Recent increases in childhood asthma have created controversies about the environmental causes. Children living in urban areas are especially vulnerable to asthma because of the high number of pollutants and allergens in their environment. Others argue that exposure to pesticides in the air and food helps cause it.
Asthma is a disease that affects breathing. It attacks and damages lungs and airways. Asthma is described as like breathing through a straw; it can be a serious threat to persons of any age. Childhood asthma attracts attention because of its potential developmental consequences. Asthma is characterized by partially blocked airways. It can occur periodically or reactively, and attacks or events can range from mild to severe. The nose, sinuses, and throat can become constricted. Breathing becomes difficult and is accompanied by coughing and wheezing. During an asthma event, the muscles around the breathing passages constrict. The mucous lining of the airways becomes inflamed and swollen. This further constricts air passages. These episodes can last for hours or days. They can be terrifying events for parents and children. Childhood asthma and its disproportionate impact on vulnerable populations is one of the foundational issues of environmental justice in the United States.
I. Causes of Asthma: Foundations of a Controversy
II. Environmental Triggers for Asthma
A. Indoor Air Contamination
B. Outdoor Air Pollution
C. Children in the City
III. Disparities in Asthma Care
IV. Costs of Asthma
Causes of Asthma: Foundations of a Controversy
Asthma is a complex disease with many causes, some known, some contested, and some unknown. Each one presents its own issues. Environmental causes are controversial because they represent a broad, catchall category. Controversies about science, industry trade secrets, and unequal enforcement of environmental laws merge with a very high level of citizen concern. There is an emerging role for public health experts and advocates in urban environmental policies around childhood asthma. There is a greater incidence of asthma among children in U.S. inner cities. Asthma often accounts for a large number of emergency room visits, especially in poor areas underserved by medical insurance. Hospitals, health care administrators, and health insurance corporations are all very interested in the causes of asthma. Employers and educators know that a number of days in school or on the job are lost because of asthma. They also have an interest in understanding the causes. Some stakeholders may fear liability for causing asthma. They have a strong interest in not being named as among those responsible.
Environmental Triggers for Asthma
The policy question posed now is what triggers an asthma attack. Others, such as public health experts and advocates, ask what can prevent it. They are concerned that focus on a trigger overlooks vectors of causality as opposed to last exposure.
Indoor Air Contamination
Dust mites, cockroach droppings, animal dander, and mold are among the environmental conditions that may cause asthma. Exposure to allergens alone may induce the onset of asthma. Exposure to secondhand tobacco smoke is also a contributor. Certain insecticides may also be triggers. Some researchers consider pesticides to be a preventable cause of asthma in children. The quality of indoor air in homes may be made worse by the increasing use of synthetic materials in the form of carpets, carpet glues, curtains, and building materials. There is concern that as these materials age, they release potentially dangerous chemicals. Manufacturers of these items strongly contest any conclusion that their products may be among the causes of childhood asthma. However, concern about release of toxins from synthetic materials has affected market trends in these products. Because many household products are believed to be possible causes of asthma, the marketplace or commerce in these products has become a point of discussion. Large bigbox retailers like Walmart are accommodating these consumer concerns about causes of asthma that consumers can control, such as dust mites and animal dander.
Outdoor Air Pollution
There is strong evidence from longitudinal studies that ambient air pollution acts as a trigger for asthma events among persons with this condition. Truck and automotive exhaust is a big part of the polluted air, especially in densely populated urban areas. Combined with industrial and municipal emissions and waste treatment practices (such as incineration), the quality of the air becomes so degraded that the total polluted air load in some urban and nearby suburban areas is a threat to the health of children. It threatens them with the development of asthma due to long-time exposure and poses the risk of initiating an attack at any time.
Children in the City
It is clear that the increasing severity of asthma in the United States is concentrated in cities among children who live in poverty. Children, as compared with adults, are especially vulnerable to air pollution and other toxic exposures, partly because they have more skin surface relative to total body mass. According to Frederica Perera, director of the Columbia Center for Children’s Environmental Health:
They consume more water, more food, and more air per unit body weight than adults by far. Today’s urban children are highly exposed to allergens, such as cockroach and rodent particles, and pollutants, such as diesel exhaust, lead and pesticides. And these elements affect them even before they are born. Preliminary evidence shows that increased risk of asthma may start as early as in the womb before birth.
The small particles of soot “are very easily breathed into your lungs, so they really exacerbate asthma,” say Peggy Shepard, executive director of the West Harlem Environmental Action, Inc., adding that she believes these diesel particles may also play a role in cancer. Shepard says that New York City is second in the nation when it comes to the amount of toxins released in the air, preceded only by Baltimore.
