II. What factors have been shown to correlate with high asthma rates in underprivileged NYC communities?
A. Poor Living Conditions
B. Level of Education and Awareness
C. Lack of Adequate Quality Health Care
D. Genetic Component
III. Evidence of asthma and poverty correlation outside NYC
Conclusion
I. Extensive research indicates an established prevalence of asthma in lower class NYC communities .
In 1999, researchers at NY's Mount Sinai Medical Center confirmed the existence of broad discrepancies in asthma's effects on different communities in New York. A disproportionate number of NYC asthmatics were shown to come from poor, predominantly minority neighborhoods. It was also noted that asthma was most dangerous to the health of poor, minority children.
Last year the NYC Department of Health reported that children from low-income areas were four times more likely to be hospitalized for asthma than children from high-income areas. For instance, East Harlem has the highest rate of asthma hospitalizations of children in the city (28.8 per 1,000). In other words, while the hospitalization rate for asthma attacks in NYC is twice the national average, in East Harlem the rate is nine times the national average! In the Hunts Point neighborhood of the Bronx, over 30% of the students reportedly suffer from asthma.
Adult asthma rates seem to follow a similar pattern. From 1992 to 1994 the Harlem Health Promotion Center along with the department of Sociomedical Sciences at Columbia University conducted a study of Central Harlem adults ages 18-65 only to find a considerable burden of asthma among them, with respondents reporting remarkably high rates of emergency department visits.
Between 1989 and 1991, the department of
Medicine at Beth Israel Medical Center conducted a survey to assess
trends and influences of geography, race, and ethnicity on hospital
admission rates in NYC, which has been cited as an area of excessive
asthma mortality. Within the boroughs of the Bronx and Manhattan, admission
rates were overly high, especially in economically disadvantaged neighborhoods
among Hispanics, followed by blacks and then whites.Yet another study conducted by Harvard University researchers and published in 1999 in the journal Pediatric Pulmonology found that black and Hispanic parents were twice as likely as white parents to have asthma, and black and Hispanic children were 2.9 times as likely as white children to suffer from asthma. The researchers concluded that a large proportion of the racial/ethnic difference in asthma prevalence was explained by factors related to income, residence and education. Seeking additional raw data, I constructed the following comparison chart of asthma-related hospital admission rates for two Brooklyn neighborhoods with drastically different average incomes.
The above data, compiled by
the U.S. Census Bureau, is available at www.infoshare.org
According to these statistics,
in the year 2000 Park Slope had an overall asthma rate of .11% (41
cases per 38,240 population), while Bedford Stuyvesant had a rate of
.54% (778/145,326), which is nearly five times greater. Analysis
of this data supports the above mentioned findings which sress that
the poor have markedly higher rates of asthma. Therefore,
one is led to believe that there is a correlation between asthma and
low income, which may or may not suggest a casual relationship.
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A » Poor living conditions
II. What are some possible factors likely to lead to high asthma rates in underprivileged NYC communities?
A strong casual relationship has been noted between high asthma rates and various indoor and outdoor environmental pollutants. Particulate matter, diesel exhaust, home allergens such as dust mite, mouse and cockroach droppings, and tobacco smoke, among others, have been found to be detrimental to the health of thousands of socioeconomically disadvantaged families residing in areas heavily saturated with these asthma triggers.
Because many homes in poor areas are older and not well-maintained, asthma triggers such as vermin, cockroaches, and mold easily proliferate. While the high prevalence of childhood asthma in low-income, inner city populations is not fully understood, it has been partly attributed to high indoor allergen levels, whose contribution to asthma is well documented. A study conducted by the Heilbrunn Center for Population and Family Health at the Columbia University College of Physicians and Surgeons investigated levels of cockroach allergens and their distribution as a function of housing deterioration in a sample of 132 Dominican and African American low-income households with young children residing in northern Manhattan, 40% of whom were on public assistance. Results showed significant positive associations between housing dilapidation and degree of allergens. In another study of 167 African American and Dominican women residing in northern Manhattan, researchers checked maternal and newborn cord blood and concluded that significant exposure to cockroach and mouse antigens and in utero sensitization to multiple indoor antigens occurred before the child was even born. ¹ Although interventions at the apartment level may be useful in reducing these indoor asthma environmental triggers, interventions at the building, neighborhood, and city levels are needed to sustain the individual efforts.
