Childhood allows for endless hours of playing. But what if enjoying a carefree childhood proved detrimental to a child’s health? For David Diaz and his mother Iris, this was a reality because of his asthma—playing outdoors led to hospital visits, missed school days for David, and missed work for Iris. Even after seeing the doctor, they often left confused and unsure how to avoid another hospital visit.
Unfortunately, stories like David’s are common. Childhood asthma continues to be a major public health problem, especially in medically underserved, impoverished communities. Today, more than 6 million children in the United States have asthma, and it’s the third leading cause of hospitalizations among children 15 years and younger. Low-income, and/or African American and Puerto Rican communities experience the greatest burden of disease, and are less likely to receive recommended treatments. The disease accounts for nearly 15 million missed school days annually and is the leading cause of school absenteeism among chronic diseases. Numbers like these prove just how widespread and costly childhood asthma—like other pervasive public health problems—is.
Before we began, the health care industry—through large, federally funded, randomized, controlled trials, had developed efficacious interventions for diverse ethnic groups of children who suffer from moderate to severe asthma. However, systematic dissemination of these interventions and existing asthma management guidelines lagged, and didn’t make their way into routine practice and “real-world” settings. The Merck Foundation decided to address this through a targeted philanthropic strategy, recognizing the need to utilize public-private partnerships, and to implement and evaluate interventions both inside and outside the health clinic. It established the Merck Childhood Asthma Network (MCAN) in 2005 as the only independent 501c3 organization focused solely on the burden and associated morbidity of childhood asthma, setting itself apart in the corporate philanthropic space by operating independently as a private foundation with the significant backing and support of a global healthcare company.
MCAN’s operating principles included a competitive and scientifically rigorous process for reviewing proposals, and substantial investment in cross-site evaluation of projects. In the first phase of MCAN’s effort (2005-2009), it funded the implementation and evaluation of effectiveness of five evidence-based interventions in diverse community settings. In Philadelphia, for example, it targeted four distinct neighborhoods with high rates of asthma-related emergency room visits through a community-based approach that included schools, nonprofit organizations, and primary care providers. The Philadelphia Project engaged trained and supervised lay-person care coordinators to built trust with local residents; they provided individualized asthma education and remediation of asthma triggers and allergens in families’ homes, while coordinating care plans with primary care providers and schools. Another example was the Head-off Environmental Asthma in Louisiana (HEAL) project, a partnership with National Institutes of Health (NIH) and a private family foundation, to assist children and their families after Hurricane Katrina in 2005 through a highly effective “hybrid” intervention of care management and mitigation of asthma triggers in the home.
In the second phase, which began in 2010, MCAN launched its most ambitious intervention, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) program. MCAN designed the initiative to better measure clinical outcomes and implementation processes using a single protocol (grounded in the same “hybrid” intervention the HEAL project incorporated) across three program sites in different geographic locations. It compared these outcomes to the outcomes of three additional sites in the same geographic locations, but where the protocol was not implemented. Using both quantitative and qualitative evaluation measures, the “protocol” intervention centers, compared to the “non-protocol” sites were more effective in reducing morbidity outcomes.
MCAN also intensified advocacy efforts, commissioning the 2010 “Changing pO2licy” report that made specific and readily actionable policy recommendations for reducing the burden of childhood asthma in the United States. To address and implement these recommendations, MCAN established a national, multi-sector advocacy coalition to improve policymaking around childhood asthma beyond MCAN funding. The US Environmental Protection Agency invited MCAN to co-sponsor an information hub for community-based asthma programs (featuring the only national online compendium of asthma resources); it also worked with the President’s Task Force on Environmental Health Risks and Safety Risks to Children in 2012 to develop and launch a federal action plan to reduce asthma disparities among certain populations.
Three fundamental practices have guided MCAN in all phases of its activities and may prove useful in tackling other large-scale public health problems:
- Design flexible, evidence-based interventions. Local populations have unique health challenges, such as higher levels of asthma triggers in certain regions due to a community’s location. Community-based programs need the flexibility to adapt interventions to those challenges and varying delivery settings.
- Use care coordinators. When addressing the needs of underserved populations, working with locally based health coordinators or managers who already have an existing relationship with the community helps ensure trust among patients and health practitioners, and boosts the chances of adherence, program retention, and overall improved outcomes.
- Foster public-private partnerships. We can’t overemphasize the value of public-private partnerships in addressing health-associated challenges at local, state, and national levels. These cross-sector relationships provide the resources and expertise necessary to resolve complex and often expensive problems. The nonprofit status of MCAN facilitated positive and productive interactions with the NIH in HEAL, and with additional public partners (EPA, CDC, AHRQ, HUD) in other co-sponsored projects.
In the case of MCAN, the adoption of these and other practices led to reduced health consequences and trauma caused by poorly managed and uncontrolled, chronic childhood asthma. The 805 children enrolled in second-phase care coordination programs, for example, missed an average of 11 days of school in the year prior to the program and reported limited activities due to asthma on about six days in the month prior to enrollment. A year into the program, they reported missing an average of four days of school in the last year and had limited activities on fewer than two days in the previous month. In an era where school absenteeism can impact a child’s overall educational success and a caregiver’s ability to earn a living, these numbers suggest major implications in addressing not only America’s childhood asthma problem, but also improving educational outcomes and contributing to economic stability.
MCAN’s experiences over the last 10 years help illuminate the challenges of implementing evidence-based programs, especially in diverse and impoverished communities. For David and Iris, participation in a MCAN-funded Care Coordination Program in Puerto Rico program made a big difference, providing the information and resources needed to control David’s asthma symptoms so that he can enjoy being a kid again.