Recently I had the pleasure of meeting Gloria Pan, campaign director of MomsRising, and learned that this unique organization has become involved in the efforts to improve air quality. After years of delays, new regulations enforcing the Air

Image from Baylor Health Care System Art for Asthma 2009 winner

Toxic Standards from 1990 amendments to the Clean Air Act were implemented last month [1]. To acknowledge that progress, thousands of MomsRising members sent thank you cards to Lisa Jackson, the current EPA administrator, for her commitment to clean air and healthy environment [2].

I would like to take this opportunity to introduce myself to the MomsRising community and convey my perspective of air quality and health. I am a mother of four young children, and also a physician practicing pulmonary (lung) and critical care (intensive care unit) medicine at Cleveland Clinic, where I am Co-Director of the Asthma Center.  These various roles inform my perspective, but people I care for in my professional and personal life compel me to be an advocate.

Poor air quality has an impact upon public health [3-5]. However, awareness of the scope and nature of this problem is not as extensive and common as it should be. Since air pollution is not as visible a problem as in the past, there is a tendency to minimize the consequences of persistently elevated levels. On behalf of health advocates, I truly appreciate MomsRising’s increasing public awareness by taking this issue up as its own.

Professional medical organizations such as the American Academy of Pediatrics, American Thoracic Society, and the American Lung Association have made their stance clear:  clean air is a necessary resource and not optional, and there should not be delays in implementing regulations to control and curtail air pollution in the interest of public health. [6,7]

As may be expected, certain groups, such as children, the elderly, and those with chronic heart and lung problems, are more susceptible to these undesirable effects.  These sensitive groups of people who detect poor air are effectively the proverbial canaries in the coalmine.

What is air pollution?
An air pollutant is any substance in the air that can cause harm to humans or the environment [8].
There are six common air pollutants that are monitored and regulated by the EPA. These include ground level ozone (which is formed from a mixture heat, sunlight, and volatile organic compounds (VOCs) created from burning of fossil fuels), particulate matter (small particles created from combustion—industry and vehicular emissions), carbon monoxide, nitrogen dioxide, sulfur dioxide, and lead. The highest pollutant levels (exclusive of lead) determine the air quality index (AQI) that is reported in weather forecasts. The AQI helps us understand whether air quality is within an acceptable and safe (AQI 0-50), unsafe (>150), or intermediate (51-150) range [9].

In addition, there are toxic air pollutants, also known as hazardous air pollutants. Currently more than 180 compounds, including mercury, lead and arsenic are identified as known or suspected to cause cancer or other serious health effects [10]. The recent regulations are meant to reduce mercury and other pollutants primarily emitted from coal-fired power plants [1].

What are the health effects of air pollution?
The adverse health effects of air pollution have been known for many years. Ozone and particulate matter have been studied most extensively. Studies of large populations have demonstrated that individuals living in high areas of air pollution suffer from heart and lung problems. One example of a natural experiment is the Utah Valley Steel Mill Study. This study demonstrated that during a year-long interruption of steel production in the Utah Valley, there was improvement in air pollution and a corresponding decrease in hospitalizations for asthma, pneumonia, and heart disease [4,5]. Interestingly, after the mill returned to capacity air pollution levels increased as did the hospitalization rates for the same conditions.

A wealth of research published in scientific journals has supported these findings. Large population studies demonstrated that not only can short term exposures make us sick (example high ozone days and asthma), long term exposures are of further concern [5]. A study of children In California found that children living in areas of poorer air quality have a lower rate of lung growth than children living in less polluted areas [11]. Also, kids who played 3 or more outdoor sports during high ozone season (spring and summertime) were more likely to be newly diagnosed with asthma [12].

Importantly, what we learned from many of these studies is that any change in air quality for the better is associated with a decrease in rates of death [13,14]. So despite the statistics and bad news, we can make a difference.

Approximately 8% of the population is reported to have asthma. It is also the most common chronic conditions in children.  The US Dept of Health and Human Services has reported staggering numbers for asthma, with 16 million adults with current asthma and an estimated total cost of asthma at $20 billion [15].   Aside from the symptoms and severity, the costs to school performance and absenteeism can be great, not to mention the time away from work for parents and caregivers.

But asthmatics are not the only ones affected. People with allergies can be more sensitive to their triggers/allergens after being exposed to air pollution. People with COPD (chronic obstructive lung disease such as emphysema and chronic bronchitis) are also affected by poor air quality. There is an increase in heart attacks and worsening of congestive heart failure and arrhythmias with worse air quality [16]. Similarly stroke risk is increased.

Mercury is associated with damage to kidneys, liver, brain and may be related to birth defects. Particularly with mercury, which accumulates through contamination of the food chain, causation is more difficult to perceive [7].

What is the science behind this observation?
A good deal of information on how poor air quality affects health has become known, but more information and research is needed. Some mechanisms include an increased inflammatory reaction in the body depending upon the composition of air pollutants, oxidative stress causing downstream changes in body chemistry, and changes in blood properties.  Ironically, in defense against all of the above, individuals can have an overly robust reaction, which in certain cases can cause more injury [17].

