Outdoor Pollution

After spending one month living and integrating into the local cultures of India, we were introduced to the society’s determinants of health. We traveled to the north and south, into urban and rural homes, and were given first-hand exposure to indoor and outdoor pollution. This paper will discuss planetary health, the integration of the environment and human action, and the results on population health. We will then advocate for the rationale of the nurses’ role in improving integrated planetary health education, and provide a public health initiative to empower nurses in India and the developing world.

All natural systems across the world from oceans to rivers, weather to air quality, are impacted by greenhouse gases. This impact is called climate change and occurs due to an increase in the concentration of carbon dioxide, nitrous oxide, methane, black carbon, and other pollutants. These toxic particles lead to substantial environmental changes (Whitmee et al.

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, 2015). Such environmental changes have been linked to a series of health problems including “diarrheal diseases, undernutrition, acute respiratory infections (particularly from household air pollution), malaria, and some categories of unintentional injuries ” (Whitmee et al., 2015, p. 1986).Health quality can be negatively affected by direct causes, such as floods, heat waves, and droughts, or indirect causes, such as livelihood loss, population displacement, and social conflict. Both direct and indirect causes have a substantial impact on human livelihood and can result in reduced food yields, depletion of natural medicines, and cultural impoverishment. Individuals living in poverty and those with multiple comorbidities have an increased risk for negative health outcomes related to the health of our planet (Whitmee et al., 2015).One major contributor to climate change is air pollution.

Air pollution is the 5thleading cause of mortality worldwide and has been labeled as a “public health emergency” by the World Health Organization (Bolton, 2016). Sources of air pollution include power plants, industrial emissions, vehicles, indoor biomass burning, and outdoor burning of solid waste. It is a major cause of both acute and chronic illnesses, including chronic obstructive pulmonary disease, lower respiratory infections, asthma, lung cancer, and adverse coronary events. Increased air particles have been linked to an increase in emergency room visits and hospitalizations (Reyna-Bensusan, Wilson, & Smith, 2018). Therefore, the purpose of this paper is to highlight major contributors to air pollution in India, and to present an educational program that may contribute to a mitigation strategy for planetary health in India. Conceptual FrameworkThe prosperity of human civilization is dependent on the earth’s natural systems. These systems include fresh air, clean drinking water, food, and energy. Humanity has flourished by harvesting these natural resources and using them to survive. The exponential growth of the human population has led to an increased requirement for these natural resources resulting in a broadened eco-footprint. Planetary health is an emerging concept interlinking human health and the health of our planet. The objective of planetary health is to ensure the welfare and continued prosperity of the human race while protecting the planet (Whitmee et al., 2015). Human growth relies on basic natural systems that the planet provides, and the deterioration of these systems can lead to chronic deleterious impacts on health. The ability of these systems to sustain human growth is thus diminished (The Rockefeller Foundation, 2017).

The concept of planetary health arose from the need for global reform and advocacy for the health of the planet. In order to support planetary health there needs to be reduction in waste, creation of sustainable products that require less energy, and substitution of safer materials from hazardous ones. Planetary health is just beginning to bring about lasting efforts and changes for the global community. It demands an increase in education and transparency, continued efforts from multidisciplinary teams working in healthcare, and advocacy for policy change. Global policy initiatives such as the Paris Climate Accord and the Sustainable Development Goals (SDGs) demonstrate an opportunity for change and solutions through social and environmental policies. The SDGs goals were developed to target social, economic, and environmental concerns with the overarching goals of ending poverty, providing for the hungry, preventing disease, and educating the youth. These goals link all cultures and countries, while striving to promote global development. The sustainable development goals are composed of 17 goals and 169 targets encompassing the integration of climate change, sustainable development, democratic governance and disaster relief. They aim to protect natural systems and reduce human illness and disease through infrastructure development (Sustainable Development Goals, n.d).Planetary Health in the Context of IndiaIndia, along with many other countries worldwide, struggles with an increase in the harmful effects of climate change. Throughout India, the air is saturated with heavy thick smoke, and piles of rubbish line the congested streets. With the rise of technology and industry booming, the middle class strives to own cars and motorbikes. There is a constant struggle in India between the need to maintain environmental quality and the desire to increase economic growth.

