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Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
Erika: [00:00:00] 1. Welcome to the ATS Breathe Easy podcast. I'm your host, Dr. Erica Moison, a pulmonary critical care medicine doctor in Portland, Oregon, and host of the Air Health R Health podcast. I'm here today with Dr. Anthony Gerber. Dr. Gerber, why don't you introduce yourself?
Anthony: Thank you, Erica. I'm Dr. Anthony Gerber. I'm the chief of pulmonary critical care and sleep medicine at the University of Kentucky.
Erika: And we are here today to talk about recent changes made by the Environmental Protection Agency of the United States in January of this year to how they value the dollar value of statistical life.
But before we get into that, why don't you tell us about your experience in air quality and balancing risks and trade-offs for improving air quality versus the cost of implementation.
Anthony: Yeah, so before I took the job at the University of Kentucky, I was on the Colorado Air Quality Control Commission for 12 years and was on the faculty at National Jewish Health in Denver.
[00:01:00] Local air commissions implement a lot of EPA related rules to improve ozone or other kinds of air quality. And those rulemaking hearings have a lot of back and forth between industry, which is the regulated community, and then considering the health effects. And so when you promulgate air quality regulation, so suppose you're going to change the amount of.
Particulate or ozone precursor that a factory can emit. It's a simple example. You know, you have to put some cost constraints on it, right? You can't just say, let's put in a $10 billion filter containing precious metals, and that's gonna solve the whole problem. There has to be some cost balance, and so typically when you put in a regulation.
You have to do some kind of a cost analysis on the industry side for whether it's, it's reasonable to do the regulation. And then on the flip side, that cost is in some ways balanced a little bit [00:02:00] against what we believe are the savings so that the, the, the, the beneficial effect on not having people going to the emergency room for an asthma exacerbation from pollution.
And so that sort of cost benefit analysis, which is it's in Colorado and I assume in most states. It's actually acquired by statute. So you have to do an economic impact analysis again, to make sure that we're not putting regulations in place that, that are just totally unaffordable or on the flip side, have, have limited statistical benefit for the, for the impact public.
So that, that's kind of the background of experience with, with this space that I have.
Erika: Yeah. And so we're here to talk about something that's a little unusual, which is the value of a statistical life, which I think all of us think the lives of our loved ones are, you know, incalculably valuable. But the EPA has now set that essentially at zero.
So can you walk us through what the value of a statistical life actually means? And, you know, what is it, what is it not?
Anthony: Yeah. So that it, it's a complicated question as you said. [00:03:00] It, it, it's putting a monetary value on something that really you, you can't value. But, but it is something that is, that's, there's, there's a lot of literature on it for, for for many areas, not just for mere quality.
And, and so let me give you a simple example about how to think about this. And so, and I'm gonna give you an analogy, which I hope, I hope simplifies a complicated process. So suppose you run a small tour agency in Alaska and you have a limitless number of customers. They all want to come to Alaska and do this tour, but your problem is you can't find anyone to lead the tours 'cause people don't want to move to Alaska.
So you've got 10 tour guides and that, and you need a tour guide for each tour. And suppose one of those tour guides dies. Now you've only got nine tour guides and you cannot replace. That tour guide, so you lose 10% of your business. That is a [00:04:00] cost from that loss of life, and it's kind of looking at a very closed economic system.
If you take that concept and move it towards the local, regional, global economy, you can roughly figure out what the productivity impact or how much value. A person is going to add to the economy over the course of their life. Now it's, it's complicated, right? Because someone who's. 62 and and is close to retiring and might work a really physically demanding job.
They may have a different amount of lifes of kind of working lifespan left than someone who writes books or does something. So there's a lot of nuance to it. But the fundamental idea is that if someone's life is cut short, there was economic value that they were gonna add through the lifespan that was lost.
And you can do a lot of fancy analysis. And, and come up with a number a, a value number for that, for those years that are lost.
Erika: And it sounds like this doesn't [00:05:00] just touch on the value of life, but that the EPA is also considering not including the healthcare costs of air pollution with which I think the a TS community is a lot more familiar.
Is that accurate?
