Two blocks south of Yale New Haven Hospital, a 10-year-old boy named Jaden* coughed and wheezed in his Section 8 apartment. When the downstairs neighbors smoked, cigarette fumes floated through the air vent into the living room. Black mold stained the carpet floor, spreading into the bedrooms where three children slept. The floor’s dense knots of carpet fibers, dust and mold spores offered a breeding ground for dust mites and cockroach eggs. The walls, after years of soaking up trapped carpet moisture, were damp to the touch.
These poor housing conditions turned Jaden’s apartment into a petri dish of asthma triggers. For people with asthma, small particles such as pollutants, mold and dust could set off an asthma attack, where the airways swell up and fill with mucus. In severe cases, without enough airflow to make any audible sound, the lips turn blue and the heart rate slows down enough to require emergency care. In each of the five years that Jaden had lived in his apartment, he had rushed to the emergency room once or twice for asthma attacks.
Hospitalizations, however, were not enough to alleviate Jaden’s asthma. Jaden used his inhaler properly and took his medicine regularly — his mom made sure of it. Following doctors’ recommendations, Jaden gave up his favorite hobbies of basketball and football. Jaden’s mom juggled working a part-time job, cleaning the apartment of asthma triggers and keeping up with Jaden’s medical appointments. But after each hospital visit, Jaden still returned to his main asthma trigger — a carpet floor of mold.
MORE THAN A BREATHING PROBLEM
According to the National Center for Healthy Housing, around 30 percent of asthma cases are linked to home environmental features, such as mold spores, dust mites, tobacco smoke, rat feces and cockroach shedding. These triggers are especially prevalent in disrepaired homes, as roof leaks build up moisture for mold growth, faulty ventilation causes dust and pollutants to proliferate and cracked floors leave potential openings for rats and cockroaches. Given that low-income families are more likely to live in poor-quality housing with asthma triggers, asthma is more than just a health problem — it is also a poverty and housing problem.
Alice Rosenthal, an attorney that specializes in medical issues of low-income families, set out to investigate Jaden’s substandard housing and address the root cause of his asthma. Rosenthal works with the Center for Children’s Advocacy in New Haven, a legal rights nonprofit for vulnerable children. At no charge to families, Rosenthal informs and advocates for their children’s rights, and, in one-tenth of her cases, represents them in court.
After spending only one hour in Jaden’s apartment, Rosenthal said that she couldn’t breathe. She instinctively wanted to sue the landlord for violating health and safety standards — a lawsuit could force the landlord to replace the moldy carpets.
Jaden’s mother, however, objected. She told Rosenthal that she still needed to maintain her relationship with the landlord in order to have a home at all. If Jaden’s family complained, the landlord could retaliate by adding them to the tenant blacklist, jeopardizing their chances of finding future housing. In a state where there are only 41 affordable homes for every 100 extremely low-income rental households, the risk of losing their home was too great. Managing Jaden’s asthma meant not only facing medical procedures, but also poor housing conditions, powerful landlords and a lack of safe and affordable housing.
POOR HOUSING, POOR HEALTH
In Connecticut, both asthma and housing are serious issues. According to the most recent Centers for Disease Control and Prevention data, Connecticut has the second highest childhood asthma rate in the nation. In 2018, nearly one out of every 10 children in the state had asthma.
Moreover, asthma disparities run rampant. Connecticut’s five largest cities — Bridgeport, Hartford, New Haven, Stamford and Waterbury — have 3.4 times more asthma-related hospitalizations than the rest of the state. These cities make up only 18 percent of the state population, but account for 44 percent of all asthma hospital costs.
The disparities persist on the city level. New Haven has the highest asthma hospitalization rates in the state. In Jaden’s neighborhood, the Hill, the rate of asthma ED visits and hospitalizations is 436 children per 10,000 residents. Three miles north in East Rock, however, the number falls to 97 children per 10,000 residents. In other words, a child living in the Hill has over quadruple the risk of asthma hospitalization than a child living in East Rock.
According to Rosenthal and Benjamin Oldfield, a pediatrician for patients with asthma, the culprits behind Connecticut’s high asthma rates are environmental factors — air pollution, smoking and poor rental conditions.
In New Haven, half of the housing stock was built more than 80 years ago, and over 70 percent of units are rentals. The bulk of New Haven’s affordable housing stock is owned by a handful of landlord giants, who own property through limited liability companies. Behind a shield of LLC protections, landlords are rarely held accountable for housing violations.
As such, most cases of housing neglect go unresolved. In a Healthy Homes assessment, the CDC found that a typical home in Connecticut had 14 housing deficiencies, from broken fans to poor ventilation. The most common issues were wall-to-wall carpeting that traps moisture, visible mold growth and mice, cockroaches, rats or bedbugs — all of which are serious asthma triggers.
Jaden’s home is not an isolated case, but part of a larger trend. There have been many cases in New Haven alone:
In February 2018, a 115-year-old cracked pipe in the Norton Towers Apartments leaked mold from the fourth floor to the basement. A 7-year-old girl went to the ICU three times for asthma attacks that were believed to be caused by the building’s mold.
