Thursday, November 01, 2001

When Asthma Doesn’t Play Fair: The Overwhelming Problem Among Disadvantaged Children

When Asthma Doesn’t Play Fair: The Overwhelming Problem Among Disadvantaged Children
Asthma Magazine
November/December 2001

Asthma can be a difficult disease to manage, particularly for young children. Asthma has been affecting more and more children during the past 20 years, particularly low-income and minority kids. Although minority and disadvantaged children are at the highest risk of developing asthma, they are the least likely to get diagnosed or treated, according to an American Lung Association report presented at the World Asthma Meeting in May 2001.

Why are so many minority and low-income kids developing asthma now? The overall stress of poverty may partially explain why so many of these children suffer from serious asthmatic episodes. For example, almost 40% of all homeless children nationwide have asthma. A Thomas Jefferson University study found asthma hospitalization rates increased directly in association with rates of poverty among blacks and whites in Philadelphia. In the same vein, asthma-related deaths in Arizona rose 11% statewide between 1980-1983, exceeding the national average, particularly among Latinos and other minorities. The state’s hospitalization rates for blacks is four times higher than for whites, the Arizona Asthma Coalition reports.

In disadvantaged urban areas like South Bronx, New York 15% of all children have asthma. Although a recent report found pediatric hospitalization rates had dropped in New York City, thanks largely [due to] a program called the Childhood Asthma Initiative, it is still a city full of asthma sufferers. Triggers such as crowded and unventilated homes, roaches, mouse and rat droppings, and animal dander are some reasons for high hospitalization rates among disadvantaged youth. Urban pollution certainly doesn’t help either, but experts don’t know exactly why asthma has exploded and become such a major health problem among these groups.

It’s a challenge that Shawn Bowen, MD, a pediatric asthma specialist for the Childhood Asthma Initiative, a partner of the Children’s Health Fun and the Montefiore Medical Center, faces every day. In practice with minority and disadvantaged populations for the past 5 years, Bowen says getting his patients’ families to embrace a proactive, preventative approach to managing their children’s asthma can be difficult. “Minority populations are high emergency room users,” Bowen says. And it’s useless to write a prescription for a newly diagnosed asthmatic child if the family doesn’t have the money to purchase the medicine. Bowen finds that he must work closely with families to make sure they follow up with the proper asthma treatment.

To successfully manage pediatric asthma, physicians say early diagnosis and treatment are crucial. Many patients of newly diagnosed asthmatics believe their child will outgrow the disease, a common myth. The reality is that untreated asthma can lead to decreased lung function and long-term lung disease later in life. Constant exposure to smoking, roaches, animal dander, and inadequate medical care will translate to missed school, emergency department visits, and overall poor health for asthmatic children. Asthma is the chronic condition responsible for the greatest number of school absences nationwide.

Asthma is a truly a disease that affects the entire family. Newly diagnosed asthma can meant a pet must be given away or other significant adjustments must be made. At the same time, when a low-income family is experiencing crisis, a child’s asthma may not be a priority, Bowen says. Recalling one situation, he says a single mother stopped bringing her child for follow-up appointments after her public assistance ended. When the organization’s nurse practitioner visited the home, she realized the loss of public assistance was a serious problem for the family’s health: not only was the child not able to get his medications, but the mother was not able to get her prescription filled for a serious psychiatric disorder. Once the situation was resolved, Bowen was able to check on his patient and make sure his asthma was controlled. “It’s a fragile situation. It requires constant monitoring,” he says.

Bowen finds that many of his patients typically don’t come for their follow-up appointments unless urged. “When people are feeling better, they don’t come for their appointments,” he says. Asthma is a chronic illness that needs to be monitored and controlled with consistent and ongoing medical care; otherwise it can flare out of control quickly.

In the case of homeless asthmatic children moving from shelter to shelter, it’s almost impossible to control risky environmental triggers like smoke, moldy carpets, pollution and stress. When faced with an asthma episode, many disadvantaged kids (and their parents) often don’t have access to the basic tools, such as a quick-relief inhaler, to help control them. “These are people who have been through a lot,” Bowen explains. Many of his patients are adjusting to a myriad of issues, including surviving welfare, leaving a domestic violence, or recovering from drug addiction or alcoholism. He and his staff try to help his patients’ families access the social services and medical resources they need.

According to experts, every aspect of a family’s lifestyle must be examined to properly manage asthma. Seasonal changes can mean renewed flare-ups, with seasons allergens, summer smog, or colr and flue season each presenting potent asthma triggers. Although a family may try to shield their child from cigarette smoke or make an effort to control his or her exposure to dust mites, the home may never be trigger-free. One study recently published in the journal Pediatrics (2001; 107:505-11) associated childhood asthma attacks with the use of a gas stove or oven for heating a common practice in the Southeast among low-income families. Keeping the oven on for heat could serve as a constant trigger, although the parents might not make the connection between their child’s repeated asthma attacks and the fact the oven is on. The high level of nitrogen dioxide and other emissions can be triggers for asthma, the report suggests.

Bowen finds a home visit and follow-up office visits are key in successfully treating his asthma patients. A Childhood Asthma Initiative nurse practitioner follows up with home or shelter visits, taking notes of potential visits. “She takes note of [such things as] the dust on the windows and the cigarette ash in the ashtray and then sits down with the family to talk about how they can cut down on triggers,” he says.

Bowen also explains how he tries to work with his patients and their families. “In my 5 years, I have not been able to get [some parents] to stop smoking,” he admits. But in other ways, he works to educate his patients as to the importance of removing carpeting, changing bedding, giving pets away, and dusting or vacuuming more often. He also tries to find a way to accommodate his patients’ alternative medicine treatments for asthma, making sure they understand the importance of taking prescribed anti-inflammatories and bronchodilators at the same time. “People swear up and down by different herbal remedies,” he says, mentioning herbal tea, Echinacea, and similar treatments. “As long as the remedies are not harmful, I try to be respectful,” he says.

Stabilizing family situations, building trust between doctor and patient, teaching and re-teaching doctor and children and parents about asthma management measures are the most important approaches to help low-income children with asthma live successful and healthy lives. The end results of these efforts is the empowerment of asthmatic kids and their families to know how they can control asthma instead of being controlled by it. Ending the viscous cycle of ER visits and hospitalizations among young patients is essential. “We have to provide asthma information in any way we can to get people to start understanding the disease,” Bowen explains.