Anthony: Yeah, so, so the way I, and, and I'm, I'm certainly not an environmental attorney, but the way I read the, what they were doing with this rule is that they were, they were acknowledging that health effects are important, right? And that is, that's the basis of the Clean Air Act, right? We, we regulate things because they are harmful to people.
So they weren't getting around the idea that this was an, that, that hurting people's health is important. What they were moving away from was trying to assign. A monetary value to it. And the way I think about monetary value is there's the statistical cost that we just described of, of losing a life, but there's the, the easier maybe to understand cost of, you know, on a really polluted day, if in a, again, I like to use numbers, if you've got a town of a [00:06:00] thousand people and on a really commuted, polluted day.
Three extra people go to the emergency room and that costs $10,000. You can really, very easily calculate those costs of, of, of, of urgent healthcare, hospitalizations, more medications, people missing, school and work. And so that's the other part of the cost that you can, through big epidemiology studies, you can stu, you can figure out.
Yeah, roughly how many people are gonna wind up in the emergency room per certain amount of pollution. And then you can, again, balance that if you are having regulation which cuts down the pollution, you can kind of come up with a, a value of, of, of what society's gaining at, you know, at the expense of, of, of the industry who's regulating the pollution.
So that's sort of the fundamental way that we come up with this is a reasonable regulation versus this one. It's just way out of proportion in terms of cost to the benefit. And so my [00:07:00] reading was that they were doing both things, that they were reducing the economic value of human life, and also not accounting for any of those other costs, which are maybe a little bit easier to understand like, Hey, I went through my inhaler early, so I had to pay a hundred bucks to extra in a copay.
So that that kind of value as well.
Erika: Yeah, a hundred bucks if you're lucky. I'm at the time of year where all my patients are messaging me about their $400 inhalers right now.
Anthony: Yeah.
Erika: My understanding is that the EPA has used this metric since the Clean Air Act was signed in back in 1970, you know, through both Republican and Democratic administrations and over and over again we see that cleaning up the air really pays off.
You know I think other analyses have shown every dollar spent reducing fine particular. Matter, we get like $77 in health benefits. So what does it mean if we remove the math from that equation, and how does that impact our understanding of pollution benefits?
Anthony: Yeah. So let me. Kind of back up and also sort of think about this from the industry [00:08:00] side.
I, I think that we, I, I really wanna focus on the impacted community as well, but I think it's important to try to understand sort of why, why we want to balance between the costs and benefits and why and why maybe there can be some frustration around, around the other end about how we calculate the cost industry.
And so and let me use an example again. So suppose you've got a. Concrete factory. And, you know, concrete factories actually have special protection because they're regarded as critically important local industries. You can't like, you know, import concrete from, from China in a big truck, big tanker. So but just suppose that you, that you regulate the pollutants from a from a concrete factory to the extent.
That they can't sell their product and they go outta business like they've gotten, or, or, or even that they've doubled the cost of concrete. So what you could argue is, okay, we're encapsulating putting in that filter and that system cost that [00:09:00] industry. You know, a million dollars, but it drove up the cost of concrete to the point where some builder, you know, where homeowners couldn't buy their homes locally because it costs so much more to put in the foundation.
So there is that potential on the industry side. To miss costs and just like on the, on the person side, on the health side, it's complicated to calculate those costs. I think that there can be a sense that that maybe we also do a bad job of really figuring out how much this might cost the community in terms of, now your concrete is more expensive, your road repairs are delayed, and so now you get more damage to your cars from going through pots.
There's all these cascading effects, which are also hard to capture, but nevertheless. The way the statute has worked is to do the best we can. So there's a number on the regulation side, there's a number on the benefit side, and we want those ratios to be somewhat [00:10:00] reasonable. And again, I'm not gonna claim to be an expert on what.
How, what math they use to make the regulation seem, seem reasonable. Obviously, they don't wanna put a regulation in place that is going to kill the industry unless it's emitting, you know, if it's asbestos, we kill the industry. Right? So, so, so there's a lot of, a lot of nuance to it, but that, but the fundamental idea is that if you can't have some idea of the savings.
On the health side, it opens up the, the ability for industry to say this is just too expensive. There, there's no counterbalance to the costs that industry is bearing and, and, and the costs that then, you know, downstream cost to society. You sort of have those unbalanced and, and my fear, I don't have proof of it.
