While fewer asthmatics in East Harlem are landing in the hospital, asthma rates in the neighborhood are on the rise, prompting a four-prong battle to control the potentially fatal disease.
“Asthma rates [among children] are one in four now. They used to be one in six to one in seven,” said Dr. Kiran Shah, an allergy immunologist at East Harlem’s Metropolitan Hospital Center. That was only five or six years ago.
The reasons for the sharp increase, Shah said, are complex: “Better reporting, better diagnosis, children are more exposed to allergens, and smoke, and smog. It’s multi-factorial.”
Asthma is a chronic respiratory disease triggered by allergens, exercise, or changes in temperature. Asthmatics can have sudden attacks that cause chest pain, coughing, and make breathing close to impossible.
It’s an ugly disease. Thania Acosta, a chronic asthmatic, wheezed painfully as she struggled to breathe in her apartment at the James Weldon Johnson Houses in East Harlem.
“It feels like someone’s holding you down under water. You can’t breathe, but they’re not letting you get up,” she said. Acosta was, essentially, drowning on dry land. She headed to the emergency room. It would be her 15th time that year.
Asthma can run in families and Acosta’s 13-year-old son Damien has the disease. Her 9-year-old daughter Krislynn has developed it too.
New York City tracks asthma by the number of people who, like Acosta, are admitted to the hospital in crisis. But not everyone with asthma ends up there. Some have less severe cases; others have better managed their disease. Only 40 percent of adult asthmatics in New York City used an emergency room in 2003. No one knows what causes asthma, but with good control of the disease and its symptoms, asthmatics can lead normal, healthy lives.
Experts do, however, know what can trigger the disease. A noxious cocktail of asthma triggers like mold, vermin, plaster dust, and diesel fumes, along with poverty, smoking, obesity, and poor medical access, have made East Harlem the asthma capital of New York. Taken together, these factors make East Harlem a dangerous place to live. Despite an overall drop in hospitalization rates, a child living in East Harlem is still three times more likely to be rushed to the emergency room, gasping for air, than a child from any other neighborhood in New York City.
Local hospitals, advocacy groups, New York City and the state are tackling the problem on multiple fronts, hoping to bring those numbers down.
The multilayered approach does seem to be working. More asthmatics in East Harlem are getting their disease under control through intervention at the preschool level, referrals from emergency rooms to clinics, home maintenance, and environmental action.
Rosemary Obiapi, health coordinator for Union Settlement Association, East Harlem’s largest social services agency, has found that identifying asthmatic children early and getting them into treatment helps keep them out of the hospital. “Asthma doesn’t start from school age, it starts from preschool,” she explained.
Working with Dr. Sebastian Bonner at the New York Academy of Medicine, Obiapi developed a system to identify asthmatic children at the organization’s six East Harlem preschools using a brief questionnaire, an asthma action plan, and a computerized health tracking system.
The organization’s preschool will not admit a child unless parents answer a few simple questions that screen for asthma. If there is cause for concern, parents must have their child diagnosed and an asthma action plan completed by a physician.
An asthma action plan turns parents, doctors and educators into a team, outlining which medications to administer, and how to adjust them as needed. The school tracks the children, monitors their treatment, and helps parents solve problems as they arise.
“We’ve achieved such tremendous results in East Harlem day care centers that asthma is basically off their radar,” Bonner said in a statement.
Last year, the New York City Department of Health and Hygiene decided to fund the expansion of the program to 90 day care centers across the city. Other centers have since modeled their program after Obiapi’s. “We have reached out to 200 day care centers so far throughout the city, reaching about 20,000 kids,” she said.
Some health care providers, like Metropolitan Hospital Center, have been taking a different approach to controlling asthma, contacting people who use emergency rooms and referring them to clinics for more consistent medical care.
Dr. Shah heads one such clinic. Shah and his team work individually with each patient, with their families, teachers, and at home, to craft a self-managed plan. “With any chronic disease,” Shah said, “you have to give enough empowerment to the patient.
