Dr Randeep Guleria: ‘Air pollution is a medical emergency… We need to act even if the cost is going to be high’

We get worried when we see the AQI rise to 400 or more. I recall a few years ago, the AQI reached 999, the maximum as it couldn’t exceed that. It could only display three digits, although it was likely around 1,400. Examining data from the last five years, more than 50 per cent of days in Delhi and the Indo-Gangetic belt had an AQI exceeding 200, falling in the poor range. Except for 2020, during the lockdown, when AQI improved. We consider PM2.5, averaging around 40 micrograms per m³. In 2021, WHO set guidelines at less than five micrograms. We are looking at a cutoff of 40. And still, we don’t reach that on most days which means over 50 per cent of the times, sometimes up to 70 per cent of the days, we breathe poor-quality air.

What is it doing? In case of children, the neonates — if you start looking at the lungs, at birth, the number of alveoli (air sacs in the lungs) is only around 20 per cent of what an adult has. As the child grows up, the lung also continues to grow. The number of alveoli increases both in number and in size. When a person is breathing air which is bad and it is going into the lungs, this leads to stunted growth. There are many studies that show that in children in such an environment, lung function is significantly poorer than what is seen in the older group. There’s also data which shows that an improvement in the air quality increases the vital capacity of these children.

In the elderly, chronic exposure leads to inflammation of the blood vessels, leading to a higher chance of stroke and heart attacks. Data suggests that there is also cognitive decline, leading to a high chance of dementia. If you look at adults, then there is data from the European Heart Association, which suggests that living in an area where air quality is bad is as much a risk for heart disease as high cholesterol or smoking. So we are adding another risk factor to heart diseases in the middle age group. Data also suggests there are a number of systemic diseases that occur or get precipitated because of the fine particles that we breathe in. If you have particulate matter that is more than 10 microns, then that is more coarse, it usually doesn’t get clogged, it stays in the nose only, it doesn’t go down into the airways. If it is between 2.5-10 microns, it usually stays in the upper airways only and it causes irritation, cough, and sometimes constricting sensation, breathing disturbances. But if it’s less than 2.5 microns, which is known as fine particulate matter, then you have ultra-fine particulate matter which is less than 0.1 microns. This fine particulate matter goes down into your lungs. And ultra fine particulate matter, can actually cross the alveoli and the blood barrier and enter the bloodstream, starting to affect other organs too because they actually enter the bloodstream and cause inflammation in various organs. Also, a lot of particles and substances, which could be substances like cadmium, even volatile organic compounds, sort of hitchhike on these particulate matters. There is data that suggests that even diabetes type two is a higher risk factor for people who live in poor-quality air. I already mentioned cardiovascular diseases, strokes, and neurological disorders. Some data suggests that even osteoporosis and joint problems get aggravated when one is constantly living in areas of air pollution. We see the acute effects of air pollution during this time of the year, especially in the elderly, children, and those who have asthma, bronchitis, and heart disease. But the chronic effect is something that we need to really look at. Another important data suggests that for those constantly living in areas of pollution, lung cancer is a higher risk.

There should be a plan in place, rather than having a knee-jerk reaction every winter and then forgetting about it. Many of us have tried to push for that. Somehow, it’s not a priority

Kaunain Sheriff M: When the air quality is bad, how do we reduce our indoor pollution?

A lot of indoor air quality is related to outdoor air quality. You could have a room which is more closed. We need more data in terms of the utility of air purifiers. It’s important to remember that when you’re using an air purifier, it also depends on the size of the room and the degree of ventilation that happens in the room. In most houses in Delhi, the rooms are not airtight. Dust comes in even otherwise if you close the door, so pollution will also come in. Secondly, if it’s a big room then the air purifier will not be able to purify or filter out the entire air. People have tried to use plants also, and there is some data that shows that green plants do help in improving the quality of air. In rural India, the use of biomass has emerged. Indoor air pollution also gets precipitated by the use of biomass. And in rural India, in villages and towns, people use more solid fuel in the form of wood, and cow dung to cook. If the kitchen is not properly ventilated, that creates a lot of smoke.

Kaunain Sheriff M: In the last 10 years, has your own OPD changed vis-a-vis air pollution? What concerns you, not just with patients with respiratory illnesses, but also with those who’ve never had any history of respiratory illnesses?

