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</o:shapelayout></xml><![endif]--></head><body bgcolor="#D2D2D2" lang=EN-US link=blue vlink=purple><div class=WordSection1><div align=center><table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width=644 style='width:386.4pt'><tr><td style='padding:0in 0in 0in 0in'><p align=center style='text-align:center'><span style='font-size:7.5pt;font-family:"Arial","sans-serif";color:black'>If you are having trouble viewing this, please click <a href="http://echo4.bluehornet.com/p/vTq6z-jrN9" target="_blank"><span style='color:#2079A4'>here</span></a>.<br><a href="http://echo4.bluehornet.com/ct/19068927:21489878000:m:1:1485567414:2D10D388A9B544C54DB2EB64153C48F8:r" target="_blank"><span style='color:#2079A4'>Add us</span></a> to your address book!<o:p></o:p></span></p><table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width=644 style='width:386.4pt;background:white'><tr><td style='padding:0in 0in 0in 0in'><p class=MsoNormal><img border=0 width=644 height=184 id="_x0000_i1030" src="cid:image001.jpg@01CDDF8C.52419E60" alt="EPA Cook Stoves
and Indoor Air"><o:p></o:p></p></td></tr><tr><td valign=top style='padding:0in 0in 0in 0in'><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>Dear Colleagues,<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>The recently released "Global Burden of Disease 2010," a <a href="http://echo4.bluehornet.com/ct/19068928:21489878000:m:1:1485567414:2D10D388A9B544C54DB2EB64153C48F8:r" target="_blank"><span style='color:#0070C0'>new systematic analysis</span></a> of all major global health risks, has concluded that household air pollution from cooking with solid fuels kills <strong><span style='font-family:"Arial","sans-serif"'>4 million people annually worldwide</span></strong>. This figure is <strong><span style='font-family:"Arial","sans-serif"'>double the previous estimate</span></strong>, and includes 3.5 million deaths associated with indoor exposures and another 500,000 deaths from cookstoves' contribution to outdoor air pollution. Additionally, millions more are sickened from lung cancer and disease, lower respiratory infections, cardiovascular disease, and cataracts associated with household air pollution. The study was funded by the Bill and Melinda Gates Foundation and represents the work of 486 co-authors from 50 countries.<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>The <a href="http://echo4.bluehornet.com/ct/19068929:21489878000:m:1:1485567414:2D10D388A9B544C54DB2EB64153C48F8:r" target="_blank"><span style='color:#0070C0'>Global Burden of Disease Study 2010</span></a> (GBD 2010), published On December 13, 2012, in the journal <em><b><span style='font-family:"Arial","sans-serif"'>Lancet</span></b></em>, is the largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors. GBD 2010 consists of seven articles, each containing data on different aspects of the study (including data for different countries and world regions, men and women, and different age groups).<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>The last of the seven articles reports the comparative risk assessment among about 60 risk factors, including household air pollution. It can be cited as:<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>A Comparative Risk Assessment of Burden of Disease and Injury Attributable to 67 Risk Factors and Risk Factor Clusters in 21 regions, 1990-2010: A Systematic Analysis for the Global Burden of Disease Study 2010.</span></strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'> <em><span style='font-family:"Arial","sans-serif"'>Lancet, 380: 2224-60, 2012. S Lim, et al.</span></em> (<a href="http://echo4.bluehornet.com/ct/19068930:21489878000:m:1:1485567414:2D10D388A9B544C54DB2EB64153C48F8:r" target="_blank"><span style='color:#0070C0'>Link</span></a>) (Download is free, but registration is required)<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>Below are selected excerpts from a summary of the article by Kirk Smith of the University of California-Berkeley. A <a href="http://echo4.bluehornet.com/ct/19068931:21489878000:m:1:1485567414:2D10D388A9B544C54DB2EB64153C48F8:r" target="_blank"><span style='color:#0070C0'>video</span></a> of Dr. Smith's presentation about the GBD study is also available. To learn more about this study and efforts underway to address this serious global health challenge, visit the Global Alliance for Clean Cookstoves at <a href="http://echo4.bluehornet.com/ct/19068932:21489878000:m:1:1485567414:2D10D388A9B544C54DB2EB64153C48F8:r" target="_blank"><span style='color:#0070C0'>www.cleancookstoves.org</span></a>.<o:p></o:p></span></p><p class=MsoNormal><o:p> </o:p></p><div class=MsoNormal align=center style='text-align:center'><hr size=3 width=680 style='width:408.0pt' align=center></div><p class=MsoNormal><o:p> </o:p></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>As chair of the skilled and dedicated expert group on Household Air Pollution (HAP), I here summarize four aspects of the assessment related to HAP:<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>First the numbers. The scale of HAP's health impact is quite large.