The Lancet Commission on pollution and health
Prof Philip J Landrigan, MD
Richard Fuller, BE
Nereus J R Acosta, PhD
Olusoji Adeyi, DrPH
Robert Arnold, PhD
Prof Niladri (Nil) Basu, PhD
et al.
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Published:October 19, 2017DOI:https://doi.org/10.1016/S0140-6736(17)32345-0
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Executive summary
Pollution is the largest environmental cause of disease and premature death in the world today. Diseases caused by pollution were responsible for an estimated 9 million premature deaths in 2015—16% of all deaths worldwide—three times more deaths than from AIDS, tuberculosis, and malaria combined and 15 times more than from all wars and other forms of violence. In the most severely affected countries, pollution-related disease is responsible for more than one death in four.
Pollution disproportionately kills the poor and the vulnerable. Nearly 92% of pollution-related deaths occur in low-income and middle-income countries and, in countries at every income level, disease caused by pollution is most prevalent among minorities and the marginalised. Children are at high risk of pollution-related disease and even extremely low-dose exposures to pollutants during windows of vulnerability in utero and in early infancy can result in disease, disability, and death in childhood and across their lifespan.
Despite its substantial effects on human health, the economy, and the environment, pollution has been neglected, especially in low-income and middle-income countries, and the health effects of pollution are under-estimated in calculations of the global burden of disease. Pollution in low-income and middle-income countries that is caused by industrial emissions, vehicular exhaust, and toxic chemicals has particularly been overlooked in both the international development and the global health agendas. Although more than 70% of the diseases caused by pollution are non-communicable diseases, inter-ventions against pollution are barely mentioned in the Global Action Plan for the Prevention and Control of Non-Communicable Diseases.
Pollution is costly. Pollution-related diseases cause productivity losses that reduce gross domestic product (GDP) in low-income to middle-income countries by up to 2% per year. Pollution-related disease also results in health-care costs that are responsible for 1·7% of annual health spending in high-income countries and for up to 7% of health spending in middle-income countries that are heavily polluted and rapidly developing. Welfare losses due to pollution are estimated to amount to US$4·6 trillion per year: 6·2% of global economic output. The costs attributed to pollution-related disease will probably increase as additional associations between pollution and disease are identified.
Pollution endangers planetary health, destroys eco-systems, and is intimately linked to global climate change. Fuel combustion—fossil fuel combustion in high-income and middle-income countries and burning of biomass in low-income countries—accounts for 85% of airborne particulate pollution and for almost all pollution by oxides of sulphur and nitrogen. Fuel combustion is also a major source of the greenhouse gases and short-lived climate pollutants that drive climate change. Key emitters of carbon dioxide, such as electricity-generating plants, chemical manufacturing facilities, mining operations, deforestation, and petroleum-powered vehicles, are also major sources of pollution. Coal is the world's most polluting fossil fuel, and coal combustion is an important cause of both pollution and climate change.
In many parts of the world, pollution is getting worse. Household air and water pollution, the forms of pollution associated with profound poverty and traditional lifestyles, are slowly declining. However, ambient air pollution, chemical pollution, and soil pollution—the forms of pollution produced by industry, mining, electricity generation, mechanised agriculture, and petroleum-powered vehicles—are all on the rise, with the most marked increases in rapidly developing and industrialising low-income and middle-income countries.
Chemical pollution is a great and growing global problem. The effects of chemical pollution on human health are poorly defined and its contribution to the global burden of disease is almost certainly underestimated. More than 140·000 new chemicals and pesticides have been synthesised since 1950. Of these materials, the 5000 that are produced in greatest volume have become widely dispersed in the environment and are responsible for nearly universal human exposure. Fewer than half of these high-production volume chemicals have undergone any testing for safety or toxicity, and rigorous pre-market evaluation of new chemicals has become mandatory in only the past decade and in only a few high-income countries. The result is that chemicals and pesticides whose effects on human health and the environment were never examined have repeatedly been responsible for episodes of disease, death, and environmental degradation. Historical examples include lead, asbestos, dichlorodiphenyltrichloroethane (DDT), polychlorinated biphenyls (PCBs), and the ozone-destroying chlorofluorocarbons. Newer synthetic chem-icals that have entered world markets in the past 2–3 decades and that, like their predecessors, have undergone little pre-market evaluation threaten to repeat this history. They include developmental neurotoxicants, endocrine disruptors, chemical herbicides, novel insect-icides, pharmaceutical wastes, and nanomaterials. Evidence for the capacity of these emerging chemical pollutants to cause harm to human health and the environment is beginning to become evident. These emerging chemicals are of great concern, and this concern is heightened by the increasing movement of chemical production to low-income and middle-income countries where public health and environmental protections are often scant. Most future growth in chemical production will occur in these countries. A further dimension of chemical pollution is the global archipelago of contaminated hot-spots: cities and communities, homes and schoolyards polluted by toxic chemicals, radionuclides, and heavy metals released into air, water, and soil by active and abandoned factories, smelters, mines, and hazardous waste sites.
