The Global Health Nexus on Climate Change and Pollution

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Pollution kills nine million people each year and sickens many more, mostly in poorer nations. The global health effects of climate change are less well quantified, but also increasing with lower-income countries again bearing the brunt of greater food insecurity, increased rates of chronic respiratory illnesses, and shifts in malarial zones. CFR’s Global Health, Economics, and Development Roundtable Series held a discussion on the global health nexus between climate change and pollution and how a more coherent approach to these issues can advance progress at a time when some policymakers, especially in the United States, are unmoved by the environmental, health, and economic consequences expected in the coming decades.

Dr. Philip J. Landrigan
Dr. Philip J. Landrigan

The featured speaker for this discussion was Dr. Philip J. Landrigan, dean for global health at the Icahn School of Medicine at Mount Sinai and recent co-chair of the Lancet Commission on Pollution and Health.

BOLLYKY: We’re going to get started.

It’s fitting that we are holding this event today. New York City is under a heat advisory, and the temperature is supposed to soar to a record high on this date. So thank you all for trudging through all that to get here.

We’re here to talk about the global health nexus between climate and pollution. The global health consequences of pollution and climate are significant. Pollution kills nine million people each year, sometimes many more, mostly in poor countries. The health effects of climate change are less well quantified, but still estimated to be quite serious and disproportionately affect lower-income nations with extreme heat events, violent storms, dust, floods, fires, shifts in vector-borne illnesses, water scarcity, and the like.

Pollution and climate arise from many of the same sources, but their health consequences, until recently, were generally considered separately. A more coherent approach to these issues through global health offers multiple benefits. First, it is simply avoiding the missteps of the past—policies that may address air pollution in the past might do nothing or worsen greenhouse emissions or vice versa. Second, focusing on the visible, immediate impacts of pollutants and climate change might offer opportunities when there is some reluctance among policymakers, particularly in the United States, to act based on the more distant consequences of environmental and climate change.

So we’re going to have a great discussion on this today. We will review the global health nexus between pollution and climate change, why these challenges should be considered together, and the opportunities for doing so even in the current difficult political environment.

We also have the ideal speaker for this discussion. Phil Landrigan is the dean of Global Health at the Icahn School of Medicine at Mount Sinai, and recently the co-chair of the Lancet Commission on Pollution and Health. There are a lot of Lancet commissions these days, but this one was truly a groundbreaking and yielded a terrific report. For the few of you that haven’t read it, I really do recommend it.

Phil has a very long, distinguished biography. It’s in your program so you can read it, but just to mention a few highlights. Phil guided the Environmental Protection Agency in establishing the Office of Children’s Health Protection. He directed the medical and epidemiological follow-up on twenty thousand 9/11 rescue workers. He will be launching soon the Global Pollution Observatory at Boston College and at the Harvard School of Public Health. So again, we are thrilled to have him here.

Today’s event will be on the record and for attribution. Anything you say may be quoted and the speaker may be identified. Basically that means anything you might say today you should expect to be potentially quoted in your obituary. (Laughter.)

So, with that ominous preamble, let me turn it over to Phil. He is going to speak for ten to fifteen minutes, then I’ll ask him a few questions to get us going. After that I will turn it over to the audience and call on you in the order I see your placards, and we’ll take it from there. We’ll end exactly on time—at 1:30.

Please.

LANDRIGAN: Well, thank you, Tom. Thanks to all of you for being here on this hot, hot day. I walked up from 54th Street; I can attest that it’s hot.

So let me tell you about the work of our global commission on pollution and the environment. I’ll just take ten or twelve minutes to sketch the highlights and hopefully set the stage for the conversation that follows.

So the commission was the work of two years. My colleague, Richard Fuller, and I—Richard chairs and NGO based here in New York called Pure Earth, which has been focused on pollution in developing countries for a long time. Richard and I started this thing in July of 2015. We had 52 members of the commission, and we worked for two years. We had a couple of full meetings of the whole commission.

The commission had several tasks. The first was to document the burden of disease and death around the world caused by pollution in all its forms, and we defined pollution here as any material put into the environment by human activity that causes harm to people or damage to the environment. So it’s not volcanic eruptions, it’s not sandstorms. But it is stuff put into the environment as the consequence of human activity.

And the specific categories of pollution that we lumped together under that rubric were what I call the two traditional forms of pollution, which are household air pollution from cookstoves and contaminated drinking water, and then the more—they’re not exactly modern—but the more—the forms of pollution that are more associated with modern life—urbanization, industrialization—which are ambient air pollution, chemical pollution—pollution of soil by chemicals—and radioactive and other hazardous materials. And so we looked first at the burden of disease and death caused by those forms of pollution.

Secondly, we had a team of economists whom we brought together to examine the economic costs of pollution, and that group was originally headed up by the late Ken Arrow, who sadly died partway through the work—through the year, and taken over by Maureen Cropper, an economist at the University of Maryland. And we made—it was a very deliberate decision to include economics in this discussion to move beyond the people who are the usual suspects in my line of work, which would be the ministry of health or the ministry of environment, because we reckoned if we wanted to move the needle on pollution and get people thinking about it constructively, we had to be able to attach a dollar cost to the damages caused by pollution as well as benefits that could be achieved by controlling pollution.

