Mitigating Childhood Asthma: Boston Uses Data and Outreach to Address Historic Harms

Historic redlining practices and restrictive housing covenants have impacted generations of American neighborhoods and contribute to present day disparities in health outcomes between communities. One study found that people living in historically redlined neighborhoods in various California cities are twice as likely to go to emergency rooms for asthma treatment compared to people living in other neighborhoods. Children living in high-density urban neighborhoods face a higher risk of developing asthma compared to children across the country and experience a “disproportionately high asthma burden,” including increased symptoms and hospitalizations. Black children are twice as likely to develop asthma than white children in the United States, with significantly higher rates of deaths.  So, how should mayors use levers within their control to alleviate the impacts of past housing policies and improve health outcomes? As housing quality is one of the most critical factors in asthma disparities, one avenue successfully pursued in the city of Boston has been improving the physical quality of existing housing stock.

The Boston Public Health Commission (BPHC) has spent more than two decades building a strong infrastructure to support residents impacted by asthma. The city of Boston administers both the Asthma Home Visit Program, which is delivered by Community Health Workers (CHWs), and the Breathe Easy at Home Program (Breathe Easy) which provides home inspections conducted by city inspectors. Families, who are referred by a medical professional, meet with a CHW in their homes to focus on asthma education, management, and connections to other social support.

Both programs target families with children who have poor or uncontrolled asthma, particularly renters with low incomes living in affordable housing. The programs work to reduce asthma inequities in neighborhoods of Boston such as Dorchester, Mattapan, Roxbury, Hyde Park, and East Boston— which feature predominately Black and Latino populations as well as the highest rates of asthma, emergency room visits, and hospitalization. To that end, the asthma programs regularly evaluate referral data to ensure they are reaching high risk children and families living in priority neighborhoods who are most in need of city services.

Through the Breathe Easy at Home Program’s online referral system, medical professionals can refer their patients for housing inspections to address concerning conditions that can make their asthma worse. The program works with landlords to address housing issues that fall under their responsibility. After a referral is made, the Inspectional Services Department (ISD) schedules an appointment within 24 hours to inspect the home. The inspector assesses the property and identifies issues that can contribute to asthma exacerbation such as mold, moisture, leaks, pests, and more. If violations are found, the inspector works with the owner or property management to correct the issues. Uncooperative landlords are turned over to the Boston Housing Court to ensure compliance, and a case is closed once all violations are corrected.

Breathe Easy at Home has been successful in facilitating healthy, safe, and stable housing for residents with asthma. Anecdotally, inspectors report that landlords tend to be more responsive to a complaint made by a clinician rather than a complaint from a tenant— with about 75 percent of cases being resolved without court intervention. The BPHC also has greater resources and partnerships across relevant municipal departments than a single tenant, allowing them to act as advocates.

In addition to addressing the quality of housing, the asthma program’s strategic use of CHWs allows them to respond to the complex needs of Boston residents to better address issues that are adversely impacting their health and well-being. Beyond housing, several other social determinants of health also impact asthma prevalence, such as income, job, and food insecurity. Each of these can contribute to high levels of chronic stress which is associated with poor asthma control and more severe asthma symptoms. In addition to in-home asthma management education and mitigation, the program also works to provide additional support to families, connecting them with health insurance, food, rent, utility resources, legal assistance, day cares, and other social services to address underlying social determinants of health affecting their control of their asthma or access to health care. 

To date, the city has conducted over 20,000 asthma home visits, and community partners have provided an additional 8,000, for a total of 28,000 asthma home visits delivered in the most common languages spoken in Boston. In addition, Breathe Easy at Home has served over 3,500 families and conducted over 8,000 home inspections to eliminate common indoor asthma triggers.

BPHC has developed critical partnerships both across other city agencies and with the community to sustain asthma delivery services at no cost to residents. The development of the Boston Asthma Home Visiting Collaborative, a multi-level partnership with various community and clinical partners, allowed BPHC to expand its reach and address asthma care coordination more effectively. Breathe Easy is guided by a steering committee of cross-sector collaborators including healthcare providers, housing enforcement and public housing officials, lawyers, and parent advocates of children with asthma who meet quarterly to discuss patterns, quality improvement, expansion strategies, and the trajectory of the program. A commitment to collaboration between the city’s housing and health-related programs, as well as strong community partnerships, have enabled the program to be more responsive to the most pressing needs of communities as they arise.

As average temperatures continue rising and air quality worsens, it will become increasingly important for cities to address the needs of residents with asthma and other respiratory conditions. By leveraging partnerships among city departments and community members, connecting people with various social support services, and advocating for rental unit improvements, Boston’s coordinated and collaborative approach to building infrastructure and service delivery around asthma serves as a model for cities working to improve the health and wellbeing of their residents.