Rabbi Braham David: We are delighted to hear from Dr. Robyn Cohen, who will share with us today the factors contributing to the high degree of asthma morbidity among low-income urban children and what a dedicated group of clinicians are doing to help them breathe a little easier.
For these Scientists in Synagogues programs, we always want to make the connection between science and Torah. For our topic today, I thought of two foundational principles of the Jewish tradition. The first is tzdakah, and the Torah obligation – both to us as individuals and as a society, to provide food, clothing, shelter, and other necessities to those in need. The second is justice – tzedek – and the belief that every human being is created Betzelem Elohim – in the Divine Image, and thus entitled to adequate and equitable health care. If certain populations of children are disproportionally impacted by asthma or another medical condition, we need to ask why – especially if race, area code, discrimination, or other bias has contributed to their condition.
During the COVID pandemic, we saw racial, and minority communities disproportionately impacted – with higher mortality rates. Racial disparities in health outcomes are nothing new in America. According to the CDC, “The data show that racial and ethnic minority groups, throughout the United States, experience higher rates of illness and death across a wide range of health conditions, including diabetes, hypertension, obesity, asthma, and heart disease, when compared to their White counterparts.”
When thinking of tzedakah, we naturally think of our obligation to provide food, shelter, and clothing to those in need. What about health care?
The Talmud (Ketubot 52b) teaches that the obligation to provide health care to family members is the same level as the requirement to provide them with food. Just as we need to provide nutritious food to our children, we also need to provide them with adequate health care. To fail to do so would be considered neglect. The burden doesn’t only rest on families. We know that doctors and hospitals must treat anyone, at least at the emergency level, without regard to their ability to pay. Maimonides, the great medieval philosopher and physician taught, “The doctor is obligated by law to heal” (Sefer Ha-Ma’or, Nedarim 4:4). This burden doesn’t rest on doctors or the health care system alone. The entire community shares the responsibility to provide health care to those who cannot afford it. Maimonides states that it is forbidden to live in a place with no doctors (Sanhedrin 17b). It is up to society to make sure everyone has adequate access to health care.
What happens when some people have worse health outcomes than others? While more people than in the past have access to health insurance due to the Affordable Care Act, disparities in health outcomes persist.
The Torah teaches us: Tzedek, Tzedek Tirdof – Justice, Justice you shall pursue. Healthcare disparities are an issue of justice. How can we pursue a more just healthcare system that will lead to more equitable health outcomes? Many have noted the doubling of the word Tzedek – Justice. Here, it has the meaning of a two-stage process. First, we must research the causes of the disparities in health outcomes. For those of us privileged not to suffer the same high rates of these illnesses, we might be tempted to minimize or rationalize the disparities. We might be tempted to look away. We need the best scientific research to find out the reasons why certain communities are suffering worse health care outcomes.
Second – we need clinicians and others dedicated to the care and healing of those who have been impacted. How can we best care for those suffering the most? While it is a mitzvah – an obligation – to provide healing, it is also a mitzvah to work for a more just and equitable society where the most vulnerable can also live healthy, happy lives.
When we open our eyes and see disparities in health outcomes, we are obligated to act. The Torah teaches, “Do not stand idly by the blood of your neighbor.” (Lev. 19:16). We are required to assist those suffering disproportionate negative health outcomes. The rabbis also teach that we are required to return lost objects, including restoring a person’s health, even if it costs us money. Modern scientific research helps greatly in these mitzvot, these sacred obligations, by opening our eyes to the fact that these disparities exist. Science further helps identify the causes of the disparities and possible ways to address them. It is up to all of us to take this data and work on solutions to correct these inequalities in keeping with our Jewish values.
You have reality, which is that there are some individuals in society who have way more than they need; some people who have exactly what they need; and then there are many, many people who are really behind and don’t have what they need. Some propose a solution to that through a lens of equality, where you give everyone the same level of support. But unfortunately, that is still going to mean there are some people that have more than they need, some who will have what they need, and others who are still behind. And so that evolves into this concept of equity, where you give people the supports that they need to overcome structural barriers they are facing. Really, though, the goal should be liberation (or justice), where you’re just completely removing those structural barriers whenever possible.
I think that’s how a lot of us in pediatrics at Boston Medical Center view the world and how we might go about repairing it. Asthma, which is one of the main conditions I deal with as a pediatric pulmonologist at BMC, can be a lens through which we look at socioeconomic disparities in the US and here in Boston.
Asthma is the most common chronic illness in American children, affecting about 4.7 million children and leading to about 800,000 emergency room visits and 65,000 hospitalizations in children per year in the US. It affects about 10% of the overall US population – but 20%-30% of children from low income or from racial or ethnic minority communities.
It is characterized by a very unsettling combination of daily symptoms – cough, wheeze, chest tightness – as well as attacks of severe respiratory distress. There’s a component of predictability to it – “Every time my child gets a cold, or every time I run around outside in the cold weather, I know that I’m going to get tight” – but there’s also an unpredictable element. All of a sudden, out of nowhere, a child could develop respiratory distress. And that is really distressing for the children and for their families.
Asthma is complicated to manage. You’re asking families to use this inhaler every day, but then when your child’s symptoms get to this point, you should add this other inhaler, and they might also be on a pill, a liquid or another oral medication. This becomes all the more complicated when you consider how asthma’s symptoms fluctuate throughout the year, and the uncertainty and competing priorities our families might face in multiple areas of their lives. For example, one of our young patients might be some of the time at mom’s house and some of the time at dad’s house, and grandma might be coming in while mom is working her second job at night. All three of these caregivers need to be versed in the child’s treatment program.
There is actual biological evidence about the pathways through which psychosocial stressors affect the human body. Studies have found correlations between Interleukin 13 (IL-13) – a circulating, inflammatory signal, called a cytokine, that triggers allergic and asthmatic responses – and many socioeconomic factors, such as a family’s savings levels, and various sources of stress in the home.
There are some strategies that we have found to be effective in helping families optimize management of asthma. Whenever I feel like a family is confused about what their treatment plan is supposed to be, I ask them to bring all the medicine they have in the house into the next appointment. Whenever a child comes into our primary-care practice for any reason, even if it’s a vaccination or a sprained ankle, they get an asthma-control screen. In this way, about 100 kids get screened every week for how their asthma is being managed; we tend to get 20-25% that say “not well.” So then, we know that there is this group of patients we need to do something for, to keep them out of the ER. We’ve developed an extensive asthma education component, a community health worker home visit program (which has been on pause since COVID), and even a program to expedite getting housing code violations fixed for buildings where families with asthma live. We saw a 33% reduction in the number of kids in the ER with asthma symptoms the year after we started this work.
Our approach, really, is to figure out the individual-, family-, and system-level barriers that are contributing to asthma in our patients, and then come up with solutions to each one of those things – so that we can fix what’s fixable. If we can identify every child with asthma, check in on their asthma control at every visit, train their providers to do the right thing, remove the barriers, improve communication, and maximize uptake of community resources – then our patients can sleep through the night, and go to school, and play outside and live the lives that we want for our own kids. And their parents will feel empowered, and not be afraid to let their kids be kids.
(This post is part of Sinai and Synapses’ project Scientists in Synagogues, a grass-roots program to offer Jews opportunities to explore the most interesting and pressing questions surrounding Judaism and science. On March 3, 2024, Congregation Beth Elohim in Acton, MA hosted pediatric pulmonologist Robyn Cohen, MD as part of its “Science with a Schmear” breakfast series; this post includes a brief summary of her talk.)
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