The macroeconomic burden of noncommunicable diseases associated with air pollution in China

RESEARCH ARTICLE The macroeconomic burden of noncommunicable diseases associated with air pollution in China Simiao Chen ID1*, David E. Bloom2 1 Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany, 2 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 * Abstract Background OPEN ACCESS Citation: Chen S, Bloom DE (2019) The macroeconomic burden of noncommunicable diseases associated with air pollution in China. PLoS ONE 14(4): e0215663. https://doi.org/ 10.1371/journal.pone.0215663 Editor: Qinghua Sun, The Ohio State University, UNITED STATES While a few studies have tried to estimate the economic burden of noncommunicable diseases (NCDs) associated with air pollution, most previous studies have methodological limitations. For example, neither the cost of illness approach nor the value of a statistical life approach accounts for economic adjustment mechanisms (i.e., they do not include substitution of labor lost due to an illness with capital or other workers), and neither approach considers disease impact on physical and human capital. Furthermore, since new evidence shows that air pollution is also linked to diabetes, previous studies did not estimate the economic costs of diabetes associated with air pollution. The total economic costs of NCDs associated with air pollution under a comprehensive framework therefore remained unexplored. Received: November 3, 2018 Accepted: April 2, 2019 Objectives Published: April 18, 2019 This study uses a human capital–augmented production function framework to analyze and estimate the macroeconomic impact of NCDs associated with air pollution in China in 1990– 2030 and in 2015–2030. It makes several contributions—beyond those of the extant literature—to understanding the economic burden of NCDs associated with air pollution. It does this by accounting for economic adjustment mechanisms and by incorporating human capital into the model. Copyright: © 2019 Chen, Bloom. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the manuscript and its Supporting Information files. Methods Funding: Research reported in this paper was supported by the National Institute on Aging, National Institutes of Health (https://www.nia.nih. gov), under award numbers P30AG024409 and R01AG048037. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funder had no In our framework, aggregate output is produced according to a human capital–augmented production function that accounts for the effects of projected disease prevalence. NCDs associated with air pollution affect the aggregate output through three pathways: 1) Mortality effect—when working-age individuals die from a disease, aggregate output decreases because physical capital is an imperfect substitute for the loss of human capital in the production process. 2) Morbidity effect—when working-age individuals suffer from a disease but do not die from it, their contribution to overall output also decreases depending on PLOS ONE | https://doi.org/10.1371/journal.pone.0215663 April 18, 2019 1 / 14 Macroeconomic burden of NCDs associated with air pollution role in study design, data collection and analysis, decision to publish, or manuscript preparation. Competing interests: The authors have declared that no competing interests exist. disease severity; for example, they might work fewer hours or with lower productivity, or they might retire earlier. We also incorporate age-specific human capital to account for education-related productivity differences between members of different cohorts who are differentially affected by NCDs. 3) Treatment cost effect—when households in which members suffer from a disease use part of their savings to cover the out-of-pocket share of their treatment costs, physical capital accumulation diminishes. Our estimates are based on the recently updated Global Burden of Disease epidemiology data, which identify four pathways through which air pollution affects health: cardiovascular diseases, respiratory diseases, cancer, and diabetes. Results Total losses from NCDs associated with air pollution in China in 1990–2030 are estimated to be $1,137 billion (constant 2010 USD) and in 2015–2030 are estimated to be $499 billion (constant 2010 USD). Cardiovascular diseases account for the highest burden, followed by chronic respiratory diseases, diabetes, and cancer. Treatment costs account for nearly 30% of the total economic burden of NCDs associated with air pollution. We also find that the share of economic burden associated with treatment costs is highest for diabetes. This is mainly driven by the fact that, on a per case basis, diabetes has a lower health burden than other diseases associated with air pollution. Discussion The NCDs associated with air pollution impose a large economic burden on China. Introduction In recent years, severe air pollution has plagued China as its economy and its citizenry reckon with the dual environmental challenges of tradition and modernization. Though many locations in industrialized countries have also suffered from air pollution problems—for example, the Meuse Valley in Belgium in 1930 [1], Pennsylvania in 1948 [2], and London in 1952 [3]— China’s situation is extraordinary because of the number of people affected, the air pollution’s intensity, and the geographical impact. Air pollution has become one of China’s most pressing public health concerns as the number of extremely polluted days has risen substantially [4]. While the World Health Organization (WHO) recommends an annual particulate matter concentration of 20 μg/m3 [5], studies suggest that the annual mean particulate matter concentration in China was five times that level in 2006–2010 [6]. Reuters reports that by the end of 2016, the concentrations of airborne pollutants in major northern Chinese cities surpassed the WHO guideline by a factor of 100 [7]. The Institute for Health Metrics and Evaluation divides air pollution into three categories: 1) ambient ozone pollution, 2) ambient particulate matter pollution, and 3) household air pollution from solid fuels. Sources of air quality deterioration include motor vehicle emissions, power generation, smelting and metal processing, industrial combustion, and others. In China, the dominant pollutants are gaseous contaminants and fine particles, of which PM2.5 (particulate matter of diameter up to 2.5 μm) is the most crucial component [8]. In Beijing, the peak hourly concentratio (...truncated)