In May 2019, black mold and soggy ceilings forced a family out of their apartment on Truman Street. The mother suffered asthma attacks from breathing in mouse droppings and mildew.
In January 2020, Robert T. Wolfe Apartments were infested with mice and insects. Residents had been complaining about leaky roofs, cracks and mold for years, but their concerns were never addressed.
Most notorious is the demolished-by-neglect Church Street South complex, which locals dubbed “Asthma Central.” Built in 1969, the 301-unit complex consisted of 22 flat-roof, concrete buildings and housed around 1,000 low-income adults and children. It was designed to knit downtown New Haven with Union Station in a “civilized urban environment [with] much to study and enjoy,” as architectural historian Elizabeth Mills Brown once described it.
Fifty years later, however, the complex had deteriorated from decades of poor maintenance. According to a 2018 survey by Yale School of Medicine professor Carrie Redlich, over 90 percent of the apartments reported mold and structural damage. Nearly all surveyed children reported respiratory problems, and one in two children had physician-diagnosed asthma. The correlation between its deplorable housing conditions and high rates of asthma were likely no coincidence.
“[New Haven] is one of the oldest communities in America, so we have a really old housing stock,” said Rosenthal. “Most of housing in New Haven is rentals, and we have some really big slumlords. Put that together in a pot, and you get a lot of poor housing conditions that I think are exacerbating children’s asthma.”
A RIPPLE EFFECT
In order to alleviate Jaden’s asthma, Rosenthal knew that she needed to combat the landlords causing his poor living conditions. Respecting Jaden’s mother’s decision not to sue, Rosenthal instead sent warnings of court involvement if the landlord refused to make mold repairs. Over the next several months, Rosenthal teamed up with Jaden’s pediatrician and pulmonologist to issue repeated threats of legal housing complaints. They sent demand letters, requesting action for a legal offense. By ignoring the black mold that has festered in Jaden’s home for decades, the landlord was in part responsible for exacerbating Jaden’s asthma, a protected condition under the Americans with Disabilities Act. After her first few demand letters went ignored, Rosenthal threatened to appeal to get the federal office of Housing and Urban Development involved.
It took six months of fighting for the landlord to get maintenance to remove the moldy carpets from Jaden’s apartment.
Shortly after, Jaden weaned off his dosage of asthma medications. He attended more days of school, and resumed basketball and football. With less time spent on managing Jaden’s asthma, Jaden’s mom gained a full-time job as an administrative assistant for the Yale New Haven Hospital.
“There’s a ripple effect,” said Rosenthal. “We improved his housing, which improved his health, which allowed him to go back to school, which allowed his mom to work, and everyone is happier.”
Jaden’s case, however, was an exception. For most landlords, demand letters simply roll off like raindrops off a roof.
HELD BACK BY FEAR
Benjamin Oldfield, a pediatrician at Fair Haven Community Health Care, writes letters to landlords as routinely as prescriptions to patients. Despite his gentle nature, Oldfield isn’t afraid to make biting charges against predatory landlords. As a practitioner of holistic care, part of his medical duties is to ensure that his patients have healthy homes in addition to healthy treatment.
The Fair Haven Community Health Care center on Grand Avenue is known as a Hogar Médico, or a “Medical Home.” The clinic resembles a Victorian-style house and is lodged across a row of Spanish-themed mom-and-pop stores. Under one roof, grandchildren and grandparents alike get comprehensive care from immunizations to colonoscopies. The clinic welcomes everyone, regardless of their ability to pay. According to Oldfield, about one-quarter of his patients are undocumented and uninsured.
Asthma is one of the most common conditions seen at the clinic, requiring check-ups every three months. When a child’s breathing is impaired by mold and other poor housing conditions, Oldfield issues demand letters to the landlord, hoping his medical clout will convince the landlord to make home remediations. At the end of every letter, he leaves his contact information and an invitation to brainstorm solutions.
More often than not, however, the demand letter fails to get passed to the landlord. The letter must be transferred by the patient, who is often low-income or undocumented and holds no position to make demands from landlords with high-priced lawyers. Much like Jaden’s mother’s reluctance to sue, Oldfield’s patients are also hesitant to deliver his demand letters due to fears of eviction, unwanted attention and deportation.
“They’re vulnerable across many layers,” said Oldfield. “If the landlord decided to kick them out, then they have no legal recourse.”
Housing remediations are also no small demand. According to Rosenthal, a professional mold removal can cost up to $20,000. If the apartment is low-income and federally subsidized, that money has to come out of the landlord’s pocket.
Luckily, asthma attacks can often be prevented by simple measures in the home.
