Dunn’s mother, Maria Cotto, has long had severe asthma. Dunn inherited the condition, though she has mostly grown out of it as an adult. Now, Dunn’s 12-year-old son also has severe asthma.
“People kind of shrug it off as not that big of a deal,” said Dunn, who lives with her family in East Harford. “But I see what it’s done to my mother, and I see what it’s doing to my son, and what it has done to me.”
In Connecticut, 10.6% of children and 10.5% of adults have asthma, according to state data from 2019. According to DataHaven’s 2021 Community Wellbeing survey, 12% of adults have asthma.
Asthma does not impact all people equally.
“In the state of Connecticut, similarly to other states in the country, this condition disproportionately affects minority populations, including African Americans and Hispanics,” said Dr. Mario Perez, an assistant professor of medicine at UConn Health who studies asthma disparities and who Cotto sees for her asthma.
DataHaven’s survey found that 11% of white, 13% of Black, and 21% of Latino adults have asthma.
Economics also seems to play a role. Only 6% of adults in wealthy towns have asthma, while 16% of adults in cities like New Haven, Waterbury, Hartford and Bridgeport have the condition. In addition, 19% of adults earning less than $30,000 per year have asthma, compared to only 9% of those earning $100,000 per year.
“Residents in city centers are typically three to four times more likely to visit the emergency room with an asthma diagnosis than residents of outer suburban areas,” said Mark Abraham, executive director, DataHaven.
Air Quality And Geography
Connecticut has long been known as the “tailpipe of the nation” due to pollution that drifts in from other states. The 2022 State of the Air report from the American Lung Association gave every Connecticut county a poor grade for ozone levels. Fairfield, Middlesex, New Haven and New London all received a grade of F, while Tolland and Windham counties received D grades, and Hartford and Litchfield were each given a C.
“We know that environmental factors, particularly factors such as air pollution, can be associated and contribute to the disease and to disease flare,” Perez said.
A 2009 study of New Haven County children recruited from the Yale Asthma Care Center found an increased risk of symptoms and inhaler use in children with asthma who had exposure to traffic-related fine particles.
Additionally, some research has suggested a link between crime and asthma rates, which highlights the need for healthier communities overall. “Having the sense that your neighborhood is more secure actually decreases the rate of asthma and asthma exacerbations,” Perez says.
City Risk Factors And Glimmers Of Hope
Melanie Stengel Photo.
Robert Carmon shows off his basketball skills on the court off Glade Street near his West Haven home. His asthma has improved since he was diagnosed as an infant.
Robert Carmon, 11, who recently moved from New Haven to West Haven, developed asthma as an infant and was rushed to the hospital by his parents on a near-weekly basis during the early years of his life. Robert has improved since C-HIT first reported on him in 2018, but the condition still impacts his life. He’d like to play on the basketball team at school but can’t because he worries his asthma will flare up. “I can play pickup games as long as I don’t play too hard,” he said.
The frequency of his trips to the emergency room has decreased, but he still goes to the hospital about once every month or so, said Robert’s father, Chaz Carmon.
Stories such as Robert’s are common in Connecticut cities. In recent years they have ranked high in the Asthma and Allergy Foundation of America’s annual Asthma Capitals Report, but this year saw marked improvement. Hartford moved from 17th worst to 69th on the list, Bridgeport dropped to 85th, from 29th in 2021, while New Haven dropped from 5th to 90th.
“New Haven saw the biggest positive jump in rank of all the 100 metropolitan statistical areas that we analyze,” said Hannah Jaffee, a research analyst with the Asthma and Allergy Foundation.
However, people shouldn’t read too much into the improved rankings because this year’s list was created based on different data sources than previous years. For example, insurance claims were examined instead of the self-reported surveys used previously. In addition, more localized data was utilized rather than the county-level data used for the report in previous years.
Even still, Jaffee said, the three most populous counties have seen some improvement.
“When we do look at the county-level data that we previously used asthma prevalence rates for Fairfield, Hartford and New Haven county, they’ve all declined over the past five years,” she said. The death rate has also generally declined in those three counties over the past 20 years, Jaffee added.
Improving Asthma Rates
Proven strategies for reducing asthma incidence and severity include working to ensure all residents have access to culturally competent health care and improving indoor and outdoor air quality for those in cities.
