Guest presentation by Mark Nieuwenhuijsen of isglobal.org

1. THE HEALTH IMPACTS OF URBAN AND TRANSPORT RELATED EXPOSURES. Mark Nieuwenhuijsen
ISGlobal, Barcelona mark.nieuwenhuijsen@isglobal.org ITS, Leeds, November 18, 2016
Medellin

2. PROPORTION OF THE WORLD POPULATION LIVING IN URBAN AREAS
Rydin et al 2012

3. CITIES
´´Cities have long been known to
be society’s predominant engine
of innovation and wealth creation,of innovation and wealth creation,
yet they are also its main source
of crime, pollution, and disease´´
Bettencourt et al 2007

4. SHENZHEN, CHINA
SHENZHEN, CHINA

5. BUENOS AIRES, ARGENTINA
BUENOS AIRES, ARGENTINA

6. KUWAIT CITY, KUWAIT
KUWAIT CITY, KUWAIT

7. ATHENS, GREECE
ATHENS, GREECE

9. Mumbai

10. Paris

16. NEW URBAN AGENDA23 PAGES, 175 ACTIONS

18. Density
Mixed land
use/diversity
Distance
Connectivity
Transport
Indoor/
outdoor
Walking
Cycling
Car
Air pollution
Noise
Temperature
UV Radiation
Cardiovascular
and Respiratory
disease
Mental health
Neurodevelop
ment/cognitive
function
Premature
mortality
Urban design Behaviour Pathways Morbidity Mortality
Policies
Transport
infrastructure
Walkability
Bikeability
Green space
Car
Public
transport
function
Cancer
Acute/chronic
mortality
Context: socio-economic, genetic, nutrition
Stress
Social contacts
Physical
activity
Nieuwenhuijsen 2016

19. EXPOSURE PATTERNS IN CITIES
Barcelona
Girona
Air pollution
Temperature
Green space
Noise

20. Tehran, Iran, 15 November 2016. Habib Kashani, a member of Tehran’s municipal council, said on Tuesday that pollution in Tehran had led to the death of 412
citizens in the past 23 days, according to the state news agency, Irna. City authorities announced that all schools would be closed on Wednesday. The concentration
of ultra-fine airborne particles (known as PM2.5) reached more than 150 this week, setting a new record. These particles of less than 2.5 micrometres in diameter
can penetrate the lungs and pass into the bloodstream and have been linked to increased rates of chronic bronchitis, lung cancer and heart disease. (Guardian
newspaper)

21. • 20 Countries
• 40 Study areas
AIR POLLUTION ASSESSMENT AND EPIDEMIOLOGY ESCAPE
7 million people die each year of air pollution
• 2008 - 2012

22. AIR POLLUTION AND
PREMATURE MORTALITY
Beelen et al 20147% increased risk for premature mortality per 5 ug/m3 PM2.5

23. AIR POLLUTION AND LUNG
CANCER
Around 20% increased risk for lung cancer per 5 ug/m3 PM2.5 or 10 ug/m3 PM10
Raaschou-Nielsen et al 2013

24. 5% increased risk of childhood
asthma per 4 ug/m3 NO2

25. NOISE AND ALL CAUSE
MORTALITY
• London TRAFFIC study – All cause mortality
Halonen et al. EHJ 20154% increased risk for premature mortality for > 60 dB vs < 55 dB

26. NOISE AND HYPERTENSION
• Odds ratio (OR)
of 1.034 [95%
confidence
interval (CI)
1.011-1.056] per
5 dB(A) increase
of the 16 hof the 16 h
average road
traffic noise level
(LAeq16hr)
[range 45-75
dB(A)].
van Kempen and Babisch 20123% increase in hypertension per 5 dB(A)

27. TEMPERATURE
Gasparrini
et al 2015

28. GREEN SPACE

29. GREEN SPACE AND MORTALITY
4% reduced risk for cardiovascular mortality for high vs low green space exposure

30. GREEN SPACE AND GENERAL AND MENTAL HEALTH INDICATORS
10-20% reduction per IQR
Triguero-Mas et al 2015
n = 8793 adults
10-20% reduced risk for poor mental over IQR green space exposure

31. GREEN SPACE AND WORKING
MEMORY
Over a 12-mo period,
we observed that an IQR
exposure increment in total
surrounding greenness
index was associated with a
5% increase in the progress
of working memory, a 6%
Dadvand et al 2015
PNAS
N=2,593 children, 7-10 yrs
of working memory, a 6%
increase in the progress of
the superior working
memory, and a 1% reduction
of inattentiveness.

