Over the past few months, everyone has had to deal with respiratory problems, either themselves or through family or friends. Corona and other respiratory infections such as influenza and RSV: respiratory problems were everywhere, dominating public opinion, occupying hospital beds, medicines were in short supply... Many people, from infants to adults, also suffer from allergies, which in some cases cause asthma attacks. Many of the elderly among us suffer from chronic obstructive pulmonary disease (COPD).
We talk about how humans and the economy are gradually destroying the natural environment. How long will we be able to breathe properly and healthily? Just as fish are unaware that they live in water, most of us forget that we live and survive thanks to healthy air.
Fortunately, air quality in Europe, including Belgium, has improved in recent decades. Nevertheless, the VMM (the Flemish Environmental Agency) has measured a further increase in air concentrations in 2021 compared to 2020 for almost all pollutants. We see an increase in the concentrations of particulate matter (PM2.5), nitrogen dioxide (NO2), black carbon (diesel soot), benzo(a)pyrene (from wood and tobacco smoke) and carbon monoxide (CO), among others.
Respiratory diseases such as asthma have increased significantly in recent decades. It is estimated that around 6% of the Belgian population over the age of 15 have experienced an asthma crisis in the past year. Reduced lung function and increased use of inhalers are also observed among schoolchildren. 15 percent of children are reported to have asthma. And 'childhood asthma' is a growing concern for young parents.
Why is this? There is no single explanation, but hypotheses have been circulating for years. Some are dubious, such as the suggestion that respiratory problems could be a side-effect of certain vaccinations. Some are controversial, such as the increase or decrease in outdoor air quality. Others, however, are supported by scientific research. First and foremost, there are exogenous factors. These include urbanisation and changing lifestyles. We live and work more and more indoors, and with less ventilation we are more exposed to indoor air pollution, mould, dust mites, fumes, smoke and chemicals. Excessive hygiene also makes us less immune, and cigarette smoke affects not only the smokers themselves, but also those around them. Asthma and other allergies are also often linked to inherited traits. A similar rise in overweight and obesity is observed, which are also linked to respiratory diseases. Some are talking about a "global asthma epidemic" or "respiratory epidemic".
NOT JUST WITH US
Corona has made us realise that we cannot isolate ourselves. No community, region, country or economy lives and breathes in its own more or less healthy bell jar. We live in a global natural habitat, not a closed biotope. The air is a shared space.
Air pollution is rising sharply in low- and middle-income countries. More than 90 percent of the world's deaths from air pollution occur in these countries. The causes are visible across many scales: the use of dirty fuels; massive imports of "our" dirty vehicles; industrial and artisanal activities in the middle of residential areas; lots of wind-blown dust due to drought; poor waste management that relies on public burning; weak or no enforcement of air quality standards by governing authorities; indoor pollution from burning biomass such as wood, charcoal or coal.
A region's location can also play an important role. Africa, for example, has the highest desert dust emissions. The continent produces about a third of the world's aerosol particles from biomass burning and is undergoing a process of highly polluting but rapid industrial growth.
In rich countries, hardly anyone dies from an asthma crisis, but elsewhere they do. Death by breathlessness and suffocation. 80 percent of the more than 450,000 asthma-related deaths occur in the Global South. The 250 to 300 million people with asthma, and the equally large group of people with other chronic lung problems, are overwhelmingly located in the global South. This while chronic respiratory problems such as asthma are often under-diagnosed, mis-diagnosed (as tuberculosis) and under-treated in Africa and other developing regions.
It is now 20 years since the World Health Organisation (WHO) published a report on the prevention and control of chronic respiratory diseases in low- and middle-income countries in Africa. But not much has been achieved. One of the Sustainable Development Goals is to reduce mortality from noncommunicable diseases by 30 percent by 2030. Most people think of diabetes and cardiovascular disease. It is often forgotten that chronic respiratory diseases also affect many more people. The goal should therefore be to find appropriate strategies to prevent and control respiratory diseases in a cost-effective way.
Such a goal will require the efforts of many governments, at local, national and international levels. Reducing air pollution will affect transport, agriculture, industry and even health services. To give a striking example of the latter, in many countries of the global south, as here, all medical materials (syringes, cloths, medical gloves...) are incinerated after use. But if the incinerator is in the middle of the hospital grounds and the doors and windows are open for ventilation and cooling, toxic substances systematically end up in the already weakened patients or newborn babies. On top of that, not all nurses, doctors and other health workers know what respiratory diseases are. A patient in respiratory distress simply does not have the strength to walk to the nearest dispensary. And if they do get to a clinic, the health worker often does not have a spirometer to measure their breathlessness, or any medicine, let alone oxygen, to do anything about it. Recently, a large study in 25 countries found that of more than 450,000 people diagnosed with asthma, almost 45 percent did not receive or could not receive adequate (corticosteroid) treatment.
POORLY VENTILATED KITCHENS
Housing also plays an important role. In countries with tropical climates, people used to cook in the open, over charcoal fires. Now people are increasingly cooking in poorly ventilated kitchens, often still with charcoal and in the presence of mothers and children. Rubbish is burnt in the streets. Highly polluting diesel cars, buses and lorries, imported from Europe, belch their black smoke. Metals needed for our modern technology (batteries, chips) are mined - sometimes by children - in artisanal mines under very unhealthy conditions, possibly leading to silicosis (severe and progressive lung disease, ed.) and increased risk of TB and other lung diseases. Occupational lung damage is also caused by poor air quality in manufacturing, construction, agricultural pesticides, literally breathtaking transport, roadside vendors and the ubiquitous survival economy. Very often people (including us) associate or confuse air pollution with bad smells, smoke is seen by some as a panacea for malaria mosquitoes, or asthmatics are seen as having mental problems. Or they are seen as evil TB sufferers, who should be cast out.
In each of these areas of life and work, respiratory problems are like the proverbial canaries that warned the miners when there were dangerous gases in the shafts. They are indicators that our airways are being damaged by unhealthy air.
AIR AS IMPORTANT AS WATER
We are convinced that only a joint effort by different governments (to ensure adequate regulations), urban planners and architects (to help determine the spatial organisation of human activities), health professionals (to detect and treat diseases), women's organisations (to provide health education), public health organisations (to provide prevention), academics (to look for interdisciplinary and applied solutions), social partners (to ensure healthy working environments), engineers (to develop, among other things, detection apps and less polluting engines) and the media (for raising awareness) will be able to ensure that the dramatic increase in chronic respiratory diseases is on everyone's radar.
There is a general lack of awareness of the effects of air pollution, particularly in low- and middle-income countries. This is certainly related to the high cost of installing and maintaining air quality monitoring stations. New sensor systems, including AI, and surveys that use citizen participation could be cheaper alternatives. Of course, there is still the question of what to do with the results.
For years we have thought that good health here and in the Global South depends on a limited number of conditions. Clean water was (not unreasonably) at the top of the list. Adequate and balanced nutrition has also received a lot of attention. As does decent housing. We are beginning to realise that healthy air is also essential. This is less the case in the Global South. But there too, air pollution kills three times as many people a year as AIDS, tuberculosis and malaria combined. And there, too, the airways are the most important pathways...
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