H5N1

Air pollution—time to address the silent killer

An editorial in The Lancet Air Pollution: Air pollution—time to address the silent killer.

On Sept 21, 2021, WHO published their new Air Quality Guidelines—a welcome update on the previous report from 2005—where they recommend new air quality levels for the six main pollutants (CO, lead, NO2, O3, PM, and SO2). Meeting these new levels is likely to be a challenge without substantive buy-in from governments globally, especially as pollutant projections worldwide are set to increase.  

As one of the biggest environmental contributors to poor health, air pollution has led to 7 million premature deaths globally each year. In 2017, it was reported that more than 90% of the global population lived in areas where the concentration of particulate matter (PM)2.5 was higher than the WHO recommended (2005) annual mean of 10 μg/m3—accounting for 12% of all deaths that same year. If the 2021 guidelines had been implemented in 2016, it is estimated that 3·3 million deaths in the WHO European region alone could have been prevented. If the levels proposed in the latest update of the guidelines are met, the burden of disease related to air pollution could be reduced by 80%.  

Emerging evidence of the health effects of air pollution is not only increasing in quality, but is also becoming more inclusive, with a wider array of countries represented and more low-income and middle-income countries (LMICs) contributing to the body of research. When it comes to the harms of air pollution, the lungs are first line of defence. Studies have shown associations of high levels of air pollutants with poor lung growth in early life, development of asthma, inflammation of airways, increased respiratory infections, and impaired lung function.  

Pollutants cause production of reactive oxygen species (oxidative stress) and reactive nitrogen species in the body, which in turn promote pathogenic pathways leading to inflammation, cell death, and mitochondrial dysfunction, among others. Sustained exposure to air pollutants bombards the lung's natural defences and culminates in lung injury and disease. Damage from pollutants does not stop at the lungs; direct or indirect damage to other organs can also occur. For example, acute myocardial infarction is associated with increased pollutant concentrations in the previous few days or hours.  

In Europe, steps are being taken to tackle the issue of pollution. The European Commission has agreed to a deal—the European Green Deal—which states that Europe will aim to be the first climate neutral continent in the world. The deal, made in December, 2019, revised the European Commission's air quality standards to align more closely with the 2005 WHO guidelines; however, the new WHO guidelines show that current European standards will not be enough to improve air quality to levels that have a meaningful impact on health. Only when the new, evidence-based guidelines are followed—and are legally binding—will Europe be able to meet its goal. 

Although ambient air pollution affects both developed and developing countries, LMICs have the highest burden in terms of adverse effects on health. WHO Western Pacific and South-East Asia regions bear the brunt of this burden. If there is to be a truly global commitment to reduce the burden of air pollution, the differing threats between regions need to be taken into account, and approaches must be adaptable and sustainable to best suit these regions and the people living there. Health inequalities must also be considered in any policies put in place.  

Governments and policy makers should be encouraged to agree to legally binding standards to facilitate responsibility and accountability. Without such measures, air quality and health could be deprioritised, as happened with the 2005 standards set by WHO. Campaigns that educate on the connection between air pollution and health and that mobilise people to make change will encourage individuals to consider steps that they can take to improve their health via improving air quality—whether that be decisions on a personal level or putting pressure on their governments to meet standards set.  

The health sector can also help to raise awareness. Respiratory clinicians could be at the forefront of educating their patients on the risks of air pollution. Although personal steps are welcome, government- and corporate-level change is needed to make significant inroads into climate change and air pollution. 

The WHO Air Quality Guidelines have been published at an appropriate time, just before COP26. With an opportunity to implement real change as world leaders meet, we hope that the new guidelines will be carefully considered, and air pollution and its associated respiratory health burden pushed to the forefront of health policy agendas. The silent killer can no longer be ignored.

Call for emergency action to limit global temperature increases, restore biodiversity, and protect health

Via The Lancet, but also published in 200 other health journals around the world: Call for emergency action to limit global temperature increases, restore biodiversity, and protect health.

