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The Smog Doctor

Photo by Larry Hirshowitz

When he came out from New England to live under the slowly clearing skies of Los Angeles in 1980, Dr. John Peters, like most newcomers, started thinking about smog. He wondered what permanent damage air pollution was doing to Southern Californians’ lungs. “I kept asking, ‘Why doesn’t somebody study the chronic effects of air pollution?’” says Peters, now a professor at the Keck School of Medicine and director of the Southern California Health Sciences Center at the University of Southern California. “Everybody knows air pollution makes your eyes water, and it makes you cough. And if that’s all it does, well, maybe you get over that and it’s not so bad. But if there are chronic effects, then we ought to know, and we really ought to be concerned.”

Until that point, Peters had focused almost exclusively on workplace exposure to toxins; throughout the 1980s, the Harvard-educated professor of preventative medicine authored papers on lung cancer in welders and kidney cancer in architects, and he had no intention of shifting his course: “I kept saying a study of the chronic effects of air pollution should be done,” he says, “but I never thought I’d be the one to do it.”

Then, in 1991, the California Air Resources Board (CARB) put out a call for just such a study, and Peters, along with a group of researchers “who had been agitating about it,” including his USC colleagues W. James Gauderman and Ed Avol, answered it. With the help of some of the world’s best health-outcome people, a raft of environmentally minded statisticians and experts in “exposure assessment,” the team came up with a plan of study. CARB accepted the proposal, and in 1993, Peters became the director of The Children’s Health Study, which began with lung tests of nearly 4,000 fourth-, seventh- and 10th-graders in 12 geographically diverse communities — some inhaling the region’s worst pollutants, some breathing air as clean as it comes.

At the outset, Peters suspected the results would be useful, at best, to health-care ­professionals. He and his peers didn't expect to make the national news, and they didn’t know that their study would become among the most comprehensive, long-term analyses of the effects of air pollution on the developing lungs of children.

“As good scientists we were bound to be open-minded and accept whatever we found, but we did not anticipate anything dramatic,” says Peters, sitting at a table in his second-floor office at the Southern California Environmental Health Sciences Center at the University of California. His office is spare and white but for a few bottles of fine red wine — “I like wine,” he admits. He has just turned 70. He is tall and thin with a neatly trimmed white beard, and has the look of a man who has paid meticulous attention to his health. He watches his language just as carefully, and speaks with the exactness of a researcher who’s loathe to exaggerate. “Given that the air is so much cleaner than it used to be, I thought if there were any effects they would be subtle and perhaps not even clinically significant.”

Some 75 published research papers later, here’s what Peters and his team found: That the lungs of children growing up among the industrial warehouses of Mira Loma develop up to 10 percent more slowly than those of their peers in the much cleaner air of Lompoc; that school absences for conditions like wheezing and sore throats shoot up — sometimes nearly double — as ozone levels soar in the Inland Empire; that, due to high levels of nitrogen oxide and fine particulate matter, mostly from internal combustion engines, nearly five times as many high-school graduates in Upland as teenagers in Santa Maria suffer from lung function far below normal — a developmental deficit, the study concluded, from which these young people may never recover.

As a good scientist, Peters won’t say he was shocked. “But I was surprised,” he allows. “We were all surprised the effects were as significant as they are. It’s the same sort of functional impairment we see from smoking.”

The Children’s Health Study recruited another 2,000 10-year-olds in 1996, bringing the total number of children observed by the researchers close to 6,000, drawn from communities — from Lancaster to San Dimas, Lake Arrowhead to Lake Elsinore — that were carefully selected for contrasts in air quality as well as high rates of education and home-ownership, what Peters calls “indices of stability” as reported in the 1990 census. The stability factor reduced the possibility that poor nutrition and social stress were contributing to high rates of respiratory illness: Unlike so many other environmental problems, often heavily concentrated in poorer areas, air pollution transcends class. “It turns out that there isn’t a high correlation between regional pollution and socioeconomic level,” says Peters. “Upland is a very upper-class community, and it’s one of the most polluted. And a lot of the lower socioeconomic-status communities — Compton is a good example — are not bad in terms of air quality. The air where I live, in San Marino, is probably worse.”

