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Ambient air pollution and CVD
Conclusions
An array of experimental and epidemiological studies have strengthened our general knowledge on the robust association between air pollution and cardiovascular mor- bidity and mortality. Causal interpretation of the expo- sure-outcome association is supported not only by the impressive consistence and concordance of so many find- ings obtained in different countries and contexts, but also by studies showing that the improvement in air quality is associated with a number of public health benefits, includ- ing clinically relevant outcomes such as lower mortality,78 longer life expectancy,97 and better lung function.98 Considering the deleterious effects on the cardiovascular system of air pollution and the increasing socio-economic burden of the direct and indirect costs of related diseases, a number of countries, especially those with better economies, have implemented initiatives that have indeed, in some of them, managed to reduce the burden of air pollution. In spite of this, as recently as 2018, the WHO issued a press release stating that half of the world's pop- ulation is still exposed to increasing levels of air pollution (www.who.int//newsroomdetails). This gloomy situation is epitomized by the fact that the more stringent Air Quality Guidelines set out by the WHO for health preser- vation (Table 2) are far from being met, particularly in the urban areas not only of rapidly developing countries such as China and India, but even in Europe. Furthermore, there is emerging evidence that even PM2.5 concentrations below the ceiling values of the WHO air quality guidelines are associated with important morbidity and mortality figures,99,100 indicating that, even in the most successful countries, further efforts to reduce ambient air pollution are warranted in order to obtain more substantial health
benefits for citizens.
So, how to tackle the formidable battle against air pol-
lution? A call for action has been made by the United Nations Sustainable Development Goals (SDG), and one of these is particularly clear: “Make cities and human set- tlements inclusive, safe, resilient and sustainable” (SGD 11). Replacing fossil fuels with renewable energy and achieving carbon net zero is as obvious as it is difficult, together with actions aimed at renewing transport fleets with zero emission vehicles or by fitting them with more effective filters and combustion engines until electric vehi- cles can come into use. In addition, we must recognize that human nutrition and the use of food from animal sources are important contributors to air pollution through ammonia produced by extensive agriculture and animal farming that is released into the air from stables, manure storage and application procedures, with the added contri- bution from food disposal. Even though the authors of this article believe that fighting air pollution and climate changes are part of the duties and responsibility of health- care professionals, we do not have a magic wand. We are also convinced that one of the best approaches is to foster efforts towards promoting a ‘green’ living and working environment.101 Very recent satellite data show increasing areas of vegetation in parts of the world, and that this 'greening' pattern is particularly prominent in highly pol- luted and urbanized countries such as China and India, in contrast to countries such as Brazil and Indonesia. The two Asian subcontinents are actively developing mitiga- tion programs tailored to expand cropland and forests, with the goal of tackling two huge and interconnected problems at the same time: i.e. air pollution and global warming.102
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