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Asthma is greatly influenced by where someone lives. People who have affordable and accessible health care, clean air, and economic stability have a greater chance of managing and controlling their asthma. The Asthma and Allergy Foundation of America’s (AAFA) Asthma Capitals™ Report ranks the largest 100 cities in the continental U.S. by how challenging they are to live in when you have asthma. AAFA publishes this report to show the nationwide burden of asthma.

For 2022, the #1 Asthma Capital was Detroit, Michigan. Detroit ranks worse than average for asthma prevalence, asthma-related emergency room visits, and asthma-related deaths. Detroit also has the sixth highest rate of poverty in all 100 metropolitan areas we analyzed. About 20% of people in Detroit are living in poverty. The city also received an F rating for air quality because of high ozone days and particle pollution.

AAFA spoke with Dr. Elliott Attisha, DO, FAAP, to get his perspective on how Detroit and other communities can improve asthma outcomes in children. Dr. Attisha is a member of AAFA-Michigan’s Board of Directors. He is the former inaugural Chief Health Officer at Detroit Public Schools Community District and current Senior Fellow for Health with Attendance Works. Dr. Attisha is passionate about improving the health of children with asthma.

Question: You have worked with children with asthma for many years. You spent the last 12 years working as a school health physician in Detroit. Can you tell us about how asthma affects the children in Detroit?

Dr. Attisha: Asthma impacts academic achievement. Children with asthma also perform worse on tests of concentration. A student who is struggling academically is less likely to feel connected and less motivated to go to school. Asthma also contributes to missed school days. Nearly 14 million missed school days annually are due to asthma.

This doesn’t account for all those days that a child is up at night coughing from uncontrolled asthma, still showing up to school but is falling asleep, having trouble staying focused, or acting out in class. The more days of missed school, the more it impacts learning. Early intervention is critical!

Though we know about the biological risk factors for asthma (genetics, allergens, respiratory infections, etc.), more recent research focuses on the role of psychosocial stressors and social determinants of health (stress, poverty and poor housing, inadequate environmental control, household dysfunction, neighborhood safety, etc.). Children are greatly affected by the harmful effects of trauma, stress, and their physical environment.

The Adverse Childhood Experiences (ACE) Hasbro Study looked at specific experiences in the home (such as a parent who died, was divorced, served time in jail, or seeing someone use drugs or be abused in the home) and the impact on childhood asthma rates. If a child had one ACE, their chance of having asthma went up 28%. If a child had four ACEs, that number climbed to 73%!

Asthma also affects a child’s mental and emotional health. There is a connection between asthma and anxiety. Students with anxiety have more severe asthma symptoms and poorer asthma control.

Question: How can Detroit or other communities improve care for children living with asthma?

Dr. Attisha: I have seen firsthand the overwhelming environmental conditions that put children in Detroit at risk for asthma. I have also seen the challenges children and families face to get their asthma properly diagnosed and treated.

One successful approach our community tried was bringing medical care to the school. Our team would visit schools in Detroit to provide asthma care to students and adjust medicines when necessary. We found that many of the prescriptions we wrote went unfilled for different reasons, such as families that didn’t have transportation, no insurance, etc.

We brainstormed with the pharmacy team and developed a medicine delivery program where medicines were delivered directly to the school. Not only did we ensure that the child received the medicine, but we also were able to teach them how to properly use an asthma inhaler with their own medicine. We also delivered refills to the school. These experiences confirm not only the burden of asthma in our community but also the upstream and creative ideas we can put into place to end those disparities.

Question: What other areas of care do you see as opportunities for change?

Dr. Attisha: Addressing asthma for children takes a team approach. This includes families, school nurses, health care providers, social workers, and the community working together to ensure that children and their families have appropriate support and resources and that the care is complete and coordinated. Here are a few ideas to get started:

  • As we work toward improving asthma care, we must take a whole-child approach.
  • We must ensure that asthma awareness and education are a priority for students, parents, teachers, and school staff.
  • Since children spend half of their awake hours at school, schools must be aware of all students with chronic conditions. Each child with asthma should have an asthma action plan on file and access to quick-relief (rescue) medicine at school. If a child’s asthma flares up at school, quick access to their medicine can help keep them safe and in school. Sadly, less than half of Michigan students have an asthma action plan on file at their school.
  • Environmental triggers must be identified and addressed.
  • All children should have a primary health care provider and medical home.
  • Children with asthma should also be screened for co-morbid issues, such as obesity, behavioral health, allergies, and psychosocial stressors.
  • Screening is just one component. We must ensure that children and their families have access to appropriate support and resources and that the care team does follow-up visits to make sure the referral was successful.
  • All schools should have a school nurse. School nurses play an essential role in coordinating student health issues, including asthma.
  • Health care providers (school nurses, primary care providers, and school-based health centers) must work closely with schools to ensure students with asthma have appropriate support and resources.
  • Schools must closely track missed school days related to asthma and intervene as early as possible so that kids can stay in school.
  • If a child’s asthma is well-controlled, they should be allowed to take part in activities at school with appropriate support in place.
  • Improving care for asthma also needs to address the upstream determinants of asthma, including poor air quality, environmental injustices, and unhealthy housing, as well as social determinants of health like poverty and racism.

Question: Are there any other resources you would like to share?

Dr. Attisha: The Michigan Department of Education Asthma Model Policy is an amazing resource. It was updated in 2022 and is based on the School-Based Allergy, Asthma, and Anaphylaxis Management ProgramTM (SA3MPROTM) and its circle of support. It has a focus on care coordination, training, and attention to environmental triggers.

How Can You Help Reduce Asthma and Allergy Disparities?

When we promote health equity, everyone’s health benefits. The only way we can reduce health disparities is if we all work together. Everyone – from people with asthma and allergies to policy makers and the health care industry – can be a part of building programs that make a lasting difference for people, families, and communities affected by asthma and allergies.

Sign up for AAFA’s community to stay up to date about the following opportunities to get involved:

  • Advocate for people affected by asthma disparities
  • Participate in patient-centered research and clinical trials
  • Get and give support with people on our discussion forums

You can also donate to support AAFA’s mission to create real and lasting change.

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