Is that if you don't have that counterweight, it, it just opens up a dialogue of this is really expensive, it's gonna cost jobs, we can't do it. And so that's my concern is that if you don't balance the, the benefit, the, the, the, the, the savings to the, to the [00:11:00] cost, then you, you, you, it opens up the door to maybe not put those regulations in place because they just seem expensive.
Erika: Yeah, and correct me if I'm wrong, but it seems like they're now only tallying cost to industry and not attempting a tally of health benefits or lives saved, which seems like it's going to skew everything. Is that framing correct?
Anthony: Yeah, that that is exactly the concern. If you're calculating the cost to industry.
And it just seems expensive, you know? Oh, these regulators are killing our industry. They're, it's gonna drive up costs of everything. And like I said, there can be a cascading effect, right? If you regulate a refinery. You know, refineries for, you know, again, I dunno if you've ever seen a refinery, refinery, they're, they're really, they kind of look like something from the Lorax.
They're just incredibly pipe like, and they, they really look and they put out a lot of pollutants and they can, but they're local, right? We're [00:12:00] not pumping in you know, refine gas to local communities. You refine it on site and then move it. So if you put in regulations that make that refinery. Just too expensive to run.
You might get a local increase in gas, then all those other health, all those other economic effects. So if you don't weigh that against what you're saving, you know, boy, we, we cut down a thousand er, ver, you know, visits and lots and lots of, deaths. You know, there's just no way to counterweight it.
And so, so the worry is that you skew it.
Erika: Yeah. And you know, you and I both sit on the Environmental Health Policy Committee of the American Thoracic Society, and this announcement is specifically applying this new value of zero to two components of the air quality index, which I imagine most lung doctors are familiar with, which include fine particulate matter in ozone.
And so just to kind of get a sense in our world of how many premature American deaths do these cause each year, and if we're kind [00:13:00] of doing this new cost benefit ratio, what impact would that have?
Anthony: Yeah. So let's start with particulate matter and there's a range of estimates of mortality. And, and the way more, the way they do it is usually by, by sort of bidding the amount of increase to a certain number of deaths. And right now we believe that partic matter in aggregate.
Causes a hundred to 300,000 premature deaths in the us and that's from heart attacks, strokes, lung disease, exacerbations. Now not all areas are gonna be affected the same way. Right. There's, you know, some areas have worth worse, particulate matter pollution. Some have better, some particulate matter can be addressed with regulation.
Others like wildfires, we, we can't address. But that's sort of your, your, your ballpark number. And I wanna be clear that, You know, we can't get rid of particulate matter pollution. What we can do is put in certain regulations that will reduce the burden. And there is pretty good evidence that if you reduce the burden by a certain [00:14:00] amount, you're gonna reduce that death burden.
And then if you take the, the death burden and sort of extrapolate it to all the other health effects, you can come up with these, these rough numbers. So and again, I'm, I'm not a healthcare economist, but if you think about, say, a hundred to 200,000. Premature deaths, and you know, those are probably not happening to your healthy 18 year olds.
They are happening to people who are more prone to having underlying disease. So their expected economic impact over their life is going to be. Less, right? But suppose the mean age of someone who experiences that excess mortality is 55 or 58 or 60. You've got 10 to 15 years of additional productivity.
And it can even extend, I mean, the sophisticated model, maybe you're gonna be that, that grandparent who helps out with your, with your children's kids so they don't have to go to daycare. And there's, there's a lot of cascading effects. And [00:15:00] so again, if you don't take that number. And create a value for it.
Then what's the incentive for you know, for example, to reduce diesel pollution from trucks? Right? That's a major reducible form of particulate matter pollution. It impacts people who live along all of our roadways. It causes excess deaths, heart attacks, strokes, all sorts of morbidity and mortality, and it costs industry money.
To fix those trucks. You know, putting in electric trucks is expensive. It requires charging infrastructure. Even putting in the best and the most state of the art. Diesel technology costs real money. It makes it more expensive for those for the trucking companies. It makes goods more expensive. There's a real cost to it.
But there's also a real benefit, and I think particulate matter is a really good one to look at because we know it causes a lot of excess mortality. So we can sort of metric, this would be the expected amount of [00:16:00] overall reduction in particulate matter pollution with cleaning up our diesel free fleet.
