Introduction This document addresses the economic implications for social equity both within cost of the public health impacts of air and between countries pollution,with particular reference to the countries of the WHO European Region. Moreover,the deleterious impact of air pollution is not confined to human health. It presents a summary of the relevant There are many other impacts that are epidemiological evidence on air worthy of consideration:those on the built pollution's health impacts,including in environment,on animal and plant health particular recent relevant work released (with further consequential impacts on the by WHO(WHO,2014a;WHO,2014b)and productivity of agricultural and forestry the preceding Global Burden of Disease resources),and on larger ecological (GBD)Study,GBD-2010(Lim et al.,2012; systems.In this perspective,addressing IHME,2013b;IHME,2014).It describes a air pollution can have significant co- methodology for calculating the economic benefits for other policy objectives and air cost of these health impacts,developed quality may simultaneously benefit from and applied in recent work by the interventions that pursue other priorities Organisation for Economic Co-operation such as climate change.Nonetheless,the and Development(OECD)(OECD,2012, subject of this study-the economic cost 2014),and presents a new estimate of the (only)of the public health impacts (only) economic costs for each of the countries of air pollution(only)-merits attention in of the WHO European Region.Finally, its own right. taking into account available information and information gaps relating to the The past few years have witnessed various sectoral sources of air pollution, substantial accumulation of new evidence the report discusses some of the key on the health effects of air pollution,on implications for policy. the economic cost of these impacts, and thus on the costs and benefits of The deleterious impact of air pollution on policy initiatives designed to combat air public health has long been assessed; pollution.As a result,it is now possible mortality and morbidity outcomes have to state-and important to communicate been extensively described.While the that,relative to many other known issue includes the complete set of environmental health risk factors,the health impacts,this study deliberately health impacts of air pollution are larger focuses exclusively on the economic than previously assumed.Moreover,this cost of the health impacts of air pollution, physical toll imposes a greater economic considering health outcomes that allow cost than previously assumed and, economic assessment. consequently,the net economic benefit to be gained by reducing this cost is far Health impacts of air pollution carry greater than previously assumed. many significant financial and economic implications,not only in terms of the Reducing air pollution and the toll it societal cost of mortality and morbidity,imposes is not primarily a matter for which is the key issue of interest for this health policy or for the health sector report,but also household,hospital and alone.Rather,it is a policy matter for all public budgets and,therefore,decision- the many sectors in which air pollution making within and outside of the is generated,and,thereby,a matter health sector.These impacts also carry requiring a whole-of-government policy
1 Introduction This document addresses the economic cost of the public health impacts of air pollution, with particular reference to the countries of the WHO European Region. It presents a summary of the relevant epidemiological evidence on air pollution’s health impacts, including in particular recent relevant work released by WHO (WHO, 2014a; WHO, 2014b) and the preceding Global Burden of Disease (GBD) Study, GBD-2010 (Lim et al., 2012; IHME, 2013b; IHME, 2014). It describes a methodology for calculating the economic cost of these health impacts, developed and applied in recent work by the Organisation for Economic Co-operation and Development (OECD) (OECD, 2012, 2014), and presents a new estimate of the economic costs for each of the countries of the WHO European Region. Finally, taking into account available information and information gaps relating to the various sectoral sources of air pollution, the report discusses some of the key implications for policy. The deleterious impact of air pollution on public health has long been assessed; mortality and morbidity outcomes have been extensively described. While the issue includes the complete set of health impacts, this study deliberately focuses exclusively on the economic cost of the health impacts of air pollution, considering health outcomes that allow economic assessment. Health impacts of air pollution carry many significant financial and economic implications, not only in terms of the societal cost of mortality and morbidity, which is the key issue of interest for this report, but also household, hospital and public budgets and, therefore, decisionmaking within and outside of the health sector. These impacts also carry implications for social equity both within and between countries. Moreover, the deleterious impact of air pollution is not confined to human health. There are many other impacts that are worthy of consideration: those on the built environment, on