Published Online: March 26, 1997

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The Baltimore schools are getting help from a local hospital to fight a near epidemic of asthma among the city's schoolchildren.

In the Oliver neighborhood, one of this city's poorest, every other row house seems to be boarded up with plywood and stamped with the following: "PRIVATE PROPERTY. NO TRESPASSING, NO LOITERING. If animal is trapped inside, call 396-6286." Some houses literally are falling down; others have ghostly burn marks above the window openings. One ancient-looking building, near the corner of North Avenue and Washington Street, has a sign that reads, "For Sale. $12,000." Even at that price, it's unlikely the house will be changing hands soon.

In the midst of this urban squalor sits Harford Heights Elementary School, a sprawling complex of brown-brick buildings that houses more than 1,700 K-5 students, nearly all of them African-American.

The school, built more than 20 years ago, is nondescript--almost bunkerlike--on the outside, but inside it's clean and neat, with potted plants hanging from the hallway ceilings. The atmosphere is warm and friendly.

Like many inner-city schools, Harford Heights offers its students a welcome sanctuary from the world outside its walls.

Some realities of modern-day life, however, know no boundaries. A disturbingly high number of students at the school have asthma, a chronic lung disease.

In this regard, Harford Heights is not unique. Asthma quietly has become one of the most serious health problems among the nation's urban poor. Visit almost any inner-city school these days, and you'll find the disease in near-epidemic proportions.

At Harford Heights, 5th grade teacher Charles Williams, who has worked at the school since it opened, has watched the problem grow steadily worse over the years.

"In my class now," he says, "I have more students with asthma than I've ever had. Once upon a time, it was like one or two. Now, I'm seeing four, five--in one class. At the moment, I have at least six kids with asthma. One of them has been home all week."

Things are so bad that the school's health clinic now has three compressor-driven nebulizers, which use air tubes and mouthpieces to deliver medicine directly to the lungs of asthmatics.

Maggie Singleton, the school nurse, has a box in her office with 40 individual mouthpieces, one for each student who is authorized to use a nebulizer. Some children come to the clinic every day for treatment, which lasts about 15 minutes; others come in only when they feel an asthma attack coming on.

Harford Heights is one of the largest elementary schools in the country, but even when you take that into account, 40 is an astonishingly high number of students at any one school to have asthma. And yet the real figure likely is much higher, experts say. By contrast, for a suburban school to have more than a handful of asthmatics is highly unusual.

"Asthma has become quite the specialty around here," says Judy Kandel, the nurse practitioner who runs the health clinic at Harford Heights.

After a steady decline in the 1970s, the prevalence of asthma, hospitalizations for asthma, and deaths due to asthma all began increasing in the 1980s, a trend that continues. An estimated 15 million Americans, or 5 percent of the population, have the disease, which is characterized by wheezing, coughing, shortness of breath, inflammation of the airways, and tightening of the chest muscles.

Studies show that a disproportionate number of asthmatics live in inner cities. In the South Bronx section in New York City, the incidence rate among children is 8.3 percent, twice the national average; Lincoln Hospital, the area's main medical center, receives more than 13,000 visits a year for the disease.

Wherever there is urban poverty, there is asthma.

In his 1995 book Amazing Grace: The Lives of Children and the Conscience of a Nation, author and education advocate Jonathan Kozol describes his shock at seeing so many children in the South Bronx carrying inhalers: "The brand that I have seen most frequently is Proventil," he writes, "a yellow and orange plastic unit, which is almost as much a standard piece of 'traveling equipment' for some of the little kids as beepers seem to be for some of the teenagers."

He adds: "I can't remember ever being in another place in the United States in which so many children spoke of having difficulty breathing."

A City Disease

Experts say the South Bronx is easily the worst place in the nation for asthma, but the disease is now raging in virtually every large city in America. In short, wherever there is urban poverty, there is asthma.

The chief culprit appears to be substandard living conditions, which create a veritable breeding ground for the allergens that can trigger asthma, such as cockroach feces and body parts, dust mites, and rat and mouse urine.

"Poverty, substandard housing that results in increased exposure to certain indoor allergens, lack of education, inadequate access to health care, and the failure to take appropriate medications may all contribute to the risk of having a severe asthma attack or, more tragically, of dying from asthma," the National Institute of Allergy and Infectious Diseases states.

But why has asthma gotten worse, especially among the poor? The reasons are unclear, but researchers have some theories.

