Copyright
Blackwell Munksgaard 2004

Indoor Air 2004; 14 (Suppl 7): 5158

www.blackwellpublishing.com/ina
Printed in Denmark. All rights reserved

INDOOR AIR

On the history of indoor air quality and health

Abstract Indoor air is a dominant exposure for humans. More that half of the
bodys intake during a lifetime is air inhaled in the home. Thus, most illnesses
related to environmental exposures stem from indoor air exposure. Indoor air
was believed to be a major environmental factor for more than a hundred years,
from the start of the hygienic revolution, around 1850, until outdoor environmental issues entered the scene, and became dominant around 1960. Main
environmental issues today are outdoor air quality, energy use, and sustainable
buildings, but not indoor air quality (IAQ). But, there is mounting evidence that
exposure to IAQ is the cause of excessive morbidity and mortality. In developing
regions indoor unvented burning of biomass for cooking is the cause of at least
2,000,000 deaths a year (mainly women and children), and in the developed
world IAQ is a main cause of allergies, other hypersensitivity reactions, airway
infections, and cancers. Cancer of the lungs is related to indoor radon and ETS
exposure. Allergies, airway infections and sick building syndrome are associated
with, e.g., dampness, a low ventilation rate, and plasticizers. In the future
more emphasis must be given to IAQ and health issues.

J. Sundell
International Center for Indoor Environment and Energy,
Technical University of Denmark, Lyngby, Denmark

Key words: IAQ; Health; Allergy; Indoor environments;

Dampness; Ventilation.
Professor Jan Sundell
International Center for Indoor Environment and Energy,
Technical University of Denmark, Niels Koppels All
,
DTU, Building 402, 2800 Kongens Lyngby, Denmark,
e-mail: jas@mek.dtu.dk

Indoor Air (2004)

Practical implications

Indoor air quality plays a major role with regard to public health. The main problems are in the developing countries
with the indoor burning of biomass for cooking and heating. The solution is a stove with a chimney. In developed
regions, good ventilation, getting rid of dampness problems, and adequate testing of new building materials would
reduce morbidity and mortality.

History

Mans origin is in the tropical or near-tropical parts of

the world. The spread into cold climates was possible
only because of inventions such as clothing, housing
and the use of re (Sundell, 1994). However, in houses
and shelters it is not only the thermal climate that has
changed. The climate shell also stops the free air
movement. The dilution of pollutants from close-toman pollutant sources is diminished. The environment
within a shelter is always more polluted from indoor
sources such as humans, open res (still a major source
of indoor air pollution in many developing regions)
building materials, indoor activities, etc. than from
outdoor air. This was and is the basis of the need for
ventilation and for discussions on indoor air quality
(IAQ). Humans arrived in, e.g., southern Europe and
China a million years ago, but in America, northern
Europe, Japan, etc. only some 10,00040,000 years
ago, a period too short for major genetic changes. So as
humans we are still accustomed to a life outdoors in the
warm regions of Africa.
As we spend most of our life indoors (in many
regions more than 90%), it is easy to understand that

the most important environment in relation to our

health is the indoor environment (Sundell, 1999).
During the breakthrough of modern hygiene, from
mid 19th century, indoor environmental issues received
much attention, as did the quality of drinking-water
and the treatment of sewage (e.g., linked to plagues
such as cholera and tuberculosis).
Ventilation comes from Latin ventilare meaning
to expose to the wind. The main purpose of
buildings is to create a climate more suitable for
persons and processes than the outdoor climate.
Consequently, the main aim of ventilation in buildings is to create an indoor air quality more suitable
for persons and processes than that naturally occurring in an unventilated building, and to reintroduce
the positive eect of being exposed to the wind,
i.e. to dilute and remove the pollutants produced by
man himself, his activities and the indoor surroundings.
Throughout history man has known that polluted air
may be detrimental to health. Greeks and Romans
were aware of the adverse eects of polluted air in,
e.g., crowded cities and mines (Hippocrates, 460
377 BC).
51

