Hrev_master [page 54] [Emergency Care Journal 2024; 20:12488] Emergency Care Journal 2024 volume 20:12488 Human health is one of the earliest biosensors of climate change, which increases the frequency and severity of many dis- eases, as reported by Bellone.1 In Europe, air pollution is becoming a severe health problem that needs to be addressed by physicians of all specialties as well as governments and the general public. Unfortunately, it is acknowledged that the Po Valley in Italy is among the most polluted areas in Europe. As physicians practicing in this area, we feel we must remind our colleagues of the increas- ing impact of the environment on the health of ourselves and our patients. Along with having a substantial negative influence on both human and environmental health, air pollution also has a financial cost since it raises medical expenses and reduces produc- tivity due to missed workdays. We can define this situation as a silent epidemic that affects all people, regardless of age. Air pollution in the Po Valley The Po Valley has been identified by the European Environment Agency (EEA) as the most polluted region in Western Europe, facing the persistent environmental challenge of air pollution. The recently published air quality data indicates that the situation in the Po Valley is so dramatic that air pollutant levels pose a risk to human health, including the development of cardio- vascular and respiratory diseases and reduced life expectancy, causing more than 1,200 premature deaths among under-18s every year in Europe.2 Despite continuous general improvements in air quality, air pollution is still a major health problem for Europeans, especially in Northern Italy, with levels of pollutants exceeding EU criteria and concentrations considerably above the most recent WHO rec- ommendations.3 The Po Valley is a heavily industrialized and densely populated area, that releases large quantities of pollutants into the atmo- sphere. Its geography and characteristic weather patterns exacer- bate the problem: the Po Valley is effectively “boxed in” between the Alps and the Apennines, creating a basin that traps air pollu- tants and causes some of the highest concentrations of particulate matter and toxic gas in Europe. In addition, the stagnant air and the lack of ventilation exacerbate the concentration and make the solu- tion to the problem difficult. Air pollution in the Po Valley exhibits distinct seasonal patterns. During the winter months, fine particu- late matter concentrations tend to spike. In contrast, during the summer ozone levels are more elevated, stemming from increased solar radiation and the presence of precursors (nitrogen oxides and volatile organic compounds) emitted from various sources. These fluctuations in air pollution levels have significant repercussions for human health4,5 and the environment. Air pollution, climate change and health The Po Valley exceeds the European guideline limits for ozone, nitrogen dioxide, and fine particulate matter (PM2.5).6 Ozone is one of the most dangerous substances for asthma suffer- ers, while nitrogen dioxide is produced mainly by road vehicles and is carcinogenic. Fine particulate matter (PM2.5 and PM10) is one of the pollutants that has the greatest negative effects on human health. It is mostly composed of airborne solid and liquid particles, up to half a millimeter in diameter, that come mainly from industry, fossil fuels used for road transport, and the burning of wood and coal. PM10 is inhalable and can have an impact on respiratory health; PM2.5 poses health risks by entering the blood- Correspondence:Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044 E-mail: poggiali.erika@gmail.com Key words: air pollution, global health, climate change, Po Valley, slow medicine, one health. Contributions: all the authors approved the final version and equally contributed to the work. Conflicts of interest: all the authors are members of the editorial board of Emergency Care Journal. The authors declare no conflict of interest. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it. Ethics approval and consent to participate: not necessary. Informed consent: not necessary. Acknowledgements: Erika Poggiali would like to thank Davide Bastoni for his insightful comments and sharing of the knowledge that everyone, especially emergency physicians, needs to be proac- tive in order to find solutions for climate change and air pollution. Received: 19 March 2024. Accepted: 19 March 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12488 doi:10.4081/ecj.2024.12488 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Two silent epidemics: air pollution and climate change. “Slow and sustainable medicine” as part of the solution Erika Poggiali,1 Lorenzo Ghiadoni,2 Daniele Coen2 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Academy of Emergency Medicine and Care, Pavia, Italy Non -co mmerc ial us e o nly stream through the lungs, causing cardiovascular diseases, respira- tory diseases, and allergies. According to EU directives and legal