1. Public Health and Air Pollution in Asia (PAPA) Program Update /The Next Phase Bob O’Keefe Secretariat Coordinating Meeting July 2005 Bangkok,

2. PAPA Program Partnership with CAI-ASIA to understand the health effects of air pollution in Asia, now and in the future –Supported by US AID, foundations, industry, others Active effort underway: –Published Scientific Review and Meta Analysis of what is known today about health effects in Asian cities –Conducting series of epidemiological studies in representative Asian cities Understand local impact Combine to provide Asia-wide understanding –Publish a Comprehensive Assessment of the state of air pollution and health across Asian cities –Build capacity of local scientists –Regular Communication of results to policy makers Overall Goal: –Quality science to inform key Asian regulatory & policy decisions

3. Health Effects of Outdoor Air Pollution in Developing Countries of Asia: A Literature Review Systematic identification of 140 peer-reviewed Asian studies 1980- 2003 Special focus on studies of daily changes in air pollution and health Conduct first ever Asian meta analysis” quantifying risks, finding initial similarities with West Identify knowledge gaps to guide future research Active communication to policy makers

4. Meta-Analysis of Asian Studies of Daily Mortality/Hospital Admissions 28 recent daily time series studies examined in depth Studies find effects of air pollution on rate of death, illness –~0.5% increase per 10 µg/m 3 of PM 10 –High levels of air pollution in Asian cities (>100 µg/m 3 ), imply a substantial public health impact Limitations –Small number of cities –Not geographically representative (poorest, most polluted countries under-represented)

5. New Research in Asian Cities Eight new studies of air pollution and health now underway in Asian Cities Acute Effects (initial cities): Bangkok, Hong Kong, Shanghai, Wuhan Strong teams, quality data Long Term (chronic) Effects Guangzhou, China pilot study in elderly cohort New! Study teams now identified and Approved in India following extensive investigator competition

6. New PAPA Studies in India Goal: Understand air pollution health effects in less-studied areas Representative time series studies of pollution and daily death Diverse, highly populated regions Public health impact could be significant Significant data challenges (air quality, morbidity, mortality - frequency, access, quality) CityRegionPopulation Chennai (formerly Madras) South 7,400,000 DelhiNorth 18,550,000 LudhiānaNorth 1,625,000

7. Ludhiana Chennai PAPA in India

9. Proposed Milestones 2005 Actively communicate results of Asia Review and Analysis in key regional and international policy forums Begin full implementation of 3 new studies in India Provide ongoing oversight, QA\QC for PAPA studies Conduct at least two additional capacity building workshops in partnership with Fogarty, ISEE Continue periodic inventory of new Asia studies; web post results Initiate, in partnership with Vietnam, ADB, NILU, and East-West, the “HCMC Air Pollution and Poverty Assessment” –Develop Final Poverty Study Design –Select local investigators –Launch study and capacity building And always, always keep an eye on Cornie…..

10. Recent Accomplishments I (Capacity & Policy Communication) Strengthening the network: PAPA investigator workshops (* denotes workshops involving international researchers from Europe, North America, and Latin America) –February 2004 (Bangkok) –May 2004* (Boston) –December 2004 (Agra) –April 2005* (Boston) –November 2005* (location to be determined) Formation of first Asian regional chapter (South Asia) of International Society of Environmental Epidemiology (ISEE) II. Support for researchers at international conferences (+ denotes PAPA symposia) HEI Annual Conferences (Boston, May 2004 and Baltimore, April 2005) International Society of Environmental Epidemiology + (New York, August 2004) Better Air Quality Conference + (Agra, December 2004)Largest non Bank Group ! International Epidemiological Association: World Congress on Epidemiology + (Bangkok, August 2005) Japan Society of Atmospheric Environment + (Nagoya, September 2005)

