Invited Perspective: Increasing Disparities in Air Pollution Health Burdens in the United States—A Concerning Trend for $\mathbf{P}{\mathbf{M}}_{2.5}$ and a Path Forward

Inequities in social determinants of health experienced by Black residents of the United States may be responsible for their increased risk of premature mortality. A recent analysis¹ of data from the National Health and Nutrition Examination Survey for the years 1999–2018 found a 59% greater odds of premature death for Black residents of the United States compared with White residents, before adjusting for other social determinants of health such as employment status, poverty, food security, education, access to health care, insurance, homeownership, and marriage status. After adjusting for these factors, the odds of premature mortality were roughly equal between Black and White US residents. For example, in Alamance County, North Carolina, the average life expectancy is 78.2 y for White residents and 74.7 y for Black, non-Hispanic residents.² Alamance County’s historically Black West End and White Level communities have documented a) withheld access to amenities such as paved roads, sidewalks, safe drinking water, and sewage treatment; b) displacement by highway construction projects; and c) exclusion from decision-making.²

Greater vulnerability to disease could portend greater susceptibility to the effects of exposure to ${\mathrm{PM}}_{2.5}$ [i.e., particulate matter (PM) with mass median aerodynamic diameter $<2.5\mathrm{\mu }\mathrm{m}$]. Positive associations between ${\mathrm{PM}}_{2.5}$ and premature mortality have long been established.^3,4 Across the United States, racial, ethnic, and economic disparities in exposure to ${\mathrm{PM}}_{2.5}$ have been associated with factors such as primary emissions from industry,⁵ utilities using coal to generate electricity,⁶ and redlining.⁷ Such factors raise questions about whether inequities in social determinants of health may also drive disparities in ${\mathrm{PM}}_{2.5}$-attributable premature mortality among Black US residents.

In this issue of Environmental Health Perspectives, Kerr et al.⁸ explore this research question using the cause-specific exposure–response curves in the Global Burden of Disease⁹ dataset to test for disparities in relative risk of premature mortality attributable to ${\mathrm{PM}}_{2.5}$ and incidence of pediatric asthma attributable to ${\mathrm{NO}}_2$ across the United States for the years 2010–2019. Although Kerr et al. explored both ${\mathrm{PM}}_{2.5}$ and ${\mathrm{NO}}_2$, we focus here on ${\mathrm{PM}}_{2.5}$-attributable premature mortality, given there was substantially greater uncertainty in the ${\mathrm{NO}}_2$-attributable pediatric asthma risk estimates due to heterogeneity among the studies that could not be accounted for through study design. Kerr et al. estimated a 16% increase in relative racial disparities in premature mortality (greatest proportion non-White decile census tracts vs. greatest proportion White decile tracts) and a 40% increase in relative ethnic disparities in premature mortality (greatest proportion Hispanic decile tracts vs. lowest proportion Hispanic decile tracts) over the 10-y period of the study, revealing that relative disparities are growing. This comparative analysis of census tracts highlights localized disparities, underscoring that one’s neighborhood often determines risk for environmentally driven mortality and morbidity.⁵

In an interesting finding, Kerr et al. noted a nationwide 28.5% decrease in ${\mathrm{PM}}_{2.5}$-attributable premature mortality over the total period of the study, concurrent with average nationwide ${\mathrm{PM}}_{2.5}$ concentrations decreasing by 43% between 2000 and 2019. However, Kerr et al.⁸ observed upticks in ${\mathrm{PM}}_{2.5}$-attributable mortality for 2011, 2014, 2017, and 2018, along with small upticks in median ${\mathrm{PM}}_{2.5}$ concentration in those same years (reported in their Figure 2A).

These conditions suggest that disparities in health effects due to ${\mathrm{PM}}_{2.5}$ exposures may increase further in the coming years as climate change–related wildfires reverse improvements in ambient ${\mathrm{PM}}_{2.5}$ concentrations made under the Clean Air Act.¹⁰ In 2020 and 2021, beyond the period of the study by Kerr et al., national average ${\mathrm{PM}}_{2.5}$ concentration increased by more than 5% each year.¹¹ In coming years, ${\mathrm{PM}}_{2.5}$ concentrations are projected to increase even more, primarily due to increasing drought and biomass,¹² with average wildfire acreage increasing each year.^10,13 Additional years of data are needed to confirm whether concurrent year-over-year increases in ${\mathrm{PM}}_{2.5}$ concentrations and ${\mathrm{PM}}_{2.5}$-attributable premature mortality are related.

