Asthma Summit Op-Ed Team 17

While one in thirteen Americans suffers from asthma, residents of the nation’s capital are disproportionately impacted.1 One in six residents of Washington, D.C. has asthma, and Children’s National Hospital, the primary pediatric health system in the city, sees one percent of the entire country’s asthma-related emergency room visits.1,2 Following the pattern of many other health inequities, D.C.’s asthma epidemic and its disproportionate impact on minority and low-income families living in Southeast D.C. is inextricable from the legacy of structural racism, wealth inequality, and neighborhood disinvestment in the city.

The prevalence of asthma is five times higher among Black and Hispanic youth compared to white youth. Not only is the prevalence of asthma higher among these populations, but the severity of asthma is greater as well; the three zip codes with the highest rates of asthma-related emergency department visits are located in Southeast D.C., which is over 90% Black. In 2014, the rate of asthma-related emergency department visits in the city zip code with the highest rate of asthma, which is 90% Black with 33% of residents living below the poverty line, was twenty-three times higher than the zip code with the lowest rate of asthma, which is 9% Black with 2% of residents living in poverty. 2

Asthma severity and prevalence have been linked in the literature to several aspects of housing quality. Common asthma triggers include cockroaches, dust mites, mold, and pet allergens, along with environmental tobacco smoke. 3 In urban homes, dust mites and cockroaches are often primary contributors to asthma exacerbations.4 In fact, cockroach allergens have been found to be a dominant factor in asthma morbidity and emergency department visits in young children living in cities. 3 These exposures are not isolated; even when controlling for household income, there is significant overlap. A recent study found a significant relationship between household smoke exposure and the presence of cockroach and mold allergens, suggesting that homes are likely to have multiple sources of asthma exacerbations. 5

The housing stock in D.C. skews older, with 80% of units built before 1978.2 Older homes present a greater risk for environmental disease factors, such as mold and pest infestation, that can contribute to asthma severity. According to a survey by the Census Bureau, pest infestation rates in D.C. are higher than the national average.6 These housing inadequacies directly impact the health of residents, particularly when it comes to asthma, and action must be taken to improve housing quality in Southeast D.C.

We are advocating for a community-based, comprehensive program that addresses the environmental asthma triggers that are prevalent in residential homes in the Southeast neighborhoods of Washington, D.C. The Children’s National Hospital Virtual Home Visit program is a recent pilot program that utilized a multidisciplinary team to assess and implement solutions for home environmental asthma triggers. The pilot program primarily consisted of renters in Southeast D.C., and found a high incidence of asthma triggers, with an average of 2.16 triggers per home.2 Outcomes of the program were promising; there was a significant reduction in the number of asthma symptoms over time.2 A similar program conducted by Children’s Hospital of Philadelphia included in-person visits and community classes.7 This program reported a 50% reduction in asthma-related emergency department visits.7 The success of these programs is evident; with our proposed modifications, a similar program could become a mainstay in community-based asthma interventions.

Our proposed program, the Reducing Asthma in SouthEast (RAISE) Initiative, would build off these existing ideas piloted by Children’s National Hospital and Children’s Hospital of Philadelphia. However, it would place greater emphasis on an extensive home visit that includes a housing assessment, tenant rights education, an asthma action plan for the family, and home improvements. Furthermore, this would be a longitudinal program to ensure continuity of care and ongoing improvements in housing quality. We would also contract with BIPOC-owned businesses in Southeast to make the home improvements, thereby investing in the communities most impacted and simultaneously addressing housing, health, and economic growth.

Given that the average emergency department visit costs approximately $2,000, we expect that the reduction in emergency department visits under RAISE would also reduce the economic burden on both families and the city.8

Our approach centers on improving housing quality through repairing home conditions that contribute to asthma exacerbations, such as dust, mold, and pests.4 As a part of RAISE, local housing specialists would perform home assessments in collaboration with the family to identify any potential triggers. Identified hazards would be then addressed accordingly through the recruitment of local BIPOC-owned cleaning, construction, and pest extermination companies. Improvements may include removing soiled carpeting, eradicating mold, installing air ventilation systems, and removing insects and rodents from the home. Along with these home repairs, RAISE would partner with nonprofit community organizations in Southeast to offer preventive supplies that have been shown to reduce asthma exacerbations, such as mattress and pillow covers, clean linens, and vacuums.

