Earth Day – A Celebration of Environmentalism and Environmental Justice for All

By Cynthia Harding, MPH, Robert Gilchick, MD, MPH and Angelo J. Bellomo, REHS, QEP, Los Angeles County Department of Public Health

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Earth Day, celebrated each year on April 22, commemorates the birth of the modern environmental protection movement.  Started in 1970 during an era when pollution was rampant in our country, Earth Day is credited with bringing the concept of environmental protection into the national political agenda.  The first Earth Day was marked by massive rallies and demonstrations advocating for a healthy and sustainable environment.  In 2017, Earth Day will be marked by a national call to action around science, with a march in Washington DC and other communities throughout the nation.

The environmental accomplishments over the past 47 years have resulted in a reduction in pollution, more regulation on industries and a national awakening of environmental justice issues.  Unfortunately, low income communities and   communities of color continue to bear a larger burden from exposure to environmental toxins, weak enforcement of environmental regulations, and a pattern of land-use decisions which placed toxic waste and industrial facilities too close to these communities. While there are many adverse health outcomes and conditions related to environmental pollution, asthma is perhaps one of the most prevalent and costly in our county and across the nation.

Asthma is a common chronic respiratory condition characterized by inflammation and hyper reactivity of the smaller airways in the lungs.  It results in shortness of breath and low levels of oxygen in the blood and can require emergency treatment and repeated hospitalizations.  While asthma affects people of all ages, the highest prevalence of active asthma occurs in children and adolescents.  Asthma can be controlled by appropriate clinical management and reduction of environmental triggers.  Triggers for asthma include poor indoor and outdoor air quality, and poor or deteriorating housing quality with higher levels of insect and rodent infestation, and mold resulting from water damage. Exposure to second-hand tobacco smoke is another air pollutant that may exacerbate asthma, and can be effectively addressed with appropriate indoor and outdoor environmental policies. 

Los Angeles County asthma rates are comparable to the rest of the nation, with a prevalence rate for current asthma of 7.4% in children age 0 – 17.  Poorly controlled asthma with frequent exacerbations in this population creates an enormous burden both in terms of morbidity in the community and associated health care costs. In one year (2014) in Los Angeles County alone, almost 21,000 children visited emergency departments due to asthma symptoms and close to 3,000 were hospitalized, which translated to over $60 million in hospitalization costs.  Nationwide, emergency department utilization with asthma as a primary diagnosis numbered 1.6 million visits in 2013.  Furthermore, African American children are disproportionality impacted by asthma with a current prevalence rate of 17.3% in Los Angeles County, more than twice the rate of other races/ethnicities, and are more likely to have uncontrolled asthma with disproportionate use of emergency departments and in-patient hospitalizations.  Although the past few years have seen a gradual decrease in overall prevalence of asthma, this encouraging trend has not been equally realized across all racial/ethnic groups.  Challenges continue to exist in addressing these alarming inequities.

Why is it that we see such disparate rates of asthma across Los Angeles County? Los Angeles has some of the worst air pollution in the nation, despite making marked improvement in air quality over the last 47 years.  Vehicle emission control measures have succeeded in driving pollution down even though the population of Los Angeles County has grown markedly.  However, gains in air quality have not been equally distributed. Low income communities and neighborhoods where people of color reside are more likely to be surrounded by freeways, heavy industry and diesel truck traffic, all triggers that exacerbate asthma.  To add to this burden, these same communities often suffer from deteriorating housing conditions, decreased access to health care, and lack of green space.  Cumulative and synergistic exposures from multiple industrial polluters disproportionately impact the health and well-being of these residents. Differences in smoking prevalence among adult caregivers also contribute to the disparate rates of asthma in children, while differences in access to primary care medical homes may account for some of the disproportionate use of emergency departments for initial treatment needs.  Lack of regular preventive and maintenance care will also result in more frequent exacerbations and complications with increased need for emergency care and hospitalization. 

Los Angeles County has been working since 2000 to address high rates of asthma through the Asthma Coalition of Los Angeles County, a broad-based coalition that serves as a collective, powerful voice for policy and systems change to prevent, minimize and manage the burden of asthma.  The Coalition brings together key stakeholders representing multiple sectors from the community, including health care, environmental justice, housing and tenant advocacy, academic institutions, and public education.  Our focus is on addressing the racial/ethnic and socio-economic inequities, strengthening research to address asthma awareness and clinical management, and improving both indoor and outdoor air quality.  It is by working through coalitions like this that we have hope that we can provide policy solutions to reduce the asthma burden in Los Angeles County. Collaboration between partners within the coalition has allowed for numerous projects and initiatives including several strategies related to improvement of environmental conditions, such as more effective advocacy for state legislation and regulation aimed at air pollution mitigation; media events to increase public awareness and engagement around the issue of unhealthy and substandard housing conditions; and support for new health care public funding options that will allow reimbursement for in home case management and mitigation of indoor asthma triggers.

