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Brussels, Tuesday 17 October 2023 Subject: Health sector calls for clean air to prevent disease and save lives Dear Minister Michal, Ahead of your vote in the Environment Council of the EU on the revision of the EU’s clean air standards (Ambient Air Quality Directives - AAQD), we, the undersigned organisations, representing the European health sector, including medical doctors, healthcare professionals, patient organisations and health insurance funds, urge you to step up on the Commission’s proposal, to reduce ill-health and health costs swiftly and significantly. The update of the EU’s clean air standards is a unique and not-to-be-missed opportunity for preventing premature death and the health burden from chronic diseases, including respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma, heart disease, strokes, and cancer, as well as infectious respiratory diseases, including COVID-19. In the coming weeks you will be deciding on the Council General Approach on the AAQD revision. To ensure that people across Europe breathe clean air for a healthy life, health groups urge you to follow concerns from people across the EU and science, and go beyond the ambition of the September 2023 European Parliament’s position. This includes especially adopting a date of 2030 for ensuring the full alignment of EU clean air standards with the guidelines of the World Health Organization (WHO), in view of the urgency to swiftly and significantly reduce the health burden of air pollution. In addition, we urge you to follow up on the July 2023 adoption of the “Budapest Declaration”1 of the Seventh Ministerial Conference on Environment and Health and show your commitment in protecting people’s health and saving on health economic cost by tightening the flexibilities and derogations foreseen in the draft law (especially article 18). Air pollution is the top environmental risk to health in Europe. Everyone is vulnerable to its impacts, and some are more at risk than others. People’s level of vulnerability is outside of individual control, as it evolves with age, health condition, socio-economic status, as well as where people live, study, or work. As evidenced in the Commission’s impact assessment accompanying 1 https://www.who.int/europe/news/item/07-07-2023-countries-of-the-who-european-region-adopt- budapest-declaration--pushing-action-to-enhance-environment-and-health the AAQD proposal2, the benefits for society far outweigh the mitigation costs for all scenarios, including the scenario of full alignment with WHO guidelines by 2030. Currently, the health burden of poor air quality and the related costs remain unacceptably high. Your leadership and political will for putting people’s health at the forefront of EU policy and preventing further ill health is crucial. Please see the Annex for the full list of health groups' demands. We are available to respond to any questions. Regards, Anne Stauffer, Deputy Director, Health and Environment Alliance (HEAL) Panagiotis Chaslaridis, Senior Policy Advisor, European Federation of Allergy and Airways Diseases Patients’ Associations (EFA) Barbara Hoffmann, Chair Advocacy Council, and Zorana Andersen, Chair Environment and Health Committee, European Respiratory Society (ERS) Hanna Boogaard, Co Chair, International Society of Environmental Epidemiology (ISEE) Europe Dr Christiaan Keijzer, President, Standing Committee of European Doctors (CPME) Dr Cale Lawlor, Senior Policy Manager for Global Public Health, European Public Health Alliance (EPHA) Xavier Brenez, CEO, Mutualités Libres/Onafhankelijke Ziekenfondsen Sara Bertucci, Policy Officer, Association of European Cancer Leagues (ECL) 2 See P. 9 in the Explanatory Memorandum that introduces the Commission’s proposal https://eur- lex.europa.eu/resource.html?uri=cellar:2ae4a0cc-55f8-11ed-92ed- 01aa75ed71a1.0001.02/DOC_3&format=PDF Annex I: background information on the health harm of air pollution In the WHO European Region, air pollution is estimated [1] to cause about 33% of new cases of childhood asthma [2], 17% of all lung cancer cases, 12% of all ischemic heart disease, 11 % of all strokes, and 3% of all chronic obstructive pulmonary disease (COPD). In addition, evidence of harmful effects of air pollution on diseases of the brain, including dementia and mental health, are rapidly emerging, and likely add to the increasing burden of disease. Recent studies have shown that children are particularly at risk of harm from polluted air, given that their lungs, heart, brain, respiratory, immune and nervous systems are still developing. Their health can already be affected at early-life stages or even before birth, with lifelong consequences. The latest science, published after the WHO Air Quality Guidelines, underlines that air pollution is harmful at much lower levels than previously thought, and that there is no safe level of air pollution. The cost of air pollution is estimated to be up to EUR 853 billion annually for the EU [3]. This includes health costs related to premature death and diseases from air pollution, productivity losses due to both workdays lost and reduction in workers’ capacity, productivity, crop yield losses, the deterioration of the natural environment landscape affecting the tourism sector, and damage to buildings. While the impact assessment on the AAQDs clearly shows that the benefits of fully aligning EU’s air quality standards by 2030 would by far outweigh the “costs”, the European Commission presented an utmost conservative impact assessment that underestimates both the health costs of air pollution and the current air pollution source prevention potential [4] leading to an inadequate ambition level for the revision. Annex II: our demands Please put health protection first in the AAQD revision: 1. Demonstrate your political will by increasing the level of ambition ● Fully align the EU’s air quality standards with the WHO recommendations and the latest science by 2030 at the latest: full alignment should be achieved for all pollutants included in the World Health Organization’s (WHO) 2021 guidelines, especially for fine particulate matter (PM2.5), particulate matter (PM10), nitrogen dioxide (NO2), and ozone (O3). ● Support legally binding limit values, to recognise and address health inequalities: clear limit values are the most protective and effective type of standards to protecting everyone, but especially the most vulnerable. A focus on average exposure will not help to reduce the burden of those suffering most. Contrary to the European Commission’s proposal, ground-level ozone (O3) should be subject to a limit value and not a target value. 