Cities, especially rapidly growing cities in industrialising countries, are severely affected by pollution. Cities contain 55% of the world's population; they account for 85% of global economic activity and they concentrate people, energy consumption, construction activity, industry, and traffic on a historically un-precedented scale.
The good news is that much pollution can be eliminated, and pollution prevention can be highly cost-effective. High-income and some middle-income countries have enacted legislation and issued regulations mandating clean air and clean water, established chemical safety policies, and curbed their most flagrant forms of pollution. Their air and water are now cleaner, the blood lead concentrations of their children have decreased by more than 90%, their rivers no longer catch fire, their worst hazardous waste sites have been re-mediated, and many of their cities are less polluted and more liveable. Health has improved and people in these countries are living longer. High-income countries have achieved this progress while increasing gross domestic product (GDP) by nearly 250%. The challenge for high-income nations today is to further reduce pollution, decarbonise their economies, and reduce the resources used in achieving prosperity. The claim that pollution control stifles economic growth and that poor countries must pass through a phase of pollution and disease on the road to prosperity has repeatedly been proven to be untrue.
Pollution mitigation and prevention can yield large net gains both for human health and the economy. Thus, air quality improvements in the high-income countries have not only reduced deaths from cardiovascular and respiratory disease but have also yielded substantial economic gains. In the USA, an estimated US$30 in benefits (range, $4–88) has been returned to the economy for every dollar invested in air pollution control since 1970, which is an aggregate benefit of $1·5 trillion against an investment of $65 billion. Similarly, the removal of lead from gasoline has returned an estimated $200 billion (range, $110 billion–300 billion) to the US economy each year since 1980, an aggregate benefit to-date of over $6 trillion through the increased cognitive function and enhanced economic productivity of generations of children exposed since birth to only low amounts of lead.
Pollution control will advance attainment of many of the sustainable development goals (SDGs), the 17 goals established by the United Nations to guide global development in the 21st century. In addition to improving health in countries around the world (SDG 3), pollution control will help to alleviate poverty (SDG 1), improve access to clean water and improve sanitation (SDG 6), promote social justice (SDG 10), build sustainable cities and communities (SDG 11), and protect land and water (SDGs 14 and 15). Pollution control, in turn, will benefit from efforts to slow the pace of climate change (SDG 13) by transitioning to a sustainable, circular economy that relies on non-polluting renewable energy, on efficient industrial processes that produce little waste, and on transport systems that restrict use of private vehicles in cities, enhance public transport, and promote active travel.
Many of the pollution control strategies that have proven cost-effective in high-income and middle-income countries can be exported and adapted by cities and countries at every level of income. These strategies are based in law, policy, regulation, and technology, are science-driven, and focus on the protection of public health. The application of these approaches boosts economies and increases GDP. The strategies include targeted reductions in emissions of pollutants, transitions to non-polluting, renewable sources of energy, the adoption of non-polluting technologies for production and transportation, and the development of efficient, accessible, and affordable public transportation systems. Application of the best of these strategies in carefully planned and well resourced campaigns can enable low-income and middle-income countries to avoid many of the harmful consequences of pollution, leapfrog the worst of the human and ecological disasters that have plagued industrial development in the past, and improve the health and wellbeing of their people. Pollution control provides an extraordinary opportunity to improve the health of the planet. It is a winnable battle.
