Good for Air, Bad for Asthma?
•Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
The ban on chlorofluorocarbons (CFCs) that occurred in 2008 was hailed as a great advance by environmentalists; CFCs deplete the ozone, and this legal move was part of the Clean Air Act.
This would have positive environmental, and, its not so hard to imagine the positive health effects as well as the air we are breathing is cleaner. However, as a result of this ban, it had unforeseen consequences on a large population. Ironically, it was those with asthma that were affected immediately, as albuterol inhalers contained CFCs. Albuterol is the first line treatment for asthma. (Personally, I recall my asthma inhaler going up from 10 dollars to 50. Sticker shock! But I could afford it.)
But as an emergency doctor, working predominantly in county or safety net hospitals, I noted so many patients, so many asthma exacerbations, are triggered, reportedly, by lack of access of medications. “I ran out of my meds” was a common complaint. The price skyrocketed 3-5 fold as CFCs were not allowed. This changed the propellant used, and as a result only firms who manufactured the new formulation would sell. This non trivial increase made it largely impossible for much of the population to access asthma medications.
•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
Environmental law is important. Many chemicals we use are bad for the environment. But I think it’s a cautionary tale of what our chemicals are used for. An evaluation of this policy would be useful as it could inform future changes in environmental safety, and probably ill effects that will occur on products that need chemicals. Drugs and therapies that depend on chemicals which may be banned, should be studied, so as not to exclude a large segment of population.
•Specify the outcomes and populations you think most affected or least affected by the policy.
The poor, uninsured, without regular physicians were largely affected I suspect.
I would like to start simple, and look at the consumption of inhalers purchased before the policy was implemented compared to after. This would have to be pharmacy level data. I would predict a sharp decrease in the amount of rescue inhalers purchased at this time. Secondary outcomes could be ED visits, admissions, deaths, but that’d be a little ambitious to start. I thought about this study a few years back, but didnt have the data that I thought I needed. I imagine someone’s written it up by now…
Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health
Unforeseen stakeholders with sometimes conflicting interests. If certain organizations, for example, pharmaceutical companies, have interest in profits, they may have accelerated the disparities in access by raising prices. Some say they were strong advocates of this whole swap to non CFC products.
Also challenging is deciding how to balance long-term impacts in environmental protection, vs. short term impacts in health.