‘I can’t breathe’: How young lungs are struggling amid rising air pollution in Delhi

As Delhi’s pollution levels peaked — on November 19, the Capital’s Air Quality Index touched 494, just short of the maximum 500 on the scale — the weekly asthma clinic for children at GTB Hospital, one of the biggest tertiary care health facilities run by the Delhi government, saw a steady stream of patients, many of them with chronic asthma.

The clinic sees around 10-15 patients every Tuesday, but it’s around this time of the year, when the temperature dips and haze covers the city, that Dr Bhaskar and his team of two, which includes a junior doctor and a technician, have their hands full.

“Asthma is a chronic condition that inflames and narrows the airways in the lungs. There could be several factors — from genetic to environmental. Most of these children are on some sort of controller therapy for asthma and many are on regular inhalers. They also have their vaccine courses, including flu and pneumococcal vaccines. But if they are surrounded by aggravating factors like dust, smoke and pollution, their symptoms worsen,” he explains.

The weekly clinic, which saw a monthly average of 40 child patients in July-August this year, has already seen 100 children so far in November — 35 new patients and 65 regular patients with chronic conditions.

“With the rising AQI, there has been a surge of patients in our hospital’s emergency department. Of the children who were brought to the hospital, almost 60-70 per cent had respiratory issues. Some of them were referred to our clinic. On Monday (November 18), our hospital’s paediatric department saw 350 child patients, of whom 190 had respiratory illness,” says Dr Bhaskar.

Krishna Koli undergoes a spirometry test. (Express photo by Abhinav Saha)

He then calls out to a staff member to bring the ‘Asthma Register’, which he maintains for his regular patients and enters Krishna’s details. Dr Bhaskar then directs a staff member to take the child for the spirometry tests.

As Krishna waits in the queue for the test, clutching his mother’s hand, his beanie now sliding down to almost cover his eyebrows, he watches the other children blowing into the mouthpiece of the spirometer device.

After a wait of 10 minutes, it’s Krishna’s turn. The technician instructs him, “You see these balls inside this tube? Inhale and then blow hard… You’ll see them rising.” Krishna blows hard, his cheeks hollow from the effort, but the balls in the device barely move.

The technician now holds a piece of paper and asks Krishna to blow on to it. He does, but the paper stays still.

Children and pollution

Children are known to be especially vulnerable to air pollution, with experts agreeing that exposure to high levels of pollutants can lead to significant, and worrying, long-term respiratory consequences — from structural changes in airways to altered immune responses and impaired cognitive development, besides worsening of existing respiratory illnesses such as asthma.

According to the Global Asthma Network, around 6 per cent of children in India suffer from the disease, a cohort for whom air pollution is an added cause of concern.

Dr Randeep Guleria, pulmonologist and former director of the All India Institute of Medical Sciences (AIIMS) who in 2011 set up the Department of Pulmonary, Critical Care and Sleep Medicine at the premier medical institution, says, “Long-term exposure to poor quality air affects lung growth. Studies have shown that children who grow up in poor AQI areas tend to have lower lung capacity as compared to those who live in areas with fresh air. Because their lungs are still developing, pollution affects their lung growth, and their lung function becomes lower… and they have higher chances of developing wheezing and recurrent attacks of asthma.”

Explaining how air pollution is especially severe on children, Dr Nikhil Modi, respiratory medicine specialist at Delhi’s Indraprastha Apollo Hospitals, says, “Because children breathe faster and are closer to the ground, they inhale more air per kg of body weight when compared to adults. When they do so, the pollutants can penetrate deep into the lungs, causing inflammation and irritation of the airways.”

In March 2021, doctors at the Paediatric Pulmonology Department of AIIMS and Vallabhbhai Patel Chest Institute studied the link between ambient or outdoor air pollution and the daily visits of children to the Emergency departments of two hospitals in the Capital — AIIMS and Kalawati Saran Children’s Hospital.

Out of 1,32,029 children screened for the study, 19,120 candidates with acute respiratory symptoms for less than two weeks and those residing in Delhi for the previous four weeks were enrolled. The study recorded a 29% increase in emergency room visits by children on ‘high pollution cluster days’ and 21% on ‘moderate-level pollution cluster days’.

Dr S K Kabra, paediatric pulmonologist and former head of AIIMS’ paediatric department, who was part of the study, says, “We could see that if there was a 10-unit increase in PM 2.5, PM 10 or NO2 levels, there was a corresponding 20-40 per cent increase in the number of children landing up in the Emergency. This is not necessarily children with prior history of asthma or respiratory illnesses, but children as a whole.”