The UN General Assembly in September, 2021, will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and the UN Climate Change Conference of the Parties (COP26) in Glasgow, UK. Ahead of these pivotal meetings, we—the editors of health journals worldwide—call for urgent action to keep average global temperature increases below 1·5°C, halt the destruction of nature, and protect health.  

Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal; a global increase of 1·5°C above the pre-industrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse. Despite the world's necessary preoccupation with COVID-19, we cannot wait for the pandemic to pass to rapidly reduce emissions.  

Reflecting the severity of the moment, this Comment appears in health journals across the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.  

The risks to health of increases above 1·5°C are now well established. Indeed, no temperature rise is “safe”. In the past 20 years, heat-related mortality among people older than 65 years has increased by more than 50%. Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical infections, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality. Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities, and those with underlying health problems.  

Global heating is also contributing to the decline in global yield potential for major crops, falling by 1·8–5·6% since 1981; this, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition. Thriving ecosystems are essential to human health, and the widespread destruction of nature, including habitats and species, is eroding water and food security and increasing the chance of pandemics.  

The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts. Allowing the consequences to fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement, and zoonotic disease—with severe implications for all countries and communities. As with the COVID-19 pandemic, we are globally as strong as our weakest member.  

Rises above 1·5°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state. This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change.  

Encouragingly, many governments, financial institutions, and businesses are setting targets to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly. Many countries are aiming to protect at least 30% of the world's land and oceans by 2030.  

These promises are not enough. Targets are easy to set and hard to achieve. They are yet to be matched with credible short-term and longer-term plans to accelerate cleaner technologies and transform societies. Emissions reduction plans do not adequately incorporate health considerations. Concern is growing that temperature rises above 1·5°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community. Relatedly, current strategies for reducing emissions to net zero by the middle of the 21st century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.

This insufficient action means that temperature increases are likely to be well in excess of 2°C, a catastrophic outcome for health and environmental stability. Crucially, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed. This is an overall environmental crisis.

Health professionals are united with environmental scientists, businesses, and many others in rejecting that this outcome is inevitable. More can and must be done now—in Glasgow and Kunming—and in the immediate years that follow. We join health professionals worldwide who have already supported calls for rapid action.

Equity must be at the centre of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond. Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed and reaching net-zero emissions before 2050. Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.

To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of encouraging markets to swap dirty for cleaner technologies is not enough. Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more. Global coordination is needed to ensure that the rush for cleaner technologies does not come at the cost of more environmental destruction and human exploitation.

Many governments met the threat of the COVID-19 pandemic with unprecedented funding. The environmental crisis demands a similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world. But such investments will produce huge positive health and economic outcomes. These include high quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.

These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the COVID-19 pandemic. But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and between countries.

In particular, countries that have disproportionately created the environmental crisis must do more to support low-income and middle-income countries to build cleaner, healthier, and more resilient societies. High-income countries must meet and go beyond their outstanding commitment to provide US$100 billion a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation and adaptation, including improving the resilience of health systems.

Financing should be through grants rather than loans, building local capabilities and truly empowering communities, and should come alongside forgiving large debts, which constrain the agency of so many low-income countries. Additional funding must be marshalled to compensate for inevitable loss and damage caused by the consequences of the environmental crisis.

As health professionals, we must do all we can to aid the transition to a sustainable, fairer, resilient, and healthier world. Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must hold global leaders to account and continue to educate others about the health risks of the crisis. We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice. Health institutions have already divested more than $42 billion of assets from fossil fuels; others should join them.

The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1·5°C and to restore nature. Urgent, society-wide changes must be made and will lead to a fairer and healthier world. We, as editors of health journals, call for governments and other leaders to act, marking 2021 as the year that the world finally changes course.

COVID-19 in Brazil: 32,316 new cases, 1,209 deaths today

Brazil's numbers are going up again. A screenshot from the CONASS PANEL | COVID-19 dashboard:

Brazil seems likely to reach 20 million cases tomorrow, and 560,000 deaths tomorrow or Thursday.

