Chapter 8

Health Is Not the Absence of Disease: Climate Change

The advent of the use of fire in human societies several hundred thousand years ago was a huge breakthrough; fire provided warmth, light, protection, and fuel for cooking. This knowledge led directly to an improved diet with far fewer germs, the development of our brains since nutrition was vastly improved, and the subsequent ability to colonize the planet. The benefit to humanity of creating energy on demand has been immeasurable.150

The one downside in regard to our health is the stress energy production has put on our lungs. We’ve all seen the pictures of what our lungs are up against: billowing fumes wafting out of smokestacks, cities enshrouded in toxic air, people wearing respirator masks as they go about their business. One cyclist in London posted images online of blackened filters from a mask he wore for a few days while riding around the center of town.

The facts back up what we all sense is happening. The World Health Organization (WHO), along with the well-respected Commission on Pollution and Health, have outlined the problem in stark detail. In an average year, air pollution causes 6.5 million premature deaths, more than 90 percent of them in developing countries.151,152 All forms of pollution contribute to one out of every six deaths worldwide; in the most affected countries, this number increases to one out of four deaths. As has been said, postal code is often more important than genetic code in determining health and life expectancy.

Alarming statistics for poorer countries tend to give those in wealthier countries a false sense of security. The truth is that every nation is affected, with 91 percent of the world’s population exposed to air that is of substandard quality, including many urban dwellers in those wealthier nations. In all communities, the weakest and most vulnerable suffer most: mortality from lung diseases is concentrated in those under five years of age and those over sixty. And according to the 2018 report by the Commission on Pollution and Health, published in the journal Lancet, these mortality numbers may be vastly underestimated. We simply do not know all of the adverse health effects of air pollution.

Indeed, the problem of noxious air worldwide is getting worse, not better. This grim reality was summed up in chilling fashion in the Commission’s Lancet article: “Pollution is one of the great existential challenges of the Anthropocene epoch . . . [It] endangers the stability of the Earth’s support systems and threatens the continuing survival of human societies.”153

One of my first brushes with the effects of air pollution came in 2009, when I was working in the pediatric pulmonary division at the Red Cross Children’s Hospital in Cape Town, South Africa. Each morning, my colleagues and I would do rounds in the pediatric ICU. One morning, we stopped to see an eighteen-month-old girl who lived in a local township and had been admitted to the hospital overnight for pneumonia. Her name was Lisedi, and she lay on a little bed in an open room, with an oxygen mask strapped to her nose, her big eyes looking up at us with trepidation. Her mother sat nearby, anxious but quiet as the attending doctor explained that Lisedi was receiving some powerful antibiotics to fight her infection.

“That little girl worries me,” Max Klein, the attending physician, commented before seeing more patients in another part of the hospital. “Her breathing isn’t right for somebody who’s already had a few doses of antibiotics.”

I nodded my head, accepting at the time that Lisedi’s fight was simply between her lungs and the bacteria she had recently picked up. In reality, her struggle had likely started years ago as we now know that toxic air exposure in children is a significant contributor to respiratory infection acquisition, especially in children like Lisedi, who live in low-income areas. Children are more susceptible to the effects of pollution, indoor and outdoor, for numerous reasons, including the fact that their growing airways are more permeable to particles, and they cannot metabolize and detoxify these particles as well as adults. The end result is that lower respiratory tract infections are the number one cause of mortality in children under five years of age, accounting for some 570,000 deaths each year. While the immediate cause of Lisedi’s illness was a bacterial infection, the air she was breathing was what allowed those bacteria to penetrate her lungs.

The morning after seeing Lisedi in the pediatric ICU, Max Klein and I attended the weekly radiology conference at the Red Cross Children’s Hospital. The room was dimmed for adequate viewing, and the radiologist started methodically putting up the morning’s X-rays for review. All was normal until we stopped at a highly unusual chest X-ray of a very young child. Nobody mentioned the name, but based on the patient’s age and history, we knew it was Lisedi. Instead of the normal lung tissue, we saw huge bubble-like structures. Max quickly asked the radiologist to compare the X-ray to the one taken the day prior, which showed no bubbles. There was some debate on what was happening until Max shut it down by saying, “She’s clearly got an infection in her pleural space. That’s the only thing that could give you those big changes in such a short period of time. That can’t be in the lung.”

The pleural space is the area between the chest wall and the lungs, normally filled with a small amount of lubricant fluid. In this patient’s case, that space was now filled with bacteria that were causing intense inflammation, as well as producing gas, giving the appearance of bubbles, that compressed the lung. Only one intervention could be done, as Max said next: “She needs two chest tubes for drainage. And she needs them right now.” A principle of curing microbial disease is that infections need a place to drain. The pleural space is closed, and it needed to be opened up by inserting a tube.

