SCOTT Schroeder, a pediatrician and an associate professor at Montefiore Medical Center, in the Bronx, is a rugged-looking man in his mid-forties who was good enough at basketball to have played in college but not, he says, for the pros. He has furnished his cramped office clubhouse-style, with sports paraphernalia and souvenirs. Its only window is an ersatz one, with curtains that Schroeder sketched on the cinder block in colored marker. When we met recently, his phone rang constantly with questions from anxious patients, and he answered each call with a jaunty mixture of benevolence and locker-room sarcasm. For Schroeder, who specializes in the treatment of asthma, taking on a patient means taking on a long-term relationship. His appointment book is full.
The Bronx is the U.S. epicenter of asthma. Rates of death from the disease are three times as high here as they are in the United States as a whole, and hospitalization rates are almost five times as high. In some Bronx neighborhoods 20 percent of the children have asthma, and so do a goodly number of adults. A local rap group wrote a song titled "Ventolin," named for a popular asthma reliever.
The Bronx may serve as a harbinger for the world. Australia, New Zealand, South Africa, Singapore, Hong Kong, parts of South America, and much of Western Europe struggle mightily with the disease. In the United States 15 million people have asthma, five to six million of them children -- more than double the number in 1980.
Asthma kills at least 5,000 Americans annually -- not a terribly large number compared with the toll other diseases take. But what the condition lacks in lethality, it more than makes up for in morbidity: it wears people down, crushes their spirits, and threatens their livelihoods. Asthma is the most common chronic disorder among children and the leading cause of both childhood hospitalizations and school absenteeism, robbing children of 10 million school days a year and their parents of an untold number of work days. According to the Centers for Disease Control and Prevention, health-care costs associated with asthma will reach $14.5 billion this year.
Just why asthma is more prevalent and more damaging than ever before is under investigation by hundreds if not thousands of scientists around the world. Scott Schroeder is not one of these. His job is to treat and contain the disease, which in the Bronx seems a Sisyphean task. I asked him where he begins, and he reached under his desk for a battered canvas sack printed with the logo of the American Lung Association. He unzipped the bag and showed me an assortment of sprays and pills and what looked like the sort of paraphernalia a drug addict might find useful. It was an incredible, almost frightening array. Schroeder explained that children with severe asthma have treatment regimens approaching those of AIDS patients. Some take as many as eight different medications a day. Assorted plastic bellows and glass and cardboard tubes are each designed to help deliver medication, which is aerated for even dispersal in the lungs, more effectively. But inhalers are seldom used with such devices. Schroeder put his lips directly over the nozzle of an inhaler, squirted, and snorted deeply. Misused this way, he said, his voice squeaking as if he had inhaled helium, the inhaler dumps medication into the mouth before it can reach the lungs. And patients tend to misuse it.
"When I first meet a patient, I spend an hour with him," Schroeder told me. "I can do this because I'm an academic physician who gets paid by the year, not by the patient. A general pediatrician working under managed care has to see four to six patients an hour -- he doesn't have the time to talk about diet, exercise, the kid's environment. And that's why these kids keep ending up in the ER. I was shocked when I first came here, because so many kids had been hospitalized fifteen or twenty times with asthma and had never seen a specialist."
Schroeder had to see a patient across town, so he offered me a lift and a quick tour of some of the region's asthma-ridden neighborhoods. The Bronx is the only one of the five New York City boroughs, he reminded me, that is part of the mainland, and for this reason it has long been a hub for trains and trucks delivering cargo. Whereas freight bound for Manhattan must be barged across the Hudson, trains can travel overland directly to the Bronx. When truck traffic largely supplanted train traffic, several decades ago, the trucks came roaring through too. Interstate 95, the major truck route from Florida to Maine, cuts straight through the Bronx, where it becomes the Cross Bronx Expressway and merges with a snarl of other full-throttle routes. Trucks make up a quarter of the traffic; among them are tractor-trailers headed for Hunts Point, a boisterous neighborhood surrounded by body shops and junkyards and crowned by the city's largest wholesale produce and flower market. A couple of thousand trucks roll into the sprawling Hunts Point Terminal Market each week, many standing with their engines humming as drivers wait their turn to unload. The wait can be hours or even days, but the drivers stay close to their rigs -- sleeping in them and rarely venturing into the market. As the trucks idle, they churn out diesel fumes, which meld with the fumes from incoming traffic into a smog that blankets Hunts Point and the bordering low-income communities of Port Morris and Longwood. Dart Westphal, a Bronx community-development activist with a special interest in the borough's history, points out that the Bronx is built on a slope (with Hunts Point in the lowest part), causing what he calls a "mini-inversion" over the East River that further deteriorates air quality. "The basic purpose of the Bronx Expressway is to carry the trucks of America," he says. "What the Bronx gets out of this is dirt and noise."