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The Asthma Trap

All it takes to control asthma is the right medication, clean air, and a reasonably stress-free life. But for millions of children caught up in the epidemic, none of those things are anywhere within reach.

Tanisha Ammons lives on the west side of Chicago in a rented four-bedroom apartment. The neighborhood is working-class. The street is reasonably quiet. The apartment’s not far from the local elementary school, and it’s an easy drive to Midway Airport, where Cornelius Cook, Ammons' husband, works the night shift. When he leaves for the airport, Ammons—who works by day as a nursing-home aide—lies in bed, listening for the sound of her four sons sleeping. For many parents, this is the day’s most peaceful time—a hard-won silence in which you can hear yourself think again. But for Ammons, bedtime is often its own harrowing beginning.

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Sometimes it's Jacquez who starts. He's the oldest at eight, a devotee of Spider-Man and Harry Potter, a sensitive kid who writes poetry. In the hours after midnight, Jacquez begins coughing. It's slow at first and then revs up, until the boy is sputtering in machine-gun intervals. Then it's Marcus, who is seven, chiming in with his own cough—a raspy hack that can go on for hours. Ammons listens to it almost nightly now, this haunting call and response between the two brothers. Marcus' cough has grown especially scary in the last year. "It sounds like he's choking," Ammons says. "He barely sleeps."

Nor does Ammons, who gets up and gives the boys cough syrup or a puff of Albuterol, or occasionally just stands in their doorway to make sure they’re all right. On a bad night, her other kids join in. Semaj, the four-year-old, coughs so violently that she doesn't even bother putting him in his own bed much anymore, preferring to keep him next to her, to make sure he doesn't turn blue. Omarion, who is two, has a chronic cough as well. And then there are the really bad nights, when the Albuterol doesn’t help and one of the boys—usually Marcus—starts struggling to breathe. This is when he has to be raced to Cook County Hospital's emergency room, where he's given drugs to release the invisible stranglehold on his airways. When it's over, and the boy is breathing normally again, Ammons relaxes—but only for a while: Marcus' symptoms usually return within days. "I never stop worrying about it," she says.

On a late fall Thursday, the streets slick in a light drizzle and the last of the season's leaves dropping wetly from the trees, Ammons and Cook have brought the two oldest boys for a doctor's appointment in an unlikely spot—a 35-foot-long recreational vehicle parked outside the boys' school, Webster Elementary. In appearance, the RV is not much different from what a pair of footloose retirees might drive to Yellowstone but for the words "Asthma Van" emblazoned emphatically in black on each side.

All four of the Ammons boys have been diagnosed with asthma, which is to say that their airways are chronically inflamed. When an asthma patient is exposed to certain "triggers"—like changes in air temperature, dust mites, or smoke, among a host of other things—the lining of those airways produces extra mucus, causing them to constrict, which in turn can lead to coughing, wheezing, and difficulty breathing. The feeling is sometimes compared to breathing through a straw. A severe asthma attack can quickly starve the lungs of oxygen. According to the National Institutes of Health, more than 5,000 Americans die this way every year. In Chicago, where the condition is particularly rampant, rates of hospitalization for asthma are twice the national average.

Asthma tends to run in families, which may make it seem like the Ammons children are experiencing little more than genetic bad luck. But genes alone can’t account for the fact that asthma has become the most common chronic illness among children in this country, affecting some 6 million kids, and its prevalence is growing at a rate that some public health experts find alarming. Since 1982, according to the National Center for Health Statistics, the number of asthma sufferers in the United States has doubled.

The progression of the disease is both baffling and frustrating: In recent years, medication used to treat asthma has grown more refined and effective, and the consensus among doctors seems to be that, when properly treated, it should be easy to control. Nonetheless, a December 2004 study by a coalition of health groups showed that nearly a quarter of children with asthma made at least one trip to the emergency room in the past year, and just over half had missed some amount of school or daycare.

