THE CRITICAL NEED FOR ENHANCING THE RESEARCH CAPACITY REGARDING THE INTERSECTION OF AIR POLLUTION AND NON-COMMUNICABLE DISEASES IN GEORGIA

Abstract

Globally, 7 million deaths are attributable to the joint effects of indoor and ambient air pollution annually, with ~94% occurring in low- and middle-income countries (LMICs). While 51% of cities in high-income countries with ≥100,000 residents meet WHO air quality guidelines, only 3% of such cities in LMICs meet them. In the country of Georgia, adverse environmental exposures cause 21% of disease burden and 25% of deaths, including 30% of disease burden and 14% of deaths among children. According to 2016 WHO data, Georgia’s mortality index attributed to ambient and indoor air pollution was 204.9, the 3^rd highest in the world. Indoor air pollution is largely a result of indoor cooking/heating using solid fuel and second hand smoke (SHS). Worldwide, 40% of children, 35% of female nonsmokers, and 33% of male nonsmokers are exposed to SHS. Annually, SHS exposure causes ~600,000 deaths (1% of mortality), with half of those deaths in women and over a quarter in children. LMICs are disproportionately impacted by SHS and related morbidity and mortality. In Georgia, the smoking prevalence is 58% in men (6^th highest in the world) and 6% in women. Moreover, prior research found that 30% of Georgian adults were exposed the SHS in the past week in public places and 54% at home; 42% reported daily exposure. Georgia’s 2017–2021 National Environment and Health Action Planhighlights that addressing air pollution is among the most prominent public health priorities. However, there is limited in-country capacity to conduct research regarding the impact of such environmental hazards on health. Thus, efforts must enhance such research capacity in order to reduce air pollution and its effects on health.

Globally, 7 million deaths were attributable to the joint effects of household air pollution and ambient air pollution in 2016 (World Health Organization 2018b). Air pollution is associated with a broad spectrum of acute illnesses and non-communicable diseases (NCDs), such as lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases (World Health Organization 2018d). Worldwide, air pollution is estimated to cause about 29% of lung cancer deaths, 43% of COPD deaths, about 25% of ischaemic heart disease deaths, and 24% of stroke deaths (World Health Organization 2018d). In 2016, ambient air pollution was responsible for 4.2 million deaths worldwide; it is estimated to cause ~16% of the lung cancer deaths, ~25% of COPD deaths, ~17% of ischaemic heart disease and stroke, and ~26% of respiratory infection deaths. Indoor air pollution – generated largely by inefficient, poorly ventilated stoves burning biomass fuels as well as secondhand smoke (SHS) exposure – is responsible for the deaths of an estimated 1.6 million people annually (World Health Organization 2002). More than half of these deaths occur among children under 5 years old. Although air pollution is an environmental health (EH) problem that affects people worldwide, low- and middle-income countries (LMICs) are disproportionately impacted. In fact, 94% of deaths due to air pollution occur in LMICs (World Health Organization 2018d). Additionally, in LMICs, indoor air pollution ranks 4^th in terms of the risk factors that contribute to disease and death (World Health Organization 2002).

SHS is a prominent indoor air pollutant, a Class A carcinogen, and a significant public health problem. Worldwide, it is estimated that 1.8 billion nonsmokers, including 40% of children, 33% of male nonsmokers, and 35% of female nonsmokers, are exposed to SHS (World Health Organization 2018g). SHS exposure is estimated to kill over 600,000 people each year (World Health Organization 2014) – more than 1% of all deaths – comprised of 28% (~165,000) among children, 47% (~282,000) among women, and 26% (156,000) among men. SHS contributes to death from ischaemic heart disease (379,000 deaths annually), lower respiratory infections (165,000), asthma (36,900), and lung cancer (21,400) (World Health Organization 2018g).Women suffer more from the impacts of SHS as they are 50% more likely to be non-smokers than men (World Health Organization 2018g). SHS exposure has been associated with adverse health outcomes in children and adolescents, including lower respiratory tract infections, middle ear infections, sudden infant death syndrome, asthmatic exacerbations, mental health disorders, cognitive dysfunction, sleep disorders, and metabolic syndrome (Johannessen et al. 2012; Adair-Bischoff and Sauve 1998; Bandiera et al. 2011; Schwartz, Bottorff, and Richardson 2014; Yolton et al. 2005). In terms of years of life lost, children are by far the most affected from SHS, as most of their SHS deaths occur from respiratory infections during the first years of life. The highest exposures to SHS are found in Eastern Europe, the Western Pacific, and South-East Asia, with more than 50% of some population groups exposed (World Health Organization 2018g). Likewise, these regions are the most affected by exposure to SHS in terms of total deaths per capita (World Health Organization 2018g). Unfortunately, only 7% of the world currently live in jurisdictions with comprehensive smoke-free laws (World Health Organization 2018g).

