Poor Air Quality, Pollution Endanger Health of Children: Designing Healthier Communities for Kids

Kim Krisberg

Nations Health. 2006;36(2) 

One in a series on children's health and the built environment in conjunction with APHA's National Public Health Week. The event, which will be held April 3-9, focuses on "Designing Healthy Communities, Raising Healthy Kids."

Seeing children play outdoors can be an encouraging sight, especially considering the wealth of electronic and mass media diversions competing for children's attention. Unfortunately, for children living with asthma and other respiratory illnesses, playing outdoors on a day with poor air quality can pose a serious health risk and end with a trip to the emergency room.

While the exact causes of asthma are still unknown — and therefore ways to prevent its initial onset are also unknown — it is possible for children with asthma to mitigate the disease's effects and prevent an asthma attack. Much of such prevention relies on individuals modifying how they interact with and live in their built environments, such as avoiding places with cigarette smoke, knowing how to keep living spaces free of attack triggers and always being aware of outdoor air quality. Still, even though individual prevention strategies are valuable, some public health and environmental advocates point to permanent changes in the built environment — which encompasses all of a community's manmade structures and daily living spaces — that if implemented could reduce children's overall pollution exposure and in turn, decrease complications associated with respiratory diseases.

In the United States, asthma prevalence increased overall by 75 percent between 1980 and 1994 and 74 percent among children ages 5 to 14, according to the National Heart, Lung and Blood Institute, which estimates that more than 7 percent of U.S. children live with the disease. In 2002 alone, asthma accounted for 12.7 million doctor visits, 1.9 million emergency department visits, almost 500,000 hospitalizations, more than 4,000 deaths and millions of dollars in health care spending. While U.S. asthma mortality rates have grown overall in the past two decades, the rate has risen disproportionately among children and black Americans, who experience asthma-related hospitalizations at triple the rate of whites. Often, such diseases are solely discussed as health problems, but more and more, people are becoming aware of the intrinsic connection to the way community design and transportation plans are realized.

"It really is about density, diversity and design," said Greg Dierkers, MEM, senior policy analyst at the Center for Clean Air Policy in Washington, D.C.

A higher level of community density will help create more walkable communities and greater use of mass transit; a diverse mix of residential and commercial uses can decrease reliance on cars; and better design --- such as designing streets in a grid pattern instead of using dead-end cul de sacs --- allows for direct travel between locations, Dierkers told The Nation's Health. Such designs, often called "smart growth," can lead to substantial improvements in air quality, especially in traffic-related emissions, he said. And change is needed: According to the Centers for Disease Control and Prevention, 25 percent of America's children live in areas that regularly exceed acceptable limits for ozone, more than a quarter of which is traced back to car emissions.

While fuel-related technology has helped reduce car emissions during the past few decades, growth in "vehicle miles traveled" is offsetting the clean air benefits, according to a report on air quality and smart growth that Dierkers co-authored in 2005. More than 50 years ago, 69 million people lived in 157 urbanized areas covering almost 13,000 square miles, but by 2000, the same 157 urbanized areas covered more than 52,000 square miles and hosted 155 million people --- a reduction in population density by about half, the report stated. In many areas, such vehicle-dependent sprawl has led to troublesome traffic congestion, which often leads to building more roads and creating more pollution.

"If you build a new road, then people will switch from other routes or from transit to fill up that space," Dierkers said. "Over a two- to three-year period, usually the road will fill in (with cars), in effect creating more traffic and air pollution."

And more traffic can mean asthmatic children are at risk for health complications. A landmark study published in the February 2001 issue of the Journal of the American Medical Association examined the impact of major transportation changes in Atlanta during the 1996 Olympic games on childhood asthma. To accommodate the summer games, Atlanta officials developed and used traffic strategies such as a 24-hour public transit system and an additional 1,000 buses for park-and-ride services. Researchers found that the transportation changes coincided with a more than 40 percent decrease in asthma emergency care visits and hospitalizations, with peak daily ozone concentrations decreasing almost 28 percent.

"There's a lot of new concrete being laid and there's a lot of emphasis now on transit-oriented development... but it's not automatic," said John Balbus, MD, MPH, director of the health program at Environmental Defense. "We need to level the playing field... (the government) subsidizes cars and roads, but it's like pulling teeth to subsidize transit."

Still, Balbus noted, reducing reliance on cars through denser development could be a "double-edged sword," as children might spend more time outside and increase their exposure to air pollution from other sources, such as nearby industrial emissions.

"We need to be reducing all sources of air pollution and make outdoor air safe, regardless of community design," he told The Nation's Health.

As important as modifying the outdoor environment is to reducing the health effects of childhood asthma, so is reducing indoor triggers, such as mold and pests, as "people spend most of their time indoors," according to Howard Frumkin, DrPH, MD, director of CDC's National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry. For the dispro- portionate number of black children who suffer from asthma, a higher likelihood of living in poor housing or housing located near high-traffic roads or factories — as well as lower access to regular health care — contribute to the population's disparate asthma rates. While there is a slightly higher prevalence of asthma among blacks, Frumkin noted, the great disparity lies in the health outcomes of asthma, with blacks three times to five times more likely to die, visit an emergency room or be hospitalized due to the disease. To help address such a disparity, stakeholders must ensure the advantages of smart growth reach all populations, he said.

"A higher quality (of housing) for everybody and reducing exposures across the population will be a great contribution to reducing the burden on minority populations," Frumkin told The Nation's Health. "Urban planning and community design needs community input at all stages... making provisions for quality and affordable housing is a very important part of public health."

