Prof. Agnes Binagwaho

Patterns of marginalization and exclusion of the vulnerable in medicine and public health have become the norm. The vulnerable, especially on the African continent, have been left out of the distribution of life-saving medical and public health interventions. When included, they have always been last in line to receive such interventions. This inequity prevents Africa from stopping the spread of diseases, resulting in preventable deaths. The repercussions of this inequitable distribution are magnified in countries whose health systems have been weakened by centuries of colonization and unfair international policies such as the structural adjustment programs that hollowed out public investment in health systems.1 A prime example that illustrates the historical marginalization of the vulner- able is the distribution of antiretroviral therapy (ART). In the 1990s, powerful administrations such as the U.S. government strongly pushed for ART to be denied to HIV/ AIDS patients in developing countries as it was considered too expensive, too complicated, and not cost-effective.2 Instead, leaders around the world called for prevention as a cheaper means of reducing the spread of the virus, leaving the 40 million infected in Sub-Saharan Africa in 2002 with no treatment options at a time when treatment was available.3 This is just one example of the countless manifestations of injustice that have pervaded our society, leaving Africa to contend with diseases that have become an afterthought on other continents.

Background Africa is undergoing both an environmental and an epidemiological transition. Household air pollution is the predominant form of air pollution, but it is declining, whereas ambient air pollution is increasing. We aimed to quantify how air pollution is affecting health, human capital, and the economy across Africa, with a particular focus on Ethiopia, Ghana, and Rwanda. Methods Data on household and ambient air pollution were from WHO Global Health Observatory, and data on morbidity and mortality were from the 2019 Global Burden of Disease Study. We estimated economic output lost due to air pollution-related disease by country, with use of labour income per worker, adjusted by the probability that a person (of a given age) was working. Losses were expressed in 2019 international dollars and as a proportion of gross domestic product (GDP). We also quantified the contribution of particulate matter (PM)2·5 pollution to intelligence quotient (IQ) loss in children younger than 10 years, with use of an exposure–response coefficient based on previously published data. Findings Air pollution was responsible for 1·1 million deaths across Africa in 2019. Household air pollution accounted for 697000 deaths and ambient air pollution for 394000. Ambient air pollution-related deaths increased from 361000 in 2015, to 383000 in 2019, with the greatest increases in the most highly developed countries. The majority of deaths due to ambient air pollution are caused by non-communicable diseases. The loss in economic output in 2019 due to air pollution-related morbidity and mortality was $3·02 billion in Ethiopia (1·16% of GDP), $1·63 billion in Ghana (0·95% of GDP), and $349 million in Rwanda (1·19% of GDP). PM2·5 pollution was estimated to be responsible for 1·96 billion lost IQ points in African children in 2019. Interpretation Ambient air pollution is increasing across Africa. In the absence of deliberate intervention, it will increase morbidity and mortality, diminish economic productivity, impair human capital formation, and undercut development. Because most African countries are still early in development, they have opportunities to transition rapidly to wind and solar energy, avoiding a reliance on fossil fuel-based economies and minimising pollution.