Quality care key to living with asthma
As Dr. Christopher Fanta tells the story, there’s good and bad news about asthma.
First the good. Asthma is a livable disease.
“It’s become so common,” Dr. Fanta says. “It’s something that so many people and schools and workplaces have to deal with. But it’s a livable disease. People with asthma can lead full, active, and even athletic lives.”
That’s the good news. The bad news is that poorly controlled asthma can have a huge impact on day-to-day lives, especially on the parents of children suffering from the disease.
“There’s nothing worse or more frightening for a parent than seeing their child gasping for air,” Fanta says. “I can’t tell you how many parents have had to cancel plans as a result of an unexpected and necessary trip to the emergency room.”
Dr. Fanta should know. He co-founded Partners Asthma Center and is its director. He is also co-author of “The Harvard Medical School Guide to Taking Control of Asthma.”
“With good medical care,” Dr. Fanta says, “the vast majority of people with asthma do very well most of the time. The problem is getting these modern treatments to the people who need them the most.”
The cause of asthma is unknown, and there is no cure. This chronic disease impacts the bronchial tubes, the passageways that allow air to enter and exit the lungs. For those who suffer from asthma, the bronchial tubes become inflamed, causing them to swell and at times to constrict tightly. As part of this inflammation, cells in the tubes may produce thick, excess mucus, further blocking the passageways, making it difficult to breathe. Asthma attacks range from mild to severe, and can result in death.
Typical symptoms of asthma are shortness of breath, tightness in the chest, wheezing and coughing. The triggers of an asthma attack are many and include dust, animal dander, cockroaches, perfume, tobacco smoke, cold weather, molds, and air pollution.
In the United States alone, roughly 15 million people have asthma, 4 million of whom are children under the age of 15. The disease accounts for half a million hospitalizations, two million emergency room visits, and 5000 deaths a year. Blacks and Hispanics are three times more likely than whites to be hospitalized for asthma or die from the disease.
By all accounts, the problem is greatest in New England, and particularly in minority neighborhoods throughout the region. Dr. Fanta offered a partial explanation. “The very high prevalence in New England could reflect our ability to detect cases — and report them,” he said.
One thing is clear. In Boston, the highest asthma rates are found in Roxbury, Dorchester, Mattapan, Jamaica Plain, and the South End.
In 2003, asthma accounted for over 6,500 emergency department visits at a rate of 11 visits per 1,000 population, as reported in “The Health of Boston 2006,” published by the Boston Public Health Commission. The rates were higher for males, blacks, and residents of Roxbury. Likewise, children under the age of five experienced the highest rate of visits, exceeding the next highest category — children between five and 17 — by more than 200 percent.
Emergency department visits for asthma by race are alarming. In 2003, the rate of visits by blacks was ten times higher than that for Asians, six and a half times greater than that for whites, and 38 percent higher than that for Latinos. Blacks and Latinos constituted almost 75 percent of all emergency department visits for asthma, further demonstrating the prevalence and severity of the disease among minorities.
Similarly, rates for hospitalization were higher for children under the age of five and residents of Roxbury. Boston has double the statewide average of hospitalizations for asthma for children age five years and younger. In 2004, Latinos experienced a slightly higher rate of hospitalization for asthma than blacks, but both groups were three times more likely to be hospitalized than Asians and whites.
Some of the causes are environmental, but Dr. Fanta distinguishes between factors making asthma worse, like air pollution, and things that may cause people to develop asthma in the first place.
“There is no question that air pollution is a problem,” explains Dr. Fanta, “that if a bus is parked outside of your window and it is revving its engine with all the diesel fumes blowing in the air, that is not good for your breathing, especially if you have asthma.”
But many have tried to link the rising number of reported asthma cases with an increase in global air pollution. “It’s not that simple,” Dr. Fanta said. “The rising prevalence of asthma is not due to an increase in air pollution in the world. But if you have asthma and live in a polluted environment, it does make things worse.”
All too often, the polluted environments are at schools.
In Boston, asthma is the most common illness of public school children and a common reason for missed days at school and frequent visits to the school nurse, according to a study produced last March by the Massachusetts Coalition for Occupational Safety and Health (MassCOSH) and the Boston Urban Asthma Coalition (BUAC).
MassCOSH is a non-profit organization that coordinates the Mass Healthy Schools Network, which promotes environmentally safe and healthy schools. BUAC serves as a clearinghouse and network to address the asthma crisis in low-income neighborhoods.
The study revealed that, during the 2004-2005 school year, a high percentage of Boston public schools had environmental conditions that are known to trigger asthma attacks. Eighty-five percent had water leaks, 63 percent had overt signs of mice, while over one-third had visible signs of mold. Furthermore, it was discovered that schools with the highest percentage of environmental problems also had a higher percentage of children with asthma.
Most striking was the Harvard Kent Elementary School in Charlestown, where almost 63 percent of the rooms inspected showed water stains. Another troublesome building was the James Curley Elementary School in Jamaica Plain, where roughly 61 percent of all rooms inspected showed overt pest signs. Both these schools have asthma rates of 12.25 and 10.69 percent, respectively, significantly higher than the estimated city average of seven percent.
For parents, the problem is complicated, especially for working class families. “If a child has a serious episode,” Dr. Fanta says, “then that probably means they’ll miss school and a parent will need to take off from work to get the child to a medical provider and stay home with them after the visit.”
The solutions are multifaceted, and should be placed in two broad categories. The first are treatments designed to relieve symptoms or treat flare-ups. The second are measures designed to prevent symptoms.
Quick relief may be found in albuterol or other short-acting bronchodilators, while other medications taken daily, such as a corticosteroid inhaler or a leukotriene blocker (examples include Flovent and Singulair), offer long-term control of symptoms. For those with strong allergies as well, over-the-counter medicines, such as histamines and decongestants can be helpful.
The way it works, Dr. Fanta explains, is that some patients with asthma have their asthma made worse by allergies, but others do not. Allergies can also cause sneezing, a stuffy or watery nose, and tearing eyes. Allergies and asthma are two distinct, but closely related medical conditions and, for those who have both, treating their allergies can greatly help their asthma.
Confusing as it may be, Dr. Fanta has one clear recommendation. “Asthma doesn’t go away when your symptoms go away,” he said. “You still have asthma even when you feel well. You still have vulnerable bronchial tubes. If you are at the wrong place at the wrong time, you are very susceptible to having an attack. So the best strategy is to take preventive medicine everyday.”
Measures designed to prevent symptoms are a little more complicated. “The approach is to reduce the exposures to asthma triggers in the home, school or workplace and to take preventive medicines,” Dr. Fanta said.
Even that has good news. “The law is on your side,” Dr. Fanta said. “Under the American with Disabilities Act, the right to breathe is protected and schools and workplaces must make every effort to improve their environments.” |
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Christopher H. Fanta, M.D.
Director, Partners Asthma Center
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