When Luis Decubas opens his kitchen cabinets in his southeast Fresno apartment, cockroaches come spilling out. Sometimes, Decubas the family feels the cockroaches crawling on them at night. They do what they can–clean the apartment, try to keep up with repairs, but they simply don’t have the money to invest in making their apartment more livable. If they did, they would probably move. Instead, Decubas calls his landlord, and the city government, begging for safe housing laws to be enforced. Eventually, the Fresno Bee began investigating substandard apartment complexes that house primarily low-income people of color. The conditions they found were deplorable and are linked to a range of health concerns from lead poisoning, which causes neurological damage and birth defects, to a particularly virulent strain of childhood asthma triggered by cockroaches.

An estimated six to seven million children in America have asthma, and most are from low-income families. In 2013, 12 percent of children in poor families had asthma, compared with eight percent of children in families that were near-poor and seven percent of children in families that had incomes of at least twice the federal poverty level. While poverty is the single most important factor, race plays as a role as well. Latino and African-American children are more likely to have asthma than white children. African-American children are six times as likely to die from it.

There are numerous environmental triggers of asthma including outdoor air pollution. But of all the triggers, cockroach allergies are among the most dangerous. Studies show that children who are allergic to cockroaches, and are exposed to them, need to go to the hospital for asthma more often than other children with asthma.

Cockroaches are not confined to high-poverty areas, but they do tend to be more prevalent there. A recent pest survey found that cockroaches were 50% more likely to be an issue in households living below the federal poverty line, and far more likely in black and Hispanic households.

The reasons for this are pretty clear: Lower income people are more likely to live in neglected buildings where landlords invest as little as possible in maintenance. When something leaks, it keeps leaking, and there is nothing cockroaches like so much as a nice damp place to nest with an abundant supply of water to drink. No matter how clean a family keeps its apartment, there is little they can do to keep their neighbors’ roaches from coming to visit through cracks in the walls, plumbing fixtures and vents.

Once the bugs appear they are incredibly difficult—and expensive—to get rid of. Those same landlords who won’t come fix the faucets are unlikely to pay for a commercial exterminator unless forced. That rarely happens. Housing code enforcement is historically inadequate. Even when enforced, housing codes are often themselves part of the problem. Many local housing codes borrow from model codes, which often fail to address important local problems like persistent pests or poor air quality. And housing inspectors often come from contracting backgrounds. They may recognize signs of shoddy construction but miss infestations altogether.

In many cases, families will simply try to handle the problem themselves. Affordable housing is increasingly scarce in many cities and families may not want to risk angering a landlord when few other options exist. Families with one or more undocumented members may be scared to alert anyone of their existence.

Treatment of infestations comes with its own problems. Pesticides have been linked to numerous conditions ranging from cancer to, yes, asthma. Families may be reluctant to use them in households with young children, or pets, for fear they may be ingested.

The single best treatment for roaches is non-chemical integrated pest management – that is, an ongoing, labor-intensive effort to change the environment to make it inhospitable to cockroaches. This requires substantial investment – both in the infrastructure where the problems exist and in working with families to educate them on how to keep the pests at bay.

Bear in mind these are families whose health challenges may also include a variety of other problems related to substandard housing and to poverty in general – from mold in the home, which also triggers asthma, to lack of access to health care.

And so asthma attacks continue as part of a wider vicious cycle in which missed school leads to poor academic performance; missed work to care for sick children leads to job and income loss; and fear of asthma attacks keeps children from participating outdoor activities necessary for maintaining a healthy weight. Meanwhile health care costs in America continue to skyrocket as we dole out inhalers, respond to acute attacks and hope for the best while failing to address the root causes. Nothing will change unless everything does.