The novel coronavirus pandemic has hit New York City particularly hard, and communities of color have been hit the hardest. I talked to Dr. Denise Serebrisky, a frontline pediatric pulmonologist at a hospital in the Bronx (Jacobi), to learn about how pre-existing diseases affect her COVID-19 patients, and how air pollution causes or worsens several of those very same diseases. The Bronx is one of the top five counties in the U.S. with the highest levels of air pollution from vehicles. This interview was compiled from a late April phone interview with Dr. Serebrisky and subsequent email exchanges.
MCPM: How is your workday being affected by this horrendous pandemic?
DS: I became infected… I developed a lot of the symptoms that were described in the literature. It was an experience and I learned with it. That’s what really is happening with this disease. Things change day by day, and you learn as you go.
I saw the disruption and challenges Jacobi went through. Protocols on how to treat patients changed every day. We did not have enough beds on the regular floor for adult patients, so they were transferred to the pediatric floor, and pediatric admissions were transferred to another hospital.
MCPM: There are many factors that contribute to COVID-19 mortality. Can you talk about some of the most important ones?
DS: Patients who were getting really sick were obese patients who had a lot of co-morbidities like cardiovascular disease, renal disease and hypertension, which predispose patients to develop severe diseases secondary to COVID-19. And some were young, between 18 and 40 years.
We know a lot about what happened in China, but we can’t extrapolate from what happened there because I don’t think that the Chinese people have the same comorbidities as in the US. The same thing in Italy, where they have an old population and not many obese people. We have a young population and many obese patients, and obesity goes hand-in-hand with diabetes, too.
MCPM: Can you tell us about the asthma severity for Bronx children compared to children in the rest of the city and state? Is asthma one of the factors that contributes to COVID-19 mortality?
DS: Asthma is a prevalent issue for Bronx residents. New York was the eighth highest among all states for asthma among children up to 17 years of age, and also ranked as one of the top in hospitalization rates among children. The asthma hospitalization rate for Bronx children is 70% higher than the rest of the city and 700% higher than the rest of the state.
Before we thought that patients with asthma might be more susceptible to COVID-19, because they have chronic lung disease, but we are not seeing that. Only 5-10% of patients with significant COVID-19 had asthma. We are still learning.
We have learned from multiple studies that children exposed to particulate matter pollution are more likely to develop asthma, and need emergency or hospital treatment. Air pollution is associated with reduction in lung function levels, but most importantly, new studies have shown that improvements in air quality over time have a significant effect in improving lung function among children.
MCPM: You mentioned particulate matter pollution. Recently there was a preliminary study from Harvard linking PM2.5, one of the deadliest air pollutants, to COVID-19 deaths. What are the diseases associated with long-term exposure to particle pollution such as PM2.5 and what effect do these diseases have on a person’s vulnerability to COVID-19?
DS: The most affected are Queens and the Bronx, communities that have had the highest concentration of PM2.5. I don’t think there are studies yet, but those patients have more cardiovascular and lung disease. It is definitely what we are seeing: The Bronx is having more patients with more severe COVID-19. Maybe those patients are more susceptible because they have been exposed to PM2.5 for a long time, and so have more chronic inflammation.
MCPM: Are children more vulnerable?
DS: I have been doing tele-visits with my patients and none of them have COVID-19. In the beginning of the epidemic pediatric patients admitted for other reasons tested positive but were not having any symptoms. Nobody knows why. There are other coronaviruses which young children get which trigger asthma and other respiratory infections. I think that is one of the problems, children can spread the disease but not get the symptoms. That is one reason why it is very difficult to contain the disease. Over the last few weeks pediatricians have seen an increased number of previously healthy children with a severe inflammatory syndrome similar to Kawasaki disease. Similar to what happened at the beginning of this pandemic, we have limited information about risk factors, clinical course, and treatments for this syndrome.
MCPM: From what you said, it would be important to test children. Also, communities of color risk being undercounted. Are you worried that we are not able to test enough people?