One senior doctor hurried to the ICU. I followed with one of the junior physicians. Upstairs, we saw little Lisedi, struggling mightily with her breathing. Alarm bells were going off intermittently on her monitor, as she was now unable to get enough oxygen into her body. The two doctors inserted the chest tubes, and with each tube insertion a huge rush of gas came out, gas produced by the bacteria.

However, after the second tube was placed, the situation worsened. Although necessary, the tubes had upset whatever delicate balance had existed in Lisedi’s body. She succumbed to an irreversible cardiac arrest soon after and passed. Bacterial pneumonia was what would be listed as her cause of death, but given where she was from, that probably wasn’t telling the whole story.

The history of air pollution and concomitant lung disease likely stretches back to the first instances of organized human society, some forty thousand years ago. These early effects were limited to the burning of wood for fire, and while this practice had little impact on our environment in terms of climate change, the short-term and long-term problems associated with wood burning were present then and remain issues today.

Burning wood has the potential to release not only noxious gases, such as carbon monoxide (CO), hydrogen cyanide, and ammonia, but also particulate matter (PM). Of all the types of air pollution, PM is thought to be particularly devastating to our respiratory system. It is divided into three sizes, measured in micrometers (one millionth of a meter, abbreviated as μm): coarse matter, which is less than 10 μm (PM10); fine matter, which is less than 2.5 μm (PM2.5); and ultrafine matter, which is less than 0.1 μm. For comparison, fine beach sand is about 90 μm, and the diameter of a human hair is about 70 μm.154

All PM is potentially harmful, but fine and ultrafine matter are thought to cause most critical health issues. Coarse PM10 particles, derived mostly from natural sources, such as soil and sea salt, are small but generally still big enough to be handled by the defense systems of the nose and upper part of the lungs and coughed or sneezed out before they reach the deep alveoli. On the other hand, PM2.5 and smaller particles can lodge deep in the lungs and cause detrimental inflammatory reactions.

Wood burning releases PM2.5, most significantly in the form of partially burned carbon. There is evidence that mummified lung tissue from ancient Egypt, Great Britain, and Peru had blackened areas, likely from wood burning. In ancient Rome, PM was such a major problem that writers coined the terms gravioris caeli (heavy air) and infamis aer (infamous air) to describe the clouds of pollution that enveloped their city. In AD 61, upon the improvement of his health after leaving Rome, Seneca wrote, “No sooner had I left behind the oppressive atmosphere of the city . . . the smoking cookers . . . clouds of ashes . . . [and] poisonous fumes, than I noticed the change in my condition.”155

Air pollution continued unabated through the centuries. One dramatic example is that of Great Britain, where people began to burn coal in the twelfth century, as the country started to run out of trees. This was sea-coal, which washes up on the beaches of Great Britain from underwater sources that become eroded by tides. It appears most abundantly on the beaches in the north; in the past, it was brought to London and burned in large amounts. With this new source of energy, the smoke from burning coal mixed with fog to blanket the city.

Sea-coal is a particularly noxious form of coal, releasing high levels of sulfurous smoke when burned. Through the centuries, various British kings tried to limit coal burning, but with little success. In 1306, Edward I banned the burning of sea-coal and tried various punishments to enforce the ban. He imposed large fines and destroyed furnaces, and even threatened the death penalty. A few people were tortured—one was executed—but England’s citizens continued to burn coal in vast quantities. In 1661, Charles II tried a more subtle approach when he employed the author John Evelyn to write a book about the effects of burning coal and other substances. In his book Fumifugium, Evelyn appealed to ancient wisdom about the power of the breath, writing, “the Philosophers have named the Aer the Vehicle of the Soul, as well as of the Earth, and this frail Vessell of ours which contains it; since we all of us finde the benefit which we derive from it.” The inhabitants of London, he continued, “breathe nothing but an impure and thick Mist, accompanied with a fuliginous and filthy vapour, which renders them obnoxious to a thousand inconveniences, corrupting the Lungs, and disordering the entire habit of their Bodies.” After documenting in part one of his book that “London is hell,” in parts two and three he recommended solutions, such as moving the sources of pollution out of the city and establishing gardens with flowers and other vegetation within city limits.156

Of course, Evelyn was ignored. With the advent of the Industrial Revolution in the latter half of the eighteenth century, coal was burned in massive amounts to power thousands of factories and locomotives. The factories were often located in urban areas, and their spewing furnaces blackened both the air and the water of industrial cities. J. G. May, an observer from Europe sent to report on England’s factories in 1814, vividly described the situation in Manchester: “There are hundreds of factories in Manchester which are five or six stories high. At the side of each factory there is a great chimney which belches forth black smoke and indicates the presence of the powerful steam engines. The smoke from the chimneys forms a great cloud which can be seen for miles around the town. The houses have become black on account of the smoke.”157

Despite the occasional protest and the obvious decline in air quality, the burning of coal continued unchecked for centuries throughout Europe and, later, in the United States. In Great Britain, the matter reached a tipping point in December 1952 with the Great Smog of London. For five days, a thick toxic cloud hung in the air, and the city endured a pollution like none of the previous “pea-soupers.” Part of the problem was the cold weather, which caused people to burn more coal. Coal-fired power stations, vehicle exhaust fumes, diesel buses, and steam locomotives also contributed to the pollution.