David Evans, who runs the Columbia Center’s “Healthy Home, Healthy Child” intervention campaign, maintains that cockroach particles pose a problem for urban areas nationwide. He says, “Simple housecleaning won’t solve the problem, because the cockroach residue tends to be present in many city neighborhoods.” According to the Harlem Lung Center, childhood asthma rates increased 78 percent between 1980 and 1993. And according to the Columbia Center, there are an estimated 8,400 new cases of childhood cancer each year nationwide.
Disparities in Asthma Care
Access to health care is an important aspect of the asthma controversy. Many low-income groups do not have health insurance and tend to use the emergency room instead of visits to a primary care physician. An asthma attack often presents that necessity. Language and cultural differences can make a tense medical situation worse. Even with regular medical intervention, differences in asthma treatment by race, gender, and class make this issue an ongoing one, and disparities in the burden and treatment of African Americans and Puerto Ricans with asthma are well documented.
Among African Americans and Puerto Ricans, rates of asthma, hospitalization, and death are higher compared with those of whites. This is especially true among children. Diff erent medicines are prescribed and used for different groups. Research shows that the use of long-term medications to control asthma is lower among African Americans and Puerto Ricans. Cost may be a factor, especially if there is no insurance coverage. Access to medical care is affected in many ways. There are shortages of primary care physicians in minority communities, and also issues of trust about the role and usefulness of medications.
Costs of Asthma
Asthma is a cause of death among U.S. children. There are 247 deaths each year due to childhood asthma. It is the leading cause of hospital admission for urban children. Asthma is also the leading cause of days of school missed. It is estimated that about 30 percent of acute episodes of childhood asthma are environmentally related.
Air pollution is considered a major cause of asthma, and asthma and public health are major regulatory justifications for clean air laws. The U.S. Environmental Protection Agency (EPA) has estimated the cost savings that resulted from the Clean Air Act. For the years 1970–1990, the EPA calculated that the annual monetary benefits of reductions in chronic bronchitis and other respiratory conditions was $3.5 billion. That is, this figure represents health care costs that would have been incurred if there were no clean air regulations. There are other costs too, of course. Also, if there were no costs and if people with asthma could get free and accessible medical attention, the cost of human resources necessary to handle the scope of the problem could be large. Additional childhood asthma benefits are projected by the EPA to accrue over the years 1990 to 2010, assuming full implementation of the Clean Air Act Amendments of 1990.
This controversy is very salient among communities and public health professionals. Schools, hospitals, nursing homes, and other places where vulnerable people live hold strong views but lack resources. Emissions from traffic, industry, and heating and cooling systems are now part of the U.S. urban landscape. Environmentalists note that the law does not cover all the pollutants and is not enforced equally. Advocates of environmental justice consider childhood asthma as proof of at least one disproportionate environmental impact. Asthma generally has resulted in a substantial increase in the sales and profits of pharmaceutical companies. This controversy is structural in that it pits public health concerns against industrial emissions and is therefore of deep significance.
There will be many ongoing issues. The environmental controversies around childhood asthma will focus on air pollution and use other controversial methods such as ecosystem risk assessment or cumulative risk assessment. Childhood asthma is a big part of the new inclusion of cities by the EPA. In the early 1990s, the visionary EPA administrator Carol Browner reduced the level of particulate matter allowed in urban air districts, effectively banning many diesel and leaded gas vehicles. She started an urban air toxics policy task force to help engage cities and the EPA, along with several other successful policy initiatives. Exxon and other oil companies responded with letters to their accounts about the new air pollution regulations. In an unusual step, the American Lung Association and other public health organizations responded in support of the EPA. As U.S. environmental policy matures into comprising all environments, including cities, continued controversy in the area of public health can be expected. Battle lines were drawn then and are much deeper now. Asthma is worse, there is greater consensus that air pollution not only triggers but also causes asthma, there are large documented environmental injustices by race and class, and there is a large overall push for sustainability.
Robert William Collin
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- Bernstein, I. Leonard, Asthma in the Workplace. New York: Marcel Dekker, 1999.
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- Christie, Margaret J., and Davina French, Assessment of Quality of Life in Childhood Asthma. London: Taylor and Francis, 1994.
- Institute of Medicine, Clearing the Air: Asthma and Indoor Air Exposures. Washington, DC: National Academies Press, 2000.
- Naspitz, Charles K., Pediatric Asthma: An International Perspective. London: Taylor and Francis, 2001.