The aim of this Lancet Commission on pollution and health is to raise global awareness of pollution, end neglect of pollution-related disease, and mobilise the resources and the political will needed to effectively confront pollution. To advance this aim, we make six recommendations. Additional recommendations are presented at the end of each Section. The key recommendations are:
(1) Make pollution prevention a high priority nationally and internationally and integrate it into country and city planning processes. Pollution can no longer be viewed as an isolated environmental issue, but is a transcendent problem that affects the health and wellbeing of entire societies. Leaders of government at all levels (mayors, governors, and heads of state) need, therefore, to elevate pollution control to a high priority within their agendas; to integrate pollution control into development planning; to actively engage in pollution planning and prioritisation; and to link prevention of pollution with commitments to advance the SDGs, to slow the pace of climate change, and to control non-communicable diseases.
Targets and timetables are essential, and governments at all levels need to establish short-term and long-term targets for pollution control and to support the agencies and regulations needed to attain these goals. Legally mandated regulation is an essential tool, and both the polluter-pays principle and an end to subsidies and tax breaks for polluting industries need to be integral components of pollution control programmes.
(2) Mobilise, increase, and focus the funding and the international technical support dedicated to pollution control. The amount of funding from international agencies, binational donors, and private foundations that is directed to control of pollution, especially pollution from the industrial, transport, chemical, and mining sectors in low-income and middle-income countries is meagre and needs to be substantially increased. The resources directed to pollution management need to be increased within cities and countries as well as internationally. Options for increasing the international development funding directed to pollution include expansion of climate change and non-communicable disease control programmes to include pollution control and development of new funding mechanisms.
In addition to increased funding, international technical support for pollution control is needed in prioritisation and planning of processes to tackle pollution within rapidly industrialising cities and countries; in development of regulatory and enforcement strategies; in building technical capacity; and in direct interventions, in which such actions are urgently needed to save lives or can substantially leverage local action and resources. Financing and technical assistance programmes need to be tracked and measured to assess their cost-effectiveness and to enhance accountability.
(3) Establish systems to monitor pollution and its effects on health. Data collected at the national and local levels are essential for measuring pollution levels, identifying and apportioning appropriate responsibility to each pollution source, evaluating the success of interventions, guiding enforcement, informing civil society and the public, and assessing progress toward goals. The incorporation of new technologies, such as satellite imaging and data mining, into pollution monitoring can increase efficiency, expand geographic range, and lower costs. Open access to these data is essential, and consultation with civil society and the public will ensure accountability and build public awareness. With even limited monitoring programmes, consisting of only one or a few sampling stations, governments and civil society organisations can document pollution, and track progress toward short-term and long-term control targets. Pollution control metrics should be integrated into SDG dashboards and other monitoring platforms so that successes and experiences can be shared.
(4) Build multi-sectoral partnerships for pollution control. Broad-based partnerships across several govern-ment agencies and between governments and the private sector can powerfully advance pollution control and accelerate the development of clean energy sources and clean technologies that will ultimately prevent pollution at source. Cross-ministerial collaborations that involve health and environment ministries, but also ministries of finance, energy, agriculture, development, and trans-port are essential. Collaborations between govern-ments and industry can catalyse innovation, create incent-ives for cleaner production technologies and cleaner energy production, and incentivise transition to a more sustainable, circular economy. The private sector is in a unique position to provide leadership in the design and development of clean, non-polluting, sustainable tech-nologies for pollution control, and to engage construct-ively with governments to reward innovation and create incentives.
(5) Integrate pollution mitigation into planning processes for non-communicable diseases. Interventions against pollution need to be a core component of the Global Action Plan for the Prevention and Control of Non-Communicable Diseases.
(6) Research pollution and pollution control. Research is needed to understand and control pollution and to drive change in pollution policy. Pollution-related research should:
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Explore emerging causal links between pollution, disease, and subclinical impairment, for example between ambient air pollution and dysfunction of the central nervous system in children and the elderly;
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Quantify the global burden of disease associated with chemical pollutants of known toxicity such as lead, mercury, chromium, arsenic, asbestos, and benzene;
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Identify and characterise the adverse health outcomes caused by new and emerging chemical pollutants, such as developmental neurotoxicants, endocrine disruptors, novel insecticides, chemical herbicides, and pharmaceutical wastes;
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Identify and map pollution exposures particularly in low-income and middle-income countries;
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Improve estimates of the economic costs of pollution and pollution-related disease; and
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Quantify the health and economic benefits of inter-ventions against pollution and balance these benefits against the costs of interventions.
Introduction
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