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.

Overall, 58 percent of communities saw a decrease in the age-adjusted rate of emergency room visits, while 63 percent saw a decrease in the rate of hospitalizations for asthma, according to a C-HIT analysis of the data. Some 36 percent saw improvement in both areas. The data compares age-adjusted rates for each town for 2005-2009 and for 2010-2014 per 10,000 people.

Jodie Mozdzer Gil Photo

Daun Barrett, center, director of Community Outreach and Parish Nursing at Griffin Hospital, gathers contact information from nurses concerned about asthma. Barrett and other health officials are pushing for more asthma education to help people better manage the disease.

Meanwhile, the state’s overall rate for emergency room visits in 2014 was lower than recent years but still was higher than it was 10 years ago. The 2014 rate was 66.2 visits per 10,000 people, down from a rate of 73 in 2011, according to a state health scorecard.

The rates help state health officials determine how well Connecticut’s 9.2 percent of adults and 10.5 percent of children with asthma manage the disease. The illness cost $135 million in hospital care in 2014, according to Connecticut hospital discharge data, an increase of about $22 million since 2009.

“This is a problem that everyone is looking at,” said Daun Barrett, the director for Community Outreach and Parish Nursing at Griffin Hospital in Derby, which serves the lower Naugatuck Valley.

Asthma Management: Bright Spot

Several towns in the Naugatuck Valley saw some of the biggest improvements in emergency room visit rates, the data show.

The improvements can be attributed to better education, more physician focus on asthma, and Putting on Airs, a state-sponsored home visit program that regional health departments have implemented, Barrett said.

In Derby the emergency room rate decreased from 115.9 visits per 10,000 people to just 78 in the latest data. In Ansonia the decrease was from 120.7 to 94.7. Seymour dropped from 70.7 to 46.2 while Beacon Falls decreased from 46.7 to 24.5.

Still, the emergency room at Griffin averages one patient a day with asthma symptoms, not counting those who end up being admitted, Barrett said.

“We want to see a decrease in emergency room visits,” Barrett said. “When you have to go to the emergency room, it’s a quick fix, not a long-term approach.”

Mixed Results

The state’s cities continue to have high rates of hospitalizations and emergency room visits for asthma. While some of those rates decreased in the most recent data, others saw increases in both measures.

In Hartford, for example, 216.6 people per 10,000 used the emergency room for asthma in 2005-2009. The rate increased to 247.1 in the latest figures, the highest in the state. The rate of those who ended up getting admitted to the hospital increased from 35 to 37.6 during the same time frame.

New Haven had the highest rate statewide of hospitalizations in both 2005-2009 and 2010-2014, although its rate had dropped in the most recent data from 63.4 to 54.6. The city saw a slight decrease in emergency room visits, from 136.6 to 132.8.

Bridgeport had the state’s third highest rate of hospitalizations in 2010-14, at 29 people per 10,000. The rate had increased from 27.5 in 2005-2009. Bridgeport’s emergency room visit rate increased during the same time, from 126.3 to 131.4.

State officials don’t know precisely why the town-by-town numbers fluctuate.

Marie-Christine Bournaki, director of the state Department of Public Health’s asthma program, said the statistics “allow us to identify where the hotspots are, and that’s where, from a program perspective, we strategize intervention in those particular regions.”

Easy Breathing

Easy Breathing, developed in 1998 by Dr. Michelle Cloutier, director of the Asthma Center at Connecticut Children’s Medical Center, helps doctors diagnose asthma and then treat it based on guidelines from the National Asthma Education and Prevention Program.

The program essentially takes research-based best practices in treating asthma, and simplifies them into color-coded charts and one-page questionnaires.

“She did all the work to make it easy,” said Dr. Ronald Angoff, who is with Pediatric and Medical Associates PC in Cheshire and New Haven, which has used the program for about 10 years.

Patients at Pediatric and Medical Associates are now asked four simple questions that could help indicate a case of asthma:

• Has the child had wheezing or whistling in the chest?

• Has the child been awakened by a cough?

• Has a cough or wheezing prevented physical activity?

• Has the child had a lingering cough after a cold?

• The questions help doctors identify children with under-the-radar asthma cases.

“We’ve seen a major decrease in acute asthma attacks,” Angoff said.

Simple laminated guides in the office help doctors quickly find the appropriate treatment depending on the symptoms, including direction on which insurers supply which medications.

“It’s about giving them simple tools that really make it easier to do Easy Breathing than to not do Easy Breathing,” said Jessica Hollenbach, a research associate with the Asthma Center at Connecticut Children’s Medical Center.

Easy Breathing has been introduced to more than 400 pediatric clinicians in more than 100 doctor’s offices around the state, Hollenbach said, and research into the results shows it helps lower hospital use for asthma treatment.

