The HIV/AIDS pandemic

The HIV/AIDS pandemic is one of the most important and urgent public health challenges facing governments and civil societies around the world. Adolescents are at the centre of the pandemic in terms of transmission, impact, and potential for changing the attitudes and behaviours that underlie this disease.
It is estimated that 50% of all new HIV infections are among young people (about 7,000 young people become infected every day), and that 30% of the 40 million people living with HIV/AIDS are in the 15-24 year age group. The vast majority of young people who are HIV positive do not know that they are infected, and few young people who are engaging in sex know the HIV status of their partners.
The importance of focusing on young people has been recognised at a global level by the 2001 UN General Assembly Special Session on HIV/AIDS, which endorsed a number of goals for young people, including:
"By 2003, establish time-bound national targets to achieve the internationally agreed global prevention goal [adopted during the ICPD+5 Conference] to reduce by 2005 HIV prevalence among young men and women aged 15-24 in the most affected countries by 25% and by 25% globally by 2010"
"By 2005, ensure that at least 90%, and by 2010 at least 95% of young men and women have access to the information, education, including peer education and youth-specific education, and services necessary to develop the life skills required to reduce their vulnerability to HIV infection; in full partnership with youth, parents, families, educators and health care providers."
Fortunately, most young people are not infected. In fact, during early adolescence HIV rates are the lowest of any period during the life cycle. The challenge is to keep them this way. Focusing on young people is likely to be the most effective approach to confronting the epidemic, particularly in high prevalence countries.

The health impact of Indoor air pollution

Indoor air pollution and health

Scope
of the problem

More than half of the world’s population rely on dung, wood,
crop waste or coal to meet their most basic energy needs. Cooking and heating
with such solid fuels on open fires or stoves without chimneys leads to indoor
air pollution. This indoor smoke contains a range of health-damaging pollutants
including small soot or dust particles that are able to penetrate deep into the
lungs. In poorly ventilated dwellings, indoor smoke can exceed acceptable levels
for small particles in outdoor air 100-fold. Exposure is particularly high among
women and children, who spend the most time near the domestic hearth. Every year,
indoor air pollution is responsible for the death of 1.6 million people - that's
one death every 20 seconds.

The use of polluting fuels thus poses a major
burden on the health of poor families in developing countries. The dependence
on such fuels is both a cause and a result of poverty as poor households often
do not have the resources to obtain cleaner, more efficient fuels and appliances.
Reliance on simple household fuels and appliances can compromise health and thus
hold back economic development, creating a vicious cycle of poverty.

According
to the 2004 assessment of the International Energy Agency, the number of people
relying on biomass fuels such as wood, dung and agricultural residues, for cooking
and heating will continue to rise. In sub-Saharan Africa, the reliance on biomass
fuels appears to be growing as a result of population growth and the unavailability
of, or increases in the price of, alternatives such as kerosene and liquid petroleum
gas. Despite the magnitude of this growing problem, the health impacts of exposure
to indoor air pollution have yet to become a central focus of research, development
aid and policy-making.

The health impact: A major killer

The
World Health Organization (WHO) has assessed the contribution of a range of risk
factors to the burden of disease and revealed indoor air pollution as the 8th
most important risk factor and responsible for 2.7% of the global burden of disease
. Globally, indoor air pollution from solid fuel use is responsible for 1.6 million
deaths due to pneumonia, chronic respiratory disease and lung cancer, with the
overall disease burden (in Disability-Adjusted Life Years or DALYs, a measure
combining years of life lost due to disability and death) exceeding the burden
from outdoor air pollution five fold. In high-mortality developing countries,
indoor smoke is responsible for an estimated 3.7% of the overall disease burden,
making it the most lethal killer after malnutrition, unsafe sex and lack of safe
water and sanitation.

Indoor air pollution has been associated with a wide
range of health outcomes, and the evidence for these associations has been classified
as strong, moderate or tentative in a recent systematic review. Included in the
above assessment were only those health outcomes for which the evidence for indoor
air pollution as a cause was classified as strong. There is consistent evidence
that exposure to indoor air pollution increases the risk of pneumonia among children
under five years, and chronic respiratory disease and lung cancer (in relation
to coal use) among adults over 30 years old. The evidence for a link with lung
cancer from exposure to biomass smoke, and for a link with asthma, cataracts and
tuberculosis was considered moderate. On the basis of the limited available studies,
there is tentative evidence for an association between indoor air pollution and
adverse pregnancy outcomes, in particular low birth weight, or ischaemic heart
disease and nasopharyngeal and laryngeal cancers.

While the precise mechanism
of how exposure causes disease is still unclear, it is known that small particles
and several of the other pollutants contained in indoor smoke cause inflammation
of the airways and lungs and impair the immune response. Carbon monoxide also
results in systemic effects by reducing the oxygen-carrying capacity of the blood.

Pneumonia
and other acute lower respiratory infections

Globally, pneumonia and other
acute lower respiratory infections represent the single most important cause of
death in children under five years. Exposure to indoor air pollution more than
doubles the risk of pneumonia and is thus responsible for more than 900 000 of
the 2 million annual deaths from pneumonia.