Sundell
In the Bible it is acknowledged that living in
buildings with dampness problems (plague of leprosy) is dangerous to your health (Leviticus 14,
3457). The remedies needed were quite thorough
(i.e. to get rid of all aected parts of the building).
Throughout the medieval era little new knowledge
evolved in this eld. The epidemiological ndings of
associations between health eects and working in
certain heavily polluted premises (Ramazzini, 1633
1714), living in crowded cities, such as London
(Arbuthnot, 16671735), and the sad history of many
young chimney sweeps (Pott, 1778) shed new light on
the importance of air pollution. Later on, the death of
persons imprisoned in very small rooms (Baer, 1882),
or the economic burden of the deaths of slaves from
suocation during transport over the seas provided
evidence of the importance of ventilation in premises
mainly polluted by man. That bad ventilation was
not only a problem in more extreme situations was
also acknowledged at that time. Gauger (1714)
remarked that it was not the warmth of a room but
its inequality of temperature and want of ventilation that caused numerous maladies. Bad air was
held responsible for the spread of disease and for the
unpleasant sensations that are experienced in badly
ventilated rooms.
The general idea up to around 1800 was that
breathing was primarily a way of cooling the
heartthe substance of air was not required, only
its coolness. But it was also common knowledge that
expired air was unt for breathing until it had been
refreshed (Wargentin, 1717 1783). The mystery of
breathing was not solved until Priestley (17331804)
discovered oxygen, and von Scheele (17421786) and
Lavoisier (1743 1794) found that air consisted of
at least two gases. The role of oxygen in breathing
was pointed out by Lavoisier (1781), even though
Boyle (16271691), and Hooke (16351703) 100
years earlier (1667) had found that the supply of
air to the lungs was essential for life, and Mayow
(16431678) had discovered that there was an
exchange within the lungs between the inhaled air
and the body.
The work of Lavoisier (1781) was especially important for understanding the human metabolism, including the quantitative association between oxygen
consumption and carbon dioxide (CO2) release. During
the following half century it was accepted that the
concentration of CO2 was a measure of whether the air
was fresh or stale.
Against the background of tuberculosis and other
diseases known to be contracted in crowded places,
John Griscom, a New York surgeon, vividly described
the need for fresh air and pointed out bedrooms and
dormitories as worst: decient ventilation (is) more
fatal than all other causes put together (Griscom,
1850).
52

Crowded rooms tend to be overheated and during this

era it was considered that the discomfort in such rooms
was due to excessive heat or, in accordance with the
view of Lavoisier, due to elevated concentrations of
CO2. Pettenkofer (18181901) started lecturing on
hygienic topics in Munich in 1847 (Pettenkofer 1847),
and when installed as the rst professor in hygiene 1853,
noted that the unpleasant sensations of stale air were
not due merely to warmth or humidity or to CO2 or
oxygen deciency, but rather to the presence of trace
quantities of organic material exhaled from the skin and
the lungs. He stated that bad indoor air per se did not
make people sick, but that such air weakened the
human resistance towards against agents causing illness. In Pettenkofers view CO2 was not important in
itself, but was an indicator of the amount of other
noxious substances produced by man. Pettenkofer
stated that air was not t for breathing if the CO2
concentration (with man as the source) was above
1000 p.p.m., and that good indoor air in rooms where
persons stay for a long time should not exceed
700 p.p.m. in order to keep the persons comfortable
(Pettenkofer, 1858). He, and a number of other authors
of this time, suggested 1000 p.p.m. of CO2 (including
CO2 from ambient air) as a limit value for an adequately
ventilated room (700 p.p.m. in bedrooms), including a
certain margin for the use of oil burners for lighting.
A number of studies of ventilation in schools,
theaters, homes, etc. were conducted with the concentration of CO2 as a measure of ventilation rate per
person. The rst Swedish professor in hygiene, Elias
Heyman (18291889) at the Karolinska Institute, made
an extensive study in Stockholm of schools with
dierent ventilation systems, including measurements
of CO2. In schools without any measures for ventilation
he measured concentrations of CO2 up to and over
5000 p.p.m., while in schools with some kind of
ventilation, he typically measured maximum concentrations of between 1500 and 3000 p.p.m. He concluded
that not even one schoolroom was adequately ventilated. He also made an interesting comment on common
complaints regarding dry air in a building with supply
of heated air (up to 60C), a sensation that he meant had
nothing to do with the air humidity but rather was an
eect of air pollutants drawn into the system from a
neighborhood chimney. Parallel to the complaints of
dry air there were complaints of mucosal and skin
problems, i.e., a description close to todays sick
building syndrome (SBS). Heyman 1881 also studied
homes and concluded that we cannot rely on natural
ventilation if we want to live in clean air. Pettenkofer
and other researchers of this era often stated that source
control is a prerequisite for good hygiene.
In his textbook on ventilation and heating Professor
Herman Rietschel at the Kgl. Technischen Hochshule
in Berlin totally built on the views of Pettenkofer
(Rietschel, 1894; 1902). The textbook is in many ways