Putting On Airs

Across the state, nurses, asthma educators and respiratory therapists visited the homes of about 938 people with asthma between 2010 and 2014 under the Putting on Airs program.

A 2010 study by researchers at the state Department of Public Health found that participants in Putting on Airs had fewer unscheduled emergency asthma doctor’s visits, fewer days missed from school or work, and fewer times using their rescue inhaler after six months.

“Asthma education is more than providing knowledge,” said Bournaki, the state asthma director. “It’s also helping the person to change their behavior and take control over their asthma. You can imagine it’s very difficult to be teaching in a context where the person is probably exhausted, going to the emergency room and being discharged.”

Bournaki said that during home visits, the asthma educator works with the patient to practice using inhalers, talks about their asthma action plan and assesses the home for environmental triggers for asthma attacks. The program involves three follow-up phone calls to touch base and gather more data.

“A lot of people, their asthma is not controlled because they’re not using the medication properly,” Bournaki said. “It’s very critical to spend time assessing how the person is administering the medication.”

Meanwhile, the Connecticut Hospital Association is working with doctors and emergency rooms across the state to also coordinate asthma education.

The initiative is training hospital workers to help patients with medications and push for more patients to have asthma action plans to keep them out of the hospital.

In 2013, only 32.7 percent of Connecticut residents with asthma had ever received an asthma action plan, shy of the state’s 40 percent goal, the latest data show.

“For the most part, [asthma is] well managed in an outpatient setting, like a community health center or a primary physician’s office,” said Madeleine Biondolillo, vice president of population health for the Connecticut Hospital Association, which launched the Connecticut Asthma Initiative last year.

Ava, 3, of Bridgeport, knows what to expect from a visit with Hen, having dealt with asthma since she was 1. She also spent several nights in the hospital after an attack in 2012. “I had always heard about wheezing, but had never really heard it before that,” her mother, Beverly Passley said.

Jodie M. Gil Photo

Megan Judkins, a nurse, helps Ariana Gomez, 7, test her breathing.

Ava is part of growing number of people in Connecticut who have used the emergency room for asthma symptoms, according to the most recent figures from the state Department of Public Health.

Each year from 2005 to 2009, Connecticut residents with asthma symptoms on average visited the emergency room 22,000 times, and were hospitalized 4,800 times.

The reasons vary: some are new asthma patients, some have new conditions that trigger their asthma, and many just poorly manage their medications, doctors say.

The visits made up 1 percent of total hospital health care charges in Connecticut in 2009, at a cost of $112.8 million. Medicare and Medicaid paid for 73.8 percent of the hospitalizations and 60 percent of the emergency room visits.

The increase is being watched by officials in the state health department, researchers at Connecticut universities and community environmental groups, as they look to help people better manage the disease, while saving money on preventable hospital visits.

And yet, the most recent numbers show that the situation is getting worse — especially for minorities and people living in urban areas.

The Numbers

In 2012, the state DPH published “The Burden of Asthma in Connecticut,” which reviewed data from school asthma tracking programs, death certificates, federal labor reports, Centers for Disease Control and Prevention surveys, state Medicaid data and hospital records.

The 166-page report reviewed data from 2000 to 2010. During that time, the rates of people who were hospitalized for asthma increased by 29.2 percent. For those who listed asthma as the secondary reason for hospitalization, the rate jumped by 86.2 percent.

Rates for people living in urban areas were much higher than their suburban and rural counterparts.

In New Haven, Hartford, New London and Bridgeport, residents were hospitalized for asthma symptoms twice as often as in nearby suburbs.

In New Haven, for example, the age-adjusted hospitalization rate  between 2005 and 2009 was 63.4 people per 10,000. In adjacent West Haven it was less than half that, at 31 people per 10,000. East Haven’s rate was even lower, at 23.4 people per 10,000.

In Hartford, the age-adjusted hospitalization rate between 2005 and 2009 was 35 people per 10,000. In adjacent Bloomfield, it was less than half of that, at 13.3 people per 10,000. West Hartford’s rate was even lower, at 7.4 people per 10,000. (Find a town’s rate by clicking on the map.)

At the same time, Hispanic and black asthma patients showed much higher rates of hospitalizations than the overall average, and than subgroups of patients who are white or other races.

In 2009 alone, white asthma patients went to the emergency room at a rate of 34.2 per every 10,000 people. Black and Hispanic patients had rates of 127.3 and 170.5 respectively.

What makes minorities more likely to visit the emergency room?

They start with higher rates of asthma, according to national and state data. Much of that can be attributed to environment.

Cities, which have high minority populations, are filled with various asthma triggers such as air pollution, mold, cigarette smoke and even proximity to rodents.