2. Protect vulnerable groups to protect everyone ● Include a comprehensive definition of vulnerable and susceptible groups in accordance with the WHO: vulnerability factors to the health impacts of air pollution are diverse and can be cumulative. The Commission’s proposal introduces a definition of sensitive and vulnerable groups that needs to be more inclusive, including explicit mention of health inequalities. ● Strengthen public information on air quality as a public health measure that prevents and protects: air quality information should be accessible, transparent, real-time and include health related messaging targeted to vulnerable groups. 3. Ensure the most health-protective enabling framework ● Close the risk of compliance delays and exemptions with limit values associated with the numerous options for postponement in the current version of the text. ● Increase the density and representativity of monitoring stations. The criteria for the location of sampling points should include the representativity of social inequalities, as well as the exposure of vulnerable and susceptible groups, such as social housing, schools, hospitals or homes for the elderly. ● Support an independent review of the evidence regularly carried out by the World Health Organization, as the core of the review mechanism foreseen. [1] European Environment Agency - Healthy environment, healthy lives: how the environment influences health and well-being in Europe - 2020 https://www.eea.europa.eu/publications/healthy-environment-healthy-lives [2] Haneen Khreis, Marta Cirach, Natalie Mueller, Kees de Hoogh, Gerard Hoek, Mark J Nieuwenhuijsen and David Rojas-Rueda. Outdoor Air Pollution and the Burden of Childhood Asthma across Europe. Eur Respir J 2019; in press https://doi.org/10.1183/13993003.02194- 2018 [3] https://ec.europa.eu/commission/presscorner/detail/en/qanda_22_6348 [4] LEZ, fuel switch and behavioral change were not taken into account in the assessment, as well as certain health benefits. Saatja: Sophie Perroud <[email protected]> Saadetud: 17.10.2023 16:53 Adressaat: <[email protected]> Koopia: <"SM Info">; <[email protected]>; <=?utf-8?Q?Agne_Nettan- Sepp_Br=C3=BCsselis?=>; 'Anne Stauffer' <[email protected]> Teema: Health sector calls for clean air to prevent disease and save lives Manused: AAQD_joint letter to Council_health groups_Estonia.pdf Dear Minister Michal, Ahead of your vote in the Environment Council of the EU on the revision of the EU’s clean air standards (Ambient Air Quality Directives - AAQD), we, the undersigned organisations, representing the European health sector, including medical doctors, healthcare professionals, patient organisations and health insurance funds, urge you to step up on the Commission’s proposal, to reduce ill-health and health costs swiftly and significantly. The update of the EU’s clean air standards is a unique and not-to-be-missed opportunity for preventing premature death and the health burden from chronic diseases, including respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma, heart disease, strokes, and cancer, as well as infectious respiratory diseases, including COVID-19. In the coming weeks you will be deciding on the Council General Approach on the AAQD revision. To ensure that people across Europe breathe clean air for a healthy life, health groups urge you to follow concerns from people across the EU and science, and go beyond the ambition of the September 2023 European Parliament’s position. This includes especially adopting a date of 2030 for ensuring the full alignment of EU clean air standards with the guidelines of the World Health Organization (WHO), in view of the urgency to swiftly and significantly reduce the health burden of air pollution. In addition, we urge you to follow up on the July 2023 adoption of the “Budapest Declaration”[1] of the Seventh Ministerial Conference on Environment and Health and show your commitment in protecting people’s health and saving on health economic cost by tightening the flexibilities and derogations foreseen in the draft law (especially article 18). Air pollution is the top environmental risk to health in Europe. Everyone is vulnerable to its impacts, and some are more at risk than others. People’s level of vulnerability is outside of individual control, as it evolves with age, health condition, socio-economic status, as well as where people live, study, or work. As evidenced in the Commission’s impact assessment accompanying the AAQD proposal[2], the benefits for society far outweigh the mitigation costs for all scenarios, including the scenario of full alignment with WHO guidelines by 2030. Currently, the health burden of poor air quality and the related costs remain unacceptably high. [1] https://www.who.int/europe/news/item/07-07-2023-countries-of-the-who-european-region-adopt-budapest- declaration--pushing-action-to-enhance-environment-and-health [2] See P. 9 in the Explanatory Memorandum that introduces the Commission’s proposal https://eur- lex.europa.eu/resource.html?uri=cellar:2ae4a0cc-55f8-11ed-92ed-01aa75ed71a1.0001.02/DOC_3&format=PDF Your leadership and political will for putting people’s health at the forefront of EU policy and preventing further ill health is