Problems such as lead paint and broken boilers have dominated the headlines about NYCHA in recent months, as the country’s largest public housing authority has taken center stage in Gov. Andrew Cuomo’s reelection campaign, and in his feud with Mayor Bill de Blasio.

The stressors facing NYCHA residents in its worst developments, though, go well beyond broken boilers. Fetid air, vermin, poorly lit hallways and stairwells, crime, sustained poverty and its concomitant health risks have the psychological effect of the erosion caused by a steady leak on a piece of concrete. Not much is noticeable at first. Over time, wear and tear begin to show on the surface, a sign of deeper problems below. Eventually, the cement erodes.

But it is the air that’s doing the most damage.

It is the air that is responsible for making asthma the No. 1 reason New York City children visit an emergency department, and the No. 1 reason children stay home from school.

Every breath does a little bit more damage, taking a toll that over the years leads to higher risks for all manner of chronic disease.

And for those with little or no income, the expense of trying to work around asthma triggers — the literal cost of fresh air — helps ensure people in poverty stay there.

“The prescription, honestly, has to be getting people into better units that are free of these triggers,” said Diana Hernandez, an assistant professor at Columbia University’s Mailman School of Public Health. “Their own home environment is so dilapidated that it becomes the thing they spend all their mental energy on, and it is hard to focus on other issues in life.”

Housing is health

The line between housing conditions and chronic disease is fairly straight. The Bronx has the highest percentage of tenant complaints regarding mice and and rats in the city, according to the health department. The borough boasts the most reported cockroach infestations. The dander from roaches and rodents triggers asthma. The Bronx has the highest asthma rate in the city. More than 17 percent of children up to age 12 have been diagnosed with asthma. In Staten Island and Queens, neither of which is considered affluent, the rate is almost half that of the Bronx.

Zoom in on a community district and the correlation becomes even clearer. The asthma rates are highest where there are the densest concentrations of public housing, according to city data.

Nearly 13 percent of Bronx residents reported mold in their apartments in 2012, according to the department of health, and in 2004 the Institute of Medicine found sufficient evidence to link indoor exposure to mold with upper respiratory tract symptoms, coughs and wheezing in otherwise healthy people, and with asthma symptoms in people with asthma.

The state Department of Health released a survey April 2 showing that 83 percent of 255 inspected apartments were found to have at least one health hazard. Infestations and mold were two of the top three problems found. An insect infestation was found in 47 percent of units.

The state Senate’s breakaway Democrats, the IDC, recently conducted their own survey across all five boroughs. They reported that of the 202 people who participated, 119 residents said they have had mold in their homes, and 43 of those currently had mold in their apartments.

Estrella, who asked her last name not be used for fear of retaliation from NYCHA, lives in a two-bedroom apartment on the top floor of a high-rise that is caked in dust and spotted with mold.

She has to sweep her ceiling every two to three days. When she does, the dust falls over everything she owns. She wipes down the furniture with a rag, but the dust lingers. In her constant battle, the dust is undefeated.

On a recent afternoon, she sat on a futon beside a pile of laundry in a crowded living room.

“I get everybody’s dust, smoke, whatever, because there is no circulation,” said Estrella, a short woman who, with her hair drawn back, looked younger than her 44 years. “If I don’t open the windows we won’t be able to breathe, so imagine when it is real, real cold and we got all the windows closed and the heat is on. We are choking in here.”

The whole of the problems created by dust and mold, by mice and roaches, by broken elevators and unreliable boilers, is greater than the sum of its parts.

“One way to think about this is the sheer number of stressors,” Hernandez said. “Stress can be good when it is acute and not prolonged. What happens with chronic stress, over the life course of kids growing up in public housing … it means they aren’t escaping those stressors.”

Chronic stress suppresses the immune system and is linked to obesity and heart disease.

Higher levels of stress are associated with poor health outcomes for pregnant women and newborns. Stress hormones are already elevated during a healthy pregnancy, and when a woman with already high levels of stress hormones becomes pregnant, she is more likely to deliver prematurely, which is one of the key risk factors for infant mortality. A healthy pregnancy doesn’t mean the baby is out of the woods because stress can interrupt a young brain’s development.

Stress also leads to anxiety and anger.

Estrella has a diagnosis of post-traumatic stress disorder, and the added stress and anxiety have left her angry, she said. She screams to her therapist, a temporary salve, but she returns home to the same stressors. She won’t invite company, she said, because it’s too hard for others to breathe and she is embarrassed that everything she owns is coated in dust.

“I’m isolated,” she said. “I’m constantly angry, and I don’t want to take it out on anybody.”

The number of stressors — physical, mental and social — pile up and make it hard to focus on anything else.

“I think [NYCHA management] feels like, ‘They’ll be alright. They’re used to that type of s---. At least they are not in the street,’” she said. “I’m grateful that I don’t have to pay for light and gas, and me and my family can live, but then you are killing us because you are not helping us.”

There are 400,000 people who live in 326 NYCHA public housing developments, more than the population of Miami or Cleveland. Those are just the people the city knows about. Many more live in units without permission, staying with friends or family as an alternative to the street. For these half-million or so, the experience varies. Some units are just fine, some have minor problems. Many tenants can live years without serious complaints.

But too many live in a constant state of fight or flight, with their adrenaline pumping, said Shoshanah Brown, chief executive officer of a.i.r. NYC, an organization that preaches self-management to those suffering from chronic diseases.

“A medical intervention that would happen in a clinical setting can only go so far for anyone who is living in a home where they are worried about the roof falling in or cockroaches running around, or losing their space because they have relatives living with them” without permission, Brown said.

