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Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
Erika: And from a fairness standpoint, often the populations living in the most polluted air are also the ones that are, you know, demanding the least from pollution. They're often, you know, economically disadvantaged and aren't particularly ordering a lot of things for delivery or traveling a lot, or generating a lot of pollution.
So it's also be, you know, behooves us to. Keep a fair lens on all this.
Anthony: [00:19:00] Yeah, I, I, that, that's a really good point. And again, they're, they're who is most impacted by pollution does not necessarily equate to their socioeconomics. And so, I mean, it can, I mean, in, in the Denver areas, some of the wealthiest areas have the worst ozone pollution, so they're pretty impacted.
But some of the least affluent areas also have the worst particulate matter pollution. And they may be. Lower consumers of the things which are causing that very pollution that is impacting them. So there's a little bit of a, of a, of a double whammy that's completely outside of the scope of most EPA related rulemaking, although there are efforts at the state level to account for that in some ways.
And I think one of the things I've wanted to communicate is that this is a complicated space economically. And so there's a lot of variables. The more of those we try to account for. You know, the more complicated it can get.
Erika: Yeah. But just 'cause something's complicated doesn't mean it's not worth the effort, you know?[00:20:00]
Anthony: Yeah. That, that, so that's, that is a great point. It, it doesn't mean that you shouldn't try and, and we accept uncertainty in a lot of things. Right. We, you know, we get in our car a lot of days and, you know, there's a risk of having a car accident. Right. We, we kind of bake that in and I think it's the easy way out is to say, this is too difficult, this is too complicated.
You can't possibly model it. There are complexities, and when you get to the biggest numbers, there's some uncertainty, but you can account for those as well. And that's one of the reasons why, for the cost effectiveness of regulation, you build in some uncertainty, right? And again, if it, if it looks like it's astronomically expensive for relatively minimal benefit.
You know, those regulations don't tend to make it into the rule book because because the regulators recognize that, that, that we need to do things that make sense both from the industry and the health. You want the biggest bang for your, for your buck. And this economics gives you a a way to, to, to put a metric on [00:21:00] that.
Erika: Absolutely. So if you had to explain to a non-expert, you know, why removing this calculation isn't just kind of an accounting change or something technical or wonky, but an actual threat to public health. What would you say?
Anthony: Yeah. And so I think that let, let's just go to, you know, to, to kind of let, let's just make up an example so people can understand.
Okay. So suppose you've got a factory and it creates pollutants and there's a filter system. It costs a thousand bucks and it eliminates 20% of the pollutants. There's a filter system that costs $10,000 and it eliminates 80% of the pollutants. And there's a filter system that costs $10 million and it gets rid of 90%.
You know, there's probably one of those solutions that makes the most sense. Now, if those pollutants are, and it depends on the cost that is being [00:22:00] born, you know, borne by the by, by the people who are impacted by the pollution, you know, if that pollution is. you know, killing thousands and thousands of people.
And again, I use the asbestos example, but there are other air toxics. You're gonna say, look, that 90% makes sense. This is so deadly and so toxic that even though it's expensive, it works. The pollution is only modestly toxic. Maybe it's that middle one that makes sense. So you're getting 80% and it's a reasonable cost.
And so that's sort of the way you have to use those numbers. Otherwise you're just sort of. Shooting in the dark and you go, well, you know, 60% of the pollutant sounds good to me. And that seems, you know, and it costs this amount of money. You're, you're just sort of making it up and, and, and, and so you, you really need, it's like a, it's like a seesaw.
If you don't have some idea of what the weight is on the other side, you can't possibly get the weight correct on the, on the regulation side. And that's why it, it's just so important. And, and again, it's not perfect. It's, it's imprecise, but you need to do your best. Otherwise [00:23:00] you just, it's unbalanced like a seesaw.
It just says all the weight on one side.
Erika: Yeah, I mean, zooming out, it just seems odd that an agency can just upend 50 years of precedent. Is this decision likely to stand or is it likely to be overturned or challenged and you know, if it does stand, what does this regulatory landscape in the United States look like over the next decade?
Anthony: I mean, there's so there's some nuance to it and I don't claim to, so these are coming. At the EPA, kind of at the, at the federal level. So when they're passing a federal law, they're not going to a federal regulation. They're not gonna try and, and consider that cost. Now, I assume that this is, this is a, a, interpretation of the Clean Air Act. You can't they're not rewriting the Clean Air Act. And so I think that different administrations could look at it differently. So I, so I'm, I'm, I'm not certain that this [00:24:00] would be durable because it's not. Written into the law, right? These are interpretations that one administration has, another administration might have it differently.