But what really tipped the balance toward a medical tragedy was a weather-related event called a temperature inversion. Normally, the warmest air is closest to the Earth, as solar radiation is absorbed and heats the air just above us. Warm air naturally rises, causing cold air above to rush in, creating wind and diluting out pollution. However, when certain meteorological conditions are met—in the 1952 London case it was the lack of wind—a warm layer of air rises above a cold layer, the cold air does not move or rise, and all of the pollution and smog becomes trapped.

So, during those few days in London, the trapped pollution just sat on top of the city, creating chaos. Visibility was minimal, making driving impossible and shutting down not only personal vehicles but buses and taxis as well. Some people died, not because of lung illness, but because they couldn’t see and fell into the Thames River and drowned. Smog (smoke combined with fog) seeped into buildings. Sadler’s Wells Theatre had to close after the first act of Puccini’s La Traviata due to poor visibility and air quality. Wembley postponed a soccer match, and there were press reports of cows asphyxiating in the fields. Worst of all, four thousand people died in the immediate aftermath, and eight thousand additional deaths during the following January and February were likely related. Undertakers ran out of caskets, and florists had no more flowers. Many thousands more suffered from illnesses because of the devastating event, and the people of Britain were in shock. Their air had been taken away from them in a dramatic fashion.158

The United States had a similar air pollution disaster a few years prior to the London incident. Donora, Pennsylvania, lies in a valley along the Monongahela River, about thirty miles south of Pittsburgh. In the 1940s, it was the site of two major industrial plants, Donora Zinc Works and American Steel & Wire, both owned by United States Steel. From October 27 to October 31, 1948, an inversion similar to the one that would later occur in London gripped the town, trapping dense smog and pollution.

The citizens of Donora began falling ill en masse, as deadly levels of pollutants, including sulfuric acid, nitrogen dioxide, and fluorine, built up in their lungs, choking them with lethal gases and subsequent inflammation. Doctors’ phones rang off the hook until an emergency call center was set up in the town hall. The nurse at the steel mill, Eileen Loftus, painted a tragic picture of the first afflicted workers she treated: “He was gasping. I had him lie down and gave him oxygen. Then another man came in, and another.”159 It was difficult to reach the patients as visibility shrank, making driving almost impossible. The Halloween parade was a truly ghostly affair, and the football team abandoned its passing game because of poor visibility. All told, twenty people died in the immediate aftermath, and fifty more succumbed the following month. Nearly half of the fourteen thousand residents fell ill. One of the fatalities was baseball Hall of Famer Stan Musial’s father, fifty-eight-year-old Lukasz Musial. Over the following decade, the mortality rate in Donora remained inordinately high.

Both of these catastrophes represented turning points in a drive toward cleaner air. In Donora, lawsuits were filed, and awareness was raised. The tragedy caught the attention of President Harry S. Truman, who in 1950 convened the United States Technical Conference on Air Pollution and referred to Donora in his conference invocation. This event paved the way for the 1955 Air Pollution Control Act and later the 1970 Clean Air Act, which set up strict regulations at state and federal levels to limit emissions from industrial and mobile (cars and trucks) sources. Great Britain followed a similar path with its own Clear Air Act of 1956 and a transition from coal as the nation’s primary source of energy.

The legally mandated changes have undoubtedly saved many thousands of lives, but today we are still struggling with poor air quality on an unprecedented scale, both in the United States and worldwide. Since the days of coal and wood burning, we have become dependent on other fuel sources, such as oil and gasoline, which release their own toxic pollutants. The United States Environmental Protection Agency has identified six types of pollutants with serious effects on human health—PM, ozone (O3), sulfur oxides (SO2), nitrogen oxides (NOx), carbon monoxide (CO), and lead.