The quality of the air in India is impacted by climate change, which is associated with changes in air quality, worsening ground level ozone, and atmospheric warming (United States Environmental Protection Agency [USEPA], 2016).Air pollution is a predominant risk factor for ill health in India and results in acute and chronic conditions, killing thousand prematurely each year. The World Health Organization (WHO) (2015) reported that acute respiratory infections were the third leading cause of death in children under 5, killing 13% of that population in India. Acute respiratory infections are significantly linked with both indoor and outdoor air pollution. Also, the primary killer of infants and children under the age of 5, killing 27% of the population, is prematurity (WHO, 2015). Researchers have reported that prenatal exposure to indoor and outdoor air pollution leads to premature births. The WHO reported that COPD and lower respiratory infections were among the top ten leading causes of death in India overall in 2012; lower respiratory infections were ranked number 5, killing 4.9% of the population.  This percentage has only moderately decreased over the last two decades (WHO, 2015). Both indoor and outdoor air pollution lead to earlier onset of COPD, and respiratory infections. From 2005 to 2007, COPD was the third most common cause of death in India, with a 22.7% increase in just two years (Institute for Health Metrics and Evaluation [IHME], 2018); however, in 2012 it became the second leading cause of death, killing 10.8% of the population (IHME, 2018). These statistics are relevant in India due to the direct correlation with rising levels of pollution.            The respiratory symptoms and disease related to pollution are drastic, yet pollution is no longer thought to be limited to just chronic and acute respiratory diseases in men, women, and children. Direct causal relationships are now being reported between pollution and ischemic heart disease, stroke, cataracts, lung cancer, adverse pregnancy outcomes, TB, asthma exacerbations, cognitive impairments, and other cancers (Ministry of Health and Family Welfare [MHFW], 2015). In India, the leading cause of death consistently from 2000 to 2016 has been ischemic heart disease, killing 12.4% of the population, 2% more than COPD (WHO, 2015).

Air pollution has been shown to be a significant risk factor for ischemic heart disease and is a greater contributor to CVD cardiovascular disease than smoking and high blood pressure (Institute for Health Metrics and Evaluation [IHME], 2015). Additionally, the Institute for Health Metrics and Evaluation (2018) reported air pollution as the second greatest risk factor for death and disability in 2016.  Air pollution exposure is also directly related to respiratory illness.  This is caused by not only the absolute volume of emissions, but how much of the pollution is inhaled by each individual. The most significant causes of pollution in India is are cook stoves, vehicle emissions, and trash burning, due to the high rates of exposure per unit emission (Sagar, Balakrishnan, Guttikunda, Roychowdhury, & Smith, 2016)Air PollutionAir pollution happens when particulate matter and chemicals are emitted into the atmosphere that are harmful to the environment or cause harm or discomfort to living species. Pollutants can be categorized as primary, secondary, or both, and can be either directly released from a source or produced from primary pollutant interactions (Downwinders At Risk, 2012).Primary pollutants are significant in India specifically due to the vast production by human activity. Although smog [smoke and fog] is a commonly discussed pollutant in South Asia, this is a secondary pollutant from primary emissions that interact with sunlight and the atmosphere. Examples of primary pollutants in India are CO2 gas from motor vehicle exhaust, and sulfur dioxide from factories and power plants. Particulate matter, another example of a primary pollutant, when combined with gas it is classified as an aerosol [solid or liquid particles and gas together] (Downwinders At Risk, 2012). Biomass burning and fossil fuel combustion includes the burning of municipal solid waste (trash, rubbish), wood, agricultural waste, and animal residue, with emphasis on the use in cook stoves. This combustion creates concentrations of particulate matter (PM) that is toxic to human health and to the health of the environment. The emissions forming the largest concentrations of particulate matter in India are: industrial plants, coal burning for heat and cooking, burning of solid waste, and exhaust emissions.

The pollution in India is so extensive that it is affecting not only its own citizens but those of neighboring countries as well. India’s contributions to national and international pollution, moreover, are worsening as the population grows (Fu, Kawamura, Pavuluri, Swaminathan, & Chen, 2010).Air pollution is monitored internationally due to the known health hazards in developing countries. Atmospheric particulate matter (PM) concentration is a specific toxin that is measured. Particulate matter is measured based on its diameter and categorized based on its effects. PM10is particulate matter that is 2.5-10 micrometers in diameter. An example of PM10, or coarse particles, is dust and particles from vehicles and construction. These coarse particles can easily enter the lungs. PM2.5are particles 2.5 micrometers or smaller in diameter, that are not visible to the naked eye. PM2.5or fine particulate matter, is produced from combustion-burning, vehicles, and power plants (Office of Air Quality Planning and Standards [OAQPS], 2017). Fine particles cause nose and throat irritation, bronchoconstriction, dyspnea, exacerbation of pre-existing lung conditions, lung cancer, decreased binding of oxygen to hemoglobin, resulting in angina and myocardial infarctions (Kampa & Castanas, 2007). The WHO constructed general guideline values for air quality standards, reporting that the annual mean of PM2.5should be 10μg/m3 and the annual mean for PM10should be 20μg/m3 (World Health Organization [WHO], 2016). μg/m3 is a measurement of the concentration of an air pollutant in micrograms per cubic meter air. India is the tenth most polluted country, with an annual overall average PM level of 134 μg/m3. Forty-two cities in India are ranked among the most polluted cities worldwide, even further exceeding these annual averages (Tobollik, Razum, Wintermeyer, & Plass, 2015). The WHO created additional guidelines for developing cities, with intentions of reducing their annual average of PM10, with more plausible goals due to the significant discrepancy among the developing countries annual averages (i.e., India’s average of 134μg/m3 in 2015). The developing countries guidelines stated that if countries can decrease their PM10from levels of 70μg/m3, air-pollution related deaths could be reduced by 15% (WHO, 2016).

