Preparing a meal in some of the world’s poorest rural areas can turn an ordinary activity into a deadly chore. Animal dung and crop scraps often fuel the indoor fires used for cooking. And before any food fills a hungry belly, thick black smoke fills a family’s lungs.

Pneumonia and other acute respiratory infections kill about 1 million people a year in low-income countries, making them the top cause of death in the developing world and the greatest threat to children’s lives. Makeshift stoves belch much of the polluted air leading to those illnesses. About 75 percent of South Asians and nearly half the world’s population use open-fire stoves inside their homes.

“The smoke is asphyxiating,” said Grant Miller, an associate professor of medicine at Stanford working on ways to get people to buy – and use – cleaner, safer stoves. “It burns your eyes and you can’t stop coughing.”

Governments and humanitarian organizations have urged people to trade their traditional stoves for safer models, many of which have chimneys that funnel smoke out of a home. But the switch from dangerous stoves has been slow to come, even though most people using them know they’re harmful.

Miller and his colleagues are studying what’s behind the reluctance and what can be done about it. They suspect much of the problem rests with the widespread approach to clean cookstove conversion, which focuses on educating people about the appliances’ health hazards and offering new models at a low cost.

Their most recent findings, published in the Proceedings of the National Academy of Sciences, boil down to this: Clean and modern cookstoves don’t have features people want. And until they’re redesigned, people are unlikely to bother with them.

“People don’t think of cookstoves as health technologies,” said Miller, an associate professor of medicine and a Stanford Health Policy faculty member at the university’s Freeman Spogli Institute for International Studies. Miller is the senior author of the PNAS paper, which published online June 11.

“They don’t think respiratory illness is the biggest health problem that they have,” he said. “And when you ask them what they want from a stove, they talk about saving time and having better fuel efficiency. They’re not talking about smoke emissions.”

In the first of two studies, Miller – joined by Yale researchers and Lynn Hildemann, a Stanford engineering professor affiliated with the Stanford Woods Institute for the Environment – surveyed about 2,500 women who cook for their families in rural Bangladesh. 

Nearly all of the women use traditional stoves, and 94 percent of them said they know the smoke from their stoves can make them sick. But 76 percent said the smoke is less harmful than polluted water, and 66 percent said it wasn’t as dangerous as rotten food.

“People know their cookstoves are bad, but they don’t think cookstoves are the most important problem they face,” Miller said. “They’d rather spend their money fixing those things and getting their kids into a good school than buying a new cookstove.”

When asked what features are most important in a stove, the women talked about things that could save fuel costs, cooking time and the hassle that goes into collecting fuel.

“A very small percent said reducing pollution was important,” Miller said.

The researchers then tried to assess more directly how Bangladeshis value new stoves. They offered 2,200 customers across 42 rural villages the opportunity to buy one of two models – one boasted improved fuel efficiency; the other had a chimney to reduce exposure to indoor smoke.

At the market prices of $5.80 for an efficient stove and $10.90 for the chimney stove, less than a third of customers ordered either model. And when the stoves were delivered a few weeks after the orders were taken, a very small number of families actually went through with the purchase of either model.  Large randomized discounts increased customer interest in fuel-efficient stoves, but did little to raise purchase rates of chimney stoves.

“A big implication is that the health education and social marketing approaches aren’t going to work,” Miller said. “You need to get inside the heads of the users and figure out what they really want and value – even if unrelated to smoke and health – and then give it to them.”

The lead author of the PNAS paper was Ahmed Mushfiq Mobarak, an economist at Yale. It was co-authored by Yale researchers Puneet Dwivedi and Robert Bailis. Their work was supported by the Freeman Spogli Institute’s Walter H. Shorenstein Asia-Pacific Research Center, Stanford’s Woods Institute for the Environment, and the International Growth Centre.

Global health disparities were the topic of a special event November 11th co-sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center and the Center for Health Policy / Primary Care and Outcomes Research.

Sir Michael Marmot, internationally renowned Principal Investigator of the Whitehall Studies of British civil servants (investigating explanations for the striking inverse social gradient in morbidity and mortality), spoke about research on the social determinants of health and taking action to promote policy change. Pointing out the extreme disparities in life expectancy for peoples in different parts of the world – including the “haves” and “have-nots” within the high-income world – he presented an overview of “Closing the gap in a generation: Health equity through action on the social determinants of health” (http://www.who.int/social_determinants/en/). That report was commissioned by the World Health Organization (WHO) and released last year; Sir Marmot served as the Chair of the Commission on Social Determinants of Health.

Criticizing those who justify initiatives in global health solely on economic grounds, Sir Marmot argued that addressing the social determinants of health is a matter of social justice.

He presented data and discussed the report’s three primary recommendations: 1. Improve daily living conditions; 2. Tackle the inequitable distribution of power, money, and resources; and 3. Measure and understand the problem and assess the impact of action.
Stating that the World Health Assembly resolution on the social determinants of health was only meaningful as a first “baby step,” Marmot urged the audience to consider how research and policy advocacy can address the social determinants of health so that all individuals can lead flourishing lives.

