e33 Air Quality

Please note:  This transcript is semi-AI generated and may contain errors.

What you ALL do ALL the time

[00:00:05] Munir Adam: Hi guys. Welcome back to Primary Care UK, it's Munir Adam here, and for this episode I'd like to start by asking you this: What's the one thing that I know you're doing right now? Driving perhaps? Maybe yes, but maybe no. On a treadmill? Again, you may be. Or you might say, listening to this episode. Well actually, that's not certain either.

[00:00:28] I mean, you might have been ignoring me, and maybe you were distracted until now. But actually, the one thing that you are certainly doing right now, is Breathing. And you were doing it a minute ago as well, I'm sure. And you plan to continue breathing, I think. So since you're doing this all the time, come day or night, whether you're inside or outside, would you not want to make sure that the air that you're breathing is clean and safe?

[00:00:55] Of course you would. And you wouldn't want the same for your patients? For your friends? For your colleagues? It's interesting, isn't it that we spend more time breathing than we do sleeping, talking, working, and pretty much anything else. And yet, some of those things we spend a lot of time thinking about.

[00:01:12] You know, there's no shortage of people talking about what's the right food to eat, or how to get good sleep. And yet, much less emphasis on making sure that what we're breathing all the time is safe. 

[00:01:25] So this episode is about what are we breathing, what harm has it done, and what harm is it doing, and what responsibilities do we have as clinicians working in the NHS.

[00:01:36] Now, the speakers today are pretty much London based, and the examples that we give are also for London. But this episode is certainly not just for Londoners. It may be that you're living in an area where the pollution is even worse than London. Or, I think there's also a good going chance that it's less.

[00:01:54] But, I doubt that the air in your area is so pure that this episode doesn't apply to you at all. And by the way, if it is that pure, let me know, drop me an email, and I might just become your new neighbor. 

[00:02:06] Now, let me be honest with you guys, when I was first approached to cover this topic I thought to myself, why would I want to cover a topic like this? I mean, why is this relevant to us clinicians? Actually, as I started to speak to the experts, I realized, and, and, you know, have you ever had that feeling where you're in a group and everybody seems to know so much about something and they're experts and you feel like you haven't got a clue? I have to admit, I felt a bit like that.

[00:02:32] But as I started to find out more, I realized this episode could easily take a couple of hours. In fact, it could be a whole series. As important as this may be to all of us, and it is important to all of us, I know you guys are really busy, you've got a lot of work to do, and we have tried really hard to compress this down into just under half an hour. And I think we've done a good job at that too. And what we haven't cut down on is the expertise that we have on board. We are going to hear from five people, five very important people in my view, who know a lot more about this than I do. 

[00:03:06] So let me tell you how this episode is structured. We're going to hear from a professor, we're gonna hear from a pediatric consultant, and we're going to hear from a mother.

[00:03:17] Actually, she's got another very important role as well. But it was that role as the mother and its relevance to this episode that actually touched me and made me feel honoured, that I was able to include a few words from her on this episode. So yeah, and then I'm going to be joined by two others who are quite involved with this topic. We're going to explore some of the relevant issues, and then after that we're going to hear some closing comments from a few of them, and that'll be it. 

[00:03:43] So, unless you're an alien from outer space who doesn't have a respiratory system, then this episode is relevant. As you know, this is season two that we're continuing, brought in partnership with Integrated Care Support Services. If you'd like to sponsor an episode or a series of episodes, do get in touch with us and the contact details are in the show notes. 

The IMPACT of Poor Quality Air

[00:04:13] Professor Fenton: I'm Professor Kevin Fenton, the Public Health Director for London. We are facing a critical challenge in our city. The link between climate change, poor air quality, and our health. Pollution, exacerbated by changing weather patterns, infiltrates our lungs, homes, and even our schools. And this translates to a rise in respiratory issues like asthma, COPD, and even lung cancer.

[00:04:38] It impacts vulnerable groups like children, the elderly, and those with existing health conditions the most. We are seeing increased hospital admissions, missed workdays, and a general decline in quality of health and life, all linked to the air we breathe. 

[00:04:56] Dr Hayden: My name is Dr Mark Hayden and I'm a paediatrician at Great Ormond Street Hospital in London. For too long the healthcare community has neglected the harm caused by air pollution to our patients and perhaps more importantly the benefits that clean air brings. We've considered this to be someone else's problem and when we did think about it we felt untrained and powerless.

