including environmental and tobacco smoke.

A similar approach was taken by researchers who analysed data from the Nepal Demographic and Health Survey 2011 to see to what extent the link can be established in Nepal.

The results estimated that stunting prevalence among children with exposure to biofuel smoke was about twice as high as the children without exposure.

The effect of biofuel smoke remained significant even after controlling for the child’s age and birth size, mother’s body mass index, education and smoking, and other environmental and geodemographic factors. This finding was consistent with the study in India, say the authors of the report.

“The study observed a high prevalence of stunted children in the Nepali population using biofuel for cooking and provides further evidence that supports the existent knowledge,” the authors reported.

Is it really a surprise?

MK Piya, one of Nepal’s leading chest physicians, said the findings do not surprise him. He believed that children who are exposed to kitchen smoke contract chest infections easily and unlike Dahal’s daughter, do not recover easily. “When a child contracts an infection time and again, all of the body’s energy is used in fighting the infection, and growth suffers,” he said.

Nutritionist Atul Upadhyay also believed that the association between kitchen smoke and stunting is possible and needs further exploration. “While focusing on nutrition and sanitation helped Nepal reduce stunting significantly, identifying more factors and acting on them could help us achieve even more gains,” he added.

Rajkumar Pokharel, Chief Nutrition Section at the Child Health Division, said that the government’s focus still remains on improving nutrition and sanitation and that kitchen smoke has not been considered an important factor in dealing with stunting. “We have focused on clean toilets and hygiene to reduce infections, and controlling air pollution is a part of hygiene,” he added.

Nutritionist Upadhyay, however, cautioned that although the report found a link between kitchen smoke and stunting, an epidemiological study is needed to establish the relationship more strongly.

Upadhyay said that the study gives the government one more reason to introduce programs to encourage people to use smokeless stoves.

But that may not be so easy. “Government policies are based on years of research. We would have to conduct randomized trials to see if kitchen smoke has a significant effect on stunting before policy decisions can be taken,” added Rajkumar Pokharel.

Meanwhile, guests arrived at Dahal’s home and she went to her kitchen to prepare tea. The guests were in a hurry, and she places her teapot on her gas stove. “We use gas whenever we don’t have time. The guests can’t be kept waiting.” It may be that traditions of hospitality trump mere health reports, and points to how important social change is in shifting the way people use fuel.