Public Health in a Changing

Environment
Bert Brunekreef, PhD
Professor of Environmental Epidemiology
Institute for Risk Assessment Sciences



Public Health in a Changing Environment

Ladies and gentlemen,

Its my privilege today to offer you anniversary entertainment, and I will do so by
telling you a few stories about public health in a changing environment. Let me start
with one that most of you are familiar with, smoking in public places. We have known
since the early nineteen fifties that smoking causes lung cancer. We have known
since the early nineteen eighties that inhaling somebody elses smoke is also bad for
you.



Then in 2008, smoking was finally banned in bars and restaurants, to the relief of
many non-smokers and to the disappointment of a small but vocal minority of
smokers and journalists.
As the example shows, changing the environment for the benefit of public health
takes time, and can be politically highly charged.
After such changes have been implemented, it is important to document the health
benefits. Smoking bans lead to abrupt and large reductions in exposure to tobacco
smoke, which turns them into fairly unique natural experiments. Investigators have
taken advantage of this, and have shown that yes, there are measurable benefits.
These do not only apply to bar and restaurant workers, but also to the visitors.

Scotland: Smoking Ban
17% reduction
UK: No Smoking Ban
4% reduction
NEJM
2008


In Scotland, smoking has been prohibited in all indoor public places since March
2006. Hospital admissions for Acute Coronary Syndrome decreased since then by
17%, compared to a decrease of just 4% in England where a smoking ban had not
yet been introduced. (1).

I have shown this example as an illustration of the links between epidemiology and
public health, the theme of this Dies Natalis. Public health is concerned with the
health of the community as a whole. It is shaped by the combined individual health
experience of all members of the community. Epidemiology is the science of public
health. We test hypotheses about causes of disease. We investigate whether new
medications are better than existing ones. We study side effects once new
medications have entered the market. We look at interactions between animal and
human health, and we study effects of dietary, occupational and environmental
exposures on human health.

Medicine Science
Veterinary Medicine
Julius
Center
Pharmaco-
epidemiology
Veterinary
epidemiology
IRAS


All of these are active areas of research at the Utrecht University. Epidemiology has
become a focus area thanks to the excellent work of many colleagues working in
three different faculties. The Julius Centre at the Medical School has a high visibility
in clinical epidemiology. The Faculty of Science harbours a strong programme in
pharmaco-epidemiology. The Faculty of Veterinary Medicine has an excellent
veterinary epidemiology unit, and my own Institute for Risk Assessment Sciences is
sponsored by all three Faculties just mentioned.

Source:
RIVM


There are many ways to measure public health. I will concentrate on a few key
indicators, life expectancy and healthy life expectancy. Life expectancy has increased
enormously over the last century in many parts of the world. This is the result of
better living conditions, and advances in medical care and treatment.

A life expectancy of 80 at birth does not mean that everyone lives to 80, and no one
lives beyond that age. Survival curves show how a population gradually dies with
increasing age, and life expectancy at birth is simply the mean of all individual
attained ages. Healthy life expectancy is the number of years lived without disease or
disability, and it can equally be represented in a survival curve as in this graph. One
could say that the aim of public health interventions and medical treatment is to
increase life expectancy. Also, the aim is to compress morbidity, so that the healthy
life expectancy becomes more and more equal to life expectancy itself. So ideally,
were trying to make everyone live until 85 or 90 or so, but without serious morbidity
and disability until almost the very end.

World Health Report 2008


There is a relationship between the Gross Domestic Product of a country and the life
expectancy of its population. For the highest income countries with GDPs above
25,000 U$ or so, the range in life expectancies is rather narrow, from more than 75 to
less than 85 years. At the low end of the GDP scale, however, the variation is huge,
showing that some poor countries are doing much better in fostering public health
than others. The distribution of income and opportunities within countries has been
shown over and over again to be a major determinant of life expectancy.

Life expectancy in the Netherlands
varies 6-7 years by level of education
Source:
RIVM


Even in a fairly egalitarian country like ours, there is a six or seven year gap in life
expectancy between those with high and low education (3). Various factors have
been shown to be related to differences in life expectancy as well as healthy life
expectancy. These include access to healthy foods, smoking and life long learning.
There are environmental determinants as well: in England, the differences in life
expectancy related to social disparity were found to be much smaller in areas with a
lot of green space compared to areas without green space (4). This provides clues to
how we can manipulate our environment to further improve public health.

Let me now turn to the environment and to changes in our environment relevant for
public health.