And that would therefore. Equate to this many lives saved and that much value from, from not losing those lives. Again, purely monetary, not not emotional, and then the cascading effect of reduced healthcare visits, reduced healthcare utilization. So that's, again, that's the importance of that, of that balance.
And these are big numbers, this isn. Five deaths. This is hundreds of thousands of deaths from these pollutants.
Erika: Yeah. And deaths are the sharp edge. Right. So along the way before that 55-year-old with some comorbidities dies, they've probably had some asthma exacerbation, COPD exacerbations, all from, you know, potentially diseases caused or worsened by particulate matter along the way.
Anthony: Yeah, and I think that that's a really good point, and I think that that. Again, I, I, I don't wanna discount that these are real costs for industry and, and I think it is important even as we're [00:17:00] advocating for public health to, to realize that. We all benefit from industry, right? We all benefit from all that stuff that gets trucked in with dirty trucks.
Most of us don't boycott the economy at large, which is dependent on these things. But at the same time, for example, if you grow up near a highway. 10% of kids who grow up in the dirtiest areas near the dirtiest highways, they have lifelong reduced lung function. There's really, if, if you get, if you do the studies and you're at that higher quartile of pollution, and these studies have been done in the Los Angeles basin area.
These kids didn't achieve their normal lung function. We can't really put a value on that. But you can imagine maybe those people can't do as physically demanding jobs. So there's effects on monetary effects of, of that pollution that we don't even account for in our models. So just like, I think there are those concerns with industries.
You [00:18:00] said the deaths are sort of the sharp edge. You can kind of put a money value to that as you start to go into the cascading costs of ER visits and. You know, not going to work because you don't want to go outside that day because you know it's gonna, you know, cause a flare to your work. Or if you're an outdoor worker, you call in sick.
There's a lot of costs, real costs to human health that you, that you can and should put a monetary value on. And I'm not saying that the costs aren't real for industry. But the costs are also real monetary for health. In addition, obviously to the intangible benefit of, of having better health.
Erika: Absolutely. And from a fairness standpoint, often the populations living in the most polluted air are also the ones that are, you know, demanding the least from pollution. They're often, you know, economically disadvantaged and aren't particularly ordering a lot of things for delivery or traveling a lot, or generating a lot of pollution.
So it's also be, you know, behooves us to. Keep a fair lens on all this.
Anthony: [00:19:00] Yeah, I, I, that, that's a really good point. And again, they're, they're who is most impacted by pollution does not necessarily equate to their socioeconomics. And so, I mean, it can, I mean, in, in the Denver areas, some of the wealthiest areas have the worst ozone pollution, so they're pretty impacted.
But some of the least affluent areas also have the worst particulate matter pollution. And they may be. Lower consumers of the things which are causing that very pollution that is impacting them. So there's a little bit of a, of a, of a double whammy that's completely outside of the scope of most EPA related rulemaking, although there are efforts at the state level to account for that in some ways.
And I think one of the things I've wanted to communicate is that this is a complicated space economically. And so there's a lot of variables. The more of those we try to account for. You know, the more complicated it can get.
Erika: Yeah. But just 'cause something's complicated doesn't mean it's not worth the effort, you know?[00:20:00]
Anthony: Yeah. That, that, so that's, that is a great point. It, it doesn't mean that you shouldn't try and, and we accept uncertainty in a lot of things. Right. We, you know, we get in our car a lot of days and, you know, there's a risk of having a car accident. Right. We, we kind of bake that in and I think it's the easy way out is to say, this is too difficult, this is too complicated.
You can't possibly model it. There are complexities, and when you get to the biggest numbers, there's some uncertainty, but you can account for those as well. And that's one of the reasons why, for the cost effectiveness of regulation, you build in some uncertainty, right? And again, if it, if it looks like it's astronomically expensive for relatively minimal benefit.
You know, those regulations don't tend to make it into the rule book because because the regulators recognize that, that, that we need to do things that make sense both from the industry and the health. You want the biggest bang for your, for your buck. And this economics gives you a a way to, to, to put a metric on [00:21:00] that.
Erika: Absolutely.