Examples from Asia include

• the high risk of maternal mortality (1 in 8) in Afghanistan;
• the steep gradient in under-5 mortality in India (with the rate almost three times higher for the poorest quintile than for the wealthiest quintile);
• less than half of women in Bangladesh have a say in decision-making about their own health care;
• a large share of the world’s population living on less than US$2 a day reside in Asia;
• social protection systems like pensions are possible in lower and middle-income countries, with Thailand as an example;
• more can be done to address the millions impoverished by catastrophic health expenditures, such as in southeast Asia; and
• conflict-ridden areas and internally displaced people, such as in Pakistan and Myanmar, are among the most vulnerable.

He also responded to questions about the role of freedom and liberty in social development – contrasting India and China – and commented on the peculiar contours of the US health reform debate.

Professor Marmot closed by noting that, in exhorting everyone to strive for social justice and close the gaps in health inequalities all too apparent in our 21st century world, he hoped he was not too much like Don Quixote, going around “doing good deeds but with people all laughing at him.” 
Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM, FMedSci, is Director of the International Institute for Society and Health and MRC Research Professor of Epidemiology and Public Health at University College, London. In 2000 he was knighted by Her Majesty The Queen for services to Epidemiology and understanding health inequalities.

At a time of unusual US interest in south Asia it is useful to see how specialists there look at the two issues explored in this book -- the Kashmir conflict and south Asian nuclearisation. Twelve of the 15 contributors are US-based and therefore it is not surprising that the book is largely by Americans for Americans. But this does not detract from its value for Indians and Pakistanis, because the scholarship is impressive and analyses mostly free of bias. The volume contains 13 essays including a short introductory one by the editors. The remaining 12 are grouped into three parts.

The four essays in the first group (Pakistan: Politics and Kashmir) are "Islamic Extremism and Regional Conflict in South Asia" by Vali Nasr, "Constitutional and Political Change in Pakistan: The Military-Governance Paradigm" by Charles H. Kennedy, "The Practice of Islam in Pakistan and the Influence of Islam in Pakistani Politics" by C. Christine Fair and Karthik Vaidyanathan, and "Pakistan's Relations with Azad Kashmir and the Impact on Indo-Pakistani Relations" by Rifaat Hussain.

Vali Nasr provides a succinct account of how Islamic fervour and Islamic extremism grew in Pakistan after 1971 and how political players in the country, especially the army, tried to make use of it for domestic political and foreign policy gains. He provides a good analysis of how the Pakistani elite is torn between de-emphasising Islam for the sake of socioeconomic gains and stressing it for political advantage. In case of the army there is the additional factor of "jihadi" usefulness in pursuing regional strategic aims.

Charles Kennedy presents an interesting analysis of how the army captures power and holds on to it. He shows how Ayub Khan, Zia-ul-Haq and Musharraf have adopted essentially the same approach in this regard -- following the stages of making things legal, eliminating political opponents, becoming president, stressing local government, intimidating bureaucracy and judiciary, fixing the constitution and orchestrating elections. Two key observations he makes at the end are "the failure to develop a stable constitutional system is the fault of both Pakistan's military and civilian leadership" and that "constitutional stability can only be achieved if there is an accommodation between the interests of the two sets of actors."

Christine Fair and Karthik Vaidyanathan have tried to assess the influence of Islam in Pakistan partly on the basis of three polls conducted to gauge Muslim reaction to war against terrorism, and partly on the basis of interviews. Two noteworthy conclusions of the authors are that there is little popular support for extremist Islam in Pakistan (the good performance of MMA in the 2002 elections is rightly attributed to the political vacuum created by Musharraf and strong post-9/11 anti-Americanism), and that the Pakistan military's current effort to control, rather than eradicate, terrorism cannot work.

Rifaat Hussain has given a detailed account of India-Pakistan relations during 1979-2004, but his effort to explain Pakistan's relations with "Azad" J and K does not go beyond the little that is generally known. The lack of detailed, unbiased information about the society and politics of "Azad" J and K, which Pakistan pretends is not under its thumb, and of northern areas, which Pakistan has unabashedly incorporated into itself, is a major knowledge-gap that handicaps the search for peace in J and K.

The four essays in the second group (India: Politics and Kashmir) are "Who Speaks for India? The Role of Civil Society in Defining Indian Nationalism" by Ainslie T. Embrie, "Hindu Nationalism and the BJP: Transforming Religion and Politics in India" by Robert L. Hardgrave Jr., "Hindu Fundamentalism, Muslim Jihad and Secularism: Muslims in the Political Life of the Republic of India" by Barbara D Metcalf, and "Jammu and Kashmir in the Indian Union: Politics of Autonomy" by Chandrashekhar Dasgupta.

In his essay Ainslie Embrie has tried to explicate the complex relationship between the state and civil society in India. The tension and overlap between secular and Hindu nationalisms have been presented with deep understanding. The Gujarat massacres of 2002 have been explained in relation to the various constituents of the Sangh parivar. Indian attitudes to matters of sub-nationalism have been explained not only in relation to Kashmir but also to the north-east and Punjab.

