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 Asthma steals joys of childhood Disease means painful attacks, long trips to the hospital and missed activities for children whose lungs swell and tighten when they try to breathe. Kerry Adaway-Williams slumps over a bowl of beef soup, too tired to stir the steaming broth. A gurgling cough, followed by another and another seizes the 12-year-old Fresno boy. He wraps his arms around his stomach, rocks back and forth and moans:
"It feels like someone is crushing the sides of me." Coughing is a signal that Kerry's lungs are irritated and he is on the verge of an asthma attack. It's a familiar sound in the San Joaquin Valley. More students carry asthma inhalers to school than take Ritalin tablets for hyperactivity and attention-deficit disorders. Fresno County has the highest rate of childhood asthma in the state. One of six children has the lung disease that makes them wheeze, according to a statewide health survey released in May. Almost 16% of third- and sixth-grade students in Parlier and Selma show signs of asthma, based on answers to a health questionnaire administered earlier this year. School nurses in Clovis estimate rates are close to 15% in their schools. No one knows why childhood asthma is so prevalent in the Valley. Less than 10% of children statewide are asthmatics. Nationally, the figure is 5.5% – a third the childhood asthma rate of Fresno County. Poverty and lack of access to health care could skew the Valley's numbers upward. But researchers speculate there is another factor: dirty air. Ozone irritates lungs. So do particulates – tiny bits of soot, vapors, metals and dust. The Valley has some of the highest levels of these pollutants in the country. Health officials cite the number of children with asthma in the Valley when advocating for stricter pollution controls. "We find a strong relationship between high ozone and particulate levels and acute illness," says Kevin Hamilton, a respiratory therapist and asthma educator who is a member of the Fresno-based Medical Alliance for Healthy Air. "Every year it seems to be getting worse and worse. I'm really worried about this. This is not a good trend," he says. Last year, doctors at Children's Hospital Central California admitted more than 800 children for asthma treatment and saw about 11,000 in its emergency room and clinics. Asthma was the third most common reason children were brought to the emergency room, behind upper respiratory infections and stomachaches. Parents blame exhaust from cars, sooty grit from diesel engines, dust from farming and fireplace smoke, along with irritants such as pollen, cigarette smoke and animal dander for triggering children's asthma attacks. Kerry's mother, Kimberly Williams, says: "The air has 110% to do with his asthma. If I could, I would put him in a bubble all summer."
Asthma attacks can lead to late-night emergency room visits and expensive doctor bills. Families often set up an entire support structure to deal with a disease that takes an enormous amount of resources. In Kerry's case, logistics fall to his mother and his grandmother, Lucille Williams. Kerry lives with his grandparents on weekdays because his mother works nights at a residential-care home. He lives with his single mother and 3-year-old half brother on weekends. Mother and grandmother share the duties of taking Kerry to doctor's appointments, sitting by his bedside when he is in the hospital and picking him up at school when he is sick. Each time he wheezes, they worry. Kerry has been admitted to the hospital six times in the past 10 years with asthma attacks. '... my heart is on fire' In her northeast Fresno kitchen, Lucille Williams listens to her grandson's hacking cough. She fears Kerry has pneumonia. It wouldn't be the first time an asthma attack had progressed to a lung infection. Kerry has a 3:45 p.m. doctor's appointment on this day in May. Lucille Williams lets him sleep until 1:30 p.m., when she insists he throw a robe over his T-shirt and boxer shorts and come into the kitchen for lunch. He shuffles out of his bedroom, eyes drooping and robe belt dragging the floor. Kerry barely tastes the soup congealing in the bowl in front of him. His grandmother slices an orange. She hopes the fruit will entice him to eat. Kerry sucks on the piece of orange. Coughs. Swallows. Coughs. An asthma attack feels "like my heart is on fire every time I try to breathe," he says. During an asthma attack, Kerry's airways swell and tighten. Think of it as a clogged drain: air trying to get into his lungs backs up, as the carbon dioxide that needs to get out can't escape through swollen and congested air passages. The effort Kerry must expend to breathe can be equated to sucking air through a straw – with his nose clamped shut – while running on a treadmill. Kerry's lungs are primed and cocked, like a gun ready to be fired. Exposure to any foreign irritant can pull the trigger.
