Over the last few decades, the air quality of Pakistan has been deteriorating to alarming levels especially during the winter season. Every year, the visible air pollution or smog grapples the big cities like Lahore, Islamabad, Karachi, Gujranwala, Faisalabad, and Peshawar. This year smog has arrived even before the start of winter. During the first week of November, the AQI touched 1000 plus in the city of Lahore making it the world’s most polluted city in 2024[1]. Air pollution has become the second leading risk factor for mortality in Pakistan, accounting for more than 9% of deaths (128,000) in 2017 alone[2].  It is also a cause of significant reduction in the life expectancy, that has shortened by 3.9 years in Pakistan[3]. The primary culprits for poor air quality are excessive and unregulated vehicular and industrial emissions, coal-fired power plants and crop residue burning[4].

Vehicular emissions from less efficient and old vehicles release significant amounts of nitrogen oxides (NOx) and particulate matter (PM10 and PM2.5) into the atmosphere. Other air pollutants include oxides of sulphur, ozone, volatile organic compounds (VOC), carbon monoxide, and methane which are produced by industries such as steel mills, cement factories, brick kilns as well as burning of agricultural residues[5].

Air pollutants have short and long-term health consequences. In short term, they increase the risk of acute respiratory infections by affecting immunity and exacerbate asthma symptoms leading to increased admissions to hospitals and burdening of the healthcare systems. Long term implications include chronic obstructive pulmonary disease (COPD), cardiovascular diseases, lung cancer, and stroke which reduce life expectancy and quality of life of the affected population[6].

Recent research on particulate matter also proves that prolonged exposure to air pollution can lead to impaired cognition (problems with a person’s ability to think, learn, remember, and make decisions), anxiety and dementia. Vulnerable populations like children, pregnant women, elderly and low-income communities are disproportionately affected by smog. While children experience stunted lung development and elderly face heightened risks of respiratory and cardiovascular diseases, the pregnant women are at higher risk of premature labour, hypertension and low birth weight of their newborns due to toxicity of PM2.5 in ambient air[7].

The global health cost of air pollution (PM2.5 alone) is USD8.1 trillion, or 6.1 percent of global GDP. It is estimated that one unit of PM2.5 causes the wastage of USD18.9 of GDP per capita. According to the estimates done by the World Bank, air pollution in Pakistan costs the country between 5.9% to 6.5% of its GDP[8]. This translates into USD20-22 billion based on GDP of Pakistan in 2023. Poor health due to poor air quality affects economy in multiple ways. Acute and chronic respiratory diseases lead to increased absenteeism and reduced cognitive function can cause reduced overall productivity of the populations. Treatment and hospital admission costs strain the pockets of the public and healthcare systems. Poor visibility on the roads during smog season increases the likelihood of road traffic accidents. Heavy smog also leads to school closures, hence loss of school days for students. Further, it deters national and international investments and tourism thus negatively impacting the economy of the country.

Social impacts of air pollution include decreased well-being and overall happiness of the public, affecting daily life activities and social interactions, in short, a low quality of life. A research study conducted in the US claims that psychological issues generated by air pollutants are also related to some criminal behaviors of people[9]. All in all, there are heavy socio-economic costs of smog and many of these costs cannot be monetized.

The flat topography of northeastern regions of Pakistan suggests that mountain ranges like Himalayas trap the air pollutants and prevent their dispersion through winds particularly during the winter season[10]. Rapid urbanization, industrialization and deforestation has resulted in reduced green cover and in turn affected the air quality, especially in big cities.

To solve the issue of air pollution, Pakistan developed National Clean Air Policy (NCAP)[11] in 2021 and revised in 2023. Provinces also have their own plans to implement the NCAP. For example, Punjab developed its Clean Air Action Plan in 2023[12]. These national and provincial policies aim to improve air quality of Pakistan by setting emission standards, promoting cleaner energy resources, and extending monitoring systems.

Despite these well documented policies and actions plans, their enforcement, monitoring and compliance is questionable. Several factors such as insufficient funding for air quality control and monitoring, lack of political will and limited public awareness also contribute to inadequate implementation of these policies.

Successful implementation of the NCAP will require active participation from all the stakeholders, including government, media, research institutions, civil society, advocacy groups and above all, the general public[13].

