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Inner-City Asthma Blues

By Dr. Paul Ehrlich

Anyone who cares about the health of our nation’s children should care deeply about the quality of asthma treatment in inner cities. Even if those who are more concerned with the financial costs than with the human costs should support more effective asthma care. The payoff for achieving control in seriously asthmatic children is almost an arithmetic certainty. Guideline-adherent asthma treatment reduces hospitalization by about 75%. Dr. Chiaramonte and I have both spent substantial amounts of time working with kids from poor and working poor families, as we recount in our Afterwords to Asthma Allergies Children: a parent’s guide, and on this website. We are always on the lookout for programs that show promise.

Thus, I can’t help being disappointed to read that a program at Johns Hopkins has been pronounced a failure. The study (published in the Journal of Allergy and Clinical Immunology) involved 321 Baltimore children, aged two to six. The children were separated into four different groups. One group received mobile clinic support, another home education support, the third received a combination of the two programs and the last group received no support.

The “Breathmobile” provided exams and prescription medication. Schedules and reminders were sent out, but fewer than half the families made appointments and only 20 percent showed up for the appointment. While there was some improvement in symptom-free days and hospitalizations, those proved temporary.  Much as I wish the Hopkins approach had been a resounding success, I can’t help but seeing it as affirmation of the choice we made with Project ERASE, which was to center our efforts in the schools, although school kids are older than the ones in this study.

“Schools are the ideal setting for helping disadvantaged children with limited access to health care precisely because they are present regularly, which is especially important for a condition that requires systematic follow up. Working parents depend on their children’s attendance at school to give them time to earn a living, and for the homeless, it provides one stable element in an often-chaotic existence.

“Having the specialist in the school saves parents the burden of taking time off from work or finding care for their other children to go to a doctor who may be located across town. Even where asthma care is available in a community clinic, there is a high rate of attrition from treatment because of the inconvenience.

“Schools are a useful base for asthma care for another reason. Teachers, administrators and, indeed, other students have a vested interest in keeping asthmatic children symptom free. Asthma is disruptive of the educational process for all these constituents as well as for patients.”

I would love to see our model revived and replicated. It involved the promotion not only of guideline-based medicine, but structure, accountability, and support for the behavioral change that is crucial to management of chronic disease.

(Photo Courtesy of bobjagendorf via Flickr)

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