New Initiative aims at expanding Global Burden of Disease estimates for pollution and climate
Authors: Howard Hu, Philip J Landrigan, Richard Fuller, Stephen S Lim, Christopher J L Murray
Journal: The Lancet Planetary Health (2018)

The Institute for Health Metrics and Evaluation (IHME) held a workshop in Seattle (March 1 and 2, 2018) to plan a new Initiative—the Global Burden of Disease (GBD)-Pollution and Health Initiative—to increase knowledge on the contributions of pollution and climate to the GBD study. The workshop attracted 60 attendees from around the world, including experts in environmental health research, economics, and policy; senior scientists based at IHME; and representatives from the US National Institute for Environmental Health Sciences, environmental non-governmental organisations, the UN Environment Programme, and major foundations. The concept of the Initiative originated from the 2017 Lancet Commission on pollution and health.1Landrigan PJ Fuller R Acosta NJR et al.The Lancet Commission on pollution and health.Lancet. 2018; 391: 462-512Summary Full Text Full Text PDF PubMed Scopus (2009) Google Scholar This report estimated that in 2015 pollution was responsible for 9 million premature deaths and 268 million disability-adjusted life-years, with the most severe impacts in low-income and middle-income countries, and called for the establishment of a Global Pollution Observatory to aggregate, analyse, archive, and disseminate data on pollution and pollution-related disease in cities and countries worldwide. The Initiative also builds on the work of the Lancet Countdown on health and climate change,2Watts N Amann M Ayeb-Karlsson S et al.The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health.Lancet. 2017; 391: 581-630Summary Full Text Full Text PDF PubMed Scopus (591) Google Scholar which reports increasing but inadequately measured climate-related deaths. A main driver of the Initiative is the recognition that estimates of pollution-related disease and death—large as they are—undervalue pollution's full impacts. This underestimation is due to constraints on the scope of the GBD study and the lack of knowledge about the global distribution and health effects of many pollutants. The GBD study limits its analysis to environmental risk factor-disease pairs for which there is definitive evidence of causality. This approach has proven highly reliable and has yielded robust estimates of the burden of disease attributable to air, water, and occupational pollution and to lead. However, there are many other environmental risk factors not yet included in the GBD study for which causal associations with disease have been established through basic science, clinical, and epidemiological studies, and many more are emerging from big-data studies.3Hu H Galea S Rosella L Henry D Big data and population health: focusing on the health impacts of the social, physical, and economic environment.Epidemiology. 2017; 28: 759-762Crossref PubMed Scopus (16) Google Scholar Furthermore, the disease and premature deaths related to climate (ie, climate variability and change) are not yet well reflected in GBD estimates. The key priorities identified during the workshop for the GBD-Pollution and Health Initiative were PM2.5 air pollution, lead, neurodevelopmental neurotoxicants, exposure science, climate change, policy and economics, and management of potential conflicts of interest in relation to judging causal relationships and effects. The Initiative needs to critically examine the contributions to GBD of endpoints such as low birthweight, diabetes, chronic kidney disease, and neurodegenerative diseases that have been reliably linked to PM2.5 pollution but are not yet included in GBD estimates (some are presently under review). The Initiative needs to undertake a critical assessment of research suggesting that lead might increase cardiovascular, renal, and all-cause mortality at exposure levels well below those previously examined. It also needs to develop new methods in exposure science to improve estimates of lead exposure in low-income and middle-income countries, particularly with respect to hotspots. Lead, mercury, organophosphate insecticides, and other developmental toxicants have widespread impacts on children's cognitive function and behaviour even at low levels of exposure. By design, however, the GBD study focuses exclusively on clearcut health impacts and restricts consideration of pollution's impacts on cognitive function to IQ decreases to scores lower than 85, a cutoff that does not capture most of pollution's effects on children's intelligence, creativity, and lifelong earning potential. Cognitive dysfunction caused by lead is, for example, responsible for wide-scale reductions in intelligence that result in estimated productivity losses of US$728·6–1162·5 billion annually, 80% of which in low-income and middle-income countries.4Attina TM Trasande L Economic costs of childhood lead exposure in low- and middle-income countries.Environ Health Perspect. 