Journal of Public Health | Vol. 39, No. 3, pp. 425–426 | doi:10.
1093/pubmed/fdx103
Editorial
Environment, health and infrastructure:
troubling questions
In 2011, this Journal published an article that asked the pro-
vocative question: ‘Are cars the new tobacco?’1 The authors
thought as much, citing the health consequences of urban
air pollution as well as other impacts including road traffic
crashes, climate change and the disruptive impact of heavy
traffic on communities. They further cited parallels including
the existence of powerful industrial lobbies, and the creation
of ‘car dependence’ (drawing a parallel with tobacco depend-
ence, although the relevant mechanisms are different) as a
consequence of urban infrastructure choices that are quite
literally cast in concrete. And they emphasized that ‘like
tobacco, the harms associated with cars are disproportion-
ately borne in disadvantaged communities.’
Subsequent accumulation of evidence lends support to this
view. In the same year that the article appeared, a report from
the UK’s Sustainable Development Commission,2 now unfor-
tunately disbanded, pointed out the multiple dimensions on
which the health and related impacts of a car-dependent society
are unequally distributed. We cannot do justice to the richness
of this report’s conclusions; readers are encouraged to seek it
out online, where it is still available at the time of writing.
Designation by the normally cautious International
Agency for Research on Cancer of ambient air pollution as a
Group 1 carcinogen;3,4—that is to say, the category for
which evidence of carcinogenicity from multiple research
designs is strongest—was probably the most under-reported
public health story of 2013. As noted in a previous edito-
rial,5 in the following year, the World Health Organization
(WHO) concluded that ambient air pollution accounted for
3.7 million premature deaths in 2012, predominantly in low-
and middle-income countries.6 Once again, a day or so of
media coverage was followed by comforting return to foot-
ball stories.
Air pollution impacts are not confined to far-away places.
Exposure to particulates and nitrogen dioxide in outdoor air
pollution probably accounts for around 40 000 deaths per
year in the UK;7 the uncertainties that unavoidably surround
such estimates should not distract us either from the ser-
iousness of the problem or from inequities in the distribu-
tion of impacts. Residents of leafy suburbs do not face the
same exposures as those living, working and walking in
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traffic-intensive urban settings; indeed that leafiness itself is
to some degree protective.
This issue of the Journal includes a special section on envir-
onment and health, foregrounding the findings of a massive
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effort by Prüss-Ustün et al. to update WHO estimates of the
global burden of disease attributable to environmental determi-
nants of health.8 They conclude that just under one-quarter of
global deaths and disability-adjusted life years were attributable
to environmental exposures in 2012—although, of course,
ambient air pollution exposures were only one contributor.
Especially, critical from a policy and equity perspective is their
observation that: ‘The lower people’s socioeconomic status the
more likely they are to be exposed to environmental risks…
Poor people and communities are therefore likely to benefit
most from environmental interventions as they are dispropor-
tionally affected by adverse environments.’
The relevant exposures and policy challenges are multidi-
mensional. In arguing for the incorporation of public health
concerns into transport planning, one of us has pointed out
the perversity of official algorithms that treat public trans-
port, walking and cycling as second-class claimants for
scarce budgetary resources,9 even as governments commit
to multi-billion-pound road investments.10 From a holistic
perspective on transport and health, like that adopted by the
Sustainable Development Commission, technical fixes like
access surcharges for fossil-fuelled vehicles and reduced
urban speed limits,11 as important as they may be, only
address part of the problem. Reliance on electric vehicles
may simply shift the pollution problem elsewhere, since elec-
tricity is an energy carrier and not a source (with a partial
exception for hybrid vehicles); particulate generation may be
less reduced than would be expected; and such measures do
not address the health equity aspects of vehicle-dependent
urban fabric.
The challenge of integrating health and health equity con-
cerns into decisions about infrastructure goes beyond trans-
port. In June 2017, at least 79 people are known to have
died in the horrific fire at the Grenfell Tower social housing
tower block in London. Investigations are ongoing; the use
of flammable, and cheaper, exterior cladding appears to
have been an important factor, potentially exacerbated by
deregulation and a lack of resources for inspection and over-
sight.12 This event, alongside the accumulating evidence of
425
426 JOURNAL OF PUBLIC HEALTH
the connections between transport policy and health, should
direct the attention of the public health community to the
larger, and perhaps more politically disruptive, question of
how to ensure that health in all policies,13 and in particular a
concern for health equity, are meaningfully incorporated in
policy and budgetary priorities related to the infrastructure
that supports our daily lives. These issues are fundamentally
about political choices—more bluntly still, about whose lives
matter, why, and how much.
Ted Schrecker, Eugene Milne
References
1 Douglas MJ, Watkins SJ, Gorman DR et al. Are cars the new
tobacco? J Public Health 2011;33:160–9.
2 Kay D. Fairness in a Car-dependent Society. London: Sustainable
Development Commission, 2011. http://www.sd-commission.org.
uk/data/files/publications/fairness_car_dependant.pdf.
3 IARC Working Group on the Evaluation of Carcinogenic Risks to
Humans. Outdoor Air Pollution: IARC Monographs on the Evaluation of
Carcinogenic Risks to Humans; Vol. 109. Lyon: International Agency
for Research on Cancer, 2016. http://monographs.iarc.fr/ENG/
Monographs/vol109/mono109.pdf.
4 Loomis D, Grosse Y, Lauby-Secretan B et al. The carcinogenicity of
outdoor air pollution. Lancet Oncol 2013;14:1262–3.
5 Milne E, Schrecker T. The view from the Acropolis. J Public Health
2014;36:523–4.
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24March2014.pdf?ua=1.
7 Royal College of Physicians. Every Breath We Take: The lifelong impact
of air pollution. London: RCP, 2016. https://www.rcplondon.ac.uk/
file/2912/download?token=EAp84pJk.
8 Prüss-Ustün A, Wolf J, Corvalán C et al. Diseases due to unhealthy
environments: an updated estimate of the global burden of disease
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11 Paton G. Petrol cars will be priced off roads to fuel electric growth.
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12 Kirkpatrick DD, Hakim D, Glanz J. ‘An Accident Waiting to
Happen’: Blame in a Deadly London Fire. New York Times 2017 Jun
25. https://www.nytimes.com/2017/06/24/world/europe/grenfell-
tower-london-fire.html?hp&action=click&pgtype=Homepage&
clickSource=story-heading&module=photo-spot-region&region=top-
news&WT.nav=top-news&_r=0.
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Geneva: WHO, 2015. http://apps.who.int/iris/bitstream/10665/
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