The major producers of these six pollutants are power plants and car engines. Other important sources, such as agriculture, are not as frequently discussed. A 2015 study published in Nature noted that, in an average year, the United States had 16,929 deaths attributable to polluted air from power plants, while 16,221 deaths were attributable to pollution from agriculture.160 Modern farming is a huge producer of toxic PM, largely from ammonia from fertilizer use and animal waste. This ammonia combines with nitrogen from car exhaust fumes and sulfate from power plants to form deadly PM2.5. This is what regularly puts the Fresno–Madera city area in California among the top five most-polluted cities in the country. Their size and long growing season put farms in California high on the list of polluters, but in the summertime, farms of the American Midwest produce up to 40 percent of the total emissions measured in their states.161

The smell of wood-burning stoves reminds us of crisp fall days, and the practice is generally regarded as a harmless way to heat our homes. But these stoves release massive amounts of PM, benzene, and formaldehyde into the air, which can travel for miles. The inhalant is no better than, or even different from, cigarette smoke, largely because most wood stoves burn fuel incompletely and inefficiently. The use of wood-burning stoves is so prevalent in some states that it is often a major contributor to PM pollution. It has been estimated that every winter in Washington State, residential wood stoves contribute 35 percent of the total small-particle pollution—the single largest contributor—10 percent more than agricultural dust and almost twice as much as the fumes emitted by cars and trucks.162 The situation in Great Britain is similar, with the PM2.5 from wood-burning stoves contributing more than twice the amount of particle pollution than automobile traffic. (The toxicity of automobiles lies more in their output of the gases nitrogen oxide, carbon monoxide, carbon dioxide, and sulfur dioxide.)163

With all of the things that we burn and consume for energy purposes today, according to the 2019 American Lung Association’s State of the Air report, a staggering 141 million Americans are exposed to unhealthy levels of air pollution, about 43 percent of the population.164 This is an increase over the numbers reported in the prior two years, a warning that we are headed in the wrong direction after decades of progress. American cities in the West, especially in California, known for outdoor activities and a healthy lifestyle, dominate the lists of most polluted cities. In the United States, Los Angeles ranks number one in ozone pollution, Bakersfield is number one in short-term particle pollution, and Fresno–Madera–Hanford is number one for year-round particle pollution. Geography is part of the problem in the West, with mountains often blocking gases that would normally disperse. Places such as Salt Lake City, surrounded by the Rockies, frequently experience temperature inversions during the winter, causing unhealthy levels of PM, ozone, and nitrogen dioxide. This phenomenon triggers a “Mandatory Action Day,” when wood and coal stoves are not to be used, along with fire pits, fire rings, and campfires. Residents are also asked to carpool, use public transportation, and consolidate trips when possible.

The worldwide data is even more concerning. As mentioned, the WHO estimates that 91 percent of the global population lives in places where air quality guidelines are not being met. Regulations, such as those in the 1970 Clean Air Act, are nonexistent in parts of Eastern Europe, in Russia, and throughout the developing world. Simple protective devices such as filters and scrubbers on top of smokestacks are not used, and basic laws governing exhaust from cars and trucks are absent. For this reason, people are exposed to a complex mix of solid and gaseous toxins from vehicle exhaust fumes, road dust, and smokestacks, and this exposure significantly contributes not just to lung diseases such as pneumonia, asthma, and cancer, but also to strokes and heart disease. We are further beginning to understand the effects of pollution on body systems not previously known to be affected: a 2017 study from Columbia University showed a significant link between air quality and the risk of osteoporosis, and a 2019 study from the University of Southern California pointed to a connection between particulate-matter exposure and Alzheimer’s disease.165,166

Today, in cities such as Beijing and Delhi, levels of PM2.5 regularly reach levels of 300 mcg/m3 or higher, with a level of 30 being the high end of the safe range. Events reminiscent of The Great Smog of London and the 1948 tragedy of Donora, Pennsylvania, occur on a yearly basis. In November 2017, levels of PM2.5 exceeded 900 mcg/m3 in Delhi, and four thousand schools were forced to close for almost a week. The chief minister of Delhi, Arvind Kejriwal, called the city a “gas chamber.” One chest surgeon commented in the New York Times, “I don’t see pink lungs even among healthy nonsmoking young people.” United Airlines suspended flights into the city, and construction projects were halted.167 This is sadly a not uncommon event in Delhi, and schools had to close there again in November 2019 due to toxic air.168 Long-term lethal health effects are sure to follow.

Unsurprisingly, of the 6.5 million deaths caused each year by air pollution (11.6 percent of all global deaths), 55 percent come from China and India, countries with large, dense populations and rapidly expanding economies.169 The problem is not just outdoor air pollution, but indoor air pollution as well, as households in developing countries regularly burn fuel for cooking and heating, producing toxic gases and PM that linger indoors because of poor ventilation. The source is usually burning wood, dung, coal, or crop waste, referred to as biomass fuels. About three billion people, concentrated in Africa, India, and China, rely on the burning of biomass fuels. In these regions, an estimated four million people die annually from indoor air pollution, with many of these deaths occurring among children under the age of five.170

Humans are not the only victims of all of this noxious air; it also pollutes oceans, poisons trees, and of course contributes to global climate change, which in turn makes fixing these issues even harder as the two problems feed off each other.

