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Every night, Guadalupe Muñoz lays awake listening to her 7-year-old daughter Carla breathe. If she hears a whistling in Carla’s chest, she knows an asthma attack is imminent.
Muñoz, who works in housekeeping at a local hotel, lives in a two-bedroom apartment with her two daughters in Oakland’s Seminary neighborhood. In an interview conducted in Spanish, Muñoz said she is certain it is her home that is causing her youngest daughter to suffer from asthma and eczema.
“Ever since I got to this apartment there was mold in one room, in the room I slept in,” said Muñoz, who was living in the apartment while pregnant. “But I never imagined that this problem was going to affect me or my daughter.”
Muñoz is not alone in being concerned about how her home might be impacting her family’s health. Mold, pests, and deteriorating, lead-based paint are common housing complaints filed by community members with the city of Oakland code enforcement department, according to a 2018 report on health and housing in Oakland. After a complaint is filed, a code-enforcement officer inspects the home, and if they confirm there are problems, the city gives the owner of the property 16 days to fix the problem. The city of Oakland defines substandard housing as conditions that risk the health and safety of household residents and the public.
Monique Berlanga, an attorney with Centro Legal de la Raza, a legal services nonprofit in Oakland, said the organization almost always recommends that families living in substandard housing conditions reach out to code enforcement if the landlord is not fixing code violations, unless the tenant is living in an illegal unit. A dwelling that does not have a certificate of occupancy from the city of Oakland, which indicates that a residential building complies with health and safety codes, is considered illegal. Berlanga cautioned that illegal units are common in Oakland and a visit from code enforcement can lead to displacement of the tenant.
County health workers and housing specialists we interviewed said mold and pest infestations are common problems they see when visiting the homes of asthmatic children living in Oakland. Scientists have linked exposure to mold, as well as to cockroaches, rodents, and other pest infestations, with asthma. For example, a 2011 study reviewing available epidemiological literature showed residential mold and dampness is associated with asthma, allergies, and upper respiratory tract infections. A 2017 study summarized and ranked known environmental triggers for asthma, which included mold and dampness, as well as dust, pets, rodents and pests, as well as other potential triggers.
“I’ve seen it over and over again, when a family moves out of the house and the symptoms are gone or they end up having some sort of remediation of the mold in the house and the kid is doing better,” said Mindy Benson, a pediatric nurse practitioner and manager of research and programs at the Claremont Clinic at UCSF Benioff Children’s Hospital.
But for many families, moving to a healthier apartment is not an option as rents in Oakland have skyrocketed and there is a shortage of affordable housing. Fear of displacement and retaliatory rental increases means many tenants are hesitant to complain to landlords or authorities about potential health hazards in their homes.
Berlanga said her clients who are recent immigrants, including some who are undocumented, are reluctant to ask for repairs.
“It’s pretty devastating to hear from our clients who are living in terrible conditions, because they would rather do that than risk harassment or retaliation for asserting their rights,” said Berlanga.
Many families we spoke to said they will first try to deal with the problem without involving the landlord through meticulous cleaning with harsh disinfectants, toxic pest sprays, and by painting over mold. Even when families do assert their rights, getting all the necessary repairs made to their homes can be an uphill battle.
“I believe that if you pay rent and you keep the apartment clean, they also have to contribute to their part of the deal,” said Muñoz, who complained to her landlord about the mold, as well as about rodents on her patio, and fleas in her carpet. When the landlord didn’t address the issues, she escalated her complaints by calling the city’s code enforcement department. “But [the landlord] never paid attention to me until the city of Oakland came three times [to check the apartment] and pest control came to check,” she said. “They told me that this was causing my daughter to have problems.”
Childhood asthma is linked to substandard housing
Decades of housing discrimination helped shape the racial and economic demographics of neighborhoods in Oakland and across the United States. New research, coupled with community advocacy, shows that the Black and brown residents of Oakland are more likely to be exposed to outdoor air pollution from industrial polluters and roadways and suffer disproportionate rates of disease and death as a result.
