Uncontrolled asthma keeps many kids from low-income communities out of school and their parents out of work, and in the worst cases puts them in the hospital — or the morgue. But it is among the most manageable diseases if patients are diagnosed, given medication (and education on how to use it), and empowered to live in environmentally-friendly homes.
Yet two academic medical pillars in Baltimore — Johns Hopkins and the University of Maryland Medical Center — have chosen profit over public health in the city’s poorer neighborhoods. They prefer to admit asthma patients, or treat them in the emergency room, rather than make the investment Hopkins’ own research has shown is required to keep residents healthy, according to a two-year investigation by Kaiser Health News and University of Maryland’s Capital News Service.
After Freddie Gray’s death focused attention on inequities in the criminal justice system, a team of reporters, data journalists and photographers began investigating inequities in Baltimore’s health system, where performance gaps fall squarely along income and racial lines. The first stories in 2016 looked broadly at the problems, and the newly published sequel focuses on asthma as an example of why chronic disease flourishes in impoverished neighborhoods.
Hopkins researchers received more than $200 million in federal funds for asthma studies over a recent 10-year period, and they demonstrated, among other findings, that it’s critical to make homes healthier and increase primary care. Eliminating cigarette smoke and dander-carrying pets, while personally difficult, can be undertaken alone. Zeroing out major triggers found in older, often dilapidated dwellings — rodents, insects and moisture-causing mold — requires some spending and cooperation from landlords. In many cases, what’s needed is patching holes that allow rats, mice and bugs in, and repairing leaky pipes and roofs that spawn dangerous mold. City government can help by removing trash piles harboring pests in rowhouse alleys.
Doing this, Hopkins’ own research has shown, costs a lot less than what’s spent on treating asthmatic patients in low-income neighborhoods. Yet Hopkins is under no pressure from Washington to turn its study results into constructive action, and in any event it can’t divert research money to other uses.
And so the cycle repeats: Poor people, when they have attacks that leave them breathless, call 911 or make their own way to a hospital E.R., where they’re sometimes admitted to stabilize their conditions. In zip code 21223 on the west side of the city, for example, residents go to hospitals for asthma problems at more than four times the rate of people from wealthier neighborhoods, according to hospital data analyzed by KHN and CNS.
Although most poor people have insurance in Maryland, usually Medicaid or Medicare, to pay these big bills, they’d be better off if they had ready access to primary care doctors who could help them keep crises at bay through medication and healthier living conditions.
This self-defeating disconnect in the system is well known to the city and state health departments, hospitals and the schools of public health in Baltimore run by Hopkins and Maryland. But the health system has no single leader to direct change and is built on self-interest: sustaining revenues from inpatient and E.R. care, paid by an array of insurers that don’t work together to drive reforms. As one Hopkins official said to reporters, “We’re a business.”
The funding incentives for hospitals are changing, however. Maryland’s unique hospital rate-setting commission is guaranteeing hospitals their revenue if they work to keep patients out of beds and the E.R. Still, the health system has demonstrated no urgency to make the up-front investments needed outside hospitals to reduce asthma episodes, keep kids in school and save money for everybody.
For now, there’s not even the will to find more money to make homes less hazardous, though U.S. Department of Housing and Urban Development Secretary Ben Carson, a former star surgeon at Hopkins, has said that makes sense. “The cost of not taking care of people,” he said, “is probably greater than the cost of taking care of them.”
There’s no “probably” about it. But the responsibility for change rests most heavily on those who have resources, expertise and political clout. Lawmakers in Annapolis and City Hall, and executives in the biggest hospitals, that means you.
John Fairhall is the former editor-in-chief of Kaiser Health News, a national news service based in Washington.