Does Race Increase Your Chances of Asthma?

New research from the CDC shows that black children are diagnosed with asthma twice as often as their white peers. After diagnosis, black children are three times more likely to face serious asthma-related events of hospitalization and death. Caused by hyper-reactive breathing passages, asthma results in oxygen being trapped by irritated airways, which prevents full exhalation. Asthma attacks and their associated wheezing, airway constriction, and inflammation leave people gasping in sips of air and in need of emergency medical attention.

But appropriate treatment can be hard for black children to access, especially for those living in low-income urban areas. The legacy of segregation and discrimination leave many black neighborhoods isolated and economically depressed. Old housing stock that exacerbates difficult breathing is poorly maintained and transportation is limited. Those suffering from asthma are often genetically predisposed, meaning more than one family member may be vulnerable to the condition. Paid time off for parents is rare, and seeing a health care specialist can be a taxing trip. 

See a text-only version of the infographic, here.

Of the various social determinants of health that affect a child’s risk of experiencing asthma and labored breathing, living environment and air quality have proven to be two of the most significant risk factors for developing and controlling asthma.

In low-income areas, the quality of both indoor and outdoor air is poor, and the CDC has found that higher numbers of children in those areas have asthma. There is a 50 percent increase in asthma for children living below the poverty line. For children living in predominantly poor zip codes, chances for a negative health diagnosis were higher compared to their peers living elsewhere, regardless of race. 

Economically depressed city neighborhoods are often in close proximity to highways and poorly managed waste sites. Smoke from burning garbage and waterways carrying toxic runoff create a difficult environment for young lungs.

Since the turn of the 19th century, the banks of the Anacostia river, hemming in a historically low-income neighborhood of Washington, D.C., were the city’s dumping grounds for industrial-grade pollutants and trash. Through community organization and legal battles, the neighborhood has garnered an upgraded storm water system diverting sewage, and the decades-old garbage fires have been extinguished. The air and water are getting back to health. Children with asthma are safer playing outdoors thanks to reduced smoke and toxic runoff.

Creating a Safe Environment

Tracie Kirkland, DNP, ANP-BC, CPNP, a clinical assistant professor at the USC Suzanne Dworak-Peck School of Social Work Department of Nursing, has more than 20 years of experience managing chronic illnesses in the primary care setting. While preventive care and medication management are crucial elements to asthma control, “one’s environment plays a major part in wellness and overall health,” Kirkland said. 

In the management of asthma, principle strategies include determining triggers and eliminating them.

“The overall goal in treating any chronic disease is to decrease the number of exacerbations in order to improve outcomes,” Kirkland said.

In her view, early detection and identifying risk factors are key. Other ways to reduce known asthma triggers include: 

  • Eliminate indoor offenders: Clean dust mites, pest feces and dander. Seal entry points and weatherproof roofs and windows to prevent the growth of mold and mildew.
  • Improve indoor air quality: Use air conditioning with HEPA filters to reduce the presence of pollen, particulates from waste burning and vehicle exhaust. Consider installing an air filter to further purify the environment, especially in the bedroom. Make sure all gas appliances are properly vented.
  • Stop allergens from accumulating: Remove carpeting to prevent the collection of allergens in the fibers. Use a hypoallergenic pillow and mattress covers to improve nighttime asthma symptoms.
  • Be prepared: Always use daily preventive control medication as directed to reduce symptoms and attacks. One of the most effective tools for home monitoring is an asthma action plan, created by the Asthma and Allergy Foundation of America. This uses a “green, yellow and red” system simple enough for children that allows them to monitor their progress. Explain that this medication keeps them in the plan’s safe “green” zone and what steps to take if symptoms increase. Share the plan with the child’s school nurse and day care providers.

Research demonstrating the link between children’s health and the toxic triggers in their home and neighborhood environments is ongoing. Meanwhile, community members are working together to clean up neighborhoods, inside and out.

Ruth Ann Norton, CEO of Green and Healthy Homes Initiative, leads an effort to improve health, economic and social outcomes while creating safe places for families to live. The intervention starts with retrofitting houses to install solid roofs and new windows, and continues by removing moisture and mold that aggravate asthma. Properly sealing cracks and crevices prevents mice and insects from re-entry.

