REGIONAL ASTHMA MANAGEMENT AND PREVENTION (RAMP), a San Francisco Bay Area regional collaborative started in 1996, promotes strategies to reduce asthma through a broad and comprehensive approach, ranging from clinical management to environmental protection. A project of the Public Health Institute, RAMP brings together diverse partners such as public health and community-based organizations, schools, medical providers, as well as environmental health and justice groups. These partners collaborate in reducing the burden of asthma with an emphasis on communities inequitably affected by the disease. RAMP's core strategies include: expanding knowledge and access to resources, creating linkages among partners, providing technical assistance to asthma stakeholders, and advocating for systems change. RAMP leads, promotes, and supports interventions in multiple settings-homes, schools, child care settings, clinical settings, and outdoor environments-and across multiple levels of the socioecological model (SEM). The SEM is a framework widely used in the field of public health. It conveys the importance of a comprehensive approach to prevention that encompasses multiple levels of intervention, beginning with individual level change and culminating with societal change. The SEM is used to address and recognize the multifaceted cause and effect of health disparities1 (Figure).
RAMP has provided ongoing leadership in addressing asthma, with long-term support from The California Endowment, The Wellness Foundation, and The San Francisco Foundation. Over time, RAMP has evolved to fully embrace the importance of addressing asthma disparities by increasing its focus on social determinants of health, the conditions in which people are born, live, work, and age. The social determinants of health are influenced by policy choices and are largely responsible for health inequities. As a Center of Excellence in the Elimination of Disparities (CEED) in the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health across the US (REACH US) program, RAMP acts to address inequities contributing to the burden of asthma in African American and Latino communities in the San Francisco Bay Area.
In this article, RAMP describes its advocacy campaign aimed at addressing the impact of diesel emissions on air quality, a social determinant of health. While just one element of RAMP's comprehensive approach to reducing the burden of asthma, this campaign provides an example of collaborative systems change efforts addressing health inequities.
PROBLEM STATEMENT
Asthma is the most common chronic childhood disease, affecting 6.3 million children nationwide.2 In California, 1 in 6 children younger than 18 years has been diagnosed with asthma.3 This rate is higher than the rates found in the United States, overall. Although asthma affects Americans of all ages, races, and ethnic groups, some populations are inequitably impacted by the disease.
African Americans have disproportionately high rates of asthma and poor health outcomes associated with asthma. One in 5 (20.1%) African Americans in California has been diagnosed with asthma-a higher rate than seen in whites, Latinos, or Asians.3 Among people with asthma, African Americans experience poorer health outcomes. Both the hospitalization rate and the rate of emergency department visits for asthma in California are more than 3 times higher for African American children than for other children, a greater disparity than would be expected on the basis of prevalence alone.4
Whereas African Americans have disproportionately high rates of asthma, Latinos represent large numbers of Californians with asthma. Currently in California, there are 1.4 million Latinos diagnosed with asthma.3 While rates of asthma are not higher for than for some other groups, the number of Latinos with asthma is greater than any other community of color in the state. Additionally, Latinos have the lowest rates of insurance coverage among all ethnic groups in California5 and Latino children have a higher rate of emergency department visits for asthma than white children.6 Since are currently the state's fastest growing ethnic group and will account for the majority of Californians by midcentury,7 the potential impact of asthma on California and this population is expected to increase unless public health efforts to address the causes of asthma and poor health outcomes are implemented.
