THE HEALTH IMPACTS OF URBAN AND TRANSPORT RELATED EXPOSURES. Mark Nieuwenhuijsen

ISGlobal, Barcelona mark.nieuwenhuijsen@isglobal.org ITS, Leeds, November 18, 2016Medellin

PROPORTION OF THE WORLD POPULATION LIVING IN URBAN AREAS

Rydin et al 2012

CITIES

´´Cities have long been known to be society’s predominant engine of innovation and wealth creation, of innovation and wealth creation, yet they are also its main source of crime, pollution, and disease´´

Bettencourt et al 2007

SHENZHEN, CHINA

SHENZHEN, CHINA

BUENOS AIRES, ARGENTINA

BUENOS AIRES, ARGENTINA

KUWAIT CITY, KUWAIT

KUWAIT CITY, KUWAIT

ATHENS, GREECE

ATHENS, GREECE

Mumbai

Paris

NEW URBAN AGENDA23 PAGES, 175 ACTIONS

Density

Mixed land

use/diversity

Distance

Connectivity

Transport

Indoor/

outdoor

Walking

Cycling

Car

Air pollution

Noise

Temperature

UV Radiation

Cardiovascular

and Respiratory

disease

Mental health

Neurodevelop

ment/cognitive

function

Premature

mortality

Urban design Behaviour Pathways Morbidity Mortality

Policies

Transport

infrastructure

Walkability

Bikeability

Green space

Car

Public

transport

function

Cancer

Acute/chronic

mortality

Context: socio-economic, genetic, nutrition

Stress

Social contacts

Physical

activity

Nieuwenhuijsen 2016

EXPOSURE PATTERNS IN CITIES

Barcelona

Girona

Air pollution

Temperature

Green space

Noise

Tehran, Iran, 15 November 2016. Habib Kashani, a member of Tehran’s municipal council, said on Tuesday that pollution in Tehran had led to the death of 412

citizens in the past 23 days, according to the state news agency, Irna. City authorities announced that all schools would be closed on Wednesday. The concentration

of ultra-fine airborne particles (known as PM2.5) reached more than 150 this week, setting a new record. These particles of less than 2.5 micrometres in diameter

can penetrate the lungs and pass into the bloodstream and have been linked to increased rates of chronic bronchitis, lung cancer and heart disease. (Guardian

newspaper)

• 20 Countries

• 40 Study areas

AIR POLLUTION ASSESSMENT AND EPIDEMIOLOGY ESCAPE 7 million people die each year of air pollution

• 2008 - 2012

AIR POLLUTION AND PREMATURE MORTALITY

Beelen et al 20147% increased risk for premature mortality per 5 ug/m3 PM2.5

AIR POLLUTION AND LUNG CANCER

Around 20% increased risk for lung cancer per 5 ug/m3 PM2.5 or 10 ug/m3 PM10

Raaschou-Nielsen et al 2013

5% increased risk of childhood

asthma per 4 ug/m3 NO2

NOISE AND ALL CAUSE MORTALITY

• London TRAFFIC study – All cause mortality

Halonen et al. EHJ 20154% increased risk for premature mortality for > 60 dB vs < 55 dB

NOISE AND HYPERTENSION

• Odds ratio (OR) of 1.034 [95% confidence interval (CI) 1.011-1.056] per 5 dB(A) increase of the 16 h of the 16 h average road traffic noise level (LAeq16hr) [range 45-75 dB(A)].

van Kempen and Babisch 20123% increase in hypertension per 5 dB(A)

TEMPERATURE

Gasparrini

et al 2015

GREEN SPACE

GREEN SPACE AND MORTALITY

4% reduced risk for cardiovascular mortality for high vs low green space exposure

GREEN SPACE AND GENERAL AND MENTAL HEALTH INDICATORS

10-20% reduction per IQR

Triguero-Mas et al 2015

n = 8793 adults

10-20% reduced risk for poor mental over IQR green space exposure

GREEN SPACE AND WORKING MEMORY

Over a 12-mo period,

we observed that an IQR

exposure increment in total

surrounding greenness

index was associated with a

5% increase in the progress

of working memory, a 6%

Dadvand et al 2015

PNASN=2,593 children, 7-10 yrs

of working memory, a 6%

increase in the progress of

the superior working

memory, and a 1% reduction

of inattentiveness.

