According to Bagai, exposure to air pollution during Delhi’s five winter months each year is estimated to be equivalent to smoking 9,000 cigarettes. The health cost is measured not just in symptoms but in lost time: 129 days, or about 4.3 months, of life expectancy are lost annually due to winter pollution exposure.
Air pollution is causing 16 times more deaths each year in India than the country recorded annually during the COVID-19 pandemic, according to pediatrician Sanjeev Bagai, who spoke at the Anil Agarwal Dialogue 2026 in Nimli, Rajasthan.
During the four years of COVID-19, about 600,000 deaths were recorded nationwide. Yet annual deaths linked to air pollution are 16 times higher than the average yearly toll during that period, Bagai said.
Despite the scale of the crisis, he noted, Indian hospitals still do not have a specific diagnosis coding for air pollution in either inpatient or outpatient department records.
“Air pollution is truly a public health emergency,” Bagai told participants at the ongoing forum.
RELEVANT SUSTAINABLE GOALS
Delhi’s Winter: Five Months, 9,000 Cigarettes
Nowhere is the impact more visible than in the national capital.
According to Bagai, exposure to air pollution during Delhi’s five winter months each year is estimated to be equivalent to smoking 9,000 cigarettes. The health cost is measured not just in symptoms but in lost time: 129 days, or about 4.3 months, of life expectancy are lost annually due to winter pollution exposure.
Over three decades of living in Delhi, that adds up to nearly 11 years of life lost.
Research cited from Berkeley Earth equates specific PM2.5 exposure levels with cigarette consumption. A full-day exposure to 22 micrograms per cubic meter of PM2.5 carries a health risk equivalent to smoking one cigarette. Eight hours at 60 micrograms per cubic meter equals one cigarette. At 511 micrograms per cubic meter, that same period equals eight cigarettes.
According to the Canadian Air Quality Health Index, 24-hour exposure at level 1 (10 micrograms per cubic meter) equals 0.5 cigarettes. At level 6 (60 micrograms per cubic meter), it equals 2.7 cigarettes. At level 10 (100 micrograms per cubic meter), it equals 23.2 cigarettes.
A Global Crisis, Underreported
Bagai said air pollution deaths remain significantly underreported worldwide. Available data suggest between 5 million and 8.1 million deaths globally each year are linked to air pollution.
Citing the State Global Health Report 2020, he noted that in India alone, 2 to 3 million deaths annually have been recorded due to air pollution.
Based on data from The Lancet 2021 and the Indian Council of Medical Research 2019, between 18 and 25 percent of all deaths are attributable to air pollution. Research from the University of Chicago indicates that air pollution reduces adult life expectancy by 8 to 10 years per person.
In Delhi, 30 percent of children have been found to suffer from irreversible lung damage, according to the Lung Foundation of India.
The Economic Toll: ₹24 Lakh Crore a Year
Bagai questioned whether the country’s policy priorities reflect the magnitude of the threat.
India’s health budget stands at just over ₹1 lakh crore. Meanwhile, the country loses around ₹24 lakh crore in productivity each year due to air pollution, roughly 8 percent of Gross Domestic Product.
“This annual loss is nearly 24 times the total health budget,” he said, asking whether it would not be more cost-effective and humane to tackle pollution directly.
The Lethal Mathematics of PM2.5
Fine particulate matter, known as PM2.5, is about one-fourth the size of a strand of hair. It is small enough to penetrate deep into the lungs and enter the bloodstream.
Bagai emphasized a direct link between PM2.5 exposure and mortality. According to the data he cited:
- Every 10 percent rise in PM2.5 levels can double mortality risk.
- A 5 microgram per cubic meter increase raises mortality by 4 percent.
- A 10 microgram increase raises mortality by 8 percent.
- A 35 microgram increase can raise mortality by up to 24 percent.
- A 1 microgram per cubic meter increase is associated with 12,000 additional deaths annually.
- A 1 microgram per cubic meter increase is linked to a 0.073 percent rise in mortality.