In 2015, for the first time, the World Health Assembly (WHA) unanimously adopted a resolution to accelerate global action to address household air pollution (World Health Organization 2018a). In 2016, the WHA adopted a “Roadmap for Enhanced Action”, which called for increased cross-sector cooperation to address the health risks of air pollution (World Health Organization 2018a). This roadmap established a process for implementing the resolution (World Health Organization 2018a) and emphasized 4 priority areas: 1) expanding the knowledge base about impacts of air pollution on health; 2) strengthening institutional capacity and enhancing infrastructure for monitoring and reporting on health trends and progress towards the air pollution-related targets of the Sustainable Development Goals; 3) leveraging the health sector to raise awareness of health benefits from air pollution reduction measures; and 4) enhancing the health sector’s capacity to work with other sectors and at all levels – local, national, regional and global – to help address the adverse health effects of air pollution through training, guidelines, and national action plans (World Health Organization 2018a).

In addition, for more than a decade, World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) has provided a major impetus for all countries to adopt comprehensive policies to counter the global tobacco epidemic (World Health Organization 2009). Nearly 90% of the world’s population lives in the 181 countries that have ratified the FCTC (World Health Organization 2016a). Most FCTC parties are LMICs (World Health Organization 2015b). The FCTC includes a range of measures including taxation, health warning labels, and other evidence-based strategies to address tobacco use. Most relevant to this proposal, Article 8 of the FCTC reads: “1) Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease, and disability; and 2) Each Party shall adopt and implement in areas of existing national jurisdiction as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or other measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places” (World Health Organization 2018e). Collectively, these international agendas indicate the need to address air pollution and to address tobacco use and SHS exposure in order to reduce related morbidity and mortality globally.

The country of Georgia has a population of about 3.72 million, a major reduction in its population from 5.35 million in 1993 and 4.39 million in 2007 (Bakhturidze et al. 2008)This decrease in population has been mainly accounted for by premature mortality and migration. Georgia is currently considered an upper middle-income country (World Bank 2019), with a GDP of 15.16 billion US dollars in 2017 (Trading Economics 2018a) and an unemployment rate of 13.9% (Trading Economics 2018b).

In 2018, life expectancy at birth in Georgia was 74.0 – 69.7 years in men vs. 78.2 years in women (National Statistics Office of Georgia 2018), giving Georgia a World Life Expectancy ranking of 98 (World Health Organization 2018c). In recent years, Georgia ranked highest among former Soviet republics (excluding the Baltic States) in progress in improving health indicators included in the United Nations’ Millennium Development Goals (Cattaneo et al. 2010). However, Georgia continues to be significantly impacted by environmental hazards. In Georgia, 21% of the total disease burden and 25% of deaths are caused by adverse environmental impacts(World Health Organization 2016b). Children are particularly sensitive to environmental risks. In LMICs of Europe, including Georgia, 30% of disease burden and 14% of deaths among children under 5 are caused by environmental hazards (World Health Organization 2016b).

Air pollution is a particularly prominent public health concern in Georgia. Table 1 highlights the top 10 risk factors and age-standardized disease burden in Georgia. Air pollution is ranked as #6 in women and #7 in men. Notably, according to 2016 WHO data, Georgia’s mortality index attributed to ambient and indoor air pollution was 204.9, the 3^rd highest in the world (behind Bosnia-Herzegovina and Bulgaria) (World Health Organization 2018f). Georgia’s ambient air pollution comes from-vehicles, energy sector, industrial facilities, and agriculture sectors; its indoor air pollution is a result of indoor cooking/heating using solid fuel and SHS.

Table 1.

Top 10 risk Factors and Associated Age-Standardized Burden of Disease in Georgia by Sex, 2015(World Health organization 2017)

Females	DALYs	Males	DALYs
Dietary risks	6109	Dietary risks	11412
High systolic blood pressure	5698	High systolic blood pressure	10253
High body mass index	3260	Tobacco smoke	8433
High fasting plasma glucose	2625	High body mass index	4840
High total cholesterol	1977	High fasting plasma glucose	3742
Air pollution	1831	High total cholesterol	3712
Impaired kidney function	1181	Air pollution	3684
Tobacco smoke	1036	Alcohol and drug use	3503
Child & maternal malnutrition	714	Impaired kidney function	1432
Low physical activity	614	Low physical activity	1124

Tobacco smoke is a major health risk factor in Georgia.Tobacco smoke is ranked #8 among women and #3 among men among risk factors and burden of disease in Georgia (Table 1). Despite Georgia ratifying of the Framework Convention on Tobacco Control (FCTC) in 2006, FCTC-recommended policy implementation was limited until 2018 when progressive tobacco control policies began being implemented. Unfortunately, tobacco use and related diseases have not declined. In Georgia, the smoking prevalence is 58% in men (6^th highest in the world) and 6% in women (World Health Organization 2015a). To further characterize tobacco use in Georgia, smoking prevalence is higher among men with lower education, lower income, and who live in smaller settlements. For women, the smoking prevalence distribution is the opposite of that among men: more educated, more affluent women and those who live in larger cities smoke at higher rates than their counterparts (Bakhturidze et al. 2008). Given the sex disparities in tobacco use, the impact of tobacco smoke on women is notable. Prior research documented that 30% of Georgian adults reported past-week SHS exposure in public places, with 54% reporting past-week exposure in the home. Moreover, 42% reported daily SHS exposure, with 39% reporting daily exposure at home (Berg, Smith, et al. 2016; Berg, Topuridze, et al. 2016). Although estimates of SHS exposure among children in Georgia are sparse, the terrain of tobacco use – alongside limited smoke-free air policies at present – suggests high SHS exposure and impact among children in Georgia.

