Highest asthma toll among big cities tied to stress, which can spur health, learning problems

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Detroit has the highest rate of asthma in young children among America’s 18 largest cities, a problem that experts link to urban ills that could affect their health and learning for the rest of their lives.

In a study done for The Detroit News and PBS NewsHour, researchers from the Johns Hopkins Bloomberg School of Public Health found about two of every three Motor City children face “adverse childhood experiences.” Those include household substance abuse, exposure to violence and extreme economic hardship that can trigger asthma.

Studies have shown that such children are nearly twice as likely to have asthma — the disease that causes breathing difficulties — regardless of the impact of allergens, air quality and other contributing factors.

More than 24,000 of Detroit’s roughly 193,800 children have asthma, or about 12.4 percent. And the Johns Hopkins researchers found more than 77,000 Detroit children, or about 40 percent of all the city’s kids, have experienced two or more stress-fueling conditions.

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Stress, poverty and trauma and can trigger health problems such as asthma in children. Detroit leads the nation's large cities with 29 percent of its children suffering from asthma.

Such experiences contribute to asthma attacks and “cause lifelong health problems,” said Dr. Christine Bethell, director of the Child and Adolescent Health Measurement Initiative at Johns Hopkins.

“It’s going to be affecting brain development, to put them behind the eight ball cognitively and behaviorally,” said Rosalind Wright, a professor of pediatrics with Kravis Children’s Hospital at New York City’s Mount Sinai Health System. “You can just (about) write the trajectory for these poor kids, and it’s no fault of their own.”

Detroit’s children from birth to 11 years old have the highest rates of asthma among their counterparts in the nation’s 18 largest cities, according to the Johns Hopkins-calculated data from 2011-12, the most recent available. Older kids, ages 12-17, have a lower rate, making Detroit’s overall asthma rate, from birth through 17, third highest in the country, following Phoenix and Philadelphia.

The high rates of asthma and traumatic childhood experiences are “absolutely a health emergency” for Detroit, said Wright, a researcher who’s done groundbreaking work on the link between emotional stress and asthma in children.

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About 12.4 percent of Detroit kids have asthma, compared with Michigan’s statewide children’s rate of 8.4 percent and the nation’s rate of 8.8 percent rate.

Local health care providers say too few resources are available in Detroit to help kids suffering from stressful situations such as poverty and exposure to violence. And treatment options for asthma often are limited by insurance plans, including those funded by the state’s Medicaid program for the poor, that may not cover recommended medications.

Medication for a child with moderate to severe asthma can easily cost $400 or more per month if it’s not covered by insurance. Qvar, a commonly prescribed daily inhaler, retails for about $234 at one well-known pharmacy chain for a one- to two-month supply, depending on the dose.

A rescue inhaler for emergencies, such as ProAir, costs roughly $65 monthly. Two are required — one for the child’s backpack and another for the school office.

If the child takes Singulair, a nightly pill, it adds about $260 per month. Infants are often prescribed vials of Albuterol for use in a nebulizer, which can cost $263 for 30 vials.

Detroit’s breathing-impaired children are part of a growing national problem in which asthma rates have exploded since 2001, increasing by 50 percent among African-Americans.

Challenges to treatment

Children who struggle to breathe find it hard to play, learn and achieve developmental milestones.

“It feels like I’m hurting, I’m dying,” said Malik Cole, a 9-year-old Detroit boy, about his breathing difficulties. His family was homeless for about a year.

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Elizabeth Secord, division chief for allergy, asthma and immunology at DMC Children’s Hospital of Michigan, said it’s difficult to secure the mental health services or the proper medications to treat the severely asthmatic kids she sees in her clinic.

“It’s almost a mandate that we have social work involved,” Secord said. “The real problem is, the kids with Medicaid (government health insurance for the poor) are the highest risk and have the most trauma, and it’s very difficult to get psychological services for this. Even those with private insurance often have to pay out of pocket.

“What we really need is a change of attitude in general about children who need psychiatric and psychological services,” she said about the stressful conditions. “People don’t factor in that prevention is much cheaper than paying for the disease.”

Secord said it’s hard to get insurance companies to pay for treatment steps recommended by the National Institutes of Health.

“We have a great deal of trouble following the (treatment) guidelines and staying within what Medicaid allows,” Secord said. “Do you know how expensive some of these inhalers are if someone tries to pay out of pocket?

“Nobody who’s working a minimum wage job can afford that. So if insurance doesn’t cover it, they don’t have it.”

Jennifer Eisner, spokeswoman for the state Department of Health and Human Services, said that while health plans cover asthma medications, there may be some restrictions due to insurers’ policies, such as requiring prior approval of the medication or quantity limits.

The state is working with insurers to develop a common formulary, or medication guidelines, describing which asthma medications Medicaid insurers must pay considering the patient’s condition and medical history, Eisner said. Medicaid is a state-federal health care program for the poor.

Dr. Elliott Attisha, a Henry Ford Health System pediatrician at two mobile health units and seven in-school clinics serving Detroit Public Schools, said a common formulary would make it easier for physicians to know if the medication they prescribe will be covered by insurance.

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“The insurance plans won’t always let you jump to those stronger medications without trying some of the lower-tier medications first, it depends on the insurance company,” Attisha said. “Keeping (medications) consistent would reduce confusion.”

Secord said confusion also happens when families are moved from one Medicaid health maintenance organization to another, sometimes without notice. She said families often don’t know who their new insurer is and occasionally are left without Medicaid coverage between plans — an allegation the state denied.

Medicaid patients covered by the Midwest Heath Alliance Plan and four other HMOs, for example, will need new insurers starting Jan. 1 because the state of Michigan did not renew their contracts this year. Among those effected are 85,000 people in nine southeast Michigan counties.