The history of indoor air quality and health

up-to-date, including its guidelines on outdoor airow
requirements, and dimensioning of both natural and
mechanical ventilation.
Beginning with the results of Pettenkofer, a number
of studies were conducted between 1880 and 1930 in a
search for evidence of the toxic eects of organic
substances in expired air, the anthropotoxin theory
(e.g., Brown-Seguard & dArsonval, 1887). Since no
proof of toxic eects could be found and since high
concentrations of CO2 as a single pollutant caused no
discomfort, the warmth of a crowded room together
with odorous, but not toxic, bodily emissions were
thought to be the main sources of discomfort in rooms
with bad ventilation (Flygge, 1905; Hill, 1914). Flygge
(1905) wrote that the objection to an evil-smelling
atmosphere was to be supported not on account of its
poisonous properties, which had never been proven to
exist, but on account of the resulting feeling of nausea.
Thus ventilation was primarily a question of comfort
and not of health. However, Winslow and Palmer
(1915) found in a study of the eects of lack of
ventilation upon the appetite for food, that there were
substances present in the air of an unventilated
occupied room that in some way, and without producing conscious discomfort or detectable physiological
symptoms, diminished the appetite. In a later work,
Winslow and Herrington (1936) obtained the same
results with heated house-dust taken from vacuum
cleaners as source of air pollution.
In their standard-setting work Yaglou et al. (1936)
studied body odor in relation to ventilation rates. They
stated that such odors, as a rule, are not known to be
harmful. They recognized, though, that Sensitive
persons are occasionally aected in a pathological way
by sitting in such rooms. Thus, again, ventilation was
primarily a question about comfort. occupied rooms
should give a favorable impression on entering, taking
into consideration such factors as odor, freshness,
temperature, humidity, drafts and other factors aecting
the senses. They showed that simple recirculation of air
did not aect the odor strength and concluded that
from the standpoint of body odor, a room can be
ventilated just as well with an outdoor air supply of
8 l sp as with a total supply of 15 l sp, about half of
which is recirculated. Recirculation is often desirable for
adequate distribution and temperature control, but one
of the disadvantages is that it smells up the ducts, fans,
etc. and unless the system is ushed frequently with clean
air, higher air quantities will be needed to obtain
satisfactory results. They also experimented with
humidifying and dehumidifying of the recirculated air
and found that both techniques, and especially dehumidifying, reduced the odor strength, resulting in a
reduced need of outdoor air supply for odor control.
Since the 1930s there has been little scientic eort
within the eld of ventilationIAQhealth in
non-industrial premises. Odor and thermal comfort

were thought of as the factors relevant in setting

guidelines for ventilation.
Historically, ventilation standards have been based
on the assumption that man himself is the main
source of indoor pollution, mainly body odors.
During the last century, health issues have generally
not been involved in reections about the need for
ventilation; instead, perceived air quality has been the
measure. The topic has been whether the odor in a
room is perceived as acceptable by visitors directly on
entering the premises, or by occupants. This measure
was used by Yaglou, and has in recent decades been
developed by Fanger and colleagues (Fanger et al.,
1988; Fanger, 1988). Fanger also, stresses the comfort
aspect of indoor air pollution in stating It is
normally the perception that causes people to complain, but also the perceived air quality may in
many cases also provide a rst indication of a possible
health risk (Fanger, 1992). Fanger has focused on
the sensory load of pollution sources, besides persons,
such as building materials, carpets, and computers,
and the impact of ventilation and indoor air humidity
(Fang et al., 1999; Wargocki et al., 1999; Wargocki
et al., 2000).
Environmental issues?