Vedi Napoli,
e pui Muori
2008 Waste
collection crisis
in Naples


The environment changes, it changes us, and we change our environment too. For
most of us, the environment we live in is almost entirely manmade. We spend 95% of
our time indoors, not outdoors. The climate we create indoors is often very different
from conditions outside. The water we drink is purified, the waste we produce is
carried away, and the food we eat is processed to the extent that our ancestors
would not recognize it as something they could possibly eat. We dont think about
these luxuries much, but with the exception of housing, these are all achievements of
the last 50 to 200 years or so.
Its only when services break down, such as waste collection in Naples last year, that
we realise we need to count our blessings more than we do.

Gas crisis in Bulgaria, Winter 2009


Similar examples are not hard to come by. When transport of natural gas to Eastern
Europe was interrupted this winter, many people were unable to heat their homes,
and reverted to burning dirty fuels increasing air pollution.
As they say, you dont miss your water till your well runs dry. This is only human, and
not something unique to our generation.

Of the great sewer that runs
below, Londoners know, as a
rule, nothing; though the
Registrar-General could tell
them that its existence has
added some 20 years to their
chance of life
The Times of London, 1891


The great sewer system of London was built in the second half of the 19
th
century.
When its chief engineer, Sir Joseph Bazalgette died in 1891, the London Times ran
an obituary which said:
.Of the great sewer that runs below Londoners know, as a rule, nothing; though
the Registrar-General could tell them that its existence has added some 20 years to
their chance of life

One could argue about whether a single sewer can increase your life expectancy by
20 years, but the quote does show a keen awareness of the link between living
conditions and public health. Interestingly, the decision to build the sewers was made
because of a unique event, the Great Stink of 1858. The summer of 1858 was very
hot, and the river Thames stank to high heaven. The Houses of Parliament are
located right next to the Thames and for weeks on end, neither lords nor commons
could escape the horrible stench from the river. This finally convinced them that
something needed to be done. Then as now, decision making in public health is
helped along by a highly visible crisis or two.

http://ehs.sph.berkeley.edu/krsmith
Indoor biomass smoke in Guatemala


Having some sort of shelter is a near universal achievement of human beings
everywhere. We build shelters to keep us warm, and to protect ourselves and our
belongings from a hostile outside world. Inside, we light coal and biomass fires for
heating and cooking.
Almost half of the world population is still exposed to very high concentrations of
smoke from these fires, above all in rural areas. An estimated 1.5 million women and
young children die every year because of this. If these people had access to it, they
would use cleaner fuels and live in homes with chimneys. Health is closely linked to
wealth, and indoor air pollution is just one example of how this works.

http://www.newscenter.philips.com
An improved wood stove


It does not necessarily cost a lot of money to clean up the indoor environment,
though. There are now encouraging examples of clean but still affordable technology
which greatly reduces indoor air pollution. Epidemiological studies are showing the
health benefits of introducing clean technology in China where coal smoke is the
main culprit (5) and also in Guatemala where wood smoke is the problem (6).



Indoor pollution from biomass and coal fires is largely confined to rural areas in
developing countries, but that does not necessarily mean that urbanisation is always
a cure. Rapid urbanisation in developing countries has now created an underclass of
about one billion people who live in slums with very little access to clean fuels, clean
water and safe food. Jonas Bendiksen has made a moving book showing what its
like to live in a slum (7). We have a long way to go before the slum dogs of this world
are provided with the basic amenities which we have learned to take for granted.

Big and Small
along the
Old Canal


We heat and cool our homes for health and comfort, and a large amount of energy is
generated worldwide for this. Heating costs money, and a few centuries ago, people
who could afford it would build two homes along the old canal here in Utrecht: a small
one for the winter because that was more economical to heat; and a large one for the
summer. The servants would live in the small house in summer and in the big, cold
house in winter. A clear example of the relationship between wealth and healthy
living conditions.

For centuries, heating meant burning coal or wood, and the resulting smoke has long
been recognized as a form of unhealthy outdoor air pollution. Complaints about coal
smoke go back several centuries in London, for example.

Monet, Houses of Parliament, London, 1905


In the early 1900s, Monet made several paintings of the Houses of Parliament,
capturing what in retrospect was heavy air pollution. There was a keen awareness
among many in London that something needed to be done, but for a long time
authorities were unwilling to tell Londoners to get rid of the open coal fires they loved
so much. An editorial published in 1925 in The Lancet went as far as to say that it
may require the death from fog of three cabinet ministers before any action is taken.

London,
December 1952


And then in December of 1952, 4,000 ordinary Londoners died in just one week
when stagnating weather conditions prevented the coal smoke from dissipating. Air
pollution increased to extreme levels. Conditions were hard to imagine. Theatre plays
had to be cancelled because even indoors, the smoke was so thick that audiences
could not see the stage. A doctor was called to a nearby patient but utterly lost his
way in his own neighbourhood. He finally found his way back to his own home, and
then called Mr. Hunter, one of his patients who was blind. The good Mr. Hunter came
over, and guided the doctor to his other patient after all, he was used to finding his
way around London without being able to see.

