Infertility, Asthma, Lost Productivity: India's Cities are Too Sick to Power its Growth

Neha and Raghav (name changed), a corporate couple living in Gurgaon, had spent five years trying to conceive. Long working hours gave way to weekend visits to doctors, and gradually, fertility treatment began to shape the purpose of their lives.

The couple went through seven failed in vitro fertilisation or IVF cycles, spending nearly ₹14 lakh along the way. Yet every report suggested that nothing was wrong.

The answer emerged only when their doctor ordered a more comprehensive set of tests. The results revealed high DNA fragmentation in the sperm, a condition that can compromise fertility.

There appeared to be no obvious lifestyle factor to explain the finding. One possibility stood out though. The couple lived in Delhi National Capital Region or NCR, where persistently high levels of air pollution could be damaging sperm DNA and making conception more difficult.

Their case, as per health experts, is not as unique as it seems.

“There is a growing trend in the number of patients coming to fertility units for treatment,” says Dr Prachi Benara, IVF specialist at Birla Fertility and IVF. “Earlier, a single IVF cycle might have been sufficient. Now, with rising pollution levels and declining gamete quality, achieving success in one cycle has become increasingly difficult, making the process far more expensive.”

India’s pollution, having been normalised and accepted as part of routine life, has now become a threat to the existence of life itself and that too, at the most fundamental level.

A 2024 study published in Reproductive BioMedicine Online found a clear association between rising levels of air pollution and declining sperm quality. In areas with moderate pollution, a rise in pollution was accompanied by a significant increase in abnormal sperm and an 8.8% decline in normal sperm compared with populations living in less-polluted regions. In highly polluted areas, the gap widened further to 11%.

Perhaps it is safe to say that, from birth through life, Indians today are not getting away with pollution at any stage. On one hand, while pollution is coming in the way of children being born, it is taking a different toll on the other, those who came into being before its cruelty began.

A few kilometres away from Gurgaon, in Delhi’s Nirman Vihar, eleven-year-old Aman (name changed) represents his school cricket team for only part of the year. Each winter brings an unwelcome interruption for the asthmatic boy. The season arrives with a persistent cough, breathlessness and night-time flare-ups, often severe enough to send him to hospital once or twice during the months when pollution hangs heaviest over the city.

But Aman was not always like this. This change in Aman’s health coincided with a change of address.

Until he was five, he lived in Bikaner, Rajasthan, where he remained largely free of asthma symptoms. His problems began after his family moved to Delhi NCR following his father’s transfer. This move for work became a choice of regret for the family, as each winter brings back the symptoms that had never been a part of Aman’s early childhood.

Aman’s family is having it equally worse, watching his treatment costs climb with every passing winter.

To be sure, health-care expenses in India are already a matter of great concern for public well-being, with pollution now rubbing salt into the wounds of households, especially those that are not far from the verge of falling back into deprivation.

India’s per capita out-of-pocket expenditure, a measure of how much each person pays directly for health care on average, which had fallen 10.2% from ₹2,336 in 2013–14 to ₹2,097 in 2017–18, has been on the rise once again. It has since shot up by 32% to ₹2,767 in 2022–23, just as when pollution levels also continue to remain high across the country.

“If current pollution levels persist, households in metro cities will face rising financial strain through recurring medical expenses,” says Anumita Roychowdhury, executive director, research and advocacy, Centre for Science and Environment.

“Doctor visits, medicines and long-term treatments are significantly increasing the cost of living,” she adds.

One way or the other, those born without the luxury of avoiding exposure to a toxic environment that kills a human being a little everyday are paying a hefty price for no fault of their own.

Worse still, they are paying for it in cities they migrated to, leaving behind their safer towns and villages; ironically these urban hubs are the same places where India hopes to build the foundation of its economic glory.

Choked Cities

Once seen as gateways to prosperity and dignity, India’s top-tier cities are today slowly taking away the same from those who came to them in search of a better future. The country’s economic hubs, magnets for millions pursuing opportunity and happiness, are also among the most-polluted urban centres in the world.

As things stand, 13 of the world’s 20 most-polluted cities are in India. In fact, no major Indian city was found to have “good” air quality, according to a 10-year assessment of air pollution across major urban centres by Climate Trends, an environmental-research firm.

None of the country’s top cities, including Delhi, Mumbai, Chennai, Bengaluru and Ahmedabad, met safe Air Quality Index, or AQI, levels at any point between 2015 and November 2025, adds the report.

Ironically, the national capital sits at the centre of this crisis. Delhi is among the world’s most polluted major cities, with concentrations of particulate matter, or PM2.5, reaching nearly 20 times the level recommended by the World Health Organisation. These fine particles, measuring 2.5 micrometers or less in diameter, doctors explain, can travel deep into the lungs and enter the bloodstream, increasing the risk of a range of serious illnesses.