The team of researchers also turned up more specific, and sometimes eccentric, points: Ice skaters, for instance, have a higher-than-average incidence of asthma due to high concentrations of pollutants trapped in the cold air of indoor skating rinks. “Zambonis might be the cause of that,” says Peters. And according to a 2002 article published in Lancet, athletes in general suffer in higher numbers from ozone pollution. “If you’re exercising, you’re breathing up to 30 times as much as when you’re sitting still, so your exposure is magnified tremendously,” says Peters. “The more sports you play, the more exercise and the more pollutants you’re getting.” As a consequence, the study found that teenagers who play multiple team sports in high-ozone communities are more likely to develop asthma than nonathletes. Where ozone levels are low, no such correlation between exercise and asthma exists.

This was a startling discovery, says Dr. James Gauderman, who has authored several key papers and overseen a team of data management types on the Children’s Health Study since 1996. “There’s a lot known about air pollution exacerbating existing asthma, but there has not been a lot out there about air pollution causing asthma. Since we had such a large group spread out across different towns with different pollution profiles, we had a large enough sample that we could break it down: We could look at kids playing no team sports, kids playing some team sports and kids playing a lot of team sports. And it was really only in that one group — kids playing a lot of team sports in a high-ozone community — that we saw an increased risk of new cases.” Because it’s such a unique result, it can’t be confirmed until another research team replicates it. “But if it holds up,” says Gauderman, “it could have some ramifications in terms of how we counsel young athletes on when to play sports. We could tailor their activity so it’s not happening during peak ozone times.”

Those “high-ozone communities” include the cities of Lancaster and Lake Arrowhead, where ozone rises on summer afternoons to levels twice as high as it is in the San Luis Obispo County town of Atascadero, and five or six times higher than Honolulu or Seattle. Fine particulate matter, or PM2.5, which the study has linked to long-term lung impairment — and which other investigations have linked to cancer — is found in concentrations three times higher in Long Beach than in Lompoc.

So what happened to the notion that the air in Southern California is steadily improving? “In general pollution has gotten better,” says Peters, “but you have to remember that it’s only the things we’re measuring that are getting better. Other things, like gas formulations, are changing — diesel technology being the big one. So if you’re measuring ozone and you’re measuring NO2, then in some ways things are improving. If you’re paying attention to particles, in some areas, things may be getting worse.”

Dissatisfied with the existing air-quality measurements as provided by the EPA, the Children’s Health Study researchers went about setting up 12 air-quality monitoring stations to measure PM10 and 2.5 (large and fine particulate matter), nitrogen oxides, ozone and acid vapor. “We established a sampler that took a two-week sample for PM2.5. That began in 1994. So we probably had as much information on fine particles coming from our study as there was available anywhere else,” says Peters. “The way you measure particles is to collect them on a filter and weigh them. Big particles, what we call PM10, weigh more than little particles. And what’s happened with diesel technology is that you don’t have the big particles — you don’t see the big black stuff coming out as much as you used to — but you have more of the ultrafine particles [PM2.5]. They don’t weigh very much, so it seems like there’s less to worry about. But it’s not true: Biologically those ultrafine particles are probably more significant and more dangerous to inhale.”

They are also responsible for the bulk of air pollution’s public-health costs. Five years ago, in a study called “Multiple Air Toxics Exposure Study in the South Coast Air Basin,” the South Coast Air Quality Management District established that diesel particulate matter accounts for 70 percent of the state’s cancer risk from airborne pollutants. And while the Environmental Working Group, a D.C.-based nonprofit, estimates the public-health impact of ozone at $521 million, measured in school absences and emergency-room visits, a Union of Concerned Scientists study recently set the costs of diesel particulate matter at a staggering $21.5 billion.