I remember, in the late ’90s, many people had breathing difficulties, coughing, and watering of the eyes. Then in 1998, the Supreme Court brought in CNG as a mandatory thing. All the buses, private vehicles, and cabs had to have CNG. That improved the quality of air in the early 2000s. That was a time when you had a little better response to treatment and fewer patients. But then there was a huge influx of vehicles, especially diesel vehicles, and we lost whatever we had gained by CNG in six to seven years. Now you’re seeing an increasing number of patients coming with breathing difficulty, worsening of asthma, and COPD. A lot of people who come to Delhi to study or to work and have had no respiratory problems start complaining of chest tightness, breathing difficulty, wheezing in the chest, and coughing at night. Interestingly, many of them, when they go back to their hometown, they say that the symptoms have become better or almost disappeared. So a lot of the pollutants that we’re breathing trigger airway inflammation and make our airways what we call hyperreactive, more sensitive, even in normal individuals. And that is why over the last few years, we’re seeing an increasing number of such patients, along with the worsening of people with underlying cardio-respiratory diseases. Air pollution is a silent killer and it causes silent problems. It causes the worsening of underlying conditions.

We see the acute effects of air pollution during this time of the year, especially in the elderly, children, and those who have asthma, bronchitis, and heart disease. But the chronic effect is something that we need to really look at

Kaunain Sheriff M: What are the conversations in terms of policy formulation that we need so as to introduce change?

The natural issue is that the Indo-Gangetic plain is a landlocked area and during winter months, when the temperature falls, there’s also very little wind velocity. So, whatever pollution we create stays at ground level and continues to accumulate there. It leads to the pollution just staying there for weeks. If there is a breeze or rain, it tends to clear out for a few days. That’s the natural phenomena and that is why there is a problem here as compared to other parts of the country. The second issue is manmade and that is because of emitting sources. It could be vehicular, electrical, probable stubble burning, related to unplanned construction. We have to change that mindset in terms of making it more environment friendly. I think trying to push for more and more public transport use will help. Then on a personal level, decrease your carbon footprint. Walking to a place rather than take a vehicle, children carpooling or using a school bus, is better. So there are simple solutions. For bigger solutions, we need to push our policymakers.

Dr Randeep Guleria, Chairman, Institute of Internal Medicine, Respiratory and Sleep Medicine, Medanta. (Express photo by Praveen Khanna)

Kaunain Sheriff M: Do flu shots give you some sort of protection when we see such high levels of air pollution?

Flu shots are basically for influenza infection (viral infections). These do tend to become more common during a change of season. There are some studies on viral infections that are COVID-related. One study showed that in China, when the SARS outbreak happened in 2003, people living in areas where the pollution level was high had more severe SARS infection. When there was an outbreak in Italy in the early days of COVID-19, the subsequent studies showed that in various districts in Italy, the mortality was linked to areas in that municipality where the air quality was bad. So, poor air quality leads to higher mortality due to COVID as compared to those where the air quality was better. A recent paper published from New York looked at New York City and long-term exposure to poor air quality and COVID mortality. It showed a similar thing. The areas in New York City where the air quality was bad, the people who had COVID, did worse as compared to areas where air quality was good. Poor air quality leads to airway inflammation. And COVID or viral infection also precipitates that, leading to a double whammy. It affects your lungs in a bigger manner and causes more harm than what would have happened. So you could extrapolate the same thing to other viral infections like influenza. And therefore, theoretically, from that point of view, a flu shot may help in terms of getting less severe flu infection.

Over the last few years, we’re seeing an increasing number of patients with respiratory illnesses, along with the worsening of underlying cardio-respiratory diseases. Air pollution is a silent killer and it causes silent problems

Annona Dutt: The Health Ministry, in its guidelines for air pollution, talks about surveillance of pollution-related diseases. How does it work and how does monitoring these diseases help?

What has really helped is that now everyone is aware of the AQI. There are a large number of monitoring stations besides portable devices. So that has actually helped in increasing awareness. If you have an area where you find that pollution level is very high it goes into the severe category. This is part of the graded response action plan. You could tell individuals who are at higher risk, the elderly, children, or those with co-morbidities, of precautions they need to take. You could also monitor to see where there’s an increase in the number of, let’s say, emergency room visits in that area because of poor-quality air. So, some interventions can be done to prevent people coming to the emergency because of the worsening of the underlying symptoms.

Dr Randeep Guleria, Chairman, Institute of Internal Medicine, Respiratory and Sleep Medicine, Medanta. (Express photo by Praveen Khanna)

Kaushik Das Gupta: It’s often said that Delhi and some other Indian cities perhaps are at a stage where, say, London was in the ’50s and some American cities were in the ’60s. Is there anything that we can learn from their experience?

