Pollution and its massive impact on health - a surgical view
21 Jun 2018
Mrs Scarlett McNally BSc MB BChir FRCS (Tr&Orth) MA MBA FAcadMEd
Why is an orthopaedic surgeon writing about air pollution? I can declare an interest with two of my children having asthma. We think of short-term respiratory effects of pollution. The long-term effects are far worse. Pollution is a major cause of ill-health across multiple systems. Pollution is implicated in strokes, ischaemic heart disease, foetal growth retardation, autistic spectrum disorder, cancers, mental ill-health, inflammation and dementia.
The Royal College of Physicians of London and Royal College of Paediatrics and Child Health produced a report ‘Every breath you take, the lifelong impact of air pollution’, listing multiple conditions where pollution contributes. It is hard to grasp their quote of ‘40,000 excess deaths due to pollution in the UK annually’. Far more are living with decades of ill-health, quantified as “the health problems resulting from exposure to air pollution cost more than £20 billion every year.” RCS England has joined the UK Health Alliance for Climate Change (UKHACC). We are stronger together. There is clear compelling evidence of the harmful effects of pollution on health. It is insidious and persistent; the mechanism is mostly inflammation.
The principal anthropogenic pollution sources are transport vehicles, power stations and factories. Outdoor air pollution includes particulates and noxious gases (e.g. Nitrogen Dioxide, NO2). Transport is a large contributor to both. It isn’t all petrol and diesel exhaust. Much of the pollution from transport is particulate matter from brakes, tyres and road particles. That aspect will continue even if we all move to electric cars.
Those in more deprived social settings bear the brunt of the ill-effects of pollution. The Chief Medical Officer describes this as “triple jeopardy”. Obesity and a diet low in anti-oxidants both worsen the effects of pollution.
Tackling pollution improves health inequalities. Now, people in most deprived areas spend 18 years longer living with ill-health (44 years vs. 26 years). This is not inevitable. We are not powerless. There are proximate causes of inequalities, or Marmot’s “the causes of the causes”; the five main ones are: smoking, nutrition, physical inactivity, alcohol and pollution. The Academy of Medical Royal Colleges brought together a report ‘Exercise, the miracle cure’, which I led, showing how exercise, at a small dose of 20-30 minutes/day, improves health, as primary and secondary prevention for an array of common conditions. A quarter of UK adults are classed as ‘inactive’. The BMA report ‘healthy transport = healthy lives” recommends walking and cycling as “effective ways of integrating, and increasing, levels of physical activity into everyday life for the majority of the population”. The big problem is culture and facilities. We need older people to exercise. I used to drive my mother out for a meal, now we go out for a walk. I led a different recent BMJ paper on the connection between physical activity and the need for social care. This cited evidence that only 20% of diseases have a genetic cause, 70% of NHS spend is on long-term conditions, the UK spends £1 billion on social care for over 65s, and the need for social care can be reduced five-fold if people increase their physical activity to ‘drop a decade’ in disability.
The “best buy” to reduce outdoor air pollution is transport. The more people who can use active transport (walking, cycling or jogging) the fewer who are in polluting cars. The scale of the possible win-win effect is huge. More people walking and cycling would improve the numbers of people getting sufficient exercise, hence further reducing their risk of surgical problems such as hip fracture, osteoporosis, bowel cancer and dementia by over 30%. Improving infrastructure for active travel and reducing motorised transport is a key means of tackling pollution and is recommended by NICE, Chief Medical Officer, WHO, RCP/RCPCH, BMA and UKHACC.
Behaviour change sounds difficult. Yet we have done it for dog poo and plastic bags. Individuals are not rational. Change requires infrastructure and a change in culture or expectation. We all think we are busy, yet we all have the same 168 hours per week. We need safe cycle lanes, parking exclusion zones around schools, cycle parking, re-training of some drivers to respect other users (e.g. giving 1.5m when overtaking cyclists and not overtaking just before turning left), re-training of some cyclists (to use lights, stop at red lights and avoid pavements) and education on driving style (to switch off the engine when idling and to brake less violently).
The Chief Medical Officer’s report ‘Pollution’ makes the point that 5% of traffic on UK roads is on NHS business. The NHS contributes 9% to Britain’s GDP and employs 1.7 million people. Each has family and friends. We could be amazing role models. Those employed in health, social care, education and local or central government comprise a large proportion of the employed. Better corporate attention to procurement, waste, transport, buildings and policies could have a huge impact.
As NICE puts it: “Many people do not understand the link between health and road-traffic-related air pollution. They do not realise that long-term exposure to typical levels of air pollution causes far more health problems than short-term exposure to higher levels [nor] that they can help reduce this pollution if they change their behaviour. Without this understanding it will be difficult to get public support for the changes needed.”
Indoor air pollution includes aerosols, fungi, damp, corrosive cleaning products, smoking, wood-burners, building materials, furnishings and insulated homes where fresh air does not circulate. This will be a focus of future UKHACC activity.
Pollution isn’t about polar bears. It isn’t even about 40,000 more people dying every year. It is about people living poorer lives with the effects of stroke or heart disease and children suffering asthma and reduced growth. We must take action because it isn’t fair. Or we must take action because the UK can no longer afford to support millions of people suffering worse health, having worse employment opportunities and costing billions in social care that might never have been needed. We have no choice.
AoMRC, Academy of Medical Royal Colleges (2015) Exercise the miracle cure and the role of the doctor in promoting it http://www.aomrc.org.uk/publications/reports-guidance/exercise-the-miracle-cure-0215/
BMA (2012) Healthy transport = Healthy lives. www.bma.org.uk/transport
CMO Chief Medical Officer annual report 2017: health impacts of all pollution – what do we know? https://www.gov.uk/government/publications/chief-medical-officer-annual-report-2017-health-impacts-of-all-pollution-what-do-we-know
McNally S, Nunan D, Dixon A, Maruthappu M, Butler K, Gray M (2017) Focus on physical activity can help avoid unnecessary social care British Medical Journal (BMJ) 21 October 2017, p108-110. https://doi.org/10.1136/bmj.j4609 or on www.scarlettmcnally.co.uk FULL TEXT
NICE (2017) Air pollution: outdoor air quality and health https://www.nice.org.uk/guidance/ng70 ‘download’
RCP/RCPCH (2016) Every breath we take: the lifelong impact of air pollution. https://www.rcplondon.ac.uk/projects/outputs/every-breath-we-take-lifelong-impact-air-pollution
WHO World Health Organization (2015) Ambient (outdoor) air quality and health. http://www.who.int/news-room/fact-sheets/detail/ambient-(outdoor)-air-quality-and-health