The Lancet Commissions

The Lancet Commission on pollution and health

Philip J Landrigan, Richard Fuller, Nereus J R Acosta, Olusoji Adeyi, Robert Arnold, Niladri (Nil) Basu, Abdoulaye Bibi Baldé, Roberto Bertollini,
Stephan Bose-O’Reilly, Jo Ivey Boufford, Patrick N Breysse, Thomas Chiles, Chulabhorn Mahidol, Awa M Coll-Seck, Maureen L Cropper, Julius Fobil,
Valentin Fuster, Michael Greenstone, Andy Haines, David Hanrahan, David Hunter, Mukesh Khare, Alan Krupnick, Bruce Lanphear, Bindu Lohani,
Keith Martin, Karen V Mathiasen, Maureen A McTeer, Christopher J L Murray, Johanita D Ndahimananjara, Frederica Perera, Janez Potočnik,
Alexander S Preker, Jairam Ramesh, Johan Rockström, Carlos Salinas, Leona D Samson, Karti Sandilya, Peter D Sly, Kirk R Smith, Achim Steiner,
Richard B Stewart, William A Suk, Onno C P van Schayck, Gautam N Yadama, Kandeh Yumkella, Ma Zhong

Executive summary Pollution endangers planetary health, destroys eco­ Published Online
Pollution is the largest environmental cause of disease systems, and is intimately linked to global climate change. October 19, 2017
http://dx.doi.org/10.1016/
and premature death in the world today. Diseases caused Fuel combustion—fossil fuel combustion in high-income S0140-6736(17)32345-0
by pollution were responsible for an estimated 9 million and middle-income countries and burning of biomass in
See Online/Comment
premature deaths in 2015—16% of all deaths worldwide— low-income countries—accounts for 85% of airborne http://dx.doi.org/10.1016/
three times more deaths than from AIDS, tuberculosis, particulate pollution and for almost all pollution by oxides S0140-6736(17)32588-6 and
and malaria combined and 15 times more than from all of sulphur and nitrogen. Fuel combustion is also a major http://dx.doi.org/10.1016/
S0140-6736(17)32545-X
wars and other forms of violence. In the most severely source of the greenhouse gases and short-lived climate
Arnhold Institute for Global
affected countries, pollution-related disease is responsible pollutants that drive climate change. Key emitters of
Health (Prof P J Landrigan MD),
for more than one death in four. carbon dioxide, such as electricity-generating plants, Mount Sinai Heart
Pollution disproportionately kills the poor and the chemical manufacturing facilities, mining operations, (V Fuster MD), and Department
vulnerable. Nearly 92% of pollution-related deaths occur deforestation, and petroleum-powered vehicles, are also of Environmental Medicine
and Global Health
in low-income and middle-income countries and, in major sources of pollution. Coal is the world’s most
(Prof A S Preker PhD), Icahn
countries at every income level, disease caused by polluting fossil fuel, and coal combustion is an important School of Medicine at Mount
pollution is most prevalent among minorities and the cause of both pollution and climate change. Sinai, New York, NY, USA; Pure
marginalised. Children are at high risk of pollution- In many parts of the world, pollution is getting worse. Earth, New York, NY, USA
(R Fuller BE, D Hanrahan MSc,
related disease and even extremely low-dose exposures to Household air and water pollution, the forms of pollution
K Sandilya LLB); Office of the
pollutants during windows of vulnerability in utero and associated with profound poverty and traditional President, Manila, Philippines
in early infancy can result in disease, disability, and death lifestyles, are slowly declining. However, ambient air (N J R Acosta PhD); Department
in childhood and across their lifespan. pollution, chemical pollution, and soil pollution—the of Health, Nutrition, and
Population Global Practice
Despite its substantial effects on human health, the forms of pollution produced by industry, mining,
(O Adeyi DrPH), and Office of
economy, and the environment, pollution has been electricity generation, mechanised agriculture, and the US Executive Director
neglected, especially in low-income and middle-income petroleum-powered vehicles—are all on the rise, with the (K V Mathiasen MALD),
countries, and the health effects of pollution are under­ most marked increases in rapidly developing and The World Bank, Washington,
DC, USA; Department of
estimated in calculations of the global burden of disease. industrialising low-income and middle-income Chemical and Environmental
Pollution in low-income and middle-income countries countries. Engineering, University of
that is caused by industrial emissions, vehicular exhaust, Chemical pollution is a great and growing global Arizona, Tucson, AZ, USA
and toxic chemicals has particularly been overlooked in problem. The effects of chemical pollution on human (R Arnold PhD); Faculty of
Agricultural and
both the international development and the global health health are poorly defined and its contribution to the global Environmental Sciences, McGill
agendas. Although more than 70% of the diseases burden of disease is almost certainly underestimated. University, Montreal, Canada
caused by pollution are non-communicable diseases, More than 140 000 new chemicals and pesticides have (Prof N Basu PhD); Ministry of
inter­ventions against pollution are barely mentioned in been synthesised since 1950. Of these materials, Environment and Sustainable
Development, Dakar, Senegal
the Global Action Plan for the Prevention and Control of the 5000 that are produced in greatest volume have (A B Baldé MS); Scientific
Non-Communicable Diseases. become widely dispersed in the environment and are Committee on Health,
Pollution is costly. Pollution-related diseases cause responsible for nearly universal human exposure. Fewer Environmental and Emerging
productivity losses that reduce gross domestic product than half of these high-production volume chemicals have Risks of the European
Commission, Luxembourg City,
(GDP) in low-income to middle-income countries by up undergone any testing for safety or toxicity, and rigorous Luxembourg (R Bertollini MD);
to 2% per year. Pollution-related disease also results in pre-market evaluation of new chemicals has become Office of the Minister of
health-care costs that are responsible for 1·7% of mandatory in only the past decade and in only a few high- Health, Ministry of Public
annual health spending in high-income countries and income countries. The result is that chemicals and Health, Doha, Qatar
(R Bertollini); Institute and
for up to 7% of health spending in middle-income pesticides whose effects on human health and the Outpatient Clinic for
countries that are heavily polluted and rapidly environment were never examined have repeatedly been Occupational, Social and
developing. Welfare losses due to pollution are responsible for episodes of disease, death, and Environmental Medicine,
University Hospital of LMU
estimated to amount to US$4·6 trillion per year: environmental degradation. Historical examples include
Munich, Munich, Germany
6·2% of global economic output. The costs attributed to lead, asbestos, dichlorodiphenyltrichloroethane (DDT), (S Bose-O’Reilly MD);
pollution-related disease will probably increase as polychlorinated biphenyls (PCBs), and the ozone- Department of Public Health,
additional associations between pollution and disease destroying chlorofluorocarbons. Newer synthetic chem­ Health Services Research and
Health Technology
are identified. icals that have entered world markets in the past

www.thelancet.com Published online October 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32345-0 1

 The Lancet Commissions

Assessment, University for 2–3 decades and that, like their predecessors, have since 1970, which is an aggregate benefit of $1·5 trillion
Health Sciences, Medical undergone little pre-market evaluation threaten to repeat against an investment of $65 billion. Similarly, the
Informatics and Technology,
Hall in Tirol, Austria
this history. They include developmental neurotoxicants, removal of lead from gasoline has returned an estimated
(S Bose-O’Reilly); New endocrine disruptors, chemical herbicides, novel insect­ $200 billion (range, $110 billion–300 billion) to the US
YorkAcademy of Medicine, icides, pharmaceutical wastes, and nanomaterials. economy each year since 1980, an aggregate benefit to-
New York, NY, USA Evidence for the capacity of these emerging chemical date of over $6 trillion through the increased cognitive
(J I Bouffourd MD); Department
of Environmental Health and
pollutants to cause harm to human health and the function and enhanced economic productivity of
Engineering, Johns Hopkins environment is beginning to become evident. These generations of children exposed since birth to only low
Bloomberg School of Public emerging chemicals are of great concern, and this concern amounts of lead.
Health, Baltimore, MD, USA is heightened by the increasing movement of chemical Pollution control will advance attainment of many of the
(P N Breysse PhD); School of
Social Work
production to low-income and middle-income countries sustainable development goals (SDGs), the 17 goals
(Prof G N Yadama PhD), and where public health and environmental protections are established by the United Nations to guide global
Department of Biology often scant. Most future growth in chemical production development in the 21st century. In addition to improving
(T Chiles PhD), Boston College, will occur in these countries. A further dimension of health in countries around the world (SDG 3), pollution
Chestnut Hill, MA, USA;
Chulabhorn Research Institute,
chemical pollution is the global archipelago of control will help to alleviate poverty (SDG 1), improve
Bangkok, Thailand contaminated hot-spots: cities and communities, homes access to clean water and improve sanitation (SDG 6),
(HRH Princess C Mahidol PhD); and schoolyards polluted by toxic chemicals, radionuclides, promote social justice (SDG 10), build sustainable cities
Ministry of the Health and and communities (SDG 11), and protect land and water
and heavy metals released into air, water, and soil by active
Social Affairs, Dakar, Senegal
(A M Coll-Seck MD); and abandoned factories, smelters, mines, and hazardous (SDGs 14 and 15). Pollution control, in turn, will benefit
Department of Economics, waste sites. from efforts to slow the pace of climate change (SDG 13)
University of Maryland, College Cities, especially rapidly growing cities in by transitioning to a sustainable, circular economy that
Park, MD, USA
industrialising countries, are severely affected by relies on non-polluting renewable energy, on efficient
(Prof M L Cropper PhD);
Resources for the Future, pollution. Cities contain 55% of the world’s population; industrial processes that produce little waste, and on
Washington, DC, USA they account for 85% of global economic activity and they transport systems that restrict use of private vehicles in
(Prof M L Cropper, concentrate people, energy consumption, construction cities, enhance public transport, and promote active travel.
A Krupnick PhD); Department of
activity, industry, and traffic on a historically un­ Many of the pollution control strategies that have
Biological, Environmental and
Occupational Health Sciences, precedented scale. proven cost-effective in high-income and middle-income
School of Public Health, The good news is that much pollution can be countries can be exported and adapted by cities and
University of Ghana, Accra, eliminated, and pollution prevention can be highly countries at every level of income. These strategies are
Ghana (J Fobil DrPH); Centro
cost-effective. High-income and some middle-income based in law, policy, regulation, and technology, are
Nacional de Investigaciones
Cardiovasculares Carlos III, countries have enacted legislation and issued regulations science-driven, and focus on the protection of public
Madrid, Spain (V Fuster); mandating clean air and clean water, established health. The application of these approaches boosts
Department of Economics, chemical safety policies, and curbed their most flagrant economies and increases GDP. The strategies include
University of Chicago, Chicago,
forms of pollution. Their air and water are now cleaner, targeted reductions in emissions of pollutants, transitions
IL, USA (M Greenstone PhD);
Department of Social and the blood lead concentrations of their children have to non-polluting, renewable sources of energy, the
Environmental Health Research decreased by more than 90%, their rivers no longer catch adoption of non-polluting technologies for production
and Department of Population fire, their worst hazardous waste sites have been re­ and transportation, and the development of efficient,
Health, London School of
Hygiene & Tropical Medicine,
mediated, and many of their cities are less polluted and accessible, and affordable public transportation systems.
London, UK more liveable. Health has improved and people in these Application of the best of these strategies in carefully
(Prof A Haines FMedSci); countries are living longer. High-income countries have planned and well resourced campaigns can enable low-
Nuffield Department of achieved this progress while increasing gross domestic income and middle-income countries to avoid many of
Population Health, University
of Oxford, Oxford, UK
product (GDP) by nearly 250%. The challenge for high- the harmful consequences of pollution, leapfrog the
(Prof D Hunter MBBS); income nations today is to further reduce pollution, worst of the human and ecological disasters that have
Department of Civil decarbonise their economies, and reduce the resources plagued industrial development in the past, and improve
Engineering, Indian Institute of used in achieving prosperity. The claim that pollution the health and wellbeing of their people. Pollution
Technology, Delhi, India
(Prof M Khare PhD); Faculty of
control stifles economic growth and that poor countries control provides an extraordinary opportunity to improve
Health Sciences, Simon Fraser must pass through a phase of pollution and disease on the health of the planet. It is a winnable battle.
University, Burnaby, BC, the road to prosperity has repeatedly been proven The aim of this Lancet Commission on pollution and
Canada (B Lanphear MD); to be untrue. health is to raise global awareness of pollution, end
Centennial Group,
Washington, DC, USA
Pollution mitigation and prevention can yield large net neglect of pollution-related disease, and mobilise the
(B Lohani PhD); The Resources gains both for human health and the economy. Thus, air resources and the political will needed to effectively
Center, Lalitpur, Nepal quality improvements in the high-income countries have confront pollution. To advance this aim, we make six
(B Lohani); Consortium of not only reduced deaths from cardiovascular and recommendations. Additional recommendations are
Universities for Global Health,
Washington, DC, USA
respiratory disease but have also yielded substantial presented at the end of each Section. The key
(K Martin MD); Faculty of economic gains. In the USA, an estimated US$30 in recommendations are:
Common Law, University of benefits (range, $4–88) has been returned to the economy (1) Make pollution prevention a high priority nationally
Ottawa, Ottawa, ON, Canada
for every dollar invested in air pollution control and internationally and integrate it into country and city

2 www.thelancet.com Published online October 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32345-0

 The Lancet Commissions

planning processes. Pollution can no longer be viewed as public will ensure accountability and build public (M A McTeer LLM); Institute for
an isolated environmental issue, but is a transcendent awareness. With even limited monitoring programmes, Health Metrics, Seattle, WA,
USA (C J L Murray MD); Ministry
problem that affects the health and wellbeing of entire consisting of only one or a few sampling stations, of Environment, Ecology and
societies. Leaders of government at all levels (mayors, governments and civil society organisations can Forests, Antananarivo,
governors, and heads of state) need, therefore, to elevate document pollution, and track progress toward short- Madagascar
pollution control to a high priority within their agendas; term and long-term control targets. Pollution control (J D Ndahimananjara MD);
Columbia Center for Children’s
to integrate pollution control into development planning; metrics should be integrated into SDG dashboards and Environmental Health,
to actively engage in pollution planning and prioritisation; other monitoring platforms so that successes and Department of Environmental
and to link prevention of pollution with commitments to experiences can be shared. Health Sciences (F Perera DrPH),
(4) Build multi-sectoral partnerships for pollution and Department of Health
advance the SDGs, to slow the pace of climate change,
Policy and Management
and to control non-communicable diseases. control. Broad-based partnerships across several (Prof A S Preker), Mailman
Targets and timetables are essential, and governments govern­ment agencies and between governments and School of Public Health,
at all levels need to establish short-term and long-term the private sector can powerfully advance pollution Columbia University, New
York, NY, USA; UN
targets for pollution control and to support the agencies control and accelerate the development of clean energy
International Resource Panel,
and regulations needed to attain these goals. Legally sources and clean technologies that will ultimately Paris, France (J Potočnik PhD);
mandated regulation is an essential tool, and both the prevent pollution at source. Cross-ministerial SYSTEMIQ, London, UK
polluter-pays principle and an end to subsidies and tax collaborations that involve health and environment (J Potočnik); Health Investment
& Financing Corporation,
breaks for polluting industries need to be integral ministries, but also ministries of finance, energy,
New York, NY, USA
components of pollution control programmes. agriculture, development, and trans­port are essential. (Prof A S Preker); Parliament of
(2) Mobilise, increase, and focus the funding and the Collaborations between govern­ments and industry can India, New Delhi, India
international technical support dedicated to pollution catalyse innovation, create incent­ ives for cleaner (J Ramesh MS); Stockholm
Resilience Centre, Stockholm
control. The amount of funding from international production technologies and cleaner energy production,
University, Stockholm,
agencies, binational donors, and private foundations that and incentivise transition to a more sustainable, Sweden (J Rockström PhD);
is directed to control of pollution, especially pollution circular economy. The private sector is in a unique Mexico City, Mexico
from the industrial, transport, chemical, and mining position to provide leadership in the design and (C Salinas PhD); Department of
Biological Engineering and
sectors in low-income and middle-income countries is development of clean, non-polluting, sustainable tech­
Department of Biology, Center
meagre and needs to be substantially increased. The nologies for pollution control, and to engage construct­ for Environmental Health
resources directed to pollution management need to be ively with governments to reward innovation and Sciences, Koch Institute for
increased within cities and countries as well as create incentives. Integrative Cancer Research,
Massachusetts Institute of
internationally. Options for increasing the international (5) Integrate pollution mitigation into planning Technology, Cambridge, MA,
development funding directed to pollution include processes for non-communicable diseases. Interventions USA (Prof L D Samson PhD);
expansion of climate change and non-communicable against pollution need to be a core component of the Children’s Health and
disease control programmes to include pollution control Global Action Plan for the Prevention and Control of Environment Program, Child
Health Research Centre,
and development of new funding mechanisms. Non-Communicable Diseases. University of Queensland,
In addition to increased funding, international (6) Research pollution and pollution control. Research Brisbane, QLD, Australia
technical support for pollution control is needed in is needed to understand and control pollution and to (Prof P D Sly DSc);
prioritisation and planning of processes to tackle drive change in pollution policy. Pollution-related Environmental Health Sciences
Division, School of Public
pollution within rapidly industrialising cities and research should: Health, University of
countries; in development of regulatory and enforcement • Explore emerging causal links between pollution, California, Berkeley, CA, USA
strategies; in building technical capacity; and in direct disease, and subclinical impairment, for example (K R Smith PhD); Oxford Martin
interventions, in which such actions are urgently needed between ambient air pollution and dysfunction of the School, University of Oxford,
Oxford, UK (A Steiner MA);
to save lives or can substantially leverage local action and central nervous system in children and the elderly; Guarini Center on
resources. Financing and technical assistance • Quantify the global burden of disease associated with Environmental, Energy, and
programmes need to be tracked and measured to assess chemical pollutants of known toxicity such as lead, Land Use Law, New York
mercury, chromium, arsenic, asbestos, and benzene; University, New York, NY, USA
their cost-effectiveness and to enhance accountability.
(Prof R B Stewart LLB); Division
(3) Establish systems to monitor pollution and its • Identify and characterise the adverse health outcomes of Extramural Research and
effects on health. Data collected at the national and local caused by new and emerging chemical pollutants, Training, National Institute of
levels are essential for measuring pollution levels, such as developmental neurotoxicants, endocrine Environmental Health
Sciences, National Institutes of
identifying and apportioning appropriate responsibility disruptors, novel insecticides, chemical herbicides,
Health, Research Triangle Park,
to each pollution source, evaluating the success of and pharmaceutical wastes; NC, USA (W A Suk PhD); Care
interventions, guiding enforcement, informing civil • Identify and map pollution exposures particularly in and Public Health Research
society and the public, and assessing progress toward low-income and middle-income countries; Institute, Maastricht
University, Maastricht, the
goals. The incorporation of new technologies, such as • Improve estimates of the economic costs of pollution
Netherlands
satellite imaging and data mining, into pollution and pollution-related disease; and (Prof C P van Schayck PhD);
monitoring can increase efficiency, expand geographic • Quantify the health and economic benefits of inter­ United Nations Industrial
range, and lower costs. Open access to these data is ventions against pollution and balance these benefits Development Organization,
Vienna, Austria
essential, and consultation with civil society and the against the costs of interventions.

www.thelancet.com Published online October 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32345-0 3

 The Lancet Commissions

(K Yumkella PhD); and School of Introduction mining, smelting, and deforestation; the global spread of
Environment and Natural Pollution is one of the great existential challenges of the toxic chemicals; progressively heavier applications of
Resources, Renmin University
of China, Beijing, China
Anthropocene epoch. Like climate change, biodiversity insecticides and herbicides; and an increasing use of
(Prof M Zhong PhD) loss, ocean acidification, desertification, and depletion of petroleum-powered cars, trucks, and buses. Increases in
Correspondence to: the world’s fresh water supply, pollution endangers the ambient air, soil, and chemical pollution over the past
Prof Philip J Landrigan, Arnhold stability of the Earth’s support systems and threatens the 500  years can be directly attributed to the currently
Institute for Global Health, Icahn continuing survival of human societies.1 Pollution, prevalent, linear, take-make-use-dispose economic
School of Medicine at Mount
especially pollution caused by industrial emissions, paradigm—termed by Pope Francis “the throwaway
Sinai, New York, NY 10029, USA
philip.landrigan@mssm.edu vehicular exhausts, and toxic chemicals, has increased culture”13—in which natural resources and human
sharply in the past 500  years, and the largest increases capital are viewed as abundant and expendable, and the
today are seen in low-income and middle-income consequences of their reckless exploitation are given
countries. Yet despite its great and growing magnitude, little heed.14,15 This economic paradigm focuses single-
industrial, vehicular, and chemical pollution in mindedly on GDP14 and is ultimately unsustainable: this
developing countries has been largely overlooked in model fails to link the economic development of human
international development and global health agendas, societies to social justice or to maintenance of the
and programmes for pollution control have received little Earth’s resources.1,2,15
attention or resources from either international agencies Scientific understanding of pollution and its effects on
or philanthropic donors. Pollution is now a substantial health have greatly advanced.16,17 New technologies,
problem that endangers the health of billions, degrades including satellite imaging,18 have enhanced the ability to
the Earth’s ecosystems, undermines the economic map pollution, measure pollution levels remotely,
security of nations, and is responsible for an enormous identify sources of pollution, and track temporal trends.17
global burden of disease, disability, and premature death. Sophisticated chemical analyses have refined under­
Pollution is intimately linked to global climate change.2,3 standing of the composition of pollution and elucidated
Fuel combustion—fossil fuel combustion in high- links between pollution and disease.19 Large prospective,
income and middle-income countries, and biomass multi-year epidemiological studies, beginning with the
burning in inefficient cookstoves, open fires, agricultural studies by Pope and colleagues20 in Utah and the Harvard
burns, forest burning,4,5 and obsolete brick kilns in low- Six-Cities study,21 have showed that pollution is associated
income countries—accounts for 85% of airborne with a much wider range of diseases, particularly non-
particulate pollution and for almost all pollution by communicable diseases, than was previously recognised.
oxides of sulphur and nitrogen. Fuel combustion is the Pollution is now understood to be an important causative
major source of greenhouse gases and short-lived climate agent of many non-communicable diseases including
pollutants that are the main anthropogenic drivers of asthma, cancer, neurodevelopmental disorders, and birth
See Online for appendix global climate change (appendix pp 1–11).6 defects in children (appendix p 11); and heart disease,
Pollution is very costly; it is responsible for productivity stroke, chronic obstructive pulmonary disease, and
losses, health-care costs, and costs resulting from cancer in adults.22–34 In the absence of aggressive
damages to ecosystems. But despite the great magnitude intervention, the number of deaths due to ambient air
of these costs, they are largely invisible and often are not pollution are on track to increase by more than 50%
recognised as caused by pollution.7 The productivity by 2050.35
losses of pollution-related diseases are buried in labour Despite these advances in knowledge, there are still
statistics. The health-related costs of pollution are hidden many gaps in information about pollution and its effects
in hospital budgets.8 The result is that the full costs of on health. These gaps include an absence of information
pollution are not appreciated, are often not counted, and in many countries on pollution levels and the prevalence
are not available to rebut one-sided, economically based of pollution-related disease; poor knowledge of the toxic
arguments against pollution control.7,9 effects of many chemicals in common use, especially
The nature of pollution is changing and, in many newer classes of chemicals;36,37 incomplete information
places around the world, it is worsening. These changes on the scope of exposures and burden of disease
reflect increased energy consumption, the increased use associated with toxic exposures at contaminated sites;38
of new materials and technologies, the rapid industrial­ and inadequate information on the possible delayed
isation of low-income and middle-income countries, and effects of toxic exposures sustained in early life.39 Also
the global movement of populations from rural areas unknown is the exact shape of the dose-response
into cities. Household air and water pollution, the forms functions used to estimate the relative risk of disease
of pollution that were historically associated with associated with pollution. In the case of fine-particulate
profound poverty and traditional lifestyles, are slowly air pollution, for example, the shape of the exposure–
declining. However, ambient air pollution, chemical response association at both very low and very high
pollution, and soil pollution, are all in­creasing.10,11 Key exposure levels and the assumptions that underlie the
drivers of these types of pollution are: the uncontrolled integrated exposure–response function40 used to estimate
growth of cities;12 rising demands for energy; increasing the relative risks of fine particulate (PM2·5) exposure in

