It’s 11 below (-24C) outside but the stove is burning and baby Almasbek Toltalkhan is warm in his family’s yurt. His mother, Nursaule, scoops him from a crib engraved with pictures of coconut palms and joggles him on her knee while the doctor readies his shot.
At 11 months old, Almasbek is just past the nebulous state of babyhood. He cannot say ‘mom’ or ‘dad’ but knows bainuu, the greeting with which Mongolians answer the phone, and he wears tartan felt pajamas. He also has a pug-like wheeze on every out-breath and has been hospitalized eight times since birth.
“Our youngest is sick very often,” says Nursaule, 25, who like many Mongolians goes by her first name. Almasbek was initially diagnosed with bronchitis in September. Pneumonia followed, and the family ended up spending most of November and December in hospital. “We would go to the hospital for ten days of treatment. Then after four or five days at home, we would have to go back again,” she says. “Last time they took him into intensive care.”
Pneumonia is now the second-leading cause of death for children under five in Mongolia. In Ulan Bator, the capital, respiratory infections have increased at a rate of 270% over the last 10 years and children living in the city have a 40% lower lung function than those living in rural areas, according to UNICEF.
In 2016, Ulan Bator overtook both New Delhi and Beijing as the capital with the highest air pollution levels in the world. The city’s topography is one factor: like Beijing, Ulan Bator was built in a river valley and surrounding mountains trap smog like soup in a pan. The extreme climate is another cause. In the world’s coldest capital, the average January low is 27.4 below (-33C) but temperatures can dip beneath -40, the point at which Fahrenheit and Celsius intersect.
Locals say winter air pollution was barely noticeable until the mid-2000s. Now, the city has among the world’s highest peaks of PM2.5—the ultrafine particles that can carry carcinogens such as arsenic and mercury and are small enough to permeate most of the body’s defensive filters. In late January, a government-installed sensor reported a PM2.5 per cubic meter rate of 3,320 in parts of Ulan Bator. That’s 133 times the level the World Health Organization (WHO) deems safe.
Mongolia is one of many urban centers, especially in developing countries, that are struggling with toxic levels of pollution as industrial emissions, automotive exhaust, and chemical releases rise. Pollution is responsible for an estimated 9 million premature deaths, or one in six of all deaths worldwide, according to an October 2017 study published in the medical journal The Lancet. More than 90% of those fatalities occurred in low or middle-income countries.
Pollution is a serious issue in cities in Africa and South America, but Asia is where the problem is most alarming. Delhi’s chief minister Arvind Kejriwal recently described his city as a “gas chamber” and pollution caused a staggering 2.5 million deaths across India in 2015. In China, the Lancet study estimates, pollution killed 1.8 million people the same year. In response to the health crisis, Beijing in 2017 canceled plans to build more than 100 new coal-fired power stations, improving air quality in the capital.
Ulan Bator’s air quality is less intensely polluted than Beijing, Karachi, Dhaka or Delhi when measured annually. But health officials say the extreme peaks in PM 2.5 levels during the winter are unlike those seen anywhere else—and that young children like Almasbek stand to suffer from it the worst. In February, with off-the-charts levels of pollution, UNICEF Mongolia warned of a looming “child health crisis.” The toxic air could be snuffing out lives in Mongolia even before they begin; preliminary data suggests a 3.5-fold increase in fetal mortality rates between summer and winter and a near-perfect correlation between stillbirths and air toxicity.
“People don’t really want to see what the potential impacts could be, they close their eyes,” UNICEF’s Mongolia Representative Alex Heikens tells TIME. “We really need to start talking about Mongolia — more than half the population is at risk.”
In Nursaule’s yurt — or ger as Mongolia’s nomadic tent-like homes are known locally — the doctor has arrived. The treatment for Almasbek’s most recent bout of pneumonia requires him to receive an injection of antibiotics every eight hours. The shots are usually administered by a neighbor, who once worked as a cleaner in a hospital. Today though, the visiting doctor flicks the syringe for air bubbles; Almasbek, distracted, fists a hunk of bread toward his mouth; Nursaule yanks down his pants. The swab. The shot. The squeal.
Nursaule’s eldest son, 4, and her daughter, 2, were born in a rural province and have few health problems. But because of his difficulty breathing, city-baby Almasbek is entirely confined to the ger. Nursaule does not fry food inside and gets up three times in the night to put coal in the stove to keep him warm. Despite this, she fears, the damage may already have been done: “When I was pregnant, I did not stay in fresh air. I was mostly in the city.”
Nursaule and her husband Alpysbai quit the Mongolian steppes where their parents herd livestock for a better life in the capital. They are not alone. A complex mixture of social and environmental factors have made nomadic life more difficult, and better schools, hospitals, and job prospects have drawn former herders to the city. Over the past three decades, around one-fifth of Mongolia’s entire population has relocated to Ulan Bator, doubling the city’s physical footprint and loading stress on the urban environment. New migrants arrive on the slopes surrounding Ulan Bator, which are crammed with tens of thousands of gers and self-built houses—almost all lacking central heating, running water, and plumbing.
Today, Ulan Bator’s ger districts are home to about two-thirds of the capital’s 1.5 million people. Here, rickety fences divvy up hillsides pocked with smoking chimneys, pylons, and long-drop toilets. The sleek hotels of the city center two miles south are invisible behind a pall of smog. On the coldest days, the stoves of hundreds of thousands of ger district homes burn in unison. Together, they use 1 million tons of coal a year. For the poorest families, even coal is too expensive: their stoves burn plastic bottles and rubber tires.
