In the News
Every Asthma Attack is its Own Perfect Storm
About a month ago, a journalist called to ask my perspective on data showing an increase in asthma ER visits in parts of California, particularly the San Joaquin Valley.
Emergency room visits for children 5 and older have more than doubled in rural Madera County and nearly doubled in Merced County. They’re up elsewhere, too; Los Angeles, for example, is up 17 percent. My response was that there’s clearly more work to be done if more than 72,000 children with asthma are going to emergency rooms in a single year.
As I hung up, it was demoralizing to reflect on the fact that all our efforts to reduce the burden of asthma for decades aren’t showing results. Does this discouraging data mean California is losing the fight?
We’re not losing, but it’s also not a fight we’ll be done with anytime soon. Some health conditions have a single cause, like a virus; asthma is not one of them – meaning we won’t discover a vaccine to cure it. 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. It requires a comprehensive, long-term response.
When a kid ends up in the ER in Merced with asthma, the list of potential culprits is long. The cause could be the region’s chronically poor air quality, but the cause of this particular child’s asthma attack on this specific day could also be a house infested by cockroaches or containing mold, both common asthma triggers. Another child’s family might need to use certain medications more consistently in managing her asthma, or get instructions from a health worker who speaks Hmong. Evidence suggests stressful experiences, like living with an abusive caregiver, can lead children to develop asthma; 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 an asthma death rate that is double that of whites in California.
When we started, we thought of asthma as a medical issue. But it has revealed itself as a social – even a moral – issue instead.
When my organization, Regional Asthma Management & Prevention, started about 20 years ago, we worked to do a better job of managing asthma by communicating with health care providers, school staff, parents and children. It was apparent, though, that clinical management could not be successful if children were continuously exposed to asthma triggers. So we started working with community health workers to identify and remove triggers from homes. That led us to try to get landlords to improve rental properties. Similarly, efforts to reduce triggers in schools expanded 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 more 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 air quality agencies to better monitor and regulate diesel pollution. Every thread we grabbed turned into something much larger and more complex.
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.
California has done groundbreaking research, including one of the largest studies linking air pollution to asthma and another identifying racial and ethnic disparities in asthma care. Both will help us understand how to manage, treat and 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 crisis.
Our health care policies are improving. The federal Centers for Medicare and Medicaid Services now says state Medicaid agencies can provide reimbursement for essential services, like asthma education, when provided by community health workers or other qualified professionals. In-home education to reduce asthma triggers – pets, tobacco smoke, dust and mold – reduces ER visits and hospitalizations but still isn’t covered by most insurers. Too many people with asthma lack access to vital services because they aren’t reimbursed. There is an opportunity for Medi-Cal to change that.
We’re getting better air-quality policies. Research showing components of air pollution not only exacerbating, but causing asthma has expanded enormously, enabling advocates to push for stronger diesel regulations. Research on mold has also evolved, and California just passed model legislation establishing it as a substandard housing condition, giving local enforcement agencies a signal to require owners to fix it.
All of these are important in the fight against asthma, but our work is not done. Until we see asthma as more than an unfortunate but inevitable problem facing Valley children and families, we will never truly make headway.
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 Legislature should pass additional bills to correct housing issues that contribute to poor indoor air quality, including controlling rats and cockroaches, both triggers. We need to ensure that families have access to affordable housing that will not make them sick.
Finally, there is climate change. The recent drought has increased dust in some communities, while others are seeing that warmer temperatures are increasing pollen counts – showing that climate change is worsening asthma. We need to double down on efforts to slow the impacts of climate change and its effects on our air quality and health.
Asthma is profoundly unfair, reflecting and magnifying other kinds of inequality. Since asthma is a societal problem, it requires a societal response – in essence, a moral choice. While California benefits from having a robust system of importing and moving goods to other parts of the country, we must insist 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 better. If we, as a society, keep choosing financial benefit above health, we’ll end up paying by making our most vulnerable residents horribly ill.
California is not losing the battle against asthma, but we’re not yet winning it either. There are plenty of opportunities, 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.
Originally published by Merced Sun-Star