Barriers to Breath: The Health Disparities of ‘Asthma Alley’


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Julia Ledee on the sidelines of the Will Cintron Soccer Fields.
Photography by Melissa Bunni Elian

Down below the elevated I-678, I-278, I-295, and I-95 highways in the Bronx, Julia Ledee, then 8 years old, sat on a metal bench on the sidelines of the Will Cintron Soccer Fields trying to breathe.

Just a few moments earlier, her coach saw her grabbing at her chest as she ran up and down the field. Knowing she had asthma, he interrupted the soccer game and pulled her to the side.

Ledee’s parents rushed over with her albuterol inhaler, and she took a few puffs. “OK, breathe with me, breathe with me,” she recalls her father saying as he held her hands up.

Cars and tractor trailers sped above on the complicated freeway junction. “Asthma for me has been a lifelong battle,” she says.

Ledee, now 30 and a climate model analyst, is just one of 24.7 million people who live with asthma in the United States.

Socioeconomic status is the strongest indicator for the condition on the neighborhood level, with rates rising among people living below the poverty level, entwined with other health disparities.

Asthma disproportionately affects communities of color.

While roughly 6.4 percent of white children have received an asthma diagnosis in the United States, the likelihood of receiving an asthma diagnosis rises to 10.0 percent for non-Mexican Hispanic children and to 13.5 percent for Black children, according to CDC data.

To understand why this racial disparity exists, you need to look at where affected communities live.

North of Manhattan, ‘Asthma Alley’

an autoshop abuts a house
Zoning and the organization of neighborhoods in the Bronx contributes to poor asthma rates. While the rest of New York City became more residential and commercial, the Bronx increased industrial zoning. Here, an autoshop shares a wall with a residence.

The Bronx lies north of Manhattan (home to dozens of the Forbes 400 wealthiest people), and south of Scarsdale, the second-richest neighborhood in the United States.

It’s ringed and bisected by highways and blanketed in mixed-use industrial zones, including the massive Hunts Point Distribution Center and two power plants, which contribute to high levels of particle pollution.

Residents bear the burden of traffic pollution for a distribution chain that extends across the country.

Around 57 percent of trucks that visit the Hunts Point meat and produce markets come from outside the city, according to a Department of Transportation study. Some trucks deliver goods to consumers thousands of miles away.

These factors create a pocket of land that’s buffered from the immense wealth nearby, with measurably poorer air quality.

The median household income in the Bronx is less than half that of Manhattan, in part a consequence of a racist housing policy called redlining.

Poverty rates are 50 percent higher in the Bronx than the city average, and the Bronx is home to the poorest U.S. congressional district. The childhood asthma rate in the Bronx is as much as 40 percent higher than the rate of childhood asthma New York City as a whole.

The Bronx illustrates how stark the line often is between rich and poor in cities across the country, and how geographically fine.

An area of the South Bronx has been dubbed “Asthma Alley,” but the same story is playing out in communities across the nation.

A condition exacerbated by allergens and poor air quality

Beneath the elevated subway line at the intersection of Westchester Avenue and E 163rd Street in the Bronx.

At a breathing rate of 5,000 gallons of air per day, or about 8 ounces of air per second, every cell in your body depends on the air you breathe.

Bacteria and viruses, dust and mold, and particulate matter trigger protective mechanisms — mucus production, airway constriction, and inflammation — to prevent the lungs from injury or absorbing harmful substances.

These responses are what people experience during an asthma flare. They can sometimes be deadly.

But these defenses in the upper tracts of the airway are less effective further down the respiratory system.

According to the National Institutes of Health, only very small particles — less than 3 to 5 microns in diameter — can enter the deepest reaches of the airway.

Pollution contains PM10, indicating particles 10 microns or smaller, and PM2.5, indicating particles 2.5 microns or smaller. These particles are estimated to be responsible for 1 in 17 asthma emergency room visits.