There is a dire need for policies and funds to assist marginalized and underserved communities—very often majority Black and Brown communities—in mitigating climate change–induced increases in disparities in health and air pollution. Congressional paralysis limits hope for major legislation to address climate change in the coming years.¹⁴ However, the White House Environmental Justice Advisory Council developed a number of specific recommendations for priority expenditure areas and guiding principles for maximizing benefit and minimizing harm through just, community-centered approaches.¹⁵ Executive actions such as the Justice40 Initiative, intended to direct 40% of benefits of some federal investments into marginalized communities “overburdened by pollution,” may therefore be the most pragmatic paths forward to support overburdened communities and mitigate climate forces that result in wildfire-generated ${\mathrm{PM}}_{2.5}$. Coupling an influx of funds for infrastructure and environmental amenities with legal remedies through Title VI Civil Rights Act complaints initiated by the West End Revitalization Association (WERA),¹⁶ a Black-led environmental justice organization in Mebane, North Carolina, has produced improved conditions for the West End and White Level communities in Alamance.²

Justice40 program implementation would benefit from application of the JEDii$ (JUSTICE, EQUITY, DIVERSITY, INCLUSION, INTEGRITY, FUNDING) framework in support of these guiding principles.¹⁷ JEDii$ is employed by WERA and its partners in the Environmental Justice Practitioners Working Group within the Citizen Science Association. This framework includes a) just outcomes for overburdened and underinvested communities to be relieved of burdens from environmental contamination and unequal access to infrastructure, b) equity for restoring People of Color communities, c) diversity in decision-making regarding people of color, d) inclusion in all levels of decision-making, e) integrity throughout processes of engagement and planning with impacted communities, and f) adequate funding for environmental justice and climate justice solutions. The JEDii$ framework requires sustained attention to fair implementation of environmental laws and regulations through each of these aspects.

Justice40’s “whole-of-government” approach to addressing environmental inequities, along with mitigation measures, provides an opportunity to frame JEDii$ principles in collaborative action to rectify historic health disparities as the United States moves toward a just transition through specific environmental and climate justice policy directives:

• Regular performance of civil rights compliance reviews to ensure equitable distribution of funds to mitigate or prevent pollutant emissions, to develop or improve the quality of amenities such as greenspaces and housing, and to enforce air pollution laws

• Redirection of funds from federal fossil fuel industry subsidies¹⁸ to local, equitable investment in improving clean energy infrastructure, health care, utilities, clean power production, and safe jobs to promote public health and welfare of underresourced communities

• Refusal to permit any new fracking or other fossil fuel excavation or processing permits that would result in large and uncertain quantities of methane released to the ambient air each year¹⁹

• Federal Clean Air Act enforcement of permits for stationary sources

• Regulation of carbon dioxide and methane as criteria pollutants with endangerment findings²⁰ based on climate forcing, using two mechanisms under the Clean Air Act: the establishment of a) National Ambient Air Quality Standards under Section 109(a)(2) and b) emissions limits under Section 111(b) and 111(d) for new and existing sources, respectively,²¹ and

• Analysis and mitigation of environmental justice impacts on nearby communities as a formal part of the process of permitting any emitting facility.

Any regulatory solutions to address climate change impacts, including greenhouse gas reductions and disparities in mortality attributable to climate change–related increases in ${\mathrm{PM}}_{2.5}$, must be legally unassailable, reducing the risk of any new climate policy’s repeal along the lines of the Clean Power Plan under West Virginia v. EPA.²² Crucially, permitting and policy decisions at all levels must directly involve impacted communities throughout decision-making processes. This will help ensure equitable air pollution management to mitigate excess cases of climate change–related ${\mathrm{PM}}_{2.5}$-attributable premature mortality in those same communities. We believe lasting improvements in climate management can be achieved through the employment of Justice40’s whole-of-government approach, implemented via the JEDii$ framework. Collaboration without silos is crucial to the realization of the positive change that impacted communities deserve to experience as a result of the implementation of any regulatory solutions.

Refers to https://doi.org/10.1289/EHP11900

Conclusions and opinions are those of the individual authors and do not necessarily reflect the policies or views of EHP Publishing or the National Institute of Environmental Health Sciences.