1. Public health and environment 1 |1 | International Cooperation on Health Air Pollution and Climate Dr Carlos Dora Coordinator Department of Public Health and Environment Key messages for mini-campaign

2. Public health and environment 2 |2 | 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

3. Public health and environment 3 |3 | PM < 10  m – Coarse PM < 2.5  m – Fine PM <1  m – Ultrafine Medgadget.com New evidence over the last 10 years: AP is a major risk to health Substantial new evidence showing that particles smaller than 2.5  m 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.

4. Public health and environment 4 |4 | Lungs exposed to tobacco and to Indoor air pollution Pathology slides - Courtesy Prof. Saldiva, São Paulo, Brazil

5. Public health and environment 5 |5 | 2 in 3 deaths are from NCDs  Cardiovascular disease, mainly heart disease, stroke  Cancer  Chronic respiratory diseases  Diabetes  Injuries Worldwide NCDs are the main cause of death Costs: Trillions of U$ dollars

6. Public health and environment 6 |6 | Deaths attributed to HAP + Outdoor Air Pollution ~ 7 million deaths globally in 2012 AP a main RF for around 1/5 of NCDs

7. Public health and environment 7 |7 | Currently public health programmes to reduce NCDs consider only other major risk factors: Tobacco Physical inactivity Diet (fat, sugar, fiber…) Excess use of alcohol

8. Public health and environment 8 |8 | First World Health Assembly Resolution on Air Pollution and Health 7 million deaths a year due to household and ambient air pollution

9. Public health and environment 9 |9 | 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

10. Public health and environment 10 | Carotid artery wall thickness (=risk of atherosclerosis) and long-term PM 2.5 exposure AQG EU LV Bauer et al, JACC 2010 % change in artery wall thickness Home outdoor PM 2.5 (µg/m 3 ) 10 Heinz Nixdorf RECALL study, Ruhr region, Germany LAQN Seminar, London, 21 June 2013

11. Public health and environment 11 | 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.

12. Public health and environment 12 | 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

13. Public health and environment 13 | 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 Evidence of health impacts of air pollution – update starting this year

14. Public health and environment 14 | 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.

15. Public health and environment 15 | 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…

16. Public health and environment 16 | Model linking emissions to air quality Inputs: Emission rates: –PM2.5 –CO Kitchen volume Air exchange rate Duration of use (hours per day) Outputs: Predicted average concentrations of: –PM2.5 –CO Assumes uniform mixing of pollutants and air in kitchen

17. Public health and environment 17 | 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. Release 17th March 2016

18. Public health and environment 18 | A larger number of people still rely upon biomass, coal or kerosene for cooking. 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)

19. Public health and environment 19 |

20. Public health and environment 20 | WHO guidelines – forthcoming Energy-efficient homes reduce air pollution & other housing risks such as... Housing risks I ndoor/outdoor air pollution Damp, mould & allergens Poor indoor ventilation Inefficient insulation/energy system Planning, transport access Urban waste, sanitation & water Heat Island Storms/flooding Health impacts Chronic/acute respiratory disease Allergies, asthma Other NCDs Cold exposures – morbidity/mortality Water and sanitation-borne disease Heat strokes Injuries

21. Public health and environment 21 | Health care facilities Diesel generators in homes and in health care: CO poisoning high PM levels Unreliable energy source Sources

22. Public health and environment 22 | The energy gap in health care in developing countries

23. Public health and environment 23 | 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 care facility in Nigeria. Solar powered refrigerator in Vietnam.

24. Public health and environment 24 | 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

25. Public health and environment 25 | Tiers of functionality in health systems – defining energy needs

26. Public health and environment 26 | Integration of land use and transport define the “shape” of a urban growth as energy “obese” or “trim” Coyoacan, Mexico City Suburban USA Sources

27. Public health and environment 27 | The Geometry of Housing Densities-Transport Energy Source. WHO, 2012/International Association of Public Transport, 2005 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.

28. Public health and environment 28 | 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 CO 2 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

29. Public health and environment 29 | 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 CO 2 emissions by 12%; shrinking business-home distance by 20% in Santiago, Chile (Barias et al, 2005) Copenhagen Zona Rosa, Mexico City

30. Public health and environment 30 | 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 Sources

31. Public health and environment 31 | 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

32. Public health and environment 32 | 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. TargetProposed Indicator 3.93.9.1. Mortality rates attributed to household and Ambient air pollution

33. Public health and environment 33 | 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*

34. Public health and environment 34 | SDG 11: cities Targetindicator 11.7Annual mean levels of fine particulate matter (i.e. PM 2.5 ) air pollution in cities (population weighted) Goal 11 Make cities and human settlements inclusive, safe, resilient and sustainable. 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.

35. Public health and environment 35 | 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

36. Public health and environment 36 | More complete estimates of exposure to air pollution from Satellite Remote Sensing, air transport models and ground monitors

37. Public health and environment 37 | Urban Air Quality Data (WHO) 1600 cities, but sparse coverage for Africa, Latin America, Middle East – no coverage in rural areas

38. Public health and environment 38 | 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

39. Public health and environment 39 | 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

40. Public health and environment 40 | 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)

41. Public health and environment 41 | 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

42. Public health and environment 42 | 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,

43. Public health and environment 43 | 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

44. Public health and environment 44 | Communicating synergies:  Physical activity  Obesity  Traffic injuries  Social capital  Cardiovascular diseases/depression  Air pollution

45. Public health and environment 45 | 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.

46. Public health and environment 46 | Health benefits from AP reduction Transport, energy, land use policies / Combustion Air pollution (PM) Climate change (CO2) Local/ short term health impacts Global/long term health impacts Climate change (SLCPs) Injuries, physical activity, noise, diet,

47. Public health and environment 47 | 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

48. Public health and environment 48 | 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

49. Public health and environment 49 | Policies that fulfill multiple social objectives Focus: main sources of air and climate pollutants Transport Waste burning Home energy Buildings Land use plans Industry 1.Health benefits from improving Air pollution Injuries, Physical activity, Noise, Diets… 2.Air andClimate pollutant reductions

50. Public health and environment 50 | 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,

51. Public health and environment 51 | 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)

52. Public health and environment 52 | 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

53. Public health and environment 53 | 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,

54. Public health and environment 54 | Framework of Collaboration Tools Knowledge Build capacity Health Sector Urban Development Sectors TRANSFORMATION

55. Public health and environment 55 | 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

56. Public health and environment 56 | 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