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The noble Baroness said: My Lords, I am delighted to introduce this debate on the report from the Science and Technology Committee on air travel and health. As the one who had the privilege of chairing the sub-committee which undertook the inquiry, I am glad to be able to bring renewed attention to bear on an area of public health which we found to be woefully neglected.
On behalf of the whole sub-committee, I should also like to pay tribute to our specialist adviser, Dr Michael Davies, OBE. The range and depth of his knowledge were invaluable in helping the sub-committee to focus on the key issues. My particular thanks go to our Clerk, Mr Roger Morgan, who not only whipped in witnesses from across the globe, some of whom were initially reluctant to attend, but also helped the sub-committee to produce a concise report written in plain English so that it attracted the widest possible readership and response. I thank him for that.
I suspect that some people were rather surprised when we began this inquiry. They could not see that there would be sufficient substance in it. However, we shall explore today how wrong we discovered those doubters to be. Air travel is big business. Quite staggering numbers of people fly both for business and pleasure. At any one time, around half a million passengers are in the air somewhere in the world. Each year, airlines carry some 2 billion people, the equivalent of one-third of the world's population. The substantial growth of air travel over the past 50 years has been steady rather than explosive and, without anyone really noticing, things have changed out of all recognition.
People from almost any circumstances of life and almost any age may now find themselves travelling by air over very long distances, as did my brother, his wife and teenage boys as they travelled to Vienna for my son's marriage on Saturday. They then travelled back here and are due to return to Australia tomorrow.
No longer can there be an assumption that air passengers are necessarily fit or even in the prime of life. Alongside changes in the volume and nature of air travel, an awareness has developed of the effects of environmental factors on health. In initiating the inquiry, our aim was to see whether the design and use of aircraft had kept pace with the understanding of those environmental factors. To the extent that risks remained, were passengers able to take properly informed decisions about whether to fly in their particular circumstances? Furthermore, were they aware of how best to avoid any health problems when they did fly? It is understandable that at least some people, and probably many more who would not care to admit it, are still scared of flying. Their concerns are fed by occasional horror stories and we determined to take a careful look at the whole area to separate the fact from the fantasy.
The main themes of our report became the identification, management and communication of health risks in air travel. We were disappointed to find a great deal less than we had expected. This was not only in relation to the communication of risk to the travelling public, but the Government, the regulators and the industry could and should do much more in managing those risks--and, indeed, in identifying them for us in the first place.
I welcome the Government's generally positive tone about our report's recommendations in their recently published response, but I do not get any particular sense of urgency from the response, which passes a great deal to a proposed new standing inter-departmental aviation working group. I should be grateful if the noble Lord, Lord Burlison, will say in his reply when the group will begin business. How often will the group have regular meetings? What status and resources will it have? When will the travelling public begin to see some tangible results?
When we began the inquiry, the bulk of expressed concerns, in particular from the general public, related to the quality of air in the aircraft cabin. There are two main issues: does the air provided deal adequately with respiratory needs; and is it sufficiently free of contamination?
To use fuel efficiently, aircraft cruise at very high altitudes--typically between 30,000 and 40,000 feet, where the air is too thin and too cold to support human life. The ideal would be to pressurise the aircraft cabin so that sea-level pressures were maintained throughout the flight. However, structures strong enough to withstand such forces would be impracticably heavy.
The compromise is that pressure within the cabin is maintained at the pressure found at around 6,000 to 8,000 feet. Such conditions would be similar to those experienced during skiing or other mountain holidays. Particularly as passengers are generally at rest, we found suggestions that conditions are intrinsically harmful to be misconceived-- although we also noted
The biggest concern about gaseous contamination involved--I cannot say this word--triorthocresyl phosphate (TOCP). In concentrated form, this chemical is extremely toxic, but it is found in lubricants in very small concentrations. Even in the worse case scenario of all--an engine's oil being lost into the pressurised air directed into the cabin--we did not find that safety levels would be breached. Moreover, there is no possibility of even that level of contamination catching people unawares because the air would be thick with nauseating oily vapours.
