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How To Stem The Global Pollution Crisis – One Country, One Transformation At A Time

Photo: Larry C. Price/Pulitzer Center on Crisis Reporting
Photo: Larry C. Price/Pulitzer Center on Crisis Reporting

When we consider worldwide pollution — particulate matter in the air; contaminated water; persistent organic pesticides; toxic heavy metals like mercury, lead, chromium; the panoply of chemical wastes and endocrine disrupters — the problems seem insurmountable and intractable. Truly, they are not.

We have the knowledge and the skills to tackle toxic pollution and restore communities to healthier living conditions.  At the Global Alliance on Health and Pollution (GAHP), we have developed a very specific tool to put that knowledge and those skills to work to help governments and stakeholders in low- and middle-income countries identify and address their most pressing pollution problems – the Health and Pollution Action Plan or HPAP.

GAHP now has four years of experience leading the HPAP process, which brings together representatives from various governmental ministries, UN agencies, local non-governmental agencies, and universities, among others. Support comes from the Swiss Agency for Development and Cooperation (SDC), US Agency for International Development, UN Industrial Development Organization, the European Commission, Oak Foundation and others.

We have completed eleven HPAPs, and started to implement several, learning important lessons and gleaning insights along the way. I will share some of those insights in this article, but first, a bit of background.

GAHP was founded in 2012 with the specific mission of reducing death and illness caused by all forms of pollution.  An estimated 9 million people die each year from diseases and chronic conditions caused by pollution.[i]  Pollution also results in an enormous loss of productivity and quality of life, tallied at more than 254 million disability adjusted years (DALYS) worldwide.[ii] Costs to the global economy reach into the trillions of dollars annually.[iii] 

Moreover, approximately 90 percent of the 9 million pollution-related deaths occur in low- and middle-income countries, those that are truly least equipped with the experience and resources to design and implement robust pollution-control programs. 

We know that with growing awareness and demand for action, fundamental shifts in political will, and the support of the global community, we can reduce these horrific numbers and improve millions of lives and the health of the planet.

The question for many iswhere to begin?

The HPAP process helps governments and stakeholders answer that essential question and give them a road map for their journey. GAHP is there to guide them along the way with its members providing needed technical assistance.

Specifically, the HPAP process has three goals:

1) Ensure that stakeholders arrive at consensus around priority pollution issues within the country;

2) Encourage national and local governments to address pollution control through legislation, enforcement, planning, and budgeting;

3) Design and advance concrete interventions to reduce pollution exposures and related illnesses. 

The HPAP process uses scientific data and local stakeholder input to identify, evaluate, and prioritize the pollution challenges that most impact public health.  It seems obvious to say that good data is imperative for any decision-making process. But for many low- and middle-income countries that data is in short supply.

The GAHP team utilizes The Lancet Commission on Pollution and Health’s combined data on environmental monitoring, burden of disease modeling and economic analyses to provide government leaders and stakeholders in affected countries with the critical information they need to evaluate their most pressing pollution problems. They then combine that data with local data where available and their lived experience to better understand what is happening at community and regional levels.  With the clarity that comes from science-based data, government leaders and stakeholders can define and prioritize their most pressing pollution problems and identify workable solutions.

The working groups are also able to identify and remove political barriers to action. For example, national governments, short on funds, often budget sparingly – if at all – for pollution monitoring, control, and cleanup. Individual ministries other than the Ministries of Environment rarely have specific responsibilities to address sources of pollution or the funding and legal or regulatory authority and ability to do so. In short, pollution is everyone’s problem but no one’s sole responsibility. It requires a multistakeholder collective and collaborative approach to solve.  Through the HPAP process, stakeholders can identify the agencies that can take ownership for solving priority pollution problems. They are then able to coordinate existing efforts to ensure their activities are included in budgets and in requests to bilateral or multilateral donor agencies and ultimately funded.