“Asthma triggers can be mitigated through housing quality improvements like better air conditioning filters and education for families about what the triggers might be. If you’re running a gas stove for cooking, and you don’t have good ventilation, it’s producing a lot of air pollution inside.”
— Mark Abraham, executive director, DataHaven
The Connecticut Asthma Program is a state-run initiative attempting to decrease asthma disparities through partnerships with health care providers while providing education about the condition and expanding access to Connecticut’s asthma home visiting program. The state has also promoted the Centers for Disease Control and Prevention’s (CDC) EXHALE framework for asthma management.
Perez says that the most effective interventions will take place before a patient ever arrives in front of him. “I think we as a society have to address everything from the environmental pollution and climate that we’re creating as humans to improving education and access to health care, but also improving the socio-economic status of the population in general.”
In the meantime, some say more can be done individually to help those with asthma. For instance, while Robert’s current school allows him to keep his asthma pump on hand, he wasn’t allowed to do that in the past. “They always said you have to keep your bag in your locker,” he said. That could cause asthma attacks to get out of control before he could get to his pump.
His father adds that each school should have a nebulizer in the nurse’s office with staff trained to administer asthma medication. That way, a student “can be on the nebulizer at least until the parents get there,” Carmon says, and if the nebulizer helps enough, the student might be able to return to class.
Cotto says it’s important for medical staff to remember that each patient is different. Cotto horrifyingly learned this when she was given epinephrine during an emergency asthma flare. While the medication can be helpful to some patients, it nearly killed her.
“I’m allergic to it. When they administered it to me, my heart stopped,” she said. When this happened in 2013, she ended up in a coma for 22 days.
After Cotto’s coma, her asthma worsened, and she could not leave the house without oxygen for many years. In 2014 she began seeing Perez, who took the time to figure out her specific triggers and a treatment plan that worked for her. Though she struggles at times, her asthma is more under control than it has been in years.
“He tried a whole bunch of different medications and finally found one that works for me,” Cotto says. “I’m actually able to leave the house without oxygen.” That’s something she hasn’t done for nearly a decade.
You can find out more about asthma in Connecticut and asthma management in general by visiting the following sites:
- The Connecticut Asthma Program
- Connecticut’s asthma home visiting program
- The CDC’s EXHALE framework for asthma management
- The Asthma and Allergy Foundation of America’s annual Asthma Capitals Report
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For the 23-year-old house cleaner, postponing medical appointments became necessary when the COVID-19 crisis affected childcare for her 2-year-old son.
“I would have to not go to my appointments sometimes because I didn’t have childcare,” she said. “When COVID struck, that’s when daycare became less reliable.” If her son sneezed or had a runny nose, daycare would not accept him, Vasquez explained.
More women than men have either missed medical appointments or postponed the care they thought they needed during the height of the pandemic, according to a recent DataHaven survey released in October of more than 5,000 randomly selected state residents.
The 2021 Community Wellbeing Survey found that 12% of women didn’t get the health care they needed in the last year, compared to 10% of men. Similarly, 34% of women postponed the medical care they thought they needed during the same time frame, while just 26% of men reported putting off care.
The numbers are higher than those reported in the 2018 community wellness survey, which found that 9% of women and men skipped medical care. More women than men, however, postponed the medical care they thought they needed, at 26% versus 20%.
“We as women tend to get everybody else taken care of and tend to neglect ourselves.”
— Cara Westcott, chief operating officer,
UCFS operates five health care centers in eastern Connecticut. The higher numbers make sense, she added, as the pandemic brought increased childcare responsibilities and remote learning challenges often shouldered by women.
Nationally, Hispanic women have been disproportionately affected when it comes to accessing medical care, according to a women’s health survey by the Kaiser Family Foundation, which found that 40% of Hispanic women skipped preventive health services and 25% skipped a recommended medical test or treatment.
The report by DataHaven, a nonprofit, also found that Latinos and low-income adults are less likely to have insurance and more likely to skip or delay medical care.
Between May 24 and August 30, 2021, 32% of women with no health insurance said they didn’t get the health care they needed in the past 12 months, compared with 25% of uninsured men, the survey found. When it came to putting off medical care, 51% of uninsured women postponed getting the care they thought they needed, compared with just 38% of uninsured men.
