The New Airborne Disease

Community Air Pollution

JOHN R. GOLDSMITH, M.D., Berkeley
Community air pollution is the new airborne disease of our generation's communities. It is caused by the increasing use of fuel, asso*

ciated with both affluence and careless waste. Photochemical air pollution of the California type involves newly defined atmospheric
reactions, is due mostly to motor vehicle exhaust, is oxidizing, and
produces ozone, plant damage, impairment of visibility and eye and
respiratory symptoms.

Aggravation of asthma, impairment of lung function among persons with chronic respiratory disease and a possible causal role, along

with cigarette smoking in emphysema and chronic bronchitis, are

some of the effects of photochemical pollution.
More subtle effects of pollution include impairment of oxygen
transport by the blood due to carbon monoxide and interference with
porphyrin metabolism due to lead. Carbon monoxide exposures may
affect survival of patients who are in hospitals because of myocardial
infarction.
While many uncertainties in pollution-health reactions need to be
resolved, a large number of people in California have health impairment due to airborne disease of this new type.

IN THE AUTUMN of 1954, during his campaign for

re-election, the citizens of Los Angeles County
addressed Governor Goodwin Knight with the ancient question, "Can this stuff kill us?" "This stuff'
was photochemical air pollution, a new phenomenon which was robbing residents of Southern California of comfort and health. Governor Knight
From the Environmental Epidemiology Unit, Bureau of Occupational Health and Environmental Epidemiology, California State Department of Health, Berkeley.
Submitted September 18, 1970.
Reprint requests to: Environmental Epidemiology Unit, Bureau of

Occupational Health and Environmental Epidemniology, California

State Department of Public Health, 2151 Berkeley Way, Berkeley,
Ca. 94704 (Dr. J. R. Goldsmith).

allocated from emergency funds resources to support a pioneering program in air sanitation at the
California State Department of Public Health.
The program had three components: a laboratory
one, an engineering one and a medical one.
In the summer of 1970 anxious citizens of
Riverside and San Bernardino Counties complained that increasing air pollution was impairing their health; the Legislature requested the
State government to determine whether air pollution in light of the current and projected control will cause mortality, morbidity, or an inCALIFORNIA MEDICINE
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crease of emphysema and other respiratory

diseases, and the Governor said that the air pollution problem was lessening, though slowly.
Between 1954 and 1970 physicians in California, acting both as medical scientists and as
well-informed citizens, had brought into focus
many aspects of the problem which is the prototype of a new class of problem-problems which
man in his affluence is unwittingly producing
and which threaten his comfort, his health and
his survival.

Chemistry, Physics, and Measurement

Of Air Pollution
"This stuff" which began to afflict Southern
California after World War II and now afflicts
many urban areas of the world is called "photochemical air pollution." It has three ingredients
and four primary effects.1 These three ingredients are hydrocarbon vapors, (that is, gasoline
vapors and related compounds), oxides of nitrogen, and sunlight. In the atmosphere over a
period of minutes to hours these ingredients
react to: (1) form a myriad of compounds including increase in the amounts of ozone and
nitrogen dioxide in the atmosphere, (2) produce
a characteristic form of damage to vegetation,
(3) interfere with visibility and, (4) produce
eye irritation, respiratory irritation and other effects on the respiratory system, and possibly also
affect the cardiovascular system.
The measurement of severity of photochemical air pollution that is most widely used is the
measurement of the oxidizing properties of the
atmosphere after air samples have been drawn
through solutions of potassium iodide. The results are reported as "oxidant." Most of the oxidant is ozone; the next most common ingredient
is nitrogen dioxide, but neither of these compounds is alone responsible for the irritation. At
the levels present, the determination of other
health effects has been extremely difficult. The
irritation is now thought to be largely due to
aldehydes, which are not oxidants but which are
also partly produced from photochemical reactions, and to a lesser extent by a series of compounds first discovered when photochemical pollution was investigated-the peroxyacetyl nitrates,
the peroxybenzoyl nitrates and related compounds. Compounds such as these are present in
extremely small concentrations; for example, dur14

