Agnes Soares, SDE PAHO/WHO A poluição do ar nos grandes centros urbanos do século 21 13o Encontro Técnico de Alto Nível: Contaminação Atmosférica e os Desafios das Megacidades São Paulo, 21 e 22 de julho de 2016 SABESP, Auditório Eng. Tauzer Quindere Agnes Soares, SDE PAHO/WHO

Air pollution and health Title of the Presentation

Diseases strongly related to air pollution Balakrishnan K et al. Environmental Health, 2013,12:77; Burnett R et al., Environmental Health Perspectives, 2014,Vol. 22:4; Smith K, Bruce N et al. Annu. Rev. Public Health, 2014, Vol. 35;

IER function*: PM2.5 and child ALRI risk Household air pollution (red) Second-hand smoking (blue) Integrated Exposure-Response: IER Typical wood cookfire releases 400 cigarettes per hour worth of smoke Outdoor air pollution (green) *Burnett et al EHP 2014

IER function for PM2.5 and child ALRI risk (linear scale) WHO IT-1 (35 µg/m3 PM2.5) Require exposure reduction to around IT-1 or less to prevent majority of attributable cases

Stroke Lung Cancer Ischemic Heart Disease COPD ug/m3 annual average PM2.5

WHO air pollution database http://www.who.int/phe/health_topics/outdoorair/databases/en/ Title of the Presentation

Number of cities and towns, 2016 World Health Organization Number of cities and towns, 2016 23 April, 2018 Region Number of towns and cities Number of countries Total number of countries in region Africa (Sub-Saharan) 39 10 47 America, LMI 102 13 24 America, HI 524 6 11 Eastern Mediterranean, LMI 53 8 15 Eastern Mediterranean, HI 31 Europe, LMI 166 9 19 Europe, HI 1553 33 34 South-East Asia 175 Western Pacific, LMI 225 4 21 Western Pacific, HI 109 5 World 2 977 103 194 LMI: Low-and middle-income; HI: high-income

Number of cities and towns with accessible PM10 and PM2 Number of cities and towns with accessible PM10 and PM2.5 data in 2016, per urban population PM10/2.5: Fine particulate matter of 10/2.5 microns or less; Afr: Africa; Amr: America; Emr: Eastern Mediterranean; Eur: Europe; Sear: South-East Asia; Wpr: Western Pacific; LMI: Low- and middle-income; HI: high-income.

World Health Organization 23 April, 2018

World Health Organization 23 April, 2018

PM10 levels by region and city size, for available cities and towns, latest year in the period 2008-2015 PM10: Fine particulate matter of 10 microns or less; Afr: Africa; Amr: America; Emr: Eastern Mediterranean; Eur: Europe; Sear: South-East Asia; Wpr: Western Pacific; LMI: Low- and middle-income; HI: high-income. PM10 values for the world are regional urban population-weighted

PM10 levels for selected* cities, for the latest year in the period 2011-2015 PM10: Fine particulate matter of 10 microns or less; Afr: Africa; Amr: America; Emr: Eastern Mediterranean; Eur: Europe; Sear: South-East Asia; Wpr: Western Pacific; LMI: Low- and middle-income; HI: high-income. *Selection criteria: for year of measurement 2011 or more recent, the largest city for each country within a region (or two cities for one country if only 2 countries available in the region. City size ranges from 140’000 to 26 million habitants.

PM10 levels for available mega-cities of more than 14 million habitants, latest available year in the period 2011-2015 WHO Air quality guideline : 20 mg/m3 PM10: Fine particulate matter of 10 microns or less.

Annual mean PM of the assessed town and cities compared to the WHO Air Quality Guidelines (AQG) WHO AQG: Annual mean PM10: 20 mg/m3 Annual mean PM2.5: 10 mg/m3 Afr: Africa; Amr: America; Emr: Eastern Mediterranean; Eur: Europe; Sear: South-East Asia; Wpr: Western Pacific; LMI: Low- and middle-income; HI: high-income; AQG: WHO Air Quality Guidelines.