At UCFS, Westcott said she saw a 25% decrease in the number of patients seen in 2020 among all populations compared with previous years.
“We saw a drop off in the number of unique patients seen from calendar year 2019 to calendar year 2020 of about 5,000 patients,” she said, “and we attribute that to people forgoing care during the pandemic, even though we did offer telehealth appointments.”
Fluctuating employment and health insurance status also played a role, she said.
The DataHaven survey, done in conjunction with the Siena College Research Institute, found that 24% of respondents reported losing a job in the past year.
UCFS, which offers medical, dental and behavioral health services, saw 20,000 unique patients each year pre-pandemic, according to Westcott. At the end of 2020,15,000 patients had been seen.
“When we started seeing those numbers dip, we put together strategies and work plans to get them back in,” she said, including launching social media and radio marketing campaigns. “Since the beginning of this year, we’ve been making a concerted effort to contact those patients we didn’t see in 2020 to get them back to care.”
Women who were forced to miss routine screening appointments like mammograms and Pap smears last year due to pandemic precautions in health care offices have all had the opportunity now to be seen, said Dr. Mark Silvestri, chief medical officer of medical and dental services at the New Haven-based Cornell Scott Hill Health Center.
“I definitely think our ability to provide telehealth services made health care accessible to women who were at home because of childcare reasons,” he said, “but for some health care needs, telehealth care is not suitable.”
Screening appointments scheduled for March to June 2020, when patients weren’t being seen in person, were rescheduled to a later date, he said.
“We kept track of all the women we were postponing at that time and immediately got them back in,” Silvestri said. The backlog in routine screening appointments evened out between late 2020 and early 2021, he added.
Vasquez was one of the women who missed her annual Pap test last year due to pandemic precautions. However, she rescheduled her appointment to nearly a year later and was seen in March 2021.
Little by little, Westcott said, she is starting to see more patients returning to health care. At the end of October, UCFS had seen 15,654 unique patients during the previous 12 months.
“We are making progress,” she said, “but it’s slow progress.”
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Once known in the neighborhood as the “mud hole,” a crime spot for “drug trafficking and all kinds of stuff,” the Learning Corridor is now a place where neighborhood residents gather to take care of their health and well-being, said Doreen Abubakar, founder and volunteer director of the Community Placemaking and Engagement Network (CPEN).
“We held a six-month in-house training about diabetes,” Abubakar said. “My sister who had diabetes brought down her blood sugar to pre-diabetic levels after she did the training.” The participants learned the importance of exercise to manage their diabetes, and residents joined the national walking club movement Girl Trek. Last year, Abubakar and her team planted native perennials and shrubs, and this year received a grant for the nursery from the Audubon Society.
But those who live in and work to improve Newhallville—a neighborhood long associated with poverty, violence, and trauma—know more work needs to be done.
Newhallville is one of thousands of neighborhoods in the U.S. where childhood opportunity is ranked “Very Low”—a designation that impacts their health, well-being and even lifespan—new neighborhood-level data from Brandeis University show.
“All our data show that two children born just a few miles apart [in New Haven, Bridgeport, and Hartford metros] experience vastly different neighborhood conditions in childhood and have a six or more year gap in life expectancy simply based on where they were born,” said Dolores Acevedo-Garcia, director of the Institute for Child, Youth and Family Policy at the Heller School at Brandeis. In fact, Newhallville ranks “Very Low” for overall child opportunity across 29 indicators, including access to green spaces, walkability, and access to healthy foods.
Residents are all too aware of the disparities cited in the study. “Just drive up four blocks or so and there are millionaires,” said Rhonda Nelson Sheffield, a 56-year-old resident and manufacturing worker who has lived in the neighborhood her entire life.
Melanie Stengel Photo.
Tammy R. Chapman in her garden. In addition to vegetables she grows medicinal herbs and plants to attract pollinators.
Newhallville is an area that has been disadvantaged since the 1960s and has become “even more economically disadvantaged over time, as evidenced by the fact that it has become poorer relative to other areas—even if its absolute poverty rates or income levels have not changed or have even improved at times,” said Mark Abraham, executive director at DataHaven.