“... Individuals are not moved to other plans without their knowledge,” Eisner said, adding that some people may be dropped from Medicaid if they no longer meet eligibility requirements.

But Secord said this has not been her experience. “Many patients report not being notified of insurance ending,” she said. “It is an issue at the beginning of every month.”

Contributing factor: Stress

Twelve-year-old Cameron Carter of Detroit still suffers from the aftermath of her cousin’s death in an Aug. 31, 2013, drive-by shooting.

Kenis Green Jr. was 12 when an angry neighbor sprayed his front porch with bullets during a family birthday party. Cameron’s brothers, Alexander Carter, now 14, and Christian Carter, now 16, were standing on either side of Kenis when he was shot. Though Cameron was not at the party, she was hospitalized with asthma in the chaotic days after the shooting and again during the one-year anniversary of her cousin’s murder.

This is not a surprise to Johns Hopkins researchers, who have studied a host of measures associated with the health and well-being of children, such as neighborhood violence and school attendance.

They found nearly 40 percent of Detroit kids are affected by two or more traumatic or stressful experiences — a higher percentage by far than in any of the other cities. Philadelphia came in second with 33.1 percent of children who were similarly traumatized, followed by Phoenix with 31.1 percent.

About two-thirds of Detroit’s kids live in neighborhoods considered safe, the study found, the lowest percentage among the cities studied.

“When I worry, I start to, like, get scared and stuff, and when I get scared by (my) asthma, it starts to mess up,” Cameron said.

For the past two years, Cameron has been home-schooled by her mother, Vickey Carter-Ivory, who says her daughter was catching too many colds at school, which was making her asthma worse.

Detroit, which in October scored lowest among big-city school districts in math and reading tests, has the highest percentage of children — 9.7 percent — who missed 11 days of school or more, according to the Johns Hopkins study.

Detroit also has the highest percentage of kids who have repeated a grade (24.4 percent); the highest percentage with attention deficit hyperactivity disorder (12.1 percent); and the second lowest share (73.9 percent) who are always or usually engaged with school. Only kids in Columbus, Ohio, scored lower, 71.5 percent, on school engagement.

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Vickey Carter-Ivory, whose nephew was killed in a drive-by shooting, has a daughter with asthma. Grief therapy sessions through a St. John Providence Health System program called Open Arms helped the family to cope.

Resources to improve health

A year of therapy helped Cameron and her brothers recover from the trauma of Kenis’ death. They attended grief therapy sessions through a St. John Providence Health System program called Open Arms.

Cameron attends weekly dance classes and is learning to better manage her asthma, Carter-Ivory said. Her brothers, Christian and Alexander, were diagnosed with asthma when they were younger but now are symptom-free. Alexander is a starting running back on the River Rouge High School football team, where he wears the No. 32 that Kenis used to wear in youth competition as a tribute to his cousin.

Some resources exist to help Detroit kids recover from stress and trauma. St. John Providence runs grief therapy sessions at the Conner Creek Community Center and in some Detroit schools. Easter Seals of Michigan recently launched a project to evaluate kids throughout Michigan, including in Detroit, for stress and refer them to services.

But many more Detroit kids could benefit from such help, according to the Johns Hopkins study, which found the city’s children are less resilient, or able to cope with stress, than children in most other big cities.

Experts said Detroit’s asthma epidemic must be fought on multiple fronts, from eliminating environmental triggers such as mold and cigarette smoke, to finding ways to reduce trauma in the lives of Detroit children.

“It’s like double and triple jeopardy,” said Wright, the Mount Sinai researcher in New York. “You have ongoing chronic stress because you’re facing a lot of these adverse childhood experiences, and that’s going to enhance your response to these other bad environmental exposures.

“We need to support families so that people aren’t exposed to these adverse childhood experiences that lead to ill health.”

About asthma

Asthma is a long-term lung disease that narrows the airways and causes recurring shortness of breath, wheezing, coughing and chest tightness. The disease often starts during childhood and sometimes can be mild, but it often can worsen and lead to more intense symptoms that, if left untreated, could result in death.

Prolonged, chronic stress triggers an overproduction of cortisol and adrenaline, chemicals intended to trigger the fight-or-flight response humans need to survive immediate danger. Too much production of these chemicals over an extended period of time can kick the immune system into overdrive — leading to asthma, delayed brain development and life-long health problems, scientists say.

PBS NewsHour report

Watch the PBS NewsHour report at 6 p.m. Wednesday on Detroit Public Television. For other locations, check your local listings. The segment also can be viewed below.  Find more information at www.pbs.org/newshour/topic/health/. Also read PBS' report on how environmental factors like stress can change our DNA and open the door to health problems.

About this report

This report is the result of a joint investigation by The Detroit News and PBS NewsHour into the relationship between Detroit’s nation-leading child asthma rate and high levels of stress among the city’s children. It is part of a two-year Detroit News series, “Surviving Through Age 18 in Detroit,” on the health risks associated with growing up in the nation’s poorest and most violent city.

Data used in this report is from Johns Hopkins Bloomberg School of Public Health, whose researchers compared data on America’s 18 largest cities from the 2011-2012 National Survey of Children’s Health and the U.S. Census Bureau’s 2008-2012 American Community Survey. It was done exclusively for this report.

The Detroit News and PBS NewsHour conducted interviews with scores of scientists, health care providers and Detroit families. PBS shot video in Detroit and New York City for a news segment to be shown Wednesday night on PBS NewsHour. The Detroit News provided print stories and still photography, and edited PBS video to appear with its online report.

kbouffard@detroitnews.com

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