What happens when government aid doesn't go where it's supposed to?
When President Barack Obama unveiled new environmental regulations to cut carbon emissions, he claimed it could prevent 100,000 asthma attacks per year. In D.C. where poverty rates are high and air quality is poor, low-income families have a hard time managing childhood asthma, with ripple effects felt in local schools, workplaces and emergency rooms. Kojo explores the far-reaching affects of a disease that affects 25 million Americans.
- Ruth Richardson Registered Nurse, Children’s National Medical Center; School Nurse in DC Public Schools
- Judy Berman Deputy Director, D.C. Appleseed
- Dr. Stephen Teach Medical Director, IMPACT DC Asthma Program
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Later in the broadcast, aerial drones have transformed the skies and battlefields abroad and some domestic airspaces. We look at what happens when they fall out of the sky.
MR. KOJO NNAMDIBut first, asthma, public health and social justice. When President Obama unveiled the new EPA regulations, cutting carbon emissions, this month, he didn't just evoke the familiar images of dirty power plants and rising sea levels, he talked about kids and emergency rooms, wheezing, cough and struggling to breath. The president claimed a 30 percent cut in carbon pollution could prevent 100,000 asthma attacks, each year.
MR. KOJO NNAMDIAsthma is responsible for a quarter of all emergency room visits, from children. And in Washington, D.C., inhalers are as common as textbooks, in some classrooms. One charter school, in the District, estimated a 1/3 of it's students suffer from asthma. Joining me, now, to discuss asthma's far reaching effects in hospitals and homes and in classrooms is Judy Berman, deputy director of D.C. Appleseed. Judy Berman joins us in studio, welcome.
MS. JUDY BERMANGood morning.
NNAMDIAlso with us in studio is Ruth Richardson, school nurse for Children's National Medical Center. She works in Ward 8, in the District of Columbia. Ruth Richardson, thank you for joining us.
MS. RUTH RICHARDSONThank you for having me.
NNAMDIJoining us by phone is Dr. Stephen Teach, the medical director of IMPACT DC. Stephen Teach, thank you for joining us.
DR. STEPHEN TEACHIt's an honor, Kojo.
NNAMDIThere's no cure for asthma, Stephen Teach, but if patients stick to a program, it can be managed effectively. Many people consider asthma, more of an inconvenience than a serious health problem. Still, nationally as we mentioned, a quarter of all children's emergency room visits are due to asthma. Why is asthma still such a big problem?
TEACHWell, it's a big problem and a growing problem, Kojo, for sure. And it's a problem which really disproportionately effects those kids can -- who can afford to have it, the least. These tend to be urban children, under resourced, principally minority kids. And we're seeing growing rates of the disease in that population throughout the, the nation and particularly here in D.C.
NNAMDIBefore we go any farther, lets take a step back. Can you explain exactly what asthma is?
TEACHCertainly. Asthma is a chronic disease. So it's a disease that, once a child develops it, he has or she has everyday. I always say, they have it on their birthday, they have it on the major holiday's, they have it throughout the year. And it's a disease of the small to medium size tubes in the lungs. So these, the tubes which get air in and out of the, from the tiny little air sacks which is where oxygen enters the bloodstream. And so those tubes get inflamed with mucus and swelling. And they also can constrict or be tightened down.
TEACHAnd so the children are trying to breath through airways which are chronically just smaller than usual. We use the analogy of coffee straws and milkshake straws. It's much easier to breath through a milkshake straw then it is to breath through a coffee straw. We tell the children that, what we're trying to do is change their coffee straws into milkshake straws.
NNAMDILet me bring our audience in on the conversation. You can call us at 800-433-8850. Have you or a family member had to deal with asthma? How big a disruption has it been in your life? 800-433-8850. You can send e-mail to firstname.lastname@example.org, shoot us a tweet @kojoshow or go to our website kojoshow.org, join the conversation there. Dr. Teach, asthma is especially common in cities. And within cities much worse for low income and minority children. Now, when asthma is treated properly it can be managed. How do race and class effect a medical issue like asthma?
TEACHWell it's absolutely true, Kojo, that on a genetic basis, asthma's more common and probably more severe among minority populations, particularly African-Americans. In addition, African-American children in D.C. and similar environments around the country, face a sort of constellation of circumstances which we call the perfect storm. They have, oftentimes, housing which is filled with typical asthma triggers, think dust, mold, cockroaches, rats, mice. And they develop sensitivities or allergies to these, to these triggers.
