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Episode #2220
Health Disparities and Environment
Brown: For years it’s been known that blacks have higher incidents of health related illnesses compared to whites. But why? Is it the environment? Are there financial reasons? Or do black people just tend to be less healthy? We’ll talk about possible causes for racial health disparities and new research efforts, next on Black Issues Forum.
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Brown: Good afternoon and welcome to Black Issues Forum. I’m Natalie Bullock Brown. According to the 2003 Racial and Ethnic Disparities Report Card published by the North Carolina Office of Minority Health and Health Disparities, African Americans as well as Native Americans and Latinos experienced significant disparities in most areas of health status including but not limited to cardiovascular disease, diabetes and cancer. Why do the health disparities exist in the first place and what’s being done to close the gap? To discuss these questions and more we have an expert panel of guests. I would like to welcome Dr. Marie Lynn Miranda, Director of the Children’s Environmental Health Initiative within the Nicholas School of the Environment and Earth Sciences. Dr. Miranda is also a faculty member in Duke’s Integrated Toxicology program. And we would also like to welcome Sherman A. James, Susan B. King Professor of Public Policy Studies and Professor of Sociology, Community and Family Medicine and African and African American Studies at Duke University. Thanks to both of you for being a part of Black Issues Forum. First we want to share with you part of an interview that Mitchell Lewis had an opportunity to conduct with Nigel Fields, an environmental health scientist with the EPA’s National Center for Environmental Research to learn about the work of the EPA and a newly funded project.
Lewis: First of all, tell us what is the mission of the EPA’s National Center for Environmental Research?
Fields: The National Center for Environmental Research is one of the research arms of EPA. Our job is to fund environmental research and environmental science, fellowships and grants across the country to answer some of our most challenging environmental questions. We focus both on ecological research and also human health research.
Lewis: And of course, the EPA recently was part of funding a project at Duke University. Tell us about that.
Fields: Yeah, we’re very excited about this. This is the Southern Center for Environmentally Driven Health Disparities and Birth Outcomes. Our mission here is to understand what contributes to disparities between populations and birth outcomes like premature birth, low birth weight and the Duke Center is going to give us a lot of insight into what those contributors are and how we can be more protective of children’s health.
Lewis: What do you see as some of the, say, specific components of the Duke Center’s project?
Fields: The Duke Center’s projects include an epidemiology study which will try to understand spatial relationships, where people are located, how they are located, and certain exposures that happen in their environments. It will also involve a clinical study where we will enroll women who are pregnant and try to understand what’s going on during pregnancy that contributes to these low birth weights, premature births and we will also have a basic science project that will involve mechanisms to understand exactly what’s going on biologically. So these three projects together, we think, will really give us a good insight into what these disparities are and how to be more protective.
Lewis: What do you hope to accomplish from this particular project?
Fields: Main mission of EPA is to protect public health and the environment. What we like to do is to understand children’s vulnerabilities and to also understand what’s going on in pregnancy as early as possible. If every child could have a healthy start we think the nation would be a much better place. It’s a great place already but we really want to improve our environment for kids. So we like to understand what’s going on in pregnancy and to improve health outcomes.
Lewis:Although the Duke project is focusing specifically with children, when you look at the adult population there is plenty of documentation on disparities of health conditions between minorities and non-minorities especially when you look at stroke, diabetes, heart disease and that sort of thing, HIV, AIDS, why has the EPA decided that it was important for them to study these specific health concerns?
Fields: That’s an excellent question. One of the things that we found out is that low birth weight, pre-term births are linked towards, or linked up with those effects later on in life. So trajectory for a child that has pre-term birth or a low birth weight, they are at higher risk of developing diabetes, cardiovascular disease, hypertension. So if we can understand what’s happening earlier on and be more protective we can hopefully reduce those disparities and see a reduction in those outcomes later in life.
Brown: All right. Given what Dr. Nigel Fields said, Dr. Miranda, I would like to start with you and just ask about the impetus behind even pursuing the grant with the EPA.
