Historical redlining associated with health disparities in children with asthma
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Key takeaways:
- Children in historically redlined neighborhoods reported greater exposure to pollutants and major trafficways.
- They also had a stronger association between pollutant exposure and poor asthma symptoms.
School-aged children residing in historically redlined neighborhoods had higher exposures to pollutants and worse asthma severity, according to a study in The Journal of Allergy and Clinical Immunology.
Historically racist policies contribute to present day health inequities, Stephanie Lovinsky-Desir, MD, MS, Herbert Irving Associate Professor of Pediatrics in Environmental Health Sciences and chief of the pediatric pulmonary division at Columbia University Irving Medical Center, and colleagues wrote.
The historical practice of redlining contributes to negative respiratory health outcomes in children residing or attending school in the affected areas.
“Our group has been interested in learning more about how historical and contemporary injustices influence health disparities today,” Lovinsky-Desir told Healio.
Historical redlining refers to the 1930s government-sponsored practice in which the Home Owner’s Loan Corporation would split neighborhoods into four categories. Those neighborhoods in “Grade D” or “redlined” were predominantly populated by people of color and systematically labeled as hazardous for mortgage lending, the authors wrote. The effects of this practice perpetuated segregation and social/environmental as well as health inequalities that exist to this day.
“A key area of interest is how public policies can have such a significant impact on health and that impact can be felt generations later,” Lovinsky-Desir said. “This is important because we need to consider how the policies we support today will not only impact us and our children, but also many others who will come afterward.”
Methods
This 52-week study used a sample of children aged 6 to 17 years with moderate to severe asthma from nine U.S. cities: Boston, Chicago, Cincinnati, Dallas, Denver, Detroit, New York, St. Louis and Washington, D.C. The children resided in urban low-income census tracts.
The study sample enrolled participants from the Inner-City Asthma Consortium, which only included children residing in low-income areas. In total, 240 children with difficult-to-control and exacerbation-prone asthma (two exacerbations requiring corticosteroids and blood eosinophils > 150 cells/mm3) were included in the analysis.
Participants also completed between one and six repeated clinical visits. Researchers collected data on school and home exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) from the Air Quality System by the Environmental Protection Agency. Ambient ozone (O3) levels were also collected.
PM2.5 and NO2 were assessed as a composite estimate of home and school exposure by weighing the concentrations according to hours spent in school, which on average was 7.5 hours a day. Exposure was calculated based on geospatially assessed monthly average concentrations of the outdoor pollutants.
Data on redlining were obtained from the Mapping Inequality project developed by the University of Richmond. Asthma burden was measured between one and six times using the Composite Asthma Severity Index (CASI) and spirometry.
Results
Among the 240 children with asthma (mean age, 10.9 years; 55.8% boys; 68.8% Black, African American or Afro-Caribbean), 40% had a BMI above the 95th percentile, and 82.1% reported a sensitization to an indoor allergen. The number of children that lived or attended a school in a historically redlined neighborhood was 90 (37.5%).
The highest percentages of homes and schools in redlined neighborhoods were in Denver (93%), Cincinnati (58%) and Detroit (52%). The lowest percentage was in Washington, D.C., at 0%.
Children who did not live or attend school in a historically redlined neighborhood were older (mean age, 12 vs. 10.3 years), more frequently exposed to environmental tobacco smoke (27.8% vs 20.7%) and used more inhaled corticosteroids and long-acting beta-agonists (70% vs 44%; P < .01 for all).
Children in different cities showed unique characteristics. Those living in Denver had greater lung function (FEV1, 2.5 ± 1.1 L/second) but also the highest NO2 (19.1 ± 3.6 ppb; P < .0001) vs. those at other sites. Compared with children living at other sites, New York City children also had high NO2 levels (16.6 ± 2 ppb) while also having shorter distances to highways (0.6 ± 0.3 km; P < .001) and better average FEV1/FVC levels (0.81 ± 0.06 L/second; P < .001) and FEF25-75 levels (2.2 ± 0.7 L/second; P < .001).
Researchers found no statistically significant difference between home and school exposure to PM2.5 or NO2. However, children in historically redlined neighborhoods experienced levels of outdoor NO2 27% higher than those in non-redlined neighborhoods (median, 15.4 ppb vs. 12.1 ppb; P < .01).