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 The Lancet Commissions

both the Global Burden of Disease (GBD) study41,42 and Gross domestic product (US$) Energy consumption (kWh)
WHO analyses are not precisely known.23 300
Vehicle miles travelled CO2 emissions (tons)
The good news is that, despite the great magnitude of 250 Population Aggregate emissions (six common pollutants; tons)

pollution and current gaps in knowledge about its 200

Growth or reduction (%)

effects on human health and the environment, pollution
can be prevented. Pollution is not the inevitable con­ 150

sequence of economic development. High-income and 100

some middle-income countries have enacted legislation
50
and issued regulations that build on new scientific
knowledge about pollution and its health effects. These 0

laws and regulations are based on the polluter-pays –50

principle; they mandate clean air and clean water and set
–100
standards at levels that prevent disease, have established 1970 1990 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
policies for chemical safety, have banned certain Year
hazardous pollutants such as lead, asbestos, and DDT,
Figure 1: Pollution, population, and GDP in the USA, 1970–2015
and have effected clean-up of the worst of the hazardous
Figure taken from reference 43, with permission.
waste sites.
Many of these proven, cost-effective control strategies
18
are now ready to be exported and adapted for use by cities
100 16
and countries at every level of income. Their application
Lead used in gasoline (1000 tonnes)

in carefully planned and well resourced campaigns can

Blood lead concentrations (μg/dL)

80 14
enable developing and industrialising countries to avoid
12
many of the harmful consequences of pollution—to 60
leapfrog over the worst of the human and ecological 10

disasters that have plagued industrial development in the 40

8
past—and to improve human health and wellbeing. 6
20
Contrary to the oft-repeated claim that pollution
4
control stifles economic growth, pollution prevention 0
has, in fact, been shown repeatedly to be highly cost- Blood lead 2
effective. In the USA, for example, concentrations of six Gasoline lead
1
common air pollutants have been reduced by about 70%
19 6

20 2
19 8

20 4
84

20 0
19 0

19 0

19 6

20 6
19 2

19 2

20 8

20 8
10
19 6
19 8

19 4
19 4

0
8

0
8

0
8
8

0
9

0
7
7
7

since passage of the Clean Air Act in 1970 and, in the

19

19

Year
same time period, GDP has increased by nearly 250%
(figure 1).43 Every dollar invested in control of ambient Figure 2: Correlation between population mean blood concentration of lead
and lead use in gasoline in the USA, 1974–91
air pollution in the USA not only improves health,44 but
Taken from data that is publicly available from the Centers for Disease Control.
also is estimated to yield US$30 in economic benefits
(95% CI $4–88).45
Another example of the economic benefits of addressing household air pollution produced by poorly ventilated
pollution is seen in the consequences of removing lead cookstoves55–57 has occurred over many years and those For the Global Alliance for
from gasoline in the USA. This intervention began efforts, along with new vaccines, antibiotics, and treatment Clean Cookstoves see
http://cleancookstoves.org/
in 1975 and, within a decade, had reduced the mean blood protocols, have contributed to promising reductions in
concentration of lead in the population by more than 90% the morbidity and mortality associated with the traditional
(figure 2), almost eliminated childhood lead poisoning, forms of pollution.58–60 However, the burgeoning problems
and increased the cognitive capacity of all American of air, water, and soil pollution produced by modern
children born since 1980 by 2–5 IQ points.46 This gain in industry, electricity generation, mining, smelting,
intelligence has in­creased national economic productivity petroleum-powered motor vehicles, and chemical and
and will yield an economic benefit of US$200 billion pesticide releases in low-income and middle-income
(range $110 billion–300 billion) over the lifetimes of each countries have received almost no international attention
annual cohort of children born since 1980,46 an aggregate or resources.49,50 Budgets for foreign aid from the European
benefit to-date of over $6 trillion.47,48 Commission, the US Agency for International Develop­ For the US Agency for
Yet, despite its harmful effects on human health, the ment, and most bilateral development agencies, private International Development see
https://explorer.usaid.gov/
economy, and the environment and, notwithstanding the philanthropists, and major foundations have not included
clear evidence that it can be cost-effectively controlled, substantive funding for control of industrial, mining and
pollution (especially industrial, vehicular, and chemical transport-related pollution.50,61 The national and local
pollution in low-income and middle-income countries) resources directed toward the study and control of
has been largely neglected.49,50 Work to control the industrial, chemical, and vehicular pollution and the
biological contamination of drinking water51–54 and to curb diseases that they cause within cities and countries are

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 The Lancet Commissions

often meagre.62 Lastly, interventions against pollution are full scale of pollution and its contribution to the global
barely mentioned in the Global Action Plan for the burden of disease are not recognised. The separation of
Prevention and Control of Non-Communicable Diseases,63 public health from environmental protection has also
which is a major missed opportunity. slowed the growth of research on pollution-related
Several factors have contributed to the neglect of disease, led to the virtual elimination of coursework in
pollution. A persistent impediment has been the flawed environmental health science from the curricula of most
conventional wisdom that pollution and disease are the medical and nursing schools, and impeded the develop­
unavoidable consequences of economic development, the ment of environmental health policy.
so-called “environmental Kuznets hypothesis” (panel 1).64–73 In the international development agenda, neglect of
This Commission vigorously challenges that claim as the modern forms of pollution can be traced to the
a flawed and obsolete notion formulated decades ago historical origins of overseas development assistance
when pop­ulations and urban centres were much smaller programmes whose goals, when they were launched at
than they are today, the nature, sources, and health effects the end of World War 2, were to reduce poverty, improve
of pollution were very different, and cleaner maternal and child health, and combat infectious
fuels and modern production technologies were not yet diseases in an era when much of the world was devastated
available. and more than 50% of countries were classified as low-
Fragmentation of the agendas for environmental health income.49,50 At that time, the predominant health
and pollution control is another factor that has contributed problems of the developing world were infectious
to neglect of pollution. In many countries, responsibility diseases and maternal and child mortality, and many
for pollution-related disease falls between ministries of overseas development programmes have been highly
health and ministries for the environment, and too often successful and have contributed to the control of these
For the World Bank Water and
belongs to neither. Air, water, soil, and chemical pollution problems.74 However, these programmes were never
Sanitation Programme see are each regulated by different agencies and studied by intended to address the more modern forms of pollution.
http://www.wsp.org/ different research groups. The consequence is that the Finally, the opposition of powerful vested interests has
been a perennial barrier to control of pollution, especially
industrial, vehicular, and chemical pollution. These
Panel 1: The environmental Kuznets curve entrenched interests, which often exert disproportionate
The Kuznets curve, developed by economist Simon Kuznets (1901–85), describes the influence on government policy, impugn the science
association between economic inequality and per capita income over the course of linking pollution to disease, manufacture doubt about
economic development.64 This curve illustrates Kuznets’ hypothesis that, as a society the effectiveness of interventions, and paralyse
develops from a primarily agrarian to an urban, industrialised economy, market forces governmental efforts to establish standards, impose
first increase and then, at a so-called “turning point” of per-capita income, decreases the pollution taxes, and enforce laws and regulations.75 These
overall degree of economic inequality in the society. These trends are shown as an interests act both within countries and internationally.
inverted U-shaped curve.65 The aim of this Lancet Commission on pollution and
health is to end the neglect of pollution, especially of the
The Kuznets hypothesis has been extended to environmental economics. Here, it is modern forms of pollution, in low-income and middle-
postulated that pollution and environmental degradation must increase in early stage income countries, to focus the world’s attention onto the
economic development, that pollution will continue to increase up to a threshold of per- silent threat of pollution-related disease, and to mobilise
capita income, and that pollution will then decrease as the economy continues to grow. the national and international resources and the political
The postulated result is that high income and economic growth eventually lead to will needed to effectively confront pollution.
environmental improvements. This extension of Kuznets’ hypothesis has become To accomplish this aim and to mobilise the resources
entrenched as conventional wisdom in global environmental policy.66.67 that will be needed to control pollution around the world,
Despite the great certitude with which the environmental Kuznets hypothesis is sometimes we have reviewed data on the health effects and economic
promulgated, empirical and theoretical research finds that the historical evidence in support costs of all forms of pollution: pollution of air, water, and
of this hypothesis is uneven, and that the underlying statistical methods are weak.70–72 soil, pollution in the workplace, and pollution by toxic
Additional shortcomings are that the environmental Kuznets hypothesis fails to consider chemicals (appendix p 15). We have also examined the
the movement of polluting industries from high-income to low-income and links between pollution and poverty, injustice, and
middle-income countries,68 does not consider the health and environmental effects of inequality. Finally, this Commission presents examples
modern classes of pollutants such as chemical carcinogens, neurotoxicants, and endocrine- of cost-effective, proven strategies that can be adapted by
disrupting chemicals,69–73 and does not consider the potential benefits to human health and cities and countries at every level of income to control
the environment of newer, non-polluting energy sources. pollution and prevent disease (appendix pp 63–107).
The conclusions from this analysis are that pollution is not the unavoidable consequence of The work of this Commission on pollution and health
economic development, and that it is much more important to formulate sound laws, builds upon work undertaken in the past decade by
policies, and regulations to control pollution than to wait for an economy to reach a magical international organisations and bi-national funders to
tipping point that will solve the problems of environmental degradation and pollution- address the challenges of modern-day pollution, such as
related disease. The goal of this Commission is to catalyse the formulation of such policies. the World Bank Water and Sanitation Programme.76,77
WHO has established a Department of Public Health

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 The Lancet Commissions

and the Environment, which has become a global leader PM2·5 air pollution and diabetes,24–26 pre-term birth,27–29
in documenting the effects of environmental threats to and diseases of the central nervous system, including
children’s health.78,79 The UN Development Programme autism in children,3,30–32 and dementia in the elderly.29,33
has taken on many components of the pollution control Soil pollution by heavy metals and toxic chemicals at
agenda. The World Bank financially supports several contaminated industrial and mining sites provides
projects to control pollution. The UN Environment another example of a potentially important, but not yet
Programme also supports several programmes to control fully characterised or quantified source of pollution-
chemical pollution, some in partnership with WHO, and related disease.38,87
supports and oversees international agreements limiting Zone 3 includes new and emerging pollutants,36,37 most
the manufacture, environmental release, and global of them chemical pollutants whose effects on human
transport of persistent pollutants,80 pesticides, hazardous health are only beginning to be recognised and are not yet
waste, and mercury. The Strategic Approach to quantified. Several of these chemicals have become widely For the Strategic Approach to
International Chemicals Management, housed within disseminated in the environment, and many are detectable International Chemicals
Management see
the UN Environment Programme, provides a platform in the bodies of most persons examined in national
http://www.saicm.org/
for discussion on control of chemical pollution and toxic surveys, such as the Centers for Disease Control’s
waste among a broad range of stakeholders (appendix national biomonitoring programme in the United States. For the Centers for Disease
pp 13–14). These global advances in controlling ambient At least some of these chemical pollutants appear to have Control and Prevention
national biomonitoring
air, chemical, and vehicular pollution are welcome81 and potential to cause global epidemics of disease, disability, programme see https://www.
have produced important gains, such as phasing lead out and death. This zone includes developmental neuro­ cdc.gov/biomonitoring/
from gasoline, endorsed by the Partnership for clean toxicants;37,88 endocrine disruptors;89–92 new classes of
fuels and vehicles, incorporating air pollution into the pesticides such as the neonicotinoids;93 chemical herbi­ For the Partnership for clean
health agenda,82 establishing programmes to control the cides such as glyphosate and nano-particles; and pharma­ fuels and vehicles see http://
www.unep.org/transport/pcfv/
addition of lead to paint,83 and creating a pollution- ceutical wastes.94–96 These emerging chemical pollu­tants
focused trust fund within the World Bank. are discussed in detail in the appendix of this For the World Bank pollution
report (pp 2–11). management and
environmental health
Pollution defined The list of diseases attributed to pollution will probably programme see http://www.
This Commission defines pollution as unwanted, often continue to expand as the environmental distributions worldbank.org/en/programs/
dangerous, material that is introduced into the Earth’s and health effects of newer chemical pollutants are better pollution-management-and-
environment as the result of human activity, that defined and new exposure–disease associations are environmental-health-program

threatens human health, and that harms ecosystems; discovered. The health effects of pollution that are
this definition is based on a definition of pollution currently recognised and quantified could thus be the tip
developed by the European Union.84 of a much larger iceberg.88 As more research becomes
To provide a framework for organising scientific available, some pollution–disease pairs that are currently
knowledge about pollution and its effects on human placed in zones 2 and 3 of the pollutome could move up to
health and to help focus pollution-related research, this
Commission has developed the concept of the pollutome
(figure 3). The pollutome is defined as the totality of all
forms of pollution that have the potential to harm human
health. The pollutome can be viewed as a fully contained
(nested) subset of the exposome.85,86 This model includes Numbers of pollution-related deaths
pollutant exposures during gestation, infancy, childhood, included in GBD estimates by zone Zone 1
adol­escence, adult life (including occupational exposures), Well characterised
Zone 1: 9·0 million health effects of
and old age. well studied pollutants.
Because knowledge about the health effects of pollution Data are included in GBD
estimates and in this report.
varies by pollution type and ranges from the well
characterised and quantified to the still emerging, we
have divided the pollutome into three zones. Zone 2
Zone 2: none Emerging, but still unquantified, health effects
Zone 1 includes well established pollution–disease at present of known pollutants. Data are not included in
pairs, for which there are robust estimates of their GBD estimates or in this report.
contributions to the global burden of disease. The
associations between ambient air pollution and non-
communicable disease are the prime example.23 Zone 3
Zone 2 includes the emerging effects of known Zone 3: none Inadequately characterised health effects of emerging
pollutants, where evidence of causation is building, but at present pollutants. Data are not included in GBD estimates or in this report.

associations between exposures and disease are not yet

fully characterised and the burden of disease has not yet
been quantified. Examples include associations between Figure 3: The pollutome

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 The Lancet Commissions

zone 1 and be included in future estimates of the global attributable to pollution using data from the GBD 2015
burden of disease. The numbers of deaths attributable to Study41,42 coordinated by the Institute for Health Metrics
the forms of pollution included in zones 2 and 3 are and Evaluation, and supplemented by data from WHO99,102
unknown. and from Pure Earth.38 Section 2 examines data on the
This Commission’s work has been informed by the economic costs of pollution and presents a detailed
work of previous Lancet Commissions and Series, notably analysis of the economic losses that result from pollution-
the Commission on Investing in Health,72 the related disease. Section 3 examines the links between
Commission on the Political Origins of Health Inequity,73 pollution, disease, and poverty and documents the
the Commission on Health and Climate Change,97 and marked inequities that characterise the global distrib­
the Series on Public Health Benefits of Climate Change ution of pollution and pollution-related disease and the
Mitigation Policies.98 This Commission’s deliberations disproportionate effects of pollution on children, the
were guided particularly closely by the findings of The poor, the elderly, and other vulnerable populations.
Rockefeller Foundation-Lancet Commission on Planetary Section 4 presents pathways and priorities, case studies,
Health15 whose 2015 report described how human activity and proven interventions that can be adopted and
is changing the global environment, increasing risk of deployed to control pollution, prevent disease, and
disease, and threatening the conditions that, ultimately, advance economic development. Section 5 outlines the
sustain all life on Earth. Commission’s plans for future initiatives.
This Commission was guided further by influential Sustainable long-term control of pollution will require
reports from international agencies, among them the that societies at every level of income move away from
2016 report from WHO,99 Preventing Disease through the prevalent resource-intensive, and inherently wasteful,
Health Environments, the World Bank’s Shock Waves linear take-make-use-dispose economic paradigm,
report100 on climate change and global poverty, the World towards a new paradigm rooted in the concept of the
Bank’s report,77 Clean Air and Healthy Lungs, and the circular economy (panel 2).15,103,104 In a circular economy,
United Nations Environment report,101 Costs of Inaction pollution is reduced through the creation of durable,
on the Sound Management of Chemicals. long-lasting products, the reduction of waste by large-
This report is organised into five Sections. Section 1 scale recycling, reuse, and repair, the removal of
synthesises information on the burden of disease distorting subsidies, the replacement of hazard­ ous
materials with safer alternatives, and strict enforce­ment
of pollution taxes.105 A circular economy conserves and
Panel 2: Circular economy increases resources, rather than taking and depleting
them. This societal transition is essential for promoting
A circular economy is an economic model that decouples smart, sustainable, and inclusive growth that reduces
development from the consumption of non-renewable pollution, promotes health, and prevents disease.104
resources and minimises the generation of pollution and
other forms of waste by recycling and reuse.104 In a fully Limitations of the Commission
circular economy, the only new inputs are renewable The Commission’s economic analysis does not include
materials, and all non-renewable materials are recycled. information about the costs of environmental damage
The underlying assumption is that waste is an inherent caused by pollution. The Commission recognises that
inefficiency, a loss of materials from the system, and thus a the ecological damages due to pollution are substantial,
cost.104 Transition towards a circular economy will reduce but considered analyses of the costs of these damages to
pollution-related disease and improve health. fall outside of the scope of our work.
The three core principles of the circular economy are Levels of pollution are changing and pollution caused
preservation of natural capital by reducing use of by industrial, vehicular, and chemical emissions is
non-renewable resources and ecosystem management; increasing in many rapidly developing countries, but the
optimisation of resource yields by circulating products and Commission’s analysis is based on data from the 2015
materials so that they are shared and their lifecycles Global Burden of Disease study, information that is now
extended; and fostering system effectiveness by designing 2 years old.
out pollution, greenhouse gas emissions, and toxic materials
that damage health. Section 1: The burden of disease attributable to
The steps needed for transition towards a circular economy pollution
include large-scale transition to non-polluting sources of In this Section, we review data for the global burden of
energy (wind, solar, and tidal), the production of durable disease and death attributable to pollution.23,38,42,99,106
products that require lower quantities of materials and less
energy to manufacture than those being produced at present; Methods
incentivisation of recycling, re-use, and repair; and This review of the burden of disease and premature
replacement of hazardous materials with safer alternatives.15 death due to pollution is based on a method for assessing
disease burden that was developed in the 1980s by

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 The Lancet Commissions

WHO.107,108 The core of this approach is the disability- In reviewing disease burden in relation to national
adjusted life-year (DALY) concept, a summary metric of income, we have relied on the 2015 World Bank income
population health that combines information on classifications (high, upper middle, lower middle, and
mortality and disease into a single number to represent low). In reviewing disease burden in relation to geo­
the health of a population, thus permitting comparisons graphical region, we have grouped countries using the
of disease burden between countries, between diseases, regional groupings defined by WHO (Africa, eastern
and over time. The DALY method is at the core of the Mediterranean, Europe, Americas, southeast Asia, and
GBD project, a multinational study initiated by WHO in western Pacific).
partnership with the World Bank and the Harvard To examine temporal trends in the global burden of
School of Public Health,108 and sustained today by disease that are attributable to different forms of pollution,
WHO102 and the Institute for Health Metrics and we have divided pollution into two broad cate­
Evaluation.41,42 gories: pollution linked to poverty and pollution linked to
To examine the global burden of disease attributable to industrial development. Pollution linked to poverty
pollution risk factors, this Commission has relied includes household air pollution, unsafe water sources,
principally on the 2015 estimates from the GBD and inadequate sanitation, the forms of pollution
study,41,42,106 coordinated by the Institute for Health Metrics associated with profound poverty and trad­itional lifestyles
and Evaluation. We also examine data from the 2012 WHO in low-income and middle-income countries. Pollution
analysis99,102,109,110 of the global burden of disease caused by linked to industrial development includes pollution
living and working in unhealthy environments. produced by industrial emissions, vehicular exhausts, and
Following the standard conservative practice of the chemical releases, and includes ambient fine part­
GBD study42,106 and WHO,99 this Commission has iculate (PM2·5) pollution, tropospheric ozone pollution,
restricted its review to combinations of pollution risk toxic occupational exposures, and soil pollution caused by
factors and disease for which there is convincing or heavy metals and toxic chemicals, including lead.
probable evidence of causal association. For this reason,
numbers presented are likely to be underestimates of the Main findings
full burden of disease attributable to the pollutome The GBD study42 estimates that pollution-related disease
(figure 3). was responsible for 9 million premature deaths in
In reviewing data on the burden of disease attributable 2015—16% of total global mortality (table 1).42,99,102 The
to soil pollution caused by toxic chemicals and heavy GBD study also estimates that disease caused by all
metals at contaminated sites, this Commission has relied forms of pollution was responsible for 268 million
on information provided by the Blacksmith Institute/ DALYs—254 million years of life lost and 14 million years
Pure Earth Toxic Sites Identification programme.38 This lived with disability.106 This information is available by
programme obtains data on pollution caused by chemi­ country and region and is presented in the appendix.
cals and metals at contaminated sites through field WHO estimates that, in 2012, unhealthy environments
studies that use a protocol adapted from a US were responsible for 12·6 million deaths worldwide—23%
Environmental Protection Agency assessment tool.111 of total global mortality—and for 26% of deaths in
Two particularly common types of contaminated sites are children younger than 5 years.99,102,109,110
used lead-acid battery recycling sites, where lead is the The most important finding to be drawn from these
principal pollutant, and artisanal and small-scale gold two analyses is that both the GBD study and WHO find
mining sites, where the principal pollutant is elemental that pollution is a major cause of disease, disability, and
mercury (which is used to extract gold from ore). We premature death. The GBD study reports that pollution
used the methods of Ericson and colleagues111 to assess was responsible for an estimated 9·0 million deaths
the burden of disease associated with lead-acid battery in 2015, whereas the WHO analysis concludes that living
recycling sites, and the methods and data of Steckling in unhealthy environments was responsible for
and colleagues112,113 to assess the burden of disease 12·6 million deaths in 2012.
associated with gold mining sites114–116 These methods are The difference between these two estimates of total
described in detail in the appendix (pp 16–19). mortality attributable to environmental factors mainly
The pollution risk factors examined by the Commission reflects differing definitions of environment. This
were: (1) air pollution: household air pollution, ambient Commission focuses strictly on pollution-related
fine particulate pollution (PM2·5), and tropospheric ozone disease, as defined above. By contrast, the WHO def­
pollution; (2) water pollution: unsafe sanitation, and inition of environment is broader and encompasses
unsafe water sources; (3) soil, chemical, and heavy metal several risk factors that were not included in this
pollution: lead (including contaminated sites polluted by Commission’s analysis, including road accidents,
lead from battery recycling operations), and mercury ultraviolet and ionising radi­ation, noise, electromagnetic
from gold mining; and (4) occupational pollution: fields, occupational psycho­ social risks, built environ­
occupational carcinogens, and occupational particulates, ments, agricultural methods, and man-made climate
gases, and fumes. and ecosystem change. Risk factors that were included