Mortage lending practices like redlining, a government policy that started in the 1930s and allowed real estate and banking industries to discriminate based on race, helped white families become homeowners while keeping non-white families in rental properties, often located near polluting industry and roadways. Even today, rental properties are more likely to be in disrepair than owner-occupied homes, meaning tenants are more likely than homeowners to be exposed to health problems like asthma that are tied to poor housing conditions.
“That racial inequity that we talk about, it stems from laws like redlining,” said Soni Johnson community development specialist at the Alameda County Healthy Homes Department. “The issue with redlining—where they already built the racial enclaves—is now we’re having gentrification happening in these enclaves where they had restricted minorities to live in, that are now desirable neighborhoods where tenants are being forced out of their housing because landlords want to sell for millions of dollars.”
Asthma is a common respiratory health condition that can affect adults and children, but in Oakland, children of color are more likely to suffer from asthma than other groups. Black children and children living in poverty are more likely to visit the hospital due to asthma than any other group, according to a 2018 joint report on health and housing in Alameda County, prepared by the Alameda County Public Health Department and Healthy Homes Department.
These findings track with the patient population that visits UCSF Benioff Children’s Hospital Oakland for asthma treatment. Benson said that typically more than half of the patients the hospital treats for asthma are Black children, but that they also see many families that recently immigrated to the United States.
“We also see asthma in new immigrants from Yemen or other countries,” said Benson. “No one has ever had asthma in their country, and they come here and they have it.”
Between 2016 and 2019, children living in the 94613 and 94605 zip codes, which includes Muñoz’s Seminary neighborhood as well as Eastmont, Castlemont, and Foothill Square, visited the hospital for asthma-related reasons more than 2,200 times. Many of these visits were by the same children who needed repeated medical care.
Buried in these numbers is Carla, who had to visit the emergency room about 12 times between 2018 and 2019 because of severe asthma attacks, and had 12 more non-emergency clinic visits during the same period.
Carla, 7, was first diagnosed with asthma two years ago, but she started displaying symptoms when she was 11 months old, said Muñoz.
“Many times [the hospital] would tell me that it was pneumonia, bronchitis, whooping cough, pre-pneumonia,” said Muñoz. “But they wouldn’t listen to me. She had trouble breathing and I went several times to the hospital until I told them ‘I am not going to move, I want you to examine my daughter because I brought her yesterday and now she has trouble breathing again,’ and that is when they told me she had asthma.”
Asthma is a disease of lung inflammation, said Benson. An asthma attack happens when a trigger (such as smoke or mold spores) enters the airways, causing a cascade of numerous, uncontrollable inflammation events.
“First, you start to wheeze a little bit and then it starts to get worse and worse and worse; every breath you take hurts you,” said Oakland high school student Brandon Coles, who is 17 and has had asthma all his life. “I cough a lot, that’s one thing that happens, and another thing that happens is your chest starts to hurt, your heart beats faster. The coughing hurts really bad when you have an asthma attack.”
Both Carla Muñoz and Brandon Coles participated in the Alameda County Public Health Department’s Asthma Start program. Some patients are enrolled in Asthma Start because of frequent emergency room visits for asthma, others are referred through Alameda Alliance for Health, the county health plan. Through Asthma Start, health workers visit the homes of asthmatic children. During these home visits, public health workers consult with the family to get their child’s asthma under control by setting goals for asthma management, explaining how to administer medication, and identifying and eliminating asthma triggers in the home. It was through Asthma START that Carla and Brandon’s families learned that exposure to mold and pests can make asthma worse. The typical family works with Asthma Start over a three- to six-month period, and has three visits from a county health worker, but the timeframe can vary based on the specific needs of each child, said Amy Sholinbeck, a case worker with the program.
“There are so many factors, every child is different, and what triggers one does not trigger another,” said Brenda Rueda-Yamashita, chronic diseases program director at the county Public Health Department. “It’s kind of like with diabetes, you have to learn what you can eat and what makes your blood sugar go up.”
Just like there is no universal asthma trigger, there is no single factor that causes someone to develop asthma, but it is thought to be related to genetics, environment, according to the Centers for Disease Control. In Oakland, some of the main factors associated with asthma are related to air quality, specifically outdoor air pollution and indoor air contamination, said Anne-Kelsey Lamb, director of the Oakland-based Regional Asthma Management Prevention organization.