Asthma is now the most common reason children in Illinois end up hospitalized, and it’s the leading cause of illness-related school absenteeism nationally. The fallout is significant: Parents miss work to care for their children and scramble to pay hospital bills; children’s grades fall off, and they consistently report feeling socially isolated. One study estimated that childhood asthma costs the nation $3.2 billion annually in health care expenses. All this begs the question: If asthma attacks are largely preventable, why aren't more of them being prevented?

Inside the Asthma Van, Sandra Peña, a jocular nurse with vivid brown eyes and gigantic hoop earrings, ushers Tanisha Ammons to a seat in the vehicle’s cramped kitchen area. Colorful medical diagrams—of lungs, alveoli, nasal cavities—are hung up on one wall. The cabinets have been stuffed with cartons of inhalers (used to pump medication into the lungs) as well as spacers (plastic holding-tank devices that make it easier for kids to use inhalers), most of them donated samples from pharmaceutical companies. Peña hands Marcus a coloring page and some crayons, while in the back, the van's driver, Joe Geraci, measures Jacquez's pulmonary function by having him exhale into a tube that’s been hooked up to a laptop computer. The mobile clinic's resident pediatrician, a petite, energetic woman named Karen Malamut, reads through the boys' medical charts.

When Peña asks Ammons who else in the extended family has asthma, she shrugs. "I have it. My sisters have it," she says. "All the cousins have it. My grandmother—oh, and my mom just found out she has it, too." She gives a wry smile and shrugs again. "Pretty much everybody's got it."

A technician at Cook County Hospital gets Esosa lined up for a lung X-ray.
A technician at Cook County Hospital gets Esosa lined up for a lung X-ray.

Health experts are divided on the question of why the number of asthma cases is increasing. Some doctors view the higher rates of asthma as a byproduct of more consistent screening and diagnosis over the past several decades. Others, however, believe that asthma is becoming more frequent and severe due to various environmental changes -- many of which are beyond a patient's immediate control. Asthma has been linked to air pollution and high ozone levels. Pollutants in indoor air -- from chemicals used in cleaning products, paint, and pesticides, to dust, mold, rodent and insect droppings, and pet dander -- may also bring on asthma attacks, particularly in newer, better insulated homes, which "breathe" less than their predecessors. Stress can exacerbate the disease. "Asthma is so multifactorial," says Robert C. Strunk, a professor of pediatrics at Washington University School of Medicine in St. Louis. "It’s not a straight line between any one thing and the disease, which can make it very difficult."

Malamut and Peña spend most of their time on the Asthma Van trying to unravel their young patients' lives—from what’s triggering the asthma to why a child may not be getting proper medication. Peña gently grills parents for information about the family's housing—whether, for example, a child sleeps in a basement room, more prone to be moldy, or whether there are many stairs to be climbed, which can be trying for an already challenged set of lungs. She asks whether anyone smokes in the house, and if she doubts the response she may lean over and sniff a parent’s clothing.

Over the course of a 90-minute appointment with Marcus and Jacquez, Malamut and Peña learn that Marcus' prescription for steroidal nasal spray—which the boys' mother says eased his symptoms immensely—ran out months earlier, and that Medicaid would not cover a refill. Jacquez, it turns out, has been using his Albuterol inhaler incorrectly, shooting the medication straight into the air rather than into his lungs. Malamut gives him a new, accordionlike spacer to better direct the drug and makes him practice with an empty pump to be sure he's getting it right. When he does, the eight-year-old beams with pride. "I need this," he says almost giddily, waving the new gadget for all to see.

Malamut then writes Marcus a prescription for an alternative nasal spray covered by Medicaid. She draws a careful, color-coded illustration to show who should receive which medicine and how often. She explains to Ammons why the cough syrup she's been giving the kids does nothing to help asthma, then bestows a warm hug upon each boy and makes them promise they'll return for a checkup next month. Ammons and Cook, openly gratified, usher the kids down the van's steep steps and herd them across the wet pavement to school.

"My goal is to have every child live as normally as possible, to show them how good it can feel just to breathe the way other kids do," says Malamut, watching the family go. "Maybe now they’ll get some sleep."

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