P ublic Health and A ir P ollution in A sia (PAPA) Program Update /The Next Phase

1. Public Health and Air Pollution in Asia (PAPA)Program Update /The Next Phase Bob O’Keefe Secretariat Coordinating Meeting July 2005 Bangkok,

2. PAPA Program • Partnership with CAI-ASIAto understand the health effects of air pollution in Asia, now and in the future • Supported by US AID, foundations, industry, others • Active effort underway: • Published Scientific Review and Meta Analysis of what is known today about health effects in Asian cities • Conducting series of epidemiological studies in representative Asian cities • Understand local impact • Combine to provide Asia-wide understanding • Publish a Comprehensive Assessment of the state of air pollution and health across Asian cities • Build capacity of local scientists • Regular Communication of results to policy makers • Overall Goal: • Quality science to inform key Asian regulatory & policy decisions

3. Health Effects of Outdoor Air Pollution in Developing Countries of Asia: A Literature Review • Systematic identification of 140 peer-reviewed Asian studies 1980-2003 • Special focus on studies of daily changes in air pollution and health • Conduct first ever Asian meta analysis” quantifying risks, finding initial similarities with West • Identify knowledge gaps to guide future research • Active communication to policy makers

4. Meta-Analysis of Asian Studies of Daily Mortality/Hospital Admissions • 28 recent daily time series studies examined in depth • Studies find effects of air pollution on rate of death, illness • ~0.5% increase per 10 µg/m3 of PM10 • High levels of air pollution in Asian cities (>100 µg/m3), imply a substantial public health impact • Limitations • Small number of cities • Not geographically representative (poorest, most polluted countries under-represented)

5. New Research in Asian Cities • Eight new studies of air pollution and health now underway in Asian Cities • Acute Effects (initial cities): • Bangkok, Hong Kong, Shanghai, Wuhan • Strong teams, quality data • Long Term (chronic) Effects • Guangzhou, Chinapilot studyin elderly cohort • New! • Study teams now identified and Approved in India following extensive investigator competition

6. New PAPA Studies in India • Goal: Understand air pollution health effects in less-studied areas • Representative time series studies of pollution and daily death • Diverse, highly populated regions • Public health impact could be significant • Significant data challenges (air quality, morbidity, mortality - frequency, access, quality)

7. Ludhiana Chennai PAPAin India

9. Proposed Milestones 2005 • Actively communicate results of Asia Review and Analysis in key regional and international policy forums • Begin full implementation of 3 new studies in India • Provide ongoing oversight, QA\QC for PAPA studies • Conduct at least two additional capacity building workshops in partnership with Fogarty, ISEE • Continue periodic inventory of new Asia studies; web post results • Initiate, in partnership with Vietnam, ADB, NILU, and East-West, the “HCMC Air Pollution and Poverty Assessment” • Develop Final Poverty Study Design • Select local investigators • Launch study and capacity building • And always, always keep an eye on Cornie…..

10. Strengthening the network: PAPA investigator workshops (* denotes workshops involving international researchers from Europe, North America, and Latin America) February 2004 (Bangkok) May 2004* (Boston) December 2004 (Agra) April 2005* (Boston) November 2005* (location to be determined) Formation of first Asian regional chapter (South Asia) of International Society of Environmental Epidemiology (ISEE) II. Support for researchers at international conferences (+ denotes PAPA symposia) HEI Annual Conferences (Boston, May 2004 and Baltimore, April 2005) International Society of Environmental Epidemiology + (New York, August 2004) Better Air Quality Conference + (Agra, December 2004) Largest non Bank Group ! International Epidemiological Association: World Congress on Epidemiology + (Bangkok, August 2005) Japan Society of Atmospheric Environment + (Nagoya, September 2005) Recent Accomplishments I(Capacity & Policy Communication)

