Fighting For Air
By Conn Hallinan and Carl Bloice
In a world beset by AIDS, the threat of a global flu pandemic, and the worrisome expansion of mega-killers like malaria, asthma hardly figures very high on anyone’s watch list. But while it cannot match the lethality of HIV or exotic viruses like Ebola and Marburg, it is, according to Dr. Wendel Brunner, Director of Public Health in California’s Contra Costa County, “a seriously disruptive disease.”
Indeed it is. Asthma is the number one cause of school absenteeism, and the number one occupational lung disease. While it strikes rich and poor alike, the burden on the latter is profoundly heavier, particularly if the victims are African-American.
And, by any measure, it is on the increase both in the U.S. and worldwide.
There are about 150 million asthma sufferers in the world, almost 31 million of them in the U.S. From 1980 to 1996, the number of Americans with the disease more than doubled, with the largest increase among children under five. Western Europe doubled its asthma sufferers in the last decade.
The disease has also become deadlier. The number of deaths in the U.S.—between 4,000 and 5,000 a year—has increased almost four-fold from 1977, and worldwide, 25,000 children die each year.
No matter who you are or where you live, asthma is a debilitating and scary disease. By inflaming the air passages in the lungs, causing them to swell, it reduces airflow, leaving a victim wheezing and gasping for breath. In severe episodes it kills. Left untreated, it causes irreversible changes in the structure of the lungs, or “airway remodeling.”
There is no cure.
It is also expensive, costing Americans about $16.5 billion annually in health care and lost workdays. Each year it leads to nine million visits to health providers, 1.8 million trips to the emergency room (ER)—one third of all pediatric ER vists are for asthma—and 460,000 hospitalizations. According to the World Health Organization, the worldwide impact of asthma exceeds that of tuberculosis and HIV/AIDs combined
While asthma is clearly associated with a number of “triggers,” ranging from industrial pollution to mouse droppings and pollen, it has an idiosyncratic quality that makes identifying causes a complex and at times bewildering endeavor.
Why do Puerto Ricans in the U.S. have four times the asthma rate of African Americans, who have, overall, the highest rate in the country? And why do Puerto Ricans have such high rates, when Hispanics generally have low rates? Why do Hawaiians have four times the rate of other Asian-Pacific Islanders? How come nearly 50 percent of the children in the Caroline Islands have asthma, while the disease is virtually absent in Papua New Guinea, just south of the Carolines? No one has a clear answer to any of these questions.
Winnowing out the reasons for this differential is a journey through a labyrinth of inadequate health care, sub-standard housing, the interrelationship between industry, transportation, and communities, and some serious educational deficiencies about how to control the disease.
Take the enormous differential in ER visits and hospitalization. “Hospitalizing is a reflection of poverty,” says Brunner. “If a community has a higher hospitalization rate, it doesn’t mean that community has a higher incidence of asthma, but it does mean they are poor.”
Studies have found that asthma sufferers who have access to primary care physicians, as well as adequate resources for medicine, have fewer ER visits and fewer hospitalizations.
“Asthma is a socio-economic disease,” says Kay McVay, RN, and former president of the California Nurses Assn., that is getting worse because, “We are moving backwards in terms of eliminating poverty and the unhealthy circumstances in which people live.”
Asthma can strike down the affluent as well as those on the economic margins, but where you live, and what you do at work, has a lot to do with whether you develop asthma.
According to the Environmental Protection Agency (EPA), 133 million Americans live in areas where pollution reaches unhealthy levels.
African Americans are more than twice as likely to live in those polluted neighborhoods as whites, and the average income in these neighborhoods is about 15 percent lower than for the rest of the nation. African-Americans had five times the number of asthma-related ER visits than whites and over three times the hospitalization rate. African Americans also had a death rate 200 percent higher than whites, and 160 percent higher than Hispanics.
“Poor communities, frequently communities of color but not exclusively, suffer disproportionably,” Carol Browner, EPA head during the Clinton Administration, told the Associated Press (AP) “If you look at where our industrial facilities are located, they are not in middle-class neighborhoods.”
Dr. John Brofman, director of respiratory intensive care at MacNeal Hospital in Berwyn, a suburb of Chicago, says air pollution makes asthma worse. “Not only do people get hospitalized, but they die at higher rates with significant air pollution,” Brofman told AP.
One reason why asthma rates are going up may be the policies of the Bush Administration. According to a recent Associated Press story, “The Government Accountability Office concluded that the EPA devoted little attention to environmental quality when developing rules for the Clean Air Act between 2000 and 2004.”
EPA scientists recently charged that the White House proposes weakening sections of the Clean Air Act that regulate the release of diesel particulates, sulfur dioxide and nitrogen dioxide, all asthma triggers. In the name of “streamlining” environmental regulations, the Bush Administration will permit some 4,000 companies in 922 communities—most of them poor, many of them predominantly minority— to increase toxic admissions from 500 pounds a year to 5,000 pounds.
The White House’s refusal to sign the 1997 Kyoto Accords or to reduce U.S. production of greenhouse gases that are warming the planet plays a role in rising asthma rates as well.
