1. The Health Effects of Air Pollution Robert M. O’Keefe, Vice President Health Effects Institute National Workshop on Improvement of Urban Air Quality of Pakistan Lahore December 2004

2. Assessing the Health Effects of Air Pollution Health Effects Institute Air Pollution and Health Effects Public Health And Air Pollution in Asia Program “PAPA” The existing Asia science literature New Asian studies Conclusions

3. The Health Effects Institute Founded in 1980 to provide impartial, high-quality science on health effects of vehicle and other emissions Joint and Equal Core Funding from –Government (U.S. EPA) –Industry (28 Worldwide Vehicle Manufacturers) –Today many partners worldwide: ADB, WHO, EU California ARB (CARB), Oil, other Industries Independent Expert Science Committees oversee and peer review all research Over 225 studies - Americas, Asia, Europe - ozone, carbon monoxide, particulate matter, diesel exhaust, benzene, butadiene, methanol, others

4. Air Pollution and Health: What we know about the effects

5. Air Pollution has Many Effects Health –Respiratory, cardiovascular morbidity –Mortality Heritage –Nitric Sulfuric Acid erosion Natural Resources –Acidification (lake and stream biology) –Mercury deposition (fish tissue) –Visibility Agriculture –Ozone crop effects (~40% reduction in rice, soy yield in Pakistan city) –*(Wahid 2003 Veranasi)

7. Many Sources of Air Pollution in Asia Combustion –Open burning –Brick Kilns –Vehicles –Trash burning –Factories –Power generation –Cooking in slums Non-Combustion –Agricultural cultivation –Street sweeping –Windblown sand –Unpaved roads –Paved roads (asbestos, rubber etc) –Construction

8. Vehicle Emissions and Exposure Must consider all effects of the system: –different vehicle types - 2 and 3 wheelers cars trucks and buses –vehicle plus fuels (and fuel components) –tailpipe emissions plus evaporative emissions –maintenance of system

9. Major Vehicle/Fuel Emissions Carbon Monoxide Diesel Exhaust Particulate Matter (PM) Lead Nitrogen Oxides (NOx) and Hydrocarbons (HC) –Precursors to Ozone and PM Nitrogen Dioxide Air Toxics –Aldehydes formaldehyde acetaldehyde others –Benzene –1,3-butadiene –Methanol –Polycyclic organic matter (e.g. PAHs)

10. Health Effects Different Pollutants have Different Effects –Carbon Monoxide - circulatory system, heart –Ozone - respiratory system, lung –Lead - nervous system, brain –PM - lung, potential effects on heart –Diesel, Air Toxics - cancer, respiratory effects There are potential effects of the Mixture

11. Health Effects Some populations more sensitive than others –Children –Elderly –people with heart and lung disease Asthma is growing –150 million asthmatics worldwide –Increasing in most countries (2% to 5% per year) –Asthmatics much more sensitive to air pollution

12. Particulate Matter (PM) Health Effects High levels of PM (e.g. 500  /m 3 ) known to cause premature death –e.g. London 1952 Recent studies in US, Europe, Asia, South America have found association of PM with death at much lower levels (< 50ugm3) –no evidence of a “threshold” (safe level) Progress made to identify a plausible biological mechanism for these effects; results not yet definitive

13. PM - The Epidemiology Studies A Number of Epidemiology Studies Europe Studies Harvard 6 Cities Study

14. PM Health Effects - India, Thailand Source: Chhabra 2001, Pande 2001, Vichit-Vadakan, 2001

15. Ozone Health Effects Known to cause inflammation in respiratory tract Effects have been demonstrated for short term, long term effects are less certain –some people appear to develop “tolerance” Reduces ability to breathe (lung function) for some people Increases hospitalization for asthma, other lung diseases New US study finds Ozone mortality effects* (Domenchi et. al 2004)

16. Ozone Health Effects Some humans have been shown to have reduced lung function (measured as FEV1) after exposure to ozone

17. Diesel Health Effects Diesel Engines have substantial advantages: –higher fuel efficiency –lower CO and CO2 emissions However, they also emit high levels of : –particulate matter, NOx, and chemicals attached to the particles (e.g. PAHs) Two major types of health effects : –acute effects (e.g. exacerbating asthma) –cancer effects

18. Diesel Effects on Childhood Illness (Brunekreef, et al Study in 24 Dutch schools)

19. Assessing Diesel Cancer Risk In general, some 30 studies of effects on workers have provided best data Consistent small (20-40%) increase in lung cancer associated with exposure Some questions about each study Leading International Agencies (WHO, IARC, US NIEHS, US EPA) have concluded diesel is a “probable human carcinogen”

20. Sulfur Dioxide Emitted from fossil fuel combustion especially from coal burning facilities, high sulfur fuels Can impair breathing in asthmatic children and adults Has been associated, along with PM, with increased aggravation of heart and lung disease premature mortality Recent study in Hong Kong (Lancet 2002) has found: substantial reductions in SO2 emissions can result in measurable improvements in mortality and illness

