A nebulizer system and a metered dose inhaler.

A nebulizer system and a metered dose inhaler. Credit: Barry Sloan

Children in this country should not die of asthma. But 145 did in 2021; three in four were Black or Hispanic. Long Island is one place where such disparities are hidden within affluence: Asthma disproportionately affects Black and Hispanic children and those in high-poverty neighborhoods. Wyandanch, a predominantly Black and brown hamlet, has some of the highest rates of asthma and the highest rate of pediatric asthma emergencies on the Island.

Of the nearly 5 million U.S. children with asthma, those in the poorest households have an asthma rate 1.5 times greater than those in the highest-income households, per the Centers for Disease Control and Prevention. Non-Hispanic Black children have higher rates than non-Hispanic white children.

As a pediatrician-in-training years ago, I worked in the emergency room at Grady Memorial Hospital — the inner-city, safety-net hospital of Atlanta, Georgia. Our asthma room would treat 10, 20, or more mostly Black or brown children at any given moment. Clipboards in hand, we would go child to child, count respiratory rates, check pulses and lungs, and give medication, as needed.

Our goals were straightforward: Keep as many children as possible from being admitted to the hospital and make sure no one died under our watch. With limited medications, we usually succeeded, sending most kids home in reasonable shape.

Many however, returned to be treated again and again. Instructions to parents on eliminating common asthma triggers — cockroaches, dust mites, and mold, for example — were usually unhelpful as most lived in low-income housing with landlords generally uninterested in investing in tenant health.

Now we have more effective medications but uninsured and underinsured families often struggle to pay for them and corresponding medical visits. While 13 million more children are insured through Medicaid or the Children’s Health Insurance Program since the 2010 passage of the Affordable Care Act, inequities persist.

Even with insurance, quality health care is not guaranteed. In 2021, while uninsured at a similar rate, Black children were still more likely than non-Hispanic white children to have poorly managed asthma, in part because they were also more likely to be enrolled in Medicaid: Children with asthma covered by Medicaid have 42% fewer outpatient visits, 48% more emergency department visits, and a 20% increase in hospitalizations compared to privately insured children, as per Medicaid data in the Journal of Pediatric Health Care.

Being poor or of color also means an increased likelihood of living in substandard rental housing where asthma triggers are more common. Homeownership is associated with better housing quality and decreased asthma-related emergency department visits. But, as a result of historical discriminatory housing policies on Long Island and across the nation, Black populations own homes less frequently than white populations (42% vs. 73%), census data shows.

Adding to the inequities, schools in communities of color are nearly four times more likely than those in predominantly white neighborhoods to be near factories and major roadways that spew asthma-triggering pollutants. Students attending schools farther from major roads are less likely to report asthma symptoms (29%) and poor asthma control (20%).

More than just a medical diagnosis, asthma is a powerful lens through which we can understand how systemic racism and structural inequities lead to poor health. We need comprehensive strategies that promote environmental justice, improve housing quality, and increase access to quality health care for all children. Otherwise, children most in need will continue to struggle with this chronic disease much as they did decades ago.

  

THIS GUEST ESSAY reflects the views of Dr. Arturo Brito, a pediatrician and chief executive of New York City-based Children’s Health Fund.

This guest essay reflects the views of Dr. Arturo Brito, a community pediatrician and the president and chief executive of New York City-based Children’s Health Fund.

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