Experts Blame Inadequate Care for Many Deaths

With modern medicine’s help, virtually no one should die from asthma. But every year about 5,000 Americans suffer fatal attacks, and half a million others are hospitalized, largely because many doctors provide insufficient care and fail to prescribe highly recommended preventive medications.

“Pediatricians and physicians in general haven’t recognized the impact of asthma,” said Dr. Craig Jones, a USC assistant professor of pediatrics and director of allergy and immunology at County-USC Medical Center. “The major factor is under-treatment.”

Americans are visiting doctors for asthma 50% more often than 15 years ago, according to the U.S. Centers for Disease Control and Prevention. But medical experts believe that many of the 14 million U.S. asthmatics are receiving outdated care, because deaths and severe attacks that could be eliminated are instead on the rise.

A main reason, they say, is that many pediatricians and family practitioners do not follow treatment guidelines provided by the National Institutes of Health since 1991.

“Inexcusable,” said Dr. Ira Finegold, president of the American College of Allergy, Asthma and Immunology. “Asthma is a disease we know how to control.”

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For decades, asthma was considered a malady that many youngsters outgrew. But a baffling upsurge--in prevalence and severity--has drawn the attention of more physicians.

“It was treated relatively nonchalantly by the medical community and in a lot of cases, it still is,” said Dr. Floyd Malveaux, dean of Howard University College of Medicine. “We need to get all practitioners up to speed.”

The National Heart, Lung and Blood Institute--an arm of the National Institutes of Health--is expected to issue new guidelines to doctors next month, including an even stronger warning that many asthmatics need daily drugs to prevent attacks, not just inhalers for emergencies. Many family physicians are starting to recognize the severe consequences of under-treatment. In the past year, some large health maintenance organizations have begun advising doctors to prescribe ongoing use of preventive medications, said Dr. Neil Brooks, a Connecticut physician who is president-elect of the American Academy of Family Physicians.

Still, he acknowledges that barriers remain. “Most problematic is the inner city, where populations are underserved, and rural America,” he said.

‘A Breakdown in the System’

African Americans and Latinos in inner cities not only suffer the most severe symptoms but also have the least access to asthma care, several studies have shown. Government medical programs rarely pay for ongoing treatment of asthma.

At Kennedy Elementary School in East Los Angeles, nurse Kathi Carlsten discovered that none of the 30 asthmatic students receive preventive medications from doctors.

“There’s a breakdown in the system somewhere--it’s sort of scary,” she said. “The physicians in the area, while they are good pediatricians, they are not specialists.”

In a novel experiment to deliver state-of-the-art care to the neighborhoods that need it most, a clinic on wheels has regularly visited Kennedy and 17 other schools on the Eastside and in South-Central Los Angeles.

The idea behind the Breathmobile, staffed by a County-USC doctor and two nurses and funded largely through a one-year $300,000 grant from the Asthma and Allergy Foundation of America, is to see if low-income children can be kept out of costly emergency rooms and intensive care wards, said USC’s Jones, the project’s director.

The Breathmobile has treated 549 Los Angeles children in 11 months. The project, hailed by parents and school officials as a life- and money-saver, is working so well that two more mobile clinics will be added next year.

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Eight-year-old Alejandro Madera of Eastman Elementary School walked into the Breathmobile one morning last summer, struggling to catch his breath. He was in the midst of a severe attack.

A USC nurse and Dr. Jean Hanley-Lopez spent 1 1/2 hours testing him and teaching Alejandro and his mother--who speaks little English--how to prevent the attacks with daily medications and other therapies.

Six weeks later, Hanley-Lopez lifted Alejandro’s Batman T-shirt and listened to his lungs with a stethoscope. His mother said the wheezing attacks that had kept him awake at night and absent from school had stopped.

“Mucho mejor!” the doctor told the boy. “Ah, muy bueno. Gimme five! Good job!”

Nearly two-thirds of the schoolchildren receiving the mobile team’s ongoing care now have their asthma under control, Jones said.

‘A Little Bit Behind the Times’

Physicians routinely prescribe “rescue” drugs--inhalers used during attacks that contain adrenaline-like medicines such as albuterol--that quickly unplug clogged airways.

But many doctors have been slow in prescribing medicines that prevent the attacks by reducing the underlying airway swelling.

Under 1991 recommendations from the National Institutes of Health, asthmatics who experience mild to severe symptoms more than once a week should take inhaled corticosteroid drugs daily. Breathing the anti-inflammatory drugs, such as Vanceril and Aerobid, eliminates virtually all symptoms with few side effects. They must, however, be used every day whether the child feels sick or not.

Specialists say many physicians are unaware that asthma is now considered an inflammatory disease that can be controlled with daily drug use.

“Many in the health care team still are a little bit behind the times too often,” said Dr. Richard Evans III, who heads the allergy division at Children’s Memorial Hospital in Chicago.

Also, many asthmatics only receive their medical care from emergency rooms, where doctors and nurses often save their lives but don’t have time to explain the disease and how to prevent attacks.

People should be suspicious about what seems like recurrent colds or bronchitis, said Dr. Vanessa Tatum, an Inglewood pulmonologist. Asthma doesn’t necessarily mean wheezing; it often manifests itself as a recurring, dry cough--usually at night--or tightness in the chest.

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With proper treatment, the changes in lifestyle can be dramatic. Olympic gold medalists Jackie Joyner-Kersee, Tom Dolan and Amy Van Dyken are asthmatics whose symptoms have been managed.

But, like diabetes, asthma may require a lifelong regimen because the disease can only be controlled, not cured.

At the mobile clinic, nurse Rosemary Valenzuela showed 11-year-old Angel Leyva how to use inhalers and a hand-held meter that measures how fast he can blow air out of his lungs. She told him to use the drugs and the meter every day, keeping a daily diary.

“How long do I have to do it?” Angel asked.

“Forever and ever,” the nurse answered.