Who dies from air pollution?

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06 Sep Who dies from air pollution?

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All populations are not equally vulnerable to the ultimate cost of air pollution – death. It is the very young and the very old living in a handful of countries who are at greatest risk of air pollution-related death. And while it is household air pollution that is the greatest risk for children, outdoor air pollution disproportionately affects the elderly. As a result, efforts to reduce air pollution will save the most lives when they target the major causes of air pollution affecting the very young and the elderly in this subset of countries.

Demographic inequalities

Sixty per cent of the estimated 6.7 million air pollution-related deaths that occurred in 2019 were among children under 15 years and adults over 70 years, according to the Global Burden of Disease (GBD). The vast majority of these deaths – 3.4 million – were among the elderly, while 700,000 deaths occurred among children under 15 years. Importantly, 476,000 air pollution-related child deaths occurred in the first month of life. Air pollution is a major threat to newborn survival. 

Of all causes of air pollution, it is particulate matter that causes the largest burden of disease – 6.5 million of the 6.7 million related deaths. Particulate matter measuring less than 2.5 micrometers in diameter – less than a 30th of the diameter of a human hair – is a major risk for human health. This “PM2·5” is emitted both outdoors and indoors from vehicles, coal-burning power plants, industrial activities, waste burning, farming practices, and household cooking and heating using coal, charcoal, wood, agricultural residue, animal dung, and kerosene. 

Air pollution is entwined with climate change because the emissions driving both come largely from the same sources. Burning fuels results in PM2·5, long-lived greenhouse gases, and short-lived climate pollutants (e.g., methane, black carbon, and hydrofluorocarbons), which are simultaneously air pollutants and climate warmers.

Both outdoor and indoor sources of air pollution contribute to deaths, but not equally. Across all ages, air pollution from outdoor sources causes 60% of related deaths, while household air pollution causes 40%. Elderly adults are more at risk of death from outdoor air pollution, while the health of children is particularly vulnerable to household air pollution. Two-thirds of air pollution-related deaths among adults aged over 70 are attributable to outdoor sources, while two-thirds of deaths among children are a result of household sources. 

Overall, air pollution-related deaths have risen slightly (2%) since 2000, but this masks the sharp rise (59%) in deaths from outdoor sources and the decline (39%) in deaths from household sources. Among children under 15, air pollution-related deaths have fallen by 50% – driven by declines in household air pollution. Among adults over 70, air pollution-related deaths have risen by 21% – driven by outdoor air pollution.

Geographic inequalities

Air pollution-related deaths are concentrated in 15 countries – China, India, Pakistan, Nigeria, Indonesia, Bangladesh, Egypt, Russia, Ethiopia, Philippines, Myanmar, Viet Nam, Democratic Republic of Congo, Brazil, and USA. More than half (9) are in Asia, four in Africa, and two in the Americas. All but the USA and Russia are low- or middle-income. China, India, Pakistan, Nigeria, and Indonesia are home to 60% of all air pollution-related deaths.

The leading causes of air pollution-related deaths and the most affected populations differ markedly across these 15 countries. For example, in nine countries, air pollution-related deaths concentrate among the elderly, while in just one country (Nigeria), they are concentrate among children under 15 years. Five countries – India, Pakistan, Bangladesh, Ethiopia, and Democratic Republic of Congo – have “double-burdens” of air pollution-related deaths among the very young and very old. 

In the nine countries where the burden is concentrated among the elderly, outdoor air pollution remains the greatest threat, while in Nigeria household air pollution contributes to the most deaths. In the double-burden countries both outdoor and household air pollution are major threats.

Since 2000, air pollution-related deaths have risen in more than half (8) countries most sharply in Egypt (44%), Philippines (42%), India (20%), Indonesia (13%), and Bangladesh (9%), driven by outdoor air pollution. In the countries with significant declines – Russia (50%), USA (42%), Ethiopia (34%), Myanmar (22%), Nigeria (14%), Brazil (14%) – household air pollution-related deaths have fallen sharply.

Health consequences 

Air pollution is a leading risk factor for death from seven leading causes including heart disease, stroke, chronic obstructive pulmonary disorder (COPD), pneumonia, cancers, neonatal disorders, and diabetes. While air pollution-related deaths from heart disease, stroke, COPD, cancers, and diabetes cluster among older adults, neonatal disorders are concentrated among newborns. Only pneumonia is a major cause of death in both populations, which is why Every Breath Counts publishes an Air Pollution and Pneumonia Scorecard.