animal and plant health (with further consequential impacts on the productivity of agricultural and forestry resources), and on larger ecological systems. In this perspective, addressing air pollution can have significant cobenefits for other policy objectives and air quality may simultaneously benefit from interventions that pursue other priorities, such as climate change. Nonetheless, the subject of this study – the economic cost (only) of the public health impacts (only) of air pollution (only) – merits attention in its own right. The past few years have witnessed substantial accumulation of new evidence on the health effects of air pollution, on the economic cost of these impacts, and thus on the costs and benefits of policy initiatives designed to combat air pollution. As a result, it is now possible to state – and important to communicate – that, relative to many other known environmental health risk factors, the health impacts of air pollution are larger than previously assumed. Moreover, this physical toll imposes a greater economic cost than previously assumed and, consequently, the net economic benefit to be gained by reducing this cost is far greater than previously assumed. Reducing air pollution and the toll it imposes is not primarily a matter for health policy or for the health sector alone. Rather, it is a policy matter for all the many sectors in which air pollution is generated, and, thereby, a matter requiring a whole-of-government policy
approach,as underlined by WHO's can engage decision-makers across Health 2020 policy (WHO Regional Office the whole of government,and the use for Europe,2015).It is therefore desirable of economic evidence provides a well- to address this problem in terms that established common ground,to this end. 2
2 can engage decision-makers across the whole of government, and the use of economic evidence provides a wellestablished common ground, to this end. approach, as underlined by WHO’s Health 2020 policy (WHO Regional Office for Europe, 2015). It is therefore desirable to address this problem in terms that
The evidence from epidemiology 1.1 GBD owing to air pollution Air pollution is the largest contributor to exposure to PM,and its long-term health the burden of disease (BOD)from the effects in particular.For this reason,this environment.WHO estimated that air report focuses on PM. pollution in 2012 was responsible for 7 million premature deaths,including Premature deaths translate into almost 600 000 in the WHO European substantial years of life lost (YLL).In Region.This is equivalent to one in eight addition,air pollution is responsible for of the total number of deaths worldwide. a range of diseases,contributing to the This finding more than doubles previous BOD,but the years of life lost to disability estimates(WHO,2014a). (YLD)are difficult to quantify and as such can only represent a relatively small Air pollution is a risk factor for several fraction of the estimated total BOD, causes of death,but cardiovascular and expressed in disability-adjusted life-years cerebrovascular causes of death account (DALYs). for the greater share of attributable mortality:80%in the case of ambient A publication by WHO1 in 2014 gives a air pollution (AAP)and 60%in the case global estimate for 2012 of 3.7 million of household air pollution (HAP)(WHO, premature deaths from AAP and 4.3 2014b). million premature deaths from HAP, cumulating in 7 million premature deaths AAP is a broader term used to describe from the joint effects of AAP and HAP air pollution in outdoor environments.The (WHO,2014b).The whole is less than the pollutants that are most harmful to health sum of its parts because the effects of closely associated with excessive AAP and HAP are not fully independent of premature mortality -are fine particulate each other.This subtraction procedure is matter(PM)PM2s particles that penetrate not applied in many cases,however-for deep into lung passageways.PM is a example,in high-income countries where mixture,with both physical and chemical HAP effects are assumed to be minimal characteristics,varying by location and -but it can be difficult to estimate where time of year,with seasonal trends.The it is relevant.Hence,WHO advises that relative contribution of local,national and the estimate for joint effects should be transboundary air pollution emissions to interpreted with caution (WHO,2014b). the air pollution mixture where people live also varies according to the geography The GBD-2010 Study,which formed of the area and the presence of other the evidence base for the recent OECD sources of pollution.PM25 is often study entitled The cost of air pollution: used as a general indicator of the air health impacts of road transport(OECD, pollution mixture.Other pollutants,such 2014),estimates the 2010 death toll from as ground-level ozone,also contribute each of the three types of air pollution- to the BOD from air pollution.However, (1)ambient particulate matter pollution by far the biggest quantifiable share of (APMP),(2)ambient ozone pollution the BOD from air pollution comes from (AOP)and (3)HAP from solid fuels-to be 1 WHO estimates for 2012 are only available at regional and global levels,not at country level.Therefore,although WHO results are used here(WHO,2014b),the detailed quantification in this report is based on the GBD-2010 Study
