George Harvey, a 5-year-old living in Harlem, behaves much like any normal, energetic child. But George struggles with a condition that is rampant in his community asthma. At times George has to slow down while playing with friends because it is hard for him to breathe and at times he wakes up at night with tightness in his chest that keeps him from falling back asleep. When his attacks are severe, his frightened parents rush him to the emergency room, something that happened twice in the past three months.
Unfortunately for George and many Harlem children, asthma a chronic inflammatory disorder that limits airflow to the lungs is a way of life. Preliminary data from the Harlem Children's Zone Asthma Initiative, an ongoing, evaluated intervention project, indicate about 25 percent of Harlem children suffer from asthma, a much higher proportion than the 5 percent to 7 percent that is the norm for American children.
Why are Harlem's children so hard hit by asthma? This is a question the doctors, researchers and community workers in the initiative are trying to answer. The innovative program run by Harlem Hospital Center; Harlem Children's Zone, a non-profit community-based organization; and the Mailman School of Public Health began screening children 12 years old and younger for asthma in 2001. About 2,200 children fall into the category of those who will be screened and offered treatment under an asthma management plan.
The area to be screened encompasses about 24 blocks, or one quarter of Harlem, stretching from West 116th Street to West 123rd Street between 5th and 8th avenues. The program will expand north to 135th Street next year and possibly farther in the future, says Dr. Stephen Nicholas, associate professor of clinical pediatrics at P&S and director of pediatrics at Harlem Hospital.
"Asthma is the No. 1 reason why kids come to the emergency room," says Dr. Vincent Hutchinson, P&S associate clinical professor of pediatrics at Harlem Hospital and medical director of the asthma project. "We're trying to decrease ER visits and asthma-related hospitalizations with the goal of decreasing school absences. When asthma is not controlled, a parent has to take a day off to stay home with the child. Over time, asthma can jeopardize both the child's education and the parent's job," Dr. Hutchinson says.
One of the impediments Harlem's asthmatic children face in receiving proper, consistent asthma care is that few pediatricians choose to practice in their neighborhood because of low levels of Medicaid reimbursement. Without good primary care, the kids' asthma gets worse. Then when a child has an asthma attack, the parents, lacking a pediatric caregiver nearby, usually have no choice but to take the child to an emergency room, says Dr. Mary E. Northridge, associate professor of sociomedical sciences and deputy director of the Mailman School's Harlem Health Promotion Center.
To lessen the healthcare access problem, Harlem Hospital is starting a family asthma clinic supported by a five-year, $850,000 grant from the New York State Department of Health. The clinic is based on the family care model of the AIDS clinic that Dr. Nicholas and his colleague, Dr. Elaine Abrams, associate professor of clinical pediatrics (P&S) and clinical epidemiology (Mailman), founded at Harlem Hospital in 1985, which enabled parents and their children to receive treatment at the same place.
The neighborhood asthma project started by surveying parents to find children with asthma. Now, community workers from the initiative visit the home of each child who appears to have asthma based on the surveys. The community workers, in collaboration with clinical staff, use the home visits to assess the adequacy of existing primary care and asthma medication and to provide a range of environmental, social, educational and medical interventions.
In George's case, a community worker in the Department of Pediatrics at Harlem Hospital, Keith Faulkner, on his first visit gave Mrs. Harvey a dust mite-proof mattress and pillow covers for the child's bed and a peak flow meter to monitor his breathing. Mr. Faulkner discussed with Mrs. Harvey additional ways to minimize dust and allergens and gave her booklets on asthma and hotline numbers to call for more information. He also arranged for her to receive a new vacuum cleaner with a special dust filter, an air purifier, and pest control services as part of the initiative.
The community workers may send a cleaning service to advise families on how to rid their apartments of possible asthma triggers. Community workers follow up at three-month intervals during the course of a year to assess the effectiveness of interventions and provide additional services where needed. As of early July, the community workers had visited the homes of more than 230 asthmatic children; they expect to visit 500 families by December.
It is not clear why certain children develop asthma. What is known is that a variety of irritants can trigger attacks, including cigarette smoke, animals, dander from pets, dust, roaches, the common cold, physical activity, mold, pollen, and air pollution. For example, George, who lives near the FDR Drive, is exposed to air pollution from that heavily used highway and from a nearby garage for garbage trucks. His family also owns a cat, exposing him to pet dander.
The initiative's team is putting the data it collects into a geographic information system in a project led by Seth Spielman, coordinator in the Columbia School of Architecture, Planning and Preservation. Once complete, the system will enable team members to see the buildings and blocks that have the most asthma cases, which might provide clues about why those areas are so asthma-prone.
"This program is actually delivering services to people rather than only doing research," says Dr. Northridge. "With a disease like asthma, both research and services are needed."
"We felt we had to use what we know and dive in with both feet rather than just do another study," "Dr. Nicholas says. It so often happens that poor, inner-city populations are studied and studied and in return get only empty promises that the research will help change things. We feel this program, as an intervention coupled with research, is very different."
The project is funded by the Robin Hood Foundation, a charity started by Wall Street executives in 1988 to target poverty in New York City.