EnglishBMJ Editorial by Camilla Kingdon president RCPCH and RFTL rider
I studied medicine at the University of Cape Town,
graduating in 1989. Over six years as an
undergraduate I was taught the science of medicine
by teachers who were superb scientists and clinicians.
I graduated with a keen sense of pathology, anatomy,
microbiology and all the specialties. Unsurprisingly,
I was acutely aware of how the politics of the day
impacted on how I practised medicine in South Africa
and from a very early undergraduate stage it didn’t
take a genius to realise that ethnicity had a direct
impact on the pattern of diseases and patient
outcomes. Yet we were not taught about the social
determinants of health—I don’t think the concept
even existed then.
Don Berwick, Emeritus President of the Institute of
Healthcare Improvement in the US, recently wrote:
“It is not a smart investment for society to keep
running healthcare as a repair shop without also
moving upstream to the real generators of illness,
injury, injustice, and disability.” My specialty of
paediatrics and child health works largely upstream
as Berwick describes. We work at the sharp edge of
the social determinants of health—whether that is
poverty, inequality, or climate change.
As paediatricians we are well aware that air pollution
is a critical issue for children across the planet.
Certain parts of the world are disproportionately
affected and so the burden of exposure is not shared
evenly or fairly. Pollution from fine particulate matter,
household burning of solid fuels, and ozone is
responsible for millions of early deaths each year and
an estimated 1 in 9 deaths worldwide, with the
highest exposures occurring in Asia, Africa, and the
Middle East.
In the UK, air pollution is the largest environmental
risk to public health and children are especially
vulnerable. Globally, more than 90% of children are
exposed to ambient fine particulate matter (PM2.5)
levels above the World Health Organisation’s Global
Air Quality Guidelines (originally set at 10mcg/m3
,
but now more ambitiously set at 5mcg/m3
). Air
pollution is linked to 16% of all deaths in children
under five years.1
After birth, babies and children are much more
vulnerable to air pollution than adults. Children
breathe faster, so they inhale more airborne toxins
in proportion to their weight, and their organs and
immune systems are still developing—therefore
toxin-induced damage is far more likely to have an
impact. We know that children with asthma are much
more likely to have recurrent exacerbations if they
are exposed to the fine particulate matter in polluted
indoor and outdoor air. Asthma is the most common
long term condition among children and young
people, with 1.1 million children currently receiving
asthma treatment in the UK. It continues to be among
the top 10 causes of emergency hospital admission
for children and concerningly, the UK has the highest
mortality rate in Europe for children and young
people with the underlying cause of asthma.
We now know that air quality impacts a child’s
development. Poor air quality has a negative
influence on memory in children and also hinders
the ability to reason and problem solve, as measured
by the Performance IQ score in a fascinating study
looking at cognitive function in children in a number
of cities in Africa.2
Just last month, a study from
King's College London found that exposure to PM2.5
particles during adolescence had a significant impact
on systolic blood pressure, especially in girls, in a
study of over 3000 teenagers living in London.
Our more deprived communities in the UK are
typically exposed to higher levels of air pollution,
and pregnancy outcomes related to air pollution are
worse among low socioeconomic and ethnic minority
groups. Likewise, emergency admissions for asthma
are strongly associated with deprivation and poverty,
and asthma outcomes are worse for children and
young people living in the most deprived areas. So,
poverty and air pollution are inexorably linked.
At the Royal College of Paediatrics and Child Health
(RCPCH) we are clear that the impact of air pollution
is a child rights issue. Children have the right to
breathe clean air and yet 90% of the children on this
planet do not. This year marked the 10-year
anniversary of the death of 9-year old Ella
Adoo-Kissi-Debrah. Ella was the first person in the
UK to have air pollution listed as a cause of death.
As a paediatrician, I don’t believe any other child in
the UK should be allowed to suffer in the way Ella
did. I want to see Ella’s Law passed and the
Government to act to bring air quality in every
community up to the minimum WHO standards and
establish the right to breathe clean air as a basic
human right. We’ve seen clean air schemes in
London, Birmingham, Bristol and other cities, but
we need to see further action across our country. This
would be a monumental win in the battle against air
pollution in the UK.
Air pollution is an emerging global emergency that
threatens the health and productivity of people across
the planet. It unfairly impacts those that have
contributed the least to this crisis—particularly
children. We must act proactively and collaboratively
to tackle this.