TEACHAnd since they're so common in the home, their asthma sort of constantly irritated, constantly triggered. In addition, the access to care is an enormous issue faced by D.C. children, in Southeast D.C., Northeast D.C., other disadvantaged parts of the city. So that access to pediatric primary care, simply isn't as easy, they're not as many docs, as many nurse practitioners, providing primary care for children or specialty care for children. And those kids struggle as a result.
NNAMDIRuth Richardson, you work as a nurse in a school in Ward 8 in the city where the asthma rates are extremely high. Some estimates show up to a 1/3 of children in low income areas are affected by asthma. Can you talk a little bit about some of the challenges that your students have with asthma?
RICHARDSONYes, I can. First of all, I'd like to quote the former illustrious surgeon general, Joycelyn Elders, when she said, "You can't educate a child who isn't healthy and you can't keep a child healthy who isn't educated." That is one of our greatest challenges. The school I work with is in historically Anacostia, Ward 8. Where we have several problems there. We have high needs and we have high poverty at our school.
RICHARDSONUnfortunately 30 percent of our students and families are homeless. Some of them live in homeless shelters, others move from place to place, living with relatives and friends. Those who are diagnosed with asthma and have an inhaler, take the inhaler with them. But if they in the shelter today, a friend tomorrow, the family the next day, the inhaler gets lost or misplaced.
NNAMDIJudy, you've spent a lot of time studying asthma and it's effects on low income families. You recently wrote a policy brief called Helping Low Income Families Manage Childhood Asthma. What did you learn?
BERMANWhat we learned was that there were a lot of challenges that are faced beyond the clinical issues that face children with asthma, just like what, what Ruth is speaking about and what Stephen is speaking about, housing that is, that contains triggers or losing your, your inhaler and that these things are common enough, that they really do require policy solutions.
NNAMDIDo you see asthma, and this question for our listening audience also, do you see asthma as a solved problem or do you still think it poses challenges? Give us a call at 800-433-8850. Judy, we're talking about kids who already tend to be behind in school, suffering from asthma and often visiting emergency clinics to manage the disease. The CDC estimates, kids miss a total of 10 million days, each school year, due to asthma. But it can also cost parents to have to miss work to care for them. Can you talk a little bit about the consequences, both direct and indirect, of asthma in low income neighborhoods?
BERMANWell, clearly asthma has an effect on children's academic achievement. If you're not in school, you can't learn. If you can't concentrate because you can't breath, you can't learn. And when your asthma is unmanaged, as Stephen was speaking about, that's when those conditions are the worst. So there's a lot that needs to happen in the schools to support children with asthma, so that they can learn effectively.
BERMANNow, when asthma -- even when asthma is managed, it requires a lot of attention, a lot of interaction with the medical, with medical institutions. And -- just to keep it under control. When asthma is unmanaged, it also requires emergency room visits and other things. And so parents whose children have asthma, if they're going to keep it under control, have to miss a fair amount of work. And if you look at the recommendations from the CDC, you'll see that the number of visits required to manage asthma is beyond what most people get, even from our paid sick-leave requirements in the District.
BERMANSo low income families can't afford, they don't have the paid sick-leave to keep their children healthy. And that's a huge problem. That's a really big problem.
NNAMDIOnto the telephones. We'll start with Mary, in Washington, D.C. Mary, you're on the air. Go ahead, please.
MARYYeah, hi. I have two comments and they both are about air quality, as triggers for asthma. I have kids who are, they both have asthma and their triggers are air freshener, scented laundry detergent and dryer sheets. And I'm wondering why that's never discussed as triggers for asthma? And your guests mention that, if you have asthma, you have it 24/7, 365 days a year. But if children are walking around wearing clothes that are giving off fumes from their laundry detergent and from dryer sheets, which we know stay on the clothing, then they're being exposed to a trigger 24/7.
MARYAnd my other comment is about air freshener, which seems to have a class distinction, it seems to be used more in lower class homes then upper class homes. And I'm wondering if that's why there are more asthma cases in lower class homes. And also in stores, like, Target and Wal-mart, you know the cheaper stores, you get a really strong smell of air freshener which you don't get in higher end stores. And it's kind of disturbing that they're able to expose the public to something which is a trigger for asthma, for many people.
NNAMDIStephen Teach, laundry detergents, dryer sheets, air fresheners, all possible triggers for asthma.