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 The Lancet Commissions

differing definitions of access to safe water. The GBD

GBD study best WHO best
estimate (95% CI) estimate (95% CI) study considers access to safe water at both the water’s
source and at the point of use, whereas WHO only
Air (total) 6·5 (5·7–7·3) 6·5 (5·4–7·4)
considers access to an improved water source.
Household air 2·9 (2·2–3·6) 4·3 (3·7–4·8)
Diseases caused by all forms of pollution were responsible
Ambient particulate 4·2 (3·7–4·8) 3·0 (3·7–4·8)
for an estimated 9 million deaths in 2015.41 Pollution is thus
Ambient ozone 0·3 (0·1–0·4) ··
responsible for more deaths than a high-sodium diet
Water (total) 1·8 (1·4–2·2) 0·8 (0·7–1·0)
(4·1 million), obesity (4·0 million), alcohol (2·3 million),
Unsafe sanitation 0·8 (0·7–0·9) 0·3 (0·1–0·4)
road accidents (1·4 million), or child and maternal
Unsafe source 1·3 (1·0–1·4) 0·5 (0·2–0·7)
malnutrition (1·4 million). Pollution was also responsible
Occupational 0·8 (0·8–0·9) 0·4 (0·3–0·4) for three times as many deaths as AIDS, tuberculosis, and
Carcinogens 0·5 (0·5–0·5) 0·1 (0·1–0·1) malaria combined (figure 5)41 and for nearly 15 times as
Particulates 0·4 (0·3–0·4) 0·2 (0·2–0·3) many deaths as war and all forms of violence.41 Only dietary
Soil, heavy metals, and 0·5 (0·2–0·8) 0·7 (0·2–0·8) risk factors (all combined) (12·1 million) and hyper­
chemicals
tension (10·7 million) caused more deaths than pollution;
Lead 0·5 (0·2–0·8) 0·7 (0·2–0·8)
however, the Commission notes that approximately
Total 9·0 8·4
2·5% of deaths due to hypertension are attributable to lead.
Note that the totals for air pollution, water pollution, and all pollution are less
than the arithmetic sum of the individual risk factors within each of these Pollution and non-communicable diseases
categories because these have overlapping contributions—eg, household air
pollution also contributes to ambient air pollution and vice versa.
Non-communicable diseases account for most of the total
burden of disease due to pollution—approximately 71%.41
Table 1: Global estimated deaths (millions) due to pollution risk factors In 2015, all forms of pollution combined were responsible
from the Global Burden of Disease study (GBD; 2015)42 versus WHO data for 21% of all deaths from cardiovascular disease, 26% of
(2012)99,101
deaths due to ischaemic heart disease, 23% of deaths due
to stroke, 51% of deaths due to chronic obstructive
in the WHO analysis and not in this Commission pulmonary disease, and 43% of deaths due to lung cancer
account for more than 3 million deaths each year, thus (figure 6).42
explaining most of the apparent discrepancy between The relative risks of all non-communicable diseases
the two estimates (panel 3).117–120 associated with pollution increase as exposure to
Some specific differences are seen between the two pollution increases. An integrated exposure–response
sets of estimates (figure 4).42,99 For example, the GBD function has been developed to describe these
study estimates that 4·2 million deaths in 2015 were associations, and the health effects of air pollution are
because of ambient air pollution, whereas WHO quantitatively consistent with those of tobacco smoke
attributes 3·7 million deaths in 2012 to this risk factor. when their relative risks are plotted against a common
The two analyses relied on similar approaches to metric of exposure to airborne fine particulates.121
comparative risk assessment, on the same sources of The sources and nature of pollution change as
exposure data, and on the same integrated exposure– countries develop and industrialise (figure 7).10,42 An
response functions40 but, in 2014, the GBD study made unsafe water source, unsafe sanitation, and household
changes to their computational methodology,42 which air pollution are considered to be forms of pollution
appears to account for most of the divergence. linked to poverty and the early stages of industrial
The GBD study estimated that 2·9 million deaths development. Airborne fine particulate pollution,
in 2015 were associated with household air pollution, tropospheric ozone pollution, occupational chemical
whereas WHO estimated 4·3 million related deaths pollution, and soil pollution by heavy metals and
in 2012. This difference can partly be explained by chemicals (including lead) are considered to be forms of
different approaches in quantifying exposure–outcome pollution linked to industrial development.
associations. The GBD study relied on the integrated Changes to the distribution of pollution-related
exposure–response curve40 to provide evidence for the diseases occur in response to the changes that accompany
effect size of non-communicable diseases, whereas WHO development.11 Thus deaths from pneumonia and
adapted relative risks for certain non-communicable diarrhoeal diseases—the diseases associated with
diseases based on epidemiological evidence. Additionally, household air pollution, water pollution, and poor
the GBD study has expanded data sources for personal sanitation—are slowly declining worldwide, although
exposure values for women, men, and children in the they still kill millions of people, particularly children in
past 2 years. poor countries. These declines reflect reductions in the
The GBD study estimated that, in 2015, 1·8 million forms of pollution associated with traditional lifestyles in
deaths resulted from diseases related to water pollution, low-income and middle-income countries, and the
whereas WHO estimated 0·84 million related deaths advent of new vaccines such as the pneumococcal vaccine
in 2012. This divergence appears largely to reflect and the rotavirus vaccine;59 new approaches to paediatric

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 The Lancet Commissions

Panel 3: WHO’s programme on pollution and health

WHO has, for several decades, been a leader in conducting • WHO has developed several tools and training programmes
crucial evaluations of the health effects of pollution, and these to build the capacity and understanding of countries and
assessments provide the scientific basis for pollution control actors working in different sectors to effectively address
policies in many countries. WHO is also a global leader in household energy as a health risk. WHO is currently
providing guidelines and in coordinating health-focused developing a Clean Household Energy Solution Toolkit
partnerships for pollution control. (CHEST) to provide the guidance and tools necessary for
WHO is now further expanding this work through the countries to implement the WHO Guidelines for Indoor Air
framework of the Sustainable Development Goals (SDGs). Quality: Household Fuel Combustion.119
WHO is the custodian agency that monitors progress towards • Monitoring access to clean energy in the home is led by
six SDG targets; this monitoring includes tracking several WHO in close cooperation with partners performing
targets measuring the environmental health-related burden of household surveys (UNICEF, USAID, and the World Bank).
disease within SDG 3. The following are examples of this work: The associated indicator, 7·1·2—the “proportion of
population with primary reliance on clean fuels and
Ambient air pollution technology”—is part of the Global Tracking Framework of
• WHO has periodically reviewed the international literature Sustainable Energy for All and is used to show progress
on air pollution and developed Global Air Quality towards SDG 7, which follows WHO guidelines criteria.
Guidelines.117 These are the primary reference points for air
pollution standards worldwide. The latest version was Climate, pollution, and health
published in 2006,117 and a committee has been formed to • WHO, the Climate and Clean Air Coalition, and UN
create an updated version in 2018. Environment Programme have joined forces in the
• WHO hosts one of the largest databases of ambient air BreatheLife campaign to address the associated crises of air
pollution measurements in cities. Currently, the publicly pollution and climate change. The campaign was announced
available WHO Global Urban Ambient Air Pollution in July, 2016, and launched at Habitat III in Quito, Ecuador. For the WHO Global Urban
Ambient Air Pollution
Database contains air quality measurements from Urban health Database see www.who.int/phe/
3000 cities, representing 103 countries. In the past 2 years • WHO has established the Urban Health Initiative to reduce health_topics/outdoorair/
alone, the database has nearly doubled in size, with more deaths and diseases associated with air and climate databases/cities
cities now measuring air pollution concentrations and pollutants in cities, while enhancing health benefits from the
recognising the associated health effects than ever before. policies and measures used to tackle climate pollution.
This database also provides inputs to the integrated models
that use satellite remote-sensing and chemical transport Water and sanitation
models to estimate ambient air pollution exposure globally, • WHO has produced authoritative guidelines and technical
including estimates for regions without any ground-level assistance on management of water quality, sanitation, and
monitoring (eg, smaller cities and rural areas). The Global wastewater, and health for decades. Along with UNICEF,
Urban Ambient Air Pollution Database also supports WHO is responsible for tracking the extent of human
monitoring of urban air quality for SDG 11 indicator 11·6: exposure to poor water, inadequate sanitation, and poor
“to reduce the adverse per capita environmental impact of hygiene.
cities, including by paying special attention to air quality Toxic chemicals
and municipal and other waste management”.118 • WHO is the leading international agency for chemical safety
Household air pollution through its Intergovernmental Panel on Chemical Safety,
• WHO has developed guidelines119 for indoor air quality which sets guidelines for dozens of commonly used
regarding household fuel combustion, which clarified the chemicals. The importance of chemicals management is
enormous health risks of burning kerosene, coal, and wood reflected by SDG target 3·9 on reducing deaths and illness
in the home, and has provided emission standards for from hazardous chemicals, and links to target 12·4 on the
home energy equipment used in cooking, heating, and sound management of chemicals and wastes. Achievement
lighting. This work filled a gap in health guidance for of sound chemicals management requires a multisector,
household energy interventions and is increasingly multistakeholder approach. To advance this work, the 2017
being adopted by development partners investing in World Health Assembly approved a Chemicals Road Map to For the WHO Chemicals Road
enhance the engagement of the health sector in the Map see www.who.int/ipcs/
improving access to energy in the homes of the poor saicm/roadmap
worldwide. management of international chemicals.

(Continues on next page)

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 The Lancet Commissions

(Panel 3 continued from previous page)

Mercury Cancer
• WHO is supporting implementation of the Minamata • WHO’s International Agency for Research on Cancer
Convention on Mercury and has developed guidance for (IARC) has the responsibility of determining whether
phasing out mercury-containing instruments in the health chemicals are human carcinogens and conducts a range of
sector.120 Urgent attention by health departments and ministries research on cancer worldwide. IARC provides evidence-
For the Health Effects Institute
is needed to address the phase out of import, export, and based guidance on cancer control to countries around
special report on the state of manufacture of mercury thermometers, sphygmomanometers, the world.
global air see https://www. and other mercury-containing instruments in health care.
stateofglobalair.org

9 IHME (2005)
therapy such as oral rehydration therapy;60 and improved
IHME (2010) nutrition of young children and pregnant women.61
8 IHME (2015) By contrast, the numbers of deaths caused by ambient
WHO
air, chemical, and soil pollution—the forms of pollution
7
associated with modern industrial and urban
Global estimated deaths (millions)

development—are increasing. The number of deaths

6
attributable to PM2·5 air pollution is estimated to have
5 risen from 3·5 million (95% CI 3·0 million–4·0 million)
in 1990 to 4·2 million (3·7 million–4·8 million) in 2015, a
4 20% increase. Among the world’s 10 most populous
countries in 2015, the largest increases in numbers of
3
pollution-related deaths were seen in India and
2 Bangladesh, as reported by the Health Effects Institute.
The increase in the absolute number of deaths and
1 DALYs attributable to pollution reflects an increased
population size, an ageing population, and increased
0 levels of air pollution in low-income and middle-income
Air pollution Water Occupational Soil, chemicals, and metals
countries.23
Figure 4: Global estimated deaths (millions) by pollution risk factor, 2005–15 An analysis of future trends in mortality associated with
Using data from the GBD study42 and WHO.99 IHME=Institute for Health Metrics and Evaluation. ambient PM2·5 air pollution finds that, under a “business
as usual scenario”, in which it is assumed that no new
pollution controls will be put into place, the numbers of
deaths due to pollution will rise over the next three
14
decades, with sharpest increases in the cities of south and
east Asia.35,121 These trends are projected to produce a more
12 than 50% increase in mortality related to ambient air
pollution, from 4·2 million deaths in 2015 to 6·6 million
Global estimated deaths (milions)

10 deaths in 2050 (95% CI 3·4 million–9·3 million).35,122

These projections are corroborated by an analysis107 of the
8
health effects of coal combustion in China. Population
6
ageing are major contributors to these projections of
growth and absolute increased numbers of deaths from
4 pollution-related disease.
A second analysis123 examining the potential benefits of
2 reducing PM2·5 pollution projects that aggressive controls
could avoid 23% of current deaths related to air pollution.
0
However, because of population ageing and consequent
n

is

at tion
l)

ts

;2 r
5)

)
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15
us

us
in
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os

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01

increases in age-related mortality from cardiovascular

ok

20
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er
l

ug

len u
lu

cid
cu

ho

d m tr

io m
m

a(
ol

an lnu

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r

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ac
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s
lp

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disease, chronic obstructive pulmonary disease, and lung

co

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ild Ma

ad
tu

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ta

na r a
ac
To

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nd

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cancer, and also because the exposure–response

To

,a

(ch
ria
ala

er

association between PM2·5 pollution and non-

,m

rp
te
DS

(in

communicable diseases is relatively strong at lower levels

AI

Risk factors and causes of exposure but weaker at higher levels, Apte and
Figure 5: Global estimated deaths by major risk factor and cause, 2015 colleagues124 note that it will be easier to achieve reductions
Using data from the GBD Study, 2016.41 in mortality in less heavily polluted areas of western

12 www.thelancet.com Published online October 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32345-0

 The Lancet Commissions

Europe and North America than in heavily polluted Air pollution disperses globally. Airborne pollutants
regions in Asia. travel across national boundaries, continents, and
oceans.126–128 An analysis129 of emissions from Chinese
Geography of pollution export manufacturers found that, on days with strong
In 2015, the greatest numbers of deaths due to pollution westerly winds (winds blowing from China across the
occurred in southeast Asia (3·2 million deaths) and the Pacific), 12–24% of sulphate concentrations, 2–5% of
western Pacific (2·2 million deaths; figure 8).42 In this ozone, 4–6% of carbon monoxide, and up to 11% of black
definition, southeast Asia includes India and the western carbon pollution detected in the western USA were of
Pacific region includes China. The highest population- Chinese origin.
based estimates of premature death and disease due to
pollution are seen in the low-income countries of sub-
Saharan Africa.42 60

Pollution and poverty to deaths caused by non-communicable disease (%)

Estimated contributions of all pollution risk factors
50
92% of all pollution-related mortality is seen in low-
income and middle-income countries, with the greatest
numbers of deaths from pollution-related disease 40
occurring in rapidly developing and industrialising
lower-middle-income countries (figure 9).42 In the most
severely affected countries, pollution is responsible for 30

more than one in four deaths.42 In countries at every level

of income, the health effects of pollution are most 20
frequent and severe among the poor and the
marginalised. Further discussion of the links between
pollution, disease, and poverty is presented in section 3 10

of this report.
Disease and death due to pollution occur most 0
frequently in the very young and the very old. Deaths due
ise e
e

er

str d
e

e
y d iv
as

as

ok

as
ic n
nc

ag ic a
ar ruct

ise

to all forms of pollution show a peak among children se

ca

di
rh m
td
om st

ng

lar
or ae
ar
lm ob

Lu

younger than 5 years of age, but most pollution-related

cu
em Isch
he
pu nic

as
ic

ov
ro

em

deaths occur among adults older than 60 years of age

Ch

di
ha
ha

ar
Isc

lc

(figure 10).42 By contrast, DALYs resulting from pollution-

Al

related disease are highly concentrated among infants Figure 6: Estimated contributions of all pollution risk factors to deaths
and young children, reflecting the many years of life lost caused by non-communicable diseases, 2015
with each death and case of disabling disease of a child GBD Study, 2016.42
(figure 11).42
7 All traditional
Air pollution All modern
Estimated global deaths attributed to pollution (millions)

Two types of air pollution—household air pollution and 6

ambient air pollution—and two airborne pollutants—fine
particulates and ozone—are considered in this Comm­
5
ission.23 Pollution caused by oxides of nitrogen and by
some short-lived climate pollutants is not fully accounted
4
for in this Commission because the burden of disease due
to these forms of air pollution is not separately quantified
3
in the GBD study.
Although household and ambient air pollution are
considered separately in deriving estimates of disease 2

burden,42,99 they are both comprised of many of the same

pollutants and often co-exist; for example, in low- 1
income and middle-income countries, household
cooking contributes to ambient particulate air 0
pollution.55,56 Accordingly, the total numbers of deaths 1990 1995 2000 2005 2010 2015

attributed to air pollution in the GBD study and in the Year

WHO estimates are less than the arithmetic sum of the Figure 7: Estimated global deaths (millions) by pollution category, 1990–2015
number of deaths attributed to each form of GBD Study, 2016.42 All modern=modern forms of pollution, comprising ambient air, chemical, occupational, and
pollution alone.35,99,125 soil pollution. All traditional=traditional forms of pollution, comprising household air and water pollution.

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 The Lancet Commissions

Deaths per 100 000 people

attributable to pollution
No data
<50
51–75
76–100
101–150 0 1000 2000 4000 6000 8000 10 000 km
151–316

Figure 8: Number of deaths per 100 000 people that are attributable to all forms of pollution, 2015
GBD Study, 2016.42

Air pollution and disease children,30,31,151,152 and neurodegenerative disease, including

PM2·5 is the best studied form of air pollution and is linked dementia, in adults.28,29,33 PM2·5 pollution may also be
to a wide range of diseases in several organ systems.23,130 linked to increased occurrence of premature birth and
The strongest causal associations are seen between PM2·5 low birthweight.27,153–159 Some studies have reported an
pollution and cardiovascular and pulmonary disease. association between ambient air pollution and increased
Specific causal associations have been established between risk of sudden infant death syndrome.160 These associ­
PM2·5 pollution and myocardial infarction,131–137 hyper­ ations are not yet firmly established, and the burden of
tension,138 congestive heart failure, arrhythmias,139 and disease associated with them has not yet been quantified,
cardiovascular mortality.24,140–143 Causal associations have and they are therefore included in zone 2 of the
also been established between PM2·5 pollution and chronic pollutome (figure 3).
obstructive pulmonary disease and lung cancer.42 The
International Agency for Research on Cancer has reported Water pollution
that airborne particulate matter and ambient air pollution This Commission considers two types of water pollution:
are proven group 1 human carcinogens.34,40,144 unsafe water source and inadequate sanitation.51 Many
Fine particulate air pollution is associated with several areas in low-income and middle-income countries lack
risk factors for cardiovascular disease, including:
hypertension,138 increased serum lipid concentrations,145 6 Soil, chemicals, and metals
accelerated progression of atherosclerosis,146–148 increased Occupation
Water
prevalence of cardiac arrhythmias,139 increased numbers of 5
Air
Estimated global deaths (millions)

visits to emergency departments for cardiac conditions,132,133

increased risk of acute myocardial infarction,131 and 4
increased mortality from cardiovascular disease142
and stroke.149 3
Clinical and experimental studies suggest that fine
airborne particles increase risk of cardiovascular dis­ 2
ease by inducing atherosclerosis, increasing oxidative
stress, increasing insulin resistance, promoting endo­ 1
thelial dysfunction, and enhancing propensity to coag­
ulation.145,147,148,150 0
Low country Lower middle Upper middle High country
Emerging evidence suggests that additional causal income level country income country income income level
associations may exist between PM2·5 pollution and level level
several highly prevalent non-communicable diseases. Figure 9: Estimated deaths by pollution risk factor and country income level,
These include diabetes,25 decreased cognitive function, 2015
attention-deficit or hyperactivity disorder and autism in GBD Study, 2016.42

14 www.thelancet.com Published online October 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32345-0

 The Lancet Commissions

acceptable water supplies and many people, particularly were responsible for 0·5 million deaths.99 As in the case
in rural areas in poor countries, have inadequate of air pollution, the total number of deaths attributed to
sanitation.52 Prevention technologies and systems exist, all forms of water pollution combined is less than the
but poverty, lack of knowledge, and other priorities arithmetic sum of the deaths due to the individual types
constrain the adoption of improvements.161 of water pollution because the various types of water
The problems of water supply and health are intensified pollution often co-exist and overlap with each other.
where industrial pollutants contaminate water systems
because treatments that control infectious agents are not Trends in disease from water pollution
effective in removing many toxic chemicals from Targeted interventions to provide modern water and
drinking water. Improved analytical techniques have sanitation infrastructure began in the developing world
allowed identification of hundreds of industrial as early as the 1950s, in the early days of international
chemicals, pharmaceuticals, and pesticides in water development assistance programmes. The Millennium
systems. Some of the worst biological and chemical
pollution of drinking water is seen in rapidly urbanising
2·5 All pollution
and industrialising lower-middle-income countries, Air
where local waterways and groundwater are heavily Water
polluted and serious health conditions are widely Soil
2·0 Occupational
reported, but no alternative water sources exist.53
The principal diseases linked to water pollution are
Estimated global deaths (millions)

acute and chronic gastrointestinal diseases, most

importantly diarrhoeal diseases (70% of deaths attributed 1·5
to water pollution), typhoid fever (8%), paratyphoid
fever (20%), and lower respiratory tract infections (2%).42
These estimates include diseases associated with an 1·0
unsafe water source, inadequate sanitation, and in­
adequate hand-washing. Polluted water and inadequate
sanitation are linked, additionally, to a range of parasitic 5·0
infections. These diseases affect more than 1 billion
people, predominantly in low-income and middle-
income countries.41
0
Water pollution also has effects on planetary health that
al

al

al

9
4

9
4

9
4
9
0
≥8
1–

–1

–2

–3

–4

–5

–6

–7
5–

-1

–2

–3

–4

–5

–6

–7
at

at

at

extend beyond its effects on human health.15 Pollution of

15
10

70
75
20

30

50
25

35

55
on

on

on

40

45

60

65
ne

ne

ne

rivers, lakes, and the oceans from agriculture, manu­

rly

te

st
Po
La
Ea

Age at death (years)

facturing, and the extractive industries can have cat­
astrophic effects on freshwater and marine ecosystems
Figure 10: Estimated global deaths by pollution risk factor and age at death, 2015
that result in the collapse of fisheries and the diminished GBD Study, 2016.42
livelihood of indigenous populations and others who rely
upon fish as a major food source.162,163
45 All pollution
Most of the deaths caused by unsafe sanitation and Air
unsafe water sources occur in children younger than 40 Water
5 years of age. Increased numbers of deaths from Soil
35 Occupational
waterborne pollution-related disease are also seen in
adults older than 60 years of age.
Estimated global DALYs

30

25
Burden of disease due to water pollution
The GBD study estimates that, in 2015, 1·8 million
42 20
deaths were attributable to water pollution, including 15
unsafe water sources, unsafe sanitation, and inadequate
handwashing. Of this total, 0·8 million deaths were 10

estimated to be caused by unsafe sanitation and 5

1·3 million to unsafe water sources. The total burden of
disease attributable to water pollution is less than the 0
n tal

ne tal
al

9
4

9
4

9
4
9
0

sum of the diseases attributable to each of its components

≥8
1–

–1

–2

–3

–4

–5

–6

–7
5–

-1

–2

–3

–4

–5

–6

–7
at
a

15
10

70
75
20

30

50
25

35

55
La eon

Po eon

on

40

45

60

65

because of overlaps between unsafe water source, unsafe

n
rly

te

st
Ea

sanitation, and inadequate handwashing. WHO data Age at death (years)

indicate that 0·28 million deaths were attributable to Figure 11: Estimated global DALYs by pollution risk factor and age at death, 2015
unsafe sanitation in 2012 and that unsafe water sources GBD Study, 2016.42 DALYs=disability-adjusted life-years.

