CHAPTER 8: WIDER ISSUES
8.1 In this Chapter, we consider
some of the main non-medical matters arising from our Inquiry,
namely: the lack of direct high-level responsibility for aviation
health; some complacency over that unsatisfactory state of affairs;
the lack of directly relevant basic factual material and of accessible
health information; the poor awareness of fitness-to-fly issues;
and the airline industry's handling of the public.
8.2 From the earliest days
of civil aviation, safety was the main concern. When the international
nature of the developing airline industry was formally recognised
by the establishment of ICAO in the 1940s, the organisation's
fundamental purpose, as noted in paragraph 3.5, was set as ensuring
that the development of commercial aviation proceeded in a safe
and orderly manner.
8.3 The national bodies that
ought to have direct interests in passenger and crew health are
noted in paragraphs 3.18 to 3.21. We were
surprised that, although DoH accepted some responsibilities for
advising the medical profession and the public on aviation-related
(as other) health questions, it regarded DETR as in the lead on
aviation health (Q 509). While the DETR Minister accepted the
lead (QQ 509 & 555), the Department had exhibited a certain
lack of vigour. When our Inquiry began, for example, there was
no centrally commissioned research into the health effects of
air travel (QQ 12 & 13). By the time our evidence-taking was
drawing to a close, the gap was acknowledged by the Minister's
announcement of new research, explicitly prompted by the Inquiry
(Q 516), and discussed further in paragraphs 9.2ff.
8.4 CAA's responsibilities are focused on air safety.
Any involvement in passenger health or comfort arises only indirectly
as a consequence of safety, particularly in relation to emergency
evacuation from aircraft (p 1). CAA does not address long-term
health effects from flying (p 16) even in relation to flight crew
(p 1, Q 60).
8.5 HSE has general oversight of employees' health
and safety but, as noted in paragraph 3.21, commercial aircraft
are largely exempt from the provisions of UK health and safety
at work legislation. As regards the remaining relevant provisions,
HSE avoids overlapping responsibilities with CAA under a memorandum
of understanding, leaving the lead essentially with CAA.
8.6 On the international scene, JAA also stated that
their primary concern was with safety and that their position
on flight crew and passenger health was the same as CAA's (p 130).
However, JAA recognised that passenger health might become more
important in the future development of aviation. Indeed, they
have set up a working group to examine this - although, reflecting
JAA's general remit, the approach will continue to be strongly
linked to air safety (p 130).
8.7 The lead on aviation
health is, in our view, unacceptably weak. However, even in relation
to safety - the main purpose of present national and international
regulatory structures - the centre of gravity is not obvious.
A full range of safety rules and regulations is in place under
ICAO, but changing them seems remarkably difficult. Although ICAO
has the authority, the reality is that it is governed by its member
States. For things to progress in ICAO, members not only have
to promote them strongly from below, but they may also have to
deal laterally with regional organisations like JAA and the European
Union at the same time (QQ 3-6, 71 & 72). This is a recipe
for inaction: as an organisation, ICAO can wait for Member States'
initiatives; and member States can wait for ICAO's lead. JAA is
in a similar position (QQ 347 & 378). We recommend the
United Kingdom and other governments to do everything they can
to reduce inertia within the international safety-focused regulatory
8.8 DETR accepted that, over
the years, airline passenger health had generally been "grafted
on" to existing structures and ran the risk that they could
"slip between the cracks" or be subject to "regulatory
overlap". It was their view that primary responsibility for
ensuring an acceptable aircraft cabin environment lay with the
airline industry and that passengers themselves
had a responsibility to ensure that they were fit to fly (Q 2).
We agree with the latter point but, as discussed in paragraphs
8.29ff, we are clear that more needs to be done to enable passengers
to assess their fitness.
8.9 Safety is paramount in
the airline industry and nobody would wish it otherwise. Our concern
is not that health is secondary to safety but that it has been
woefully neglected. We welcome DETR's belated acceptance
that it has the lead within the United Kingdom, and we recommend
the Government to ensure that concern for passenger and crew health
becomes a firm priority.
8.10 It remains the case
that there is no international regulatory focus for monitoring
and developing practices and procedures on passenger and crew
health. We recommend the Government actively to pursue the
strong UK interest in passenger and crew health through its international
contacts with JAA, ICAO and other appropriate organisations, and
we urge them all actively to promote health. This will both
benefit air travellers in other countries and also help to minimise
the possible impact of greater attention to health on competition
within the international airline industry.