These asthma disparities are in part the result of societal inequities, such as inequitable access to quality clinical care. People of color make up the majority of uninsured Americans.8 Even among those with access to health care, there is considerable evidence that people of color experience discrepancies in care compared to that received by whites.9 Evidence of racial and ethnic disparities in health care is remarkably consistent across a range of illnesses and health care services.10 Research in different settings throughout the United States has repeatedly documented that African Americans and Latinos are less likely to receive appropriate asthma medications for preventive care, acute exacerbations, or postemergency department care.11 These differences in diagnosis, quality of care, and treatment methods lead to consistently poorer health outcomes among people of color.10
Underlying the racial and ethnic disparities, asthma disparities also exist on the basis of income level. Lower income is associated with higher asthma hospitalization rates and worse symptoms. For example, the rate of asthma hospitalizations is 3 times higher among people from places where the median income is less than $20000 compared to people from places where the median income is greater than $50000.12 These income-based asthma disparities are directly connected to the asthma disparities based on race and ethnicity, as African Americans and Latinos in have disproportionately high rates of poverty.13 One examination of asthma prevalence in children suggests that asthma risk is particularly high among children with "disadvantages in both racial status and socioeconomic status."14(pS174)
Research suggests the distribution of asthma according to race and socioeconomic status is created by larger inequalities in society.14(pS181) Significant inequities in exposure to environmental risks, both indoor and outdoor, exist for low-income communities of color. This context is critical. Even with the best quality of clinical care, an individual will continue to suffer from asthma if frequently exposed to environmental triggers. For example, mold, rodents, and cockroaches are asthma triggers associated with physically deteriorating housing, schools, and child care settings. Similarly, several research studies have shown that outdoor air pollution is higher among African American and Latino communities in the Bay Area due to the proximity of ports, freeways, and other polluting facilities.15 This is particularly noteworthy because, in addition to exacerbating asthma, certain components of outdoor air pollution are associated with the development of new asthma cases.16
By associating differences in health outcomes with social determinants of health, policy change becomes a key solution to address the problem.17 RAMP aims to reduce disparities in access to quality clinical care and support for asthma management, as well as disparities in exposure to environmental asthma triggers. RAMP also recognizes the importance of raising a public health voice to challenge the social and economic policies at the root causes of such inequities.
To minimize environmental asthma triggers, RAMP has worked to reduce diesel exhaust, a complex mixture of air pollutants. Many of the compounds in diesel pollution increasingly have been associated with asthma, leading to high rates of asthma occurrence, reduced lung function, increased respiratory symptoms, increased doctor visits and use of medications, increased risk of emergency department visits and/or hospitalization, and increased allergic inflammation and the development of new allergies.18
Diesel exhaust is emitted by trucks, school buses, trains, ships, harbor craft, off-road vehicles, as well as cargo-handling and industrial equipment with diesel engines. Thus, communities located near ports, rail yards, freeways, other truck routes, distribution centers, and industries experience a disproportionate diesel exhaust burden. For example, West Oakland, a Bay Area community where 58% of the residents are African American and 19% are Latino, is surrounded by a port, freeways, and multiple industries. West Oakland residents are exposed to approximately 5 times more diesel particulates than residents in other parts of Oakland.19 Given this environmental burden, it is not surprising that the asthma hospitalization rates for children in West Oakland (158.2/10000) are more than 10 times higher than children in other neighborhoods within the same city.20 Data in other low-income communities of color in the Bay Area mimic similar correlations.21
RAMP'S WORK TO REDUCE DIESEL POLLUTION
In 2003, RAMP began to focus on the issue of diesel pollution as scientific research identified a connection between diesel and asthma, suggesting that in addition to being an asthma trigger, diesel contributes to the onset of asthma in otherwise healthy people.22 At this same time, asthma coalitions and community groups began to discuss the impact of diesel in their Bay Area communities, particularly its disproportionate impact on low-income communities of color. This helped to raise diesel pollution as a priority public health issue. In response to this combination of community interest and scientific research, RAMP employed a 2-pronged approach: (1) local and regional reduction efforts through the creation of a regional diesel collaborative and (2) state-level policy change through the adoption of diesel reduction regulations. This 2-pronged approach represented a comprehensive set of strategies across the SEM aimed at addressing a social determinant of health.
