Ft. Asthma—The Bronx
By Samuel De Leon, MD
Chief Medical Officer, Vice-President of Medical Affairs
Urban Health Plan, Inc.
Thirty-odd years ago, the neighborhood where I work was the poster child for urban blight. Thousands of buildings were burned, victims, as legend had it, of landlords who could no longer profit from their properties and had them torched for insurance money. In the middle of it stood a police precinct, called by cynical officers “Ft. Apache, the Bronx”, inspiring a Paul Newman movie of the same name.
Today, the South Bronx is still one of the poorest counties in New York State, but it is also a community of strivers anchored by employment at the Bronx Terminal Market, the nation’s largest wholesale produce market, and has seen significant development—most famously the new Yankee Stadium.
And yet, in one sense, it still stands out from the landscape in a negative way—our zip code has the highest rate of asthma in the country. The Asthma Center I work for is making significant strides in treatment. Our success in lowering the rate of hospitalizations for our clients has attracted favorable attention from the State of New York. Part of it is the better primary medical care provided by our full-time staff, including, yours truly; I am a pulmonologist. Part of it is the “worst of the worst” treatment provided by Dr. Larry Chiaramonte, one of the founders of this website. Like Dr. Chiaramonte, I have a very personal commitment to good asthma care: my native Puerto Rico has even higher rates of asthma than the South Bronx, and my own father has had severe asthma for as long as I can remember (although it has improved since I took over his treatment). Providing better asthma care to my fellow Hispanics is a passion for me.
The South Bronx has many structural challenges in reducing the incidence of asthma. Because of the Hunts Point Terminal Market, it has an extraordinary level of particulate pollution from tractor-trailer diesel traffic. Much of the housing stock is afflicted with major allergens from cockroaches and mice. In multi-family dwellings, meticulous housekeeping in one’s own apartment is not enough to protect you from neighbors’ habits,including smoking. And then there’s automobile traffic more than 80 times a year from the Stadium—we get it coming and going.
One thing I have learned about practicing in a community setting is that it is very important to be attuned to the cultural sensitivities of the population. At very least, that means speaking the language, and our staff is substantially bi-lingual. But it also means being highly sensitive to the way patients talk about their health and the way they receive information. Every ethnic or socioeconomic group has its quirks. As Dr. Ehrlich has written, educated middle-class patients are phobic about inhaled corticosteroids (ICS), even though they are by far the best current way of controlling asthmatic inflammation. That said, these are the kinds of things I recommend for dealing with patients like ours.
1) Always start with three minutes of chitchat. This helps them loosen up, and may also reveal important clues to their health. If you ask a direct question, you will get an inadequate answer. You can’t say, “is your asthma controlled?” You have to say, “How many times a day do you use your nebulizer or abuterol? One…two…three?” If you use it three or four times a day, it isn’t controlled, and they are probably not taking their ICS as directed.
2) We have a great electronic health record system, but when I take information, I always make eye contact with the patient, because when you lose eye contact, you lose their full attention. I also keep the screen tilted so they can see it. “Sharing” the information with them builds trust, even if they can’t read it from across the desk.
3)My patients don’t like taking medicine, but they like taking vitamins. By calling a medication like Singulair an “asthma vitamin,” I increase the chance that some patients will take it conscientiously. Of course, this does make for a certain amount of confusion when they ask the pharmacist, “which one is my asthma vitamin?” and I have had more than a few confused phone calls from drug stores, but it’s worth it if their asthma is controlled.
If I could wave a wand, I would do more about the environmental triggers. Better regulation of trucks servicing the Hunts Point Terminal Market, and support stations would replace the trucks’ need to idle the truck to keep their air-conditioning up and running. A just-in-time system for loading and unloading. More freight traffic to the Hunts Point Terminal Market would be delivered by rail. I would get more baseball fans to arrive by train as well. And as long as I’m wishing, I would like to see our air sprayed with water at night to help the diesel particulates settle to the ground, and a gekko lizard for every apartment to eat roaches and mice. But enough magic. The community health center model of coordinated care is probably the best we can do, and considering our results, it is very good indeed.