Children show poor asthma outcomes in high environmental injustice areas in Atlanta
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Key takeaways:
- Children living in high environmental injustice census tracts have more exposure to pollutants and impaired lung function.
- Study results call for community-level interventions in asthma equity.
Children living in census tracts with greater environmental injustice experienced poorer asthma outcomes, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Researchers found that children aged 6 to 18 years with asthma from census tracts of metropolitan Atlanta that ranked highest in environmental injustice included racial and ethnic minorities with a lower socioeconomic status, Jocelyn R. Grunwell, MD, PhD, assistant professor of pediatrics in the division of critical care medicine at Emory University and attending physician at Children’s Healthcare of Atlanta, and colleagues wrote.
The children were more often exposed to hazardous pollutants and more likely to live next to railroads and heavily trafficked roadways as well, the researchers said.
These children also tended to have longer durations of asthma, greater historical asthma-related health care utilization, poorer symptom control and quality of life, and more impaired lung function.
Study design
The study used the U.S. Department of Health and Human Services’ Environmental Justice Index (EJI) to determine how the level of environmental injustice these children experienced impacted asthma exacerbation burden, asthma control and lung function over 12 months of follow-up, as well as if children with high levels of environmental injustice exhibited differing clinical features of asthma at enrollment. The EJI is based on a battery of composite indicators and provides a score to estimate the effects of environmental burdens for a particular census tract.
Study participants aged 6 to 18 years (n = 575) were identified from routine clinical encounters at Children’s Healthcare of Atlanta. After informed consent, a research visit was completed for characterization procedures.
Next, researchers reviewed medical records for each participant for 12 months for an occurrence of an asthma exacerbation that had to be treated with systemic corticosteroids, an ED visit, or a hospitalization. For participants who consented to an in-person follow-up visit at 12 months, spirometry was performed as well as an asthma control and quality of life determination.
The participants were divided into three groups — low injustice (n = 190; mean age, 11.3 years; 51.6% boys), moderate injustice (n = 190; mean age, 11.2 years; 61.6% boys) or high injustice (n = 195; mean age, 11.5 years; 59.5% boys) — based on EJI results.
Study findings
Census tracts with high injustice had a significantly greater proportion of racial and ethnic minorities vs. moderate and low injustice groups (84.3% vs. 76.6% and 48.5%; P < .05 for both). The high vs. moderate and low injustice group also reported significantly more poverty, unemployment and persons who rent homes and significantly lower household incomes, levels of education, health insurance access and internet access. Households in this group were also slightly younger and reported having more disabilities and less English fluency.
Air pollution was high in each group, but exposure to diesel was higher in the high injustice census tract group compared with low and moderate groups. They also had more homes within a 1-mile buffer of an U.S. Environmental Protection Agency toxic release inventory site and homes built before 1980, as well as less green space, less walkability and closer proximities to railroads, roadways and highways.
Participants from moderate and high injustice census tracts had a longer duration of asthma and significantly more lifetime and current health care utilization for asthma. They also had more tobacco smoke exposure.
Researchers found that 84% of participants had evidence of sensitization to at least one aeroallergen (low, 77.7%; moderate, 88.4%; high, 86.6%), and 74% had multiple aeroallergen sensitization (low, 66.1%; moderate, 76.9%; high, 77.2%).
Participants from moderate and high injustice census tracts had a significantly higher chance of being sensitive to dust mite (low, 56.3%; moderate, 71.9%; high, 71.7%; P = .015) and cockroach (low, 21.4%; moderate, 40.5%; high, 31.7%; P = .007), with no differences in mold, pollen, or pet dander sensitization. They also had higher fractional exhaled nitric oxide and serum IgE concentrations.
Asthma symptom control was significantly poorer in moderate and high injustice vs. low census tracts, whereas asthma quality of life was poorer in children from high vs. moderate and low injustice census tracts. These scores correlated with six-item Asthma Control Questionnaire scores in the combined sample (r = –0.709; P < .001).
Differences in quality of life were driven by the symptom and emotional domains of the Asthma Quality of Life Questionnaire instrument (symptom domain, P = .009; emotional domain, P = .007), with no significant differences in the activity domain for low vs. moderate vs. high.
Lung function of participants from moderate and high census tracts had lower FEV1 than participants in the low census tract. More participants from high injustice census tracts had FEV1 values below the lower limit of normal (P = .01)..
At 12 months, 155 participants reported an asthma exacerbation with systemic corticosteroids. The occurrence was significantly greater in participants from high injustice census tracts compared with low injustice tracts. A similar occurrence was seen with ED visits.
Also at 12 months, 203 of the 575 participants completed an in-person follow-up visit. Findings showed that high environmental injustice census tracts continued to have poorer asthma symptom control, quality of life and lung function than those in lower environmental injustice census tracts.
Authors of this study emphasize that their results show disparities in environmental justice in metropolitan Atlanta that require further study and consideration into community-based interventions for asthma equity.
Perspective
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Andrea Pappalardo, MD, FAAAAI, FACAAI
These findings are most definitely significant. Although the authors clearly acknowledge the limitations of the EJI, their findings illuminate how asthma in communities affected by environmental injustice has a longer duration and is plagued by significant morbidity.
As we are actively looking to understand how pollution affects our bodies, these findings illustrate an association with where pollution is high, asthma morbidity is sure to follow. Even in this study where everyone was unfortunately exposed to significant air pollution, the differential exposure to diesel and proximity to traffic/railways was significant.
These findings also show that race is a social construct. It is not the race that is driving these worsened asthma outcomes, but rather the downstream effects of racism and social injustice that cause those who are either socially disadvantaged and/or from a historically marginalized community that influence these persistent asthma disparities.
I work in Chicago. In neighborhoods that are directly affected by environmental injustice, I have seen directly how events — such as the Hillco explosion in Little Village and pollution along the Industrial Corridor — influence asthma prevalence and morbidity.
Families often don’t feel they have a voice to stand up against these injustices, and this is reflected in the findings of this study. With higher environmental injustice comes more hazardous/toxic sites, worsened transportation infrastructure and increased pollutants.
These findings should directly influence public policy to systematically eliminate environmental injustice and to regulate pollution for the benefit of all of our lung health now and well into the future.
Where someone lives, works and plays matters. Many people have stories regarding their exposures that they live with every day but may not consider them relevant. It is up to us to help our patients correlate their symptoms to their lived environment and also provide them with the words and voice they need to stand up to injustice.
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Grunwell JR, et al. J Allergy Clin Immunol Pract. 2024;doi:10.1016/j.jaip.2024.02.015.
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