International Cooperation on Health

Air Pollution and Climate

Dr Carlos Dora
Coordinator
Department of Public Health and Environment

Key messages for mini-campaign

1| Public health and environment

 Cooperation WMO/WHO on Air Quality and Health

Gaps and opportunities:

• Air Pollution and its sources are important risk to health
• WHA resolution – stronger contribution by health sector
• Better data, evidence of effective interventions,
communications to support demand for clean policies
• Capacity to estimate health benefits from policies in
polluting sectors. Track health gains of policy change
• Part of SDGs for health, energy and cities

2| Public health and environment

New evidence over the last 10 years: AP is
a major risk to health
Substantial new evidence showing that particles smaller than 2.5mm
penetrate deep into the lungs and effect the body more systematically
leading to diseases like stroke, heart disease, in addition to the
cancers, COPD and pneumonia/URLI.

PM<10mm – Coarse
Medgadget .com

PM<2.5mm – Fine

PM<1mm – Ultrafine

3| Public health and environment

 Lungs exposed to tobacco and to Indoor air
pollution

Pathology slides - Courtesy Prof. Saldiva, São Paulo, Brazil

4| Public health and environment

 Worldwide NCDs are the main cause
of death

2 in 3 deaths are from NCDs

Cardiovascular disease, mainly heart
disease, stroke
Cancer
Chronic respiratory diseases
Diabetes
Injuries

Costs: Trillions of U$ dollars

5| Public health and environment

 Deaths attributed to HAP + Outdoor Air
Pollution
~ 7 million deaths globally in 2012
AP a main RF for around 1/5 of NCDs

6| Public health and environment

 Currently public health programmes to
reduce NCDs consider only other major
risk factors:

• Tobacco
• Physical inactivity
• Diet (fat, sugar, fiber…)
• Excess use of alcohol

7| Public health and environment

 First World Health
Assembly Resolution on
Air Pollution and Health

7 million deaths a year due to household and

ambient air pollution

8| Public health and environment

 The resolution:
• key role health authorities in raising awareness about the potential to save
lives and reduce health costs, if air pollution is addressed effectively.
• Need for strong cooperation between different sectors and integration of
health concerns into all national, regional and local air pollution-related
policies.
• It urges Member States to develop air quality monitoring systems and
health registries to improve surveillance for all illnesses related to air
pollution;
• It urges Member States to strengthen international transfer of expertise,
technologies and scientific data in the field of air pollution.

Road Map for and enhanced

global response to the adverse
health impact of air pollution –
adoption May 2016

9| Public health and environment

 Carotid artery wall thickness (=risk of atherosclerosis)
and long-term PM2.5 exposure

in artery wall
% change

thickness

AQG Home outdoor PM2.5 (µg/m3) EU LV

Heinz Nixdorf RECALL study, Ruhr region, Germany
10 | Public health and environment
LAQN Seminar, London, 21 June 10 2010
Bauer et al, JACC
2013
 IARC 2012 finding: Diesel a carcinogen

LONDON/GENEVA (Reuters) - The air we breathe is laced with

cancer-causing substances and is being officially classified as
carcinogenic to humans, the World Health Organization's cancer
agency said on Thursday.

11 | Public health and environment

 Ischemic and thrombotic effects of diluted diesel
exhaust inhalation in men with coronary heart
disease
Myocardial ischemia during 15-minute
exercise-induced stress and exposure to
diesel exhaust or filtered air in 20
subjects

Mills et al, NEJM 2007

12
12 | Public health and environment
 Evidence of health impacts of air
pollution – update starting this year
• Normative work
– WHO Air Quality Guidelines:
provide the scientific evidence on the health impacts
of air pollution as well as recommendations on
pollutant levels safe for health

– WHO Indoor air quality

guidelines for household fuel
combustion: provide guidance on policies and
the impact of different fuels/technologies (for
cooking, heating & lighting) on health

– WHO Housing and Health guidelines:

including guidance on indoor air and on household
energy use and energy efficiency with relevance to
AP

13 | Public health and environment

 Indoor emissions
• Outdoor  indoor
• Evidence base stronger
than for other approaches
• Implementation practicality
– via design, production,
standards, etc
• Some options (clean fuels),
are relatively independent
of user behaviour.

14 | Public health and environment

 The home: Household energy
fuels and technologies used
for cooking, heating and
lighting
New Air Quality Guidelines:
1. Use only very efficient
cookstoves (following
emission rates provided by
WHO)
2. Don't use Kerosene
3. Don't use Coal
4. Use clean fuels – LPG,
Biogas, ethanol…

15 | Public health and environment

 Model linking emissions to air quality
Inputs:
Outputs:
• Emission rates:
• Predicted
– PM2.5
average
– CO
concentrations
• Kitchen volume of:
• Air exchange – PM2.5
rate – CO
• Duration of use
(hours per day)
Assumes uniform mixing of pollutants and air in kitchen

16 | Public health and environment

 Release 17th March 2016

A first global review of

household lighting
• A major proportion of African households rely
primarily upon highly-polluting kerosene and about
a third in South-East Asia use kerosene.

