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The United States has spent decades cleaning up air pollution. In 1970, the Clean Air Act (CAA) imposed sweeping federal regulations on air emissions and established the National Ambient Air Quality Standards (NAAQS), a metric still used today to measure air quality and protect public health. These regulations were strengthened in 1990 when an amendment to the CAA imposed further regulations on hazardous emissions.
Air quality in the U.S. has improved since the CAA—between 1970 and 2020, emissions of the six most common pollutants decreased by 78%—but an overwhelming number of Americans still breathe unhealthy air outside and find little respite within their homes. This can have serious health implications, especially with long-term exposure.
Air pollution is the “greatest external threat to human life expectancy,” shortening the global average life span by 2.3 years. This is more than three times that of alcohol use and five times that of transportation injuries.
For people with asthma—7.7% of the U.S. population—air pollution can be especially harmful. Numerous studies have linked poor air quality to the worsening of asthma symptoms. Exposure to pollutants can induce asthma attacks, aggravate symptoms, and increase hospitalization rates. Exposure to emissions from vehicles and burning fossil fuels, as well as to secondhand smoke, is also a known risk factor for the development of asthma in children.
Finding a solution to the effects of air quality on asthma rates and severity gets more complicated when you consider how both factors intersect with race, location, and socioeconomic status.
I’m a mixed-race, middle-class asthmatic from California. As a consequence, my experience with diagnosis, treatment, and management looks wildly different from those without my privilege. I had access to healthcare and medications. I had a support system that advocated for my health. I lived in a progressive state, working to reduce air pollution for longer than I’ve been alive. That’s not the case for many asthmatics, often people of color, who face historical and structural barriers to resources, care, and even prevention.
As expected, air quality worsens as you move into urban areas, which the Census Bureau defines as “densely developed residential, commercial, and other nonresidential areas.” About 80% of the U.S. population lives in an urban area, and on average, these areas experience 47.5 days of extremely poor air quality, as compared to 3.8 days in rural areas. All told, this means that most Americans spend 13% of their year in poor air quality.
The burden of these statistics is not carried equally across either racial or socioeconomic groups. Your race and socioeconomic status directly impact your exposure to pollution, not just where you live. On average, people of color are exposed to and breathe in more air pollution, with both Black and Hispanic populations experiencing higher exposure rates than white populations.
However, separating location from race and socioeconomic status can be difficult. The United States has a long history of oppression and discrimination that impacts where people of color, especially Black Americans, live and work. Historical redlining, for example, has been linked to disparities in air pollution exposure. It’s even been shown to worsen some of the environmental risk factors that cause asthma. The now-illegal practice limited the development of green spaces and eventually raised city temperatures, two factors that can increase asthma risk.
It’s in part due to policies like these that people of color make up 52% of those who live in areas affected by at least one form of pollution, despite making up only 4.6% of the U.S. population.
All of this helps us to understand why Black, Hispanic, and Indigenous populations have the highest asthma rates, deaths, and hospitalizations of any other racial groups in the U.S. The numbers are staggering. Black Americans are 42% more likely than white Americans to be living with asthma. Puerto Ricans have the highest rates of asthma when compared to any other racial or ethnic group in the country. American Indian and Alaskan Native children are 50% more likely to have asthma than other groups. The body of research only continues to grow.
Addressing the structural and societal inequalities that have created these problems takes time and persistence—and while that work is being done, people with asthma still need to find a way to move through a world that already makes it difficult to breathe.
“As easy as breathing” takes on a different meaning when you have asthma in a world with unclean air. Even in the best of circumstances, managing asthma can feel like a constant guessing game. The situation becomes more alarming when you factor in the social and structural barriers that people of color with asthma face. Apart from putting these communities at higher risks for asthma, it can also prevent them from receiving care for their condition.
One of the most important components of asthma management is regular appointments with a primary care provider. However, that requires having a primary care provider. The legacy of discrimination in the medical field is well known, and this long history of mistrust between the Black community and medical professionals has created many racial disparities in healthcare, including asthma care.
Black Americans, for example, are more likely to rely on the emergency room (ER) for medical treatment, rather than a primary care provider. While data on how other racial groups view medical providers needs further research, it isn’t hard to see how other people of color may be repeatedly discouraged by similar mistrust of doctors.
Closing these gaps, and many others like them, is central to taking the disproportionate effects of asthma off of communities of color. This work takes many forms, from making changes that dismantle systemic racism in the medical community to smaller-scale projects, like replacing gas stoves in the homes of kids with asthma. That’s work The Children’s Hospital of Philadelphia (CHOP) is undertaking with its CAPP+ Home Repairs Program. You can read more about their work ahead.
For those of us with asthma, it takes a combination of changes both big and small to manage our condition. That’s on a good day when it’s not aggravated by the air around us. While it may seem bold to claim that cleaning the air improves asthma outcomes, the link is well established. Environmental improvements and health outcomes go hand in hand. Asthma is just the start.
— Riyana Straetker