The first prong was the development of a regional diesel collaborative. When planning efforts for the collaborative began, many environmental justice groups in the Bay Area had already been working locally to address diesel pollution. Yet there had not been a well-developed structure to support a coordinated movement nor was there a broad and formal inclusion of a public health voice, both of which could fortify advocacy efforts and drive outcomes. RAMP recognized that while focusing on diesel pollution would be a significant departure from traditional asthma work, it was essential for the organization to evolve its collaborative efforts to address the environmental injustices contributing to asthma disparities. RAMP partnered with the Pacific Institute, Urban Habitat, and the West Oakland Environmental Indicators Project to initiate a broad planning process with multiple stakeholders from across the Bay Area to develop a regional strategy to reduce diesel pollution. These extensive planning efforts with community residents and community-based public health, labor, and environmental justice organizations led to the formation of the Ditching Dirty Diesel Collaborative (DDDC) in late 2004. The DDDC's goal is to reduce diesel pollution, particularly in the communities facing an inequitable burden. Its work is grounded in the needs of those most impacted by diesel pollution. It reaches across the levels of the SEM by engaging individuals, organizations, and institutions in a range of strategies, including policy change. These efforts included the development of a report on the health costs of freight transportation, participation in the development of a state freight transportation action plan, engagement of the local air quality management district on a variety of clean air rules, and advocacy on regulations related to air quality at rail yards.
RAMP's role in the DDDC is to be a support organization for the grassroots leadership essential for such a movement. Since its inception, RAMP has served on the DDDC's Steering Committee, which determines broad vision and policy for the group. RAMP's assistance is focused on financial sustainability, strategic planning support, and policy formation and implementation, among other roles. Additionally, RAMP coordinates the DDDC's Idling Committee. This group led a campaign to promote enforcement of a state antiidling law for diesel trucks. To facilitate a large-scale norm change, the DDDC conducted the broad education and outreach needed to ensure compliance with the policy.
While supporting local and regional activities, RAMP simultaneously pursued state-level advocacy efforts to reduce diesel pollution, representing the outer-most level of the SEM. In 1998, the California Air Resources Board (CARB)-the state's primary regulatory body for air quality-identified particulate matter (PM) from diesel-fueled engines as a toxic air contaminant following an exhaustive 10-year scientific assessment process.23 This declaration resulted in the development and eventual implementation of the Diesel Risk Reduction Plan, a set of ambitious regulatory and voluntary steps, each focusing on a different sector of diesel pollution including port equipment, trucks, and construction equipment. The goal is to drastically reduce diesel PM levels by 85% by 2020.23
Two of CARB's diesel regulations-the off-road rule and the on-road rule-are particularly noteworthy, given their scope and impact. The off-road rule addressed a wide range of off-road diesel equipment, most commonly construction equipment but also smaller equipment like mowers.23 Diesel pollution from these sources is surprisingly significant. Before the regulations were adopted and implemented, off-road vehicles were responsible for nearly one-quarter of the total PM emissions from mobile diesel sources.23 The goal of this regulation is to achieve emission reductions by requiring fleet owners to modernize their fleets and install exhaust retrofits.
The passage of the off-road rule was a significant victory for clean air and public health. CARB projected a 73% reduction in diesel PM by 2020 from emission levels anticipated in the absence of the regulation.23 In terms of health outcomes, CARB estimated the implementation of this regulation will help eliminate approximately 4000 premature deaths statewide by 2030. Asthma-related health improvements will include an estimated 840 fewer hospital admissions due to respiratory causes and 110,000 cases of asthma and other lower respiratory symptoms.24 The full array of health benefits will result in estimated economic benefits due to savings from avoided deaths and in health care costs between $18 billion and $26 billion.24
CARB's on-road rule, the second diesel regulation, was a major undertaking affecting a significant portion of the transportation sector, including more than 400000 diesel vehicles registered in the state and another half million out-of-state trucks that visit California each year. These vehicles represent a significant source of diesel pollution, accounting for 39% of statewide diesel PM emissions from all mobile diesel engines; according to a 2005 CARB estimate.25 The on-road rule requires owners to upgrade their vehicles by equipping them with diesel particulate filters and, in some cases, new engines.
