When Stephen Luby, MD, first arrived in Dhaka, Bangladesh, in 2004, he barely registered the hazy atmosphere. The 45-year-old epidemiologist from Nebraska had spent several years in Karachi, Pakistan, where soot-choked air was as predictable and intractable as open sewers and rutted roads. It didn’t distract him then from his mission to save lives with modest, affordable health interventions, such as hand-washing training and directions to local clinics. It wasn’t going to distract him now.
Luby was focused on his new job with the U.S. Centers for Disease Control and Prevention, where he would be investigating emerging infections in a region considered a global hot spot. “I believed in what I was doing.”
As Luby, his wife, Jeni, and their four children moved into their U.S. embassy-furnished house in a quiet enclave of Dhaka, they found a rattling electrostatic air purifier the size of a small refrigerator.
“I thought, ‘Where is the data showing that thing has any effect?’” recalled Luby, now a professor of medicine at Stanford and director of research at the Center for Innovation in Global Health. “I turned it off. It stayed that way for eight years.”
Over time, though, Luby became aware of a catastrophic airborne health threat facing tens of millions of people, and a likely culprit was the production of a ubiquitous building material: the humble brick. The realization forced Luby to rethink basic medical assumptions, and to challenge development community dogma that was failing to address the issue.
Now, after more than eight years of research, analysis and on-the-ground negotiations, Luby is poised to launch a plan to transform the brick kiln sector in Bangladesh and, ultimately, across South Asia.
Consistently ranked among the world’s least livable cities, Dhaka is a cacophonous overflowing sprawl of more than 10 million people, with a population density of 44,500 per square kilometer. While other metrics of misery have declined in the face of the country’s burgeoning economy, air pollution remains a scourge during the dry, winter months. Dhaka’s air quality index, a representation of pollutant concentration over a specified period of time, hovers above 150 — a level considered unhealthy for all groups — but often spikes much higher between November and February.
“When you open the door to go out in the morning, there’s a haze of smoke that hits your face,” said Alex Yu, MD, a postdoctoral scholar in infectious disease who works in Luby’s Stanford lab. “You have a chronic low-grade cough. We call it Dhaka lung. People don’t want to go out, but life has to go on.”
Still, when a Bangladeshi colleague of Luby’s suggested they install air particulate sensors in Dhaka households as part of a 2011 influenza and pneumonia study, Luby was skeptical. “I was looking at it primarily through the lens of the pathogen — what organism was causing problems,” Luby said. “I was not attuned to air quality. I hadn’t really thought about the science.”
The findings were stark: Air pollution had a huge impact on respiratory infections, but indoor air pollution — the focus of most related public health community efforts — wasn’t the only culprit. It turned out that the most important determinant of indoor air quality was outdoor air quality. Surprised, Luby shifted his focus to the environment’s effect on health.
“It’s different from a medical model that says let’s wait until they get sick and treat them in clinic,” he said. “We need to think, like a physician, about how we can treat the environment.”
Air pollution is among the largest contributors to mortality worldwide, hastening the deaths of more than 7 million people a year, according to the World Health Organization. Although the model-based WHO estimate is contested by some health experts, pollution’s damaging impacts are clear. Microscopic particles of soot, ash and other pollutants can penetrate deep into lungs and bloodstreams. Resulting long-term inflammation and organ damage can lead to pneumonia, heart disease, strokes, premature births, early onset lower respiratory infection in children and a host of other ailments.
Luby realized that if he could determine what was driving the outdoor air pollution in Dhaka, he might be able to lift the curse of pneumonia, the leading killer of children under the age of 5 globally.
To the source
Once Luby began looking for a pollution source that might be causing such deadly infections, his research quickly led him to brick kilns. As Bangladesh’s population and economy has grown, so has its need for building materials. In a land of few trees and minimal manufacturing capacity, bricks fit the bill. Primarily burning coal, thousands of kilns ringing Bangladeshi cities turn out about 25 billion bricks a year. It’s a familiar story throughout South Asia. Brick kilns across the region have a global warming impact equivalent to that of all U.S. passenger cars.
In Bangladesh, a single brick kiln spews up to 53 tons of carbon monoxide in one season, the annual equivalent of more than 180 passenger cars in the United States. The country’s 5,000 or so kilns are responsible for about 40 percent of airborne particulate matter during winter (kilns operate only during rainless winter months so bricks can be left outside to dry).
Perhaps unsurprisingly, hundreds of thousands of people who live downwind from kilns face an elevated risk of cardiovascular and respiratory disease, and tens of thousands of adults die from pollution-related illnesses each year, according to modeled estimates.
Research by Allison Sherris, a graduate student in Stanford’s Emmett Interdisciplinary Program in Environment and Resources, suggests a correlation between spikes in airborne particulate matter and increased rates of pneumonia among children in Dhaka. Sensors reveal a strong signal of sulfate, a chemical common to coal burning, in the city’s air.
