Look to the Environment for Diagnostic Help

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Look to the Environment for Diagnostic Help

Jim Windell

          Is a patient’s address important in making a diagnosis prior to initiating treatment?

          That was a question raised by Renee N. Salas, M.D., M.P.H., in a recent article she wrote in the New England Journal of Medicine.

           Dr. Salas began thinking about that question when treating a young girl whose asthma kept getting worse, despite patient and family compliance with treatment prescribed by the doctor.

           The doctor was well aware that evidence has linked pediatric asthma exacerbations to exposure to traffic-related and particulate-matter (PM) air pollution, ground-level ozone, and pollen. It seemed reasonable to assume that certain environmental exposures were interfering in the girl’s treatment for asthma.

           Then, Dr. Salas, an emergency medicine doctor, reports that she looked up the girl’s address. That’s when the light bulb went on. The girl lived in a neighborhood that was previously redlined. Redlining is a now-banned racist housing practice that supported segregation and limited the economic opportunities available to Black families. Her house and her neighborhood were in very close proximity to a highway. The doctor could easily conclude that this girl had been far too often exposed to high levels of traffic-related air pollution from the combustion of fossil fuels. But that wasn’t all that Dr. Salas could glean from knowing where this young girl lived.

           For instance, she could determine that the girl was subject to a kind of structural racism. That form of structural racism is “environmental racism.” Environmental racism includes the use of racist practices in determining which communities receive health-protective infrastructure, such as green space, and which receive health-harming highways and industrial complexes.

           Dr. Salas was aware that many communities that were once subject to redlining are hotter than non-redlined communities. This in part because of a dearth of green space and an overabundance of human-made materials, such as asphalt, that create an urban heat-island effect. These are conditions certain to affect a child with asthma or other health conditions. Heat has implications for exposure to ground-level ozone, which is generated from a chemical reaction of air pollutants with heat and sunlight. Climate change, as we’ve all become aware due to the latest report from the International Panel on Climate Change, is definitively increasing the intensity and frequency of extreme heat. In addition, climate change is intensifying pollen seasons – with implications for children and their health.

           In Dr. Salas’ opinion, environmental racism and climate change are not only complex, interconnected, system-level challenges, but they directly and indirectly contribute to individual-level health harms. These harms threaten what the healthcare and medical community is all about — equitably preventing harm, improving health, and saving lives.

           She concludes by writing that environmental racism contributes to disproportionate exposure of people of color to air pollution and contributes to increased risk for multiple health harms. Incorporating aspects of environmental racism and climate change into clinical practice could lead to better treatments for patients. Better treatments might include educating patients and families about steps they can take to adapt to or minimize exposure to PM, ozone, and pollen levels. But knowing about environmental racism raises the questions about the responsibilities of all of us to address larger systemic issues.

           We can all strive to influence policy decisions that have health and equity considerations.

           To read the original article, find it with this reference:

Salas, R. (2021). Environmental Racism and Climate Change — Missed Diagnoses. The New England Journal of Medicine. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2109160


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