HARTFORD, Conn. (AP) — Amid the balloons, cake and games at his best friend's birthday party on a farm, 5-year-old Carter Manson clutched his small chest.
"He just kept saying 'I can't breathe, I can't breathe,''' his mother, Catherine, recalled tearfully. "I picked him up and told him it was OK and to just breathe. Just breathe."
It was the first time Carter had an asthma attack in public, and the inhaler he sorely needed was in the family car. Catherine calmed her terrified son and ran to get the inhaler; only then was Carter able to breathe easily.
"You say in your head as a parent that I'm going to be prepared next time," Catherine, 39, said.
"But anything can trigger them," she said.
Black children are more likely to have asthma than kids of any other race in America. They're more likely to live near polluting plants, and in rental housing with mold and other triggers, because of racist housing laws in the nation's past. Their asthma often is more severe and less likely to be controlled, because of poor medical care and mistrust of doctors.
About 4 million kids in the U.S. have asthma. The percentage of Black children with asthma is far higher than white kids; more than 12% of Black kids nationwide suffer from the disease, compared with 5.5% of white children. They also die at a much higher rate.
Across America, nearly 4 in 10 Black children live in areas with poor environmental and health conditions compared to 1 in 10 white children. Factories spew nitrogen oxide and particulate matter. Idling trucks and freeway traffic kick up noxious fumes and dust.
The disparities are built into a housing system shaped by the longstanding effects of slavery and Jim Crow-era laws. Many of the communities that have substandard housing today or are located near toxic sites are the same as those that were segregated and redlined decades ago.
"The majority of what drives disparities in asthma, it's actually social and structural," said Sanaz Eftekhari, vice president of corporate affairs and research of the Asthma and Allergy Foundation of America. "You can tie a lot of the asthma disparities back to things that have happened, years and years and decades ago."
Asthma is treatable. It can be managed with medicine, routine appointments and inhalers. But Black children often struggle to get treatment, and are more likely than white kids to end up in the emergency room with asthma symptoms.
Kamora Herrington, a community organizer in Hartford, Connecticut, doesn't need to study the statistics to know that the children of her city are suffering.
"We know that our emergency rooms in the middle of the night during the summer are filled with children who can't breathe," Herrington said.
The prime cause, she said, is just as apparent.
"People need to demand change for real and people need to not be reasonable. At what point do you say, this is bull —--? White supremacy and racism have everything to do with it."
The stubborn mold spores reappeared, no matter how hard Catherine Manson scrubbed the walls of her apartment, outside of Connecticut's capital of Hartford.
As the mold began to spread further throughout the home, it dotted the walls of the bathroom and even on the bottom of one of the family's sofas. Catherine became increasingly worried about her family's health, noticing both she and the kids were coughing more. Their nebulizer treatments became more frequent while they lived there, and Catherine herself was prescribed an albuterol inhaler and diagnosed with asthma.
The property was owned by two different landlords during the four years the family lived there. The first didn't attempt to fix the mold; the second tried, but failed, Catherine said.
The family thought the apartment would be a good place to raise their children. After all, it was in a relatively quiet neighborhood and affordable.
But as the mold worsened, the family increasingly felt stuck and unable to leave. It was at the height of the COVID-19 pandemic and funds were tight. Catherine suspects the mold began to form because the owners failed to address a leaky roof. The family noticed water and moisture on the walls, whenever it snowed or rained.
"I was so angry," she recalled. "Everybody was lacking funds. There was nothing we could have done different."
The family finally moved in 2021.
It's a common problem for Black families.
The nation's discriminatory housing policies make Black Americans more likely to live in rental housing. Throughout the 20th century, federal housing policies promoted homeownership and wealth generation — but those benefits were largely inaccessible to Black families.
Rental units are much more likely to have deficiencies or inadequacies and fewer means to address problems that increase exposure to asthma triggers.
In Connecticut, more than half of Black households rent, compared with a quarter of white households. In Hartford, almost 7 in 10 Black households rent.
