Air Pollution, Poverty and Health in Ho Chi Minh City Stakeholder Forum 3 February, 2004 Ho Chi Minh City, Vietnam

Background

Who Are We - ADB Asian Development Bank is a regional development bank, which provides loans and grants to governments in support of economic and social development. The overarching objective of ADB is poverty reduction in Asia. ADB supports a range of projects in Vietnam, which are coordinated by its Resident Mission in Hanoi. http://www.adb.org

Who Are We: CAI-Asia CAI-Asia is a multi-stakeholder initiative set up by ADB, World Bank and USAEP to promote better air quality management in Asia Currently CAI-Asia has 120+ institutional members including Ho Chi Minh City, Hanoi, Vietnam Register CAI-Asia undertakes knowledge management, capacity building, regional dialogues, promotion of air quality management policies, pilot programs and workshops. In Vietnam USAEP is acting as the local coordinator of CAI-Asia and the local CAI-Asia network http://www.cleanairnet.org/caiasia

Who Are We -The Health Effects Institute Founded in 1980 to provide impartial, high-quality science on health effects of vehicle and other emissions Joint and Equal Core Funding from Public and Private Sources Independent Board and Expert Science Committees oversee and review all research Over 200 studies - Americas, Asia, Europe - ozone, carbon monoxide, particulate matter, diesel exhaust, benzene, butadiene, methanol, others Program on Public Health and Air Pollution in Asia (PAPA) to inform regional decisions about improving Asian air quality (map shows study sites as of January 2005) http://www.healtheffects.org/

Who Are We - NILU http://www.nilu.no/ Norwegian Institute for Air Research (NILU) conducts environmental research with emphasis on the sources of airborne pollution, atmospheric transport, transformation and deposition and is also involved in the assessment of the effects of pollution on ecosystems, human health and materials. NILU has implemented a range of air quality monitoring and management projects in Asia. NILU currently implements the NORAD funded HCMC air quality monitoring project with its local partner HEPA http://www.nilu.no/

Air pollution and health Air pollution is a growing environmental problem in Asian cities due to growing urbanization, motorization and industrialization Health impacts of air pollution are considerable. World Health Organization estimates that about 480,000 people die prematurely in Asia each year due to exposure to ambient air pollution. Many hundreds of thousands develop health problems or experience decreased health because of pollution. They miss work or school because of air pollution. Air pollution costs Asian cities hundreds of millions of dollars per year.

Why a program on air pollution, poverty and health? Asian Development Bank is the main regional developmental organization in Asia. The main mandate is poverty reduction through sustainable development. Air pollution is a substantive developmental problem. Evidence from Europe, USA and Latin America indicates that there is a linkage between air pollution and poverty in terms of health impacts. Clean Air Initiative for Asian Cities took the initiative to develop a program that will research the linkage between air pollution, poverty and health in Asia. HCMC proposed: relatively good quality data on air, health, and poverty and enthusiastic local counterpart organizations

Main Hypotheses The poor are subject to higher exposures of air pollution. The poor are more susceptible to air pollution e.g. due to poorer nutrition, access to medical care and other factors. Air pollution exacerbates or perpetuates the conditions of poverty.

Outputs The proposed project in HCMC will give answers on the linkage between air pollution and poverty in HCMC. The project will result in a methodology that can be used to study the linkage between air pollution and poverty in other Asian cities. Capacity building

Main components of the Project Study of the impact of air pollution on respiratory health of children in HCMC a) Exposure assessment to multiple sources of air pollution. b) Health prevalence survey c) Survey of perceptions and economic costs 3. Policy implications and awareness raising

Air Quality Monitoring In HCMC

AQ Monitoring Sites 4 sites funded by Danida 5 sites funded by NORAD AQMS installed by NILU As part of NORAD

Automatic transfer + QA/QC

Suspended particles = main problem PM10 measured since 2001

Ozone 27 October 2004

Concentration decrease with distance from street Short term sampling on the street HX and DBP 3 hourly samples 10 days a month PhuLam: 12 h sample 10 days a month

Average diurnal variation CO

T=1.4xU

Model applications Wind fields Model tests HCMC Vietnam Main traffic routes impact

Ho Chi Minh City Emission inventory, traffic

The NILU Now-cast model

Exposure models

Component 1. Impact of air pollution on acute lower respiratory infection (ALRI) in children of HCMC

Proposed Objectives of the Childrens’ Study Estimate the effect of short-term exposure to air pollution on hospital admissions for ALRI in young children (<5 years) in HCMC Compare the magnitude of the effect of air pollution on poor children vs. other children

Proposed Methods of the Childrens’ Study (1) Case ascertainment Identification of ALRI admissions, clinical and socio-demographic characteristics from computerized records at Pediatric Hospitals 1 and 2 Poverty status determined by access to free care (health card) Exposure assessment Estimates of daily average exposure for each case using data from the HEPA air monitoring network

Proposed Methods of the Childrens’ Study (2) Statistical Analysis: Estimate relative risk of admission to hospital for ALRI using case-crossover analysis Collaborators: Biostatisticians TBN, HEPA/NILU, DOH/Pediatric Hospitals 1 and 2

Overview: Case-crossover Methodology Used to study impact of short-term time-varying exposures on acute events Cases of disease are identified The exposure of each case is estimated during an effect and a control period Relative risk is calculated based on contrasting the exposure levels in the effect and control periods

Major Design Decisions Why short-term effects? Much of the existing global literature is comprised of studies using comparable methods Why children? We care about this vulnerable sub-population Health data on children are available in HCMC Why ALRI? A major public health issue in developing countries – two recent literature reviews on the effects of air pollution on ALRI

Some Outstanding Issues Should hospital admissions for asthma be studied? Adequacy of data quality? What should be the timeframe for the study (retrospective and/or prospective)? Should very young children (<1 year) be included?