Beyond the hard, cold figures, there remains the stark reality that diminished lung function may be a precursor for emphysema, chronic bronchitis and possibly even lung cancer later in life. “There’s a connection that’s not clearly established,” says Peters, “but what we do know is that if you have low lung function as an adult, on the average your life is going to be shorter. You’re going to be more likely to die of heart disease or lung disease. So the assumption is that if it’s happening at 18 years old it’s going to do the same thing to you when you’re an adult.” We are, in essence, dooming children in smoggy areas to a lifetime of health problems, the genesis of which lies almost exclusively with our dirty cars and trucks.

In the wake of a 2004 article in The New England Journal of Medicine establishing the link between reduced lung volume and childhood exposure to air pollution, the Children’s Health Study received nationwide attention: It provided, finally, an unassailable testament to the lethal consequences of continuing air pollution. It established methodically documented physical evidence that air pollution inhibits the healthy development of children’s lungs. In a summary of the studies, “Breathless in Los Angeles: The Exhausting Search for Clean Air” — a title Peters wrote himself — the authors recommend mitigating measures: Install air-filtration systems in schools, locate parks, day-care centers and sports fields away from high-traffic thoroughfares, supplement at-risk children’s diets with vitamin C to fight the oxidizing effects of dirty air. They also acknowledge the drawbacks of almost any secondary solution: Vitamin C may actually be a pro-oxidant and air conditioning increases energy consumption and therefore emissions from power plants. Even moving to a cleaner-air community isn't ideal. If everyone moves to Ventura and works in downtown Los Angeles, air poisoned by traffic congestion will eventually be impossible to escape. “This isn’t like dietary fat, where you can tell an individual to cut down,” says Gauderman. “It’s an exposure that’s all around us, and if you live in Southern California, there’s no way to avoid it.” The only real solution, he concludes, is to “keep the pressure up to regulate and reduce pollution levels generally.” In other words, mandate more fuel-efficient vehicles — something California struggles to do against continuing legal threats from the auto manufacturers’ lobby.

I tell Peters it seems that there should have been more alarm over the results of the Children’s Health Study. “It does, doesn’t it?” he says. “I don’t know what has to happen. Maybe we need a Cindy Sheehan of air pollution camping out in Sacramento.”

Recently, Penny Newman, executive director of the Center for Community Action and Environmental Justice, enlisted Peters in her group’s battle to stop the building of warehouses on 700 acres in Mira Loma, a small rural community where air quality has deteriorated due to a glut of industrial development. “Dr. Peters actually came to [Riverside County] Board of Supervisor meetings,” says Newman. “He explained the significance of what they had found in the study, and its direct impact on Mira Loma. He made it so it wasn’t a theoretical thing anymore.” But she laments that the Children’s Health Study has not had a more sweeping regulatory impact – it has not, for example, halted the state’s plan to expand the ports without stricter air-quality controls. “I remember years ago we’d have officials saying, ‘We can’t make public-policy issues without sound science.’ Now we have sound science. Nobody has picked it apart. Yet we’re continuing with policies that are in direct conflict with the science.”

Until those policies change and the problem of Southern California air quality is solved, Peters intends to keep collecting data – he’d like to see the Children’s Health Study carry on well into the next half-century. “We’ll follow these subjects into their 20s, and even their 30s,” he says, “to see the long-term effects.” One theory is that men’s lungs will recover in adulthood, since male lungs grow long after female lungs stop growing, at around age 18. Another is that the damage remains for life. “That’s something we won’t know for a decade,” says Peters. “But we plan to figure it out.”

The study’s goals were somewhat stymied when two school districts — one of the dirtiest, Mira Loma, and one of the cleanest, Lompoc — refused to continue in the study, citing more pressing educational concerns than testing lung function. But new children have been recruited, and the dollars that stopped coming from CARB in 2004 have been replaced with a seven-year, $17 million grant from the National Institute of Environmental Health Sciences. Peters is confident there’s much more to learn. “Who knows when this will ever end?” he says. “There’s always more to know.”


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