Even in places where it is not as bad as Delhi, the situation is far worse than what human life should have to tolerate.

For instance, Mumbai had its own fair share of global shame when tech multi-millionaire Bryan Johnson walked out of entrepreneur Nikhil Kamath’s podcast last year, citing poor air quality. This was him despite wearing an N95 mask inside a five-star property. That day, the AQI in India’s commercial capital, which by the way sits by the sea, was recorded at about 10 times the level in California, where Johnson lives.

“Air pollution has been so normalised in India that no one even notices anymore despite the science of its negative effects being well known,” Johnson wrote in a post on X, explaining his walkout.

Here, one would be severely mistaken to think that India’s top cities, in return for the opportunities they provide, are taking their toll only through the air. As the evergreen poet and playwright William Shakespeare put it so well in his classic Hamlet, “When sorrows come, they come not single spies, but in battalions.”

As it turns out, the water in these cities is not drinkable either.

In a striking revelation last year, around 13–16% of Delhi’s groundwater samples were found to contain uranium, a naturally occurring radioactive element used as fuel in nuclear power plants, at concentrations exceeding the permissible drinking-water limit set by the Bureau of Indian Standards, according to the Annual Ground Water Quality Report 2025.

Similarly, in the south, a series of studies revealed that at least four of Hyderabad’s six major water supply sources, catering to about 80% of the city’s drinking-water requirement, are critically polluted. Before these individual cases came to light, a NITI Aayog report in 2018 had raised alarm bells across the country with an estimate of about 70% of India’s surface water being polluted and unfit for human consumption.

In response, experts now believe it is high time pollution was seen as an epidemic in India.

“With such high levels of air and water pollution, we are making the cities that are supposed to drive India’s economic prosperity increasingly unlivable,” says Vishal Dagar, assistant professor of economics at Great Lakes Institute of Management (GLIM). “While pollution and Covid-19 are not directly comparable, evidence suggests that pollution causes greater cumulative mortality, more years of life lost and higher economic costs, making its toll equally tragic.”

Indore, the country’s supposedly cleanest city, has already faced a tragedy that should unnerve the nation, with sewage waste entering drinking-water supply. In December last year, at least 22 people, including an infant, died in its Bhagirathpura locality in what has now become a grim record of India’s water-contamination disasters.

What made this water crisis particularly more painful is that Indore also serves as a key economic centre for Madhya Pradesh, just as several other polluted cities are vital to India’s economic growth.

It is in these cities that the hopes and future of a developing India lie. But what economic hopes will they fulfil if they cannot even provide clean air and water, a necessity for human survival?

In other words, India’s pollution crisis is as much an economic crisis as it is a health crisis, which requires immediate policy attention.

Belittled by Beijing

Last winter, as pollution was at its peak in Delhi, Yu Jing, spokesperson for the Chinese embassy in India, posted a note on X saying that China, like India, knew the struggle with pollution all too well and had made serious efforts to tackle it, from which India could learn.

Interestingly, she shared screenshots of air quality readings over Beijing and its surrounding areas and over Delhi NCR. The difference between the two readings was both insulting and deeply worrying at the same time. Beijing recorded an AQI of 68, indicating moderate air quality, while Delhi NCR registered at 447, which falls in the hazardous category.

“In the coming days, we’ll share a bite-sized series exploring how China tackled air pollution, step by step,” Jing said in the post. It obviously felt less like a friendly suggestion and more like a taunt directed at Indian officials, delivered in the pointed style of Chinese diplomatic messaging.

Indian officials, meanwhile, have long been uncomfortable with comparisons with China. This is because, unlike India, China does not operate under a democratic political system. Beijing exercises a degree of control over businesses and economic activity that New Delhi gave up decades ago in its pursuit of a more open, market-oriented model of capitalism.

“It is hard to take lessons from China, which is not a democratic country,” says Arvind Virmani, former NITI Aayog Member and chief economic adviser (CEA).

Yet even within a democratic and market-oriented model, it is worth asking whether the Indian government and industry have got the basic policy actions right when they were needed, especially when ordinary children, elderly people, women and men have been losing days from their lives to pollution.

Look no far, the answer lies in Delhi itself. India’s capital was never born the polluted city that it is today. It was made one through decades of unchecked urbanisation.

According to various studies, PM2.5 in Delhi comes from a range of sources, including transport, industry, households and neighbouring states. Still, vehicular emissions alone have been estimated to contribute around a quarter of ambient PM2.5 in Delhi during winter.

Now, just look at the scale of Delhi’s vehicle problem. At more than 1.5cr, the number of registered vehicles in Delhi is more than the combined total of registered vehicles in Mumbai, Kolkata and Chennai. Even if one goes back in history, the direction of travel was visible much earlier. By the turn of the millennium, Delhi had 34.23 lakh registered vehicles, far exceeding Mumbai’s 9.7 lakh and Chennai’s 11.5 lakh.

