Socioeconomic and Environmental Factors in the High Incidence of Asthma in Brownsville

Nur 4010

June 19, 2017

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Introduction

As a general rule, respiratory issues have priority in terms of patient acuity. How important is it, then, to look at asthma, a chronic condition that requires lifestyle modification, yet can also have sudden onsets with fatal results. With proper management, the complications of asthma can largely be avoided. Nonetheless, its annual cost in the US exceeds $50 billion in medical treatment, with another $5.9 billion in economic losses stemming from 14.4 million missed days of school and 14.2 million work call outs. (Malcarney, Seiler, and Horton, 2013, p.402) Another issue is that certain groups are more affected than others due to social and economic factors that place them at greater risk. Thus, asthma can be assessed as a medical problem or as a political or socioeconomic one.

Asthma is unique in that it typically manifests in childhood. According to Malcarney, Seiler, and Horton (2013), it is the most common chronic condition among children in the US. (p.402) The early appearance has lifetime consequences. A child with even a mild case may have to alter living conditions and activity patterns. Davis (2008) points to the tendency for people to remain indoors during times of poor air quality. (p.39) This limits physical activity, or clients avoid certain streets, parks, or even homes of others, which in turn affects social and psychological development. Heikkinen, Quansah, Jaakkola, and Jaakkola (2012) state that “asthma patients often limit physical exercise to avoid respiratory symptoms… This may predispose asthma patients to severe long-term health risks and impair the prognosis of asthma.” (p.397) This strategy, though, has been found by Bake, Viklund, and Olin (2014) to be ineffectual- even indoors, there may be enough exposure to pollen to trigger an attack. (p.1281)

Population Profile

The Ocean Hill-Brownsville section of Brooklyn ranks as one of the borough’s lowest in terms of socioeconomic status. Tellingly, the neighborhood also has some of the city’s highest rates of health risks, including prevalence and emergency treatment of asthma. The issues plaguing Brownsville read like a list of asthma risk factors and triggers. According to King et. al (2015), only 18% of Brownsville residents have a college degree, compared with a 41% citywide rate. (p.6) As education level often dictates employment options and earning potential, this ensures a high poverty rate. With 37% of residents living below the poverty line, Brownsville is Brooklyn’s poorest area, among the poorest in the city, and the unemployment rate of 16% also outstrips the citywide rate of 11% (King, et. al, 2015 p.6). High poverty leads to illegal activity. Brownsville’s 180 hospitalizations due to assault was the highest of any neighborhood in the city, and Brownsville had an incarceration rate of 348/100,000 adults 16 and over, the second highest of any neighborhood and over three times the average for Brooklyn (96) and New York City as a whole (93) (King et. al, 2015 p.7).

The neighborhood also faces health risks. In 2011, 73% of all homes had at least one maintenance defect, including mice or other pests (King et. al, 2015 p.5). Lovasi et. al (2013) found in their study that 31% of participants were allergic to the cockroach, making it the most common asthma trigger. (p.496) Another contributor is tobacco. In Brownsville, 14% of residents smoke. (King, et. al, 2015 p.8). Brownsville had the 10th highest number of tobacco retailers per capita of all city districts in 2011 (King et. al, 2015 p.5). One other contributor to asthma is poor prenatal care. The preterm birth rate of 13.3% of all births is second highest of any neighborhood, while the neighborhood also has one of the city’s highest rates of teen pregnancy (King et. al, 2015 p.7).

With multiple risk factors it is not surprising Brownsville has one of New York City’s highest concentrations of asthma sufferers. Brownsville’s rate of childhood asthma hospitalizations, 61 per 10,000, was roughly double the rate for Brooklyn, 32/10,000 and the citywide rate of 36/10,000, while the rate of adult asthma hospitalizations, 621/100,000, was well above twice Brooklyn’s rate of 263/100,000 and the city’s overall rate of 249/100,000 (King et. al, 2015 p.12). Although asthma can be managed through medications, poverty removes that option for many residents of Brownsville. King et. al (2015) found that 18% of residents lacked health insurance, and 11% went without needed care. (p.11) 40% of Brownsville area children miss at least 20 days of school per year, the worst ranking of any city neighborhood for that category (King et. al, 2015 p.7). While not all absences are attributable to asthmatic episodes, some are. Repeated absences mean these children fall behind, contributing to the lower educational levels found in the neighborhood. Frank, Hong, Subramanian, and Wang (2013) suggest psychological stress is also a trigger. (p.38) Given Brownsville’s high crime, high unemployment, and low educational achievement, there is a correlation.