crucial. Please see the Annex for the full list of health groups' demands. We are available to respond to any questions. Regards, Anne Stauffer, Deputy Director, Health and Environment Alliance (HEAL) Panagiotis Chaslaridis, Senior Policy Advisor, European Federation of Allergy and Airways Diseases Patients’ Associations (EFA) Barbara Hoffmann, Chair Advocacy Council, and Zorana Andersen, Chair Environment and Health Committee, European Respiratory Society (ERS) Hanna Boogaard, Co Chair, International Society of Environmental Epidemiology (ISEE) Europe Dr Christiaan Keijzer, President, Standing Committee of European Doctors (CPME) Dr Cale Lawlor, Senior Policy Manager for Global Public Health, European Public Health Alliance (EPHA) Xavier Brenez, CEO, Mutualités Libres/Onafhankelijke Ziekenfondsen Sara Bertucci, Policy Officer, Association of European Cancer Leagues (ECL) *** Annex I: background information on the health harm of air pollution In the WHO European Region, air pollution is estimated [1] to cause about 33% of new cases of childhood asthma [2], 17% of all lung cancer cases, 12% of all ischemic heart disease, 11 % of all strokes, and 3% of all chronic obstructive pulmonary disease (COPD). In addition, evidence of harmful effects of air pollution on diseases of the brain, including dementia and mental health, are rapidly emerging, and likely add to the increasing burden of disease. Recent studies have shown that children are particularly at risk of harm from polluted air, given that their lungs, heart, brain, respiratory, immune and nervous systems are still developing. Their health can already be affected at early-life stages or even before birth, with lifelong consequences. The latest science, published after the WHO Air Quality Guidelines, underlines that air pollution is harmful at much lower levels than previously thought, and that there is no safe level of air pollution. The cost of air pollution is estimated to be up to EUR 853 billion annually for the EU [3]. This includes health costs related to premature death and diseases from air pollution, productivity losses due to both workdays lost and reduction in workers’ capacity, productivity, crop yield losses, the deterioration of the natural environment landscape affecting the tourism sector, and damage to buildings. While the impact assessment on the AAQDs clearly shows that the benefits of fully aligning EU’s air quality standards by 2030 would by far outweigh the “costs”, the European Commission presented an utmost conservative impact assessment that underestimates both the health costs of air pollution and the current air pollution source prevention potential [4] leading to an inadequate ambition level for the revision. Annex II: our demands Please put health protection first in the AAQD revision: 1. Demonstrate your political will by increasing the level of ambition ● Fully align the EU’s air quality standards with the WHO recommendations and the latest science by 2030 at the latest: full alignment should be achieved for all pollutants included in the World Health Organization’s (WHO) 2021 guidelines, especially for fine particulate matter (PM2.5), particulate matter (PM10), nitrogen dioxide (NO2), and ozone (O3). ● Support legally binding limit values, to recognise and address health inequalities: clear limit values are the most protective and effective type of standards to protecting everyone, but especially the most vulnerable. A focus on average exposure will not help to reduce the burden of those suffering most. Contrary to the European Commission’s proposal, ground-level ozone (O3) should be subject to a limit value and not a target value. 2. Protect vulnerable groups to protect everyone ● Include a comprehensive definition of vulnerable and susceptible groups in accordance with the WHO: vulnerability factors to the health impacts of air pollution are diverse and can be  cumulative. The Commission’s proposal introduces a definition of sensitive and vulnerable groups that needs to be more inclusive, including explicit mention of health inequalities. ● Strengthen public information on air quality as a public health measure that prevents and protects: air quality information should be accessible, transparent, real-time and include health related messaging targeted to vulnerable groups. 3. Ensure the most health-protective enabling framework ● Close the risk of compliance delays and exemptions with limit values associated with the numerous options for postponement in the current version of the text. ● Increase the density and representativity of monitoring stations. The criteria for the location of sampling points should include the representativity of social inequalities, as well as the exposure of vulnerable and susceptible groups, such as social housing, schools, hospitals or homes for the elderly. ● Support an independent review of the evidence regularly carried out by the World Health Organization, as the core of the review mechanism foreseen. [1] European Environment Agency - Healthy environment, healthy lives: how the environment influences health and well-being in Europe - 2020 https://www.eea.europa.eu/publications/healthy- environment-healthy-lives [2] Haneen Khreis, Marta Cirach, Natalie Mueller, Kees de Hoogh, Gerard Hoek, Mark J Nieuwenhuijsen and David Rojas-Rueda. Outdoor Air Pollution and the Burden of Childhood Asthma across Europe. Eur Respir J 2019; in press https://doi.org/10.1183/13993003.02194-2018 [3] https://ec.europa.eu/commission/presscorner/detail/en/qanda_22_6348 [4] LEZ, fuel switch and behavioral change were not taken into account in the assessment, as well as certain health benefits. Sophie Perroud EU policy coordinator Health & Environment Alliance (HEAL) ***not working on Fridays*** MUNDO MADOU Visitors and deliveries: Avenue des Arts 7/8 Head office: Rue de la Charité 22 B-1210 Bruxelles Tel: +32 2 329 00 80 E-mail | Website | Newsletter | Twitter | Facebook | Transparency