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