Children in vs. not in redlined neighborhoods also had closer proximities to highways (median, 0.86 km vs. 1.23 km, respectively; P < .01). Air pollutants and proximity correlations were observed solely in historically redlined neighborhoods (r = -–0.24 for PM2.5 and –0.22 for NO2; P < .05).
Higher levels of PM2.5 were significantly associated with higher CASI in children from redlined neighborhoods (P < .005). In this same group, researchers found links between elevated PM2.5 levels and lower lung function. They also observed a positive association between NO2 and lung function as measured by FEV1 (adjusted beta = 0.07; 95% CI, 0.02-0.1), FEV1/FVC (adjusted beta = 0.02; 95% CI, 0.01-0.03) and FEF25-75 (adjusted beta = 0.13; 95% CI, 0.02-0.24).
No association was found between NO2 and respiratory outcomes when data were stratified by redlining (P > .005). Also, no significant associations between air pollution and respiratory outcomes were found.
“The key findings were that children who lived and/or attended school in historically redlined neighborhoods across several major U.S. cities had greater exposure to pollutants and lived closer to major traffic sources than their peers who did not live or attend school in redlined neighborhoods,” Lovinsky-Desir said.
She added that children who lived or attended school in redlined neighborhoods had a stronger association between pollutant exposure and poor asthma symptoms. They were more greatly impacted by air pollution than their peers.
“I don’t think these findings are surprising,” she said. “We know that environmental factors can impact health. What is significant about the findings is that this is the first study to examine the historical practice of redlining and the influence on contemporary environmental injustice and poor health outcomes in children.”
Even though similar studies have been conducted in adults, this is the first looking at respiratory health outcomes for children, according to Lovinsky-Desir.
“It is striking when you consider that the government-sponsored public policy of redlining occurred almost a century ago and yet the children who live in these communities three and four generations later are still impacted by it,” she said.
When asked about how doctors can use these study findings to improve care, Lovinsky-Desir explained that we are hearing about social determinants of health and how they impact health outcomes at an increased rate, which in turn should prompt physicians to be aware of what the social determinants of health are, learn how to screen for risk factors in culturally sensitive ways and educate themselves on the resources within their communities to which they can connect their patients.
“Our study demonstrates that it is the children who live and/or go to school in historically marginalized communities who need the greatest access to these resources,” she said.
Public health policy should also be considered when taking into account this study’s findings.
“It is imperative that we focus attention on those communities that have been impacted the most by environmental racism,” Lovinsky-Desir said. “Thus, the findings of this study highlight the importance of centering resources and efforts on communities that have been historically redlined as a way to advance health equity.”
Perspective
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Unfortunately, this finding is not surprising, but it is very significant and adds insight into the ways that structural racism has persistent health consequences.
For example, prior studies in Baltimore have demonstrated that current life expectancy is lower in historically redlined areas. Studies of other cities, including Pittsburgh, have demonstrated persistent impact on adult asthma morbidity.
The present study sheds light on the impact for children, both in the risk for air pollution exposure at home and at school. The increased pollution exposure among children living in the redlined neighborhoods was associated with more severe asthma.
These findings support what we see in our clinic while caring for patients with asthma. At the Hopkins BREATHE Center, we study childhood asthma in home-based, community-based and school-based studies.
We continue to find disparities in the likelihood of exposure to air pollution as well as other exposures that are important for healthy development, including access to healthy foods and safe greenspace to exercise and play. We are currently partnering with Baltimore City Public Schools and the city’s health department to implement a school-based asthma management program to support children living with asthma.
The study focuses on both home and school exposures. This focus highlights the opportunity to consider neighborhood-level interventions and underscores the need to consider the relevance of school exposures to children’s health. The disparities that persist in school infrastructure are astounding, and interventions in schools have the opportunity to impact hundreds and thousands of children at a time. Advocating for improvement in school facilities, particularly in historically marginalized communities, is something that can be done at the local, state and national level.
Health care professionals should consider the totality of the lived experience and try to better understand barriers to health care and healthy lifestyle for patients and their families.
References:
Huang SJ, et al. PLOS One. 2022;doi:10.1371/journal.pone.0261028.
Schuyler AJ, et al. Am J Respir Crit Care Med. 2022;doi:10.1164/rccm/202112-2707OC.
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