Barriers

A big challenge towards management of health is the ability of the client to take ownership. With asthma, the client has little control, because the triggers sometimes cannot be avoided. An asthmatic client may clean the home to remove dust or pests, not smoke, remove carpeting, and not keep pets. However, the client cannot control what goes on in other apartments in the building, nor can the client manipulate the weather or local traffic. If the home is located near a major roadway, there will be exhaust. Financially, the client may lack the means to relocate, and so must modify what risk factors he/she can control, and to learn coping methods with factors that are outside control. In short, as Frank, Hong, Subramanian, and Wang (2013) state, urban living and overcrowding increase exposure to triggers. (p.38) A second barrier to solving the asthma problem in Brownsville is the lack of a singular cause. Shmool, Kinnee, Sheffield, Clougherty (2016) assert that multiple factors, including PM_2.5, NO₂, and ozone, play a role in triggering an attack, and these can vary widely from one point in the city to another, and even vary by time of day, making it difficult to pinpoint a precise cause. (p.111) Kazuhiko et. al (2015) suggest that ozone and pollen likely have a synergistic relationship in triggering an asthma attack. (p.9)

Another challenge is the overall fiscal health of the neighborhood. Medications can help achieve long term stability and respond to acute flare ups. Working with a nurse or respiratory therapist can help the client develop stronger, more efficient breathing patterns. However, if the client is uninsured, this treatment is unavailable, and the client is forced to rely on emergency room visits. Indeed, Frank, Hong, Subramanian, and Wang (2013) point out that the high prevalence of emergency room asthma visits is not so much a reflection on severity but on the lack of adequate coverage. (p.11)

Another development that may adversely impact Brownsville’s asthmatics is gentrification. While this may bring the promise of economic prosperity, it also means further crowding and changing traffic patterns. A number of major roads cross Brownsville, including Atlantic Avenue, Kings Highway, Eastern Parkway, Jamaica Avenue, and Rockaway Avenue. Adjacent to Brownsville, the City Council recently approved on April 20, 2016 a rezoning plan for East New York, specifically calling for “medium-density, mixed-use development along key corridors.” (City of New York, 2016) This runs counter to the findings and recommendations of residences along major streets brought up by Barrett (2012), Perez, Lurmann, Wilson, Pastor, Brandt, Künzli, and McConnell (2012), and Price, Plante, Goudreau, Boldo, Perron, and Smargiassi (2012). Bushwick is another adjacent area undergoing gentrification. Some of Brownsville’s major roads are shared with these neighborhoods, so Brownsville’s residents have a stake. Chen and Whalley (2012) note that even with improvements to mass transit to reduce pollution in the long run, pollution increases in the short term as a result of construction and traffic diversions associated with it. (p.69) Brownsville, and New York City in general, is served with multiple subway and bus lines. Chen and Whalley (2012) conducted an analysis of air quality in the days prior to and after the opening of Taipei’s commuter rail system in 1996 and saw rapid drops in carbon monoxide levels. (p.60)

