A Breath Of Fresh Air

The crowning achievement in urban health came in the late-19th and early-20th centuries, when a series of broad changes transformed the social and material environment for millions of inner-city Americans. Important policies aimed at improving children's health, working conditions, housing, and public sanitation translated into dramatic improvements in the health of the average American. And they happened, largely, because Americans in the Progressive Era had come to recognize that "health" is inextricably linked to the much broader social, economic, and environmental conditions in which people live.

In more recent decades, however, this enlightened ideal regrettably gave way to a narrower, segmented thinking about health care in which the health of people was considered separately from the conditions of their environment, housing, and workplace. Epidemiologists -- scientists who study causes of disease and how illness is distributed in populations -- increasingly focused on individual "risk factors," such as smoking and diet, while neglecting the social influences that affect both health and behavior. As medicine became consolidated as its own sovereign profession, doctors also concentrated on changing individual risk behaviors, often leaving political and industry influences on health blameless. This shift still characterizes the way most experts think about the epidemic of urban asthma, and it is evident in the political response to the disease.

Odd as it may seem, the asthma scourge creates an opportunity for a promising sort of coalition politics, one in which traditional environmentalists concerned about dirty cities join advocates in the low-income housing community, health-care officials, and others to promote new thinking and real results. Just such an approach is under way today in California, where our State Department of Health Services has partnered with neighborhood advocacy organizations, local health agencies, and environmental groups to develop a system that provides a unique view of patterns of urban asthma. The results are helping policy-makers and community advocates target the intersection of social deprivation, environmental injustice, and adverse health to find solutions to our asthma epidemic.

Poor and minority children suffer a disproportionate burden of asthma, at least in part because of the environmental conditions where they live. In homes, schools, and workplaces, mold, dust mites, and even cockroaches trigger acute attacks and may promote the development of the disease itself. Also implicated are broader environmental hazards -- from elevated ozone to diesel fumes and other airborne pollutants -- which are also more concentrated in poor communities. In addition, poor people and children of color are less likely to get preventive care for asthma because they lack decent health insurance. This means they are more susceptible to ongoing symptoms as well as more serious attacks that lead to emergency-room treatment and hospital stays.

The preventive regimen for asthmatics is now well established. Nearly all children prone to asthma can remain largely attack-free through monitoring and relatively simple medications. But children of the poor, in addition to living in hazardous environments, are less likely to have access to this preventive approach.

Typically, "solutions" to the epidemic have been piecemeal. Environmental groups focus on air-pollution issues while housing experts lobby for cleaner, safer homes. Health-care and labor-rights advocates seek improved access to care, especially for children, without a coordinated effort to address the root causes. These piecemeal efforts -- cleaning up outdoor air without corresponding improvements in homes, schools, and workplaces, for example -- can result in high costs without measurable health benefits. And they obscure broader thinking about the relationship among issues affecting class, race, income, and public health.

With an eye toward better solutions to urban-health crises like asthma, the national Institute of Medicine and the Pew Foundation's Environmental Health Commission have pushed for better coordination of research on how environmental conditions affect human health. In 2002, Congress responded, funding a new, national Environmental Public Health Tracking Program. In California, this initiative is helping our team of researchers evaluate patterns of asthma in Alameda County, which is part of the San Francisco Bay area. Along with asthma, rates of unemployment, poverty, overcrowding, and homeownership are merged with locations of schools, roadways, and toxic sites, and are displayed in a geographic information system being developed for the Internet. Maps that can be printed from this system provide strong evidence to push for changes in land-use decisions, housing developments, and even diesel-truck routes, which can result in a multipronged assault on causes of asthma.

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For all the attention given to the problem of asthma over time, it is maddeningly difficult to answer a simple question: How much asthma exists? Diagnosing it can be highly subjective, and clinicians often disagree even about a single patient's condition. There is no single test that can be used to establish the diagnosis, and no "asthma registries" indicating how many people in a community have the disease. To further complicate matters, a large percentage of the affected population suffers from asthma symptoms but never encounter the health-care system. In the absence of complete information, public-health agencies have tried to make the best of limited data -- relying on reported hospitalizations or emergency-room visits for asthma attacks, for instance. But these indicators represent only the tip of the iceberg for asthma treatment; doctors' office visits and obtaining medication are far more common and preferable events, but much harder to track.