It also certainly doesn't preclude local, state and regional. Groups from trying to do that kind of consideration in their rulemaking. So I'm not sure what it does for rulemaking around particular federally mandated statutes that are gonna be implemented at the local level. But for example Colorado, 10 or 15 years ago put in rules to try and regulate, pollutants from fracking. And they did that. That was not related to EPA regulations that was driven locally and they considered the costs and the benefits. And so that kind of cost benefit is not gonna be precluded by this. And, and looking into the future, whether or not a different administration could, could reinterpret I think is an open question now to, to [00:25:00] get back though, I think to the bigger, the bigger issue.
You know, I, I do think that industry. Has felt that the that the voices and the microphone and kinda the megaphone of, of the impacted community may have drowned out their economic concerns. Right. So, and again, I, that example I gave you with a concrete plant, which is a bad example 'cause concrete gets special regulations 'cause it's known to be important.
But it's an example of how you can have these cascading effects where hitting. Hitting an industry might really disrupt the local economy, and they have felt that those things aren't accounted for. So if I was looking for a better path forward, I would wanna make sure that. That we are working on both ends and trying to do it in an unbiased manner.
We're really trying to calculate the benefit. And health, obviously it's intangible. Intangible and doing our best to have the modeling account for the, for the real cost. And again, there, there are [00:26:00] thresholds, right? We need concrete, we, we can't put concrete out of, out of business, you can't build. And so just making sure that we have that balance.
And, and what I look at from this is that. Yeah, I mean maybe there's a short term pause, but in general, we should all think about how did we get here? How did we get to a place where we weren't gonna consider that health impact? Cost, and what can we do in the future to to build systems where kind of both sides recognize the importance of considering the cost industry.
And considering the benefit to health in a way that makes sense and that we keep working on that methodology together to come up with solutions that work. 'cause by the way, local communities also don't want regulations that put out their critical businesses, you know? No. You know, we can't live without some of these things.
So, so I see both sides of the, of the picture, and I think we just have to be mindful moving forward. To make sure that, that we are trying to balance as carefully [00:27:00] as we can. So, but just getting rid of the data, like let's sweep it under the rug and pretend it isn't there. That is not a durable solution either.
It, it, it, and it, and it creates podcasts where we all are sitting here going, how can you not consider. The cost.
Erika: Yeah. And I think, you know, for those of us in clinical medicine, obviously we think of our patients and I instantly thought of, you know, how else might this affect those of us in the a TS community.
You know, obviously our, we use the government to weigh cost of saving lives and healthcare, job safety, occupational medicine, drug and device safety and more. Is this limited to the EPA as far as we know, or are we zeroing out everyone's life?
Anthony: No, no, no. This. So, you know, I think that, that, let's be clear that there's a, this is not a broad upending of the way that people do cost benefit analysis.
And to give you an interesting example you know, we're seeing a lot of locally polluting data centers get [00:28:00] put into different places, right? And, you know, if you're a local leader, it brings jobs. It, it, it, there, there are benefits, but. As you start to have diesel generators and other things creating electricity, there's going to be a, a cost and people are gonna get upset.
And so, you know, as, as people, you know, as that industry matures and people start to, Hey, I don't wanna live near a data center unless it's better regulated, you'll start to see people look at the cost and the benefit of, and, and that's really been the, the history of regulation of industry. And, you know, people regulate.
Because the cost becomes unbearable to people living there, be it from noise or dirty air, and the whole field grew up around trying to put a. Number value to what that kind of perceived cost is. So there's lots of, of places where we can still do that. Local regulation state regulation, and I'm sure there are other categories of the federal [00:29:00] government.
But I think we, we, we do have to again. You know, recognize that this was an assault on that tr on that attempt to balance recognizing that, that, that there is nothing per, you know, perfect about how we measure the numbers, but that does not mean we shouldn't try. And that I think, I think that that, you know, I've tried to express that I've some sympathy to the, to industry.
But, but just pretending that there aren't costs on the, that's not a, a durable answer and we need to do better than that.
Erika: Absolutely. And in its statement, the EPA it, well, it is reported that the EPA stated it is actually very hard to find this statement directly from the EPA Now that the not monetizing does not mean that they're not considering or valuing human life, but how they're planning to do that is, the data on that seems very limited.
And do we have any indication about what that may mean in practice, if you know, the health benefits to improving the environment are, yeah. Just kind of [00:30:00] in theory acknowledged, but not, but excluded an economic analysis.
Anthony: So I think you hit the nail on the head. So the reason why the value-based system was developed was to, was to at least create imperfect, but some kind of a framework for whether a regulation makes econ, you know, makes economic sense now.