8.11 In the effective national (and international)
policy vacuum on passenger health and comfort noted above, aircraft
manufacturers and airlines have accepted responsibility. Both
directly and through airline representative bodies, they professed
high ideals (pp 99, 104, 107, 110, 224 & 229). We were surprised,
however, at the degree of complacency amongst them.
8.12 AUC and the airlines are understandably concerned
not to scare the travelling public (pp 57, 99 & 104). As British
Airways stated, "we want to be absolutely honest with the
customers and potential customers, but we do not want to frighten
them" (Q 323). But such honesty requires an acknowledgement
of risk and uncertainty where that exists. The representative
of ATA told us that, while USA-based airlines often had a small
general health brief in in-flight publications, it did not include
DVT - because they could "not say definitively that there
is a direct causal relationship between air travel and DVT and,
as such, we do not wish to frighten our passengers unnecessarily"
8.13 On behalf of British airlines, BATA did not
consider that there were any significant health issues about which
they should have serious concerns currently (p104); ATA (p 110)
had similar views. British Airways felt that much of the public
concern about health in the cabin environment was only anecdotal
The airline Emirates stated that there was no evidence to suggest
that the cabin environment was unhealthy or adversely affected
passengers or crew (p 229).
8.14 Among the manufacturers, Boeing felt the need
for more research into the possible causes of flight crew and
passenger symptoms and complaints (p 204). Airbus Industrie said
they were "ready to consider improvements to aircraft design
if there is a clear link with passenger or crew health" (p
8.15 We had expected AUC (set up by CAA to represent
the interests of air passengers to regulatory authorities and
service providers) to help get attention focused on these matters.
However, it had no human or material resources to commission research
and was essentially reactive, although its representatives said
they would lobby for regulatory change if they thought it was
necessary (p 57, QQ 157-169).
8.16 The charge made by Mr
Kahn (Q 94) that the industry was "in a state of denial"
about passenger health was considered as reasonably fair by the
Consumers' Association (Q 206) and not disputed by the AUC (Q
208). The charge is perhaps a harsh one, but the industry could
do more to avoid such charges. To all those with responsibilities
for passenger and crew health, we have to say that absence of
evidence of harm is not the same as evidence of the absence of
harm. Without succumbing to the impossible counsel of perfection
that everything should be demonstrated to be completely safe in
all possible circumstances, there is much scope not only for more
positive responses to health issues when they are raised, but
also for pro-activity in detecting, examining and dealing with
new and emerging concerns.
of basic factual material
8.17 As noted in paragraph
2.9, the starting point of our Inquiry was to be a review of current
knowledge about the health implications of the commercial aircraft
cabin environment and the extent to which this informed current
practice. While we acknowledged the possibility that there might
be some gaps in that knowledge, we were surprised to find that
there were so many. There are very few published or easily available
recorded data on the majority of questions in which we were interested.
In the absence of the facts, it is not surprising that there is
also a serious lack of knowledge about the relationships between
aircraft cabin environment factors and health, particularly in
relation to cabin occupants already in a poor state of health.
In the absence of accessible and authoritative information, it
is not surprising that rumour and speculation thrive.
OF THE FLYING PUBLIC
8.18 We were told many times
that, with the rapid development of commercial aviation in recent
years, the demographic spectrum of travellers has been widening
as air travel has become increasingly attractive and available
to the general public. While that coincides with common sense,
none of our witnesses provided detailed factual evidence to support
8.19 As noted in paragraph
3.51, CAA recently commissioned research to study the size and
shape of aircraft passengers to enable them to set appropriate
safety standards for emergency evacuations. What needs to be known
in terms of passenger health encompasses a much broader range
of issues. To enable proper judgements to be made about any potentially
adverse impact of cabin environment factors on travellers' health,
various facts about the flying public are required - as a minimum,
material on their age, sex, height, weight, social status and
general health status, in each case associated with the class
and duration of travel.
8.20 Such data are not available.
On our behalf, the Parliamentary Office of Science and Technology
conducted extensive searches for this sort of material and was
able to find only the limited material outlined in Box 1 (see
paragraph 2.3) covering a few general conclusions about trends
in UK-origin leisure and business travel.
OF AIR-TRAVELLERS' HEALTH
8.21 Epidemiology is the
study of the statistics of health and disease, in particular the
presence and incidence of ill health in a selected population,
and its relationship with factors of medical or environmental
significance. It can be a very powerful tool in understanding
complex interactions of factors. Whilst there have been some recent
small-scale studies on DVT in travellers (see paragraph 6.16),
the general epidemiology of ill health connected with flying is
non-existent. Moreover, that knowledge could not be established
quickly because, as noted in paragraph 7.73, a standardised basis
for reporting in-flight medical incidents is only just about to
be introduced, and there are no formal systems for detecting and
reporting post-flight ill health.
