The air killing women in Kenyan households

This is the first instalment of a two-part series on the dangers of household air pollution.

Mid-last February, I meet Umi Ahmed in her tiny-tin room at Mukuru Kayaba in Starehe Sub-County, Nairobi County.

It’s some minutes past 10am and on this Monday, the sun is already out and hot. But this squeezed room has no window and Ms Ahmed has turned on the electricity bulb. Without it, the room would be engulfed in darkness.

She shares the room with her husband and five children-four sons and one daughter, all in 14 - 29 years, age bracket.

Starehe, where Mukuru Kayaba is situated, is one of the densely populated areas in Nairobi with 210,423 people, captured in the 2019 Census, congested in a 20.6 square kilometre land area. There are 10,205 people per square kilometre.

There are rows of silver corrugated iron sheet rooms patched together with alleys in between, where smelly water waste flows freely.

The door serves two purposes - an entry and a window.

She ushers me into the room which is stuffy with kerosene odour. Her pregnant 21-year-old daughter is sleeping on the lower decker of a bed in the room.

You can feel the chest heaviness in her breath.

Behind the door is a table packed with cooking utensils and a kerosene stove. A black-sooted sufuria with black tea and a blue cup sit on the stove.

“We had sugarless black tea for breakfast. We have nothing to eat for lunch or supper," she says as she holds her chest to let out a painful cough.

Her situation explains why she is stuck to using kerosene. This year marks 25 years since she started using the fuel.

"If I cannot afford food, where am I going to get money to buy a cylinder of gas?" she asks.

“I wouldn't be using kerosene had there been gas for Sh30 like kerosene."

Ms Ahmed links her chronic cough and chest tightness to inhaling smoke from the kerosene stove.

Her 14-year-old son is equally affected.

"He never sleeps. He wheezes throughout the night and complains of severe irritation of sinuses" she says.

"Huwa analia akisema ' Mama nisaidie, kuna nyama hapa ndani,' (He often cries saying 'Mother, help me, there is flesh in here (sinuses)'."

Kerosene, wood, coal, charcoal, crop waste and dung make up unclean and unsafe fuels that World Health Organization (WHO) flags up as causes of household air pollution that kills 3.2 million people, globally, annually.

Worldwide, according to Google Trends, in the past 12 months, indoor air pollution has been the most searched topic in 13 countries with Kenya, coming second after Philippines. This means the global population is concerned about exposure to pollutants causing respiratory and cardiovascular diseases.

WHO estimates that 800 million people were exposed to household air pollution in Africa, as of 2019. Consequently, Sub-Saharan Africa accounts for 30 per cent of the global disease burden from household air pollution.

In Kenya, the Ministry of Health writes, in its National Strategic Plan for the Prevention and Control of Non-Communicable Diseases (2021-2026) that non-communicable diseases make up 39 per cent of annual deaths, with cardiovascular diseases causing most deaths at a 13.8 mortality rate.

And the leading cardiovascular diseases are stroke, which kills more women (6.4 per cent) than men (5.8 per cent) and ischemic heart diseases causing 4.7 per cent deaths among men and 4.6 per cent, among women.

While chronic respiratory diseases are responsible for approximately 1.73 per cent of deaths out of which 1.92 per cent are men and 1.5 per cent, women.

There is a difference between indoor and household air pollution as explained by the WHO team which responded to my queries on the subject.

Indoor pollution is the air pollution typically found in buildings, homes and other closed environments caused by both natural like radon and mould, and man-made sources such as textiles, flooring, cleaning products and tobacco smoking.

Household air pollution is a type of indoor air pollution generated in and around the home from the use of inefficient technologies such as stoves and lamps paired with fuels like wood, coal, charcoal, crop waste, dung or kerosene for activities like cooking, heating, and lighting.

Household air pollution contains health-damaging pollutants, including carbon monoxide and very small particles that penetrate deep into the lungs and enter the bloodstream, impacting the body systemically.