Within a city, the air is more likely to contain ozone, carbon monoxide, nitrogen dioxide, sulfur dioxide, and particulate matter, the five components used by the Environmental Protection agency to create the Air Quality Index.

Outdoor air pollutants have in turn been shown to impair the effectiveness of asthma medication.

I-87 runs along an apartment complex in the Bronx.

The Bronx, an outlier among New York City boroughs in continuing to permit noxious land uses, is a leading example of how one’s immediate environment can exacerbate respiratory issues, no matter the advice for managing a health condition.

The health impact is dire.

While 9.2 percent of New York students overall were identified as having asthma, that number rose to 15.5 percent of 4- and 5-year-old Bronx children, according to a 2009 study.

This is due in part to allergen exposures in their households and particle pollution in the air outside.

Similarly, children in Manhattan’s North Harlem neighborhood in New York City are hospitalized at three times the rate of the city average.

The American Lung Association State of the Air 2021 Report found that across the nation, people of color are more than three times more likely than white people to be breathing the most polluted air.

The federal government has implemented nationwide guidelines for asthma management, but serious barriers prevent families from implementing these guidelines.

From a lack of healthcare professionals in low-income neighborhoods to the prevalence of mold, dust, and pests in low-income housing and the high costs of healthcare, families in hot spots face a host of factors that push the rate and severity of asthma much higher than the national average.

The effects reach beyond asthma, with higher incidence of heart attacks, strokes, and respiratory diseases. Deaths in the Bronx from COVID-19 were double that of the city average early in the pandemic.

On the ground, these health inequities are visible inside people’s homes and in their communities.

Doing all the right things, and finding her condition worsen

Amy O., 37, an associate merchandiser, used a window fan to circulate air in her ground-level apartment. At the end of summer, the wall in her apartment was dusted with soot.

After years of seeking treatment for breathing problems, a nurse practitioner diagnosed sports-induced asthma in Amy O., who prefers not to share her last name, while she was in high school in Connecticut.

She moved to the Bronx after college in 2006, and found herself reaching for her pump more often.

“I was living there trying to get back to my running and being more active and going to the gym, but that’s when I realized my asthma had gone just a million times worse,” she says. “And the reason for that would just be the environment.”

Amy, an associate merchandiser, lived in a ground-level apartment facing the street, which was constantly clogged with trucks heading to and from the nearby expressway.

She kept a fan in her window to bring fresh air into her apartment in the spring and summer, but “by the end of the season, my wall would actually be blacked from the exhaust fumes.”

“Here I’m thinking I’m getting fresh air from outside at night. But actually I was bringing all the exhaust into my home by having a window fan,” she says.

Amy is a case study in the way that many of the factors thought to be protective of asthma — education, employment, access to healthcare, a dedication to taking her medication, and exercising — can fall short amid structural and social determinants.

A large tractor trailer passes by apartment buildings at Bathgate Avenue in the Bronx.

Amy now lives in the Bedford Park area of the Bronx, near the New York Botanical Garden. She uses air purifiers at home, and runs and bikes in the park when she can.

There’s no complete solution, she says.

“It doesn’t matter how good of an endurance athlete you are, how much you bike, how much exercise, you just never know when [asthma] is going to hit you,” Amy says.

Environmental justice advocates have argued since the 1980s that health equity requires shared environmental decision making, access to green spaces, and mitigation of heightened exposure to pollution in urban areas.

“You can do all that work, but still you have those different environmental factors,” says Amy. “I can do all the work that I want to do. I still am in an environment where there’s parkways and highways and roadways that cut through the Bronx.”

Seeking care and finding an empathy gap

Anonna Ahmed, 20, stands on a pedestrian bridge over the Bruckner Expressway in the Bronx. She says the care she received for her asthma was subpar.

In a poem about living with asthma in the Bronx, 20-year-old college student Anonna Ahmed borrowed the spelling of her borough for the bronchiole tubes in her chest:

“the bronch’s was always hard to navigate.

it took the doctors four days at first to understand what was going on –

They still get confused sixteen years later.