32. PHYSICAL INACTIVITY
• Approximately 2.1 million deaths each
year are attributable to insufficient physical
activity

34. 10%
20%
30%
Risk
reduction
Woodcock et al 2010
40%
50%

35. ADDED PA THROUGH CYCLING
Donaire-Gonzalez et al 2015
Cycling amounted to 2.1 (95% CI¼0.84, 3.55) hours/week extra of physical
activity for bicycle commuters versus motorized commuters.

36. CYCLING
• What are the health benefits and risks of
cycling for a cyclist:
- increase in physical activity
- Increased risk of traffic injuries- Increased risk of traffic injuries
- Increased inhalation of air pollution
For the general population; reduced air
pollution

38. Example model: Barcelona BICING case study
Rojas-Rueda
et al 2011

39. HEALTH IMPACT ASSESSMENT OF THE BICING SYSTEM
CO2e
Built Environment /
Mode Choice
Active Transport
Policy
• Scenario:
– 25 427 daily bicing
commuters “new” to
cycling (assume 90%
of Bicing user
previously drove)
– 4.34 km/work-day
RR=0.72
Traffic
Injuriy
Physical
Activity
Air Pollution
Mortality
Economic
Evaluation
Life
expectancy
• Impacts:
– Change in mortality
in commuters who
shifted from car
travel
– CO2 emissions
savings
Rojas-Rueda et al 2011

40. Results: mortality in new cyclist
population (n=25 427)
Air pollution Motor vehicle
crashes
Physical
activity
Relative Risk
Bike vs Car
1.002 1.0007 0.80
Attributable 0.002 0.0007 -0.23Attributable
fraction of
mortality
0.002 -0.23
Deaths / year +0.14 +0.03 -12.46
Economic evaluation
Benefit of lives saved (€/year)c
18,420,000
Rough estimate of Bicing costs (€/year)
15,000,000
Rojas-Rueda et al 2011

41. HEALTH IMPACTS OF ACTIVE
TRANSPORTATION
There are great health benefits of moving from car to public and active transportation.
Benefits from physical activity well outweigh the risks of air pollution and traffic incidents
Mueller et al 2015

43. HEALTH IMPACT ASSESSMENT URBAN AND
TRANSPORT RELATED EXPOSURES IN BARCELONA
Methodology:
All-cause mortality
• Risk assessment methodology
• Population attributable fractions (PAF)
Life expectancy impactLife expectancy impact
• Life table analysis to estimate average change in life expectancy
• Standard life table methods
Economic impact
• Economic assessment following value of statistical life (VoSL)
approach
• VoSL = 3,202,968 € for Spain (2012)

44. STUDY SETTING: BARCELONA
Population N=1.6 million (≥20 years N=1.3 million)
Area 101 km2
(high population density)
Climate 18 ºC mean temperature, hot summers, mild
winters, low precipitationwinters, low precipitation
Vehicle fleet 500,000 cars and 300,000 motorcycles + large
daily suburban commuter fleet
Urban design Narrow street canyons
Dense construction of semi-tall buildings
(5-6 stories)
Green spaces 7 m2 per resident

45. EXPOSURE RECOMMENDATIONS
Physical activity
(WHO)
150 minutes of moderate-intensity aerobic
physical activity or 75 minutes of vigorous
intensity aerobic physical activity weekly
Air pollution (WHO) PM2.5 = 10 µg/m3
Noise (WHO) Day time (7:00-23:00 hr) outdoor activity noise
levels ≤55 dB(A)levels ≤55 dB(A)
Heat (not available) Modifying urban plan may provide cooling of up
to 4 ºC
Green space
(EC, WHO)
Access to green space ≥0.5 ha within 300 m
linear distance