Miranda: Well, we had done a lot of work on health disparities particularly those related to environmental exposures and with sort of children in elementary school. And then we started moving early and earlier. And we became increasingly convinced. I think Nigel made this point very well that we are not even getting things right for kids at the moment that they’re born. You know, blacks are twice as likely in North Carolina to be born low birth weight than non-Hispanic whites are. And there is the whole series of both childhood illnesses and adult illnesses that are associated with it. So in childhood you are more likely to have asthma, sudden infant death syndrome, you are more likely to have low behavioral or learning disorders if you are born low birth weight. So we became—we found ourselves focusing earlier and earlier and earlier in children’s lives and realized we really want to understand why it is that we have these very significant disparities in pregnancy outcomes even after you control for poverty and even after you make sure that women are getting access to prenatal care. It’s a much more complicated question than one might think originally and because there is this whole cascade of health effects that follow if we don’t get it right at the very beginning we became very committed to working on this and our commitment in particular to working on this within the context of the American South is really the driving impetus for our whole research group.
Brown: And I understand that the research has really just begun because the funding just fell into place recently. Is that right?
Miranda: May 1st. It was a good day. [LAUGHTER}
Brown: Okay. Tell me a little bit more about the sort of work that you have been doing at Duke even before the grant came into place, just dealing with health disparities.
Miranda: So I direct something at Duke called the Children’s Environmental Health Initiative which is a research, education and outreach program committed to fostering environments where all children can prosper. So we work primarily in low income and minority communities. We spend all of our time—we spend most of our time trying to help local health departments, state health departments, federal agencies, community groups, church groups, figure out ways to make children’s programs preventive in their approach as opposed to mitigative so let’s not wait until kids get sick. Let’s figure out places that are likely to make children sick and put some pressure on policy makers to get changes put into place. And the technical bailiwick of my research group is spatial analysis of data which means that for every piece of information that we collect there is always a spatial location attached to it. And we kind of exploit that information about where people are and where they work and how they navigate through space and time to get additional analytical insights from that.
Brown:Dr. James, let’s get you in here. Would you please talk about the work that you have been doing dealing with health disparities, racial health disparities in particular and then how you fit into the Duke research.
James: Well, I’ve been working on racial health disparities for about three decades now. And my work prior to joining Dr. Miranda’s team dealt primarily with hypertension and diabetes which are very important parameters of disparities affecting the black population. And I am a social epidemiologist so I am interested in the contribution that social factors make to health disparities: poverty, economic stress, stress resulting from racism, lack of social supports—these kinds of things that really sort of make people vulnerable in adulthood.
Brown: Can I ask you really quickly, what sort of general findings have you found in your 30 years of experience?
James: Well, with respect to, say, cardiovascular disease, it’s very clear that low income and unemployment and low education levels are very powerful forces in making African Americans especially vulnerable to morbidity and mortality from cardiovascular disease. Only within the last 10 years or so have researches begun to look at racial stress as an additional contributor. Above and beyond poverty and low SES to the extraordinary burden of ill health that African Americans face. And the signals in respect to the contribution of racism, a little bit mixed and so we still have to refine our tools in terms of being able to get a good assessment, a good idea of the effects of racism on health. But the work is getting better and better all the time. And, of course, we can think about race induced stress in terms of interpersonal relationships, things that people are exposed to in their work environment or in public spaces. But we can also think about in terms of racial residential segregation and how racial residential segregation which affects the black population incredibly in this country blocks opportunities for upward social mobility. And, of course, I said earlier that low SES and poverty are very powerful determinants of health disparities. And so if society is organized in such a way that blacks and to some degree Latinos are sort of boxed into residential areas where there aren’t resources available to help them to live in a healthy way, the schools aren’t particularly good, then they can’t really move up and take full advantage of the opportunities that exist in society for the majority population.
Miranda: And that’s actually exactly where the spatial analysis comes into play because if we are interested in pursuing for example this idea of racial residential segregation, if all the people in both of our large epidemiological study and in our clinical study we know a lot about where they live and what their exposures are both in terms of environmental exposures, but also what is the quality of the neighborhoods, the quality of the housing stock, what kinds of stores and community resources and churches and daycare centers and different things like that are around them, we can start looking at this question in a much—using these techniques from spatial statistics, we can start looking at this question in a very sort of hardnosed analytical way which is one of the reasons we are so excited to be combining the expertise of someone like Dr. James with, you know, those of us who have spent a little too much time thinking about matrix algebra. [LAUGHTER]
Brown: Well, I appreciate you jumping in because that was exactly what I was going to ask is how does his research and his expertise fit into this especially when you are talking about birth outcomes. And can you talk a little bit more about just the methodology for the research. What exactly are you looking at and is it specific to North Carolina? Are you looking at the general region? Talk a little bit about that.