NOVEMBER 1970 * 1 13 * 5

ing very intense air pollution episodes there may

be as much as 10 parts per hundred million of
peroxyacetyl nitrates. Thus, the measurement of
atmospheric pollutants is not a simple matter for
the chemist and many of the measurements are
often not specifically significant, which makes it
difficult for the toxicologist to interpret them.
Atmospheric pollution does not only include
"this stuff," even in Southern California, for carbon monoxide (which does not produce specific
symptoms) and lead are also found in motor
vehicle exhausts, the former resulting from incomplete combustions of most of the hydrocarbons and the latter resulting from the breakdown
in the processes of combustion of organic lead
added as tetraethyl or tetramethyl lead. The
measurement of carbon monoxide is relatively
simple and its concentration is the highest of all
the important pollutants. Its primary effect on
health is due to its specific impairment of the
oxygen transport function of the blood. Measurements of lead have not been systematically carried out because the analysis is technically difficult for the chemist. It has been established that
there are increased amounts of lead deposited in
and stored in the bodies of persons exposed to
motor vehicle pollution.
Air pollution such as has caused increases in
mortality in England, New York, Tokyo and
other places is different from "the stuff" that
affects Southern California in that it is predominantly not an oxidizing atmosphere but a reducing atmosphere and largely consists of sulfur
oxide and particulate matter. It is now thought
that the most serious health consequences of pollution of this type are the result of the oxidation
of sulfur dioxide to sulfur trioxide in the atmosphere and the hydration of sulfur trioxide to
form sulfuric acid mist. This is several times
more toxic and more lastingly harmful to health
than is the molar equivalent concentration of
sulfur dioxide.
In the presence of sulfur dioxide, oxidant, the
customary index of photochemical pollution,
would be low since the sulfur oxide pollution is
a reducing atmosphere and will counteract the
oxidant present by interacting with it in the solutions of the analytic instrument.

)f ominous significance in the summer of 1970

was the occurrence of periods of severe pollution

in New York and the eastern seaboard of the

United States as well as Tokyo during periods
when sunlight is likely to be particularly intense.
These areas with their high motor vehicle emissions probably are experiencing the first serious
attacks of a new form of atmospheric pollution
which is a hybrid between the oxidizing and the
reducing pollution. Measurements of what has
been occurring during the summer of 1970 are
not yet available but the likelihood that photochemical reactions are occurring which yield oxidant which, reacting in the atmosphere, would
yield substantial amounts of sulfuric mist is to
be expected. If so, the health consequences
could be more severe than any of the previous
pollution episodes which have been studied.
In the near vicinity of large power plants, factories and other pollution sources, there are other
kinds of pollution of a more special variety; but
the two major forms which are likely to produce
health consequences community-wide in large
metropolitan areas are of the photochemicaloxidant type first observed in Southern California
and the sulfur oxide and particulate form first
observed in England and the eastern coast of the
United States. A hybrid between these has not
yet been proven but most likely has first become
manifest during the summer of 1970.
Exposure to heavy metals, to malodor of sulfur compounds, to compounds of organic decomposition, to soots and smokes of various forms,
to vegetable and mineral dusts and to fumes
from mining, smelting and metallurgical operations of course afflicts many other people and
may interact with the two predominant forms of

community-wide pollution.

Engineering Aspects of
Atmospheric Pollution
The patterns of emission of photochemical pollution are related to the use of motor vehicles.
There is a higher amount of emission during
weekdays than during weekends because motor
vehicles are used more intensively during that
time. There is a higher concentration of measured pollutants during the winter on the average
than during the summer because the amount of
air movement in the areas where air pollution
occurs is less during the winter on the average.
Therefore, the volume in which motor vehicle
exhaust is diluted is less. The primary pollutants