2013; 121: 1097-1102Crossref PubMed Scopus (128) Google Scholar Two strategies were discussed for overcoming this issue: to re-examine whether the GBD study can consider effects on health and wellbeing of less severe IQ losses; and to establish an approach that assesses the impacts of neurotoxicants on intelligence and lifelong economic productivity as a part of a new human-capital construct that is being developed as a collaboration between the World Bank and IHME.5Horton R Offline: Jim Kim finds his voice.Lancet. 2017; 390: 1726Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Advances in exposure science and data analytics can greatly increase information on levels and geographical distribution of multiple pollutants, especially in countries that undertake little or no environmental monitoring. Examples include expanding the use of satellite imaging—currently used in the GBD study to estimate levels of particulate matter air pollution—to generate estimates of nitrogen oxides, ozone, and other air pollutants and to identify mines, smelters, factories, and other hotspots of lead and other ground-level pollutants; integrating arsenic concentrations in groundwater with soil, geology, climate, and elevation data to model global groundwater arsenic contamination;7Amini M Abbaspour KC Berg M et al.Statistical modeling of global geogenic arsenic contamination in groundwater.Environ Sci Technol. 2008; 42: 3669-3675Crossref PubMed Scopus (295) Google Scholar and using low-cost personal samplers such as silicone wrist bands8O'Connell SG Kincl LD Anderson KA Silicone wristbands as personal passive samplers.Environ Sci Technol. 2014; 48: 3327-3335Crossref PubMed Scopus (164) Google Scholar to measure exposures to pesticides, phthalates, and other industrial compounds. The Initiative can also leverage advances in source apportionment to disentangle the relative contributions of motor vehicles, coal-fired power plants, and biomass burning to PM2·5 air pollution-related disease burden.9Hopke PK Review of receptor modeling methods for source apportionment.J Air Waste Manag Assoc. 2016; 66: 237-259Crossref PubMed Scopus (336) Google Scholar Workshop participants supported the plan to incorporate in the GBD study estimates of disease burden related to suboptimal temperature as a first step towards assessing disease due to climate, but noted that much work will be needed to quantify the health impacts of other climate-related effects such as vector-borne disease, coastal flooding, severe weather, and food insecurity. Estimates of the health impacts of climate will also be particularly relevant to an ongoing IHME initiative that aims to generate forecasts of disease burden. Translating the GBD study's findings on pollution-related disease into policy will require to expand the focus to include economic analyses, and to identify the ministries that are responsible for the control of sources of pollution in cities and countries worldwide. In India, for example, it was reported at the workshop that 16 national ministries have responsibilities that concern pollution emitted by power plants, industry, crop burning, vehicles, and indoor cook stoves. As the GBD study develops a new evidence-based system for scoring risks, it will be important to determine mechanisms—such as those adopted by the International Agency for Research on Cancer—to minimise conflict of interest in the assessment process related to new and potentially contentious risk-outcome pairs that involve chemical pollutants. The definition of these strategies will require the input of the GBD study's Scientific Council and Independent Advisory Committee. The challenges confronting the GBD-Pollution and Health Initiative are formidable. Nonetheless, we believe that this Initiative is timely and that by leveraging the GBD study's enormous global influence,10Murray CJL Lopez AD Measuring global health: motivation and evolution of the Global Burden of Disease Study.Lancet. 2017; 390: 1460-1464Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar the Initiative's findings will inform low-income and middle-income countries on how to pursue the Sustainable Development Goals while avoiding the health and environmental tragedies that have plagued past development. We declare no competing interests. We acknowledge the input of the workshop's 55 other participants, especially the Early Career Scientists: Marissa Baker, Rebecca De Buen, Joey Frostad, Samuel Sellers, Rachel Shaffer, and Megan Suter Consideration of local geographical variations in PM2·5 concentrations in ChinaGlobal efforts have been made to reduce air pollution. The Lancet Commission on pollution and health estimates that in 2015, air pollution was responsible for 9 million premature deaths and 268 million disability-adjusted life-years, with the most severe effects on individuals residing in low-income and middle-income countries.1,2 Although various factors have been used to understand air pollution-related mortalities in low-income and middle-income countries,2 geographical variations of air pollution concentrations in low-population dense and rural regions are often overlooked. Full-Text PDF Open Access