March 23, 2001

Asthma Mysteriously Hits Record Number of Fresno Valley Children

EDITOR'S NOTE: Increases in the incidence of asthma among inner- city residents, especially young children, have brought considerable media and medical attention. But in California's San Joaquin Valley, kids in the small towns are showing symptoms of asthma in extraordinary numbers, and no one is quite sure why.

By Mary Jo McConahay

FRESNO, CA — Cozette Grauth carries an inhaler, likes to sleep with a fan going even when it's cold, and drives her father crazy when she forgets to tell him she has run out of asthma medicine.

Although Cozette, 12, has not been in an emergency room for a year, she could suffer more attacks. This is the asthma capital of California, with the number of children afflicted booming.

"I always wait until she goes to sleep before I do, to make sure she is not wheezing," said Cozette's father Michael. His wife Vonda, Cozette's mother, died during an asthma attack in l999.

Of the Center for Disease Control's top 50 cities for asthma, only Chicago and New York rate higher than Fresno. In part, this reflects a nationwide trend — asthma is up 75 percent since l980, now afflicting 17 million. In l991 the National Institutes of Health declared it a national health emergency.

But no one knows why this Central Valley region is taking such an undesired lead. Newly launched studies by the NIH, UC Berkeley and UCSF may take years to find answers (see accompanying story).

Most studies on children with asthma concentrate on inner cities, so its strong presence in this predominantly rural region is attracting attention.

Throughout the lush Valley, with its vast stretches of high- production agricultural land and food processing plants, the office drawers of small town school nurses are stuffed with inhalers and the occasional nebulizer, marked with students' names.

A radio station announcement in Spanish advises farm workers, in touch with dust and pesticide residue in the fields, to have a second set of clothes waiting at the door at home, and "don't pick up your kids until you wash your hands."

"Right before a rain you can see the outset — sneezing, and the eyes of the kids with asthma get red," said Anne Gonzales, a school counselor in San Joaquin, half-way between Raisin City and Tranquillity, amid miles of almond trees.

Gonzales' young daughter has asthma, too. It has become a civic cause, joining business people and educators with health workers.

"I just talked to the mother of a 6-year old who said, `What do I do? She's not responding to medications. How can I find a doctor who will work with me?'" said American Lung Assn. local director Sandra Eaton. "I spend 100 percent of my time like this."

A parents' group is campaigning to change the beginning of the school year to September, which has fewer poor air quality days, as many believe air pollution triggers asthma.

A chronic inflammatory lung condition that can be set off by allergies among other triggers, asthma closes down airways so breathing is hard. Death is rare - of 2.2 million asthma sufferers in California, 667 died in l997, the last year for which numbers are available.

But mortality rates have increased since the l970s, and doubled nationally in the last 20 years.

Because children have small-er airways, they run greater risk. Some school nurses report more days absent for asthma than common colds.

A strict program of preventive care can keep the condition under control, but it can be expensive. A steroid inhaler — the most common mode of treatment — can cost $80, for instance, and the average monthly cost for medication can reach $130 for a child.

"This is difficult for the poor, and the medically indigent are limited by public insurance to drugs that are less than the best," said Kevin Hamilton, director of the Community Medical Centers Asthma Education project, whose agency turns no one away for lack of funds. Central Valley towns have some of the state's highest unemployment rates, even in boom times.

But a child's ability to get well is also related to time — even white-collar parents who are out of the home 12 to 15 hours a day don't have schedules that permit them to medicate four times a day, for instance. And some advocates for youngsters with asthma say despite NIH guidelines, physicians do not educate parents and patients properly, indeed may not even understand treatment well.

When Hamilton lectures, he walks in with a handful of prescriptions and a plastic bag filled with devices typical of the collection an asthmatic's parent must manage, and asks, "Would you know what to do?"

Meanwhile, others ask, "Why Fresno?" Some suggest the local man- made environment may be part of the answer.

The agricultural industry — $3 billion in 200 crops in Fresno County alone — feeds not only the state but the world, and provides employment. No one suggests farming and ranching be curtailed.

But the rivers are blocked so soils absorb pollutants, which blow around on wind which cannot leave the bowl-like valley. And now the non-farm population is booming, including families who work in Silicon Valley, at least two hours away, but cannot afford to live there.

Urban sprawl means year-round grass — a huge potential trigger — which needs to be watered, causing higher mold counts — another trigger.