An Asthma Allergy Foundation of America report examining asthma disparities found that Black renters were more likely to report the presence of mice, cockroaches or mold in their homes. Black people also live in older housing at higher rates, exposing them to triggers like dust and mold. In Hartford, 63% of Black households live in structures built before 1960, according to DataHaven, a nonprofit community organization.
"So many of our children are living in these just utterly disrepair homes with mold, open cracks, leaking, and vermin," said Dr. Jessica Hollenbach, co-director of the Asthma Center of Connecticut Children's.
Pollution is also a major factor in asthma rates
In Connecticut, poor neighborhoods in the state's five largest cities — Bridgeport, Hartford, New Haven, Stamford, and Waterbury — have high concentrations of kids with asthma.
Those same communities are at a higher risk for chemical and environmental exposures that are known asthma triggers.
A recent Environmental Protection Agency National Emissions Inventory shows Fairfield, Harford, New Haven and New London counties produced more than 10% of the state's total nitrogen oxide emissions. All four of the counties include census tracts with the highest combined asthma rates.
Nitrogen oxide gases are typically emitted from vehicle exhaust, coal, oil, diesel and natural gas burning and can cause health issues such as eye irritation and asthma aggravation.
Dr. Mark Mitchell, a former director of Hartford's health department and a founder of the Connecticut Coalition for Environmental Justice, has tried to sound the alarm on Hartford's asthma rates.
The coalition began investigating and advocating for environmental justice after concerns arose about a regional landfill expansion and possible links to high rates of asthma, cancer and other diseases in communities neighboring them. Mitchell recalled how, in the mid '90s, he examined about 30 kids and found that a third of them had asthma. He urged the state to look into what he believed was a clear pattern of disparities.
"They told me … we don't really know who has asthma and doesn't have asthma, and besides, it's not unusual for a third of inner-city kids to have asthma," said Mitchell, who is now associate professor of climate change at George Mason University.
The state's health department did not respond to multiple requests for comment on its efforts to combat its asthma rates.
Mitchell said his research and work have led him to believe that the state's asthma rates are heavily tied to traffic-related air pollution, as well as other air pollutants.
Black people suffer the brunt of it. Exposure to pollutants — specifically, fine particulate matter — is often disproportionately experienced by Black and Hispanic populations, while the emissions are disproportionately caused by white populations.
Between 2018 and 2021, more than 21% of children in East Hartford had asthma — compared to 13% statewide, according to DataHaven.
Kamora Herrington has lived in Hartford for much of her life. She launched a gathering space, Kamora's Cultural Corner, for residents in a north-end neighborhood in Hartford — a mostly Black area of the city facing many socioeconomic challenges and the rippling effects of racism that have led to high poverty rates, poor health outcomes and shortened life expectancies.
Herrington remembers that for decades, where a garden now sits, rows of milk delivery trucks would idle daily, pouring black smoke into the air and clouds of dust. Toxins seeped into the ground as trucks were also repaired on the lot. Across the street sat low-income apartments and multifamily houses; children played nearby. They're still there today.
The ground is too toxic to plant in, so they use raised flower beds. They're raising funds to do an environmental cleanup of the lot.
But she wonders about the health impact on generations of Black children who have traversed the neighborhood and the city's north end. While people may prefer to blame Black parents, saying they should make better choices for their families, she points to the years of inequities that have led people to live where they can.
"As a Black woman who is also a Black mother, I have experienced ridiculous amounts of blame and abuse from a larger system that understands they're culpable but understands that the issues are so big, that it's a whole lot easier to say, 'Black mommy, you're the problem,'" she said.
Since much of the city's rental housing stock predates the 1960s, Herrington noted, it often lacks air conditioning or proper ventilation — a burden on asthmatic children during hot summers.
Abimbola Ortade, an activist and board member of Hartford's Black Lives Matter 860 chapter, recently lost his sister to COVID. Like many Hartford residents, she had asthma for most of her life, and diabetes, a combination that proved deadly. Ortade also has asthma, along with two of his children. He worries frequently about their future — and his.
