Roach top right

Blighted Housing Fuels Rise in Asthma Rates Among Minority Children

By Michael Gibbons

Last year, within nine months, asthma attacks sent Lionel to the ER five times and hospitalized him another five times. He might very well be on that pace again this year.

INNER CITY ASTHMA 2 Each time he returns home, Lionel re-enters an environment hostile to his airways, a rented house in a blighted section of Boston, moldy from a leaky roof and infested with mice and cockroaches. Lionel’s mother is too intimidated to press her landlord to make repairs. Why? She’s afraid antagonizing him might get her evicted. She couldn’t afford a security deposit on another place; Boston landlords usually want first and last month’s rent in advance. So she and her highly allergic son remain with the roaches. It’s better than homelessness.

“Since she cannot afford to move, she feels trapped,” write the authors of a recent study called, “There’s No Place Like Home: How America’s Housing Crisis Threatens Our Children.”

Hundreds of thousands of low-income American children like Lionel suffer disease, serious injury, malnutrition and educational failure because they live in ramshackle housing, contend Megan Sandel, MD, and Joshua Sharfstein, MD, two pediatricians at Boston Medical Center and Children’s Hospital.

Their study documents how housing even can be lethal, as in the case of three children in Cleveland confirmed to have died of pulmonary hemorrhage due to inhaling the fungus stachybotras atra from rotting drywall and ceiling tiles. The Centers for Disease Control and Prevention suspects this toxin has caused 60 cases of bleeding lungs and 18 deaths in Cleveland.

“If you have poor ventilation in a house, you will end up with many asthma triggers, more moisture and therefore more mold growth,” Dr. Sandel observes. “Some people have poor window guards, so they can’t use their windows. They must make a choice between not having proper ventilation or opening a window and placing their child in danger of falling out.”

Asthma, the most common chronic illness among American children, afflicting more than 5 percent of them, is far more likely to victimize poor children for two reasons. First, the poor often must live with asthma triggers such as rats, mice, cockroaches, dust mites, mold, inadequate heat and crowding. Secondly, many poor families cannot afford to seek asthma treatment because making rent, even to live in squalor, consumes more than half their incomes.

More than 5,000 people die from asthma each year, and the death rate for African Americans is twice as high as the rest of the population, according to the Asthma and Allergy Foundation of America (AAFA).

Drs. Sandel and Sharfstein say theirs is the first report to link poor housing to poor health nationwide. They are calling upon the federal government to increase spending on affordable housing.


More federal dollars would help, but the emerging epidemic of asthma calls for a more urgent response than tapping one’s foot and waiting for money to upgrade housing projects to trickle out of Washington. Inner-city asthma outreach programs offer a more aggressive and satisfying way to combat asthma’s rising morbidity and mortality among low-income minorities.

One such program is starting up in Cleveland under the auspices of the American Association for Respiratory Care (AARC). The AARC received a $17,600 grant in October from the EPA’s Division of Indoor Air Quality for a pilot study in which RTs from Rainbow Babies and Children’s Hospital will teach asthmatic children and their parents about asthma triggers and asthma management. Tim Myers, RRT, and Rob Chatburn, RRT, will direct the project.

“We are going to look at 1,000 asthmatics, predominantly inner-city minorities,” explains Janet Boehm, RRT, who helped secure the EPA grant. “We plan to give patients over the age of 5 a peak performance kit once they are admitted. Therapists will do an educational intervention, discuss their disease and its triggers. We will target indoor air quality in public housing. Cockroaches, pets, smoking, mold buildup from drippy faucets, all could be asthma triggers.”


Patients will be called upon to assist in the research. Whenever they feel short of breath, they are to perform peak flow meter readings to verify and record their attacks. A week later, in a follow-up phone interview, they’ll be asked to pick the most likely cause of their attack from a checklist and to discuss ways to eliminate that trigger.

“In phase one, we’ll identify the indoor triggers,” says Boehm, an educator at Youngstown State University, Youngstown, Ohio. “In phase two, with more money, hopefully, we’ll eliminate them.”

For example, if patients identify cockroaches repeatedly as a likely cause, Boehm et al will petition the federal government to eradicate the pests without using sprays. If mold is implicated, they may try to persuade local hardware stores to donate washers to tighten up leaky faucets.

“Our hypothesis is that RTs do this intervention better than other health care professionals,” Boehm says. “They can offer patients the most specific training about peak flow meters and medications, and can adequately decrease ER visits and, therefore, costs. Hopefully the research will support that hypothesis.”

When she announced this project at last year’s Summer Forum meeting in Phoenix, then-AARC President Dianne Kimball, RRT, suggested that this pilot study could help to raise the profession’s profile across the country. “There is the potential to extend this (project) nationwide under our banner,” she said.


Meanwhile, asthma care is going mobile in Los Angeles and elsewhere.