3 exposure to PM, and its long-term health effects in particular. For this reason, this report focuses on PM. Premature deaths translate into substantial years of life lost (YLL). In addition, air pollution is responsible for a range of diseases, contributing to the BOD, but the years of life lost to disability (YLD) are difficult to quantify and as such can only represent a relatively small fraction of the estimated total BOD, expressed in disability-adjusted life-years (DALYs). A publication by WHO1 in 2014 gives a global estimate for 2012 of 3.7 million premature deaths from AAP and 4.3 million premature deaths from HAP, cumulating in 7 million premature deaths from the joint effects of AAP and HAP (WHO, 2014b). The whole is less than the sum of its parts because the effects of AAP and HAP are not fully independent of each other. This subtraction procedure is not applied in many cases, however – for example, in high-income countries where HAP effects are assumed to be minimal – but it can be difficult to estimate where it is relevant. Hence, WHO advises that the estimate for joint effects should be interpreted with caution (WHO, 2014b). The GBD-2010 Study, which formed the evidence base for the recent OECD study entitled The cost of air pollution: health impacts of road transport (OECD, 2014), estimates the 2010 death toll from each of the three types of air pollution – (1) ambient particulate matter pollution (APMP), (2) ambient ozone pollution (AOP) and (3) HAP from solid fuels – to be Air pollution is the largest contributor to the burden of disease (BOD) from the environment. WHO estimated that air pollution in 2012 was responsible for 7 million premature deaths, including almost 600 000 in the WHO European Region. This is equivalent to one in eight of the total number of deaths worldwide. This finding more than doubles previous estimates (WHO, 2014a). Air pollution is a risk factor for several causes of death, but cardiovascular and cerebrovascular causes of death account for the greater share of attributable mortality: 80% in the case of ambient air pollution (AAP) and 60% in the case of household air pollution (HAP) (WHO, 2014b). AAP is a broader term used to describe air pollution in outdoor environments. The pollutants that are most harmful to health – closely associated with excessive premature mortality – are fine particulate matter (PM) PM2.5 particles that penetrate deep into lung passageways. PM is a mixture, with both physical and chemical characteristics, varying by location and time of year, with seasonal trends. The relative contribution of local, national and transboundary air pollution emissions to the air pollution mixture where people live also varies according to the geography of the area and the presence of other sources of pollution. PM2.5 is often used as a general indicator of the air pollution mixture. Other pollutants, such as ground-level ozone, also contribute to the BOD from air pollution. However, by far the biggest quantifiable share of the BOD from air pollution comes from 1.1 GBD owing to air pollution The evidence from 1. epidemiology 1 WHO estimates for 2012 are only available at regional and global levels, not at country level. Therefore, although WHO results are used here (WHO, 2014b), the detailed quantification in this report is based on the GBD-2010 Study
3.22 million,0.15 million and 3.48 million, breakthroughs in exposure assessment respectively (Lim et al.,2012). and epidemiological method -and is not indicative of large increases in the The GBD-2010 Study does not attempt actual death toll from year to year.On to estimate a composite figure for the the contrary,the implementation of joint effects of these.However,whether clean air regulations and other mitigation one adds together all three types of air measures has succeeded in limiting the pollution at 6.85 million premature deaths actual change in the global premature or only the two main types at 6.7 million death toll from air pollution to a relatively premature deaths (and whether one modest increase.Moreover,as is detailed subtracts to arrive at a composite figure below.there has been a modest decrease for joint effects),the result exceeds by a rather than an increase in mortality from clear margin each of the other identified air pollution within the WHO European risk factors in the global death toll,with Region.Therefore a two-fold message the exception only of high blood pressure needs to be communicated:improved at 9.4 million,and tobacco smoking at knowledge has led to larger estimates 5.7 million. of the BOD from air pollution;however, improved practices have helped in The reported BOD from air pollution reducing emissions of air pollutants and has increased over time.This is reduce overall population exposure, mainly the result of recent advances especially in Europe. in knowledge -mainly from critical 1.2 The evolving evidence As is reported in WHO (2014b),the much previously reported (for 2008): estimate of the global mortality from a leap from 1.3 million to 3.7 million (in HAP (for the year 2012)is more than 2010).The increase in the latter (AAP)is twice as much as its previous reported the most dramatic and it is illuminating estimate(for 2004):a leap from 2 million to track this increase over successive to 4.3 million.In the case of AAP the studies.Table 1.1 reports the estimates latest estimate is almost three times as in four successive studies. Table 1.1.The reported change in estimates of premature deaths from AAP in successive studies,2000-2012(selected years) Study Year 2000 Year 2008 Year 2010 Year 2012 Estimated number of premature deaths WHO-GBD 2000b ≈0.8 million WHO-BOD(2008)° ≈1.3 million GBD-2010 Studye ≈3.4 million WHO-BOD 2012 ≈3.7 million Sources:data reported in or extracted from: Cohen et al..2004 (p.1414): d Lim et al.,2012 (p.2238); Cohen et al.2005(p.1302); IHME,2013a; aWHO.2011: tWHo,2014b(p.1). 4