To control and regulate air pollution and pollutant emissions, India, in 1981, formulated the Air Prevention and Control of Pollution Act, and developed the National Ambient Air Quality Standards. The most recent update to the standards and policy was in 2009, issuing a national annual mean regulation in India of PM10: 60μg/m3 and PM2.5: 40μg/m3. The annual mean concentrations differ between states in India, with large health and environmental disparities based on population, climate, altitude, and other state specific risk factors. Although there are some cities in India that do not greatly exceed the Indian National Guidelines, the country as a whole is lagging very far behind the international standards (Tobollik, Razum, Wintermeyer, & Plass 2015).As discussed above, several steps have been taken in an effort to control air pollution in India. Due to the notable amount of pollutants in the air, the focus of control should be centered on individual or community-produced emissions instead of particulate matter caused by outdoor exhaust emissions, such as power plants. A major focus should be placed on the prevention of pollution from municipal solid waste and biomass burning, as these are man-made contributions (Gurjar, Ravindra, & Nahpure, 2016).  While more research is necessary, the current evidence has determined that these non-exhaust emissions may be the dominant source of air pollution in India, surpassing power plant and factory emissions (Gurjar, Ravindra, & Nahpure, 2016).Municipal Solid Waste / Trash pollutionUncollected solid waste contributes to flooding, air pollution, and diseases such as, but not limited to, respiratory disease and illness, diarrhea, and dengue fever (Hoornweg & Bhada-Tata, 2015). Improper solid waste management causes air, soil, and water pollution.

Dumping of waste contributes to land and groundwater contamination, clogged drains, and creates an increase in stagnant water for insect breeding. Trash incineration is widely practiced globally: it is predicted that almost half of the 2 billion tons of garbage produced each year is burned. Low and middle-income countries are impacted significantly more from the global waste management costs because of their lack of management services. This impact is expected to increase and worsen, particularly in India, due to rapid urbanization (Vreeland et al., 2016).The health impacts from solid waste are hazards that are expected to grow. Currently, India’s annual accumulation of trash is between 34 and 45 million tons, and these numbers will likely quadruple by 2030, which will generate over 150 million tons of trash annually in India alone (Guttikunda, Goel, & Pant, 2014). Improper solid waste management through incineration of waste is a consequential contributor to urban air pollution in India. According to research from 2008, more than 90% of solid waste in cities and towns across India is directly disposed of on land in an uncontrolled, poorly managed manner (Ashfaq & Khatoon, 2013). In most regions of India, it is not uncommon to see trash scattered around cities and rural neighborhoods in heaps through which cats and cows scavenge for food. Another common sight is trash piled together in small bundles being burned as a form of waste management. These trash piles consist of accumulated paper, plastic, food, plants, fabrics, rubber, and other forms of waste. Open garbage burning emits enormous and dangerous concentrations of chemical pollution augmenting the hazard.There are very few cities in India at this time that operate sanitarylandfills or that have any formal waste management system; therefore, open waste burning commonly occurs in medium and small cities. In both rural and urban neighborhoods, people do not have any option other than open waste burning (Guttikunda, Goel, & Pant, 2014). In addition to illness and disease, there are acute and immediate dangers in burning waste. Because there is no regulation on the separation of trash, the items incinerating may be corrosive, reactive, or flammable, and result in toxic emissions when burned. Unless there is significant policy change and mandated waste management procedures in place, any of the waste that is uncollected is likely to be burned.