Then we had a group of mainly social scientists and some political scientists who looked at the nexus between pollution, poverty, and social injustice, and then finally we had—we had a diverse team of political scientists, engineers, smart people who thought about solutions to the problem. I’d like to acknowledge Alex Preker, who is sitting over here, a physician and economist who was a member of the commission and contributed in a lot of ways.

So let me—with that introduction, let me run through the highlights of the findings. The main finding in regard to disease and death is that pollution kills nine million people each year. That’s three times more deaths per year than AIDS, malaria, and TB put together. It’s more than ten times as many deaths as are caused each year by wars, terrorism, and all forms of violence put together. It’s a huge number. It’s far more than Ebola, which killed fewer than a million people in its worst year. It’s more than road accidents, which are about two or three million. It’s more than tobacco, which is about seven million. It’s a big number. It is exceeded only by the number of deaths caused by dietary exposures in all their myriad forms and hypertension. Those are the only two that are bigger.

We also are quite sure that the number of deaths currently attributed to pollution in the Global Burden of Disease Study, which was our primary source—we are quite convinced that this is an undercount of the full magnitude of pollution because many of the links between pollution and disease have not yet been established and—or quantified.

Types of pollution: ambient air pollution kills about seven million people per year—sorry, six million per year—household air pollution about three million; lead about a half million; occupational exposure is about a half million; chemical exposure is about a half million and going up. If you are quick at the arithmetic, you will see that the sum there is greater than the total of seven million I quoted, and that’s because there is some overlap between them; for example, indoor and outdoor air pollution overlap, and the sum is less than the—the totality is less than the sum of the parts.

In many—we found that in many parts of the world pollution is getting worse, especially ambient air pollution is clearly getting worse, especially in the rapidly industrializing cities in low- and middle-income countries—China, India, Sub-Saharan Africa, parts of Southeast Asia, parts of Latin America. Ambient air pollution is getting worse. Chemical pollution is getting worse, but very poorly quantified.

I should—a little methodological aside—it’s much easier to measure air pollution than almost any other form of pollution because of the fact that today we can take advantage of satellite imagery, and satellites looking down, as long as they have some ground truth verification, can actually get quite good indications of levels, and patterns, and time trends in air pollution.

Water pollution is harder to assess. It requires sampling and chemical testing. Soil pollution, the same, and chemical pollution the same, so we’re always a bit behind the curve in assessing any form of pollution other than—other than air pollution.

Pollution is very disproportionately, very unfairly distributed around the world. Ninety-two percent of the deaths due to pollution took place in low- and middle-income countries, and in practically every country, the majority of disease and death due to pollution is in poor populations, marginalized populations, indigenous peoples, and such.

The cost analysis looked mainly at two costs of pollution. We looked first of all at productivity losses, the economic losses that result when people are taken out of the workplace by illness or premature death, and we calculated that those amount to between 3 and—about 2 percent of the gross domestic product of rapidly developing countries. We looked also at health care costs—the direct and indirect health care costs that result when a person—when people are made sick by pollution, and we found that in a country like the United States, those costs amount to about 1.7 percent of the global health budget. But in rapidly developing countries, the best data we had was from Sri Lanka. In Sri Lanka, the costs of pollution-related disease were close to 7 percent of the total global health budget. So putting those productivity losses and the costs of health care together, especially in rapidly developing countries that are trying to bootstrap themselves up, it can be a huge anchor that holds down the whole economy, and that was one of the economic themes that we put out there.

The economists also put together some very nice data showing that reducing pollution brings major economic benefits. This was a tough exercise. You know, it’s relatively easy for a factory to tell you what are the costs of putting on a stack scrubber, for example, or of a chemical factory telling you what it’s going to cost to clean up their liquid effluent before they discharge it into the river. They know what the equipment costs, they know what the maintenance costs are, and so on.

By contrast, the costs of pollution itself are spread across large populations. They extend over many years. The data are not neatly collected in one place; the health statistics are buried in hospital budgets, the labor costs are buried in labor budgets, and it takes a lot of hard work by dedicated economists to pull these costs together. But when the teams do that, they—a very nice analysis by USEPA calculated that for every dollar invested in the control of air pollution since the passage of the Clean Air Act in 1970 in the USA, that the return has been $30 on the one (dollar), which is pretty good—better than Bernie Madoff could get you—(laughter)—and then another one that I was involved in, a number of years ago we looked at the economic benefit that accrued from the single action of taking lead out of gasoline. Those of you who are my age—about half of you at least—will recall back until the mid-1970s, virtually all of the gasoline sold in this country had lead. Lead was added to gasoline from the 1920s until the 1970s to increase engine performance, and the consequence was that lead was everywhere. Lead was all over our cities, in corridors along the highways between the cities, and in the people. The average blood lead level of American children back then was close to twenty micrograms per deciliter, which is a level that if a pediatrician were to see it today he would—they would hit the panic button and—but it was considered normal. We all grew up with that.

And when EPA took lead out of gasoline in 1976—it was the beginning of a ten-year process—over the next decade blood lead levels in American children fell by 90 percent—more than 90 percent. The incidence of acute lead poisoning dropped to very low levels, and then two further consequences that were not entirely anticipated: one was that the average IQ of children born in this country since 1980 is about five points higher than that of children born before 1980, and the second has to do with the fact that an IQ point is worth money; it increases a person’s earning capacity over their lifetime. The economists amongst us told us that an IQ point is worth about $10,000 to a child over that child’s lifetime. I mean, we all know very bright people who underperform and not such bright people that get elevated in various ways, but at least as a statistical proposition, an IQ point is worth money—$10,000 over the lifetime.