There is an increasing demand for HPAP implementation.  With support from US Agency for International Development, The European Commission the Swiss Agency for Development and Cooperation and the Oak Foundation, twelve countries in Africa, Central and Southeast Asia, and South America have undertaken the HPAP process with ten countries already approving their plans.  New HPAPs begun in 2020 are nearing completion despite the COVID-19 pandemic, which undeniably slowed work and forced some countries to divert funds earmarked for pollution programs to urgently needed healthcare.

The Swiss Agency for Development and Cooperation has recognized the value of the HPAP process, citing the number of countries completing the HPAP to measure country development progress in its Health Framework for 2021-2024.

The early accomplishments of the countries that have adopted the HPAP process are notable.

• In Madagascar, following the completion of the HPAP process in 2018, President Andry Nirina Rajoelina and Prime Minister Christian Ntsay declared pollution to be a National Priority in 2020 with an announced commitment to work towards solving the country’s problems. UNICEF donated seven air quality monitoring sensors to support Madagascar’s efforts to combat air pollution.

• In Thailand, as a result of the priorities identified through the HPAP process, the Thailand Environment Institute, with support from Pure Earth, GAHP and UNEP, with funding from the Oak Foundation and the Swiss Agency for Development and Cooperation, brought together government agencies and farmers to discuss ways to reduce crop burning—a first and very important step toward tackling a major source of air pollution in the country.

• In the Republic of Tajikistan, the government’s Committee for Environmental Protection validated the “Pollution Management and Health Protection Plan” in December 2020, affirming the HPAP as the country’s main plan to deliver upon its obligations under the Stockholm Convention on Persistent Organic Pollutants (POPs).

While outcomes that reduce pollution and improve health are the long-term goal, many other benefits arise along the journey through the HPAP process.  Most significant are fundamental shifts in thinking and behavior at both the highest level of government and on the street. These transformations enhance a country’s ability to solve pollution problems and put long-term strategies in place.

Here are four essential transformations we have seen occur during the HPAP process.

1. By examining epidemiological principles and reviewing the Global Burden of Disease data from the Institute for Health Metrics and Evaluation (IHME) and in The Lancet Commission report, HPAP participants come to understand why pollution exposure is such a significant risk factor for poor health and how it is contributing to many leading causes of death in their country.


Madagascar was the first country to undertake the HPAP process, and we were admittedly learning along with our first working group. When Andrew McCartor, Pure Earth’s Vice President of Strategy and Partnerships, told the assembled group that environmental pollution was the number one risk factor for death in Madagascar, one of the country’s ministers stood to correct him.

 “That’s not true,” the minister said. “Diarrheal disease is the greatest killer in our country.”

It was a revelatory moment for us. In fact, both McCartor and the Minister were correct.

Diarrheal disease — often caused by water- and food-borne pathogens — was the leading cause of death, according to latest IHME Global Burden of Disease data. Pollution, however, was the single greatest risk factor and was cumulatively responsible for almost one in three deaths in Madagascar. In addition to water pollution (a risk factor for diarrheal disease), air pollution and particularly PM2.5, inhalable particles smaller than 2.5 micrometers in diameter, are risk factors for four of the top ten causes of death in Madagascar, including stroke, lower respiratory infections, ischemic heart disease, and hypertensive heart disease.

“I don’t think everyone in the room had thought about the nexus of health and pollution in this way,” McCartor says. “To reduce some of these non-communicable diseases, we need to think outside of the medical sphere and address root contributors, such as pollution. This was the first eye-opening moment of our HPAP process.”


The same was true in Indonesia where the government of Central Kalimantan lacked local scientific data to draw cause-and-effect conclusions about respiratory disease and exposure to smoke from annual forest burning and peatland fires.

“Pollution is like a ghost issue. Most of the impact of the pollution is chronic, so we don’t see the full impact for five, ten, or more years in terms of disease and death,” says Vovia Witni, a Program Officer with the Indonesian NGO Yayasan Tambuhak Sinta (YTS) and a member of the HPAP working group.