According to a 2019 DataHaven report, the average household in Newhallville earned $33,113 annually, compared with $73,781 statewide. Nearly 4,054 residents were living in households with incomes less than twice the federal poverty level. In Newhallville and nearby Dixwell combined, as much as 83% of children under 18 were considered low income, the data from 2017 show.
One mile in radius, Newhallville is situated within a metro that offers vastly different opportunities to children living just a few blocks apart from each other. The Brandeis researchers refer to this difference as the Child Opportunity Gap.
In the New Haven metro area, the Child Opportunity Gap is 90 points—the poorest scoring neighborhood had a score of 6, while the highest-scoring neighborhood scored 96.
Barriers To Healthy Food
Across the country, cost and distance are barriers to healthy food. In Newhallville, 30% of households do not possess a vehicle, compared with 9% of households statewide, according to DataHaven.
“We live in a food desert,” said Devin Avshalom-Smith, whose grandparents migrated to Newhallville from North Carolina nearly 65 years ago to find work. Avshalom-Smith is working with Gather New Haven and the New England Brewing Company to secure funding for the Big Starr Street Garden and Little Starr Street Garden and has plans to distribute fresh produce to Newhallville residents. He is also circulating petitions to qualify to run in a Democratic primary for alder in the 20th Ward.
“There’s nothing here except the corner store,” Sheffield said.
Melanie Stengel Photo.
Madison Roscoe, 6, of New Haven checks out books dropped off at the Learning Corridor.
Sheffield’s friend Jeanette Sykes, founder of the nonprofit Perfect Blend, which helps students prepare for college, also grew up in Newhallville. “We should get fresh vegetables and not have to go all the way to Hamden or the downtown New Haven Stop & Shop,” Sykes said. “It’s expensive, too. The local stores mostly carry canned things that have more sodium.”
Despite the challenges, Tammy Chapman, founder of Newhallville Community Matters, is proud to be a resident of a neighborhood that has been listed on the National Register of Historic Places since 1988. The neighborhood was once home to the Winchester Repeating Arms Company.
“There’s deep roots here,” Chapman said. “There’s generational families. And so, there’s no shame. You’re having a tough time, you can call the neighbor down the street who may have a connection to the food pantry.”
During the height of the pandemic, neighbors quickly identified people who they thought might be in need. “At some point, we were all panicking because there was very little flour, very little milk and these types of items,” Chapman said. “But if people had extra—and the churches were wide open distributing food bags—those places made it a little bit easier. I found people working together really, really well. That’s the beauty of the community that I represent.”
Residents also began planting vegetables on porches in pots or in side and back gardens. Chapman grows tomatoes, green beans, and lettuce and is frequently bagging extra produce for neighbors.
Neighborhood Investments
Over the last few years, several community groups have made investments to help improve the quality of life in Newhallville.
Melanie Stengel Photo.
Alex Martinez helps Salamatu Mohammed get started riding one of the bicycles provided for use by the Learning Corridor. Martinez is a Newhallville resident and works for the Community Placement Engagement Network. (CPEN )
The Beulah Heights Social Integration Program provides grants of up to $15,000 for rent and utility assistance for residents in the Newhallville, Dixwell and Fair Haven neighborhoods. Only 30% of Newhallville residents own homes, Brandeis data show. “Investors are buying houses here, and they are pricing us out,” said Sheffield, who rents an apartment. Her parents own their house across the street from where she lives.
ConnCAT is responding to the lack of access to capital with a plan to disburse $600,000 to families in Newhallville and Dixwell for basic needs and to create Black-owned businesses.
The Hispanic Health Council’s office on Sherman Avenue provides support for mental health and substance use disorders. Now, caseworkers are addressing rising anxiety levels from pandemic isolation. “A lot of our families have issues with depression and anxiety,” said Carlos Rivera, director of Behavioral Health Services. “On top of it, they’re afraid to go outside [because they are unvaccinated due to fear of vaccination]. They lock themselves in.”
Now, Newhallville is attracting an influx of people. The neighborhood is “becoming very mixed,” Chapman said. “Especially last year, people from New York and New Jersey were coming into smaller areas. We’re seeing students from Albertus Magnus, Quinnipiac, Southern and Yale. People are coming in because they feel and see something that is, I would say, unique.”
C-HIT intern Ishan Rangarajan, a student of math and economics at Princeton University, compiled data for this story.