4 breakthroughs in exposure assessment and epidemiological method – and is not indicative of large increases in the actual death toll from year to year. On the contrary, the implementation of clean air regulations and other mitigation measures has succeeded in limiting the actual change in the global premature death toll from air pollution to a relatively modest increase. Moreover, as is detailed below, there has been a modest decrease rather than an increase in mortality from air pollution within the WHO European Region. Therefore a two-fold message needs to be communicated: improved knowledge has led to larger estimates of the BOD from air pollution; however, improved practices have helped in reducing emissions of air pollutants and reduce overall population exposure, especially in Europe. 3.22 million, 0.15 million and 3.48 million, respectively (Lim et al., 2012). The GBD-2010 Study does not attempt to estimate a composite figure for the joint effects of these. However, whether one adds together all three types of air pollution at 6.85 million premature deaths or only the two main types at 6.7 million premature deaths (and whether one subtracts to arrive at a composite figure for joint effects), the result exceeds by a clear margin each of the other identified risk factors in the global death toll, with the exception only of high blood pressure at 9.4 million, and tobacco smoking at 5.7 million. The reported BOD from air pollution has increased over time. This is mainly the result of recent advances in knowledge – mainly from critical 1.2 The evolving evidence As is reported in WHO (2014b), the estimate of the global mortality from HAP (for the year 2012) is more than twice as much as its previous reported estimate (for 2004): a leap from 2 million to 4.3 million. In the case of AAP, the latest estimate is almost three times as much previously reported (for 2008): a leap from 1.3 million to 3.7 million (in 2010). The increase in the latter (AAP) is the most dramatic and it is illuminating to track this increase over successive studies. Table 1.1 reports the estimates in four successive studies. Table 1.1. The reported change in estimates of premature deaths from AAP in successive studies, 2000–2012 (selected years) Study Year 2000 Year 2008 Year 2010 Year 2012 Estimated number of premature deaths WHO-GBD 2000a b ≈ 0.8 million WHO-BOD (2008)c ≈ 1.3 million GBD-2010 Studyd e ≈ 3.4 million WHO-BOD 2012f ≈ 3.7 million Sources: data reported in or extracted from: a Cohen et al., 2004 (p.1414); b Cohen et al. 2005 (p.1302); c WHO, 2011; d Lim et al., 2012 (p.2238); e IHME, 2013a; f WHO, 2014b (p.1)
The GBD-2010 Study was based on of mortality and morbidity,for each evidence incorporating the results of relevant disease (see Lim et al.,2012). several critical breakthroughs in the resulting in each risk factor being more technology and methods of epidemiology, accurately assigned to its relative share as well as continuing advances in in the given number of premature toxicology and the clinical knowledge deaths and DALYs in any given year of diseases.Of these,the following (see Lim et al.,2012 and IHME,2013b). developments deserve particular men- tion. There are at least three areas in which future studies are likely to generate Advanced monitoring methods have new results.The first is through the use been employed,including remote- of better and more complete data for sensing satellite technology,to estimate existing risk-outcome pairings,especially in low-and middle-income countries emissions and ambient concentrations of pollutants (see,inter alia,Brauer (see WHO Regional Office for Europe, et al.,2012;Evans et al.,2013,and 2014).This need not necessarily entail Amann,Klimont Wagner,2013). any change to established exposure- response functions and may involve a There is a much-improved understand- more complete gathering of hospital ing of the relation between emissions/ records.The second is through the concentrations of pollutants and selection of the air pollutants to be used the exposure of populations to such for estimating health impacts.Whereas chemicals,and of the relation between the effects of AAP are now measured population exposure and the health through theeffect ofPM2sitisincreasingly impacts of it-resulting in the use of accepted that other pollutants are of new integrated exposure-response relevance (see EEA,2013a;EC,2013). functions (currently undergoing con- In particular,there is now an increasing tinuing refinement)(WHO Regional focus on the independent impact of Office for Europe,2013a;2013b). exposure to nitrogen dioxide (NO,)(see A