I grew up in Grand Terrace in San Bernardino County and have been working since I was 16 years old, often in customer service jobs. I’ve had my ups and downs at work and in life, particularly since the big recession hit. I moved back in with my parents, who live in Riverside, in 2010. But I never much worried about health insurance. I’m still young–I’m 30–and I’ve never been seriously ill or injured. I don’t have a wife or kids.

But in the last couple years, my chronic childhood asthma has returned with the vengeance. It’s a terrible feeling. My lungs get inflamed and constricted, and my breathing becomes labored. When I lost that job, I took some solace in the fact that my timing might be good. Obamacare would be starting soon, with sign-ups in the fall of 2013.

That didn’t mean I was stoked about the idea. I’m a libertarian, and I’m not a fan of President Obama in general, or his health plan. But I needed the care. So I went to the Covered California website, which I’d learned about from TV ads.

I found the website a little bit confusing, but I eventually figured out how to sign up for a Bronze plan. That is the cheapest kind of plan, though Bronze plans often have high deductibles. I thought I was done, but I wasn’t. Months went by and I never received a confirmation from Covered California. I wondered what had happened.

The answer came in the mail. Covered California sent me a letter saying that I wasn’t eligible to sign up for one of their plans–I didn’t make enough money. That rejection surprised me; I didn’t know that your income could be too low. But it’s true that I didn’t have a lot of money. My unemployment payments, which I hadn’t included on the form, had run out. My only income at that time was from a part-time gig playing guitar at my church.

Instead, the letter (and subsequent rejection letters) would inform me, I was eligible for Medi-Cal, California’s version of Medicaid, the federal program to cover the poor. I wasn’t happy about this, but I had no choice: I needed some coverage because of my potentially life-threatening condition. So I had to go to another website and apply for Medi-Cal, and received a package in return asking me to pick a plan within Medi-Cal. But before I could choose, I was automatically put on the Inland Empire Health Plan.

The hard part was trying to get health care with my Medi-Cal plan. Making an appointment to see a doctor who could renew my prescription for asthma drugs and inhaler was incredibly difficult. The only appointment at first was two months out. Then, the day before, the doctor’s office called to cancel. I rescheduled again for another month or so out—and the clerk called again to cancel.

At that point, I got very persistent and demanded an appointment immediately. I told them I wasn’t taking no for an answer. I knew that if I had nothing to stop an asthma attack, I could die. I had been borrowing the inhalers of a couple of friends to get by and they might not be around the next time an attack came on.

Eventually, after many calls (and after another patient canceled, creating an opening), I got an appointment at the regional health center in Riverside, just off Indiana Avenue, not far from where I live. The doctors there would take my IEHP coverage. It was an eye-opening experience. The place was jammed, and people were waiting for hours for a doctor. It took me three hours to get seen by a doctor, even though I was an easy case. My asthma didn’t need to be diagnosed, and all I really needed was an inhaler.

The outcome, however, was less than optimal. I had previously used a ProAir inhaler, which uses the drug albuterol sulfate, which has been very effective in controlling my asthma. But under the new health plan, they switched me to a different inhaler with a drug, Ventolin, that doesn’t give me the same strong relief. (It doesn’t help that the Ventolin cartridge is twice as big). I only learned about the switch at my local CVS pharmacy when I tried to fill the prescription. When I asked about the switch, I was told that I didn’t have a choice. Ventolin was what IHEP covered.

I’m not sure what I’d do if I had to continue on the Medi-Cal health plan with IHEP. The good news is: I don’t have to. I just got a full-time job and soon will be eligible for benefits again. I’m thankful I won’t have to be one of people in line again, waiting hours to be seen, mired in red tape, and worried about taking my next breath.