Exposure to outdoor air pollution from industry, truck traffic, and wildfire smoke are all associated with new asthma cases in Oakland and other cities, according to a 2021 study. Though scientists have established the link between exposure to outdoor air pollution and asthma, the findings of these population-level studies have yet to influence clinical care at the physician’s office.
“We don’t ask about environmental triggers and neighborhoods as part of any of the typical asthma questionnaires. I think it should be considered, but it isn’t,” said UCSF’s Benson. “I don’t think we have the data to show for it yet. We need things like the Aclima study, which looked at asthma hospitalizations and zip codes, and found [hotspots] all along the I-880 corridor where all the trucks travel.”
Health workers still have a hard time directly tying exposure to poor outdoor air with new asthma cases or asthma flares. “I know it plays a factor for sure, but I just don’t know how much,” said Benson. Rueda-Yamashita and others say one of the major problems related to elevated asthma rates in Oakland is the age of the homes. Older homes typically have more problems with ventilation, which can lead to mold, as well as lead paint, which can cause lead poisoning.
The COVID-19 pandemic made existing respiratory health problems worse
Health workers were worried that a confluence of risk factors in 2020 would lead to a spike in the number of hospital visits for Oakland children. Asthma is a known risk factor for COVID-19, which targets the respiratory system. And due to pandemic-related lockdowns, people were spending more time inside their homes, which for some Oakland residents meant more time in contaminated air or crowded spaces. That, compounded with more smoky days from wildfires, had health workers bracing for an influx of emergency-room visits from asthmatic children.
However, Oakland health workers we interviewed said anecdotally that there was a substantial drop in the number of children visiting the emergency room for asthma in 2020.
“Our number of visits for asthma has just plummeted,” said Benson. “It’s good news, but when we’re looking at our numbers and staffing patterns, it’s like ‘what is happening? Where are all the kids? Where are the coughing kids?’”
Data on the number of hospital visits among Oakland children for asthma care in 2020 was unavailable when The Oaklandside requested it from ACPHD, but national studies have supported the perception among local healthcare workers that visits were down. In a March 2021 study, scientists compared pediatric hospital admissions across 77 intensive care sites in the United States before the COVID-19 pandemic and at the beginning of the pandemic. Researchers saw a 32% decrease in pediatric hospital admissions between April-June 2020, with asthma being the health condition with the biggest drop year-over-year. The decline in children visiting the hospital and emergency room for asthma during the COVID-19 pandemic was recorded internationally, with researchers noting fewer asthmatic children visiting hospitals throughout the United States, as well as in the United Kingdom and South Korea, according to the Center for Infectious Disease Research and Policy. The reasons why asthma hospitalizations plummeted during the COVID-19 pandemic are still being researched.
“Everybody is projecting a different story,” said Rueda-Yamashita. “[The decline] may be because families maintained a cleaner home, they may have washed their hands more frequently. All of this could lead to why people are staying away from the emergency room. I don’t think it’s any one thing, and we won’t know for a few years.”
An April 2021 study showed that the decline in asthma hospitalizations due to the pandemic is likely not because patients are avoiding the hospital for fear of contracting COVID-19, but instead because of changes in occupational, environmental, and behavioral factors.
Better medication adherence, social distancing, hand-washing, disinfecting surfaces, as well as environmental changes like school closures, less participation in school sports, and less exposure to pollen and other outdoor allergens are all cited as possible reasons why children have been able to control their asthma during the pandemic.
Benson and Rueda-Yamashita both said that school closures were likely a major factor in the decline in hospital visits seen in Oakland. Like many homes in Oakland, schools are typically older and have poor ventilation. Schools are also a major source of transmission for the common cold and flu, which can make asthma worse.
School closures meant children with asthma stayed at home in 2020, and even if the home environment contains mold or other asthma triggers, staying in a stable and familiar place can help keep asthma symptoms under control, explained Rueda-Yamashita.