If you look at pictures from the London smog of 1952, it looks very much like how Delhi looks during the winter months — dull, grey, and dark. And in 1952, in a short span, I think it was 12 days or so, 4,000 people died and they could directly link that to air pollution. That led to a lot of hue and cry and legislations came up which was followed very strictly. That led to the air quality improving. The same story is that of Los Angeles or even New Mexico and we did some of this during the late ’90s and early 2000s with CNG. There are solutions that we can learn from others. But we have to really understand that this is a medical emergency, this is a silent killer, it’s actually affecting not only us but the health of subsequent generations. And that is why we need to really act even if the cost of that action is going to be high. We don’t invest so much here because we keep saying that we need more evidence. There’s enough evidence and we need to find practical solutions. We can’t copy the solution from the West because our issues are different.

Ivinder Gill: As the director of AIIMS, did you make any recommendations to the government on pollution? How many of them were taken seriously?

We’ve had major discussions on air pollution, to the extent that one has tried to convince people. Sometimes you’re told that you need more data, or that pollution in India is different from the kind in West, and, therefore, we may have different health effects. Someone once told me that our lungs are different, more sturdy and that we have better immunity. This is something that we heard in COVID too. But that data doesn’t stand. We need some action plans so that every year we see some improvement in AQI. It is not going to happen overnight. But there should be a plan in place, rather than having a knee-jerk reaction every winter and then forgetting about it. Many of us have tried to push for that. Somehow, it’s not a priority, if I can put it that way.

Dr Randeep Guleria, Chairman, Institute of Internal Medicine, Respiratory and Sleep Medicine, Medanta. (Express photo by Praveen Khanna)

Rupsa Chakraborty: Could the outside pollutants become trapped and circulate inside cramped areas with low ventilation and affect the health, particularly of those with tuberculosis?

In the case of lower socioeconomic status, especially when houses are poorly ventilated, the air quality can be worse inside. As for TB, air pollution can affect your overall immunity and, therefore, lead to a higher chance of getting tuberculosis. Immunity may be low by virtue of a low socio-economic status too. If you’re living in a crowded area, then transmission of TB becomes more common because it’s a droplet infection. If a large family lives together and one of them is positive, then he or she can give the infection to the others.

Ankita Upadhyay: Are Delhi government measures, which include shutting schools, the odd-even rule, and using artificial rain, beneficial?

Honestly, I don’t think they are of much use. This is not a long-term solution.

Jatin Anand: Is there something that can be done throughout the year to rein in pollution?

One is to look at regular traffic. Subsidise the cost or the sale or the price of electric vehicles, making them so cheap that people go for them rather than going for diesel vehicles. It’s not very difficult, and there is a market for it. Similarly, find a solution that the farmers are willing to accept or give them an incentive to not do stubble burning. Make sure that there’s no illegal construction, and construction is done in a way that dust doesn’t rise. Have a lot of green paths so that the dust on the roadside doesn’t tend to go up into the air. It’s a step-by-step process.

Suanshu Khurana: Information such as fomite transmission was being spread as a public health advisory during COVID. Keeping in mind the things we’ve learned, if COVID were to return, what would be the key advisory points?

The reason that happened was because this was a new virus that people didn’t know anything about. There was a fearful reaction. What we’ve learned is that we need to be more vigilant in terms of surveillance. We need to pick up an outbreak early and when it spreads. If you have a virus that has mutated to become more virulent then it will translate to more hospital admissions. So testing all patients who come with the flu-like illness and get admitted, in the ICU, will give you some red flag to monitor a change in the pattern. The second are simple measures like wearing a mask, and hand washing. These are time-tested and were also the only things that worked in the 1918 Spanish flu pandemic when we had no antibiotics, antivirals or vaccine.

Kaunain Sheriff M: With respect to long Covid, we’ve seen cases of blood clots in the brain, and gastric issues. What do we know so far?

The issue is that it’s a multi-system problem. So you need to have someone who looks at the individual holistically. People have clots, and disturbed sleep, people have what is known as brain fog and panic attacks. And then, of course, you have organ involvement. For example, if you have lung damage, you have breathing difficulty. If you have heart problems, then your cardiac function gets impaired. The other thing is that in some individuals, over a period of time, it tends to improve, while with symptoms have persisted. The theory is that the virus goes away, but the viral particles stay and continue to cause an ongoing inflammatory reaction. The other is that it causes a disturbance in your sympathetic and parasympathetic system and that imbalance which happens in the body leads to multi-organ involvement and it takes a long time for the body to come back to a steady state. We are still learning and most of us are treating it more from the symptom point of view, rather than a definite treatment protocol.