"Asthma has sort of caught us by surprise, we don’t understand it," says U.S. Surgeon General David Satcher in a recent comment about dramatic increases in childhood asthma reported by the Health People 2000 program.
The Centers for Disease Control and Prevention reported a 61 percent increase in asthma rate between 1982 and 1994, with a sharp upward trend in 1990.(1)
According to the American Lung Association, more than 5,600 people die of asthma in the U.S. annually -- with a 45.3 percent increase in mortality between 1985 and 1995.
This is pretty serious stuff but hardly a state secret, so I’m wondering why Satcher was taken by surprise. I certainly wasn’t. I’m curious that no one is screaming for improved indoor air quality standards -- beyond the ridiculous and politically precious demands for smoking restrictions.
Could someone just open the window, please?
Indoor air-related health problems began to increase after the gasoline shortages of the 1970’s. In fact, with the benefit of 20/20 hindsight, we could probably have predicted some of the respiratory distress that resulted from federal government regulations focused on reducing energy use in commercial and residential buildings. It turns out that energy efficient buildings concentrate the levels of contaminants trapped inside -- by policies and products designed to reduce "excessive" energy wasting fresh air.
Whoops. Weather-tight buildings don’t allow for natural air flow. And the EPA knows it. Way back in 1988, the EPA noted "the air within homes and other buildings can be more seriously polluted than the outdoor air in even the largest and industrialized cities... the current trend toward sealing off homes to conserve energy may have serious health consequences."(2)
The problem is that the really crappy stuff in the air is invisible. So it’s easy to target a diesel truck or a smoker, but not so easy to admit that we’re gasping from our demands for increased building energy efficiency (can you say ‘hermetically sealed,’ children?)
ASHRAE, the American Society of Heating, Refrigerating and Air Conditioning Engineers, states quite clearly that "Dilution of indoor air is defined as a process that adds outdoor air (which is assumed to be less contaminated) to reduce the concentration of contaminants. This dilution can range from the use of ‘100% outdoor air’ to a combination of outdoor and re-circulated indoor air that has been filtered." Simply: the solution to indoor air contamination is dilution of indoor air with (gasp) fresh outdoor air.
Poor indoor air quality is no medical secret
Dr. Satcher’s puzzlement is particularly odd because the connection between energy efficient building and increased asthma rates sure hasn’t missed the attention of the medical community.
"The elucidation of the multiple causes of illnesses secondary to indoor air pollution can be addressed by greater attention to design, construction, and operation of buildings where people live and work,"(3) note authors writing for the specialist journal Asthma.
"Increasingly recognized as a potential public health problem since the outbreak of Legionnaire's disease in Philadelphia in 1976, polluted indoor air has been associated with health problems that include asthma..."(4)
"Indoor pollution is a major public-health issue, say representatives from government and the medical profession who participated in a recent workshop in Ottawa. Researchers are certain that indoor pollution causes many of the allergy-related problems and asthma, bronchitis, rhinitis, coughing and others respiratory problems experienced by North Americans."(5)
"Poor indoor air quality has been suggested to be related to the increase in the prevalence of asthma that has occurred in the western world, especially among children and young persons. Apart from the home, school is the most important indoor environment for children... Although the pupils attended school for a minor part of their time, our study indicates that the quality of the school environment is of importance..."(6) According to one environmental engineer with EPA, there has been "a general decline in school ventilation in the decades of asthma increase."(7)
"Decreased ventilation after the energy crisis in the United States in the 1970s..." could certainly contribute to the asthma problem, notes the editorial accompanying an article in the New England Journal of Medicine.(8)
Poor indoor air quality isn’t the only culprit in the Great Asthma Conundrum.
Lest I be accused of bashing only the US Environmental Protection Agency (which deserves to be disbanded and reinvented with a real scientific mandate), allow me to add: the National Institutes of Health, the Centers for Disease Control and Prevention, medical journals and, most of all, the gullible mainstream press.
Driven by a thousand fears gaily and daily promoted in pre-digested press and video releases sent to popular news outlets, parents are currently afraid to expose their children to: 1) sunshine (melanoma), 2) fresh air (pollution), 3) fruits and vegetables (pesticides), 4) bicycles, skates and skateboards (and, of course, dreaded trampolines), 5) contact sports (physical injuries), 6) truly competitive activities (psychic injuries), 7) unsupervised play time (random murderers) and, apparently, 8) rational thought (sigh!).
So what happens when children stay inside, don’t eat fruits and vegetables, have no unsupervised play time, can’t freely bike, run, bounce, climb or generally bumble through childhood? They get fat. That’s fat, folks -- as in 24% obese adolescents today v 15% in the 1970’s. Satcher further notes that in 1995, 35% of Americans are overweight v 26% in the mid-1970’s. Pretty heavy stuff.