[00:05:17] This failure to speak up was brought home to me in 2021 when the South London coroner found that the death of Ella Kissy Debra from asthma was contributed to by air pollution. He also found that clinicians had failed Ella's mother, Rosamund, by not discussing the impact of air pollution on Ella's asthma and how to address it.

[00:05:36] The toxic particles found in air pollution cross into the blood and affect every organ, including crossing the placenta into the fetus. There is now strong evidence of harm in multiple conditions, and also of the benefits that clean air brings. 

[00:05:49] Rosamund: My name is Rosamund Adukisi Debra. I am the founder and director of the Ella Roberto Foundation. I'm also WHO Breathe Life ambassador. I am involved in advocacy for clean air due to my late daughter passing away from a severe asthma attack. I work and advise health professionals, raise awareness amongst the public to do with clean air.

[00:06:15] It impacts the most vulnerable and they tend to be people mainly who live near main roads where there's a lot of traffic. They could be in areas where there are landfills or constructions. Research has shown at the Parliamentary Inquiry for Racial Inequality and Air Pollution that it also depends on people's race, people's economic status and sometimes people's class.

[00:06:42] Munir Adam: Hmm. So it's a very important problem then, and it's linked to inequalities, and in fact that's aligned with other work that we're trying to do as well. 

[00:06:51] Let's now also try to understand why it's relevant to us as health professionals.

[00:06:56] Professor Fenton: Why is educating health professionals important? This is because climate change isn't just an environmental issue. It's a public health emergency. Health professionals are on the front lines, diagnosing and treating the consequences of poor air quality every day. Equipping them with the knowledge of these links empowers them to better advise patients, advocate for cleaner air policies, and ultimately, protect our collective health.

[00:07:24] Now, imagine if every GP could discuss air quality during routine checkups, advising patients on protective measures like reducing outdoor exposure during peak pollution times. Imagine healthcare settings prioritizing green spaces and promoting sustainable practices. By integrating air quality awareness into their daily practice, health professionals can become powerful change agents, urging patients to adopt healthier lifestyles, and advocating for cleaner air regulations.

[00:07:57] Munir Adam: And I'm now joined by Jo Sauvage and Karen Exley, and they'll introduce themselves and say a little bit more about, what's this all about?

[00:08:09] Jo Sauvage: So hello, my name's Jo Sauvage and I am a GP and I work in the inner city of London. My practice is in fact in Old Street, so if anyone knows London and anyone knows Old Street, it is one of the most polluted parts of London.

[00:08:23] I came to this really, as part of my job in London to really promote the importance of of the impact of poor air quality on health. And in London, we have a particularly important impact story, the death of a young girl, , where the impact of poor air quality was cited as a factor in causing her death. So for us in London, the impact of air quality on the health of our residents has become very, very important. 

[00:08:55] Munir Adam: I see. I can understand how that would make you want to drive change, but this is a tragic, isolated incident. Or is that not the case? 

[00:09:05] Karen Exley: Unfortunately not. So hello, I'm Karen Exley and I work at the UK Health Security Agency where I lead the air quality and public health program there.

[00:09:14] So our role is to really understand how air pollution affects our health and then look to develop tools and resources to support actions to improve air quality and ultimately protect public health. And it really does have a significant impact on our health. It contributes to illness, hospital admissions and mortality.

[00:09:33] Now, organizations such as the World Health Organization have estimated that every year around 7 million deaths are due to exposure from outdoor and household air pollution. Wow. And in the UK, we've estimated that long term exposure to air pollution is in effect equivalent to 29, 000 to 43, 000 deaths.

[00:09:53] So it really is a major environmental risk to health. 

What actually happens

[00:09:57] Munir Adam: Gosh, they're big numbers. But what's actually going on here? What's the problem with the air? What exactly is it in the air that's causing such deaths. 

[00:10:07] Karen Exley: Well, air pollution is, it's a complex mixture of particles and gases that can be from natural or human origin.

[00:10:15] So some examples are particulate matter. So that's a generic term that we use. It describes a complex mixture of solid and liquid particles, and they can be of varying sizes, sizes, shapes, and composition. So for instance, if you live near a busy road, a lot of the particulate matter might be emissions from vehicles nearby, or perhaps, um, you live near the seaside and actually salt in the air, windblown dust, these all contribute to this particulate matter and it comes in different sizes.