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The idea is to create incentives to reduce costly visits to the emergency room caused by asthma attacks. In Fresno, families and insurers spend approximately $35 million a year on these ER visits. Asthma attacks are triggered by pollution, dust mites, mold from swamp coolers, and tobacco smoke. Reduce these elements—especially those in the home—and you’ll reduce ER visits. But our current model of insurance doesn’t pay for medical professionals or equipment to prevent asthma attacks; it only pays to treat them with medicine. Says Anne Kelsey Lamb of the Bay Area-based community collaborative RAMP (Regional Asthma Management and Prevention): “We know what works to address asthma hospitalization—and we can get almost immediate results—but we could never secure a consistent funding stream.”

That’s where the financiers come in, using a tool that’s known as a social impact bond. Investors will put up money for vacuum cleaners and nurse’s home visits and other things that would reduce trips to the ER. If those investments can save the healthcare system at least $5,000 per child, then investors will make money by sharing in additional savings, all the while improving people’s physical and financial health.

The trial is now in full swing, with 200 children who average 1.5 ER visits a year divided into treatment and control groups. The results—expected in two years—are highly anticipated both in the financial world and in Fresno, which has among the highest rates of childhood asthma in the country. (Some official estimates say one in six Fresno children has asthma; others say one in five.)

“If asthma were an infectious disease, there’d be guys in white suits and yellow tape when the ratio hit one in a thousand.” says Kevin Hamilton of Clínica Sierra Vista, who has been working on the treatment and prevention of asthma in Fresno since the 1970s. Instead of bringing in white suits, Hamilton is welcoming investors in black suits, and he’s excited about the project’s implications: “This could change the way we treat chronic illness like diabetes and congestive heart failure. Instead of viewing chronic conditions as a constant leach on the system, this is a way to save money and even make money.” If all goes as expected, the program will reduce ER visits by 30 percent and cut hospitalizations in half.

For this first-ever demonstration of healthcare bonds’ potential in the U.S., the California Endowment put up $1.1 million as an investment; the Central California Asthma Collaborative and Clínica Sierra Vista have provided outreach workers to visit the homes of children with asthma and do evaluations and education. To build a case that profits can be made by investing in preventive healthcare, the non-profit Social Finance, Inc. and a social enterprise company called Collective Health are working to verify savings and prepare to get investors to put up money for the second phase of the project. In phase two, Social Finance and Collective Health will issue a bond to outside investors that will cover 3,500 children, and will offer investors the opportunity to recoup their investments with additional interest—provided the kids stay out of the ER.

When I spoke with him recently, Nirav Shah, a director at Massachusetts-based Social Finance, was preparing to travel to California to check in on the investment by visiting a few homes of children with asthma who are participating in the program. Shah’s background is in finance and banking, with a stint at the federal Office of Management and Budget. He says this project has caused him to reframe the general idea of the bottom line of “profit maximization” that he used to use for hedge fund investors into a more concrete effort to “align financial mechanisms with social progress,” for society in general.

For Shah, the first challenge is to merge the study results with data from insurance companies to show rigorously that preventing asthma attacks saves them money. Eventually, insurers could either invest the money in prevention themselves, or they could sell bonds, allowing outside investors to take on the risk of the vacuum cleaners in exchange for a share of the savings on ER costs. Shah has also been talking with big investors who might put up money for the bonds in the next phase.

Some socially focused investors quickly get the “narrative” of the initiative, and want to invest their money where they can improve people’s lives and ensure the long-term health of the U.S. economy. But another crowd is attracted to investments with little risk—and Shah is working to do analytics to convince them that social impact bonds fit the bill. For risk-averse investors, the greatest argument for investing in vacuum cleaners in Fresno may be that it’s a “counter-cyclical” investment, which means that even if the economy takes a dive, the kids in Fresno will still be earning money by staying out of the ER.

When we talk about little kids gasping for air and counter-cyclical investments in the same breath, I start to feel cognitive dissonance. Is reframing asthma (and other chronic conditions like diabetes and congestive heart failure) as a money-maker really the way to address the failures in our healthcare system? Will this motivate us to reduce air pollution? Everyone I spoke with felt that the experiment in Fresno would change not only the health of the kids but also the incentives of the insurance and investment industries. They hoped to use the project as leverage in the rollout of the Affordable Care Act, which has incentives for quality and outcome over volume. For Shah, financializing asthma attack prevention is a first step in the leveraging of nascent markets in pollution reduction, carbon credits, and affordable housing toward a cleaner environment and better health for everyone.