India has been experiencing significant air pollution due to economic growth, urbanization, and continuous increase in population. The increase in population leads to an increase in trash and vehicular traffic. Biomass/biofuel burning, which includes the burning of agricultural residues, dried animal manure, and waste, are a major contributor of trace gases and aerosols (Fu, Kawamura, Pavuluri, Swaminathan, & Chen, 2010). Aerosols are composed of particles in the air that include dust, viruses, soot, bacteria, sulfates, nitrates, and carbonaceous matter consisting of black and organic particles (Menon, Hansen, Nazarenko, & Luo, 2002). These particles, particularly carbonaceous particles, contribute significantly to climate change due to their role in influencing the amount of sunlight that reaches the earth's surface. Black carbon specifically, has the ability to heat the earth's surface by absorbing heat instead of reflecting it back to the atmosphere. Carbonaceous particles have been shown to contribute to global warming as well as deaths associated with air pollution (Menon, Hansen, Nazarenko, & Luo, 2002).The burning of trash produces fine particulate matter, volatile organic compounds, nitrogen oxides, carbon monoxide, and polycyclic aromatic hydrocarbons; many of these sources of air pollutants are most likely carcinogenic, according to the International Agency for Research on Cancer (Vreeland et al., 2016). It has been estimated that more than half of the Indian population is living in regions that exceed the Indian Annual National Ambient Air Quality standards, and 99.5% of the Indian population live in areas that exceed the World Health Organization Guidelines of 10μg/m3, in part due to the waste management systems (Vreeland et al., 2016).

Results suggest that even 1 minute of direct exposure to trash burning emissions is equivalent to an entire day of breathing in ambient air (Vreeland et al., 2016). A study in rural Punjab researched health effects of agriculture crop residue burning, on residents aged 20-35 and 10-13. The results found significant decreases in mean values of pulmonary function tests (PFT) among healthy subjects, after burning crop residues. Pulmonary function tests revealed corrected PFT values among 20-35-year-old participants after the completion of burning, however, the damage among the younger participants was likely irreversible as their PFT values remained significantly low after the completion of burning (Awasthi et al., 2010). This study, in addition to others, reveal that burning of solid waste is a serious environmental health hazard that children are more susceptible and sensitive to due to their exposure to trash burning emissions (Awasthi et al., 2010). Cooking StovesWorldwide, 2.8 billion people rely on the burning of solid fuels, coal, and biomass (wood, dung, and crop residue) for cooking, heating, and lighting. Of the 2.8 billion globally, 780 million of these individuals live in India. More people are cooking with solid fuels today than the total Indian population in 1980. When solid fuels are burned, there is incomplete combustion which produces and emits toxins (MHFW, 2015). Cook stoves are used inside homes daily, with limited ventilation, which augments exposure. Indoor pollutants that individuals are exposed to are 1,000 times more likely to reach the lungs than pollutants from outdoor exposure (Sukhsohale, Narlawar, & Phatal, 2013). Large amounts of particulate matter, carbon monoxide, metals, hydrocarbons, oxygenated organic compounds, and chlorinated organic compounds are some of the pollutants expelled, depending on the fuel and stove type used (Behera & Jindal, 1991). Cooking with traditional stoves releases a particulate toxin in the form of PM2.5, a form of particulate matter (PM). The quantity of PM2.5 emitted during cooking, is equivalent to smoking 400 cigarettes an hour (MHFW, 2015).

Due to this significance, cook stoves are an important area of contention in relation to air pollution in India. Biomass burning, and the combustion of solid fuels for household cooking, is a significant contributor to air pollution; the indoor pollution causes direct effects in the home, and it is a major contributor to ambient fine particulate matter, or outdoor air pollution. Indoor pollution from household cooking accounted for more than 50% of PM2.5pollution globally in 2010 (Chafe et al., 2014). According to Chafe et al. (2014), household cook stoves supply 25% of the ambient air pollution in India specifically.Cook stove use is one of the most significant pollutants in India for a multitude of reasons. Cook stoves contribute to indoor and outdoor air pollution as stated, and it is one of the greatest culprits, solely due to human activity. The particle escape fraction of indoor air pollution from cook stoves is 100%, meaning that all particles formed from combustion inside the home, or from the cook structure, are then incorporated into ambient air. Ninety percent of all fine particles generated indoors will reach the outdoor air (Chafe et al., 2014).It is important to describe the different types of stoves and fuels that are commonly used for cooking in India. In India and across most of the world, the traditional method of cooking is known as a ‘cook stove’. ‘Traditional cook stoves’ are a method of cooking over a three-stone fire; it may also be made from mud or metal, with three raised points on which cooking utensils are placed. The space between the three risers is where wood, logs, leaves, hay, straw, dung, coconuts etc. are placed to serve as fuel. These burned products are listed as solid fuel, or biomass fuel (Ekouevi, Freeman, & Soni, 2014).