standards, concentrations of PM10 exceeding 50 µg/m3 are deemed dangerous, and this threshold should not be surpassed for any location for a specified number of days annually, typically set at 35 days. Recent observations indicate that in January 2024, there have been multiple instances where this critical threshold was exceeded.7 An article titled “Impossible to live like this: Italy’s Po Valley blighted by air pollution among the worst in Europe” appeared in The Guardian in September 2023. The article high- lighted the dire circumstances in Crotta d’Adda (Cremona, Lombardy) due to pollution from vehicles, industry, and farm ani- mal waste, which created an unbearable and potentially noxious stench that caused headaches, dizziness, vomiting, and swollen eyes.8 During the COVID-19 pandemic, the relationships between air pollution and health became more and more significant, show- ing once again the importance of actions aimed at improving the quality of air.9,10 Infants and children are particularly sensitive to pollution and climate change and bear its consequences for a longer time11,12 through multiple pathways.13 Exposure to heat waves during fetal development is associated with increased risks of preterm birth and low birth weight, as well as infant death and hyperthermia, heat stress, and kidney diseases in children. Climate change has also a negative impact on children’s and teenagers’ mental health, increasing mental health–related emergency department visits.14,15 Major floods and hurricanes have caused drowning, physical injury, and traumatic stress in children.16 Exposure to wildfire smoke is associated with asthma flare-ups, wheezing, pneumonia, and bronchitis in childhood.17 Air pollution is a well-known trigger of asthma attacks in chil- dren with the disease and is now understood to be a cause of asth- ma,18 but it is also a risk factor for respiratory infections, bronchi- tis, and impaired lung growth and function.19 The “Air pollution and child health: prescribing clean air” report,20 written by WHO for the first Global conference about air pollutants and health (November 2018), clearly underlines how the pediatric population is at specific risk: 93% of children under the age of 15 are exposed to particulate levels that are higher than those recommended by guidelines about air quality. In the United States, children have had more allergies and asthma attacks requiring emergency department access due to the increased levels of airborne pollen as a result of higher temperatures and rising levels of carbon dioxide, which have resulted in longer growing seasons and increased pollen pro- duction.21 The WHO estimated that venoms in the air caused 600,000 deaths in children in 2016. Italy distinguished itself nega- tively, with 98% of the children exposed to too high levels of par- ticulates. These are astounding numbers, and something must change. According to a recent 9-year observational study conducted by the Pediatric Emergency Unit of IRCCS Azienda Ospedaliero- Universitaria of Bologna (Italy), children with bronchiolitis may be more likely to require hospitalization if they are exposed to out- door air pollutants, especially high concentrations of PM2.5, C6 H6, NO2, and PM10. Based on these results, the authors strongly recommend avoiding open-air exposure of infants during rush hours and in the most polluted areas.22 Collaborations between governments, industries, and local communities are essential to solving the problem. The main com- ponents of this process are financial incentives, education, and community involvement, but we all need to contribute to the trans- formation. Imaging as a cause of climate change As doctors, we are fearful of climate change and air pollution, but we are part of the problem since healthcare contributes signif- icantly to this dramatic scenario. We must reflect on the evidence that medical imaging contributes significantly to the CO2 emis- sions, that are the most important cause of global warming. In 2023, the amount of CO2 production in the world (fossil origin) was the largest.23 Among the common cardiac imaging techniques, CO2 emissions are lowest for transthoracic echocardiography (0.5– 2 kg per exam), increase 10-fold for cardiac computed tomography angiography, and 100-fold for cardiac magnetic resonance. A con- servative estimate of 10 billion medical examinations per year worldwide implies that medical imaging accounts for approxi- mately 1% of the overall carbon footprint. In 2016, CO2 emissions from magnetic resonance imaging and computed tomography, cal- culated in 120 countries, accounted for 0.77% of global emissions. A significant portion of global greenhouse gas emissions is attributed to health care, which ranges from 4% in the United Kingdom to 10% in the United States.24 The Choosing Wisely campaign celebrated its 10th birthday in 2022. This initiative has taught patients and doctors that overuse is an equity issue, and that avoiding overuse can protect patient safety.25 Promoting appropriateness in imaging, including the economic and radiological cost