Pollution, by Region, 2019

increase substantially the number of hospitalizations (as a measure of morbidity). AAP is a major source of many potentially fatal diseases (as shown in figure 3.7) and increases the frequency of hospital stays or days staying home from work. Common pollutants such as CO, NO2, and PM have been found to increase hospital admissions for cardiovascular and all cardiac diseases, cardiac failure, ischemic heart disease, and myocardial infarction.10 Short-term exposure to higher PM2.5 levels in particular increases the risk of hospital admissions for cardiovascular and respiratory diseases (Dominici et al. 2006).

Global Comparisons

The Middle East and North Africa has the world’s highest rates of morbidity and mortality due to AAP. Measured in terms of disability days in a lifetime (figure 3.13, panel a), it surpasses even South Asia, which has the highest PM2.5 concentration (as shown earlier in figure 3.1). Similarly, the Middle East and North Africa emerges as the region with the highest AAP-related mortality rates worldwide, trailed closely by South Asia (figure 3.13, panel b).

FIGURE 3.13

Global Morbidity and Mortality Rates Related to Air Pollution, by Region, 2019

a. Average lifetime disability daysa

80

Disability days within a lifetime 60

40

20

0 East Asia and PacificEurope and Central Asia Latin America and the CaribbeanMiddle East and North AfricaNorth AmericaSouth AsiaSub-Saharan Africa 100 b. Death rates

Deaths per 100,000 people 75

50

25

0 East Asia and PacificEurope and Central Asia Latin America and the CaribbeanMiddle East and North AfricaNorth AmericaSouth AsiaSub-Saharan Africa

Source: Data from the Global Burden of Disease (GBD) tool of the Institute for Health Metrics and Evaluation (IHME) Global Health Data Exchange (http://ghdx.healthdata.org/gbd-results-tool). Note: “North America” includes Canada and the United States. a. The data are calculated from information on years lived with disability (YLD)—years lived with any short-term or long-term health loss— taking into account the different life expectancies at birth in different regions.

That both death rates and YLD—years lived with any short-term or long-term health loss—are higher in the Middle East and North Africa even though South Asia has higher PM2.5 concentrations has much to do with the fact that many air pollution-induced diseases (those shown in figure 3.7) are affected by comorbidities that also raise the risk of suffering from such diseases. For example, the relation between obesity and the effects of air pollution has been heavily studied, and it has been found that AAP may aggravate obesity-induced diseases (see, for example, Sun et al. 2009; Yang et al. 2018). The Middle East and North Africa has much higher obesity rates than South Asia and substantially higher rates of physical inactivity, according to WHO Global Health Observatory data. These differences contribute to the higher AAP-related YLD and death rates in the Middle East and North Africa even though AAP is higher in South Asia.11

Impacts of Air Pollution on COVID-19 Risks

Increased AAP has been linked to a significantly higher probability of severe illness or death from COVID-19. Exposure to polluted air has decisive effects on the risk of suffering from a serious course of, or dying from, COVID-19 in the United States (Wu et al. 2020); several Asian cities (Gupta et al. 2020); the Netherlands (Cole, Ozgen, and Strobl 2020); and northern Italian municipalities (Coker et al. 2020). Higher AAP (a one-unit increase in PM2.5 concentrations) is associated with an almost 10 percent increase in deaths from COVID-19 (Coker et al. 2020; Wu et al. 2020).

The prevalence of COVID-19 cases is also positively related to AAP, as is the number of hospitalizations (Cole, Ozgen, and Strobl 2020). In a panel of 120 Chinese cities, an increase of 10 µg/m³ in PM2.5 and PM10 was associated with an increase of daily confirmed cases of 2.2 percent and 1.8 percent, respectively (Zhu et al. 2020).

Conversely, decreased AAP during lockdowns may have saved lives. Decreased air pollution, mainly because of reduced traffic mobility and hence reduced emissions from the transportation industry, may have had a mortality benefit considering deaths linked to polluted air.12 It is estimated that during the lockdown period, almost 300 deaths were avoided because of air pollution reductions in Casablanca and Marrakech, with more than 60 percent of these avoidable deaths being related to cardiovascular diseases (Khomsi et al. 2020).

Competitive Disadvantage: Air Pollution’s Economic Costs

The many health impacts of air pollution also have profound implications for the economy throughout the Middle East and North Africa. Among the many adverse impacts on human capital, air pollution has

been linked to lower cognitive performance. Long-term exposure to air pollution has negative effects on individuals’ performance on verbal and math tests. These effects become more pronounced as people age and are especially prevalent for males and those who are less educated. Considering the impact of decreased cognitive performance on the decision making of elderly people, the brain-aging process induced by air pollution may entail substantial health and economic costs (Zhang, Chen, and Zhang 2018).

Labor Supply and Productivity

Various channels can drive the response of labor supply to increases in air pollution. As noted earlier, exposure to polluted air is associated with adverse health outcomes that could reduce labor supply when workers are either too sick to work or must take care of sick relatives. Indeed, neighborhoods near pollution sources (for example, industrial sites such as refineries) show an increase in labor supply once pollution levels drop, because of a closure of pollutant sources (Hanna and Oliva 2015).

For people who are informally employed, these health impacts have severe consequences, because absence from work corresponds to a loss of income. In the Middle East and North Africa (excluding the GCC countries), almost two-thirds of employment is in the informal sector (Gatti et al. 2014), leading to loss of pay for affected people who cannot work, not only for themselves but for the families they support.

Beyond the lost workdays due to illness, paralleling air pollution’s effect of decreasing cognitive abilities, it also decreases labor productivity (Graff Zivin and Neidell 2012; He, Liu, and Salvo 2019), which depresses economic output. This finding implies that even people who were not hospitalized or unable to show up for work were not able to unlock their potential in terms of contributing to value-adding activities.

Targeted policies to limit or reduce air pollution not only would improve air quality and decrease adverse health effects on the affected population but also could generate considerable environmental and economic side benefits such as increasing labor productivity (OECD 2016). Hence, environmental protection policies to increase air quality can also be viewed as investments in human capital (Graff Zivin and Neidell 2012).

GDP Losses

Globally, AAP causes staggering welfare losses. Economic losses stemming from premature mortality alone (that is, without considering the morbidity impacts) exceeded an estimated US$3.5 trillion in 2013 (World Bank and IHME 2016). In the Middle East and North Africa, AAP incurs large economic costs through both premature mortality and forgone