AJPH EDITORIALS
News/Marist poll, notes that only
16% of marijuana users cite “to
have fun” as their reason for using;
more (19%) cite pain relief.6
Profitable industries carry con-
siderable clout in state capitols;
profitable industries with a rabid
fan base, all the more so.
LEGALIZING AN
INDUSTRY
Legalizing an industry has many
consequences. Fiala et al. give us
a baseline regarding one, namely
aggressive marketing efforts. I
agree that a comprehensive public
Managing Childhood Asthma as a
Strategy to Break the Cycle of Poverty
See also Dong et al., p. 103.
As the second most common
chronic disease of children—
surpassed only by tooth decay and
cavities—asthma is a health prob-
lem that warrants new perspectives
and approaches to treatment. There
are significant disparities by race and
socioeconomic status, and the costs
to children, families, and the health
system are substantial.
PREVALENCE
The documented prevalence
of asthma in children in the
United States doubled from 1980
to 1995, increased more slowly
from 2001 to 2010, and seems to
have plateaued in recent years.1
Nationally, 8.4% of children have
asthma diagnoses, but studies
have shown rates closer to 30% in
some high-poverty urban areas,
like Harlem, New York, and
parts of Detroit, Michigan
January 2018, Vol 108, No. 1 AJPH
health response should contem-
plate advertising restrictions, but
fear that much more will be
needed if legalization involves
a for-profit industry. There are
many other, safer ways to legalize
marijuana, such as restricting
supply to a government monopoly
or to nonprofit organizations
whose charters reserve a majority
of seats on their governing boards
for public health and child welfare
advocates and that define their
mission as meeting existing de-
mand (to undercut the black
market) without undertaking
marketing efforts designed to
increase consumption.7
(http://bit.ly/2yJVWhr).2,3
Trends have shown persistent
but decreasing racial dispar-
ities in children hospitalized
for asthma (2001–2010),
but no concurrent improve-
ment for asthma death rates.
Among children with asthma,
Black children were four
times more likely to die of asthma
than White children.4
COST
The annual cost of asthma in
the United States (collectively for
adults and children) is estimated
to exceed $56 billion. Most costs
are directly related to treatment,
and include medication, emer-
gency department visits, and
hospital stays. A smaller pro-
portion is attributed to indirect
costs, like missed work days and
Jonathan P. Caulkins, PhD
REFERENCES
1. National Academies of Sciences,
Engineering, and Medicine. The health
effects of cannabis and cannabinoids: the
current state of evidence and recom-
mendations for research. Washington,
DC: National Academies Press; 2017.
2. Richter KP, Levy S. Big marijuana—
lessons from big tobacco. N Engl J Med.
2014;371(5):399–401.
3. Pacula RL, Kilmer B, Wagenaar AC,
Chaloupka FJ, Caulkins JP. Developing
public health regulations for marijuana:
lessons from alcohol and tobacco. Am J
Public Health. 2014;104(6):1021–1028.
4. Kleiman MAR. Against Excess: Drug
Policy for Results. New York, NY: Basic-
Books; 1992.
5. Crombie N. Fifteen Oregonians tapped
to help shape rules for regulating
loss of productivity (http://bit.
ly/2zwpKh3). These calcula-
tions, although weighty, don’t
even begin to cover the potential
impact that uncontrolled asthma
can have on kids—through de-
creased quality of life, comor-
bidities, and negative impact
on learning outcomes. Poorly
controlled asthma is a well-
documented health barrier to
learning, primarily through its
impact on sleep and attendance.
Over time, impaired learning
can lead to poor third-grade
reading and math scores, which
are associated with decreased
likelihood of graduation and,
ultimately, with reduced earning
potential.5 In essence, unless we can
significantly improve treatment—
ABOUT THE AUTHOR
Delaney Gracy is with Children’s Health Fund, New York, NY.
Correspondence should be sent to Delaney Gracy, Chief Medical Officer, Children’s Health
Fund, 215 W. 125th St, Suite 301, New York, NY 10027 (e-mail: dgracy@chfund.org).
Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This editorial was accepted October 15, 2017.
doi: 10.2105/AJPH.2017.304195
marijuana. The Oregonian. May 4, 2015.
Available at: http://www.oregonlive.
com/marijuana/index.ssf/2015/05/
meet_the_people_who_will_advis.html.
Accessed September 25, 2017.
6. Ingraham C. 11 charts that show
marijuana has truly gone mainstream.
Washington Post. April 19, 2017. Available
at: https://www.washingtonpost.com/
news/wonk/wp/2017/04/19/11-charts-
that-show-marijuana-has-truly-gone-
mainstream/?utm_term=.ef47abaa0575.
Accessed November 8, 2017.
7. Caulkins JP, Kilmer B, Kleiman MAR,
et al. Considering marijuana legalization:
insights for Vermont and other jurisdic-
tions. Santa Monica, CA: RAND; 2015.
and access to treatment—asthma is
and will be a driving factor in the
cycle of poverty for many children.
CLINICAL CARE
Certainly clinical care needs to
be optimized, and there is much
room for improvement, but
evidence-based guidelines for
management of asthma are
among the strongest and most
widely used in pediatric care.6
Although quality measures fo-
cused on pediatric care are usually
few in national data sets, metrics
for asthma that apply to children
are typically among those in-
cluded. The Asthma Control
Test is widely endorsed as an
effective and standardized way to
measure and track the control and
effectiveness of treatment in indi-
vidual patients. We can still do
better, but in many ways there
Gracy Editorial 21
AJPH EDITORIALS
has been focus, standardization,
creation of best practices, and im-
provement in the clinical man-
agement of asthma in children.