A timely transition to electric vehicles (EVs), therefore, should have been a natural part of the response. Yet experts argue that India’s recent awakening to electric mobility came far too late.

While India has moved towards EV transition through measures such as incentives under the production-linked incentive scheme for automobile manufacturers and Delhi’s own EV policy, China has already emerged as the world’s largest EV market and manufacturing hub.

What began there as part of an effort to address pollution has also grown into a major industrial opportunity, with China accounting for nearly three quarters of global electric-car production in 2025.

“India is way too late in the transition to electric mobility. It should have happened more than a decade ago,” says Venugopal Garre, managing director and India head of research at brokerage Bernstein, who listed suggestions for India’s next policy actions in a letter to Prime Minister Narendra Modi earlier this year. “Instead, policy hesitation and industry resistance delayed the progress.”

“Worse, we are giving incentives to cash-rich incumbents who should be held responsible for driving the transition,” adds Garre, arguing that even though it is late, India’s EV push is happening half-heartedly by not providing stronger demand side support to increase adoption and phase out internal combustion engine or ICE vehicles.

A Broken Model

With India still playing catch up in EVs, governments today are left with little more than ad hoc measures.

Delhi Chief Minister Rekha Gupta recently announced that the Delhi Municipal Corporation would be provided a grant to procure 30 EV-based mechanical road sweeping machines to expand mechanised cleaning to smaller roads where the facility was currently unavailable, with road dust being considered a significant source of particulate pollution.

Experts, however, don’t seem impressed. “Traffic restrictions and electric road sweepers may help under specific conditions, but they cannot address emissions from power generation, industry, construction, road dust, waste burning, and regional transport,” says GLIM’s Dagar, who studies environmental economics.

This is where India’s growth model feels absolutely broken.

Consider this: estimates suggest that industry, including the micro, small and medium enterprises (MSMEs) and cash-rich corporations, is the leading contributor to air pollution in India and accounts for a significant share of the country’s water pollution.

More importantly, most of the time, these businesses make their profits while paying little regard to the environment. Earlier this year, a peer-reviewed study authored by researchers at Madras School of Economics found that only 4.48% of factories in India’s organised manufacturing sector reported expenditure on pollution-control equipment in 2022–23.

Yet, a familiar fear holds the government back from taking any substantial action against the industry. “There is a difficult trade-off for policymakers, where weak enforcement allows pollution to persist, enforcing environmental regulations risks job losses and economic slowdown,” says Abhishek Saxena, former public-policy expert at NITI Aayog.

For perspective, if we look at MSMEs, although they operate on thin margins, they form, in many ways, the backbone of India’s industrial economy, accounting for approximately 35.4% of manufacturing, 48.58% of exports and 31.1% of the country’s gross domestic product (GDP). Further, with over 7.47cr enterprises employing more than 32.82cr people, the sector holds its position as the second largest employer after agriculture.

The corporate sector, meanwhile, accounts for about half of the gross value added in the Indian economy and is expected to lead India into innovation and channel productivity.

In that context, the government’s Economic Survey this year expressed caution over any “command-and control-approach”, which prescribes emission standards or technology norms that do provide certainty in terms of reducing pollution but “could impose high compliance costs and weaken incentives for innovation.”

And while the survey did favour a measure like a “pollution tax”, CEA V Anantha Nageswaran cautioned against an immediate implementation, saying, “It’s not that the idea is flawed. But we all know that many things that are conceptually sound and elegant, when translated into practice, are met with the law of unintended consequences,” in an interview with Outlook Business following his presentation of the survey.

In simpler words, it all boils down to the government’s fear that fighting pollution may come at a greater economic cost, just as the country is aiming to become a developed economy. This is a deeply flawed idea, though.

While the Indian economy has never come close to the growth trajectory that China managed to maintain for almost three decades, including annual GDP growth of as much as 15% in the middle of the 1980s, India’s economic activity has made it more polluted, yet without providing the amount of resources required to deal with it.

“Public funding here is a genuine constraint because pollution control in India competes with housing, water, transport, health, education, and climate adaptation,” rues Dagar.

Due to this, governments end up blaming each other, society ends up blaming seasonal triggers such as stubble burning and Diwali celebrations, while policy discourse ends up missing the woods for the trees.

Slow Poison

In January this year, several Indian central and state government officials gathered at the World Economic Forum’s annual meeting in Davos, Switzerland, making the journey with a uniform objective, to woo investors and uplift sentiment after a series of blows from the US in the form of tariffs had punctured India’s economic prospects.