Environmental issues were up to around 1960 largely

focused on IAQ. With Silent Spring in 1962, Rachel
Carson (followed by numerous other writers) changed
the view on environment, from all environments
(with a focus on indoor air) to nature. Around this
time reports on health problems due to the polluted air
in industries, etc. were also more often presented, again
moving the focus from non-industrial indoor air.
Environment was suddenly synonymous with
ambient air and industrial surroundings. Environmental protection agencies, as well as authorities dealing
with occupational safety and health, grew strong in
many regions of the world. IAQ in non-industrial
indoor environments was not on the list of environmental problems!
Not until the problems that arose with regard to
radon in the late 1960s, formaldehyde in the early
1970s, house dust mites and SBS (sick building
syndrome) in the late 1970s, and allergies during the
last decade did health issues related to indoor air again
enter the scientic agenda.
Today there is mounting evidence of the importance
of indoor air pollution, and thus ventilation, from a
public health perspective.
The present situation

Exposures in indoor environments and health eects

due to such exposures vary between regions of the
world. The situation today worldwide reects human
53

Sundell
history. In many developing regions the situation is
close to what was common in now developed regions
centuries ago, with indoor unvented burning of
biomass producing extremely polluted indoor air,
resulting in severe health eects (Smith, 2003). In
developed regions buildings have vented cooking
appliances (electricity or gas), central heating, new
building- and furnishing-materials, a low rate of
ventilation, and a high prevalence of allergies, and
SBS. In between are, for example, the former eastern
European countries with relatively modern building
constructions and building materials, but with a high
ventilation rate (due to the low price of energy, and
leaky building constructions), and a relatively low
prevalence of allergies, but more of other airway
diseases.
A limited number of studies have been conducted in
developing regions regarding IAQ and health. The
studies have dealt mainly with the associations between
indoor air pollution, due to unvented burning of
biomass, and health eects such as acute respiratory
infections (ARI), chronic obstructive pulmonary disease (COPD), and lung cancer. WHO has calculated
that the burning of solid fuel for cooking and heating
in developing countries might be responsible for nearly
4% of the global burden of disease, i.e., approaching 2
million premature deaths per year (Smith, 2003). Thus,
the problems related to IAQ in many developing areas
are immense. At the same time, the solutions seem
obvious, generally involving the use of techniques that
were developed centuries ago in the now developed
world (a vented stove!).
Studies on exposures in indoor environments and
health eects in developed countries have been
conducted mainly in northern Europe and North
America. The evidence is strong regarding an association between IAQ and lung cancer, allergies, other
hypersensitivity reactions (including sick building syndrome (SBS), and multiple chemical sensitivity
(MCS)), and respiratory infections (ARI) (Sundell,
1999). Many other health consequences due to poor
IAQ are known (e.g., Legionnaires disease) or suggested. As allergies are rapidly increasing worldwide,
more in the developed than in the developing world,
and are strongly associated with exposures in indoor
air, major interest is now being directed towards the
question as to which exposures indoors can be
associated with this increase in morbidity. In many
regions of the world around half of the population is
aected, young people more then the elderly, and in
many regions the incidence has practically doubled
every 15 years during recent decades. In Europe
allergic diseases are more common in connection with
a western lifestyle and favorable social and economic
conditions, but this is not true for other regions, such
as USA or Peru. Globally the situation is very
complex.
54

