Air conditioning and heat-related health effects Marie $ O'Neill Environmental Epidemiology Program, Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA ‘Abstract: The Earth's climate is expected to continue a warming trend over the next decades, resulting in inereased frequency of hot ‘eather and potentially negative effects on human health asa result. Air conitioning has been cited asa preventive intervention strategy ‘in several research reports, Tis aticle discusses the evidence regarding airconditioning and heat related health effects end ruses questions bout the broader implications of recommending widespread use of this technology. Potential drawbacks of air conditioning, including ‘equity concems, energy use and indoor air quality, are described, Finally, approaches are suggested that could advance the dual goals of slowing the pace of climate change while sill protecting vulnerable populations fro temperatures the health consequences of increasing global Keywords: climate, heat, mortality, airconditioning, socioeconomic factors, weather Introduction A number of epidemiological studies have documented inereased mortality and morbidity associated with extreme heat (Whitman et al 1997; Semenza etal 1999; Keatinge et al 2000; Braga et al 2002; Curriero et al 2002; Hajat et al 2002; Basu and Samet 2003). With projections of increasing lobal temperatures as aresult of human activities, and hence inereased frequency of heat waves and hot days (Galfen and Ross 1998; Easterling et al 2000), the toll on health could rise in the coming years without preventive interventions. To develop strategies to protect people from health events associated with extreme heat, studies have been undertaken toidentify those most vulnerable and factors that might help prevent heat-related illness andor death. Being elderly or very young, bedridden, living alone, having a low educations! level, being of black race, living in an urban setting, living in a neighbourhood lacking an active street life and public ‘gathering places, and lacking sir conditioning have all been associated with the risk of heat-related mortality (Semenza etal 1996; McGeehin and Mirabelli 2001; Klinenberg 2002; (O'Neill et al 2003), Access to air conditioning seems to be an intuitively logical protective factor when discussing heat- related health effects, and has been recommended as preventive intervention (Semenza 1999; Semenzaet al 1999; Keatinge et al 2000; McGeehin and Mirabelli 2001). Existing research Studies identifying these factors have used a varity of design. including case-conto, time series and sociological approaches with direct interviews and neighbourhood observations. One way of evaluating the effects of air ‘Applied Environmental Science and Public Health 2003:1(1) 9-12 ©2003 Open Mind Journals Limited. All rights reserved. conditioning in mitigating heat-related health effects is by making use of ecologic data on the prevalence of air conditioning in a particular geographic area. In 12 US cities from 1986 to 1993, a lower expected risk of heat-related ‘mortality was observed in cities with a higher prevalence of airconditioning (Braga etal 2001). Similar results were seen in another study of 11 US cities (Chicago and Atlanta were common to both these studies), where cities with a higher prevalence of air conditioning had lower heat-related mortality, even when controlling for latitude (Curriero etal 2002). However, in examining four time periods from 1973 10 1994, the associations between heat and mortality were similar even though the prevalence of air conditioning in the US overall was increasing (Curriero et al 2002). By contrast, an evaluation of long-term trends in heat-related mortality in North Carolina, South Finland and southeast England (1971-1997) showed that in ll three locations, heat- related mortality dropped, in spite of rises in average summertime temperatures (Donaldson et al 2003). The authors attribute the drop in North Carolina to th prevalence of air conditioning, and the decreases in all three regions to increasing prosperity. Results from these studies should be interpreted with caution in light ofthe study design. Jin Europe and in low- and middle-income countries where air conditioning prevalence even in hot climates is much ower than in the US, studies show evidence of higher thresholds for heat-r suggesting that populations can adapt to the prevailing eased mortality in warmer countries, Correspondence: Mare O'Nal SPH Environmental Epidemiology, 401 Park Dre Suite 415M, Boston MA G2215, USA; tel *1 617 384 8753;fax +1 617 384 8745; eral moncl@rsphharvaréedsOnell! temperatures (Keatinge et al 2000; Wilkinson et al 2002), and differences other than air conditioning prevalence may explain these patterns. ‘Air conditioners are relatively common in the United States, with over 80% of homes having air conditioning (US Census Bureau 2002), and are projected to be found in virtually all US homes by the year 2050 (McGeehin and Mirabelli 2001). The presence of air conditioning is also an important consideration when evaluating the effects of air pollution on health. Air conditioners decrease the penetration ‘of outdoor air to indoors and hence the ventilation exchange rate in general, so ambient monitors of air pollution levels are less representative of exposure to air pollutants among people who have air conditioning than among those who rely on open windows and doors for ventilation (Janssen et 1 2002). Indeed, associations between