In addition to poor housing quality and lack of building maintenance, which lead to pest infestation, members of the lower classes are also often exposed to high rates of outdoor pollution. Many poor neighborhoods house industries that subject them to increased outdoor pollution. According to George Thurston, an NYU environmental medicine professor, more people go to the hospital with asthma attacks on days that air masses have highest pollution concentrations. Moreover, areas near airports and high levels of truck exhaust have long been shown to have higher asthma rates. In areas like Hunts Point and Washington Heights, pollution from cars and diesel trucks contributes to poor air quality which in turn adversely affects asthma rates in these neighborhoods.
"The worst asthma rates are in low income communities of color that have more than their share of polluting facilities... In Harlem, where there are bus depots; in the South Bronx, where there is a lot of truck traffic, in Queens, where there are a lot of power plants sited... [To alleviate these problems,] the city could create express bus lanes, cut down on truck traffic, and more equitably distribute polluting facilities," stated Leora Hanser, the NYC legislative director for the New York League of Conservation Voters, which commissioned the map above.²
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B » The level of asthma education and awareness was found to play a crucial role in poor communities with high asthma risks. A number of community education, prevention, and promotion programs aimed at raising awareness and educating New Yorkers in underprivileged neighborhoods have succeeded in minimizing asthma's effects on their lives.
When the New York City Childhood Asthma Initiative was mobilized five years ago, NYC childhood asthma hospitalization rates in all five boroughs decreased significantly. "In 1998 there were 10,727 hospitalizations for asthma among children ages 0-14 years old (7.2 hospitalizations per 1,000 children), representing a decline of 27.4% from the 14,780 (9.9/1,000) in 1997. Hospitalization rates decreased by a dramatic 28.3% in the Hunts Point-Mott Haven community of the South Bronx, a neighborhood where the Department of Health has implemented an intensive community-based asthma management program. Major decreases in asthma hospitalization rates also occurred in other New York City neighborhoods: by 42.8% in Washington Heights; by 38.6% in Fordham; by 36.3% in Williamsburg-Bushwick; by 25.8% in Central Harlem..."³ The NYC Childhood Asthma Initiative provided funding for community based organizations to implement a variety of asthma activities in neighborhoods, stressed improved asthma diagnosis and management practices through conferences held for nurses, social workers, and other health care professionals, and developed multilingual educational materials for families. These local initiatives and educational outreach efforts to help people manage athma enabled many asthmatics and their families to attain a better quality of life.
On a more critical note, the fact that these programs made a difference suggests that prior to their installment, the residents of the latter underprivileged areas lacked the much needed information, case management services, and quality care on the part of medical providers, housing organizations, day care centers and school personnel. This data indicates that instituting asthma awareness and training programs in poor communities is one way of achieving improved results.
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C » Lack of adequate quality health care
Residents of poor NYC neighborhoods often receive substandard health care. Inaccessibility to proper medical care is an issue of great concern to many financially disadvantaged New York families, some of whom lack health insurance altogether. As a result, hundreds of inner-city children suffer from asthma without receiving a medical diagnosis and appropriate follow-up care.
The Albert Einstein College of Medicine Division of General Pediatrics published a study in 1994 estimating the prevalence of asthma and wheezing among inner city children to be substantially higher than the rates estimated from national survey data, with a considerable proportion of cases representing undiagnosed asthma.
During the 1999-2000 school year, the department of Epidemiology and Social Medicine of Montefiore Medical Center at the Albert Einstein College of Medicine conducted a survey of six NYC elementary schools in the Bronx and found that among the 74% of parents who returned the surveys (4,775/64,333), 20% (949/4,775) identified their children as asthmatics and 12% (589/4,775) as possible asthmatics who had asthma-like symptoms but lacked a medical diagnosis.
A study published in August of 1998 found that African American patients were 36% less likely than their Caucasian counterparts overall to visit an asthma specialist and filled fewer prescriptions for medications. A recent study in the journal Pediatrics also found that many inner-city children with persistent or severe asthma were not using the recommended treatment of inhaled anti-inflammatory medication on a daily basis. The latter fact may be in part attributed to limited access to quality health care. Underuse of inhaled anti-inflammatory medication may in turn be one of the many aspects contributing to excess hospitalization.