The on-road rule will result in significant reductions of diesel pollution. In 2020, the regulation is expected to create a 43% reduction in diesel PM from emission levels that would be anticipated in the absence of the regulation.25 This regulation is also anticipated to have significant health effects. CARB estimates approximately 9400 premature deaths statewide will be prevented by the year 2025 as the result of this regulation. Asthma-specific health effects will include an estimated 1000 fewer hospital admissions due to respiratory causes and 150000 fewer cases of asthma and other lower respiratory symptoms.26 Economic benefits due to savings from avoided deaths and in health care costs are estimated to be between $48 billion and $69 billion.26
The policy gains that resulted from the passage of these 2 regulations did not signify the end of the advocacy efforts on these issues. Since these regulations were adopted, the California economy has suffered like many others. The state's budget gap has ballooned into the billions of dollars. Regulations, such as the off- and on-road diesel rules, have been attacked as being too economically challenging to implement. RAMP and other advocates continue to defend the regulations by opposing both legislative and regulatory efforts to roll them back, arguing that the health and economic costs from pollution are too high to ignore.
In all of these advocacy efforts, the creation of the regional diesel collaborative, the passage of regulations, and the opposition of roll backs, RAMP's efforts were a key element in a larger environmental health and justice movement in the state. California has a well-established history of progressive and successful environmental health and justice efforts. RAMP strategically chose to lend its leadership and public health voice to this movement with the acknowledgement that collaboration leads to success. In its work with asthma coalitions in communities across California, RAMP serves as a vital source of information on emerging policy opportunities. It is able to mobilize a network of advocates to create broad-based support for policy change. Through this leadership role, RAMP brings strength and numbers to support necessary advocacy steps such as writing letters of support, providing testimony at hearings, meeting directly with key decision-makers, and conducting media advocacy. Frequently, these advocates are physicians and representatives from public health departments, hospitals, clinics, and insurers, who are influential in the policy realm and are able to effectively bring a public health perspective into the policy debate. RAMP and its partners help policymakers understand and appreciate the concrete health impacts of these policies and their impact on asthma.
CONCLUSION
Next steps
A review of the advocacy work of RAMP and its partners suggests several next steps are needed to explore new terrain for public health approaches to asthma prevention. RAMP will continue its work on diesel pollution reduction by defending existing regulations and supporting new ones, as well as with ongoing community and regional mobilization with the DDDC. RAMP also recognizes that diesel pollution occurs within the context of numerous environmental risk factors concentrated in poor communities. The policies that produce those underlying inequities must become a part of an expanded advocacy focus. The emphasis on cleaner technology is an important first step, but by itself, it is insufficient. As other public health campaigns have discovered over time, from the control of infectious diseases in 19th-century cities to the contemporary confrontation with increasing rates of obesity, the built environment is the larger context in which many public health risks become evident.
There also is a convergence between approaches aimed at improving air quality and the mitigation strategies that must be employed to confront the potentially dire consequences of climate change. Reduction in asthma and other respiratory conditions are the public health cobenefits of reductions in greenhouse gas emissions. This makes climate change mitigation a potentially rich arena of activity for public health advocates concerned about asthma.27,28
However, from the perspective of the SEM, it is also important to be mindful of how the work of RAMP and its evolution fits within a larger framework of prevention. A comprehensive approach to asthma management and prevention requires complementary and effective strategies ranging from sound clinical management and education of individuals and their families, to broad community and societal interventions that reduce asthma triggers in the environment. Reducing asthma disparities requires the confrontation of underlying inequities in housing and school conditions, as well as in access to health care and exposures to outdoor air pollution. RAMP leads and participates in new activities aimed at significantly expanding public health efforts that positively impact asthma. RAMP has demonstrated there is a public health practice associated with all levels of the SEM and a comprehensive approach to asthma management and prevention must embrace that practice.