Dr. Peyton Eggleston, a professor of pediatrics at Johns Hopkins Hospital here and an expert on inner-city asthma, believes it all boils down to this: People are spending more time indoors. "To me," he says, "that's the thing that makes the most sense. And when people stay inside their houses, they're exposed to more allergens.

"People have TVs, so they stay indoors," he says. "They have air conditioning--and lots of people in the inner city do have air conditioning. Crime is another reason. And because their housing is old and poor, and because their lives are chaotic, they have a higher exposure to a lot of different allergens, including cockroaches. They can't and don't clean up their environment in the same way that a middle-class family can. I mean, half the houses [in the inner city] don't have vacuum cleaners, and yet there's a lot of wall-to-wall carpet being used."

Dr. Eggleston discounts outdoor air pollution, which some researchers have cited as a possible contributing factor. Air quality, he points out, has been improving in most of the nation's cities. "And yet asthma is increasing," he says. "So I don't think outdoor pollutants are really related to the problem." In fact, he recommends that asthmatics get fresh air as often as possible.

Doctors at Johns Hopkins are all too familiar with asthma, which accounts for 10 percent of the hospital's emergency room visits.

Whatever the reasons for the growing number of asthma cases, the effects are far-reaching. According to the Asthma and Allergy Foundation of America, nearly 3 million workdays are lost each year because of the disease. Moreover, it is the nation's leading cause of school absenteeism.

Help From the Hospital

It's lunch hour on a cold, gray December day, and the health clinic at Harford Heights Elementary is buzzing with activity. Several students have dropped in to be treated for asthma. One of them, 11-year-old Dominique Williams, was sitting in his classroom when he started to feel dizzy. "And my chest was hurting," he says.

Ms. Singleton, the nurse, checks his breathing. "Right now," she says, "his lungs actually sound quite clear." She determines that the boy doesn't need to use the nebulizer; his inhaler, which he keeps in the clinic, should do the trick.

Meanwhile, a lanky boy named Craig Lyles, dressed in baggy green pants and black Fila sneakers, is hooked up to the nebulizer, a small metal box that emits a steady humming sound.

"Craig used to come in every day at noon for this," Ms. Singleton says. "But he had a pretty bad attack back in October and ended up being hospitalized. Then his doctor changed his medicine around. So now he comes in only when he needs it, and he takes his other medicine more consistently."

Like Dominique, Craig was sitting in his class when he felt the stirrings of an attack, so he hightailed it to the clinic.

After a few minutes, the nebulizer suddenly stops working. "That's weird," Ms. Singleton says. "Something must be wrong with the outlet." She picks up the machine, with Craig still attached, and moves them both to another room, where she plugs in the nebulizer. Still nothing. Finally, she bangs it with her fist, and it starts humming again. The nurse leaves the room, but a few moments later she hears a loud crash. Craig, who is constantly in motion, has managed to pull the nebulizer off the table and onto the floor. Ms. Singleton rolls her eyes. "And I wonder why they don't work," she says. "Craig, honey, you need to sit still, please."

"I didn't do that!" he replies. "It was moving by itself!"

Ms. Singleton rolls her eyes again.

Fifteen minutes later, Craig is finished.

Judy Kandel, the nurse practitioner who runs the clinic, tells the boy, "Will you please go home and tell your mom that you got a treatment here, OK? And that you'll probably need another treatment in a few more hours." Craig nods his answer yes and runs out the door, saying, "I gotta go. Bye!"

Doctors at Johns Hopkins, about a mile south of Harford Heights, are all too familiar with asthma, which accounts for 10 percent of the hospital's emergency room visits.

Five years ago, the hospital's office of community health decided to create a program that would address the problem in the immediate neighborhood. Dr. Eggleston was pegged to run the pilot effort, called the Oliver Community School-Based Asthma Program.

Dr. Eggleston and his staff launched the initiative at four elementary schools, including Harford Heights. With the help of a $50,000 grant from the Abell Foundation, a local charity, the program was inaugurated in 1992.

Daphne Morgan, a registered nurse, coordinates the effort out of a small office at the Harford Heights health clinic. The goal is to teach children with asthma how to manage their disease, which in turn will reduce school absences and decrease emergency room and overnight hospital visits.

"By making [the asthma program] school-based, you have the asthma kids 'captured.' And we can stay in touch with them once they've been identified."