Maybe those frightened folks hiding in their "climate controlled" habitats watching sports instead of playing them are gonna live forever. But existing in an atmosphere of unspecified anxiety over statistically insignificant health risks doesn’t meet my definition of living.
The Obesity-Asthma Connection
Guess what? Obesity is implicated in asthma, too -- as well as a whole range of other life dulling maladies, from diabetes (another "epidemic" according to Satcher), heart disease, strokes, back problems and plain old indigestion. "The prevalence of overweight was significantly higher in children with moderate to severe asthma than in their peers, and being overweight was associated with significantly more severe asthma symptoms," conclude the authors of one study.(9) "The risk of overweight based on a BMI in the 85th percentile or greater was significantly associated with the following measures (increased) of asthma severity," they continue.
"Many study subjects had medical problems considered to be related to obesity: 30 percent had asthma," observe another group of authors.(10)
Yet another of the 158 studies retrieved from Medline in a simple search under ‘obesity+asthma’ states, "The difference in obesity between children with asthma and controls was significant for both sexes and across the 4.5 to 10.9 years and 11 to 16 years age groups."(11)
Who’s gonna pay this time?
The American Lung Association notes that the total estimated cost of asthma in 1993 was $12.6 billion, including direct and indirect expenditures. In the U.S., asthma is the number one cause of school absences attributed to chronic conditions, leading to an average 7.3 school days missed annually. According to another ALA fact sheet, "...one study estimated that in 1994, school days lost to asthma amounted to $673.2 million in caretaker's time lost from work, including outside employment and housekeeping." Hey, kids, that’s more than the inflated figures for smoking-related costs. Let’s blame someone and sue to recover the costs.
If I were a commercial or residential building developer, I’d keep a hand on my wallet and my lawyer’s phone number on speed-dial. ASHRAE might do well to invest in some malpractice insurance, too. The fast food industry is already on the run. Why not the building engineers, too?
Please, no! Not "Asthma-Free Kids"
According to Vol. 47, No. 4 of the National Vital Statistics Reports, in 1977, there were 5,338 deaths from asthma. Among chronic illnesses in children, asthma is the most common. Approximately 33 percent of asthma patients (14.8 million cases in the U.S.) are under the age of 18. This is a real health problem -- and it’s not caused by television violence, guns or tobacco. What’s a government to do? May I suggest nothing?
How about looking at the health costs associated with the mindless drive for energy efficiency? How about considering the Infamous Law of Unintended Consequences before we leap into the idiocy of a Global Warming treaty? How about considering the deadening effect on the spirit of reporting meaningless health statistics claiming to relate (you fill in the blank) to "premature death."
Let’s NOT think up new ways for government to "save the children." Let’s NOT pay attention to the health scares and immeasurably small "risks" touted by the advertising revenue-hungry medical journals and precious web sites like the slick, pharmaceutical company funded efforts C. Everett Koop.
Let’s DO open the windows, get out and play, eat heartily and well and most important of all, pass on to kids the sheer joy and wonder of living an false-fear-free life. There’s enough really scary stuff out there (like the EPA or NIH or CDC or even the IRS).
References:
1. http://www.cdc.gov/nchswww/datawh/statab/pubd/asthma.htm
2. U.S. Environmental Protection Agency and the U.S. Consumer Product Safety Commission, "The Inside Story: A Guide to Indoor Air Quality." 1988.
3. The sick building syndrome. II. Assessment and regulation of indoor air quality. Ruhl RA, Chang CC, Halpern GM, Gershwin ME J Asthma 1993 30:4 297-308.
4. The indoor air we breathe. Oliver LC, Shackleton BW Public Health Rep 1998 Sep-Oct 113:5 398-409.
5. Indoor air quality a major public-health issue, workshop told. Cohen L CMAJ 1995 Jul 1 153:1 92-3.
6. Asthma among secondary schoolchildren in relation to the school environment. Smedje G, Norbäck D, Edling C Clin Exp Allergy 1997 Nov 27:11 1270.
7. "The First Family's Asthma Problems" Ben Lieberman, Competitive Enterprise Institute, http://www.cei.org/OnPointReader.asp?ID-621.
8. Thomas A.E. Platts-Mills et al., "Asthma And Indoor Exposure To Allergens," The New England Journal of Medicine, May 8, 1997, p. 1384.
9. Association of being overweight with greater asthma symptoms in inner city black and Hispanic children. Luder E, Melnik TA, DiMaio M J Pediatr 1998 Apr 132:4 699-703.
10. Childhood obesity. Medical and familial correlates and age of onset. Unger R, Kreeger L, Christoffel KK Clin Pediatr (Phila) 1990 Jul 29:7 368-73.
11. The relationship between asthma and obesity in urban minority children and adolescents. Gennuso J, Epstein LH, Paluch RA, Cerny F Arch Pediatr Adolesc Med 1998 Dec 152:12 1197-200.
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