So bear with me as I do the arithmetic. We have four million babies born in this country each year. Give them each five IQ points, so that’s 20 million new IQ points per year times $10,000 per year, is $200 billion per year for each annual crop of babies born in the United States since 1980, which is a big number. It’s a real number, so those are the economic benefits.

Despite the great health costs, despite the great economic costs of pollution, one of the striking findings that came out of our analysis is how badly neglected is pollution in the international development agenda and in the global health agenda—just a tiny amount of money allocated to pollution relative to the dollars that go to confront other problems, which is not to say that money should be taken away from AIDs, or malaria, or TB—far from it—but that the tiny amount of money that goes into pollution control is—verges on scandalous. And one of the obvious goals of our commission was to do something about that.

We thought a lot about the topic which is the topic today, the nexus between pollution and climate change. One of the major findings is that pollution and climate change both come from pretty much the same sources. They are like the two children of a common mother. Combustion of fuels—biomass in poor countries, fossil fuels in rich countries—accounts for 85 percent of particulate air pollution. It accounts for pretty nearly all pollution by oxides of—sulfur oxides and nitrogen oxides, and it’s also the major source of the carbon dioxide and the short-lived climate pollutants like black carbon that drive global climate change. So they come from the same place, and any action that’s taken to reduce the amount of fuel combustion that takes place around the world is going to benefit the climate as well as the quality of the air that we breathe.

So that’s all the bad news. Let me tell you the good part. The good part was that our commission came to the conclusion that pollution control is a winnable battle, and we thought that, from a political point of view, it’s probably a battle that can be won much more rapidly than the battle against climate change.

One of the issues here is that when pollutants other than—when toxic pollutants, not CO2, are put into the air, most of them don’t last that long whereas CO2, as you know, lasts for decades or centuries. And if pollution is controlled at source, prevented from being released in the first place, the benefits are quite readily apparent. We have good data from the United States, published a couple of years ago in the New England Journal of Medicine, showing that in the forty-five years since the passage of the Clean Air Act in 1970, levels of the six major air pollutants have fallen in this country by 70 percent—seven-zero. It’s a huge decline, and that’s at a time, by the way—in a time span when the GDP in this country has increased by 250 percent. I’m obviously not saying that pollution control is responsible for the growth in GDP—that would be a foolish statement—but the point is that it’s possible to control pollution and at the same time grow the economy of a country. And so we advanced that argument.

We pointed to the fact that countries—like the USA, like Europe, like Japan, like Australia—have developed a tool kit to control pollution: laws, policies, regulations, technical fixes like stack scrubbers. There’s a whole mix. And as a result of those, we’ve achieved great progress.

And then we concluded—we concluded the report by saying that the ultimate solution to pollution as well as to climate change is going to have to be—I know this is a bit idealistic—but it’s going to have to be a change in the way society does business. The current economic model in which we are operating, which has been described as the take, make, use, dispose model, it’s ultimately just not sustainable, especially as the world’s population grows from seven, to eight, to nine billion people. It’s just not sustainable.

But we were nonetheless optimistic, and we argued—perhaps a bit unrealistically—but we argued that switching to cleaner sources of fuel—solar and wind in particular—could end both pollution and climate change and so—and offers a pathway forward.

I think I should stop there. I’ve talked a few minutes too long already and—

BOLLYKY: Not at all.

LANDRIGAN: —let’s open it up.

BOLLYKY: Great. So this idea of focusing on the more immediate health impacts of climate change is not—

LANDRIGAN: And pollution.

BOLLYKY: And pollution. But to focus just for a second on climate change, this integrated approach is not entirely new. The Obama administration also had a big focus in his second term on addressing climate change through the surgeon general, emphasizing the health impacts of climate as a way of making the problem real and immediate in a way that emphasizing the long term environmental and economic impacts alone might not.

Obviously, pollution has had more success in terms of time to its more immediate effects. Where do you see the lessons that can be learned from the fact that there wasn’t that much traction on emphasizing the health consequences of climate change? What can we incorporate from that experience in trying to leverage now whatever momentum there might be on pollution to move both climate and pollution goals—where are the opportunities?

LANDRIGAN: All right. So I think it maybe begins with the fact that pollution is in your face. It’s—when you are in a polluted city, when you are in New Delhi on a bad day, for example, it’s awfully hard to deny the existence of pollution when you can’t see across the street. And the illness that results from inhaling that dirty air, or the illness that results when you drink a glass of dirty water is pretty obvious and pretty unmistakably linked to the exposure. You just can’t deny it, you can’t walk away from it.

So that makes it easier in the case of pollution than in the case of climate change to talk about the links between the external event and the disease in people. But I think that it offers both—that nexus offers both an opportunity and a lesson for the climate change people. I think the climate change people, notwithstanding what President Obama did, have largely lived in a world of numbers. They’ve talked about levels of CO2. They’ve drawn very careful maps showing the rising levels of the sea in coastal cities. But they haven’t—as much as I would like anyway—talked about the impacts of climate change upon people, maybe because a lot of them have been geologists and meteorologists whereas more of the people looking at pollution come from medical and public health backgrounds. I’m not sure what the origins are, but those may be some of the correlates.