More recently we have begun to work broadly on environmental justice issues, by developing a prevention framework to target those communities most burdened by multiple exposures to environmental toxins and by working with agency partners to strengthen regulatory oversight.  A critical part of this work is supporting residents to both document their needs and health conditions as well as to design solutions for their communities.  For example, in one highly burdened community we have worked with State and local regulators to identify and rank all facilities that handle hazardous substances whose emissions potentially threaten the health of adjoining residents. We share the inventory with community members who frequently notify us of other facilities that are operating without appropriate permits.  We then work with facility operators and the regulatory agencies towards full compliance. We meet with the community and regulators quarterly to review progress in achieving compliance, improving environmental conditions, and reducing cumulative health risks.  

What will you do to celebrate Earth Day?  As public health professionals, we will march for science.  Science is undeniably one of the key pillars of our work.  But we also will speak up for health as a right for all in our communities, and fight for an environment that allows all to be healthy.  We will continue our work to support community-led efforts promoting policy change that prevents environmental health threats, particularly threats that disproportionately burden low-income communities and communities of color. We are broadening our coalitions to include those who plan and build cities and housing developments, so that health is incorporated in the design.  Lastly, we are working closely with regulatory agencies to ensure better enforcement of existing regulations that reduce toxic pollution. Through these efforts, we will ensure a Los Angeles County where communities are empowered, and where health and justice are at the center of decision-making.

The Chief Health Strategist Role in Tarrant County, Texas: Building Walkable Streets and Greener Food Carts

By Vinny Taneja, MBBS, MPH, Director of Tarrant County Public Health

Fort Worth and Arlington are both located in Tarrant County, a fast growing community of approximately 2 million individuals living within 902 square miles. Like many large urban communities, neighborhoods vary significantly by culture, race/ethnic background, income, education, green space, housing, crime and many of other social determinants of health.

All of us deserve a fair chance at a healthy, long and fruitful life. Health equity simply means attainment of the highest levels of health for all. It is easier said than done. What is surprising to many is that the social, environmental and economic conditions around us determine and impact our health more than we can imagine. Due to their significant role in affecting health outcomes, these conditions have been dubbed social determinants of health.

Imagine if you live in a neighborhood with no sidewalks. If there is traffic on the street, you may be less inclined to walk due to fear of getting hit by a car. Now imagine walking on this busy street with your dog or with your kids. Also, think about where you are going: is it just for a walk in a sea of homes, or to somewhere with a purpose? Walkability is one example of how our environment shapes our health. In fact, research shows us that our ability to pound the pavement has a really profound affect. While 43 percent of people with safe places to walk within 10 minutes of home meet daily physical activity recommendations; only 27 percent of those without safe places to walk get their steps in.

Healthy neighborhoods are not just about streets though. There are many areas such as education, employment, healthcare access, community engagement, crime rates, transportation, planned development, housing, and race/ethnic background that can all have an impact on health.

How is Tarrant County addressing health equity?

Tarrant County Public Health (TCPH) is a nationally accredited health department. As part of the accreditation process, TCPH led the efforts in the community-wide development of the 2014 Tarrant County Community Health Improvement Plan (CHIP). The CHIP illuminates four priority issues affecting Tarrant County: education, environment, health care access and partnerships. The collaborative effort of this process has moved diligently toward improving health and wellness, along with addressing health disparities in Tarrant County communities.

For example, for the reasons listed above, an environmental goal is to improve the walkability surrounding elementary school neighborhoods. After gaining support from the community, Texas Christian University’s Harris College of Nursing, Blue Zones Project Fort Worth and TCPH worked with C. C. Moss Elementary School to develop and implement a sustainable walking school bus program called Walking Wednesdays. C. C. Moss is located in a community in dire need of infrastructure improvements to make it a safer environment for kids to walk and bike to school. With help from the City of Fort Worth, the program addresses such issues as dilapidated sidewalks, inadequate school zone speed limit signage and ineffective crosswalks. By partnering with Silver Sneakers, a fitness program for seniors offered by a local chapter of the YMCA, the children who walk are building relationships and bridging the generational gap, while they stay physically active on their way to school.