IAQ exposures causing health effects

In developing regions of the world it is obvious that

burning of biomass (especially for cooking) produces a
deadly mixture of pollutants. More than 2,000,000
people, mainly women and children, die because of this
yearly (Smith, 2003). This is one of the main environmental/health issues of the world, but so far little
recognized.
In the developed world we have, besides radon and
ETS as causes of cancer of the lungs, focused on volatile
organic compounds, VOCs, particles, allergens, and
agents of microbial origin. In total, not much is
understood with regard to IAQ and illnesses, including
allergies. In order to give prominence to the state-of-theart regarding scientic knowledge concerning exposures
in non-industrial indoor environments and health,
multidisciplinary reviews of the total scientic literature
have been conducted in the Nordic countries (NORDWORKS), and in Europe (EUROWORKS). The incidence of asthma and allergy has increased throughout
the developed world over the past 30 years. The short
interval over which this increase has occurred implies
that it is due to changes in environmental exposures
rather than to genetic changes. Changes in indoor
environments warrant special attention since indoor
air constitutes a dominant exposure route. Increased
exposures to allergens and/or adjuvants (enhancing
factors) may each be partially responsible for the
increase. A number of multidisciplinary reviews of the
scientic literature on associations between indoor
exposures health/asthma and allergies have been conducted (Andersson et al., 1997; Ahlbom et al., 1998;
Bornehag et al., 2001; Wargocki et al., 2002b; Schneider
et al., 2003; van Odijk et al., 2003).
Today there is scientic evidence that concentrations
of single VOCs, or total mass of such (measured)
compounds TVOC, are not a valid measure of health
risks, and that there is a need for more relevant risk
indicators for exposure to organic compounds in
indoor air in non-industrial environments (Andersson
et al., 1997). With regard to particles in indoor air,
there is limited scientic knowledge with regard to their
importance from a health point of view (Schneider
et al., 2003) in contrast to such exposures in ambient
air. This may be due to a limited number of studies,
and diculties in health relevant characterization of
particles (so far, mainly mass or number).
Apart from spores, microbes are the source of a number
of dierent substances, such as microbial volatile organic
compounds (MVOC), toxins, glucans. So far, it has not
been established which of these substances are the cause
of the increased prevalence of health eects in damp
buildings (Bornehag et al., 2001). It is not scientically
proven that some molds are more important from a
health perspective. In total, not much is known regarding
the health relevance of microbial growth indoors.

The history of indoor air quality and health

The ''lamp-post effect''

In general, scientic studies have not shown an association between health eects and commonly measured
agents such as VOC, TVOC, particulate matter, and
microbially produced matter. This fact should not be
interpreted in such a way that measurements are
without meaning, or that chemical compounds, particulates, and microbes do not matter. Instead, the results
can be viewed as a result of the lamp-post eect,
meaning that we search where we can see easily (under
the lamp-post), and not in between the lamp-posts.
In indoor air research measurement we have used
techniques and methods developed for other environments (ambient air, and industrial air), techniques and
methods that apparently are not suitable!
Building factors and health
Dampness

In a large number of studies (including more than

100,000 persons) an association has been found between
living or working in a damp building and health
eects, such as cough, wheeze, allergies and asthma
(Sundell, 1999; Bornehag et al., 2001). However, there
are indications that also other health eects such as
general symptoms (e.g., tiredness, headache, etc.), irritation and airway infections are associated with dampness. Relative risks, commonly indicated by odds ratios,
are similar for infants, children and adults, in homes and
at workplaces, in the range of 1.42.2. Relative risks are
in the same range regardless of the outdoor climate.
From present-day scientic literature it is not possible to make a more precise health-relevant denition
of a damp building, or to specify which agents in
damp buildings are the causes of health eects.
Ventilation

The association between ventilation and health is

rarely studied. A European multidisciplinary scientic
review group has deemed only 30 scientic studies to be
conclusive on the matter (Wargocki et al., 2002a). The
scientic evidence indicates that ventilation rates (outdoor air) below 25 l/s per person in commercial and
institutional buildings are associated with an increased
risk of SBS, increased short-term sick leave, and
reduced productivity (Sundell et al., 1993; Sundell,
1994; Wargocki et al., 2002b).
Studies on the association between health eects and
ventilation rates in homes are rare. However, the
literature on dampness, especially as regards
condensation on window panes, suggests that
inadequate ventilation in homes constitutes a major
risk factor for health eects (cough, wheeze, asthma and
airway infections) (Sundell et al., 1995; Bornehag et al.,
2001; Wargocki et al., 2002a). It is well established that

ventilation rates in homes have been reduced during

recent decades, as a result of energy conservation
measures in Nordic and other western countries. This
development may be associated with the increase in
allergies. In former eastern Europe, the same development is now rapidly taking place as a result of the
increased cost of energy, and thus increased tightening
of buildings, resulting in reduced ventilation.
Building materials