Chronic
obstructive pulmonary disease

Women exposed to indoor smoke are three times
as likely to suffer from chronic obstructive pulmonary disease (COPD), such as
chronic bronchitis, than women who cook and heat with electricity, gas and other
cleaner fuels. Among men, exposure to this neglected risk factor nearly doubles
the risk of chronic respiratory disease. Consequently, indoor air pollution is
responsible for approximately 700 000 out of the 2.7 million global deaths due
to COPD.

Lung cancer

Coal use is widespread in
China and cooking on open fires or simple stoves can cause lung cancer in women.
Exposure to smoke from coal fires doubles the risk of lung cancer, in particular
among women who tend to smoke less than men in most developing countries. Every
year, more than one million people die from lung cancer globally, and indoor air
pollution is responsible for approximately 1.5% of these deaths.

Disproportionate
impacts on children and women

Household energy practices vary widely around
the world, as does the resultant death toll due to indoor air pollution. While
more than two-thirds of indoor smoke deaths from acute lower respiratory infections
in children occur in WHO's African and South East Asian Regions, over 50% of the
COPD deaths due to indoor air pollution occur in the Western Pacific region.

In
most societies, women are in charge of cooking and - depending on the demands
of the local cuisine - they spend between three and seven hours per day near the
stove, preparing food. 59% of all indoor air pollution-attributable deaths thus
fall on females. Young children are often carried on their mother's back or kept
close to the warm hearth. Consequently, infants spend many hours breathing indoor
smoke during their first year of life when their developing airways make them
particularly vulnerable to hazardous pollutants. As a result, 56% of all indoor
air pollution-attributable deaths occur in children under five years of age.

In
addition to the health burden, fuel collection can impose a serious time burden
on women and children. Alleviating this work will free women's time for productive
endeavours and child care, and can boost children's school attendance and time
for homework.

Millennium Development Goals are guiding
international action

Tackling indoor air pollution in the context of household
energy is linked to achieving the Millennium Development Goals, in particular
to reducing child mortality (Goal 4), to promoting gender equality and empowering
women (Goal 3), to opening up opportunities for income generation and eradicating
extreme poverty (Goal 1), and to ensuring environmental sustainability (Goal 7).
WHO reports the "proportion of the population using solid fuels for cooking" as
an indicator for assessing progress towards the integration of the principles
of sustainable development into country policies and programmes. Yet, the central
role of household energy is not currently reflected in the political responses
to achieve the Millennium Development Goals.

Measures to reduce indoor air
pollution and associated health effects range from switching to cleaner alternatives,
such as gas, electricity or solar energy, to improved stoves or hoods that vent
health-damaging pollutants to the outside, to behavioural changes. There is an
urgent need to investigate which interventions work and how they can be implemented
in a successful, sustainable and financially viable way.

What
WHO is doing

WHO, as the global public health agency, is advocating for
the integration of health in international and national energy policies and programmes.
WHO collects and evaluates the evidence for the impact of household energy on
health and for the effectiveness of interventions in reducing the health burden
on children, women and other vulnerable groups. WHO's programme on household energy
and health rests on four pillars:

• Documenting the
  health burden of indoor air pollution and household energy: WHO will
  provide a regular update of the links between household energy and health and,
  where feasible, offer support to key research undertakings.
• Evaluating
  the effectiveness of technical solutions and their implementation: Developing
  simple tools for monitoring the effectiveness of interventions in improving health
  and building the capacity to conduct such evaluations will help generate much
  needed information from ongoing small- and large-scale projects. This information
  will provide the basis for the development of a catalogue of options that review
  both the effectiveness of interventions, and lessons learnt in relation to their
  implementation.
• Acting as the global advocate for health as a central
  component of international and national energy policies: Ultimately,
  policy-makers will want to know whether it pays off to invest in large-scale operations
  to reduce indoor air pollution. In terms of health, a recent cost-effectiveness
  analysis of different interventions suggests that improved stoves and switching
  to kerosene and gas represent cost-effective solutions. In addition, WHO is working
  on a cost-benefit analysis of interventions that - beyond health - will take into
  account all the benefits associated with improved household energy practices.
  
• Monitoring changes in household energy habits over time:
  Information about the energy habits of poor, mostly rural households is scarce
  and WHO has the responsibility to work towards progress in this area and to report,
  on a yearly basis, the Millennium Development Goal Indicator 29 "percentage of
  population using solid fuels".

Key partners include the Partnership
for Clean Indoor Air, the United Nations Environment Programme, the United Nations
Development Programme and the World Bank as well as many research institutions
and non-governmental agencies around the world. WHO is already actively taking
part in projects in several developing countries, including the most sophisticated
scientific indoor air pollution study to date undertaken in Guatemala, and work
in China, Lao People's Democratic Republic, Mongolia, Nepal, Kenya and Sudan.
In the future, work will focus even more on those countries and populations most
in need.