According to Dr Rajesh Chawla, Senior Consultant, Respiratory and Critical Care at Delhi’s Indraprastha Apollo Hospitals, pollution affects children across age categories. “For children under five, exposure can result in reduced lung growth, increased risk of asthma development, and chronic bronchitis. Studies indicate potential permanent reduction in lung capacity by 10-15%. Children aged 5-10 years may experience decreased lung function growth, increased susceptibility to respiratory infections, and higher risk of developing chronic respiratory conditions in adulthood. Cognitive development may also be impacted due to reduced oxygen delivery to the brain,” he says, adding regular pulmonary function monitoring throughout childhood can help track these impacts and guide interventional measures.

Dr Lancelot Pinto, senior pulmonologist and epidemiologist at Hinduja Hospital in Mumbai, a city that dealt with high AQI levels last year, says the impact of pollution could be more permanent than we imagine. “Adult Indians generally have significantly lower lung function when compared to other populations. We have traditionally said that it might be because we are Asians. But now there is a stronger sense that inadequate childhood growth and exposure to environmental pollution contribute to lungs not fully developing,” he says.

Krishna gets home

It’s 4 pm and the OPD at the asthma clinic is winding up for the day. The mother and son prepare to head home to Nandgram in Ghaziabad, where Soni’s two younger children — eight-year-old Anjali and five-year-old Kartik — have been waiting. Her husband Doulat Ram, who does house painting jobs, is out at work.

After collecting their medicines from the hospital pharmacy, Soni and Krishna go to a nearby general store to buy a packet of biscuits and apple juice — they haven’t eaten since they left home five hours ago. “We will take an auto from the hospital to Dilshad Garden and from there, two more rickshaws till we get home. It costs me Rs 100 in all,” she says.

The sun hasn’t been out since morning and the smog hangs low. Sitting in the auto that’s now weaving its way through the traffic, Soni says Krishna had to be brought here after he suffered an asthma attack on November 16, a day after she and her husband took the children out for a rare picnic to India Gate. The AQI at India Gate that evening was above 408 — ‘severe’.

Krishna Koli at his house’s terrace. (Express photo by Abhinav Saha)

“The next morning (November 17), Krishna started coughing and had difficulty breathing. He used the inhaler, I got him to inhale steam and took him to the nearby clinic, where they put him on a nebuliser. But he didn’t get better and I decided to get him here,” she says.

Soni says Krishna’s illness began sometime in 2020, when he would have frequent bouts of coughs, followed by fever, and she would manage with cough syrups and, if his condition worsened, take him to the local doctor. The family lived in East Delhi then. But last year, while on a visit to his aunt’s in Ghaziabad, Krishna had a coughing fit and collapsed.

The family rushed him to a hospital in Ghaziabad, where he was admitted for a few days after which he was referred to the asthma clinic at GTB Hospital.

At their one-bedroom home in Deendayal Puri, Nandgram, a neighbourhood with narrow lanes and closely built houses, Krishna is greeted by his siblings Anjali and Kartik, who unlock the door after climbing onto a chair. The house is on a floor above a private school, where the children study.

Krishna Koli, with his mother Soni, on his way to collect medicines at the hospital. (Express Photo by Abhinav Saha)

“We decided to shift here because the hospital is close by, the rent (Rs 2,500 a month) is lower than in Delhi and the children don’t have to travel to school. Also, I can keep a watch on Krishna. There have been several occasions when I have had to bring him home after he fell ill in school,” she says, opening a file that’s bulging with Krishna’s prescriptions.

Over the last three years, she says, the family has spent about Rs 30,000 on Krishna’s treatment. “He has fallen sick about 20 times in this period. Since GTB Hospital is far away, we rush him to local doctors in case there’s an emergency,” she says.

Soni says she doesn’t let Krishna go out to play; he isn’t allowed spicy or fried food either. “Thankfully, Krishna doesn’t like fried food and prefers roti and dal. He probably knows it’s better for him,” she says.

As Anjali and Kartik step out to buy snacks, Krishna walks out to the school’s terrace, an extension of their house. The terrace is his space — it’s here that he spends time with himself, looking out at the grey sky, watching his siblings run around. He now leans against the terrace wall, watching Anjali and Kartik as they walk down the dusty lane that’s lined by a wide, open drain.

“It’s sad that he can’t do a lot of things that other children can,” says Soni. At times like these, she has often considered shifting to Chandigarh, the city she grew up in and where she has her family. “At least the air there is much cleaner… May be Krishna will be healthier,” she says.

That day, November 19, Chandigarh recorded an AQI of 238 — ‘poor’.