11. Recent Accomplishments II (Capacity and Quality) III. Training Workshops (in addition to collaboration with international experts, all workshops include PAPA investigators as trainers and trainees) Time Series Training Workshop #1 – included participants from India, Indonesia, Malaysia, Philippines, and Vietnam (Delhi, December 2004) Workshop on Assessing Health Effects of Short Term Exposures to Air Pollution (Ho Chi Minh City, anticipated August / September, 2005) Time Series Training Workshop #2 (Chennai, anticipated September, 2005) IV.QA/QC: Ensuring Internationally Accepted Standards of Excellence in Research QA Site Visits (Hong Kong, Shanghai, Wuhan, Bangkok, May 2005) QA Site Visits (Chennai, Delhi, Ludhiana, anticipated Fall 2005)

12. Recent Accomplishments III ( Presenting PAPA\global science to policy makers ) Multi stakeholder regional presentations (Nov 04-present, partial list) –“Quantifying Effects of Air Pollution in Asian Cities” –“Adverse Effects of Air Pollution in India” –“Command and Control Strategies fro Asia” –“Public Health and Air Pollution” –“Poverty Air Pollution and Health” PAPA Review Presentations In: Pakistan; China; India; Vietnam; Japan; Indonesia; US; Europe To: Industry (auto, oil, others), Government (National EPAs CDCs NGOs; Science and medical communities; International agencies UNEP etc) Press -Presentations often in context or regulatory decisions -With or by PAPA local expert (ISOC\local PI) Multi language Reviews; Presentations Upcoming: Beijing (new fuel standards) Vietnam (Euro II)

13. PAPA: Looking Ahead A Special Challenge: Understanding the interaction among air pollution, poverty, and health –In Asia high levels of air pollution, dense population, extensive poverty are prevalent –Some initial evidence (mostly from West) that the poor face worse effects from air pollution Potential Public health implications could be significant

14. Higher Risks Among the Less Educated Evidence from HEI Reanalysis Attained education inversely associated with PM relative risk in ACS and Six-Cities studies An indicator of social class Due to differences in true exposure? Sensitivity to air pollution?

15. Why the Poor May Suffer More Health Effects From Air Pollution Likely higher exposures to air pollution –Living close to traffic –Roadside occupational exposures –Small and medium scale enterprises / Cottage industries –Use of solid fuels for cooking (indoor air) The poor may be more susceptible to air pollution –Poor nutrition / immunosuppression –Higher incidence of ‘diseases of poverty” (TB, ALRI) –Lack of timely access to health care Limited evidence from the West, but with - high pollution, high urban population density; significant poverty -Clear need to explore this issue in the Asian context

16. New! HEI Partnership in HCMC to understand Poverty, Air Pollution and Health HEI-PAPA, as part of Clean Air Initiative for Asian Cities (CAI-ASIA) Nhu partnership with HCMC Dept of Health (lead); Department of Natural Resources and Environment (DONRE); Department of Labor Invalids and Social Affairs (DOLISA) International experts from East-West Center; UC Berkeley; Norwegian Institute for Air Research; ADB, USAEP To plan and carry out a new study in Ho Chi Minh City to assess poverty-air pollution-health intersection –Are the poor are exposed to higher levels of air pollution? –Are the poor more susceptible to its effects? Study results inform Vietnam policy decisions Study design transportable\replicable in other cites

17. Air Pollution, Poverty and Health: Key elements of initiative I Assessment of respiratory health of children (ALRI others) of different SES –Designing targeted case-control and panel studies to provide quality local data of poverty effects II Household survey to assess –exposure to multiple sources of air pollution –health prevalence (status) –Perceptions, coping mechanism and economic burden III Policy impact study (integrating above for policy making) Strong commitment to capacity building throughout

18. Roadside Monitoring Station Maintained by HEPA, with assistance from NILU

19. Kirk Smith, Sumi Mehta, Aaron Cohen, Le Van Khoa, Vo Tan Dam, Bjarne Sivertsen, Mr. The, Phan Quynh Nhu, Ms. Van Collaborators ADB PAPA NILU East-West Center UC Berkeley HEPA US AEP Multiple Vietnam Government Agencies

20. Thank You!