Witni suffers from asthma and knows firsthand the difficulties of breathing freely during the burning season. She uses an inhaler, stays indoors as much as she can, and keeps an oxygen mask handy at home. Even so, she says, at the beginning of the HPAP process, not all participants were ready to acknowledge the impact of air pollution on the health of the community.

In the absence of local data, the HPAP working group relied on the 2019 IHME Global Burden of Disease (GBD) data, which found that six of the top ten causes of death in Indonesia are respiratory and cardiovascular diseases that can be connected to air pollution.

The GBD data helped members of the HPAP working group make the important connection between pollution and disease.  “It was important that everybody was aware that the pollution that exists directly affects the health of the community,” says Witni.

2. The simple act of bringing together representatives from multiple ministries breaks down silos and begins a deeper, more complex cross-disciplinary cooperation – a critical component to building and sustaining momentum on action to solve pollution.

On more than one occasion when we have assembled HPAP working groups, we discovered that representatives from different ministries are meeting each other for the first time.  They have stepped outside of their silos to come to the HPAP table. This is critical because solving pollution problems requires interdisciplinary effort and cooperation.

“For me, [the HPAP process] is a way to develop partnerships with ministries that don’t usually talk to each other,” says Jean-Benoit Manhes, UNICEF Madagascar deputy representative and member of the HPAP working group. “Once people start talking to each other, that creates opportunities for renewed action against known villains, such as water pollution, and to take on newer challenges, such as air pollution.”

In Southeast Asia, crop burning creates severe local and transboundary air pollution, but efforts to solve the problem have been fragmented.  The government of Central Kalimantan, Indonesia, for example, uses a disaster management approach in response to Karhutla, the seasonal burning of forest and peatland.  They try where possible to extinguish the fires and warn the public when the Air Quality Index (AQI) spikes to dangerous levels. But the fires continue to occur every year because of longstanding farming practices and an influx of new industries clearing swaths of forestland for new plantations.

As Simpun Sampurna, a community representative of Kalimantan Community and Indigenous Peoples’ Empowerment and Assessment Foundation explains, “The Dayak people have been burning land to open agricultural land [since] long ago. The prohibition on burning land greatly affects the food security of the community. If the land is not burnt, the farmers cannot cultivate the land unless the government can provide heavy equipment to clear land.”

By listening to voices such as Sampurna’s and bringing numerous ministries into the process, the HPAP working group developed a plan to reduce and ultimately eliminate Karhutla in a way that supports the community’s need for food security. Suggestions include streamlining the existing contingency and action plans, supporting enforcement of existing laws, increasing resources to prevent and battle unplanned fires, educating farming communities about dangers of some types of burning, and providing alternatives, including equipment to clear land.

“There is a certain thought process when [the stakeholders] are all in this room and they’re sharing these different pollution issues,” says Lucile Okio, GAHP’s HPAP manager. “The process may bring forward “light bulb” moments in government representatives that come to these meetings and allow them to make connections they may not have seen before. This, in turn, can strengthen their case when asking their ministries for funding for pollution-related projects as their priorities are clearly connected to priorities in other ministries as well.”

During the HPAP process in Senegal, air pollution surfaced as a top priority.  Senegal has developed an air quality monitoring network that is slated to have seven stations in Dakar.  The program is well regarded, its value understood.

“If you know how polluted you are, you can think about good strategies for improving air quality and you can inform the people daily about the level of pollution and their risks,” says Aminata Mbow Diokhané, chief of the Center for Air Quality Management within the Senegalese Ministry of Environment and Sustainable Development.

And yet, Diokhané and her team have struggled to keep the monitoring stations working because, as she notes, “government [budgets] do not supply enough money for maintenance.”

Historically, in countries struggling to fund their most urgent needs, maintenance has been an undervalued and often deferred expense.  The HPAP working group was able to demonstrate how essential maintenance is to the continued operation and success of Senegal’s air quality management program, thus elevating an obscure — and vulnerable — line item in one department’s budget to a necessary expense in the country’s attack on air pollution.