Miranda: So we are looking at North Carolina. In the first project that Nigel talked about it’s our spatial epidemiology project. We have 15 years of the detailed birth record data and so that means that all the births in the state of North Carolina over a 15 year period. So that is about a million and a half observations. My kids are in there. And what we are doing is for all 100 counties in the state we are identifying where those moms were located and then linking them up to census data, linking them up to environment exposure data, road network data, community resource data etcetera so that we can sort of look within this very large study context that what sorts of things are happening. And we have the clinical obstetrics project which is all in Durham County to be in the project you have to be in Durham County because in addition to all that other data that I just talked about we have much more detailed data on Durham County since Durham is the host to Duke University. We always make Durham our key study County. We always make Durham County our key study county. So as a consequence over the past 10, 15 years we have built up an enormous set of spatial data resources on the county. So we know things for example, we have all of the crime data already mapped for Durham County. We have all of the housing code enforcement data so houses that were below code, we have all of that mapped. We have the location of all of the parks and recreational centers and community resources—all of that is really well mapped for Durham County. And then the animal study which is to me one of the most sort of unique components of this, is we are suing mice because we certainly wouldn’t want to expose pregnant women, we wouldn’t want to expose deliberately to pollutants, but we did a little bit of work in the spatial epidemiology project and found out that with this, some preliminary funding that we got from the university, found out that we were seeing some relationships between air pollution exposure and pregnancy outcomes. Turn to our neonatology colleagues who have done a lot of work with mouse models, and said, “Well, here’s what we are finding in this study over here. Can you work something up in the mouse model and in particular what we are interested in is not just looking at exposure to ozone or to exposure to particulate matter but look at them at the same time because we are seeing some interesting things over here.” So this is one of the first animal studies that is looking at multiple pollutant exposures. And the other thing that is really unique about it is it’s looking at multiple windows. We are exposing the mice prenatally and we are exposing them postnatally. And we are seeing that there is a little bit of like biological priming that’s going on. So that’s led us now to go back to the clinical study and the spatial epidemiology study—
Brown: With people—
Miranda: That’s right. And to look really carefully at these windows that maybe we have identified a little bit through the mouse model, these windows like well, let’s look really carefully at exposure during the second trimester of pregnancy because that seems to be important in the mouse model here and delve into that a little bit more. So there is this constant communication and synergy so while I said, for example, that Dr. James is most involved with that first project, in fact, when we get together we tend to talk about all of the projects at the same time because they are so closely related to each other.
Brown: Right. Dr. James, talk a little bit about—especially from your angle of expertise, the challenges in doing this sort of research and especially with the three different approaches going on at the same time.
James: Well, one of the great challenges of course is terminology because different kinds of scientists use different terms. And so developing a common language for interdisciplinary research is a challenge and it can only be overcome with time and with conversation and so I think that Dr. Miranda’s team has already made a lot of progress in that regard. But I bring—I’m a social scientist by training and so I am very interested in developing or applying theoretical perspectives about how stress works, how stress gets into the body to complicate health, in this case it would complicate reproductive health. And so what’s really special and unique I think about this particular project is that it—when we think about the environment we not only are talking about physical environmental exposures such as kinds of metals that Dr. Miranda just talked about but social environmental exposures as well: crime, fear of being a victim, noise, all kinds of things that can put people, that keep people on edge, that make them fearful that cause their cardiovascular system to sort of be revved up much of the time. And they may think they have gotten used to it, they have adjusted to these difficult sort of social circumstances in their environment but biologically you see they are homeostasis has been set at a much higher level than would be the case in someone who lives in a much more kind of tranquil environment.
Brown: And when you say homeostasis what do you mean?
James: I mean balance, sort of internal physiological equilibrium. So the body is always responding to input from the outside and that input, of course, can be some physical, some adverse physical factor or it can be a social insult. It can be the perception that you are not being treated fairly or it can be interpersonal conflict. As I said before it could be a drive-by shooting. Those kinds of things that sort of create very different living conditions if you will, or where—characterize different kinds of living environments for poor people versus rich people, poor black people, versus whites, for Latinos compared to whites. And so all of these things really impact one’s physiology. And compromise, we believe a woman’s ability to deliver full term healthy babies.
Brown: So now this is an $8 million grant from the EPA. And because the layperson is not really going to understand how that money is applied, how will the grant help what you are talking about? I mean, how do you even begin to measure that and begin to talk to women that might participate or come from the records that you are pulling from to understand where—you know, what their experiences have been?