While imprecise, these indicators are suggestive of overall trends. For example, emergency-room visits due to asthma have increased in recent years. Yet we know that hospitalization and emergency-room figures tend to paint a distorted picture of the overall problem, one skewed heavily toward poor patients who are more likely to depend on the emergency room for their basic health-care needs. Consider the conclusions of a recent study in the Annals of Allergy, Asthma & Immunology, which found that African American asthmatics in Chicago are six times more likely than whites to go to the emergency room and 12 times more likely to be hospitalized. If one were to map these results, the asthma problem would appear to be six to 12 times worse in inner-city neighborhoods with a high proportion of low-income families.

To gain a more complete understanding of the challenge, our department created a partnership with the largest private health-care provider in the county, Kaiser Permanente of Northern California, and the largest public provider of care for the poor, Medi-Cal (our Medicaid system). Both programs already maintained extensive databases of patients and a broad spectrum of asthma "events" -- emergency-room visits, but also physician visits, the use of asthma medication, and more. Using these data, we mapped our findings by neighborhood and came up with some vivid pictures. Several areas -- particularly those with many low-income families and people of color -- showed alarming spikes in emergency-room visits for asthma cases, especially among children. Often these neighborhoods were dealing with poor housing and acute environmental issues, such as proximity to freeways, major shipping ports, or industrial facilities.

But more affluent neighborhoods with quality housing at a distance from freeways and industry often showed elevated rates in other asthma indicators, such as purchases of prescription asthma drugs. These data tell us that the asthma epidemic doesn't afflict poor communities alone; it is distributed widely throughout the county, although its appearance may vary by community social status. Surely there is a quality-of-care component, with poorly managed asthma being concentrated in less-affluent communities. This picture did not fit the agenda of any single "interest group"; environmental advocates could certainly find evidence for framing asthma as an environmental issue, but groups working for health-care reform, fair housing, or other social-justice issues could all make similar claims.

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As our work in Alameda County continues, it is teaching us important lessons about our own institutional biases. A case in point: As environmental-health specialists, we were initially concerned with pollution arising from traffic and industry and its likely link to asthma. Even before the asthma data became available, however, many of our community-based partners insisted that this concept of "environment" was too narrow. It is noteworthy that many of these community advisers came from grass-roots organizations and brought an appreciation of the social, economic, and environmental issues related to asthma. They recognized that pollution can threaten human health, but also that health is a function of many less tangible factors: patterns of economic development, crime, and access to health clinics, grocery stores, and even green space.

The group agreed: While air pollution is important, it is only the beginning of a description of "community environment" as it relates to health and well being. Neither health nor pollution could be separated from fundamental social-justice concerns such as housing rights, school quality, jobs, or the distribution of resources in communities. The asthma picture merely reiterated this fact and provided an opportunity around which actors with diverse interests could crystallize.

The final chapters of this story have yet to be written. Locally, the California program -- following recommendations from the Alameda County project advisory team -- has been collaborating with individuals and groups committed to environmental justice, community economic development, and access to quality health care, schools, and housing. The California story, which is applicable to urban health in general, remains a demonstration of how "narrow" environmental health issues refused to remain in their neat little boxes. Instead, they not only cut across issues of class, race, income distribution, and public health but provided organizing opportunities in which the connections among all of these issues become visible. By making these connections, we can go back to the future and forge new collations for urban health.

Geoffrey Lomax is the former research director for the California Department of Health Services' Environmental Health Tracking Program. Eric Roberts is the program's research manager and Paul English is its principal investigator. This work was funded by a cooperative agreement with the Centers for Disease Control and Prevention's National Center for Environmental Health. The opinions expressed are those of the authors and not necessarily those of the sponsors. For more information on the California Environmental Health Tracking Program, visit www.catracking.com.