[00:10:46] So really tiny particles at 2. 5 microns in diameter are the most studied. And we know that these get inhaled and enter our body, essentially. And many people might know air pollution causes respiratory effects, but we actually know it causes a wide range of effects, uh, cardiovascular disease, and also many other effects that are emerging from the evidence, such as potentially diabetes, dementia, and cognitive decline.

[00:11:14] Munir Adam: Really? I didn't know that. I thought it was just a lung problem. So I would imagine that London's probably not the, uh, the nicest place, as far as air pollution is concerned. We normally associate that with being congested areas, but it'd be useful to know where we are in the grand scheme of things when you look at a global level.

[00:11:30] Karen Exley: Well, we're certainly not as bad as other places. Um, I was thinking about going back in history a little bit. And if you think in the 1950s, there were these big smogs in the UK and people couldn't actually see in front of their hand. Others may be aware of what happened in Asia where agricultural forests burning, so you get this big, thick smoke happening. Now, we're not as bad as that anymore. Air pollution in the UK has really improved significantly. But we're still not meeting all of the targets that have been set; these legal targets to improve air quality. 

Clean Air vs Net Zero

[00:12:02] Munir Adam: Can you just explain that a little bit? Cause I sometimes hear the term net zero being floated around.

[00:12:06] What is it that's actually the aim? And what's the target that we have to reach and by when? 

[00:12:12] Karen Exley: Well, there's lots of targets. Um, so, first of all, we have the Clean Air Strategy that the government published a little time ago. And that has targets for a number of pollutants, so I mentioned particulate matter, but there's also nitrogen dioxide, sulfur dioxide, volatile organic compounds, etc.

[00:12:31] So, nitrogen dioxide. So this is a gas. It's another pollutant that we've been talking about. And it's a key one in the UK because we've had limit values for nitrogen dioxide of 40 micrograms per cubic metre. And in most places in the country, in the UK, we failed to meet that limit value. And that is why certain places in the UK have now had low emission zones.

[00:12:53] Jo Sauvage: The question around net zero is very different. Net zero is really around how, in particular, both as a country but the NHS as well, begins to tackle some of the carbon problems. So how do we decarbonise the NHS? And this has many different manifestations. It can be about how we, um, prescribe more effectively, how we reduce our utilization of certain high carbon intensive medications such as inhalers.

[00:13:24] That is a significant program of work within which there is also an element which is around reducing our contribution towards carbon through travel. Now, obviously the two are linked because travel and transport are net producers of environmental pollutants. So when the NHS speaks about Net Zero, there is the co benefit of achieving some of those greener targets; but also through other things such as active travel, more walking, et cetera, both reducing one's contribution towards carbon, but also reducing one's personal contribution to poor air quality. 

Protect yourself & Protect your patients

[00:14:03] Munir Adam: Okay. Thank you for that. 

[00:14:06] Some listeners will be thinking, tell me what I need to do differently. What, what can I be doing in my day to day work to make a difference to all of this?

[00:14:13] Jo Sauvage: Yes. So certainly in London, we became much more aware of this as an issue further to the Air Quality Summit, which was hosted by the Mayor of London, and that was in February of 2022.

[00:14:28] And that was really around how did London, as a capital city, respond to the fact that one of our children had died, and there was air quality as a key contributor. Further to that, we have been working very much on how do we begin to get messages to go out into General Practice about certain days in London where air quality is really quite severely impacted. It's really about creating an awareness. We have to begin with starting to tell the story so that people understand the impact. 

[00:15:01] In conversation with our patients, we could be having conversations around many different factors. For example, exercise is something that we do talk about a lot, but recognizing that in an urban environment, people may choose to exercise along the main road. It is important that the messages that we're giving aren't unintentionally also exposing people detrimentally to environmental pollutants. It's really surprising how if you go for a run or a job, but don't do it on the main road, just a road back. the exponential reduction in particulate matter and environmental pollutions does fall off.

[00:15:38] So I suppose what we're trying to do is to help create awareness and education amongst our clinicians so that when they are having conversations with patients and residents about how to best manage long term conditions, both in terms of preventing deterioration, but also primary prevention. So reducing the impact of various factors detrimentally on our health, they are aware that air quality is an important factor, an important risk, and therefore can start to include it in the conversations that they have with residents. 

[00:16:11] Munir Adam: We don't usually even mention air quality at all when we're having conversations about lifestyle advice. And actually, does it take longer?

