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It's Not Easy Breathing Green

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If you are one of 20 million Americans suffering from asthma, chances are you've noticed the recent change in inhaler technology. The new ones lack chlorofluorocarbons (CFCs), first developed during World War II as pressurized propellants to dispense potent insecticides such as DDT. CFC inhalers have been delivering the drugs to the wheezing lungs of asthmatics for three generations while adding ozone-depleting chemicals to the atmosphere. But by January 2009, CFC inhalers will no longer be available for sale in the United States. Inhalers using hydrofluoralkanes (HFA) as propellants are being substituted in their place. For asthmatics, like me who grew up on the old propellants, the new HFA inhalers don't deliver that same blast of sweet-tasting aerosol and initial buzz one could expect from CFC inhalers. And they're much more expensive. While millions have made the switch to the new HFA inhalers, four to five million asthmatics have yet to adopt the new green technology, according to Laurie Tarkan in a recent article in the New York Times.

The shift to HFA inhalers is a direct result of the 1987 ratification of the Montreal Protocol, heralded by Kofi Annan as "perhaps the most successful international agreement to date." Over the last two decades, 191 countries have phased out over 95 percent of ozone-depleting substances such as chlorofluorocarbons in an effort to protect the Earth's ozone layer in the upper atmosphere. It is a success story unrivaled in the history of international environmental governance. Green consumers can feel good knowing that their switch to HFA inhalers is an environmentally friendly choice. And drug manufacturers like GlaxoSmithKline can point to legitimate strides made as good corporate citizens in addressing global climate change through their commitment to the phase-out of CFCs in their devices. The technology changeover has cost the company an estimated $1 billion. (But asthma drugs are big moneymakers for pharmaceutical companies. Just two asthma drugs made up twenty percent of GlaxoSmithKline's $32 billion in worldwide pharmaceutical sales in 2005.) Patients, companies, and insurers have shared in the burden of those costs. HFA inhalers, at about $40 each, cost three times more than the old CFC inhalers.

The unfolding tragedy is that those who can least afford it are the ones most affected by the shift to the new green economy. Uninsured inner-city neighborhoods like Harlem, where an estimated one in four children suffers from asthma, have historically been the last communities to benefit from the introduction of new drugs in asthma treatment. Underprivileged asthma sufferers are far more likely to seek relief in the cough and cold section of the local store or the hospital emergency room than in the clinical allergist's office. With the HFA inhalers, the cost of their immediate-relief medicine triples. The risks of reliance on cheaper, over-the-counter inhalers are great. The doubling of asthma deaths in the 1960s in England, although debated in the medical literature, was attributed in large part to self-medication by asthma patients with over-the-counter bronchodilators manufactured by American pharmaceutical companies. Paul Stolley, an epidemiologist and physician at Johns Hopkins School of Hygiene and Public Health in the early 1970s, called it "the worst therapeutic drug disaster on record. There's nothing else--not even thalidomide--," he exclaimed, "that ranks with it." Similar concerns arose in the 1980s as sales of bronchodilator inhalers and asthma deaths both climbed.

In poor, urban communities of color, where African-Americans are three to five times more likely to be hospitalized and die of asthma than whites, the increased costs of HFA inhalers could prove disastrous. Impoverished urban residents already suffer from living with a disproportionate share of bus depots, hazardous waste facilities, and polluting industries, as well as high levels of indoor exposures to cockroach allergens and pesticides, that combine to create ecological conditions in which it is much more difficult to breathe. Health care in American society has increasingly moved from a model of public health to consumer choice, where health has become a purchasable commodity. But if green corporate and consumer choices end up harming some more than others, leaving behind those who lack purchasing power, our actions as environmentally responsible citizens will have been in vain. As Van Jones, founder and director of Green for All argues, "we need to build a green economy strong enough to lift people out of poverty." And we need to build a green economy that protects the environment and health, of not just some, but of all.

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