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Commentary

Moving Upstream on Childhood Asthma and Housing


Gregory D. Kearney, DrPH, MPH; Abraham O. Kuranga, MD

T he Dangerous Stream or the River Story1


is a parable that public health practitioners
love to tell because it describes the use of our
most powerful weapons: prevention and intervention.
In one version of the story, a group of fishermen are
In several ways, the story is analogous to the public
health problems associated with health care delivery
and asthma treatment. For example, the children
hopelessly floating down the river are comparable
with the low-income, uninsured patients who keep
gathered on the bank of a river when they notice a returning to the emergency department (ED) with
child floating down the river waving her arms and an acute asthma attack time after time. The patient
yelling for help in desperation to avoid drowning. is seen by the attending physician, treated, receives
One of the fishermen jumps into the river, swims over, an increased dosage of inhaled corticosteroids, and
grabs the child, and pulls her to safety. Shortly after- returns to his or her rental home filled with a plethora
ward, another child is seen floating down the river of environmental allergies. Such triggers might in-
yelling and waving her arms and another fisherman clude mildew and mold from a leaking roof, scurrying
jumps in and pulls the child to safety. This cycle con- cockroaches and rodents, secondhand smoke, chem-
tinues and soon there are many children floating down ical sprays, perfumes or air fresheners migrating
the river. Among the frenzy of fishermen pulling the from neighboring apartments; potentially the same
children to safety, one of the fishermen is seen getting environment that spawned their asthma attack and
out of the river and walking away. The remaining fish- brought them to the ED in the first place.
ermen become very angry at the fisherman but have It is a scene that Rishi Manchanda,2 MD, is familiar
no time to stop. Finally, after many hours, fewer and with and illustrates in his book and TED Talk, The
fewer children are floating down the river, until there Upstream Doctors. Manchanda clearly articulates
are no more children left to rescue. As the fishermen that health begins where people live, work, eat, and
finally get a moment to catch their breath, they no- play. He advocates that health care providers (HCPs)
tice the fisherman who left earlier walking down the need to move upstream by considering the social
river bank towards them. Angrily, they shout at him, determinants outside the clinical setting as part of the
How could you possibly leave us here in the river patient diagnosis. He underscores what researchers
when we needed your help to save all of these drown- have been unveiling with epigenetics: where people
ing children? The fisherman calmly replies to the live has a large influence on personal health and that
others, While I knew we had to save the chil- social and environmental factors, such as housing en-
dren from drowning, it occurred to me that someone vironments and neighborhoods, help shape our ge-
should go upstream to find out why the children were netic makeup and are important predictors for deter-
falling into the river. When I went upstream, I found mining health outcomes.
the planks on the old bridge had rotted through and as
the children tried to cross the bridge, they were falling
into the river below. So, I asked several villagers to re- Asthma
place the planks with new boards and now the chil-
dren can cross safely. Asthma is considered one of the most serious aller-
gic diseases among children in developed nations.3
Asthma can be characterized as a chronic inflamma-
Author Affiliations: Department of Public Health (Dr Kearney), Department tory disease of the airways that causes symptoms such
of Internal Medicine/Pediatrics (Dr Kuranga) Brody School of Medicine, East
Carolina University, Greenville, North Carolina.
as coughing, wheezing, chest tightness, and short-
The authors declare no conflicts of interest.
ness of breath.4 In the United States, asthma affects
Correspondence: Greg Kearney, DrPH, MPH, Department of Public Health,
a staggering 8.6%, or 1 in 11 children, younger than
Brody School of Medicine, East Carolina University, MS 660, Lakeside Annex 18 years.5 In 2014, an estimated 48% of children with
#8, Greenville, NC 27834 (kearneyg@ecu.edu). asthma reported having 1 or more asthma attacks
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved. and was the leading cause of death for nearly 200
DOI: 10.1097/PHH.0000000000000532 children.5 Asthma disproportionally impacts minority

March/April 2017 Volume 23, Number 2 www.JPHMP.com 187

Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
188 Kearney and Kuranga 23(2), 187191 Commentary

