The great smog of 2018

Natural and man-made factors are well on their way to making the prevalence of cancer a dystopic reality for India. Urgent interventions are needed.

Written by Manish Kohli | Updated: October 16, 2018 1:05:17 am

The “Great Smog of London” of 1952 paled in size and diameter compared to the area involved with smog.

Dateline, September 2018: After a heavy monsoon season, which dumped over 4,000 billion cubic millimetres of precipitation, civic authorities were severely stretched with treating flood victims and the increased cases of acute gastroenteritis, Japanese encephalitis, dengue and malaria. While some parts of the country experienced a bumper harvest, others recorded heavy flooding. Several parts in southern India and in the Indo-Gangetic plains saw 500 million people being affected by the floo. Once the flood waters receded, a heart-stopping surprise emerged. Authorities started to detect alarmingly high levels of fluoride, mercury, beta-endosulphan and heptachlor in tap and groundwater across multiple states.

October-November 2018: The winter schedule for crop burning in north India had started and thick plumes of smoke from the burning fields were asphyxiating the skies and descending like dark claws on the population across major northern Indian cities. Given cold temperatures, increased coal and wood burning had also begun. During the daytime, the intense haze cut off sunlight and made breathing difficult. At night, the roads became un-travelable and road accidents piled up unrelentingly. The “Great Smog of London” of 1952 paled in size and diameter compared to the area involved with smog.

December 2018: Particulate matter recorded in 2018 shot through the roof and was already 10 times higher than the previous all-time high in November 2017. National and international flights were being diverted in a chaotic ensemble that had begun to draw international attention; international businesses began evacuating families of staff; multiple embassies closed to ensure staff safety.

January 2019: A newly-released report on India’s national cancer statistics projected that the population in the country living with cancer had officially crossed 5 million and was at an inflexion point to take off sharply. The “global capital of tuberculosis” that India was with an incidence of 2.2 million tuberculosis cases added each year and which caused the treasury an estimated $340 billion in loss of productivity between 2004 and 2016 now had a far larger and costly health scourge — cancer.

Let’s hope and pray that none of these scenarios come true. Yet it is plausible that they could, at least to some extent, with natural and man-made reasons contributing to fiction becoming fact.

An errant monsoon, unchecked industrialisation which pollutes the food, water and air chain or the excessive use of pesticides and reverse boring of farmlands are natural and man-made triggers that can contribute in their own ways to a massive exposure of carcinogens to swathes of human populations rapidly. Carcinogens are cancer-causing factors that induce and initiate the formation of a cancer by damaging the DNA unit in normal body cells. National and international experts have agreed that the impact of environmental carcinogens and toxic pollutants from industrial outputs has seeped deep into India’s food, water and air channels and this will impact the cancer census negatively across all age groups, including the young.
The link between cancer and environmental carcinogens is irrefutably established. Cigarette smoke, a type of man-made environmental insult, has over 200 well-documented carcinogenic agents as does tobacco chewing. Drinking carcinogen-contaminated water or eating food grown with such water or with excessive pesticides or in soil conditions with high levels of lead, nickel and other heavy metals allows these carcinogens to enter the food chain and interact with the approximately 70 trillion cells in the human body of a 70-kilogram person. If the DNA protecting mechanisms of the body are not strong this will cause DNA damage setting off a chain reaction that, over time, results in cancer. The body’s “normal” cell becomes a mutated monster and an “abnormal” cancer cell and then spreads unchecked.

Just like water and food-based toxins, volatile organic compounds (VOCs), which are emitted into the air after burning crops, are another source of such insults to humans. They add sulphur, nitrous oxide carbon monoxide, methane and other organic compounds to the air. Many of these VOCs are known to cause cancers of the upper aero-digestive tract of humans (meaning cancers of the throat, lungs, food pipes and stomach). Over time and constant exposures, dust and high particulate matter from farm bush, wood and coal fires also have similar physical and chemical damage risks leading to many illnesses including cancer.

India is trying to establish a comprehensive cancer prevention and care policy for its population, which includes the setting up of a National Cancer Institute network. The Government of India (GoI) recognises the loss of upward of $250 billion between 2012 and 2030, estimated by a Harvard task force, to cancer by way of loss of productivity. This figure pales in front of the “real” cost of cancer care — not included in this figure, it is the cost to the public exchequer in delivering cancer care. With the exponential rise of cancer drug costs in the most affluent societies becoming a financial calamity for many families, India is unlikely to have the ability to cover these costs for her patient population.

The GoI has launched several category “A” national intervention strategies to lessen the impact of tobacco-related cancers and cervical cancer in women. It is unclear if the productivity metrics to measure the impact of these programmes have been satisfactorily met. The Indian Council of Medical Research (ICMR) has also initiated a National Cancer Registry Programme, which is yet to mature in gathering national-level cancer epidemiological data that has received peer and policy recognition. The same is the case for the Surveillance, Epidemiology and End Results (SEER) programme in the US or the National Cancer Registration and Analysis Services (NCARS) in the United Kingdom. Thus, several challenges in India’s war against cancer remain even as the problem multiplies in its magnitude.

India’s massive population and competing large-scale environmental challenges from industrialisation will undoubtedly collide. The fallout from this mix on cancer and, indeed, overall health is difficult to calculate, but we may be reaching an inflexion point soon and preparing for measures to save lives, healthcare costs and promote healthcare economics is critically needed.

January 2020: After the recent general election in May 2019 and acting on the recommendations of an expert task force created to study the impact of the “Great Smog of India, 2018”, the new government increased the funding for healthcare from the current 1.2 per cent to 5 per cent of the annual gross domestic product. The prime minister and president announced on India’s 70th Republic Day that, “the National Health Policy draft of 2015 has received policy implementation status and an Indian-National Institute of Health (I-NIH) has been established whose mandate now covers a nation-wide programme of large-scale civic education on health, environment and medical research that will lead to the prevention and control of infectious and non-infectious chronic illnesses”.

Perhaps these will be the headlines we will read soon? The sooner, the better.

The writer is professor and consultant, Department of Oncology, Mayo Clinic, Rochester Minnesota. Views are personal.