46. Urban and TranspOrt Planning Health
Impact Assessment tool (UTOPHIA)
Current exposure
estimates for
Barcelona
Recommended exposure
levels (‘counterfactual’)
Comparison current
exposure to recommended
exposure
Exposure response
Natural all-cause mortality
rate for Barcelona from Exposure response
function (ERF) from
literature
Calculation of RR and PAF
for the estimated exposure
difference
rate for Barcelona from
literature
(1,108/ 100,000)
Calculation of attributable
preventable mortality by
multiplying the PAF with
the mortality rate

47. RESULTS
Physical activity 70% of population insufficiently active
Air pollution PM2.5 = 16.6 µg/m3
Noise Day time (7:00-23:00 hr) outdoor activity noise
level = 65.1 dB(A)level = 65.1 dB(A)
Heat ≥100 days exceeded ‘minimum mortality
temperature percentile’ (21.8 ºC) daily mean
temperature
Green spaces ≥30% of residents do not live within 300 m linear
distance to a green space ≥0.5 ha

48. PM2.5 Noise
Heat Green spacesHeat Green spaces
CURRENT ENVIRONMENTAL EXPOSURE LEVELS IN BARCELONA

49. HEALTH IMPACT ASSESSMENT
Health Impacts:
Under compliance with exposure recommendations…
• 2904 deaths preventable (95% CI: 1568-4098)
• Increase in average life expectancy by 360 days (95% CI: 219-493)
• Economic savings of 9.3 bn € (95% CI: 4.9-13.2)
All natural deaths adults ≥20 years N=15,049 (2012)
Almost 20% of mortality in Barcelona is attributable to urban and
transport planning related exposures

50. ESTIMATED ATTRIBUTABLE DEATHS
1154
659
800
1000
1200
1400
659
599
376
116
0
200
400
600
Physical activity
(95% CI: 858,1577)
Air pollution
(95% CI: 386,834)
Noise
(95% CI: 0,1009)
Heat
(95% CI: 324,442)
Green spaces
(95% CI: 0,236)

51. PREVENTABLE DEATH
• Number of estimated preventable deaths (N=2904) is much larger
than annual number of traffic fatalities in Barcelona (N=30, 2012)
N=30
N=2904
http://lowcarbon.inforse.org/

52. SOLUTIONS?
• Solutions to the physical inactivity and environmental mortality
burden can be found in changes to urban and transport planning
http://lowcarbon.inforse.org/

53. Woodcock et al 2013

56. CAR FREE CITIES
• Car free cities can have a considerable benefit on health through
potential reduction in air pollution, noise, and heat island effects and
increase in physical activity and green space and thereby improving
health
• The move towards public and active transportation in this must be
understood as crucial, as physical activity is one of the main driversunderstood as crucial, as physical activity is one of the main drivers
for health and lack of time has been repeatedly listed as a detriment
of physical activity
• Urban and transport planning practices such as making cities
denser, providing mixed land-use (e.g. home, work, shops), street
furniture, safe urban environments and pedestrian and cyclist-
friendly amenities could promote positive physical activity patterns
and build them into daily routines

57. Physical inactivity
Air pollution
Noise
• Leading risk factors in GBD Study
• Cause ≥5 million deaths globally
Green space
Exposures in cities
Heat
• Few green spaces despite
benefits for physical and mental
health
• Motorized traffic exposes
40% of Europeans to ≥55
dB(A)
• Emissions cause anthropogenic heat that together with
re-radiation of construction contribute to urban heat islands
Green space

58. Epidemiology 2017 (in print)

59. GREEN AND LIVEABLE
• Greening cities has many health benefits including
longer life expectancy, fewer mental health problems,
better cognitive function, better mood and healthier
babies
• It mitigates air pollution, heat and noise levels.• It mitigates air pollution, heat and noise levels.
• Replacing roads and parking with green environments
can be one way forward to change an environment from
detrimental to beneficial.

61. Hamburg

63. SYSTEMIC APPROACHES
• It is important that we have a more
systemic approach to our cities,
bringing together
• Urban planners• Urban planners
• Transport planners
• Environmentalist
• Public health professionals
• Economists

64. STAKEHOLDER INVOLVEMENT
• The planning of car free and green cities
requires long term political commitment at
the highest level and public acceptance.
• Citizen and business participation is• Citizen and business participation is
essential to obtain commitment for the
proposed changes and vision.
• Favourable media interest

68. http://www.transglobalhealth.
org/#/joint-phd-
degree/research-projects/

70. Page 70