• Only an extremely low proportion of households use

primarily PV for lighting, although household level
data on renewables needs improvement.

17 | Public health and environment

 African girls in homes with polluting
cookstoves spent long hours weekly
collecting fuel, while boys spent a bit less,
but in homes using cleaner stoves and fuels,
only a few hours are spent collecting wood
(the gender difference persists)

A larger number of
people still rely upon
biomass, coal or
kerosene for cooking.

18 | Public health and environment

19 | Public health and environment
 WHO guidelines – forthcoming
Energy-efficient homes reduce air pollution & other
housing risks such as...
Housing risks Health impacts
• Indoor/outdoor air pollution • Chronic/acute respiratory disease
• Damp, mould & allergens • Allergies, asthma
• Poor indoor ventilation • Other NCDs
• Inefficient insulation/energy system • Cold exposures – morbidity/mortality
• Planning, transport access • Water and sanitation-borne disease
• Urban waste, sanitation & water • Heat strokes
• Heat Island • Injuries
• Storms/flooding

20 | Public health and environment

 Sources
Health care facilities
Diesel generators
in homes and in
health care:
CO poisoning
high PM levels
Unreliable energy source

21 | Public health and environment

 The energy gap in health care in developing
countries
% of Health Care Facilities with No Electricity Access
Uganda (2007) 58%
Tanzania (2006) 50%
Guyana (2004) 38%
Sierra Leone (2012) 35%
Ghana (2002) 31%
Nigeria (2011) 30%
Kenya (2010) 26%
Bangladesh (1999-00) 23%
Zambia (2005) 20%
Rwanda (2007) 18%
Ethiopia (2008) 14%
Namibia (2009) 4%
Egypt (2004) 1%
Gambia, The (2004) 0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

22 | Public health and environment

 Access to clean/sustainable energy in
Health Care
• Energy efficient medical technologies
• Substitute diesel generators for sustainable sources (solar, hydro…)
• Access to sustainable transport
• Energy efficient buildings …

Solar suitcase powering a health Solar powered refrigerator in

care facility in Nigeria. Vietnam.
23 | Public health and environment
 Low energy medical devices – in resource
constrained settings
• LED lighting – for better visual
management of patients
• Battery-powered ultrasound –
enables early treatment of multiple
births, breach births, and placenta
previa
• 1-3 Watt fetal heart monitors -
identify and manage birth
complications
• Digital blood pressure devices –
hypertension management

Including energy in WHO pre-

qualification of medical
technologies
24 | Public health and environment
 Tiers of functionality in
health systems – defining
energy needs
25 | Public health and environment
 Integration of land use and transport define the
“shape” of a urban growth as energy “obese” or
Sources “trim”

Suburban USA

Coyoacan, Mexico City

26 | Public health and environment

 The Geometry of Housing Densities-Transport Energy
Medium density (European)
cities achieve largest energy
efficiency gains in comparison to
North America.

Longer vehicle travel distances =

more pollution emissions –
although tailpipe controls may
mitigate some emissions.

Public transport systems are less

efficient in low-density/sprawl –
destinations are too dispersed. So
patronage declines sharply.

Source. WHO, 2012/International Association of Public Transport , 2005

27 | Public health and environment

 Housing Density – also a determinant of home energy
efficiencies, e.g.
Multi-unit buildings share walls, utility points and energy systems
Planned, multi-unit development is an also an entry point for scaling up resilient,
energy-efficient building technologies
– Cities with higher densities and mixed residential/commercial neighborhoods had
significantly lower CO2 emissions than suburban areas with strictly separated zones.
(Glaeser & Kahn, 2008)
– In Toronto, a low-density suburban development used 2.5 X more energy than a
condominium development in the centre city (Norman J., et al 2006)
Many developing cities, however, also are growing horizontally - in low-density
extremes of slums and suburbs – the latter pictured below.