We also propose incorporating education into the home visit. This would include providing residents with information on tenant rights as well as asthma prevention and treatment. Given that the majority of residents in Wards 7 and 8 (61% and 78%, respectively) are renters, it is critical that they have information available about their rights to safe, quality living conditions.9 We hope that this approach will both address current housing issues and empower residents to advocate for themselves should housing challenges arise in the future.

RAISE would also educate the entire family unit about asthma medication and appropriate administration. One study found that asthma and COPD patients frequently made at least one error in administering medication through a nebulizer.10 This speaks to the challenges of medication adherence among the pediatric asthma population. Incorporating the family in the child’s medication plan and providing up-to-date nebulizers would help to improve asthma outcomes. This education component would be provided by community health workers recruited from St. Elizabeth’s East,11 which is scheduled to open in Ward 8 by 2024, and with local organizations such as Community of Hope.12 Utilizing community resources must be prioritized as part of an effort to remedy the systemic health and social inequities that disproportionately impact Southeast D.C.

To ensure continuity of care and continued quality housing conditions, RAISE would include a follow-up home visit three months after the initial assessment and repairs. This would allow the program to track improvements and further understand the factors that contribute to the disproportionately high levels of asthma in Southeast D.C. The team would return to the home to perform maintenance assessments, address any concerns or questions about asthma management, and provide wellness checks.

The RAISE Initiative recognizes the fundamental links between structural racism and historical disinvestment in housing and asthma inequities within the neighborhoods of Southeast D.C. It seeks to remedy them through an evidence-based wraparound program that directly improves housing quality, empowers patients and families through culturally competent health education, and funnels resources back into impacted communities by contracting with local BIPOC-owned businesses.

Refrences

1. 2019 National Health Interview Survey (NHIS) Data | CDC. Published January 11, 2021. Accessed January 24, 2022. website

2. Fox E, Kachroo N, Phoenix J, et al. PROMOTING HEALTHY HOUSING FOR CHILDREN WITH ASTHMA THROUGH A VIRTUAL HOME VISIT PROGRAM: A PILOT PROJECT SUMMARY REPORT.; 2021.

3. Busse WW, Mitchell H. Addressing issues of asthma in inner-city children. J Allergy Clin Immunol. 2007;119(1):43-49. doi:10.1016/j.jaci.2006.10.021

4. Malveaux FJ, Fletcher-Vincent SA. Environmental risk factors of childhood asthma in urban centers. Environ Health Perspect. 1995;103(Suppl 6):59-62.

5. Teach SJ, Crain EF, Quint DM, Hylan ML, Joseph JG. Indoor environmental exposures among children with asthma seen in an urban emergency department. Pediatrics. 2006;117(4 Pt 2):S152-158. doi:10.1542/peds.2005-2000M

6. Comparison of 2007 AHS Data for the Washington, DC-MD-VA Metropolitan Statistical Area and 2007 National AHS Data. National Center for Healthy Housing

7. Philadelphia TCH of. Community Asthma Prevention Program (CAPP). Published May 5, 2014. Accessed January 24, 2022. website

8. Urgent care vs. ER. Accessed January 26, 2022. website

9. Census Reporter: Making Census Data Easy to Use. Accessed January 24, 2022. website

10. Biswas R, Patel G, Mohsin A, Hanania N, Sabharwal A. Measuring Competence in Metered Dose Inhaler Use Using Capmedic Electronic Inhaler Monitoring Tool. Chest. 2016;150(4, Supplement):14A. doi:10.1016/j.chest.2016.08.017

11. New Hospital at St. Elizabeths East | newhospitals. Accessed January 24, 2022. https://newhospitals.dc.gov/page/new-hospital-at-st-elizabeths-east-0 12. Community of Hope. Accessed January 24, 2022.
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