by Prof Sir Stephen Holgate, UKRI Clean Air Champion and Special Advisor to the RCP on Air Quality, MRC Clinical Professor, University of Southampton.

Evidence demands a health-based campaign to make clean air a human right mirroring the UN right to clean water and sanitation

Air pollution is a major environmental risk to health, as stated by the WHO.  Why then haven’t the medical and health professions taken greater ownership of this wicked problem?

A great public health gain in recent times has been the introduction in 2007 of a new law that makes it illegal to smoke in  public enclosed areas and workplaces.

One of the problems is that “modern” air pollution, in contrast to that experienced from coal burning in the 1950s, is for all intent and purposes invisible. Whereas carbon, as black soot, and SO2 dominated the smog 70 years ago,  it is now much smaller particles (PM10, PM2.5 and ultrafines) along with NO2, volatile organic chemicals (VOCs) and ozone (O3) that make up a significant amount of the UK’s dirty air problem, especially in urban settings.

Particulates, especially PM2.5 and smaller (PM0.1 and ultrafine PM) behave more like gases and when inhaled are absorbed, circulated, and deposited in almost every organ of the body.  Apart from the particles themselves, that penetrate cells to interfere with metabolism (especially enhancing oxidant formation as a stress response), their payload of toxic hydrocarbons and metals place a further enhanced oxidant stress in addition to broader effects (e.g. DNA damage and carcinogenesis, inflammation and premature tissue aging).

Such responses occur in multiple organs from conception to old age contributing across the life course to lung diseases (asthma, COPD, pulmonary fibrosis, bronchiectasis and increasing susceptibility to infections such as SARS CoV-2  and common respiratory virus infections), cardiovascular diseases including stroke, 2 diabetes, dementia and cognitive decline, as well as Parkinson’s disease and other neurodegenerative diseases.

Pollution interferes with fetal lung, cardiovascular and CNS development and is now a well-recognised driver of cancer (especially lung, breast, liver, pancreas and other GI cancers). It accelerates the aging process of organs even in the developing baby.

Put simply, air pollution is the modern-day equivalent of tobacco smoking and as such, wreaks its destructive influence at all stages of life.

So, recognising the importance of good air quality on human health, a legitimate question to ask is why the health and medical professions have not taken greater ownership of the problems and solutions that are needed? This lack of professional engagement has been brought into sharp focus in the Prevention of Future Deaths report by the Assistant Coroner for South Thames following the second inquest on Ella Adoo Kissi-Debrah, a nine year-old girl from Lewisham, who tragically died from catastrophic asthma after 30 hospital admissions, many requiring resuscitation in intensive care.

In closing the two-week inquest which included detailed factual and medical expert evidence, the Assistant Coroner for South Thames, Philip Barlow QC, stated that air pollution made a “material contribution” to Ella’s death as a “significant contributory factor to both the induction and exacerbations of her asthma”. He also recorded that “Ella’s mother was not given information about the health risks of air pollution and its potential to exacerbate asthma”. The Coroner’s findings mark a culmination of tireless campaigning by Ella’s family since her death in 2013, to bring attention to the critical issue of air pollution and its impact on human health, especially among the vulnerable and children. Indeed, this is the first time that a Coroner has found that air pollution was a contributory cause of illness and death. This finding will have far-reaching consequences “for other people and other cases” as acknowledged by the Coroner, and once again highlights the need for further action from governments around the world to reduce dangerous levels of air pollution.

Following the Inquest, 20th April 2021, the Coroner delivered a Prevention of Future Deaths (PFD) Report restating that air pollution was a significant contributory factor to her asthma, and that during the course of her illness between 2010 and 2013 she was exposed to levels of NO2 and particulate matter (PM2.5 and PM10) in excess WHO Guidelines, the principal source being traffic emissions. During this period there was an acknowledged failure to reduce the level of nitrogen dioxide to within the limits set by EU and domestic law which possibly contributed to her death.

There was no dispute at the inquest that atmospheric air pollution is the cause of many thousand premature deaths every year in the UK. Delay in reducing the levels of atmospheric air pollution is the cause of avoidable deaths. Ella’s mother was not given information by health professionals about the health risks of air pollution and its potential to exacerbate asthma. If she had been given such information, she would have taken steps which might have prevented Ella’s death.

The MATTERS OF CONCERN in the PFD Report were stated as: 

  1. The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
  2. There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed, and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
  3. The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels: Undergraduate, Postgraduate and Professional guidance.

June 17th is National Clean Air Day. It is also the deadline for government and other organisations to respond to the Prevention of Future Deaths Report. Evidence demands a health-based campaign to make clean air a human right mirroring the UN right clean water and sanitation. The time has now arrived for doctors and other health professionals to stand up for cleaner air and do their best to drive this through central and local government; to inform patients and the broader public and to provide them with things they can do to help. In short doctors and other health professionals need to become champions to act against this public health catastrophe. 

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