Primary emissions from building materials refer to the

emissions from the materials themselves. The level of
these emissions is highest immediately after manufacture, and is expected to diminish radically during the
rst six months, and to have disappeared substantially
after the rst year of use. Secondary emissions denote
the emission of pollutants that is caused mainly by
actions on the material. Factors that aect a material
may be moisture and alkali in the building structure,
high surface temperatures or dierent treatments with
chemicals such as oor cleaners, waxing, etc. Secondary emissions may increase in time and may last for a
long period (Sundell, 1999).
Owing to the fact that primary emission has been the
subject of greatest interest, there has been a rapid
development towards low-emitting materials. This
has reduced the emission of commonly measured
organic compounds, mainly rather stable volatile
organic compounds, from building materials. Whether
this development has reduced health complaints in
new buildings is not known. Today, secondary emissions
are regarded as being of greater signicance for health.
Indoor air chemistry

Many harmless organic pollutants in indoor air react

with, e.g., ozone, producing highly reactive compounds,
that quickly react on/with skin or mucous membranes
(Sundell et al., 1993; Weschler, 2000). Many of these
compounds (e.g., free radicals) are not easily measured,
but may be far more relevant from a health point of
view than their precursors. This indoor air chemistry
occurs in the air, but also on room surfaces. Humidity,
ventilation rate, PVC, wood, cleaning agents, airfresheners, etc. must be viewed in a new light.
Two studies
The carbonic acid, organic matter, and microorganisms in air,
more especially of dwellings and schools. Carnelly, Haldane
and Anderson, (1887)
Background

Health eects due to indoor air exposures are common

resulting in excessive death rates among poor people.
55

Sundell
But what are the causative agents? Organic chemicals,
lack of ventilation, microbes?
Aim

To identify health-relevant exposures in homes.

Methods

Measurements of CO2, organic chemicals, and

microbes in typical homes (n 60) in Perth and
Dundee in Scotland 1885. Measurements were made
without warning during the night (00300430). A
mobile laboratory (horse and van) was used for
quick analyses of samples. Results were analyzed
against the registrations of deaths (population
150,329), including causative illness, and data on
the home.
Results

Doseresponse relationships were found between

death rate and the size of the apartment (number
of rooms), number of persons per room, and
airborne pollutants such as CO2, microbial matter,
and organic compounds. The causes of death were
mainly diarrhea, measles, convulsions, accidents
(including overlaying), premature birth, bronchitis,
and whooping cough. In single-room apartments the
mean number of occupants was 6.6, while in apartments of four or more rooms the mean number per
room was 1.3. In some single-room apartments
there were 12 persons living (thus the risk of
overlaying).
The study found doseresponse relationships
between death, number of rooms in the apartment,
number of persons per room, microbial matter,
organic compounds and CO2. Still the study is not
conclusive with regard to the causative agent(s)
(multivariate analyses were not used at that
time). But it shows that crowded environments are
dangerous.
Dampness in buildings and health (DBH), Bornehag, Sundell,
Sigsgaard and the DBH study group (20002010)
Background

Allergies are increasing and dampness in buildings is

strongly associated with allergies and airway infections.
But what agents in indoor air are responsible?
Aim

To identify exposures in homes that are the cause of the

increased incidence of asthma and allergies.
56

Methods

1 An epidemiological cross-sectional questionnaire

study on housing and health involving 14,077 preschool children (response rate 80%).
2 A case-control study of 200 +200 sick and healthy
children with extensive measurements of chemical
and microbial exposures, and an extensive clinical
examination of the children.

Results

Risk factors for allergies among small children are,

e.g., allergic symptoms in the family (atopy), male sex,
urban living, living in multifamily houses, dampness,
PVC-ooring, phatalates, a low ventilation rate, electronic equipment Exposure to pets, and farming life
are seemingly protective but this eect may be
largely inuenced by selection bias, resembling the
healthy worker eect (Bornehag et al., 2004a).
Results from the study will be presented in scientic
articles in future years and will include associations
between health eects and exposures, and exposures
and building characteristics. Also results regarding the
validity of sel- reported symptoms, and building
characteristics will be presented.
But what really matters needs to be analyzed and
tested in interventions and climate chamber studies.
Comment

Two studies conducted 115 years apart are basically

dealing with the same problem: Why are people
becoming ill from being indoors? What are the
causative agents? Basically the same type of exposures
are measured, but we can measure more accurately
today. We are still searching, though we do not know
much more today than a century ago!
Conclusions