Asthma, not lead, the leading plague

Lead paint, which is what sparked the most recent political firestorm, remains a relatively small problem in NYCHA units. For years, the city failed to conduct the required annual lead inspections, according to an ongoing federal investigation, but most cases of lead poisoning occur in private homes, not public housing, according to city health commissioner Mary Bassett. In 2016, the rate of children with elevated lead levels was less than 2 percent across the entire city, and the health department estimates that among children living in NYCHA housing, it is less than half of that.

Lead poisoning, when it does occur, is serious, but it is low on the list of what makes life in substandard New York City housing so dangerous.

Poorly functioning boilers present more prevalent problems. They mean brutally cold conditions, and days without hot water — making it harder for residents to wash their hands to fight communicable disease, or get a good night’s sleep. When children don’t sleep, they do poorly in school. For adults, insufficient sleep has been linked to the development of chronic diseases like diabetes, cardiovascular disease, obesity and depression.

Lead and boilers have been props in the recent political theater surrounding NYCHA. Cynthia Nixon, who is challenging Cuomo in the Democratic gubernatorial primary, visited a facility in Brooklyn and chided both Cuomo and her ally de Blasio for neglecting deteriorating conditions there. Cuomo secured $250 million from the state budget in additional funding to make boiler repairs. But NYCHA has an estimated $25 billion in unmet capital needs as a litany of other problems have gone unaddressed.

Asthma remains the No. 1 plague for children in public housing.

And the toll of an asthma attack lingers well past the patient’s return from the emergency room — an expensive and often avoidable visit.

Trips to the emergency department mean a child isn’t in school. More school absences correlate to lower graduation rates and lower lifetime earnings. Children who miss 15 days of school in a year are considered chronically absent. Children who are chronically absent before the second grade are much less likely to read at grade level by third grade, and children who are chronically absent for any year of high school are seven times more likely to drop out, according to the Robert Wood Johnson Foundation.

“It takes you out of school so disproportionately that it takes you out of college,” said Amanda Parsons, vice president of community & population health at Montefiore Health System.

College graduates, on average, live nine years longer than those without a degree.

David missed so much school that the Administration for Children’s Services started asking questions about Estrella’s fitness to be his guardian, she said.

Roaches and rodents aren’t only a problem because they trigger asthma; infestations change how people eat.

David’s asthma prevents him from running around. As a result, he has gained weight. Estrella would add more fresh fruits and vegetable to his diet, but where would she put them?

It does no good to try and keep fresh fruits on the counter if they will be consumed by roaches and mice before they can be eaten as a snack. Food left in decades-old refrigerators stands little chance against roaches, so tenants often have an incentive to consume everything they have in one sitting.

The city invests millions of dollars to bring fresh fruits and vegetables to low-income neighborhoods and provide residents with an alternative to processed and fast food that’s high in sodium, a contributing factor in hypertension and heart disease, the No. 1 killer in New York. But none of that is practical for a family living in an apartment where leaving bananas on the counter or peaches in the refrigerator is akin to laying out a welcome mat for bugs.

In an effort to tackle the problem herself, Estrella recently shelled out $180 from her monthly benefits check to rent a new refrigerator from Rent-A-Center because the city would not supply one that could keep out roaches.

Conditions outside an apartment can further exacerbate problems. Elevators in NYCHA buildings are out, on average, once a month, according to the mayor’s management report, and it takes about 10 hours to repair. For people living with asthma, that’s more than inconvenient; it’s a health hazard.

When the elevator is out, Estrella won’t risk having her son climb nearly two dozen flights.

“He could die on me,” she said. So she pays $12 for a cab ride to her mother’s house, drops off David and then takes the bus back. She’ll climb the flights, but it isn’t easy because there are no windows. The air gets thicker and dustier as she climbs. She’ll walk five floors, go into the hallway for about five minutes and then climb another five flights.

Once outside the building, a primary concern is safety. When neighborhoods aren’t safe, people are more likely to stay indoors, among the allergens.

Hernandez, taking stock of all the stressors thousands of tenants face every day, compared it to concrete that slowly degrades.

“This is what happens with chronic stress,” she said. “The stress is coming in so many different forms that it eventually starts to deplete physiological functions and introduce opportunities for chronic disease.”

The cycle continues as people turn to sugar, salt, smoke, alcohol and drugs to cope with the enormous stress.

“These children never escape the bounds of that hardship,” Hernandez said. “That starts to weigh on them and their little bodies — those little bodies become adult bodies.”

Estrella’s efforts to make her public housing apartment a healthier environment for her son, and herself, have largely come to naught.

Staff from the city have frequented her apartment, promising repairs, but rarely does anything get fixed. The vents in her bathroom or hallway rarely work to circulate the air. Even on a mild March afternoon, with both living room windows open, the air had a stale quality. Being on the top floor doesn’t help. Water leaks down from the roof, exacerbating the mold and the dust. Particulates from cigarette smoke drift upward.

She has a litany of unfilled work orders, problems that have been left unattended for years. She needs new cabinets and new windows. The humidity has warped the door so that there is now a large space between the floor and the bottom of the frame, plenty of room for dust and roaches from the hallway to come through. The place needs to be painted. The stove is busted. She needs the mold remediated.

But it’s the air to which she keeps returning. It’s the air that is literally killing her and her son.

Estrella, who never had asthma attacks until she moved into this apartment, has begun waking in the middle of the night, gasping for air.

Even their dog has coughing fits.

“To tell you the truth, all I want them to do is give us air,” she said. “We really need the air because we are dying up here. … I’m grateful for New York City housing. I just feel like they could help us out. Let us breathe. Just give us some air. That’s all I want. I need the air. I can’t do it no more. Some nights we can’t breathe. It’s crazy.”