About a month ago, I received a call from a journalist wanting my perspective on recent data showing an increase in asthma emergency room visits in certain parts of California, particularly in the Central Valley.
The rate of emergency room visits for children 5 and older more than doubled in rural Madera County and nearly doubled in Merced County. My response was that there’s clearly more work to be done if more than 72,000 children with asthma are going to the emergency department in a single year.
When I hung up the phone, I felt demoralized: I and so many of my public health colleagues across California have been working to reduce the burden of asthma for decades. If we’re still seeing discouraging data, does that mean California is losing the fight against asthma?
The answer is that we’re not losing, but it’s also not a fight we’ll be “done with” any time soon. Asthma is a complex chronic disease, and its prevalence and severity are shaped by an array of factors from access to medical care to climate change to transportation policy to income inequality.
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When a kid ends up in the ER in Madera with asthma, the list of potential culprits is long. Sure, the cause could be the region’s chronically poor air quality, but the cause of this particular child’s asthma attack on this particular day could also be housing infested by cockroaches or mold, which are common asthma triggers.
Another child’s family might need to use certain medications more consistently, requiring instructions on how to manage his or her asthma from a community health worker who speaks Hmong. We have evidence suggesting stressful experiences, like living with someone who is abusive, could lead children to develop asthma, so that child needs a social worker.
Finally, while every asthma attack is its own perfect storm, asthma hits low-income communities and communities of color particularly hard.
We started off thinking asthma was a medical issue, but it quickly revealed itself to be a social – and even a moral – one. When my organization, Regional Asthma Management & Prevention, started about 20 years ago, we worked to do a better job of medically managing asthma by communicating with health-care providers, school personnel, parents and children.
It was apparent, though, that clinical management could not be successful if children were continuously exposed to asthma triggers in their homes, schools and neighborhoods. So we started working with community health workers to identify and remove triggers in the home, and that led us to trying to get landlords to improve their rental properties.
Recognizing that neighborhoods with high asthma hospitalization rates tended to have a concentration of refineries, ports, railways and freeways led us to collaborate with community activists, public health colleagues and others on the Ditching Dirty Diesel Collaborative.
Any thread we grabbed turned into something much larger and more complex.
As our understanding of the magnitude of the asthma challenge has grown, progress has been made. For example, the Centers for Medicare and Medicaid Services recently passed a policy that state Medicaid agencies can provide reimbursement for essential services, like asthma education, when they are provided by community health workers or other qualified professionals.
In-home education about asthma triggers has been shown to reduce ER visits and hospitalizations, but it still isn’t covered by most insurers and too many people with asthma currently lack access to these services because they are not reimbursed. There is an opportunity for California’s Medi-Cal program to change that.
Our work is not done. For example, as the California Air Resources Board develops a Sustainable Freight Initiative, it should build a healthier, fairer freight system by adopting technical solutions (like electrification) and land-use solutions (like routing trucks out of neighborhoods). And we need to double down on efforts aimed at slowing the impacts of climate change and its accompanying effects on our air quality and health.
The fact is that asthma is profoundly unfair – and it reflects and magnifies other kinds of inequality in our society. Since asthma is a societal problem, it requires a societal response. California is certainly not losing the battle against asthma, but if we’re honest we’ll admit we’re not yet winning it either.