Having asthma makes Kerry more vulnerable on hot, smoggy days or on cold, still mornings when wood smoke hangs like a soggy, wool blanket over the Valley. But Kerry's friends, who don't have respiratory problems, also are at risk from ozone and particulates. Pound for pound, they inhale more air than adults. They're exposed to more pollutants because they spend more time outdoors than most adults, and their developing lungs are more sensitive to ozone, dust and soot. Trips to the hospital By late afternoon, Kerry is in the doctor's office and on the verge of a full-blown asthma attack. Beads of sweat pop up on his forehead. His cheeks are red. His eyes swim beneath a glassy film, shimmering in the glare of fluorescent lights. "How are you feeling, now?" Kimberly Williams asks, leaning close to Kerry, who sits doubled over in the doctor's waiting room. "My chest hurts," he says, between barking coughs. Kerry's mother sighs. His lungs may be so inflamed and clogged, he will need to spend the night in the hospital. She is thinking about October 2001, when Kerry had a severe asthma attack. Doctors at Children's Hospital struggled to stabilize his breathing. Kerry winces at mention of going to the hospital. He doesn't want to miss a Pinedale Elementary School day at Grizzlies' stadium. He slouches deeper into the plastic chair. Fresno pediatrician Razia Sheikh thumps Kerry's back with the heel of her hand, listening through a stethoscope. Sheikh hears wheezing, an indication Kerry's lungs are not letting air flow easily in or out. Kerry's airways are having an asthmatic response. Bands of muscles are squeezing Kerry's airways. The pressure blocks air from reaching millions of tiny air sacs in his lungs, where oxygen is exchanged for carbon dioxide through cell walls. Kerry coughs, trying to dislodge a sticky wall of mucus that completes the blockade inside his airways. If Kerry's lungs don't respond to medication, the doctor warns: "He may end up going to the emergency room." No one but the mother of an asthmatic can understand what that means, says Kimberly Williams. "You're in a waiting room; you've been there for hours, your child's head against your shoulder. He can't breathe; it's midnight and you have to be at work ..."
Kerry starts to moan. "I missed a history test," he mumbles, catching his breath between explosive coughs. The Pinedale Elementary sixth-grader has a 3.5 grade-point average. He doesn't like missing school, where he is a student body officer. But he will miss 11 days of classes by the end of the 2001-02 school year. Missed school days Children who are exposed to smog are more likely to get colds, flu and other respiratory infections and have more severe allergy symptoms, research indicates. School absences are more common on smoggy days or a few days after a smog alert. In one study of 2,081 California students in the fourth through 12th grades, respiratory-related school absences jumped 83% when ozone levels increased. Living within 550 feet of heavily traveled roads, where exhaust levels are high, increased doctor visits for children with asthma by as much as 2 1/2 times that of children living on less-congested streets, according to a California Department of Health Services study in San Diego. Asthma is the No. 1 reason for school absenteeism at Fresno Unified schools. Children identified as having asthma increased almost 200% in the past dozen years, far outpacing the growth in enrollment during that same time. Fresno Unified School Superintendent Santiago Wood points a finger at the air for causing most of the 2,000 average daily absences in his 81,000-student district. Wood himself wheezes from severe allergies and suffers from recurring sinus infections that he believes are connected to local air quality. Last year, for health reasons, he contemplated leaving the Valley and his job at the helm of the state's fourth-largest school district. He decided to stay after trying alternative medicine that eased his symptoms. Last month, however, the superintendent's health problems returned, and Wood says he can't rule out a move based on medical necessity. "I don't want to sound and appear to be negative, but certainly we've got to keep all our options open."