[00:16:20] Not necessarily. So one of the points I'm hearing from you is about the health of the patient that's in front of you. And a lot of these chronic disease management and lifestyle advice conversations are often traditionally between a nurse and a patient. Now we have a range of other healthcare professionals that are involved with this as well.

How NOT to make the air dirtier..

[00:16:39] Munir Adam: Is there also something about sharing that responsibility, and it applies for clinicians and patients, in terms of what we can be doing to improve the air? 

[00:16:48] Jo Sauvage: That's absolutely correct, because we have to remember that whilst we are consumers of air, we are also all producers of potentially poor air quality, and that's in terms of the choices that we make, how we choose to move from A to B, whether we choose to drive, or instead, whether we choose to cycle, or walk, or use public transport. So there are lots of choices that we as individuals can make, which will have an impact on the environment within which we live. 

[00:17:15] Further, there is a strong role that we can have as clinicians, as advocates for improving air quality. In particular, in London, one of the things that we discovered is that there is an absolute association between exposure to poor air quality and living in some of the more deprived parts of London. And that's because you will find that some of the major roads pass through all of London, but housing may be more located on roads of poor air quality. So it's absolutely linked with everything that we are trying to do at the moment. Improving the health of our population, but also really thinking about the impact of inequalities in our communities.

[00:17:56] And so air quality is just like all the other factors that are linked with inequalities. And so it is an important factor that we must advocate for change around. 

[00:18:06] Munir Adam: And I'm glad you're saying that Jo, because isn't that the problem? Those who are living in those deprived areas, air quality is likely to be way down their list of priorities if they're barely making ends meet. And something about addressing that inequality. 

[00:18:19] I just want to try and understand a little bit more about where this pollution is. Because I have to be honest, for me, is when we're talking about car and how much tax you have to pay. Euro 6 and things like that. Just don't get out too much. Is that the solution?

[00:18:33] Karen Exley: Unfortunately, no. So yes, you're right. Transport is a, is a great contributor to outdoor air pollution, but so is domestic wood burning, coal burning, industry as well. But we spend most of our time indoors and there's still potential to have poor indoor air quality. So the way that we, we cook and heat our homes, for instance, the products that we choose, some of them have chemicals that can be released, the volatile organic compounds, tobacco smoke as well, of course, secondary exposure to that.

[00:19:07] And Jo was talking about housing earlier, this is a really important factor. Poor ventilation, lack of maintenance, that increase in damp and mold, which is linked to the death of another young child recently. The coroner came with a report about damp and mold being related to the death of a young boy.

[00:19:26] So it's not just outdoors where you can be affected by poor air quality. We know less about the size of the problem from indoor exposure. But we know there are simple things that people can do. About drying wet clothes indoors. If you need to do that, make sure you've got adequate ventilation so we're not building up that damp and mold.

[00:19:47] Thinking carefully about the chemicals and products you use within your home, making sure you're using them according to the manufacturer's guidelines. 

[00:19:56] Munir Adam: Now, when it comes to a discussion about healthy eating, you can just see almost any package out in the supermarket and it's got clearly color labeled calorie counts and things.

[00:20:06] It's much harder to know the effect of the food we eat is having on the environment, I would have thought. So practically speaking then, would you want, you know, from the listeners, let's have some key practical points. This is how we can all make a little difference. 

[00:20:22] Jo Sauvage: So I think it's really important, first of all, for clinicians to be aware of the impact of air quality on health. And there are organizations such as GAP, Global Action Plan, where advocating for improvements in air quality is a key mission. They also produce a suite of information and patient facing resources that can help clinicians in having those conversations with patients.

[00:20:49] And that's really useful to have something that you can hand a patient to advise them of the things that they might be able to do differently. 

Useful tools and resources

[00:20:58] Karen Exley: The Chief Medical Officer for England published a report on air pollution last year. So that goes from health effects, who's affected, all the way through to different interventions and actions.

[00:21:08] The NHS published a couple of years ago a national bundle of care for children and young people with asthma. And that now includes a whole environmental impact section. So I would highly recommend that. NICE has published guidance as well on both outdoor and indoor air pollution. And most recently The WHO has published, um, a e learning approach on air pollution and health for health workers.

[00:21:34] And one final plug, we did something with the Health Education for England, which is just a very basic introduction to air pollution and health. 