8.22 There have been some
studies on symptom or sickness reports from aircrew, usually in
response to complaints about the aircraft cabin environment (pp
204, 213 & 245), but self-reporting or anecdotal studies of
this type are of very limited scientific value and may indicate
only where more formal research is needed.
8.23 Professor Sir Colin
Berry, Professor Denison and Dr Murray all suggested that study
of aircrew medical records should provide valuable information
on any long-term effects on health from disinsection and other
potentially hazardous cabin factors (QQ 224 & 231-235). However,
we were surprised to find that systematic recording over time
of the health status of flight crew or cabin crew is not carried
out by licensing authorities or airlines (see paragraphs 3.44ff).
Thus, apart from mortality data on flight crew obtained by research
on company pension records,
there are no recorded data on crew health by which retrospective
epidemiological studies could be carried out. CAA has proposed
carrying out further studies on pilot licence medical records,
but these are currently in abeyance (p 39) and, in any case, may
not contain morbidity (illness) information useful for assessing
OF THE RELATIONSHIP BETWEEN CABIN FACTORS AND HEALTH
8.24 The design parameters
for the aircraft cabin environment have largely been set to maintain
efficient operational performance by flight crew, based on a wealth
of laboratory and field investigations (pp 86 & 251, Q 47).
As a result of the selection and accreditation process, flight
crew are people in robust health. However, some passengers will
be in less than full health, and there appears to be little or
no soundly-based knowledge about the potential for adverse impact
of cabin environment conditions on them, or on those who might
have personal risk factors which could render them vulnerable
to conditions in the aircraft cabin.
8.25 Additionally, much of the evidence given to
us about the health effects of flying is based either on anecdote,
which is scientifically unreliable, or on extrapolation from studies
carried out in ground environments, notably in relation to DVT
(see paragraphs 6.13-6.14) which is also scientifically unsound.
As discussed in previous Chapters, the cabin environment at cruising
altitude is very different from any ground environment, not only
in many individual respects but also, and particularly, in the
potential for interplay between those effects.
BASE FOR MEDICAL ADVICE TO FLYERS
8.26 The various deficiencies
noted in the preceding paragraphs severely limit the amount of
medical knowledge on which advice to intending passengers can
be based. For example, the AUC told us that they had agreed with
DETR to expand the currently brief section in their booklet Flight
Plan on general medical advice to intending passengers. They
said that one of the reasons why this had not already been done
was that they were not sure what to say in it. They noted significant
gaps in research that needed to be filled, particularly on DVT,
before they could advise people what they should do (Q 171). We
were also pleased to note that DoH planned to extend and improve
the guidance it provides to the public (in Health Advice for
Travellers), at least in relation to DVT (Q 544).
8.27 The absence of a broad and detailed knowledge
base means that neither the general public, nor their professional
health advisers, can easily obtain reliable high-quality information,
particularly about unusual sets of circumstances. The implications
of this for individuals' assessment of any potential health risks
from the aircraft cabin environment about which they may be concerned
are discussed further in the next section.
8.28 Given these gaps in the knowledge base, we were
pleased to hear about the DETR/DoH research proposal noted in
paragraph 8.3. Drawing on the points made throughout this Report,
our suggestions for the topics needing to be covered are summarised
in paragraph 9.3.
of accessible health information
FOR THE PUBLIC
8.29 The principal sources
of initial advice and guidance to members of the public on flying
and health are either official publications or articles in the
media. The two official publications are Health Advice for
Travellers (DoH) and Flight Plan (AUC).
However, unless these are provided with the tickets at the time
of booking, the public is unlikely to be aware of their existence.
In addition, the information contained in the editions current
during our Inquiry
was very general. Neither contained any information on health
related to the aircraft cabin environment itself, nor on additional
risks to those whose health was already poor.
8.30 Neither publication would be of any assistance
to someone not in robust health seeking information on which to
base a decision on whether to fly - or even whether they needed
to seek professional advice. The question is how people are to
judge this for themselves without carefully framed guidance -
such as the risk categories we have proposed in relation to DVT
(see paragraph 0).
8.31 AsMA drew our attention (p 198) to the leaflet
Useful Tips for Airline Travel that they publish with the
ATA. This usefully outlines the main features of the cabin environment
and contains helpful advice. While it does not refer to DVT explicitly,
it does encourage movement "to prevent leg compression and
blood pooling" and notes that "one good exercise is
to flex and extend the ankle joint every 20-30 minutes".