World Health Organization Number of cities and towns included for the PM10 and PM2.5 comparison over a 5-year period, by region. 23 April, 2018 Region Number of towns and cities Number of countries Total number of countries in region Africa (Sub-Saharan) 2 47 America, LMI 13 7 24 America, HI 343 6 11 Eastern Mediterranean, LMI 16 15 Eastern Mediterranean, HI Europe, LMI 32 5 19 Europe, HI 277 30 34 South-East Asia 53 Western Pacific, LMI 33 21 Western Pacific, HI 3 World 796 68 194 LMI: Low-and middle-income; HI: high-income. Regions with less that 5 cities were not included in the analysis.

World Health Organization Trend in PM2.5 or PM10 based on cities available in several versions of the database, by region1. 23 April, 2018 Region Trend over the mean period 2008-20132 Africa (Sub-Saharan) NA America, LMI America, HI Eastern Mediterranean, LMI Eastern Mediterranean, HI Europe, LMI Europe, HI South-East Asia Western Pacific, LMI Western Pacific, HI World3 1 Criteria for inclusion: cities with measured PM2.5 or PM10 values in the three database versions covering a period of 3 years or more, or in two versions and covering a period of 4 years or more. 2 : No more than 5% change over the five-year period; : More than 5% decrease over the five-year period; : More than 5% increase over the five-year period. 3 The mean for the World is based on weighting by regional urban population. LMI: Low- and middle-income countries; HI: High-income; NA: Not available. Results are based on 795 cities and are to be interpreted with caution, as 1) cities included might not ensure representativeness, 2) yearly variations due for example to climatic changes can be important and 3) a 5-year comparison does not necessarily represent trends, in particular when changes are limited.

Percentage of cities with increasing and decreasing PM2 Percentage of cities with increasing and decreasing PM2.5 or PM10 annual means, by region Amr: America; Emr: Eastern Mediterranean; Eur: Europe; Sear: South-East Asia, Wpr: Western Pacific; LMI: Low- and middle-income; HI: high-income. *The world figure is regional population-weighted.

Percentage of city population experiencing increasing and decreasing PM2.5 or PM10 means, by region Amr: America; Emr: Eastern Mediterranean; Eur: Europe; Sear: South-East Asia, Wpr: Western Pacific; LMI: Low- and middle-income; HI: high-income.

Air Pollution Management and Control in Latin America and the Caribbean Title of the Presentation

Air pollution is a major public health risk in the Americas 152,000 deaths attributable to ambient air pollution in the Americas in 2012 (WHO, 2014) 80,000 deaths attributable to household air pollution in LAC for the year 2012 (WHO, 2014) Air pollution accounts for about 1 in 8 deaths overall Contributes significantly to NCDs: cancers, cardio-vascular diseases, chronic obstructive pulmonary diseases, and asthma Contributes significantly to lower respiratory infections

Number of cities monitoring PM10 and PM2.5 per population size in LAC City population size Number of cities PM10 PM2.5 ≥100,000 <500,000 455 11 34 ≥500,000 <1000,000 57 5 ≥1000,000 <5000,000 35 14 8 ≥5000,000 <10,000,000 ≥10,000,000 3 2   555 44 54 Highly urbanized – 2/3 or more of the population live in cities with > 20,000 inhabitants 1 in 5 residents of the Region lives on less than 2 US$ a day (World Bank, 2010) ~70 million people in the Region still live in extreme poverty (ECLAC, 2012) Most inequitable region in the world – the gap between the richest and the poorest quintiles increasing The main pollutants regulated in the LAC are fine PM, NO2 and SO2. PM10 is regulated in 19 countries; NO2, in 18 countries; and PM2.5, in 13 countries.. Only 37 out of 100 cities with 500 000 inhabitants or more have had any measurement of air pollution done in the recent years. PM10 measurements were performed in 44 cities, and PM2.5 in 54 cities There are approximately 555 cities with more than 100 000 inhabitants in LAC, and in those cities live approximately 282 million inhabitants. Within these, 57 cities have more than 500 000 inhabitants; 35 more than one million inhabitants; five, Puebla (Mexico), Rio de Janeiro (Brazil), Santiago (Chile), Bogota (Colombia), and Lima (Peru) have more than five million inhabitants; and three are megacities (Buenos Aires, Argentina; Mexico City Metropolitan Area, Mexico and Sao Paulo, Brazil) with more than 10 million inhabitants PM10 is regulated in 19/33 countries; PM2.5 is regulated in 13/33 countries Riojas-Rodríguez, H; Soares da Silva A; Texcalac-Sangrador JL; Moreno-Banda GL. Air pollution management and control in Latin America and the Caribbean and implications for climate change. Rev Panam Salud Publica. 2016 (forthcoming)

