1. Kearney, Gregory D. DrPH, MPH
  2. Kuranga, Abraham O. MD


Article Content

The "Dangerous Stream" or the "River Story"1 is a parable that public health practitioners love to tell because it describes the use of our most powerful weapons: prevention and intervention. In one version of the story, a group of fishermen are gathered on the bank of a river when they notice a child floating down the river waving her arms and yelling for help in desperation to avoid drowning. One of the fishermen jumps into the river, swims over, grabs the child, and pulls her to safety. Shortly afterward, another child is seen floating down the river yelling and waving her arms and another fisherman jumps in and pulls the child to safety. This cycle continues and soon there are many children floating down the river. Among the frenzy of fishermen pulling the children to safety, one of the fishermen is seen getting out of the river and walking away. The remaining fishermen become very angry at the fisherman but have no time to stop. Finally, after many hours, fewer and fewer children are floating down the river, until there are no more children left to rescue. As the fishermen finally get a moment to catch their breath, they notice the fisherman who left earlier walking down the river bank towards them. Angrily, they shout at him, "How could you possibly leave us here in the river when we needed your help to save all of these drowning children?" The fisherman calmly replies to the others, "While I knew we had to save the children from drowning, it occurred to me that someone should go upstream to find out why the children were falling into the river. When I went upstream, I found the planks on the old bridge had rotted through and as the children tried to cross the bridge, they were falling into the river below. So, I asked several villagers to replace the planks with new boards and now the children can cross safely."


In several ways, the story is analogous to the public health problems associated with health care delivery and asthma treatment. For example, the children hopelessly floating down the river are comparable with the low-income, uninsured patients who keep returning to the emergency department (ED) with an acute asthma attack time after time. The patient is seen by the attending physician, treated, receives an increased dosage of inhaled corticosteroids, and returns to his or her rental home filled with a plethora of environmental allergies. Such triggers might include mildew and mold from a leaking roof, scurrying cockroaches and rodents, secondhand smoke, chemical sprays, perfumes or air fresheners migrating from neighboring apartments; potentially the same environment that spawned their asthma attack and brought them to the ED in the first place.


It is a scene that Rishi Manchanda,2 MD, is familiar with and illustrates in his book and TED Talk, "The Upstream Doctors." Manchanda clearly articulates that health begins where people live, work, eat, and play. He advocates that health care providers (HCPs) need to move "upstream" by considering the social determinants outside the clinical setting as part of the patient diagnosis. He underscores what researchers have been unveiling with epigenetics: where people live has a large influence on personal health and that social and environmental factors, such as housing environments and neighborhoods, help shape our genetic makeup and are important predictors for determining health outcomes.



Asthma is considered one of the most serious allergic diseases among children in developed nations.3 Asthma can be characterized as a chronic inflammatory disease of the airways that causes symptoms such as coughing, wheezing, chest tightness, and shortness of breath.4 In the United States, asthma affects a staggering 8.6%, or 1 in 11 children, younger than 18 years.5 In 2014, an estimated 48% of children with asthma reported having 1 or more asthma attacks and was the leading cause of death for nearly 200 children.5 Asthma disproportionally impacts minority and low-income groups, especially black children, living in low-income households.6 From 2012 to 2014, black children were twice as likely to be hospitalized for asthma and 4 times as likely to die of asthma as white children.7 Costs and quality of life associated with asthma are responsible for estimated health care costs of more than $56 billion each year.8


Despite advancements in treatment and promising breakthroughs in research, there is still no cure for asthma. However, the evidence is clear that when children with allergic asthma encounter allergens such as dust mites, mold, or chemicals from cleaners or solvents, it can trigger the body's immune system, which can further exacerbate an asthma attack. Evidence-based research and clinical recommendations clearly support avoidance of environmental allergen exposures in the home as key actions for reducing asthma attacks.4,9


ECAPP Pilot Project

It is now well established in the literature that targeted, multicomponent, home-based interventions are effective for reducing asthma symptoms.10 To test the efficacy of reducing asthma among children in our local community, we initiated a pilot project that we named the Eastern Carolina Asthma Prevention Program (ECAPP). The objective of the study was to assess the effectiveness of a home-based intervention by measuring asthma-related symptoms, ED visits, unscheduled physicians visits, and quality of life among high-risk, minority children (5-17 years) living in poor-quality housing conditions. To carry out this project, we used the King County Asthma program model as the framework for our project.11 Over a 6-month period, we enrolled low-income families with children with moderate to poorly controlled asthma (N = 19). Each home visit consisted of an environmental health professional and an asthma case manager, with follow-up to the child's HCPs. Assessments for each child included an evaluation of asthma morbidity-symptom frequency, health care utilization, pulmonary function, and airway inflammation (fractional exhaled nitric oxide)-and an indoor housing evaluation to identify environmental asthma triggers. As part of the intervention, we provided intense asthma education, instructions on proper medication technique, and instructions on using environmental intervention products (eg, mattress and pillow covers, nontoxic cleaning products, proper vacuuming) to the child, parent, and/or caregiver. At the end of the study, significant reductions were identified in the number of children's ED visits, asthma symptoms, airway inflammation, and an increased use of controller medicine.12


Undoubtedly, the results from our efforts showed marked improvement. However, that is not where the story should end. While our families (including children) were receptive to asthma education and compliant with medication, we consistently found social factors, related primarily to indoor poor-quality housing, as a major issue. To elaborate, nearly all of our families were living in substandard rental housing. Many homes we visited suffered from disrepair including leaky roofs, moldy walls, deteriorating carpet, and plumbing leaks. Frequently, homes needed extensive pest control for rodents and cockroaches, far beyond the simple baits and traps that we provided. Repeatedly, we found heating and air-conditioning systems that had never been cleaned or serviced and typically contained biological growth, a dirty filter, and were laden with dust. Gaping holes, broken windows, and stained ceiling from leaking roofs were often observed as catalysts for increased humidity and moisture inside the home. Typically, tenants were uncomfortable discussing housing issues with landlords because they said they had feared evacuation and no place else to live. In some cases, children did not have a bed and slept on the floor or children had a bed, but with no sheets and just a blanket. Our conversations with parents often included not having enough money to pay utility bills or for asthma medicine. In many cases, we heard families mention they could not afford to move and that transportation for doctor's office visits was also a challenge. Granted, our persistent and focused efforts to reduce asthma paid off, without the support of a network of services to address housing and social determinant issues, the probability that the children in our study will return to the ED is highly probable.