As physicians, we are tasked with addressing the downstream effects of dangerous trends in society, such as the use of tobacco or the worsening quality of our air. One physician pushing back against this status quo is Heather Zar, a doctor on the faculty at the Red Cross Children’s Hospital in Cape Town, who through innovative research is bridging not only the wide gap between public policy and the role of doctors, but also the gaps between rich and poor, and between developed and developing countries.171

The Drakenstein Child Health Study, which began in 2012, is Dr. Zar’s latest and most ambitious undertaking, and aims to shine a bright spotlight on what pollution is doing not only to our lungs, but to our brains, to our immune systems, and even to the bacteria that colonize us.172 A main goal of the study is to understand why pneumonia is the leading cause, worldwide, of both death and illness among children under five years old, and to figure out what can be done about it. If Dr. Zar is successful, we’ll learn how to prevent bouts of childhood pneumonia like the one that killed little Lisedi.

Drakenstein is an area just inland from Cape Town, on South Africa’s eastern coast, and as in most of the country, many of the inhabitants of the region are poor, live in a semi-urban environment, and are exposed to a multitude of indoor pollutants and infectious agents. Dr. Zar and her colleagues chose Drakenstein, but in reality, the study could have been conducted in almost any part of South Africa, or in any other African nation: the continent accounts for just 18 percent of the global under-five population but 42 percent of total deaths for this age group each year.

Dr. Zar and her colleagues decided to study the children even before they were born. Potential effects on a child’s lungs are known to start in utero, so Dr. Zar’s team enrolled mothers who were twenty to twenty-eight weeks into their pregnancies, with a plan to study their children’s habits up to the age of five, as well as the habits of their mothers and their entire households.

The usual suspects for harming children’s health are present in Drakenstein’s homes: the buildup of indoor pollution from smoking tobacco and cooking with biomass fuel. Dr. Zar’s team is also studying the nutrition of the mothers and their babies, the genetics of the babies and their parents, and psychosocial issues that different families deal with. Finally, the team is analyzing the microbiome of the children, a new area of inquiry that is emerging in the study of childhood pneumonia.

A term that emerged in the late 1990s, microbiome is defined as the collection of microorganisms that live in a particular environment, including in and on humans. We have always known about bacteria living in the human gut and on the skin, but newer molecular techniques have allowed us to catalog the vast number and scale of organisms living in every organ of the human body. Overall, some ten thousand trillion organisms live in every human; for each one of our cells, there is a microbial cell which lives in and on us.173 The vast majority of these organisms live in the large intestine, but some inhabit organs previously thought to be sterile, such as the bladder and the lungs.

Today, we know that hundreds of species of bacteria colonize our lungs, including Provatella, Fusobacterium, and Streptococcus, along with fungi, such as Candida and Saccharomyces. Many of these bacteria and fungi clearly perform important functions, primarily keeping other harmful bacteria out by producing inflammatory proteins that both kill invading bacteria and induce the lung cells to produce bacteria-fighting proteins.174

Knowledge of the microbiome is forcing scientists to rethink how lung diseases occur as well as how they might be treated. Those patients with COPD, cystic fibrosis, and asthma have all been shown to have very different lung bacteria compared with subjects without lung disease, likely making them more susceptible to other seasonal infections. We also know that exposure to household air pollution significantly changes the populations of bacteria in the human lungs, and smoking alters this microbiome in the lungs, nose, and throat. Dr. Zar and her colleagues want to find out whether disruption of the lung microbiome from exposure to pollutants is the primary mechanism by which harmful bacteria are able to cause infections in children with pneumonia. To this end they are culturing the bacteria in the lungs and noses of their young subjects and matching the results to levels of pollutants in their environment.

With 1,140 mother-child pairs having completed one full year in the study in 2016, some definitive results of the Drakenstein Child Health Study have already been reported. They showed that many children were being raised in a toxic environment—one-third of the women smoked while pregnant, and 56 percent of the newborns had detectable cotine (a nicotine byproduct) levels in their urine samples. There were also high levels of biomass fuel exposure in the homes. The rates of pneumonia were elevated in the cohort as a whole, despite all the babies being appropriately immunized. Among the babies who contracted lung infections, their lung function, measured at one year of age, was lower than that of children who were able to remain infection free (adults with pneumonia generally recover all of their previous lung function, barring a very severe infection).175

Decreased lung function is known to put children at increased risk of contracting pneumonia again, as well as developing asthma. But there are other implications for these children beyond the lungs. Data clearly shows that decreased pulmonary function in adults leads to more dementia and cognitive impairment later in life. Some findings on this effect in children are emerging, too, and the Drakenstein Study team plans to add to this information by examining MRI brain scans of some of their subjects to find out if respiratory infections and pollution influence brain development. If the answer is yes, it would provide another important reason to start cleaning up the air that we all breathe.