and low-income groups, especially black children, liv- Undoubtedly, the results from our efforts showed
ing in low-income households.6 From 2012 to 2014, marked improvement. However, that is not where the
black children were twice as likely to be hospitalized story should end. While our families (including chil-
for asthma and 4 times as likely to die of asthma as dren) were receptive to asthma education and compli-
white children.7 Costs and quality of life associated ant with medication, we consistently found social fac-
with asthma are responsible for estimated health care tors, related primarily to indoor poor-quality housing,
costs of more than $56 billion each year.8 as a major issue. To elaborate, nearly all of our fam-
Despite advancements in treatment and promising ilies were living in substandard rental housing. Many
breakthroughs in research, there is still no cure for homes we visited suffered from disrepair including
asthma. However, the evidence is clear that when chil- leaky roofs, moldy walls, deteriorating carpet, and
dren with allergic asthma encounter allergens such as plumbing leaks. Frequently, homes needed extensive
dust mites, mold, or chemicals from cleaners or sol- pest control for rodents and cockroaches, far beyond
vents, it can trigger the bodys immune system, which the simple baits and traps that we provided. Repeat-
can further exacerbate an asthma attack. Evidence- edly, we found heating and air-conditioning systems
based research and clinical recommendations clearly that had never been cleaned or serviced and typically
support avoidance of environmental allergen expo- contained biological growth, a dirty filter, and were
sures in the home as key actions for reducing asthma laden with dust. Gaping holes, broken windows, and
attacks.4,9 stained ceiling from leaking roofs were often observed
as catalysts for increased humidity and moisture in-
ECAPP Pilot Project side the home. Typically, tenants were uncomfortable
discussing housing issues with landlords because they
It is now well established in the literature that tar- said they had feared evacuation and no place else to
geted, multicomponent, home-based interventions are live. In some cases, children did not have a bed and
effective for reducing asthma symptoms.10 To test the slept on the floor or children had a bed, but with no
efficacy of reducing asthma among children in our sheets and just a blanket. Our conversations with par-
local community, we initiated a pilot project that ents often included not having enough money to pay
we named the Eastern Carolina Asthma Prevention utility bills or for asthma medicine. In many cases, we
Program (ECAPP). The objective of the study was heard families mention they could not afford to move
to assess the effectiveness of a home-based interven- and that transportation for doctors office visits was
tion by measuring asthma-related symptoms, ED vis- also a challenge. Granted, our persistent and focused
its, unscheduled physicians visits, and quality of life efforts to reduce asthma paid off, without the support
among high-risk, minority children (5-17 years) liv- of a network of services to address housing and social
ing in poor-quality housing conditions. To carry out determinant issues, the probability that the children
this project, we used the King County Asthma pro- in our study will return to the ED is highly probable.
gram model as the framework for our project.11 Over
a 6-month period, we enrolled low-income families
with children with moderate to poorly controlled Strategies for Reducing Asthma Symptoms
asthma (N = 19). Each home visit consisted of an en-
vironmental health professional and an asthma case Based on the published literature and results from
manager, with follow-up to the childs HCPs. As- our pilot study, we strongly recommend efforts that
sessments for each child included an evaluation of go beyond the clinical setting for evaluating asthma
asthma morbiditysymptom frequency, health care symptoms among children in low-income households.
utilization, pulmonary function, and airway inflam- To guide clinical and community action towards im-
mation (fractional exhaled nitric oxide)and an in- proving asthma and environmental housing quality,
door housing evaluation to identify environmental the interplay between key strategies must take into
asthma triggers. As part of the intervention, we account the following (Figure): (1) an evaluation
provided intense asthma education, instructions on of the social determinants of health (eg, housing
proper medication technique, and instructions on us- environment) as part of the HCP patient evaluation;
ing environmental intervention products (eg, mattress (2) enhancement and enforcement of local codes to
and pillow covers, nontoxic cleaning products, proper improve housing conditions; (3) involvement of a
vacuuming) to the child, parent, and/or caregiver. At case manager or community health worker (CHW)
the end of the study, significant reductions were iden- to assist patients with asthma and their families,
tified in the number of childrens ED visits, asthma and, (4) cost reimbursement to those providing de-
symptoms, airway inflammation, and an increased use livery of high-quality, in-home, asthma visits and
of controller medicine.12 services.

Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
March/April 2017 Volume 23, Number 2 www.JPHMP.com 189

connecting families with needed services and resource


providers in the community such as faith-based orga-
nizations to help repair a leaking roof or free legal
services for dealing with unfit landlords.