A chulha is a traditional Indian cooking stove; chulha in Hindi means stove. The original chulha is a U shaped stove, with a front opening, made from a clay and cow dung mixture. Wood, sticks, cow dung, straw, crop waste, etc. are placed in the center as fuel, and the clay/cow dung mixture is routinely re-coated on the cooking surface. For all types of traditional stoves, the chulha and the three-stone fire, women must squat or sit on the floor to cook. Liquid petroleum gas [LPG] cook stoves use canisters that burn during cooking, providing a fuel type that is a relatively cleaner option compared with India’s other fueling methods; however, the stove and gas canister are cost barriers. Liquefied petroleum gas (LPG) is a fossil fuel, and still produces gaseous emissions especially with limited ventilation. Electric coil stoves are available in India, as they are marketed as a cleaner form of cooking; however, due to the cost, this is not a common item in most households (Global Alliance for Clean Cookstoves, 2018).In 1991, almost 4,000 non-smoking women were studied in order to assess the effects of various cooking fuels and their respective health effects. Women exposed to any form of indoor air pollution, regardless of the fuel type, had increased rates of chronic bronchitis, airway obstruction, dyspnea, postnasal drip, cough, and exacerbated asthma. Mixed fuel and biomass fuel users had the highest prevalence of respiratory symptoms in comparison to liquefied petroleum gas [LPG] users (although the LPG population was still symptomatic). They also found that chronic bronchitis rates were significantly higher among chulha users, compared with kerosene and liquid petroleum gas users (Behera & Jindal, 1991). The data collection year of this study, 1991, is significant because the health impacts and detriments continue to be the same three decades later.An analysis of 200,000 Indian adults found an association between self-reported tuberculosis (TB) and exposure to wood smoke, with more frequent self-reported TB among persons who burn biomass rather than cleaner fuels.

Among North Indian residents, there was an association found between the use of biomass fuel and tuberculosis defined by clinical measures as well (Bruce, Perez-Padilla, & Albalak, 2000). In addition to respiratory infections, pollution from biomass fuel is an obvious cause of eye irritation, and studies performed in northern India likewise found a possible association between cataracts and blindness with in home cooking. Evidence from developing countries show that indoor air pollution increases the risk of COPD and acute respiratory infections in childhood, low birth weight, increased infant/perinatal mortality, pulmonary TB, nasopharyngeal and laryngeal cancer, cataracts and lung cancer (Bruce, Perez-Padilla, & Albalak, 2000). It is estimated that the exposure to indoor air pollution is responsible for nearly 2 million excess deaths in developing countries, and 4% of the global burden of disease. Moreover, although there are confounding factors in studies researching potential evidence of cause and effect, it is known that indoor air pollution poses a serious threat to global public health and outdoor air pollution (Bruce, Perez-Padilla, & Albalak, 2000).The health burdens of indoor air pollution disproportionately affects women and children due to their increased exposure. Although tobacco smoking has been seen as the primary risk factor for COPD in the general community, studies researching COPD in India attributed air pollution as one of the primary risk factors. A 2017 study found that exposure to indoor air pollution beginning in infancy, and throughout childhood, specifically from burning solid biomass, fuel, and mosquito coils, leads to earlier onset of COPD and an overall decrease in lung function (Rajkumar et al., 2017). One study reported on the prevalence of bronchial asthma in women from villages near Chandigarh city. Researchers noted an overall prevalence of bronchial asthma as 0.6%.

The prevalence of women who had bronchial asthma who used liquid petroleum gas for cooking was 0.2%, and the prevalence among women with bronchial asthma using traditional cook stoves for cooking was 0.9%, considerably higher than the general population. An important finding of this study was that 2.9% of women using a chulha for cooking had chronic bronchitis, while the overall prevalence in that community was only 1.9% (Murthy & Sastry, 2005). In India, symptoms including eye irritation, headache and diminished vision were significantly higher in women (non-smokers) using biomass burning for cooking. Additionally, there was a higher prevalence of abnormal pulmonary function, chronic bronchitis, bronchial asthma, cataracts, and anemia, among biomass users compared with other fuel users. Dyspnea, postnasal drip, cough, and abnormal lung function testing were found among housewives cooking in the home, with constant indoor smoke exposure regardless of fueling products (Sukhsohale, Narlawar, & Phatal, 2013). Among housewives inhaling indoor pollution from cook stoves, with no prior history of smoking, there was a there is a 12.5% prevalence of chronic bronchitis (Sukhsohale, Narlawar, & Phatal, 2013). Dr. Padmavati, an Indian cardiologist, noted in the first publication in international literature on health impacts of household air pollution. She found an alarmingly high incidence of cor pulmonale, a serious heart condition that is a sequelae of chronic lung disease, in an entirely non-industrial population in India. Young patients were found to have acute severe congestive heart failure, with high mortality rates (Padmavati & Pathak, 1959). The researchers noted that “the very squalid living conditions and the smoke-filled atmosphere in which these patients lived were undoubtedly contributory factors to the rapid progress of the disease” (Padmavati & Pathak, 1959, p. 347).

