Leaving a Generation Gasping for Breath

Children today should be breathing easier. They live in a time of cleaner skies, less tobacco smoke and fewer dangerous chemicals in the air.

Instead, the teens, toddlers and infants of the ‘80s and ‘90s are a generation gasping for breath.

Surging quietly to the proportions of a global epidemic, childhood asthma has turned more common and more deadly. Among all races and walks of life. All over the world. And no one can figure out why.

Something in the contemporary environment has transformed the way many children react to the air they inhale, often within months of taking their first breath. But what? Pollution? Maybe allergies to dust mites and cockroaches, or invisible gases wafting through homes. Or such fundamental lifestyle choices as diet or family size. Poverty could have something to do with it.

Every expert has a favorite theory--and some have uncovered intriguing clues--but medical and environmental science have failed, despite an intensive worldwide investigation, to identify the keys to the riddle.

“This is one of those true mysteries,” said Dr. Floyd Malveaux, dean of Howard University College of Medicine in Washington, D.C., and one of the nation’s leading asthma experts. “I think it has to do with the living conditions. Where you live, how you live, what you are exposed to. But there is no one specific thing or we would have uncovered it by now.”

Surprisingly, the phenomenon has stricken not baby boomers--who breathed air more polluted than any other generation’s--but their offspring. Through the 1960s and 1970s, asthma declined, then began to soar in 1979, and has been climbing virtually every year since.

In America, more than 5 million children are the faces behind this medical enigma, living breath by breath with the chronic inflammation of airways known as asthma. That amounted to 1 in 13 children in 1993--79% more than in 1982, according to the National Center for Health Statistics. More adults also are developing asthma, but not at the same pace.

Anttwon Suggs was a child who lived in this age of asthma.

One day last March, in his kindergarten classroom at Burbank Elementary School in Long Beach, the 5-year-old started gasping for breath. He stood up, struggling to ask his teacher for help, but she scolded him for misbehaving before she realized he wasn’t clowning around.

At the school nurse’s office, panic began to set in. Anttwon’s eyes bulged with terror as he fought to draw oxygen through his clogged airways and school aides called for help. His mother, Tracey Hill, rushed the two blocks to the school, arriving before paramedics.

Fighting back her own hysteria, she patted Anttwon on the back to calm him as her only son drew his final breath and died.

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Until recent years, doctors only rarely saw asthmatics suffer attacks so severe that they wound up in the intensive care ward or, tragically, in an early grave. Now, asthma attacks kill 14 Americans of all ages every day--more than three times as many as 20 years ago--surpassing 5,000 deaths a year. And the death and hospitalization rates have accelerated, especially among preschoolers and African Americans, despite dramatic medical advances and new drugs that have rendered most attacks controllable.

“When you talk to physicians who have been around for a long time, it was rare to see individuals coming in with such acute distress because of asthma,” Malveaux said. “Now it occurs more frequently. Individuals seem to be getting into more trouble.”

African American children like Anttwon face the gravest threat of all. For unknown reasons, blacks--especially those reared in inner cities--develop asthma more often than other races, and their attacks are far more severe. Black youngsters are six times more likely to die of the disease than whites and three times more likely to be hospitalized, according to the Centers for Disease Control and Prevention.

For Latino children, asthma has mirrored the rise among whites. Many doctors, though, believe Latinos in major cities such as Los Angeles and New York are starting to suffer the same rampant severity afflicting African Americans. People of Puerto Rican heritage have an extremely high incidence of the disease.

One of the most extraordinary aspects of this epidemic is its pervasiveness. Every developed area of the world seems to share a sharp rise in the prevalence and severity of asthma: Farm towns, modern suburbs, urban ghettos, tropical isles, desert pueblos and alpine villages all are afflicted.

New Zealand, Australia and Great Britain suffer some of the world’s highest asthma rates along with the United States. Within this country, New York and Chicago are the worst. What on earth, medical experts wonder, could a baby in the Bronx or a kindergartner like Anttwon in Long Beach share with a toddler reared on a sheep farm in Auckland?

“The increase has been found worldwide, and it’s somewhat hard to believe,” said Peter Gergen, director of epidemiology at the National Institute of Allergy and Infectious Diseases. “It could be different explanations in different places. At this point, we have no idea.”

Welfare class, working class or wealthy, asthma is transforming the lives of millions of families. Despite the myth that it’s a mild condition kids outgrow, doctors increasingly say it is lifelong and life-threatening. It’s the No. 1 chronic disease afflicting American children, and it’s not unusual for an asthmatic child to miss 20 to 40 days of school each year.