Indoor environmental housing quality and laws


Americans spend upward of 90% of time indoors,
making the home environment a significant contribu-
tor for exposure to asthma triggers.20 For a child with
allergic asthma, poor indoor air quality conditions
can trigger an allergic response leading to an ED or
unscheduled doctors visit. Mandatory disclosures
and requirements for lead paint abatement and car-
bon monoxide detectors have been successful for
addressing health and safety concerns in rental hous-
ing. However, state provisions related to indoor air
FIGURE Interconnected Strategies to Support Children With Asthma in quality issues have been less successful. Housing codes
Low-Income Households With Poor Indoor Environmental Quality
covering mold and secondhand smoke have largely
depended on a range of factors, and laws vary ac-
cording to individual states and local jurisdictions.21
Social determinants of health Landlord-tenant laws commonly include provisions
typically addressing underlying issues such as struc-
When evaluating low-income children with asthma, tural, plumbing, or ventilation that can contribute
it is critical that social factors outside the clinical set- to dampness leading to mold,22,23 but because no
ting be considered. Across numerous studies, evidence standards on mold exist, the issue often becomes
shows that children with asthma in lower socioeco- subjective and remains controversial. Clinical and
nomic status households are significantly more likely home-based visit interventions by CHWs can be
to experience asthma symptoms, asthma-related effective for treating asthma symptoms. However,
hospitalizations, and ED visits than higher-income developing strategies to push authorities to enforce
households in children with asthma.13,14 For HCPs, local housing codes, adopt policies on smoke free
medical evaluations for children with asthma should multi-housing units, and providing free legal aid to
include social determinants of health as well as an renters to assist with taking action against negligible
environmental history focused on allergens, including landlords may be necessary.24
the home environment. Manchanda stresses that
HCPs should think outside the clinic and build
bridges with those who work with where health Cost reimbursement
happens so that medicine can do a better job of Reports of annual average costs associated with
improving health in the social and environmental asthma-related ED visits have been estimated at ap-
conditions that make people sick.2 proximately $1052 for one ED visit25 and more than
$3600 for an inpatient, overnight stay.26 Evidence sup-
Community health workers ports that considerable cost savings can be attained
through upstream prevention and intervention tech-
As frontline public health workers, CHWs are trusted niques through home-based visits.27 Results from our
individuals who understand the social context of com- pilot study identified that associated costs with pro-
munities in which they live in and serve.15 CHWs viding just two home visits, which included intense
can help patients manage chronic health conditions,16 asthma education, environmental evaluation of the
while achieving cost-benefit savings for health insur- home, intervention products, travel and salaries, were
ers and improving quality of life for families.16-19 In- considerably lower by almost one-half compared with
tegrating CHWs into local asthma programs can of- an estimated cost of just one ED visit.
fer tremendous benefit to low-income families with The Patient Protection and Affordable Care Act
asthma by ensuring follow-up physician visits, pro- (ACA) requires that Medicaid expansion plans cover
viding asthma education, and needed support for (certain) preventive services to seek care through
instructions on proper medication technique and home health.28 Unfortunately, many states have yet
compliance.10,18 Hidden benefits of CHWs can include to take advantage of the new provisions under ACA

Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
190 Kearney and Kuranga 23(2), 187191 Commentary

to provide these services.29 Pathways for equitable (NHIS) data: 2014 lifetime and current asthma. http://www.cdc.gov/
Medicaid reimbursement at the state level for these asthma/nhis/2014/data.htm. Updated March 1, 2016. Accessed
October 12, 2016.
supportive services need to be fully explored and inte- 6. Woods ER, Bhaumik U, Sommer SJ, et al. Community asthma ini-
grated into the fabric of local communities to support tiative to improve health outcomes and reduce disparities among
families that have children with asthma. Medicaid can children with asthma. MMWR Suppl. 2016;65(1):11-20.
7. US Department of Health and Human Services, Office of Minority
play a significant role in building effective commu- Health. Asthma and African Americans. http://minorityhealth.hhs.
nity asthma programs to low-income and medically gov/omh/browse.aspx?lvl=4&lvlid=15. Updated 2016. Accessed
underserved populations.30 Local health departments October 13, 2016.
8. US Department of Health and Human Services, Centers for Dis-
are well positioned to deliver preventive, home-based ease Control and Prevention. Asthma in the US. Vital Signs.
services because they are they are central to the Medi- https://www.cdc.gov/vitalsigns/asthma. Updated 2011. Accessed
caid population and traditionally employ CHWs and October 13, 2016.
9. Horner CC, Bacharier LB. Diagnosis and management of asthma
environmental health professionals. Acting together, in preschool and school-age children: focus on the 2007 NAEPP
they can provide in-home asthma consultations, in- guidelines. Curr Opin Pulm Med. 2009;15(1):52-56.
door environmental assessments while collaborating 10. Postma J, Karr C, Kieckhefer G. Community health workers and
environmental interventions for children with asthma: a systematic
with their local, building, and code enforcement de- review. J Asthma. 2009;46(6):564-576.
partment to address poor, rental housing problems in 11. King County Asthma Program. Healthy Homes Asthma Project
the community. Web site. http://www.kingcounty.gov/depts/health/chronic-
diseases/asthma/health-care-providers/past-programs/healthy-
homes-2.aspx. Updated June 27, 2016. Accessed October 22,
2016.
Conclusions 12. Kearney GD, Johnson LC, Xu X, Balanay JA, Lamm KM, Allen DL.
Eastern Carolina Asthma Prevention Program (ECAPP): an environ-
Until a cure for asthma has been realized, it is imper- mental intervention study among rural and underserved children
ative that communities establish a network support with asthma in eastern North Carolina. Environ Health Insights.
2014;8:27-37.
of clinical, prevention, and intervention strategies to 13. Williams DR, Sternthal M, Wright RJ. Social determinants: tak-
strengthen and provide necessary needed support for ing the social context of asthma seriously. Pediatrics. 2009;123
families with children in low-income households. (suppl 3):S174-S184.
14. Chen E, Schreier HM. Does the social environment contribute to
Provisions under ACA provide new opportunities asthma? Immunol Allergy Clin North Am. 2008;28(3):649-664.
for public health practitioners to move upstream 15. Community Health Workers Section, American Public Health
and to be involved with prevention and intervention Association. https://www.apha.org/apha-communities/member-
sections/community-health-workers. Accessed October 22, 2016.
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InternationalUniversity of North Carolina Evidence-Based Prac-
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March/April 2017 Volume 23, Number 2 www.JPHMP.com 191

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Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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