As pollution worsens in the Indian capital, parents are facing an impossible choice: stay or go.

Amrita Rosha, 45, is among those choosing to flee with her children. Both of them — Vanaaya, 4, and Abhiraj, 9 — suffer from respiratory problems due to rising pollution and need medication.

Every year for the past decade, a blanket of smog has enveloped Delhi when winter approaches, turning day into night and disrupting the lives of millions of people. Some of them, particularly young children with less developed immune systems, are forced to seek medical care for breathing issues.

Rosha ensures her children get top health care — including doctors’ visits, steamers, inhalers and steroids — and trips outside Delhi to escape the choking air.

While wealthy families like the Roshas can escape, it’s a different story for those without the means to leave.

About 15 miles away in a Delhi slum, Muskan, who goes by her first name, looks on with worry at the remaining medicine drops for her children’s nebulizer, a machine which turns liquid medication into fine mist to be inhaled through a face mask or mouthpiece.

The mother rations its use because she struggles to afford more.

“We give half-half (of the dosage) of the medicines to our children,” she said, referring to Chahat, 3, and Diya, 1. They’ve been on nebulizers since each of their first winters, as early as they were born.

Muskan bought the $9 nebulizer after weeks of hard work on the streets. She makes a living picking up rags and other pieces of refuse, and her husband is a day laborer.

“When they cough, I feel scared that my children may die. I’m filled with regret, as I keep worrying about something awful happening to them,” she said.

Leaving Delhi

The suffering of Delhi’s children, year after year, has become impossible to ignore.

“Children are having to rely on steroids and inhalers to breathe … all of north India has been pushed into a medical emergency,” Delhi’s Chief Minister Atishi, who goes by her first name, said last month.

The Supreme Court has stepped in to monitor the measures introduced to curb pollution, which is generally caused by a combination of factors including vehicular emissions, crop burning and construction work, along with unfavorable meteorological and climatic conditions.

This has included banning cars, demolition and construction work, and spraying roads with water. Authorities have also increased public transport and cracked down on crop burning.

Despite these measures, Delhi has remained the most polluted city across India in November for eight years, according to the Centre for Research on Energy and Clean Air.

Manjinder Singh Randhawa, a doctor in the pediatric intensive care unit at the Rainbow Children’s Hospital, said this year he has been diagnosing younger children with asthma in “a very critical state” for the first time.

In the long-term, pollution can have a serious impact on the respiratory, immune and cardiovascular systems, he added.

In some parts of Delhi last month, pollution levels exceeded 1,750 on the Air Quality Index, according to IQAir, which monitors global air pollution. Any reading above 300 is considered a health hazard.

During these weeks the pollution levels for PM 2.5, smaller particles which can penetrate deep into the lungs, spiked to more than 70 times the health limits set by the World Health Organization. It was over 20 times that level this week. Studies indicate that inhaling PM 2.5 can lead to cognitive impairment in children.

A costly escape

Some parents, like Deepthi Ramdas, prioritized their children’s health and relocated years ago. When her son Rudra was born three years ago, she did not think leaving Delhi would ever be on the cards. But that changed when she saw him admitted to a pediatric intensive care unit in January 2022.

The doctors told her she should leave Delhi if she wanted her son’s lungs to develop, Deepthi recalled. Since she had family in the southern state of Kerala, she decided to go.

“It was not an easy decision. I had to quit my job which I loved… and because my husband had to continue to be in Delhi for work… we got into a long-distance marriage,” she said.

But Deepthi finds relief in knowing Rudra has had no breathing issues in Kerala. They visited Delhi in the first week of December to meet their father. “We hoped since he is 3 now (that) his lungs would be stronger, but within a few days Rudra had an attack and was on nebulizers again,” Deepthi said.

“Looking at him like that was heartbreaking. There is no way I am moving back to Delhi,” she said, sharing pictures of Rudra from when he was in hospital in 2022 to him playing outdoors in Kerala in October.

Anxiety in the air

Many parents in Delhi are living under anxiety fueled by their inability to escape the city due to work and other commitments.

When Urvee was expecting, she recalls her husband, Prateek Tulsyan, responding to news of pollution by saying he’d ensure there were enough air purifiers at home to protect his child. However, nine months after delivery, Reva had her first attack.

Urvee added: “I am constantly checking her temperature, do not allow her to go out or eat anything that may exacerbate her condition. I am now an over-protective parent.”

If she hears Reva sneeze, she knows a cough is coming, followed by congestion and then the need for the nebulizer.

Urvee said they’ve decided to move to Guwahati, northeast India, where the air quality is better, during the high pollution months next year.

“I am born and brought up here, comfortable here, so to create another home there won’t be easy but we have no choice,” she said.

No way out

Muskan and her neighbors in the Delhi slum are not as fortunate.

She runs to the shared nebulizer when her children show symptoms like chest pain, coughing or vomiting. She says the children ask for it themselves and use it with practiced precision. But not everyone is able to afford to have the machine at home.

Some of her neighbors rush to the nearest private clinic and pay about 80 rupees or $1 for each treatment.

One of them is Deepak Kumar, a daily wage worker with four children. His youngest and only daughter, Kripa, 1, is using a nebulizer for the second consecutive winter season since her birth.

“The doctor asked us to buy it, but we do not have that kind of money,” he said.

One visit to the doctor costs more than his daily wage.

Nights are the worst. When there are no doctors available, he relies on balms and steam to help his daughter get through the night. Even when she is sleeping well, the mounting debt due to medical expenses keeps him awake.

“Yes, I am in debt of 20,000 rupees ($235) and to pay that off I am trying to work even harder,” he said.

Many like Kumar have come to Delhi from different parts of India to seek a better life, but they’re stuck.

“It should not be so hard to live in the capital,” he said.