Long-term implications
The work of RAMP has several long-term implications for the field of public health.
First, the more public health practice moves from the inner to the outer levels of the SEM, the less the work is about specific diseases or populations.
While the DDDC identified asthma as an anchor issue around which to mobilize constituents, there has always been the recognition that the impact of its work is far greater. For example, when the DDDC directed its focus on the Port of Oakland and its ancillary shipping, rail, and truck traffic as major sources of diesel pollution, it was no longer just about asthma. Diesel pollution contributes to high rates of asthma, other respiratory illnesses, certain cancers and heart disease, and impacts the overall quality of life. Similarly, the populations affected by diesel pollution were no longer only African Americans and Latinos, even though they make up the majority of residents in the adjacent neighborhoods. The health of anyone living in West Oakland and surrounding areas is at risk. For clinical management or health education to be effective, a detailed knowledge of asthma as a disease process must be supplemented by cultural competence with specific racial or ethnic populations. In contrast, work in the outer rings of the SEM as evidenced by RAMP and its work with the DDDC, requires understanding the larger context in which asthma as a disease is manifest and identifying the needed skills in multiethnic community organizing and policy advocacy.
Second, RAMP's work to reduce diesel pollution involved the formation of new partnerships and alliances.
When RAMP was in its infancy and focused more exclusively on the clinical management of asthma, it had ground breaking success in bringing together public health departments with physician provider groups, hospitals, and managed care plans. RAMP applied this collaborative model to its work on outdoor air pollution. This led to new alliances with environmental justice organizations, community advocates, and sometimes challenging relationships with regulatory bodies, such as the air quality district or other agencies, including the port. These alliances are essential when focusing on policy change. RAMP recognized that data and science alone do not change public policy-political action is also essential. This means forming new, sometimes unlikely, relationships and building broad base support incorporating diverse perspectives and spheres of influence.
Third, movement toward the outer levels of the SEM challenges standards of evidence, both for public health practice and health outcomes.
Clinical management can be guided by clinical trials and controlled studies. Health education can be correlated with behavior change through pre- and posttests. In contrast, work to reduce the disparate burden of asthma by reducing PM through reductions in diesel pollution is significantly more difficult to measure. Even if reductions in PM are associated with reductions in asthma hospitalizations, for example, it is not clear (a) if and how the work of RAMP and its partners affected the policies and practices that produced the reduction in PM and (b) to what extent the reduction in PM caused the reduction in asthma hospitalizations, as opposed to related asthma hospitalization prevention activities such as improved clinical management or reduction of indoor triggers in homes and schools. As a result, it would be extremely difficult to say that collaborative advocacy to reduce sources of diesel emissions as a strategy to reduce the burden of asthma is an "evidence-based" practice. It is not unlike tobacco, in which a multifaceted campaign was able, over decades, to achieve significant reductions in smoking rates, with difficult attributions to corresponding reductions in disease rates. Yet RAMP proceeds on the basis of evidence suggesting a comprehensive, multistrategy approach to reduce the burden of asthma is essential and that activities at the outer levels of the SEM are keys to success. Therefore, it is important not to allow traditional standards of evidence-based practice discourage exploration of new forms of practice based on sound public health judgment. It is equally important to develop research strategies to provide the evidence base for new forms of practice for which traditional research methods might not apply.
Finally, there are important lessons to be learned from RAMP for future public health efforts.
Movement toward the outer levels of the SEM creates intersections for work previously conducted on behalf of specific diseases and populations. For example, RAMP and its partners recognize there are underlying policy issues that must be confronted. These include land use policies that have historically led to the inequitable distribution of health enriching resources to poor and minority communities.29 With this premise in mind, public health practitioners and community advocates have come to understand the fundamental role that the built environment plays in the obesity epidemic or in community violence. If the common themes of this evolving public health practice become the focus of investment and programmatic support, the payoff will transcend a model focused on a single disease or population that will more broadly create healthier communities.
REFERENCES