PHYSICAL INACTIVITY

• Approximately 2.1 million deaths each year are attributable to insufficient physical activity

10%

20%

30%

Risk

reduction

Woodcock et al 2010

40%

50%

ADDED PA THROUGH CYCLING

Donaire-Gonzalez et al 2015

Cycling amounted to 2.1 (95% CI¼0.84, 3.55) hours/week extra of physical

activity for bicycle commuters versus motorized commuters.

CYCLING

• What are the health benefits and risks of cycling for a cyclist:

- increase in physical activity- Increased risk of traffic injuries- Increased risk of traffic injuries- Increased inhalation of air pollution

For the general population; reduced air pollution

Example model: Barcelona BICING case study

Rojas-Rueda

et al 2011

HEALTH IMPACT ASSESSMENT OF THE BICING SYSTEM

CO2eBuilt Environment /

Mode Choice

Active TransportPolicy• Scenario:

– 25 427 daily bicing commuters “new” to cycling (assume 90% of Bicing user previously drove)

– 4.34 km/work-day

RR=0.72

TrafficInjuriy

PhysicalActivity

Air Pollution

Mortality

EconomicEvaluation

Lifeexpectancy

• Impacts:– Change in mortality

in commuters who shifted from car travel

– CO2 emissions savings

Rojas-Rueda et al 2011

Results: mortality in new cyclist population (n=25 427)

Air pollution Motor vehicle crashes

Physical activity

Relative Risk Bike vs Car

1.002 1.0007 0.80

Attributable 0.002 0.0007 -0.23Attributable fraction of mortality

0.002 -0.23

Deaths / year +0.14 +0.03 -12.46

Economic evaluation

Benefit of lives saved (€/year)c18,420,000

Rough estimate of Bicing costs (€/year)15,000,000

Rojas-Rueda et al 2011

HEALTH IMPACTS OF ACTIVE TRANSPORTATION

There are great health benefits of moving from car to public and active transportation.

Benefits from physical activity well outweigh the risks of air pollution and traffic incidents

Mueller et al 2015

HEALTH IMPACT ASSESSMENT URBAN AND TRANSPORT RELATED EXPOSURES IN BARCELONA

Methodology:

All-cause mortality • Risk assessment methodology• Population attributable fractions (PAF)

Life expectancy impactLife expectancy impact• Life table analysis to estimate average change in life expectancy• Standard life table methods

Economic impact• Economic assessment following value of statistical life (VoSL)

approach• VoSL = 3,202,968 € for Spain (2012)

STUDY SETTING: BARCELONA

Population N=1.6 million (≥20 years N=1.3 million)

Area 101 km2

(high population density)

Climate 18 ºC mean temperature, hot summers, mild winters, low precipitationwinters, low precipitation

Vehicle fleet 500,000 cars and 300,000 motorcycles + large daily suburban commuter fleet

Urban design Narrow street canyonsDense construction of semi-tall buildings (5-6 stories)

Green spaces 7 m2 per resident

EXPOSURE RECOMMENDATIONS

Physical activity (WHO)

150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous intensity aerobic physical activity weekly

Air pollution (WHO) PM2.5 = 10 µg/m3

Noise (WHO) Day time (7:00-23:00 hr) outdoor activity noise levels ≤55 dB(A)levels ≤55 dB(A)

Heat (not available) Modifying urban plan may provide cooling of up to 4 ºC

Green space (EC, WHO)

Access to green space ≥0.5 ha within 300 m linear distance

Urban and TranspOrt Planning Health Impact Assessment tool (UTOPHIA)

Current exposure estimates for Barcelona

Recommended exposure levels (‘counterfactual’)