“Oh my yes, it’s a problem,” said Virginia Hayes, nursing director at the Los Angeles Unified School District. “And it’s growing more and more, especially in our communities here. There has to be a reason why there’s such an increase in asthmatic children.”

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Like frustrated detectives, medical researchers have spent a decade hunting for clues. They count cockroaches and dust mites in city apartments and suburban tract homes. They put adult asthmatics in sealed chambers and gas them with various pollutants to see how well they breathe. They probe children’s diets, family income, birth weights, number of siblings, viruses and whether they were breast-fed.

They inquire about smokers in the household, and even check the stove to see whether it is gas or electric.

Asthma experts suspect that one of these environmental or societal factors--perhaps all of them--have changed in the last two decades to sensitize more youngsters, altering the immune cells in their respiratory tracts at an early age. Most asthmatic children suffer their first attack before their third birthday.

The asthma upsurge defies logic because it is the complete opposite of what medical experts had expected. Asthma is the “only [disease linked to the environment] that is heading exactly in the wrong direction,” said Richard Jackson, who heads the CDC’s National Center for Environmental Health. And it comes at a time when all indications are that children’s respiratory health should be better, not worse.

“Everything that has been associated with making asthma worse is getting better,” Gergen said. “Every known risk factor is going down--cigarette smoking, pollution.”

Also, knowledge about how to treat asthma has vastly improved in the last 15 years. There are daily medications to calm the inflamed airways to prevent attacks. Pocket-sized inhalers for emergencies that can be tucked into a child’s jeans. Lifesaving breathing machines that are carried in a shoulder pack. Support groups for parents. Asthma camps for kids. Curricula for schools.

Asthma symbolizes “both the success and failures of medicine’s conquest of disease,” said Dr. Neal Halfon, a UCLA pediatrician who has studied socioeconomic factors in asthma. “At the same time that our treatment regimens and strategies of care have expanded with proven efficacy, the prevalence, morbidity and mortality are all increasing.”

Epidemiologists point out that whenever any disease becomes more common it could merely be reflecting a new diagnostic fad. But most consider that unlikely for asthma because there are no new diagnostic techniques and the rates have jumped worldwide. Also, the surge in deaths and hospitalizations is unequivocal, and that offers strong evidence that the disease has metamorphosed into a more lethal form.

Childhood asthma has risen so quickly--in one generation--that experts say genetics cannot be blamed.

“Genetic patterns just don’t change that fast,” said Dr. Richard Evans III, who heads the allergy division at Children’s Memorial Hospital in Chicago. “It has to be environmental.”

The Allergy Connection

At the root of the asthma epidemic lies a related, and just as puzzling, phenomenon: A surge in childhood allergies.

In nine out of 10 cases, children with asthma are also afflicted with allergies, and the more allergies, the more severe their asthma.

“We know increasing prevalence of allergies is behind the increasing prevalence in asthma,” said Dr. Fernando Martinez, a pediatric pulmonologist at the Respiratory Sciences Center at the University of Arizona. “It used to be about 20%, but now up to over half of the population of children in the world are allergic.”

The mechanism behind asthma is a normal reflex of the sentries that protect the human body against invasions by allergens or infection. It’s simply a defense that has become too powerful for the body’s own good.

For some reason, the immune cells that guard an asthmatic’s bronchial tubes are in a perpetual state of inflammation. And like jittery soldiers firing at a shadow, the immune cells compound the problem by overreacting to common things in the air such as pollen, perfume or cat hair. Upon exposure to such perceived enemies, the cells fire so many antibodies that the airways to the lungs become jammed with mucus and squeezed by bands of constricting muscle, triggering an attack.

If you have asthma and suffer a severe flare-up, the pathways to your lungs become so narrow that getting oxygen to your lungs is like trying to suck a thick milkshake through a small straw. You inhale faster and faster, trying to gasp for air so hard that your chest starts to compress. When you exhale, you cough or make a whistling sound--the familiar wheeze. Unless your antibodies are shut off and the swelling is quickly reduced--usually by inhaling medications--suffocation can result.

The tendency to overproduce these antibodies to allergens runs in families, but not everyone who has the susceptible allergy genes becomes asthmatic. Indeed, when one twin has asthma the other only infrequently does. And children emigrating to Western countries suffer a higher rate of asthma and allergy than those who stay in their home countries--pointing toward environmental or social factors.

