This is the first in a series of three Perspectives examining air pollution as a NCD risk factor. The first Perspective will look at the causes of air pollution; the connection between air pollution and NCDs; and the increasing recognition of the need to address air pollution within health and broader sustainable development agendas. The second will examine the legal and regulatory measures available to governments to address air pollution, as well as relevant constitutional and other legal provisions that have been utilised to hold governments to account. The third will examine the challenges to the recognition of air pollution as a NCD risk factor.
Tobacco consumption, harmful use of alcohol, unhealthy diet and physical inactivity have long been recognised as the four key modifiable risk factors for the four main types of Non-Communicable Diseases (NCDs): cardiovascular disease, diabetes, chronic respiratory diseases and cancer. This relationship has traditionally been expressed by a four by four matrix encapsulating the four diseases and four NCD risk factors (see Figure 1). However, more recently, global attention has been afforded to another NCD risk factor that threatens millions of lives and requires a shift in thinking outside the traditional four x four box – air pollution. Globally, air pollution causes an estimated 7 million deaths from cardiovascular disease, chronic respiratory disease and lung cancer each year. Of those deaths, it is estimated more than 90 per cent occur in low- and middle-income countries – embodying the intrinsic link between the economic, social and environmental factors underpinning the 2030 Agenda for Sustainable Development.
Figure 1: WHO’s 4 x 4 NCD Agenda
Air Pollution – what is it and what are the causes?
Air pollution occurs where the environment is contaminated by any chemical, physical or biological agent that modifies the natural characteristics of the atmosphere.
Air pollution comprises both household (indoor) and ambient (outdoor) air pollution.Every year, 3.8 million premature deaths occur from exposure to indoor air pollution. This is commonly associated with the use of inefficient technology and polluting fuels such as firewood, biomass or charcoal for heating and cooking in the household resulting in damaging household air pollutants. Exposure to indoor air pollutants is particularly high among women and young children in low- and middle-income countries. Of the 3.8 million deaths associated with household air pollution, 27 per cent are due to pneumonia, 18 per cent due to stroke, 27 per cent from ischaemic heart disease, 20 per cent from chronic obstructive pulmonary disease and 8 per cent from lung cancer. Household air pollution is responsible for 45 per cent of pneumonia-related deaths in children under 5 years. Rates of household air pollution mortality are projected to decline after 2020 due to the decline in the use of unclean fuels in the household.
In comparison, ambient air pollution associated with industrialisation and urbanisation is on the rise, particularly in low- and middle-income countries. This is due to increases in fossil fuel combustion and other pollutants associated with transportation, heat and power generation, such as oil and coal power plants and boilers, industrial facilities including mining, and waste management. Ambient air pollution is estimated to have caused 4.2 million premature deaths in 2016, with 91 per cent occurring in low- and middle-income countries, particularly in the World Health Organization (WHO) South-East Asia and WHO Western Pacific regions. It is estimated that 58 per cent of outdoor air pollution-related premature deaths were due to ischaemic heart disease and strokes, 18 per cent due to chronic obstructive pulmonary disease and acute lower respiratory infections respectively, and 6 per cent of deaths were due to lung cancer.
Worldwide, the air pollutants most frequently monitored are gases (sulphur dioxide, nitrogen dioxide, ozone, and carbon monoxide) and Particulate Matter (PM) which, according to WHO, affects more people than any other pollutant. PM components include sulphate, nitrates, ammonia, sodium chloride, black carbon, mineral dust and water. The International Agency for Research on Cancer has classified ambient air pollution and PM in ambient air pollution as a proven group 1 human carcinogen. The most health-damaging PM are those with a diameter of 2.5 microns or less (≤PM2.5) due to the ability to penetrate the lung barrier and enter the blood system.
The 2005 WHO Air Quality Guidelines offer global guidance on thresholds and limits for key air pollutants that pose health risks, including PM, ozone, nitrogen dioxide, and sulphur dioxide. 97 per cent of low- and middle-income countries with populations above 100,000 have air pollution levels exceeding these Guidelines. For example, a number of cities in India and China record average annual concentrations of PM2.5 over 10 times greater than the recommended threshold. With more than 50 per cent of global deaths due to ambient air pollution in 2015 occurring in these two countries, it is clear that there is a need for urgent action to combat the damaging impact of air pollutants.