James: Well, I’ll begin and then I will defer to Dr. Miranda for an elaboration. Fortunately we have really very rich data from the US census on the kinds of neighborhoods that people live in. So we have data on crime, we have data on housing value. We have data on unemployment. We have data on poverty. So we can characterize neighborhoods really quite carefully in terms of the social conditions within which people live and the kinds of resources that are available to them in order to solve the problems of day to day living. And in addition to that you see Dr. Miranda’s team can also characterize the physical environment, the trace metals that are in the atmosphere to which people are exposed. And unfortunately exposure to these adverse physical factors is correlated with exposure to these adverse social factors so there is a double hit, if you will. And again, that is the quality of the different kind of situation to be born into if you will then to be born into an environment where those conditions do not apply.
Brown: Right. Dr. Miranda, I guess this is a two part question. How long will the research take to complete and once completed how do you apply what you learn from the research in the real world to make a difference?
Miranda: The center is funded by the EPA and it’s funded on a five year cycle so we have five years worth of funding that that $8 million, it’s $7.7 million but we would be happy to take an additional $300 thousand should it become available. But it’s spread over five years. Spread over these three projects. We also have a community outreach and translation corps which is meant to for the general findings and children’s’ environmental health that we already know in the early years of the center that the community outreach and translation corps will be working in communities, helping pregnant moms to understand some environmentally related prenatal care. So for example, our first project that gets started this week is our community outreach and translation coordinator is going to work with the WIC program, the Women, Infant and Children’s program in the state of North Carolina to develop some outreach materials on fish consumption because of the potential for exposure to methyl mercury in fish consumption. So to work with some alternative, most of the outreach materials are sort of these print pamphlets that people are not too taken with so we have some more creative ideas. We have a really very creative community outreach person who is leading us with the WIC program. Then as we start to see results coming from the center, then the community outreach and translation corps, that arm of the center, one of the main things that they are charged with is trying to figure out, well, what are the implications? So some of the implications might be changes in clinical practice. So if, for example, we can do a better job of identifying which women might be at particular risk for a low birth earlier on in pregnancy there may be additional testing or additional monitoring or additional care that you would want to provide to those women or you might want to think more carefully about monitoring women with particular chronic illnesses during pregnancy. You know, chronic hypertension or diabetes etcetera. And in addition if we discover for example, that there is a relationship between exposure to air pollution and pregnancy outcomes, then it is incumbent upon us to communicate that quite clearly to policy makers in Washington, DC who are in charge of setting the regulatory standards associated with air pollution. Alternatively if we find that there is some relationship between contaminants in water and pregnancy outcomes, because right now most of those environmental standards are not—have not been informed by any studies of pregnancy because we just really haven’t looked at that particular health endpoint and its relationship with environmental exposures. In addition, if we find out things about sort of a combination of environmental exposures or social stressors or maybe even just social stressors, I think that’s telling us something—it’s likely to tell us something as a community about what do we need to be doing in terms of housing rehabilitation, you know, we oftentimes I think just—we justify programs on narrow basis but if what we—if we discover that this neighborhood quality and community, the strife of the community is important for pregnancy outcomes, which in turn are important for a childhood illness which are in turn important also for adult illnesses then all of a sudden you have a much broader basis for making the argument for improving the quality of housing in our low SES neighborhoods or not just improving the quality of housing but providing mechanisms for people to come together whether it be through community centers or other types of support networks.
Brown: Dr. James, given the work that you do specifically and the way that it fits into this particular grant, what are your hopes for the outcomes?
James: Well, I certainly hope that we are able to provide data to policy makers that will make policy development and enforcement more scientifically based. I mean, that is our first obligation as scientists, to provide high quality data to the decision makers.
Brown: And let me just ask you, if it—does it have to be—in order for policy makers to respond and actually do something about what you tell them, I am figuring that they are not really going to respond unless it is scientifically based. I mean, and what is the likelihood that they will respond?
James: Well, they might not respond even if it is scientifically based. I think that one must take a multi-pronged approach to try to solve these problems and providing good scientific information is just one of the things that I think should be done. Also we need important stories, we need compelling stories. Policy makers like to hear people talk about their experiences and then finally I would say that we also need to provide this information not only to policy makers but to community people so that community people can use the information to bring about improved living conditions for themselves.
Brown: Thank you so much. I’m sorry to cut you off. But we’ve got to go. I’m Natalie Bullock Brown and I am reminding you to be encouraged no matter what. Thanks so much for tuning in.
[END OF RECORDING]
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