The Ghettoization of Asthma

I dread the summer, when hot, humid air combines with smog and soot from factories and traffic to inflame and constrict my airways. I am an asthmatic, one of 14 million in this country, a number that's growing at epidemic rates. From 1982 through 1994, the prevalence rate of asthma increased 61% in Americans of all ages, and 72% in children, among whom it is the number one chronic disease and reason for absence from school.

Approximately five million American children have asthma, whose severity can range from shortness of breath to an acute, life-threatening event. No child should have to die of asthma, which is highly manageable with medication and environmental controls. Yet asthma deaths in children and young people age 5 to 24 nearly doubled between 1980 and 1993, according to the National Institute of Allergy & Infectious Diseases (NIAID).

Children Fighting for Breath

Asthma is increasing among Americans of all incomes and races. But inner-city children are truly the canaries in the coal mine for this disease, aggravated by emissions from the combustion of coal, gasoline and diesel fuels, among other factors (see below). I'd dread the summer a lot less if I didn't live in New York City, which has the country's highest asthma mortality rate. So would the residents of Harlem, Williamsburg and the South Bronx -- low-income, minority communities with the highest asthma death rates in this city.

Children, who spend a lot of time playing out-of-doors and near the ground, where pollutants settle, breathe a proportionately greater volume of air than adults, yet have narrower airways. This makes them more vulnerable to airway obstruction from inhaled irritants. Maria Durkan, parent coordinator for a daycare center in Ironbound, a Newark, New Jersey neighborhood, says she's certain that air pollution is hurting the respiratory health of the children she works with. Durkan points out that Ironbound got its name because it was ringed by railroad tracks and iron trestles, and is now riddled with factories, waste dumps and a commercial waste incinerator, which trucks in and burns garbage from other cities. In the spring of 1998, Ironbound Community Corporation (ICC) did a survey of health records of 33 children in Durkan's daycare, all from low-income families. "One third had either asthmatic or bronchial conditions," says Joe Della Fave, ICC executive director.

Asthma can be tricky to diagnose, often masquerading as something else, like the sort of congestive flu or cold that frequently triggers an attack. Symptoms range from wheezing and/or persistent cough to repeated episodes of bronchitis or pneumonia. Asthma often originates with a genetic predisposition in families with a history of asthma or allergies. Colds, flus, and psychological and emotional stress also play a role.

Allergens that commonly trigger asthma include dust mite excrement, pet dander, mold spores, cockroach parts and rodent urine. Irritants include cigarette smoke, ozone (O3, your basic vehicular smog), particulate matter (PM 2.5, very fine pieces of soot, dust or smoke, under 2.5 microns in size), sulfur dioxide (SO2 from coal-burning plants), and nitrogen oxides from unvented gas appliances and wood-burning fireplaces and stoves. Common respiratory irritants such as fragrances and vapors from paints and pesticides can also provoke asthmatic reactions.

Substandard Air

While research has identified many asthma triggers, studies have not been able to pinpoint an exact cause for asthma's increase. Hillel S. Koren, Ph.D., of the Environmental Protection Agency (EPA), points out that the nation's overall air is cleaner, thanks to the Clean Air Act of 1970, so dirty air can't be causing asthma. But the fact is that air quality is not improving for everyone. In 1995, 18 million American children -- more than 25% -- lived in areas where air quality failed to meet federal standards, according to the EPA. "It may be possible to explain some of the increases in asthma rates by looking at the disparities of air pollution burdens that exist among communities," write Luz Claudio, M.D., and others in the June 1998 Environmental Health Perspectives. Dr. Claudio, of Mt. Sinai Medical Center in New York, notes that the percentage of the population living in areas that fail to meet federal air quality standards is 52% for whites, 62% for African Americans and 71% for Latinos.

"A lot's been made of this -- how if we got rid of pollution we'd still have asthma," says George Thurston, Sc.D., associate professor at New York University School of Medicine, who says he encountered this assumption time and again from Congress when he testified during the Clean Air Act standards review process. In 1993, Thurston concluded a three-year study of asthmatic children at a rural Connecticut summer camp. Periods of elevated ozone showed a significant association with exacerbation of asthma. Despite the Clean Air Act, "It is clear from this work that summertime haze air pollution remains a serious health threat to children with asthma," Thurston concluded in The American Journal of Respiratory and Critical Care Medicine.

Thurston underscored the fact that the children's asthma symptoms increased even when ozone levels were below the then-current EPA standard. In fact, Thurston testified before the Senate Subcommittee on Clean Air that, because "significant adverse effects are well documented down to the 80 ppb [parts per billion] level, the EPA proposal provides no margin of safety." Despite his and others' arguments for a stricter standard, the 80 ppb standard was adopted in 1997. The American Lung Association estimates that 27 million children live in areas with ozone levels that exceed even these new standards.

