Estimates of the Environmental Burden of Disease

Attributed to Outdoor Air Pollution in Jakarta,

Indonesia
Extended Abstract # 682

Hernani Yulinawati
University of Hawaii at Manoa, Department of Urban and Regional Planning, 2424 Maile
Way # 107, Honolulu, HI 96822, hernani@hawaii.edu

INTRODUCTION

In most urban environments, outdoor air pollution (OAP) is a major problem, particularly
from particulate matter (PM). The largest source of PM is fuel combustion from both
mobile (e.g. cars, trucks, and buses) and stationary (e.g. power plants and boiler) sources,
but other sources such as road dust, biomass burning, manufacturing processes, and
primary pollutants from stationary diesel engines also contribute. To measure the effects
of air pollution, PM is selected because it has been used in epidemiological studies
spanning five continents and has demonstrated an association between mortality and
morbidity, and daily, multi-day or long-term (a period of more than a year) exposures to
concentrations of pollutants.1

In a recent estimate of the global burden of disease (GBD) based on average urban
concentrations of PM10 and PM2.5 (particulate matter less than 10m and 2.5m in
diameter), OAP was estimated to account for approximately 1.4% of total mortality, 0.5%
of all disability-adjusted life years (DALYs), and 2% of all cardiopulmonary disease.2,3,4
The burden of disease in major cities will vary due to factors such as the amount of fossil
fuel used, weather, underlying disease rates, and population size and density. The disease
burden of a population, and how that burden is distributed across different subpopulations
(e.g. infants, women), are important pieces of information for defining strategies to
improve population health. For policy-makers, disease burden estimates provide an
indication of the health gains that could be achieved by targeted action against specific
risk factors. These measures also allow policy-makers to prioritize actions and direct
them to the population group at highest risk.

Ostro has developed a method for estimating the environmental burden of disease (EBD)
at national and local level attributed to OAP, which is similar to that used to estimate the
GBD.1 For a given city or region, the quantitative assessment of the health impact of
OAP, using PM (either PM10 or PM2.5) measurements, is based on four components: an
assessment of the ambient exposure of the population to PM, based either on existing
fixed-site monitors or on model-based estimates; a determination of the size of the
population group exposed to PM and the type of health effect of interest; the incidence of
the health effect being estimated; and concentration-response functions from the
epidemiological literature that relate ambient concentrations of PM to selected health
effects as shown in Table 1.

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Table 1. Recommended Health Outcomes and Risk Functions to Calculate the EBD.1

Suggested 
coefficient
Relative risk (RR)
Outcome & exposure metric Reference (95% Subgroup
functiona
Confidence
Interval)
All-cause mortality & short- Meta-analysis RR = exp [ (X-Xo)] 0.0008 All ages
term exposure to PM10b & expert (0.0006-
judgment 0.001)c
Respiratory mortality & short- Meta-analysis RR = exp [ (X-Xo)] 0.00166 Ages 5
term exposure to PM10 (all- (0.00034, years
cause mortality for upper bound 0.003)
where applicable)
Cardiopulmonary mortality & Pope et al. RR = [(X+1)/(Xo+1)] 0.15515 Age 30
long-term exposure to PM2.5 [2002]; R (0.0562, years
Burnettd 0.2541)
Lung cancer & long-term Pope et al. RR = [(X+1)/(Xo+1)] 0.23218 Age 30
exposure to PM2.5 [2002]; R (0.08563, years
Burnettd 0.37873)
a
X = current pollutant concentration (g/m3) and Xo = target or threshold concentration of pollutant
(g/m3).
b
Not used in DALY calculations and should not be added to other mortality estimates.
c
Presentation of a range rather than a point estimate is preferred.
d
Personal communication with B. Ostro.

The objectives of this paper are to estimate the EBD attributed to OAP in Jakarta using
PM measurements based on Ostro’s method and to discuss the Jakarta’s government
policies for reducing the burden. It is hope that these estimates will help Jakarta’s
government to formulate more effective air quality management for improving public
health.

ESTIMATIONS OF THE DISEASE BURDEN ATTRIBUTED TO OUTDOOR

AIR POLLUTION

Several studies have been undertaken to estimate or rank disease burdens from
environmental risk factors on regional, national or global levels. Table 2 summarizes the
selected study results related to OAP. Table 3 shows the exposure variables, theoretical
minimum, disease, and data sources for assessing urban OAP risks that are used to
estimate GBD in 2000.