Since the London Smog of 1952, there have been enormous improvements in air
pollution in the developed world. Nevertheless, we have learned over the last two
decades that fine particles and ozone are still of concern.

Utrecht
Decrease in life expectancy due to
anthropogenic fine particles (IIASA)


Exposure to manmade fine particles is estimated to reduce life expectancy in Europe
by nine months on average and by more than one year in more heavily polluted
places like Holland. Air pollution nowadays is very much a function of population
density, and thats why The Netherlands gradually has become a hot spot in maps
like this.
One year of life expectancy may not seem much in view of the average life
expectancy of 80 or so years. However, it is more than the mortality and disability
effects of all traffic accidents combined, and its the same order of magnitude as the
estimated effects of the obesity epidemic. So it is clearly important to establish how
robust this estimate is, and to show that reduction of air pollution increases life
expectancy.

NEJM
2009
Life expectancy increases in the US are
associated with decreases in air pollution


A recent study from the US suggests that this is actually the case: the investigators
found that life expectancy over a period of 20 years increased most in areas that had
experienced the largest decreases in air pollution (8). (Moreover, the magnitude of
the change was exactly as predicted from earlier observational studies (9).) This is
another example of how epidemiology takes advantage of changes in the
environment to study the effects on public health.


You must have the impression by now that epidemiology is all about studying whats
bad for public health. But thats not quite true. I do admit that studies are most often
prompted by some sort of public health problem, but scientifically, it is equally
interesting to find out why some of us do not get sick.

A Bavarian farm
Slide courtesy Erika von Mutius


An example is the finding that children who grow up on traditional farms develop
fewer allergies than their urban counterparts. Its not completely clear why this is so,
but high exposure to various microbial components on the farm is one explanation.
Now we cant all go back to living on the farm, so investigators are trying to squeeze
the farm environment into pills called probiotics. Results of trials have been mixed so
far, but one interesting study suggests that probiotics may prevent allergy especially
in children born by caesarean section (10). The idea is that such children are born
sterile, and have more difficulty developing a protective gut flora early in life.

Source: IPCC 2007


When we discuss a changing environment, it is inevitable to talk about climate
change. Climate change raises many concerns, as temperatures are projected to
increase by up to several degrees centigrade over the next century. We think that at
least part of the warming is due to manmade emissions of greenhouse gases.
Climate change may affect public health in many ways. Climate change makes our
summers warmer, and our winters less cold. Both hot and cold weather kill people
so an increase in heat waves not necessarily will lead to more annual deaths as there
may be fewer cold related deaths.

Cold weather kills far more people
in the UK than heat waves do
Annual deaths from HEAT Annual deaths from COLD


In fact, analyses from the United Kingdom show many more cold related deaths in
winter than heat related deaths in summer. Climate change in the UK is already
reducing cold related deaths, without actually increasing heat related mortality (11).
In Canada, which is much colder in winter than the UK, this is paradoxically not so;
and this is because Canadian homes are much better in shielding you from the cold
than the British are (12).
Heat waves do not kill young and healthy people; they kill subjects who are old, frail
and alone. After the dramatic events in France during the heat wave of 2003, an
emergency warning system was developed. When another heat wave struck in 2006,
the emergency warning system was estimated to have reduced the number of deaths
by more than 60% (13). But the key question is: how many months or years will the
vulnerable subjects live on after theyve been saved from the heat wave?

ERJ 2009
Heat related mortality has
increased in Stockholm


An interesting study from Stockholm provides a few clues. Stockholm is not known
for having hot weather in summer, but even there, more people die on warmer days.
Interestingly, the effect of warm weather on mortality seems to have increased in the
last fifteen years. Since the early nineteen nineties, elderly Swedes have increasingly
received influenza vaccinations at the beginning of the winter season. It now looks
like this vaccination programme serves to increase the pool of susceptible subjects
likely to die from hot weather the next summer (14). Similarly, effective programmes
reducing immediate heat wave effects on mortality will increase the pool of
susceptible subjects likely to die from influenza and other infections the next winter
season.

The Grim Reaper.


The story is a familiar one: the Grim Reaper will get you eventually, and saving you
from one cause of death today will set you up to die from another one tomorrow. This
is more generally true for all causes of death: the demise of infections as leading
cause of death one hundred years ago set the scene for cardiovascular disease and
cancer to become dominant. And the recent successes in reducing cardiovascular
deaths have now propelled cancer in our country to become the major cause of
death.