The dangers we face from indoor and outdoor air pollution are staggering, given the huge number of people exposed to noxious air. The good news is that there are steps we can take right now, and we know that by taking these steps we can improve the situation immensely. This includes creating cleaner cars, building cleaner power plants, and burning carbon-based fuels, such as coal and wood, to completion to minimize smoldering output.

We have begun many of these initiatives in the United States, and they have been working. Despite setbacks in air quality in the past few years, since 1970 emissions of the six most common pollutants have dropped by 70 percent, even while our population, economy, and energy use have all significantly increased. Equally remarkable is the documented effect of cleaning up the air on human lung function and development. In a study published in 2015 in the New England Journal of Medicine, three cohorts of children in Los Angeles had their lung function checked annually over a four-year period, starting at age eleven. The first group started in 1994, followed by a second group in 1997, and a third group in 2007. Throughout this period, the air quality in Los Angeles improved significantly. The results show that for the later cohorts of kids, average increase in pulmonary capacity over the four-year period was greater. With fewer noxious chemicals, their lungs were able to grow larger, which will undoubtedly lead to longer life spans in the future.176

Other studies have demonstrated this very tight correlation between local pollution levels and health outcomes. The Utah Valley is an area of Central Utah where low smoking rates are the norm. The Geneva Steel mill, however, was a significant source of PM10 in the area for several decades from when it opened in 1944 until its closure in 2001. A strike occurred during the winter of 1986–87, and researchers used this opportunity to measure the effects of PM10 on local health outcomes. Compared to other winters, levels of PM10 during the winter of 1986–87 were much lower in the Utah Valley. Also significantly lower during the period of the strike were hospital admissions of children for asthma, bronchitis, and pneumonia: there were seventy-eight admissions for asthma and bronchitis during both the winter of 1985–86 and the winter of 1987–88, while during the strike year the total was only twenty-three.177 A similar study in the Southwest analyzed health effects of a copper smelters’ strike that lasted from July 1967 to April 1968 and affected New Mexico, Arizona, Utah, and Nevada. The mortality rate in the region dropped 2.5 percent because of the strike.178

Isaac Newton’s third law of motion states that for every action, there is an equal and opposite reaction. For a long time, breathing polluted air led to declining lung health. We now have proof that the equation can be reversed—an intelligent attempt to clean up our air can have widely positive effects on the lungs and overall health.

Nonetheless, experts have warned that controlling pollution effectively over the long term lies in how we generate energy to heat our homes, drive our cars, and produce goods and services. We will need to embrace renewable sources of clean energy, such as solar, wind, and hydropower, along with clean use of biomass and geothermal sources. Arguments against this approach, that it will cost too much money, or that it will impede progress, have been shown to be false. The United States and other countries have received extraordinarily positive economic returns from a concerted effort to clean up polluted air.

The world has focused most recently on climate change and reduction of carbon emissions. The Kyoto Protocol began international cooper­ation on this issue in 1997, then was replaced by the Paris Agreement in 2015. As of 2019, 194 nations have signed on, with the United States initially on board. This changed in November of 2019, when the United States federal government signaled its plan to withdraw after a one year waiting period, throwing the potential success of global cooperation on this looming environmental disaster in doubt.

Air pollution specifically has traditionally been dealt with at the individual country level. In the United States the Environmental Protection Agency has handled the majority of issues, while in Europe the European Environment Agency has set standards. Both regions have seen improvements in air quality over the decades, but as mentioned, many areas are still exposed to substandard air quality. Air pollution can be difficult to regulate with one agency or agreement, because so many different sources contribute: agriculture, road transport, energy production, natural phenomena, local businesses, and households. Successful international cooperation on an environmental issue is not without precedent, however, as demonstrated by the hugely successful Montreal Protocol, which in 1987 laid out a plan to limit ozone-depleting chlorofluorocarbons (CFCs).179 With the entire world on board, a healing ozone layer has been seen every year since.

Outside of the United States and Europe, other countries have taken on the issue of air quality with variable success. China in 2013 issued the Air Pollution Prevention and Control Action Plan, which successfully reduced PM2.5, PM10, and toxic gasses in seventy-four cities, with an estimated 47,240 lives saved between 2013 and 2017.180 Significant problems with air quality still exist in China, but this initiative is encouraging. India passed the Air (Prevention and Control of Pollution) Act in 1981, but despite this legislation, air quality has steadily worsened over the decades, and India is home to twenty-two of the world’s thirty most polluted cities, with an estimated 141 million people breathing air that is ten times more noxious than WHO limits.181,182

In the United States, leadership at the federal level has recently been lacking, but many states are showing the way forward. With respect to clean energy generation, results are impressive. Kansas, Iowa, and Oklahoma are leading the way in wind energy production, with, respectively, 36, 34, and 32 percent of their total utility power generation from wind in 2018.183 Texas, number one in the country in total wattage produced, now has more wind capacity than coal-fired capacity in the state. Renewable energy providers in California produced 34 percent of the electricity used in 2018, with solar power accounting for 10 percent of that total.184 Mississippi added enough solar energy in 2017 to power twenty-five thousand homes every year.185

Existing clean energy sources will likely not be enough to replace fossil fuels completely, and new technologies will need to be developed. This is happening today with the production of biogas from animal-waste breakdown and the capturing of energy from the ocean. Advances are coming in fusion energy technology, which involves the combination of two lighter atomic nuclei into one, with the subsequent release of energy (in contrast to nuclear fission energy).