In GBD of 20002, the estimates of the total disease burden were based solely on the
effects of PM on mortality in adults and children. Because the epidemiological studies
suggested that mortality impacts were likely to occur primarily among the elderly, the
World Health Organization (WHO) estimates indicated that 81% of the attributable
deaths from OAP and 49% of the attributable DALYs occurred in people aged 60 years
and older. Children under 5 years of age accounted for 3% of the total attributable deaths
from OAP and 12% of the attributable DALYs.3

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Table 2. Results of Environmental Disease-Burden Studies.5

% of Total
Premature DALYs (95%
Incidence/ Disease
Risk Factor Reference Deaths/ Confidence
Year Burden of
Year Interval)
Study Area
Outdoor air de Hollander, 22,000 8,500 75,900 (45,100- 3.0%
quality (long 1999 106,500)
term) (Netherlands)
Outdoor air de Hollander, 530,000 1,100 2900 (1,500- 0.12%
quality (long 1999 4,700)
term)
Outdoor air Murray, 1996 not reported 568,000 7,254,000 0.5%
quality (Global)
Outdoor air USAID, 1990 9-51 million 300-1,400 not reported not reported
quality (Bangkok) restricted
activity days

Table 3. Environmental Risk from Urban Outdoor Air Pollution.2

Exposure Theoretical Sources for hazard

Outcomes Sources for exposure estimates
variable minimum estimates
Estimated 7.5 µg/m3 for Mortality from PM10 estimated for 3211 cities ACS-CPS II
annual PM2.5, combined respiratory & with population larger than prospective study of
average of 15 µg/m3 for selected cardiovascular 100000 & national capitals risk factors for
PM2.5 or PM10 causes in adults >30 based on measured annual mortality in more
PM10 years, lung cancer, acute average concentrations of PM10 than one million
respiratory infection & total suspended particulates; Americans for adult
mortality in children <5 in 304 cities, with a combined estimates;
years; cardiovascular & population of 559 million with systematic review
respiratory morbidity an econometric model of the & new meta-
scale & composition of analysis of time-
economic activity & geoclimatic series studies of
factors mortality in
children <5 years

The differences orders of magnitude between least developed and most developed
regions will be even greater as exemplified by the disease burden in the Sub-Saharan
region which is known to be much higher than the mean values in the developing world.
Also, the rural/urban differences or the differences for high-risk communities even within
one nation are likely to be important. However, environmental disease burden is
relatively poorly studied in the developing countries. 6 In term of OAP problems,
developing and developed countries share the same magnitude. This is true especially
between urban areas in developing countries and developed countries.

APPLICATION OF EBD ATTRIBUTED TO OUTDOOR POLLUTION IN

JAKARTA, INDONESIA

Table 4 shows, with population of 8,347,083 (Census 2000) and the annual mean PM10
concentration of 102.5μg/m3 (1998), the estimates burden from exposure to OAP in
Jakarta are: 3,500-6,000 deaths/year of all-cause mortality and short-term exposure to

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PM10 (all ages), 45-590 deaths/year of respiratory mortality and short-term exposure to
PM10 (ages <5 years), 1,500-5,000 deaths/year of cardiopulmonary mortality and long-
term exposure to PM2.5 (Age >30 years), and 120-400 deaths/year of lung cancer and
long-term exposure to PM2.5 (Age >30 years).

Table 4. Annual number of deaths from outdoor air pollution for Jakarta

Outcome & Exposure Subgroup Mortality rate of disease Population Deaths from
metric group exposure to OAP
(deaths/person/year) (deaths/year)
95% CI
All-cause mortality & short- All ages 0.007 8,347,083 3,500 – 6000
term exposure to PM10
Respiratory mortality & Ages 5 0.00334 350,000 45 – 590
short-term exposure to PM10 years
(all-cause mortality for upper
bound where applicable)
Cardiopulmonary mortality & Age 30 0.0023 4,000,000 1,500 – 5,000
long-term exposure to PM2.5 years
Lung cancer & long-term Age 30 0.00014 4,000,000 120 – 400
exposure to PM2.5 years