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In compelling new research, Martinez discovered that newborns who later turn out to be allergic often are far more likely to have unusual immune cells in their airways within nine months after birth. While in infancy, they seem to develop an abundance of the type of cell that lacks a protein, called interferon gamma, that reins in the allergic reaction.

By failing to control the allergy antibodies, the body overreacts to foreign invaders in the bronchial tubes and triggers asthma.

The children, however, were not born that way--the composition of cells in their umbilical cords appeared normal. So the transformation didn’t happen in the womb, but in the early months of life. Figuring out what in a baby’s environment upset the normal balance of the cells could pave the way to a cure for asthma.

“We’re talking about a lifelong disease that starts in early childhood,” Martinez said. “If we can find out what’s different in their immune system compared to other people, perhaps we can modify it.”

In Europe, the intrigue intensified when the Berlin Wall came down. As East and West Germany reunited in 1990, asthma experts realized that it was a perfect test case. Although ethnically, genetically and geographically similar, the two sides of Germany were separated for more than a generation, so it was a unique opportunity to compare the impact of social and environmental factors on asthma.

The results were striking.

Children in Munich, in West Germany, suffered 50% more cases of asthma and three times more allergies than those in Leipzig and Halle, in East Germany, according to a study of 8,000 children. On the other hand, those in East Germany contracted 50% more cases of bronchitis than their western neighbors.

“What we found was very strange,” said Martinez, who collaborated on the research with German scientists. “I think we are facing a true phenomenon here.”

Bronchitis and asthma both involve inflammation of the airways, but there is a clear difference: Asthma is mainly triggered by allergies, while bronchitis is aggravated mostly by infections and irritants.

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Something about the contemporary Western lifestyle seems to raise the risk of allergy-induced asthma.

Pollution is a possible explanation. East Germany had high levels of uncontrolled industrial pollution--mainly sulfur, which is known to irritate airways and trigger bronchitis. West Germany suffered more from the classic form of pollution found in modern Western cities--vehicle exhaust.

Could the culprits behind the asthma surge be the rising numbers of cars, buses and trucks and their possibly allergy-provoking emissions? This theory remains unproven because there are other factors that divided life in the east and west.

“I think some form of outdoor air pollution is contributing,” Martinez said, “but I don’t think it’s the only factor, or even the main factor.”

A social factor has fascinated the investigators even more than the pollution questions. The fewer siblings a German child had, the more allergies he or she suffered. Also, East German families that had low asthma and allergy rates used day-care centers--where children frequently catch germs and viruses--10 times more than West Germans.

Immunologists suspect that children who come down with a respiratory virus in infancy are less prone to allergies and asthma later in life because their bodies switch on the types of immune cells that block the allergy antibodies.

That leads to an intriguing theory: Are more children in industrialized nations getting asthma because families are smaller and there are fewer sick siblings spreading germs? Perhaps those who escape the flu become more prone to asthma instead.

‘In a Room Without Air’

Darrell Phillips, Subject No. 1169, sits behind thick glass in a sealed chamber, pedaling an exercise bike and breathing air mixed with sulfur dioxide, a key element of urban air pollution.

For every million parts of oxygen that Phillips inhales, he breathes less than one part sulfur dioxide--a concentration that, although seemingly small, is worse than would be found in the air of even the most heavily industrialized U.S. cities.

After just 10 minutes of slow pedaling, Phillips is obviously suffering an asthma attack. He wheezes, coughs and tries to clear his throat of phlegm. A test shows he has lost 54% of his breathing ability within minutes.

“It’s like being in a room without air,” says Phillips, 25, who has had moderate asthma since he was 6. “I felt it almost immediately.”

For Henry Gong and William Linn, leading researchers on the health effects of air pollution, the smog chamber at Rancho Los Amigos Medical Center in Downey offers a rare opportunity--experimenting on humans.

Not only can researchers see firsthand how an asthmatic reacts to various degrees of pollution, but they can check for microscopic changes in the cells of bronchial tubes that indicate unusual immune activity.

Gong says that while sulfur has an obvious and immediate irritating effect on asthmatics, he theorizes that ozone--the main ingredient of Southern California smog--could be inflicting more subtle damage to cells that over time causes asthma.

“Ozone and sulfur dioxide seem to affect the immune cells differently. There’s an immune dysfunction going on,” said Gong, chief of environmental health at the medical center.

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Little about the asthma phenomenon is as puzzling as its link to air pollution.