TEACHAbsolutely, Kojo. And I think what the caller is really getting at is indoor air quality. You know, the president, in his recent announcements about outdoor air quality, carbon based emissions from power plants, which we actually had the honor of hosting at Children's National, a couple of weeks ago, we hosted the president for that announcement. The president was really focusing on outdoor air quality. One of the most important parts about asthma and triggers, however, is -- as the caller says, indoor air quality.
TEACHAnd indoor air quality refers to the particulates, the floating material in the home which can irritate these small to medium sized airways. So we tend to think about cigarette smoke, candle smoke, incense smoke, anything that burns. And anything that gives off a fragrance, perfume, scented laundry detergent sheets. All of these things are putting small particulates into the air, those particulates are breathed into the airways and can irritate them, worsening asthma symptoms, both chronically and acutely.
NNAMDI800-433-8850, Mary, thank you for your call. How has asthma effected you or your child's performance in school? Have you ever had to miss work to help manage your child's asthma? 800-433-8850. You can send e-mail to email@example.com. We move on now to Lillian in Lanham, Md. Lillian, you are on the air. Go ahead, please.
LILLIANHello, Kojo. Thanks for having me. I heard somebody say that once you have asthma, you gonna live with it forever. And I tend to not quite agree with that. I was originally from Africa and I moved to the U.S. when I was 40, yeah, 41. And throughout my life in Africa, I never had asthma. But as soon as I came to the U.S., I just suddenly dealing with asthma. And then it's so (word?) , so bad that sometimes, I have to wake up in the nighttimes, sit up and, you know, trying to lead.
LILLIANAnd I have an inhaler, I take Allegra everyday. But unfortunately, this year I lost my mom, so I had to go to Africa. When I was going, I was so scared, saying if I have to have the attack in asthma, I was not gonna survive it. Then when -- as soon as I got into the plane, my asthma seized. And when I got to Africa, two weeks I was there, I didn't cough for one day. I had a good sleep, I didn't sleep for one -- I didn't -- I had no asthma for two weeks. And then I came back to the U.S. and after four days, I was so happy, oh my asthma is gone. After four days, back to here I was.
NNAMDIWell, lets talk with Dr. Stephen Teach, both about, A, the alleged permanents of asthma and, B, about symptoms that our caller, Lillian, said that she didn't have in Africa and has here.
TEACHOh, for sure, Kojo, it's a really dynamic disease that changes within any given individual through the course of their lifetime. You know, one of the things that I like to point out to families, is that asthma is far more common in little boys, before puberty, and in girls and young women, after puberty. And at often times will remit to a degree in boys and gets worse in girls and young women. And then disease in adults, as well, can be very labile, can come and go, worsen in severity, disappear completely for a few years and then come back.
TEACHAnd it's very contextual, as the caller pointed out. You know, the allergens and triggers and exposures present in one environment may simply be absent in another.
NNAMDIWe have got to take a short break. When we come back, we'll continue this conversation on asthma and health equity here in Washington, D.C. But we're still inviting your calls at 800-433-8850. You can send email to firstname.lastname@example.org. How much more do we have to do to address asthma in D.C.? What would make your life easier as a parent or a teacher or a teacher of a kid with asthma? 800-433-8850. You can send email to email@example.com. I'm Kojo Nnamdi.
NNAMDIWelcome back to our conversation about asthma and health equity in D.C. We're talking with Judy Berman, deputy director of D.C. Appleseed. Ruth Richardson is a school nurse for Children's National Medical Center who works in the Ward 8 section of the city. And Dr. Stephen Teach is medical director of IMPACT D.C.
NNAMDIStephen Teach, for the most part, poor families stick with the emergency room rather than going to a primary care provider to manage attacks before they happen. This is an expensive way to treat asthma. What can we do about so many families relying on the emergency room?
TEACHWell, we can engage those families, Kojo, and try to work with them to help them understand that asthma is a chronic disease, best managed in the primary medical care home. So our program, IMPACT D.C. or Improving Pediatric Asthma Care in the District of Columbia, seeks out those kids who are using the E.D. as a primary source of asthma care. We reach out.
TEACHWe bring those children in, their moms, their dads and we try to help them re-conceptualize the disease from an acute to an episodic disease to the chronic disease that it is, helping them control the triggers, use medications consistently to control the disease and keep them out of our emergency department and in school and doing the things that kids are supposed to be doing.