So far, markets have been cruel to Fresno, which had 56 percent of its mortgages go underwater in 2009, but it’s possible that someday markets could also prove to be kind.

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In most respects, my childhood was normal. Every day, my mom would pack my lunch, and my dad and our dog, Reeses, would walk me to Cole Elementary School. When we reached the spot where the chain-link fence met the blacktop, we’d wave goodbye. Then, with my lunch pail in hand, I would join the hordes of elementary school children and line up to wait with my classmates for our teacher to walk us, single-file, into our classrooms.

But recess and P.E. were less normal, even if I didn’t notice it at the time. My classmates and I would grab the essentials for playing outdoors: red bouncy balls, jump ropes, and basketballs. And a handful of people would reach for their inhalers. When I asked what the inhalers were, the response I got was “medicine.” For what? I asked. To breathe, was the answer. I left it at that.

Sometimes, my friends with asthma would have to stop for a moment while we were playing tag or soccer, or they would walk when we were supposed to be running laps. Once, during P.E., a girl in my class had an attack. Her face was red and she was crying, saying that she couldn’t breathe. We all crowded around her, and my teacher told us to step back and give her air. Another student ran inside to get her inhaler. After a few hits of her medicine, the girl calmed down and began to breathe normally. That’s when I began to understand that asthma was more than just breathing from a device before going outside for recess.

In Fresno, bad-air days were so common that I feel I’ve always known the term. Those were the days when outdoor physical activity was discouraged by the Environmental Protection Agency. It meant cancelled sports practices, indoor games in place of recess, and inhalers ready at hand. When I was in high school, I’d regularly drive past the Baz Allergy, Asthma & Sinus Center, where on the building wall was an electronic sign that reported the daily air quality. Percentages of pollen or mildew would vary. But the reading for air quality never did: it was always “unhealthy”–except when it was “very unhealthy.” I used to wonder what point there was in having daily updates that never changed.

When I was 17 and a junior in high school, I came down with a bad cough that lingered for weeks after the rest of my cold symptoms were gone. My mom, slightly worried, took me to the doctor. During my appointment I had to blow on a hollow, straw-like device with a small bead inside and hash marks for measurement on the outside. My breath was only strong enough to get the bead to the halfway mark. That was when my doctor told me that I, too, had developed asthma. She said it was probably the result of living with the bad air in Fresno. I got a prescription for an object that I was very familiar with: an inhaler. I was now one more person among the 157,000 with asthma in Fresno County.

Fresno is in a valley, and smog and pollution get trapped inside. Geography is only part of the problem, though. Growing up, I never learned much about the Fresno air. I knew that it was bad, but I didn’t know why. I certainly never learned about things that could be done to improve it. And I never learned how to protect myself from it.

I hope that changes for kids today. I accepted my asthma diagnosis without much agonizing, because so many of my friends had the same problem. Having asthma in Fresno is normal. But it shouldn’t be.

Lauren Alejo is a literary journalism student at the University of California, Irvine and an intern at Zócalo Public Square.

*Photo courtesy of sarahalex4.

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Where symptoms are concerned, little has changed since Seneca’s time. The cardinal symptoms of asthma–respiratory distress, wheeze, and cough–remain the same. The anxiety suffered during attacks echoes Seneca’s description of “gasping out your life-breath.” My experience of watching my sons struggle to breathe, as well as my own episodes of acute asthma, closely match Seneca’s account. So do the experiences of asthmatics through the ages, from ancient to modern.