Other contamination concerns related principally to the transmission of infection, particularly following the practice since the 1960s of re-circulating half of the cabin air. This efficiency measure obviously holds out the prospect of re-circulating germs that may be in the air. However, it has long been the practice to filter the air before re-circulation. The latest high-efficiency particulate air--or HEPA--filters are designed to be extremely good at this.
We found no reason to doubt the design claims for such filters, but we were, however, astonished to find that filtration was not required. We asked the Government and the regulators to make filtration to best HEPA standards mandatory in re-circulatory systems. The Government's response to this is disappointing. They accept that HEPA filtration is key, but then say only that the yet to be established aviation health working group,
A predominant theme among the complaints we received from the general public related to air quality in the aircraft cabin. People were concerned that it was stuffy and somehow bad, and in particular that they were more likely to catch infections. We found no evidence that air quality was bad; however, we were disappointed to find that airlines have no routine monitoring arrangements that would quell any continuing disquiet among the general public.
I am pleased to note the Government's acceptance that research into general air quality is a priority. I am pleased, too, that the Government accept our recommendation for action in the light of ASHRAE's present work to clarify and extend air quality standards. It is, however, disappointing that the Government continue to rely on a voluntary approach to the committee's recommendation for a complete ban on in-flight smoking.
On general ventilation matters, I am again pleased to note that the Government are acting on the committee's recommendation to resolve the present muddle over the JAA and FAA standards. I must, however, take issue with the Government's rejection of
Paragraph 18 of the Government's response states that the recommendation in 5.17 of the report is based on a misunderstanding. If so, it is a misunderstanding that is shared by the authoritative JAA witness from whom we took the evidence. I draw attention to his reply to Question 363, which appears on page 144 of the volume of evidence supporting the committee's report. Can the noble Lord, Lord Burlison, throw a little more light on this matter in his reply?
So far as concerns the transmission of infection, there are understandably no data on minor infections--I refer, for example, to coughs and colds. However, we found remarkably few documented cases of the transmission of major infections. If the systems can contain infections such as TB, it is not unlikely that they are effective also for minor infections.
We must not be complacent about disease transmission; however, a sense of proportion has to be maintained. It seems likely that the air quality in aircraft cabins is among the best that people will encounter. It is probably substantially better than the quality of air that people experience in crowded circumstances on their way to and from the airport. Indeed, the air quality in this Chamber is unlikely to be as good as that in an aircraft cabin.
Any problem is, of course, reduced if those who are likely to infect others are dissuaded from flying in the first place. I am pleased to note that the Department of Health will be considering how to broaden the dissemination of health advice for intending airline passengers.
Long before the publicity surrounding the sad death of Emma Kristofferson last September from the consequences of a deep vein thrombosis (DVT) following a flight from Australia, we were clear that the risk of DVT was the principal issue arising from the inquiry. I should emphasise that in general the risk is only a small one. This is no occasion for some of the more alarmist commentaries. But the risk is real and serious, particularly for certain categories of people. Moreover, it is not difficult to deal with.
There has been much debate about whether specific aspects of the aircraft cabin environment, such as lower oxygen levels or reduced pressure, might have some bearing on DVT risk. We found insufficient evidence to form a judgment about that. Indeed, we were astonished to find that so little work has been done on what are, for some people, life and death questions.
Putting any additional risk from the aircraft cabin environment to one side, there is no doubt about the risk associated with prolonged immobility. This has been known since the 1940s, when Professor Keith Simpson found a surprising increase in DVT-related deaths in those who had sat in deckchairs overnight while sheltering from air raids. It is clear that the circumstances in which people might sit immobile for long periods occur commonly in air travel. That
I am pleased to note that the Government accept our recommendation about the need for urgent research to answer the important questions about the incidence of travel-related DVT. Pending the eagerly-awaited outcomes, our report assembled--as far as were aware, for the first time--the existing medical knowledge about the risk factors for DVT, together with advice on suitable precautions for individuals in various risk categories. We recommended that these be used to provide the guidance that intending passengers need.
