Stop normalizing poverty: How can African children achieve their true lung health potential?

INTRODUCTION

The British Thoracic Society (BTS) launched a Global Health Group in 2019 in partnership with the Pan African Thoracic Society (PATS).^[1] The Group proposes a symposium for the BTS winter meeting each year and offers a summary of this for the Journal of PATS. The first symposium, in February 2021, addressed five major respiratory exposures/diseases in Africa: air pollution, childhood pneumonia, post-TB lung disease, asthma, and chronic obstructive pulmonary disease (COPD).^[2] The second symposium in December 2021 focused on chronic respiratory diseases in low-income and middle-income countries (LMICs).^[3] This third symposium in November 2022 tackled lung health in African children in the context of poverty. This manuscript is not a comprehensive review of the literature but a reflection of the proceedings of the symposium.

THIS STORY STARTED LONG, LONG AGO: THE LEGACY OF POOR LUNG HEALTH ACROSS THE GENERATIONS

Lung health can be defined as the ability to lead a good quality of life, free of infections, and exposures that could limit the lung’s capacity to breathe. In this definition, it is clear that for one to attain maximal lung capacity and thus health, there are a multitude of factors that can set one on a lung health trajectory from the intrauterine period.^[4]

In pulmonary medicine, an individual’s lung capacity has been intimately linked to ethnicity with this being rooted in colonial history and racism.^[5,6] Unfortunately, lung health disparities have not been viewed through a lens of socioeconomic, environmental, and other factors that are known to influence lung capacity.^[7,8] Lung health is determined before a baby even takes its first breath from the intra-uterine environment. Factors such as epigenetics are beyond the scope of this review.^[9]

IN THE BEGINNING, THERE WAS FIRE: BUT IS THIS THE “KILLER IN THE KITCHEN” OR JUST SMOKE AND MIRRORS?

Household air pollution due to the combustion of dirty-burning fuels for cooking, heating, and lighting in and around the home has been estimated to cause between 2 and 4 million deaths/year.^[29,30] Pneumonia in young children and COPD and cardiovascular disease in adults are the main diseases associated with morbidity and mortality due to household air pollution.^[29,30] Clean cookstoves and fuels have been promoted as solutions to household air pollution that would improve health and save lives.^[31]

In 2009, Romieu et al. reported the findings of a household-level randomized controlled trial of a chimney biomass-burning cookstove with a chimney versus continuation of traditional cooking methods on lung health in 552 women and 668 children in rural Mexico.^[32] A major finding was poor adherence to the intervention. No statistically significant effect was seen on lung function decline in women or acute lower respiratory tract infections (ALRIs) in children in intention to treat analyses.

In 2011, Smith et al.^[33] reported the findings of a household-level randomized controlled trial of a biomass-burning cookstove with a chimney versus continuation of traditional cooking methods on physician-diagnosed pneumonia in 518 children <19 months old in rural Guatemala (RESPIRE). No statistically significant effect was seen on the primary outcome in the intention to treat analysis.

In 2012, Hanna et al.^[34] reported the findings of a household-level randomized controlled trial of a biomass-burning cookstove with a chimney versus continuation of traditional cooking methods on multiple health and other outcomes in adults identifies as primary cooks from 2651 households in rural India. No statistically significant effect was seen on the primary outcome in intention to treat analyses.

In 2016, Tielsch et al.^[35] reported the findings of a cluster randomized step-wedge controlled trial of a biomass-burning cookstoves versus continuation of traditional cooking methods on ALRI in 5254 children under the age of 3 years in rural Nepal. No statistically significant effect was seen on the primary outcome in intention to treat analyses.

In 2017, Mortimer et al.^[36] reported the findings of a community level cluster randomized controlled trial of two biomass-burning cookstoves versus continuation of traditional cooking methods on pneumonia in 10,750 children under the age of 5 years in rural Malawi (CAPS). No statistically significant effect was seen on the primary outcome in intention to treat analyses.

In 2017, Alexander et al.^[37] reported the findings of a household level randomized controlled trial of an ethanol-burning cookstove versus wood- or kerosene-burning cookstoves on blood pressure in 324 pregnant women in urban Nigeria. No statistically significant effect was seen on the systolic blood pressure in the intention to treat analysis.

In 2019, Kirby et al.^[38] reported the findings of a community level cluster randomized controlled trial (174 clusters; 1582 households) of an environmental home-based intervention package including a biomass-burning cookstove with a chimney versus continuation of traditional cooking methods on caretaker reported acute respiratory infection in children in Rwanda. This trial did find a statistically significant effect on the primary outcome in the intention to treat analysis with a prevalence ratio of 0.75, 95% CI 0.60–0.93, P = 0.009.

In 2021, Jack et al.^[39] reported the findings of a household-level randomized controlled trial (1414 pregnant women) of liquefied petroleum gas (LPG) burning cookstoves versus biomass burning cookstoves versus continuation of traditional cooking methods on birthweight and physician-diagnosed severe pneumonia in the 1^st year of life in rural Ghana (GRAPHS). No statistically significant effect was seen on these primary outcomes in intention to treat analyses.

In 2021, Checkley et al.^[40] reported the findings of a household-level randomized controlled trial of an LPG burning cookstove versus continuation of traditional cooking methods on blood pressure, lung function, and respiratory symptoms in 180 women in rural Peru. No statistically significant effect was seen on these primary outcomes in intention to treat analyses.

In 2022, Clasen et al.^[41] reported the findings of a household-level randomized controlled trial of an LPG burning cookstove versus continuation of traditional cooking methods on birthweight of 3061 live births in Guatemala, India, Peru, and Rwanda (HAPIN). No statistically significant effect was seen on the primary outcome in intention to treat analyses.

These ten clinical trials conducted across diverse settings/ countries, with a range of cookstove/fuel interventions on several different indicators of health, are broadly consistent in finding no statistically significant effects on the primary health outcomes of interest.

It is, therefore, time to accept that the introduction of clean cookstoves and fuels in place of traditional cooking methods is not an effective (or cost effective) solution for improving human health and saving lives based on current clinical trial evidence. It is important that the search continues for effective solutions for improving human health, where household air pollution and other problems of poverty are common. It is also important that while this search continues, stretched health budgets are used wisely and on interventions that are proven to be clinically and cost-effective.

CONCLUSION

Lung health in LMICs is affected by multifaceted problems starting from intrauterine stage and continues during their childhood growth. Poverty is a major risk factor for lung disease affecting the normal growth and development of children growing up in LMICs. There are opportunities for LMIC policy and decision makers to work on strategies to improve lung health for their children through health education, vaccination, appropriate nutrition, prevention of risk factors, and promotion of interventions to maximize healthy lung development in children, rather than normalizing poverty. The evidence from randomized clinical trials of cleaner cookstoves/fuel interventions does not support their use as effective or cost-effective interventions for improving child lung health. It is important that limited child health budgets are used wisely on proven effective and affordable approaches to achieve optimal lung health in the early life and across the life course.