“During the past two decades, the prevalence of asthma in the United States has quadrupled, in part become of climate-related factors,” concludes Paul Epstein, MD, MPH, is his New England Journal of Medicine study on the impact of global warming on health.
Environmental triggers, or allergens, are not restricted to what comes out of smokestacks and tailpipes, however. Some of the most insidious are the ones people live among: dust mites, rodent and cockroach droppings, mold, animal dander, and nitrogen dioxide from poorly vented stoves and heaters. While these triggers can be found anywhere, they tend to be more prevalent in substandard housing.
There is even a psychological dimension to asthma. An Ohio State University study of 338 Chicago neighborhoods found that asthma rates went up or down depending on how secure people felt in their neighborhoods. People in areas with elevated crime rates—which were generally poorer areas with high numbers of minorities—tended to lock themselves into their apartments.
“If residents feel uncomfortable about walking outside or leaving windows open for fresh air, they may be continually exposed to higher levels of indoor allergens such as dust mites and cockroaches,” writes Christopher Browing, co-author of the study and assistant professor of sociology at Ohio State University. “This may be particularly bad in poor neighborhoods where housing is substandard and there are more allergens such as mold that could trigger asthma.”
Health professionals say the stress that goes along with poverty can play a role. “Many of my patients live very chaotic and stress-filled lives trying to survive in school, work, and foster healthy relationships with their peers,” says Nancy Lewis, RN, MSN, a family nurse practitioner at the Department of Health in San Francisco. “Add to this asthma triggers and a lack of regular checkups with primary health providers, and it sets up patients to end up hospitalized or worse—dead.”
Brunner also points out that the disease itself creates stress. “It is very disruptive of family life. Parents have to keep getting up in the middle of the night, and everyone has to go to school or work the next day.”
The pattern the Ohio State University study uncovered, and its link to income, is repeated across the nation. New York City has twice the national hospitalization rate for asthma as the rest of the country, but East Harlem has nine times the national rate. The depressed community of Bedford Stuyvesant has five times the rate of more affluent Park Slope. The average per capita gross income in the former is $7,406, for the latter, $18,666. Both are in Brooklyn.
The Heilbrunn Center for Population and Family at Columbia University even found that exposure to asthma-causing antigens “occurred before the child was born.” The study discovered, “a significant exposure to cockroaches and mouse antigens and in-utero sensitization to multiple indoor antigens.”
Where you are employed makes a difference as well. According to the American Lung Association, more than one in three adults who suffer from adult-onset asthma can trace their disease to the over 400 substances in the workplace that can trigger asthma. Nursing, food preparation and clerical work tend to be among the most common asthma-linked jobs.
However, according to Dr. Anne Krantz, MPH, and toxicology division chief of occupational medicine at John H. Stroger Jr. Hospital, Cook County, Il, the most common problem is “when someone takes a pre-existing asthma condition into a job and the job makes it worse.”
Krantz says avoiding jobs that either trigger asthma or exacerbate it may be difficult because “income disparity sometimes forces people to take jobs or stay on them in spite of the fact the job gives them asthma or makes it worse,” adding, people in poor communities “don’t have the economic or social mobility of other populations.”
Some industries, like ports, are a particular problem.
“Diesel pollution is omnipresent on the docks,” says Steve Stallone, a spokesperson for the West Coast International Longshore and Warehouse Union (ILWU), “It covers all the equipment, the containers, the men’s clothes, so you know what they are breathing in.” According to Stallone, “Most longshoremen will tell you they have respiratory problems. They are always short of breath.”
Diesel particulates stimulate the production of IaE antibodies, which according to a study by the Department of Health and Human Services, enhances an individual’s response to allergens.
You don’t have to live in a huge city or work in industry to join the asthma fraternity, however. Fresno, in the heart of California’s agricultural-centered Central Valley, would hardly seem ground zero for an asthma crisis. But fully 30 percent of the city’s school children have asthma.
Figures show Fresno has a worse ozone problem than Los Angeles. Ozone is considered an asthma trigger. From 1999 to 2004, Fresno failed federal air standards 38 percent of the time, but a Federal Appeals Court recently allowed the county to put off meeting federal standards until 2010
Fresno residents are pressuring local air quality officials to confront the problem, but they are finding it an uphill battle against powerful interests. “It’s DOA—development, oil and agriculture,” says Medical Advocates for Health (MAH) lawyer, Susan Britton, “those are the primary economic drivers in the Valley.”
MAH lobbies local officials to improve air quality standards.
Last year the Bush Administration exempted agriculture from pollution controls, even though the industry is responsible for 25 percent of Fresno’s problem.
If asthma is a complex disease, what to do about it is equally complex.
Education makes a difference, as programs in New York City and Los Angeles have demonstrated.
The National Asthma Education and Prevention Program in Los Angeles found that 67 percent of inner-city children with asthma got control of their disease if they were educated and treated by the organization’s “breathmobile.” Only 10 percent in a control group without access to the breathmobile managed to do so.
New York City’s Department of Health’s intensive, community-based asthma management program found that education and treatment had a dramatic impact in reducing the seriousness of the disease. Hospitalizations were reduced 28.3 percent in the South Bronx; 42.8 percent in Washington Heights; 38.6 percent in Fordham; 36.3 percent in Williamsburg-Bushwick; and 25.8 percent in central Harlem.
