Nissi Hamilton had a system. By the time each of her seven children turned 3, they had to be out of the house and in school.

The coronavirus pandemic has disrupted that, as it has for many families. Now all her school-aged children are learning virtually. She starts her days with a refrain familiar for many: “You’ve got 10 minutes to log in!”

She lives in Houston with her husband, and former husband, and two other adults in a home in Riverside Terrace near Brays Bayou. It makes it easier, she explains.

Because, throughout the pandemic, which is dragging on with no end in sight, mothers like her have had to make many hard decisions — decisions about when, and whether, to allow their children to play sports or return to school and when, and how, to prioritize their own work, all while trying to keep a cooped-up family happy.

Asthma has complicated it all the more for Hamilton. Two of her children suffer from it, and it hospitalized her husband when he was a child. She’s added air purifiers and plants to the house. She’s mindful of the detergents and cleaning products she uses. On good days, everyone can get out outside, even if it’s just to play basketball in the driveway. But Hamilton has to be more mindful than most.

In August, the Houston region suffered five straight days of unhealthy air, according to AirNow, which tracks five major pollutants by levels set by the Environmental Protection Agency. But with so many other types of toxics, pollutants and triggers in Houston, finding good information can be one more chore. “I'm not checking the pollen every day,” she says. “Who has time to do that? My best option is to make sure I have enough space in the house and that I'm living as far away as I can from any type of plant.”

With so much still unknown about the coronavirus, the intersections with underlying health issues like asthma and long-term exposure to air pollution are still emerging. But the mothers who are more often bearing the added care burdens of a pandemic cannot wait for the journal articles and webinars when they have a family to protect right now.

Environmental control

The Centers for Disease Control and Prevention produced information that people with moderate to severe asthma might be more at risk of getting “very sick” from the coronavirus, advising those with the chronic disease to follow their asthma plans, stock up on medicines and avoid disinfectants that could trigger an attack.

But what’s been missing from these individualized public health recommendations, Dr. Alison Kenner says, is the collective public response. “They’re both tied to our environment in so many ways. This is about our shared breathing space. I’m not at all surprised by the way we’ve been unable to address COVID-19 as an environmental or collective condition, because we’ve been unable to address asthma” that way.

Dr. Kenner is an associate professor at Drexel University and author of Breathtaking: Asthma Care in a Time of Climate Change. Implicit in many of the recommendations for both asthma and the coronavirus, she explains, is the ability for an individual to control the environment, whether a home, classroom or neighborhood. That burden, as the pandemic is showing, Dr. Kenner says, is “going to fall more heavily on mothers.”

These recommendations, she says, also tend to presume that the patient is “white, middle class and able-bodied and misses the fact that people, especially people in marginalized communities or children, for example, are not in the position to have control over the spaces where they’re breathing.”

As a Black woman, Hamilton is living in a specific intersection of asthma and the pandemic. Black Americans experience higher rates of death from the disease than people of other races, and Black children have, as a group, the highest prevalence of asthma in the U.S. About 13.4 percent of Black children have asthma, compared with about 7.4 percent of white children.

These days, Hamilton says she especially values the sidewalk and trees in her front yard. Her verdant Third Ward neighborhood is not a fenceline community. But it was sliced up by the construction of State Highway 288 in the late 1950s, choking it off from the hundreds of acres of leafy trees and trails at Hermann Park.

Likewise, there are no facilities in Third Ward that must report their inventories of toxic chemicals to the EPA, but there is a pattern to where those facilities are located. As Hamilton says, “You don't see them in white neighborhoods, right?”

In clinic, Dr. Harold Farber knows that “how you breathe starts with what you breathe,” and for many families, the problem can start there. Dr. Farber sees his job as helping patients stay out of the emergency room, but he recognizes the barriers that exist for many families, including a lack of access or transportation and enough negative experiences to foster distrust. The professor of pediatrics in the pulmonary section at Baylor College of Medicine and Texas Children's Hospital points to the host of both indoor and outdoor air quality considerations for parents, including air pollution, pollen, tobacco and vape smoke, air fresheners and more. Many of these are difficult for any parent to control.

For some parents, though, there are the additional “issues of lower housing quality, of environmental racism, of crowding,” he explains. “You may be in multi-unit housing, and while you may not be a smoker, your neighbor may be, and that can easily contribute to your breathing problems.”

So the best practices of environmental control become complicated, too. Recommendations can be exhausting and expensive: stuffed animal toys should be machine washable and laundered once a month, carpeting should be removed to reduce dust mite exposure, homes should have high-efficiency air filtering, etc.

No mother can completely control the environment. Air pollution like soot, linked to lung disease and premature death, can blow all over the region. Outdoor molds and pollens can travel for miles. And when it comes to pollution and toxic emissions, serious concerns about what little reporting is required mean that most Houstonians are operating with incomplete information at best.

Like the highly individualized policy responses to the current pandemic — wash your hands, wear a mask, lower your voice, stay home if you can — environmental control recommendations are more feasible for some than others. They just can’t protect everyone, because not everyone breathes the same air.

'You did your job that day'

Throughout Hamilton’s life, which includes being sex trafficked and lacking stable housing, she has dealt with the struggle for control. After her eldest son was diagnosed with asthma, she learned how difficult it can be to get adequate care with Medicaid. That system, she says, has little incentive and often insufficient resources to help patients like her son.

Sometimes, that was as simple as a doctor having a breathing mask that fit him. It took more time, already a limited resource, to find the doctors within constrained options in an unequal insurance system. All of it was necessary, she says, though, “so you can go home and feel good as a mom that you did your job that day. You know your kid has what they need to live another day.”

This is a mother’s burden. Though Dr. Kenner didn't focus on how family dynamics play out with asthma care in her research, she says she has heard the stories about mothers being the ones who are expected to carry inhalers for their children and owning the responsibility. Hamilton has owned it, too, and tried to empower herself with the best information, not seeing a doctor’s visit alone as enough.

It’s one reason why she sees a need for more mothers in leadership positions, something she has experience with serving in the Navy, running for Houston city council and now working as an advocate with Moms Clean Air Force. “I don't think you have to be a mother to understand,” she says. “But it would be definitely different for a mother. These issues would stop being so short-term, and then we can actually start attacking things.”

Every day presents decisions for parents like Hamilton. She’s devised an ingenious living arrangement to share the burden while she balances the risks her son faces when he says he wants to continue playing football. But she’s also planning movie nights and making homemade desserts, too. She’s trying, as best she can, to control her environment. “Now’s the best time to meet women right where they are, not where you would prefer them to be,” she says, “and ask them what they need.”

Binkovitz is a writer living in Houston, Texas. Her work has appeared in the Washington Post, Houston Chronicle, NPR and Smithsonian Magazine. She can be found on Twitter @leahbink.

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