One of the most impactful statements I have heard in trying to understand how racism affects our world is “Racism is not the shark, it’s the water.” When I was a pulmonary fellow, I remember learning about race-adjusted equations when learning about pulmonary function testing.. To explain it, one of my faculty advised thinking about the difference in body types between two Michaels- Michael Phelps, who is all torso, and Michael Jordan, who is also tall but with longer legs. Off hand comments about “seated height” and “torso ratios” were thrown around, but to be honest, it was not deeply explored. In the 80+ hour weeks of working in the ICU or on a busy pulmonary consult service, trying to pursue my research and learn about this nearly infinite field of life and death decisions, I have to confess that I didn’t explore it further.
It was my work later in air pollution and learning more about red lining that caused me to think about this again. If we are saying that it is normal for black people to have lower lung function, and that may not be true, how many people with actual lung illness are we missing? How does that impact their lives? Everything suggests that areas of high air pollution damage the lung growth of children and increase their risk of disease. And we know that red-lining has led certain communities to grow up in more polluted air.
My podcast guest today directs a pulmonary clinic in the heart of a historically red-lined district, and she is working hard to help understand how racism and the history of red-lining not only impacts the health of communities but also how the very ways we use to measure lung function are affected and what we can do about it.
Dr. Neeta Thakur is a pulmonary and critical care physician at the University of California San Francisco. Dr. Thakur completed a dual degree program in public health and medicine at the University of Arizona focused on community health. I met her when she was my senior resident in the Internal Medicine residency program at UCSF, and she stayed at UCSF to complete her Pulmonary and Critical Care Medicine fellowship. Dr. Thakur serves as the Medical Director of the San Francisco General Hospital Chest Clinic, and studies how social and environmental stress negatively affect people suffering from asthma and COPD.
On the podcast episode, we discuss how people living in historically red-lined districts are exposed to more air pollution and suffer greater health consequences from it.
We also cover the history of lung measurement, and how it came to be adjusted for “racial factors.” Undoing this is not as simple as it sounds, and Dr. Thakur covers what the studies show on the utility of these adjustments, when they might be useful, and how we move forward to decrease health disparities.
I have often returned to think about myself as that pulmonary fellow first learning about race-adjustment in lung function equations. It should have brought me to a screeching halt. I am ashamed to admit it did not. I know I am not alone in this. What we are taught is carefully curated to maintain a certain “innocence” of those in our profession or community who came before. We see this on a global scale across our world in which some histories are told and some are not. We see this in the refugees who are welcomed and those who are not. We see this in who is newsworthy and who is not. We even see it in the local school board fighting about whose history should be taught and whose children should be comfortable and whose should not.
One of the books that should definitely be taught, and I’m sure it is often not, is James Baldwin’s “The Fire Next Time.” I did not read it until after college, though it would have done me much good, I am sure, to have read it earlier in life. In regards to lung function testing and race, as well as being part of the healthcare system in general, I have found myself returning over and over again to the line, “But it is not permissible that the authors of the devastation should also be innocent. It is the innocence which constitutes the crime.” It is a crime, against morality if not the law, that we concentrate air pollution in the communities of those who are already facing life with fewer resources. That air pollution then causes disease and disability, which gives them even fewer resources to live their lives. Then, when we try to measure whether disease has been caused, we change the way we measure disease, to say that it is not there when it is.
This is the water in which we are swimming or, more accurately, the air we are all breathing. Sadly, it has a lot of toxic elements, and we all need to do our part to clean the air and clear the air about why it was so polluted in the first place. Facing the racism in our own communities and in our own professions is uncomfortable but vital work. It requires a great deal of humility and a commitment to demanding and doing better science and is a call to stop reacting defensively when true harm is revealed to us.
TLDR= Don't Light Things on Fire and Breathe them into your Lungs
To Do:
1- To learn more about the history of air pollution’s impact on health, you can go back to the first season for a host of episodes. For example, podcast Episode 2 with Dr. Matt Drake and Episode 17 with Dr. Ritz. Learn about how red-lining can affect those asthma risk in Episode 27 with Prof. Shandas.
2- I am serious about the importance of hope! Learn more about how policy can work- listen to Episode 12 about cleaning up diesel school buses with Dr. Adar and Episode 16 with the American Lung Association’s analysis of the economic stimulus and decrease in asthma we might see with a transition to electric vehicles
3- Listen about one person’s story with asthma growing up in a previously red-lined district by listening to Ashia Allen, a patient of mine.
4- For more about air pollution and air toxics in the Portland Metro area, listen to Episode 5 with Mary Peveto and Episode 7 with Prof. Linda George
5- If you haven’t read “The Fire Next Time,” be sure to do so. If you are in healthcare and care for those with respiratory illness, “Breathing Race into the Machine” is certainly worth reading.
6- Finally, consider a donation to the American Thoracic Society, which works tirelessly for clean air and has funded research like that done by Dr. Thakur early in her career. Full disclosure, I volunteer as a member of the ATS Environmental Health Policy Committee.
References
Baldwin, James. “The Fire Next Time.”
Contreras MG, Keys K, Magaña J, Goddard PC, Risse-Adams O, Zeiger AM, Mak ACY, Samedy-Bates LA, Neophytou AM, Lee E, Thakur N, Elhawary JR, Hu D, Huntsman S, Eng C, Hu T, Burchard EG, White MJ. Native American Ancestry and Air Pollution Interact to Impact Bronchodilator Response in Puerto Rican Children with Asthma. Ethn Dis. 2021; 31(1):77-88. PMID: 33519158
Nardone A, Casey JA, Morello-Frosch R, Mujahid M, Balmes JR, Thakur N.Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study. Lancet Planet Health. 2020 01; 4(1):e24-e31. PMID: 31999951.
Nardone A, Neophytou AM, Balmes J, Thakur N. Ambient Air Pollution and Asthma-Related Outcomes in Children of Color of the USA: a Scoping Review of Literature Published Between 2013 and 2017. Curr Allergy Asthma Rep. 2018 04 16; 18(5):29. PMID: 29663154;
Neophytou AM, White MJ, Oh SS, Thakur N, Galanter JM, Nishimura KK, Pino-Yanes M, Torgerson DG, Gignoux CR, Eng C, Nguyen EA, Hu D, Mak AC, Kumar R, Seibold MA, Davis A, Farber HJ, Meade K, Avila PC, Serebrisky D, Lenoir MA, Brigino-Buenaventura E, Rodriguez-Cintron W, Bibbins-Domingo K, Thyne SM, Williams LK, Sen S, Gilliland FD, Gauderman WJ, Rodriguez-Santana JR, Lurmann F, Balmes JR, Eisen EA, Burchard EG. Air Pollution and Lung Function in Minority Youth with Asthma in the GALA II (Genes-Environments and Admixture in Latino Americans) and SAGE II (Study of African Americans, Asthma, Genes, and Environments) Studies. Am J Respir Crit Care Med. 2016 06 01; 193(11):1271-80. PMID: 26734713;
Nishimura KK, Galanter JM, Roth LA, Oh SS, Thakur N, Nguyen EA, Thyne S, Farber HJ, Serebrisky D, Kumar R, Brigino-Buenaventura E, Davis A, LeNoir MA, Meade K, Rodriguez-Cintron W, Avila PC, Borrell LN, Bibbins-Domingo K, Rodriguez-Santana JR, Sen S, Lurmann F, Balmes JR, Burchard EG. Early-life air pollution and asthma risk in minority children. The GALA II and SAGE II studies. Am J Respir Crit Care Med. 2013 Aug 01; 188(3):309-18. PMID: 23750510