Robert Hardgrave's essay covers much the same ground although the focus is more squarely on the BJP and the RSS. He speaks of sections within the RSS that want to align "Hindu" India with the west against Islam. At the same time he underscores how the demands of power have moderated the ideological temper of the BJP. Both Embrie and Hardgrave have written with western readers in mind and much of the ground they have covered would be familiar to Indians.

Barbara Metcalf's essay about Muslim Indians draws attention to the fact that the post-9/11 war against terrorism evoked no response from them, unlike the case with Muslims elsewhere. She has explained thoughtfully the reasons for this as well as for the rise in anti-Muslim sentiments in India from the 1980s. The contents of this essay can provide useful insights to Indians and Pakistanis. Metcalf warns that Hindu extremism can help recruit Muslim terrorists in Pakistan and Bangladesh and, in the long run, possibly within India itself. She also makes a case for declaring organisations like the VHP "terrorist" in the light of Gujarat killings.

Chandrashekhar Dasgupta's essay on J and K and autonomy is "balanced" by Indian standards. He writes that New Delhi should "accommodate Kashmiri demands for autonomy to the maximum extent compatible with the legitimate regional interests of Jammu and Ladakh and with the requirements of democracy and good governance in the state as a whole. The interests of Jammu and Ladakh can be protected by a mix of regional autonomy; devolution of power to lower (district, sub-divisional and panchayat) levels; and an equitable inter-regional revenue-sharing formula." But while offering this sound advice, Dasgupta has carefully steered clear of examining its practical implications.

The four essays in the final group (India's and Pakistan's Nuclear Doctrines and US Concerns) are "The Stability-Instability Paradox: Misperception, and Escalation Control in South Asia" by Michael Krepon, "Pakistan's Nuclear Doctrine" by Peter R. Lavoy, "Coercive Diplomacy in a Nuclear Environment: The December 13 Crisis" by Rajesh M. Basrur, and "US Interests in South Asia" by Howard B. Schaffer. In the reviewer's view, this is the most interesting of the three sections in the book and merits careful reading in both India and Pakistan.

Michael Krepon has explored the ramifications of the use of force by south Asia's nuclear-armed adversaries. He stresses the danger emanating from the two sides drawing (largely for public consumption, in the reviewer's view) opposing lessons from tests-of-will like the Kargil war and Operation Parakram. A useful point to note is how Krepon has, over the years, shifted stress from nuclear confidence building measures(CBMs) to conflict resolution in reducing nuclear risks in south Asia. This can be seen from the following sentences in his concluding paragraph: "Much could go badly wrong on the subcontinent unless Pakistan's security establishment reassesses its Kashmir policy and unless New Delhi engages substantively on Islamabad's concerns and with dissident Kashmiris" and "The best chance of defusing nuclear danger and controlling escalation lies in sustained and substantive political engagement." Nuclear CBMs can only do so much.

Nuclear Doctrine

Peter Lavoy's essay is a good piece on Pakistan's nuclear doctrine. He has listed eight separate "uses" for Pakistan's nuclear weapons. In specific relation to India, there are four, viz (i) Last resort weapons to prevent military defeat or loss of territory; (ii) Deterrent to conventional military attack; (iii) Facilitators of low-intensity conflict; and (iv) Tools to internationalise the Kashmir issue. He has drawn attention to the fact that Pakistan's nuclear "redlines" are vague which, the reviewer might add, is true of all countries that reserve the right of "first use."

Rajesh Basrur's essay is about the coercive and nuclear dimensions of Operation Parakram. His narrative of events, diplomatic moves and public statements is valuable for separating chaff from wheat. He has drawn attention to how much India's "compellence strategy" was played out through the US, which had forces in close vicinity. During the confrontation both India and Pakistan sought to "create a fear of nuclear war in the global community, especially the US". He also highlights the fact that India decided to withdraw its forces when Pakistan ceased "responding" to Indian pressure.

The book has no conclusion. The last essay is by Howard Schaffer on US interests in south Asia. Schaffer writes about how the relatively low US interest in the India-Pakistan hostile relationship began to climb in the 1980s when the threat of nuclear war entered the calculus. He says "The US has now come to regard Kashmir less in terms of the equities of the issue -- the lot of the Kashmiri people, the morality or immorality of the insurgency in the Kashmir Valley. Instead it sees the dispute primarily as a tinderbox that could be the flashpoint of a nuclear conflagration." He concludes his essay with the comment that "Washington's view of US interests in the region and the way it goes about promoting them" is unlikely to become more consistent than in the past. Both are valid observations and Indians and Pakistanis would do well to mull over their many implications.

It is not stated in the book, but this volume had its beginnings in a conference at the Asia-Pacific Research Centre in Stanford in early 2003. This was soon after Operation Parakram and before India-Pakistan relations began to thaw in late 2003. Although contributors have updated their narratives to mid-2004, the milieu in which the arguments have evolved was a period of considerable tension. The peace possibilities that have opened up in early 2004 and have got slowly augmented since have, therefore, not been adequately factored in. The book has avoided making any kind of prediction about peace prospects in south Asia although the very title of the book leads the reader to expect some exploration in this area.