Air pollution impacts of COVID-19–related containment measures

Via Science Advances: Air pollution impacts of COVID-19–related containment measures. The abstract: 

Responses to the COVID-19 outbreak resulted in one of the largest short-term decreases in anthropogenic emissions in modern history. To date, there has been no comprehensive assessment of the impact of lockdowns on air quality and human health. 

Using global satellite observations and ground measurements from 36 countries in Europe, North America, and East Asia, we find that lockdowns led to reductions in NO2 concentrations globally, resulting in ~32,000 avoided premature mortalities, including ~21,000 in China. However, we do not find corresponding reductions in PM2.5 and ozone globally. 

Using satellite measurements, we show that the disconnect between NO2 and ozone changes stems from local chemical regimes. The COVID-related lockdowns demonstrate the need for targeted air quality policies to reduce the global burden of air pollution, especially related to secondary pollutants.

Finland: Emergency situation at Olkiluoto nuclear plant

Google Maps

Via Foreigner.fi: Emergency situation at Olkiluoto nuclear plant. Excerpt:

The Finnish Radiation and Nuclear Safety Authority (Stuk) is investigating what it has called "a serious operational disruption" involving high levels of radiation at the Olkiluoto nuclear power plant. 

The facility, located on the west coast between the cities of Rauma and Pori, was forced to undergo an emergency shutdown (scram) on Thursday shortly after noon. 

According to Stuk, the problems in the plant started "when radiation measurement systems detected higher levels within the plant." However, the nuclear watchdog said "no radiation has been released into the surroundings from the facility" and the radiation situation in the vicinity of the plant is "normal." 

Previously, the operator of the plant (TVO) reported "a plant emergency situation" occurred at 12:22 in which "an isolation of main steam lines has launched an isolation which has isolated also the containment." (sic). 

However, in a subsequent communication, the operating company TVO changed the phrase "emergency situation" to "disturbance" to describe what happened. 

The second statement read: "There has been a disturbance at Olkiluoto 2 (OL2) nuclear power plant at 12.22, where the main steam line’s isolation has been triggered and the containment has been isolated."

Eluru on Wikipedia

Wikipedia now has an entry on the Eluru outbreak. It will doubtless be revised as we learn more, but this seems to be a good summary of the current situation. Excerpt:

Samples from patients and of the local water were collected the same day to determine the cause of the outbreak. Specialists from several worldwide and Indian scientific and medical institutions, such as the All India Institutes of Medical Sciences, the World Health Organization, the Indian Council of Medical Research, the National Institute of Nutrition, Centre for Cellular and Molecular Biology, and the Indian Institute of Chemical Technology had been sent to assess the situation and analyze the samples.  

However, the tests did not detect any water pollution or known virus infections (including COVID-19) upon analysis. Andhra Pradesh's Health Department reported that "initial blood test did not find any evidence of viral infection."  

Blood samples have also been tested for bacterial infections, such as meningitis, and antibodies. Viruses such as SARS-CoV-2, Japanese encephalitis, dengue, chikungunya, hepatitis and rabies have been ruled out as the cause, as have been water contamination, since "people not linked to the municipal water supply [have also] fallen ill", and air pollution. Blood tests and CT scans were not able to establish the cause or origin of the disease and cerebral spinal fluid tests "turned out to be normal."

As of 7 December 2020, the disease has been determined as non-contagious. 

During the COVID-19 pandemic, the state of Andhra Pradesh was one of the hardest hit areas in India, with over 800,000 cumulative cases by the time the disease initially appeared.  

Preliminary lab results suggested that organochlorine substances may be the cause. They are used as pesticides as well as in anti-mosquito fogging. On 7 December 2020, Indian health authorities unofficially declared "Mostly yes, but we are waiting for the laboratory report [for confirmation]" when asked about organochlorine being the disease-triggering agent.