After a complete retrofit, Green and Healthy Homes reports that asthma-related hospitalizations decrease by 66 percent, school attendance increases by 62 percent, and the rate of turnover on the property from year to year decreases 6 percent.

“When homes are safe and healthy, families can put down roots," Norton said. "It creates a more stable environment for children and parents. They are able to breathe, literally and metaphorically. Having a sound roof over their heads helps level the playing field for children of color.”

But controlling a chronic illness under these conditions is challenging. The following socioeconomic factors can help explain the disproportionate number of black children with asthma:

  • Secure housing: Clean, safe, and free of pests, mold, mildew and secondhand smoke.
  • Access to medical care: Ability to get a timely appointment convenient to home.
  • Safe schools: Structurally sound and free of pests, mold, mildew and violence with positive role models and trusted adults for guidance.
  • Built environments: Playgrounds that are well-maintained, places for recreation, clean air and waterways, no hazardous waste and crime-free neighborhoods.
  • Transportation: Affordable, reliable and convenient ways to get to and from work, health appointments, schools and grocery stores.
  • Freedom from poverty: Ability to provide for basic needs of food, electricity, clothing, housing and communication. A stable home and reliable utilities are necessary to employ preventive measures that control asthma.
  • Absence of racial segregation and discrimination: Equal rights and treatment. A history of discrimination has led to mistrust between the medical establishment and people of color, fracturing patient-provider confidence.
  • Social support: Family, friends, teachers, coaches and health care providers as advisors and supporters in times of need. Chronic illnesses like asthma require long-term support tapping resources in all areas of a child’s life.
  • Education: Having basic needs met so that higher learning can occur. Kids with well-controlled asthma have better school attendance and, when not distracted by worry over their health, are more likely to focus on success.
  • Employment: Safe, reliable and consistent employment that pays a living wage. This is the economic foundation on which to build a stable, healthy home. 

According to health experts and community activists, education and care coordination will bring better outcomes for children with asthma. Norton urges health care providers to call on community resources to help improve care for their patients.

“We are not health care workers, per se, but we certainly share goals,” she said. “Improving housing can make long-term changes in the health of these kids.”

Solving the Burden for Families

Lisa Bell is a certified asthma educator who provides asthma care to children in the community. Today she arrives on the Breathmobile recreational vehicle to neighborhood schools in Baltimore. Bell, who is also a nurse practitioner, checks lung capacity and teaches kids how to use control and rescue medications. She assesses for household triggers and educates parents on remediation.

“By bringing care to [patients], it eliminates other barriers to care like transportation and makes specialty asthma care more accessible,” Bell said. “By providing care at the schools, children do not need to miss time from school for appointments, and parents do not need to miss an entire day of work.”

Overall, community health initiatives help reduce:

  • Health expenses: Rescue and control inhalers, special equipment, provider fees and hospital bills.
  • Exhaustion: Symptoms worsening at night and worry over attacks lead to sleeplessness.
  • Stress: Frequent calls to 911 for emergency care of a child who can’t breathe.
  • Instability: Missed days of work and school lead to income insecurity and falling behind in school.
  • Genetic burden: Asthma tends to affect several members of one family, taking a toll on children and parents when multiple diagnoses are found. 

Kirkland said she uses office visits to talk about medication use and how active a child's asthma might be. She also reviews her patients’ asthma action plan and encourages collaboration between family members and schools to note triggers and assess progress. 

“The overarching goal is to improve patient outcomes through engagement and feedback and to work collaboratively with our social workers to assess the environmental conditions in homes where individuals may be coming in contact with triggers,” Kirkland said.

Changes in health outcomes are possible. Community leaders like Norton promote health care providers and community health experts to work hand-in-glove to remedy the asthma burden that falls so disproportionately on black kids.

“We either go forward to do what has been empirically shown to work," Norton told Kaiser Health News, "or we continue to bury our heads in the sand, and kids will continue to go to the hospital instead of the classroom.”

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Citation: Nursing@USC, the online Family Nurse Practitioner program from the University of Southern California