INTERVENING IN THE HOME
Oldfield had a 17-year-old patient, Chris*, who suffered from asthma since his early childhood. When his family moved into a new apartment, Chris’ asthma worsened. Oldfield tried upping his asthma regimen to three medications per day, but Chris’ chest still tightened even while sitting still. Suspecting that the abrupt increase in asthma flare-ups was due to a housing change, Oldfield referred Chris to Putting on AIRS, a state-funded asthma intervention program that checks people’s homes for asthma triggers.
Betty Murphy, the program coordinator of Putting on AIRS, is a mastermind at connecting the medical and environmental pieces of health. With almost 40 years of public health experience under her belt, she strives to dedicate her last few years before retirement to helping families with asthma. She works seven days per week and visits homes across three districts in Connecticut. Murphy has every symptom of a workaholic, except that she works not from a compulsion to be busy all the time, but because she “love, love, loves” her job.
Putting on AIRS works like a team of detectives, with Murphy at the lead. During home visits, the team looks for hints of what could be exacerbating the child’s asthma. The asthma educator assesses the family to see if they can properly administer the inhaler medication. The environmentalist searches for potential home triggers, from bathroom mold to left-out cereal boxes that might attract cockroaches. Murphy reviews the doctor’s orders and information collected from home visits to map out an intervention that educates the family, addresses home triggers and informs the doctor’s treatment plan.
“Asthma is never one thing,” said Murphy. “You can fix the environment, but if you’re not taking the medications, your asthma won’t get better.”
During Chris’ home visit, the asthma educator helped make sure that he followed the appropriate medication procedures. The environmentalist, however, found cigarette fumes flowing into Chris’ apartment. Unlike Chris’ old smoke-free apartment, his new apartment permitted smoking, and both of his neighbors smoked. To help purify the air, Murphy ordered air filters to be installed and directed the family to close their windows from smoke.
After installing air filters, Chris did not have any serious asthma attacks for 4 months, a new record for the year.
“It’s not a slam-dunk total success, but it shows that home interventions could change the course of asthma, potentially more so than medication can,” said Oldfield.
Simple fixes such as air filters cost less than $100 to purchase, but can save hundreds of dollars in hospital costs. A CDC evaluation found that home visits for asthma can reduce hospitalizations by 87 percent and missed school days by 82 percent. For every 100 participants, there was a net savings of over $26,000 from prevented emergency visits.
Still, the home visits are limited by resources, funding and poverty. Putting on AIRS is fully funded by the CDC at no cost to families, and most repairs are little tweaks or behavioral nudges, like providing plastic bins to help families store items and prevent dust accumulation. According to Murphy, they can only install air filters if the state budget allows for it, which varies from year to year. This means that Chris was able to get air filters as a state donation, not a state obligation. A $20,000 mold removal, which many low-income housing units need after decades of neglect, would likely be out of the question.
AN UPHILL BATTLE
Small interventions are also parried by small obstacles, and for people in poverty, these obstacles are confronted on a daily basis. Even though Murphy pulls the strings on asthma home interventions, there is still an endless stream of factors outside of her control. The child’s only caregiver could be addicted to smoking, which disproportionately affects low-income communities. Parents often cannot afford to take time off work to take their children to the clinic if it closes before 5 p.m. If the family gets evicted, then past home interventions are rendered useless, and the child may get exposed to a swath of new asthma triggers found outdoors and in homeless shelters.
Dorothy Novick, a pediatrician who sees low-income patients with asthma at the Children’s Hospital of Philadelphia, compared “treating poverty” to “treating cancer.” Even when all cancer treatment options get exhausted, by the unstable nature of the disease, some children still die from cancer.
“Poverty is very much the same way. You do everything there is to do, but there are situations where poverty is bigger than you,” said Novick. “I feel as passionate and concerned about my patients as ever. But there are times my efforts feel futile because of how little we as a society invest in our most vulnerable communities.”
Connecticut’s health system has taken multiple innovative approaches to asthma, such as Rosenthal’s medical-legal partnership, Oldfield’s medical home model and Murphy’s home visiting program. The Yale Center for Asthma and Airway Disease boasts “world class medical treatment to asthmatics” on their website. Still, these interventions are only band-aids to the systemic issues at the root of asthma disparities. They don’t fix the unlivable housing conditions in segregated, low-income neighborhoods of color, level the power imbalances between landlords and tenants, nor curb the unaffordable costs of safe housing and health care. Such fixes require policy change that makes housing and health care available to everyone, especially families that are financially and politically disenfranchised.
Although Jaden and Chris’ asthma improved with their housing, their stories are the rare exceptions. Rosenthal still has clients who eat dinner on gnawed tables and sleep with mice scuttling over their blankets. To avoid lawsuits, landlords will claim to “fix” asthma triggers by painting toxic bleach over black mold or tossing a few snap-traps in homes littered with crumbly rat feces. Oldfield still has yet to hear back from a single landlord of his undocumented patients. And Murphy is often unable to help families who work multiple jobs and cannot afford to take time off work for home visits.
“People shouldn’t live like that,” said Rosenthal. “If housing was a right and health care was a right, I think we’d be a lot better off.”
*Name has been changed to maintain confidentiality.