Incorporation of air pollution into the broader global health and sustainable development agendas
Air pollution within World Health Assembly mandates
At the 68th World Health Assembly (WHA) in 2015, Member States adopted resolution WHA 68.8 Health and the Environment: Addressing the Health Impact of Air Pollution, marking the first time the World Health Assembly had debated the topic. At the 69th World Health Assembly held in 2016, Member States welcomed a new ‘Road map’ for accelerated action on air pollution and its causes. The 2016 – 2019 Road Map is formulated on the basis of four categories of action: expanding the knowledge base; monitoring and reporting on health trends and progress towards Sustainable Development Goals (SDGs) air pollution-related targets; global leadership and coordination at global, regional, country and city levels, including ensuring synergies with other global processes such as the SDGs and the Paris Agreement; and institutional capacity strengthening through setting relevant policies at national levels or in cities, and implementation of WHO recommendations on air quality. The latter category includes reference to setting relevant policies at national or city level, supporting the implementation of recommendations from WHO Air Quality Guidelines and rolling out policies and plans that ensure clean indoor air through better access and sustained adoption of clean fuels and technologies in the homes of rural and poor populations. The Roadmap clearly identifies the need for coordination between policymakers and stakeholders in a range of areas including health, environment, transport, finance, energy, agriculture, trade and investment.
WHO’s Thirteenth General Programme of Work 2019 – 2023 (WHO General Programme of Work), approved at the 71st World Health Assembly in May 2018, outlines WHO’s commitment to contributing to the enjoyment of better health and well-being through five platforms, including platform five of addressing the health effects associated with climate change in Small Island Developing States and other vulnerable settings. The WHO General Programme of Work specifically notes that WHO will ‘scale up its efforts’ to prevent air pollution-related disease and will continue to work on the interrelationship between climate change, health and the impact of air pollution.
In response to resolution WHA 68.8, WHO held its first global conference on air pollution and health from 30 October to 1 November 2018, in collaboration with UN Environment, World Meteorological Organization (WMO), the Climate and Clean Air Coalition to Reduce Short-Lived Climate Pollutants (CCAC) and the UN Economic Commission for Europe (UNECE), bringing together almost 900 participants from Ministries of Health, Environment, other national departments, sectors such as industry and energy, civil society and academia. One of the aims of the conference was to ‘advance collaboration’ between WHO and relevant United Nations (UN) agencies, including UN Environment and the WMO, in addressing the impact of air pollution on health. The conference recognised an aspirational goal of reducing the number of deaths from air pollution by two thirds by 2030. While traditionally viewed as an ‘environmental’ hazard, air pollution has begun to feature more prominently in the global health agenda in recent years. This is aided in part by the increase in research outlining the significant impact of this environmental hazard on morbidity and mortality, the associated economic costs, and increasing leadership from WHO.
Air pollution as a NCD risk factor
In September 2018, the Third UN High-level Meeting on the Prevention and Control of NCDs (Third UN HLM on NCDs) formally recognised air pollution as a key NCD risk factor. The Outcome Document of the Third UN HLM on NCDs included a commitment to ‘increase global awareness, action and international cooperation on environmental risk factors, to address the high number of premature deaths from non-communicable diseases attributed to human exposure to indoor and outdoor air pollution’.
These commitments within the health governance agenda sit alongside existing and emerging international commitments to limit air pollution, and climate change more broadly, within the context of a fragmented array of multilateral and regional governance frameworks.
In terms of global frameworks, the Stockholm Convention on Persistent Organic Pollutants, which entered into force in 2004 and has 182 parties, aims to protect human health and the environment from Persistent Organic Pollutants that are resistant to biodegradation and remain in the environment for long periods. In June 2014, the inaugural session of the United Nations Environment Assembly (UNEA)– the main governing body of UN Environment – adopted Resolution 1/7 on Strengthening the role of the United Nations Environment Programme in Promoting Air Quality. The resolution recognises that ‘air pollution is an impediment to national sustainable development’. Resolution 3/8 on Preventing and Reducing Air Pollution to Improve Air Quality Globally, adopted at the third session of the United Nations Environment Assembly held in December 2017, reaffirmed the call in Resolution 1/7 for Member States to take action across sectors to reduce all forms of air pollution.