Studies during 150 years indicate that non-industrial

IAQ plays a major role from a public health point of
view. Today, as before, we still suspect organic and
microbially produced compounds to be causative, but
it has not been possible to show which compounds are
the important agents. We are still shing.
However, there is, in spite of a lack of scientic
interest, good knowledge regarding the importance of
indoor air pollution in developing regions. Unvented
burning of biomass for cooking is a main killer in the
world. What is needed is to use technologies used in
the developed world during centuries. The problem is
the total cost, as this is a problem for so many homes.
Research within this area in developed regions of the
world has had a low priority over the last half century,

The history of indoor air quality and health

compared with research on ambient air or industrial
air. Most of the (necessary, low-budget) science has
been driven by what we can easily measure. However,
exposures (TVOC, single VOCs, mold spores, etc.) that
have been measured are seemingly of little importance
for health eects. Besides, the science on the biological
mechanisms involved (regarding, e.g., SBS, MCS, and
allergies) is largely missing. There is a need for this
science to grow up and search for other possibly
relevant compounds, and to go more deeply into
biological mechanisms.
We know that building characteristics such as
dampness, a low ventilation rate, and certain building (furnishing) materials are important, but we really
do not know how, or why.
From the history of IAQ/health it can be learned
that the development that started in philosophy, later

divided into, e.g., medicine and technology. During the

last few decades most scientic eorts have been in
specic disciplines such as building physics, HVAC
engineering, architecture, medicine (a number of disciplines), organic chemistry, microbiology, sociology,
psychology, physics, economy, etc., mostly with little
interaction. The trend has followed the general development within sciences from philosophy (general
science) into more and more specialized sciences.
Today the basic academic training is within a very
specialized science. and by far the most research and
training related to IAQ/health is within single disciplines.
What is needed is a new multidisciplinary paradigm
where generalized knowledge (putting ndings in a
total perspective) is as important as within-science
knowledge.

References
Ahlbom, A., Backman, A., Bakke, J.V.,
Foucard, T., Halken, S., Kjellman,
N.-I.M., Malm, L., Skerfving, S., Sundell,
J. and Zetterstrom, O. (1998)
NORDPET, Pets indoors A Risk Factor or
Protection against Sensitization/Allergy,
A Nordic Interdisciplinary Review of the
Scientific Literature Concerning the
Relationship between the Exposure to
Pets at Home, Sensitization and the
Development of Allergy, Indoor Air, 8,
219235.
Andersson, K., Bakke, J.V., Bjorseth, O.,
Bornehag, C.-G., Clausen, G., Hongslo,
J.K., Kjellman, M., Kjaergaaard, S.,
Levy, F., Molhave, L., Skerfving, S. and
Sundell, J. (1997) TVOC and health in
non-industrial indoor environments,
Indoor Air, 7, 7891.
Bornehag, C.-G., Blomquist, G., Gyntelberg,
F., Jarvholm, B., Malmberg, P., Nielsen,
A., Pershagen, G. and Sundell, J. (2001)

NORDDAMP: Dampness in buildings
and health, Indoor Air, 11, 7286.
Bornehag, C.-G. Sundell, J., Bonini, S.,
Custovic, A., Malmberg, P., Skerfving,
S., Sigsgaard, T. et al. (2004a)
Dampness in buildings as a risk factor
for health effects. Euroexpo: A multidisciplinary review of the literature (1998
2000) on dampness and mite exposure in
buildings and health effects, Indoor Air,
in press.
Bornehag, C.-G., Sundell, J., Hagerhed, L.
and Sigsgaard, T. (2004b)
Association
Between Ventilation Rates in 390 Swedish
Homes and Allergic Symptoms in
Children: a Nested Case Control Study,
Indoor Air, accepted.
Bornehag, C.-G., Sundell, J., Sigsgaard, T.
(2004c) Dampness in buildings and
health (DBH): Report from an ongoing
epidemiological investigation on the