Other health risks associated with climate change for this country include a changing
distribution of vector borne diseases; more food and waterborne diseases because of
the warmer temperatures; a prolonged pollen season which may be bad news for hay
fever patients; and more dust mite allergy because dust mites do better in mild
winters than in cold ones (15). But here we already encounter a possible interaction:
the way we build and operate houses is also changing, and in our own investigations
of dust mite allergens in homes over the last twenty years we have been unable to
see an increase (16, 17). The projected sea level changes are not large enough to
give us wet feet in the next century. But this may be very different for other low lying
areas in the world which do not have the sea defences we have erected after the
devastating 1953 flood. Worldwide, global warming is expected to seriously
aggravate public health consequences of poverty such as access to safe food and
water.

Source: IPCC 2007
Temperature variations over
the last 800,000 years


It is important to realise that climate change has been the rule, not the exception on
planet earth. Long term climate records have been pieced together by geologists, ice
core investigators, ocean scientists and archaeologists. This evidence shows that
human civilisation developed in the last 12,000 years or so when the climate was
relatively warm and stable. For much of the last 800,000 years, the climate was much
colder, dominated by prolonged periods of glaciation which made much of the
northern lands on this earth uninhabitable. The line in the graph shows that the warm
temperatures were having now are really exceptional. In all likelihood, dramatic
climate change will be upon us again in the deep future. Some of this is related to
regular variations in the earth orbit around the sun, and in the position of its axis; not
much we can do about that. But some of it is related to ice sheets which may or may
not melt, ocean currents which may or may not change, and volcanoes which may or
may not erupt. Evidence quoted by the IPCC suggests that the next ice age is still
some 30,000 years away a very long time, but in geologic terms just a split second.



Some scientists have looked at the records from the deep past, and into the deep
future and it makes for interesting reading. Three examples are the Dutch book The
Human Measure by geologist Salomon Kroonenberg (18), The Long Summer by
archaeologist Brian Fagan (19) and The Long Thaw by David Archer whos an
ocean scientist (20). All describe the same evidence base of ice ages which come
and go, sea levels that changed by more than a hundred meters, and CO
2
levels
which were twenty times higher than today in the deep past. But their outlook is
rather different. Kroonenberg suggests that we need to adapt to climate change
rather than trying to avoid it; our distant ancestors have survived the previous ice
age, and we should be better capable to handle the next one. In fact, he compares
the current warm period to a terminal patient, whose life expectancy can be extended
a bit by pumping CO
2
into the air. His reasoning is that manmade global warming
may make the next ice age less cold. Thats what Archer suggests as well but his
concern is that sea levels will rise so much that at least 10% of the earth population
will be displaced already in the next few centuries, creating widespread potential for
conflict over scarce resources. Sharp and immediate reductions in greenhouse gas
emissions are needed to avoid these and other adverse effects of global warming.
Apart from the technical and political challenges associated with this, there is also an
important dilemma here. A few billion people still live in extreme poverty, and a lot of
energy will be needed to create living conditions which will allow them to lead healthy
and productive lives. In the process, greenhouse gas emissions are likely to go up
rather than down in the near future.

Worldwide CO
2
emissions are accelerating
PNAS 2007


Indeed, in recent years, CO2 emissions have been accelerating rather than slowing
down. If it took us fifty years to do something about a minor issue such as smoking in
public places, we should perhaps not be too optimistic that we can seriously take on
climate change in a much shorter period of time.

JECH 2009


So what does this all mean for those of us working in Epidemiology and Public
Health? Is climate change, as some suggest, the White Horse of the Apocalypse,
spreading disease everywhere (21)? Or is it something more familiar, affecting public
health by changing the distribution of natural resources in ways that we have seen
before?
Time will tell, and I am sure that future generations of epidemiologists will have a very
interesting time studying the effects of these and other changes in the environment
on public health.

PRSM 1965


In the meantime, the prospect of dramatic environmental change should not stop us
from developing and advocating ways to improve public health on our lonely planet. I
would therefore like to end with a quote from Sir Bradford Hills famous 1965 paper
on Environment and Disease (22):

All scientific work is incomplete - whether it be observational or experimental. All
scientific work is liable to be upset or modified by advancing knowledge. That does
not confer upon us a freedom to ignore the knowledge we already have, or to
postpone the action that it appears to demand at a given time. Who knows, asked
Robert Browning, but the world may end tonight? True, but on available evidence
most of us make ready to commute on the 8.30 next day.

Thank you for your attention!


With that, and with the view from my office window, I would like to thank you for your
attention!
References

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