Overall, biomass fuel and kerosene for cooking were associated with stillbirths, independent of maternal ante-natal and natal risk factors. Biomass smoke strongly increases the risk for acute respiratory infections in children, COPD, lung cancer, ischemic heart disease, and TB in women, as well as blindness, cataracts, asthma, and adverse pregnancy outcomes (low birth weight, prematurity, early infant death) (Lakshmi et al., 2013).  Banerjee et al. (2012) studied rural premenopausal women in India who had engaged in cooking for the previous 5 years or more. Among biomass fuel users, compared with LPG fuel users, they found a significant increase in inflammatory cells in the women’s blood and sputum. In comparison, biomass fuel users also had higher levels of circulating proinflammatory cytokines, lymphocyte, monocyte, and neutrophils, thus chronic biomass smoke triggers a chronic inflammatory response within the body. There was an evident rise in oxidative stress, depletion of SOD (an antioxidant enzyme), and higher rates of airway inflammation among women using biomass as fuel compared to controls (Banerjee et al., 2012). Similarly, compared with controls, women using biomass as fuel were found to have more neutrophils, lymphocytes, and eosinophils in their sputum. After full sputum assessment of biomass burners, there was a positive association with markers of airway inflammation and oxidative stress (Dutta et al., 2013). Continuous exposure to biomass smoke through household cooking causes a constant state of inflammation; perpetuated inflammation, when chronic, can cause worsening tissue damage leading to various diseases.The issue of indoor air pollution is critical because of the high magnitude of the population that has exposure.

Household, indoor air pollution has been a continuously detrimental health hazard in India, maintaining its ranking as the second highest risk factor for disability and life years lost, and has caused one million premature deaths annually. Indoor air pollution is a grave issue due to the amount of exposure individuals are susceptive to on a daily basis (Guttikunda, Goel, & Pant, 2014). National exposure models have been developed over the last 30 years to estimate the average PM2.5 exposures among women, men, and children. Using measurements of short term and 24-hour household concentrations, the average solid fuel using household’s PM2.5levels in India are as follows: 337 μ g/m for women, 204 μ g/m for men and 285 μg/m for children (MHFW, 2015, p. 10). The permissible 24-hour mean particulate matter level per the WHO guidelines for air quality for PM2.5 is 25μ g/m (WHO, 2006). It has been recognized that household air pollution from the combustion of solid fuels, not only produces pollution indoors but due to the ability of the chemicals and pollutants to exit through windows, chimneys, and gaps in walls and roofs, household air pollution worsens outdoor air pollution, contributing to 25% of the ambient air pollution in India (MHFW, 2015).Outdoor Exposure: Exhaust EmissionsThe global burden of disease assessment listed outdoor air pollution among the top 10 health risks in India (Institute for Health Metrics and Evaluation [IHME], 2013). As Indian cities are increasing in size and population, there is an increasing need for vehicles for both public and personal transportation. This increasing transportation demand puts pressure on the cities infrastructure and environment (Guttikunda, Goel, & Pant, 2014). Outdoor air pollution was ranked the 5thmost prominent contributor to mortality and the 7thmost prominent contributor to the overall health burden in India. Although the population, and urbanization, is drastically increasing, India still has inadequate public transportation, causing even more need in the personal sector.