In other ways, much has changed about asthma since the Roman period. Most striking is the transformation in the frequency and severity of the condition. Until the early 20th century, asthma was an uncommon and mild condition that, in spite of the fears that it generated in sufferers, rarely led to death. Most Western clinicians regarded the condition as compatible with a long and healthy life. During the last hundred years, however, the distribution and significance of asthma have altered dramatically. The prevalence of the disease has risen steadily across the world. By the year 2000, approximately 5 million Britons and 15 million Americans suffered from asthma. Similar patterns were evident in developing countries: according to the World Health Organization, asthma afflicted 300 million people worldwide in 2006.

Also, as the recent heartbreaking death of the Pulitzer Prize-winning journalist Anthony Shadid makes clear, asthma can no longer be considered a mild condition, as it was prior to the mid-20th century. It’s now a disease that can and does kill. Asthma is responsible for approximately 200,000 deaths worldwide each year. In spite of dramatic improvements in the management of asthma, the epidemiological pattern and clinical severity of the disease appear to have shifted substantially in the modern world.

How can we account for these transitions? Why has the prevalence of asthma increased, and why has it become more deadly? We don’t fully know. In part, the rising prevalence of asthma may be the result of improved diagnosis and greater awareness. However, this cannot be the whole story, since the severity of the condition also has increased. Substantial changes in our environment and lifestyles have probably increased our exposure to allergens and irritants that trigger attacks. Rising levels of vehicle pollution, increased concentrations of house dust mites in carpeted, centrally heated and insulated homes, dramatic shifts in diets, more sedentary lifestyles, and the psychological stress associated with hectic modern lives all may have contributed. Underlying these trends is an increase in allergic reactions of all types: modern populations appear to be more sensitive to environmental triggers such as animals, foods, and pollen.

While epidemiological research has uncovered many of the most likely environmental triggers of asthma, isolating the precise cause in individual patients is more difficult. As my family discovered on holiday in Wales a few years ago, our youngest son’s asthma is exacerbated primarily by cats. My own asthma is more often generated by exposure to certain plants or dust. Asthmatics cannot merely manage their symptoms; they must also learn what allergens or irritants to avoid. In Anthony Shadid’s case, it was reported that immediate exposure to horses, to which he was severely allergic, caused his death.

Paradoxically, the severity of asthma appears to have increased in the face of substantial improvements in treatment. In the past half century, the management of asthma has been revolutionized. New preventative steroid inhalers, more selective bronchodilators or relievers, the availability of nebulizers at home and in the hospital, and greater attention to early diagnosis have eased the lives of asthmatics. Certainly, the range of hospital support and medication available to my sons far surpasses what was available to me during the 1960s and 1970s. The development of novel immunological tools may further transform the lives of patients with severe and fragile forms of asthma, and improved management already seems to be reducing the number of deaths from asthma.

With such an abundance of effective medical treatment, many of us forget the power of disease. Particularly in the West, we have become accustomed to being able to cure or prevent many acute illnesses or to manage most chronic conditions. Infectious diseases have largely retreated; the range of remedies for chronic inflammatory or degenerative conditions, including heart disease and arthritis, has increased; and modern surgical skills are exceptional. Even the fear of cancer is being slowly allayed by improved diagnostic and therapeutic approaches. We live longer and generally healthier lives than our ancestors, and we have access to a greater range of effective treatments than earlier generations.

However, our confidence can be our downfall. Diseases can change, and so can their impact. At one level, modern asthma is recognizably the same disease as its ancient counterpart. It continues to render patients breathless and anxious just as it did with Seneca. At another level, in the wake of dramatic changes in the modern environment and modern lifestyles, asthma has become a killer. That doesn’t mean we should panic. As the number of successful international athletes with asthma suggests, you can be asthmatic and healthy. But it does mean we should remain vigilant. The loss of Anthony Shadid should remind us not only of our limited capacity to control disease but also of the stubborn and appalling uncertainty of life.

Mark Jackson is a professor of the history of medicine and director of the Centre for Medical History at the University of Exeter. His books include Allergy: The History of a Modern Malady and Asthma: The Biography.

*Photo courtesy of Perfecto Insecto.

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