In 1995, the Division of Clinical Immunology at Mount Sinai Medical Center concluded that despite advances in medicine, asthma morbidity rates have risen dramatically over the past two decades, especially in minority and socioeconomically disadvantaged populations. The researchers attempted to assess whether an outpatient intervention program specifically targeted at a high-minority population in East Harlem would be successful in reducing asthma morbidity. Eighty four patients were selected, 45 became part of an intervention group followed by an asthma specialist, the rest were cared for by a general internist or pediatrician. Patients in the intervention group were found to have dramatically reduced total walk-in and emergency visits as well as hospitalizations, while patients in the nonintervention group showed no changes.
The data above suggests that asthma may well be widely undertreated in the poorest sections of NYC, which may partly explain the higher rates of asthma-related hospitalizations. Having limited or no access to the care of medical specialists trained to diagnose and manage asthma i.e. allergists, immunologists, and pulmonologists, many find themselves in hospital emergency rooms. Such sporadic visits are not at all the answer to the problem. They are in fact merely short-term solutions that fail to provide continuous care and the vigilant treatment their condition calls for in order to keep it under control. In fact, if asthma goes undertreated, it only worsens and the disease process turns into a vicious cycle, causing long term decline in lung function and even death.
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D » Because a number of NYC lower class neighborhoods carry a marked racial and ethnic composition, some argue that genetics may be in part responsible for the disproportionately high asthma rates among the minority populations of NYC's Washington Heights, Harlem, and the South Bronx (blacks and Latinos in these neighborhoods represent the highest risk groups for asthma.) It is for this very reason that the American Lung Association labeled asthma as a discriminating disease.
Indeed, based on a study of 3,000 Hispanics in NY (published in the American Journal of Respiratory and Critical Care Medicine), mainland Puerto Ricans have been shown to have a higher rate of asthma as compared to the entire Hispanic population and all other ethnic groups. The occurrence of childhood asthma is three times as high in Puerto Rican children than in non-Hispanic white children. Puerto Ricans reported a 13.2% asthma prevalence rate as opposed to 5.3% among Dominicans and other Latinos. Puerto Ricans also have a higher asthma death rate compared with other Hispanic groups, whites and blacks.
See also Asthma and Genetics
III. Evidence of asthma and poverty correlation outside NYC
Hospitalization rates for asthma in NYC have been shown to be highest in poor urban neighborhoods. This trend, however, also prevails in the rest of the U.S. For example, a small area analysis of asthma hospitalization rates in Boston was carried out by the department of Medicine at Boston University School of Medicine to determine whether this pattern would hold in a medium-sized city and to identify characteristics of neighborhoods with high hospitalization rates, including their relative use of inhaled anti-inflammatory medication. Asthma hospitalization rate was positively correlated with poverty and with the proportion of nonwhite residents and inversely correlated with income, level of education and medication use. Consequently, researchers once again found asthma hospitalization rates to be highest in poor inner city neighborhoods.
Similar findings have also been observed on a national scale, as reported by the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (NCHS):Asthma emergency department visits per 10,000 population, 1998
Conclusion
Between 1982 and 1996, the prevalence rate of asthma rose from 34.8 to 55.2 per 1,000 persons, an increase of 59%. Various hypotheses have been proposed to account for the dramatic rise in asthma rates. Some maintain that the current increase in asthma occurrence is due to regular vaccination which weakens people's immune systems. According to this theory, people in developed countries tend to overprotect themselves with widespread immunization, which fosters an underdeveloped immune system (since the human body is no longer expected to fight off as many invaders, it loses its edge to the extent that the immune systems of some individuals begin to overreact to the smallest irritants.) On a par with this conclusion stands a recently published article titled "Lifestyle May Be to Blame for Rise in Asthma" which claims that the growing prevalence of asthma cases may be linked, in part, to cleanliness and abundance. "In the best countries in the world, the ones that have the cleanest air, the best food, the best vaccinations, the incidence of allergy and asthma is at its highest..."
Ironically, this theory disregards the very pressing facts supported by many a research findings discussed above. The latter outline a conclusively different picture in which the highest incidence rates of asthma in NYC and the U.S. at large were found predominantly in poor, minority neighborhoods that face a comparatively lower quality of life with regard to living conditions, air quality, and availability of health care. These disturbing facts demand immediate attention and action on the part of the public and government alike.
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