Nursaule and Alpysbai rarely regret moving to the city. For the most part, their circumstances have improved: their eldest is in kindergarten; they own a small plot of land and a partly-built brick house. Still, the question of Almasbek’s health nags. Nursaule needs to keep him warm, but doing so adds to the pollution he breathes. “I miss the fresh air of the countryside,” she says, restocking her stove with coal hefted from a tarpaulin-covered pile outside. “Sometimes you go out and almost nothing can be seen. It’s scary.”
Babies and young children are especially vulnerable to pollution because they have small lungs, breathe more rapidly than adults, and their immune systems are not fully developed. For some newborns, their very first breath is toxic: UNICEF staff visiting a western province this winter recorded PM2.5 levels 14 times higher than the WHO’s safe level—inside a hospital’s maternity ward.
The harm this does goes way beyond asthma and breathing difficulties. Airborne chemicals not only complicate pregnancies and harm babies’ lungs, they can irreversibly stunt brain growth — even while a baby is still in the womb. Dr. Frederica Perera, director of the Columbia Center for Children’s Environmental Health, tells TIME that prenatal exposure to certain toxins can change the structure of DNA or how it expresses itself, which is particularly dangerous because a fetus’ brain develops at such a rapid pace. “Think of it like complex dance choreography. One misstep somewhere could derail the whole program,” she says.
Children exposed to toxins in the womb are more likely to exhibit neurological disorders and behavioral problems, and have lower IQs and disease resistance. “Not only do these very early exposures result in immediate adversarial impacts in children, but then can play out over adolescence, adult life, and possibly be transferred across generations,” Perera adds.
Uugantsetseg Ganbat, an obstetrician and a director of a local family health center, sees the impact of toxic air on the 70 to 90 pregnant mothers that visit her clinic in the ger district every month. Tone—or contraction—of the uterus is a nearly ubiquitous complaint, she says: it can lead to the fetus being starved of oxygen, birth defects, and miscarriages. “There would almost be no single mom who doesn’t have any complications, whose tests are all fine. This kind of normal pregnancy doesn’t exist,” Uugantsetseg tells TIME.
Treating infants diagnosed with respiratory infections has also become complex, Uugantsetseg says: “Nowadays respiratory infections progress very quickly. Treating them is more difficult and sometimes requires a combination of different medicines.”
As a result, medical facilities are dangerously stretched. At a nearby district hospital, a gastrointestinal unit was converted to an additional baby ward with two or three babies to a bed. Doctors at Uugantsetseg’s clinic recently diagnosed a two-day-old boy with pneumonia. Whether he developed the infection in the womb or outside was unclear, she says, but he was blue when his parents brought him in.
Two hours after Almasbek’s pneumonia injection, his father Alpysbai’s cobalt blue Hyundai truck pulls up outside their ger. At the black market down the hill, where a graveyard of rusted construction cranes separates secondhand Korean and Russian trucks, vendors hawk snow-dusted timber piles, sacks of coal, and used auto parts.
Selling his truckload of coal at the black market has afforded Alpysbai precious hours with his family. He removes his boots with soot-caked hands, plays with his three children, and eats from a plate of horse meat and potatoes. Less than two hours later, Alpysbai’s cousin calls and it’s time to leave for Mongolia’s largest illegal coal mine. He won’t return until around 5am the next day—when he will sleep for two or three hours before driving the night’s haul back down to the black market.
Alpysbai knows that the coal he sells contributes to illnesses in children, but sees no other choice. “When I see my son getting sick all the time, I sometimes regret moving to the city,” he says, “but my income from herding wasn’t enough. We moved to Ulan Bator for the children’s future. I myself did not study in a university. But I want my children to study in a big university.”
After a back injury forced him out of a construction job, Alpysbai spent his savings on the secondhand porter truck: in summer he sells pebbles and sand to builders; in winter, coal. One porter’s worth from the nearby Nailakh mine—which supplies 70% of the ger district’s coal—sells for about $100 and heats a home for two months, he says.
But digging it from the ground is perilous. Officially, 12 miners die every year at Nailakh, where only a handful of some 200 mineshafts are legal to enter. But with many artisanal miners like Alpysbai arriving clandestinely at night, it’s impossible to know how many bodies are buried beside the coal seams. Not many tunnels have timber supports, and few miners can afford ventilators. Still, Alpysbai considers himself lucky to even have a job. “If I am in good health, my children’s future will be fine,” he says. “If I get sick and become unemployed, the future will not be bright for them.”
Coal and other commodities once meant bigger business in Mongolia. The country became the world’s fastest-growing economy in 2011 on the back of a mining boom — and some began calling it “Minegolia.” It recorded double-digit GDP growth the following two years and the World Bank at the time said the country was “at the threshold of a major transformation driven by the exploitation of its vast mineral resources.” But the boom proved short-lived and although designer boutiques and glass and steel hotels went up in the capital, few Mongolians felt the benefit of the promised transformation.
When metal prices collapsed and China’s coal demand slackened, the value of Mongolia’s currency plummeted, national debt soared, and foreign investment calcified. From a high of 17.3% GDP growth in 2011, Mongolia posted 1% growth in 2016. A Louis Vuitton store that had opened in 2009—with a bespoke herders’ saddle and caviar case as its centerpiece—shuttered last July. Social projects — like a 2013 Mongolian parliament-approved master plan to rehouse tens of thousands of ger-dwellers in new-build apartments connected to the grid—also stalled.
Mongolia has taken some steps to address its air pollution crisis. A World Bank-backed project to replace ger stoves with cleaner burning models temporarily improved air quality, but implementation problems and an influx of new migrants meant its gains were quickly undone; last year the Mayor of Ulan Bator put a freeze on the city registering new arrivals until 2020.
But until a lasting fix for Mongolia’s social challenges can be found, mothers like Nursaule will be forced to burn coal to keep their gers warm, fathers like Alpysbai will risk their lives underground—and babies like Almasbek will struggle to breathe.