Despite these promising innovations, air pollution remains a problem, and polluters need to be continually monitored. The warning offered in the American Lung Association’s 2019 State of the Air report should not be ignored. It postulated that air quality in the United States has deteriorated in the past few years not because of specific pollutants from man-made sources, but from the growing plague of extreme wildfires. In the United States, wildfires have been concentrated in California, where 2017 and 2018 saw the deadliest and most destructive fires in the history of the state, destroying thousands of houses and causing many to flee.186 The fires in the Amazon rainforest and then in Australia horrified people throughout the world in 2019 and 2020, and the health effects of these two events will be felt for years. Given that climate change is fueling these fires, the frequency and lethality of these events are expected to increase.

Addressing climate change and embracing clean energy sources will be a major part of our effort to improve air quality after recent setbacks. In the face of such enormous challenges, the goal of clean energy sounds almost quaint. But if we manage to make a total commitment to clean energy sources, we could accomplish something for the first time in the thousands of years of our civilized existence: living an advanced lifestyle without polluting the air that we breathe. And if we are able to achieve this goal, we will go a long way toward keeping our lungs and bodies healthy.

150. Steven R. James, R. W. Dennell, Allan S. Gilbert, et al., “Hominid Use of Fire in the Lower and Middle Pleistocene,” Current Anthropology 30, no. 1 (February 1989): 1–26.

151. World Health Organization, “Air Pollution,” WHO website, 2020, https://www.who.int/airpollution/en/.

152. Philip J. Landrigan, Richard Fuller, Nereus J. R. Acosta, et al., “The Lancet Commission on Pollution and Health,” Lancet 391 (2018): 462–512.

153. Philip J. Landrigan, Richard Fuller, Nereus J. R. Acosta, et al., “The Lancet Commission on Pollution and Health,” Lancet 391 (2018): 465.

154. American Lung Association, “Particle Pollution,” American Lung Association website, February 25, 2020, https://www.lung.org/our-initiatives/healthy-air/outdoor/air-pollution/particle-pollution.html.

155. Jim Morrison, “Air Pollution Goes Back Way Further Than You Think,” Smithsonian Magazine, January 11, 2016, https://www.smithsonianmag.com/science-nature/air-pollution-goes-back-way-further-you-think-180957716/#BZ1IdR9y0MdRzJvy.99.

156. John Evelyn, Fumigugium (Exeter, UK: University of Exeter Press, 1976), https://archive.org/details/fumifugium00eveluoft/page/n5.

157. W. O. Henderson, Industrial Britain Under the Regency (Abingdon, UK: Routledge, 2006), 105.

158. Rob Baker, “‘A Proper Pea-Souper’—The Dreadful London Smog of 1952,” Flashbak, December 4, 2017, https://flashbak.com/proper-pea-souper-dreadful-london-smog-1952-391180/.

159. Edwin Kiester Jr., “A Darkness in Donora,” Smithsonian Magazine, November 1999, https://www.smithsonianmag.com/history/a-darkness-in-donora-174128118/.

160. J. Lelieveld, J. S. Eans, M. Fnais, et al., “The Contribution of Outdoor Air Pollution Sources to Premature Mortality on a Global Scale,” Nature 525 (2015): 367–371.

161. Deidre Lockwood, “California Farms Are a Silent but Sizable Source of Air Pollution,” Scientific American, February 6, 2018, https://www.scientificamerican.com/article/california-farms-are-a-silent-but-sizable-source-of-air-pollution/.

162. State of Washington, Department of Ecology, How Wood Smoke Harms Your Health, pdf file, https://fortress.wa.gov/ecy/publications/publications/91br023.pdf.

163. “Emissions of Air Pollutants in the UK, 1970 to 2018—Particulate Matter” (PM10 and PM2.5), Department of Environment Food & Rural Affairs, gov.uk. https://www.gov.uk/government/publications/emissions-of-air-pollutants/emissions-of-air-pollutants-in-the-uk-1970-to-2018-particulate-matter-pm10-and-pm25.

164. American Lung Association, “State of the Air 2019,” American Lung Association website, https://www.lung.org/assets/documents/healthy-air/state-of-the-air/sota-2019-full.pdf.