It advises intending passengers to delay their trip if they are
not well or have a contagious disease and to consult their physician
if they have a history of blood clotting disorders or have any
other questions about their fitness to fly.
8.32 Another source of information for passengers
is the airlines themselves. The material most obviously targeted
at passengers is in airlines' in-flight magazines (p 124), although
it is open to question how many passengers read the health-related
articles they may contain other than by chance. We noted that
the half-page guide to "good health for travellers"
in the May 2000 edition of British Airway's in-flight magazine
High Life was about three-quarters of the way through its
200 pages. The guide contained advice on exercise to avoid "blood
circulation from becoming sluggish, something which can happen
if you sit still for a long period, which might cause circulatory
problems for some people". However, all this was accompanied
by a stern warning that a doctor should be consulted before starting
the exercise programme and that, by participating in it, passengers
released the airline from any responsibility for any health consequences
that might arise as a result.
8.33 British Airways have recently introduced a pre-flight
travel guide, Fly, that is issued with their tickets (Q
319). While the Summer 2000 edition we saw made no reference to
in-flight health, British Airways confirmed during the evidence
session (Q 325) and in later correspondence that they planned
to include appropriate material within it, alongside the development
of health-related information on their web site.
We understand that other aviation organisations are also developing
the provision of flight health information over the Internet.
8.34 Airlines and their agents
are in the front line of selling tickets to passengers. In our
view, they could and should do a great deal more to inform their
passengers about air-travel health issues. We make more concrete
proposals in paragraphs 9.5ff.
8.35 An important source
of information for passengers is journalism. The challenge for
journalists in this area is to provide accurate information without
causing unnecessary concern,
particularly among those who have some fear of flying - who, as
Mr McKenzie Buchanan noted (Appendix 4), probably number many
more than those who openly admit it. This calls for careful judgement
about language and presentation. It cannot be right to side-step
potential health problems by knowingly underplaying the significance
of cabin factors for health. It is equally unacceptable to overplay
the health significance of such factors.
8.36 In our recent Report
Science and Society,
we commented extensively on the role of the press and other media
in informing and educating the public on scientific matters, and
of the need for them to act responsibly in presenting sometimes
complex questions of uncertainty and risk. All those points apply
in the handling of information about the health effects of flying,
and we again commend to journalists the guidance outlined in Chapter
7 of Science and Society.
8.37 It is entirely possible to deal with aviation
health in a balanced way that develops awareness, knowledge and
understanding of the complicated and potentially emotive questions
that arise. For example, we commend a series of Consumers' Association
reports recently published in Holiday Which? namely In-flight
medical emergencies (January 1996); Health in the air (Winter
1999); and Are you sitting comfortably? (Spring 2000).
Journalism is not always so balanced. In Box 6 are some sample
headlines of articles published during our Inquiry. We understand
the importance of a headline in gaining the reader's attention
and, as noted, some of these do so in a reasonable manner. The
others seem to us to be arguably sensational.
8.38 Sensationalism is sometimes
continued in the articles themselves. In this connection, we must
comment briefly on the work of Mr Farrol Kahn, who was either
the author of, or a substantial source for the views quoted in,
a number of these. Mr Kahn has done a lot to raise the profile
of flying and health, and we felt that his contribution could
be helpful in our deliberations. His written evidence was broad-ranging
and peppered with apparently impressive references (p 44). Disappointingly,
these did not stand up to examination (QQ 87-151). For example,
in paragraph 24 of his memorandum (p 44), Mr Kahn implied that
Kenyon et al supported his contention that filters were
changed less frequently than specified. During his oral evidence,
Mr Kahn seemed first to confirm this (Q 138) but later attributed
the view to Professor Hocking (Q 143). Separately, Professor Hocking
stated that, to the best of his knowledge, he had not published
any information on this (p 236). After several reminders, Mr Kahn
said in correspondence that the attribution to Professor Hocking
was a mistake and he could not provide the confirmatory material
he had offered (Q 144) as this had been given to him in confidence.
8.39 During examination, Mr Kahn said that he was
not a doctor or scientist, but was an interested observer, medical
writer and journalist (QQ 109, 113 & 147). He claimed to be
a medical expert "by accretion" (Q 109), but his expertise
is limited. As Dr Giangrande noted (p 234), the view half-attributed
to him by Mr Kahn that "when you breathe in and out you are
not replenishing your blood plasma" (QQ 108 & 109) is
nonsense. This carelessness with facts is not limited to medical
or technical points. Mr Kahn's paraphrase of British Airways'
rejection of his request for research funding ("passenger
health is not a Board-approved priority theme" - Q 128) is
not the obvious intent of the letter.