Strongly associated with DVT risks is the question of seat size. We were amazed to find that minimum seat space is regulated only from a safety point of view. The minimum standard is set to allow an aircraft to be evacuated in 90 seconds. No account is taken of the health or the comfort of the passengers in the aircraft. During the course of our inquiry research was being undertaken to review the changed size and shape of the average passenger to ensure that minimum standards remain adequate. I am glad to note the Government's acceptance of our recommendation of the urgent need to capitalise on this research to devise a set of unambiguous definitions for seat space.
Point 13 of the response also endorses our recommendation against the use of the seriously misleading phrase, "economy class syndrome". Although seating is less spacious in economy class, sitting immobile in a business or first-class seat can equally lead to DVT. In any case, the risk does not come from immobility alone. Individuals can do a great deal to alleviate their risk by avoiding alcohol and caffeine, both of which encourage dehydration. They can also drink more water than usual and flex their leg muscles from time to time.
My final comments relate to the treatment of airline passengers. These are the customers on whom the airlines depend, although that reliance is not always evident from the treatment that passengers receive. I am glad to say that our inquiry dented the apparent complacency among the Government, the regulators and the industry about air travel health issues. I look forward to real advances in the information made available not only at check-in and around the time of take off, but also at the time of ticket purchase. That early information is vital so that, as necessary, timely medical advice can be sought by those who should be concerned about their fitness to fly. I encourage the Government, and others, to attach a high priority to these points--in particular, to the development of effective means of both encouraging intending passengers to consider whether they are fit to fly and of meeting the demand placed upon them.
The committee was obviously delighted by the extensive coverage received by our report on its publication. However, the topic deserves more than a day's good headlines. These matters impinge on the lives of millions of people every day in this country, and elsewhere. I look forward to listening to the contributions from other noble Lords today and, indeed, to the Minister's response. I beg to move.
Lord Clinton-Davis: My Lords, I congratulate the noble Baroness and also the committee on their work. I congratulate the noble Baroness, even if she was occasionally caught out by some of the abbreviations that were used!
Over the past year I have suffered a stroke. I hope that the House will be sympathetic towards me on that score. First, I declare an interest as president of the British Airline Pilots Association (BALPA). I only wish that I could speak with the same fluent expertise with which that body addressed the sub-committee, albeit in writing.
I have not had an adequate opportunity to consider the views of the Government which were communicated to the House of Lords late in the day. Most of my comments are sympathetic to the committee's views. However, I resent and rebut the criticisms of airline trade unions which have been recorded by the Select Committee and also by the Government at paragraph 4 of their response. It is for regulators and airlines, of course, to make their own reply to the points which have been made. However, as far as BALPA is concerned, the criticisms are not worthy of the committee.
Let me say at the outset two things. First, BALPA was requested to keep its submission short. Accordingly, it omitted certain points which it considered important but which had been dealt with elsewhere. For example, it is misleading to suggest a lack of attention on the part of airline trade unions to the health of aircrews. That is a principal raison d'etre of the trade unions concerned. Indeed, it is one of the principal matters which BALPA, and I as its president, have to contribute to the safety of air passengers. I think that the airline trade unions, and my own union
It is not the role of the CAA--even if it is provided with additional funding--to do that. It is for employers to take all necessary steps to ensure a healthy working environment. The CAA should be responsible for staff on the flight deck and the Health and Safety Executive should be responsible for passengers beyond the flight deck. That view has always been taken by the union which I represent.
Airlines do a certain amount to alert the travelling public to some of the risks that they take. But they do not do enough to alert the public to all the inflight health risks, perhaps for obvious reasons. It appears that, so far as can be ascertained, the numbers affected are very small. Nevertheless, I might stress that the research is ongoing. It is only recently that those associated with the industry have become more aware of what is at stake. More should now be done in the way of prevention, in particular as regards long-haul flying. For example, passengers could be advised to drink large quantities of water and to monitor their blood pressure prior to flying. There could be provision of inflight exercise programmes which, notwithstanding the comments that have been made, are, I think, very important. Many of the major airlines currently do so.