And I think one of the—the opportunity then for the climate change people is perhaps two-fold: one is to talk more explicitly and to do the work which will support the talk of establishing—I’m sorry—(coughs)—it’s the pollution—(laughter)—establish the links between—establish the links between climate change and health, and do scenarios.

I’m reminded back in the ’70s when people in this country—Physicians for Social Responsibility, which was a group of doctors, and nurses, and others who were concerned about nuclear war, did what they called scenarios for each city. And they did basically—it looked like a bullseye on a map—what would happen if an atomic bomb landed on Wall Street—if it was a two-kiloton bomb, what would happen in the first kilometer, what would happen in the second kilometer, what would happen—and they—basically making the point that all politics are local, that all damage is local, and that people are going to be hurt.

The climate change people haven’t done that very effectively, and I think the pollution people have done it almost inevitably; it was hard to avoid doing. And if the two communities can come together and work together, which makes sense given the common origin of the two problems, I think some progress could be made.

BOLLYKY: Great. And who do you see as the actors leading the push? Given the particular political moment that we are in the U.S. right now, the U.S. may not be the nation actively pursuing these issues, to put it diplomatically. One of the striking findings in your Commission report was on chemical pollution. With issues like that, it seems like there might be a role for consumers. Also, the New York Times a month ago announced that China will be creating a new ministry of ecological environment to focus on environment and pollution. Are there other countries that might lead if the U.S does not? Or, perhaps I’m being too pessimistic on the U.S., and you are more hopeful for a role for American leadership.

LANDRIGAN: Well, let me start with people outside the U.S. I think China has been a big leader here. I mean, obviously China as a long way to go on pollution. Anybody who has been in Beijing knows that. But still they have—in the current five-year plan they have targets on air, water, soil pollution. In the five-year plan they have set up this new ministry. The different provinces, of course, are semi-autonomous; not everything comes from the central government, but nonetheless, China is making some—has plans in place that are going to enable it to make some real progress if they follow through. The fact that China is approaching 20 percent of its energy now coming—in five years will be coming from renewables—that’s huge. They’ve become a world leader in producing the infrastructure which enables the use of renewable energy. I think some countries—and China is big so it’s an obvious example—but some countries are going to step into the vacuum of leadership from here.

I think there’s also a role for international agencies. My colleagues and I presented this material in January to the World Bank, and Jim Kim himself was there and spoke of the opportunity for the World Bank to take leadership in this area and combine investments in the energy development with concern for the environment and for human health. So I think the bank and possibly other U.N. agencies—UNDP, for example; UNEP, World Health—can have a role to play so that as—

And then within the U.S., those of us who have spent a lot of our lives here know that, just as in China, not everything flows from Washington. And some of the states have shown great initiative—California, for example—in insisting that we seek a path forward. So I’m cautiously optimistic.

BOLLYKY: All right, those of you that would join in that optimism or would like to express your pessimism, this is your time. (Laughter.) I will call on you in the order that I see you—except when you all your placards go up simultaneously—(laughter)—so I’ll just do my best.

I’ll start with Alan, and then Emmanuel, and then Jay.

Q: OK, thank you very much.

Taking your point about the health issues of global climate change—and I think you are absolutely right. The global climate change community has not done enough with that, having been part of the pollution community before and also the anti-nuclear-war community.

But what about pocketbook? People think about that as well and, you know, FRAM used to have an ad, pay me now or pay me later, and I don’t know how effective it was in selling air filters, but it felt effective.

What do you think about focusing on that as well as on the health issue because people are beginning to understand, in Miami and in other places, that rising sea levels are going to cost them a lot of money.

LANDRIGAN: Yeah, no, I think that—I mean, that’s the same logic that led us to include economists on our commission, all right? I think that—I think that environmental economists can do some great work in that area making the local case, yeah.

BOLLYKY: Great. Emmanuel?

Q: Thank you. I’m Emmanuel d’Harcourt from Vital Strategies.

So my question is a little bit of a continuation from Thomas’s. So the case is laid out in the report extremely clearly unlike other—like the case for other problems, some of which you mentioned—is compelling. But yet there are so many of these problems for which compelling data exists, particularly as a, you know, life-long public health person that’s—you know, that’s had experience where what seems like a slam-dunk case somehow doesn’t win in court.

So I was curious to hear—continuing your previous answer in terms of in the U.S.—why—because, you know, in some ways Obama and even Clinton or supposedly good-thinking presidents didn’t do that much, and you could argue that there is a whole elite that is—that should know better. I’m not talking about, you know, the Trump base—but that are—that are actively blocking things.

And then at the opposite end of the spectrum, I’d be curious to know what—for countries at the lowest end, like the Sierra Leones, and the Liberias, and the Congos, and CARs—what do you think can motivate those countries that could gain—you know, would benefit even more in some ways from the gain to invest what little they have in decreasing pollution?

LANDRIGAN: Sure. Well, in response to the first part of your question, we gave a lot of thought to why it is that pollution has been so neglected, and our finding was that there were several causes. One is that until publication of this report, nobody had ever previously looked at all forms of pollution put together. There’s been some great work on air pollution. The air pollution work has always been the most advanced, and there is good work on air pollution, but relatively less on water, and far less on the chemical pollution. And so by putting them all together and amassing the sum total of human misery that results from all forms of pollution, we figured that would do something to elevate the profile.