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Today, at age 7, Robert’s asthma has stabilized. With the help of his dad, Chaz Carmon, he inhales a steroid-based medicine each morning and evening, and he carries a rescue inhaler in his backpack in case an asthma attack comes in school or elsewhere.
Steve Hamm Photo.
Robert Carmon, and dad, Chaz demonstrate the inhaler used twice daily to control Robert’s asthma.
Robert is a bright and energetic child, yet he’s not able to play organized sports because of his asthma. “It’s hard on him,” says his father. “I just hope he grows out of it.”
Asthma, one of the most widespread chronic conditions in the United States, afflicts approximately 26.5 million people nationwide, or about 8.3 percent of the population. The cause is not known and there is no medical cure. The disease disproportionally affects people who live in economically disadvantaged urban neighborhoods. In New Haven’s Newhallville and Dixwell neighborhoods combined (the Carmons live in Newhallville), an estimated 17 percent of residents report asthma, more than double the national rate, according to the Community Alliance for Research and Engagement (CARE).
Connecticut’s asthma rate is worse than the nation’s. It’s 11 percent for children and 10.5 percent for adults—and rising. Neighborhoods in Bridgeport, Hartford and New Haven are among the hardest hit. Automobile exhaust, cigarette smoke and mold and vermin in sub-standard housing are among the triggers. “Your ZIP Code matters. It’s a determinant of health,” said Marie-Christine Bournacki, coordinator of the asthma program for the Connecticut Department of Public Health.
In Hartford’s North Meadows neighborhood, for instance, asthma in children from birth to age 4 accounted for 1,738 visits to hospitals per 10,000 residents in 2016, according to DataHaven. In comparison, the rate in Madison, a wealthy coastline town, was just 78. The median household income in Madison is $108,231; while in North Meadows it’s $20,434.
Leaders of government and health care say the key to making progress in working class neighborhoods is to focus more effectively on some of the medical, social and environment factors related to the disease, and to better coordinate society’s responses. Dr. Beverley Sheares, associate professor of pediatrics at Yale School of Medicine, said: “In these settings, asthma is a symptom of what it means to live in poverty so really you have to change the lives of poor people.”
The Emergency Department
When children suffer severe asthma attacks, their parents often take them straight to the emergency department (ED) of the nearest hospital. That’s the right thing to do, say emergency medicine physicians, because it’s difficult for parents to gauge the seriousness of an attack.
At Connecticut Children’s Medical Center in Hartford, emergency physicians treat from 1,500 to 2,000 children per year for moderate to severe asthma. Guidelines for treating asthma in the ED are well established, and the liquid steroid medications they administer stay in the body for up to 72 hours, making it less likely that kids will suffer another attack right away.
In the past year, Connecticut Children’s introduced a new process for treating patients more quickly—by having nurses engage with them soon after they arrive. Previously, it took an average of 75 minutes to treat asthma patients. Now it’s 34 minutes—and the goal is 20. “Kids come in struggling to breathe. To be able to immediately treat them and see a quick turnaround is pretty amazing,” said Eric Hoppa, a pediatric emergency attending physician at Connecticut Children’s.
But emergency physicians say more effective treatment of asthma in the ED is not the long-term solution to the problem. EDs can stabilize people and provide instructions on how to use inhalers and other medications, but they can’t follow them home to monitor their health, to make sure they’re using inhalers correctly, or to spot asthma triggers in the home. That’s why neighborhood clinics and outreach programs are so important.
Steve Hamm Photo.
Marc Maldonado, 2, from Fair Haven Heights, is examined by Dr. Pamela Kwittken, pulmonary specialist at the Fair Haven Community Health Care asthma clinic.
Neighborhood Clinics
Economically disadvantaged people typically seek care at community health centers, and Connecticut has a strong network of centers operating in 38 cities and towns. Recently, some of the centers have begun establishing specialized asthma clinics so they can spot the disease earlier, treat it more consistently, and help patients manage it over the long term.
In New Haven, Fair Haven Community Health Care opened its new Respiratory, Airway and Allergy Clinic (RAAC) in June. It’s staffed by a physician who is certified in treating allergy and asthma, an occupational health specialist, a nurse and a care coordinator who investigates the social determinants of each patient’s asthma. The goal is to help them make adjustments in their lives that will reduce triggers. All of the health center’s patients diagnosed with asthma, and those who show signs or symptoms, are referred to the clinic, which is one of a few of its type in greater New Haven.