MANAGEMENT
And yet, families are clearly
still struggling, and costs related
to poor asthma control are the
drivers of the massive asthma-
related expense burden to the
health care system. Asthma
management is hard. Patients and
caregivers need to have a fairly
good understanding of physiol-
ogy. They also must manage
inhaled medications (often mul-
tiple) that require good tech-
nique for optimal effect, learn to
predict and respond to seasonal
patterns and other illnesses that
can perpetually change asthma
medication needs, and often deal
with fear, stigma, and errone-
ously low expectations for disease
management potential. Addi-
tionally, parents and caregivers
must coordinate with, provide
medication for, and inform
schools and anyone else who
cares for the child about their
child’s specific needs and triggers.
Behavior change for disease
management is always difficult.
But for a child to achieve good
asthma control, not only the
patient likely needs to change
behavior, but also the caregiver,
and other people in the house-
hold as well. If the child is
persistently exposed to their
triggers—such as cigarette
smoke, perfume, cockroaches,
or even pets—good control and
good outcomes may be very
difficult to achieve.
22 Editorial Gracy
SUPPORTIVE
INTERVENTIONS
And so we must think outside
of the box—or more literally,
outside of the clinic—for sup-
portive interventions. Several
home-visiting programs focusing
on trigger identification, abate-
ment, and management have
shown promising evidence of
impact—on asthma control for
patients, on quality of life for
patients and their families, and on
financial return on investment for
asthma-related costs to the health
system.7 A home-visiting, envi-
ronmental intervention approach
is a major shift for health care in
the United States. We face the
questions we must always con-
sider when making treatment or
service delivery changes based on
external data or a pilot program’s
success. How do we know if
a pilot program will have gen-
eralizable results? How do we
know when, where, and under
what conditions it will or won’t
work? And if I am the one im-
plementing, how do I know how
I am doing? Will this service or
program be billable and sustain-
able, and if not, what data do we
need to advocate for change? In
an evidence-based and value-based
care era, individually and collec-
tively, we have to decide how we
will invest our time and resources.
HOME VISITS
The article by Dong et al. in
this issue of AJPH (p. 103) offers
a comparative analysis of several
different pediatric asthma man-
agement programs that target
trigger abatement through home
visits. In this study, the authors
show that all programs assessed
improved patient Asthma Con-
trol Test scores and decreased
emergency room utilization.
They also show that the de-
mographics of the population
served will likely affect the
baseline, and possibly the degree
of change. Of particular value, as
part of this project, the authors
implemented and demonstrate
the effectiveness of a tool designed
to assess the impact of home-
visiting programs targeting trigger
abatement, which is flexible
enough to apply to a somewhat
heterogeneous group of programs.
This type of tool has the potential
to be very important in creating
needed cross-program compari-
sons, setting benchmarks of suc-
cess, accumulating impact data
to support intervention re-
imbursement, and facilitating the
impact assessment of individual
programs.
DRIVE CHANGE
In a time when our health
system is increasingly focused on
quality measures, value-based
care incentive models, and
quantitative impact assessment,
well-designed tools, methods,
and comparative values are keys
to meaningful data and the as-
similation of information that can
drive change. This kind of change
is urgently needed by millions
of children across the country
who struggle with uncontrolled
asthma, and for whom educa-
tional success, and even eco-
nomic success, are at risk.
Delaney Gracy, MD, MPH
ACKNOWLEDGMENTS
I thank John Carlson, MD, PhD, assistant
professor, Department of Pediatrics, Sec-
tions of Allergy & Immunology and
Community Pediatrics and Global Health,
Tulane University School of Medicine,
for his asthma expertise in preparing this
editorial. I also thank Dennis Walto, CEO
of Children’s Health Fund, for his insight
and support.
REFERENCES
1. Akinbami LJ, Simon AE, Rossen LM.
Changing trends in asthma prevalence
among children. Pediatrics. 2016;137(1):
e20152354.
2. Nicholas SW, Jean-Louis B, Ortiz B,
et al. Addressing the childhood
asthma crisis in Harlem: the Harlem
Children’s Zone Asthma Initiative.
Am J Public Health. 2005;95(2):
245–249.
3. Clark NM, Shah S, Dodge JA, Thomas
LJ, Andridge RR, Little RJA. An evalu-
ation of asthma interventions for preteen
students. J Sch Health. 2010;80(2):80–87.
4. Asthma Disparities Working Group. The
Coordinated Federal Action Plan to Reduce
Racial and Ethnic Asthma Disparities. US
Environmental Protection Agency. 2012.
Available at: https://www.epa.gov/asthma/
coordinated-federal-action-plan-reduce-
racial-and-ethnic-asthma-disparities.
Accessed November 8, 2017.
5. Gracy D, Fabian A, Roncaglione V,
Savage K, Redlener I. Health Barriers to
Learning: The Prevalence and Educational
Consequences in Disadvantaged Children.
New York, NY: Children’s Health Fund;
2017.
6. Guidelines for the Diagnosis and Manage-
ment of Asthma: Expert Panel Report 3 (EPR
3). Bethesda, MD: National Institutes of
Health, National Heart, Lung, and Blood
Institute; 2007.
7. CDC’s National Asthma Control Program:
An Investment in America’s Health. Atlanta,
GA: Centers for Disease Control and
Prevention; 2013.
AJPH January 2018, Vol 108, No. 1
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