Every Asthma Attack Is Its Own Perfect Storm

The More We Study the Disease, the More Complex We Understand It to Be

About a month ago, I received a call from a journalist wanting my perspective on recent data showing an increase in asthma ER visits in certain parts of California, particularly in the Central Valley. The rate of emergency room visits for children 5 and older more than doubled in rural Madera County and nearly doubled in Merced County. But other parts of the state have also seen increases—Los Angeles, for example, saw a 17 percent increase. My response was that there’s clearly more work to be done if more than 72,000 children with asthma are going to the emergency department in a single year.

When I hung up the phone, I felt demoralized reflecting on the fact that I and so many of my public health colleagues across California have been working to reduce the burden of asthma for decades. If we’re still seeing discouraging data, does that mean California is losing the fight against asthma?

The answer is that we’re not losing, but it’s also not a fight we’ll be “done with” any time soon. We’re not working on a communicable disease for which we might discover a vaccine. Asthma is a complex chronic disease, and its prevalence and severity are shaped by an array of factors from access to medical care to climate change to transportation policy to income inequality. This requires a comprehensive, long-term response. Some health conditions have a single cause, like a virus; asthma is not one of them.

When a kid ends up in the ER in Madera with asthma, the list of potential culprits is long. Sure, the cause could be the region’s chronically poor air quality, but the cause of this particular child’s asthma attack on this particular day could also be housing infested by cockroaches or containing mold, which are common asthma triggers. Another child’s family might need to use certain medications more consistently, requiring instructions on how to manage his or her asthma from a community health worker who speaks Hmong. We now have evidence suggesting stressful experiences, like living with someone who is abusive, could lead children to develop asthma, so that child needs a social worker. Finally, while every asthma attack is its own perfect storm, asthma hits low income communities and communities of color particularly hard: This is most striking for blacks, who have 40 percent higher asthma prevalence, four times higher asthma ER visits and hospitalization rates, and two times higher asthma death rates than whites in California.

We started off thinking asthma was a medical issue, but it quickly revealed itself to be a social—and even a moral—one. Here’s a bit of history: When my organization, Regional Asthma Management & Prevention, started about 20 years ago, we worked to do a better job of medically managing asthma by communicating with healthcare providers, school personnel, parents, and children with asthma. It was apparent, though, that clinical management could not be successful if children were continuously exposed to asthma triggers in their homes, schools, and neighborhoods. So we started working with community health workers to identify and remove triggers in the home, and that lead us to eventually trying to get landlords to improve their rental properties. Similarly, efforts to reduce triggers in schools expanded out of the schools themselves and into the community, as well as to policymakers, like a statewide association of school board members and the state legislature. Recognizing that neighborhoods with high asthma hospitalization rates tended to have a concentration of refineries, ports, railways, and freeways with heavy truck traffic led us to collaborate with community activists, environmental justice advocates, and public health colleagues on the Ditching Dirty Diesel Collaborative to pressure regional and state air quality agencies to better monitor and regulate diesel pollution. Any thread we grabbed turned into something much larger and more complex.

Diesel is a good example. The presence of such high concentrations of diesel sources led us to more fundamental questions about why major transport corridors went through neighborhoods typically made up of people of color who were disproportionately poor. So our work expanded to better understand how land-use and transportation decisions are made. In effect, what began as an initiative focused on a single disease with an emphasis on clinical care has expanded to include policy advocacy for improved outdoor air quality, participation in land-use and transportation planning, and promoting health equity.

As our understanding of the magnitude of the asthma challenge has grown, progress has been made. California has done ground-breaking research, such as one of the largest studies linking air pollution to asthma and another study identifying racial and ethnic disparities in the quality of asthma care, helping us understand how to best manage, treat, and—importantly—prevent asthma. To keep kids out of the ER, school-based health centers, community clinics, and mobile clinics help high-risk children before they’re in a crisis. And community health workers have developed culturally competent ways to talk with families about the risks of tobacco smoke—and helped them strategize how to keep it out of the house without making family members feel bad.

We’re making progress with better healthcare policies, too. Recently a federal agency, the Centers for Medicare and Medicaid Services, passed a policy that state Medicaid agencies can provide reimbursement for essential services, like asthma education, when they are provided by community health workers or other qualified professionals. In-home education to reduce asthma triggers—pets, smoking, dust, and mold—has been shown to reduce ER visits and hospitalizations, but it still isn’t covered by most insurers and too many people with asthma currently lack access to these vital services because they are not reimbursed. There is an opportunity for California’s Medi-Cal program to change that.

We’re also making progress on better air-quality policies. Scientific research showing components of air pollution not only exacerbating, but causing asthma has expanded enormously, enabling advocates to push through stronger diesel regulations across the state. Research on mold has also evolved, and California just passed model legislation establishing it as a substandard housing condition, giving local enforcement agencies a clear signal to require owners to fix mold problems.

All of these things are important in the fight against asthma, but our work is not done. Until we see asthma as more than just an unfortunate but inevitable problem facing certain children and families, we will never truly make headway against this complex disease.

For example, as the California Air Resources Board develops a Sustainable Freight Initiative, it should build a healthier, fairer freight system by adopting technical solutions (like electrification) and land-use solutions (like routing trucks out of neighborhoods). The California legislature should pass additional bills to eliminate substandard housing conditions that contribute to poor indoor air quality, including controlling rats and cockroaches, both triggers. We need to ensure that families have access to affordable, safe, and healthy housing that will not make them sick.

Finally, there is climate change, which is being increasingly recognized as a public health issue. The recent drought has increased dust in some communities, while others are seeing that warmer temperatures are raising pollen counts—showing that climate change is already worsening asthma. We need to double down on efforts aimed at slowing the impacts of climate change and its accompanying effects on our air quality and health.

The fact is that asthma is profoundly unfair—and it reflects and magnifies other kinds of inequality in our society. Since asthma is a societal problem, it requires a societal response—in essence, a moral choice. While California benefits financially from having a robust system of importing and moving goods to other parts of the country, we must stand up and say that it can’t occur at the expense of our children’s health. As Silicon Valley bolsters the Bay Area economy, we can’t let that translate into families being forced into unhealthy housing conditions because they can’t afford anything else. There are numerous other examples. If we as a society keep choosing financial benefit above health, we’ll end up paying with the health of our most vulnerable residents.

California is certainly not losing the battle against asthma, but if we’re honest we’ll admit we’re not yet winning it either. We simply haven’t made enough of the choices—the policy and systems changes—that we’ll need to make. There are plenty of opportunities before us, and our efforts can make a difference for the 5 million Californians diagnosed with asthma. But it’s going to take all of us working together for the long-term.


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