The department also established the Cultural and Linguistic Competency Policy and Procedures to ensure staff develop and maintain health services that are culturally competent, consumer-guided and community-based, and that help eliminate health inequities. One example is the creation of a Spanish Language Translation Committee, which provides appropriate health-literate communication in the form of written information. Another example is the hiring of bilingual staff to meet the growing needs of our diverse Tarrant County community.

We recognize that training is a key component for the successful implementation of policies. TCPH’s Center for Health Equity (CHE) has trained TCPH staff and the community on the basics of health equity, cultural competence, diversity, social justice and NACCHO’s Roots of Health Inequity. Most recently, the CHE has developed a Limited English Proficiency (LEP) training to assist the Women, Infants and Children (WIC) staff to improve communication with clients.  

TCPH strives to promote “health in all policies,” a concept defined by the Public Health Institute as “a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas.” This means that we weave in public health best practices when we build new roads, zone new real estate, or even approve licenses for food vendors. For example, in 2016, TCPH helped the Tarrant County Food Policy Council increase access to healthy foods through three City of Fort Worth ordinance amendments. The results of the ordinance amendments are:

1) Push cart snack vendors were once only authorized to only sell frozen desserts. With a new amendment, vendors with self-propelled carts can now sell fresh produce in residential areas.

2) Fruit and vegetable vendors could once only sell on private property. The city ordinance change now allows the sale of healthy foods on public property, including residential areas. This change increases access to healthy foods in food deserts, where fresh options are limited.

3) The urban agriculture ordinance was amended to allow urban farms to operate in our city, as long as they adhere to certain safety and zoning requirements.

Finally, the department added health equity to the staff development curriculum. We are building traditional and non-traditional partnerships to address health literacy, healthcare access, disease reduction, infant mortality, breast and cervical cancer, access to affordable nutritious foods and integrated transportation.

TCPH is working diligently to advance health equity on our journey to becoming the Fort Worth’s Chief Health strategist by reaching as many residents as we can, no matter where they live or what language they speak, and incorporating the science of public health in to all of the places that touch residents’ lives every day.

More than the ACA: We Can’t Stop Fighting Now

By Dr. Oxiris Barbot, First Deputy Commissioner, NYC Health Department

This op-ed originally appeared on huffingtonpost.com

Oxiris Barbot

Oxiris Barbot

Since the start of the new presidential administration, the onslaught of policies and executive orders have been met with outcries from communities, organizations and elected officials. In the medical community, there was an almost unprecedented bipartisan opposition to the White House’s proposed American Health Care Act. To some, the protection of the Affordable Care Act has given us a rare time to celebrate, rest and regroup.

Now is not that time.

Not one of us should have the delusion that an insurance card will be a game changer when it comes to addressing longstanding and dire health inequities. If we truly want to ensure America’s health, activists, physicians and medical organizations can’t just mobilize for preservation of the Affordable Care Act. We must respond with equal vigor to immigration reform, housing quality and segregation, civil rights and other policies that could shape the nation for generations. When 80 percent of health is determined by the context of our lives, confining advocacy to access to medical care is reckless and irresponsible.

In a brave new world, here’s how we move forward:

#1 Collect Data for Action

Medicine and health rely on facts. There can be no alternatives. The need to collect robust data and shape the narrative of health has never been more urgent. By quantifying the human toll of defunding Planned Parenthood, reducing SNAP benefits through the Farm Bill and block-granting Medicaid, we proactively treat more patients than a doctor could during a shift in the ER, or an entire career.

At the New York City Health Department, our data-driven health equity blueprint, Take Care New York 2020, guides our programs, policies and investments to improve overarching population health indicators—premature mortality, infant mortality and self-reported health status. We track these indicators because they plainly tell us how well our society is keeping people from dying before their time, protecting the sanctity of childhood and supporting residents in not only living, but thriving. As importantly, we track disparities within indicators over time to learn more about the hardwired social conditions that perpetuate inequities.

While scientific discoveries and evidence-based approaches form the foundation of medicine, they remain inadequate in wholly addressing the issues of the unquantifiable human experience. Letting data and test results speak for themselves without context robs us of the imperative to bear witness to the brutality inflicted on our communities by repressive and oppressive policies.

#2 Work with Movements and Across Issues

Government shapes health through legislation and regulation, but social justice movements influence the norms upon which legislation and regulation are based. Access to health insurance isn’t the only health issue.

Read more.

Marking National Public Health Week, “Healthiest Nation 2030,” by Defending the CDC’s Support for Prevention in Local Communities

by Chrissie Juliano, MPP, Director of the Big Cities Health Coalition

This year’s American Public Health Association’s (APHA) National Public Health Week (NPHW) challenges us to think about what the “Healthiest Nation 2030” means. As we focus on this charge, we find ourselves again working to defend huge cuts in public health funding at the Centers for Disease Control and Prevention (CDC) and elsewhere.