</span></strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'><o:p></o:p></span></p><ul style='margin-top:0in' type=disc><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>3.5 million direct premature deaths annually in 2010 – compared to 3.3 million for outdoor air pollution (particles and ozone) and 6.3 million for active and passive smoking.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>0.5 million more from the outdoor air pollution due to household fuels — what one might call "secondhand cookfire smoke."<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>This makes ~4 million total attributable to HAP from cooking fuel.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>0.5 million of the total are child pneumonia deaths.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>The rest are adult deaths (men and women) from lung cancer, cardiovascular disease (CVD), and COPD. Cataracts are also included, but they cause very few deaths.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>In terms of absolute impacts, men are more affected than women. This counterintuitive result is because men have so much higher background rates of the major diseases. Thus, although women have higher exposures and higher elevations in risk for these diseases, men end up with the larger burden. In relative terms, as indicated below, however, women are more affected by HAP.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>In terms of DALYs (lost healthy life years), HAP is the 2nd most important risk factor for women and girls globally among those examined and 5th for men and boys. It is 1st for both sexes in South Asia and for women and girls in most of sub-Saharan Africa. HAP is 6th for both sexes in East Asia.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>HAP is the most important single environmental risk factor globally and in poor regions. Behind outdoor air pollution (OAP) in richer countries, of course, and in China, where OAP ranks fourth among all risk factors examined.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l0 level1 lfo1'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>2.8 billion people rely on solid fuels for their main cooking fuel in 2010, a number that seems to have been roughly stable globally for the last decade or so. This are now more people than anytime in human history relying on solid fuels for cooking.<o:p></o:p></span></li></ul><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>Second, the bottom lines:</span></strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'><o:p></o:p></span></p><ul style='margin-top:0in' type=disc><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l1 level1 lfo2'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>Most of the impact is now understood to occur in adults.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l1 level1 lfo2'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>But still, Acute Lower Respiratory Infections (ALRI) (pneumonia)) deaths in children are significant — 500k globally — even with much lower background ALRI death rate globally.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l1 level1 lfo2'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>Household cooking fuel emissions contribute substantially to outdoor air pollution in many countries — 25-30% in India, for example — "secondhand cookfire smoke."<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l1 level1 lfo2'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>The new integrated exposure-response (IER) analyses provide excellent new cross-risk-factor validation of the effects we find for a range of diseases — lung cancer, COPD, ALRI (IERs link epidemiological evidence across the four particle categories - outdoor air pollution, secondhand tobacco smoke, HAP, and active smoking).<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l1 level1 lfo2'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>HAP plays a large role in non-communicable diseases (NCDs) which are now understood to be so important in India and other low and mid-income countries.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l1 level1 lfo2'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>It is important to remember that interventions that do not reduce all the way to the clean levels used for comparison (see next section) will not produce the full health benefits. Based on studies across combustion particle sources in the GBD, it is now believed that the impacts are highly non-linear at the levels commonly experienced in households cooking with solid fuels. Thus, for example, a reduction of a factor of two in smoke exposures at these high levels will produce far less than a reduction of 50% in health impacts. Need to reduce exposures down to levels in the range of the WHO Air Quality Guidelines to do so.