Letter from the Netherlands.

Abstract

Anyone who thought that after the COVID-19 pandemic, life would go back to the way it was before has been disappointed. In retrospect, the cracks in society were already visible before the pandemic. The impact of the pandemic may pale in comparison to the current crises unfolding before our very eyes. We have to deal with ecological, climatic, technological, social, economic and geopolitical problems that aggravate and reinforce each other in several areas. In addition, the magnitude and severity of the COVID-19 pandemic itself may also have been partly determined by the problems we now face globally. A topic of discussion was the extent to which air pollution played a role in the spread, virulence and contagiousness of SARS-CoV-2.1 In addition, air pollution plays a key role in the development of other respiratory and non-respiratory diseases. Prof. Orie and colleagues were ahead of their time with their Dutch hypothesis, by assuming that both genetic and environmental factors could determine whether a person develops an obstructive airway disease.2 In a sense, they were among the first respiratory environmentalists. Estimates suggest that air pollution reduces mean life expectancy by about 2.2 years in Europe, and causes more than 6.5 million deaths worldwide each year. Asthma, COPD and lung cancer are sequelae of poor air quality, yet cardiovascular complications appear to account for the majority of mortality. Hence, the pursuit of clean air should be on every agenda, not only for pulmonologists, but also for cardiologists. Although smoking cigarettes is the ultimate form of air pollution: nitrogen dioxide (NO2), Particulate Matter (PM 2.5, PM 10) and ozone are the usual suspects when referring to air pollution. Ultrafine Particles (PM 0.1) are relevant but still not mentioned enough, as the risks have not yet fully crystallized. Air pollution and climate change are interrelated and will increase disease burden.3 Global warming will escalate with extreme heat episodes and wild fires; it promotes plant pollen and mould growth as well as infectious diseases, and increases the risks of air pollution. Although Europe formulated a green deal agreement, it remains an almost impossible task to form global climate agreements. Hence, the change may have to come from bottom up, by channelling our behaviour into control of our carnivorism, addiction to travel and energy dependency (Figure 1). The 3R principle should be leading: Reduce, Reuse and Recycle. Although the principles of air pollution and global warming are generic, a number of problems are more specific to the Netherlands and Western Europe. In the Netherlands, the development of asthma in children can be attributed in at least one fifth of cases to exposure to NO2 from diesel exhaust. Hence, the Netherlands is a negative leader in Europe, due to the promotion of diesel cars in the past. Particulate matter has many sources, including engine combustion. However, wood burning is an underestimated source of PM production, even in the Netherlands. The contribution of wood burning to air pollution exceeds that of the Dutch private car fleet. Reducing residential biomass combustion appears to be difficult, especially with the boycott on gas imports from Russia with energy prices skyrocketing. Hopefully, the recent Australian decision to ban biomass combustion as source of ‘renewable’ energy will be a shining example for European legislation.4 Soil contamination with nitrogen due to intense livestock farming has a negative impact on local biodiversity and is under scrutiny in the Netherlands. Furthermore, livestock farming entails probably the most important source of secondary PM. While low-emission farms may be a step in the right direction, it makes much more sense to remove meat from our menu. In addition, plant-based food has beneficial effects in terms of cardiovascular disease and diabetes. Third, shipping and aviation are undeniable sources of air pollution as well as greenhouse gases (GHGs). However, this negative impact on air quality is often marginalized due to the major economic interests of the Netherlands as a transit country. Despite advances in reducing emissions, this is still going too slowly; it is like watching the grass grow. Every reduction in emissions leads to further improvement in health. In the Netherlands there is a unique respiratory collaboration between the patient federation (Dutch Lung Foundation), scientists (Netherlands Respiratory Society, NRS), (paediatric) pulmonologists and their associations (Netherlands Paediatric Society, NVK; Netherlands Society of Pulmonary Physicians, NVALT) and the organization representing all respiratory stakeholders (Lung Alliance Netherlands) to motivate government, business and citizens to achieve clean air. The recent reduction of permitted ceilings for NO2 and PM by the WHO is helpful in demanding tighter policies as soon as possible, ergo 2030. Yet the relationship between care and air pollution is more complex than one would expect at first sight. Healthcare is not only a victim, but also a perpetrator and contributes to an average of 4.4% of the CO2 emissions worldwide, in the Netherlands as much as 7%–8%. Most of the footprint is caused by the energy consumption of buildings, from heating and lighting, and equipment, from ventilation to computers. Carbon footprint hotspots, for example in minimally invasive surgery, include production of waste, disposables and anaesthetics. Large teaching hospitals in the Netherlands produce more than 1 million kilograms of waste per year. In addition, up to 50,000 metal instruments are discarded per hospital per year after single use. Travel movements of employees and patients contribute more than a fifth to the emissions of GHG. If all initial patient contact with hospitals were to be made online in the Netherlands, this would save 100 million kilometres in patient travel per year. The use of eHealth might increase these savings. Obviously, in less densely populated countries that return would even be higher. Development and use of medication with associated waste is a third pillar of GHG emissions. In particular for respiratory diseases: Propellants in pressured metered dose inhalers (pMDI) are potent GHGs. These propellants account for approximately 0.5% of the total CO2 production in healthcare, and 0.032% of the total CO2 footprint worldwide. However, not only the release of GHG from inhalers is polluting, also the (micro) plastic burden of dry powder inhalers should be taken into account.5 From 2025, most pMDI will be equipped with a new propellant with a 90% reduction in global warming potential. In the Netherlands, many healthcare professionals have united in recent years to strive for green healthcare. They advocate the so-called ‘3R’ principle in healthcare and the reduction of travel movements by patient and healthcare providers. International visits to conferences must also be taken into account. Furthermore, green healthcare programs should be included in educational programs and curricula. These bottom-up movements are now also gaining a foothold in institutions, universities, hospitals and government, resulting in a Dutch green deal for sustainable healthcare. The interplay between air pollution, global warming and healthcare is complex. Uniting health care professionals and organizations with a focus on clean air and green care seems to have a profound effect on public support in the Netherlands. There is an urgent need to take action for clean air. In addition, healthcare should also reflect on its own role in a pursuit of sustainability and clean air. The 3R approach should be leading in daily life and in care protocols. None declared.