and the carbon cost of medical imaging in decision-making, could avoid medical imaging overuse and can also protect planet safety. To treat and cure every patient without endangering the environment or the health of the world, we must examine what we have done and work toward a “slow and sustain- able medicine” — the so-called “one health” approach. References 1. Bellone A. We can and must do something. Emerg Care J 2024; https://doi.org/10.4081/ecj.2024.12290 2. European Environment Agency. Europe’s air quality status 2023. Available from: https://www.eea.europa.eu/publica- tions/europes-air-quality-status-2023 3. Panunzi S, Marchetti P, Stafoggia M, et al. Residential expo- sure to air pollution and adverse respiratory and allergic out- comes in children and adolescents living in a chipboard indus- trial area of Northern Italy. Sci Total Environ 2023;864: 161070. 4. Stafoggia M, De' Donato F, Ancona C, et al. Health impact of air pollution and air temperature in Italy: evidence for policy actions. Epidemiol Prev 2023;47:22-31. 5. Ranzi A, Freni Sterrantino A, Forastiere F, et al. Asthmatic symptoms and air pollution: a panel study on children living in the Italian Po Valley. Geospat Health 2015;10:366. 6. European Environment Agency. Italy – air pollution country fact sheet. Available from: https://www.eea.europa. eu/themes/air/country-fact-sheets/2023-country-fact-sheets/ italy-air-pollution-country 7. European Space Agency. Air pollution fluctuations over the Po Valley. Available from: https://www.esa.int/Applications/ Observing_the_Earth/Air_pollution_fluctuations_over_the_P o_Valley 8. Giuffrida A. ‘Impossible to live like this’: Italy’s Po Valley blighted by air pollution among worst in Europe. The Guardian, Thu 21 Sep 2023. Available fom: https://www.the- guardian.com/world/2023/sep/21/italy-po-valley-blighted-air- Editorial [Emergency Care Journal 2024; 20:12488] [page 55] Non -co mmerc ial us e o nly pollution-worst-europe 9. Pala D, Casella V, Larizza C, et al. Impact of COVID-19 lock- down on PM concentrations in an Italian Northern City: A year-by-year assessment. PLoS One 2022;17:e0263265. 10. Bontempi E, Carnevale C, Cornelio A, et al. Analysis of the lockdown effects due to the COVID-19 on air pollution in Brescia (Lombardy). Environ Res 2022;212:113193. 11. Perera FP. Multiple threats to child health from fossil fuel com- bustion: impacts of air pollution and climate change. Environ Health Perspect 2017;125:141-8. 12. Perera FP. Children’s health and the perils of climate change. London: Oxford University Press (in press). Preview available from: https://scholar.google.com/scholar?hl=en&q=Perera+ FP.+Children%E2%80%99s+health+and+the+perils+of+cli- mate+change.+London%3A+Oxford+University+Press+%28i n+press%29 13. Perera F, Nadeau K. Climate change, fossil-fuel pollution, and children's health. N Engl J Med 2022;386:2303-14. 14. Clemens V, von Hirschhausen E, Fegert JM. Report of the intergovernmental panel on climate change: implications for the mental health policy of children and adolescents in Europe — a scoping review. Eur Child Adolesc Psychiatry 2022;31:701-13. 15. Vergunst F, Berry HL. Climate change and children’s mental health: a developmental perspective. Clin Psychol Sci 2022;10:767-85. 16. Intergovernmental Panel on Climate Change. Climate change 2021 — the physical science basis: summary for policymakers. October 2021. Available from: https://www.ipcc.ch/ report/ar6/wg1/chapter/summary-for-policymakers/ 17. Xu R, Yu P, Abramson MJ, et al. Wildfires, global climate change, and human health. N Engl J Med 2020;383:2173-81. 18. Thurston GD, Balmes JR, Garcia E, et al. Outdoor air pollution and new-onset airway disease: an official American Thoracic Society Workshop report. Ann Am Thorac Soc 2020;17:387- 98. 19. Brumberg HL, Karr CJ; Council On Environmental Health. Ambient air pollution: health hazards to children. Pediatrics 2021;147:e2021051484. 20. WHO. Air pollution and child health: prescribing clean air. Available from: https://www.who.int/publications/ i/item/ WHO-CED-PHE-18-01 21. Neumann JE, Anenberg SC, Weinberger KR, et al. Estimates of present and future asthma emergency department visits associated with exposure to oak, birch, and grass pollen in the United States. Geohealth 2019;3:11-27. 22. Dondi A, Manieri E, Betti L, et al. Exposure to outdoor air pol- lution and risk of hospitalization for bronchiolitis in an urban environment: A 9-year observational study. Pediatr Pulmonol 2023;58:2786-94. 23. Battle MO, Raynor R, Kesler S, Keeling R. Technical Note: The impact of industrial activity on the amount of atmospheric O2, Atmos. Chem Phys Discuss 2023; https://doi.org/ 10. 5194/acp-2022-765 24. Picano E, Mangia C, D'Andrea A. Climate change, carbon dioxide emissions, and medical imaging contribution. J Clin Med 2022;12:215. 25. Baron RJ, Lynch TJ, Rand K. Lessons from the choosing wise- ly campaign's 10 years of addressing overuse in health care. JAMA Health Forum 2022;3:e221629. Editorial [page 56] [Emergency Care Journal 2024; 20:12488] Non -co mmerc ial us e o nly