new understanding has arisen of WHO Regional Office for Europe,2013a; the link between air pollution and Holland,2014).The third area in which lung cancer (see Beelen et al.,2008; new results are likely to be generated Silverman et al.,2012;Fajersztajn et al., is through the expansion of the list of 2013;Raaschau-Nielsen et al.,2013), diseases against which the relevant risk paving the way for the classification by is paired.For now,including in GBD- the International Agency for Research 2010 Study,the calculation of the BOD on Cancer (IARC)of outdoor air of air pollution has been restricted to pollution as a human carcinogen(IARC, four main disease groupings:cancers, 2012,2013;Benbrahim-Tallaa et al., and cardiovascular,cerebrovascular 2012). and respiratory diseases.However, there is evidence to suggest that air .A fuller understanding has emerged pollution may also play a part in a range of the cardiovascular,cerebrovascular of other diseases,including neonatal and and respiratory health impacts of neuropsychological impairments(see,for air pollution (see,inter alia,Shah et example,Guxens Sunyer,2012). al.,2013;Wellenius et al.,2012;and Laumbach Kipen,2012). Therefore.it cannot be ruled out that A more comprehensive and more continuing improvements in knowledge consistent methodology is being will result in more evidence on the used to assemble and analyse the deleterious health impacts of air pollution epidemiological evidence base,in being uncovered and presented,further order to establish the relative risk increasing the magnitude of the estimated of each relevant risk factor in terms BOD. 5
5 of mortality and morbidity, for each relevant disease (see Lim et al., 2012), resulting in each risk factor being more accurately assigned to its relative share in the given number of premature deaths and DALYs in any given year (see Lim et al., 2012 and IHME, 2013b). There are at least three areas in which future studies are likely to generate new results. The first is through the use of better and more complete data for existing risk–outcome pairings, especially in low- and middle-income countries (see WHO Regional Office for Europe, 2014). This need not necessarily entail any change to established exposureresponse functions and may involve a more complete gathering of hospital records. The second is through the selection of the air pollutants to be used for estimating health impacts. Whereas the effects of AAP are now measured through the effect of PM2.5, it is increasingly accepted that other pollutants are of relevance (see EEA, 2013a; EC, 2013). In particular, there is now an increasing focus on the independent impact of exposure to nitrogen dioxide (NO2 ) (see WHO Regional Office for Europe, 2013a; Holland, 2014). The third area in which new results are likely to be generated is through the expansion of the list of diseases against which the relevant risk is paired. For now, including in GBD- 2010 Study, the calculation of the BOD of air pollution has been restricted to four main disease groupings: cancers, and cardiovascular, cerebrovascular and respiratory diseases. However, there is evidence to suggest that air pollution may also play a part in a range of other diseases, including neonatal and neuropsychological impairments (see, for example, Guxens & Sunyer, 2012). Therefore, it cannot be ruled out that continuing improvements in knowledge will result in more evidence on the deleterious health impacts of air pollution being uncovered and presented, further increasing the magnitude of the estimated BOD. The GBD-2010 Study was based on evidence incorporating the results of several critical breakthroughs in the technology and methods of epidemiology, as well as continuing advances in toxicology and the clinical knowledge of diseases. Of these, the following developments deserve particular mention. • Advanced monitoring methods have been employed, including remotesensing satellite technology, to estimate emissions and ambient concentrations of pollutants (see, inter alia, Brauer et al., 2012; Evans et al., 2013, and Amann, Klimont & Wagner, 2013). • There is a much-improved understanding of the relation between emissions/ concentrations of pollutants and the exposure of populations to such chemicals, and of the relation between population exposure and the health impacts of it – resulting in the use of new integrated exposure-response functions (currently undergoing continuing refinement) (WHO Regional Office for Europe, 2013a; 2013b). • A new understanding has arisen of the link between air pollution and lung cancer (see Beelen et al., 2008; Silverman et al., 2012; Fajersztajn et al., 2013; Raaschau-Nielsen et al., 2013), paving the way for the classification by the International Agency for Research on Cancer (IARC) of outdoor air pollution as a human carcinogen (IARC, 2012, 2013; Benbrahim-Tallaa et al., 2012). • A fuller understanding has emerged of the cardiovascular, cerebrovascular and respiratory health impacts of air pollution (see, inter alia, Shah et al., 2013; Wellenius et al., 2012; and Laumbach & Kipen, 2012). • A more comprehensive and more consistent methodology is being used to assemble and analyse the epidemiological evidence base, in order to establish the relative risk of each relevant risk factor in terms