Fuel poverty – it’s a term we in Britain are familiar with. It conjures up images of pensioners struggling to stay warm in winter, or families huddled under blankets, forced to choose between heating and eating.
Now, as temperatures soar across the planet, billions of people in cities from Bogota to Bangkok are dealing with the same but opposite problem: they can’t afford to keep cool.
The world has never been hotter – just this week, the record for the hottest day was broken for the second day in a row, when the world average surface temperature reached 17.15 degrees.
That might not sound particularly high – but the global average has been pushed up by lethal 40 and 50 degree heat waves in places like India, Pakistan, and Sub-Saharan Africa.
Heat stress already kills around half a million people every year – around the same number as HIV and malaria – and that number is set to rise fivefold by 2050, according to the World Health Organization.
Some estimates put those numbers significantly higher – one study suggested that heat contributes to 630,000 deaths in India alone every year.
But extreme heat isn’t just a killer. It also affects educational performance, workplace productivity, and can worsen existing health problems, overwhelming hospitals and clinics already struggling to stay afloat.
There is a solution: air conditioning.
Even one hour in a room with air conditioning can dramatically reduce a person’s overall risk of developing heat exhaustion. Unlike fans, which simply move the existing air around in a space, air conditioners lower the temperature of the air, making the room cooler and allowing the body to regulate.
“Air conditioning literally saves lives,” explained Lucas Davies, a Professor at the University of Berkeley California and expert on energy economics.
Adoption of household AC has brought down heat-related deaths in the US by more than 80 per cent over the last 60 years, studies have shown.
It’s estimated 195,000 lives were saved worldwide in 2019 thanks to air-con, according to research published in the Lancet.
But for poor families in Africa and Asia who suffer the burden of the world’s hottest climates, the price tag for air conditioning is often just too high. Even the smallest units cost a minimum of £400 to install, before the problem of the monthly electricity bill comes in.
One former Telegraph correspondent in Pakistan estimates his monthly bill for cooling his home office could climb as high as £1,000 a month.
In places like India, where the average salary for a low-income household is £50 a month, it’s easy to see why AC ownership currently stands below 10 per cent.
Air conditioning does create environmental problems – it literally pumps hot air into the atmosphere, and it’s a vicious cycle – cities that use it incidentally heat up even more, making its need more pressing.
AC systems also use powerful greenhouse gases called hydrofluorocarbons (HFCs), thousands of times more potent than carbon dioxide, a point climate activists frequently highlight when arguing we should abandon AC altogether.
But whilst people in the developed world expect air conditioning to make their homes, offices, and cars more comfortable – in the global south, it’s not about luxury.
“I understand the arguments about emissions, but in the hottest parts of the world, air-con is simply a matter of life or death,” stressed Prof Davies.
What heat does to the body
Extreme heat – defined as a period of high heat and humidity with temperatures above 32 degrees for at least two to three days – has the highest death rate of any type of natural disaster globally, including flooding, hurricanes, landslides, and tornadoes.
“There are several ways you can die in extreme heat,” explained Dr Ollie Jay, Professor of Heat and Health at the University of Sydney.
The first is heatstroke, which happens when the body’s core temperature rises above 40 degrees. Blood is directed away from major organs to try and keep the skin’s surface cool, meaning key functions are deprived of oxygen and stop functioning properly.
If a person is unable to cool down, this can cause seizures and multi-organ failure. It’s what the beloved TV doctor, Michael Mosley, died off in Greece this year whilst walking in scorching temperatures.
“People with heart disease are also more likely to die, because of the extra work the heart has to do to maintain blood pressure when your body is trying to respond to the heat to keep cool – it can lead to a catastrophic cardiovascular event,” said Prof Jay.
Kidney failure is another killer in extreme heat. The kidneys are responsible for fluid balance, making them particularly sensitive to heat when they become starved of water via sweat. During heatwaves, hospitals see 30 per cent higher admissions for kidney-related problems.
In the hot sugarcane fields of El Salvador and Nicaragua, health authorities raised alarm bells in 2020, after abnormally high numbers of agricultural workers began dying of irreversible kidney damage and quickly found the culprit: heat stress.
Heat exposure also has an acute effects on children, even before they are born, and can result in pre-term births, low birth weight, stillbirth and congenital anomalies. The complications of pre-term birth, in particular, are the largest contributors to neonatal deaths.
There is also ample evidence that heat affects cognitive abilities and exacerbates underlying health conditions, particularly in those over 65 who are not as able to regulate their core body temperature. Exposure to heat can cut as much as a year off of a person’s life expectancy.
Global inequality in AC access
More than 90 per cent of households in the US have air conditioning, and Europe is following suit – some 130 million air-con units were installed in the region this year.
In sub-Saharan Africa, by contrast, fewer than four per cent of homes are air conditioned and almost all of them are high-income households.
In Asia, the situation is slightly better. Roughly 15 per cent of the region’s overall population have the systems in their houses. But the figure falls to less than 10 per cent in poorer countries like Indonesia, the Philippines, Vietnam, and India.
Rich countries of course aren’t immune to heat-related deaths. Around 3,000 people are thought to have died of heat stress in the UK last summer, and the US records about 1,300 heat-related deaths every year.