Monitoring stations in 77 cities distributed in 17 /33 LAC countries PM10 – 44 cities PM2.5 – 54 cities Coverage ~133 million people. Only 77 cities distributed in 17 out of 33 LAC countries have official information on ground level air pollutants, covering approximately 133 million inhabitants. The annual mean of inhalable particles concentration in most of the cities are above WHO Air Quality Guide-lines (AQG), and notably only Bolivia, Peru, and Guatemala have actually adopted the guidelines. Most of these cities do not have information on PM2.5, and only a few measure Black Carbon. 17 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Guatemala, Jamaica, México, Peru, Uruguay, Honduras and Venezuela Riojas-Rodríguez, H; Soares da Silva A; Texcalac-Sangrador JL; Moreno-Banda GL. Air pollution management and control in Latin America and the Caribbean and implications for climate change. Rev Panam Salud Publica. 2016 (forthcoming)

Mean annual levels of PM10 and PM2 Mean annual levels of PM10 and PM2.5 in LAC cities with ground level monitoring stations compared to WHO AQG PM10 (µg/m3) PM2.5 (µg/m3) Tier 1 70 35 Mortality risk 15% > AQG Tier 2 50 25 Mortality risk ~ 6% < Tier 1 Tier 3 30 15 Mortality risk ~ 6% < Tier 2 AQG 20 10 Minimum level with observed effect WHO Air Quality Guidelines, update 2005 http://www.who.int/phe/health_topics/outdoorair/outdoorair_aqg/en/ The WHO has set the AQG and three interim targets for PM10, and PM2.5 to help countries with high PM concentrations to gradually improve their air quality. The acceptable limits for these pollutants was established in the regulations in LAC countries, and their com-parison against the WHO-AQG are shown in Table 1. National standards for the air con-taminants varies among countries, but in most of them, the standards are well above the WHO-AQG. Guatemala, Peru and Bolivia have adopted the WHO-AQG, for PM10 and only Guatemala for PM2.5 Note PM2.5 - 25 μg/m3 24-hour mean PM10 - 50 μg/m3 24-hour mean Riojas-Rodríguez, H; Soares da Silva A; Texcalac-Sangrador JL; Moreno-Banda GL. Air pollution management and control in Latin America and the Caribbean and implications for climate change. Rev Panam Salud Publica. 2016 (forthcoming)

Sulphur content in diesel

Historically decreasing trends Mexico City has registered only 20 “clean” days until mid June 2016 according to national air quality standards. Historically decreasing trends Legislation updated in 2015 in a participatory process Difficulties on implementing and sustaining interventions to reduce vehicle emissions The city has imposed upopular measures - a judge who ruled in favor of around 100 people who took refuge by regulations forcing cars over six years to stop circulating a day week. Passing this into circulation more than one million old cars in the city, which combined with collective fleet of polluting buses, lack of collective transport alternatives to the car contributed to the situation. Mexico City has registered only 20 “clean” days in 2016 according to national air quality standards.