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 The Lancet Commissions

Development Goals (MDGs) accelerated this work, and countries. Disease due to chemical contamination of
MDG Target 7C called on the global community “by 2015, drinking water is included in zone 2 of the pollutome
to halve the proportion of the population without (figure 3).
sustainable access to safe drinking water and basic
sanitation”. To track interventions against water pollution Soil, heavy metal, and chemical pollution
and waterborne disease, WHO and UNICEF established Comprehensive assessments of the health effects of
the Joint Monitoring Programme for Water Supply and most forms of soil, heavy metal, and chemical pollution
Sanitation.54 have not yet been published. Lead is an exception, and
Substantial progress has been made in reducing water has been studied extensively. Newer research on a
pollution and waterborne disease. Between 1990 few contaminated sites is beginning to report data
and 2015, 2·6 billion people gained access to improved for disease burden at these sites; at present, these
drinking water sources, 2·1 billion people gained access estimates are limited to DALYs and do not include
to improved sanitation, and the MDG Target 7C was met deaths.
5 years ahead of schedule. In this time, the number of
children dying from diarrhoeal diseases decreased by Lead
For WHO data on numbers of almost 60%, from approximately 1·5 million deaths in People have used lead for centuries but, until the modern
water pollution-related 1990 to slightly greater than 0·6 million deaths in 2012. era, it was largely an occupational poison.164 In the
mortalities see http://www.
who.int/healthinfo/mortality_
However, despite this progress, 2·4 billion people are still 19th and 20th centuries, lead moved beyond the
data/en/ using unimproved sanitation facilities, including workplace into air, water, and soil in countries around the
946 million people who still practise open defecation. world as a consequence of sharp increases in lead
production that accompanied the Industrial Revolution.
Geography of water pollution and disease In the early 20th century, lead was incorporated, for the
Population-based estimates of the number of deaths first time, into mass-market consumer products such as
from water pollution are highest in sub-Saharan Africa lead-based paint and gasoline. Global contamination of
(figure 12).42 Large numbers of deaths are seen also in air, water, and soil resulted. Global production of lead has
some southeast Asian countries. In the past two decades, more than doubled since the 1970s and continues to rise.
China has greatly reduced mortality from waterborne Increasing global manufacture of batteries for products
infectious disease.42 ranging from mobile phones to cars, is the main driver of
Importantly, these data do not reflect deaths from this increase.165 82% of deaths due to lead occur in low-
chemical pollution of water, because data for levels of income and middle-income countries.
chemical contamination of drinking water are not In adults, chronic exposure to lead is an established
available for most low-income and middle-income risk factor for hypertension, renal failure, cardiovascular

Number of deaths
per 100000 people
attributable to water
pollution
1–4
5–20
21–50
1000 2000 4000 6000 km
51–100
101–204

Figure 12: Number of deaths per 100 000 people due to water pollution, 2015
GBD Study, 2016.42

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 The Lancet Commissions

disease, and stroke, especially among workers exposed in

their occupations. Large-scale epidem­iological studies26 Panel 4: Pollution and neurodevelopment
based on a national probability sample have confirmed Foetuses, infants, and children are particularly sensitive to neurotoxic pollutants, even at
that the causal association between lead, hypertension, very low levels of exposure, because of the vulnerability of early-stage development of the
and mortality from cardio­vascular disease is evident even human brain.91,174–176 Toxic exposure during so-called windows of vulnerability in early life
at very low blood lead concentrations. can cause lasting damage to brain function. Lead poisoning in childhood has, for
Neurodevelopmental toxicity is the most important example, been linked to reduced cognitive function and also to juvenile delinquency,
consequence of lead toxicity in children.166 The neuro­ violent crime in adulthood, and lifelong reduction in economic productivity.37 Neurotoxic
behavioural sequelae of paediatric lead exposure include pollutants are also linked to autism,152 attention deficit and hyperactivity disorder,89,177 and
cognitive impairment,167–170 shortening of attention span conduct disorders.173
with increased risk for attention deficit or hyperactivity
Exposure to neurotoxic pollutants is widespread as a result of fossil fuel combustion,
disorder,171 and increased risk for antisocial and criminal
industrial and agricultural production, and the extensive use of toxic chemicals in
behaviours.172,173 These effects can persist across the entire
consumer products.30 Routine biomonitoring studies have detected many dozens of toxic
lifespan and result in decreased school performance,
pollutants in the bodies of children and pregnant women.175
increased risk of drug abuse and in­ carceration, and
decreased economic productivity. Lead causes neuro­ Pollutants known to be toxic to the developing brain (in addition to lead) include
behavioural damage in children at even the very lowest mercury, combustion by-products such as polycyclic aromatic hydrocarbons and fine
blood concentrations. WHO states that “there is no particulate matter, organophosphate pesticides, brominated flame retardants,
known level of lead exposure that is considered phthalates, and polychlorinated biphenyls.88 Many more commonly used chemicals,
safe” (panel 4).30,32,37,88,91,173–177 whose developmental neurotoxicity has not yet been discovered could be causing
undetected damage to children today.
Trends in lead exposure The social and economic costs of early life exposure to neurodevelopmental toxicants are
Despite continuing increases in global lead production, great. Large economic and social gains can be realised through prevention of these
bans on the use of lead in petrol, paint, plumbing, and disorders.32
solder have produced substantial reductions in lead
exposure and disease burden. Lead has now been
removed from gasoline in more than 175 countries. for 12·4% of the global burden of idiopathic intellectual
Despite these advances, several sources of occupational disability (panel 4). The GBD analysis indicates that
and community exposure to lead persist.38,178,179 Lead- deaths in 2015 that were attributable to lead are as
glazed pottery is a notable source of exposure in several follows: cardiovascular disease (465  000 deaths),
countries.169,180 Infants in the womb can be exposed to ischaemic heart disease (240  000), cerebrovascular
lead via transplacental transfer, and nursing infants can disease (155 000), ischaemic stroke (68 000), haemorrhagic
be exposed to lead in breastmilk.181 Children are at risk of stroke (87 000), hypertensive heart disease (47 000), and
exposure to lead-based paint in older housing182,183 and to chronic kidney disease (28 000).42
lead that leaches into drinking water from lead pipes and WHO estimates that, in 2012, lead was responsible for
solder.184 Informal (so-called “backyard”) recycling of 13·9 million DALYs109 and that childhood lead exposure
used lead-acid batteries is a widespread source of lead is responsible for mild to moderate mental retardation
exposure for both workers and communities.185 of 0·6 million children annually.190
Estimates from the GBD study42 indicate that lead was
responsible for 0·5 million premature deaths and for Pollution at contaminated sites
9·3 million DALYs in 2015. This estimate is based Polluted soil at contaminated sites threatens the
entirely on adult deaths (15 years and older). Half of environment and human health in communities world­
these deaths occurred in people aged 70 years and older. wide. Most contaminated sites are relatively small, but
These estimates do not reflect exposures to lead at the aggregate number of people affected globally by the
contaminated sites.186 Although lead has caused child many hundreds of thousands of extant sites is large.191
mortality in episodes of acute poisoning at heavily Polluted sites are most commonly contaminated by
contaminated sites in low-income and middle-income informal, small-scale, unregulated local industry or
countries,187 it is not a major contributor to child artisanal activity.191–193 Sites can be contaminated by
mortality globally. current industrial and mining activity, or they can be
Cardiovascular diseases, including hypertension, abandoned, legacy sites that were contaminated by
coronary artery disease, stroke, cardiac arrhythmias, and previous operations.194
peripheral arterial disease, account for the overwhelming The contaminants at polluted sites that pose the greatest
majority of deaths attributable to lead in adults.26,188 These threats to health are environmentally persistent substances
associations are evident at blood lead concentrations as such as metals, persistent organic pollutants (including
low as 5 μg/dL.188,189 The GBD study42 estimates that lead persistent pesticides), and radionuclides. The metals most
exposure accounts for 2·5% of the global burden of commonly encountered at polluted sites include mercury,
ischaemic heart disease. Lead is also estimated to account lead, chromium, and cadmium.

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 The Lancet Commissions

remediation, has been funded by the US Federal

Panel 5: Superfund legislation Government since 1980199,200 and additionally by state
Legislation to control contaminated waste sites was enacted in the USA in the aftermath governments. In Europe, similar programmes have been
of a series of environmental and public health disasters.199 The major trigger occurred at created and, since 2004, they have been subsumed under
the Love Canal (Niagara County, NY, USA), an unused channel between Lake Erie and Lake the Environmental Liability Directive of the European
Ontario into which the Hooker Chemical Company had dumped toxic wastes from Commission, which establishes a framework to prevent
the 1940s until the 1960s. When it was full, the canal was covered with a clay seal, and damage and remediate hazardous sites based on the
homes and a school were built on top of this clay. However, the waste did not stay polluter-pays principle.201
underground. The canal filled with water and, by 1976, heavy rain regularly caused toxic
sludge to bubble up into the basements of the overlying homes and into nearby streams. Burden of disease due to soil pollution by metals and chemicals
By the time this site was recognised as a hazardous waste site, Love Canal contained an at toxic sites
estimated 21 000 tonnes of discarded chemicals. Within a few years, a second major Based on data from the Blacksmith Institute/Pure Earth
waste site was discovered near Louisville, KY. Known as the Valley of the Drums, the site Toxic Sites Identification programme, we estimate that
contained thousands of steel drums full of chemical wastes that had accumulated over about 61 million people in the 49 countries surveyed to-
several decades. date are exposed to heavy metals and toxic chemicals at
contaminated sites. Because this estimate reflects
These events made it clear to policy makers and the public that hazardous waste was an
exposures at only a fraction of the total number of
environmental and public health emergency. In response, the US Congress passed the
contaminated sites worldwide, further investigation will
Comprehensive Environmental Response Compensation and Liability Act on
be required before the full magnitude of exposures at
Dec 11, 1980. The law became known as the Superfund Act because it authorised the
such sites and their contribution to the global burden of
creation of a large fund that, from 1980 to 1995 was supported by a tax on the chemical
disease can be estimated.202
manufacturing and petroleum industries, the two major producers of toxic chemical
Two types of contaminated sites that have begun to be
wastes. Many of the new hazardous waste sites subsequently being discovered were the
studied in detail are used lead-acid battery recycling sites
result of actions by polluters who no longer existed. The tax was based on the polluter-
and artisanal and small-scale gold mining sites
pays principle and was intended to provide resources to remediate abandoned sites. In
(table 2).112,113,203 Lead poisoning from informal battery
1995, the US Congress allowed the tax on the chemical and petroleum industries to
recycling is seen in low-income countries in all regions of
expire. Since that time, remediation of hazardous waste sites in the USA has been
the world.187,204–206 Artisanal and small-scale gold mining
supported through general tax revenues.
takes place worldwide, but is most highly concentrated in
Africa.207 Details on methods for these analyses can be
found in the appendix (pp 17–18).
Artisanal small-scale gold Used lead-acid batteries Total median DALYs We estimate that between 6 million and 16 million people
mining (range)
are exposed to dangerous concentrations of lead each
Population Median Population Median year at used lead-acid battery recycling sites.185,203 These
exposed DALYs exposed DALYs
exposures result in the loss of an estimated 0·87 million
Africa 10·90 1·91 4·11 0·32 2·23 (0·97–3·49) DALYs annually.203 We also estimate that between 14 million
Eastern Mediterranean 0·30 0·05 1·54 0·10 0·15 (0·04–0·27) and 19 million artisanal and small-scale gold miners
Europe 2·35 0·43 1·45 0·07 0·19 (0·09–0·28) are at risk of occupational exposure to elemental mercury.112
Americas 0·37 0·07 5·53 0·22 0·50 (0·24–0·76) These exposures result in an estimated 2·9 million DALYs
Southeast Asia 0·37 0·07 3·73 0·13 0·29 (0·08–0·50) lost annually to elemental mercury poisoning.112
Western Pacific 0·19 0·35 3·73 0·13 0·48 (0·20–0·76)
Total 16·70 2·96 16·80 0·87 3·83 (1·61–6·06) Occupational pollutants
DALYs=disability-adjusted life-years.
Recognition of the health consequences of toxic
occupational exposures dates to 200 BC,164 and many of the
Table 2: Estimated exposed populations (millions) and DALYs attributable to artisanal and small-scale diseases caused by occupational exposures were well
gold mining and used lead-acid battery recycling by region, 2016112,113,203
known by the 1700s.208,209 The major epidemics of industrial
disease that ravaged workers’ health in the 19th and
Human exposure to contaminated soil at toxic sites can 20th centuries are, however, of relatively recent origin.
result from ingestion, inhalation, or dermal absorption.195 Such diseases include coal workers’ pneumoconiosis,210
Ingestion is the most common pathway. Children are at silicosis,164 bladder cancer in dye workers211 leukaemia and
greatest risk of exposure because they play close to the lymphoma in workers exposed to benzene,212 and
ground and because of their common oral exploratory asbestosis, lung cancer, mesothelioma, and other
behaviour.196–198 malignancies in workers exposed to asbestos.213 These
In high-income countries, substantial progress has conditions can be traced to the rapid, initially largely
been made in identifying and remediating contaminated uncontrolled, industrialisation and reckless exploitation of
industrial sites and, thus, in reducing exposures and natural resources that characterised the Industrial
associated disease. In the USA, the Superfund Revolution in western Europe, North America, Japan,
programme (panel 5),199 a national programme for site and Australia.

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 The Lancet Commissions

In high-income countries, the worst occupational Pollution sources not currently quantified
exposures have now been controlled by legislation and Many hundreds of new synthetic chemicals have entered
regulation, backed by strong enforcement, and rates of world markets in recent decades, come into widespread
occupational disease are down.164,214 Substantial progress use, and are now beginning to be recognised as potential
has been made in controlling exposures to occupational threats to health. These chemicals have become
carcinogens. Central to this success has been the work of extensively disseminated in the environment, are
WHO’s International Agency for Research on Cancer, detectable in the bodies of almost all people examined in For IARC monographs on
which has produced independent and objective analyses national surveys, and have the potential to cause global the evaluation of cancer
risks to humans see
of the carcinogenicity of hundreds of chemicals. These epidemics of disease, disability, and death. Most http://monographs.iarc.fr/
analyses guide cancer control programmes in countries chemicals have undergone little or no assessment of their
around the world safety or potential hazards to human health.
By contrast, occupational exposures to toxic pollutants Because the effects of these new chemicals on human
have become highly prevalent in the past 50 years in low- health are only beginning to be recognised and their
income and middle-income countries.42 The worst of contributions to the global burden of disease are not yet
these exposures tend to occur in informal, small-scale, quantified, they are currently placed within zone 3 of the
locally owned establishments where child labour is also a pollutome (figure 3). Such emerging chemical pollutants
frequent problem.176 are described below.

Burden of disease due to toxic occupational pollutants Developmental neurotoxicants

Occupational pollutants cause a wide range of Evidence is strong that widely used chemicals and
diseases.164,215–217 The GBD study42 considers the burden of pesticides have been responsible for injury to the brains
disease attributable to two types of occupational of millions of children and have resulted in a global
pollutants. These are occupational carcinogens— pandemic of neurodevelopmental toxicity.37,88 The
asbestos, polycyclic aromatic hydrocarbons, silica, manifestations of exposure to these chemicals during
sulphuric acid, trichloroethylene, arsenic, benzene, early development include loss of cognition, shortening
beryllium, cadmium, chromium, diesel exhaust, second- of attention span, impairment of executive function,
hand smoke, formaldehyde, and nickel—and occupational behavioural disorders, increased prevalence of attention
particulates, gases, and fumes. deficit and hyperactivity disorder, learning disabilities,
The GBD study42 estimates that, in 2015, toxic dyslexia, and autism.37
occupational risk factors (not including occupational Prospective epidemiological birth cohort studies have
injuries or ergonomic factors) were responsible for been a powerful instrument for detecting associ­
0·88 million deaths globally and for 18·6 million DALYs. ations between prenatal exposures to developmental
Carcinogens were responsible for 0·49 million (55%) of the neurotoxicants and disease.218 Examples of pollution-
deaths from occupational exposures to toxicants and for related diseases in children that have been identified
9·8 million DALYs. Asbestos was responsible for through prospective studies are: cognitive impairment,
nearly 40% (0·18 million) of all deaths caused by with decreased IQ in children exposed prenatally to
occupational carcinogens. Exposures to particulates, gases,
and fumes in the workplace were responsible for an 100 Occupational particulates, gases and fumes (male)
estimated 0·36 million deaths and for 8·8 million DALYs. Occupational particulates, gases and fumes (female)
90
Occupational carcinogens (male)
WHO data indicate that, in 2012, occupational Occupational carcinogens (female)
80
Global estimated deaths (thousands)

pollutants were responsible for 0·36 million deaths.110

Occupational respiratory carcinogens (arsenic, asbestos, 70

beryllium, cadmium, chromium, diesel exhaust, nickel, 60

silica) were responsible for 0·1 million of these deaths;
50
occupational leukaemogens (benzene, ethylene oxide,
ionising radiation) for 3000 deaths; occupational 40
particulates, dusts, fumes, and gases for 0·23 million 30
deaths; and acute occupational poisonings for
20
27 000 deaths. WHO estimates that, in 2012, occupational
exposures were responsible for 13·6 million DALYs.109 10

0
Age distribution of deaths linked to toxic occupational
o4

o9

14

19

24

29

34

39

44

49

54

59

64

69

74

79

us
pl

pollutants
to

to
to

to
to

to

to
to

to

to
1t

5t

to

to

to

to

80
10

70
15

75
20

30

50
25

35

55
40

45

60

65

Most deaths attributable to occupational pollutants and, Age at death (years)

especially, to occupational carcinogens occur in people
Figure 13: Global estimated deaths due to occupational carcinogenic and particulate exposures by age at
aged 50 years and older (figure 13).42 This pattern reflects death and gender, 2015
the long latency of most occupational cancers.213 GBD Study, 2016.42

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 The Lancet Commissions

PCBs;219 reduced IQ and shortening of attention span in The neonicotinoids are a novel class of neurotoxic
children exposed prenatally to methyl mercury;37 pesticides that were developed in the 1980s and whose
microcephaly at birth, anatomical and functional delays use has risen substantially in the past decade. The
in brain development, and autistic behaviours in child­ neonicotinoid imidacloprid is now the most widely used
ren exposed prenatally to the organophosphate pest­ insecticide in the world.228 In the USA, agricultural use of
icide, chlorpyrifos;220,221 autistic behaviours in children neonicotinoids was nearly 4 million kg in 2014.229
ex­posed prenatally to phthalates;89 cognitive impairment, Neonicotinoids target nicotinic acetylcholine receptors
shortened attention span, and disruptive behaviour in the insect nervous system.230 They are water-soluble and
in children exposed prenatally to brominated flame can persist for years in soils, dust, wetlands, and
retardants;177 and neurodevelopmental delays in groundwater and are detected in commonly consumed
children exposed prenatally to polycyclic aromatic foods. Substantial evidence indicates that neonicotinoids
hydrocarbons.32,175 can have negative effects on the behaviour and health of
An important unanswered question is whether there bees and other pollinators at environmentally relevant
are additional chemicals in use today whose ability to concen­trations.231,232 These chemicals are a suspected cause
cause silent injury to the developing human brain has of bee colony collapse disorder. Despite their extensive use
not yet been discovered.88,222,223 and known neurotoxicity to insects, very little information
is available on the possible human health effects of the
Endocrine disruptors neonicotinoids.228
Endocrine disruptors are chemical pollutants that mimic, Chemical herbicides account for nearly 40% of global
block, or alter the actions of normal hormones.78,90–92 They pesticide use and applications are increasing.226 A major
include phthalates, bisphenol A, perchlorate, several use is in production of genetically modified food crops
pesticides, such as the orthophosphates, brominated engineered to be resistant to glyphosate (Roundup), the
flame retardants, and dioxins. Many endocrine disruptors world’s most widely used herbicide. Glyphosate-resistant,
are also developmental neurotoxicants. These chemicals so-called “Roundup Ready” crops, now account for more
are manufactured in volumes of millions of kilograms than 90% of all corn and soybeans planted in the USA, and
per year and are used widely in consumer products such their use is growing globally. Glyphosate is widely detected
as soaps, shampoos, perfumes, plastics, and food in air and water in agricultural areas, and glyphosate
containers. Exposures in utero to even extremely low residues are detected in commonly consumed foods.
doses of endocrine-disrupting chemicals during early Epidemiological studies of agricultural workers who
development can lead to permanent impairments in were exposed occupationally to glyphosate and other
organ function and increased risk of disease. Prenatal herbicides have found evidence for increased occurrence of
exposures have been linked to autistic behaviours in non-Hodgkin lymphoma in these people. Toxicological
children224 and to anomalies of the reproductive organs studies of experimental animals exposed to glyphosate
in baby boys.225 show strong evidence of dose-related carcinogenicity at
several anatomical sites, including renal tubule carcinoma
Pesticides and haemangiosarcoma. On the basis of these findings,
More than 20  000 commercial pesticide products, the International Agency for Research on Cancer has
including insecticides, herbicides, fungicides, and determined that glyphosate is a “probable human
rodenticides are available on world markets. More than carcinogen”;233 this finding is contested by glyphosate’s
1·1 billion pounds of these products are used in the USA manufacturer.
each year and an estimated 5·2 billion pounds globally.226 Thousands of tonnes of pharmaceutical waste are
Some of the heaviest applications occur in low-income released into the environment each year, especially in
and middle-income countries where use and exposure high-income and middle-income countries, and measur­
data are scant. Experience with three categories of able concentrations of several pharmaceuticals are detected
pesticides—the organophosphate insecticides, the in urban wastewater.95,96
neonicotinoid insecticides, and the synthetic herbicide The sources of pharmaceutical waste pollution include
glyphosate—illustrate the challenges posed by these new discharges from pharmaceutical manufacturing plants,
and inadequately tested pesticide chemicals. hospitals, agriculture, and aquaculture. Anti-inflam­matory
The organophosphate insecticides are a large and agents, antibiotics, oestrogens, anti-epileptics, caffeine,
widely used class of pesticides. Members of this class of and cancer chemotherapy agents are among the
chemicals are powerful developmental neurotoxicants, compounds most commonly detected. In some locations,
and prenatal exposures are associated with persistent concentrations of the anti-inflammatory drug diclofenac
deleterious effects on children’s cognitive and be­havioural have been reported to exceed predicted no-effect levels.234,235
function and with long-term, potentially irreversible, Concern is increasing that these compounds could damage
changes to brain structure that are evident on MRI.220 freshwater and salt water marine species through a range
Toxicological studies of rodents exposed perinatally to of toxicological mechanisms, including endocrine
organophosphates produce parallel findings.227 disruption.