Pakistan must learn from evidence-based successful policies and strategies developed by countries such as China to reduce the PM2.5 levels in their most polluted cities. Since 2013, the China National Environmental Monitoring Centre has expanded the air pollution monitoring network, with now more than 2,000 stations across the country. This monitoring network provides a key data source for air pollution control[14]. The Chinese government took loans from World Bank and local banks to provide financing for enterprises to reduce air pollutants and carbon emissions by increasing energy efficiency, investing in clean energy, and tightening air pollution controls. They implemented major changes in all the sectors. For example, in the transport sector, majority of the public buses, trains and private transport have been shifted to electric power especially in big cities where air quality was mostly very poor a decade ago. The government offered incentives to replace domestic coal burning with methane gas during winter. They also invested heavily in solar and wind energy generation capacity[15]. With timely and dedicated efforts, China has been able to reduce carbon dioxide emissions by 2.5million tons a year[16].

To address the air quality crisis effectively, Pakistan must adopt a multifaceted and integrated approach[17]

• It all starts with monitoring of air quality. Strengthening air quality monitoring systems and ensuring stricter enforcement of existing regulations are crucial. This includes upgrading the air quality monitoring infrastructure, increasing the number of monitoring stations, and employing advanced technologies for real-time data collection and analysis.
• Transitioning to cleaner energy sources, such as solar and wind power, can significantly reduce air pollution. A plan should be put in place to gradually replace existing coal power plants with cleaner sources of energy generation.
• Industrial technologies should be upgraded to minimize emissions, and sustainable agricultural practices should be promoted, such as no-till farming and crop residue management[18].
• Stricter vehicle emission standards should be implemented, and use of electric and hybrid vehicles should be incentivized.
• Educating the public about the health impacts of air pollution and precations to reduce personal exposure is essential. Therefore, public awareness campaigns, school programs, and community workshops should be conducted to foster a culture of environmental responsibility.
• It is critical to promote research linking air quality with health and economy. We must fully understand the cost we are paying for poor air quality.
• We must collaborate with international organizations and neighboring countries to address the transboundary air pollution. Sharing best practices, accessing funding for clean air quality projects, and participating in regional initiatives can bolster Pakistan’s efforts to improve air quality.

The urgency of addressing air quality issues in Pakistan cannot be overstated. The health and well-being of millions of citizens, as well as the country’s environmental sustainability, hinge on immediate and decisive action. Policymakers, business community, farmers, civil society and citizens must work together to implement effective solutions, ensuring a cleaner, healthier and sustainable future for all. The air we breathe is a shared resource, and protecting it is a collective responsibility that demands our utmost commitment.

[1] https://www.iqair.com/world-air-quality-ranking

[2] https://www.stateofglobalair.org/sites/default/files/soga_2019_pakistan.pdf

[3] https://www.hrw.org/news/2023/12/06/pakistans-air-pollution-shortens-lives

[4] https://www.adb.org/sites/default/files/project-documents/51347/51347-001-tacr-en.pdf

[5] https://doi.org/10.1016/j.esd.2022.12.001.\

[6] https://www.who.int/teams/environment-climate-change-and-health/air-quality-energy-and-health/health-impacts#:~:text=Air%20pollution%20is%20a%20risk,(household%20air%20pollution%20only).

[7] DOI: 10.7759/cureus.33906

[8] https://openknowledge.worldbank.org/server/api/core/bitstreams/8aa74fcb-8b70-5e1f-87b9-478674c1d6b1/content

[9] https://mitsloan.mit.edu/ideas-made-to-matter/psychological-economic-and-social-costs-air-pollution

[10] DOI: 10.1007/s13762-024-05754-x

[11] https://mocc.gov.pk/SiteImage/Misc/files/NCAP%20(28-02-2023)%20v1.pdf

[12]https://epd.punjab.gov.pk/system/files/230419%20Gazette%20Notification%20Punjab%20Clean%20Air%20Action%20Policy%20%281%29.pdf

[13] https://www.mocc.gov.pk/SiteImage/Policy/NCAP%20(28-02-2023).pdf

[14] https://doi.org/10.1016/j.coesh.2020.100227

[15] https://www.worldbank.org/en/results/2020/06/21/china-fighting-air-pollution-and-climate-change-through-clean-energy-financing

[16] https://www.worldbank.org/en/results/2020/06/21/china-fighting-air-pollution-and-climate-change-through-clean-energy-financing

[17] https://energyandcleanair.org/wp/wp-content/uploads/2023/11/CREA_Briefing_Air-Quality-Governance-in-Pakistan-A-review_12.2023.pdf

[18] https://doi.org/10.1016/j.scitotenv.2023.166161

Blog Post by: Dr. Mahrukh Shams, MBBS, MPH