Across the Valley, school nurses count the increase in asthmatics by the number of inhalers locked in medicine cabinets. Becky Bartsch had more children at Cole and Red Bank elementary schools in Clovis with inhalers this past school year than she ever had seen before. She counts 37 children at Red Bank who need inhalers before they run out to the playground at lunch on a day in May. Many of the children carry the palm-size devices in their pockets or backpacks, but about a dozen choose to keep their inhalers in a drawer in the nurse's office. They come to Bartsch when they need their asthma medicine. If every child with an inhaler had to come to her office to take medicine, Bartsch says, shaking her head, "it would be out of control." Asthma has led to tragic consequences at schools in the Valley. In 1996, a Hanford elementary student left his classroom wheezing and coughing. He collapsed and died while members of the office staff tried to assemble a nebulizer, which opens airways more effectively than an inhaler. The 11-year-old boy's mother sued. She contended school administrators never told her that a special note from a doctor would have allowed her son to keep a pocket-size inhaler with him. A jury awarded her $9 million in 1999. The amount was reduced by a judge to $2.23 million and an appellate court upheld the lower amount this May. At his doctor's appointment, Kerry is admonished to keep with him at all times an inhaler of Proventil, a "rescue" asthma medicine, to stop attacks. Dr. Sheikh assembles a machine, called a nebulizer, with an aerosol bronchodilator to open Kerry's lungs. Kerry starts the breathing treatment, sucking up the mist through a plastic pipelike device. The medicine tingles. He gags and coughs. The doctor tells him to take a break. He sprawls facedown on the examining table. Orange Nike tennis shoes – size 11 1/2 – hang over the edge, looking heavy enough to pull all 5 feet, 6 inches of him over. Kerry begins to snore. Kimberly Williams frowns. She prods Kerry to get up and continue the breathing treatment. Kerry's bronchiole tubes slowly begin to relax and open.
Sheikh sends him home, with a prescription for a steroid to reduce inflammation in his lungs, and a cough syrup. Kerry sleeps most of the next day, but he is well enough a day later to join his sixth-grade class at the downtown Fresno baseball stadium for the Grizzlies game. Kerry was diagnosed with asthma at age 2 1/2. His mother and grandmother thought a lingering cold caused his constant coughing. They had no idea it meant his lungs were overreacting to irritants. Until he was 7, he couldn't participate in athletic activities because exercise caused him to wheeze. A new generation of asthma medicines that reduce inflammation and muscle constriction – AdVair, Singulair, Nasonax – helps keep Kerry's asthma under control so he can now play outdoor sports. The medications are a godsend, but no guarantee he won't have asthma attacks. Medicines are costly On a sunny spring day, Kerry's grandmother remains on guard watching him play baseball on the Pinedale field. Kerry was sick two days earlier, and Lucille Williams isn't sure her grandson should be chasing fly balls and grounders. Her eyes are glued on No. 67 in left field. Kerry halfheartedly punches a hand in his mitt; he looks tired. She has Kerry's "rescue" asthma medicine in her purse, she says, patting the leather bag for reassurance. Kerry's asthma medications aren't cheap. The palm-size inhaler inside Lucille Williams' handbag costs $120. If Kerry is sick and taking frequent puffs of the medicine, the inhaler can be empty before the end of the month and has to be refilled. Kerry keeps inhalers in several places – his grandmother's and mother's homes, another in his mother's car and he stashes one in his backpack. Medi-Cal pays for two inhalers each month. Kerry's mother and grandmother spend as much as $300 a month out-of-pocket for his other inhalers and other medical expenses.