[00:21:43] Jo Sauvage: So I will add as well that in London, in particular, we've had real opportunity through harnessing clinical leadership and the formation of the London Region Air Quality Programme Office, which is a multi agency response to the impact of poor air quality in London, drawing in the capacity, the capability of the UK Health Security Agency, NHS London, but also the Mayor of London office to actually respond to to develop a communications program, if you like, so that we're linking information gathered through Imperial around air quality in London with alerts, which are published on a daily basis, which publish information around air quality and when there are changes to that. Now those are also available nationally, so that's really helpful for me as a GP to understand what the air quality is like in the area where I work today. Receiving alerts can also remind me to talk to patients about the importance of air quality.

[00:22:48] Munir Adam: One convenient way that people access information and reminders these days is of course through their mobile phone. And I wonder if there are any apps that might serve that purpose? 

[00:22:58] Jo Sauvage: In London, we do have apps. City Air, which has access to daily information. 

[00:23:05] Karen Exley: Yes, along with that, the government has something called the Daily Air Quality Index, and that provides current and forecast information on daily increases in air pollution. And you can have that delivered to your phone, and there are a number of apps across the country where people can pick up that information. And also weather apps actually provide now that sort of information. 

[00:23:29] And I just want to point out as well, so we have these sort of short term increases in air pollution, which we call episodes of air pollution. But even that daily levels of air pollution that we're exposed to throughout our lifetime are causing ill health. 

[00:23:43] Munir Adam: Can't run away from it, can we? We've got to breathe and we've got to breathe the air and the air is going to be the product of what we're producing. So thanks both so much for that. A good reminder for all of us. 

Final take-home comments...

[00:23:53] Munir Adam: A final take home message. 

[00:23:55] Jo Sauvage: Each and every one of us are contributors to air quality and we should really think about our actions in everything that we do. My particular bugbear is people who may turn on their engines and then look at their mobile phones and leave their cars, idling. Now that is a very unnecessary contributor. Remember to turn your car engine off, even if you're sitting in traffic. And it's important to remember to tuck this into any opportunity that you have in conversations with your patients about the importance of air quality, just as it's important to speak about smoking.

[00:24:31] Munir Adam: Well, that makes me feel a bit better about owning an electric car, despite the, as we know, electricity prices that have rocketed in the last couple of years. But anyway, Jo and Karen, thank you so much for all of that.

[00:24:44] Now let's hear a final message from Dr Hayden and then from Professor Fenton. 

[00:24:50] Dr Hayden: It is time that we recognize poor air quality is our problem as healthcare professionals and do what we can. We need to educate ourselves using the resources attached to alerts like this. We need to engage with our patients on how to protect themselves from air pollution and help them to advocate for their right for clean air. In the words of one young patient, we need to not look away.

[00:25:12] Professor Fenton: The fight for cleaner air is a collective effort. Let's join hands, health professionals, policy makers, and citizens alike, to build a healthier, more sustainable London for everybody.

[00:25:27] Munir Adam: And so, if you live in London, this is definitely relevant. But actually, wherever you live, unless you know that the air that you're breathing is very clean, this is relevant. And you know, I, it's, it's not that at the end of this you might be thinking about ten things that you could do differently in every consultation. But rather, the awareness raising we hope this has given you will mean that when the opportunity comes up, when the situation arises, you might just respond in a slightly different way, a slightly cleaner way, shall we say.

[00:26:00] Well, look, if you guys are listening and thinking there's something I can do differently from now on. Even if it's just this very small thing, let's try and each make a little bit of difference. 

[00:26:08] Munir Adam: But that's it for today. We'll include those important resources in the show notes as always. That's it for today, and until next time, keep well and keep safe. And I'd like to leave you with the final words from Rosamund. 

[00:26:23] Rosamund: In Ella's inquiry, it was established that at the time she was ill, during those days, there was a lack of information. The coroner made recommendations specifically that everybody in health, undergraduate, graduate and postgraduate level, needed to skill up and learn about the impact of air pollution on health. Health professionals should also use their leverage to ask government and policy makers to bear this in mind when they are coming up with policies. Health professionals have the ultimate voice and this could help clean up the air in the future. 

[00:26:59] Munir Adam: Primary Care UK was developed by Therapeutic Reflections Limited to inform, educate, support, and unite the primary care workforce. Specifically, it is not for the general public or patients. All information and advice contained therein is time, location, and context dependent and is general advice only.

[00:27:39] No guarantees are provided with respect to the accuracy of the content. The hosts, contributors, and the organizations they represent do not accept liability for any actions, consequences, or effects that result directly or indirectly from the content provided. Please refer to the episode description.

[00:27:55] Thank you for listening.