Health professionals have an urgent window of opportunity to engage in tackling air pollution and inequality through supporting a radical reallocation of urban street space for walking and cycling. The public wants it and public health demands it, say Deepa Shah and Robert Hughes

The myth of covid-19 as a great leveller is, or at least should be, dead. We know beyond reasonable doubt that covid-19 has harmed people on low incomes more than the wealthy, that it is more likely to kill people of colour than those who are white, and that your occupation matters—not just for healthcare workers, but also for other “frontline” professions like transport workers. We can either ignore this, or we can try to tackle it and the root causes. 

Assuming we choose the latter, one place and mechanism where we can start is the cities where many of us live, and the toxic air we breathe. That air pollution disproportionately affects people on low incomes and from minority ethnic backgrounds is well documented, contributing to comorbidities which underlie some of the increased risk of severe covid-19. Worryingly, emerging evidence also seems to suggest that there may be an association between exposure to air pollution and covid-19 outcomes. 

Among all the suffering we’ve seen due to covid-19, one positive has been the chance to breathe cleaner air and the opportunity to enjoy spaces that were so dominated by motor traffic before the pandemic that we’d almost given up on them. Green spaces have been full. Children have been playing on the streets. The reduction in traffic associated with lockdown has given many of us the confidence to cycle and to encourage our patients to do the same. The cleaner air has probably also helped to modestly, but usefully, reduce the levels of acute coronary and respiratory admissions at a time of unprecedented pressure on health systems. But lockdown clearly can’t, and shouldn’t, go on forever, especially in its most strict form. So what next? 

It is increasingly clear that we must decide between two potential urban air pollution (and health) futures. The dystopian one involves people who can afford to climbing into their cars in increasing numbers, and the rest of us, including those who can’t or don’t want to drive, breathing dirtier air. We all suffer from having streets that are choked by cars: road traffic injuries increase and population health suffers. We don’t need to imagine this—pollution and traffic data from China post-lockdown illustrate it all too clearly. 

Alternatively, one positive legacy of covid-19 can be a radical rethinking of how we get around cities and how we use our limited—but never more valuable—urban street space. We can build a “new normal” that is healthier and more equitable through quick, cheap, and effective interventions, like modal filters (to exterminate rat runs), school streets (to encourage safe walking and cycling to school), pop-up protected cycle lanes, and changing pedestrian crossings to prioritise people on foot. We don’t need to look far to see what this can look like; the way that the Dutch design and use their cities shows that all objections to creating liveable streets can be overcome. Those who cannot cycle benefit too when cars are not the default. 

Having breathed cleaner air during lockdown, and experienced the joys of quieter streets, it is unsurprising that people want to breathe clean air like never before. The Clean Air Fund has just released a report with polling from five countries (India, Poland, Nigeria, Great Britain, and Bulgaria), which shows strong demand for action on air pollution after this pandemic. Seventy one per cent of Brits are worried about air pollution as a public health issue, and 67% support stricter air pollution laws and/or their enforcement. In Nigeria 92% of the people polled worry about air pollution and 94% support stronger air pollution laws. In short, people don’t want to go back to the bad old days of air pollution making us all sick. 

Nevertheless, it remains to be seen whether governments—at both national and local levels—will listen to their people and public health and climate science advice, or short sighted lobbying from polluting industries. Will we see the radical change that can enable people friendly cities, or short term tokenism? The history of how the Dutch challenged urban car dominance several decades ago, and success stories from closer to home show that public health evidence and public support alone are not enough; ambitious political leadership is crucial. Here are some ways that you can play your part in enabling it. 

Firstly, change your practice: Are you talking about air pollution enough? Do you ask pregnant women, parents of children with asthma, and patients with COPD and bronchiectasis if they live and walk on busy roads? Being aware of the risk to their health that this brings, and offering advice about taking alternative quieter side streets can help. Of course, these interventions in the GP surgery, clinic, or emergency department offer only partial solutions here, but sensitively telling our patients the truth about these risks can only amplify demand for cleaner air and liveable cities. 

But don’t stop there; more radical change is needed, and you can play a part here too. This is the time to lend your voice; never has it been more valued or trusted. Health professionals vocally and effectively making the case for a rethinking of our cities—pointing out how it can make them healthier and more equitable—can be a game changer. 

Specifically, why not:

• Help to enable both staff and patients to get to your clinics or hospital safely through writing to your local council (ideally through your trust CEO or CCG lead) to encourage them to urgently implement emergency active transport plans (see the Key Workers need Streetspace campaign). 
• Support local campaigns for school streets schemes, which enable children to walk or cycle to school and play outdoors safely.
• Work with and through your networks such as the royal colleges and LMAs to lobby for change locally and nationally; you are more influential than you may think. 
• Join the Doctors Against Diesel campaign.

Robert Hughes is a senior fellow in child health and development at the Clean Air Fund. He is also a clinical research fellow at the London School of Hygiene & Tropical Medicine.

Deepa Shah is a GP in Hackney and clinical lecturer in community medical education at Queen Mary University of London.

Competing interests: RH is a senior fellow at the Clean Air Fund (a UK registered charity working to address air pollution globally). RH was also involved in setting up Key Workers need Streetspace.