11. Recent Accomplishments II(Capacity and Quality) • III. Training Workshops • (in addition to collaboration with international experts, all workshops include PAPA investigators as trainers and trainees) • Time Series Training Workshop #1 – included participants from India, Indonesia, Malaysia, Philippines, and Vietnam (Delhi, December 2004) • Workshop on Assessing Health Effects of Short Term Exposures to Air Pollution (Ho Chi Minh City, anticipated August / September, 2005) • Time Series Training Workshop #2 (Chennai, anticipated September, 2005) • IV. QA/QC: • Ensuring Internationally Accepted Standards of Excellence in Research • QA Site Visits (Hong Kong, Shanghai, Wuhan, Bangkok, May 2005) • QA Site Visits (Chennai, Delhi, Ludhiana, anticipated Fall 2005)

12. Recent Accomplishments III(Presenting PAPA\global science to policy makers) • Multi stakeholder regional presentations(Nov 04-present, partial list) • “Quantifying Effects of Air Pollution in Asian Cities” • “Adverse Effects of Air Pollution in India” • “Command and Control Strategies fro Asia” • “Public Health and Air Pollution” • “Poverty Air Pollution and Health” • PAPA Review Presentations • In: Pakistan; China; India; Vietnam; Japan; Indonesia; US; Europe • To: Industry (auto, oil, others), Government (National EPAs CDCs NGOs; Science and medical communities; International agencies UNEP etc) Press -Presentations often in context or regulatory decisions -With or by PAPA local expert (ISOC\local PI) Multi language Reviews; Presentations • Upcoming: • Beijing (new fuel standards) Vietnam (Euro II)

13. PAPA: Looking Ahead • A Special Challenge: Understanding the interaction among air pollution, poverty, and health • In Asia high levels of air pollution, dense population, extensive poverty are prevalent • Some initial evidence (mostly from West) that the poor face worse effects from air pollution • Potential Public health implications could be significant

14. Higher Risks Among the Less Educated • Evidence from HEI Reanalysis • Attained education inversely associated with PM relative risk in ACS and Six-Cities studies • An indicator of social class • Due to differences in true exposure? • Sensitivity to air pollution?

15. Why the Poor May Suffer More Health Effects From Air Pollution • Likely higher exposures to air pollution • Living close to traffic • Roadside occupational exposures • Small and medium scale enterprises / Cottage industries • Use of solid fuels for cooking (indoor air) • The poor may be more susceptible to air pollution • Poor nutrition / immunosuppression • Higher incidence of ‘diseases of poverty” (TB, ALRI) • Lack of timely access to health care • Limited evidence from the West, but with - high pollution, high urban population density; significant poverty -Clear need to explore this issue in the Asian context

16. New! HEI Partnership in HCMC to understand Poverty, Air Pollution and Health • HEI-PAPA, as part of Clean Air Initiative for Asian Cities (CAI-ASIA) • Nhu partnership with HCMC Dept of Health (lead); Department of Natural Resources and Environment (DONRE); Department of Labor Invalids and Social Affairs (DOLISA) • International experts from East-West Center; UC Berkeley; Norwegian Institute for Air Research; ADB, USAEP • To plan and carry out a new study in Ho Chi Minh City to assess poverty-air pollution-health intersection • Are the poor are exposed to higher levels of air pollution? • Are the poor more susceptible to its effects? • Study results inform Vietnam policy decisions • Study design transportable\replicable in other cites

17. Air Pollution, Poverty and Health: Key elements of initiative • I Assessment of respiratory health of children (ALRI others) of different SES • Designing targeted case-control and panel studies to provide quality local data of poverty effects • II Household survey to assess • exposure to multiple sources of air pollution • health prevalence (status) • Perceptions, coping mechanism and economic burden • III Policy impact study (integrating above for policy making) • Strong commitment to capacity building throughout

18. Roadside Monitoring Station Maintained by HEPA, with assistance from NILU

19. Collaborators • ADB • PAPA • NILU • East-West Center • UC Berkeley • HEPA • US AEP • Multiple Vietnam Government Agencies Kirk Smith, Sumi Mehta, Aaron Cohen, Le Van Khoa, Vo Tan Dam, Bjarne Sivertsen, Mr. The, Phan Quynh Nhu, Ms. Van

20. Thank You!