One in five households includes a person with asthma, but no one knows exactly
which of many factors are to blame.
By Jennifer L. Boen of The News-Sentinel
Grayen Bowers and his family rang in the new millennium in a hospital emergency room. It was one of numerous hospitalizations the toddler had before he was finally diagnosed with asthma.
Five-year-old Devin Hubbard's trip to the zoo last fall could have been his last. While riding a pony during the outing, the Fort Wayne youngster broke out in hives and began to struggle for breath. He was having an asthma attack.
In March, Andrew Bosell, 10, joined other fifth-graders from J.R. Watson Elementary School in Auburn on a field trip to a maple syrup farm. In the boiling room, where the sugary fumes filled the air, Andrew began coughing and gasping for air. It took several days of hospitalization before his asthma was under control.
"I felt really scared," Andrew recalled.
The three boys are among an estimated 5 million children and 12 million adults in the United States diagnosed with asthma. In fact, one of five households includes an asthmatic. Andrew, Grayen and Devin are among the fortunate ones because they received aggressive treatment that saved their lives.
But an alarming number of people aren't so lucky. Asthma is killing people, and more cases of it are being reported. Yet no one seems to know the answer why.
How does this illness creep into an infant's lungs, causing the baby's straw-sized airway to gradually close, or move fleetingly into a healthy adult, constricting, choking, squeezing out breath and life with viselike power?
Researchers point to many possible factors: indoor air pollution, lifestyle, less-resistant immune systems. But no one is sure to what extent these factors may contribute to the increase in asthma cases and asthma-related deaths.
In 1998, the most recent year statistics are available, 5,434 people died from the disease in the United States, with the death rate among 5- to 24-year-olds doubling over the last two decades, according to the U.S. Centers for Disease Control and Prevention.
In Indiana, 1,079 people died from asthma between 1989 and 1998, including 38 in Allen County, according to State Department of Health records. And still, the records could be skewed because there is no requirement to track asthma-related deaths, some of which may be blamed on bronchitis, pneumonia or other ailments.
"Based on the trends in the 1990s, unlike other chronic diseases, statistics for asthma have been going in the wrong direction." said Dr. Stephen Redd, chief of Air Pollution and Respiratory Health in the Centers for Disease Control's National Center for Environmental Health.
"There really is an epidemic of asthma. The prevalence of asthma and deaths from asthma have gone up. There's this huge problem of increase," said Dr. Norman Edelman, dean of the School of Medicine at State University of New York at Stony Brook and consultant to scientific affairs for the American Lung Association.
Twelve-year-old Jon Flasch was one of the unlucky ones. He died in May 1999 at his Indianapolis home, while his parents tried to revive him from an asthma attack.
"The word here is you can die from asthma, and you can die quickly," said Jon's father, Charles Flasch, who said Jon was treated for the illness since the age of 6, when asthma was diagnosed.
About 5 percent of the U.S. population has asthma, with the highest proportion, 7.4 percent, in the school-aged group. Asthma is now the No. 1 reason for children's hospitalizations and missed school days and the primary reason for half a million emergency room visits and nearly 2 million hospitalizations annually in the United States.
Historically, the incidence was higher — or perceived to be so — in poor neighborhoods, but the disease is increasingly hitting suburbia. Among Allen County's 14 high schools, suburban Homestead High School has nearly a 10 percent asthma rate, among the highest in northeast Indiana.
While suburban kids may see the doctor with more regularity, lending to higher rates of diagnoses, some research points to newer, tighter-built houses as the culprit. The homes seal out fresh air and seal in fumes, odors and pollutants that could trigger asthma.
The direct and indirect costs of asthma likewise are skyrocketing. According to the National Center for Health Statistics, Americans annually spend about $7.5 billion on asthma treatment, with almost half the amount associated with hospitalization and emergency-room use. Another $1.2 billion is blamed on the loss of worker productivity due to parents caring for asthmatic children who miss school.
Although African Americans have only a slightly higher incidence of asthma than whites, they are four to six times more likely to die from the disease. Lack of accessible, affordable health care — particularly for costly medications — is partly to blame.
Such is the case for Philip Harris, 18. The Fort Wayne man's asthma prescriptions can easily cost more than $200 a month, but he no longer qualifies for Medicaid and his health insurance has not yet started at his new job. These days he depends more on an inhaler containing a rescue medication, rather than on a preventive drug — a key reason for the rise in deaths from the respiratory disease, experts say.
Allergens, pollution, increased time indoors and even fewer illnesses in childhood may all be leading to the rise of the disease, which has more than tripled in the last 10 years worldwide.
"I wish I could give one reason," said Dr. William Martin II, director of the Asthma Clinical Research Center at Indiana University School of Medicine in Indianapolis.
"Clearly the environment does play a role, although we do not have good cause-effect mechanisms to link pollution with asthma," Martin said.
"There is also a hypothesis that childhood infections are, ironically, protective to asthma," raising the question of over-immunization of children.
Much has been discovered about the disease in recent years. Before 1980, physicians typically viewed asthma as a disease caused by spasm of the airways brought on by an allergic response, a virus or some other irritant such as smoke.
In the mid- to late 1980s, inflammation within the airways was widely recognized as a factor, and treatment protocols began to change.
In 1991, the National Institutes of Health/National Heart, Lung and Blood Institute convened the first Expert Panel on the Management of Asthma, which published recommendations for treating asthma with both bronchodilating and anti-inflammatory drugs.
Six years later, the second expert panel published updated guidelines reflecting the importance of regularly monitoring the flow of air in the asthmatic's lungs and stressing patient education.
But the guidelines, which can be time-consuming for doctors to explain to patients, are frequently not followed by primary-care physicians, some experts say.
"There are data nationally that indicate physicians do not treat the inflammatory condition adequately," Martin said.
Portions of the 1997 guidelines are already outdated, noted Betsy Hardesty, an inner-city Fort Wayne nurse practitioner with advanced training in asthma treatment.
New drugs and methods of administering them are changing so rapidly that physicians not specializing in respiratory diseases are hard-pressed to keep up with the latest asthma treatment developments, she said.
Additionally, doctors are reluctant to label people with asthma because of many reasons, including insurance issues and the impact on patients and families.
"I have wondered, how many times in the hospital does it take before someone puts the necessary label on it so you can start the treatment?" said Grayen's mother, DeAnna Bowers.
"I kind of understand why the doctors hesitated to call it asthma. Asthma carries a certain label. When you think of an asthmatic child, you usually think of a child that has to sit inside, when all the other kids are outside playing."
Whatever the reasons for the rise in rates and deaths, asthma is one disease for which public health efforts are not working, said Surgeon General David Satcher at the 1999 International Conference of the American Lung Association and American Thoracic Society in San Diego.
"The challenge of medicine is how to transfer information about new medications and new technologies to the person who can benefit," Martin said. "This stands true not only for guidelines for asthma but for numerous diseases.
"But it will take everyone. You need the print media and television and radio and practitioners – primary care and nurses – to be involved in educating the public. The incidence (of asthma) is increasing," Martin added. "We don't really know why. That's why we need research."
Experts agree that deaths will decrease if the disease is better managed.
"Asthma management involves social issues, community issues — not just giving patients the right drug," said Edelman. "Proper management is not just `take the medicine and call me if you're not doing well.' "
The records of Parkview, Lutheran, St. Joseph and Whitley hospitals show most chronic asthmatics live in the inner core of the counties. However, outlying areas also show that significant numbers of asthmatics have sought emergency treatment from one of the major hospitals.
