In the South Bronx, older apartment buildings' leaky roofs and drafty walls let in dust, rodents, and rainwater that mix with cigarette smoke and pet dander to create a perfect storm of asthma triggers.

Renters' requests to improve their housing rarely get attention from landlords. Alan Shapiro, MD, and his colleagues found a way to offer their patients with asthma some assistance. They write letters to landlords that explain, for example, how mold conditions could cause their tenants serious flare-ups and subsequent emergency room visits. The letter then asks that the landlords immediately remediate the structural problems.

"We find that writing letters from a medical perspective does bring a greater level of attention from the landlord," said Dr. Shapiro, senior medical director of the Community Pediatric Programs of the Children's Hospital at Montefiore in New York and medical director for Children's Health Fund's New York Flagship Program. Even

landlords who have ignored complaints for months sometimes hire companies to assess and correct problems in the apartment or move the patient to a newer, better maintained apartment.

Landlords are important but often reluctant participants in community asthma intervention efforts. "Landlords have control over a big portion of the environmental conditions of the home," said Kristen Grimes, MAOM, CHES, asthma project manager for Children's Health Alliance of Wisconsin. "(But) not every landlord is going to do this just for the good of their tenants."

Appealing to landlords' wallets has proved a successful strategy for health care practitioners in the Wisconsin Asthma Coalition. An educational brochure tailored to tenants and landlords discusses how restricting smoking and banning pets reduces the need to heavily clean apartment carpets and walls when tenants vacate the rental property. Plus, an anti-smoking rule reduces the risk of fire. Offering smoking cessation classes and providing special pillow case covers, mattress covers, and food storage containers to patients during these educational sessions encourages tenants to take immediate steps toward establishing trigger-free apartments.

Even these tactics do not work in all cases. Sometimes clinicians can only refer patients to legal services to permanently reduce triggers and, even if they are successful, shortfalls in existing housing codes can drag the remediation work out for months.

For example, New York City's Department of Housing Preservation and Development classifies mold as a major health violation only when it covers up to 25 square feet of the apartment. Less significant mold hazards and mice and cockroach infestations are considered minor violations, meaning landlords can take up to 90 days to respond to the complaint.¹

"The longer you wait, the sicker kids get," said Robert Morrow, MD, a community family physician and clinical associate professor in the department of family and social medicine at Albert Einstein College of Medicine in the Bronx.

New legislation introduced in this state could help identify and reduce asthma triggers more quickly. Intro 750, the Asthma Free Housing Act, would give health care practitioners the ability to request that state health authorities investigate certain apartments and would require that corrections be made within 21 days.²

"It's one aspect of the work against asthma," Dr. Morrow said. "If there is better enforcement, we're in a better position to move forward."

References

1. Jonas J. An 'act' that means action: housing bill requires repairs. City Limits. 2007, April 16. Available from: www.citylimits.org/content/articles/viewarticle.cfm?article_id=3309

2. The Coalition for Asthma-Free Homes. The impact of poor housing conditions on the health of asthmatic New Yorkers. Available from: www.maketheroad.org/pix_reports/CAFHReportMay09.pdf

Contact Kristen Ziegler at kziegler@advanceweb.com.