Despite all the open spaces, air pollution in the valley can be extreme. Particulates —tiny specks of matter that can trigger an asthma attack — are abound. In 1996, Fresno came in third among all metropolitan areas for particulate air pollution — after two other Central Valley areas, Visalia-Tulare-Porterville and Bakersfield.

Dr. David Pepper, Medical Director of the Asthma Program, suggests the rise might be related to "the way we as a society function," using cars instead of mass transport, urban sprawl. And, he adds, "Divorce rates are higher and jobs change more."

Asthma can be exacerbated by stress, which is not like air pollution or pollen counts. "How do you measure stress?" Pepper asks, "The Central Valley has a different ladder than the one you find in Silicon Valley, but still people are clawing their way up."

For the time being, health workers focus on control and education. Recently Sarah Moreno of the San Joaquin Health consortium drove past grape orchards where thousands of raisin trays lay ready for collection. Vagrant dust — a potential trigger — hung in the air with passing vehicles. Cotton baled in long rectangles stood alongside acres of bushes stripped bare by chemical defoliants.

At San Joaquin Elementary School, armed with slides and years of experience, Moreno briefed teachers: Don't be reluctant to encourage medications, including the inhalers, which can save a kid's life.

"Asthma is manageable. Asthmatic kids can shine at sports," she said.

Mary Jo McConahay has written on health and population issues for Sierra and other publications.



Soaring Asthma Makes Fresno Laboratory for Research

By Mary Jo McConahay

MENDOTA, CA — Raul Romero, age 9, hates having an asthma attack because even though it hurts he can't cry — there's not enough breath in his lungs. "Then I feel like I'm going to drown."

Raul, unlike the kids who are the focus of most of the work on asthma, lives under open skies in this town of 7000, the "Cantaloupe Center of the World," near a wildlife refuge and cropland as far as the eye can see.

Scientists, puzzled by high asthma rates are looking for answers:

"Fresno has the country's third highest rate of asthma mortality — no one is sure it's pollution, but it is also one of the places with the highest number of days in which air quality standards are exceeded each year," said University of California Berkeley epidemiologist Kathleen Mortimer, director of the Fresno Asthmatic Children's Environment Study (FACES).

A study by the state's Environmental Protection Agency (EPA) showed a strong correlation between high ozone air pollution levels and childhood asthma attacks in Sacramento, some 135 miles north. Other researchers have determined airborne pollutants have damaging effects on lung function and cause airway spasms.

The FACES investigation, a collaboration with the California Air Resources Board and EPA, looks at the long-term effects of air pollution on children — does it stunt growth? Does it debilitate in other ways?

Last fall investigators began to follow 400 children aged 6 to 10 with physician-diagnosed asthma who live within 6 miles of an air quality monitoring station. The five-year study could have regulatory implications if it shows current standards do not sufficiently protect the public, especially children.

Is there a way to identify vulnerable children? Dr. Pedro Avila, a clinical professor in the Department of Medicine and Pediatrics at UC San Francisco, wants to determine the genetic markers that might allow doctors to diagnose it in the Latino population "as soon as a baby is born." A tandem study is underway among Puerto Ricans in New York.

While some may have a propensity to develop asthma a child or adult will only begin to show symptoms if a trigger is present. But in most cases a doctor can only diagnose the wheezing, cough or hard breathing as "asthma" with a history of events — a challenge in this region where many farm workers are of Mexican origin and move often.

If his new study can identify the marker, it means that when babies or adults arrive wheezing, a doctor's office can do a simple test and begin treating for asthma right away. Early diagnosis means earlier targeted treatment, key to remission.

Avila expects to finish collecting data from 200 subjects in the field early this year, when the laboratory and office phase of the study will begin.

Another study emanates from an unlikely-sounding place: California State University Fresno's School of Business.

Kathy Moffett, Director of the University's Information Systems Laboratory (ISIS) is working with the Asthma Education Project to develop an early warning system that might advise asthmatics of conditions likely to trigger an attack.

Using geographic mapping systems, the ISIS project aims to find patterns of asthma severity, and match them with other variables and triggers — such as wind direction on "burn days" — and literally warn asthmatics in the pinpointed area not to play outdoors, for instance.

The project, which is just beginning, is taking on priority, said Moffett, a Professor of Information Systems, "because the Central Valley is the U.S. asthma capital, and it seems to disproportionately hit minorities."

"We have a large population moving out of work in the fields to jobs who aren't covered by insurance. We are looking for situations where education really helps." When the mapping finds clusters of asthma it can also pinpoint the schools kids are likely to attend, and direct special asthma education there to faculty, students and parents.

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