The District has a child asthma problem—an “epidemic, in a way,” says Ankoor Shah, a pediatrician and assistant professor at George Washington University.

Shah, who is also the medical director of Children’s National Health System’s asthma clinic, rattles off the statistics: Fourteen percent of children in D.C. have asthma, and Children’s National takes the bulk of those cases. As the largest provider of primary, urgent, and intensive care for D.C.’s kids, the hospital sees about 1 percent of the entire country’s emergency department visits for asthma.

What Shah can also say with certainty is that this epidemic “disproportionately affects poor, urban minority children. And the severity is worse, specifically when you think about Wards 7 and 8.”

Children’s National emergency room data show that children who live in Ward 8 have 20 to 25 times the number of ER visits, total, as their counterparts who live in more affluent Northwest neighborhoods. Ditto hospitalization rates for asthma, which are 10 times higher for Ward 8 kids, Shah says. (The median family income in those districts steadily declined between 2006 and 2015, to about $31,000 in Ward 7 and $24,000 in Ward 8; the same is not true for average incomes in areas like Ward 2, which increased over the same period.)

Exacerbating, if not directly contributing, to these asthma cases are poor housing conditions, Shah says.

He is part of the medical team for Alina, a 10-year-old public housing resident who lives with her mom and siblings in Greenleaf Gardens, a sprawling and notoriously vile Ward 6 apartment complex slated for redevelopment. (Because she is a minor, City Paper gave Alina a pseudonym.)

City Paper wrote about Alina in March, months after she endured an extended hospital visit prompted by an episode of respiratory failure. At the time, her doctors submitted a letter to the DC Housing Authority, arguing that her living conditions—an apartment saturated in mold and riddled with pests—put her at risk for repeated hospitalizations, and of death.

Though Alina’s attorneys submitted a housing transfer request to the Authority, they say that the agency has stalled on providing her family with a reasonable accommodation. The family is “still living in the same mold-infested apartment,” says a spokesperson for Shearman & Sterling LLP, the law firm representing Alina pro bono.

And in early May, Alina went to the hospital again. She presented with “the worst pulmonary function her doctors have seen in her to date,” the spokesperson says.

“There are so many children in which poor housing is the leading cause of their poor asthma,” Shah tells City Paper. “The way I know this is: A child is living in a house with mold, mice, pests, cockaroaches, and when the child is at home, the symptoms flare up. When they’re not at home, they’re fine. But the family has an inability to get out of the home.” All of the items on his list—mold, mice, pests, cockroaches—can be allergens.

The executive director of the DC Housing Authority, Tyrone Garrett, has asked the federal department of Housing and Urban Development to provide DCHA with some 2,400 housing vouchers, which would give it the ability to relocate families living in some of the Authority’s most dilapidated housing units—including units like Alina’s. (In April, DCHA announced that it is seeking a co-developer to help it rehabilitate Greenleaf Gardens.)

But even if HUD disperses those vouchers to DCHA, whose clients would use them to rent housing units on the private market, it often takes months for families to successfully transfer to a new home, if they’re able to do so at all. In the meantime, they’re stuck living in units making them sick.

“There are cases here where [our patient’s] housing is so bad, we are at a loss—we think, is this child safer to be out of the house, or even be homeless and looped back into the system, than living in this home that could be killing this child?” Shah says.

Alina’s mother, Felicia Ross, told City Paper in March that both she and her other two children also have asthma. But Alina has fared worse, suffering from allergic bronchopulmonary aspergillosis (ABPA), the body’s more extreme response to mold allergens.

The conditions are difficult to shake. Continued exposure to toxic environmental factors will continue to exacerbate respiratory ailments—in some cases, regardless of how much or what kind of medication doctors prescribe to patients. In others, once families move out of the home containing allergens, Shah says he’s seen children stop using their inhalers altogether.

“You could keep adding more and more and more” prescriptions to a patient, Shah says, but if health providers focus exclusively on patients’ medication at the expense of environmental contributors, “you’re only doing half the treatment. There are lopsided treatment plans for some kids that are very sick, and we need the environment part to kick in. A lot of that is out of our control.”

Shah adds that, to convey the urgency of some patients’ housing conditions, he and colleagues have taken to frequently writing letters to landlords and housing providers, including the DC Housing Authority, explaining that ameliorating environmental irritators is as significant in solving a patient’s health crisis as timely medical treatment.

“This is a social justice issue in the city. Healthy housing is a core component, if not a main driver, to improve childhood asthma in the city,” Shah says. “Kids who are poor are having worse asthma outcomes. It’s something that’s urgent that we need to work on now.”