Fighting TB in San Jose: New Urgency with Federal Funding at Risk

By Tara Perti, MD, MPH, Assistant Health Officer and Tuberculosis Controller at the Santa Clara County Public Health Department

Tuberculosis (TB) remains an enormous global problem and is one of the top ten causes of death in the world.  As we live in a global community, infectious diseases common in other countries also affect the United States.  In the United States, in 2015, 9,557 patients were diagnosed with TB disease

The ACA Replacement Would Devastate America’s Health

By Leana Wen, MD, MSc, FAAEM, Baltimore City Health Commissioner

This blog originally appeared on statnews.com. 

As a physician who has treated patients in the emergency department before and after the Affordable Care Act was instituted, I have seen firsthand how it has transformed the lives of many of my patients. And as the health commissioner for Baltimore city, I have seen how it has safeguarded the lives of more than 40,000 residents in my city, and millions more around the country, who would otherwise be uninsured.

ACA Repeal Would Mean Massive Cuts To Public Health, Leaving Cities And States At Risk

By Chrissie Juliano

This blog was originally posted in Health Affairs.

When the Affordable Care Act (ACA) was passed a little over six years ago, it brought with it the promise of health insurance for all Americans. It also sought to begin to shift the paradigm for health care in this country, emphasizing value over volume, and recognizing the importance of prevention coupled with appropriate access to care.

Repeal of ACA would imperil a little-known part with a huge impact

By GRETCHEN MUSICANT

The debate about the future of the Affordable Care Act (ACA) is in full swing, and many know that repealing the ACA would leave almost 20 million Americans without health care coverage. This is of great concern.

But the fact that repealing the law would also decimate the already-fragile public health system in America is not known to many policymakers or members of the public.

To End HIV/AIDS, Cities like Ours are Leading the Way by Setting Bold Goals

By Anthony Stamper, Denver Department of Environmental Health

This was originally published as an op-ed in The Hill newspaper.

On December 1st, communities across the nation will commemorate World AIDS Day. First memorialized in 1988, World AIDS Day offers the opportunity for people worldwide to unite in the fight against HIV, show support for people living with HIV, and remember those who have died. We know that in the U.S. the number of people living with HIV and AIDS is concentrated in cities, and that cities are also the most ambitious leaders in the fight against the disease. This World AIDS Day, Denver can report some major victories in fighting the disease that policy makers at every level should study carefully.

Live Today: The Big Cities Health Inventory 2.0 – Success and Challenges

By Chrissie Juliano, MPP, Director of the Big Cities Health Coalition

Today we launch version 2.0 of our Big Cities Health Inventory (BCHI), an online, open access data platform that allows the public health field, media, researchers, the public, and policymakers to look across more than 50 health and socio-demographic indicators from 28 cities – in total more than 17,000 data points. We also have a number of case studies available, highlighting innovative work in our member cities.

November is National Diabetes Month: How We’re Fighting Diabetes in Long Beach, CA

By Kelly Colopy, Director, Long Beach Department of Health & Human Services

November marks National Diabetes Month in America, and it could not be more important for us to seize this chance to educate more Americans about the disease, and help them find out more about what they can do to fight it. More than 29 million U.S. adults have diabetes, and 25% of them don’t know it. Additionally, about 86 million adults—more than a third—have prediabetes, and 90% of them don’t know it. This wave of chronic disease costs money. More than 20% of health care spending is for people with diagnosed diabetes. A 2012 study estimates the total costs of diagnosed diabetes at $245 billion.

Congress Took 233 Days To Respond. Here’s How To Prepare For The Next Zika

Dr. Ferrer is a member of the Coalition's Alumni Council, as the Former Director of the Boston Public Health Commission. This blog originally appeared on HealthAffairs.com.

Barbara Ferrer

October 27, 2016

Congress recently passed federal funding for the nation’s response to the Zika virus, and the manner in which they provided those funds exposed a serious flaw in the way our nation handles disease outbreaks. In the time between the White House’s initial request for funding in February and the passage of the bill in September, the outbreak escalated dramatically, nearly unchecked by federal lawmakers. The entire process took a grand total of 233 days, which is simply far too long. It did not need to be this way.

Battling AIDS in Houston Latin-American communities

Note: this article was originally printed as an op-ed in The Hill newspaper.

By Chrissie Juliano, contributor

October 15 will mark National Latinx AIDS Day across America, which is an opportunity to take stock of the great strides made towards defeating the virus and eliminating the stigma it can create. (The term Latinx serves as a gender-neutral alternative to Latino/Latina).