If the culprit is lurking in urban air, which pollutant is it? The main ones, such as ozone, particulates, sulfur or nitrogen dioxide? Or the invisible toxic chemicals that are less carefully monitored? And what’s the source? It could be automobiles, diesel buses, power plants--all have been suspected, and although nothing has been proven, nothing has been ruled out.

Paradoxically, asthma rates are climbing in American cities during the same years when the air, because of pollution laws, has been cleaner than in the previous two decades. Ozone, sulfur, nitrogen dioxide, lead and particulates peaked in most cities in the 1960s and 1970s, and industries have cut their emissions of dozens of toxic contaminants such as benzene, hydrochloric acid and chromium.

Also, if pollution were to blame, why would asthma rates be growing in remote regions such as New Zealand and the Canadian province of Saskatchewan?

“It’s a puzzle because the worsening of asthma has been observed in places that do not have much in the way of air pollution,” said David Bates, an epidemiologist specializing in respiratory diseases at the University of British Columbia in Vancouver. “On the other hand, in places that do have a lot of air pollution, like the northeastern United States, and Seattle and Toronto, we have evidence that pollutants are related to emergency visits for asthma.”

Separate studies in Los Angeles, Houston, Seattle, Detroit, Toronto, Philadelphia and Atlanta, among others, found that considerably more people are hospitalized or die from respiratory ailments when ozone or particulate pollution increases.

But can pollution cause people to get asthma in the first place? Is a 3-year-old child who develops the disease the victim of some insidious damage from air pollution?

All the research has shown mixed--even contradictory--results, and there is no consensus.

In a study of 24 U.S. cities, a team led by Harvard University epidemiologist Douglas Dockery found no correlation between severity of pollution and the prevalence of childhood asthma.

“This does not imply that acute air pollution episodes do not trigger or exacerbate asthmatic attacks,” Dockery reported in the May issue of Environmental Health Perspectives. “However, air pollution does not appear to contribute to the increased prevalence of new cases of asthma.”

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If pollution were to blame, it would be logical to assume that the number of asthmatics would be highest in Los Angeles, the nation’s smog capital. But apparently it’s not.

“Asthma rates don’t seem to be higher in Southern California than they are in other parts of the country,” said epidemiologist John Peters, director of the Environmental Health Sciences Center at the USC School of Medicine.

After studying 12 Southern California cities, Peters found that the highest percentage of children had asthma in areas with the least smog. In school surveys, 12.6% of children in the Central Coast town of Atascadero had asthma, compared with 5.7% in East Los Angeles.

The USC and Harvard studies, however, may simply show that families rearing asthmatic children intentionally stay away from the most polluted cities.

Muddying the issue even more, another large study--this one of California adults--found three times more asthma in the smoggiest cities. The link to adults, but apparently not children, leaves scientists puzzled.

The upshot is “we can’t rule out” pollution as a cause of asthma, said Hillel Koren, the U.S. Environmental Protection Agency’s director of human studies.

“Even though general air pollution is down, there is always a question of localized concentrations,” he said. “Maybe people in the inner city are being exposed more, not less, than they used to be because of more diesel exhaust, more highways.”

UCLA immunologist Andrew Saxon says carcinogenic gases in diesel exhaust--called polycyclic aromatic hydrocarbons--can cause people to develop asthma by altering the behavior of genes that control allergic reactions.

“Maybe,” Saxon said, “sitting behind a bus stop is what does you in. Is it the occasional acute exposure or the chronic low-dose exposure? What we’re looking at is a long-term trend, why this disease has gone from extremely rare to extremely common.”

In Saxon’s experiments, adults who inhaled diesel fumes comparable to a few days of breathing Los Angeles air had immune cells that produced four to five times more allergy antibodies than those who were unexposed.

“I think we have one of the causes,” Saxon said. “What it does is make a larger at-risk population.”

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Still, said EPA epidemiologist William McDonnell, “there is no obvious evidence,” despite years of experimentation, proving pollution as the main culprit. “In this epidemic of asthma,” he said, “what we’re finding wouldn’t make a dent.”

In North Carolina, the homes of 250 unborn babies are about to become living asthma laboratories. Federal scientists are gearing up for an unusual experiment to intervene in infants’ lives even before they are born to see if their chances of developing asthma can be reduced.

The homes of low-income pregnant women, mostly African American and Latino, will be scoured to remove indoor allergens that could promote childhood allergies. Bed linen will be lined with plastic covers to deter dust mites. Carpets will be cleaned. Cockroaches will be exterminated.

Over the next six years, the team at the National Institute of Environmental Health Sciences will check to see how many children have developed asthma and compare the rate with similar low-income households in North Carolina where no steps were taken.