A second factor has been fragmentation amongst the agencies that are supposed to be responsible for these things, so to give you a little snippet of U.S. history, when the Environmental Protection Agency was created in the early 1970s, it was basically created in response to Rachel Carson’s book Silent Spring, and most of the components of the EPA—the air pollution people and the water pollution people—were basically pulled out of the department of what was then Health, Education and Welfare, and then a few other pieces were brought in from the Department of Agriculture and the Department of Energy. So what resulted, an unforeseen consequence of the formation of EPA, was that the environmental people were separated from the health people, and the environment people were measuring levels of chemicals in air or water, and the health people were counting bodies, but the two didn’t talk to each other. And we hoped that publication of our report might do something to bring those two communities together.

A third factor is the costs have been invisible. As I said earlier, the costs of pollution are spread out, not easily calculated, and consequently not counted, and hopefully the economic work that our commission did addresses that.

And then finally, that really, as you alluded, there are vested interests who have a great interest in keeping things going just as they are and have no interest in acknowledging the problem or doing something about it. So I think those are the reasons that pollution has not been given the attention that it deserves in the developed countries.

When it comes to the very poor countries of the world—like Sierra Leone, like CAR—it’s important to understand that the types of pollution that they are confronting are not at all the types of pollution that we are seeing here. So they are only beginning to see the forms of pollution that are associated with modern industrial, urban, Western life. Most of their pollution is still indoor air pollution from cookstoves and water pollution from human waste. So it’s a whole different strategy for dealing with pollution in those countries.

BOLLYKY: Great. Next, I had Jay.

Q: This isn’t—oh. Thanks for your remarks. Jay Koh from the Lightsmith Group.

You’ve talked about the common sources of the causation on the climate side of things and on the pollution side of things, and I think it’s a great point. I’m wondering if you could give us a perspective on the interrelationship between the two on the effects side of the equation or, more broadly speaking, climate change’s impact on health.

So, you know, Gina McCarthy just went over to the Chan School of Public Health from the EPA. You know, increasing temperature and humidity should have an exacerbating impact on airborne pollutants. We’re seeing health effects—like today—increased by average temperature rise. Extreme weather events like the Houston experience spread petrochemicals across a huge chunk of Texas, Louisiana, and Florida, which we’ll see really interesting, you know, class-action litigation over in the next like decade or so.

So I’m just wondering how—you know, how much analysis has really been done about the causal impact of the exacerbation of these effects by climate change, either directly through heat and humidity changes or through other vectors like tick-borne disease or mosquito-borne diseases.

LANDRIGAN: Yeah, so that’s a great question. Actually, when I get up to Boston in a month, Gina McCarthy is going to be my colleague in some of the work that we’re going to be doing to carry on the work of this commission.

So I think there are several interconnections here. You touched on one. On very hot days when the urban heat effect and the pollution are both high, there is going—there are clearly bad synergies that haven’t yet been adequately mapped out. So for example, heat increases risk for cardiovascular disease and stroke through dehydration, through just basic overheating, and air pollution has been linked to an increased incidence of cardiac arrhythmias, increased incidence of acute myocardial infarction, increased incidence of death from heart disease and stroke. And it stands to reason when the two co-occur—as is happening today in New York and happens in other cities around the world—that there are probably synergistic effects that haven’t yet been adequately charted, I would think.

A whole bunch of diseases—vector-borne diseases, not just tick-borne diseases—are going to—are becoming more severe around the world as the world gets warmer. Dengue, chikungunya fever, Zika virus are three. The spread north of tick-borne diseases in North America, the increasing range of malaria, and also the movement of malaria mosquitos up the mountains—like in Kilimanjaro, they are now trapping mosquitos at far higher altitudes than they did ten or twenty years ago. Those are all quantifiable consequences of climate change that, for the most part, haven’t yet been adequately enumerated and incorporated into the calculations of the global burden of disease that we relied upon.

BOLLYKY: Great. I have Kimball and then Craig.

Q: Thank you. OK, so I work with the U.N., and World Bank, and Vital Strategies, and others on the issue of household air pollution, so a large chunk of your pollution. So one of the things that we’ve found is that people are resistant to evidence—that’s number one.

LANDRIGAN: Resistant to—

Q: Governments and civil society are resistant to evidence, so for instance, the World Health Organization now takes the position that cleaner fossil fuels, like natural gas, are an important transition solution for health in going to a green—whenever that occurs, OK? But there is such an anti-fossil fuel bias that the developed nations and the donors don’t want to give to the developing nations who actually want that solution.

My organization is dealing with a quarter of the world’s population right now. We have requests from over 20 governments to help them create bottled gas sectors to replace biomass. You can’t burn biomass cleanly. So they’ve gone with us to the donors and asked for money, but the donors say we don’t believe in that solution.

Now this also comes to the issue of coordination of ministries. One of the important comments you made was that there is no coordination between ministries. We all know that health ministries have relatively little impact on primary economic planning, especially in developing countries, so you have to get the ministry of finance to buy in. And also, on the donor side, coordination between agencies, as you pointed out, in terms of defining problems that everybody can agree to and then define a solution, and an action plan, and a schedule to solve the problem is very difficult.