The report also raised several other issues. Air crews deserve similar protection to that received by the rest of the working population from the regulations on noise at work. I may have missed it, but the Select Committee ought to have referred to that.
The committee referred to in-flight medical emergencies. Every long-haul passenger aircraft should be required to ensure that medical emergency kits such as defibrillators are readily available. Air-to-ground access to professional medical advice should also be available.
The committee recommended that aircraft should be fitted with ozone converters. That would minimise the health problems associated with ozone plume. BALPA has also recommended that the Meteorological Office should look into providing ozone plume forecasts in advance so that the phenomenon can be avoided altogether.
I have spoken for long enough. BALPA always has looked, and in the future always will look, to whatever opportunity is available to enhance the safety of the travelling passenger and the air crew. It has no greater duty than that.
Lord Colwyn: My Lords, I, too, congratulate the committee on its interesting and stimulating report, and I thank my noble friend Lady Wilcox for the way in which she opened the debate this afternoon. I picked up my copy of the government response to the report as I entered the Chamber and admit that, as yet, I have not had a chance to read it.
I have no particular qualifications for contributing to the debate, other than an interest in health and the way that it can be maintained naturally. I also have some experience of helping during three or four in-flight emergencies over the past 20 years.
The last of those occurred approximately a year ago on a flight with the Emirates airline, when I helped to dispense glycogen to a passenger who had lapsed into hypoglycaemic coma owing to a very delayed take-off and, I assume, a long delay in the provision of suitable refreshment. That must be a fairly common problem for diabetics. In this case, the airline should be congratulated on the high standard of its emergency medical kit. I hope that the committee's recommendation to,
I am sure that the airlines are aware of the existence of new medical technology, especially tele-medicine links, which can make the management of emergencies much easier. Communication with experts should be possible within minutes. People like me are often quite capable of carrying out instructions in an emergency but do not always have sufficient experience to make medical decisions in life-threatening circumstances, other than those which might be expected during a normal working day. In the emergency which I have described, I remember discussing with a young doctor whether the drug should be administered intramuscularly or intravenously.
The committee has not shown much concern for the problems of cabin relative humidity. I should have thought that in-flight dehydration would be one of the most serious hazards of long-haul flight. Many passengers fly infrequently, and the tendency to drink alcoholic or caffeinated beverages before or during a flight, resulting in an abnormal production of urine, can lead to central dehydration.
A recent survey by Boeing showed that relative humidity can fall to between 5 and 10 per cent. As recommended levels for comfort in buildings are between 30 and 70 per cent, that represents a dramatic reduction. However, the committee received evidence that low humidity is beneficial for the aircraft structure and equipment in that it reduces moisture and condensation, thus limiting corrosion and opportunities for bacterial and fungal growth. However, I believe that passengers should be warned of possible problems and, as the noble Lord, Lord Clinton-Davis, said, actively encouraged to drink plenty of water.
Together with my noble friend Lady Wilcox, I was surprised not to find any reference to the health problems of cabin crew. It is not clear to me whether or not those crews gave evidence. During the speech of the noble Lord, Lord Clinton-Davis, my attention was drawn to paragraph 4, and I am delighted that, in their response, the Government were also surprised at the lack of attention to the health of air crew by regulators, airlines and air crew trade unions.
I expected to hear from those groups as I believed that the incidence of sickness among crew was relatively high throughout the world. Because of the nature of their work, flight attendants breathe significantly more oxygen than do passengers. They are also exposed to significantly more toxicity. Many airlines require random drug tests for crews and insist that cabin air is not a factor. Yet complaints from pilots are rare. But, of course, they are provided with separate, purer, oxygen-rich air in the flight deck. I am delighted that pilots are treated well, but low oxygen and low humidity strain the respiratory tract.
A recent series of tests which measured oxygen saturation of the blood showed that a progressive lowering of oxygen saturation levels occurs during long flights. I do not have the exact figures but I use similar measurements while working on some of my patients with sedative drugs and have learnt that a drop from 98 per cent saturation of oxygen to 92 per cent requires dramatic action. Pesticide residues and toxic chemical vapours that originate from hydraulic spills could well be involved. Vaporised hydraulic fluid is a known neurotoxin and it is possible that hazardous oil fumes may react with other chemicals to cause ill health.
