Health Costs due to Road Traffic-Related Air Pollution An impact assessment project of Austria, France and Switzerland Rita K. Seethaler The Urban Transport Institute Australia

Targets A common methodological framework Comparable empirical results

The main partners Austria: France: Switzerland: Federal Ministry of Environment, Youth and Family Affairs Federal Environment Agency France: Agency for Enivronment and Energy Management ADEME Switzerland: Federal Department for Environment, Transport, Energy and Communications

Three disciplines co-operate... Air Pollution: Exposure assessment of the residential population (particulate matter PM10, traffic share) Epidemiology: Exposure-Response relationship for selected health outcomes (air pollution attributable cases) Economy: Evaluation of monetary health costs (willingness-to-pay)

Structure of the study

PM10 Population Exposure: General Methodological Framework Main Steps acquisition and analysis of data on the ambient concentration of particulate matter annual mean PM10 mapping using empirical dispersion models or statistical methods estimation of the road traffic related PM10 fraction calculation of population exposure by superposition of the PM10 map on the population distribution map

Differences in PM10 Modelling Differences in Measurement Methods of Ambient Concentration of Particulate Matter (state of art 1999) Austria network of Total Suspended Particulate (TSP) measured by beta attenuation and TEOM. NOx emission inventory available. France until recently used the Black Smoke (BS) method exclusively, some sites are now equipped with PM10 samplers (TEOM sampler). No emission inventory for PM10 available. Switzerland changed the national monitoring network from TSP to PM10 measurements by gravimetric filter samplers. PM10 emission inventory available.

Population Exposure to Total PM10 Frequency distribution of PM10 population exposure

Population Exposure to PM10 without traffic-related share Frequency distribution of PM10 population exposure

Population weighted annual PM10 averages Interpretation with regard to the considerable variability of road traffic PM10 Higher relative contribution of road traffic to total PM10 in city centers Typical values are 40-60% in cities and <30% in rural areas (Swiss model)

Public Health Impact Assessment of Air Pollution: Calculation of attributable number of cases

Health outcomes included in the assessment . Health outcome Age Total mortality Adults, ³ 30 years of age Respiratory hospital admissions All ages Cardiovascular hospital admissions All ages Chronic bronchitis incidence Adults, ³ 25 years of age Acute Bronchitis Children, < 15 years of age Restricted activity days Adults, ³ 30 years of age Asthmatics: asthma attacks Children, < 15 years of age Adults, ³ 15 years of age

Definitions and sources (references)     Definitions and sources (references) Health outcome Definition Sources (References) Long-term mortality (adults  30 years) death rate, excluding violent death / accidents aged 25-75 and >30 years, respectively Dockery DW et al, 1993 Pope CA et al, 1995 Respiratory Hospital Admissions (all ages) ICD9 460-519, all ages ICD9 466, 480-487, 493, 490-492, 494-496, all ages ICD9 480-487, 490-496, all ages Spix C et al, 1998 Wordley J et al, 1997 Prescott GJ et al, 1998 Cardiovascular Hospital Admissions (all ages) ICD9 410-436, all ages ICD9 390-459, all ages ICD9 410-414, 426-429, 434-440, all ages Poloniecki JD et al, 1997 Medina S et al, 1997 Chronic Bronchitis Incidence (adults  25 years) symptoms of cough and/or sputum production on most days, for at least three months per year, and for 2 years or more, age >=25 years Abbey DE et al, 1993   Bronchitis episodes (children <15 years) bronchitis in the last 12 months (parents or guardian’s answer), ages 10-12, 8-12 and 6-15 years, respectively Dockery DW et al, 1989 Dockery DW et al, 1996 Braun-Fahrländer C et al,1997 Restricted Activity Days (adults  20 years) any days where a respondent was forced to alter normal activity, due to respiratory disease ICD9 460-466, 470-474, 480-486, 510-516, 519, and 783, age 18-65 years Ostro B et al, 1990  Asthma attacks (children < 15 years) lower respiratory symptoms, age 6-12 years asthma, age 7-15 years lower respiratory symptoms, age 7-13 years Roemer W et al, 1993 Segala C et al, 1998 Gielen MH et al, 1997 Asthma attacks (adults  15 years) wheeze, age 18-80 years shortness of breath, age 18-55 years wheeze, age 16-70 years Dusseldorp A et al, 1995 Hiltermann TJN et al, 1998 Neukirch F et al,1998    

Calculation example of the additional cases per 10 g/m3 PM10 and 1 million inhabitants e.g. in Switzerland: 337 = 7‘794 x 0.043 fixed baseline increment expected baseline frequency at exposure of 7.5 g/m3 Relative risk for an increase of 10 g/m3 D10 = P0 x (RR-1)

Short term and long term effects of air pollution The effects of air pollution have two dimensions in time: First, for some people, the level of pollution on a given day or week may trigger morbidity or death. These are acute effects, well established in many highly qualified time series studies in Europe and abroad. These short term effects may move the event of death from a considerable number of people forwards. There is, however, a further aspect of air pollution, ultimately leading to earlier death: recurrent cumulative exposure may enhance morbidity, including e.g., chronic bronchitis. People with these diseases (to which air pollution contributed) have impaired health and shorter life expectancy, thus, they may die earlier, although the EVENT of death may not always be closely related to the daily level of pollution. This overall effect of air pollution on life-expectancy is captured by the cohort studies whereas the short-term studies capture only one part of the overall problem. (Dr. Nino Kuenzli et al.)