So this resistance to evidence, bias which can’t be overcome, the mismatch between what developing countries want and developed countries are willing to do, and the issue of not pricing consequences—your economic, and social, and political scientist stuff is very important because pricing consequences and showing that it’s immediately valuable, it gets people to do stuff. For instance, nobody prices the immediate consequences of longer life expectancy to a pension system or an insurance system in these developing countries. The pricing of the loss of a—of a productive year for a rural worker is not priced.

So getting all these problems dealt with and getting action—what’s the solution? What’s the low-hanging fruit given the array of problems which—both in terms of problem definition, and solution definition, and implementation?

LANDRIGAN: Well, we give a lot of thought to those issues, and I think you are absolutely right that, if we’re going to move the needle on these things, we have to get beyond the ministry of health and the ministry of environment because they are always sitting at the bottom end of the table. It’s got to be—finance, development, transport, energy are probably the big ones—maybe defense. And so they—that’s the first thing.

I think in a lot of ways the low-hanging fruit here is operating through cities. You know, we had—we had one-and-a-half heads of state on the commission. We had Carlos Salinas, the former president of Mexico, and we had Princess Chulabhorn of Thailand, who is not a head of state, but very close to the head.

And it’s clear that you need to get people that run things in charge, and in a lot of—I think in a lot of cases—anybody who lives in New York has seen this—that mayors have a lot more power to effect change within their sphere of influence than national leaders. And so we’re spending energy these days talking to the various groups of cities that are focusing on cleaning up the environment within cities.

I think that, in terms of the different types of pollution, I would—I would venture to say that air pollution, both ambient as well as household air pollution, are the two—are the two easiest to clean up. Water pollution is more difficult because it’s multi-source and hard to track, and chemical pollution is very hard to track and going to take an awful lot of work on the ground.

BOLLYKY: Is there a lower- or middle-income country, city that you would see as a positive example on attacking these issues? You mentioned that there are good agents of change over—

LANDRIGAN: Mexico City.

BOLLYKY: Mexico City?

LANDRIGAN: Mexico City. You know, it’s in a bowl at eight thousand feet, bad air pollution problems, and when Salinas was president down there, he did some great work.

BOLLYKY: Great. Craig, and then we’ll go to Philippe, and then Linda, and then Carol. Thank you for your patience.

Q: Thanks. I’d like to follow up on this question of indoor air.

BOLLYKY: I’m sorry—will you just say your name and your affiliation?

Q: Sorry, Craig Charney. I run a survey research firm called Charney Research, which focuses on the developing world. I knew Philip in an earlier life when we were both focusing on occupational safety and health.

The question of indoor air really strikes me because I had not realized that the figure of three million was quite as large as you said. Is it principally a question of cookstoves? Is it also smoking, either as primary or secondary smoke? What are we focusing on there—because the interesting thing is that within each house there’s only one or two sources.

LANDRIGAN: It’s virtually all cookstoves.

Q: Really?

LANDRIGAN: Yeah. We did not include cigarette smoking. We did not include cigarette smoking in our analysis. I mean, some people smoke and hover over the cookstove, but it’s mostly cookstoves.

Let me digress a bit on that. One of the things we looked at was the—was the link between pollution and non-communicable disease, and in a country—in a rich country like the United States, the major cause of non-communicable disease is smoking, and alcohol, and diet, and lack of exercise, and obesity—what have been referred to collectively as behavioral and metabolic risk factors. But if you go down to the lower middle-income countries and the low-income countries, it turns out that the predominant cause of non-communicable diseases are, in fact—is, in fact, pollution. And in those—in the really low-income countries, it’s household air pollution from cookstoves.

Q: That’s fascinating. It really underlines what low-hanging fruit they are—that represents because we talk about one point source per household.

LANDRIGAN: Yeah, mostly. Yeah.

BOLLYKY: Great. Philippe?

Q: Thank you. This has been fascinating.

Philippe Burke. I’m with Apache Capital in New York. We’re a hedge fund with an environmental impact strategy.

I was curious if you could shed some light on—I’m trying to understand the most likely impact one would have from one of the following two approaches. So you gave the example of walking across the street in downtown Delhi, seeing the air—the ambient air—knowing that you don’t exactly know what the impact is, most likely, but you know it’s probably not a good one versus walking across the street somewhere in middle American, beautiful blue sky, no pollution, you walk into a Walmart, let’s say, and you think about buying a blue, plastic pail, and you see the ticket price. But you really don’t know what was involved in the manufacture and distribution. But suppose that you could turn the ticket price—the ticket on the other side and you would see that, you know, that it’s either a dollar amount of environmental damage associated with the manufacture and distribution of that product or, you know, seventy-five fish were killed, or thirty children in some faraway land are going to have their IQ drop by one point.

I’m trying to think—if your—did your research give you any insight on which one of those two is most likely to generate change—either seeing the immediate impact and not exactly knowing what it is, not being able to measure but on yourself, versus measuring it—it’s somewhere around the planet, but actually you know what the number is. Which is likely to generate change in your mind?

LANDRIGAN: I think it’s self-evident, right? We didn’t—

Q: The former?