are nitrogen oxides, hydrocarbons and carbon

monoxide. When measured, lead can be detected
as a primary pollutant closely associated with
carbon monoxide. The secondary pollutants are
photochemical oxidants and nitrogen dioxide.
These pollutants tend to reach their peak in the
middle of the day or in the afternoon if the
cloud of polluted air travels for some distance.
Since with sunset the incidence of ultraviolet
energy from the sun is halted, the secondary pollutants fall to very low levels during the night.
The contribution to community-wide photochemical pollution of the two more obvious forms
of engine exhaust-that from jet aircraft and that
from diesel vehicles-is trivial compared with the
relatively less visible contribution of many millions of automobiles with higher-than-needed
engine capacities and under-used passengercarrying capacities.
In 1970 the present control strategy for motor
vehicle emissions consists of restrictions on the
emissions of carbon monoxide and of hydrocarbons but the control of these two substances has
been achieved at a cost of increasing the emissions of oxides of nitrogen. Starting with 1971
model cars, controls over oxides of nitrogen will
also be required, and in order to use catalytic
exhaust control systems, as well as to prevent
health hazards from lead additives, it has now
become clear that it is necessary to reduce and
eliminate lead in motor fuel. This strategy,
though necessary, is not sufficient to provide air
quality free of health effects in the foreseeable
future.
Pollution concentrations tend to increase during periods of atmospheric stagnation when the
so-called "temperature-inversion" keeps the upward diffusion of pollutants restricted to a few
hundred feet, thus forming what amounts to a
lid over the Southern California or other air
basins due to the inversion in the temperature
gradient with altitude. Such inversions are more
common and more intense during the winter
than during the summer but the inversion's effect on the intensity of photochemical pollution
is generally greatest in the late summer and early
fall because during that period there is a sufficient amount of sunlight to cause the photochemical reactions to proceed.
Control efforts have kept a great deal of pollution from entering the atmosphere. Control
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programs for motor vehicle exhaust have reduced

the emission of carbon monoxide and hydrocarbons from new motor vehicles by fairly substantial although still inadequate amounts.
For all these reasons the maximal intensity of
pollution has not increased during periods during which measurements have been made, but
the number of areas (and hence the proportion
of the population affected by elevated air pollution concentrations) has steadily increased as the
State's population has increased. During recent
years the populations of recently developing portions of the metropolitan complex, such as San
Bernardino and Riverside in Southern California,
and the Livermore Valley in Northern California,
San Diego and Sacramento, have increasingly
felt the characteristic eye irritations, smelled the
characteristic odor and reported concern about
the effects of air pollution on respiratory diseases.

The Clinical Results

Increasing Mortality. Because the London episodes have shown short-term increases in mortality, it was natural that this be the most urgent
question for investigation in Los Angeles. Air
pollution occurs in association with low windspeeds and these are also associated in Los Angeles with high atmospheric temperatures. One
of the first episodes that was carefully studied
occurred in 1955 in association with a heat wave
with a week of temperature above 100 degrees.
During this episode there was an excess of about
1000 deaths in Los Angeles over its actuarial expectation. The study of this episode and others
in which the high temperature and high air pollution levels were more separated has now made
it clear that the excessive temperature could
have accounted for all of the excess deaths in
1955. Subsequent studies have not shown that
there is a short-term increase in mortality which
can clearly be attributed to air pollution of the
photochemical type.
One of the possible reasons for failing to find
such an effect could be that the methods are not
sensitive enough, but another reason may be that
the intermittency for photochemical air pollution
compared with the persistence of the sulfur oxide and particulate pollution may 'make the
former less likely to produce effects on mortality
because of cumulation of toxic materials in the
16

NOVEMBER 1970 *

13 * 5

air. Even though episodes of high air pollution

have occurred on successiye days in California,
during the night the oxidant level drops to relatively low levels.
The result of studies of the possible role of
carbon monoxide has not been negative. A suggestive report has been published by our group2
noting that increases in the case fatality rates for
hospitalized myocardial infarction are apparently
associated with community carbon monoxide exposures. Current work on the long-term analysis
of mortality, corrected for time of year and temperature, also provides some suiggestive evidence
of a small contribution of elevated levels of carbon monoxide.
It is thus reasonable to conclude now, from
what data is available, that an acute mortality
disaster from photochemical pollution has not
occurred and because of the photochemical nature of the pollution and its intermittency it is
probably not likely to occur with expected future
patterns of pollution. Carbon monoxide may be
makiig a small contribution to mortality which
is detectable only by analysis of special types of
data.
Chronic Disease Mortality in Relation to Air
Pollution. Data available from many countries
indicates that in urban compared with rural
areas there is increased frequency of lung cancer
and increased frequency of chronic respiratory
disease. In the United Kingdom where these data
have been studied carefully, the role of air pollution in lung cancer mortality is not considered
established, though there is no question that
there is an urban factor in the disease. The factors responsible for the urban excess are not
clearly identified. What is clear is that in the
Scandinavian countries there is an even greater
proportional urban excess of lung cancer and a
relatively modest amount of community urban
air pollution compared with the United Kingdom. In California no urban excess of lung cancer has been shown for the usual reported
statistics but prospective studies of mortality experience of members of the American Legion
and their wives do show that if residence for the
last ten years is considered as a basis, that there
is some excess of lung cancer in urban areas; but
this excess is not substantially greater in Los
Angeles than in other metropolitan parts of the
State, nor is the general lung cancer mortality

