Preventing Asthma: Searching “Upstream” for the Evidence

Felix Aguilar, MD
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UCS | December 9, 2014, 4:16 pm EST
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The buzzing sound of a hand-held nebulizer has become background noise at my clinic. It sounds like a hive of bees moving noisily. Everyday children and adults in South Los Angeles get asthma treatments at community clinics because of exacerbations, also known as asthma attacks. I am a family physician with over a decade of work at community clinics in the poorest areas of Los Angeles.

This post is part of the series
Science and Democracy: Community Voices

Image: Letizia Tasselli/Flickr

As an immigrant, I came to the U.S. as a child; and I had to struggle with my family to get appropriate healthcare. Since the days I was an undergraduate and a medical student at University of California, Irvine, I committed myself to serve the underserved.

L.A. is heavily impacted by asthma. According to the Los Angeles County Department of Public Health, nine percent of children countywide have asthma. African-American children have the highest rates of asthma (25%) compared to Hispanic children (8%), non-Hispanic White children (7%), and Asian/Pacific Islander children (4%).

One of the parents of a child patient of mine described her son’s asthma attack as a seeing a fish out of water, gasping for air. I empathize with her concern for her child. A 2008 survey showed that parents of Hispanic and African-American children worry more about their child’s asthma but have lower expectations for symptom control and functionality, more competing priorities, and more concerns about medications than white parents.

Dr. Felix Aguilar with a patient receiving a nebulizer treatment.

Dr. Felix Aguilar with a patient receiving a nebulizer treatment.

From my work in community clinics and public health clinics, I realized that to tackle the health problems of poor communities the solutions have to be broad and include multiple sectors. It is not enough to try to cure patients but to prevent disease. We need to be “upstreamists” as Dr. Rishi Manchanda urges us to be in his book “The Upstream Doctors.” We need to look “upstream” for what is causing problems within our communities, instead of only addressing the symptoms.

The 2009 National Asthma Survey showed that in the United States, African Americans and Hispanics are twice as likely as Whites to have insufficient medications to treat their asthma. As a family physician I treat patients and their families with asthma. As a trainer of the Physician Asthma Education Program (PACE) of the National Heart, Lung, and Blood Institute, I also train other physicians in how to treat asthma.

However, medicines are not enough.  A 2004 USC Children’s Health Study showed that air pollution is linked to asthma. The USC researchers studied 1800 children from schools in 12 southern California communities and measured lung function annually for eight years. They found lower lung-function growth rate associated with PM10, PM2.5, NO2 and acid vapor.  The study noted, “By age 18, lungs of many children growing up in smoggy areas are underdeveloped and will likely never recover. 18-year olds growing up in polluted communities in Southern California have a 5-fold risk of having abnormal lungs—related to a package of traffic-related pollutants (e.g., PM, NO2, elemental carbon). The study asserted that pollutants of harm “derive from vehicle-related emissions and combustion of fossil fuels.” John Peters, MD, the study’s senior author, stated “When we began the study 10 years ago, we had no idea we would find effects on the lung this serious.”

Thus, the ten-year USC Children’s Health Study found that children are more vulnerable to air pollution. In the more polluted communities, children have more school absences, more asthma exacerbation, and measurably reduced lung function. They also found that new cases of asthma in active children were related to high ozone levels.

Alarmingly, according to data from the CDC, the asthma rates have gone up over the last decade for both Hispanic and non-Hispanic black children. Someone has to do something. The South African poet, June Jordan, wrote the answer: “We are the ones that we have been waiting for.” It is up to physicians, scientists, to reduce the burden of asthma in this country. We need to be upstreamists. The importance of treating asthma patients cannot sideline the importance of reducing or eliminating ambient pollution to reduce future victims. Physicians have to work together with other scientists to battle pollution so that the sounds of asthma nebulizers stop being the background noise of many communities.

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  • Richard Solomon

    The need to be ‘upstreamists’ is relevant to asthmatic adults who are not of African American nor Hispanic descent. My wife had 3-4 episodes of asthma over the course of a few months in the fall of 2003. Her PCP attempted to intervene with medicines. But, with the benefit of hindsight, these efforts were clearly inadequate. In Feb 2004 she ended up in the hospital with a severe attack that the ER could not manage. After 2 days in intensive care and 5 days more in a regular room where she received active treatment she was released to come home. It still took her one month of recovery at home before she was ready to return to work, however. The hospitalization cost $40,000. The missed work cost her employer 5 weeks of lost productivity.

    Ongoing treatments with inhalers, steroid based meds, and allergy shots brought her both some relief but also some other problems. She had 3 incidents of shock to the allergy shots before these were finally stopped. Her use of the steroid based meds for ‘longer term relief’ led to type 2 diabetes in 2006 for which she now takes oral meds. It also led to high blood pressure which she admittedly did not handle very well. So, in 2010 she had a ‘minor stroke’ the consequences of which she is still living with.

    It was only when we moved to another community later in 2010 that her asthma has finally remitted significantly. Ie, different plants to which she is ‘allergic’ and less pollution overall. Now she only needs to use an inhaler 2-3 times a month rather 2 times than daily. She uses a steroid based medicine only when a serious cold or flu gets her breathing poorly again. Fortunately, these are only needed for 2-3 days. Then she can stop them before her diabetes worsens.

    Overall, the financial costs of her asthma have been very great indeed. Her diabetes and high blood pressure will require treatment for the rest of her life. The cost in terms of the quality of her life is immeasurable.