New suburb in China Guragaon, India

28 | Public health and environment

 Integration of housing, services/schools and
recreation reduces travel & promotes active
travel
• Land use planning one of most effective measures to promote physical
activity (WHO, 2009)
• & reduce pollution: e.g. schools within walking distance to homes –
reduce CO2 emissions by 12%; shrinking business-home distance by
20% in Santiago, Chile (Barias et al, 2005)

Copenhagen Zona Rosa, Mexico City

29 | Public health and environment

Sources Sustainable transport health benefits

• Reduce air pollution

• Increases physical activity
• Reduces traffic injury
• Frees urban road/parking for
green spaces
• Facilitates more equitable access
to mobility
• Eases movements of elderly,
children, disabled, women
• Promotes social cohesion in local
communities

30 | Public health and environment

 Tracking
• Air pollution exposures and trends
• Health impacts of air pollution
– Sentinel health outcomes
• Sources of air pollution
• Mitigation policies – adoption,
enforcement …
• Air pollution related disease trends

31 | Public health and environment

 SDG 3: Health
Goal 3 Ensure healthy lives and promote well-being for all
at all ages
Target 3.9 By 2030, substantially reduce the number of deaths and
illnesses from hazardous chemicals and air, water and soil
pollution from contamination.
Target Proposed Indicator

3.9 3.9.1. Mortality rates attributed to household and Ambient air

pollution

32 | Public health and environment

 SDG 7: Energy
Goal 7 Ensure access to affordable, reliable, sustainable, and
modern energy for all

Target 7.1 By 2030, ensure universal access to affordable, reliable

and modern energy services

Target Indicator
7.1 7.1.1 Percentage of population with electricity access

7.1.2 Percentage of population with primary

reliance on clean fuels and technologies at the
household level*

33 | Public health and environment

Goal 11 Make cities and human settlements inclusive,
safe, resilient and sustainable.
SDG 11: cities
Target 11.7 By 2030, reduce the adverse per capita environmental
impact of cities, including by paying special attention to
air quality, municipal and other waste management.

Target indicator
11.7 Annual mean levels of fine particulate matter (i.e.
PM2.5) air pollution in cities (population weighted)

34 | Public health and environment

 Estimates of outdoor air pollution exposures
used by WHO for BOD estimates
Brings together existing data from:

1. Satellite remote sensing (sparsely covereed areas)

2.Urban ground monitoring stations – pollutant
concentrations
3. Estimates of air pollution levels based on emissions
from sectors (e.g. transport, industry, power production,
etc.)

Mathematical models - combining information from monitoring, from

satellite remote sensing, chemical transport models to fill gaps and improve
estimates

35 | Public health and environment

 More complete estimates of exposure to air
pollution from Satellite Remote Sensing, air
transport models and ground monitors

36 | Public health and environment

 Urban Air Quality Data (WHO)
1600 cities, but sparse coverage for Africa, Latin America, Middle East
– no coverage in rural areas

37 | Public health and environment

 Estimating Burden of Disease and Death
due to exposure to air pollution (and other
risks to health)

Burden of disease is estimated from:

1. Air pollution concentrations & human exposure
2. Evidence from epidemiology about the health impacts of
air pollution
1. Diseases affected
2. Disease response to levels of AP (dose-response curves)
3. Baseline disease rates

38 | Public health and environment

 Assess Expected Health Impacts from
Proposed Policies
(e.g as part of EIAs, SIAs)
State:
• Plan development that benefits populations
• Respond to consumer demand for more sustainable
practices
• Avoid and manage risks
Corporations:
• Avoid risks, costs and liabilities
• Secure and maintain a social license to operate
• Corporate social resposibility
Communities/individuals:
• Access to information, public participation, access to
justice

39 | Public health and environment

 Global Platform on Air Quality and Health

• To ensure best estimates of human exposure to air pollution will continue to

be regularly available for Burden of Disease estimates, as well as to ensure
accountability, transparency and wide access of these results worldwide.
• Established in January 2014,
• A wide collaboration with international agencies including UNECE, WMO,
UNEP, JRC, IIASA, World Bank, space research agencies (e.g. NASA,
JAXA), as well as national agencies and research institutions.
• Yearly meetings to update on progress and results.
• Task forces to provide improvements in methods and outputs from one year
to the next.

First year
– improvements in data integration and statistical fusion, (using data from
monitors, atmospheric transport models and satellite remote sensing).
– First database of source apportionment studies (n=500)

40 | Public health and environment

 Cost benefit analysis including all relevant health
information/indicators
e.g. WHO HEAT – quantifying health gains from cycling infrastructure investment in
terms of avoided traffic injuries and health care costs

www.euro.who.int/transport/policy/20070503_1
41 | Public health and environment
 Monitoring trends in public space and related
risks and benefits, building on what we have:
e.g. in air pollution
– Local air pollution levels
– Global databases on Air Pollution in homes and in Cities
– Data presentation – combining many risks to health combining
satellite imagery, ground-level monitoring,

42 | Public health and environment

 Action Research into health impacts of
sector policies interventions
• Use by children,
disabled and the
elderly
• Physical activity or
neighbours
• Injuries and safety
• Air pollution and
noise levels

43 | Public health and environment

 Communicating synergies:

Physical activity

 Obesity

 Air pollution

 Traffic injuries

 Social capital

44 | Public health and environment

 Where should we go next?
1. Include health in planning scenarios for sector policy
options: ex-ante, through HIA, CBA, health gains expected
from public space strategies/interventions in cities and
regions
2. Evidence on the effectiveness of interventions: Research
on health impacts of policy packages / public space
interventions adoption and follow-up
3. Improve global tracking of public space policies, risks to
health and health impacts: for monitoring and evaluation
of trends and consequences of interventions on health and
wellbeing.