hospital admissions and airbome particles in 14 US cities were significantly lower in those cities with a higher prevalence of air conditioning (Janssen et al 2002). It is not possible to determine conclusively thatthe difference in health effects is because of less exposure to outdoor-origin pollutants in areas with more air conditioning, or whether it is because air conditioning prevalence is a marker for other variebles, such as socioeconomic conditions (either atthe individual or the ‘community evel), which may affect response to air pollution exposure, or both factors combined. By the same reasoning, studies showing differences in heat-related mortality by prevalence of air conditioning have the limitation that air conditioning prevalence may be associated with other factors that affect susceptibility and/or exposure to heat Another way of evaluating the effects of air conditioning is by using individual-level data on whether the person had access to an air-conditioned environment and of what type. (One study of 2275 US deaths between 1980 and 1985 found that the death rate during hot weather for those with central airconditioning was 42% less than for those without central airconditioning (Rogot et al 1992). The same study showed that single room air conditioning did not confer a substantial benefit over no airconditioning at all. In acase-control study of the 1995 Chicago heat wave, controls foreach heat-related death were identified, matching on age and neighbourhood, Having working air conditioners or any access to air- conditioned environments were protective against heat- related mortality (Semenza et al 1996). By definition, air conditioning is designed to reduce exposure to ambient temperatures when it is hot. It is well known that among other factors, humidity, clothing, activity and solar radiation influence an individual's physiological sesponse to weather, and several constructs incorporating these parameters have been developed that can be used in health studies (Steadman 1979; Kalkstein and Valimont 1986; Hoeppe 1999). Societal factors related to air conditioning and heat exposure Although the proximate caus ofheatrelated health effects is physiological, other societal, economic and politica factors are important determinants of vulnerability and should be considered when developing intervention strategies. A sociological study involving direct interviews of individuals who had lived through the 1995 Chicago heat wave sheds Highton the diverse factors that affect vulnerability to heat (Klinenberg 2002). In Chicago, factors influencing whether an individval had access to an air-conditioned environment ‘or even natural ventilation from opening windows or using fans, included their sense of security in their neighbourhood ‘or home (some were too worried about break-ins to open their windows or leave their home to go to a cooler place), their social contacts and their mobility. Concer about being able to afford the utility bills also affected whether people used their air conditioning (Klinenberg 2002). In a recent article, joumalist Malcolm Gladwell points ‘out that merely to recommend air conditioning asa preventive ‘measure does not address the point that poorer people may not be able to afford either to buy or to operate air conditioners, especially if these air conditioners are not efficient users of energy (Gladwell 2002). The US government sets energy efficiency standards for air conditioners, and in 2001 the Clinton administration increased the minimum standard (DOE 2002). In the spring cof 2002, the Bush aiiministration lowered that efficiency standard (DOE 2002). As a result, on very hot days, power demand from multiple air conditioners. built to the new minimum standerd, will be higher, resulting in projected energy demands by the year 2020 that would require fifty ‘more power plants than would otherwise have been needed (Gladwell 2002), In addition to the resulting increased emissions of greenhouse gases, the electricity prices would likely be higher, again affecting those living atthe economic ‘margins most, Gladwell suggests that had Chicago's feet of air conditioners been built to higher efficiency standards, the 1995 heat wave would have had lower mortality because the power grid would not have been so quickly overcome. Power outages have been reported in other countries, including Australia and Greece, during heat waves (Kovats and Koppe 2003). Clearly, the issue of overall residential ‘Applied EnvironmencalSclance and Publie Hesieh 2003:1(1)and commercial electricity demand is relevant for other countries when considering management of energy consumption and distribution, and planning fr hea-elted contingencies. In addition o energy eficeney concer, the wan heat island effect (the phenomenon of urban air being 2-10°F (1-5°C) higher than in ural/suburban locations on hot ays) contributes to the overall power demand in cities where health impacts of hot temperatures may be concentrated Interventions to reduce these effets, including planting of trees and increasing reflectivity of ity surfaces, are underway in several ites and may be improving the overall quality of life in these areas (EPA 2000) Many people of limited economic means live in urban aweas subject to the heat island phenomenon, where extra energy is required to run air conditioners on hot days, Inthe US, the Low Income Home Energy Assistance Program (LIHEAP) maintains statistics on the expenditure and consumption of energy for