My noble friend reminded us that there is no fresh air in aeroplanes. All air is processed through engines, where it can become laced with toxic chemicals. It is also likely that any chemical spills or leaks from the aircraft could be close to air intake doors. I am sorry that the report made no mention of the "sick aircraft" syndrome, which is widely known in the United States. Minor problems are fixed on a temporary basis and any fluids that have leaked during a flight are routinely topped up and the aeroplane is kept in the air. Sadly, it is more important to maintain departure times than to deal permanently with such defects when they are discovered.
Health problems related to toxic chemical poisoning are often delayed and time released. Low-level exposure results in burning eyes, nausea, headache, fatigue and flu-like symptoms. How many passengers do noble Lords know who say that they always contract flu or respiratory problems after long flights?
Finally, I turn to deep vein thrombosis. There is a mass of evidence to show that it is a problem, and that it is brought on by many factors, including dehydration, toxicity and the lack of exercise. The noble Lord, Lord Graham of Edmonton, will later tell us of his experiences. Perhaps he is lucky to be here this afternoon.
Lord Graham of Edmonton: My Lords, I join other noble Lords in expressing appreciation to the noble Baroness, Lady Wilcox, for the excellent way in which she summarised a year of very hard work. When I was privileged to attend her committee, I was enormously impressed by the width of experience that was available--it helped her to compile the report. Time and again, it is clear that Members of the House comprise men and women who have been, and often still are, heavily engaged at the chalk face and who deal with major problems. I pay tribute to the noble Baroness.
All that I had hoped the committee would achieve is contained in the report. I am a layman in this regard. As the noble Lord, Lord Colwyn, pointed out, perhaps I am lucky to be here. My luck depended on the service provided by Whipps Cross hospital, which is not unknown to the noble Lord, Lord Jenkin. He had the privilege of being the chairman of the relevant trust for some time and he knows about the quality of the work carried out at the hospital. When I developed difficulties, my local GP immediately sent me there, and I was treated.
I congratulate the committee on the range of matters that are covered--I had not appreciated how many were involved. I was affected because I had deep vein thrombosis. I ask the House to bear with me later when I explain the experiences of many people. My attention was drawn to them through the ongoing study.
I felt--I was going to say a real clot, but I shall change the word--a real ninny when it happened to me. I spoke to so many people, one of the whom was the noble Lord, Lord Colwyn, who pointed out that
I am delighted to see the recent initiative of British Airways in recommending to passengers what they should avoid doing if they are travelling long-distance. I am not gunning for the airlines or anybody else, because that is an exercise in futility. As the noble Baroness said, we have had 40 or 50 years of warnings in relation to these matters. Now we have a catalyst, and that catalyst is the noble Baroness's report. The phrase that comes to my mind is that things will never be the same again. Its impact has been to make people sensitive to the issues. The general public realise that they have responsibilities in this regard, as well as the airlines. But above all, the Government have a responsibility. The Government, the committees and the inter-departmental committees must all be seen to be working and effective. I do not believe that Ministers will now be able to say to me, as they did three years ago when I first raised the issue, "There is little evidence of this."
The evidence of Dr Edgerton comes straight to my mind. There was no facility at Heathrow to deal immediately with his wife who had suffered a DVT. He was told that there was a hospital at Ashford 30 minutes away, which deals very efficiently with such problems. That is no good a 30-minute journey away. Such a facility needs to be at Heathrow. I raised that matter with my noble friend Lord Whitty who told me that an investigation had taken place. There is now an alertness, which did not exist before, as to ways in which we can avoid those dangers.
I simply want to draw to the attention of the House one or two matters which have come to my notice. I hold up this simple cushion which is like a honeycomb. The company which makes them is called Roho International and is located in Belleville, Illinois. The cushion is designed to spread the load and to spread the weight, which in my case is considerable. It is an aid. I do not know whether it is therapeutic or whether it will be really effective. But that is something that has been drawn to my attention.
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