45 | Public health and environment

 Health benefits from AP reduction
Injuries, physical activity,
Transport, energy, land use

noise, diet,
Local/
policies / Combustion

short term
Air pollution (PM)
health
impacts

Climate change (SLCPs)

Climate change (CO2) Global/long

term health
impacts

46 | Public health and environment

 A New Urban Health Project
 Inform /support demand/ adoption of policy
choices/behaviours that:
• mitigate Air Pollution
• mitigate Climate Pollutants (SLCPs, CO2)
• maximize health benefits.

 How? Equip/engage city actors in health, planning,

development, government…, with:
• Health knowledge – interventions with greatest health benefits.
• Tools for health assessment and for M&E/scenarios.
• Strengthened institutional and technical capacity.
• Framework of collaboration, monitoring and evaluation.
• Communication/awareness raising

47 | Public health and environment

 Audiences
• Part of the implementation of the WHA resolution
68.8
• International efforts on sustainable Energy,
Transport, Energy, Waste Management, Land Use
• Cities already organized to address air pollution,
climate change, health (ICLEI, C40, Clean Air
Asia, Healthy Cities…)
• 5 to 7 pilot cities for in-depth work - model for
other cities

48 | Public health and environment

 Policies that fulfill multiple social objectives
Focus: main sources of air and climate pollutants
• Transport
1. Health benefits
• Waste burning from improving
• Home energy • Air pollution
• Injuries,
• Buildings • Physical activity,
• Land use plans • Noise,
• Diets…
• Industry 2. Air andClimate
pollutant reductions

49 | Public health and environment

 How to trigger transformation?
1. Enabling cross-sectoral cooperation
• In the health sector to:
– Engage in local policy processes for air and climate pollution and health
– Document which policies have greatest benefits for health, air quality and
climate
– Communicate about benefits/savings to those policies

• In development sectors to:

– Be aware of health costs associated to air and climate pollutants.
– Support opportunities to increase health co-benefits through air and climate
pollutants reduction measures
– Engage in health promotion, air quality and climate protection

• Communications:
– Parliamentarians, mayors, interest groups, mothers of children with asthma,
patient groups,

50 | Public health and environment

 How to trigger transformation?
2. Mainstreaming air pollution reduction
into key public health programmes and
thinking
• Include AP in mainstream public health
programmes – e.g. prevention of heart disease,
stroke, COPD, asthma, pneumonia

• Engagement with professional associations,

(heart, lung, GPs, Nurses, CHWs)

51 | Public health and environment

 How to trigger transformation?
4. By connecting data-bases – developing joint
analyses of local data
• Air & climate pollution data
– air quality monitoring (place – GIS, time, pollutants) at local level
– air pollution sources (EI, SA) in each city

• Data on AP sources

• Health Data
– Health databases (vital statistics, morbidity, use of health services, health care costs
by condition, health insurance payments…)

• Capacity to analyse/link data bases, report on the linkages between

health and SLCPs/air pollution.

• Big data, data mining experience/capacity

52 | Public health and environment

 How to trigger transformation?
1. Enabling cross-sectoral cooperation
• In the health sector to:
– Engage in local policy processes for air and climate pollution and health
– Document which policies have greatest benefits for health, air quality and
climate
– Communicate about benefits/savings to those policies

• In development sectors to:

– Be aware of health costs associated to air and climate pollutants.
– Support opportunities to increase health co-benefits through air and climate
pollutants reduction measures
– Engage in health promotion, air quality and climate protection

• Communications:
– Parliamentarians, mayors, interest groups, mothers of children with asthma,
patient groups,

53 | Public health and environment

 Framework of Collaboration
Tools Knowledge

Urban
Health
Development
Sector TRANSFORMATION
Sectors

Build capacity
54 | Public health and environment
 Products
• Knowledge Base – policies that realize health benefits from
actions to reduce SLCPs in cities.
• Urban health tool kit including:
• Guidelines to conduct SHIA (for AP policy options and different urban
scenarios)
• Technical guidelines to use assessment tools (BoD, CBA, Health co-
benefits)
• Monitoring and evaluation – analysis of health
• Communication
• Capacity building events and web-based training (free access)
• Evaluation of local experiences/ engagement of specific target
groups
• Network of cities mainstreaming SLCP and health

55 | Public health and environment

 Possible areas for cooperation
• Global Platform – models to integrate
different data, validation of equipment,
indices, real time AQ information…
• Cities – geo-referencing, mapping sources,
• Linking policies to AQ trends
• Communciations

56 | Public health and environment