Policy and action plans have been adopted or developed to address EH hazards and SHS. In relation to the former, Georgia recently released its 2017–2021 National Environment and Health Action Plan, which is conceptually and strategically linked to the United Nations’ 2030 Sustainable Development Goals and Health 2020. Given the aforementioned statistics, among the most prominent EH priorities is reducing air pollution. In relation to SHS, legislation effective May 2018 in Georgia progressively advanced tobacco control. One component of the legislation is to implement a national comprehensive smoke-free air policy; thus, this is a critical time for monitoring its implantation and changes to indoor air quality. However, in-country capacity to conduct research regarding EH, particularly related to air, is limited.

As part of developing the 2017–2021 National Environment and Health Action Plan, a needs assessment of specific EH (and NCD) related research training was conducted. This assessment aimed to identify ongoing specific gaps and needs relevant to addressing the growing public health concerns related to NCDs and EH, specifically in conducting research and in research translation to inform public policy and practice. Below we list 3 prominent themes, many of which have been identified in other LMICs (Berg, Cohen, et al. 2018):

First, despite significant progress in enhancing research capacity in Georgia over the past decade, additional efforts are needed, particularly in EH-related research. Over the past decade, important progress has been made in building an infrastructure when little to none existed. Despite the important strides made, there are several current challenges. Public health infrastructure, while improving at a solid pace, remains fragile. Public health training programs have progressed but remain insufficient in the area of EH. In-country research expertise regarding NCDs in relation to EH is relatively scarce in light of the needs for EH expertise in Georgia. Given these challenges in terms of research infrastructure and training and mentorship capacities, there is a need to continue to enhance public health infrastructure, more fully integrate content regarding NCD risk factors and EH into existing public health curriculum, and develop senior researcher expertise to both lead EH-related efforts and guide junior researchers.

Second, and relatedly, there are limited ongoing opportunities to engage young investigators in research related to NCDs and EH. In order to develop junior investigators with such expertise, applied research experiences are needed. The existing or ongoing in-country research opportunities regarding NCDs in relation to EH are limited in terms of volume and range of topics and methods. Moreover, while capitalizing on what in-country opportunities currently exist, providing junior investigators opportunities to engage in ongoing research in this area and opportunities to initiate and participate in new research projects are needed.

Third, critical gaps in research dissemination and knowledge translation from evidence to policy and practice continue to exist, not only in Georgia but globally. Specifically in Georgia, several key challenges to and opportunities for dissemination and translation of findings have been identified, language barriers, limited experience in scientific writing, and opportunities missed in terms of engaging with advocacy groups, policymakers, and other key stakeholders (Berg, Cohen, et al. 2018). Moreover, challenges to conducting research and devoting careers to focused areas of research exist due to limited research and training funding sources and limited researcher time to focus on their research programs (Berg, Cohen, et al. 2018). Thus, efforts are needed to address these critical gaps.

To provide additional context, global research is critically important in addressing global health. International health sciences research is essential in informing public health efforts across the world. For example, research regarding tobacco products, their marketing, and their use in other countries has been critical in informing US tobacco control efforts (Berg, Fong, et al. 2018; Parascandola and Bloch 2016) and is particularly critical when specific countries provide pivotal opportunities to make rapid advances to address a public health issue. This is the case in Georgia. Georgia’s existing infrastructure, paired with key leaders in EH and NCDs and existing opportunities for research and training, provide a solid foundation to advance research aimed at addressing air pollution during this pivotal period. Indeed, this is important globally, as pollution is the largest environmental cause of disease and premature death in the world today, an estimated 9 million premature deaths in 2015 (16% of all deaths worldwide), which three times more deaths than from AIDS, tuberculosis, and malaria combined and 15 times more than from all wars and other forms of violence (Landrigan et al. 2018). This is particularly timely as efforts to address air pollution have lagged in recent years (Watts et al. 2018).

In conclusion, adverse environmental exposures cause 21% of disease burden and 25% of deaths in Georgia, including 30% of disease burden and 14% of deaths among children. Georgia’s mortality index attributed to ambient and indoor air pollution is the 3^rd highest in the world. Among other indoor air pollutants, SHS exposure is a major indoor air pollutant that is particularly prominent and problematic in Georgia. Georgia’s 2017–2021 National Environment and Health Action Planhighlights that addressing air pollution is among the most prominent public health priorities. However, there is limited in-country capacity to conduct research regarding the impact of such environmental hazards on health. Thus, efforts must enhance such research capacity in order to reduce air pollution and its effects on health.