Science has come a long way since HIV and AIDS became a part of the national consciousness in the early 1980’s, but as experts have learned, if those advances are not shared with everyday people, and if awareness about the disease and how to prevent it does not grow, then disease rates can continue to climb, despite breakthroughs in the laboratory.

New York Leading the Way with Paid Family Leave

By First Deputy Commissioner Oxiris Barbot, MD, New York City Department of Health and Mental Hygiene, and Deputy Commissioner George L. Askew, MD, FAAP, Division of Family and Child Health

Today is National Child Health Day. On this day, and every other day, we at the New York City Department of Health and Mental Hygiene are pursuing an ambitious child health agenda with the goal of advancing health equity by undoing injustice.  

For New York City’s children, inequities in social, environmental and economic conditions can determine health outcomes well before birth. Strong family relationships and community supports, however, can protect against toxic environments shaped by poverty and racism. Unfortunately, many working parents must choose between bonding with a new child and returning to work because their jobs fail to provide paid time off, making paid family leave a key policy for advancing child health equity.  

Congress Finally Funded the Zika Fight – Here’s How We Can Respond Quicker to the Next Outbreak

By Chrissie Juliano, MPP, Director of The Big Cities Health Coalition

Before Congress left town this week for the end of this year’s campaign season, they provided funds to respond to the Zika outbreak – an exercise that took them far too long.

Since Zika emerged in the U.S., and the Administration first requested funds in February, the Zika virus has infected more than 3,300 Americans in the states and almost 20,000 in the U.S. territories, and those numbers continue to rise daily. In Puerto Rico alone, an estimated 50 pregnant women are infected each day, presenting daunting odds for their unborn children. Mosquito season is winding down in some parts of the country, and exists year round in others, but regardless, experts believe the worst is yet to come, as additional cases of Zika surface and the health system begins to care for these Zika-disabled children.

In Houston, Flood Response Success is about Taking the Long View

September is National Preparedness Month, so we asked the City of Houston, a Big Cities Health Coalition member, to share the lessons learned from their 2016 "Tax Day Day Flood." How did the public health department assist Houston residents, and did they consider their job done once the streets were dry?

by Raouf R Arafat, MD,MPH, Assistant Director, Houston Health Department

From April 16-18, 2016, the Houston area experienced widespread flooding.  First responders conducted 1,200 high-water rescues; over 6,700 houses were damaged in the region; overall property damage was estimated at $5 billion. Eight residents perished when their vehicles were trapped in high water. Four months later, Houston Health Department employees are still attempting to address the needs of flood victims through long-term case management.

The View from Boston: As the World Gathers in Rio, It’s Time for All of Us to See Zika as a Global Outbreak

With the Olympics in Rio, a high-risk area for Zika infection, people around the world are thinking about taking precautions. While the games are occurring during the winter months in Brazil, when the risk of mosquito-borne diseases is lower, much of the buzz around the Zika virus has been focused on Rio, where the disease is transmitted locally because the main vector, the Aedes Aegypti mosquito, is plentiful. Although the disease burden is heaviest in hotter, climates, residents of Northern cities like Boston are not immune from this virus and have a role in stopping its spread.

What Does Health Equity in Action Look Like?

Public Health – Seattle and King County (PHSKC) serves over 2 million people with a staff of 1500 employees and is the 13th most populous county in the United States. In addition to the city of Seattle, our County includes 38 other cities, international air and seaports, and a diverse population that speaks about 150 different languages. We have an annual budget of about $318 million and are the largest health department in Washington State.

Philadelphia’s Historic Win-Win for Kids: Funding Poverty Reduction Programs with a New Tax on Sweetened Beverages

By Cheryl Bettigole, MD, MPH
Director of Chronic Disease Prevention, Philadelphia Department of Public HealthOn June 16, 2016, 13 of the 17 members of Philadelphia’s City Council voted in favor of Bill No. 160176, the Sugar-Sweetened Beverage Tax. Cheers erupted from the groups that had rallied in favor of the tax: pre-K providers, city parks advocates, parents committed to better educational opportunities for their children, the public health community, and many more. And social media went wild.

Blanket Prescription: How Every Citizen in Baltimore Can Now Save a Life from Opioid Overdose

Every year, tens of thousands across our country die from a preventable illness. We have seen the number of people dying from overdose quadruple nationally and in Baltimore City, where I serve as Health Commissioner, we continue to see more people dying from overdose than from homicide. This is particularly tragic because there is a medication, naloxone, which can completely reverse the effect of an opioid overdose, and has been proven to save lives.