The burden of disease from air pollution differs across the 15 countries where these deaths are concentrated. For example, in China, India, Bangladesh, Myanmar, Viet Nam, and Brazil air pollution causes heavy burdens of death from heart disease, stroke, and COPD, and cancers in Russia and the USA. In contrast, pneumonia is a major cause in Nigeria, Egypt, Ethiopia, Philippines, and Democratic Republic of Congo and neonatal disorders in Pakistan, Nigeria, and Ethiopia.

The latest Air Quality Life Index reports that particulate pollution is reducing global average life expectancy by two years relative to a world that met the new, more stringent WHO guideline (5µg/㎥). They conclude that air pollution is the single greatest threat to human health globally.

Solutions

Reductions in air pollution can deliver many benefits to human health, including significant declines in deaths from chronic diseases, pneumonia, and neonatal disorders. But success will depend on action in the specific populations in the countries where the burden of air pollution-related deaths is highest – and ensuring that the solutions match the major causes of air pollution-related deaths.

In countries where outdoor air pollution is the greatest contributor to related deaths, countries will need to set ambitious climate action targets (e.g., 2°C and 1·5°C) together with the strongest clean-air policies, as recommended by the Lancet Commission on Air Pollution and Health. They will need to monitor air quality in real-time and make that information available to the public. Currently, only seven of 54 African countries have reliable real-time air quality monitoring.

Urgent action is also needed to increase household access to clean cooking fuels and technologies. According to the World Health Organization, only eight of the 15 countries have achieved more than 50% population access to clean cooking including the USA (100%), Egypt (100%), Brazil (96%), Russia (86%), Indonesia (85%), China (79%), India (68%), Viet Nam (65%). Rates remain below 50% in Pakistan (49%), Philippines (48%), Myanmar (31%), Bangladesh (25%), Nigeria (15%), Ethiopia (8%), and Democratic Republic of Congo (4%).

Although efforts to improve both outdoor and household air quality have so far failed to produce solutions at scale, there are promising signs with the rapid development of new technologies for monitoring air quality, pollution-reducing and capturing materials and transportation, and clean air farming techniques.

Preliminary results from the multi-country Household Air Pollution Intervention Network (HAPIN) trial suggest that an LPG stove and fuel intervention can overcome barriers to exclusive clean fuel use and reduce exposure levels to household air pollution to within WHO air quality targets. More trials are underway.

The stakes are high. Solutions that can reduce air pollution to the levels required for better health will help countries accelerate progress to multiple Sustainable Development Goals, including:

      •  3.2.1 Reduce child (0-4 years) deaths to at least 25 per 1,000 births
      • 3.9.1 Reduce % of adult (15+ years) deaths attributable to PM2·5 air pollution
      • 7.1.2 Increase % population with access to clean fuels and technologies for cooking to 100%
      • 11.6.2 Reduce annual mean levels of fine particulate matter (PM2·5 and PM10) in cities

Call to Action

To accelerate declines in air pollution-related deaths, Every Breath Counts is calling for special action in the 15 countries where these deaths are concentrated. Specifically, governments and their development partners must set national targets to reduce air pollution-related deaths by 50% by 2030, monitor and publish regular estimates of air quality and report progress to the target, and introduce new measures to achieve the target including by:

      • Reducing average PM2·5 exposure by 50% (or until it achieves the updated WHO targets of not more than 5μg/m3 per year and 15 µg/m3 for more than three days per year)
      • Increasing the proportion of households with access to clean cooking fuels and technologies to above 70%, with a special focus on protecting households with newborns and children under 15 years
      • Establishing a multi-sector, multi-government Clean Air Taskforce with representation from the health, energy, agriculture, industry, and urban development ministries in national, state, and local governments

This will require more investment in air pollution reduction by national governments, regional political bodies, and international development actors. Only a small number of bilateral and multilateral agencies and organizations are promoting the health and pollution agenda which receives less than 1% of official development assistance, according to the State of Global Air Quality Funding 2021.

In the remaining years to 2030, it is vital that the health sector works together with the climate change and clean air movements to put air pollution reduction center-stage of national, regional, and global health agendas.

September 2022