heating and cooling. I the fiscal year of 2000, low-income households consumed 20% less nergy for cooling than the werage household although the proportion oftheir total income devoted to cooling expenses ‘was almost four times greater than for non low-income ‘households (DHHS 2002). These statistics illustrate how, on average richer households are greater energy consumers and therefore are contributing disproportionately to the production of greenhouse gases, Though the statistics are not broken out by urban versus rua, lower income urban dvillers are purchasing energy for cooling that, doar for dollar, doesnot provide as great level of comfort due tothe urban heat stand effect. Potential drawbacks of air conditioning Anotherissue of public health concer isthe possible adverse health effects associated with the use of ai conditioning/ recirculated ai. Several published studies suggest tharpeople indoors are more comfortable an experience fewer health symptoms as ventilation with outdoor air increases (Seppanen et al 2002; Sieber et al 2002). In many countries, buildings ae naturally ventilated, which requires no energy. Some research has shown that artificial ventilation (air conditioning) by inadequately maintained or ageing ‘mechanical systems can result ina higher prevalence of health symptoms or complaints of building occupants, compared to naturally ventilated structures (Vincent et al 1997; Costa and Brickus 2000: Graudene etal 2002). However, 0 snudies suggest that a properly maintained air-conditioned ‘Air conditioning and heat-related health effects building can provide better indoor air quality and fewer symptoms among building occupants (Niven etal 2000). In spite ofthese conflicting results, natural ventilation provides energy advantages, suggesting that such an approach deserves further consideration in building design, especially among countries currently using much more than their share of the ‘world’s energy: In buildings that are partially or completely naturally venilated, people are tolerant of a wider range of temperatures than inartfcially ventilated environments, and appreciate the sense of personal control over the environment through such actions as opening @ window or dressing appropriately tothe weather outdoors (Tones and West 2001). 1a the US, hybrid approaches (combination of natural and artificial ventilation) are beginning to draw interest from architects, engineers and designers (Kosik 2001). A farther ‘impetus to exploration of altemative ways of ventilating buildings is that certsin diseases can be spread by air conditioning systems and related equipment. In 1993, for ‘example, three outbreaks of Legionnaires’ disease were reported inthe US and linked to cooling towers used for air conditioning (Anonymous 1994), Concluding remarks Installing airconditioning in al homes in geographie settings where temperatures rise to the point of potentially compromising heath i nota sustainable o etistic public health recommendation. Proving airconditioned pubic spaces (cooling centres") where people can come in hot weather for relief and health protection is « common snterventon programme for eat waves (Kalkstein etal 1996, Smoyer-Tomic and Rainham 2001) although other factors Influence whether the most vulnerable people willbe able to ake advantage of these services, The irony i that sir condoning commonly relies on fosi fuel combustion to futon (in seas where haste main power source), thus farther onrbating tothe overal problem of global waning. In spite of the limited number of studies of air conditioning as a means of preventing heat-related health effects, providing a coo! environment though use ofthis technology wil continue to bea part of prevention strategies in many areas. Future studies could evalute trade-offs in the use of airconditioning, including whether exposure to brut changes of temperature when going in and ou of at conditioned spaces can have adverse physiological effects Since sr conditioning technology is continuing to penetrate in the US and elsewhere, increasing appliance energy efficiency standrds, developing sustainable energy an including natural ventilation design features in homes ounces ‘Applied Environmental Science and Public Health 2003:1(1)on and buildings can meet the goals of health and environmental protection more responsibly. At the same time, energy assistance to the poor as well as improvement of social conditions could reduce disparities in the impacts of heat morality. Alliances between health researchers and policy makers willbe needed to make the case for approaches that advance the dual goals of slowing the pace of climate change ‘while stil protecting vulnerable populations from the health consequences of inereasing global temperatures. Acknowledgements Support for this work was provided by a training grant from the National Institute for Environmental Health Sciences (NIEHS) 5 T32 £S07069-22, NIEHS ES00002 and EPARS27353. I thank Gary Adamkiewicz, Shakoor Hajat {ind Sari Kova for their helpful comments and suggestions. References [snonymous]- 1994. From the Centers for Disease Control and Prevention ‘Lepionmires disease aseocited with cooling towers ~ Massachusetts, Michigan, and Rhode Island, 1993. JAMA, 272426. ‘Basu R, Samet J, 2005, The relationship between elevated ambient tenperarate and mortality: a review ofthe epidemiologic evidence. Epidemiol Rev, 24190202 ‘Braga ALF, Zanobeui A, Schwartz J, 2002. 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