In terms of regional frameworks, the United Nations Economic Commission for Europe Convention on Long-Range Transboundary Air Pollution and its eight protocols set out the general principles of international cooperation for air pollution abatement. The Association of Southeast Asian Nations Agreement on Transboundary Haze Pollution entered into force in 2003 due to concerns of rising levels of emissions of air pollutants in the region and, in particular, haze pollution from land and forest fires. There are a number of other regional frameworks including the Regional Action Plan for Intergovernmental Cooperation on Air Pollution for Latin America and the Caribbean and Regional Frameworks in Southern, Eastern, Northern, Western and Central Africa.
Climate change and air pollution
There are many synergies between air pollution and climate change. Many of the sources of air pollution, such as transport, buildings, industry and land use are also sources of climate change. Air pollutants can also drive climate change. For example, ozone and black carbon warm the atmosphere, while sulphates and organic carbon cool the atmosphere. Similarly, the main driver of climate change – fossil fuels – is also a major driver of air pollution. Measures to reduce climate change are therefore closely associated with air pollution mitigation.
In relation to climate change, the Paris Agreement entered into force in November 2016, building upon the United Nations Framework Convention on Climate Change. These agreements aim to strengthen the global response to the threat of climate change, with many of the pursuant policies relating to the reduction of air pollutants. Nationally Determined Contributions (NDCs) made in line with the Paris Agreement commonly include air pollution-related objectives and measures. For example, four countries – Mexico, Chile, Nigeria and Canada – list black carbon in their NDCs, while others make explicit reference to air pollution co-benefits or objectives, see for example the NDCs of the United Arab Emirates and Nepal.
Air pollution and sustainable development
The nexus between health, environment, and economic development is clearly illuminated in the context of air pollution. Action to address air pollution ultimately contributes to poverty alleviation. A 2016 World Bank study found that exposure to ambient and household air pollution in 2013 cost approximately $5.11 trillion in welfare losses due to premature death globally. This equates to 7.4 per cent and 7.5 per cent of GDP in South Asia, and East Asia and the Pacific respectively.
It is therefore critical to address air pollution to ensure environmental, health, economic and, ultimately, sustainable development. The relationship between air pollution and sustainable development is clearly enshrined within the 2030 Agenda for Sustainable Development, with 193 Member States of the United Nations committing by 2030 to substantially reduce the number of deaths and illnesses from pollution and contamination with specific reference to air pollution (Target 3.9); increasing substantially the share of renewable energy in the global energy mix (Target 7.2); reducing the adverse per capita environmental impact of cities, including by paying special attention to air quality and municipal and other waste management (Target 11.6); providing access to safe, affordable, accessible and sustainable transport systems (Target 11.2); and taking action to combat climate change (Goal 13). Air pollution mitigation also indirectly benefits other SDGs, including those targeting poverty (Goal 1), gender (Goal 5), and inequality (Goal 10). The Ministerial Declaration of the 2018 high-level political forum on sustainable development recognised that PM in air in many cities is above WHO air quality guidelines, leading to higher rates of NCDs and increasing the risk of premature mortality.
Amid a mounting global commitment to address air pollution, and an increasing focus on air pollution as a NCD risk factor, it is evident that a shift in thinking outside the box will be required by governments, intergovernmental organisations, civil society and industry.
In our second paper we will look at the regulatory responses available to countries to combat air pollution. We will explore examples from around the world and consider legal challenges brought by civil society against governments for failing to adequately implement legal and policy interventions to combat air pollution.
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 World Health Organization, ‘9 out of 10 People Worldwide Breathe Polluted Air, but More Countries Are Taking Action’ (News Release, 2 May 2018).
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 Ibid; Kurt Straif, Aaron Cohen and Jonathan Samet (eds), Air Pollution and Cancer (IARC Scientific Publications, No 161, 2013).
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 Strengthening the role of the United Nations Environment Programme in promoting air quality, UNEA Res 1/7, 1st sess, UNEP/EA.1/Res. 1/7 (27 June 2014).
 Preventing and Reducing Air Pollution to Improve Air Quality Globally, UNEA Res 1/8, 3rd sess, UNEP/EA.3/Res. 8 (30 January 2018).
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