Yet, amid all the investment commitments announced and the statements made in efforts to project India as an attractive destination for global capital, the headline that resonated most with the Indian public came from former International Monetary Fund deputy managing director Gita Gopinath.

Speaking at the event, Gopinath said the impact of pollution on the Indian economy “is far more consequential than any impact of any tariffs imposed on India so far”. The damage, she pointed out, extends beyond the environment, reaching families, workforce participation and the country’s long-term development.

There is ample evidence to explain that concern.

A recent report by Dalberg, a global consulting firm, estimates that air pollution cost India around $260bn in 2024 alone, equivalent to nearly 6% of the country’s GDP.

But to the common mind, the real scale of that loss becomes clearer only when the bill is broken down.

The biggest cost is people who are at work but are unable to function at full capacity because of pollution-related health problems. This phenomenon, known as presenteeism, cost the economy an estimated $87.2bn. Premature deaths added another $82bn by shrinking the country’s working-age population.

If this is not enough, consider what the government’s short-term responses to severe pollution are doing to workforce productivity and human capital of tomorrow.

Under measures such as the Graded Response Action Plan, physical classes for younger students are frequently suspended and shifted online, while older students move to a hybrid mode of learning.

For children from the most vulnerable households studying in government schools, many of whom lack reliable access to smartphones, laptops or internet connectivity, each closure risks widening an educational gap that already exists.

“Whenever there is any suspension of classes, several of the children do not come back to the school and get engaged in some work, which disturbs their learning and detaches them from education,” says Beetika Upadhyay, a teacher at PM Shri Primary School Ukhlarsi Number 1, a government school situated along the Delhi-Meerut corridor.

Canadian-American economist Alex Tabarrok explained this more clearly just before the Covid pandemic crisis began in India.

“Pollution is an attack on human capital. So, at a time when countries are investing in increasing human capital, pollution is working against them,” he said at a seminar in New Delhi.

Moreover, the damage does not stop at the workforce.

During periods of severe pollution, fewer people venture outdoors, businesses see fewer customers and consumer spending takes a hit, resulting in an estimated $74bn loss in economic activity.

Even absenteeism, which is the problem of workers or students not going to work or school, the relatively smaller cost in this calculation, added more than $3bn to the bill.

To be mindful, cases of both presenteeism and absenteeism have, once again, as much to do with the kind of water being consumed as with the air being inhaled.

Estimates suggest that severe water pollution can reduce GDP growth in downstream regions of middle-income countries like India by almost half.

Studies also find that being downstream of polluted stretches in India is associated with a 9% reduction in agricultural revenues and a 16% drop in agricultural yields.

This essentially means that even though pollution chokes urban dwellers more, it punishes farmers equally through their incomes, extending its economic cost from urban to rural India.

Various studies indicate that air pollutants can settle on crops and affect their growth, while contaminated irrigation water can carry heavy metals and other pollutants into agricultural soil and food crops.

For the marginal farmer, this means dealing with lower yields and poorer quality produce, pushing him into a spiral of low incomes and declining quality of life.

All put together, the fear that stricter environmental policies would entail economic costs is misguided. Pollution silently hollows the economy from within, killing the same economic prospects that policymakers want to protect. It does so like slow poison.

Health is Wealth

There is an archaic folklore in economics that says that even though pollution is an unpleasant outcome, it is the cost that a fast-growing economy must pay to rise to prosperity, much like the US in the West and Japan in the East paid in order to rise to economic glory in a relatively shorter period of time.

India, at the moment, is trying to do exactly the same, so much so that the country plans to add nearly 100GW more of coal capacity in the next decade, at a time when its air is already heavier than the rest of the world, while also building water-intensive artificial intelligence or AI data centres when its people do not even have enough clean water to drink.

This is indeed a moment of rush for a country whose demographic window is about to run out in a couple of decades, leaving it with little time to become rich before it gets old. This is accompanied by a feeling that pollution could be dealt with once the country becomes rich, just the way Western countries did it.

However, for a country whose biggest growth engine is its population and workforce, China has refused to accept the cost of pollution the way India is paying it.

As ever, among the most farsighted of the world’s major economies, China has understood that pollution cannot be allowed to hollow out the workforce and incomes of its people if the country wants to become wealthier and the largest economy in the world.

Its model of development, in which crisis is turned into an opportunity, and public and industrial policy are kept aligned with national interests, has not just produced far higher economic growth than India, but has also provided the country with the means to deal with the pollution that comes out of it.

Economic growth, after all, is no less than the churning of the cosmic ocean in Hindu mythology. It produces both nectar and poison. The question is whether a country has the means and the foresight to deal with the poison while making the most of the nectar.

For India, the choice then is not between growth and environment. Instead, it is between a model of growth that silently consumes the same people who make it possible and one that protects the workforce, incomes and human potential on which prosperity depends.