Association for Public Policy Analysis & Management

Globally over 4 million deaths per year are attributed to exposure to smoke from household air pollution (HAP), more than deaths from HIV/AIDS, tuberculosis and malaria combined. Despite a growing body of evidence that exposure to smoke leads to a myriad of acute and chronic health conditions for both women and children, relatively little is known about how various dimensions of the cooking environment affect health outcomes. While the global community, through the Global Alliance for Clean Cookstoves and other venues, focuses their attention on cleaner cooking technologies as a solution to this critical public health problem, other aspects of the cooking environment are under studied. There are few studies focusing on populations in sub-Saharan Africa, and few that compare outcomes and explore determinants in both rural and urban settings. The research questions this paper addresses are twofold. First we explore the prevalence of a wide variety of HAP related acute and chronic health problems for a sample of 700 primary cooks split between rural and urban field sites in Malawi, where HAP is the leading risk factor for morbidity and mortality. Second, we explore the association of numerous cardiopulmonary, respiratory and neurological symptoms with fuel type, stove type and kitchen ventilation. We run a series of multi-level logistic regression models to understand the determinants of health outcomes.

We find that primary cooks in rural areas have significantly higher odds of all cardiopulmonary symptoms analyzed (e.g., chest pain, difficulty breathing, rapid breathing etc.), and respiratory symptoms such as persistent phlegm and cough, relative to their urban counterparts. Controlling for individual- and household-level confounding, low quality firewood is associated with significantly higher odds of primary cooks experiencing shortness of breath while climbing, cough and phlegm at night, itchy skin rash, difficulty concentrating, forgetfulness, and dizziness compared to high quality firewood. Charcoal has a significant protective effect on chest pain and difficulty breathing, but significantly higher odds of persistent phlegm and itchy skin rash, compared to high quality firewood, when including confounders. Use of crop residues as a fuel has a significant association with higher odds of shortness of breath at rest, phlegm at night, dry irritated eyes, forgetfulness, dizziness but protective effect on cough in the morning, relative to high quality firewood, controlling for confounders. The addition of covariates removes significant association between traditional stove use or indoor cooking, and the odds of any respiratory, cardiopulmonary, irritation and neurological symptoms.

Our findings underscore the importance of promoting higher-quality biomass fuels along with improved cooking technologies, in heavily biomass-dependent Malawi. Policy-makers must target separate interventions for rural and urban areas that differ in their stove use (charcoal stove-users are largely concentrated in urban areas) and fuel availability. Given evidence of lagging improved cookstove adoption in sub-Saharan Africa, and our findings related to the influence of reliance on low quality fuelwood on health outcomes, future interventions could involve tree planting for high quality fuelwood and encouraging cultivation of crops like pigeon pea that meet dual household needs of fuel and food.