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Children's Health Protection

Letter from Pamela Shubat, Ph.D., to Administrator Jackson regarding Asthma Disparities and the Living and Learning Environments

March 31, 2011

Lisa P. Jackson, Administrator
United States Environmental Protection Agency
1200 Pennsylvania Ave, NW
Washington, DC 20460

RE: Asthma Disparities and the Living and Learning Environments

Dear Administrator Jackson:

The Children’s Health Protection Advisory Committee (CHPAC) is writing this letter to urge renewed action to address disparities in childhood asthma. As evidenced by historical rates of asthma emergency room visits and hospitalizations, asthma disparities have disproportionately increased among children of color. The Centers for Disease Control and Prevention (CDC) have reported that Black children are 2-3 times more likely to be hospitalized and 5 times more likely to die from asthma. Although access to care may be a contributing factor, the environmental exposures for children who live in substandard housing also play an important role. Substandard housing, overcrowding, and deteriorating conditions in indoor environments impact the lives of children with asthma daily in living (home, shelters) and learning (schools, childcare, Head Start) environments. In general, CHPAC believes that the relationship between asthma and the indoor environment deserves much greater attention.

We recognize that the President’s Interagency Task Force on Environmental Health Risks and Safety Risks to Children is currently addressing ways to reduce asthma disparities and we commend the Environmental Protection Agency (EPA) for collaboratively working with other federal agencies to host the December 2010 Interagency Asthma Disparities Work Group meeting. In this letter, we recommend specific actions that EPA can take, both within the agency and with other key federal stakeholders, to advance the effort to reduce disparities in asthma in living and learning environments. Attached to this letter is detailed information (Indoor Environment Workgroup Report on Asthma Disparities) which provides the context for these recommendations.

Recommendations for Intra-agency Actions
  • CHPAC recommends that EPA develop standardized housing and school inspection protocols that objectively measure asthma trigger exposures, using the most recent scientific data.
  • CHPAC recommends that EPA establish indoor exposure limits for allergens and chemicals that cause or exacerbate asthma.
  • CHPAC recommends that further research be undertaken by EPA to develop standardized testing methods and exposure limits for new building materials that may contribute to asthma, such as emissions of volatile organic compounds (e.g., formaldehyde) and other agents that can cause or exacerbate asthma.
  • CHPAC recommends that EPA explore the connection between the environment and root causes of asthma and as appropriate promulgate regulations.
  • CHPAC recommends that EPA continue to promote and disseminate best practices and information for individual, public, professional and government audiences using best communication strategies for control of asthma triggers through:
    • Promoting and funding model programs that have been shown to be effective in learning and living environments (see attached report)
    • Promoting and supporting the distribution of Tools for Schools and HealthySEAT.
    • Developing messages that highlight the link between childhood asthma and academic achievement.
    • Disseminating business case studies which demonstrate to health care payors as well as public health agencies the cost-effectiveness of environmental interventions in the prevention of asthma exacerbations. For example, the Asthma Regional Council for New England has developed a document, “Investing in Best Practices for Asthma: A Business Case.”
Recommendations for Interagency Actions
  • CHPAC recommends that EPA collaborate with other federal agencies and programs, such as the Department of Education (ED) and the Department of Health and Human Services (HHS) Office of Head Start (OHS), to develop national standards for healthier learning and living environments.
  • CHPAC recommends that EPA partner with the Department of Housing and Urban Development (HUD) to require public and other federally assisted housing to be “smoke-free”.
    • EPA should promote “smoke-free” policies in homes and cars for all children.
    • EPA should support the availability of environmentally safe federally assisted housing for children with asthma (e.g., Seattle’s “Breathe Easy Homes”).
    • CHPAC recommends that EPA work with other federal agencies, such as HHS and HUD, to standardize certification of community health workers and utilize them to implement evidence-based asthma trigger reduction strategies at the community level.
    • CHPAC recommends that EPA reach out and partner with the HHS Center for Medicare and Medicaid Services and others to provide asthma trigger reduction supplies and services for all eligible children with asthma.
    • CHPAC recommends that EPA work with ED and OHS to implement policies that support professional development programs which provide school personnel (including principals, teachers, school nurses, building engineers, maintenance staff, food service managers, and coaches) with the knowledge and resources needed to maintain and promote healthy school environments.
    • CHPAC recommends that EPA work with CDC to promote surveillance in order to target environmental interventions to children and communities at greatest risk.
    • CHPAC recommends that EPA work with ED and HHS to support federal and state policy that promotes improvements in the school nurse to student ratio (to a national goal of one to 750), recognizing the role of school nurses in managing asthma and reducing asthma triggers.

    Finally, CHPAC recommends that the President’s Task Force on Environmental Health and Safety Risks to Children be reconvened, with a formal public meeting co-chaired by the EPA Administrator and the HHS Secretary, to consider these recommendations. HUD and ED as well as CDC should be active participants in this meeting. CHPAC notes that a meeting of this type has not occurred for nearly a decade. Such a meeting could stimulate more focused and effective action across many agencies to renew the efforts to eliminate asthma disparities. Disparities in asthma morbidity and mortality should not exist in the United States when evidence-based tools and methodologies for reducing gaps in care are so readily available.

    CHPAC strongly urges EPA to consider these recommendations in an effort to close gaps in asthma outcomes and to take the lead in convening leaders and stakeholders in the battle to eliminate asthma disparities in the United States. These recommendations should also be utilized to reduce environmental triggers of asthma in other environments where children spend significant time (e.g., hospitals, clinics, libraries, play areas). In summary, CHPAC recommends that EPA should advocate for a public health approach to eliminating asthma disparities, crossing boundaries and work along with other key stakeholders for fundamental and systemic changes to improve outcomes for disadvantaged children with asthma, thereby reducing asthma disparities.

    Respectfully submitted,

    Pamela Shubat, PhD
    Children’s Health Protection Advisory Committee

    Peter Grevatt, Director, Office of Children's Health Protection
    Mike Flynn, Director, Office of Radiation and Indoor Air
    Gina McCarthy, Assistant Administrator, Office of Air and Radiation
    Cynthia Giles, Assistant Administrator, Office of Enforcement and Compliance Assurance
    Lisa Garcia, Associate Assistant Administrator for Environmental Justice, Office of Enforcement and Compliance Assurance

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