LANDRIGAN: Yeah, the former. I mean, we didn’t study that per se, but I think from—if I can generalize from many other spheres of experience, it’s—clearly the immediate threat is what humans—

Q: Even if you don’t know what it is?

LANDRIGAN: Yeah, yeah, yeah. I mean, just consider the allocation of resources in American medicine. Dan Fox and I worked on this many years ago. Something like 97 percent of the total health spending in this country is dedicated to the care of people who are already sick. Some people say 5 percent goes to prevention, some say 3 (percent). It depends what you count. But in any event, it’s a small percentage.

And yet the dollars that go into disease prevention are far more cost effective than the dollars that go into treatment, but human beings are wired to deal with immediate threats. I think it’s just who we are. We’re primates.

BOLLYKY: That is an interesting analogy to the calorie counts, and—

Q: I was just thinking of that, right.

BOLLYKY: —which are at least direct in the sense that calories are directly experienced by the consumer. It’s an interesting question of whether or not the results of calorie countries—the impact of such policies are generalizable to things that won’t be directly, necessarily, affecting the consumer.

Linda.

Q: Hi. Is that on?

I am a film producer, and I’m interested in the ways in which information is communicated in a mass—to a mass audience. And I’m intrigued by your comment that the climate change people haven’t talked about the impact on people.

So following up pretty much on what Philippe said, I’m wondering would it not be productive for you on this new commission that you are doing to include advertising people, communicators to think through—it should not be that hard to create either a continuing character, which is the modern Smokey the bear kind of person who would be the messenger about what this information means to each person—

LANDRIGAN: Yeah, I—

Q: —or some kind of a local strategy involving communication.

I’m just—what I’m saying is to get beyond the ivory tower and to really think about how you take the next step and get the information out to the masses.

LANDRIGAN: I think that’s a great idea. We did not have such a person on the commission. We just—we didn’t think of it. We had 52 people, we had lots of disciplines, but we didn’t have any filmmakers, or advertising people, or professional communicators.

I’d be happy to talk with you about that.

Q: I’d be happy to talk with you.

BOLLYKY: Some of you who may have been pulled in to all the progress literature coming out—Steven Pinker’s book Enlightenment Now or Hans Rosling’s book Factfulness. Both books have sections on climate, and they’re interesting to read to see how that issue fits into the broader narrative of the march toward progress. In Factfulness, the argument is that climate folks have tried to scare people, and using very large numbers, and in doing so they have missed out—they have missed out in quantifying the problem in realistic, direct human terms.The Pinker argument is more that, long-term, climate change is much ado about nothing, and we will find a way to adjust.  

Both books have, by and large, been very well-received, and I think they say something about where we are on climate change. We still have great divisions about what the human impact of the problem will be, even twenty to thirty years into climate change being a topic of great political or popular attention. We still don’t understand or agree on what the human consequences will be.

LANDRIGAN: Could I offer a reflection on that?

BOLLYKY: Please.

LANDRIGAN: So I’m—some of you will know that I’m a pediatrician, and I still see patients and families, especially consultations where people come and ask about various toxic exposures—lead, pesticide, plastics and things like that. And one of the things I’ve learned over the years is that you fail utterly in those conversations if you simply try to scare the hell out of people. It simply doesn’t work. They either blow you off and say it doesn’t matter; we’re just going to have to live our lives, or they—or they—a few of them get paranoid and try to live in a bubble. But in either case it’s a failed means of communication. And the only way that you succeed in communicating this information to people and getting folks to change their lives is to give them actionable data that they can use to empower themselves to take matters into their own hands.

The actions they might take would be kind of trivial—like not microwaving in plastic—but it gives them something to do, and they feel they are doing something about the issue, and they will respond and take ownership.

Q: Hi. All of the last few questions have related to my question, which was about dissemination. And I’m an educator, so I care a lot about that. And I know that a lot of young people, students, really care deeply and want to do something.

But the first question was how do we get ahold of your report because I’ve never seen it. I’m sure some of the medical and health people here have, but I think it would be good if it’s—and if it’s not readable by the general public, perhaps some way of getting material out to doctors—put it in doctors’ offices, and so on.

But really mostly I was going to ask more about the same issue that you are bringing up. The social media is the way to go as we’ve learned. I guess it’s Instagram that’s the best one—(laughter)—although I don’t have it, but apparently that’s the in-in-in—most effective.

But all of these things, it seems to me—perhaps there should be a whole other group that does brainstorming about getting the public to be stirred because I think we’ve seen what happens when more and more people really care about an issue.

LANDRIGAN: Yeah, I couldn’t agree more. We did work hard to write the report in accessible language. The report is on—it’s open access. It’s online, it’s free, at no charge. If you are having trouble locating it, give me your email address and I will send it to you when I get back to my office. But it’s—The Lancet is an open-access journal.

And we worked very hard to publicize the report when it came out last October/November. We had three thousand media hits around the world, and all sorts of media, read or viewed by an estimated two billion people.

The problem, of course, is that most of that is one pass. It’s not sustained. And I think both of you are correct, that we need to have a strategy for keeping the message going.

BOLLYKY: I was impressed with the media coverage the Commission report got upon its release. As you said, it’s hard to keep that going, but it did—as health reports come out and as papers in a medical or a scientific—(inaudible, background noise). But all the initial attention was positive.