These faults are continued in his journalism. Dr Perry stated
that Mr Kahn completely misreported two alleged cases of TB transmission
(p 267). Mr Scurr was surprised to find that Mr Kahn not only
claimed credit for DVT-related research that was not his but also
purported to summarise the findings which, at the time, were not
known (p 283). We acknowledge that some of the professionally
written material promulgated under the aegis of the Aviation Health
Institute is very helpful. However, we have been concerned at
the confused thinking, lack of substance and erroneous statements
in some of the other material presented to us and the public by
Mr Kahn, the Institute's founder director. In spite of his evident
enthusiasm for his cause, sadly we have not found him to be a
reliable source of scientific and medical information.
Examples of headlines
Health risks to air passengers bring calls for stronger warnings
Guardian - 3 May 2000
What that holiday flight really does to your body
Daily Mail - 30 May 2000
How safe is Airplane Air?
Wall Street Journal - 9 June 2000
Inquiry into blood clot danger for air travellers
Independent on Sunday - 2 July 2000
Fasten your seatbelts - it could be a sickly ride
Mail on Sunday - 2 July 2000
Are planes bad for you?
Daily Telegraph - 3 July 2000
The sky high cancer risk (the flight path of a 747 to Japan is a trip through radiation hell)
Guardian - 11 May 2000
Long-haul passengers pass out from "oxygen shortage"
Sunday Times - 14 May 2000
Flying can prove fatal in economy class
Independent on Sunday - 28 May 2000
It's high flyers who may be laid low - a survey claims airlines are neglecting in-flight health
Daily Telegraph - 22 June 2000
INFORMATION FOR HEALTH
8.40 There is much more information
available for health professionals. As indicated by the references
throughout the evidence submitted to us (reproduced in Volume
II of this Report), much of this is of a highly specialised nature.
Being also mainly journal-based, such material is of limited use
to busy general practitioners and practice nurses for quick reference.
8.41 Doctors and nurses in
general practice may only rarely be asked to give an opinion on
fitness to fly and, if asked, they need to have appropriate reference
material readily to hand. We were surprised to learn that
the current edition of the DoH book Health Information for
Overseas Travel aimed at health professionals did not contain
information on medical considerations for travel and on the significance
of pre-existing medical conditions (Q 26), and we were pleased
to find that this was being remedied in a revised edition already
in preparation, and the Minister confirmed that it would, in particular,
deal with deep vein thrombosis and immobility (Q 533). We recommend
that DoH monitor the use of the revised Health Information
for Overseas Travel to ensure that, with further additions
and amendments as necessary, the publication provides the user-friendly
authoritative information source that is needed by health professionals.
8.42 Other broad-ranging
guidance is currently rather limited. Two UK publications to which
our attention was drawn are Aviation Medicine
and the chapter on aerospace medicine in the Oxford Textbook
However, both of these are essentially scientific texts for doctors
with special interests in aviation medicine rather than practical
guides for general practitioners. A better model, because it is
designed for doctors who deal with passengers rather than with
aircrew, is the American Medical Guidelines for Air Travel.
8.43 Into this gap, the airlines
have themselves placed material on fitness to fly and related
courses for health professionals (QQ 315 & 317), free of charge
(Q 321), and they acknowledged the demand for such guidance (QQ
315 & 317). During the preparation of this Report, British
Airways opened its new health web site,
to which its useful guide for doctors, Your Patient and Air
Travel, has been transferred. The Aviation Health Institute
has also promulgated Contra-indications to Air Travel: Guide
101 See paragraph 8.3. Back
Although, commendably, British Airways was actively and materially
supporting research into DVT (Q 304) Back
Irvine D and Davies D M (1999), Aviation, Space, and Environmental
Medicine; 70:548-555, as cited by Varig (p 288) Back
CAA also publishes a leaflet, Travelling Safely, but dealing
only with safety issues. Back
As noted in paragraph 8.26, revisions are in prospect. Back
We have been very conscious of this responsibility in framing
our Report. Back
3rd Report, Session 1999-2000, HL Paper 38. Back
The text of which is reproduced as a footnote to Q 128. Back
3rd edition, British Medical Association Publishing Group, 1993. Back
3rd edition, Oxford University Press, 1996. Back
Aerospace Medical Association, Alexandria, Virginia USA, 1997. Back
Published in General Practitioner, 23 June 2000 Back