Literature Review

In an urban environment, a key trigger is exhaust from vehicles- cars, trucks, buses, construction equipment, and motorcycles- that ply the streets and highways and idle at traffic stops. Around the globe, studies have been conducted and have conclusively demonstrated a relationship with exposure to exhaust and asthma. In urban areas, dense housing tends to place large numbers of residents close to major streets. Barrett (2012) notes that a large proportion of children in Los Angeles was found to be living within 75 meters of a major roadway, contributing to tens of thousands of incidences of asthma and bronchitis. (p.436) Perez et. al (2012) also based their study on Los Angeles and warn that while denser housing can contain sprawl and reduce dependence on the automobile, reducing CO₂ emissions by 20%, there is the countereffect of more housing in proximity to emissions, which raises asthma rates. (p.1619) Price et. al (2012) conducted a longitudinal study in Montreal, and found a correlation between living within 50 meters of a major road and the onset of asthma symptoms by age 2, and an even higher percentage of asthmatic children at age 6. (p.115)

An area that remains inconclusive is the role of trees. Lovasi et. al (2013) note the role in trees in curbing pollution, yet their findings do not support the hypothesis that increased tree coverage decreases asthma rates, although they also note that the presence of IgE to tree pollen does not confirm respiratory symptoms such as cough, wheeze, rhinitis, or asthmatic attack. (p.497) Kazuhiko et. al (2015) state that although pollen was shown conclusively to be a trigger, pollen counts only reach high levels for a short duration, compared to ozone and particulate matter. (p.8)

Researchers have also found connections between asthma and socioeconomic factors. Patel, Henderson, Jeffreys, Smith, and Galobardes (2012) conducted a study of college students and found higher rates of asthma among those of lower socioeconomic status. This conclusion was also reached by Frank, Hong, Subramanian, and Wang (2013). Lovasi et. al (2013) state that poverty and belonging to an ethnic or racial minority reflect higher rates of asthma. (p.494) Mitchell et. al (2012) state that asthma has an overall prevalence of 9.1%, with higher rates among lower economic classes and minorities. (1607) Frank, Hong, Subramanian, and Wang (2013) conducted a study connecting the asthma rate for a neighborhood to its incarceration rate. They found that of 466 participants, those with a history of incarceration had a significantly higher rate of asthma than persons with no prior incarcerations; formerly incarcerated persons with asthma also had more emergency room visits. (Frank, Hong, Subramanian, and Wang, 2013, p.40) It is not postulated that poverty in itself is a cause of asthma. Rather, Frank, Hong, Subramanian, and Wang (2013) suggest that impoverished and minority neighborhoods have disproportionately higher rates of incarcerated individuals, which places a burden on the households of those individuals, leading to stress and lifestyle behaviors such as smoking. (p.38) Lack of education is the topic of the study conducted by Malcarney, Seiler, and Horton (2013). As stated earlier, Brownsville has one of New York City’s highest rates of preterm labor, another general indicator of low socioeconomic level and low education. This becomes significant because Duijits (2012) has found links between low birth weight and preterm birth with the development of asthma. (p.6)

Interventions

Increasing Tree Cover

Several New York City developments have significance for asthma in Brownsville. Under Mayor Bloomberg, the city launched the Million Trees NYC initiative. This would lead to improvements as tree cover removes carbon dioxide, traps particulate matter, retains precipitate water, and provides shade to lower temperatures. (Lovasi et.al, 2013, p.494) The MillionTreesNYC site states that “one tree can remove 26 pounds of carbon dioxide from the atmosphere annually, the equivalent of 11,000 miles of car emissions.” (2015) The ability of trees to regulate temperature cannot be understated. Sheffield, Zhou, Shmool, and Clougherty (2015) state that due to rising temperatures, fluctuations in ozone levels are disappearing. (p.3) Without lulls in ozone production, asthmatics are susceptible to more frequent attacks. Most trees were planted in parks, though there were also a number planted along city streets.