Thus, there is a biologic feasibility as to why this can occur. That in combination with the multiple studies that have demonstrated poor health effects in larger populations underscore the relevance and importance of this problem.

What can we do?

1) Understand the problem - MomsRising increasing awareness of this problem and using creative means to educate others is a big step in demystifying the health consequences of air pollution. Concepts such as the ‘lag effect’ and ‘what you can’t see won’t hurt you’ contribute to the decreased awareness that air pollution is an important factor.

2) Support organizations that are working to keep air clean - We have a big health advocate in the EPA as well as other organizations such as the American Lung Association. We need to continue to engage and support the mission of clean air. Certainly, compromise is necessary, but there must always be a strong stance in favor of public health and the greater good.

Cost and health analyses have demonstrated that the regulations put forth since passage of the Clean Air Act in 1970 prevented hundreds of thousands of premature deaths and avoided millions of other cardiac/pulmonary illnesses [18]. By 2020, millions of asthma flares will be prevented, as well as hospitalizations and premature deaths [19]. The health cost savings as well as the time/absences from school and work can reap great benefit.

3) Be part of the change through small but habitual changes in your daily behavior - Although it is easy to blame large companies or factories and plants with large smokestacks as the culprit, we must realize that we can make a difference. Vehicular traffic and burning of fossil fuels is a big contributor to pollution. It adds to the ozone problem in the summer time and the particulate matter pollution throughout the year. Take advantage of car-pooling or use public transportation when you are able. Importantly, not allowing your vehicle to idle makes a big difference. This means when the car is stopped, turn off the engine. In fact many cities and school systems have passed ordinances to limit idling times by cars, trucks, and buses.

(And while we’re at it, please support tobacco-smoke free spaces—we have to watch our individual smokestack output and how it affects us and others around us too!)

So please get involved! Once you understand the problem, support organizations that promote air quality and health, you can also be a voice—through MomsRising’s platform or on your own!

Ultimately, it is our individual and shared responsibility to ensure that canaries in our country and the world do not become silenced by inaction while our country debates and refutes rigorous scientific evidence that will save them. Thank you, MomsRising, for doing your part!

Sumita B. Khatri, MD MS
Cleveland Clinic Respiratory Institute
Assistant Professor, CWRU Cleveland Clinic Lerner College of MedicineReferences:

1. http://www.epa.gov/mats/actions.html.  accessed 2-10-12
2. http://www.momsrising.org/page/ moms/moms-say-thanks-to-epa-administrator-lisa-jackson-for-protecting-kids-from-mercury-and-arsenic] Accessed 2-10-12
3. Dockery DW, Pope CA, Xu X et al. An Association between Air Pollution and Mortality in Six U.S. Cities. N Engl J Med 1993; 329:1753-1759.
4. Pope CA. Respiratory disease associated with community air pollution and a steel mill, Utah Valley. American Journal of Public Health 1989; 79 (5): 623-628.
5. Pope CA, Dockery DW. Health Effects of Fine Particulate Air Pollution. J Air & Waste Manag. Assoc. 56: 709-742.
6. http://www.thoracic.org/advocacy/comments-testimony/epa-power-plant-air-toxics-rule.php
7. Toxic Air: The Case for Cleaning Up Coal-fired Power Plants. Available at www.lungusa.org  Accessed 2-10-12.
8. http://www.epa.gov/ebtpages/airairpollutants.html  Accessed 2-10-12
9. www.airnow.gov  Accessed 2-10-12
10. http://www.epa.gov/oar/toxicair/newtoxics.html Accessed 2-10-12
11. Gauderman WJ, Avol E, Gilliland F et al. The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med 2004; 31: 1057-1067.
12. McConnell R, Berhane K, Gilliland F et al. Asthma in exercising children exposed to ozone: a cohort study. Lancet 2002; 359: 386-391.
13. Laden F, Schwartz J, Speizer F, and Dockery DW. Reduction in Fine Particulate Air Pollution and Mortality;Extended Follow-up of the Harvard Six Cities Study. Am. J. Respir. Crit. Care Med. 2006; 173( 6); 667-672.
14. Pope CA, Ezzati M, Dockery DW. Fine-Particulate Air Pollution and Life Expectancy in the United States. N Engl J Med 2009; 360:376-386
15. http://www.ahrq.gov/qual/qrdr10.htm Accessed 2-10-12.
16. Miller KA, Siscovick DS, Sheppard L et al. Long-Term Exposure to Air Pollution and Incidence of Cardiovascular Events in Women. N Engl J Med 2007; 356:447-458.
17. Bernstein et al. Rostrum: Health Effects of Air Pollution. J Allergy Clin Immunol 2004;114:1116-23.
18. http://www.epa.gov/air/sect812/retro.html. Accessed 2-10-12.
19. http://www.epa.gov/air/sect812/prospective2.html. Accessed 2-10-12.