Amid the sadness and loss brought by the COVID-19 pandemic, one silver lining of 2020 was supposed to be the celebration of the 50th anniversary of the Clean Air Act. For many years, there was a great deal to celebrate as the law has been very successful in cleaning up our air.  Between 1970 when it was signed and 2017, the levels of six common pollutants (ozone, lead, pollutant particles, carbon monoxide, nitrogen dioxide, and sulfur dioxide) dropped 73%.

The past few years, however, have seen a striking reversal in our air quality, with no signs of improvement. The American Lung Association reported in its 2020 “State of the Air” report that 45.8% of Americans, or 150 million people, live in counties with either unhealthy levels of ozone or particle pollution. This number has risen steadily in every report since 2017, when the number was documented at 125 million people.

Michael J Stephen MD Michael J. Stephen M.D.

Globally, the situation is even worse. The World Health Organization estimates that a staggering 91% of the world’s population live in places where air quality guidelines are not being met. This leads to the yearly premature death of 4.2 million people from outdoor air pollution and another 3.8 million from indoor air pollution. Most of these deaths are among the very old and very young. 

The typical causes of toxic air deaths are respiratory infections, asthma, chronic obstructive pulmonary disease, and lung cancer, but little known is that pollution is also a major contributor to ischemic heart disease and strokes. Newer data also connect poor air quality to neurodevelopmental disorders in children and neurodegenerative diseases like Alzheimer’s in adults.

All of this would be anathema to our ancestors, who understood the importance of the quality of our breathing, not just for health but for spiritual well-being. In the book of Job, the suffering man’s friend Elihu comments that “the Spirit of God has made me, and the breath of the Almighty gives me life.” This same concept is embodied in the New Testament, in which the apostle John says that Jesus “breathed on his disciples,” giving them the Holy Spirit.

The sanctity of breath is not limited to the west. The principles of Buddhism and Hinduism are based on an understanding of the breath; indeed, the study of breathing, and the harnessing of its potential, is the only recognized way to nirvana. As the Vietnamese Buddhist monk Thích Nhất Hnh has written, “Breath is the bridge which connects life to consciousness, [and] unites your body to your mind.”

The lungs are a miracle of design, packing some 480 million gas exchange units, or alveoli, into a small area. Arranged on end, the tubes of our lungs would stretch for fifteen hundred miles. Each day we take some 20,000 breaths, about 7.5 million breaths each year. This work is all done by an organ that resembles a sponge, with a thin lacy structure, the alveoli under constant stress from being in direct contact with the environment and all its pollutants, bacteria and viruses. 

Problems with our breath have been building for several decades. Of the four leading causes of death between 2000 and 2018, mortality from chronic respiratory disease was the only one to increase. Lung cancer is the leading cancer killer in America. Interstitial lung diseases like sarcoidosis increased 100% between 1980 and 2014. There are five million more people in the U.S. with asthma in 2017 compared to 2001. 

More recently, things have taken several dramatic turns for the worse, from the vaping crisis that affected so many of our young people to the rampant wildfires throughout the globe, and, of course, the COVID-19 crisis, which has put thousands on ventilators and has so far killed over 500,000 Americans. We have not taken threats to our air seriously enough.

It is likely that the wildfires have contributed the most to our worsening air quality over the past several years. It is also the case that, in the long term, they will be the hardest to contain. That’s because the underlying cause is climate change, an environmental and health crisis that needs broad support here and throughout the world to slow and even reverse.

Environmental health crises can be overcome. Air pollution harms health and can be deadly, and more than 50 years ago, dense, visible smog in many cities and industrial centers were harming the health of Americans, and it prompted the passage of the 1970 legislation and major revisions made in the subsequent decades were designed to improve its effectiveness and target newly recognized air pollution problems such as acid rain. The Clean Air Act was designed to protect public health and welfare from different types of air pollution caused by a diverse array of sources, and passage of this landmark legislation has saved countless lives. While we enjoy healthier air thanks to the Clean Air Act, climate change poses new risks to our air quality. We know air pollution harms health and can be deadly, and new research suggests that exposure to particle pollution can even increase the death toll from COVID-19.

The most recent “State of the Air” report from the American Lung Association is a warning, one that with signs of obviously declining lung health due to the pandemic we can no longer choose to ignore. The year 2020 was the year our breath was taken away, but with a concerted effort to support the science behind cleaning up our air, hopefully in the future we will look on it not as a year of crisis, but as a turning point to a healthier breath and planet.

To initiate action today, I am committing to the upcoming American Lung Association 2021 Fight For Air Climb – Philadelphia to raise much needed funds for research (http://action.lung.org/goto/michaelstephen). Lung diseases have traditionally been underfunded. An example is lung cancer, which causes 22 percent of cancer deaths each year but receives only 6 percent of federal dollars for cancer research. The right to healthy breath is a universal right, and with everybody’s effort we can get the clean air we all need and deserve. 


Michael J. Stephen M.D. is an Associate Professor of Medicine at Thomas Jefferson University in Philadelphia and head of the Adult Cystic Fibrosis Center. He is the author of the recent book Breath Taking, which is an in depth analysis of the power, fragility, and future of the lungs.

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