In 1995, the Southern California chapter of the AAFA retrofitted a massive Winnebago motor home into an asthma clinic on wheels. The mobile clinic visited 18 schools that year, treating and educating nearly 700 low-income and uninsured asthmatic children and their families.

Impressed L.A. County officials financed two more of these 36-foot mobile units, called Breathmobiles, and today all three make regular stops at 65 schools throughout the county from their base at the University of Southern California Medical Center. The program has captured the attention of teaching hospitals in New York, Chicago and other cities.

“We tried a lot of other things before developing this concept,” says Francene Lifson, executive director of the Breathmobile program. “People didn’t have bus fare to get to an asthma clinic. So we bring the ER to them.”

An allergist, an RT and a nurse ride on every unit with, occasionally, a personal finance consultant and a medical resident. They take medical histories; give physical exams; perform spirometry, peak flows and other diagnostic tests; dispense meds; teach patients how to use MDIs, spacers and nebulizers; and discuss bedding encasings and other environmental control measures.

Each Breathmobile visits about 22 schools in six weeks, then repeats the cycle, meeting 1,000 new patients per year. In its first year, the Breathmobile enabled 67 percent of children to gain control over their asthma. Elementary school students had 80 percent fewer absences and high school students 50 percent fewer absences.

“The outcome studies are really dramatic,” Lifson says. “We know we are helping a lot of children.”

A half-dozen new Breathmobiles are slated for Phoenix and other metropolitan areas this year. “Lots of people want to duplicate our program,” Lifson says. “The concept is really taking hold.”


National efforts are under way as well, according to Dr. Sandel. Reacting to the fungus deaths in Cleveland, the Department of Housing and Urban Development (HUD) now is accepting applications for a grant to study cost-effective home remediation methods.

The federal Home Loan Bank has awarded a grant to the city of Boston to eliminate asthma triggers in poor housing.

And the Clinton Administration wants to expand the government’s Section 8 program by issuing 120,000 additional Section 8 vouchers to eligible families to help them afford suitable housing.

Health officials are starting to acknowledge the problem, concludes Dr. Sandel, who continues her own efforts to prevent childhood disease rather than treat it after the fact. “My goal in life is to put myself out of business,” she says.

Michael Gibbons is associate editor of ADVANCE.

The Wages of Fouling Our Nest

By Michael Gibbons

You’ve stepped outside, smelled the air, noticed a haze and concluded it’s too smoggy today to go jogging. How great an effect does your decision not to jog have on your overall quality of life? Can it be quantified?

Epidemiologists didn’t ask themselves such questions back in 1985 when they drafted the American Thoracic Society’s original policy statement on the adverse effects of ambient air pollution. They focused on traditional lab values such as lowered FEV1 and other physical measures.

Times have changed. The ATS plans to incorporate intangibles such as quality of life and ethical issues when it revises its air pollution policy statement this year, according to Jon Samet, MD, a member of the ATS revision committee.

For one thing, the new ATS policy will address the emerging issue of environmental racism, the realization that racial minorities concentrated in urban industrial settings bear a disproportionate burden of pollution exposure, Dr. Samet told delegates at the 1999 ALA/ATS conference last April in San Diego.

Committee members also will weave into the new statement a concept known as “mortality displacement,” which states that, because of pollution exposure, people already in poor cardiovascular health are on course to die earlier than they would otherwise.

Politicians refer to policy statements by organizations such as the ATS for guidance when crafting the nation’s environmental laws. That’s why the ATS should delve deeply into quality of life issues this time around, one speaker at the seminar urged.

“I would argue it’s time we wake up and smell the sulfur dioxide,” declared Cynthia Rand, PhD, of Johns Hopkins University Medical Center, Baltimore.

The 1985 document considered eye, nose and throat irritation from urban smog “not medically important” because they aren’t quantifiable lab values like, say, increased plasma viscosity, Dr. Rand said. Researchers dismiss “pollutant burdens” as trivial, but they are the symptoms people know and understand, she insisted. Residents around a polluting plant wouldn’t know if their FEV1 drops, but they do notice odors and eye irritation.

“Cough, wheeze, nausea, pain and headache don’t translate to lab values, but we have incorporated them into evaluating the health of people with COPD and asthma,” Dr. Rand pointed out.

Furthermore, studies have associated malodor and increased ozone levels with mood disturbances such as irritability and reduced tolerance for frustration, she added. One study even has correlated elevated pollution levels with a higher frequency of 911 calls.

Greater political sensitivity isn’t the only reason to revise the ATS policy, however. Empirical science also has advanced since 1985, Dr. Samet explained. The original policy was written before scientists developed biomarkers and other sensitive monitoring techniques. For example, one recent paper used biomarkers to show that ozone exposure increases active aldehydes in airways, independent of smoking status.

The ATS will revise its policy statement again around 2010. That document, Dr. Samet predicted, will reflect new discoveries about why some people are more genetically susceptible to pollution-related health problems.

Michael Gibbons is associate editor of ADVANCE.