The motorized vehicles in India have an increased use of diesel fuel and increased highway freight which contributes in worsening air pollution (Khilnani & Tiwari, 2018). Epidemiological studies have provided evidence that demonstrates that fine particulate matter and traffic related air pollution, or coarse particulate matter, have a statistically significant correlation with mortality risk, cardiovascular, respiratory, and allergic diseases (Poschl, 2005).Traffic related air pollution with high concentration levels of fine air particulate matter, nitrogen oxides, and ozone, are among the prime factors that may be responsible for the strong increase in allergies in industrialized countries over the past decades. The chemicals detected in urban roads, window dust, and major urban traffic junctions, were fine particulate matter with degrees of nitration, relating to allergic health effects. These pollutants are likely to trigger immune reactions, promote the genesis of allergies, and enhance the intensity of allergic diseases and airway inflammation (Poschl, 2005). Researchers Lahiri et al. reported a higher prevalence of sputum eosinophilia and neutrophilia, with a significant increase in the prevalence of respiratory symptoms in both adults and children, attributed directly to high outdoor air pollution levels. Chronic eosinophilia and neutrophilia induces inflammation and chronic stress on the body, causing poor health outcomes (as cited inCentral Pollution Control Board, 2008).A prospective cohort study performed by Puett et al. (2014) focused on long term exposure to traffic related pollution, PM2.5 and PM10(fine and coarse particulate matter, referring to indoor and outdoor pollution) and chronic health effects. It was noted that populations with unsafe ambient, outdoor pollutant exposure, regardless of former smoking status, had an increased risk of lung cancer. Further evidence found a stronger association with lung cancer mortality among individuals who never smoked or quit at least 10 years before diagnosis.

After additional assessment of significance, Puett et al. (2014) found a positive association of increased lung cancer risk among people living within 50m of a primary road (an interstate, highway or road with opposing directions of traffic and defined exits) regardless of occupation.The distribution of health burdens related to pollution targets low income, rural populations in India.  5.7% of children, below 18 years of age in rural regions of Bangalore, had asthma, in comparison to 16.64% of children younger than 18-years old living in urban areas; there was a 2.9x higher prevalence among children living in urban areas. The prevalence of asthma in school-children living in areas of high traffic, but of affluent socioeconomic status was 19.34%. The prevalence of asthma in school-children who live in heavy traffic zones, but of less affluent socioeconomic status was 31.14%. The social influences between rural and urban areas, higher and lower socioeconomic status, show obvious disparities (Murthy & Sastry, 2005). Dust is also a major concern in many Indian cities, and it is associated with traffic exhaust pollution. Dust is produced and emitted from the wear and tear of tires, materials on the roads, pavements, and street construction. The increasing prevalence is directly correlated with population and urbanization uptick (Guttikunda, Goel, & Pant, 2014). Previous studies of atmospheric particulate matter in India have produced the most significant contribution to air pollution, with emissions from vehicle exhaust, road dust, biomass burning, coal combustion, and secondary organic aerosols (Vreeland et al., 2016).This data shows that there are obvious health effects from direct vehicle emission exposure. It is undoubtable that health outcomes are disproportionately affected by social factors. Levels of the ambient air pollution of PM2.5 and PM10, from transportation sources alone, is expected to double by 2030 if no action is taken (MHFW, 2015, p. 7).The Role of Nursing            Prevention of disease, and curative care, have been the leading components of the nursing role, and as nursing theory evolved, preventative care continues as the focal characteristic. District nursing, or community-based nurses, evolved as the first formal role while Florence Nightingale simultaneously developed nursing as a profession and occupation. Public health nurses starting in the mid-19thcentury utilized their understanding of how culture, political and psychosocial problems affect health and illness throughout communities. By the early 1900’s nurse’s capacity extended beyond caring for the ill, and included advocacy, community organizing, health education, and political reform (Kulbok, Thatcher, Park, & Meszaros, 2012).

Many of the nursing roles that developed in the 19thcentury persist today.           From a broader perspective, nursing is integral to the definition of global health because of the unique skill set, cultural sensitivity, and interprofessional involvementthat nurses practice. Nursing is a profession that places a priority on improving health and achieving equity in health for all people worldwide. Nurses, with their focus on improving patient outcomes have a significant role in the overall improvement of the health of the planet. As noted in the seminal document, Safeguarding health in the Anthropocene epoch: report of the Rockefeller Foundation-Lancet Commission on planetary health, health care providers “have an essential role in the achievement of planetary health: working across sectors to integrate policies that advance health and environmental sustainability, tackling health inequities, reducing the environmental impacts of health systems, and increasing the resilience of health systems and populations to environmental change” (Whitmee et al., 2015, p.1974). Nurses have endless opportunities on a global level; global health is concerned with impacting healthcare on a local, national and international level. The role of nursing is more complex than only providing direct patient care.  Nurses, in addition, possess the ability to shape policy, improve lives, and build health capacity nationally and internationally. Nurses produce and implement models that add aid to the development of sustainable, quality care. Improving health worldwide is a daunting task, with many obstacles, however nurses are poised to meet these challenges. By educating nurses worldwide on how individuals and families can improve their health, the global nursing community can contribute substantially to mitigating the effects of climate change. In addressing the effects of air pollution, actions taken by nurses to meet these challenges reach beyond treating patients on an individual level; the level of care extends beyond the traditional clinical boundaries. The majority of populations in India have limited access to healthcare, resulting in poor morbidity and mortality outcomes. Continuing health care beyond individual one-time treatment with a traditional public health preventative model, is the foundation of global nursing. Healthcare providers, especially nurses, are a driving force in influencing planetary health. Nurses make up the largest segment of the healthcare workforce in the world (Wilson et al. 2016).

