A study published Tuesday showed that moving low-income families from high-poverty neighborhoods in the Baltimore area into “high opportunity” ones can control kids’ asthma better than commonly used medications.
Researchers from the Johns Hopkins University and the Baltimore Regional Housing Partnership recruited families enrolled in the nonprofit’s housing mobility program who had a child with persistent asthma. The program assists families living in neighborhoods marred by poverty and urban blight to relocate to areas with much lower poverty rates and higher average incomes via housing choice vouchers, which limits rent to about a third of household income, with the federally-funded nonprofit picking up the rest of the tab.
Between 2016 and the beginning of the pandemic in 2020, researchers collected data from 123 families — 106 of whom moved during the study period — on their child’s asthma symptoms and exacerbations; allergen exposures; neighborhood characteristics; caregiver depression and stress; and experiences of discrimination both prior to moving and up to a year after.
The study, published in the Journal of the American Medical Association, showed that moving reduced asthma symptoms more than inhaled corticosteroids — considered the best medications for long-term asthma control — and it worked about as well as expensive injections for severe asthma.
Before they moved, participant families were concentrated in what has been called Baltimore’s “Black Butterfly,” neighborhoods with majority Black residents and a history of chronic disinvestment. Most families relocated to suburban communities in Anne Arundel, Baltimore, Harford and Howard counties.
Black children in the U.S. suffer from asthma at two to three times the rate of white children, and those with asthma are twice as likely to visit the emergency department or to be hospitalized with an attack. Ninety-eight percent of the children enrolled in the study were Black.
The median household income in census tracts where families lived pre-move was $32,342, and the areas had a median of 87% Black residents. In post-move communities, median income was $83,333 and 19% of residents were Black. A median of 26% of households lived below the poverty line in census tracts where study participants originally resided, versus 4% of households in their new neighborhoods.
Children with asthma saw average symptom days cut almost in half after relocating, from 5.1 days to 2.4 days on average within a two-week period. When adjusted for age and sex, this translates to 59% lower odds of experiencing asthma symptoms on any given day. Similarly, the percentage of study participants who suffered an asthma flare-up in a three-month time period decreased by nearly half post-move, from 15.1% to 8.5%.
Those improvements can be partly attributed to a more comfortable social setting, improved safety and lower stress levels reported by their parents, researchers said. By contrast, decreased exposure to certain allergens such as mice and rodents that can trigger asthma in some children was not found to have a substantial impact.
While asthma interventions have traditionally focused on identifying triggers and minimizing them at home, it may be hard for some families to keep up with pest management, for example, or frequent cleaning to control pet dander.
The new research highlights why it’s important to understand the role that stress and neighborhood environment play in driving childhood asthma in distressed communities, and to incorporate those considerations into program design, said Dr. Craig Pollack, lead author of the study and professor in the Department of Health Policy and Management in the Johns Hopkins Bloomberg School of Public Health.
The housing mobility program has assisted 5,500 families in Baltimore and surrounding counties to move to neighborhoods with less poverty, lower crime rates and better schools since 2003. There are currently 14,000 families on the program’s waitlist, said Pete Cimbolic, study co-author and managing director of operations and program evaluation at Baltimore Regional Housing Partnership. They are able to assist 150-250 new families per year as others leave.
“It’s a depressingly long time that somebody might be on a waiting list,” Cimbolic said. Only about one in five households that are eligible for a housing voucher actually receive one, he said, due to scarcity of funding and federal limits on the number of vouchers available.
One criticism of housing mobility programs — which, like Baltimore’s, were often formed to remedy racial segregation driven by federal public housing policy — is their framing of majority Black neighborhoods as inherently defective and majority white neighborhoods as the aspirational standard. Critics have also pointed out that resources may be better spent investing in poor neighborhoods versus facilitating escape from them.
While Cimbolic agreed “there is a need for direct and significant investment” in historically redlined and segregated neighborhoods, it will take decades “to undo that in a meaningful way” so that all of the same opportunities that currently exist in higher-resourced neighborhoods can be found in those communities as well, he said. In the meantime, housing mobility programs serve an immediate need for families “that are experiencing real harm and who have expressed a desire to change where they live,” Cimbolic said.
“We’re empowering them to make the same choice that middle-income and upper-income people make every day,” he said.
Pollack said that place-based and mobility strategies for combatting poverty are often “pitted against each other” unnecessarily “as a zero-sum game.” Both are important, he said; “I think that it can be a ‘yes and’ approach where you’re helping provide choices for families that wish to move, as well as working to provide resources to support neighborhoods.”