“Maybe they’re getting meds on a more regular basis,” she said.
These observations track with Muñoz’s experience. Muñoz said that she noticed Carla’s asthma was maybe 70% better during the pandemic, likely because she was in a controlled environment, living with just her family. When Carla was attending school in-person, Muñoz would frequently have to leave work to pick up Carla because her asthma would flare during P.E. class, recess, and sometimes even if there was just a lot of dust in the classroom.
How unhealthy are Oakland homes?
Soni Johnson has worked for the Alameda County Healthy Homes Department for more than 20 years. When inspecting a home in Oakland, she can expect to see a few things: The home or apartment is often older and crowded, sometimes with multiple families living together under one roof, and the conditions are substandard, with mold, pest infestations, and peeling paint.
Johnson and her co-workers at the agency might be referred to a client’s home because a child has tested positive for lead during a blood lead level screening, which is required for all families on Medicaid or other forms of public insurance.
Between 2016 and 2017, Healthy Homes and Asthma Start partnered on a study called “Pay for Success,” which is assessing whether pairing health coaching from Asthma Start and a home inspection from Healthy Homes can deliver better health outcomes for asthmatic children and reduce costs for the insurer, Alameda Alliance for Health. The families that participated in this study were all enrolled in the county health plan, and their children visited the hospital for asthma care in the 12 months prior to the study start date.
“It was also looking at whether you could take two county entities and partner them together and get a better result,” said Rueda-Yamashita, director of Asthma Start.
Roughly 205 households participated in the study, and about 85-90% of the children enrolled were living in Oakland, said Rueda-Yamashita. Case workers for Asthma Start focused on helping families build an asthma control strategy and Healthy Homes specialists conducted health and safety assessments of the home, as well as put down pesticides, installed speck meters, which measures levels of particulate matter in the homes, and sent in janitorial services for a one-time cleaning. If there were advanced problems with the home, Healthy Homes would reach out to the property managers or owners to fix things.
The study period has closed, and Healthy Homes has returned to their primary focus of helping families address lead exposures, and Asthma Start resumed their typical programming. The data from the study is currently being analyzed by UC Berkeley researchers and an actuary to see if this partnership between the Alameda County agencies to deliver comprehensive health and housing services could help the county’s health care plan save money through asthma prevention.
Larry Brooks, director of Alameda County Healthy Homes, said if it works the program may be adopted statewide or even nationwide.
“It is so apparent, when you go into homes of children who are referred to us because they’re in the ER for an asthma attack and we go in and see all the asthma triggers in the home,” said Brooks.
For the past seven years, Hilda Ramos has lived in an apartment in Oakland with her husband, elderly father, and two young sons. The apartment has numerous problems, including black mold, which is commonly associated with water-damaged buildings, and deteriorating paint. Ramos said both of her children have trouble breathing because of the mold, and one was prescribed an inhaler. Ramos creates a concoction of bleach and water to scrub the mold off the walls and windows, but the mold keeps coming back.
The Ramos family is not alone in their struggle. A review of code enforcement records by The Oaklandside revealed the mold problem in Oakland homes is widespread. Between March 2020 and March 2021, there were more than 160 complaints filed that mention mold, mildew, water, or some form of moisture intrusion. But comparing the most recent complaints to previous years shows that mold problems might have been underreported during the pandemic. In 2017, there were 313 complaints related to mold and 164 related to precursors to mold (moisture, leaks, water, etc.), according to a 2018 report by the ACPHD and Healthy Homes.
The numbers from code enforcement do not capture the full extent of the habitability problems in Oakland. Families living in hazardous conditions are often reluctant to file a complaint with code enforcement or withhold rent until repairs are made for fear of retribution from their landlord, despite it being within their rights as tenants to do so.
Some families will consult an attorney at a legal services nonprofit like Centro Legal de la Raza to learn more about their rights before demanding repairs from their landlord or calling code enforcement. Between 2016-2019, Centro Legal served about 3,200 Oakland tenants, according to data provided by the organization. Of these tenants, roughly 950 reached out with habitability concerns. Centro Legal did not have data about the immigration status of their clients but did say that English is a second language for about half.