<o:p></o:p></span></li></ul><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>Third, many will wonder why the results show so much larger effects for HAP compared to what was found in the previous CRA for 2000 published in 2004 (1.6 million premature deaths). </span></strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'><o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>There were actually factors that tended to decrease the attributable burden in the new estimates:<o:p></o:p></span></p><ul style='margin-top:0in' type=disc><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l3 level1 lfo3'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>~40% of the world use solid fuels for cooking in 2010, down from the ~50% estimated for 2000. This is based on much more robust estimate of global household solid fuel use for cooking informed by ~600 nationally representative household fuel use surveys compared to ~50 last time.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l3 level1 lfo3'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>We were able to be more careful in separating out cooking fuel only. There is much less confusion with heating fuels than before.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l3 level1 lfo3'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>The risks for COPD were less than before, based on the new systematic reviews and meta-analyses.<o:p></o:p></span></li></ul><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>Fourth, there were other differences, however, that led to higher estimates:</span></strong><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'><o:p></o:p></span></p><ul style='margin-top:0in' type=disc><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l2 level1 lfo4'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>Evidence now allows us to add estimates for two new categories of disease: cardiovascular disease (CVD) and cataracts.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l2 level1 lfo4'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>As CVD is the chief cause of mortality in nearly all countries, the additional burden is substantial.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l2 level1 lfo4'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>Evidence of effects in men now for all adult endpoints except cataracts.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l2 level1 lfo4'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>We now using a low counterfactual (~7 ug/m3 annual PM2.5 — same as the OAP group used) — equivalent to cooking with gas.<o:p></o:p></span></li><li class=MsoNormal style='color:#666666;margin-top:3.75pt;mso-margin-bottom-alt:auto;line-height:12.75pt;mso-list:l2 level1 lfo4'><span style='font-size:9.0pt;font-family:"Arial","sans-serif"'>This allows the HAP results to reflect the full benefit that could be expected from moving the 40% of households with solid fuel to the low pollution experienced by 60% of world population using gas or electricity for cooking.<o:p></o:p></span></li></ul><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>The net result was a major increase in the estimated burden.<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>Kirk R. Smith, MPH, PhD <br>2012 Tyler Laureate <br>Professor of Global Environmental Health <br>Director of the Global Health and Environment Program <br>School of Public Health <br>747 University Hall <br>University of California<o:p></o:p></span></p><p class=MsoNormal><o:p> </o:p></p><div class=MsoNormal align=center style='text-align:center'><hr size=3 width=680 style='width:408.0pt' align=center></div><p class=MsoNormal><o:p> </o:p></p><p style='mso-margin-top-alt:7.5pt;margin-right:3.75pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:12.75pt'><span style='font-size:9.0pt;font-family:"Arial","sans-serif";color:#666666'>— US EPA and Winrock International<o:p></o:p></span></p><p style='mso-margin-top-alt:7.5pt;margin-right:11.25pt;margin-bottom:5.0pt;margin-left:7.5pt;line-height:13.5pt'><span style='font-size:10.0pt;font-family:"Arial","sans-serif";color:#777777'> <o:p></o:p></span></p></td></tr></table></td></tr></table></div><div align=center><table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width=867 style='width:520.2pt'><tr><td style='padding:.75pt .75pt .75pt .75pt'><table class=MsoNormalTable border=0 cellspacing=3 cellpadding=0 width="100%" style='width:100.0%'><tr><td style='padding:.75pt .75pt .75pt .75pt'><div align=center><table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width=688 style='width:412.5pt;border:solid #5B7EBC 1.5pt'><tr style='height:40.5pt'><td width=100 style='width:60.0pt;border:none;background:white;padding:0in 0in 0in 0in;height:40.5pt'><p class=MsoNormal><img border=0 width=32 height=32 id="_x0000_i1029" src="cid:image002.png@01CDDF8C.52419E60" alt="U.S. Environmental Protection Agency"><o:p></o:p></p></td><td width=575 style='width:345.0pt;border:none;background:white;padding:0in 0in 0in 2.25pt;height:40.5pt'><p><span style='font-size:7.5pt;color:gray'>This message was intended for: <a href="https://mail.cadmusgroup.com/owa/redir.aspx?C=dbb2e0f53d6d4c35ad951c62ed359517&URL=mailto%3a%2525%2525TO_EMAIL%2525%2525"><span style='color:windowtext'>tmiles@trmiles.com</span></a> <br>To view EPA's privacy and security notice, please click </span><span style='font-size:10.0pt;color:gray'><a href="http://www.epa.gov/epafiles/usenotice.htm"><span style='font-size:7.5pt;color:#5B7EBC'>here</span></a></span><span style='font-size:7.5pt;color:gray'>.<br>You were added to the system October 25, 2010. 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