Up Close: Jessica Elf

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Household Pollutants Compound Disease Burden

Dr. Jessica Elf’s interest in the health effects of environmental pollutants is rooted firmly in tobacco control. “The tobacco industry, and their tactics for marketing and promoting their product regardless of the cost to global health, will always keep tobacco control work at the forefront of my research.” Elf is a post doctoral fellow in the Department of Medicine at the Johns Hopkins School of Medicine, and with the Schroeder Institute for Tobacco Research and Policy Studies at the Truth Initiative in Washington, DC.

While serving as a Peace Corp volunteer in Timor Leste she became interested in the health effects of unclean cooking fuels. “My host-families cooked over wood using a 3-stone cooking stove, and the burden of collecting wood, and the high concentrations of pollutants produced by burning wood to cook meals, quickly became apparent.”

It’s widely accepted that smoking is bad for people’s health and that it increases the risk for someone to get tuberculosis (TB), but what is not yet definitively known is if people who are highly exposed to air pollution are also at higher risk for TB, and by how much. As Elf noted “We think this may be the case, because exposure to air pollution leads to changes in immune function in our lungs and in our bodies. And this would be particularly concerning for the Indian population, because an estimated 81% of those living in rural communities and 26% living in urban communities use wood as a cooking fuel. Kerosene is also used for lighting in approximately 30% of homes, and while DHS shows only 3% of Indian homes using kerosene for cooking, 22% of the homes in our study population reported using kerosene for cooking.”

Dr. Elf explained that the dual burden of air pollution and TB are common to the majority of countries with the highest burden of TB, but it’s especially concerning in India, where TB is not driven by the HIV epidemic, but rather by social and economic factors. “Household sources of air pollution likely play an important role, and we also suspect that ambient air pollution from road traffic, trash burning, and coal burning for energy generation, may increase the risk for TB. So we’re exploring these types of exposures in India, as well. If our suspicions are correct, reducing air pollution exposure is a modifiable risk factor that may have important implications for TB control in India.”

Elf’s research leverages ongoing clinical studies underway by the Indo-JHU research partnership. “We are integrating our studies of pollutants with ongoing TB or HIV clinical studies so we can identify how exposure to pollutants affects the health of these populations,” Elf said. With a UJMT Fogarty grant, she spent a year in Pune traveling to homes with counselors Sunita Patekar and Vaishali Kulkarni outfitting participants with personal air monitoring backpacks and installing home air monitoring equipment for a period of 24 hours—primarily in low-income areas where neighbors live very close together and there are few cleaner burning alternatives.

“In one household we visited, the family was extremely concerned about their exposures to smoke from wood and other sources, so they used LPG (liquid petroleum gas) for cooking, which is a cleaner alternative. However, their house was made entirely of corrugated metal and they shared walls with several neighbors. During our visit, large billows of smoke filled the living space, and they told us that while they use only LPG, neighbors burned wood for cooking several times a day, and regularly burned tires and other materials as part of work activities in close proximity to their home. So they were absolutely aware and concerned about their exposure, but they didn't feel they had resources to make any changes. I found this to be true among many of the homes I visited.”

Elf’s research on air pollution and TB in India is overseen by Dr. Jonathan Golub, CCGHE Deputy Director Dr. Amita Gupta, and the Indo-JHU partnership at BJGMC in Pune, India. She also works with Dr. Golub on tobacco interventions for people living with HIV in South Africa. “We are working to develop effective smoking cessation strategies specifically tailored for the HIV-positive population, because they smoke at a much higher rate than the general population and may experience greater health impacts due to HIV infection.”

Elf is working to change health practice and government policy to improve TB prevention and treatment outcomes. “At the end of the day I want healthcare providers for patients with TB and HIV to know about the effects of tobacco and air pollution exposures, and to include reducing exposure to pollutants among their prevention and care priorities. Additionally, programs and governments must invest in the quality of their air—it’s not only beneficial to health, it’s an ethical imperative.”