“A July 2024 report in The Lancet noted that 11 percent of total deaths in Delhi are attributable to PM2.5. Every 10 microgram per cubic meter increase raises mortality by approximately 3.6 percent.
Exposure duration matters. More than 15 minutes in highly polluted air can trigger respiratory distress. One to two days of continuous exposure can cause heart attacks and strokes. Three to five days can lead to sudden cardiac arrest.
Data from the Indian Institute of Technology Delhi show that PM2.5 causes cardiac inflammation, activates platelets and leads to thrombosis and arrhythmias.
It affects not only the lungs but nearly every organ system, Bagai said. Air pollution has been associated with asthma, Alzheimer’s disease, dementia, depression, mood swings, autism in children, Parkinson’s disease, neurodegeneration, anemia, insomnia, chronic kidney disease, osteoporosis and fractures.
The Invisible Burden on Children
Children are particularly vulnerable.
They inhale more pollutants relative to their body weight and have limited immunity. Pollution levels often increase with rising relative humidity in the morning, when children are on their way to school.
Bagai cited a survey in which many children reported avoiding school or wishing to leave Delhi because of pollution.
Displaying images of healthy and polluted lungs, he explained how damaged alveoli release reactive cytokines, causing inflammation and oxidative stress. Over time, the strain spreads beyond the lungs to the heart, kidneys, brain and metabolic systems.
A one-unit rise in PM2.5 leads to 8.4 percent more recorded illnesses, and pollution has been associated with a 10.65 times higher disease burden.
Pollution Before Birth
Air pollution also affects pregnancy. Bagai said exposure is linked to preterm birth, autism spectrum disorders, infertility, maternal hypertension, placental complications and increased premature mortality. Stillbirths may rise by about 14 percent.
Structural abnormalities such as cleft lip, absent ears, microcephaly, spinal deformities and single kidney have been observed. Exposure up to 12 months before conception may already trigger genetic changes that cannot be fully reversed by moving to cleaner air during pregnancy.
Pollution is neurotoxic due to oxidative stress. It increases the risk of motor neuron disease, memory loss and dementia.
Living in a Plastic World
Alongside air pollution, Bagai warned of a growing microplastic crisis.
Microplastics have been detected in the brain, liver, placenta, kidneys and coronary arteries. They have been found in 40 to 60 percent of people. Between 2016 and 2024, microplastic levels in the human body increased by 20 percent.
Global microplastic production in 2019 was estimated at 6 billion tonnes per year. These particles can take up to 500 years to degrade. About 84 percent originate from waste dumps.
An average person inhales approximately 75,000 to 120,000 microplastic fibers annually. Air samples show filament fibers 1 to 5 micrometers thick, with concentrations ranging between 25 and 5,000 micrograms per cubic meter.
Microplastics have been found in heart attack patients and are linked to hypertension and cardiovascular problems. Chemicals such as bisphenol A and phthalates, common in plastics, have been linked to miscarriage, stillbirth and structural abnormalities in newborns.
Plastic waste persists for centuries. Heat and sunlight increase microplastic release from bottles. Heavy metals can bind to microplastics, allowing them to adhere to cell membranes and persist in the body.
A Call for Policy and Accountability
Bagai stressed that the data linking air pollution to death and disease are already available. Underreporting, he said, may be as high as 20 percent, and the current estimate of 2 to 3 million annual deaths in India could double or triple with better documentation of pollution-linked asthma and cancer.
Municipal corporations still use outdated road-cleaning methods that resuspend dust into the air. In many regions, weak hospital systems and poor documentation obscure the true toll.
As pollution levels rise sharply, Bagai called for strong policy measures, a clear public agenda and firm financial commitment. The numbers, he argued, are no longer abstract. They are measured in shortened lives, damaged lungs and mounting economic losses.
The question is no longer whether air pollution is lethal. It is whether the country is prepared to treat it with the urgency it demands.
To access the proceedings and presentations of AAD 2026: https://www.cseindia.org/page/aaddialogue2026
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