One in seven New Zealand kids have breathing difficulties. Most of them are able to manage it with medication, but a growing number of children are ending up in hospital. In the third part of a series on kid's health, Isaac Davison looks at how housing is mostly to blame.
Matire Harwood, a GP at Papakura Marae, is scanning through her appointment schedule for a Friday.
She works two days a week at a prefabricated clinic in the marae's carpark. In previous jobs her days were taken up by kids with minor coughs and elderly patients getting their blood pressure medication.
In Papakura, her days are different.
"14 out of 25 appointments are kids with respiratory problems," she says of her last day's work.
Among the appointments was a three year-old girl with pneumonia, who had a temperature of 40C. She opens up the girl's medical file on her computer, and notes that there are eight other children under 10 years old living in the same home.
• SEE MORE: How one family copes with severe breath problems
It is like this every time she works here. Around half of her workload is children with asthma, pneumonia,and other respiratory conditions like bronchiolitis or bronchiectasis. Many of them are repeat visits.
"It's a young community, teenage parents, poor housing situations, intergenerational poverty, and a lot more respiratory conditions than you would expect anywhere else," Harwood told the Herald.
Because she only has 15 minutes per appointment, she checks their airways, sometimes prescribes medicine, and gives some advice. But many of them will soon be back, because they are returning to the same problem - their house.
Falling through the cracks: Boy thought he was 'too dumb to learn'
How one family copes with severe breathing problems
More hospitalisations every year
Around one in seven New Zealand children have breathing difficulties. Most of them have mild asthma, and manage it day to day with medication or even grow out of it.
But those who have severe respiratory conditions often end up in hospital. Over the last 20 years, hospitalisations have steadily risen for these preventable illnesses, which are linked to cold and damp housing.
Hospitalisations for bronchiolitis, which causes shortness of breath in children, have doubled since 2000. Of greater concern are admissions for a condition called bronchiectasis, which have tripled over the same period.
Usually associated with elderly patients, bronchiectasis is caused by damage to the airways from infections or viruses. It scars a person's lungs for life.
"It's an area that we don't want to see on the increase," said Asthma Foundation chief executive Letitia O'Dwyer.
"It's going up in some areas, which is surprising for something as serious as bronchiectasis."
Child pneumonia and asthma hospitalisation rates are steady or falling, but serious inequities persist. Pacific kids are seven times more likely to die from pneumonia than other New Zealanders, and Maori kids four times more likely.
O'Dwyer said there had been significant advances in medication for asthma and other respiratory conditions. Education tools were also improving - an interactive story called Sailor the Puffer Fish, which is used to teach kids how to manage their asthma, has been performed for thousands of primary students and was this year translated to Te Reo Maori.
But any progress has been undermined because many New Zealand children are still living in substandard homes.
"You can have the best treatment in the world but you've still got to make sure that all those other things like housing are fixed," O'Dwyer said.
"Paediatricians and the treating physicians at those hospitals get incredibly frustrated that those kids have bounced backwards and forwards, just going back into those homes then coming down with other respiratory illnesses."
Harwood said she sent letters every week to Housing New Zealand, pleading with them to find warm, dry homes for families who were living in rundown rentals or garages.
At last count, 4600 individuals or families were waiting for social housing in Auckland. The wait for a new house was around three months.
It is disruptive and stressful for families to be shuffled from house to house, Harwood said. The top priority, if New Zealand kids are to be kept out of hospital, should be on improving the country's poor rental stock.
Turning around a big ship
The first significant step towards making rental properties safe to live in began last month, with the introduction of mandatory insulation rules.
Further minimum standards for rentals will be introduced in 2021 relating to ventilation and heating, and all rentals will have to comply by 2024.
They have been hailed as a significant step by child health advocates. But it could be more than a decade before they make any impact on child hospitalisation rates.
"It will be like turning around a large ship," said Otago University's Dr Nevil Pierse, deputy director of the housing research unit He Kainga Oranga.
"We're putting some of the blocks in place that are needed. But they are an absolute minimum. The rules still need to come in, and be enforced."
"We'd expect a little dip [in hospitalisations] but the big payoff is over the long-term."
He added: "Get back to me in 15 years."
Families in cold rental properties can also get help through the Healthy Homes Initiative, which assesses whether they need new curtains, bedding or insulation and part-funds the renovations.
Initially available only to families whose children had rheumatic fever, it was expanded in 2016 to families with preschool children who had a housing-related condition.
Papakura Marae clinical director Rawiri Jansen said the scheme was useful for minor alterations like new curtains. But because of underfunding, more significant maintenance like repairing windows could take months.
"It's not much use getting a winter draught fixed in spring," he said.
Maori asthma patients treated differently
The other key factor in reducing respiratory hospitalisations is addressing the inequity that leads to higher rates of Maori and Pacific people ending up in hospital .
When Maori kids walk into a GP clinic, they are often treated differently. And it can have real-life consequences.
University of Auckland Medical School research concluded that higher asthma admission and death rates were not a result of cultural, socioeconomic or genetic factors, but because of differences in medical management.
Further studies have found that GPs regarded Maori as non-compliant, and did not give Maori children prescriptions because they assumed their parents would not give the medicine to them. Maori were also less likely to be given an asthma prevention plan.
Harwood said the system was simply not designed for many Maori and Pacific patients.
"You've got a 15 minute consult, it's easier to just prescribe the drugs and hand it over. Without thinking, actually do I need to talk to Mum and Dad about stopping smoking? Do I need to ask about whether they're living in the garage, is the house warm and dry?"
The health sector is increasingly recognising the role of racism in unequal treatment, and DHBs and medical schools have introduced training to combat racial bias.
How to get your house warm and dry - and get help paying for it
• Open curtains and windows during the day and close them at night. Windows should be opened for 20/mins a day on fine days and a few minutes a day in winter.
• Open windows while cooking or after a shower, or use extractor fans if you have them. Dry your washing outside or in the carport/garage.
• Use draught-stoppers, like a rolled up dry towel, at doors and windows.
• After a cold night, wipe condensation off walls and windows. Remove any mould immediately with diluted bleach or vinegar
• Check what heater is best for your home - choose electric heaters over portable gas heaters, which are more expensive.
• If you need help buying curtains, bedding or heating, you might qualify for the Healthy Homes Initiative/Kainga Ora . You can refer yourself or get your GP to do it.
• If your kids are unwell, you can get help in heating your home or paying power bills from Work and Income .
• You can also get free or discounted curtains at a curtain bank .
• If you are renting, your landlord is now legally required to have installed ceiling and floor insulation (where possible).
• If you are a homeowner on a low income or in a pre-2008 house, you can get a discount on your insulation through the Warmer Kiwi Homes programme.
For more information, go to: www.health.govt.nz/your-health/healthy-living/warmer-drier-homes