In both rural and urban areas, nurses provide direct care, encourage sustainable practices based on their population, and provide leadership in lessening the significant ecological footprint (Kurth, 2017). To magnify and utilize nurses’ contribution in achieving international goals, nurses must have the proper skill set, knowledge, and education to guide patients. It is important for nurses to have the best evidence and understanding of cultural and societal factors for true change to occur (Wilson et al., 2016).Nurses have the opportunity to educate patients about cooking methods, waste management, transportation, but more importantly, they can have a significant impact on widespread adoption of change at a community level (Kurth, 2017). The nursing role in addressing planetary health begins with educating students, staff, patients,and communities.  Education around planetary health strategies on a local level is the first step for action and can have a significant impact on all health system levels.With the limited number of healthcare workers across the country, nurses must be knowledgeable on prevention and the mitigation of pollution, in order to train others. The most important aspect of patient teaching, and ensuring receptivity, is finding a common ground. This can be done by discussing personal stories and providing advice that is relevant to the specific population, using local community members instead of outsiders. Nurses can help plan and build resilient systems, through the use of practice, research, and the global healthcare workforce (Kurth, 2017).Proposed InterventionTechnology is utilized as a tool in health care systems to increase patient outcomes, educate healthcare professionals, and enhance interprofessional collaboration. Technology creates the opportunity to link global communities together, to combat the effect of climate change, and aid the study of planetary health. The Train-The Trainer (TTT) approach is a model that is commonly utilized as a teaching strategy in which education is given to a trainer who will then educate others. People who train others retain 90% of the material they teach.

The TTT method is derived from the diffusion theory which is based on an idea that people adapt to new ideas or information because of their trust in the social systems (Baskaran, 2014). The TTT method has been used to educate many different health care professions about conditions such as Alzheimer’s, HIV, STDs, substance abuse, and there is supporting evidence that the TTT approach results in enhancing providers’ knowledge, attitudes, and self-efficacy (Brimmer et al., 2008).The foundation of our intervention is based on the TTT model through the implementation of the internet website www.gnepph.org. This website targets nurses in developing countries, specifically India, and arms them with the information to teach themselves and then teach others in their hospitals, communities, and clinics. The main objective of our website is to decrease harmful effects of air pollution by providing education to nurses to increase their knowledge of climate change, and give them the resources necessary to educate their patients on harm reduction strategies. This project will educate nurses on a global level in order to improve the health of our planet, and protect India from the acute and chronic illness. Specific recommended interventions include the use of personal protective devices, ventilation of homes, clean energy stoves, and use of public transportation. We anticipate that the immediate outcome will be that nurses will have improved knowledge of the TTT program which will include information on climate change, planetary health, and the prevention and protection of the climate effects on health. Long term goals are that nurses will gain the ability to use their knowledge to educate patients, families, community members, and co-workers.

The exploitation of natural resources has led to the degradation of the planet. We have compromised the health of our planet at the expense of the prosperity of our population. The misuse of precious resources has led to environmental changes, causing a series of health problems including respiratory illness, diarrheal disease, malnutrition, and cardiac fatalities. After spending weeks navigating throughout communities in India, it became apparent that in order to bring change, we must understand their unique culture. As outsiders there may be severe resistance or hesitancy from locals to listen, trust, or follow through with ideas and recommendations. Teaching local nurses about climate change is necessary to improve health outcomes throughout all communities in India. Nurses are trusted individuals who have a significant role in the overall improvement of the health of their patients and the planet. Nurses have the ability shape policy, advocate for patients, and prevent adverse health outcomes. Developing and empowering nurse leaders, educators, and health care workers across the world has the ability to shape future generations to come. In conclusion, climate change has numerous negative effects on our planet that impacts every level of human existence, specifically throughout communities in India. Nursing is an international profession that is uniquely qualified to help combat issues of environmental change. We have demonstrated that the nursing profession can assist to ameliorate these threats and augment the tools to make a measurable and real difference in the health, and quality of life of people in emerging economies, such as India.