NNAMDIRuth Richardson wanted you to add a couple of issues that tend to complicate this conversation a little more.
RICHARDSONGood morning, Dr. Teach. I was telling them that asthma has two other conditions that go with it. As you know, asthma is a triplet. You have asthma, you have allergies and you have eczema, some people call it eczemia. And so sometimes when we see the students, we don't just see them for asthma, we see them from a combination of one of the three, two of the three and sometime all three together. Could you speak on that?
TEACHAbsolutely. We call that a topic triad. And you've described it well. I would add in, in addition, is food allergy, an increasingly troubling condition among young children and an issue in and of itself for the school nursing community. And really we do need to approach all three of these problems as united whole.
NNAMDIYou know, Judy, we see a lot of different factors at play here, housing conditions especially in poor neighborhoods are full of asthma triggers. Air quality in our cities is a factor as well as how we handle asthma in schools. What can government do in terms of policy to help deal with this problem?
BERMANWell, I think one of our earlier callers hit that nail on the head in terms of regulating indoor air quality. There's a lot more that can be done to make sure that our schools are what we call asthma friendly. And that would include things like educating the entire community about not using scented products, about cleaning products that are unscented, making sure that mold and other sort of environmental problems in the school are remediated.
BERMANFixing the heating systems. There are some kids whose asthma is triggered by cold, other kids whose asthma is triggered by heat, making sure that that is consistent -- the temperatures are consistent. It's something that can be very, very helpful for children with asthma. The other thing that we can do is work on our affordable housing. Clearly, homelessness is another issue because families who are homeless have very little control over their housing environment.
BERMANBut even those who are stably housed in affordable rental housing don't necessarily have the resources to ameliorate conditions in their homes that can trigger their child's asthma. So those are just a couple of the things that...
NNAMDIRuth Richardson, you spent a lot of time working in schools with students who have asthma often. Those on the ground can see the simplest solutions. What changes would you -- would make your job easier?
RICHARDSONWell, one thing I'd like to advocate for is that if we could investigate the home environment, we would like to make it as allergen free as possible. And that is that there's no smoking, there's no pets, there's no carpet, that they use air conditioners, that they would use things to make breathing a lot easier and keep the children free from asthma and asthma symptoms.
NNAMDIOn to Christian in Silver Spring, who I think has some more suggestions for us. Christian, you're on the air, go ahead please.
CHRISTIANHello, Kojo. Hello, panel. I just wanted to say, I had a cousin who passed away several years ago at a very young age from asthma. And my young nephew who's 11 years old has asthma as well. And I work in the HVAC industry and there are just a couple simple things you can do for those who have indoor AC. UV lights can go a long way as far as to breakdown bacteria and make sure it doesn't get cycled through the home.
CHRISTIANAnd electrostatic filters can do the same as well. A lot of folks go with the disposable filters that are only about 6 percent efficient. Electrostatic filters are 97 percent efficient and can really pat down on a lot of the dust and allergens and some of the triggers. So I just wanted to offer some kind of fixes just in the homes. We spend quite a bit of time in the home, so just something to think about.
NNAMDIChristian, thank you very much for your suggestions. We move on now to Randy in Washington, D.C. Randy, your turn.
RANDYAll right, thanks for taking my call, Kojo. I've got a question and a kind of comment, kind of a two-part thing here. What's the difference between fragrance-free and unscented? And what happens is you go look at a product that says unscented and you look at the ingredients and then right there near the top is fragrance. Well, okay, that's kind of stupid. And it has a fragrance or a scent, whatever you want to call it.
RANDYFor example -- and the other thing is, they seem to be -- the manufacturers seem to be getting rid of -- or the stores are discontinuing carrying some of these products because I remember years ago I used to get and some of my friends used to get Ivory shampoo that was unscented and it was great. We all loved it. And then, poof, it evaporates from the shelves. And it's either Ivory is getting rid of it or the stores don't get enough sales through it so they discontinued carrying it. And then the manufacturer ends up seizing producing it.
NNAMDIDr. Stephen Teach, what can we tell from the labels on our products?
TEACHWell, I think what we're trying to do is get unscented products as much as possible, Kojo. And that can be sometimes very tricky and a bit of trial and error. What we tell our families is if you can see it in the air, like smoke, or you can smell it in the air like a fragrance, it really shouldn't be in the home of a child with asthma.
NNAMDIJudy, asthma is a medical problem, but I've heard this is as much an education issue as it is a health issue. To what extent would you say asthma is indeed an issue having to do with education?