You know, I would say, look, if you're gonna consider the value of a human life, it's, it's, it's priceless. And so now, so, so, so, so it creates a slippery slope where, how can you know, then the statute, again, the cleaner act is derived around benefit to human health, and so they cannot. Avoid considering it, right.
That's the law. But the effort to put a number to it has actually been to make the regulations reasonable. Because again, if you, what is the, if, if you don't try to put, if
Erika: it's my kid, you can't do any pollution. But if it's your kid, you can pollute a [00:31:00] little bit.
Anthony: Yeah, exactly. If you don't,
Erika: as long as I don't like, as long as I like your kid.
Anthony: If you don't try to put a number on it. Then you're, it, it just makes it even harder to come up with a, with, with what the, the right, you know, with whether regulation is too expensive or, or, or, or, or is cost effective. And so that's the problem is that, again, I think we started the, the, the discussion with this.
If you don't have that number on that side and you just say, yeah, we value human life. What's the, you know, we value it for, is it a hundred dollars? Is it a thousand? I mean, how, or do we say we value human life, but we sure value our economic productivity much more than it. So it's sort of, you know, that's the concern is that you don't have any way.
Is the, is the public who is impacted by this to understand how the EPA is valuing our lives. And so that, I think that that's the, that's the real problem here is that they can say they're valuing it, but we don't know if it's, is it a thousand dollars? Is it a hundred? That we don't [00:32:00] know what that number is.
And that, to me, you know, and again, it's an imprecise number, but we should least. Do something with it. It
Erika: should be more than zero.
Anthony: It should be more than zero. And the, and I'm a believer, the more data you have. The better. And I just wanted to kind of comment. You know, we, we had a lot of, and this is tangential, you know, we had a lot of dissatisfaction with sort of the net impact of COVID regulations, right?
And what people said is, we didn't have the data and we adopted a certain course. And maybe in hindsight, some of those regulations with schools were harmful. And so the, the message there was don't do things without data. Here we have an ex, and so here we have a, you know, another health related impact and we're saying, let's do it without data.
And so I don't like inconsistency and I, I have a lot of sympathy. The argument that we made some decisions during COVID, that, that in hindsight, we didn't have the data to know whether they were net benefit or net harmful. Here we have a system that is [00:33:00] trying to come up with that and rather than trying to refine the science we're saying.
And let's just not do it. And so I don't like that inconsistency. And I think it's, it's instructive to consider that how we're considering, you know, in one area, oh, you, you didn't have the data here. Let's just not even look at the data. I think we do, we need better consistency across our kind of how we look at health.
Erika: Absolutely. In this case, we have over 50 years of data.
Anthony: We have a lot of data, and it's a well developed field and to pretend that that work hasn't been done doesn't serve anyone well.
Erika: Yeah. Are there any historical parallels with this action that come to mind? You mentioned COVID and that's what I'm gonna.
Think about for a while 'cause it's true. We were, you know, acting with the idea that, you know, almost in the, what you were mentioning every life is, you know, immeasurably valuable and, you know, people felt the burden of that more than I think we were appreciating at the time. Any other historic parallels?
Parallels?
Anthony: You know, I think that, that I would probably. And I'm, I am not necessarily [00:34:00] saying health related, but I would go to like the insurance industry for historical parallels. So, you know, there are homes and areas which people won't insure, right? They just won't do it because the perceived risk, you know, there, there, there's a perception that you lose money on that.
And so they'll, they'll, they'll put a value on your house and they'll kind of put a risk around you, for example. You can't build houses in fire prone areas where the firehouse and the system that put out the fire is more than a certain number of miles away. So they do a lot of actuarial science around.
We would be bringing in this amount of money insurance, but it wouldn't pay the bills. So there are just so many examples of where we're able to come up with that, those balances. And I, I'm, I'm, I'm almost hard pressed to think of something on the other end where you just say. Let's not even try. You know, really most of our economy in modern society, you know, works on that principle.
It's not uniform, [00:35:00] right? I mean, there are probably things that we do where the perception of risk is, is much bigger than the risk, but the perception drives it. So example, you know, airlines are really safe. But we have a whole system to keep them safe. 'cause people just are horrified by the idea of an airline crash.
So it isn't always apples to apples, but I have a hard time thinking of something where. We just don't even think about it. Like we, you know, we don't even have a, we're just gonna say, it just doesn't matter. Let's not look at the data. It'll be like taking cars and saying, you know, let's just get rid of crash tests.
Like, let's just pretend that, that they're perfectly safe and that the technology is good enough so you shouldn't have that data in front of you. So, so there are so many examples in society where we try and make those cost benefit analyses and why. We are singling out health effects here and those indirect costs to not try and do this analysis.
