A session at the American Thoracic Society 2018 International Conference examined the factors that contribute to disparities and potential partnerships between doctors and lawyers on behalf of patients.
If you see a power plant, chances are it’s in a poor neighborhood. Professionals paying high rents can complain about a ceiling leak, but for the poor, asking for a healthy home might bring risk of assault or eviction. Within the higher asthma rates across populations of minority children is the story of Maria Brisuela of Chicago, who saw her son was suddenly coughing and tired all the time, and learned it was due to asthma brought on by mold in her building.
These are the realities that low-income people face, and they translate into higher rates of asthma and chronic obstructive pulmonary disease (COPD). But there are ways for clinicians to help their patients—not only to combat disease, but to fight the forces causing it, according to a panel that appeared Sunday at the American Thoracic Society 2018 International Conference, being held in San Diego, California.
John R. Balmes, MD, professor of environmental health sciences at University of California at Berkeley School of Public Health, launched the session with data: African Americans and those with low socioeconomic status (SES) have higher prevalence of asthma and worse clinical outcomes; with COPD, the racial disparities are less stark, but there are ties to SES; COPD is strongly linked to smoking, which is much more common among those at low-income levels.
Both diseases have strong associations with elevated levels of air pollution, especially traffic-related pollution, Balmes said. Living near a port—with emissions from trucks and trains—is emerging as a major risk. “Rich people don’t live near a port,” he said.
People of color and with lower SES are more likely to live in areas where they are exposed to toxic emissions, with fewer “health-promoting amenities,” such as parks, green spaces, or grocery stores that sell fruits and vegetables. That last part is a double whammy, Balmes noted, because the antioxidants in healthy foods would be beneficial.
He discussed “dirty jobs,” including construction and farm labor, which tend to go to immigrants and people of color. Not only are the jobs hard and full of exposures, but the people who do them are under stress. “They are vulnerable because of that stress,” and the combination of air pollution and psychosocial stress adds to their health risk.
Balmes said it’s essential to understand how the combination of having an unhealthy job in an unhealthy neighborhood creates a “cumulative risk” from which the poor feel they cannot escape. It’s hard to “capture the interplay on health,” that the combination of genetics, behaviors such as smoking and drinking, and neighborhood exposures place on a person. While some studies have been done on the effects on children and on how maternal health is affected by traffic-related pollution, better biomarkers are needed to measure this stress.
“More research is needed for a better understanding of the effects of neighborhood levels of air pollution,” he said. Like other speakers, Balmes said the poor typically have little control over the housing or workplace conditions that affect their health status (a recent series by The Philadelphia Inquirer on toxic conditions in city schools noted that parents face penalties for failing to enroll their children).
“The economic system in this country perpetuates environmental inequality,” he said.
Cleaning the Air
Sonali Bose, MD, a pulmonologist at John Hopkins Medicine, uses HEPA (high efficiency particulate air) filters to create cleaner indoor environments for Baltimore families, especially those with children. While large public health interventions that clean up the ambient environment might be preferred, “the timeless can be over several decades,” she said. “A lot of interventions that affect indoor air pollution are in control of the residents.”
Using an indoor air filter allows families where members are suffering from asthma to improve their environment—at perhaps a lower cost than a biologic, as 1 questioner pointed out—by clearing up particulate matter so common in urban settings, particularly from traffic. She presented data to show that HEPA filters are quite effective, but there are some challenges. Some families say they can’t afford the electricity to run them. And, HEPA filters don’t stop people from smoking. Bose said this is frustrating when children are being exposed to secondhand smoke; unfortunately, “they are not at liberty to change a lot of the behaviors that they’re being exposed to.”
The next step, she said, is to start focusing on better air quality for pregnant women. “Gestation is a period of rapid lung growth, and is linked to later childhood outcomes,” she said.
Would payers, including Medicaid, ever cover a HEPA filter, 1 person asked. “I wish,” Bose said. “If the level of evidence shows there is truly a benefit,” and leads to fewer healthcare costs associated with asthma, then perhaps, she said. But not soon.
Advocating for Patients
Drew Harris, MD, a pulmonologist and an assistant professor of Public Health Sciences at the University of Virginia, presented the concept of medical—legal partnerships—which give clinicians a place to send patients who are suffering health effects because of exposures in their apartment or workplace. He asked what the audience knew about growing awareness of social determinants of health—and many knew that social and environmental factors drive disparities. And then he listed the barriers, at the provider and system level.
“There’s confusion over ownership,” Harris said. Right now, addressing social determinants of health is still at the stage of “process measures,” but this is changing. The key is to connect providers and health systems with community resources so doctors have a place to send patients, because they don’t want to bring up problems they can’t solve.
And problems abound. In his own research, Harris has encountered tenants who feared retaliation from an employer if they complained about toxic dust. Housing is equally fraught. “Assaults have occurred when people advocated for themselves,” he said. “These are very complicated problems.”
The idea of partnerships between doctors and lawyers to advocate for patients began in Boston decades ago, Harris said, when a group of physicians hired counsel to sue on behalf of groups of patients who kept showing up with asthma attacks due to infestations and mold in their housing.
Laws vary by state, but Harris said a good partnership has certain core elements: (1) a leading healthcare institution, (2) a legal aid organization (3) a funding mechanism, (4) an ability to screen cases, (5) an ability to train users of the system.
Harris doesn’t have data yet showing that partnerships improve asthma control, but he does know that helping people reduce utility shutoffs reduces stress. And, “Doctors are more likely to discuss these issues with patients if they have a legal resource.”
He then introduced Brisuela, who had moved with her son, Joseph, to a 1-room basement apartment in Chicago when she was working and attending school. At first, when Joseph started coughing, Maria Brisuela thought he had a cold. But when the weather warmed and the cough and fatigue continued, she knew something was wrong. Joseph had asthma.
“When summer came, I started noticing mold in the apartment, on the furniture, even my clothes,” she said. “I told the landlord. He accused me of being dirty.”
Brisuela did not give up. She got in touch with a Legal Services attorney and got out of the apartment, sued, and got an inspection report that found “the place was not fit for people to live in.” The landlord settled. Today, her son is off his inhaler.
And while the settlement helped, Brisuela said, “It was about the justice.”