From New Orleans to the Bronx, Asthma Control is a Struggle
Image: David Rosenstreich, MD
As we read of the issues facing New Orleans five years post-Katrina, the mold that triggers severe asthma in hundreds of children remains a serious problem. Environmental mold is also prevalent in the substandard housing where many of our Bronx patients live.
Mold exposure in a home is a respiratory risk, even for people who are not allergic. There are many kinds of household mold: Alternaria is one of the more common ones measured. In New Orleans, where there are many damp houses, it's particularly bad. In the Bronx, poor-quality housing with leaks in the roof and pipes generates moisture and mold in the walls. Brick apartment buildings are particularly vulnerable: the mortar between the bricks cracks as it ages, and when it rains water can get inside. Even in a house or apartment building that looks fine from the outside, the walls become damp after a rain. Even if the walls are repaired, the water can't be stopped from coming into the house. The only way to fix this is by replacing the mortar (a process called repointing), a costly repair that landlords and homeowners may be reluctant to do. While mold contamination may be a more significant problems in New Orleans, in the Bronx, in areas by the water like Hunts Point and Soundview, household mold can be a problem.
"The most promising area in improving asthma outcomes is better access to treatment."
Any allergen present in large amounts inside a home can be a problem for adults and children with asthma. In the Bronx, one significant risk factor tends to be cockroaches. A high percentage of children with asthma are allergic to cockroaches; those who live in homes with high cockroach populations suffer from asthma and comorbidities such as allergic rhinitis.
Beyond the household walls, the issue of how we can improve the inner city structural environment arises. This is a large, difficult, and multifaceted matter to tackle. Exposure to air pollutants and auto exhaust is high on the list of asthma risks. Data shows that children living within a certain distance from a major highway have higher asthma complication rates, and the Bronx is veritably crisscrossed with these kinds of roadways. Exposure to home heating oil—the heating method for many Bronx apartments—has also been shown to be an asthma irritant. As physicians we have limited, if any, control in changing this. Getting individual landlords to make these structural changes would be a major feat in itself, with limited success.
Asthma-related hospitalizations and deaths have declined over the past decade. Trends like the use of corticosteroid inhalers and other preventive medications, better overall awareness, and physicians' increased attention to asthma have resulted in an overall improvement in treatment. I think the most promising area in improving asthma outcomes is better access to treatment. When we compare asthma rates in the inner city to those in a higher socioeconomic area, the major issue is access to care. When suburban children and adults with asthma start to feel bad, they'll call their doctor to head it off. Inner-city patients get care from clinics and often don't have access to a doctor when the clinic is closed. So on evenings and weekends, while they're waiting for their next chance to see a physician, their asthma will worsen and they'll wind up in the emergency room. Better, more consistent access to care would significantly improve asthma rates for these patients. Beyond that, encouraging physicians to use better medicines will help, but it's not an easy task to accomplish because of the high costs and insurance limitations.
As a clinician, I have noticed that over the past four or five years more and more patients are coming in with Medicaid-managed plans like HealthFirst, which have made a big difference in their being able to access appropriate medical evaluations and medication for their asthma. When people take their asthma medicine they do much better, so this alone has made a significant improvement. Overall, if physicians pay closer attention to the latest advances in asthma care, we can make a significant improvement in the lives of our asthmatic patient in the Bronx.
David Rosenstreich, MD
Chief, Division of Allergy and Immunology (Department of Medicine)
Professor of Medicine, Microbiology & Immunology, and Otorhinolaryngology - Head & Neck Surgery
Director, Bronx Asthma Project