There is also ambient air pollution, commonly referred to as outdoor air pollution. It’s found in both cities and rural areas. Among the most common outdoor pollution sources include residential energy use for cooking and heating, vehicles, power generation, agriculture, waste management, and industry.

Carbon monoxide

When kerosene (liquid), charcoal and firewood (solid fuels) burn, they produce carbon monoxide and particulate matter of 2.5 microns (PM2.5) in diameter, equivalent to the diameter of a strand of human hair, explains Dr James Mwitari.

Dr Mwitari is a senior research fellow and principal investigator at the Work for Clean Air Africa project based at Kenya Medical Research Institute (Kemri).

“We are supposed to breathe in oxygen but when you burn kerosene, charcoal or firewood in the household, you alter the composition of the air by introducing the particulate matter and carbon monoxide. So instead of breathing in oxygen, you end up inhaling air that is completely polluted and injurious to your health.”

As highlighted in the 2022, State of Air Quality and Health Impacts in Africa by Health Effects Institute, short-term exposure to household air pollution triggers asthma symptoms such as wheezing, coughing and chest tightness, being too breathless to eat, speak or sleep, drowsiness, confusion, exhaustion or dizziness.

Long-term exposure results in ischemic heart disease, lung cancer, chronic obstructive pulmonary diseases like emphysema and chronic bronchitis, lower respiratory infections such as pneumonia, stroke, type 2 diabetes, and adverse birth outcomes such as low birth weight or preterm birth.

 “That fine particle of 2.5 microns in diameter has the capacity of going through the airway up to the lungs and alveoli, and while there, it is able to create risk of developing pulmonary diseases,” Dr Mwitari says.

The pulmonary diseases include pneumonia, bronchitis, asthma and cancer of the lungs

As explained by the National Cancer Institute, alveoli are where the lungs and the blood exchange oxygen and carbon dioxide when one breathes in and out. Oxygen breathed in from the air passes through the alveoli and into the blood and travels to the tissues throughout the body.

Dr Mwitari says: “When it settles on the alveoli, it makes the exchange of oxygen difficult."

Additionally, the particulate matter obstructs the airways and affects the lungs, that’s why they will find themselves struggling to breathe.

On the other hand, carbon monoxide causes cardiovascular diseases such as stroke.

“When carbon monoxide combines with haemoglobin, it causes carboxyhemoglobin, which is like a clot. When the blood clots, it’s unable to reach the brain and that’s how people die because of stroke," says Dr Mwitari.

WHO recommends use of electricity, piped natural gas, LPG, biogas, alcohol or ethanol, for cooking or heating since they are clean fuels.

But in the Kenyan perspective where Kenya National Bureau of Statistics shows 53 per cent of the population is poor, use of these alternative fuels is insignificant.

A 2019 Ministry of Health, Kenya Household Cooking Sector study, shows only 5.8 per cent of Kenyans use LPG. Those using electric coil stove are 0.3 per cent, biogas stove, 0.1 per cent and zero per cent for solar cooker.

Poverty, joblessness and lack of small quantities of LPG, force households to continue using the affordable but dangerous fuels.

Worse still, they cannot afford medical check-up to treat the respiratory or chronic diseases they have since developed, like is the case of Ms Ahmed.

She says she doesn't have money to cover related medical expenses.

Her only source of income is cleaning jobs in nearby suburbs of South C and South B in Nairobi.

“In a week, I can get one or two jobs and earn Ksh300 ($2.29) or Ksh500 ($3.82) for each job,” she says.

“Sometimes, two weeks elapse without landing a single job. I’m the breadwinner, my husband doesn’t work and depends on me to feed the family.”

The husband, Sefu Thufa, says whenever she lights the stove, he goes outside because the smoke irritates his throat.

What Ms Ahmed and Mr Thufa don’t know is that their pregnant daughter and unborn grandchild, are in danger as long as she remains in the polluted room.