Ultimately, GAHP was able to obtain donor funding for the ministry to bring one of its failed reference monitors back online this year – and now is pointing its efforts toward convincing government officials to commit to an annual budget for repairs, maintenance, and training.   

We have observed these small but critical breakthroughs multiple times as the HPAP process identifies underlying causes of persistent problems or bottlenecks and gets group support for resolving those issues. 

“All these ministerial departments now have the necessity to work together to identify the main issues on pollution and health and how to tackle the problems and avoid what they see as exclusive priorities,” says Mohamadou Sall, Ph.D., professor of population studies and Director of the Institute for Training and Research in Population, Development and Health Reproduction at the Cheikh Anta Diop University.

3. Participants find common ground by focusing on the health benefits of reducing pollution.

Human health is a galvanizing issue, a common denominator to which everyone can relate.

The HPAP process at its very core is about determining which pollution problems are the most damaging to the health of the affected residents and which efforts are most likely to be effective in solving them.

Each working group establishes its own priorities based on the unique circumstances in its country. Air pollution has topped most of the lists, not only because of its huge health impact but also because of its close links with the climate crisis. There is a growing awareness of the dangers of particulate air pollution, especially PM2.5. The most significant source of PM2.5 — burning fossil fuels for energy generation and transportation — also produces carbon dioxide and other gases that contribute to global warming.

Pesticides and endocrine disruptors also have taken priority in several countries burdened with legacy chemical dumps. In countries with significant artisanal and small-scale gold mining, mercury contamination also is a high priority. In biodiverse areas, such as Indonesia or the Amazon rainforest, artisanal and small-gold mining (ASGM) is also a significant concern for wildlife and ecosystems – and not just because of habitat destruction. Mercury used in the process is highly toxic and its more dangerous bioavailable form, methylmercury, is well known to bioaccumulate in the food chain. Mercury’s neurotoxic effects imperil humans, as well as critically important and endangered animal species.

In Madagascar, indoor air pollution, caused largely by cooking stoves, garnered the top spot, followed by ambient air pollution and chemicals and contaminated sites. Because UNICEF and other agencies are already combatting water pollution, a longstanding problem in Madagascar, the HPAP working group elected to prioritize air quality problems, which are responsible for a significant burden of disease and have historically received less attention.

Mercury contamination from small-scale mining has also been a persistent problem in Central Kalimantan, Indonesia where NGOs Pure Earth and YTS have worked together for more than a decade to educate miners about other, less toxic ways to extract gold from ore. The heavy metal pollution ranked second on the Central Kalimantan HPAP priority list, behind air pollution, which the working group determined affects more people.

Pesticide contamination is a major priority for Azerbaijan, where agricultural and household pesticides containing persistent organic pollutants (POPs) were widely used long after the chemicals were banned elsewhere. Under Azerbaijan’s 2007-2020 National Implementation Plan, more than 2,000 tons of obsolete pesticides were collected, repackaged and transferred to special burial sites; however, many deteriorating stockpiles remain. Through its Toxic Sites Identification Program (TSIP), Pure Earth has identified and assessed more than 70 remaining pesticide sites in which the chemicals are open to the environment and risk contaminating residential areas — providing valuable information that informed the Azerbaijan HPAP process.

“I think it would have been very hard to start the HPAP process without the TSIP,” says Rovshan Abbasov, Pure Earth’s Azerbaijan country coordinator and a member of the HPAP working group.

Rovshan, a professor of environmental sciences at Khazar University in Baku, supervised the clean-up of a former fertilizer and pesticide storage facility in Salyan in 2017, a joint project undertaken by Pure Earth, Jianji Toxic Waste Storage, and Azerbaijan Ministry of Agriculture, with additional funding from the European Commission/UNIDO Trust for Mutual Understanding, and Government of Azerbaijan. The project, Rovshan said, was instrumental in informing the work of the HPAP group, as a concrete example of successful collaboration. 

