Malawi has one of the highest rates of death among infants and the under-fives (69 and 110 per 1000 live births respectively in 2009) despite having made progress towards meeting the Millennium Development Goal of reducing child mortality.

Pneumonia is the leading cause of death and one of the commonest causes of morbidity: around 300 per 1000 children under the age of 5 are diagnosed with pneumonia every year.

Exposure to smoke produced when biomass fuels (animal or plant material) are burned in open fires is a major avoidable risk factor for pneumonia.

In Malawi, where at least 95% of households depend on biomass as their main source of fuel, biomass smoke exposure is likely to be responsible for a substantial burden of this disease.

Smoke from burning biomass in open fires also causes other health problems including chronic lung disease, lung cancer, heart disease, stillbirth, and low birth weight; it is also thought to be an important driver of global climate change.

The problem of biomass smoke exposure is seen across Africa where around 700 million people burn biomass fuels to provide energy for cooking, heating, and lighting.

The problem extends right around the globe where around half the world’s population is dependent on biomass fuels for their day-to-day energy requirements.

Around 4 million people die every year around the world from the effects of biomass smoke.


There are now particularly efficient biomass-burning cookstoves that substantially reduce smoke emissions and exposures.

Some of the more advanced biomass-burning cookstoves reduce emissions by as much as 90% by incorporating technologies (e.g. fans) that improve combustion efficiency.

Other ways of reducing biomass fuel use and smoke exposure include cleaner fuels, better ventilation, and changes in cooking behavior.

Access to smoke exposure reduction technologies is limited by poverty in much of the developing world.

The Global Alliance for Clean Cookstoves (GACC) was launched in 2010 to tackle the lack of access to clean affordable energy through public-private partnerships.

A central aim of the alliance is for 100 million homes to adopt clean and efficient stoves and fuels by 2020.


The trial will be conducted in rural Malawi.

150 villages will be randomly assigned to an intervention or control group.

In the intervention villages, all households with a child up to the age of 4.5 years will receive two Philips fan-assisted stoves to fully replace their traditional cooking methods (mainly open fires).

In the control villages, all households with a child up to the age of 4.5 years will continue with their traditional cooking methods.
Included villages will stay in the study for 2 years.

The main outcome of interest is pneumonia in children under 5 years of age.

Other outcomes include measures of air pollution and economic and social impacts of the stoves.