The WHO team says: “A pregnant woman breathing in lots of smoke can transfer the toxins in the air to their unborn child. The pollutants in the smoke are also a big health risk for children. Breathing in polluted air can impact the development of their lungs, brains and other body parts.”

Dr Mwitari adds: “Pregnant women are at the greatest risk because they end up giving birth to low-weight children of less than 2.5kg.”

“That spells danger as this means the child has not fully developed and that increases its risk to death.”

With the massive loss of jobs due to the economic disruptions caused by Covid-19 and sharp rise in cost of LPG and electricity, millions of households' disposable income has been condensed - the unsafe cooking and lighting fuel remains the only option. As such, more households are trapped in the indoor air pollution.

The International Labour Organisation estimates 208 million will be unemployed this year, an increase by three million from the previous year.

“I'm using this stove because I have no option,” says Nancy Achieng'.

Ms Achieng' lost her social work job with a local organisation in 2020 at the peak of Covid-19 pandemic.

In 2018, when she got the job earning her a monthly wage of Ksh24,000 ($183.49), she spent some Ksh2,3001($7.58) to buy a six-kilogramme gas cylinder. It cost her Ksh690 ($5.28) to refill.

But re-introduction of 16 per cent Value Added Tax (VAT) on LPG in 2021 shot up the prices. Although legislators halved the VAT, the gas cylinder and refilling costs are nearly equivalent to the urban poverty line.

A six-kilogramme gas and cylinder that sold at Ksh2,490($19.04) shot to Ksh3,840($29.36). The cost of refilling also went up to Ksh1,540($11.77) from Ksh1,050($ 8.03).

The price of the 13kg gas and cylinder also increased to the average Ksh7,430 ($56.81) from Ksh4,295 ($32.84). The refilling rates also hit the roof, retailing at Ksh3,330 ($25.46), up from Ksh2,250($17.20).

Son's throat

In the context of Kenya National Bureau of Statistics poverty cluster, Ms Achieng' is monetary poor. This is because as an urban resident, her monthly income does not accumulate to Ksh5,995.4($5.83).

For those in the rural, the poverty line is Ksh3,252 ($24.86).

"I had to sell it because I lost my job," says Ms Achieng’ who says the smoke suffocates and causes her elder son’s throat and eye irritation.

"I don’t have Ksh1,400 ($10.70) to pay all at once to refill the cylinder," she says as she breastfeeds her one-year-old son.

She heads a single-parent household and just like Ms Ahmed, cleaning jobs are her only way of raising an income to feed her sons, pay rent and electricity bills, among other needs.

"With the stove, I can buy kerosene for Ksh40($0.31)to prepare breakfast and supper. It's not much; black tea for breakfast and a cup of mixture of maize and beans that goes for Ksh20 ($0.15) for supper. I add Ksh20 ($0.15) worth Irish potatoes and life goes on," she says.

Ms Achieng’ says an electric cooker isn't an option as the high cost of electricity is repulsive. She pays Ksh500 ($ 3.82)  every month for electricity, which powers her other electronics and lighting bulb.

Since November last year, the cost of electricity has sharply risen.

On November 20, 2022, I spent Ksh1,000 ($7.65) to buy 53.15 units. Four months later, the same amount bought 17.34 units less.

On March 22, 2023, I received only 35.81 units for the same amount of money.

In Esther Aromba's household, electricity is a luxury. She is not connected to electricity and so she lights the house with a kerosene tin lamp.

In addition, she uses a charcoal stove to cook.

This, however, puts her household at a greater risk of developing respiratory and cardiovascular diseases owing to double exposure to pollutants.

Her husband is jobless but does loading work for a pay of as little as Sh10. Together they are raising four children in a single room house in Mukuru Kayaba. Its window is as small as the width of an exercise book.