21. 1992199319941995 0 20 40 60 80 NO 2 SO 2 O3O3 PM 10 Micrograms per cubic metre Year AIR POLLUTANT CONCENTRATIONS 1988 - 95 IN HONG KONG HALF YEARLY MEAN LEVELS Fuel restriction on sulphur 50% reduction in SO 2 after the intervention No change in other pollutants

22. -6-6 -5-5 -4-4 -3-3 -2-2 -1 0 15-6465+15-6465+15-6465+ REDUCTIONS IN DEATHS AFTER SULPHUR RESTRICTION All causesCardiovascularRespiratory % Reduction in annual trend -1.8% -2.8% -1.6% -2.4% -4.8% -4.2%

23. Air Toxics Health Effects Benzene –a “known human carcinogen” –studies in U.S. and Chinese workers have shown link between exposure and increased leukemia Metals –Range of effects, heart, reproductive, –cancers 1,3 Butadiene –a “probable” or “known” human carcinogen –studies in laboratory animals and US and Czech workers have shown effects Aldehydes, PAH’s –Cancers, Irritants

24. Air Pollution and Health in Asia: The Public health and Air Pollution Program (PAPA)

25. The Problem: Air Pollution in Asia: High Levels in Many Cities (2000-2001) Source: Benchmarking Report on Air Quality in Asian cities Stage 2, 2004 (forthcoming) SPM Limit = 90 µg/m 3 (WHO, 1979) 0 50 100 150 200 250 300 350 400 Bangkok Busan Chongqing Colombo Hong Kong Jakarta Kolkata Manila Mumbai New Delhi Osaka Pune Singapore Seoul Shanghai Tokyo concentration in µ g/m 3 SO2NO2SPMPM10 PM 10 Limit = 50 µg/m 3 (USEPA, 1997) SO 2 Limit = 50 µg/m 3 (WHO, 1999) NO 2 Limit = 40 µg/m 3 (WHO, 1999)

26. Lancet October, 2002

27. Environmental Burdens Premature Deaths source: WHO Global Burdon of Disease

28. The Challenge: Expanding current science base to inform Asian air regulatory decisions Air pollution poses clear health effects Western research is relevant to Asian populations, however extrapolation poses challenges –Population characteristics –Pollution sources and mixes Are observed risks similar?, greater?, smaller? A clear need for representative air pollution & health studies of local Asian populations

29. PAPA Program Partnership with CAI-ASIA to understand the health effects of air pollution in Asia, now and in the future Active effort underway: –Published Scientific Review and Meta Analysis of what is known today about health effects in Asian cities –Conducting series of epidemiological studies in representative Asian cities Understand local impact Combine to provide Asia-wide understanding –Publish a Comprehensive Assessment of the state of air pollution and health across Asian cities –Build capacity of local scientists Overall Goal: –Quality science to inform key Asian regulatory & policy decisions

30. Health Effects of Outdoor Air Pollution in Developing Countries of Asia: A Literature Review Systematic identification of 140 peer-reviewed Asian studies 1980-2003 Special focus on studies of daily changes in air pollution and health Conduct first ever Asian meta analysis” quantifying risks, finding initial similarities with West Identify knowledge gaps to guide future research Active communication to policy makers

31. Studies of Air Pollution and Health in Asia 1980–2003

32. Many Health Effects Studied

33. Daily Mortality: Initial Results: Asian Risk Estimates Similar to West * Estimates Using Pre-GAM Results (without revision)

34. New Research in Asian Cities To strengthen base of Asian Health Science: Eight new studies of air pollution and health now underway in Asian cities Acute (short term) effects studies in Bangkok, Hong Kong, Shanghai, Wuhan Strong teams, quality data Long Term (chronic) effects Guangzhou, China pilot study in elderly cohort New! Study teams now identified in India: Chennai; Delhi; Ludhiana

36. PAPA: Looking Ahead A Special Challenge: Understanding the interaction among air pollution, poverty, and health –In Asia high levels of air pollution, dense population, extensive poverty are prevalent –Some initial evidence (mostly from West) that the poor face worse effects from air pollution –Could be due to: Different exposures (roadside, indoor, occupational) Poorer SES\health status (nutrition, medical care) leading to higher susceptibility Other factors –Potential Public health implications could be significant New study under design in Ho Chi Minh City to understand poverty effects

38. Conclusions Air Pollution from many sources, including vehicles, fuels have been shown to have effects on mortality, morbidity Problem will grow with economic expansion WHO estimates place air pollution mortality in hundreds of thousands across South Asia, Eastern Mediterranean region (including Pakistan) While studies are extrapolated from developed world, initial PAPA Review and analysis tend to confirm results in Asian populations, though many limitations exist The PAPA program is building a better base of Asian health and air pollution science –New studies across Asia, with capacity building as a priority –Role of poverty in air pollution to be assessed

39. Conclusions Better air monitoring needed over long term –To determine current status, monitor ongoing progress and assess health, communicate to public However, Pakistan urban conditions also warrant near term action –“Visible emissions” wide-spread –Dense population level, clear exposure –Acute effects commonplace –Provided basis of action in many countries (UK, HK, others) before comprehensive monitoring

40. Thank You! Bob O’Keefe rokeefe @healtheffects.org www.healtheffects.org