association between indoor environmental factors and health effects among

children in Sweden, Indoor Air, 14
(Suppl. 7), 5966.
Carnelly, D., Haldane, J.S., Anderson, A.M.
(1887) The carbonic acid, organic matter
and micro-organisms in air, more especially in dwellings and schools. Philosophical Transactions of the Royal Society,
Series B, 178, 61111.
Fang, L., Clausen, G. and Fanger, P.O.
(1999) Impact of temperature and
humidity on chemical and sensory emissions from building materials, Indoor
Air, 9, 193201.
Fanger, P.O. (1988) Introduction of the olf
and decipol units to quantify air pollution
perceived by humans indoors and outdoors, Energy and Buildings, 12, 16.
Fanger, P.O. (1992) Sensory characterization of air quality and pollution sources.
In. Knoppel, H.Wolko, P., eds. Chemical, Microbiological, Health and Comfort
Aspects of Indoor Air Quality State of
the Art in SBS, Dordrecht: Kluwer Academic Publishers, pp. 5971.
Fanger, P.O., Lauridsen, J., Bluyssen, P. and
Clausen, G. (1988) Air pollution sources
in offices and assembly halls, quantified
by the olf unit, Energy and Buildings, 12,
719.
van Odijk, J., Kull, I., Borres, M.P., Brandtzaeg, P., Edberg, U., Hanson, L.A., Host
A. et al. (2003) Breastfeeding and allergic disease: a multidisciplinary review of
the literature (19662001) on the mode of
early feeding in infancy and its impact on
later atopic manifestations, Allergy, 58,
833843.
Schneider, T. Sundell, J., Bischof, W., Bohgard, M., Cherrie, J.W., Clausen P.A.,
Dreborg S. et al. (2003)
EUROPART,
Airborne particles in the indoor environ-

ment, An European interdisciplinary

review of scientific evidence on associations
between exposure to particles in buildings
and health effects, Indoor Air, 13, 3848.
Smith, K.R. (2003) The global burden of
disease from unhealthy buildings:
preliminary results from comparative risk
assessment, Proceedings of Healthy
Buildings 2003, 1, 118126.
Sundell, J. (1994) On the association between
building ventilation characteristics, some
indoor environmental exposures, some
allergic manifestations and subjective
symptom reports, Indoor Air (Suppl. 2)
(contains all historical references).
Sundell, J. (1999) (Principal author) Indoor
Environment and Health, Stockholm,
Sweden: National Institute of Public
Health.
Sundell, J., Andersson, B., Andersson, K.
and Lindvall, T. (1993) Volatile organic
compounds in ventilating air at different
sampling points in the building and their
relationships with the prevalence of
occupant symptoms, Indoor Air, 3,
8293.
Sundell, J., Pershagen, G., Wickman, M. and
Nordvall, L. (1995) Ventilation in homes
infested by house dust mites, Allergy, 50,
106112.
Wargocki, P., Sundell, J., Bischof, W.,
Brundrett, G., Fanger, O., Gyntelberg,
F., Hanssen, S.O., Harrison, P., Pickering, A., Seppnen, O. and Wouters, P.
(2002a) Ventilation and health in nonindustrial indoor environments, Report
from a European multidisciplinary scientific consensus meeting, Indoor Air, 12,
113128.
Wargocki, P., Sundell, J., Bischof, W.,
Brundrett, G., Fanger, O., Gyntelberg,
F., Hanssen, S.O., Harrison, P., Pickering, A., Seppanen, O. and Wouters, P.

57

Sundell
(2002b) Ventilation and health in nonindustrial indoor environments, Report
from a European multidisciplinary scientic consensus meeting, Indoor Air, 12,
113128.
Wargocki, P., Wyon, D.P., Baik, Y.K.,
Clausen, G. and Fanger, P.O. (1999),
Perceived air quality, sick building syndrome (SBS) symptoms and productivity
in an office with two different pollution
loads, Indoor Air, 9, 165179.

58

Wargocki, P., Wyon, D.P., Sundell, J.,

Clausen, G. and Fanger, P.O. (2000)
The effects of outdoor air supply rate in
an office on perceived air quality, sick
building syndrome (SBS) symptoms and
productivity, 10, 222236.
Weschler, C.J. (2000) Ozone in the indoor
environment: concentration and chemistry, Indoor Air, 10, 269288.
Weschler, C.J. and Shields, H.C. (2000) The
influence of ventilation on reactions

among indoor air pollutants: Modeling

and experimental observations, Indoor
Air, 10, 92100.