EPA to Asthmatic Kids:

Hold Your Breath

By Robert M. Goldberg

Today, the Clinton administration will issue a proposal that could take away asthma inhalers from inner-city children to protect the Earth's ozone layer.

This is not a sick joke, or the product of an overheated conservative imagination. Rather, the Environmental Protection Agency wants to announce a ban on chlorofluorocarbon-powered inhalers in Montreal at the international meeting on ozone protection as a shining symbol of America's international environmental stewardship. Never mind that such a ban would increase the cost and difficulty of treating childhood asthma, and that inner-city children are already six times more likely than other children to die because of inadequate asthma care. Even though such inhalers account for less than 1.5% of total CFC emissions world-wide, the EPA is likely to get its wish.

Under the Montreal protocol on ozone-depleting substances, 155 countries have agreed to phase out production of CFCs and other ozone-depleting substances. An amendment to the protocol introduced by the U.S. in 1990 accelerated the international phase-out. However, that amendment left one important feature of the protocol intact. It still allows each member country to exempt from the ban certain CFC-containing products deemed "essential." Since the treaty was ratified, asthma inhalers have been exempt because of their public health importance. And each year, the EPA nominates other products for exemption. This time around, however, the EPA wants to tell the world it will no longer ask to exempt inhalers.

EPA Administrator Carol Browner says that the goal of the ban, like her many other environmental initiatives, is to ensure that U.S. children are protected from environmental health risks. Ms. Browner claims that more environmental regulations will protect asthmatic children most of all, since they are among the most vulnerable to environmental threats. Hence, taking asthma inhalers away from children is being done in the name of children's health.

It's true that non-CFC asthma products do exist, and that some work better than those containing CFCs. But different patients' asthma symptoms respond differently to each of the available medicines, and specialists are opposed to reducing that range of products simply for the sake of environmental correctness. In addition, poorer children are especially reliant on generic inhalers with CFC propellants, which can cost one-eighth the price of newer brand-name products without CFCs. Ultimately, these two factors contribute to the fact that only half of all children are following the inhalation schedule necessary to keep their asthma under control. An expert panel of the National Institute for Allergies and Infectious Diseases found in 1995 that failure to comply with treatment explains the 300% increase in asthma-related deaths among children between 1980 and 1993.

Why would the EPA want to hasten the elimination of a medicine that's essential to keeping kids alive? The Montreal protocol doesn't require it. And a large number of member countries are opposed to such a quick phase-out.

Yet the EPA wants America to be the first country to develop a solution for the elimination of CFC-powered inhalers. So, despite resistance from doctors, the EPA has pushed the Food and Drug Administration for tougher regulations. Under the proposed new FDA rules, if one CFC-free inhaler hits the market, any CFC-powered inhaler delivering the same medicine would have to go. In this way, all those who use CFC inhalers--about 95% of asthma inhaler users--will be deprived of the opportunity to use the inhaler that works best for them.

Dozens of medical groups and hundreds of allergists have urged the FDA not to go ahead with its planned termination, pleading that a change in medicine will compromise children's health. The Joint Council of Allergy, Asthma and Immunology has told both the FDA and the EPA that their proposal will unfairly punish poor children and the elderly, who have the highest risk of asthma-related sickness and death. Even the FDA panel that made this proposal expressed concerns about the impact on such children of wiping out a whole class of CFC-powered inhalers.

The question is why the EPA is willing to invite those consequences. In a letter to the FDA, the EPA claimed that the U.S. is forced under the terms of the Montreal protocol to limit exemptions to cases where no non-CFC substitutes are available. Since CFC-free devices do exist, the EPA argues, the ban must apply. The EPA objects to the FDA's intention to weigh the benefits of reducing CFC emissions compared to the negative effects for asthmatics. Incredibly, the EPA

wrote to the FDA that domestic assessments of impact cannot be considered in the FDA's decisions if they conflict with U.S. treaty obligations. In other words, the FDA cannot consider the health impact of a ban on CFC-powered inhalers on U.S. children because it is at odds with the EPA's desire to demonstrate America's commitment to environmental vigilance.

Worse, even as the EPA is hell-bent on snatching asthma inhalers away from children and the elderly, it had no problem exempting other products that have nothing to do with children's health. Among the other CFC-laden products the EPA has decided not to ban document-preservation sprays and foam insulation for coaxial cable. It has also spared CFC-emitting fire extinguishers even though the EPA found some alternatives are already on the market and in use. The EPA's Ms. Browner apparently believes that preservation sprays and coaxial cable are more important than medicine for asthmatic children.

This is what we have come to expect from the Clinton administration: Children are shamelessly invoked as a justification, even for policies that hurt children. When it comes to their inhalers--well, what's a few innocent lives, particularly of children in the inner city, compared to President Clinton's goal of showing international leadership on environmental protection? If children lose access to inhalers, they'll just have to hold their breath until the ozone layer is repaired.

Mr. Goldberg is a senior research fellow at the Center for Neuroscience, Medical Progress and Society, George Washington University.

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