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 The Lancet Commissions

Further information on these emerging chemical The costs of pollution-related disease include: (1) direct
pollutants is presented in the appendix (pp 2–11). medical expenditures, including hospital, physician, and
medication costs, long-term rehabilitation or home care,
Research recommendations and non-clinical services such as management, support
To increase knowledge of pollution and its effects in services, and health insurance costs; (2) indirect health-
human health, this Commission recommends that related expenditures, such as time lost from school or
research be undertaken to: (1) define and quantify the work, costs of special education, and the cost of
burden of neurodevelopmental disease in children and investments in the health system (including health
the burden of neurodegenerative disease in adults infrastructure, research and development, and medical
attributable to PM2·5 air pollution (zone 2 of the training); (3) diminished economic productivity in
pollutome); (2) define and quantify the burden of persons whose brains, lungs, and other organ systems
diabetes attributable to PM2·5 air pollution (zone 2 of the are permanently damaged by pollution; and (4) losses in
pollutome); (3) define and quantify the burden of pre- output resulting from premature death.
term birth and low birth weight attributable to PM2·5 air Pollution-related disease is responsible also for
pollution (zone 2 of the pollutome); (4) better quantify intangible costs, such as those of poor health in people
the burden of disease caused by chemical pollutants of made ill by pollution, disruption of family stability when
known toxicity at contaminated sites, such as lead, a person of working age becomes disabled or dies
mercury, chromium, arsenic, asbestos, and benzene prematurely as a result of pollution, and the loss in years
(zone 2 of the pollutome); and (5) discover and quantify of life to the person themselves.
health effects associated with new and emerging A method to estimate the tangible costs of pollution-
chemical pollutants, such as developmental neuro­ related disease was developed in the early 1980s by an
toxicants, endocrine disruptors, novel classes of expert committee convened by the Institute of
insecticides, chemical herbicides, and pharmaceutical Medicine.239 The core of this method is calculation of the
wastes (zone 3 of the pollutome). so-called “fractional contribution” of pollution to
causation of a particular disease.41 This environmentally
Section 2: The economic costs of pollution and attributable fraction is defined as ‘‘the percentage of a
pollution-related disease particular disease category that would be eliminated if
Premature death and disease due to pollution impose pollution was reduced to the lowest feasible levels.’’240
great costs on national budgets and health-care This fractional contribution is then multiplied by the
spend­ing, especially in rapidly industrialising low-income number of cases of pollution-related disease in a
and middle-income countries. Diseases caused and population and by the average cost per case to calculate
exacerbated by pollution result in medical expenditures the total costs of pollution-related disease.
and in pain and suffering. Pollution-related disease can The cost of a case of illness is often measured by the
reduce labour force participation, labour market product­ medical expenses incurred when a person is ill (the direct
ivity, and economic output. In children, pollution-related costs of illness) and by the loss in productivity when a
disease can cause failure in school and perpetuate person dies prematurely or is disabled (the indirect cost
intergenerational poverty. Early life exposures to neuro­ of illness).241 This method has been used to estimate the
toxic pollutants such as lead and mercury can impair costs of pollution-related disease in children242–244 and of
cognition, diminish the ability to concentrate, and disrupt occupational disease in workers,245 has enabled
behaviour, thus reducing lifetime earnings. The costs of quantification of the effects of pollution-related disease
disease and premature death caused by pollution, on GDP, and has provided a means to calculate costs that
especially the more modern forms of pollution, are are typically externalised and not captured by standard
rising rapidly.236 accounting methods, and thus were previously hidden.7
The costs of pollution-related disease are often Information derived from this so-called full-cost
overlooked and undercounted because they are associated accounting method has proven to be a powerful lever for
with non-communicable diseases of long latency that shaping public policy and is an effective antidote to one-
extend over many years, are spread across large sided arguments for not taking or delaying action against
populations, and are not captured by standard economic pollution that are based solely on the costs of
indicators.7–9,237 These costs are much more difficult to pollution control.7,9
calculate than the costs of pollution control, which are The cost of illness approach to calculating costs of
usually tangible and concrete.238 Although the costs of pollution-related disease works reasonably well in
pollution-related disease can have large effects on the countries with strong public health data systems and
budgets of health ministries and increase spending in robust information about the costs of disease. However,
health systems, they are typically buried in general health it is less applicable in countries without those resources.
expenditures and hospital budgets, hidden in productivity Therefore, the GBD study and WHO estimates of the
reports, do not affect the budgets of environment burden of disease due to pollution are based primarily
ministries, and are not attributed to pollution.9 on data for premature deaths and do not adequately

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 The Lancet Commissions

reflect the full burden of pollution-related disease disease costs; for instance, by expanding estimates from
because, in many countries, researchers are not able to those made solely in terms of productivity losses and
capture information about pollution-related morbidity. effects on GDP. The VSL method has been used by
In countries where data are available relating pollution governments in high-income countries and in Colombia,
to morbidity and to the costs of disease, these costs are Malaysia, Mexico, and Peru, amongst others, to estimate
often substantial. Such studies suggest that the the benefits of reducing pollution.246
morbidity costs resulting from pollution-related dis­
ease might conservatively increase mortality costs Methods
by 10–70%,236,246,247 and some individual country studies This Commission uses both approaches in the current
suggest that the increment might be even greater: analysis. Economic losses from pollution-related disease
25% for Colombia,247 22–78% for China,248 and 78% for are therefore measured in terms of lost productivity and
Nicaragua.249 health-care costs, and the costs of pollution-related
A second shortcoming in using the cost of illness disease are also presented using estimates derived from
approach to estimate the health costs of pollution is that WTP studies. Costs associated with air, water, and lead
it can never capture the intangible losses caused by pollution are included in this analysis, but costs
pollution-related disease, even when comprehensive data associated with soil pollution are not yet available and are
are available. For example, this method can neither not included. To calculate the VSL in countries where no
measure the family disruption that follows the premature original studies are available, we have extrapolated
death of a mother or a father nor can it quantify the grief estimates from other countries, taking differences in
that follows the death of a child. Those losses are separate income levels into account.246,253 This method is described
and qualitatively different from losses in income in the appendix (pp 25–28).
generated or in goods produced.14 Similarly, a method The economic benefits that result from the control of
that is based solely on the effect of pollution on GDP pollution and prevention of pollution-related disease are
cannot fully describe the negative effects of pollution on the same as the costs that result from pollution-related
societal health, on diminished visibility in national parks, disease. Losses in economic productivity are a key
on ecosystem services, or the benefits of pollution control component of the costs of pollution-related disease. When
in enhancing national welfare.72 pollution-related disease results in the death of children or
To overcome these shortcomings in the cost of illness adults of working age, the economic output that those
approach, economists have devised a second strategy to people would have produced is lost forever. The productivity
assess disease costs: the so-called “willingness-to-pay” losses associated with premature mortality are measured
method. This metric is a measure of how much people by calculating the output that an individual would have
are willing to pay to reduce the risk of premature produced over his or her working life, summing these
death.250–252 This approach captures individuals’ pre­ losses to the present.
ferences for avoiding increases in risk of death by Pollution-related disease also reduces the productivity of
analysing their behaviour in risky situations (the revealed ill people while they are working. Hanna and Oliva254
preference approach) or in hypothetical choice situations estimated that the closing of a heavily polluting refinery in
involving changes in their risk of death (the stated Mexico City, Mexico, increased the hours worked by people
preference approach). living near the refinery by 3·5%. Zivin and Neidell255 found
To aggregate data from willingness to pay (WTP) studies, that a 10 ppb reduction in ground-level ozone increased the
economists have developed the Value of a Statistical Life productivity of farm workers in California, USA, by 5·5%.
(VSL) concept. The VSL is defined as the total of what Chang and colleagues256 report that each 10 µg/m³ increase
many people would pay for small reductions in the in outdoor PM2·5 concentrations reduced the productivity
probability of dying over the coming year that, together, of factory workers by 6% in northern California, USA.
add up to saving one life. For example, if each of 10 000 Similarly, water pollution has also been shown to reduce
people were willing to pay US$100 over the coming year to adult productivity. An estimated 35 million people in
reduce their risk of dying by 1 in 10 000, one statistical life Bangladesh are exposed to concentrations of arsenic in
would be saved and the VSL would equal $100 × 10 000, groundwater that exceed 50 µg/L and 57 million people are
or $1 000 000. exposed to concentrations above the WHO standard of
Multiplying the number of lives lost to pollution by the 10 µg/L. Carson and colleagues,257 who performed this
VSL provides an estimate of the health costs associated study, estimate that reducing arsenic concentrations to the
with pollution. Multiplying the number of lives that WHO standard would increase annual hours worked by
pollution control would save by the VSL provides an the average household in their sample by 6·5%.
estimate of the benefits of pollution control. A method to measure lost output is to calculate its effects
Although the VSL method has the disadvantage of on a worker’s contribution to GDP. Table 3 shows
relying on estimates of what people say they will pay to reductions in GDP that result from pollution-related
reduce mortality risks, it overcomes many of the deaths as a percentage of a country’s GDP. Losses are
limitations that hinder efforts to estimate pollution-related reported by World Bank income group and pollutant

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 The Lancet Commissions

category (lead exposure, ambient air pollution, household

Ambient Unsafe water and Lead exposure Total
air pollution, unsafe water, and unsafe sanitation. Because air pollution unsafe sanitation*
the magnitude of productivity losses is sensitive to the and household
interest rate used to discount losses to the present (discount air pollution
rate), this Commission gives results using two different High income 0·044% (0·048%) 0·0028% (0·0033%) 0·0027% (0·0029%) 0·050% (0·054%)
discount rates (1·5% and 3%). For country-level data see Upper-middle income 0·13% (0·15%) 0·019% (0·027%) 0·0054% (0·0059%) 0·15% (0·18%)
appendix (pp 43–47). Lower-middle income 0·32% (0·40%) 0·28% (0·40%) 0·012% (0·013%) 0·61% (0·82%)
Because pollution-related disease is most common in Low income 0·62% (0·86%) 0·70% (1·03%) 0·012% (0·013%) 1·33% (1·90%)
heavily polluted, low-income countries, productivity World 0·092% (0·11%) 0·033% (0·047%) 0·0042% (0·0046%) 0·13% (0·16%)
losses due to pollution-related disease are dis­
Results without parentheses discount future output at the rate of growth in per capita GDP plus 3%. Results in
proportionately high in these countries. Thus, in low- parentheses discount future output at the rate of growth in per capita GDP plus 1·5%. For the calculations see appendix
income countries, product­ ivity losses due to (pp 25–26). *Includes, but is not limited to, no hand washing with soap.
pollution-related disease represent between 1·3%
Table 3: Productivity losses as a percentage of gross domestic product (GDP) by pollutant and World
and 1·9% of GDP. By contrast, in lower middle-income
Bank income group
countries, these losses amount to between 0·6%
and 0·8% of GDP. In low-income countries, the largest
productivity losses due to pollution-related disease result exceed the reduced mortality risk and lost productivity
from lack of access to safe water and sanitation, followed measured in this chapter, and also include reductions in
by exposures to air pollution. Household air pollution morbidity due to diarrhoea, especially among children,
alone causes losses of between 0·49% and 0·68% of GDP and associated reductions in malnutrition.
in low-income countries. Two studies that combine results from the medical
In upper middle-income and high-income countries, literature to estimate the global benefits of various water
most economic losses attributable to pollution-related and sanitation interventions suggest benefit-cost ratios
disease are due to ambient air pollution. These losses greater than 1 for many interventions on the basis of
comprise a smaller fraction of GDP than in low-income health benefits and time savings. The average benefit-cost
and lower middle-income countries because there is ratio for deep borehole wells with hand pumps is 4·64,
generally less pollution in these countries and prevalence whereas household water treatment with bio-sand filters
of pollution-related disease is lower. An additional factor yields an average benefit-cost ratio of 2·48.258,259 A cost–
that reduces the estimated costs of pollution-related benefit analysis finds that improved water supplies,
disease in high-income countries is that more than 82% of according to the WHO definition, yield a return of US$2
deaths due to air pollution in these countries occur in for every dollar invested.
people age 65 years and older. This reduces the calculated Despite general acceptance that well targeted water and
costs because the international definition of working age sanitation interventions have positive benefit-cost ratios,260,261
is 15–64 years of age and, hence, the economic contribution the scale of these benefits can be questioned, given the
of premature death in people older than 65 years is not number of uncertainties that are usually involved.262,263 Site-
counted. In upper middle-income and high-income specific analysis and examination of the range of probable
countries, estimated economic losses due to pollution- benefit-cost ratios can provide useful input to the process of
related disease in 2015 were more than US$53 billion. making policy and project decisions.264
Additional economic costs of coal combustion not Neurotoxic pollutants can reduce productivity by
included in this analysis are costs related to disease and impairing children’s cognitive development. It is well
premature death in coal miners due to injuries and coal documented that exposures to lead and other metals
workers’ pneumoconiosis; costs of lung cancer in coke (eg, mercury and arsenic) reduce cognitive function, as
oven workers; ecological and community costs of measured by loss of IQ.168 Loss of cognitive function
mountain top removal and strip mining; losses in property directly affects success at school and labour force
values near mines and along railroad rights-of-way; loss of participation and indirectly affects lifetime earnings. In
timber resources; and crop losses due to water the USA, millions of children were exposed to excessive
contamination.9 concentrations of lead as the result of the widespread use
of leaded gasoline from the 1920s until about 1980. At
Pollution benefit-cost analyses peak use in the 1970s, annual consumption of tetraethyl
Benefit-cost analyses of water and sanitation improvements lead in gasoline was nearly 100 000 tonnes.
and improved cookstoves must account for the health It has been estimated that the resulting epidemic of
benefits of these interventions, the time savings for subclinical lead poisoning could have reduced the
households who no longer need to collect water or number of children with truly superior intelligence
firewood, and the benefits associated with improved (IQ scores higher than 130 points) by more than 50%
childhood health, such as greater educational achievement. and, concurrently, caused a more than 50% increase in
The health benefits associated with a project to improve the number of children with IQ scores less than 70
water quality (eg, home disinfection of drinking water) (figure 14).265 Children with reduced cognitive function

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 The Lancet Commissions

Average IQ=100
mean lifetime earnings by about 0·5%. A 2015 study in
Chile270 that followed up children who were exposed to
lead at contaminated sites suggests much greater effects.
A 2016 analysis by Muennig271 argues that the economic
losses that result from early-life exposure to lead include
6 million
not only the costs resulting from cognitive impairment
“mentally 6 million but also costs that result from the subsequent increased
retarded” “gifted”
use of the social welfare services by these lead-exposed
children, and their increased likelihood of incarceration.
Pollution-related disease has substantial effects on
40 70 80 120 130 160 health-care expenditure. To quantify these costs, it is
IQ necessary to know the number of cases of each category
of pollution-related disease in a population and the
Average IQ=100
57% increase average health-care expenditure per case (appendix
pp 29–31). These data are available for some high-income
countries272 but not for low-income and middle-income
countries, except for Sri Lanka.273
Respiratory disease, cardiovascular disease, stroke, and
2·4 million cancer account for the largest proportion of the DALYs
9·4 million “gifted” from pollution-related disease. Air pollution is
“mentally responsible for half of the DALYs associated with lower
retarded”
respiratory tract infections and chronic obstructive
pulmonary disease worldwide, and for a quarter of the
40 70 80 120 130 160
IQ
DALYs resulting from ischaemic heart disease and
stroke.42,106 Globally, 24% of the DALYs associated with
Figure 14: Model of intelligence losses associated with a mean 5-point drop cancers of the trachea, bronchus, and lungs are attributed
in IQ of a population of 100 million to air pollution. The proportions of DALYs linked to each
Figure taken from reference 265, with permission. of these non-communicable diseases are higher in
low-income and middle-income countries than in
due to lead did poorly in school, required special high-income countries (table 4).41,42 For country-level
education and other remedial programmes, and could calculations see the appendix (pp 57–62).
not contribute fully to society when they became adults. Based on information from seven high-income
Grosse and colleagues46 found that each IQ point lost to countries, it can be estimated that air pollution, which
neurotoxic pollution results in a decrease in mean accounts for 2·4% of all DALYs in these countries
lifetime earnings of 1·76%. Salkever and colleagues266 (panel 6),42 accounts for 3·5% of their total health
who extended this analysis to include the effects of IQ on expenditure; in 2013, this amounted to US$100 billion.
schooling, found that a decrease in IQ of one percentage In Sri Lanka, a rapidly industrialising lower middle-
point lowers mean lifetime earnings by 2·38%. Studies income country where the burden of pollution-related
from the 2000s using data from the USA267,268 support disease is proportionately much larger than in high-
earlier findings but suggest a detrimental effect on income countries, air pollution accounts for 6·5% of all
earnings of 1·1% per IQ point.269 The link between lead DALYs. Estimated expenditures on disease due to air
exposure and reduced IQ46,168 suggests that, in the USA, a pollution in Sri Lanka account for 7·4% of all health-care
1 µg/dL increase in blood lead concentration decreases expenditures.

Lower respiratory Tracheal, Ischaemic heart Ischaemic Haemorrhagic Chronic Cataracts

infections bronchial, disease stroke stroke obstructive
and lung cancer pulmonary
disease
High income 12% 8% 13% 9% 11% 16% 1%
Upper-middle income 34% 30% 24% 20% 24% 41% 14%
Lower-middle income 57% 38% 35% 28% 31% 52% 25%
Low income 64% 48% 43% 36% 22% 51% 35%
Global 53% 24% 28% 37% 27% 44% 19%

Calculations based on data from the GBD 2015 Mortality and Causes of Death Collaborators (2016)41 and the GBD 2015 Risk Factors Collaborators (2016).42

Table 4: Percentage of disability-adjusted life-years attributable to air pollution (household air pollution plus ambient air pollution) by disease and
country income group

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 The Lancet Commissions

Globally, unsafe water and sanitation, including poor

hand hygiene, are associated with 96% of DALYs due to Panel 6: Summary of Commission’s estimates of the health
diarrhoeal disease and with 95% of the DALYs linked to costs of pollution-related disease
typhoid fever. In low-income countries, these percentages • In high-income countries, health-care spending on
are even higher (97% for both diseases). Health-care diseases caused by air pollution alone amounted to 3·5%
expenditures on pollution-induced diarrhoea and typhoid of total health expenditures in 2013.
are difficult to quantify due to inadequate data. However, • In Sri Lanka, the only low-income or middle-income
the costs of treating these diseases, especially for children, country for which data are available, health-care spending
represent only a small proportion of the health costs to on diseases due to air pollution accounted for an
society from these diseases274,275 and the impoverishing estimated 7·4% of health-care spending in 2013.
effect of these diseases can be as great, if not greater, than • The costs of lost productivity from pollution-related
the direct cost of illness. For example, in children who disease are estimated to be between 1·3% and 1·9% of
survive diarrhoea, effects on nutritional status and school gross domestic product (GDP) in low-income countries,
attendance are likely to far outweigh the costs of and between 0·6% and 0·8% of GDP in low-middle
treatment. Repeated bouts of diarrhoea interfere with the income countries.
body’s ability to absorb nutrients and, in countries where • In high-income and upper-middle-income countries, the
many children are malnourished, compound the effects cost of lost productivity associated with pollution-related
of poor nutrition.276 The negative effects of poor nutrition disease is estimated to have exceeded US$53 billion
on labour force productivity277 and the effects of diarrhoea in 2015.
and other childhood diseases on school attendance are • When the willingness-to-pay method is used to estimate
well studied.278 All of these effects are magnified in the amount that people would be willing to pay to avoid
settings where poor households forego medical treatment premature death due to pollution-related disease, the
but still suffer substantial impoverishment from the loss total is estimated to be more than US$4.6 trillion, which
of household income or long-term disability, where the is 6·2% of global economic output.
foregone treatment is a low-cost intervention that could
have restored full labour market participation.
We define welfare losses from pollution-related disease each pollutant category, measured in 2015 US dollars at
as equal to household WTP to reduce pollution. When the market exchange rates and as a percent of gross
VSL method is used to estimate the global costs of national income (which represents the sum of incomes
premature deaths attributable to pollution, the total earned by all residents of a country), and summarised
in 2015 was more than US$4·6 trillion, or 6·2% of world by World Bank income category. The method used to
GDP (table 5).42 calculate these damages is identical to that used in the
This estimate of WTP to reduce pollution greatly exceeds Institute for Health Metrics and Evaluation-World Bank
the estimated costs of pollution-related disease that are study;279 however, this Commission presents all figures
derived from productivity losses alone for two reasons. converted to 2015 US dollars at market exchange rates
Firstly, what people will pay to reduce their risk of death is rather than using purchasing power parity dollars.
much greater than the present value of lost output. When Because the ability to pay to reduce mortality risks
a person dies at age 35 years, the present value of increases with income, it is highest for high-income
productivity losses is about 20 times per capita GDP; in countries. The value of avoided mortality as a percent of
low-income countries, the ratio of the VSL to per capita income is, how­ever, much higher as a proportion of
GDP is between 40:1 and 50:1. Secondly, the VSL is applied income for low-income and middle-income countries—
to all premature deaths, not only those of adults at working between 8·3% and 9·4% of gross national income,
age. Because 75% of deaths associated with lead pollution, reflecting the fact that most pollution deaths occur in
64% of deaths associated with ambient air pollution, these countries.
33% of deaths associated with unsafe water and sanitation, Ambient and household air pollution together
and 56% of the deaths associated with household air constitute the largest category of welfare damages for all
pollution occur at age 65 years or older, these deaths are groups of countries. In high-income and upper middle-
excluded from economic calculations based on producti­ income countries, the damages associated with ambient
vity losses. The VSL approach values these deaths by what air pollution outweigh the damages associated with
people are willing to pay to avoid them. By contrast, the household air pollution—ie, eliminating all deaths due
method based on productivity losses presented in table 3 to ambient air pollution would yield higher benefits than
assigns no value to deaths that occur at age 65 years eliminating all deaths due to household air pollution.
or older. The reverse is true in lower middle-income and low-
Although pollution damages are highest, in absolute income countries. The damages from unsafe water and
terms, in high-income countries, they are highest as a sanitation remain substantial, constituting 39% of
proportion of income in low and middle-income damages in low-income and 27% of damages in lower
countries. Table 5 shows the damages associated with middle-income countries.

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 The Lancet Commissions

Ambient air pollution and Unsafe water and unsafe Lead exposure Total
household air pollution sanitation*
High income US$1691 (3·52%) US$159 (0·33%) US$303 (0·63%) US$2153 (4·48%)
Upper-middle income US$1691 (8·37%) US$89 (0·44%) US$118 (0·59%) US$1898 (9·40%)
Lower-middle income US$367 (6·38%) US$143 (2·49%) US$28 (0·49%) US$538 (9·36%)
Low income US$18 (4·83%) US$12 (3·30%) US$0·740 (0·20%) US$31 (8·33%)
Total US$3767 (5·06%) US$404 (0·54%) US$451 (0·61%) US$4622 (6·21%)

For the calculations see appendix (pp 27–28). *Includes, but is not limited to, no hand washing with soap.

Table 5: Welfare damages (in billion US$) and as percentage of gross national income by pollutant and World Bank country income group (2015)42

The welfare losses presented in table 5 (for country- the reductions in air pollution that will arise from
level calculations, see appendix pp 48–52) can also be strategies to slow the pace of global climate change.2 The
used to estimate WTP for policies to control pollution. evidence for health benefits of climate mitigation was
Table 6 shows estimates of the amount a person reviewed in the Lancet Commission on Health and
exposed to pollution would be willing to pay to reduce Climate Change.97 The annual marginal benefits of
the risk of death from exposure to each pollutant source avoided mortality from reductions in air pollution that
to zero, converted to 2015 US dollars at market exchange will result from greenhouse gas mitigation strategies are
rates.42 For country-level WTP calculations, see the estimated to range from US$50–380 per ton of CO2
appendix (pp 53–56). This WTP estimate is the product abated, and are projected to exceed marginal abatement
of the VSL and the mortality risk associated with the costs in both 2030 and 2050.
pollutant, which is also shown. The WTP values
indicate what a person would be willing to pay to reduce Research recommendations
their risk of death due to pollution, assuming that they We make several recommendations related to research on
understood the risk. Some of these numbers might the economic costs of pollution. Research is needed to
appear low—for example, the WTP per person for an improve estimates of the morbidity costs of pollution. This
improved water source in low income countries is requires measuring the morbidity associated with
US$15 per person; however, this would almost be pollution, which is more difficult than estimating mortality.
sufficient to cover the capital costs of installing a This improvement also requires valuing morbidity
borehole well (approximately $20 per person).280 endpoints, which are more diverse than mortality.
Moreover, measures to control pollution yield benefits Additionally, work is needed to improve estimates of
beyond reductions in mortality risk, such as the non-health benefits of reducing pollution. For
convenience and comfort, in addition to health benefits. traditional pollution problems, these estimates should
Reducing outdoor air pollution and smoke from include the value of time savings associated with water
burning solid fuels provides aesthetic and ecosystems and sanitation interventions and improved cookstoves
benefits, and the health benefits of clean air. and the education benefits associated with reduced
Although high, these numbers almost certainly illness in children. For ambient air pollution, estimates
underestimate the full economic burden of pollution- should include the aesthetic value and the ecosystem
related disease because of inadequate data in many benefits of cleaner air.
countries on pollution and disease prevalence, poor
knowledge of the toxic effects of many chemicals in Section 3: Pollution-related disease, poverty,
widespread use,36,37 and lack of information on the and the SDGs
possible effects later in life of toxic exposures sustained The former Secretary General of the United Nations, Kofi
in early life. An issue that contributes to this Annan, has declared that “the biggest enemy of health in
underestimate is that calculations of productivity losses the developing world is poverty.”283 Pollution, poverty,
due to pollution understate the total value of output lost poor health, and social injustice are deeply intertwined.
due to premature mortality because deaths of persons Pollution and pollution-related disease most affect the
over age 64 are not counted in these calculations. It world’s poor and powerless.284 Pollution’s victims are
should also be noted that the economic approach for often the vulnerable and the voiceless. To understand the
calculating productivity effects reflects only losses in links between pollution, poverty, and pollution-related
output that are captured in GDP, and thus does not disease, it is necessary to elucidate the complex and
capture productivity losses in domestic work (child care, multidimensional nature of poverty.285 Poverty is not
cleaning, and cooking) or in the informal sector.281 Finally, simply a lack of money. Poverty results also in reduced
GDP does not measure societal wellbeing.14,282 access to education, health care, nutrition, and sanitation
The estimates presented here also do not capture the and impedes participation in legal and political processes,
health savings that have been projected to result from when such processes exist, and in civil society. When

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 The Lancet Commissions

Ambient air pollution Household air pollution Unsafe water sources Unsafe sanitation Lead exposure
High income US$1472 (4·0) US$98 (0·7) US$11 (0·1) US$1 (0·007) US$264 (0·7)
Upper-middle income US$523 (6·8) US$214 (2·9) US$13 (0·2) US$5 (0·1) US$47 (0·6)
Lower-middle income US$85 (6·9) US$66 (5·7) US$39 (3·1) US$23 (1·9) US$10 (0·7)
Low income US$13 (4·1) US$23 (7·4) US$15 (4·8) US$11 (3·6) US$1 (0·4)
Average US$459 (6·2) US$123 (4·6) US$25 (2·0) US$14 (1·3) US$64 (0·7)

Numbers in parentheses are number of deaths associated with the pollutant per 10 000 people associated with the pollutant. For the calculations see appendix (pp 27–28).