It, I I I, I'm having a hard time thinking of a lot of areas where we, where we, where we do that.
Erika: Yeah, [00:36:00] absolutely. Is there something you wish people understood about this issue that you don't think is being captured in the news or what we've already covered?
Anthony: Yeah, and I, and I think that that again.
I don't want to vilify industry. You know, we, we all use the products of industry. They're useful and there are times when I have seen regulations that have. People have tried to promulgate that just don't make sense that the juice isn't worth the squeeze. They're too expensive. And so I, I think it is fair to say, yeah, you know, the, the regulated community they have a voice and a stake and they're important.
And so I, you know, I, I don't want people to perceive that. And I think the general, a lot of the media comes across as saying. You know, how can they not be looking at, at, at, at the cost of this? So, I wanna be very clear. We need to look at both sets of costs. There is a cost to the regulation, but we also have to look at the benefit.
And I think that, that that [00:37:00] mixture we need to get right. And I think that both communities, the regulated community and the health impact a community need to work together to try and get those numbers right, not just sort of cut off the one, you know, one side of it doesn't make any sense. So.
Erika: Absolutely. And I think one of the things is, you know, there always tends to be this bifurcation that the regulated community is separate from the impacted community, but we're actually all one community. Right? You know, we all need this industry in our communities. We are all impacted by these health effects.
And so I think that also just kind of helps us remember that this is all one and the same.
Anthony: Yeah, it's a great point and I will go back to the Colorado situation where the rulemaking, the regulated community and the health impact community and the regulators. It was a community. It was the same people.
Showing up to the same meetings, trying to come up with, with consensus. And as you got to know the people on both sides, there were, there were no villains in the attorneys [00:38:00] representing, for example, wastewater treatment plants who, when there was concern about hydrogen sulfide pollution from them you know, that's a byproduct of sulfide.
It's a byproduct of, of, of of human waste. And so. There were no villains, there was just trying to come up with, with best solutions, recognizing that, you know, wastewater is part of being human. We generate that, it generates pollutants and we, how can we think through this? So there are no villains.
It's one community, and the answer is to work better as a community, as a, as a whole community, rather than trying to, trying to polarize and turn this into a little bit of a, of kind of a false dichotomy of. Regulated and impacted and realize that there's a lot of intersection. You know, you might be in the impacted community and have a job that is directly impacted by the regulation or vice versa.
So really important to realize that we're all in this together, and that when you try and create an arbitrary schism. [00:39:00] That in the long run is not going to lead to, to the most optimal solutions, at least. I, I think that cooperation and collaboration is a way to get there, not trying to put a line in the sand and, and, and, and, and stop people talking.
Erika: Absolutely. Well, in case it's not clear, the American Thoracic Society opposes these changes by the EPA and you and I both serve on the Environmental Health Policy Committee. And I understand that multiple members of our committee actually have an article in review for one of our a TS journals to try to help clarify the a TS position on that.
And is that correct?
Anthony: It's, and I think, again, it, it, this is not, I don't, I don't think this is super controversial. This is not trying to go out on a limb. Of, of, you know, if we need to get rid of all industries so we can all, you know, return to, you know, quiet agrarian lifestyles. This is pragmatic, that let's look at the costs on both sides and that, and that we don't feel that limiting, that we don't feel that that [00:40:00] limiting the dialogue is a way to get to consensus or durable solutions.
And obviously when you have patients who are. I couldn't go to work today. I can't go take care of my grandkid today because they wanna play outside and the, it's too polluted. I can't buy my inhaler. We see those real costs and they have to be considered if, if you, and again, we have tools to consider them.
It's not. And so I think that, that there's a. Pretty good group of scientists and it's a science oriented community in a TS and you, we, I think there's a belief that, that the more an analysis you do. The better solution you will get. And I think that that's one of the messages from the, from the piece that we're putting together.
And I think of the ATS in general, you know, we, we, we like to talk to people, you know, if, if, if we are happy to communicate why it's important and why considering the health impacts isn't a. Isn't, you know, at odds [00:41:00] with having industry. It's designed to get it to work together and to create durable, sustainable solutions that will be in place 5, 10, 20 years from now as opposed to changing every time we get a, a swing in the political climate.
Erika: Absolutely. Well, thank you very much for your time and for your science and service for cleaner air. Is there anything else you wanna add?
Anthony: No, that's it. Thank you for having me. And it was you're, you're a great podcast host.
Erika: Well, looking forward to seeing you at ATS.
Anthony: Equally. Thank you so much.