Syndemic responses to COVID-19 should include an ecological dimension

Correspondence in The Lancet: Syndemic responses to COVID-19 should include an ecological dimension

Richard Horton argued persuasively that COVID-19 should be addressed as a syndemic of biological and social interactions. When planning the “national revival” he calls for, I consider it crucial that this syndemic approach includes an ecological dimension. Studies have found that widespread anthropogenic ecosystem degradation has played a crucial role in explaining why the rate of emergence of zoonoses has been increasing over the past 40 years. 

For example, deforestation, intensified agriculture and livestock production, and climate change have been linked to the emergence of Ebola virus, HIV, Nipah virus, severe acute respiratory syndrome coronavirus, and Zika virus. Unless reversed, the anthropogenic destruction of habitats will probably lead to the continued emergence of new zoonoses from the estimated 700 000 other unidentified viruses with zoonotic potential. 

As argued in the recent Living Planet Report, COVID-19 is “nature sending us a message”: we need to cut human consumption to within the planet's “safe operating space”. For the vital reasons Horton outlines, this needs to be done in a way which promotes, rather than exacerbates, national and international socioeconomic equity. National revival plans could play an important role in this process but should be subordinate to international plans that are based on determinations of both global equity and ecological constraints.

Regional and global contributions of air pollution to risk of death from COVID-19

Via Cardiovascular Research: Regional and global contributions of air pollution to risk of death from COVID-19. The abstract:

Aims 

The risk of mortality from the coronavirus disease that emerged in 2019 (COVID-19) is increased by comorbidity from cardiovascular and pulmonary diseases. Air pollution also causes excess mortality from these conditions. Analysis of the first severe acute respiratory syndrome coronavirus (SARS-CoV-1) outcomes in 2003, and preliminary investigations of those for SARS-CoV-2 since 2019, provide evidence that the incidence and severity are related to ambient air pollution. We estimated the fraction of COVID-19 mortality that is attributable to the long-term exposure to ambient fine particulate air pollution. 

Methods and results 

We characterized global exposure to fine particulates based on satellite data, and calculated the anthropogenic fraction with an atmospheric chemistry model. The degree to which air pollution influences COVID-19 mortality was derived from epidemiological data in the USA and China. We estimate that particulate air pollution contributed ∼15% (95% confidence interval 7–33%) to COVID-19 mortality worldwide, 27% (13 – 46%) in East Asia, 19% (8–41%) in Europe, and 17% (6–39%) in North America. Globally, ∼50–60% of the attributable, anthropogenic fraction is related to fossil fuel use, up to 70–80% in Europe, West Asia, and North America.  

Conclusion 

Our results suggest that air pollution is an important cofactor increasing the risk of mortality from COVID-19. This provides extra motivation for combining ambitious policies to reduce air pollution with measures to control the transmission of COVID-19.

Richard Horton: Reasons for hope

In The Lancet, its editor Richard Horton writes: Offline: Reasons for hope.

Fatigue. Despair. Misery. Cracks are beginning to appear in our mental resilience. 10 months of this calamity. How much more can we bear? It was always so. When the Bishop of Winchester died of plague in 1626, John Milton issued a searing cry of anguish in his Elegia Tertia. The great poet was just 17 years old, “sad...with no companion, and many sorrows clung to my soul”. He sought to commemorate this “grim killing” of a revered literary figure, a “dreadful death, fearsome with her sepulchral torch”. “Why does it please you”, Milton asked, “to stain your hands with human slaughter, and to have sharpened sure arrows against a noble breast, and to have driven a half-divine soul from its home?” 

It would be easy to sink into despondency. Governments are struggling. The public is restless. We need hope. There was one buoyant piece of news last week. The UK's National Health Service (NHS) committed itself to becoming the world's first carbon net zero health system by 2040. WHO's Director-General, Tedros Adhanom Ghebreyesus, welcomed the news, noting that “Health is leading the way to a greener, safer planet.” The NHS has appointed Nick Watts, who has blazingly led The Lancet's Countdown on Health and Climate Change, as its first Chief Sustainability Officer. This news is certainly one reason for hope.