Table 6: “Willingness to pay” per person (in US$, 2015) to reduce risk of death associated with pollution, by World Bank country income group and
pollution type42

families lack access to food, clothing, and shelter, they do protection of the most vulnerable.292 Pollution and
not have the resources to support even a minimum level pollution-related disease are often reflections of
of health. environmental injustice. Many countries recognise the
This Section of the Commission report presents data right to a healthy environment as a basic human right
documenting that pollution and pollution-related disease linked to the right to life and other fundamental human
are concentrated among the poor and contribute to the rights.293,294 The right to a healthy environment also
intergenerational perpetuation of poverty. Pollution- includes the right to safe food and water and adequate
related disease can result in lost income and increased housing.293,294
health-care costs, thus imposing disproportionately great Recognition of the right to a healthy environment
economic burdens on poor families and communities.286 requires that all members of a society have unfettered
In children, early-life exposure to neurotoxic pollutants access to information about sources and patterns of
can impair cognitive function and diminish the ability to pollution; that they have the power to participate in
concentrate, further contributing to school failure and environmental planning and decision making; and that
reducing lifetime earnings. In example, a long-term there is an environmental regulatory agency and an
follow-up study144 of children exposed to lead reported independent judiciary that protect the environment from
that an elevated blood lead concentration at age 11 years polluters, and the poor against pollution.295
was associated with lower cognitive function and reduced Pollution and pollution-related disease are often
socioeconomic status at age 38 years, with diminished reflections of environmental injustice. Robert Bullard,
IQ, and downward social mobility. Moreover, poverty can widely regarded as the father of the environmental justice
worsen health, for example, by forcing people to live in movement,296 defines a core principle of environmental
environments that make them ill, without decent shelter, justice as “all people and communities are entitled to
clean water, or adequate sanitation.287 When people live equal protection of environmental and public health laws
near polluting factories or downstream from hazardous and regulations.”297 Bullard stresses that environmental
waste sites, or when poor women have no alternative but justice is a far-reaching concept that involves much more
to cook with traditional stoves in close quarters, or when than equal enforcement of laws and regulations. In
children are forced to pick by hand through electronic Bullard’s view, environmental justice is a basic human
waste to recover precious metals to sustain themselves and civil right and requires meaningful and timely
and their families,288 poverty can exacerbate poor health. involvement of people and communities in decisions
Without political influence and with little power in that affect their environment and wellbeing. In 1991
most countries to control or prevent pollution, the poor Bullard and his colleagues, at the first National People of
have limited ability to determine the fate of their Color Environmental Leadership Summit adopted
communities. Their dependence for survival on tight 17 Principles of Environmental Justice.298 These principles
social networks further restricts their mobility and were developed as a guide for organising, networking,
opportunities. The result of these interconnected forces and relating to government and non-government
is that poverty is a trap that often spans generations. The organisations.
poor have disproportionately heavy exposures to Environmental injustice is the inequitable exposure of
pollution and disproportionately high amounts of poor, minority, and disenfranchised populations to toxic
disease, disability, and premature death.289,290 A major chemicals, contaminated air and water, unsafe
challenge to enlightened heads of government is to workplaces and other forms of pollution, and the
balance economic development that lifts people and consequent disproportionate burden among these
communities out of poverty against pollution control and populations of pollution-related disease, often in violation
the prevention of pollution-related disease. of their human rights. Environmental injustice has been
Pollution threatens fundamental human rights: the characterised as a form of structural violence.299 In many
rights to life, to health, and to wellbeing.291 It jeopardises instances, environmental injustice is linked to so-called
the rights of the child, the right to safe work, and the “structural racism”.300

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 The Lancet Commissions

encourage poor people to leave agriculture and other

Panel 7: India’s judicial system for pollution traditional occupations. Although small-scale mining is
During the UN Conference on Environment and Development in 1992, India committed to relatively profitable for the miners, it is highly
providing judicial and administrative remedies for the victims of environmental damage. exploitative in that the majority of the profits accrue with
To fulfil this commitment, India became the third country in the world to start a National brokers and retailers, and the burdens of disease and
Green Tribunal, a judicial body exclusively established to judge environmental cases. The environmental degradation fall almost entirely upon
National Green Tribunal was formed on Oct 18, 2010. The focus of this body is on the mining communities. Regional conflicts and wars,
effective and expeditious resolution of cases relating to environmental protection and frequently driven by a desire for natural resources
conservation of forests and other natural resources. The National Green Tribunal is (namely oil, minerals, and timber) further aggravate
mandated to make final judgments on applications and appeals within 6 months of their these problems.
filing. The National Green Tribunal is comprised of judges, who are supported by Environmental injustice exists in countries at all levels
environmental experts to provide informed guidance on environmental issues, to validate of income and development and in all regions of the
the Tribunal’s legal judgments. world,284,301–303 as can be seen in the following examples
and case studies.
Cases such as the Vedanta Bauxite Smelter in Orissa, the Thermal Power Plants in Andhra
Pradesh, and the Jaitpur Nuclear Power Plant in Maharashtra have seen controversy and
Combating environmental injustice
protests. The involvement of the National Green Tribunal has resulted in amicable solutions
To advance environmental justice and reduce the
to these cases, ensuring the people of the affected regions a safe and liveable environment.
inequitable exposure of the poor and the marginalised,
Before establishment of the National Green Tribunal there were numerous cases in which
countries must develop legal mechanisms that provide
large industries were confronted by local people fighting for the environment.
recourse for environmental injustice. India’s green court,
for example, provides citizens with access to an
Global spread of extractive industries: oil and gas independent judiciary that has the power to redress
production, mining, and smelting pollution injustices. Such a system, when connected with
Social and economic factors that have contributed to the openly shared data on toxic exposures and health can
global spread of environmental injustice and the in­ serve as a powerful mechanism to address environmental
equitable exposure of poor and marginalised populations injustice (panel 7).
to pollution and disease include globalisation, which has Environmental injustice in North America is well
caused the movement of hazardous industries such as documented. Recurrent racial and ethnic disparities have
chemical manufacture, steel making, pesticide production, been documented in North America in exposures to
and shipbreaking from higher income countries to low- various forms of pollution. A study of the ambient air
income and middle-income countries. This movement has pollution in New York City have documented that almost
entailed low wages, little or no environmental and all diesel bus depots, places where buses idle their
occupational regulation, and weak public health infra­ engines for hours while emitting pollutants, are in
structure. The consequences of these occupational and minority, mostly disadvantaged neighbourhoods. Dis­
environmental conditions are disease and injury in proportionately increased pre­ valence of asthma and
underprotected workers, diseases caused by toxic other respiratory diseases have been documented among
chemicals in residents of communities near polluting children in these com­munities.304 In the so-called “Cancer
facilities, and industrial explosions. Examples include the Alley” region of Louisiana, an 85 mile stretch along the
chemical explosion in Bhopal, India where a pesticide Mississippi River where 125 companies manufacture a
production factory that had been trans-shipped from quarter of all petrochemical products made in North
the USA detonated and killed and injured thousands or America, the US Commission on Civil Rights determined
workers and local residents; the global trade in asbestos that the African-American community was economically
that results in shipment of 2 million tons of asbestos disadvantaged and disproportionately affected by
annually to the world’s poorest countries, where it will pollution from hazardous facilities.305 Another case
produce epidemics of lung cancer, mesothelioma, and study306 of environmental injustice in the USA relates to
other malignancies;214 and the global trade in banned and the exploitative uranium mining operations on Native
restricted pesticides. American (Navajo) lands. Mining operations there
Transboundary transfers of hazardous and toxic depleted and contaminated the scarce water supply and
wastes, such as electronic wastes and chemical wastes, produced high prevalence of lung cancer in Navajo
from high-income to low-income and middle-income underground miners, who suffered intense occupational
countries are a further cause of the global spread of exposures to radon.306 A final example involves the
environmental injustice. The global spread of artisanal disproportionate exposures of Hispanic farm workers to
and small-scale gold mining and the concomitant spread acutely toxic organophosphate pesticides, such as
of occupational and community-wide exposure to parathion. Several cases of acute pesticide poisoning have
elemental mercury and methylmercury are another resulted. Many of these workers are undocumented
example.112,113 The expansion of gold mining is driven by immigrants and, hence, afraid to protest environmental
large increases in the global price of gold, which injustice and pollution.307

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 The Lancet Commissions

In Canada, environmental injustice occurs in the Similar events have been recorded in relation to gold
traditional lands of First Nations (indigenous peoples). mining in Ghana.
First Nations are battling the Alberta Oil Sands Project in In Latin America, environmental inequality is evident in
northern Alberta308 and exposure to Canada’s worst air a series of clashes between extractive industries,
pollution hotspot in Ontario’s so-called “Chemical Valley”, particularly the mining industry but also oil and gas
where 40% of the country’s chemical manufacturing is production, and indigenous communities. Examples
located.309 include the Tia Maria copper project in Peru, operated by
Environmental injustice issues are also prevalent in Mexico’s Southern Copper Corporation, the world’s second
Europe.310 In central and eastern Europe, some minority largest copper mining company, and the USA-based
Roma people and refugee and displaced communities Newmont Mining Company’s US$4·8 billion Conga gold-
from Kosovo have faced environmental injustice. In copper project, Peru’s biggest mining investment. Protests
Kosovo, camps for displaced Roma were located in an area against the inequitable placement of these enormous
polluted by toxic tailings from a lead mine. In Durres, projects on lands belonging to native peoples and the
Albania, refugees from Kosovo were housed in a disused resulting disproportionate burdens of pollution,
chemical plant that had previously produced sodium environmental degradation, and disease are reshaping
dichromate and lindane, compounds classified by the basic paradigms of resource-based develop­ ment. These
International Agency for Research on Cancer as class 1 struggles have forced contemporary legal systems,
(proven) human carcinogens.311 including legal systems in the high-income home countries
In Asia, the sustained economic growth that has enabled of mining conglomerates, to accommodate indigenous
substantial reduction in poverty has simultaneously world views and to correct, rather than perpetuate the
increased toxic pollution and environmental inequity.312 In unjust effects of economic growth upon the poor.313,317
China, a highly publicised example involved a paraxylene With the worldwide spread of toxic chemicals and
chemical factory in the city of Dalian, where residents modern-day pollution, interest has grown in investigating,
feared that typhoons could breach chemical storage tanks documenting, and mapping environmental injustice.
and flood lower socioeconomic areas of the city with toxic Information produced through these efforts, especially
material.313 information documenting patterns of pollution at the local
In India, a well studied example of environmental level, can provide powerful leverage to disproportionately
injustice is the disproportionate siting of mineral and exposed communities who are struggling to reduce their
metals extraction facilities in the Adivasi belt of central exposure and their inequitable burden of pollution-
and northeast India where 70 million Adivasis—tribal related disease.
people—live in extreme poverty and are disproportionately In Europe, the Environmental Justice Atlas, a global For the Environmental Justice
exposed to air, water, and soil pollution produced by these online database, now lists information on about 2000 sites Atlas see https://ejatlas.org/

facilities.313 In a landmark case linking the mining industry around the world where pollution and environmental
in the Adivasi belt to environmental injustice,314 the Indian injustice are documented or suspected. Linked to this
Supreme Court observed that the fundamental rights of database is Environmental Justice, Organisations,
citizens, guaranteed by the Constitution, included “the Liabilities and Trade, a global research project supported
right of enjoyment of pollution-free water and air for full by the European Commission that is compiling The Map
enjoyment of life”. of Environmental Justice, an atlas of maps documenting
In Africa, extraction of natural resources is a major the distribution of pollution and environmental injustice
driver of environmental injustice and pollution. In around the world.318
Zambia, the lead and zinc mines at Kabwe are among the Pure Earth, a New York-based environmental non-profit
world’s most polluted places. Although these mines are organisation has developed a Toxic Sites Inventory
no longer active, the residue left behind after decades of Program that includes information on about 3500 polluted
extraction by overseas-based companies have sites—active and abandoned mines, smelters, factories,
contaminated soil and the local water supply. Children in and hazardous waste dumps—a number that is still
Kabwe have blood lead concentrations that are 5–10 times growing.38 This database focuses on contaminated sites in
higher than the threshold concentration recommended low-income and middle-income countries and has served
by the US Centers for Disease Control and Prevention.315 as a resource to the work of this Commission.
Mineral extraction has also been associated with In the USA, the Environmental Protection Agency has
environmental injustice in post-apartheid South Africa, developed an open-access mapping tool, EJSCREEN, that For EJSCREEN see
where large-scale gold mining has resulted in epidemic is available on the EPA website and makes data on https://www.epa.gov/ejscreen

silicosis among miners, many of them economic environmental injustice publicly available. This tool
migrants from the poor countries of southern Africa overlays 12 environmental factors, including information
surrounding South Africa.313 Gold mining was also the on levels of airborne particulate matter, lead paint, and
cause of the 2010 tragedy in Zamfara State, Nigeria, in proximity to water discharges with six demographic
which 163 people in deeply impoverished communities, factors, including income level and percentage of the
including 111 children, died of acute lead poisoning.316 population classified as minority. The resulting maps

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 The Lancet Commissions

enable people to check their neighbourhoods and to people living in rural areas, indigenous peoples, people
directly examine the intersection of pollution with poverty. with disabilities, and other marginalised groups are
The global distribution of pollution and pollution- especially likely to lack these basic services.
related disease illustrates the connections between A sharp gender gap is evident in the health and social
pollution, poverty, and environmental injustice. 92% of effects of water pollution and inadequate sanitation.
pollution-related deaths occur in low-income and middle- Girls are particularly severely affected by inadequate
income countries (figure 8). In countries at every level of access to safe water because the task of collecting water
income, the health effects of pollution are most frequent falls disproportionately on them and because lack of
and severe among the poor and the marginalised. By far, water introduces a problem with menstrual hygiene. The
the largest share of pollution-related diseases is the many hours that girls in poor communities must spend
outcome of urban and household air pollution. However, fetching water increase the risk that they will miss school
water pollution and toxic occupational exposures are also and, thus, remain trapped in their communities by lack
crucial contributors to mortality and morbidity. of education. If a school does not provide safe, private
toilets, monthly periods can also force girls to miss class
Air pollution, poverty, and environmental injustice or to leave school altogether.322
In 2015, more than 99% of deaths due to household air Of all deaths due to toxic occupational exposures,
pollution and approximately 89% of deaths due to 92% occur in low-income and middle-income countries.
ambient air pollution occurred in low-income and This distribution reflects the fact that high-income
middle-income countries.319,320 Several cities in India and countries have largely solved their worst problems of
China record average annual concentrations of PM2·5 occupational exposure and reflects the international
pollution of greater than 100 μg/m³, and more migration of polluting industries from high-income
than 50% of global deaths due to ambient air pollution countries to poor countries.323,324
in 2015 occurred in India and China. As a consequence of globalisation and production
Ambient air pollution in rapidly expanding mega-cities outsourcing, pollution and pollution-related disease have
such as New Delhi and Beijing attracts the greatest public become planetary problems.325,326 Dumping hazardous
attention; however, WHO documents that the problem of materials produced in high-income countries in poorer
ambient air pollution is widespread in low-income and countries is a clear intersection between global pollution
middle-income countries and finds that 98% of urban and environmental injustice. This dumping includes
areas in developing countries with populations of more shipment of pesticides, industrial waste, and toxic
than 100 000 people fail to meet the WHO global air quality chemicals that are no longer permitted in North America
guideline for PM2·5 pollution of 10 μg/m³ of ambient air or the European Union to poor countries. For example,
annually. in 2006, 500 tons of toxic waste were transported from
Household air pollution offers an even starker example Amsterdam in the vessel Probo Koala and dumped in
of the strong links between pollution and poverty.57 sites around Abidjan, Côte d’Ivoire. The toxic gas
Deaths due to household air pollution are highly produced by the release of these chemicals resulted in
concentrated in the world’s poorest countries.57 An 17 deaths and in more than 100 000 cases of respiratory
estimated 3 billion people in low-income and middle- and gastrointestinal disease.327,328 A second example has
income countries, mostly in rural communities, use been documented at a large electronic waste site at
solid fuels (firewood, biomass, or charcoal) and Agbogbloshie in Accra, Ghana.329 This site contains
traditional stoves for heating and cooking.57 In sub- thousands of broken computers and other electronic
Saharan Africa, for example, firewood is the main source components shipped from European countries in
of fuel, as it is in many parts of south Asia. The use of containers labelled “secondhand goods”; the European
biomass fuels is closely linked to gender inequality. Union allows export of genuinely reusable electronic
Without access to the cleaner fuels and cookstoves goods, but the material shipped to Agbobloshie is usually
available to many urban households, rural women in broken beyond repair and hardly reusable.326 Electronic
these regions and their children are disproportionately waste dumpsites in poor neighbourhoods can be found
exposed to toxic fumes from smoky open fires. As they worldwide, especially in the Asia-Pacific region. It is
cook food for the family or study by the light of the stove, estimated that the global electronic waste market will
these women and children court sickness and premature quadruple in the next decade, from US$9·8 billion
death in a way their urban counterparts do not. in 2012 to $41·4 billion in 2019.330
International action to address the global problem of
For the Basel convention see Water pollution, poverty, and environmental injustice dumping led to development of the 1989 Basel
http://www.basel.int/ Poor water and inadequate sanitation and hygiene are Convention on the Transboundary Movement of
also highly concentrated in the world’s poorest countries. Hazardous Wastes and to conventions on persistent
An estimated 2·5 billion people lack access to a basic organic pollutants,80 pesticides, mercury, hazardous
toilet; 1 billion people defecate in the open; and waste, and chemicals. The European Union also joined
748 million people lack clean drinking water.321 Poor the cause and has issued directives to limit international

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 The Lancet Commissions

dumping that include restrictions on hazardous of the World Commission on Environment and
substances and on waste electrical and electronic Development on “our common future” stated that
equipment, both promulgated in 2002. Although these sustainable development must assure the poor that they
conventions and directives are limited by weak receive a fair share of the resources required to sustain
enforcement and by structural impediments, such as the their economic growth.333 With the growing recognition
requirement in the Rotterdam Convention for complete that pollution not only exacerbates poverty but leads to For the Rotterdam convention
unanimity amongst all participating countries before a environmental injustice, sustainability of development see http://www.pic.int/
pollutant can be proscribed, they have, nonetheless, is now also increasingly linked to equity. As observed in
helped to slow the global movement of toxic substances the Human development report 2011 by the United
and reduce toxic pollution. Nations Development Programme,334 sustainability and
equity might not always be mutually reinforcing
Pollution, poverty, and the UN’s SDGs (although they can sometimes be), and the most feasible
The SDGs were adopted by the United Nations in alternative solutions might require explicit and careful
September 2015 to guide the international development consideration of the trade-offs involved. Such an
agenda until 2030. The SDGs are intended to advance approach to pollution control will not only yield positive
human dignity in countries around the world.331 It is of synergies between sustainability and equity but also
note that the predecessor to the SDGs, the Millennium ensure that the SDGs regarding poverty, pollution, and
Development Goals that guided global action until 2015, environmental justice are comprehensively met.
made no mention of pollution at all. By contrast, SDGs The Regional Action Plan for Intergovernmental
focus on the issue to an extraordinary extent, as noted in Cooperation on Air Pollution for Latin America and the
the introduction, and as befits an issue so integral to the Caribbean, prepared by UN Environment Programme in
fight against poverty. The main provision is, appropriately, the context of the Latin America and the Caribbean
in SDG 3 on good health and wellbeing, where SDG 3·9 Forum of Ministers of Environment is an example of a
commits the world community, by 2030, to “substantially high-level plan that sets out common directions for
reduce the number of deaths and illnesses from national governments to work together on broad
hazardous chemicals and air, water, and soil pollution issues.335 This Action Plan promotes collaboration
and contamination”.332 The other pollution-specific goal is towards the creation and adoption of national and local
SDG 6 on water and sanitation, in which SDG 6·3 calls, policies and programmes to reduce emissions of key
by 2030, to “improve water quality by reducing pollution, pollutants and to achieve improvements in urban air
eliminating dumping and minimizing release of quality in the region. The Action Plan covers broad
hazardous chemicals and materials, halving the supportive activities such as technical assistance, policy
proportion of untreated wastewater and substantially cooperation, methods, research, and awareness raising
increasing recycling and safe reuse globally”. and monitoring. The Regional Action Plan will support
However, the SDGs do not leave the issue there. Given and encourage the national and local administrations to
the close linkages between poverty and exposure to toxic develop and implement practical local plans to reduce
pollution and the need to reduce, if not eliminate, both, the effects of air pollution.
the SDGs seem to recognise that some actions to achieve
the broader goals, such as SDG 1 (end poverty) and Research recommendations
SDG 2 (end hunger), could, if unchecked, result in To reduce the inequitable exposure of the poor and the
exacerbation of pollution exposures. Hence, pollution marginalised to pollution, this Commission recommends
control must be central to agricultural and industrial two key strategies. First, we recommend funding of
development, if development of these is to be truly research to document and map the disproportionate
sustainable. To this end, the SDGs make repeated effects of pollution upon the poor, women, and girls be
references to preventing and reducing pollution. These adopted as a priority by international health agencies.
include SDG 2·4 (improving soil quality), SDG 7 (clean Additionally, a special focus should be placed on overseas
energy), SDG 9·4 (clean technologies and industrial development assistance to protect indigenous peoples and
processes), SDG 11 (sustainable cities and communities), their communities from pollution and its harmful effects.
SDG 12 (responsible consumption and production), and
SDGs 14–15 (water and land conservation). Achievement Section 4: Effective interventions against
of these SDGs will also positively affect environmental pollution: priorities, solutions, and benefits
justice and fulfil SDG 10 (reduced inequalities). A key message of this Commission report is that, with
Importantly, measures to reduce greenhouse gas leadership, resources, and a clearly articulated, data-driven
emissions and short-lived climate pollutants, such as strategy, much of the world’s pollution can be controlled
black carbon, will help achieve SDG 13 (climate action). and pollution-related disease prevented. Strategies to curb
The SDGs are explicitly about sustainable development pollution have been developed, field-tested, and proven
but, for development to be sustainable, it must both cost-effective. These strategies were developed initially in
combat poverty and ensure equity. In 1987, the Report high-income countries and are now moving into