BERMANOh, I think it absolutely has everything to do with education. Like Ruth was saying earlier, if you're not healthy, you can't learn. If you're not there, you can't learn. These issues seriously impact our kid's academic achievement. And so to that extent, it is very much a school issue as well as this building and facility maintenance. You know, kids spend a huge amount of time in school. And if that's not a healthy environment, then their entire lives are impacted.
NNAMDIOn to David in Washington, D.C. David, you're on the air, go ahead please. Hi, David, are you there? David is no longer on the phone. We will move on, therefore, to Gail in Arlington, VA. Gail, your turn.
GAILHi. I just wanted -- I know that the major focus of this conversation of this conversation is the impact on poor children in the D.C. area. But I wish that someone would speak to the issue of the increase in asthma among children nationwide.
NNAMDIYes, Ruth Richardson would love to speak about that.
NNAMDIRuth Richardson would love to speak about that, it's all children.
GAILSo my granddaughter is 10 years old and she's black, but she's not poor. And she goes to a private school, so there's none of those rats, roaches, any of those other things that were brought up at the beginning, and yet she suffered from it her entire life. So in speaking about that, could she speak about some of the environmental causes, the things -- the chemicals and things that are now in our environment that weren't there, you know, 30, 40 years ago.
GAILI grew up -- and if you had one kid in your entire school who had asthma, that was odd. So there's an increase. It has something to do with other than rats, roaches, smoke, I mean, really, for children who are not poor and have, you know, good environments that there's still a huge increase among children.
BERMANI think that's absolutely true. I mean, all kinds of kids are impacted by asthma. I think the issue -- and the reason we're focusing on the low-income community has to do with the fact that it's more prevalent in the low-income community and that low-income families tend to lack some of the resources necessary to address the conditions. And so, I would agree with you 100 percent, there's clearly something going on in the environment, whether it's the increases in...
BERMANCarbon emissions, right.
NNAMDI...which is what the president was pointing to. That's one of the major differences between 30 years ago and now.
BERMANSure. There's a lot of things impacting our environment. But I think we need to be particularly attentive to the needs to low-income families to make sure that they have the same resources available, the time off from work, the finances to make modifications to their home and those kinds of things that can make treating asthma even worse.
NNAMDIAs you've been just hearing, Stephen Teach, the discussion has turned a little bit to the fact that the rate of asthma has gone up not only in poor neighborhoods but in general, and the rate of E.R. visits in poor neighborhoods have gone up. But where would you say we are overall in terms of progress on asthma here in Washington, D.C. and what more we need to do.
TEACHGreat question, Kojo. You know, the overall number of kids with asthma in the District has been rising steadily over the last decade. And that's probably due to a really complex set of reasons that have to do with, you know, the rise in allergic disease overall. It's a real fundamental kind of disregulation of the immune system very early in life that leads to increased rates of food allergy, asthma, eczema, seasonal allergies, you know, like hay fever, among all populations -- black kids, poor kids, white kids, rich kids -- throughout the nation.
TEACHIn D.C., we've seen the rates of asthma continue to go up. That's the bad news. The good news, Kojo, is that we're getting among those kids with asthma, there's really good evidence that the disease is, on a population basis, coming under better control. We're seeing actually rates of emergency department visits for asthma, among kids with asthma, actually plummeted about 40 percent in the District.
TEACHAnd that's due to the efforts of ourselves and others really across the primary and specialty care continuum, the D.C. school nurses, public advocacy groups, housing groups. A lot of us have come together to target this issue and really important progress is being made. That said, there's a lot of work left to do. And I applaud everything and endorse all the ideas that have come up on this call.
TEACHAnd I think a lot of these are going to -- a lot of the next wave of progress will be on the policy end. Everything from making inhalers more widely available for kids who need them to working on housing issues, to air quality in the schools and education of primary care providers to make sure that they're able to provide the asthma care their kids need.
NNAMDIAfraid that's all the time we have on this topic. Dr. Stephen Teach is medical director of IMPACT D.C., Judy Berman is deputy director of D.C. Appleseed and Ruth Richardson is a school nurse for Children's National Medical Center who works in the Ward 8 section of the city. Thank you all for joining us. We're going to take a short break. When we come back, aerial drones have transformed the skies and battlefields abroad and then some domestic airspaces. We look at what happens when they fall out of the sky. I'm Kojo Nnamdi.
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