The policy is not free from risk, as trees produce pollen, itself an asthmatic trigger. This is a potential issue, as a hallmark of public health is to encourage physical activity. Heikkinen, Quansah, Jaakkola, and Jaakkola (2012) demonstrated the connection between exercise and improved outcomes for asthmatics, yet it has also been shown that asthmatics may avoid exercise or going outdoors. Of 727 participants in their study on long term exposure to tree pollen and asthma rates, Lovasi et. al (2013) found an overall rate of 19% of participants allergic to tree pollen, 28% of children had asthma at age 5, and 36 % had asthma at age 7. (p.494) Yet the rates for both cohorts are greater than the number of children allergic to pollen, so it cannot be the only factor. Kazuhiko et. al (2015) echo this find by comparing pollen counts, OTC allergy relief sales, and emergency visits for asthma, concluding that a pattern of asthmatic flare ups in April occurred before pollen counts had risen, meaning that these asthma attacks were due to triggers other than pollen. (p.3) Kazuhiko et. al (2015) find that the pollen types most correlated with asthma are oak, birch, and maple, with beech, poplar, and elm having mild to low contribution. (p.11) The city can use that information when planning which species of tree to plant in the future, favoring species that are less reactive, or spreading trees with high reactivity further apart.

Traffic Regulations

Since ozone and other greenhouse gases are triggers for asthma, the issues of asthma reduction and pollution reduction overlap. One measure cities have implemented to combat both is to limit the number of vehicles in operation on certain days. Davis (2008) studies the efficacy of one program- Hoy No Circula began on November 20, 1989 to ban car use in Mexico City once a week based on license plate number. (p.39) It was hoped traffic would decrease and emissions would drop sharply, resulting in fewer respiratory episodes. Ultimately, the plan was a failure. According to Davis (2008), people drove at times the ban was not in effect, or purchased older, poorer quality secondary cars to drive on days they could not operate their primary vehicles. (p.63) The result was that pollution actually increased until 1993. (Davis, 2008, p.51) Nonetheless, other cities adopted similar measures. Launched in 2016, Delhi’s city government banned even numbered plates on odd days, and vice versa, from 8AM until 8PM, with a fine for violations. (Government of Delhi Transport Department, 2016, p.1) The plan was more successful in Delhi than Mexico City. In early November 2015, PM_2.5 levels in India’s capital topped 600mcg; after implementation, levels dipped below 400. (Environment Pollution Authority, 2016, p.2) Other cities have implemented similar plans. In fact, Delhi looks not to Mexico City but to Paris as its inspiration. Delhi’s Environment Pollution Authority (2016) cites that Paris saw an 18% reduction in traffic and a 6% drop in pollution when it started a traffic program in 2014. (p.8) New York City has recently considered congestion pricing.

Stakeholders

The treatment of asthma in an area like Brownsville carries high responsibility for a number of stakeholders. For politicians and administrators, the need to address asthma in the communities, especially in a disadvantaged neighborhood like Brownsville, is challenging. Policymakers have to meet the demands of the sick in their jurisdictions to improve access to healthcare, but also face demands to improve economic opportunities. These two goals are not always compatible, and may well be antagonistic.

For providers, the question of asthma prevalence is crucial. With shifts in health care costs and reimbursement, there are greater calls for accountability. Since asthma rates hover near 10%, it becomes incumbent to look for ways to demonstrate better management, reduced exacerbations, and improved quality of life among those with asthma.

For the general public, the reason is not so clear. Employers gripe about high overhead due to the cost of providing coverage for employees. However, employers are neglecting the cost of an asthmatic worker, or the caregiver of an asthmatic child, needing to miss work on any given day due to an attack that may have been prevented with adequate coverage. The price of asthmatic medications is considerably less than the cost of several emergency room visits per year. There is much political debate about the Affordable Care Act stemming from the argument, appealing to many, that the covered and working public should not have to shoulder the financial burden of providing coverage for those without it. However, many fail to realize that emergency rooms still treat regardless of the ability to pay- in short, the public would still carry the fiscal obligation of providing care for the underprivileged, since the emergency room would remain their lone option. Malcarney, Seiler, and Horton (2013) state that under the Affordable Care Act, Medicaid allowed states to push more preventative strategies outside the formal clinical setting; among those was the Monroe Plan in New York, which targeted children and saw emergency room visits decline by 78% and asthma hospitalizations drop by 60%. (p.404)