But people in the West undeniably have better access to cool spaces in homes, businesses, schools, and hospitals.
Our homes are generally better-protected from temperature extremes and only a minority of the population faces the gruelling task of working outdoors for extended periods.
Our healthcare systems are also better equipped to deal with an influx of patients during heatwaves.
But crucially, the global north is a lot cooler and less humid than the global south – even in heatwaves.
“When you look at the US from a global perspective, it’s actually a cold country. When you compare the temperature data to India [where it was 50 degrees for two months this year] it’s overwhelmingly different in terms of both how hot it gets and the number of hot days,” said Prof Davies.
Studies suggest that households in hot climates typically adopt air conditioning once their annual income surpasses $10,000. While this threshold seems relatively low, it remains unattainable for many low-income countries. For context, the average income in these nations hovers around $1,036, according to the World Bank.
And affording the monthly costs of air con, which can easily run to £100-£200 per month even for families that use it sparingly, can plunge those making over the $10,000 mark into poverty, too.
Exacerbating the poverty cycle
In Pakistan, virtually everyone from low-income households who uses air conditioning spends more than 10 per cent of their monthly income on operating these systems, explained Dr Enrica De Cian, professor in environmental economics at the University of Venice – the same percentage of income threshold that the British government uses to define fuel poverty in the UK.
In the slums of Delhi, where the crowded urban desert offers little respite from the heat, many are forced to take out high-interest loans to afford AC units in their homes.
One maid, who works for a middle-class family and earns just $50 a month, told reporters at Global Health Now that purchasing AC wasn’t a choice.
After enduring summers of extreme heat, she borrowed $216 from her son’s employer to buy a second-hand air conditioning unit. She wanted her children to be spared the nausea, headaches, and dehydration that accompany 50-degree heat. That employer deducts $15 a month from the family’s salary – pushing them further into poverty.
But neighbours without AC units are worse off, she told the publication. They haven’t been able to work for weeks, the effects of heat having taken a significant toll on their bodies.
“There are not only huge inequalities when it comes to AC, and it also leads inequality to persist,” said Prof Davies.
“It matters in the short run – on the hot day itself, it means there’s more death and discomfort. But over decades and generations, it makes it harder for low-income households to emerge from poverty.
“It’s hard for children to study in a house that’s hot, and it’s hard to get up and go to work if you haven’t slept well because it’s too hot in your house.”
This April, schools in Asia and North Africa were forced to close for weeks on end due to a particularly savage heat wave, affecting 40 million pupils.
Poorly built schools with tin roofs, no fans, and no AC offered little in the way of protection from the heat.
On top of the obvious health concerns, in 40-degree heat, children couldn’t focus. There was little point, as the teachers couldn’t teach. In Bangladesh, the government allowed only a handful of private schools with AC to stay open.
There’s no doubt heat intensifies inequalities, experts have stressed, widening already severe learning gaps between developing nations in the tropics and developed countries. But sending kids to overheated schools could seriously threaten their health. It’s a catch-22.
Adults face a similar problem.
In less well-developed economies, where a higher percentage of the population is employed in labour-intensive work like construction, workers exposed to extreme heat can collapse or even die on the job. But having to down tools when temperatures reach above 40 or 50 degrees – and potentially miss out on earnings – could also be a death sentence.
A recent study found that the world’s wealthiest regions, including Europe and North America, experienced an average 1.5 per cent loss of GDP per capita per year due to extreme heat.
By comparison, low-income regions – such as India and Indonesia – recorded a 6.7 per cent GDP per capita loss yearly.
What’s the answer?
By 2050, temperatures will regularly reach at least 35 degrees in around 970 cities, most of them in Asia, Africa and North America.
As global temperatures and incomes rise, air conditioner sales are poised to increase dramatically too. The number of AC units is set to skyrocket by 244 per cent globally by 2050, according to the International Energy Agency.
However, models predict air conditioning will remain a luxury available largely to high-income households.
At least 80 per cent of the world’s richest 10 per cent households will have air conditioning by 2050, compared with between 2 per cent and 23 per cent of the poorest 10 per cent, Dr De Cian of the University of Venice told The Telegraph.
But some places are already tackling the inequality problem head-on.
One county in the US state of Arizona, where temperatures have reached over 40 degrees this summer, has rolled out ‘cooling hubs’ for residents who can’t afford to run their AC.
A similar initiative is taking place in Tower Hamlets, East London, where a handful of day centres have opened as ‘cool spaces’ for the homeless this summer.
A clinic in Delhi became the first to set up a heat stroke emergency room this year, where doctors douse patients – mainly men working in small, poorly-ventilated factories – in ice to try and bring their body temperatures down.
Others take their own initiative. Take a drive through Bangkok’s heaving city centre and you’ll see hoards of people stuffed into shopping centres – not to buy new clothes, but to benefit from the industrial AC.
For most, however, there will still be no way to avoid the suffering brought by heat waves.
“Air conditioning in many parts of the world has to be at least part of the solution, there aren’t any great alternatives. We need more innovation to figure out how to make AC more energy efficient, cheaper, and better,” said Prof Davies.
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