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Pollution-related morbidity and mortality is often seen as a Third World problem, but it is estimated that air pollution leads to approximately 1,600 premature deaths in Ireland every year
Poor air quality is also linked to an increased risk of cardiovascular disease, respiratory disease and dementia, among other conditions. In recognition of the health effects of air pollution, the latest Vhi Hot Topics webinar focused on how GPs can address the health effects of climate change in clinical practice.
“Ninety-nine per cent of the world’s population are breathing in air that contains levels of pollution above the World Health Organization (WHO) recommended guidelines. It’s true that low and middle income countries suffer the highest exposure…but it’s also a problem in high income countries, which sometimes surprises people, and it does lead to quite substantial morbidity and mortality,” said Professor Debbi Stanistreet, Head of the Department of Public Health and Epidemiology in the School of Population Health at the Royal College of Surgeons in Ireland, where she also leads the Climate Health and Medical Education Network.
“We know from recent studies that different air pollutants have been linked to the main causes of blindness, glaucoma, macular degeneration, retinopathy, and cataract, and there’s also quite a substantial body of evidence that links air pollution to pregnancy-related morbidity. That would include premature birth, reduced birth weight, increased risk of pre- and post-partum complications, and increased miscarriage risk and preeclampsia. There is a recent, I think, very concerning study published in the Lancet last year showing evidence of particulate matter being present in the foetal liver, lung and brain tissue of second trimester pregnancies. There was strong correlation with residential exposure to air pollution. And then of course, importantly, other studies have demonstrated a link between cognitive function and air pollution, and that includes cognitive functioning in children,” she explained.
“There are local studies as well that have been carried out in Ireland that demonstrate the relationship between [air pollution] and cardiovascular and respiratory hospital admissions as well as an increased incidence of dementia. It highlights the ongoing public health impact that we have here on our own doorstep.”
Prof Stanistreet conducted a poll of attendees, asking how often they use their knowledge of air pollution in their daily clinical practice. Despite growing evidence of the negative health impacts, only 13 per cent said they frequently apply their knowledge of air pollution to their clinical practice. While 27 per cent said they sometimes apply these learnings to patient care, 60 per cent rarely or never do. When asked how often they advise patients on which fuels to use to minimise air pollution, only six per cent said frequently. More than 70 per cent said they never or rarely advise patients on the matter.
Dr Colm Byrne, Consultant Geriatrician at the Mater Hospital, pointed to the 2002 study conducted by Clancy et al, which compared rates of non-trauma, respiratory and cardiovascular deaths in the 72 months before and after the ban on coal sales in Dublin. The results showed a 5.7 per cent decline in adjusted non-trauma death, a 15.5 per cent decline in respiratory deaths and a 10.3 per cent decline in cardiovascular deaths.
Air pollution leads to approximately 1,600 premature deaths in Ireland every year
Dr Byrne and his team conducted a study examined the impact of different air pollutants – fine particulate matter (PM2.5), PM10, nitrogen dioxide (NO2), ozone, and sulphur dioxide (SO2) on admission for all strokes in Cork and Dublin from 2013 to 2017. They found that during winter in Dublin, there was an association between stroke and increased NO2 and PM2.5.
Dr Byrne said the strong association during winter “suggests that domestic solid fuel burning of wood, peat, coal etc is a significant part of this”.
The Irish Longitudinal Study on Ageing (TILDA) has also shown that indoor particulate pollution from open fires is linked to a decline in cognitive function in older adults in Ireland. The study found that exposure to particulate matter from indoor open fire usage is similar to outdoor commuting exposure.
But how can GPs apply clean air principles in clinical practice? Dr Byrne presented a case study to demonstrate: a 72-year-old woman with hypertension, type 2 diabetes and COPD presents with worsening dyspnoea and fatigue over the past six months. She lives in an urban area with heavy traffic and frequently uses an open fireplace for heating during winter. She does not smoke. Physical examination reveals mild bilateral wheezing and an oxygen saturation of 94 per cent on room air. He gave the following four potential interventions:
Recommend wearing a high-efficiency particulate air mask when indoors.
Counsel her on reducing exposure to indoor air pollutants.
Advise staying inside during peak traffic hours.
Suggest the use of an in-home air purifier with HEPA filtration.
He said all of these measures would improve the patient’s long-term health outcomes. In particular, he advocated for advice on reducing exposure to indoor air pollutants.
“It is something I’ve brought into my clinical practice,” he said. “I ask people, do you have an open fire, and if they are coming in with a lot of respiratory infections, I advise them to look and see if they can use an alternative heat source, use an electric fire instead of an open fire.”
Vhi Head of Sustainability Emer Haughey provided some tips for GPSs on how to reduce their own impact on pollution.
“Healthcare, globally, accounts for nearly 5 per cent of all emissions. That’s twice as much as aviation so as practitioners, as part of the healthcare industry, we really have to think about our role,” she said.
She advised GPs to start small. She commented on a hospital that she is working with at the moment that ran a ‘switch it off’ campaign, encouraging staff to turn off computers and medical equipment when not in use.
The hospital achieved a 12 per cent reduction in costs as well as significant reductions in carbon emissions.
She also advised attendees to look at waste management. She pointed out that all clinical waste is incinerated and, consequently, has a high carbon footprint. “This is an area we’ve been focusing on a lot,” Ms Haughey said.
“When we started looking at the numbers we realised that a lot of the clinical waste that we were considering as clinical waste really wasn’t. A huge amount of it was recyclable. So we created a clinical waste pilot, putting green bins into our urgent care settings and from there we realised there’s so much more we can do in terms of recycling.”
Prof Ceppie Merry is Clinical Lead for Integrative Medicine and Health Coaching at Vhi 360. She advocates for a holistic approach to health care, combining a range of therapeutic approaches including pharmacological treatment, herbal medicine, culinary medicine, acupuncture etc.
She explained that Western medicine has become “reductionist”, focusing on specific systems.
“Integrative medicine says, let’s stand back and let’s take all the beauty and all the amazing things of Western Cartesian medicine, but let’s also layer in all of the things that we left behind in whole body systems” medicine.
An integrative medicine consult combines three cornerstones, Prof Merry said. Firstly, every patient receives tailored culinary advice. The second cornerstone is breathwork and the third is “connecting people to their North Star”.
“By that I mean figuring out with the patient what’s really important to them? What drives them? What actually matters? Patients are driven by wanting to get to their granddaughter’s communion next May or their daughter’s wedding in two years. So find out what drives somebody and constantly reconnect them to that, so that every time you talk about any health intervention, you’re linking it back to their true sense of purpose,” she said.
Prof Merry said an integrative approach to care not only benefits the patient. By using less invasive approaches, it also has benefits for the planet.
InformationVhi 360 Hot Topics is a series of educational webinars focused on key subjects of interest to support the primary care healthcare workforce in delivering improvements to patient care in primary care settings. These are conducted in partnership with MedCafe.ie. Recording of this Vhi 360 Hot Topics Webinar can be found on https://www.medcafe.ie/webinars/874
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