Does Civilization Cause Asthma?

Asthma is growing at an alarming and puzzling rate in industrialized countries, and the answers to the mystery of its origins may lie in our very attempts to prevent childhood disease

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."

Schroeder can't be sure that the diesel fumes spewing from those eighteen-wheelers are in any way responsible for the poor health of his patients. But he thinks they are, and so do other clinicians I spoke with. Scientists are equivocal. Studies done in the 1990s found that the former East Germany, with its heavy pollution from industry and domestic coal burning, had far less asthma than the ostensibly cleaner West Germany. Likewise, asthma is more common on the pristine, factory-free Isle of Skye, off the west coast of Scotland, than in Cardiff, the relatively gritty capital city of Wales. Douglas Dockery, a professor of environmental epidemiology at the Harvard School of Public Health, says that even if air pollution does not cause asthma, it can and does provoke symptoms in asthmatics. "It's very clear that in the United States asthma is worst in poor areas, and that we're seeing an increase of the disease in these areas," he says. "This makes us think that there must be environmental characteristics involved." Some scientists believe that diesel fumes are particularly potent asthma irritants, but most seem to agree with Dockery that symptoms are provoked by any number of pollutants, and that substances found indoors are often more irritating than auto and truck emissions.

Schroeder took a call from a patient on his cell phone as he pulled off the expressway and into one of Hunts Point's residential neighborhoods, a row of five-story walk-ups. "This is where a lot of my patients live," he said. "Asthma Central." We passed a schoolyard whose playground, a concrete island splattered with graffiti and broken glass, was padlocked. The basketball backboards had been ripped from their stems, leaving only concrete supports. A few blocks down was a public swimming pool; the day was hot and humid, but the pool was deserted. "Kids here spend their time indoors," Schroeder said. His patients spend even less time outside than other neighborhood children, because they are afraid that their lungs will go into spasm and their airways will shut down and no one will be nearby to save them. He told me that mothers sleep in the beds of some of his young patients every night.

We passed few chain stores and no pharmacies but quite a few "botánicas" -- shops specializing in herbal remedies and potions, many of which are for the treatment of asthma. Not all are worthless. Several contain ephedrine, the active ingredient in a widely advertised over-the-counter asthma remedy. Ephedrine is not recommended as the first line of treatment for asthma attacks, but many people here make ample use of it rather than seeking conventional medical care.

"It's tough to get a cab in the Bronx, and a lot of people don't have cars," Schroeder said. "So access is a problem. When kids have an asthma attack, their mothers call 911 and get an ambulance, which takes them to the emergency room. The kid is hospitalized and stabilized and given some medicine and released. A few months later the kid is back."

The Atlantic Monthly; May 2000; Does Civilization Cause Asthma? - 00.05 (Part Two); Volume 285, No. 5; page 90-100.