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 The Lancet Commissions

middle-income countries. They are based on law and air and water quality and improvements in health. The
regulation, rely heavily upon technology, are subjected to health benefits include reductions in disease incidence
For the Minamata convention continuous evaluation, are backed by strong enforcement, and prevalence, improvements in children’s health,
see http://www. and incorporate the polluter-pays principle. These reductions in the numbers of premature deaths, increasing
mercuryconvention.org/
programmes are held accountable to targets and longevity, and substantial enhancements in quality of life.
timetables. These successful, effective strategies for Indirect benefits include enhancing gender equity,
pollution control can be used as models and adapted to alleviating poverty, increasing tourism, improving
local circumstances in cities and countries at every level of education, and enhancing political stability. Pollution
income. Their application can enable developing cities and control makes cities more liveable and attractive, benefits
countries to leapfrog over the worst of the human and ecosystems, improves the economy and, when coupled
ecological disasters that have plagued economic with efforts to transition to clean fuels and to control
development in the past. emissions of greenhouse gases, pollution control can help
A second key message is that control and prevention of to slow the pace of global climate change and accelerate
pollution provide several benefits, both short-term and the transition to a cleaner, more sustainable, circular
long-term, for societies at every level of income. The direct economy.81,336,337
benefits of pollution mitigation include improvements in These many benefits of pollution control underscore the
reality that pollution is much more than merely an
Panel 8: China’s recent experience environmental challenge; pollution is a profound and
pervasive threat that affects many aspects of human health
In its 13th Five-Year Plan, for 2016, the Government of China acknowledged the dangers and wellbeing.
posed by pollution344 and set specific targets for environmental improvement and Pollution control today builds on the successes of the
restriction of resource use. past. The industrially developed countries were the first
Air pollution to control pollution, and many of their control strategies
• China adopted The Air Pollution Prevention and Control Law in 1987. This law and its were adopted in the aftermath of environmental and
subsequent revisions have resulted in an 10% national decline in particulate matter public health disasters caused by pollution. Thus, in
less than 2·5 µm (PM2·5) between 2014 and 2016, despite extremely high particulate mid-19th century London, UK, putrid contamination of
concentrations in certain cities such as Beijing.345 A 2016 amendment to the law the River Thames and recurrent epidemics of cholera
explicitly mentioned, for the first time, the connection between environmental led to regulation of public drinking water sources338 and
protection and public health.346 to the construction of large conduits for the removal of
• China has increased its reliance on non-fossil energy sources (predominantly human waste and industrial pollution that now form the
renewables and nuclear) from 9·4% of total energy use in 2010 to 12·0% in 2015, Thames Embankment.339 Episodes of severe air pollution
surpassing the 12th Five-Year Plan target of 11·4% by 2015. The most recent Five-Year with substantial loss of life, such as the Great Fog
Plan347 aims to increase non-fossil energy use to at least 15% by 2020, and to at of London in 1952,340 and the Donora, Pennsylvania
least 20% by 2030. episode in the USA led to the passage of clean
• China has implemented a vast network of stations to monitor air quality in more than air legislation. Occupational and mining disasters
400 cities. The capacity to track emissions has been central to developing policy and catalysed the development of worker health and safety
implementing data-driven regulatory frameworks.348 legislation. The discovery of contaminated toxic sites in
the USA at Love Canal in New York and the Valley of the
Water pollution Drums in Kentucky led to legislation mandating
• China’s most recent water pollution legislation, the Water Ten Plan, was adopted in clean-up of hazardous waste sites—the Superfund
April, 2015.349 This plan sets metrics and targets for ten major polluting industries. legislation.175 An epidemic of congenital methylmercury
Among key targets to be met by 2020 are: more than 70% of water in seven key rivers poisoning in Minamata, Japan341 led to global action to
shall reach Grade III or above; more than 93% of urban drinking water sources shall protect human health and the environment against
reach Grade III or above; reduce groundwater extraction and control groundwater mercury and culminated in adoption of the Minamata
pollution; and use of groundwater falling under the “very bad” category shall decrease Convention.198
to around 15%. In response to the rapid, poorly controlled growth of
• The Ministry of Environmental Protection estimates that the Water Ten Plan will boost cities and the global spread of industrial production and
GDP by ¥5·7 trillion (US$91 billion), with a ¥1·9 trillion benefit to the affected chemically intensive agriculture, low-income and middle-
industries.350 income countries have become increasingly engaged in
Soil pollution pollution control. Targeted interventions to control water
• The 13th Five-Year Plan calls for the establishment of laws to monitor, prevent, and pollution, improve sanitation, and reduce waterborne
remediate soil pollution. The goal is to make 90% of polluted arable land safe for diseases were among the earliest efforts to control
agricultural use by 2020, increasing to 95% by 2030.351 The Ministry of Environmental pollution in low-income and middle-income countries,
Protection estimates that the actions of the 13th Five-Year Plan could add ¥2·7 trillion and began as early as the 1950s. Bangladesh has long been
($411 billion) to the nation’s GDP and create around 2 million jobs.352 in the forefront of this work,342,343 China has made
• The Five-Year Plan also details a nationwide soil quality monitoring programme.353,354 extraordinary progress in control of water pollution and
prevention of waterborne infectious disease (panel 8),344–354

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 The Lancet Commissions

and Peru has embarked on a programme to improve mine Additional benefits are produced by controlling urban
drainage.355 air pollution by upgrading public transportation,
Air pollution control programmes are developing in encouraging active transport (walking and cycling),
cities in several low-income and middle-income reducing sulphur content of motor fuels, promoting use
countries, including Mexico City,356 Ulaanbaatar,357 and of low-emission and zero-emission vehicles (while
New Delhi.358 China is embarking on a national effort to concurrently cleaning the energy supply), and restricting
reduce air pollution that includes a plan to dramatically car and trucks from city centres. These interventions not
increase reliance on non-polluting, renewable energy only improve air quality, but will also reduce childhood
sources, and is on track to nearly triple its solar capacity asthma, reduce incidence of cardiovascular disease,
between 2015 and 2020, adding 15 to 20 GW of solar stroke, and diabetes in adults, and enhance the quality of
capacity per year.123,359–361 urban life.372,373
Most countries now have programmes in place to Another benefit in controlling pollution is that
address some aspects of pollution, and almost all have remediation of highly contaminated sites in densely
established frameworks for regulatory control of industry,
although staffing, resources, and enforcement capacity
are variable.362 This Section of the Commission report Panel 9: Partial successes in reducing air pollution from cookstoves
enumerates the benefits of pollution control, describes China’s National Improved Stove Programme
key elements of successful pollution control strategies • China’s National Improved Stove Programme (1982–92) has distributed 180 million
and the responsibilities of stakeholders, and it concludes improved cookstoves to people in rural areas of China, in conjunction with provincial
with recommendations. programmes. This programme is among the world’s largest and most successful
national programmes for improved stoves.363 The initiative aimed primarily to increase
The benefits of pollution control efficiency and thus reduce the use of biomass fuel. Middle-income households were
Examples of pollution control and its benefits are targeted in this programme, and households were expected to purchase the stoves
presented in this section, panels 9 and 10,119,131,363–367 and in themselves.364 All improved cookstoves had chimneys, and some had blowers for
the appendix (pp 63–107). more efficient combustion.
One benefit afforded by pollution control is reduction • With regard to the primary objective of achieving better fuel efficiency, China’s
of household air pollution by providing liquefied programme lowered household air pollution levels, but, unfortunately, this
petroleum gas and bio-gas and by providing affordable reduction was not sufficient to meet China’s indoor air quality standards and
electricity that is produced by non-polluting, renewable substantial exposures remained. A fundamental problem was that the stove designs
energy sources to replace wood chips, coal, charcoal, and did not reduce emissions, but focused on fuel efficiency and, at best, moved the
cow dung as cooking fuels. These interventions not only smoke outside, where it still caused exposures. Nevertheless, the programme
reduce exposures to airborne particulates, thereby showed that large-scale effects could be achieved by a well organised and well
improving health, but they also produce short-term and supported effort that was coordinated nationally, but with substantial local
long-term economic returns to local communities participation. Additionally, an epidemiological study of household stove
because households (especially women) are able to spend improvement that was undertaken in a cohort of 21 232 Chinese farmers followed
less time collecting wood, or processing dung for from 1976 to–1992 showed that stove improvement was associated with a greater
cooking, and thus have more time to devote to than 30% reduction in incidence of lung cancer.365
economically productive activities (for women) or
education (for girls).368 Indian National Programme on Improved Chulha
A second benefit is improvements in sanitation that • A second national programme at a similar scale to the Chinese programme, the Indian
are achieved by providing clean water and toilets. These National Programme on Improved Chulha stoves, which operated from about 1984
interventions not only reduce prevalence of waterborne to2001, was reported to have had little effect on fuel efficiency nationally, and even
disease but they also allow more children, especially less in reducing long-term exposure to smoke.366
girls, to attend school.369 These improvements benefit Gyapa Stoves Project, Accra, Ghana
tourism and help lift the economy in developing • An African example of a successful cookstove intervention was the Gyapa Stoves
countries, since a reputation for clean beaches, an Project in Accra, Ghana. In 2000, 95% of Ghanaian households used solid fuels to
unpolluted environment, biodiversity, and safe food and power stoves.367 This was a much higher percentage than the estimated 73·4% for the
water can help to lure discerning tourists and increase rest of northwest Africa. Many homes in Ghana were poorly ventilated and the burning
their spending.370 of solid fuels, such as savannah wood, was inefficient and contributed to deforestation
Another benefit is seen in shifting the energy sector and ecosystem imbalance. To address this problem, EnterpriseWorks/VITA, Shell
from coal-fired power plants to cleaner gas-fired plants, Foundation, and USAID partnered in 2002 to implement a programme to replace
and, better yet, to low-polluting renewable energy sources traditional coal-pots with improved stoves called the Gyapa Stove. The Gyapa stove
such as wind, tidal, geothermal, and solar. These requires 50–60% less fuel than traditional stoves and produces less smoke. This project
interventions not only reduce pollution and improve the was unusual in that it aimed to create a sustainable business model that helped the
cardiorespiratory health of entire popu­lations, but they local economy by creating jobs to manufacture the stoves. In 2008, 68 000 stoves
will also sharply reduce greenhouse gas emissions, and were sold in Accra and Kumasi. Air quality was found to have improved by 40–45%.
increase the efficiency of electricity generation. 371

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 The Lancet Commissions

Panel 10: Cleaner fuels and indoor air health, and integrate pollution control into development
strategies are the first step to dealing with pollution.
In the past 2 years, major advances have made clean fuels more available in several
Defining and prioritising interventions enables a focus
countries. Examples of programmes to introduce cleaner fuels are the following:
on cost-effectiveness and creates roadmaps for
The Indian liquefied petroleum gas programme comprehensive solutions.
• In 2016, India set a goal of providing access to liquefied petroleum gas to 50 million The key societal underpinnings for successful pollution
additional poor families in 3 years through a large programme that was operated control at any level of development include courageous
through the national oil companies. In 2016, more than 10 million households have and visionary leadership by heads of government—
already been targeted through the national Give it Up campaign, in which middle class mayors, governors, and heads of state—along with an
families voluntarily give up their liquefied petroleum gas subsidy to a family who are engaged, informed, and empowered civil society. It is
below the poverty line, and corporate responsibility funds are earmarked for the also important that there be a shared societal
upfront costs. commitment to protecting human health and advancing
social justice and a carefully designed, evidence-driven
Ecuador’s electric induction stove programme
package of pollution control policies.
• In Ecuador, the national government has developed a major programme to change
Effective plans to control pollution require support
every traditional cookstove in the country to an electric induction stove. Electric
from many sectors of society and, therefore, must
induction stoves are 50% more efficient and faster than gas or normal electric
involve collaborations among many agencies and
cooking, and have other advantages, including improved safety. This transition is
organisations within and outside governments, and
possible because Ecuador has nearly universal electrification, much of it derived from
nationally and internationally. These stakeholders must
hydroelectric projects. Other countries, including Paraguay and Bhutan, also have
be fully inte­grated into a city’s or a country’s development
hydropower potential, and both are currently undertaking preparatory studies.
agenda. If they are to be successful, these efforts must
• Ultimately, it is clear that any household use of solid fuel has negative effects on
include not only ministries of health and environment,
health and that the eventual goal should be the elimination of solid fuel and its
but also ministries of finance, energy, industry,
replacement with cleaner sources of energy. In the interim, in areas and countries
agriculture, and transport. Pollution control policy
where elimination of solid fuel is not immediately possible, transition to the cleanest
cannot exist in isolation.
biomass stoves should be strongly encouraged.119 Millions of lives can be extended
Successful strategies rely on a mix of primary
every year among the poorest populations in the world by such a transition, but the
prevention approaches that eliminate pollution at source,
challenges are still great.
coupled with downstream pollution control technologies,
• Progress in implementing clean energy is tracked by the International Energy Agency
such as filters and stack scrubbers, that remove pollutants
at both the national and sectoral levels, which has shown some advances in the
from the waste stream after they have already been
generation of cleaner energy nationally, but inadequate progress in meeting
formed. Examples of highly transformative strategies for
transportation goals. The International Energy Agency concludes that “strong actions
pollution control that are based on primary prevention
linked to stated targets need to be pushed forward to achieve the clean energy
include shifting the mix of energy sources in a city or
potential”.
country away from polluting fuels toward non-polluting,
renewable fuels;377 use of safer feedstocks in industrial
populated areas will reduce the prevalence of poisoning production, such as feedstocks produced by the
by toxic chemicals and heavy metals, will enhance land burgeoning technologies of green chemistry, which
values, and encourage urban redevelopment. Brownfield eliminate use of hazardous feedstuffs and production of
remediation projects have been successful in covering materials that can cause injury to human health and the
the expense of clean-up by the private sector.200 environment;378 incentivising the adoption of clean
Reductions of exposures to lead from pottery production technologies; and enhancing access to
(panel 11)374–376 and paint will reduce childhood lead efficient, affordable public transportation.379 Primary
poisoning and thus enhance the intelligence, creativity,169 prevention can also be achieved by banning highly
and economic productivity of entire societies.46 hazardous and carcinogenic materials such as asbestos,
A final benefit of pollution control results from bans on benzene, PCBs, and DDT, as has been successfully
the production and use of asbestos, which will reduce achieved in many countries. Primary prevention of
asbestosis, lung cancer, and malignant mesothelioma pollution based on the elimination of pollution at source
and will therefore produce substantial gains in economic is inherently more effective than downstream control
productivity by preventing serious illness and premature technologies, such as stack scrubbers or water filters that
death and will also result in reductions to health-care reduce the amount and toxicity of pollutant emissions
costs. In conclusion, well designed and executed pollution after they have already been formed. Primary prevention
control strategies will advance attainment of many of the of pollution at source is also essential for accelerating
UN’s SDGs.16 transition to a more sustainable, circular economy.
Further elaboration of these themes and case studies on
Essential components of pollution control programmes pollution control are presented in the appendix
Planning processes that prioritise interventions against (pp 63–82). The key elements of all successful pollution
pollution, link pollution control to protection of public control plans are discussed in the following sections.

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 The Lancet Commissions

Establish ambitious but attainable targets and

timetables for pollution control Panel 11: Mexico’s challenge: combating lead pollution
Targets and timetables are essential for programmes to Pottery is produced in more than 10 000 artisanal, mostly small scale, workshops
control pollution; these provide benchmarks and metrics across Mexico. Most workshops use inexpensive, low temperature kilns that are not
for assessing progress towards pollution control. This capable of firmly binding lead glaze to the clay. Lead is therefore released from the
Commission recommends establishing specific glaze into food. Lead has been used for centuries to glaze pottery in Mexico, and
numerical targets and deadlines for pollution control and pottery is a pervasive source of population exposure to lead.374–376 Beginning in
prevention of pollution-related disease in every city and the 1990s, the Mexican Government determined that prevention of lead poisoning
country, along with incentives for meeting deadlines and must be a national public health priority and launched a multipronged approach
penalties for failing to meet them. strategy that included interventions against the use of lead in pottery.
Pollution control targets must be appropriate for each The following are key elements of the control strategy:
country’s level of income and development and guided by • Undertake a comprehensive survey of artisanal workshops, to identify those using
the WHO pollution control targets. These targets will be lead-based glazes
most effective when they are focused on pollution sources • Track producers and distributors of lead-based glaze and distributors and producers of
that are established to be priorities and must be integrated lead-free glaze to understand the routes to market
into commitments to meet the SDGs and to reduce • Notify producers and intermediaries that Mexican federal standards impose an
greenhouse gas emissions. absolute prohibition on the use of lead-based glazes in ceramics used for preparing or
serving food
Prioritise interventions • Engage with producers of lead-free glaze to assist them in improving their product to
It is crucial that pollution control programmes establish better match the appearance of lead-glazed ceramics and to facilitate distribution
and adhere to a robust, systematic, and transparent • Create market incentives for use of lead-free ceramics
system for prioritising pollution control that is based on • Strengthen enforcement of the federal lead glaze standard through improved
assessment of health effects, environmental damages, monitoring and targeted inspections
and cost-effectiveness of control of various pollution • Launch a broad communications campaign to educate pottery makers and the public
sources. A robust system for assigning priority will avoid about the dangers of lead-glazed pottery and to advertise the high quality and
the pitfall of prioritising interventions on the basis of enhanced safety of lead-free glazes
political expediency380,381 or because they happen to be an
item in the evening news.
Quick, highly visible successes are extremely important that might be specific to a specific culture), and
in gaining public support for a pollution control occupational risks, including asbestos; (6) review the
programme. It is therefore essential that intervention benefits of interventions against pollution and health
plans identify pollution sources whose early control will improvement, considering the roles of gender equity,
result in quick wins. Rapid, measurable improvements in alleviation of poverty, slowing of the pace of climate
public health, especially in the health of children, are change, increased tourism, economic growth, improved
powerful levers for building public and political support. education, and political factors (panel 12);382–387 (7) bring all
Key steps in ranking pollution sources in terms of their relevant agencies into the prioritisation process,
health effects, a key process of an effective health and including senior representatives of ministries of health,
pollution action plan, are as follows: (1) examine the environment, industry, development, finance, transport­
frequency and severity of disease attributed to various ation, energy, planning, and legislative branches, and civil
types of pollution using data from national sources and society, if possible; and (8) begin implementation with
data from the GBD study, and use this information to those programme areas where past experience will be a
prioritise interventions against pollution; (2) for each type strong return on investment, as measured by benefit to
of pollution apportion the relative contributions of public health and the possibility for early victories:
different exposure sources; (3) evaluate the efficacy of examples include removing lead from paint or pottery,
new programmes that have potential to reduce health cleaning up highly visible toxic hotspots, banning
effects from each pollution source, review existing asbestos, or publishing a ranked list of the most important
programmes for efficacy and reach, and identify pollution sources in a city or country, involving the media
performance gaps and legal, regulatory, and enforcement in advertising early successes.
gaps; (4) identify potential interventions (new and
expanded) for those exposures for which there are Establish robust systems for environmental monitoring
dramatic effects on health outcomes and measurable and public health tracking
indirect benefits, and evaluate these interventions for High quality metrics that monitor pollution and track
cost-effectiveness; (5) focus not only on high-visibility progress towards national and local pollution prevention
sources of pollution, but also on pollution sources that and disease control goals are essential to the success of
historically have received less attention, such as household any health and pollution action plan. Early establishment
air pollution, contaminated sites, lead (including lead in of public health and environment monitoring systems
pottery glazes, lead in paint, and lead from other sources should therefore be a priority. Evidence-driven updates at

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 The Lancet Commissions

negative (ie, polluter-pays) and positive (ie, beneficiary-

Panel 12: Cost-effective policies to improve access to safe water and sanitation pays) ways. These scenarios can be analysed and
Disinfection kits for home drinking water and ceramic filters are low-cost technologies juxtaposed against a scenario in which no changes are
for purifying drinking water in rural households without access to safe water. Latrines are made, to identify more sustainable pathways.388–390
a cost-effective solution to open defecation. Chlorination of home drinking water costs Monitoring air pollution typically involves a combination
between US$50 and $125 per lifeyear saved; ceramic filters cost between $125 and of ground-level monitoring and atmospheric dispersion
$325.382 modelling to determine air pollution concentrations and
their distribution.391,392 Low-cost air pollution monitors to
A seemingly attractive solution to improving access to safe drinking water and improving
measure levels of pollutants on the ground represent an
sanitation would be for donors to distribute chlorination kits, filters, and latrines free of
important advance.393 The use of satellite-based remote
charge. Empirical studies have shown, however, that this approach is ineffective and
sensing to estimate levels of air pollution is gaining
wastes resources because not all households will use disinfection kits for home drinking
increased attention, although the coverage and
water, even when they are provided free of charge. A better solution would be to charge
interpretation of satellite data is still being refined.394
for the technology and subsidise the purchase. Studies suggest that people who pay
The importance of accurate epidemiological data for the
something for a product are more likely to use it.383 Another effective approach is to
prevention and control of disease has been recognised
distribute vouchers to households that can be redeemed when a kit is purchased.384
since the work of pioneers such as William Farr,338 who
Requiring households to redeem the voucher separates the households that are likely to
documented patterns of disease and death during the
use the kit from those that are not.
great cholera epidemic in Britain of 1848–49. National and
Lowering the price of ceramic drinking water filters and latrines, which have a large international programmes for the systematic collection,
upfront cost, can substantially increase their uptake.385,386 However, subsidies can be consolidation, evaluation, and rapid dis­semination of data
expensive. Microfinancing schemes that spread the cost of water filters or latrines over on morbidity and mortality have become a core
time have been effective in increasing uptake at a lower cost to funders than total component of the global public health infrastructure.395,396
subsidies.387 This approach allows a larger number of households to be covered for a given There are still many gaps in knowledge, especially in
expenditure of funds and has the added benefit of gaining household and community poor countries with insufficient resources for systematic
ownership of the improvement. Composting toilets might have some advantages in data collection.397 Therefore, only a third of the world’s
some circumstances, for example where there is no sewage system. population and only 5% of Africa has usable information
on causes of death. China and India have both been
regular intervals are crucial. We encourage governments redeveloping their verbal autopsy registration systems, in
to consider creation of a central data coordination system which cause of death is based on data provided by field-
that acts as a focus and point of reference for all data on trained personnel, and these data systems are im­
pollution—household, ambient, and occupational. This proving.398 Limitations in the quality of public health data
system should provide validated information and reduce the accuracy of global estimates of the burden of
synthesised reports to the public and could be a basic disease related to pollution.
source of raw data for regulators, researchers, and
policy makers. Accountability
The economic costs of pollution include not only Accountability is of paramount importance, and
productivity and health costs, but also costs resulting programmes for pollution control and prevention must
from destruction of ecosystems and loss of key species be continuously assessed and held accountable to targets
such as pollinators and fish stocks that convey great and deadlines using both process metrics (the number of
benefits to human beings and are crucial to sustaining regulations established, monitors installed, or tests
life on earth. Like the economic losses that result from performed) and outcome measures (reductions in levels
pollution-related disease, the costs of environmental of pollution in air and water, or improvements in health
degradation are mostly invisible. These costs are not status). Monitoring data and data on progress toward
captured by standard economic indicators and are buried achieving targets and timetables must be made publicly
within the uncounted, unpaid costs of modern industrial accessible to citizens and civil society.399–401
and agricultural production. Carefully selected metrics provide an essential
For the Health Effects Institute The Economics of Ecosystems and Biodiversity is a foundation to monitoring and accountability. The Health
http://www.wsp.org/ global initiative sponsored by the UN Environment Effects Institute has developed a taxonomy of metrics
Programme that addresses the challenge of quantifying that can be used to track the progress of pollution control
the economic losses that result from environmental programmes. Regarding air pollution programmes, a
degradation. This initiative applies a structured approach summary of metrics suggested by The Health Effects
to valuation of ecological losses, explores the visible and Institute include regulatory metrics, emissions metrics,
invisible costs and benefits that flow from ecosystems and pollutant metrics.399
into the economy, and evaluates how these flows might
change under different policy interventions. The Establish a sound chemicals management programme
initiative examines the potential consequences of policy A high proportion of the 140 000 chemicals and pesticides
reforms that realign incentives and fiscal policy in both in commerce have never been adequately tested for safety