Patients are provided with and taught to use specialized medication and equipment like AeroChambers. They know “which is the controller medication, which is the rescue medication, when to use the rescue medicine, when to call us,” Shah explained. “They become their own provider.”
Patients who do need attention can reach Shah via the internet. A special program called eHealth Coach allows him to answer patients’ questions remotely and intervene before a crisis develops. But if one should, the patient goes to Shah’s clinic, not the emergency room. “An ER doctor is probably not as good at knowing the patient and knowing about asthma,” he explained.
As a result of their specialized attention to asthma, the hospital had 2,000 fewer pediatric emergency room visits and at least 600 fewer hospital admissions in 2006.
Local organizations like Little Sisters of the Assumption Family Health Service believe controlling asthma starts at home. Much of the housing in East Harlem is old and poorly maintained, harboring known asthma triggers like peeling paint, mold, roaches, and mice.
The organization spends a full year with a family, teaching them to use safer cleaning products and vermin repellants, special vacuums and bedding. Many of these families are also contending with construction dust, which can land asthmatics in the hospital.
The median value of housing in East Harlem rose 165 percent between 1990 and 2000, according to an Institute for Children and Poverty study. As a result, the area has seen a flurry of new construction and redevelopment, ranging from large-scale projects like the East River Plaza shopping center, to landlords renovating individual apartments.
“Sometimes you walk in a building and you can taste the plaster,” Sister Susanne Lachapelle, nursing coordinator for the organization said. “The place will be full of dust and the kids will be back in the emergency room.”
The plan is simple and cost effective. Ray Lopez, the program’s environmental coordinator, taught Acosta to filter grit from construction on a nearby community center through her air conditioner. “What we spend per year, with one family in one apartment, is equal to one night in the intensive care unit,” Lopez explained.
A preliminary evaluation has shown a 75 percent reduction in emergency room and hospital use among families who completed the home program, Lachappelle said.
Those battling asthma on the environmental front have been working to reduce diesel exhaust, which has been shown to lodge deep in the lungs and trigger asthma attacks.
“There is an extremely disproportional amount of environmental hazards in northern Manhattan that contribute to poor air quality,” Laurel Turbin, environmental health coordinator for WE ACT for Environmental Justice, said.
East Harlem is home to one-third of Manhattan’s eight bus depots, one of two sewage treatment plants, and both a garbage truck depot and parking lot. There are seven local truck traffic routes from 96th to 125th streets alone. An estimated 25 percent of the thousands of trucks rumbling through the area each day violate state emissions standards. These vehicles, Turbin said, are often left with engines idling.
East Harlem is primarily a low-income, minority neighborhood. Thirty-eight percent of residents live below the poverty line and 88 percent are black or Hispanic. The concentration of pollution-generating city infrastructure, local activists maintain, amounts to environmental racism.
In 2000, the organization filed a lawsuit against the Metropolitan Transportation Authority under Title VI of the Civil Rights Act of 1964 to call attention to the issue.
Some relief may be in sight. As of September, under New York state law, school buses are no longer allowed to idle on school grounds. In November 2007, city and state officials began ticketing owners of trucks and boilers in East Harlem for emissions violations as part of the New York State Department of Environmental Conservation’s new Stop Smoking Initiative for Trucks and Boilers.
Mayor Michael R. Bloomberg and Borough President Scott M. Stringer are both pushing “green” initiatives like Bloomberg’s Million Trees NYC and Stringer’s Go Green East Harlem to clean the neighborhood’s air. They have also joined forces to create the new East Harlem Asthma Center of Excellence, a meta-center that aims to cut hospitalizations in half by 2010. Details for the center are still sketchy.
It took decades for the asthma rate to build and it could be decades more before residents can breathe easy. But Shah is optimistic. If everyone continues to work together, he said, in five years from now we could be hearing “not only a different story, a better story.”