For example, some localities require that developers guarantee a certain percentage of new housing be affordable, as an "integral part of smart growth is providing housing for all," Frumkin noted. And public health workers will be key in keeping good health at the forefront as smart growth gains momentum.

"Transportation and urban planners were traditional public health partners that grew apart temporarily... in the early century, architects very much thought they were doing public health (work)," Frumkin said. "Now, we need to have open and active communication with those allied professions... there needs to be public health leadership to encourage change on the local level."

Communities Facing Industrial Hazards

While better transportation planning and affordable housing can improve childhood respiratory complications, some communities face dangers from proximity to industrial pollutants --- with worries that such exposure is affecting children's academic and physical development as well. In Ohio, Dick Wittberg, PhD, executive director of the mid-Ohio Valley Health Department, has been urging the government to conduct a comprehensive health study on children in Marietta, Ohio, after his own studies raised concerns that exposure to nearby industrial pollutants may be affecting their development.

"Looking out over the Ohio River, there's no haze in the air; this is not a (Los Angeles) type of environment," Wittberg said. "We don't have stinky air for the most part, but I've also never been one to equate smells with dangers."

With the outskirts of town located about three miles away from a metal alloying plant, the area around Marietta has the highest releases of manganese metal dust in the nation, with the nearby plant emitting about a half million pounds of manganese each year, according to Wittberg. In the mid- 1990s, while working on his master's degree, Wittberg was involved in an environmental study that found the relative risk of exposure to manganese around the plant was more than 10 times higher than the next highest toxic emission. While the study was part of a temporary consulting job, Wittberg said he "hasn't been able to let go."

A few years later, Wittberg and his wife conducted a study to compare fourth-grade children in Marietta to children in Athens, Ohio, about 50 miles away. If manganese is a harmful neurotoxin, its effects would first be seen in children, he said. Using a test the Environmental Protection Agency employs to measure neurotoxin exposure --- with measures such as visual acuity, balance and learning disabilities --- Wittberg and his wife tested 19 matched pairs of students from each community, finding that the "Marietta kids did statistically significantly worse."

"Quite frankly, I was not expecting to find a difference between the two... I would have been happier if I had found nothing," Wittberg told The Nation's Health.

Wittberg emphasized that his study doesn't trace the differences back to manganese and that a much more formal study needs to be conducted before any conclusions are drawn. Fortunately, though, because of Wittberg's work and advocacy, EPA and ASTDR have begun developing protocol to do just such a study, but it remains to be seen whether the study will be funded and ultimately conducted.

"To me, the differences in my study said we needed people who were competent to come in and do a study," Wittberg said. "If there is evidence of a health problem, we are required to make sure that it is examined as closely as it can be and that we don't rest until we're sure people aren't being hurt."

Similar industrial pollution concerns have prompted residents in southern Louisiana to take air quality into their own hands. In 2000, Anne Rolfes founded the Louisiana Bucket Brigade, an environmental health and justice organization that works with communities neighboring oil refineries and chemical plants, teaching residents to take their own air samples using ordinary buckets.

"For me, it was a fundamental case of injustice, of people with no power living next to these enormous plants," Rolfes told The Nation's Health. "For the people who were involved and standing up to the plants, it really came down to a pragmatic issue of their health. The power of the bucket lies in the fact that people are trained to take samples for themselves... it changes a very vague complaint into concrete documentation of toxic harm."

To build the air testing tool, brigade participants take a run-of-the-mill bucket, put a seal on top and punch a hole or valve through it. A vacuum seal is then created that when opened, draws an air sample into a bag placed inside the bucket. Among the toxins that residents have discovered after taking bucket samples ranged from the neurological toxin hydrogen sulfide to reproductive and developmental toxins xylene and toluene, Rolfes reported. The communities decide what to do with the air quality results, often going to the media after attempts to engage companies have failed, Rolfes said, adding that when companies "finally do respond, ultimately it's because they're embarrassed."

"When people take a sample, it really confirms what they believed all along," she said. "People are generally made to feel stupid and belittled and when they prove what they've been saying all this time, it gives them incredible power."

In 100 percent of the cases, Rolfes said, problems stem from the proximity of refineries and plants to residential neighborhoods. In the case of the Diamond community of Norco, La. --- a traditionally black neighborhood --- in which a nearby chemical plant agreed to buy residents' contaminated land, the plant's fenceline was located just 25 feet away from residents' homes. Unfortunately, the state's black residents bear an unfair burden of such pollution: More than 50 percent of those who live within three miles of a refinery are black, even though blacks make up about a third of Louisiana's population, according to Rolfes.

Out of the disastrous aftermath of Hurricane Katrina, which devastated parts of the state in August, could come opportunities to better zone and design residential areas, but Rolfes said she doubts that will occur.

"That's why we're in this mess --- because we planned stupidly," she said. "But I don't think things will change after Katrina."

Such change is slow, but public health professionals can help illustrate the link between community design, air quality and children's health, because public health workers "get it --- we get the link," said Nse Obot Witherspoon, MPH, executive director of the Children's Environmental Health Network and immediate past chair of APHA's Environment Section.

"Without a doubt, if we don't have an impact or some proactive way to stop this, we're going to continue to see huge respiratory issues in our children," she told The Nation's Health. "So we have to ask ourselves as a nation: Is that okay?"

For more on the built environment, air quality and children's health, visit www.cdc.gov/healthyplaces or www.ccap.org. For more on the work of the Louisiana Bucket Brigade, visit www.labucketbrigade.org. For more news from The Nation's Health, visit www.thenationshealth.org.

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