As Laura Spinney pointed out in her history of the 1918 influenza pandemic, Pale Rider (2017), humanity was left transformed once the infection ebbed. Out of tragedy came regeneration. “The 1918 pandemic accelerated the pace of change in the first half of the twentieth century, and helped shape our modern world.” Societies bounced back. The 1920s ushered in a new era of intellectual and artistic creativity. Governments embraced health and made it an explicit political priority—“The state of a nation's health came to be seen as an index of its modernity or civilisation.” The conditions for universal health care were created. There was a “psychological shift” across the world. Although we are still in the midst of a dreadful coronavirus syndemic, if we lift our gaze we can see a better future ahead, a future that is up to us to define. Our societies can revive, stronger, smarter, and kinder. The first step is to reinvigorate our conversation about what tomorrow should look like. That conversation has started.  

Fran Baum and Sharon Friel recently proposed the need for a social as well as a biological vaccine to solve the challenge of COVID-19. They argued in the Medical Journal of Australia that we need to go beyond a biomedical vision for solving this syndemic. By a social vaccine, they mean “a metaphor designed to shift the dominant biomedical orientation of the health sector towards the underlying distal factors that cause disease and suffering”. 

They set our four foundational requirements for health—a life with security, opportunities that are fair, a planet that is habitable and supports biodiversity, and governance that is just. Each of these requirements determines the components of a social vaccine. A life with security demands a universal system to guarantee social protection, employment, and shelter; progressive taxation; and international treaties to ensure peace and security. 

Opportunities that are fair include (at a minimum) universal and free education; racial, sex, and disability discrimination laws; decent jobs; and environments that enable healthy choices. A planet that is habitable requires a zero carbon future; protection of biodiversity; and elimination of fossil fuel subsidies. Finally, governance that is just means a universal franchise; robust systems of political accountability; and strong civil society organisations, protected by legislation. 

They write, inspiringly, that, “A global social vaccine will enable a new way of living that is healthy, just, convivial, and sustainable, and will inoculate future society against a return to a world growing increasingly less healthy, sustainable, and equal.” 

Or turn to Rene Loewenson and colleagues who wrote a powerful call to reclaim a comprehensive public health in BMJ Global Health last month—“Biosecurity is not equal to public health”, they insisted. 

Something is stirring in the heart of our society. In health, the debate about our future is intensifying. Old assumptions are being questioned. New directions are being proposed. Amid the carnage of COVID-19, a renaissance of hope is emerging. It's time to join the conversation about the world to come.

My own thoughts on the world to come are here.

Doctors alarmed by surge in hospital visits as toxic smoke engulfs west coast

Via The Guardian: Doctors alarmed by surge in hospital visits as toxic smoke engulfs west coast. Excerpt:

A month after hundreds of wildfires started spewing toxic smoke along the entire west coast, doctors are seeing the alarming health effects of air pollution piling up.  

In northern California’s Stanford Health Care system, hospital admissions have jumped by 12% in recent weeks, including a stunning 43% jump in cerebrovascular conditions such as strokes. In Oregon, health officials reported nearly one out of 10 people visiting the emergency room had asthma-like conditions due to the smoke. And in San Francisco, doctors had to cancel their clinics for recovering Covid-19 patients, because the air was so unhealthy that just getting to their appointments could make patients more sick.  

A growing body of scientific evidence paints a dire picture of the effects of wildfire smoke on the human body. Experts told the Guardian earlier this month that the smoke can have an almost immediate effect on people’s health, causing asthma, heart attacks, kidney problems and even mental health issues to surge.

Now, as the west coast reckons with an unprecedented stretch of hazardous air, scientists and health experts are growing even more concerned about the immediate and long-term consequences of continuous exposure to the harmful pollution. 

In the Bay Area, despite firefighters gaining control of the nearest blazes started by lightning strikes in August, smoky conditions have persisted, turning the sky orange and keeping people inside their homes. 

“We’re on the 30th consecutive day of our ‘Spare the Air’ alerts,” said Kristina Chu of the Bay Area air quality management district on Wednesday. “That’s an all-time record,” she explained; the previous longest was 14 days.