## 1 Introduction
### Maritime Emissions and Their Effects
#### 1.1.3 Box 2. Links between Black Carbon Emissions and the Coronavirus Pandemic in Italy  
There were already many studies in 2020 exploring links between levels of air pollution, including black carbon (BC) emissions in Italy, and the incidence and outcomes of cases of the coronavirus [34; 35; 36; 37; 38; 39; 40; 41]. Evidence from initial studies indicates that black carbon (BC) increased the severity of the coronavirus pandemic in three ways: (1) BC makes people more susceptible to getting the virus because of their weakened underlying health conditions caused by BC air pollution. Specifically, when BC particles are taken into the body through routine breathing of BC-polluted air, the extremely small size of the BC particles facilitates their penetration into lungs. The lung damage thus becomes a pre-condition that increases the likelihood of the person contracting the coronavirus. (2) Among people who get the virus-from whatever source-BC exacerbates the seriousness of the damage to patients' lungs because their lungs are already weakened by breathing BC-polluted air. This effect on lungs, in turn, affects coronavirus patients' prospects for short-term and long-term recovery. (3) Airborne particles of BC transport the virus beyond localized outbreaks and thus increase the geographic extent of the pandemic. Many studies have focused on Italy because of its relatively high rate of deaths per 100,000 population (the rate was 59.02 as of 19 September 2020) and because of the role of cases early in the public phase of the pandemic in Europe. \begin{table}
\begin{tabular}{c c c c c c c} \hline \hline  & **2000** & **2005** & **2010** & **2015** & **2016** & **2017** \\ \hline Italy & 19.69 & 19.42 & 19.00 & 17.68 & 16.34 & 16.50 \\ France & 14.78 & 14.78 & 14.84 & 12.83 & 11.98 & 11.96 \\ Germany & 15.05 & 14.58 & 15.38 & 12.98 & 12.09 & 12.09 \\ Spain & 12.11 & 11.96 & 11.73 & 10.67 & 9.90 & 9.91 \\ European Union & 16.18 & 15.99 & 16.00 & 13.97 & 13.08 & 13.09 \\ EU-28 pre-UK departure & & & & & & \\ Italy & & & & & & \\ cf. EU & 1.2 & 1.2 & 1.2 & 1.3 & 1.2 & 1.3 \\ cf. WTO guidelines & 2.0 & 1.9 & 1.9 & 1.8 & 1.6 & 1.7 \\ cf. Italy 2000 & & 99\% & 96\% & 90\% & 83\% & 84\% \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Italy’s Levels of PM\({}_{2.5}\) over the Period 2000–2017 Compared with Other European Countries. As research continues to progress in Italy and other countries in the coming months and years, the results should explicitly be brought to bear on the central issues of the present article, including how much of a problem ships' emissions are for public health. Inference from the preliminary evidence thus far suggests that ships' emissions, including their black carbon emissions in particular, have contributed to the extent and severity of the coronavirus pandemic and can reasonably be expected to do so again in the future. In any case, it is useful to be aware of the global context of the problems addressed here for Italy. Accordingly, a report by the World Health Organization [17] summarizes the evidence about the effects of fine particulate matter (PM\({}_{2.5}\)) including black carbon on health as follows:  
The WHO 'estimates that around 7 million people die every year from exposure to fine particles in polluted air that penetrate deep into the lungs and cardiovascular system, causing diseases including stroke, heart disease, lung cancer, chronic obstructive pulmonary diseases, and respiratory infections, including pneumonia. Ambient air pollution alone caused some 4.2 million deaths in 2016. WHO recognizes that air pollution is a critical risk factor for noncommunicable diseases (NCDs), causing an estimated one-quarter (24%) of all adult deaths from heart disease, 25% from stroke, 43% from chronic obstructive pulmonary disease, and 29% from lung cancer. PM\({}_{2.5}\) includes pollutants, such as sulfate, nitrates and black carbon, which pose the greatest risks to human health.'