Short-term PM2.5 exposure disproportionately increases pediatric ambulance dispatches among girls and children under age five in India

Abstract Exposure to fine particulate matter (PM 2.5 ) remains a major driver of healthcare system strain in India, where annual concentrations average 48 μg/m 3 -nearly tenfold the WHO guideline. To examine how short-term PM 2.5 exposure affects acute healthcare utilization, we merge daily high-resolution PM 2.5 estimates with 1.1 million pediatric ambulance dispatch records across 11 states and union territories, and apply a two-stage fixed-effects instrumental variable approach leveraging thermal inversion duration to isolate exogenous variation in pollution. We find that a 10 μg/m 3 increase in PM 2.5 leads to same-day increases in ambulance dispatches of 3.78% (95% CI: 2.56–5.20) for all causes, 3.25% (1.58–4.84) for illness, and 6.07% (2.84–9.17) for injury. Cumulative seven-day effects remain elevated for all-cause (2.33%, 0.72–4.18) and illness (2.60%, 0.82–4.72) dispatches, indicating persistent impacts on emergency care demand. Girls experience disproportionately larger increases -5.41% (3.01–8.35) versus 2.38% (0.18–4.04) in boys-likely due to delayed care-seeking, greater baseline vulnerability, and higher exposure to non-accidental trauma. Children aged 0–4 years show the largest and most sustained increases in dispatches, whereas older children exhibit attenuated or null responses, reflecting age-related differences in susceptibility and access. Reducing annual PM 2.5 to India’s national guideline (40 μg/m 3 ) could avert 20 (6-35) pediatric ambulance dispatches per 100,000 children annually-a 10.1% reduction; achieving the WHO standard (5 μg/m 3 ) could prevent 65 (21–111)-a 32.8% reduction. These findings underscore the urgent need for targeted air quality improvements to reduce acute healthcare burdens and strengthen emergency response capacity in India’s strained healthcare system.