We cannot do more of the same and expect different results… The way forward We cannot do more of the same and expect different results… We need Integrated, inter-sectoral policies Put health as an objective and an indicator of effective intervention Link air pollution policies to climate change policies and to clean energy for all agenda – work on integrated urban health policies Use the SDGs to include environmental health indicators in the country’s own commitment with the sustainable development agenda – what is measured gets done!!

WHA 69.18 - a road map for an enhanced global response to the adverse health effects of air pollution expand the knowledge base on health impacts of air pollution and effectiveness of interventions to reduce air pollution; enhance national and global capacities to assess air pollution, propose interventions, and develop systems for monitoring and reporting air pollution health impacts and trends; and support the development and coordination of action plans and policies at city, regional and national levels. WHA69.8 available at: http://www.who.int/phe/news/may2016/en/ The WHA approved a roadmap for air pollution [WHA69.18] that gives general guidance on the role of the health sector on the matter The road map will also strengthen the capacity of the health sector to lead intersectoral actors in policies that aim to prevent air pollution-related diseases The first resolution, Health and the environment: a road map for an enhanced global response to the adverse health effects of air pollution builds on last year’s first-ever World Health Assembly resolution calling for action to reduce health risks caused by air pollution (WHA68.18). The road map is a major milestone that sets out a concrete course of action to reduce an estimated seven million annual deaths globally as a result of air pollution exposure. Air pollution is recognized as a leading environmental health risk. Key elements of the road map include stepped-up actions by WHO and Member States to:

Lifetime of Air Pollutants 16 identified measures, implemented by 2030, would reduce warming in LAC by 0.5oC in 2070 halving the rate of warming projected by the Reference Scenario, and reduce some near term climate change impacts on vulnerable areas, such as the Andes. 8 of these interventions are meant to reduce Black Carbon emissions. Near-term measures would improve the chance of not exceeding the 2oC target. SLCF emission reductions IS NOT an alternative to CO2 mitigation.

0.5C warming avoided Source: UNEP

Knowledge needed for effective policies: Source contributions to Air Pollution and climate change- relative contribution from power generation, transportation, industry, home energy etc. varies between cities and regions Evidence on the effectiveness of interventions: sustainable mobility, energy-efficient homes, clean cookstoves, and clean power sources not only reduce pollution, they generate multiple other health & equity co-benefits Tracking of air pollution and related health impacts: local data to inform about trends and effectiveness of policy measures What % of these deaths in major cities are due to transport-pollution? in Latin Caribbean, 46% of road deaths are among motorcyclists. Furthermore, two-stroke scooters and motorcycles can also be a dominant source of air pollution. In Colombia, Dominican Republic and Uruguay they represent more than 50% of the fleet. This issue needs to be addressed in urban policies. Knowledge needed for effective policies An inventory of the sources contributing to Air Pollution and climate change Monitor health effects of policy interventions: sustainable transport, energy-efficient homes, clean cookstoves, and clean energy sources Tracking of air pollution and related health impacts: disaggregated data to inform about trends and effectiveness of policy measures

Take home messages Air pollution is a major preventable cause of disease and death in the Americas - Adopt the WHO AQG The modifiable sources of air pollution are mostly in transport, power generation, and home energy; and varies between and within countries, cities and regions – produce/use souces inventories Integrated interventions towards sustainable mobility could reduce air pollution, mitigate climate warming, and produce health co- benefits (less traffic injuries, reduced disease burden) Other examples: BRT, space for cycling and walking, energy efficiency in the household (e.g. heating, cooking), cleaning fuels, and innovative power generation (solar, wind). Focus on interventions most beneficial to health and equity. Take home messages: challenges and opportunities implement WHA69.18 resolution Improve risk communication!!! Strengthen democratic participatory processes – negotiated solutions and targets

Thank you! Gracias! Obrigada! soaresag@paho.org Curitiba, Brazil, 2012, by ®Eugenia Rodrigues