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Many experts suspect that minority children in metropolitan areas are disproportionately affected by asthma because of what they breathe indoors, not outdoors.

Dr. Darryl Zeldin, head of clinical studies at the National Institute of Environmental Health Sciences, expects to see cases cut in half among children in homes where mites and roaches are removed.

Still, Zeldin concedes that the researchers might not prevent asthma, just shift the household threats that induce it. “Maybe we’ll prevent the children from being sensitized to dust mite or cockroach, but maybe instead they’ll become sensitized to fungus or dog hair or cat hair,” he said.

Man-made pollutants in indoor air also may deserve some of the blame. Homes and office buildings are more tightly sealed and poorly ventilated than in the 1970s, so they contain more formaldehyde, paints, solvents and secondhand smoke. Children who live in homes with gas rather than electric stoves also seem more likely to have asthma and allergies because of exposure to nitrogen fumes, according to some European studies.

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Cockroaches became a top suspect this year when Johns Hopkins University showed that 38% of asthmatic children in low-income or inner-city Baltimore homes are allergic to the insects’ residue. The more roaches in the home, the more severe the asthma.

Many experts suspect that asthma is a colorblind disease, and that the problem in inner cities is driven by unsanitary living conditions, fragmented families, high stress and improper medical care. Although its prevalence is virtually the same among poor and non-poor blacks, it does appear that the lower the income, the more severe the asthma and the greater the chance a child will die.

“I think the common denominator,” Evans said, “is poverty.”

In inner cities, children’s bodies are being sensitized early in life to a dizzying array of substances.

“There are a lot of things that are more economic than racial,” said Dr. Vanessa Tatum, an Inglewood pulmonologist who chairs an asthma education program at the American Lung Assn. of Los Angeles County.

“In older homes, or government-sponsored housing, they tend to have poorly kept environments. There are more dust mites, cockroach allergens, molds or fungi caused by stagnant water [and dirty] air-conditioning filters.”

Still, there is no evidence that such substances have increased in homes over the last 20 years, and it seems overly simplistic to focus on roaches and other allergens as the root of the epidemic.

“It’s the way you react to the allergens, not the allergens themselves,” Martinez said. “There’s something else going on. But we don’t have any clue.”

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ON THE WEB

* “The Mystery Epidemic” text and photographs will be available Tuesday on The Times’ web site, along with additional asthma information. Point your browser to: https://www.latimes.com/asthma

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

How Asthma Attacks

Asthmatics for unknown reasons have an abundance of highly sensitive immune cells along their airway walls. These cells secrete excessive antibodies that leave the airway walls in a chronic state of imflammation. When these cells become exposed to an allergen, such as pollen or cat hair, the imflammation worsens. Mucus becomes thicker and the muscles around the airways tighten, clogging the already narrow path to the lungs. Wheezing, coughing, shortness of breath and sometimes death results.

Deaths

U.S. deaths from asthma have more than doubled since 1979. Most are preventable with proper medical care.

Prevalence by Age

Asthma has been increasing in the U.S. since the late 1970s, especially among children. Severity is also worsening.

Prevalence by Race

African Americans in the U.S. are afflicted at a 22% higher rate than whites. Black children also die from asthma up to six times more frequently. Officials do not track other races.

Sources: NCHS, National Health Interview Survey; “The Human Body”; AMA Encyclopedia of Medicine.

Easing Symptoms

Here are some steps that can help reduce symptoms:

* Reduce dust mites by encasing mattresses, box springs and pillows in special zippered plastic cases.

* Vaccum often but not when asthmatic is home.

* Vinyl, leather or wood furniture is preferable to upholstery.

* Wood floors are preferable to carpet.

* Wash bed linens, pillows, blankets and stuffed toys once a week in hot water.

* Control cockroaches, mold and fungus.

* Remove animals from the house, especially cats.

* Reduce exposure to outdoor allergens by closing windows, using air conditioning and remaining indoors when pollen counts or smog levels are high.

* Avoid exposure to tobacco smoke.

* Avoid physical activities and stay indoors on smoggy days and during Santa Ana winds.

* Ensure gas appliances have proper flues or ducts.

* Avoid wood smoke, household sprays and paints.

* Inhaled steroids such as prescription drugs Vanceril or Aerobid, used every day are considered the most effective way to manage asthma and prevent attacks.

For more information call the Asthma and Allergy Foundation at 1-800-624-0044.

Source: National Institute of Health, Global Initative for Asthma, 1995.