greater in Los Angeles compared with other

parts of California.3
The same general statement may be made for
chronic respiratory diseases such as emphysema,
which has been studied less because of difficulties of classification and the more recent development of upward trends in mortality from the
condition. Suspicion nevertheless attaches to the
possible role of photochemical air pollution in
emphysema because nitrogen dioxide, one of the
products of the photochemical reaction, is capable, in experimental animal exposures, of producing emphysema. This has been observed in
a number of species after long-term exposures
to concentrations which occasionally occur for
shorter periods in polluted California cities. The
association of air pollution with chronic respiratory disease mortality in Great Britain is well
established and widely accepted. Similar studies
also indicate an effect of pollution on chronic
bronchitis morbidity.
The Relationship of Air Pollution Exposure to
Chronic Respiratory Disease. The earliest reported clinical complaints concerning air pollutiQn was the clinical report of the aggravation
of asthma. Only one systematic study has been
carried out. It was done in 1956 in Pasadena by
Dr. Schoettlin and Mr. Landau,4 who found that
there was a significant excess of asthma in days
in which the photochemical oxidant exceeded 0.20
ppm as an hourly average based on the potassium iodide method. The association of the frequency of asthma attacks to levels of photochemical air pollution was low. The study indicated
that a small fraction of asthmatic subjects appeared to be responding to photochemical air
pollution, perhaps between 5 and 10 percent of
adult asthmatics, but no response of childhood
asthmatics was detected in this study. Such studies need to be repeated because there may have
been changes in the nature of photochemical
air pollution with the beginning of the motor
vehicle exhaust control program, and additional
data is needed for the guidance of physicians.
However, it can be assumed that a short-term
effect of photochemical air pollution on a fraction of adult asthmatics has been established, and
such persons should be protected from further
exacerbations of their disease by appropriate
medication or by the use of activated charcoal
filtration of indoor air supplies or by their leaving the area where exposure is likely to occcr.

Motley, Leftwich and Smart5 first studied the

effects of air pollution on patients with emphysema and advanced chronic bronchitis and
showed that when those individuals were kept
in rooms from which the oxidant was removed
by activated charc-oal filtration of the air supply,
these individuals had improved respiratory function. If the same sort of patients were placed in
these rooms during periods when the oxidant
was not elevated, they did not have any improvement. When persons without this clinical syndrome were put in such rooms they did not have
any increase in lung function. From this the
authors inferred that photochemical oxidants impaired lung function in persons with these conditions and this supposition seemed realistic
though it was not confirmed until recently.
Remmers and Balchum,6 and Ury et al7 have
now shown from data obtained by exposing persons with chronic respiratory disease in rooms
from which the oxidant either was or was not
filtered according to the research design, that
there is a statistically significant association of
airway resistance with photochemical oxidants.
Not every individual appears to be affected, however. In studies of relatively healthy persons,
Deane and Goldsmith` have shown that during
a time of year in which photochemical pollution
was unlikely, that there were increased symptoms of chronic respiratory disease among outside plant workers from 50 to 59 years of age in
Los Angeles compared to comparable groups
studied in comparable fashion in San Francisco.
However, using the forced expiratory volume in
one second there were no differences in lung
function between these two groups.
Impairment of Function. It has been established that commonly occurring levels of photochemical oxidant can interfere with respiratory
function, causing changes in airway resistance
in persons who have chronic respiratory conditions, though whether or not persons who do not
have these conditions are affected is not certain.
The amount of carbon monoxide present in
Southern California, particularly during the winter periods when the atmospheric inversion is
unusually intense, is often sufficient to impair
by 5 percent or more the oxygen transport function of the blood. Under experimental conditions, similar, or even lesser, exposures have been
shown by Beard and Wertheim9 to be capable
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of interfering with accurate estimation of intervals of time. This has -led to a suspicion that
'carbon monoxide may be interfering with the
capacity to operate motor vehicles. However, a
statistical study of the association between photochemical oxidant levels and motor vehicle accidents and between the carbon monoxide levels
and motor vehicle accidents showed a highly
significant effect of photochemical oxidants but
no effect for carbon monoxide.
Wayne et al'0 showed that high school track
team members had significantly less satisfactory
performance during periods when the photochemical oxidant was elevated than during other
periods.
Goldsmith and Hexter" and Thomas et al'2
showed that there is a statistically significant association of elevated content of lead in the atmosphere with elevated levels in the blood. Investigators in Sweden and Finland have shown
that in association with blood lead levels in this
range, usually considered to be within normal
limits, there is an impairment in function of an
enzyme, delta amino-levulinic acid dehydratase,
which affects porphyrin synthesis, and that there
is also increased excretion of delta amino-levulinic acid in the urine. Such an effect is likely
to be present in California populations but has
not yet been demonstrated.
Eye Irritation. Photochemical pollution is responsible for very widespread eye irritation affecting at least 75 percent of the population of
Southern California. The proportion affected
certainly has not diminished. However, there is
no good evidence that the widespread and persisting eye irritation is necessarily associated with
any disease of the eye or conjunctiva. In contrast, it is usually agreed that there is a relationship between respiratory irritation and respiratory diseases.