I have Alan, and then we still have a few minutes after that, so you will be subjected to more of my questions unless you ask your own. So, Alan—

Q: OK, just following up on the public dissemination, my career has basically been in public understanding of science. You can tell how successful I’ve been at that by how much people know.

But I’m wondering, one of the things that people care about is, as you said, doing something about it, and part of that is collecting data. I was part of something called the Baby Tooth Survey back in St. Louis where mothers gave their teeth—and you gave a tooth for science and data, and people were very much involved.

What kinds of things can you think of—people taking individual measurements in their home of temperature or outside the door—what kinds of things could be done to involve people in the data collection that would then feed into a larger whole? The bird survey is a good example. I mean, there are lots of specific—what would be most effective do you think in terms of that?

LANDRIGAN: Yeah, I think information is a powerful driver. The story of Beijing—so when Gina McCarthy was the administrator of EPA, she had the idea—at least it’s attributed to her; you may know better, Tom, than I, but it’s attributed to her—was her thought to put the air pollution monitor on the roof of the U.S. embassy in Beijing, and to make those data publicly available.

Well, as soon as the data started getting out there, there’s a lot of bright kids in China who—some of whom developed their own little air pollution monitors, and they started putting information out, and all of sudden there was a groundswell of information from the people, which forced action, you know. I think data are very powerful.

BOLLYKY: It was international news when the State Department did the same in Delhi, as you may remember—

LANDRIGAN: Yes, right, right.

BOLLYKY: —and there was a lot of pushback on that. And they stuck with it to their credit.

It’s automatically on.

Q: Oh, OK. Hi, thank you. Kavita Desai with the U.N. Foundation.

So what struck me from your presentation is how much your research links in with the U.N.’s global goals or the sustainable development goals—

LANDRIGAN: Uh-huh.

Q: —from specifically targets around clean cookstoves and energy to sustainable production and consumption being one of the seventeen goals.

I’m just wondering—as we come up to July, there will be the high-level political forum to review all of the goals and, broadly, the full agenda—how this data and this research can be plugged into these bigger forums where you do get people from different ministries—they are not just the environment ministry, but from also health and the social sectors—to try and inform policies and kind of feed back into the larger system.

LANDRIGAN: Yeah, that’s a great question. So actually, one of the sustainable development goals, Goal 3.9, speaks directly to reducing disease caused by pollution. So my colleague, Richard Fuller, who was at the table when they were writing the health goal, Goal #3, and he got 3.9 in there.

We did a mapping analysis in the commission report charting out how many of the different SDGs would be advanced if pollution were to be prevented, and it’s about two-thirds of them. There’s a little chart in there.

BOLLYKY: Great. Noelle-Claire.

Q: So my name is Noelle LeCann from the AlphaSource Climate Fund.

So I’m just wondering, do private investors have a seat at the table where they can actually seed some of these ideas, and get them off the ground, and be helpful?

LANDRIGAN: Yeah, we’ve talked to private investors. I don’t—there was not an investor, per se, on the commission, but we’ve certainly started to have those conversations, yes.

Q: Maybe we can be part of that dialogue.

LANDRIGAN: And I’d be happy to continue them, absolutely, yeah.

BOLLYKY: Is there a particular area where you think those investors might be helpful, or that there is particular interest, or a chance for progress?

LANDRIGAN: Renewables.

BOLLYKY: Renewables, yeah. Great. I have Jay—well, let’s ask Alex because he hasn’t had a question yet, and he was on the commission, so it’s the least we can do. So please—

Q: Yeah, I just wanted to follow up on the investor side. I do wonder whether or not one could reach out a bit more to the whole investment area of sustainability, which has now become a very big topic. That probably has more traction than pollution because there is a lot of—there is a lot of money in that business, and if one can find the angle where there would be a win-win, both with the sustainability and the pollution, then even though people may not be so focused on the pollution side, you get the benefit of those kind of investments. And that’s a big area today, and there’s a lot of money going into that.

BOLLYKY: And Professor Greenberg, I think you get the last question.

Q: Somewhere I read—and it may well be in your commission report—but that establishing solar panels on individual homes in developing economies is, in a sense, an easy way, an investment-friendly way of developing energy and power without pollution.

Has that gotten any traction? I’m not sure where I read that, but I was just fascinated by the concept because it seems so straightforward, you know, au courant, and doable.

LANDRIGAN: So people have talked about what have been called “leapfrog” technologies, and my favorite example is the cell phone. When I—back in the day when I was eradicating smallpox in Africa when I was working for CDC, we had one person on the team whose job—all day, every day—was to try to place the daily call back to Atlanta from Africa to report on the day’s progress. And it was a full-time operation trying to get a call through the wire, and we figured that communication in Africa would never get off the ground because they would—there just weren’t enough resources to wire the continent. And along came the cell phone and the satellites up there, and we leapfrogged—or leaptfrogged over the need to wire the continent.

People have held out the notion that little solar panels attached to whatever, whether it’s a composting toilet or a stop light, have that transformative power. I think it remains to be seen in the practical world whether it pans out.

BOLLYKY: And at least in the U.S. there is a trade component to this, of course, in that solar panels are becoming a little more expensive than they used to be. (Laughter.) So we may be moving in the opposite direction.

But I want to thank Phil so much for being here and wish him best of luck in his new post.

LANDRIGAN: Thank you. Thank you. (Applause.)

(END)