It’s really hard to tell which walls are closing in sometimes.”

She describes the medical care she’s received over the years as subpar. In her high school days, doctors typically listened to her talk about her asthma symptoms and then promptly moved on after ascertaining that she had a diagnosis.

In 2018, while seeking healthcare on her own, Ahmed was berated by the doctor for delaying a checkup after difficulties breathing. “You couldn’t even breathe for 2 weeks and you didn’t think to come in?” she says the doctor told her.

“I’ve been having breathing problems my whole life,” Ahmed says. “She was kind of mean about the whole thing.”

The median household income in the Bronx is less than half that of Manhattan, in part a consequence of redlining. Asthma rates rise with the poverty level.

The doctor had Ahmed take an EKG, then gave her pain medication for “nerve pain.”

Two weeks later at a follow-up visit, Ahmed says the doctor yelled at her for missed blood work she was unaware had been ordered.

“I was like, I’m sorry. This is my first time. I tried not to cry because it was my first time out in the world. She chastised me for that,” Ahmed says.

After Ahmed explained how the pain pills had made things worse, the doctor suggested an asthma pump, finally inquiring whether she might have asthma.

That was “something somebody should ask the first appointment,” Ahmed says. “I left as fast as I could and went to the pharmacy, but I never went back.”

Ahmed’s experience is not unique. One issue is that healthcare workers in the Bronx are overtaxed: There are more than four times as many general practitioners per 100,000 residents in Manhattan.

The American Medical Association notes that disparities in the system result in worse health outcomes, and primarily affect marginalized populations.

Bias, prejudice, stereotyping, and clinical uncertainty contribute to the disparity of care and outcomes.

When the best intervention would be leaving

Julia Ledee, 30, a climate model analyst, was diagnosed with asthma as a child on the soccer field. She says her symptoms eased when she left the Bronx for a period of time.

Construction dust. Car fumes. The dust kicked up when the building’s heating system turned on.

Ledee has lived in the Bronx for her entire life, in many neighborhoods, and says there are always triggers.

“In the spring, there’s allergies. In the summer, the humidity. In places that I lived as a kid, the apartments are older or we lived in an older house that was converted into apartments, and there’s mold behind the drywall,” Ledee says. “And that made me extremely sick and triggered my asthma.”

When she left the Bronx, though, her symptoms eased.

In high school her family rented a house 30 miles north in Croton-on-Harmon in Westchester. “I instantly remembered an improvement in air quality,” she says.

Schools there placed an emphasis on being active and spending time in the outdoors on hiking trails or on the track. “They would bring kids upstate on the weekends for a hiking thing. And there was a ski team,” Ledee says.

On a team, she was taught about building cardiovascular endurance and strength to become a better athlete.

“When I played sports in the city, it wasn’t necessarily that approach. That was my first time where I [was] pushed to my limits, where I could see what I could do with asthma. I wasn’t scared,” she says.

After experiencing the suburbs, Ledee now lives in one of the greener areas of the Bronx, the Bay Country Club neighborhood, which she chose over a move to Harlem.

“You are literally unable to find places where you can breathe fresh air,” she says.

Ledee is determined to work on expanding her lung capacity and spending lots of time outside in the years ahead, hopefully breathing a little easier.

“I feel like my whole life I was like, OK, just be careful. Don’t overexert yourself. And here’s an inhaler.”

Living with asthma in the Bronx — more photos:


Melissa Bunni Elian is a multimedia journalist based in Yonkers, New York. Elian is a Fujifilm ambassador whose work has been featured in The Washington Post, The New York Times, The New York Times Magazine, and NPR, and by companies like Google, who commissioned her in 2017 for the Lynching in America Project by the Equal Justice Initiative, exhibited at The Brooklyn Museum. Her independent projects focus on stories from the African diaspora, social justice, and issues of structural inequality.


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