Toxic air

Thus, the combination of pollutants in the poorly-lit small room leaves a high saturation of toxic air, accelerating development of health complications.

Ms Aromba too, does not have a regular job. Every day, she anticipates a call from her pre-Covid-19 clients. They pay her Ksh300 ($2.29) at any given time.

As she waits, she keeps herself busy selling ripe bananas and mangoes when in season. On a good day, she makes a profit of Ksh100 ($0.76), all of which buys small quantities of vegetables, maize flour, charcoal, and snacks for breakfast for their two young children.

“I often cough out phlegm covered in soot. And the breath smells of charcoal,” she says sitting on a stool behind a curtain partitioning the room.

The room is dim, I can't see her face. Neither can we do the interviews outdoors. There is nowhere to stand. In between the narrow corridors, her neighbours have put out their clothes to dry and water is dripping all over. So, I turn on the torch on my mobile phone. It feels intrusive but at least we can look into each other.

Over our heads are strings of soot hanging from the iron sheets, collar beams and rafters; the dirt that has suffocated her system.

In July 2020, she says she had a scare of her life.

“I was struggling to breathe. My chest felt like it was locked,” says Ms Aromba who has used both charcoal and kerosene for the past 18 years.

She visited a local dispensary for treatment and the doctor advised her to shift to LPG.

“I told him I use charcoal because I can afford it in small quantities,” she says.

Accessibility to the small quantities of kerosene has also facilitated her continued use of the unsafe fuel despite continued rise in prices.

As of December 14, 2020 a litre of kerosene went for Ksh83.56 ($0.64) but on March 22, 2023 it was Ksh145 ($1.11).

Presently, she spends Ksh20 ($0.15) to buy kerosene that lasts three days, a rise from Ksh10 ($0.076), more than two years ago.

Her children complain of eye-irritating smoke from the kerosene lamp, and so she burns a candle to help them do their homework.

But a candle is equally unclean under WHO air quality guidelines.

It is listed alongside gasoline lamps, kerosene or paraffin lamps, oil lamps, candles, or open fires as polluting sources of light.

She says her husband has, since 2020, complained of eye irritation and difficulty in breathing.

Meanwhile, Winfred Ndung'e’s case is a paradox and tells of why poverty shackles households not just in Kenya, but across the world, to killing fuels.

In 2020, she stopped using a kerosene stove after she checked into Mbagathi Hospital, a public health facility in Nairobi County, wheezing and coughing out black phlegms.

The doctor told her the problem was cooking with the stove inside a poorly ventilated house. He said she had inhaled pollutants from burning the kerosene and advised her to either stop using the stove or cook outdoors.

She opted for a charcoal stove instead.

“The problem is that I can't cook outdoors because there is no space,” says Ms Ndung'e. Her house has no window.

She has to keep the door open while cooking since her children remain indoors as she cooks. She says they often complain of dizziness.

“Whenever I'm talking or singing, I feel like I'm running out of oxygen. So, I often abruptly stop to catch a breath,” she says.

For these women, it's a reality that they are left with no options, in view of the fact that health experts recommend cooking outdoors to minimise exposure levels.

“Reduce exposure levels by ensuring the rooms or the houses are well ventilated, and keep the windows open when cooking,” advises Dr Mwitari.

“Cook under chimneys and ensure use of very dry wood as it produces less particulate matter.”

He adds: “Cook outdoors when there is no possibility of using clean fuel.”

Infographic

For millions of women, however, keeping their rooms well ventilated or cooking outdoors, is undoubtedly impossible.

But the shift to clean and safe fuel is certain if the government and its development partners do as Ms Aromba recommends.

“Create employment opportunities for unskilled women to earn a monthly income of more than Sh15,000. Sell gas in small affordable portions like is done with charcoal and kerosene. Until then, please don’t talk about using gas,” she challenges duty bearers.

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In the second-instalment, we elaborate on how possible it is for households to shift to clean and safe cooking and lighting fuels.