Asthma can impact children’s lives catastrophically. “If they’re not treated properly, they miss a lot of school; they sit at home and play electronic games and don’t socialize; and they don’t go outside to exercise and get fresh air,” said Dr. Pamela Kwittken, the physician at Fair Haven’s RAAC clinic.
That’s why it’s essential for children in particular to have asthma action plans. These take-home documents describe the treatment the patient requires routinely and what to do if they experience a severe attack. Fair Haven began routinely creating action plans 1½ years ago and now more than 50 percent of the childhood asthma patients have them.
The next step for the Fair Haven clinic is forging a formal partnership with Milford Health Department’s Putting On Airs, part of Connecticut’s home asthma education program, which helps asthmatics and their families follow action plans and reduce the triggers in their homes.
Steve Hamm Photo.
The staff at Fair Haven’s asthma clinic includes Fran Torres, a nurse, Dr. Pamela Kwittken and Nancy Arvelo, care coordinator.
Outreach Programs
Under Putting On Airs, teams of health workers conduct a series of three home visits with asthma sufferers. The teams typically include a health educator, who makes sure inhalers and other medications are being used properly, and an environmentalist, who looks for dust-mite-infested carpets, moldy bathrooms, mice and cockroaches.
Recently, the regional team at the Stratford Health Department, which runs Putting on Airs for much of Fairfield County, added a third member—a community health worker. Two other health districts elsewhere in the state will follow suit in the coming months.
The community health worker on the Stratford team, Millie Seguinot, helps translate between English and Spanish during home visits, explains the use of inhalers in simple language, and looks for social issues that impact a family’s ability to control the asthma. In addition, she refers families to social service agencies for food and clothing—and helps them make arrangements with their children’s schools.
One Bridgeport family kept canceling appointments with Putting On Airs. Language was an issue. Seguinot visited the mom on her own and learned that she didn’t understand the asthma action plan nor how to administer medications for her daughter on a regular basis. After Seguinot explained things carefully and helped with scheduling, the mom was able to follow the plan and became more comfortable with additional visits from the team. “It’s important to have somebody that these families can relate to. It might be language, culture, ethnicity or even physical appearance,” Seguinot said.
Better Housing
One of the reasons for Connecticut’s high rate of asthma is that much of the urban housing stock is more than a century old, and many urban people live in rentals (72 percent in New Haven). Old buildings tend to harbor asthma triggers, such as mold and dust mites, and landlords are often reluctant to replace carpets where dust mites hang out, or to repair faulty exhaust fans.
It’s not feasible to replace all of the substandard housing, but with advice from the Putting On Airs teams and support from city health departments and doctors, people can pressure their landlords to improve conditions.
Alice Rosenthal, staff attorney for the Center for Children’s Advocacy, recounts a success story in New Haven that provides a blueprint for others. A 12-year-old boy with severe asthma lived with his mom and two siblings in a rundown apartment where grimy old carpets covered the floors. His mom vacuumed the carpets frequently and even paid to have them steam cleaned, but it wasn’t enough. She asked repeatedly for the landlord to remove them. No go.
Finally, after the boy’s primary care doctor, a pulmonologist and Rosenthal wrote letters urging the landlord to take action, he did so. “Now, the boy is not missing school and, because he’s healthier and using less steroids, he can get outside and play sports,” Rosenthal said. Plus, because the mom doesn’t have to be at home all the time, she’s now working—and the family is doing much better economically.
Rosenthal coordinates a partnership with Yale New Haven Children’s Hospital where the two organizations collaborate on addressing the social determinants of health.
There’s no magic bullet for addressing asthma, or poverty either. For now, government and health care leaders agree, the key is increasing awareness of what can be done to prevent asthma attacks or respond to them. With adjustments in living situations and proper health care, asthma doesn’t have to keep kids—and their parents—living in misery and fear. They can all breathe easier.
Graphic by Marie K. Shanahan
Please note: At the time of the publication of 2016 Community Health Needs Assessments, the DataHaven analysis of hospital encounter data was only available for certain towns and zip codes, while other data are available for towns statewide or by region.