Air pollution and mortality: long-term frailty and terminal trigger Death triggered By air pollution Not by air pollution Frailty level A B Due to air pollution C D Not due to air poll.

(susceptibility for death) Contribution of Air Pollution CASE A : long-term + terminal trigger of death Frailty (susceptibility for death) SMOG EPISODE Death Cumulative exposure Chronic Bronchitis Time Birth Age at death

Quantitative results: Health effects attributable to road traffic-related air pollution In Total (Austria, France and Switzerland) 300,000 cases of acute bronchitis in children 25,000 cases of chronic bronchitis in adults 25,000 hospital admissions 162,000 asthma attacks in children 295,000 asthma attacks in adults 16 Million days with restricted activity in adults 21,000 cases of premature mortality (long-term)

Comparison: fatal road accidents and air pollution related mortality 20000 18000 1970 Road accidents 16000 14000 1996 Road accidents 12000 absolute number of cases 10000 1996 air pollution rel. premature deaths 8000 6000 4000 2000 Austria France Switzerland

Years of life lost due to road accidents or air pollution related mortality (1996) 50000 100000 150000 200000 250000 300000 350000 Austria France Switzerland number of Life years lost From Road accidents (ø 40 years lost) from Air pollution related mortality (ø 10 years lost)

Overview of the costs of morbidity Costs of illness Costs of averting- behaviour Treatment costs Loss of production Avertive expenditures collectively borne collectively borne collectively borne Intangible Costs Treatment costs Loss of production Avertive expenditures Disutility associated with indvidually borne individually borne individually borne morbidity individually borne Market Prices available Market Prices not available Private Costs (= individual WTP) Social Costs (individually and collectively borne)

The value of a prevented fatality based on willingness-to-pay Example: Policy measure for risk reduction from 4 cases per 10,000 inhabitants to 3 cases per 10,000 inhabitants. Risk reduction: 1 case per 10,000 Inhabitants = 0.0001 Individual willingness-to-pay for a risk reduction of 1 case in 10,000 inhabitants = 100 EURO. Value of a prevented fatality: 100 EUR/0.0001 = 1 Million EURO

Willingness-to-pay cost factors used for the monetary assessment of mortality Tri-lateral study (A,F,CH); 1.4 adjusted down Jones-Lee M. (1998); Fatal road accidents 1.2 Mio EUR 2.6 Mio EUR 3.1 Mio EUR Source Department of Health (UK) Instiute of Environm. Studies, Norway (1997) ZEW, Centre for Europ. Econ. Research (1998) ISI Frauenhofer Institute (1998) WTP-value ExternE (1995) 0.9 Mio EUR 1.4 Mio EUR

Willingness-to-pay cost factors used for the monetary assessment of morbidity Health outcome Respiratory hospital adm. Cardio-vascular hosp.adm. Chronic Bronchitis (adults) Acute Bronchitis (children) Restricted activity days Asthma attacks Source ExternE (1995) Chestnut L.G. (1995) Maddison D. (1997) WTP (EUR) 7,870/adm. 209,000/case 131/case 94/day 31/attack

Health costs due to air pollution   Health costs due to air pollution     Austria 8.1 France 58.3 Switzer-land 7.1 All three countries 73.4 Total (mill. Euro) 6 700 38 900 4 200 49 700 Attributable to road traffic (mill. Euro 2 900 21 600 2 200 26 700 Inhabitants (mill.)    

Traffic-related Monetary Health Costs Austria, France and Switzerland Total health WTP-costs: 27 billion EUR p.a. = 1.7% of GDP (Partial assessment: 3.5 billion EUR p.a.) Per capita WTP-costs: 360 EUR p.a. Predominant part: 70% of costs for premature mortality Morbidity WTP-costs: 7 billion EUR p.a. 75% for chronic bronchitis, 22% RAD

The “At least approach” Lowest assessed level of 7.5 g/m3 for health effects Not all PM10 related health effects are considered (infant mortality, respiratory symptom days) The effect estimate reflects the air pollution mix of an urban environment. Specific independent effects of single pollutants are not considered. Seasonally limited air pollution related health effects are not considered (e.g. ozone exposure in summer) Willingness-to-pay value of fatal road accidents of 1.4 Mio EUR is reduced of 61% according to higher age of air pollution related victims. This WTP value is lower than values used in other European studies (e.g. ExternE: 2.1-3.0 Mio. EUR)

Outlook – research needs Data improvement for the assessment of exposure and transport-related share Effects of ozone, effects of other pollutants additive to PM10 effects Age distribution at time of death Simultaneous effects of noise and air pollution Monetary valuation of health impacts: Elements included in WTP Situational effects on WTP, age effects on WTP, other effects Appropriate measure of uncertainty