Veronica Tate, 66, said she developed asthma when she moved to Hartford two years ago.

“Last August, I had this tightening of my chest,” Tate said.

Her doctor thought it was allergies, and prescribed some medicine. But it kept getting worse.

“One night I woke up and I couldn’t breathe,” Tate said. “I couldn’t catch my breath.”

Why The ER?

Many assume people use the emergency room because they lack health insurance. But as more people gain access to insurance, and the numbers of emergency room visits continued to rise, the Connecticut Coalition for Environmental Justice started asking people why they kept going to the emergency room.

“The first focus group really blew me away,” said Sharon Lewis, the executive director of CCEJ. “It (the reason) was not what we would ever think it was.”

The reasons, Lewis said, came down to the quality of health care people said they were getting at community health centers. The main problem, Lewis said, was the lack of comprehensive services at community health centers.

If a patient needed an X-Ray, he or she had to travel to another center where they have the equipment. For someone without much money or a means of travel, the cost of taking public transportation to one, maybe two, maybe three other centers was daunting.

“If you go to the emergency room, it may take 12 hours, but when you leave you’ve got everything done,” Lewis said.

Of the 110 people CCEJ interviewed, only one person said she didn’t have health insurance.

“We need to think of the entire chain of things and how they work before you say people are using the emergency room for the wrong reasons,” Lewis said.

Other researchers have found that a poor relationship with a primary care doctor can lead patients to wait until symptoms are severe before seeking help.

Dr. Kenneth Robinson, the medical director at the emergency department at Hartford Hospital, said he doesn’t ask patients why they opted to come to the hospital.

“Generally in my mind, the complaint of acute shortness of breath is a very appropriate reason to go to an emergency department,” Robinson said.

“I want them to always feel comfortable to come to the emergency department,” Robinson said. “I don’t want to put that thought in their head by asking them why.”

Programs To Help

Hen, the chief of pediatric pulmonology for Bridgeport Hospital, and also affiliated with Yale-New Haven Children’s Hospital, stood in the waiting room of his office recently, waiting for his next appointment — a child in the state HUSKY program being treated for asthma.

The child never showed.

It gets him, because Hen sees the quarterly visits as the way to keep the children out of the emergency room.

“Part of the reason we see asthma kids every three months is to reinforce the education, reinforce the care plan, that you have to stick to your medication,” Hen said.

Some of his patients have ended up in the emergency room. When he looks through their records, Hen said he finds they are the ones who have multiple no-shows, or haven’t scheduled an appointment for eight months.

Jodie M. Gil Photo

Dr. Jacob Hen examines Ava Passley, 3. Ava’s mom, Beverly, looks on.

Hen said that regular treatment of asthma symptoms could prevent about 130 children’s deaths each year nationally.

“I could change those statistics,” Hen said. “Anybody could.”

Hen said community programs are one solution to the problem. If trusted community members can reach families in their churches, at school, then the education might be more likely to resonate, he said.

Several efforts are underway across the state.

Putting on Airs, a statewide program run by regional health districts, sends health inspectors into the homes of asthma patients.

Mary Buckley-Davis runs the Putting on Airs program for the Ledge Light Health District in New London. She said she helps families identify triggers such as mold, scented candles or areas where dust mites can affect a person with asthma.

Sometimes she just goes over the medications patients are using. Some simply mix up their daily medicine with their “rescue” medicine. Some are not filling the prescriptions.

“Many of my clients lead incredibly complicated lives,” Buckley-Davis said. “Truly, they don’t know where their next meal comes from, so asthma gets pushed down the priority list.”

But that extra help can make a big difference. A state review of the program found a decrease in the number of emergency visits to a doctor or hospital for asthma six months after a home visit. A majority of clients said they were missing less work and school because of their symptoms.

Action Plans

Another state program focuses on the need to get asthma patients set up with action plans.

The Easy Breathing Program includes a questionnaire doctors can ask to help determine if patients have asthma, and get them on a treatment plan. The costs include training medical providers.

While prescription costs increased for children in the program, the cost of hospitalizations decreased, especially for chronic asthma sufferers, according to a 2009 study by researchers at the Connecticut Children’s Medical Center in Hartford.

Passley has a color-coded guide to track Ava’s symptoms and respond with the appropriate medicine. On a normal day, when Ava is in the green zone, she’ll take a morning nasal steroid spray and a morning and evening pump of inhaled beclomethasone.

If Ava hits the yellow zone — which can happen as triggers come on, or when she gets a cold or other illness — the doses increase, and she might also need a liquid steroid.

The red zone includes worsening symptoms, and that means it’s time to go to the emergency room.

“It’s really simple,” Hen told Ava. “If you do your stuff every day, you don’t get sick.”    

A website in Spanish on asthma is available here.