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Should air pollution be noted on death certificates?

Disease certificates note the direct cause of death, for example, heart disease or lung cancer, but rarely do they ever mention the underlying causes behind the death. Air pollution needs to be noted as a cause of death, writes Dr Sanjay Kulshrestha for News9Live. However, some dispute this claim.

Burning of crops in southeast Punjab - a major driver of northern India's pollution crisis. (Image credit, Neil Palmer (CIAT) [CC BY-SA 2.0 (]). Stubble burning concept.
Burning of crops in southeast Punjab – a major driver of northern India’s pollution crisis. (Image credit, Neil Palmer (CIAT) [CC BY-SA 2.0 (])
The article notes a study in the journal The Lancet Planetary Health that found that India suffered 2.4 million deaths in 2019 due to pollution. The data was derived from the Global Burden of Disease database and the Institute for Health Metrics and Evaluation in Seattle. The overall death toll was attributed to dirty air from cars, trucks, and industry, with deaths rising 55 percent since 2000. India ranked first in the global pollution death toll list.

“No law prevents doctors from writing that particular death was linked to air pollution,” said Dr Kulshrestha. He believes that more studies must take place to indicate a direct role played by air pollution in a person’s death. He writes that the inclusion of pollution as a causative factor in death certificates could bring more attention to the severe effects that pollution can have.

However, this claim has been countered by Dr Lancelot Mark Pinto. He argues that air pollution should remain omitted from death certificates as it is almost impossible to make the case that air pollution was the sole cause of death. 

“As a pulmonologist, I can say that pollution of all sorts may be responsible for lung cancer (taken as an example) but I have no way to prove that it was only pollution that caused this kind of a cancer in a patient,” said Dr Pinto. 

Dr Pinto notes that it is all but unheard of that an individual would die instantaneously from air pollution. While few exceptions may occur – such as an acute exacerbation of a condition such as asthma during a period of severe pollution – air pollution does not kill an individual quickly, or in isolation of other comorbidities. The effects of air pollution instead manifest over time, contributing to a number of conditions. 

As such, air pollution could be one of any number of factors that may have contributed to the development of a disease that eventually kills an individual. Obesity, for example, contributes to many conditions, but it alone will not be a cause of death. Smoking, drinking alcohol and high-sugar diets all contribute to the development of disease, but these are all omitted from death certificates as they will not directly kill an individual. 

Both Dr Pinto and Dr Kulshrestha may disagree on the placing of air pollution on the death certificate, but both are in agreement that far more studies need to take place on the effects of air pollution on health. They also agree that government programmes should be created and expanded to counter well known pollution issues such as indoor biomass stoves and crop burning.

There is, however, already an expanse of studies reporting air pollution as having catastrophic health impacts, with more conditions being linked to pollution every year. A number of damning studies have flagged air pollution as a key risk to a number of health issues and premature deaths. Health Issues India has discussed many of these in previous articles.

While previously it was largely assumed that air pollution only played a role in the development of respiratory pathologies such as asthma or emphysema, it is now known that the particulate matter is absorbed through the lungs and into the blood. As a result of the inflammation this causes, numerous conditions are either exacerbated, or developed as a result of the effects of pollution, such as heart disease and diabetes.

According to an elongated study conducted at the University of Washington, air pollution also raises the risks of dementia. For many who have dwelled within India’s urban “smog chamber” environments for their whole lives, there lies a grave potential for either a life cut tragically short by other conditions, or the development of dementia far earlier than would otherwise be expected. 

“We found that an increase of one microgram per cubic metre of exposure corresponded to a sixteen percent greater hazard of all-cause dementia. There was a similar association for Alzheimer’s-type dementia,” said lead author Rachel Shaffer, who conducted the research as a doctoral student in the University of Washington Department of Environmental and Occupational Health Sciences.

One report, titled “State of Global Air 2020” named India and sub-Saharan Africa as two of the world’s major air pollution hotspots. The report claimed that long-term exposure to both outdoor and household air pollution contributed to over 1.67 million annual deaths from stroke, heart attack, diabetes, lung cancer, chronic lung diseases and neonatal diseases in India in 2019. The report also claimed that India’s catastrophic air pollution issues were responsible for the deaths of more than 116,000 infants within the first month of life in 2019. 

The effects of air pollution are well documented to cause damage to health, and as a result have a significant economic impact. As Health Issues India previously reported, a study conducted by researchers from the Global Observatory on Pollution and Health at Boston College, the Indian Council of Medical Research, and the Public Health Foundation of India found that air pollution accounted for $36.8 billion worth of economic damage to India. Part of this economic loss was attributable to premature deaths caused by air pollution in 2019.

Whether air pollution warrants a direct addition to death certificates is up for debate. However, air pollution is undeniably a major issue in both a healthcare, and an economic sense. Given the number of conditions linked to air pollution, as well as the sheer number of deaths linked to it, it is easily among India’s most prominent health concerns, warranting far more attention than currently given.

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