Industry, dreading more regulation, fought hard for laxer standards. George Wolff, Ph.D., principal scientist at General Motors, disputes Thurston's study. "The higher the temperature, the higher the ozone. But hot, humid weather also affects asthma. You have to separate out the temperature and the humidity from the ozone," says Dr. Wolff, who, while on GM's payroll, served as chair of the EPA advisory committee panel on ozone and particulate matter during the Clean Air Act standards review.

Asthma's Multiple Factors

Asthma triggers, however, exist in combination. "Asthma is a multifactorial disease: All interventions need to be used to tip the scale," says Richard Jackson, Ph.D., Director of the National Center for Environmental Health at the Centers for Disease Control and Prevention (CDC). Laboratory studies on asthmatics, as Koren and others note, have shown that exposure to smog or particulates can cause a more severe asthmatic reaction to an allergen than exposure to the allergen alone.

"I worry about what the avenue traffic will cause for his asthma, and the fumes from the gas station nearby. I worry about the heat of the summer because we don't get good ventilation," says Lydia Ortero, a Harlem resident and mother of a 12-year-old son with asthma. She also worries about getting adequate housing and medication, and placing her son in one of the few public schools where the nurse is allowed to administer asthma medication. Clearly it is impracticable for a parent to isolate one factor.

Ortero spoke at a two-day conference at the New York Academy of Medicine in May 1998. Kevin Weiss, M.D., Director of the Center for Health Services at the Rush Primary Care Institute in Chicago, where asthma mortality is at twice the U.S. rate, delivered alarming news: Nationally, the most extreme increase in asthma over the past 10 years has been in the 0-5 year-old age group. In addition, the prevalence gap between blacks and whites may be narrowing -- not that rates for blacks are decreasing, but that whites are catching up.

As the facts and anecdotes mounted up, it became clear that poverty, along with its many stresses, is a major contributing factor to asthma. Many poorer neighborhoods, such as the South Bronx, lack adequate medical facilities. Low income seems to be a more important factor than race, Weiss said. Children from low-income zip codes in New York City are five times more likely to be hospitalized with asthma, Lori Stevenson, M.P.H., from the New York City Depart-ment of Health, reported.

Lots of scary figures on vermin were also presented. High exposure to cockroaches results in a threefold increase in hospitalization for asthma, according to Daniel Rotrosen, M.D., an allergist with NIAID. Jeanne Fox, of EPA's Region 2, also spoke about indoor air and non-toxic roach control, such as the use of boric acid.

At this and other points in the conference, when cockroaches and housekeeping were discussed, several members of the audience took to the mike in protest. "You're saying it's our fault, we have only ourselves to blame, not industry, not the diesel bus parking lots, the trucks at Hunt's Point Market, freeways that strangle our neighborhood," said Marian Feinberg of South Bronx Clean Air Coalition. Seven out of eight major bus depots on Manhattan Island are located in Harlem and the South Bronx.

Environmental Justice

Many community activists, and scholars such as Robert D. Bullard, author of Unequal Protection (Sierra Club Books, 1996), say that the siting of polluting facilities in minority communities is due to environmental racism. Bullard and others have documented the clustering of transportation arteries and industrial and waste facilities in and around communities of color. In some areas, like the South Bronx, the EPA hasn't installed its new air monitors, despite community demands.

When residents fight the siting of new facilities, bus parking lots and truck depots, they are told that they can't use asthma as a reason because no studies have been done there. Yet Dr. Claudio, who proposed a study on ambient air pollution and asthma in the South Bronx, has just had her application turned down. "There've been plenty of studies elsewhere. I don't think we need more studies. We should try driving less, putting controls on diesel buses and trucks, and tighter controls on industries upwind," says Patrick Kinney, Ph.D., an assistant professor at Columbia University School of Public Health.

Living on East 91st Street in Manhattan, a block from the FDR Highway, Nicole Bullard, 19 (no relation to Robert), and her mother are trying to cope with asthma's multiple factors. Though they can't afford store-bought mattress encasements, Mrs. Bullard wraps their mattresses and pillows in large plastic bags to try and block dust mites. She launders and mops regularly. For two years, the family has been trying to get the city housing authority to transfer them to public housing in a neighborhood with better air quality -- away from the gas station right across the street, the bus stop, the taxi and limousine garages, factories and heavy truck traffic. "In hot weather, when we have to open the windows, the fumes come into our apartment and I can't really breathe," says Nicole, whose brother died of asthma in 1996.

Any asthmatic can tell you we'd breathe easier if the air were cleaned up. This, however, will require strong, fresh winds of political and consumer change. We need to pressure government to enforce clean air standards and make them stricter -- and to respond promptly to needs like the Bullards' and the Orteros.' Industry will have to be made to comply, and the clustering of polluting facilities in low-income, minority communities must stop. As wealthier white communities won't accept them either, asthma may prove to be a unifying issue for environmental change. For the atmosphere at ground level is every person's condition, and increasingly, as War, the inner-city Long Beach band, sang in 1968, "the world is a ghetto."