165. Diddier Prada, Jia Zhong, and Elena Colicino, “Association of Air Particulate Pollution with Bone Loss over Time and Bone Fracture Risk: Analysis of Data from Two Independent Studies,” Lancet Planetary Health 1, no. 8 (2017): e337–e347.

166. Diana Younan, Andrew J. Petkus, Keith F. Widaman, et al., “Particulate Matter and Episodic Memory Decline Mediated by Early Neuroanatomic Biomarkers of Alzheimer’s Disease,” Brain 143, no. 1 (November 20, 2019): 289–302.

167. Hari Kumar and Kai Schultz, “Delhi, Blanketed in Toxic Haze, ‘Has Become a Gas Chamber’,” New York Times, November 7, 2017, https://www.nytimes.com/2017/11/07/world/asia/delhi-pollution-gas-chamber.html.

168. “Dangerous Air Pollution in India Forces Delhi Schools to Close for 2nd Time in Two Weeks,” CBS News website, November 15, 2019, https://www.cbsnews.com/news/air-pollution-in-india-delhi-forces-schools-industry-closed-health-problems-today-2019-11-15/.

169. Landrigan et al., “The Lancet Com-mission on Pollution and Health,” 462–512.

170. World Health Organization, “Air Pollution,” WHO website, 2020, https://www.who.int/airpollution/en/.

171. Tony Kirby, “Heather Zar—Improving Lung Health for Children in Africa,” Lancet 376 (September 4, 2010): 763.

172. Kirsten A. Donald, Michelle Hoogenhout, Christopher P. du Plooy, et al., “Drakenstein Child Health Study (DCHS): Investigating Determinants of Early Child Development and Cognition.” BMJ Paediatrics Open 2, no. 1 (2018): e000282.

173. Ron Sender, Shai Fuchs, and Ron Milo, “Revised Estimates for the Number of Human and Bacteria Cells in the Body,” PLOS Biology 14, no. 8 (2016): e1002533.

174. Miriam F. Moffatt and William O. C. M. Cookson, “The Lung Microbiome in Health and Disease,” Clinical Medicine (London) 17, no. 6 (December 2017): 525–529.

175. Diane M. Gray, Lidija Turkovic, Lauren Willemse, et al., “Lung Function in African Infants in the Drakenstein Child Health Study. Impact of Lower Respiratory Tract Illness,” American Journal of Respiratory and Critical Care Medicine 195, no. 2 (2017): 212–220.

176. W. James Gauderman, Robert Urman, Edward Avol, et al., “Association of Improved Air Quality with Lung Development in Children,” New England Journal of Medicine 372, no. 10 (March 5, 2015): 905–913.

177. C. Arden Pope III, “Respiratory Disease Associated with Community Air Pollution and a Steel Mill, Utah Valley,” American Journal of Public Health 79 (May 1989): 623–628.

178. C. Arden Pope III, Douglas L. Rodermund, and Matthew M. Gee, “Mortality Effects of a Copper Smelter Strike and Reduced Ambient Sulfate Particulate Matter Air Pollution,” Environmental Health Perspectives 115, no. 5 (2007): 679–683.

179. United States Environmental Protection Agency, “International Treaties and Cooperation about the Protection of the Stratospheric Ozone Layer,” USEPA website, September 24, 2018, https://www.epa.gov/ozone-layer-protection/international-treaties-and-cooperation-about-protection-stratospheric-ozone.

180. Jing Huang, Xiaochuan Pan, Xinbiao Guo, and Guoxing Li G, “Health Impact of China’s Air Pollution Prevention and Control Action Plan: An Analysis of National Air Quality Monitoring and Mortality Data,” Lancet Planetary Health 2, no. 7 (July 2018): e313–e323.

181. “Why Is India’s Pollution Much Worse Than China’s?” BBC News website, November 6, 2019, https://www.bbc.com/news/world-asia-50298972.

182. Steven Bernard and Amy Kazmin, “Dirty Air: How India Became the Most Polluted Country on Earth,” Financial Times, December 11, 2018.

183. Ryan Wiser and Mark Bolinger, “2018 Wind Technologies Market Report,” US Department of Energy, 8, https://eta-publications.lbl.gov/sites/default/files/wtmr_final_for_posting_8-9-19.pdf.

184. California Energy Commission, “Renewable Energy,” State of California website, 2020, https://www.energy.ca.gov/programs-and-topics/topics/renewable-energy.

185. Amanda Levin, “2017 Clean Energy by the Numbers: A State-by-State Look,” National Resource Defense Council website, 2018, https://www.nrdc.org/experts/amanda-levin/2017-clean-energy-by-the-numbers-a-state-by-state-look.

186. Tim Arango, Jose A. Del Real, and Ivan Penn, “5 Lessons We Learned From the California Wildfires,” New York Times, November 4, 2019, https://www.nytimes.com/2019/11/04/us/fires-california.html.