The importance of carrying an inhaler doesn't always sink in with Kerry. He has lost inhalers under couches and at friends' houses. "One time in a month," Kimberly Williams says, "he lost all of his medicine and they had to be replaced." Says Kerry: "Sometimes it's hard for me to accept the fact I'm sick." When he starts seventh grade in August, Kimberly Williams gives her son a lecture. "You don't take your inhaler and you can die." Seventh grade presents new challenges for Kerry – from an algebra class to a budding interest in girls. But it's a sixth-period P.E. class that starts about 2 p.m. that causes special concern. Running around the track is part of the curriculum. On most days, Kerry comes home after school and goes straight to bed. "I just want to sleep," Kerry says at the end of a day in early September. Kerry's mother isn't sure if it's a growth spurt or her son's asthma causing his lethargy. Kerry has sprouted 2 inches in the past four months – from the 5 feet, 6 inches he measured in May to 5 feet, 8 inches. Immune systems are one theory Theories abound about possible causes of childhood asthma. Genetics, indoor and outdoor pollutants and childhood obesity are subjects of study. A hypothesis, dubbed the "hygiene" theory, contends children's living environments may be too clean. The idea is that children's immune systems don't get the turbo-charge they need from infections early in life to kick their immune systems into gear and protect them from developing chronic diseases. "We appear to be getting more sensitive, as the environment gets cleaner," says Robert Phalen, director of the Air Pollution Health Effects Laboratory at the University of California at Irvine. But a growing body of evidence shows children's lungs are affected by ozone and fine particulates. Children in polluted cities have about a 10% decrease in the growth of their lung capacity. A simple way to explain the injury: children aren't able to blow up a large balloon and they aren't able to blow it up as quickly, says James Gauderman, associate professor at the University of Southern California's Department of Preventive Medicine. Researchers continue to debate whether the lung damage is long-lasting and whether breathing ozone causes asthma and other chronic lung diseases, but they suspect it does. They know the corrosive gas aggravates the conditions.
A recent study at the University of California at Davis found breathing high concentrations of ozone may permanently change the lungs of young monkeys. The primates exposed to ozone develop fewer branches in their airways, have more air sacs and produce more mucus cells, among other abnormalities. Whether the same structural damage occurs in children's lungs – and whether it is irreversible – remains to be determined, but lung growth in baby humans occurs after birth, as it does in infant monkeys. Fresno children may provide researchers with more clues about air pollution's toll on the lungs of asthmatics. About 250 children are being enrolled in a five-year, state-sponsored study to identify health effects of breathing ozone and particulates. Thus far, only one study links smog to the development of childhood asthma. The Children's Health Study, a massive undertaking to follow children in 12 Southern California communities, found that youngsters living in smoggy cities and who participate in three or more vigorous sports are three times as likely to get asthma as their sedentary counterparts living in cleaner cities. Children with no history of asthma were followed from 1993 to 1998. Those who played high-activity sports, such as football, tennis and soccer, in smoggy cities had the greatest likelihood of developing asthma. Living day to day When seventh grade starts, Kerry wants to play football. Kastner Intermediate coaches ask the 210-pounder about joining the team. But Kerry's mother dissuades him. "I'm just so scared about his asthma," she says. She doesn't want Kerry breathing hard on smoggy afternoons, when football practices and games are scheduled. Kerry misses a day of school in early September that his mother blames on the dirty air. "I know for a fact it was the air," Kimberly Williams says.
Kerry can't pinpoint what makes him sick. He just wakes up unable to take a deep breath. His mom possesses a sixth sense about his asthma attacks. Kimberly Williams can tell by the look of the sky and the feel of the air if it's a bad day for Kerry to be outside. She also watches weather, pollen and air-quality reports to check conditions. Except to go to school, Kerry stays indoors on bad-air days. Sept. 13 is one of those choking, smoggy days that makes Kerry's mother worry. Television weather forecasters advise people to stay inside. Kimberly Williams hesitates about sending Kerry to Kastner. She suspects he will be sick before the school day ends. But Kerry's physical education teacher keeps his class inside, away from the smog. Kerry doesn't need to leave school early; he's not wheezing or complaining about being out of breath when he gets home. It's a reprieve. For now. Kimberly Williams fears there will be asthma attacks and hospital visits to come as tule fog – and the sooty particles it soaks up – hovers over the Valley: "I just think the winter is going to be really bad."
MYTH: Living in a dry environment like the San Joaquin Valley can help reduce respiratory diseases such as asthma.
REALITY: One in six Fresno County children has asthma, the highest rate in the state. |
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2002 The Fresno Bee
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