Interaction of Cigarette Smoking and

Air Pollution
There is abundant evidence that cigarette
smokers are much more likely to manifest critical
effects of community air pollution than those who
are not. This derives from epidemiologic studies
of lung cancer and of chronic bronchitis and
emphysema. The interaction is probably greater
than additive and may be physiologically synergistic in the sense that cigarette smoking impairs
18

NOVEMBER 1970 *

13 * 5

the defense mechanisms against air pollution exposure.

Cigarette smoke contains oxides of nitrogen,
particulate matter, benzo(a)pyrene and other
potential carcinogens and carbon monoxide, and
it even contains small amounts of lead. Many
cigarette smokers have sufficient carbon monoxide exposure so that they have carboxyhemoglobin levels in excess of 5 percent; careful physiologic analysis shows that the additional exposure of cigarette smokers to carbon monoxide
does not necessarily have an additive effect but
a more complex form of summation. The cigarette smoker has more difficulty excreting carbon
monoxide between cigarettes if the atmosphere
is polluted with carbon monoxide than he would
if it were not; hence the cigarette smoker during
periods of carbon monoxide pollution is likely to
have a higher carboxyhemoglobin level than during non-polluted periods. Cigarette smokers tend
to have a higher blood lead level than non-cigarette smokers and this is probably due to the
persisting residual effects of lead arsenate sprays
used many years ago in areas where cigarette
tobaccos are now grown.
A number of sources are available for further
information13,14.15,6 but for current information
the American Medical Association's Archives of
Environmental Health is recommended.

The Physician's Responsibility

The physician has two responsibilities in the
field of air pollution. One is to his patients,
through providing adequate specific protection
for sensitive individuals against the specific effects of air pollution when it is elevated. This
includes advising them to reduce physical activities and to stay indoors in order to reduce the
overall exposure to pollutants and their inhalation, recommending specific respiratory protection where indicated through the use of bronchodilator drugs and activated charcoal filtration,
and treating exacerbations of respiratory conditions which may be caused by atmospheric pollution.
The second role of the physician is to help
shape public policy regarding pollution by applying knowledge of the respiratory and other
health hazards that come from polluted air
whether from occupational exposure, cigarette
smoking or community air pollution. Since the

TABLE 1.-Estimated health effects of community air pollution in California. Range for estimates of the
persons likely to be affected in one year.
Los Angelesa

Effects

I
II
III
IV
V
VI
VII

Population
Excess Mortality
Aggravation of Disease
Causation of Chronic Disease
Inpairnent of Function
Sensory Irritation
Storage of Potentially Harmful Pollutants
Interference with Well-Being

9,500,000
100-500
50,000-500,000
50-5,000
100,000-2,500,000
9,000,000
2,500,000
9,300,000