Component 2. Household Survey of Exposure, Health Perceptions and Costs

Household Survey Survey of households from poorer and wealthier wards Households with young children identified, but all household members included Three sets of activities: Exposure assessment (HEPA, CASE, EWC, UC Berkeley) Health prevalence survey (HCMC DPH, Medical University) Public perceptions and economic burden of air pollution (TBN, EWC)

Exposure Assessment Aims to estimate pollution actually inhaled Assesses impact of local ‘hot-spots’/ microenvironments for exposures Exposure to traffic related pollution (roadside exposures, commuting) Cooking with solid fuels (wood, coal) and/or poorly combusted kerosene Environmental tobacco smoke (ETS) Occupational exposures (roadside vendors, small scale industries, etc.) Assesses difference between household concentrations and individual exposures

Approaches to reach human exposure Ambient concentrations in a variety of microenvironments, Neighbourhood concentrations, Outdoor/indoor concentrations, and /or Personal (individual) exposures assessed by time and location Exposure assessment in specified receptor points (outdoor and indoor?) Exposure assessment for populations with high roadside exposures Total exposure studies (micro environmental modelling) of high-risk sub-populations We may perform:

Exposure and health Diary Method When What Where hour of day day of week season of year Diary Method Individual air pollution exposure estimate What Where activity levels which affects respiratory ventilation Indoor/outdoor (window open/closed) Geographical location

Health Prevalence Survey Assess respiratory health symptoms of all household members Based on internationally accepted survey instruments In conjunction with exposure results, may provide information on risk factors for respiratory illness Possibility: additional health assessment (PFT) of householders

Public Perceptions and Economic Burdens of Air Pollution Assesses people’s opinion how air pollution impacts their lives Understanding perceptions can help predict the public’s willingness to modify lifestyle to improve environment Cost of treatment, Lost income, Lost Time, school absenteeism Differential impact of policies to remediate air pollution exposures (relocation of roadside vendors)

Some outstanding issues Proper definition and identification of poorer and wealthier wards to be included in the survey Sample determination (size and distribution across city) Identification of capacity building needs (skills and equipment) Degree of linkage with Component 1

Component 3. Policy implications and awareness raising

Policy relevance The results of the project may indicate a linkage between air pollution, poverty and health in HCMC If they do …..

Policy Implications Results may justify interventions targeted to poorer households and sources that affect especially the poorer households In identifying the policy implications it will be important to distinguish between national and local level policy issues Policy implications can be aimed at decision makers on air quality management, public health, city planners, or poverty.

Examples of methodologies to assess policy implications Assess the impact of different AQM policy measures on the spatial distribution of air pollution in HCMC, and the impact on different population groups Assess the impact of different health or poverty policy measures (e.g. access to healthcare) on health of population groups affected by air pollution Assess the impact of urban renewal measures on exposure to air pollution by different population groups Assess the required institutional response capacity

Awareness Raising Progress of the study will be documented on the CAI-Asia website and the PAPA website Important outputs of the project will be translated in Vietnamese An international workshop is planned for 2007 to present the findings of the project.

Institutional set-up of project and implementation arrangements

Overall Project Structure Project is a grant from ADB to the government of Vietnam. Recipient of the grant will be HCMC Peoples Committee. HCMC Peoples Committee to issue a decision to set up the project, project office, and Steering Committee. ADB will enter into a partnership with HEI for the implementation of the program. APPH Project will become part of the Public Health and Air Pollution in Asia (PAPA) Program, which HEI implements on behalf of CAI-Asia. The International Oversight Committee from PAPA program will be requested to provide scientific oversight of the project.

Project running time and budget Project expected to run for 30 months or 2.5 years. Proposed start date for the Project 15 June 2005 ADB expected to contribute $ 600,000 from Poverty Reduction Fund HEI expected to contribute $ 200,000 Vietnamese government agencies to contribute $120,000 (in kind – staff time, office space, local transport, etc.) – 20% of official ADB contribution

Methodology development This is a pioneering program for Asia. The HCMC project aims to develop a methodology which will be tested in the HCMC project Visiting researchers from other Asian cities will be invited during the project to visit HCMC to observe the study. Participants from HCMC project will be invited by CAI-Asia to conferences and workshops to make presentations on the project.

Suggested Executing and Implementing Agencies Executing Agency: DONRE, based on its overall mandate for environmental protection and air quality management Implementing Agencies: HEPA: air pollution related aspects DoH: health related aspects DOLISA: poverty related aspects All implementing agencies will be required to make information available and to assist in assessment of policy and discuss policy relevance Program will actively contribute towards capacity building of the implementing agencies Additional services will be contracted in consultation with Executing and Implementing Agencies from e.g. NILU on air quality monitoring and CASE on sample analysis.

Next Steps Draft Memorandum of Agreement (MoA) on the Project, circulate for comments to DONRE, DOH, DOLISA and get endorsement (covering agreement) of MoA from HCMC PC and MPI Draft TA paper to get formal approval for project within ADB Coordinate with DONRE and HEPA the steps to be taken to get approval from Vietnam’s side Detailed technical planning coordinated by HEI to prepare draft research protocols Sign TA letter between GoV and ADB Sign Partnership Agreement between ADB and HEI

Thank You for your time for your ideas and your support for the Project.