Asthma, Ortade said, is merely one example of how structural racism fuels health disparities that are likely to worsen as Black children go through life — including the toll of toxic stress on their mental health.
"In my neighborhood, you've got to worry about the police killing you, stress killing you, heart failure or asthma killing you," he said.
Ortade is critical of elected officials and what he believes is a reluctance to truly address the disparities and root causes.
Asthma, he said, "is like a ticking time bomb."
Black kids have other things working against them when it comes to asthma risks
Low birth weight, which is highest among Black babies, is one risk factor.
The confluence of toxic stress, racism and discrimination that many Black people endure, heightens the risk of preterm births and low birth weights — and the disorders, like asthma, that may follow. These factors are present regardless of socioeconomic level.
Segregated or low-income communities are less likely to have easy access to health care facilities or specialty medical clinics, which are predominantly in or next to white or higher-income communities.
Advocates say increasing representation of Black doctors — including pulmonologists, allergists, immunologists and researchers — is key to better care, eliminating bias and disrupting valid mistrust in doctors.
Catherine Manson said it's been challenging to find the right health care professionals to help control her kids' asthma.
"I feel like the pediatricians are not as knowledgeable as they should be," Manson said. "As a parent, you have to make those decisions on your own. I'm the advocate for my kids."
Asthma can be particularly disruptive for Black children and their families beyond its health implications, creating a trickle down effect in other facets of their lives.
Carter, and his 9-year-old sister Caydence who also has asthma, have missed weeks of school, leaving them behind in schoolwork. And in turn, their parents were forced to miss work to care for them – putting a strain on the family's finances.
"I'm the parent, the teacher, the nurse," Catherine said, of the toll. "It feels like you're kind of failing them."
There have been efforts to bring asthma under control
Dr. Melanie Sue Collins, director of the Pediatric Pulmonary Fellowship and Cardiopulmonary Lab at Connecticut Children's, pointed to the hospital's Easy Breathing program, which involves more than 330 pediatricians in more than 90 practices in Connecticut and has been adapted for use in schools.
More than 150,000 children have been screened and more than 41,000 have been diagnosed with asthma. The program focuses on improving diagnosis rates and creating a standardized approach to help keep asthma under control.
"I think the biggest issue is that asthma is a chronic disease that requires care every single day," she said. "And what I see many of my patients and families struggling with is the basic needs of life."
HUSKY Health, which includes the state's Medicaid and the Children's Health Insurance Program, covers about 22% of the state population.
On a federal level, resources have been put toward various housing and health grant programs. An Asthma Disparities Subcommittee was formed by the National Institutes of Health in 2010 and published a federal action plan in 2012. And the Affordable Care Act broadened coverage access for millions.
But advocates say more asthma-specific legislation and funding is needed. Overall asthma rates have trended downward in recent years but rates among Black children remain outsized and disparate.
In Connecticut, the prevalence of asthma in the state's public school system has slightly decreased over time but about 1 in 8 students have asthma. The incidence among Black students is about 50% higher.
That often means absenteeism — and in the near and long term, failure.
"If you miss school, you can't succeed in school," Collins said of a fraught cycle many kids encounter. "And if you don't succeed in school, you have a really difficult time having a life where you can do things comfortably, whether it's eating, having shelter or a successful job."
After seemingly endless years of stress, things are improving for the Manson children. Catherine has done well adhering to the children's asthma control plan. The hard work appears to be paying off.
Carter is playing flag football, something that would have been unheard of just a year ago, and Caydence is running track.
Carter hasn't used his inhaler since last November. They haven't missed a day of school this year. It's a win his mother is proud of.
Still, worry lingers in the background as the seasons change and potential triggers loom.
"I've missed work, their dad has missed work," said Catherine, who now works in the medical field as a patient service representative, after leaving a beloved career in part to focus on her family's health.
"But you have to pay the bills. Then you miss work and you miss money and that comes out of your budget. It affects everything."