There are few places in the world with higher rates of asthma than Red Hook, where one in four people struggle to breath.

By way of comparison, the two adjoining neighborhoods — Carroll Gardens and Cobble Hill – have rates of 8 percent – when combined with Red Hook. New York City as a whole has 5 percent population with asthma. Only East Harlem, where 19 percent of the population is diagnosed with asthma, approaches Red Hook’s 26.4 percent rate in asthma, according to the most recent local study, conducted in 2009 by the Red Hook Initiative, a local community group.

The Centers for Disease Control and Prevention (CDC) estimates about 25 million people in the United States have asthma. Every day nine people die from the disease in the country.

So why do so many in Red Hook suffer from asthma?

The answer is elusive. Poverty is often cited as a cause. But that is not the full answer. Consider that while the United States is 15th in the list of countries with the highest rate of asthma, the worst affected countries are Scotland, where 18.4 percent of population has asthma, New Zealand with 15.1 percent and Australia with 14.7 percent. Meanwhile, more impoverished countries have lower rates, like Romania, with 1.5 percent, Albania, 1.3 percent and Indonesia, where only a mere 1.1 percent of population has asthma.

“It becomes a question of how much of allergic materials are you exposed to, how many cockroaches and mice in combination with air pollution in combination with mold exposure and stress and all of these things come together,” says Dr. Matt Perzanowski, associate professor of Environmental Health Sciences at Columbia University Mailman School of Public Health. “It’s a perfect storm in an area like Red Hook.”

Marilyn Russell, a single mother of three, said she was diagnosed with asthma 16 years ago but then it suddenly went away when she was still a child. That phenomenon, said Perzanowski is not uncommon. “Asthma is somewhat transient over the course of life,” he said.

“One night I woke up and I was struggling to breathe, I told my husband to take me to the hospital,” said Russell, standing in front of a Red Hook park. “It feels like your lungs are a balloon but can’t release the air, you want to breathe but you can’t get anything in there and you hear the wheezing.”

“When you use your rescue inhaler, you breathe it in and try to hold your breath for a couple of seconds to let the medicine work, you use two puffs on the inhaler, one at a time, the first one is hardest, the second one is usually easier – then it’s like instant relief and you can actually breathe again.” She was apprehensive about her asthma when she was pregnant. “I was concerned about using the inhaler – the doctor said it is more dangerous if I can’t breathe.”

Red Hook is a neighborhood with a few parks, a gentle waterfront, a century-old tavern known as Sunny’s Bar and is home to the largest public housing project in the borough, the Red Hook Houses. Some 11,000 people live in Red Hook, most of them African American and Hispanic. The poverty rate, according to the Red Hook Initiative, is 20.6 percent – compared with 16 percent for the state as a whole. Even as Red Hook experiences the arrival of such consumer magnets as Ikea and Fairway and gentrification that has seen a boom in housing prices – a townhouse that went for $525,000 in 2005 is on the market for almost $2.5 million today — almost 72 percent of the population lives in the Red Hook Houses.

Red Hook Houses is a vast complex with some 2900 apartments spread over 30 buildings that are often in a poor state of repair. The New York City Housing Authority has a backlog of 420,000 repair orders. District Council 37, New York City’s Largest Public Employee Union reports that “tenants can wait two years or more for even minor repairs.”

“The government needs to upgrade public housing, they got all the money for it and they did not do anything, they are not cleaning it,” said Darlene Bobb, a resident of the projects. “We do not have to live like animals.”

In fact, in its 2009 asthma survey, the Red Hook Initiative reported that a third of those who said they had asthma also reported mold in their apartments.

“What is pretty clear is having a damp home is related to asthma symptoms,” Perzanowski said. The point is underscored by a 2004 report by the Institute of Medicine, a Washington-based nonprofit, which connected mold and water damage to asthma symptoms. Red Hook was among the neighborhoods hit hardest by Hurricane Sandy, where flooding and water damages were extensive.

But environment alone does explain why one neighborhood would have such high asthma rates. Genetics, too, may well play a role. A “risk gene related to detoxifying some of the air pollutants,” as Perzanowski said “was slightly more common in African Americans and Hispanics.” Red Hook’s population is 56.4 percent African-American and 42 percent Hispanic. “To disentangle race and this ethnicity from socio-economic status in this country is very difficult,” he added. “There is some suggestion that there might be a genetic component as well – that African American and Hispanics are more likely to develop asthma.”

The costs of life and medical care are tremendous. In 2007 it amounted to $56 billion, according to the CDC, an increase of 6 percent from the year 2002. 40 percent uninsured patients could not afford prescription medicine and a further 11 percent insured patients were also unable to pay for their medicine. CDC also reports that from 2001 to 2009, asthma diagnoses grew by 4.3 million, and that the “rates rose the most among black children, almost a 50 percent increase.”

In addition, the report went on, “more than half, 59 percent, of children and one-third of adults who had an asthma attack missed school or work because of asthma in 2008.”

IKEA and Fairway have brought increased truck and car traffic; it is a rare weekend day when Ikea’s vast lot is not packed. Red Hook, once a shipping center, still has a container terminal and a modest shipping traffic; the cruise ship Queen Mary II docks here. All these increase the levels of pollution, or as Perzanowski puts it, “combustion particles” in the air.

“We talk of particles like soot coming out of a truck or a chimney and the burning of diesel fuel as opposed to combustion particles released by heating oil in higher income neighborhoods like Upper East Side,” he said. Although, they too trigger allergies, poverty can worsen the situation.

“We observed in one of our study where we were looking at cockroach exposure and combustion byproduct exposure, we found that it was a combination of those two that led to kids being more likely to develop allergies,” said Perzanowski. So while it may be a combination of any given factors that trigger asthma in one group of people, it might be a completely different set of reasons for another group.

Consider the case of Pakistan, a developing country where asthma rates are low. “One of the causes of greater risk of asthma is the harsher climate of America as opposed to Pakistan, it is also the prevalence of high polluting industries and occupational hazards, like inhaling polluted or contaminated air in and around factories,” said Dr. Shahab Ahmed Khan, of the District Headquarter Hospital in Faisalabad. Even Islamabad, the capital which is also known as the asthma capital, has a rate of only 5 percent. The cause: mulberry trees, whose pollen and fruit trigger allergic reactions.

Meanwhile, in neighborhoods like Red Hook, the breathing difficulties, questions and research continues. Perzanowski recently was awarded a $720,000 by the Department of Housing and Urban Development to examine the links between mold and asthma.