Dr. Peyton Eggleston
Professor of Pediatrics,
Johns Hopkins Hospital

Every semester, Ms. Morgan selects 12 asthmatic students from each school to participate in a pullout course, developed by doctors at Georgetown and Howard universities in nearby Washington, called the A+ Asthma Club, which consists of six one-hour sessions. Meanwhile, four community health-care workers--one for each school--visit the students' homes three times a year to meet with parents, who are taught how to treat their children's asthma, how to keep their homes clear of cockroaches and other allergens, and how to obtain proper medical care.

The health-care workers provide the families with free mattress and pillow encasings (which help contain dust mites), free peak-flow meters (which measure the speed at which air is blown from the lungs), and free cockroach extermination.

More than 450 children have participated in the program. And while asthma continues to be a huge problem in the Oliver community, the initiative seems to be making a difference.

An informal survey shows that nearly half the program's participants had visited the emergency room for acute asthma at least once in the six months before they entered the program, and 16 percent required hospitalization. During the six months after the program ended, however, only 12 percent visited the emergency room, and only 5 percent were hospitalized.

"We think this has been an effective program," Dr. Eggleston says, "and we think it's done a lot more than other asthma programs.

"And we think it's because of the venue," he says. "By making it school-based, you have the asthmatic kids 'captured.' And we can stay in touch with them once they've been identified."

Alma Brown, the principal of Dr. Bernard Harris Elementary School, one of the four participating schools, is a fan of the program.

"Children here used to be absent a lot because of asthma," she says. "But once the program started, attendance for those students increased. Also, a sense of security increased for those students because it's pretty scary when they have an attack and they don't feel in control. This program has given them a sense of security because they know what to do. They're better able to manage their symptoms before they get to a critical stage."

The program, Ms. Brown adds, has also helped improve the historically rocky relationship between Johns Hopkins Hospital and the Oliver community. "There was the sense," she says, "and probably still is the sense, that Hopkins does a lot of research but they don't give a lot to the community. This program certainly dispels that theory."

Learning To Take Control

On a recent day, Ms. Morgan arrives at Johnston Square Elementary School, a 30-year-old red-brick building that houses 575 students, where she will begin one of the A+ Asthma Club courses.

During the six-week course, the students will learn the basics of asthma.

The nurse, who is wearing an indigo-cloth Yoruba tribal outfit called a buba, rings the buzzer at the school's entrance, but it doesn't seem to be working, so she knocks on the door until someone lets her in. Inside, she meets Vera Moore, a community health-care worker who will help her set up for the presentation.

On the floor of the stage in the school's auditorium, the two women spread out a large comforter for the children to sit on. A few minutes later, 10 students--seven boys and three girls--amble in and plop down.

Ms. Morgan passes out booklets to each student and says: "Everybody listen up. My name is Daphne, and I'm the asthma nurse. I want you to open your folders and look for the page that looks like this." She holds up her own booklet to the first lesson, which is called, "So You Have Asthma, Too."

During the six-week course, the students will learn the basics of asthma: how to know when an attack is coming, how to control the disease with proper medication, how to avoid allergens that can bring on an attack, and the like. Today, however, Ms. Morgan spends most of her time going over the rules of behavior. She gives each student a "passport" and tells them that they will get stickers if they behave well during the classes. If each student has six stickers by the end of the course, the children will be treated to a pizza party, and the student with the most stickers will get a prize.

One of the boys in the course is a 10-year-old named Jeffrey Allen. He had his first asthma attack last September. "I was wheezing," he says. "It felt like something was pounding into my chest.

"My mother took me to the hospital, and they put me on the asthma machine three times," he says, referring to a nebulizer. He missed three days of school, and when he came back, his teacher told him about the A+ Asthma Club. His younger brother, who also has asthma, is attending the course, as well.

Mary McCrea has been the principal of Johnston Square Elementary, where 95 percent of the students qualify for free lunches, for about a year and a half. "I was surprised when I got here," she says, "because I've never been around so many people with asthma, and I've been in the school system for a long time. I think we have at least 50 or so, out of 575 students. A little less than 10 percent. And those are the ones I know about. There may be a few others that we don't know about."

Like Ms. Brown, she gushes about the asthma program. "Oh, it's wonderful," she says. "It's helping the students cope better. The majority of our children who are involved with the program have found that they have a little buddy system, a real support system, with the other students in the program. They see that they're not alone, that there are many others who have asthma."