Strategies for Reducing Asthma Symptoms

Based on the published literature and results from our pilot study, we strongly recommend efforts that go beyond the clinical setting for evaluating asthma symptoms among children in low-income households. To guide clinical and community action towards improving asthma and environmental housing quality, the interplay between key strategies must take into account the following (Figure): (1) an evaluation of the social determinants of health (eg, housing environment) as part of the HCP patient evaluation; (2) enhancement and enforcement of local codes to improve housing conditions; (3) involvement of a case manager or community health worker (CHW) to assist patients with asthma and their families, and, (4) cost reimbursement to those providing delivery of high-quality, in-home, asthma visits and services.

FIGURE. Interconnect... - Click to enlarge in new windowFIGURE. Interconnected Strategies to Support Children With Asthma in Low-Income Households With Poor Indoor Environmental Quality

Social determinants of health

When evaluating low-income children with asthma, it is critical that social factors outside the clinical setting be considered. Across numerous studies, evidence shows that children with asthma in lower socioeconomic status households are significantly more likely to experience asthma symptoms, asthma-related hospitalizations, and ED visits than higher-income households in children with asthma.13,14 For HCPs, medical evaluations for children with asthma should include social determinants of health as well as an environmental history focused on allergens, including the home environment. Manchanda stresses that HCPs should think outside the clinic and build bridges with those who work with "where health happens" so that medicine can do a better job of improving health in the social and environmental conditions that make people sick.2


Community health workers

As frontline public health workers, CHWs are trusted individuals who understand the social context of communities in which they live in and serve.15 CHWs can help patients manage chronic health conditions,16 while achieving cost-benefit savings for health insurers and improving quality of life for families.16-19 Integrating CHWs into local asthma programs can offer tremendous benefit to low-income families with asthma by ensuring follow-up physician visits, providing asthma education, and needed support for instructions on proper medication technique and compliance.10,18 Hidden benefits of CHWs can include connecting families with needed services and resource providers in the community such as faith-based organizations to help repair a leaking roof or free legal services for dealing with unfit landlords.


Indoor environmental housing quality and laws

Americans spend upward of 90% of time indoors, making the home environment a significant contributor for exposure to asthma triggers.20 For a child with allergic asthma, poor indoor air quality conditions can trigger an allergic response leading to an ED or unscheduled doctor's visit. Mandatory disclosures and requirements for lead paint abatement and carbon monoxide detectors have been successful for addressing health and safety concerns in rental housing. However, state provisions related to indoor air quality issues have been less successful. Housing codes covering mold and secondhand smoke have largely depended on a range of factors, and laws vary according to individual states and local jurisdictions.21 Landlord-tenant laws commonly include provisions typically addressing underlying issues such as structural, plumbing, or ventilation that can contribute to dampness leading to mold,22,23 but because no standards on mold exist, the issue often becomes subjective and remains controversial. Clinical and home-based visit interventions by CHWs can be effective for treating asthma symptoms. However, developing strategies to push authorities to enforce local housing codes, adopt policies on smoke free multi-housing units, and providing free legal aid to renters to assist with taking action against negligible landlords may be necessary.24


Cost reimbursement

Reports of annual average costs associated with asthma-related ED visits have been estimated at approximately $1052 for one ED visit25 and more than $3600 for an inpatient, overnight stay.26 Evidence supports that considerable cost savings can be attained through upstream prevention and intervention techniques through home-based visits.27 Results from our pilot study identified that associated costs with providing just two home visits, which included intense asthma education, environmental evaluation of the home, intervention products, travel and salaries, were considerably lower by almost one-half compared with an estimated cost of just one ED visit.


The Patient Protection and Affordable Care Act (ACA) requires that Medicaid expansion plans cover (certain) preventive services to seek care through "home health."28 Unfortunately, many states have yet to take advantage of the new provisions under ACA to provide these services.29 Pathways for equitable Medicaid reimbursement at the state level for these supportive services need to be fully explored and integrated into the fabric of local communities to support families that have children with asthma. Medicaid can play a significant role in building effective community asthma programs to low-income and medically underserved populations.30 Local health departments are well positioned to deliver preventive, home-based services because they are they are central to the Medicaid population and traditionally employ CHWs and environmental health professionals. Acting together, they can provide in-home asthma consultations, indoor environmental assessments while collaborating with their local, building, and code enforcement department to address poor, rental housing problems in the community.



Until a cure for asthma has been realized, it is imperative that communities establish a network support of clinical, prevention, and intervention strategies to strengthen and provide necessary needed support for families with children in low-income households.


Provisions under ACA provide new opportunities for public health practitioners to move upstream and to be involved with prevention and intervention measures that can move the needle toward reducing asthma exacerbations, improving indoor housing environments, and lowering health care costs. As public health practitioners, we need to capitalize on these opportunities by assisting clinical providers by extending asthma care from the clinic to the community setting through home-based visits. The estimated return on investment by achieving these prevention and intervention strategies can potentially have tremendous medical and health cost benefits for communities and low-income families that have children with uncontrolled asthma.




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