“I had given brick kilns very little thought,” Luby said. “Now, I can talk for days about kiln designs, technology, regulation, combustion. I can find specific data that substantiate the problem, then hold onto them like a bulldog.”
But good data about the magnitude of the problem is hard to find. Yu and graduate student Nina Brooks are trying to fill that gap and quantify the adverse health effects that can be attributed to brick kilns. They are comparing rates of asthma, chronic obstructive pulmonary disease and other air-related illnesses in communities with and without kilns.
“This is about saving people’s lives,” Brooks said. “Human-generated waste is what’s killing so many people — mostly poor people. It’s preventable.”
As research continued, Luby’s team found mounting evidence that the global development community’s approach to mitigating health effects of air pollution was systematically flawed. For years, funders poured hundreds of millions of dollars into improving people’s health by targeting indoor air quality and advocating for cleaner-burning cookstoves. After more than three decades of promoting the stoves in Bangladesh, less than 2 percent of households were using them.
To Luby, it was a self-perpetuating cycle of failure that had overlooked the key connection between outdoor and indoor air pollution. “Money comes available when an idea gets a certain amount of currency,” Luby said. “People will do things because funding is available.”
The pattern is familiar to people trying to solve health problems in the developing world. “The solutions that seem like they should be the most sustainable, effective and beneficial to people and the environment are not always feasible on the ground,” said Erin Mordecai, PhD, an assistant professor of biology who studies the ecology of infectious disease. “For example, improving access to clean, reliable, piped water would lift billions of people out of poverty, improve quality of life and reduce transmission of disease. But aid often focuses only on stopgap solutions like medicines and treatments once people are infected, which leave them vulnerable to reinfection after the initial treatment wears off or aid programs dry up.”
“It was clear people preferred their old cookstoves,” Luby said. “They cooked their chapatis better. I never thought it was going to be easy to change the way several thousand kilns make bricks, but I thought it’s got to be easier than changing the way 40 million households cook their meals.”
Luby was at a point where he was ready to lay the groundwork for a plan of attack, which coincided with his 2012 hiring at Stanford, where he is also a senior fellow in the Stanford Woods Institute for the Environment.
To start, he gathered a team of Stanford researchers, including renowned political scientist Francis Fukuyama, PhD, and geophysicist Howard Zebker, PhD. Fukuyama, who, like Luby, is a senior fellow at the Freeman Spogli Institute for International Studies, helped Luby understand governance issues and formulate a politically effective message to incentivize kiln owners to switch to cleaner technologies. Zebker, a professor of electrical engineering and of geophysics, is an authority on developing space-borne radar systems and using remote sensing data to study earthquakes and other phenomena. He laid the groundwork for a satellite imaging program to pinpoint kiln locations, something that’s difficult to do using unreliable government records.
“This problem seems to be one in which you could have a huge payoff both locally and for the world as a whole if you could get to the proper solution,” Fukuyama said. “Most problems promise to improve life much less.”
Luby and his colleagues burned through iteration after iteration. “We definitely pursued some dead ends,” he said.
Among the team’s biggest failures was a pollution-scrubbing technology they spent months developing. At the invitation of a member of India’s parliament, Luby traveled across the state of Punjab to pitch the idea to industry leaders. Without an incentive to install the $5,000 device, kiln owners balked.
Eventually, a game plan began to materialize. Luby and his team used the satellite data to start building a website that gives people information about nearby kilns, and teaches them how to nudge kiln owners toward making their operations more efficient and profitable. The site will help users pinpoint kilns that violate local ordinances and design standards, and join a larger discussion among public- and private-sector stakeholders.
Working with Greentech Knowledge Solutions, a Delhi-based leader in improving brick kiln efficiency, Luby’s team formulated affordable technology options, such as transitioning from a fixed chimney to a zigzag kiln, in which the flames from the kiln’s fire and a mechanized coal feeder circulate around the circumference of the kiln to take advantage of natural air drafts. The method improves combustion efficiency — a major incentive for kiln owners whose primary expense is coal — and reduces black carbon emissions by more than 80 percent.
The plan also includes a mechanism to provide loans for the cost-saving upgrades, a significant step for an industry that mostly operates in an informal economy. Seasonal and with few fixed assets, brick making is considered by the Bangladeshi government to be temporary, and therefore ineligible for government-backed bank loans.
“When we initiated this project, I saw that everyone, including the government and media, was blaming brick manufacturers for generating air pollution,” said Debashish Biswas, a Bangladeshi anthropologist working with Luby. “But thinking from the kiln owners’ perspective is important. Rather than impose changes on them, we need to identify the best viable strategy to solve the problem.”