Health and housing advocates said that Oakland residents from the immigrant community, particularly those who are undocumented, are often hesitant to bring up any complaints to the landlord for fear of losing their status. This is borne out by a 2014 report by Change Lab Solutions which found that most vulnerable tenants, such as people living with disabilities, non-English speakers, or undocumented residents, are unlikely to file complaints with code enforcement about substandard living conditions.
“It seems like the landlords are taking advantage of undocumented immigrants,” said Johnson. “Those particular places are not well maintained. They’re more run-down and there’s a lot of deferred maintenance, a lot of code violations of components not working, like heat. A lot of tenants or parents are afraid to bring anything up to the landlords.”
Centro Legal attorneys spend a lot of time educating clients, many of whom are recent immigrants or are in the country without status, about Oakland’s tenant protection laws to try to empower them to assert their rights to safe and healthy housing.
“I tell my clients, ‘don’t be fearful, speak up, we all have rights, regardless of whether we pay a dollar in rent, a thousand dollars in rent, speak ‘good English’ or ‘not good English’,” said Araceli Tellez, resident and community services coordinator at the Oakland Housing Authority, who also spent nine years working for Healthy Homes. “Undocumented or not, we all have rights as human beings. Don’t be afraid to speak up to have a healthy life for themselves and their kids who deserve it.”
Another problem is Oakland’s system of inspecting housing. Currently, Oakland has a reactive code enforcement system which depends on the tenant or a community member filing a complaint before inspectors are sent out. A proactive rental inspection program would ensure that all rental properties are inspected on a routine basis, or more frequently depending upon the landlord’s record of compliance. Johnson said a proactive rental inspection program is the “gold standard”, and could help detect habitability violations before they lead to major health consequences for residents.
“I would like to see cities like Oakland have a proactive rental inspection program to try to combat some of the hesitancy we know is occurring,” said Brooks.
What are the options for tenants living in substandard housing?
Typically, the attorneys at Centro Legal advise their clients to approach habitability problems in stages. First, tenants should make a request for repairs in writing and give the landlord some time to address them. If that doesn’t work, the tenant can file a rent board petition, contact code enforcement, and even sue for persistent habitability problems the landlord refuses to fix. Despite these recommendations, many tenants are hesitant to complain to landlords or reach out to government officials.
“Tenants don’t want to rock the boat at all,” said Johnson.
Recent updates to state and local building codes have also given tenants more power. The previous definition of substandard housing conditions only allowed code enforcement officers to assess for “dampness.” In 2015, state lawmakers passed SB 655, which added “mold” to the list of substandard housing conditions. The bill also gave local governments the authority to recognize mold complaints. The city of Oakland updated the list of substandard housing conditions in 2019 to include “visible mold growth, as determined by a county health official or code enforcement officer.” Now, if a tenant calls code enforcement and mentions there is moisture intrusion or mold in their home, it should immediately trigger a response from local officials.
Some code enforcement officers are still getting used to the new rules. The team at Healthy Homes said in an interview that they recommend tenants describe any mold in the home as “dampness” or “moisture intrusion” to trigger a response from code enforcement. Also, because there are so many types of mold, code enforcement may not respond right away, but describing “dampness” or “moisture intrusion” could get a quicker response.
Berlanga said she tries to be realistic with her clients, and reminds them that a visit from code enforcement will not necessarily lead to a resolution for families living with substandard conditions, particularly mold.
“There’s not anybody within the Alameda County Public Health Department, including in environmental health, that does mold remediation,” said Rueda-Yamashita. “Unfortunately, mold remediation is not inexpensive. Sometimes landlords will take care of it or they won’t, sometimes homeowners will take care of it or they won’t.”
Guadalupe Muñoz filed three complaints to the city of Oakland’s code enforcement office about the mold in the bedroom she shares with her asthmatic daughter, Carla, according to code enforcement records reviewed by The Oaklandside. Muñoz estimates she reached out to her landlord more than 20 times about habitability concerns. Eventually her landlord replaced the carpets. Muñoz said the new carpets made Carla’s asthma a little bit better, but there are still problems with rats on the patio and mold in her bedroom.