Home Checkup

It's dark when Lorraine Matthews, one of the asthma program's community health-care workers, pulls up in front of a two-story, red-brick row house on North Avenue, a few blocks from Harford Heights Elementary.

Ms. Matthews, accompanied by Ms. Morgan, has arranged to meet with Rosalind Benston and her son, Shawn Moore, a 5th grader at the school. Shawn, 10, was first diagnosed with asthma when he was 5 months old. He enrolled in the Oliver Community asthma program three years ago.

Ms. Benston, a 30-year-old single mother who works as an office manager at an apartment-management company, welcomes Ms. Matthews and Ms. Morgan into her living room.

"Now that I know how to control his asthma, I'm not afraid anymore."

Rosalind Benston
Mother of 10-year-old with asthma

Shawn, wearing a white T-shirt, green jeans, and black sneakers, is sitting on a couch, clutching a Nintendo Game Boy. The house is clean but cluttered. On one wall is a large black-velvet painting of Jesus walking on water.

Ms. Matthews has visited the house before, so she knows that Ms. Benston has taken steps to keep the dwelling free of dust and insects. So for tonight's session, she intends to quiz Shawn to find out if he's doing all the right things to keep his asthma under control.

"Do you have a peak-flow meter?" she asks the boy.

"Yes," he says.

"Do you know how to use it?"

"Yes."

"Go get it."

Shawn runs upstairs and returns a few minutes later with the device.

"It looks brand-new!" Ms. Matthews says. "Show me how to use it."

Shawn takes a deep breath and then blows hard into the meter. He's supposed to keep a daily diary of his peak-flow readings, but he hasn't been doing this lately. Ms Matthews gives him a calendar and urges him to use it. Shawn promises to do a better job of monitoring his breathing.

Ms. Matthews asks the boy if he knows how to tell if his inhaler is full, half empty, or empty. "I don't know," he says, grinning.

"Go get a pan of water," she says. Shawn goes to the kitchen and returns with a water-filled glass bowl, which he places on the coffee table. Matthews tells him to put the inhaler cartridge in the water. It sinks.

"What's that mean?" she asks.

"I don't know," Shawn says, smiling.

"He knows," his mother says.

Shawn plays dumb, but eventually he gives the correct answer: "It's full."

"Are you sure?" Ms. Matthews asks.

"Yes."

Recently, Shawn was at his grandmother's house when he had an asthma attack. He ended up at the emergency room at Johns Hopkins, where he spent half the night hooked up to a nebulizer. He missed three days of school.

"I wish I would outgrow it," he says.

"We have to deal with managing it now," Ms. Matthews tells him.

Before Shawn got involved in the Oliver Community asthma program, his mother knew relatively little about the disease. "I was scared when he used to get sick because I couldn't control it," she says.

Now, however, she knows what to do when her son feels an attack coming on. She's learned that cigarette smoke can trigger an attack, so she tries to keep Shawn away from places where people are likely to smoke. And if her son happens to come into contact with smoke, she can handle the situation. "If we go to the mall," she says, "and someone is smoking, then he'll get sick, so I'll have to take him outside."

She adds: "Now that I know how to control his asthma, I'm not afraid anymore."

Daphne Morgan's point about unavailable phone service makes it clear that inner-city asthma is much more than a medical problem.

The home visit lasts about an hour. Afterward, Ms. Morgan explains that it was a typical session with a family that has been in the program for a while. For a new family, she says, Ms. Matthews would have looked around the house to see how clean it was, and she would have asked about such things as telephone service and health insurance.

"Actually, that was a good visit, in the sense that it was comfortable for us," she says. "There are some houses where the parents are very congenial, but the environment is just not comfortable."

At some homes, she's seen rats running around on the floor. "Right around your feet," she says. "And some houses smell really bad. But I always try to remember that it's their home, and if they can live with it all the time, then I can live with it for a few minutes. So I don't make a big deal about it."

One family enrolled in the program lives on a narrow street that Ms. Morgan calls "drug row."

"I don't allow the community health-care worker to go to that home without someone going with her," she says. "And usually it's me.

"I didn't realize how dangerous that street was until one day we went there to drop off some forms, and I stayed in the car because she was only going to the door," she says. "And the houses next door to this house are both abandoned. And one of the houses has no windows and doors. And these people were just pouring in and out of this house. I thought, 'What is this?'"

She says it slowly dawned on her that she was parked in front of a crack house.