San FrancisCob

3,800,000
0
50-10,000
0-30
1,000-25,000
250,000
100-1,000
2,000,000

San Diego

1,300,000
0
10-250
0-15
250-5,000
150,000
50

500,000

Remainder
ot State
5,600,000
0
25-750
0-100

200-3,500
100,000
125

300,000

alncludes Orange, San Bernardino and Riverside Counties.

blncludes Alameda, Contra Costa, Santa Clara, and San Mateo Counties.

public policies for reducing photochemical pollution are mostly directed at the motor vehicle,
the physician has a responsibility for encouraging reduction in motor vehicle usage during periods when pollution is likely to be high and for
finding adequate replacements for the internal
combustion engine for mass transportation in
California metropolitan areas. This latter is clearly the only long-term way in which this problem
will be adequately solved.

Discussion
For most of their history, the health professions have been devoted to providing protection
and treating illnesses due to trauma, infectious
agents or natural environmental exposures.
Now man is capable of producing exposures
by his technology, which are affecting not only
the workmen, but the community's citizens, including the aged and infirm, infants and persons
recovering from surgery or anesthesia. Once
again the physician is called on to not only protect his patient but to protect his community,
this time from man-made airborne disease. The
physicians in California and the West must play
a critical role in controlling emissions from motor
vehicle exhausts which are now producing a new
form of airborne disease. The magnitude of the
problem is shown in Table 1, which lists the
major types of effects of community air pollution
in California in approximate order of decreasing seriousness. While the numbers of people
likely to be affected are not well established,
improved estimates are possible with additional
studies. Only items V (sensory irritation) and
VII, (interference with well-being) are commonly recognized by the public as being related

to air pollution. Even though disease-causing

effects of air pollution are certain to be present,
their effect on a given individual may depend
also on inherited sensitivity, other pollutants,
occupational exposures and smoking. Thus air
pollution as a factor in clinical disease tends to
be overlooked by the clinician.
Certain localized forms of community air pollution may be present outside of urban areas,
and this accounts for the disproportionately high
estimates in Table 1 for Column 4 "Remainder
of the State." Exposure to aerial application of
pesticides, to pulp and paper plant, cement plant,
and fertilizer plant effluents are among the examples. Line VI "Storage of Potentially Harmful
Pollutants" represents a new concept. There is
good evidence that lead is being stored in excess
in Los Angeles, which accounts for the large
number of affected people. Possibly the same
thing occurs elsewhere in the State, but it has
not been as well studied. Carbon monoxide is
stored more briefly with a half-time of a few
hours and is not included in the totals in the
table since it also affects oxygen transport functions. Beryllium, other metals, and possibly
chlorinated hydrocarbons, are thought to account
for a few individuals in this category. The estimates in Table 1 are very rough and preliminary.
Control of photochemical pollution can be considered a test case for the adequate management of environmental hazards which are affecting man's health and will affect it in the future.
Just as physicians have led in the fight for safe
community water supplies, for food sanitation,
for the adequate labelling and evaluation of
drugs and for occupational health services, so
now they must take their place in the fight to
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19

prevent the spread of a new class of airborne

diseases,-those diseases produced by automotive
technology interacting with the -meteorology
which once led the American Southwest to be
considered a highly attractive place, eVen for
people with chronic respiratory conditions.
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1. Goldsmith JR: Los Angeles smog. Science J (Lond) 5: 44-49,
1969
2. Cohen SI, Deane M, Goldsmith JR: Carbon monoxide and survival from myocardial infarction. Arch Environ Health 19: 510-517,
1969
3. Buell P, Dunn JD, Breslow L: Cancer of the lung and Los Angeles-type air pollution. Cancer 20: 2139, 1967
4. Schoettlin C, Landau, E: Air pollution and asthmatic attacks in
the Los Angeles area. Public Health Rep 76: 545, 1961
5. Motley 14, Leftwich C, Smart R: Effects of polluted Los Angeles
air (smog) on lung volume measurements. JAMA 171: 1469-1477,
1959

6. Remmers JE, Balchum OJ: Effects of Los Angeles urban air pollution upon respiratory function of emphysematous patients. USPHS
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NOVEMBER 1970 * 1 13 * 5

7. Ury H, Hexter AC: Relating photochemical pollution to, human

physiological reactions under controlled conditions. Arch Environ
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