Getting to the Roots of Asthma

For the past five weeks, 60-year-old Christine Valdivia has been spending her Monday nights at the West Contra Costa County Health Center learning about a condition she was diagnosed with five years ago. The Bay Area county started an asthma clinic in September to help local residents, who suffer from the disorder more often and with more vigor than those in more affluent neighborhoods. Similar patterns prevail throughout the state.

Minorities and low-income populations endure disproportionately high incidences of asthma, and for more than a decade health professionals have been addressing the disparities through education and medical outreach. In addition to a classroom portion that teaches about asthma’s causes, irritants and treatments, doctors at the health center work with patients to develop a personalized plan. When it comes to managing symptoms, this approach seems to be working.

Valdivia could barely talk when she first showed up. For this El Sobrante resident living with aggravated asthma has meant trouble sleeping at night, a frequent post nasal drip, and bothersome allergies. But in the past month-and-a-half she’s shown considerable improvement. “It’s an overview of what I kind of already knew, but with some more details,” she says. “You know what you should do but sometimes you slack off so it’s good to go over it.”

Despite increased education outreach for more than a decade, asthma diagnosis continue to climb. The greatest rise, almost 50 percent in just the last 10 years, was among black children. The clinics may be successful in lowering hospitalizations, but it’s become evident that to restrain this chronic disease will require a more comprehensive intervention. That’s where organizations like Regional Asthma Management and Prevention, a statewide advocacy collaboration, are focusing their efforts.

“There has been an evolution and growing awareness that there needs to be a focus on the upstream factors,” RAMP Director Anne Kelsey Lamb says. Upstream factors refer mostly to policies related to substandard housing, air pollution and land use. Lamb offers this example: just south of Contra Costa, Interstate 880 cuts through Oakland while Interstate 580, just to the east, runs through more affluent stretches. Diesel trucks, which emit particle proven to stunt lung growth and cause inflammation, are not allowed to use I-580, concentrating the pollution in low-income areas. “Policy decisions definitely contribute to the inequalities,” she says. “Such big disparities are largely avoidable.”

Asthma – a chronic respiratory disease that when triggered can lead to wheezing, coughing, chest pain, and shortness of breath – is the manifestation of multiple genetic, environmental, and social influences. While the medical world still hasn’t figured out exactly what causes the onset, research is beginning to emerge that suggests environmental influences and stress present in urban communities may play more influential roles than previously credited. “Everyone is focusing on get your pet out of the house, but really we have these huge societal issues we haven’t addressed,” says Karen Cohn, a member of the San Francisco Asthma Task Force and program manger for the city’s Children’s Environmental Health Promotion Program. to enforce public housing codes.”

Roughly five million Californians – or one in eight – have been diagnosed with the disorder. In any given year, close to 40,000 of those will be hospitalized and 500 will die because of it. But if you’re black or live in an area where the median household income is $20,000 or less, you have a 40 percent higher chance than a white person of being among the afflicted, according to the California Department of Public Health. Black and Latino kids living in urban areas are up to six times more likely than whites to die as a result of having the condition, the most common chronic childhood disease.

Studies, such as the National Institutes of Health National Cooperative Inner City Asthma Study, started coming out in the early 90s that pointed to environmental factors like cockroach and mice allergens as a leading cause of inner-city asthma. They also noted low-income populations didn’t have access to or properly use medication. In response, experts advocated educational intervention, something California has been a leader in.

While these allergens are a culprit, what isn’t explained is that simply cleaning your house better might not be enough. According to a 2013 CDPH report, about 40 percent of those with asthma are renters, which can make it difficult to reduce exposure to triggers in the home. Older buildings that are more densely packed with people are more susceptible to roach infestations and mold.

So part of outreach education is now starting to include things like how to file a complaint if your rental unit isn’t up to code or how to get the walls checked for mold. And on the other side CDPH is training public housing code enforcers on these issues. Some community programs, such as one in Richmond, are working to change windowpanes out for residents to prevent indoor dampness and improve indoor air pollution.

Researchers at the University of South California found that children living in areas with higher concentrations of nitrogen dioxide and particulate matter in the air had lower rates of lung growth. Not only that, the lungs of many who grow up in smoggy areas will likely never recover. If someone with low lung function were to get a cold it could lead to more severe symptoms or a longer recovery. The long-term risks, however, are more dangerous. Lung function grows steadily as children age and then declines by 1 percent a year throughout adulthood. Low lung function is second only to smoking when it comes to mortality risks.

“It’s such a complex issue,” says Meredith Milet, an epidemiologist with CDPH. “It has to been addressed through a multifaceted program.”

While it’s well-known smoking and poor air quality are asthma risk factors, fewer people are aware that experiencing childhood trauma can also lead to respiratory issues. Since the poor, particularly kids, are less insulated from stress it exacerbates health inequalities, such as obesity, that are associated with asthma. Individuals with high levels of distress early in life have a 300 percent higher chance of developing chronic obstructive pulmonary disorder as adults, Cohn says. The San Francisco Asthma Task Force recommended in 2011 the city also create a training program and screening tools so medical workers can assess patient trauma levels and, if needed, refer them to intervention services.

“We want to make sure we’re looking at the whole patient,” Cohn says. “We should be talking to them at the hospital, teaching them in the clinic and then helping them a home. “

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