“I have big hopes,” Rovshan says. “We have started to flatten the pollution curve and the attempts to help our country and neighboring countries are improving the situation.”

4. Once the HPAP process is complete and priorities are agreed upon, the “road map” gives government agencies and stakeholders direction and a framework they can use to develop and implement solutions. 

Because a clean environment is a public good, the responsibility to provide and protect the environment falls largely to the government. The HPAP process engages government ministries at every step. And with its established methodology, the HPAP emphasizes outcomes that can be measured and quantified in ways that make sense to finance ministers.  Following the completion of the program, GAHP staff members collaborate with government representatives in developing concept notes to present to funders.

“In my opinion, you cannot do this without the government being onboard,” says Judith St. Fort, Pure Earth’s regional director for Africa.  “One thing we’ve learned throughout the process is that the HPAP cannot be imposed on the government.”

In Tajikistan, for instance, the Coalition “Toxic Free Tajikistan” and the government’s Committee for Environmental Protection initiated the HPAP to fulfill that country’s obligations under the Stockholm Convention on Persistent Organic Pollutants (POPs). The plan, which prioritizes the cleanup of obsolete pesticides that accumulated in the country during the Soviet Union era and continue to contaminate food, water and soil, has received significant political and legal support from the government.

In Senegal, the Minister of Environment officially endorsed that country’s HPAP as the plan that should be used to reduce disease and death caused by pollution.

The Madagascar HPAP continues to serve as a central planning document for that country’s government.

In Indonesia, YTS was invited to present the Central Kalimantan HPAP at a parliamentary webinar on health and pollution issues hosted by AirQualityAsia in cooperation with the Green Economy Caucus of the House of Representatives. The online event gave the NGO access to an important government audience and drew positive responses about the HPAP from the Members of Parliament (MPs). 

“I think non-profits are doing really good work on the ground and for them to be able to present that work before the MPs was very important,” says Shazia Z. Rafi, President of the board and Convenor of AirQualityAsia and organizer of the webinar. “These NGOs never get face time with the federal legislature.”

Call To Action

In some low- and middle-income countries, governments can fund pollution-mitigation projects on their own. Most affected countries, however, need funding from outside sources in the form of grants and donations to fund critical pollution-mitigation projects.  Either way, the HPAP program provides stakeholders with a well-considered, science-based plan to show funders how the money will be spent and how the investment can make a real impact.

As Richard Fuller, Chair of the GAHP Board of Directors notes, “If you just write a report, it becomes a doorstop. But once you have a set of action steps, you have the plan to keep talking about and pushing to make things happen.”

Cleaning up toxic pollution worldwide is a tall order. And like a journey of a thousand miles, it begins with the first step. The Health and Pollution Action Plan program helps countries take that first very important step on the road toward a healthier world for us all.

This post is from Rachael Kupka, Acting Executive Director, Global Alliance on Health and Pollution.

[i] Institute for Health Metrics and Evaluation (IHME). (2019). Global Burden of Disease. Available at: http://ghdx.

[ii]  Landrigan, Philip & Fuller, Richard & Acosta, Nereus & Adeyi, Olusoji & Arnold, Robert & Basu, Niladri & Baldé, Abdoulaye & Bertollini, Roberto & Bose-O’Reilly, Stephan & Boufford, Jo & Breysse, Patrick & Chiles, Thomas & Mahidol, Chulabhorn & Coll-Seck, Awa & Cropper, Maureen & Fobil, Julius & Fuster, Valentin & Greenstone, Michael & Haines, Andy & Zhong, Ma. (2017). The Lancet Commission on pollution and health. The Lancet. 391. 10.1016/S0140-6736(17)32345-0.

[iii] UNICEF and Pure Earth (2020). The Toxic Truth: Children’s Exposure to Lead Pollution Undermines a Generation of Future Potential. Available at: ( unicef-and-pure-earth-call-for-urgent-action-to-protect-800- million-children-affected-by-lead/)