In extreme cases, the city has filed lawsuits over housing habitability issues
Filing a lawsuit against a landlord for failing to remediate housing habitability problems can be an option for tenants, but many private attorneys are reluctant to take on a case where mold is the main concern because it is hard to prove the underlying cause of household mold, said Berlanga.
In situations where mold is the primary habitability concern, Berlanga recommends her clients file a petition with the city of Oakland Rent Board, citing a “decrease in services,” and provide evidence of all the habitability concerns in the home. A tenant doesn’t need an attorney to file a petition with the rent board, but groups like Centro Legal can help prepare the paperwork.
“What was really frustrating, though, is when a tenant makes a rent petition and they’re successful, and they get a rent reduction or a retroactive rent reduction, but if the landlord still refuses to make repairs, then what’s the tenant’s recourse? They can either sue or bring another rent board petition. So it’s not ideal,” said Berlanga.
“Mold absolutely impacts asthma, but it doesn’t mean there’s anybody who is going to pay for it,” said Rueda-Yamashita.
In some cases, the Oakland City Attorney will prosecute landlords who refuse to comply with the city’s housing habitability standards. In May 2020, the Oakland city attorney sued three landlords for refusing to comply with more than 35 notices from the city and exposing tenants to unsafe living conditions, including lack of electricity, vermin, and multiple fires, among other tenant rights and habitability violations.
City Attorney Barbara Parker said that attorneys working in her office’s Neighborhood Law Corps receive complaints about tenant protection concerns and substandard housing weekly. Parker’s office tries to resolve tenant protection concerns without filing a lawsuit, but her office has filed several tenant protection-related lawsuits each year for the past several years.
“I think if the city attorney’s office had more staffing and could prosecute some of these cases, that may not be liquid enough or lucrative enough for a private attorney to take on, that could be really important,” said Berlanga. “But at the end of the day, most of the time, you’re relying on nonprofits or private attorneys to do enforcement.”
Parker said the City Attorney’s office would benefit from more resources. In 2020, her office launched the Housing Justice Initiative which draws on partnerships with local nonprofits as well as the city’s Rent Adjustment Program to strengthen the city’s capacity to protect Oakland tenants.
“There isn’t one ideal place for complaints: we play an important part in enforcing local, state, and federal law, but we are not alone in that work, nor should we be,” wrote Parker in an email. “It’s crucial that we work with our partners in the nonprofit and private bar to ensure that, among other things, individuals have access to justice.”
It’s been about five years since Muñoz first told her landlords that the mold in her apartment is making her daughter Carla sick.
“I even told the landlord, is it because I am Latina and I am asking for my rights? My daughter is the one that is sick, not his family,” said Muñoz. “My family is at risk, and you need to pay attention to me. It was then when I started doing something.”
Despite working with the Asthma Start program to reduce household triggers, writing letters, and filing complaints with code enforcement, Muñoz said her landlord has yet to remediate the mold in her bedroom and rodents on her patio. But she is not giving up.
“They believe I am a person that bothers them too much,” Muñoz said. “But I’m like: what can I do? If I don’t fight for my daughter, who will?”
The Oaklandside obtained asthma-related hospital visits among children 17 years old and younger in Oakland between 2016 and 2019 by zip code via a record request from the Alameda County Department of Public Health.
Data for the following zip codes were provided: 94601, 94602, 94603, 94605, 94606, 94607, 94608, 94609, 94610, 94611, 94612, 94613, 94618, 94619 and 94621.
ACPHD masks data with less than 10 values and combines the 94613 and 94605 zip codes because of the small amount of data available.
Child population data by zip code comes from the U.S. Census Bureau American Community Survey five-year population estimates for sex by age (2015-2019). Estimates by zip code were downloaded from Census Reporter.
This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2020 Data Fellowship. Special thanks to Aaron Williams and Danielle Fox who contributed to this reporting, and Adriana Morga for providing interpretation and translation support. Héctor Alejandro Arzate and Madeleine Bair with El Tímpano also supported community engagement and translation efforts for this article.