DS: There are lot of barriers to being able to access testing for every facility and every place, it will take several months. I’m sure there are a lot of people dying at home and in different facilities and not being tested.
DS: There are probably a lot of factors! Definitely one of them is the disproportionate rate of obesity and diabetes, and because these groups have limited access to care or to medication, or even to proper programs where they can go for support. If they do not have programs to help them control on a regular basis, they will not be able to manage these chronic diseases. In New York City, we know that the prevalence of obesity, diabetes and hypertension among this population is higher than in the white population.
Another issue is: living in areas that are more populated makes it more difficult to do social distancing than in more affluent areas or upper New York. There are a lot of people who can’t work from home. White people started isolating even before the government started with all the regulations, they were able to work from home, they have their own cars, don’t have to use public transportation. I think those are factors that contribute to that inequality.
MCPM: Moments of crisis often expose the weak points of a system. This pandemic has revealed major problems in the U.S. health system. Although this comes as no surprise to residents and for those who fight for more equitable communities, the crisis has also revealed the dramatic consequences of air pollution inequity. What are some of the things that could be done to improve our health system, and eliminate inequity in health outcomes?
DS: Definitely COVID-19 is clear evidence that there is inequality in just basic care. Different racial groups don’t have similar access to basic primary care. Preventive medicine should be the basis of any health care system, but our health system is based on paying for acute care instead. Things could have been different if money had been placed beforehand on prevention, so everybody would have had access to primary care physicians, to manage their obesity, cardiovascular disease, hypertension.
Also, most of these patients don’t have the money to pay for medication. In New York City all children have insurance until they are 18, but this is not the case for adults. Most of the adult physicians say that it’s very difficult to manage patients with chronic diseases because of medication prices.
MCPM: What can scientists and organizations such as our own do to help frontline workers like yourself and other health workers who are struggling right now?
DS: Continue showing data – that’s really very important. Show data about different populations, especially what you have shown on New York City and the state, the impact that PM2.5 can have on the different respiratory conditions, cardiovascular disease, on adults and children and how that can lead to more morbidity and mortality. I think that that can have more of an impact and really help to change the regulations. It is data for politicians who are interested in changing regulations. Many politicians are not interested in changes that imply a lot of economic investment, especially at the beginning, or the changes may not be aligned with their vision. You can help by publicizing the long-term implications of these changes in the life of city residents. Also correlate that with the long-term savings, for, say, hospitalizations, number of lives, premature birth. That can help citizens and politicians get together and change regulations.
MCPM: Are you thinking of any regulations in particular?
DS: If we’re talking about fine particles, then change to electric vehicles, change the way highways are designed, especially in the South Bronx. And definitely, where housing is located.
MCPM: Where are most of your patients from?
DS: Jacobi is located in the North Bronx but most of our patients come from the South Bronx. The schools are located in polluted areas. The roads surrounding the South Bronx are busy all the time! It’s not like there is one hour of the day where there is no traffic, it’s continuous.
MCPM: Is there anything else that you would like people to know about your experiences in New York City working as a pulmonologist during this pandemic?
DS: Besides COVID-19, what we discussed before about the chronic exposure to PM2.5 and asthma in children. There are a lot of studies looking at the increased rate of asthma in the Bronx and the number of obese, and hospitalization. Not only does it affect acutely, but there are studies on how chronic exposure to air pollution can lead to chronic changes in the lung function of children. There are studies done in England showing that by controlling chronic air pollution those changes are reversible. I know air pollution is associated with premature birth and heart attacks and cardiovascular diseases. That has a really great impact on the health of children and is important for regulators to know.
Author’s Note: The disproportionate impact of air pollution and the novel coronavirus on communities of color is no surprise to the residents of these communities, nor to public health authorities and health workers. The pandemic has exposed major structural inequities in our health system and our society. This is a national tragedy, and a preventable one. We need to learn the lessons from this pandemic, and we need to commit to ending racial disparities in this country, once and for all.
To find out more about the link between COVID-19, air pollution and race, read my recent blog, Numbers that Take Your Breath Away.