Author: Pat Carpenter
Minority children in Texas are at higher risk for asthma, according to recent reports. One million children in Texas are considered asthmatic — more than ten percent of all children in the country diagnosed with the disease — and African-American and Puerto Rican kids are six times as likely to die from it as their counterparts, says a report from the National Center for Health Statistics. In the Southeastern region of the state alone, which includes the Houston-Galveston area, 76,450 children ages fourteen and under are afflicted with the condition. In 1997, 10,600 emergency room visits were related to pediatric asthma care, and over 200,000 hospitalizations in the state are still reported each year due to the disease.
Part of the problem, according to experts, is industrialization. Dr. David Rosenstreich, M.D., director of the division of allergy and immunology at the Albert Einstein College of Medicine in New York City, reports that incidences of the disease are not only increasing in the United States, but also in most developed nations. Twenty-one million Americans are currently living with the potentially fatal disorder, and that number is likely to increase.
Dr. Rosenstreich, who also served as a senior investigator on the InnerCity Asthma Study, which aims to identify factors related to the development of asthma in children, says that genes, allergies, environment, and socioeconomic factors related to quality and access to care are major contributing factors. Inner-city children in urban areas, like Dallas, Austin, and Houston, are far more vulnerable to elements that can cause or aggravate symptoms of the disease, and they are far less likely to have quality health insurance and access to outpatient health care. This would seem to validate one of the studies released this year by the non-profit organization, the Commonwealth Fund, which states that lack of health insurance is directly related to less access to care.
“If you look at inner-city children, they’re sensitized to more allergens and exposed to more allergens at higher levels in their homes, allergens that are difficult for them to avoid,” said Dr. Andrew Liu of the National Jewish Medical Center in Denver, who is also a part of the Inner-City Asthma Consortium. The Consortium, a federally-funded project involving ten medical centers nationwide, is designed to evaluate the severity of asthma in cities, as well as test treatments that block related allergic responses.
Perhaps even more disturbing is that the risk of the disease significantly increases with race. Twenty percent of Puerto Rican children have asthma, and thirteen percent of African-American kids do, as compared with eight percent of the national juvenile population. Over the last eight years, the asthma mortality rate has dropped — except in the case of minority children. Part of this could be due to genetic characteristics that make certain minorities, such as African-Americans, more sensitive to allergies and the adverse side effects that accompany the overuse of rescue remedies. But genetics alone are not enough to account for such a huge discrepancy.
In minority children, “the prevalence of asthma is about forty percent higher, but the difference in the adverse outcomes is three times, four times higher for hospitalizations,” said Dr. Laura Akinbami, researcher at the National Center for Health Statistics. “Given that we have the tools to prevent those things, that does reach the level of a public health crisis.”
The outrage surrounding this is particularly poignant when we consider that lack of health insurance could be one of the primary culprits. Poor children have less access to outpatient care — this has been proven. Many of them also lack health insurance — 1.2 million in Texas alone. These factors, combined with non-profit studies confirming that lack of access to quality healthcare is linked with lack of health insurance, would strongly suggest that lack of health insurance is a factor in the poor management of pediatric asthma. Asthma is a disease capable of being controlled with proper management, as many physicians will readily report, but that includes regular medical maintenance, which is much more difficult for poor families with inadequate, or no, health coverage to do. Instead, these families tend to rely on emergency rooms for acute attacks.
Texas Children’s Hospital in Houston, which sees one percent of all pediatric asthma patients in the United States, is working on this problem through the educational initiative, Texas Emergency Department Asthma Surveillance (TEDAS). TEDAS is designed to educate families on managing the disease, and doctors on more accurately diagnosing children’s severity and chronicity. Pediatric asthma patients seen through Texas Children’s, and four other program-participating hospitals’ emergency departments, were enrolled in a database in which their demographics, as well as their doctors’ diagnoses and evaluations were recorded. They then participated in an educational-based intervention. Asthma educators spent approximately thirty minutes with each patient, and then followed up in two weeks, then three months, to evaluate the program’s efficacy.
The results of TEDAS, a fairly simple and straightforward initiative, were significant. Emergency department staff was able to better assess patients’ chronicity and severity in even very young individuals, patients’ families and caregivers felt more confident in their ability to manage the condition, and well-asthma visits to physicians increased among participants. In addition, the program decreased the number of participants’ subsequent visits to the emergency room by forty percent.
“We see projects like TEDAS as laboratories developing models that can be replicated throughout the country,” said Gary Rachelefsky, M.D., TEDAS advisor and former president of the American Academy of Allergy, Asthma, and Immunology.
Other states have instituted similar programs with similar results. The five-year advertising campaign in New York City, the Childhood Asthma Initiative, reduced hospitalizations for asthma by one-third. In central Connecticut, the educational-based Easy Breathing Program also significantly cut emergency department visits and hospital stays.
“In a way, each [emergency department] visit represents a failure,” said Marianna Sockrider, M.D., of Texas Children’s Hospital. “Managing asthma often comes down to good care and well visits. Ideally, if families take control of their children’s asthma — following action plans, using medication and controllers, communicating with their primary care providers — most of those [emergency department] visits aren’t needed.”
What many doctors seem to miss, however, is the extent to which the lack of quality health insurance may impede this management process. It’s difficult, if not impossible, for a poor family with no health insurance to afford the necessary medications, to see the doctor several times a year, and to constantly monitor their children’s activities. TEDAS, and other initiatives, are of vital importance, but so, too, are initiatives to make sure that families are insured. Similar results may be seen if more aggressive action was taken to enroll such children in low-income, and more affordable, health insurance plans.
Massachusetts may be on to something with its requirement that all individuals get some kind of health coverage, but that such plans — even private plans — could be subsidized by the state if one is below a certain income level. In the end, it’s a collaborative effort; we, as a country, got ourselves into an industrial, pollution-based mess that is now causing or aggravating many diseases. Now it’s our job to take care of each other and get ourselves out of it.