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 The Lancet Commissions

or toxicity.36 Information on potential toxicity is publicly from stationary pollution sources include legally
available for only about half of the commercial chemicals mandated reductions in emissions of oxides of nitrogen
with high production volume that are in widest use, and and sulphur, mandatory reviews of emissions from new
information on developmental or reproductive toxicity is sources, and source-specific emissions standards.
available for fewer than 20% of these widely used Application of these standards has resulted in reductions
chemicals.402 Because of the failure to test chemicals for in levels of major air pollutants by more than 70% in
toxicity, populations around the world today are exposed California, produced measurable improvements in
to hundreds of untested chemicals and recurrent children’s respiratory health,44 and has accomplished
episodes of disease and environmental degradation these goals in a time when the GDP has risen sharply,
have resulted.36 thus documenting, yet again, that control of pollution
To address the problem of population exposure to does not stifle economic development or societal
untested chemicals of unknown hazard, high-income advancement.43
countries are beginning to develop chemicals manage­ Application of the polluter-pays principle is an
ment programmes.403,404 Mandatory testing of chemicals important component of environmental regulation. The
for safety and potential toxicity, coupled with the imposition of legally mandated requirements that
imposition of controls or bans on the manufacture and polluters pay for their pollution and its clean-up create a
use of toxic chemicals are the two linchpins of these powerful incentive to adopt new, more efficient
policies.36 High-income countries have the resources to production technologies that will reduce pollution.
establish their own chemical testing programmes such Application of the polluter-pays principle forces
as those supported by the European Chemical Agency and polluting industries to acknowledge and account for the For the European Chemical
the US National Toxicology programme. Low-income previously externalised costs of pollution. Lastly, Agency see https://echa.europa.
eu/information-on-chemicals
and middle-income countries must rely on results from application of the polluter-pays principle can generate
those testing agencies and on findings on chemical revenues that help to support the costs of pollution
safety and toxicity promulgated by international bodies control programmes.
of high repute that are independent of the chemical As a corollary to imposing the polluter-pays principle, it
manufacturing industry such as WHO’s Inter­national is important that governments also end subsidies to
Programme on Chemical Safety,109 the International polluting industries such as coal, oil, gas, and chemical
Agency for Research on Cancer, UN Environment production. When polluting industries are granted
Programme,101 and the Ramazzini Institute. subsidies by governments, these governments and the For the Ramazzini Institute see
taxpayers who support them are indirectly paying to be http://www.ramazzini.org/en/
Establish and enforce environmental laws and polluted.
regulations and base regulation on the polluter-pays A competent, independent, non-corrupt judiciary
principle provides an essential back-up to environmental laws and
A strong body of law405 and clear, transparent, impartially regulation.407 An independent judiciary is needed to
enforced regulations are crucial components of policy ensure the fair and impartial application of regulatory
packages for pollution control in all countries. standards and to protect people, especially indigenous
Experience in the USA documents the importance of people and their lands, from the damaging effects of
law and regulation in reducing pollution. Through polluting industrial activities. For further discussion on
national regulations established under the US Clean Air existing national and international chemical control
Act, the USA has reduced concentrations of six common legislation and agreements, see the appendix (pp 13–14).
air pollutants by 75% since 1970 while increasing GDP by
nearly 250% (figure 1).43 Every dollar invested in control Engage with the private sector
of ambient air pollution in the USA is estimated to yield This Commission emphasises that multiple stakeholders
US$30 in benefits (95% CI $4–88).45 should be involved in controlling pollution and
The State of California has also deployed a suite of preventing pollution-related disease, including top
laws and policies to control air pollution that, in some government leaders, but also key civil servants, business,
instances, are even stronger than US federal academia, and civil society. Carefully listening to the
regulations.406 California’s policies to reduce traffic- views of the most important and influential stakeholders
related air pollution include low-emission vehicle (both formal and informal) can help to ensure that all the
standards, a low-sulphur gasoline standard, diesel parties who can advance (or derail) programmes are
emissions standards, and financial incentives for taken into account.77
replacement and retrofit of high-polluting vehicles. Enlightened business leaders can be powerful
Additional policies that have been very successful advocates for pollution control and disease prevention.
include requirements for cleaner diesel fuels in marine The creation of incentives by governments for non-
vessels and railroad locomotives, and requirements for polluting industries can be powerful catalysts for
cleaner diesel fuels for stationary diesel engines and innovative action, as seen by the rapid development of
agricultural equipment. Policies to reduce emissions solar power systems and the organic food industry.

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 The Lancet Commissions

Support city-level initiatives to encourage active civil society, and health professionals—can make to
transport: reward walking and cycling, increase access pollution control.
to and affordability of public transport, and minimise
use of motorised transport Responsibilities of governments and major foundations
Cities now house more than half of the world’s population, National, state or provincial, and city governments are
a fraction that is growing rapidly, are responsible for powerful actors in efforts to control pollution and prevent
75% of greenhouse gas emissions, and account for 85% of pollution-related disease. Governments in countries at all
global economic activity.408,409 Cities, especially rapidly levels of income have made remarkable victories against
growing cities in low-income and middle-income pollution.
countries, have some of the world’s highest concentrations Leadership by the head of government—the President,
of ambient air and chemical pollution and the highest Prime Minister, Governor or Mayor—is of the utmost
prevalence of disease caused by these forms of pollution. importance. Heads of government are uniquely well
Important initiatives are now underway in cities around positioned to educate the public and the media about the
the world to reduce emissions of both pollutants and importance of preventing pollution-related disease and
greenhouse gases, and to make cities more resilient and can create a vision for a country or a city without pollution.
sustainable. Several organisations at the local, national, These heads of government also have the power to bring
and global levels have contributed to this progress and they together several agencies within their governments—
include the Regional Plan Association in New York, the health, environment, finance, transport, industry, energy,
World Bank’s Eco2Cities initiative, and the UN Department and development—to make pollution control a priority.
of Economic and Social Affairs urbanisation planning Heads of government also have great power to address
programmes. the so-called “political economy” of pollution.415 Much
Mayors have been powerful actors in efforts to control pollution, especially industrial pollution, is produced by
pollution and pollution-related disease, and visionary vested interests that profit by externalising the costs of
mayors have resurrected formerly blighted cities and production and discharging unwanted wastes into the
turned them into places of extraordinary beauty and environment. These individuals and organisations will
high livability.410 This Commission commends initiatives typically resist efforts to control pollution. Heads of
to launch urban design and planning initiatives that government have unique power to overcome this
reimagine cities through building green spaces, parks, resistance and to negotiate just settlements that reduce
and walkways, encouraging active transport (such as pollution and achieve social justice. Experience in
walking and cycling), and increasing access to and countries at all levels of income shows that pollution
affordability of public transport. Such programmes are control can be accomplished in the face of powerful
discussed in detail in the 2016 Lancet Series on City opposition, but that the task is seldom easy and requires
Planning and Population Health.411.412 committed leadership and broad partnerships across
civil society.
Willingness to confront vested interests
Planning and prioritisation processes regarding health Responsibilities of international agencies
and pollution do not always proceed smoothly. The International development organisations, including UN
analyses regarding trade-offs between economic agencies, multilateral development banks, bilateral
development and pollution are nuanced and vary funding agencies, private foundations, and non-
substantially from industry to industry and country to governmental organisations, have important respon­
country. In general, when public health externalities are sibilities in pollution control and prevention of
included in the assessment, even primary industries like pollution-related disease that complement and extend the
heavy manufacturing and mining achieve better long- role of governments. These agencies should elevate
term macroeconomic performance when strong controls pollution prevention within the agendas of international
for pollution management are in place.413,414  However, development and global health and substantially increase
these analyses can be complex and often contentious. the resources they devote to pollution, establishing it as a
Projections of growth rates and of the burden of priority in funding mechanisms.
pollution-related disease should look at sliding ranges of These agencies should build on existing global data
benefit, since low-polluting industries might provide platforms to develop a central platform to monitor and
substantial net benefits to a community. Heads of coordinate information on all forms of pollution globally,
government who successfully confront vested interests, and should consider convening a bi-annual conference
bring agencies together, reduce environmental injustice, on pollution.
control pollution, and prevent pollution-related disease International agencies should also provide resources to
can reap great praise, build a legacy, help the world reduce pollution-related disease in low-income and
achieve the SDGs, and earn an honoured place in history. middle-income countries by:
The next section of this Commission report outlines the (1) encouraging the development of action plans
contributions that various stakeholders— government, regarding health and pollution, both nationally and

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 The Lancet Commissions

regionally, and of specific pollution control projects that

set time targets; (2) building data tracking systems to Panel 13: Case study: the power of civil society in controlling urban air pollution
collect information on pollution and disease; National and city governments have key roles in solving pollution problems. But
(3) supporting direct interventions against pollution governments cannot act alone. The political will to create, implement, and sustain
where such actions are urgently needed to save lives; successful pollution control policies over the long term requires the involvement of
(4) supporting interventions against pollution when citizens and civil society from many sectors. For example, in the winter of 2010–11, hourly
international action can leverage local action and air quality data from Beijing began, for the first time, to be publicly released by both the
resources; (5) building professional and technical Chinese Government and the United States Embassy. Soon thereafter, so-called
capacity within governments; (6) strengthening the “airpocalypses” during winter were documented, and Beijing’s air quality data began to be
capacity of universities in low-income and middle- discussed extensively in local and international media. This unprecedented access to
income countries to research environmental health real-time air quality data spurred software developers to build apps, pushing the data out
science and to train future health and environmental to millions. Through apps, social media, and general media outlets, the citizens of Beijing
professionals; and (7) supporting research programmes began, for the first time, to feel the air pollution problem in new, immediately accessible,
in environmental health science in partnership with and data-driven ways.
international academic institutions, including clinical
Since that time, China has invested in several programmes to mitigate air pollution.
and epidemiological studies to learn more about the
An expanded network of air quality monitors has been installed in Beijing and across the
undiscovered links between pollution and non-
country. Stricter regulatory policies have been implemented. New emergency action plans
communicable disease.
for high-pollution days have been developed and promulgated. Simultaneously, public
This Commission also calls on international
interest in pollution has not waned. In 2015, a popular television journalist, Chai Jing,
foundations and private donors to come together with
made an independent documentary “Under the Dome” that discussed the effects of air
governments around the world to establish dedicated
pollution on health, which went viral across the country and then the world. The number
international development funding specifically dedicated
of research publications on air pollution in Beijing have exponentially increased.
to the control of industrial, vehicular, mining, and
chemical pollution. Such funding will be most effective It is difficult to pinpoint the exact contributions of the policy, activism, technology,
in curbing pollution when its award is contingent upon research, and media communities to the successful pollution control effort in Beijing and
host countries’ implementation of the polluter-pays their effects on each other, but clearly their combined efforts are beginning to make a
principle and ending financial subsidies and tax breaks positive difference. Since 2014, government sources in Beijing have reported year-to-
for polluting industries. year decreases in annual average PM2·5 concentrations, and these findings are consistent
Several design options for dedicated pollution control with data for decreasing concentrations of PM2·5, as calculated from the monitor on
funding could be considered. The first is a new the United States Embassy.350
standalone fund analogous to GAVI (the Vaccine Although Beijing and China still have a long way to go to clean their air, this case study
Alliance) or the Global Fund to Fight AIDS, Tuberculosis documents the power of community involvement in pollution control and the crucial
and Malaria, in which private philanthropists and importance of data.
foundations provide start-up monies that are then
periodically replenished by governments. Another option
is a large trust fund that is hosted and managed by an represent poisoned populations. These organisations can
existing global institution, such as a multilateral highlight omissions in policy and advocate for change.416
development bank or a foundation. Alternatively, a virtual The best of these organisations provide solid policy
fund with contributions based on explicit agreements support to government action and take a long-term,
could be used. Finally, expansion of existing funding broad view of issues in their actions and recom­
instruments for international development assistance mendations.417
could be used, including funds specifically designated
for pollution control. Responsibilities of health professionals
Physicians, nurses, and other health professionals have
Responsibilities of citizens and civil society important responsibilities in helping societies to confront
Citizens and civil society organisations in countries and the challenges of pollution and pollution-related disease
cities around the world have important responsibilities as they have educated societies around the world about the
in the prevention of pollution, and non-governmental dangers of nuclear war and global climate change.
organisations have an important role in many countries Health professionals can begin by controlling pollution
in holding governments and companies accountable for and reducing carbon emissions from hospitals and
pollution control and prevention of pollution-related health-care facilities and by reducing pollution and
disease. Civil society organisations can contribute to carbon-intensive energy sources in their own lives.
pollution control by acting as watchdogs, by serving as Health professionals can support local, regional, and
representatives of the public interest, and by advocating national planning efforts and emphasise the links
for specific policies, regulations, and practices between pollution and health, develop new
(panel 13).350 Civil society groups, especially those that are transdisciplinary educational curricula that build
well funded and science-based, are a powerful force to knowledge of environmental health science and about

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 The Lancet Commissions

the health effects of pollution, and support research in Section 5: Conclusion—the way forward
exposure science, environmental science, health policy Pollution is the largest environmental cause of disease
research and health economics. and premature death in the world today. Pollution poses a
Partnerships between government, civil society, and massive challenge to planetary health15 and deserves the
the health professions have proven powerfully effective concentrated attention of national and international
in past struggles to control pollution. For example, in leaders, civil society, health professionals, and people
the ultimately successful effort to remove lead from around the world. Yet, despite its far-reaching effects on
gasoline, which was fiercely resisted for many years by health, the economy and the environment, pollution—
the lead industry, partnerships were built between especially the rapidly growing threat of industrial,
govern­ment agencies, health professionals, and civil vehicular, and chemical pollution in low-income and
society organisations. middle-income countries—has been neglected in the
international assistance and the global health agendas.
Interventions against pollution Strategies for control of industrial, chemical, and
Table 7 gives a brief overview of interventions, effective automotive pollution in developing countries have been
policy solutions, and institutional needs by pollution type. deeply underfunded.49,50
Strategies to improve water and sanitation and to reduce The goal of this Commission is to raise global awareness
indoor air pollution typically take the form of subsidies, of the importance of pollution, to end neglect of pollution-
especially in low-income countries, whereas policies to related disease, and to mobilise the resources and the
reduce pollution from stationary and mobile sources political will that are needed to effectively confront
usually rely on regulation, often in the form of standards. pollution.
Many of these strategies are policy-based and enforcement- To achieve this aim and advance progress toward the
based,418 not requiring large governmental investments. elimination of pollution, members of this Commission

Ambient air (outdoor) pollution Household air pollution Water pollution and sanitation Contaminated soil and water

Short-term Identify sources of key pollutants to enable Review current interventions—eg, Expand campaigns for Create inventories of polluted sites; test
interventions targeted interventions; target control of cleaner fuels and cookstoves—and handwashing and improved solutions with low-cost pilots for highly
stationary sources and install dust determine the most scalable strategies; sanitation; review and expand toxic sites; clean-up of high-impact sites;
management systems; establish monitoring targeted education campaigns; expand successful small-scale facilities; provide technical assistance and training
systems; mandate improved fuel quality and support for successful current systems develop planning for river
engine standards; and design and implement basin-wide construction of
effective enforcement systems sanitation facilities; initiate
construction of expanded
sanitation facilities
Medium-term Establish requirements for cleaner vehicles, Expand access to clean fuels and cleaner Expand individual household Establish disposal facilities; expand
interventions including testing stations (controls on diesel cookstoves; upgrade heating and other connections for water and sewers remediation projects; develop
vehicles, catalytic converters, converting to solid fuel systems remediation industry; support brownfields
gas); provide incentives for use of electric and pilot projects
hybrid vehicles; upgrade public transport fleets
Long-term Expand or upgrade public transit; facilitate Full (possibly universal) access to clean Upgrade existing drainage and Establish regional and national toxic sites
interventions active commuting by constructing walkways fuels sewage treatment remediation programmes
and cycle paths; create mechanisms to
discourage vehicle use
Policy and Undertake source apportionment to identify Define the target population; identify the Define the target population; Establish policy and targets; generate
institutions the most important sources of pollution; responsible government agency with a calculate the level of service specific policies for small and
establish and prioritise control targets and mandate for health improvement; required to achieve goals; medium-sized enterprises, artisanal and
timetables; establish a high-level intersectoral formulate a practical strategy for community involvement small-scale gold mining, and other
Steering Committee; involve the public and upgrading or switching fuels; define strategy; establish a financial sectors; provide a clear mandate to the
civil society organisations financial incentives strategy responsible government agency; define
local powers and responsibilities; define
and enable structures of financial support

Building capacity Achieve adequate monitoring and testing of Establish monitoring Contracts or agreements with Establish regulations and standards;
major air pollutants and emission sources; mechanisms;identify, review, and utilities providers; and strengthen approve technical support providers—eg,
develop understanding of source support local distributors and providers community-level partnerships laboratories, testing firms—; expand
contributions; use vehicle testing stations regulation of active polluters; impose the
so-called polluter pays principle; end
government subsidies for polluting
industries
Common gaps and Expansion to less well resourced secondary Reduction or elimination of use of solid Financial sustainability in an era Requirement of special measures at
structural issues cities fuels for heating of increasing water shortage large-scale sites, such as polluted rivers

Table 7: Short-term, mid-term, and long- term interventions against pollution and the infrastructure and actions required to support them

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 The Lancet Commissions

and contributors to this report have initiated a series of the Global Alliance on Health and Pollution, the World
activities within different sectors and countries that will Bank, WHO, the UN Environment Programme, and the
extend beyond the life of this Commission and are UN Development Programme. New programmes to
intended to prevent pollution and save lives. At a global educate global leaders and government agencies about
level, several authors of this Commission are in early proven solutions to pollution are also in development.
stages of designing a Global Pollution Observatory, to be Activities to strengthen the involvement of the public
housed within the Global Alliance for Health and and civil society in pollution control are essential because
Pollution. This new observatory will be an international, public concern provides a major impetus for governments
multidisciplinary collaboration that is focused on to act against pollution. A new website is being developed For this pollution website see
coordinating information regarding all forms of pollution by the Global Alliance on Health and Pollution to show http://www.pollution.org

in countries around the world and developing solutions current and, in some cases, real-time data related to
based on successes already achieved in other countries. pollution in countries across the world. This geocoded
We intend that this observatory will operate in close website links databases showing air pollution, water
partnership with the Institute for Health Metrics and pollution, and soil contamination. Users can zoom down
Evaluation, UN agencies, Future Earth, the Planetary to the communities where they live, see the available
Health Alliance, and major non-governmental organ­ information, and post their own stories and pictures about
isations concerned with the wellbeing of the Earth’s pollution. The website will incorporate a link for people to
environment. A major function will be to provide data connect with local government organisations for solutions.
that assist countries in prioritising pollution initiatives, These efforts are only the beginning, and there is much
tracking pollution, and using pollution control metrics, more to be done. This Commission encourages all efforts
including investments against pollution in countries to bring the issue of pollution to public attention and
around the world and to make these data publicly and supports all solutions to reduce the enormous health
easily available. The precise metrics to be followed are burden of this major, yet often hidden, global threat.
under consideration, but possibilities include monitor­ing Contributors
country-by-country data on the status of regulations PJL and RF developed the concept and objectives for the Commission.
against each type of pollution; measuring exposures to The full Commission met on two occasions (Nov 9–11, 2015, and
June 16–17, 2016) in New York, NY, USA, with an additional meeting in
key pollutants, country-by-country and regionally; January, 2016 (limited to the Health and Pollution working group, also in
reporting detailed country-by-country statistics on disease New York). The Commission formed four working groups to examine
and premature death by pollution risk factor, to track the burden of disease associated with environmental pollution, to
performance towards the goals suggested in this report; calculate the economic costs of documented pollution-attributable global
deaths and DALYs, to explore the intersection between pollution and
tracking national and international investment into inequality, and to evaluate and develop strategies and roadmaps for
expanded research on disease and death due to pollution successful pollution control. Each working group was responsible for the
(especially soil pollution caused by heavy metals and toxic design, drafting, and review of their individual sections. Working Group
chemicals), including studies to discover new and 1 (Health) was led by PJL. Working Group 2 (Economics) was led by
MLC and AK. Working Group 3 (Environmental Justice) was led by KS.
previously unrecognised health effects of pollutants; Working Group 4 (Interventions) was led by DHa and RF. Working
tracking investments related to interventions against Group leaders, along with Yewande Awe of the World Bank and Tim
pollution, country-by-country (which can be broken down Kasten of UN Environment comprised the Report Steering Committee.
by source of investment and whether the investment is All authors contributed to the identification of key issues and the
selection of four main report sections. As co-chairs of the Commission,
national or international and public or private); and PJL and RF planned and coordinated all activities of the Commission,
developing a database to report the cost-efficacy of the development and review of the report drafts, and the preparation for
interventions against pollution, measured in terms of external peer review. PJL and RF reviewed and edited all sections of this
health outcomes. report. All authors reviewed each stage of the report and approved the
final version. PJL wrote the first and subsequent drafts of the
In partnership with The Lancet, the Global Alliance on Introduction, with input from OA, MLC, RF, AH, AK, KVM, JP, and
Health and Pollution plans to revisit the data on health KRS. For Section 1, PJL wrote the first and subsequent drafts, with input
and pollution periodically, and to publish updated from NB, RB, SB-O’R, JIB, PNB, TC, CM, JF, VF, DHu, BLa, KM, CJLM,
FP, LDS, PDS, KRS, WAS, OCPvS, and GNY. For Section 2, MLC and
information on global trends in pollution, pollution-
AK wrote the first and subsequent drafts, with input from MG, PJL,
related disease, and pollution control on a regular basis. KVM, and ASP. For Section 3, KS wrote the first and subsequent drafts,
The Global Alliance on Health and Pollution will also with input from OA, AH, PJL, KVM, MAM, JRo, KRS, AS, and GNY. For
explore hosting a biennial conference on pollution that will Section 4, DHa wrote the first draft, with subsequent drafts written and
edited by RF and PJL, with input from NJRA, OA, RA, ABB, NB, AMCS,
include UN agencies, governments, and representatives
JF, AH, DHu, MK, BLo, KM, MAM, JDN, JP, JRa, JRo, CS, KRS, AS,
of civil society and will review pollution control strategies, RBS, KY, and MZ.
share project successes, and explore opportunities and
Declaration of interests
the most cost-effective strategies for pollution control. BLa served as an expert witness in California for the plaintiffs in a public
At the country level, work is underway to expand health nuisance case of childhood lead poisoning, in a Proposition 65 case on
and pollution planning in partnership with governments behalf of the California Attorney General’s Office, in a case involving
lead-contaminated water in a new housing development in Maryland, in
in low-income and middle-income countries. This work a Canadian tribunal on a trade dispute about using lead-free galvanised
involves multiple organisations and agencies, including

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 The Lancet Commissions

wire in stucco lathing, and as a plaintiff on a case involving lead- References

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