"The family, it turns out, is involved with drugs, as well," Ms. Morgan says. "They don't have beds. The first day that I went in there, the kid that we had enrolled was actually sleeping on a sofa pillow on the living room floor. She was home that day because she was sick. She had been to the emergency room the night before.

"We had just enrolled her in the program," Ms. Morgan says. "She hadn't gone to any sessions yet. She was sound asleep on the floor, sleeping like a log. And people were coming and going, walking over her. So that's a really tough house.

"However, the parent, even though she is caught up in drugs, is very conscious of taking care of the kid. She makes sure that she gets to her appointments, and she tries to make sure that she gets to school. She works with us to try to use all the resources that we have."

The house, Ms. Morgan says, doesn't have a phone. "A lot of the families don't have phones because they may have huge phone bills that they didn't pay. It's a big problem for us.

"If a kid has an attack, the neighbors may not have a phone, either, and because of the drug trade in the neighborhood, there aren't any pay phones. The city takes them out," she says. "So you could die. How are you going to call 911 if your son or daughter is having an asthma attack?"

Beyond Social Barriers

Ms. Morgan's point about phone service makes it clear that inner-city asthma is much more than a medical problem. In fact, under most circumstances, the disease is relatively easy to control. Many asthma sufferers take some kind of daily preventive medicine to thwart attacks.

"But this is a concept that is not easy for people who live on a sort of day-to-day basis, who don't plan ahead very far, who respond to crises in their environment by habit, to understand," Dr. Eggleston says. "It requires planning and understanding. It means they have to change a lot of behavior." In other words, poverty and asthma are a bad fit.

Middle-class families, on the other hand, are used to the idea of preventing bad things before they happen, and they have the resources to make the concept work--by buying health insurance, for example.

"But people in the inner city don't have access to good medical advice and care," he says. "And the system is hard for people to work with here. It's hard in some very obvious ways but also in some very subtle ways. For example, transportation to your doctor is not easy because nobody has a car. So you have to take a bus."

The federal health program has a three-month limit on prescription drugs, which makes it difficult for asthma sufferers to maintain a constant supply.

That can take a long time, Dr. Eggleston says, and when you finally get there you may have to wait a long time to see the doctor. "It's not inconceivable to spend half an afternoon going to see a doctor. And middle-class people would not put up with that."

Then there's the matter of getting a prescription filled. "The people in this neighborhood," he says, "if they want a new prescription, their doctor has to write it out for them, and it has to be handed over to the pharmacist. You can't call it in. That's a Medicaid rule."

The federal health program also has a three-month limit on prescription drugs, which makes it difficult for asthma sufferers to maintain a constant supply. "Medicaid doesn't want people to waste their services," Dr. Eggleston says, "so they pretend that there's no such thing as a chronic disease."

People with private health insurance, on the other hand, usually can get one-year, refillable supplies of drugs. "And if they start to run out," he says, "all they have to do is call up their pharmacy and drive over and pick it up.

"So there are a lot of medical and social barriers that make asthma a hard disease to take care of," Dr. Eggleston says, "even if you have a good attitude.

"One of the things that Daphne [Morgan] and the community health-care workers do is try to help people work the system and figure out how to take care of their disease under the circumstances that they have to live with," he says. "You really have to do some tricks of education to get them to change their behaviors and to understand that changing behaviors is important. But once they've been through a few months of doing this, and they understand that they haven't had to go to the emergency room, and they haven't gotten up in the middle of the night, and they haven't gotten sick, it does sort of sink in. And it's easy to keep it going. But getting there is very time-consuming."

Word about the Oliver Community School-Based Asthma Program seems to be spreading. In fact, so many people have called to find out about the effort that Dr. Eggleston decided to organize a one-day seminar titled "Confronting Asthma Where It Lives." Slated for April 10, the conference is designed for school and community nurses, managed-care providers, educators, public health administrators, and community leaders.

Dr. Eggleston hopes the seminar will lead to the establishment of similar school-based asthma programs around the country.

Meanwhile, the program will expand to four more Baltimore elementary schools next year, and Dr. Eggleston has dreams of seeing it used throughout the entire school system in the coming years. Administrators have resisted the idea, mainly because of worries about how to pay for such a large-scale effort.

But skeptics would be advised to talk to Alma Brown, the principal of Harris Elementary. "You begin to wonder how you managed before the program," she says. "And you really see the value of it. You know, some things come and go, and they're kind of faddish. This is not. It addresses a critical need."

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