In the early 1990s, WHO and United Nations Environment Program (UNEP) ranked
Mexico, Bangkok, and Jakarta as the worst air polluted cities. Both Jakarta and Bangkok
have similar OAP problems. Transportation sector or emission from mobile sources
contributed 70% of air pollution in both cities. Bangkok and Jakarta established a lot of
efforts to decrease their air pollution. However, Bangkok seems to achieve a better result
than Jakarta. Some interventions to reduce air pollution problems have been
implemented by the Bangkok’s authority, including: phasing-out leaded gasoline to
unleaded gasoline; reducing gasoline’s sulfur content; developing mass rapid transit
system to reduce the extensive use of private cars; and having clear energy policy that
promoting the use of renewable fuels (natural gas, bio-fuels). Jakarta also did similar
policy interventions, but they came later and the implementation of some are troubled due
to lack of enforcement.

SUMMARY

Estimates of disease burden from environmental risk factors have shown that
environmental conditions are, globally, major determinants of population health. To the
more obvious application in environmental health policy, improving environmental
disease burden estimates may have benefits to those generally engaged in environmental
protection and health. Such estimates can also be used for the purpose of environmental
advocacy, large-scale civic planning, and potential monitoring and evaluation of efforts
to reduce the human consequences of environmental pollution and degradation, in this
case OAP.

The EBD attributed to OAP is relatively poorly studied in Jakarta, Indonesia. Limited
access to source of data in detail (i.e., annual average PM10, age group mortality rates)

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has made difficulties in the calculation, thus the results are relatively rough, but quite
robust to portray the health problem in Jakarta related to OAP. It is believed with
sufficient data, EBD attributed to OAP can be used to evaluate the health impacts and
Jakarta’s air quality policies in the past and at present. From there, the future EBD
estimation can be expected to decrease with the implementation of better policy
interventions.

If Jakarta could reduce the annual mean PM10 concentration to the new WHO Air Quality
Guidelines of 20μg/m3, about a half of the all-cause mortality for all ages and respiratory
mortality for ages under 5 years could be avoided. Besides targeting the fulfillment of
the stationary (industrial) emission standards, currently the government of Jakarta
implements the inspection and maintenance regulation for all motor vehicles (previously
for public transportation only), rapid development of mass transit (busway), and
alternative fuels. It is hoped that these policies, along with a strong enforcement, will
bring improvement in Jakarta’s public health.

REFERENCES

1. Ostro, B. Outdoor Air Pollution: Assessing the Environmental Burden of Disease at

National and Local Level. WHO (Environmental Burden of Disease Series No. 5):
Geneva, Switzerland, 2004.

2. Ezzati, M.; Lopez, A.D.; Rodgers, A.; Hoorn, S.V.; Murray, C.J.L.; the Comparative
Risk Assessment Collaborating Group. The Lancet. 2002, 30, 1347-1360.

3. The World Health Report 2002. WHO: Geneva, Switzerland, 2002.

4. Cohen, A.J.; Anderson, H.R.; Ostro, B.; Pandey, K.D.; Krzyzanowski, M. et al. In
Comparative Quantification of Health Risks: Global and Regional Burden of Disease
Attributable to Selected Major Risk Factors; Ezzati, M., Lopez, A.D., Rodgers, A.,
Murray, C.J.L., Eds.; WHO (Environmental Burden of Disease Series No. 2):
Geneva, Switzerland, 2004.

5. Pruss, A.; Corvalan, C.F.; Pastides, H.; de Hollander, A. Introduction and Methods:
Assessing the Environmental Burden of Disease at National and Local Levels. WHO
(Environmental Burden of Disease Series No. 1): Geneva, Switzerland, 2001.

6. Pruss, A. Methodology for Assessment of Environmental Burden of Disease: Report

on the ISEE Session on Environmental Burden of Disease. WHO, 2000.

7. Syahril, S.; Resosudarmo, B.P.; Tomo, H.S. Study on Air Quality in Jakarta,
Indonesia: Future Trends, Health Impacts, Economic Value and Policy Options.
ADB, 2002.

KEY WORDS
Environmental burden of disease, air pollution, particulate matter, Jakarta