Comparison current exposure to recommended exposure

Exposure response Natural all-cause mortality rate for Barcelona from Exposure response

function (ERF) from literature

Calculation of RR and PAF for the estimated exposure difference

rate for Barcelona from literature (1,108/ 100,000)

Calculation of attributable preventable mortality by multiplying the PAF with the mortality rate

RESULTS

Physical activity 70% of population insufficiently active

Air pollution PM2.5 = 16.6 µg/m3

Noise Day time (7:00-23:00 hr) outdoor activity noise level = 65.1 dB(A)level = 65.1 dB(A)

Heat ≥100 days exceeded ‘minimum mortality temperature percentile’ (21.8 ºC) daily mean temperature

Green spaces ≥30% of residents do not live within 300 m linear distance to a green space ≥0.5 ha

PM2.5 Noise

Heat Green spacesHeat Green spaces

CURRENT ENVIRONMENTAL EXPOSURE LEVELS IN BARCELONA

HEALTH IMPACT ASSESSMENT

Health Impacts:Under compliance with exposure recommendations…

• 2904 deaths preventable (95% CI: 1568-4098) • Increase in average life expectancy by 360 days (95 % CI: 219-493) • Economic savings of 9.3 bn € (95% CI: 4.9-13.2 )

All natural deaths adults ≥20 years N=15,049 (2012) Almost 20% of mortality in Barcelona is attributabl e to urban andtransport planning related exposures

ESTIMATED ATTRIBUTABLE DEATHS

1154

659800

1000

1200

1400

659599

376

116

0

200

400

600

Physical activity (95% CI: 858,1577)

Air pollution (95% CI: 386,834)

Noise(95% CI: 0,1009)

Heat(95% CI: 324,442)

Green spaces (95% CI: 0,236)

PREVENTABLE DEATH

• Number of estimated preventable deaths (N=2904) is much larger than annual number of traffic fatalities in Barcelona (N=30, 2012)

N=30

N=2904

http://lowcarbon.inforse.org/

SOLUTIONS?

• Solutions to the physical inactivity and environmental mortality burden can be found in changes to urban and transport planning

http://lowcarbon.inforse.org/

Woodcock et al 2013

CAR FREE CITIES

• Car free cities can have a considerable benefit on health through potential reduction in air pollution, noise, and heat island effects and increase in physical activity and green space and thereby improving health

• The move towards public and active transportation in this must be understood as crucial, as physical activity is one of the main drivers understood as crucial, as physical activity is one of the main drivers for health and lack of time has been repeatedly listed as a detriment of physical activity

• Urban and transport planning practices such as making cities denser, providing mixed land-use (e.g. home, work, shops), street furniture, safe urban environments and pedestrian and cyclist-friendly amenities could promote positive physical activity patterns and build them into daily routines

Physical inactivityAir pollution

Noise

• Leading risk factors in GBD Study• Cause ≥5 million deaths globally

Green space

Exposures in cities

Heat

• Few green spaces despite benefits for physical and mental health

• Motorized traffic exposes 40% of Europeans to ≥55 dB(A)

• Emissions cause anthropogenic heat that together with re-radiation of construction contribute to urban heat islands

Green space

Epidemiology 2017 (in print)

GREEN AND LIVEABLE

• Greening cities has many health benefits including longer life expectancy, fewer mental health problems, better cognitive function, better mood and healthier babies

• It mitigates air pollution, heat and noise levels.• It mitigates air pollution, heat and noise levels.• Replacing roads and parking with green environments

can be one way forward to change an environment from detrimental to beneficial.

Hamburg

SYSTEMIC APPROACHES

• It is important that we have a more systemic approach to our cities,

bringing together • Urban planners• Urban planners• Transport planners• Environmentalist• Public health professionals• Economists

STAKEHOLDER INVOLVEMENT

• The planning of car free and green cities requires long term political commitment at the highest level and public acceptance.

• Citizen and business participation is • Citizen and business participation is essential to obtain commitment for the proposed changes and vision.

• Favourable media interest

http://www.transglobalhealth.

org/#/joint-phd-

degree/research-projects/

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