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In Breathtaking: Asthma Care in a Time of Climate Change, Alison Kenner uses a multi-sited ethnography to examine the myriad infrastructures and material practices of care in the United States that mediate the relationship between disordered breathing and the environment. By tracing connections between lived experiences of asthma, environmental conditions and our bodies, the book allows us to imagine new carescapes that could help to make the world more breathable, writes Priyanka deSouza

Breathtaking: Asthma Care in a Time of Climate Change. Alison Kenner. University of Minnesota Press. 2019.

Asthma is a chronic disease that has no cure. It can only be managed over the lifetime of an individual through medication, behavioural interventions and environment controls. Climate change is leading to rising levels of air pollution, seasonal allergies, wildfires and other extreme events, intensifying incidences of asthma. Are we prepared for this growing global epidemic?  In Breathtaking, Alison Kenner uses a multi-sited ethnography to trace the contours of asthma – a disease with such heterogeneous symptoms and triggers that the medical community has considered abandoning the catchall term ‘asthma’  altogether – by examining the myriad infrastructures and material practices of care in the United States that mediate the relationship between disordered breathing and the environment.

Asthma is a relatively ‘slow disaster’. Kenner has done us a service by detailing how tenuous networks of care in the US can be, and how contingent they are on larger structural policies.  In the flare of the COVID-19 pandemic, this has never felt truer. The current moment is a crisis of care, and Kenner’s book allows us helpful insights into how we can rebuild our broken systems when this calamity is over.

In Chapter One, Kenner’s rich description of how individuals live with asthma from day to day, and over the course of their lives, provides texture to the ‘emplaced’ or contextual nature of the disease, and the variety of relationships that form different modes of care. She describes the very different experiences of breathing for different asthmatics, which constantly frustrate researchers’ desire to categorise and classify asthma using standardised practices and language. Kenner thus adds nuance to the ‘language of asthma’.

In Chapter Two, she goes on to describe three main techniques of controlling asthma: breath control; environmental control; and asthma control. The latter relies on a biomedical approach to ‘control’ asthma in a clinical manner, while the former methods engage with people’s present, lived experiences in complex ways. Kenner highlights the importance of context, which determines and mediates each of these means of care. For example, in the US, good health insurance is key to caring for asthma using a regime of medicines. Having control over one’s home is key to controlling breathing environments, but this might not be possible if one has to rely on difficult landlords, for example. By using the analytic of care, Kenner is able to escape the narrow boundaries of the biomedical paradigm with its focus on the individual to show how the work of care always exceeds this and is contingent on larger structures of power. By tracing relationships between individuals, management practices and the environment, Kenner is able to capture the different histories, structures and contexts that shape experiences of asthma in a single powerful narrative.

The different modes of care that Kenner describes in this book are enacted at different spatial and temporal scales, from the individual and the home to larger communities of practice. In Chapters Three to Five, Kenner unravels the modes of asthma care starting at a particular scale, which sometimes overlap and are sometimes in tension with other techniques of care at other scales. Importantly, Kenner continuously shows how larger structural factors intersect with each.

In Chapter Three, Kenner expands on the Buteyko breathing technique and the incredible success many individuals have had in using it to manage their disease. She describes the history of the technique, and her own experience with it, in a manner that makes me acutely aware of my own breathing rhythms. Buteyko breathers rely on a regimen they practise over time to retrain their breath. Such a regimen requires individuals to practise breathing techniques for a minimum of 60 minutes per day and emphasises personal healing and empowerment. Kenner recognises that not all individuals have 60 minutes to spare every day. Moreover, few mainstream asthma techniques promote this practice. She posits from interviews that this is likely because it has no industry sponsors or supporters, thus highlighting the control that larger capitalist forces have over the array of treatments available to the lay public.

Chapter Four documents how the many available apps modify relationships of care for asthma, while also reflecting various care logics. Patients using these apps experience these logics in a manner that is mediated by their relationship with the larger chronic care infrastructure. For example, some apps are focused on reinforcing daily asthma health maintenance activities that can be shared with medical practitioners to strengthen doctor-patient care relationships, if such a relationship exists. Other apps are focused on allowing users to better understand the nature of their disease, by layering details of environmental quality on data about the user’s experience of breathing. Still others are used by public health practitioners to better understand the triggers of asthma. Kenner beautifully documents the many layers of activity in the app-scape, including the investment of insurance companies in apps and the work of Apple in developing research toolkits. She ends the chapter by speculating on the potential of apps, through techniques of data visualisation that allow better connections to be made between asthma and the quality of the environment.

In Chapter Five, Kenner calls out the public health dimensions of asthma through documenting her involvement with ‘The Climate, Health, and Home’ project in Philadelphia, a workshop series that enfolds education about climate change and public health services to produce what she terms a ‘carescape’:

a place-based landscape of services and relationships knit together by macro-level factors that include not only federal and state policies, economic conditions, new technologies and health delivery services but also the specific needs of the population (150).

In this chapter, Kenner focuses on how the ‘slow violence’ of asthma is embedded in larger public infrastructure like transit services, housing, zoning and school buildings that have been shaped by forces such as structural racism, which make certain populations more vulnerable to emerging climate-related events such as heatwaves. Kenner highlights the need for different organisations working on public health and environmental justice to coalesce in new ways to tackle these larger systems to care for people suffering from asthma.

She helpfully ends the book by making specific recommendations at different scales to foster new ‘webs of care’ for asthma in the age of climate change. Specifically, Kenner calls for high-quality health care to be made accessible for everyone. Almost all of Kenner’s interviewees told her that access to rescue inhalers, when their symptoms crop up, makes a huge difference.  Her second recommendation is that every prescription for an inhaler be accompanied by a lesson in the Buteyko breathing technique. Her third recommendation is for governments in the US at all levels to invest in care for the built environment. Finally, she argues for the US to take serious action on climate change.

Overall, Breathtaking takes asthma from the biomedical world, and using a multi-sited ethnography, traces connections between the experience of asthma, the environment and our bodies, allowing us to imagine new carescapes that could make the world more breathable.

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Note: This article gives the views of the authors, and not the position of USAPP– American Politics and Policy, nor of the London School of Economics.

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About the reviewer

Priyanka deSouza – Massachusetts Institute of Technology
Priyanka deSouza is a PhD candidate in the Department of Urban Studies and Planning at the Massachusetts Institute of Technology.

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