By tracking emission reductions, the initiative could earn credits from global climate change funds. These credits, one for each ton of CO2 kept from the atmosphere, could then be traded or sold to industrialized countries trying to meet emission reduction targets. The earnings could then be used to finance kiln upgrades and ongoing oversight of measures to meet efficiency and climate objectives.
“We’re doing something completely novel here,” Luby said.
The plan was in place, but Luby still lacked a key ingredient: a resourceful and influential partner to facilitate and oversee the initiative. The perfect candidate turned out to be nearby.
Founded in 1972 to help refugees after Bangladesh’s war for independence from Pakistan, Building Resources Across Communities is the world’s largest nongovernmental organization. Luby was familiar with its numerous, respected branches because he taught classes at the organization’s school of health for several years.
With training from Greentech, the BRAC construction group could provide technical expertise to kiln owners on improving manufacturing practices, including support for construction and management upgrades. Its small-enterprise program could provide loans to kiln owners for upgrades, while ensuring adherence to standards and repayment. Its presence in tens of thousands of communities across Bangladesh made it an ideal partner.
Luby was mindful that the project’s fate rested on his pitch, so he approached the director of BRAC, Fazle Abed, with trepidation. When they met, Abed held up his hand to signal his need to speak first. “I really appreciate what you’ve done for our school, and what you’ve done for Bangladesh,” Abed told Luby. BRAC would join the effort.
“It struck me how much these big decisions are based on trust and relationship,” Luby said.
The lesson is not lost on colleagues of Luby’s, such as Desiree LaBeaud, MD, an associate professor of pediatrics at Stanford who has conducted extensive epidemiological field work in Kenya. “For the successes we have had, our trusted long-term relationships across sectors have been the driving force for sustainable improvements in our communities.”
There was just one major sticking point left.
“As in many policy problem areas, the chief issue is to build a stakeholder coalition in favor of the kind of reforms that are necessary, and to find ways to get around those players who are opposed to change,” Fukuyama said. “In the case of the brick kilns, it was assumed that the existing kiln owners would not accept the medical evidence that what they were doing was harmful.”
Luby’s anxiety over this possibility came to a head in January 2013. He had invited influential stakeholders, including representatives from government agencies, nongovernmental organizations and brick-dependent construction firms, to a dialogue in a Dhaka convention center aimed at gathering feedback on kilns’ health hazards, as well as incentives for change. Would the kiln owners come? If so, what would they say? Would they protest or demand major concessions? Jamil Hussain, vice president of Bangladesh’s national brick manufacturing association, told Luby he likely would not show. He was wary of bad press and criticism for his already maligned industry.
Luby hired professional meeting facilitators and barred media coverage. Hussain showed up at the last minute. So far, so good. Luby braced himself for reaction to a colleague’s presentation about the health impacts of kilns. There was a long moment of silence, then Hussain rose and asked to address the audience. “I was at the edge of my seat,” Luby said. “I thought this could be a shouting match. It could go off the rails.”
Instead, Hussain told the crowd, “We don’t dispute anything you just said. Brick kilns do damage the environment and human health. What I’m asking for is your help in solving this problem. I’d like you to help us so that people don’t hate us.”
Luby was stunned. And, now, instead of having to advocate for the project, he could focus on finding a solution.
Luby’s concept, with its various incentives, had struck a chord for Hussain and other kiln owners wary of complicated and expensive pollution-reduction systems pushed by the central government. “If the new technology is economical and environment-friendly, if it’s not harmful to our business, everyone should be interested,” said Hussain. “This approach makes it possible for us to follow the regulations of the government and maintain our business. That’s why we listened to Dr. Luby.”
Working closely with kiln owners is another way Luby butts up against what he considers a systemic bias toward top-down solutions in the global development community. “We often get pushback,” Luby said. “‘Why are you working with these guys? These guys don’t wear ties. They’re not educated.’” Luby’s answer is simple: “‘These guys have 85 percent of the market. Why don’t we work with the market leaders? They have a business model that works.’ It pushes against this idea that we should leapfrog to the modern, that we should do it like we do in North Carolina or wherever.”
Luby’s team hopes to pilot various technological interventions at Bangladeshi kilns to generate results that would nudge kiln owners, government regulators and others toward change. He’s seeking funding of $4 million to $8 million for pilots at about 10 Bangladeshi kilns this spring and at another 30 to 45 kilns two years later. Eventually he’d like to see the industry transformed, which he estimates would cost $30 million to $80 million.
Luby’s ready for an uphill battle. “Problem-defining research is most highly rewarded in academia,” he said. “One step that donors interested in a sustainable future can make is to fund solution-oriented research and reward leading researchers who engage in it.
“We know the problem,” Luby said. “People get rich by destroying the Earth or human health. If we can’t figure out how to change that incentive system, we will destroy our future.”