Policy Recommendations

Since asthma is a chronic condition affecting children, education should not be limited to those afflicted or health care providers, but expanded to the public school system. The Department of Health and the Department of Education could collaborate on a program identifying schools with high prevalence of asthmatic students, and targeting those schools for programs such as pamphlets students could take home with tips on how to remove triggers from the home, or information for teachers on what to do in case of an asthmatic attack in the classroom; school nurses could provide the necessary teaching. The city currently runs the Open Airways program, which provides education for children and information for parents without charge in public schools. (New York City Department of Health and Mental Hygiene, 2016) In New Orleans, counselors collaborated with school nurses and providers to create individualized plans for children with asthma based on each participant’s specific triggers, coupled with education on improving home air quality. (Mitchell, et. al p.1608) This allowed afflicted households to have specific plans in place. Mitchell et. al (2012) followed up with participants and saw marked improvements in household conditions, resulting in more symptom free days. (p.1609-1610) Malcarney, Seiler, and Horton (2013) note that the National Asthma Education Prevention Program sponsors teaching sessions in schools and community centers, saving a range of $5.30 to $14.00 per dollar spent. (p.402-403) Malcarney, Seiler, and Horton (2013) note that several insurance companies, such as Optima, Priority Health, and Neighborhood Health Plan, have asthma education programs, and all have seen substantial returns and savings. (p.403) Bake, Viklund, and Olin (2014) assert that asthmatic symptoms lag several days after exposure. (p.1281) Kazuhiko et. al (2015) also note that there is a delay of several days between peak pollen counts and a subsequent spike in OTC allergy relief meds or emergency room visits. (p.6) With this in mind, another solution would be to publicize warnings on days following high pollen counts so that affected people can take precautionary measures.

Concerning traffic, Sheffield, Zhou, Shmool, and Clougherty (2015) find that ozone production follows a pattern, with low levels from 4-6 AM and peaks at 12-2 PM. (p.3) Since these times roughly correspond to both times of low and high traffic volume and low and high daily temperatures, the city can attempt to manipulate traffic patterns centered around peak times. Bike lanes and even jogging lanes can help. Heikkinen, Quansah, Jaakkola, and Jaakkola (2012) point to several random controlled trials in which asthmatics who exercised regularly had increases in oxygen consumption as well as improvement in FEV1 among the intervention group, along with a reduction in the average number of inhaler puffs of beta2-agonist meds from the first week of the exercise program to the last week. (p.402) Perez et. al (2012) also point out that denser housing would also increase physical activity because it would promote walking rather than driving. (p.1625)

Yet increased congestion and traffic mean more emissions. One policy recommendation would be to accompany a rezoning plan with another for reducing overall emissions. (Perez et. al, 2012, p.1624) A second would be to limit the number of new residences placed along major streets, since they will be the most trafficked. Major streets could be reserved for commercial developments, while residences are placed further away on side streets. In their study in Los Angeles, Perez et. al (2012) concluded that thousands of cases of asthma could have been averted if residences were placed further away from highways and major roads. (p.1622) The Delhi government instituted its alternate day ban on vehicle operation in large part “to protect public health in a city where every third child has impaired lungs.” (Environment Pollution Authority, 2016, p.1)

Summary

The urban landscape combines high density housing with vehicular traffic and its consequent greenhouse emissions. Combine this with the stresses of poverty- lack of coverage, homes in disrepair, poor gestational and neonatal care, and the recipe is set for asthma and other respiratory illness. New York City as a whole may have a smaller carbon footprint than other major US and world cities due to a credible mass transit system and relative walking distance to most amenities. Yet asthma still remains a major health concern for the city, especially in certain neighborhoods like Brownsville. Navigating an issue like asthma presents many challenges because there is no single treatment, and no cure, for asthma, while at the same time the necessities of continuing to foster growth and prosperity with housing and economic opportunity has to be balanced against the knowledge that these developments may actually worsen the current asthma epidemic. New York City is not alone in this struggle, and can look to both learn from the experiences of other cities and be a leader in innovating new strategies to improve asthma rates.

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