Access to health care is clearly a major variable. Many children in these communities are on Medicaid, which studies show means they will have worse asthma and use fewer preventative medicines than children on private health plans.
De Calvert, RN, MSN, and a Kaiser Permanente staff nurse in pediatric asthma, is careful not to over generalize about the access issue, but agrees, “There are more disease management problems with people on welfare or Medical.”
The number of Americans without health coverage—46 million at last count—is growing, and more and more employers are either refusing to offer health care or forcing employees to contribute more to their plans. A study by the Financial Times found that between 1998 and 2003, the number of employers with fully paid health plans dropped from 35 percent to 28 percent.
A good health plan is no armor against the triggers that induce asthma, however. Communities aiming to reduce those triggers are increasingly trying to pressure the federal government to enforce EPA guidelines on “environmental justice.”
According to the guidelines, “No group of people, including racial, ethnic, or socioeconomic group, should bear a disproportionate share of the negative environmental consequences resulting from industrial, municipal, or commercial operations or the execution of federal, state, local, and tribal environmental programs.”
But both the EPA General Inspector and U.S. Civil Rights Commission found that the government has done virtually nothing to implement the guidelines. From 1993 to 2005, the EPA received 164 complaints alleging civil rights violations in environmental decisions. It rejected 117 of them, accepted 47, but dismissed 28 of the 47. A decision is still pending on the other 19.
In spite of indifference on the federal level, local communities, public health agencies and politicians have cobbled together coalitions, which have made significant progress in reducing asthma triggers. Such a coalition in Contra Costa County won the first agreement in the nation on reducing oil refinery “flare offs.”
Volatile gases that accumulate during the refinery process are routinely ignited into controlled fireballs, or “flare offs.” But many of the gases involved are potential asthma triggers.
Similar coalitions have formed around the issue of diesel pollution at West Coast ports. Under the slogan “Saving Lives,” the ILWU has joined with local communities and Los Angeles Mayor, Antonia Villaraigosa, to reduce diesel pollution by 20 percent at the ports of Los Angeles and Long Beach over the next four years. Between them, the two ports emit 1,760 tons of diesel particulates each year. West Coast ports handle 49 percent of all U.S. cargo.
“The thousands of men and women I represent and work for raise their families under a cloud of port pollution,” says ILWU International President James Spinosa. “They have made a simple demand of their union: while they want a good living, they do not want to pay with their lives for a stronger economy.”
The ILWU is making reducing diesel pollution part of its bargaining strategy for the next West Coast contract, and plans to try and spread the issue to other places. “The ILWU is going to enforce this coastwise, and we’re taking it to the East Coast through the ILA (International Longshoremen’s Assn.). We are also raising this internationally,” says Stallone, “so that pollution will not have a homeport anywhere.”
Stallone says the Union is also working with communities in West Oakland, Ca. that are concerned about diesel emissions from freeways. “We are concerned because our people come out of those communities. We work in it and we live in it.”
According to the EPA, a $100 million retrofit of pollution generating diesel engines could save $2 billion in health costs.
None of this will be easy, and part of the problem is how public health is constructed and financed in the U.S.
“It is very difficult for local health programs to address these problems,” says Brunner. He points out that the average size of a health department in the U.S. is 16 employees, “which includes everyone from the director to the janitor.” The system, he says, “is just too fragmented.”
It is also under-funded. Brunner is in the process of cutting $3.5 million out of his $16 million budget, and trying to rustle up foundation grants, while juggling country, state and federal money. In the end, something gets cut.
Lewis sees the impact of such cuts everyday. “Primary care in San Francisco, like other counties throughout California, has suffered gradual cutbacks annually. Our public health nursing staff has been cut repeatedly over the years.”
While money may be short, the dedication to do something about asthma is strong.
“This is a condition we can influence, if not the incidence, at least the amount of hospitalization,” argues Brunner, ticking off his department’s program for beating back the beast:
*Insuring access to primary health care
*Helping families reduce asthma triggers in their homes and apartments
*Improving the quality of medical care, including educating doctors.
The Contra Costa County Health Department also holds classes to educate community members on how to interpret local and state air quality regulations, as well as EPA rules, including their rights under environmental justice guidelines. It also brings together community members and the staffs of regulating bodies in town hall meetings. The Department is presently working closely with schools and Kaiser Permanente to try and figure out a formula for on-site treatment of asthma attacks.
Kaiser RN De Calvert is optimistic about making progress against the disease. “Asthma does not have to be debilitating. It doesn’t have to mean lost time at school and work. The means to control it are available.”
One of those means is education, although as Lewis, who works with teens and young adults, points out, “It is a very labor intensive process involving patient teaching.”
Ultimately it is a problem bigger than a city or county or even a state, and goes to the heart of the present crisis in health care.
“I think these deaths and hospitalizations reflect a public health and primary care system in decline throughout our nation,” says Lewis. “The sad truth is that these deaths are preventable. How advanced is our health care system if our patients are dying from treatable and preventable diseases?”