In the South Bronx, Young Asthmatics Often Wind Up in an Ambulance
Calls to 911 for asthma are higher in the South Bronx than in any other New York City neighborhood. Efforts are underway to reverse the trend.
Last October, 9-year-old Benjamin Rivera was in math class at P.S.130 in the South Bronx when he started wheezing. A lifelong asthmatic, Benjamin had had attacks at school before, and was given an inhaler each time. But this one seemed different; he was laboring to breathe, and wasn’t responding well to the inhaler. “My throat was tight,” recalled Benjamin.
The school nurse called his mother, Frances Rivera, and she left work at a nonprofit in the South Bronx to check on him.
It was the fourth time she’d received a call like that in 10 days. The other times, she was asked to pick her son up from school. But when she arrived that day, the school nurse decided that since Benjamin hadn’t recovered after two doses on the inhaler, he had met the school’s threshold to call 911.
Within minutes, Benjamin and his mom were in an ambulance, heading to Montefiore Hospital, about three miles away. There, he was put on a nebulizer with Prednisone, a corticosteroid, and he recovered quickly enough to be discharged in a few hours.
Benjamin’s predicament is common in his neighborhood. The South Bronx, with a population of about 600,000, was responsible for more than 5,000 asthma-related calls to 911 during 18 months in 2015 and 2016, according to public 911 logs. By comparison, about 6,000 calls came from all Manhattan, where more than 1,600,000 live.
Asthma rates in the South Bronx are especially high among schoolchildren aged 5 to 14, according to the city Department of Health. And though public schools are equipped with nurses, and some even have health centers, the prescription for many asthma patients is a trip to the hospital.
“We’ve had asthma deaths over the years, that’s why [the threshold] is low,” explained Helen Aguila, a pulmonologist working with the New York City Office of School Health. “Also, a nurse’s office isn’t a controlled setting. We cannot monitor oxygen, and don’t know where the child is going,” she added.
South Bronx neighborhoods like Hunts Point and Morrisania have had some of the highest asthma-mortality rates in the city, according to the city Department of Health, though it’s hard to establish the extent to which schoolchildren are affected.
The question of whether to call 911 is just one of the difficult issues that face young asthmatics, their families and their health-care providers.
Before school nurses can administer an inhaler — a step that often prevents a trip to the ER — they must get authorization forms signed by the child’s parents and doctor. But schools struggle to get the forms signed for every asthmatic kid. And if a child without a form suffers an attack at school, parents must pick them up, or an ambulance will take them to the hospital.
“Fall is the peak [season] for asthma. We were having quite a few children that came in with asthma symptoms, but we had no medication order for them. So I had to call 911,” said a school nurse in the Bronx who asked not to be named because she wasn’t authorized to speak to the press.
At Benjamin’s school, which enrolls 100 asthmatic children out of roughly 500, this happened two or three times last fall.
In bigger schools, it can happen up to eight times per school year, said the nurse.
According to Aguila, from the Office of School Health, only about 40 percent of the needed asthma medication forms are submitted by parents.
As simple as bringing a form to school might sound, the process can be stymied by “psycho-social issues,” as Aguila put it. The South Bronx is the poorest congressional district in the U.S., with low education and high incarceration rates. These factors can diminish the amount of attention and time that parents allocate to asthma management and prevention.
“The biggest problem with asthma is compliance; patients don’t use their medicine the way they should,” said Dr. Acklema Mohammed, a pediatric general practitioner at the Urban Health Plan clinic in Longwood, South Bronx. She has practiced in the community for more than 30 years. “This is a very ER-oriented community,” she said, meaning that people often resort to urgent care, because they failed to do preventive care and take medication.
And emergency-room visits are expensive. Benjamin, like thousands of other New York children, is covered by the Children Health Insurance Program, or CHIP. For them, the hospital bill amounts to zero. But a 2014 study on emergency charges for asthma patients found that the average cost of an visit is around $1,500. The Centers for Disease Control and Prevention estimate that asthma-related costs in the U.S. amount to as much as $56 billion per year, including missed work and school days, as well as early deaths.
A Lifetime of Asthma
Benjamin has had asthma all his life. His 15-year-old sister, Alexandra, also had respiratory issues as an infant, but outgrew them.
Benjamin’s asthma was so serious that the family had to get rid of carpet when they moved into their home. Dust mites trigger his asthma, as do cold weather, exercise and pollen. And then there’s South Bronx’s notorious pollution. The Riveras point to the nearby industrial area in Hunts Point. “All of Hunts Point is full of trucks,” said Richard Rivera, Benjamin’s father.
As an infant, Benjamin was taken into the Emergency Department for asthma twice. The past year had not been particularly bad for him until last fall, said Frances, his mother. So the series of attacks that culminated in the ambulance ride baffled the family. They also worried about the effect on his studies.
“I was [saying] my goodness, my son is gonna be left back if he keeps missing” class,” Frances said. “He’s missing way too much school for something that is part of his life,” echoed Richard.
Asthma is one of the leading causes of kids missing school. When Benjamin’s asthma went out of control last October, he was sent home six times over about 10 days, his parents said.
On a recent afternoon at the Riveras’ home, while Benjamin grabbed cheese and crackers from a plate, his mother showed his Asthma Action Plan. Benjamin’s doctor put it in place after the ER visit so his parents and school could monitor him better.
The plan — a form with sections marked in green, yellow and red according to the severity of symptoms — is promoted by the Centers for Disease Control and Prevention as a way to keep track of symptoms and adjust medication. It instructs children’s caregivers on what to do when asthma worsens.
Prevention and Outreach
When families’ initiatives falter, some institutions try to take over.
Benjamin’s school, P.S. 130, participates in the American Lung Association’s Open Airways initiative. The training prepares school nurses to educate students on asthma.
But though children may benefit from attending the workshops, they don’t always bring parents along.
“I don’t recall any time that they have done any type of asthma initiative in the school,” said Frances Rivera. “It would be nice for parents to sit in one of those.”
“I haven’t heard anything from the school about asthma, it never came up during parent meetings,” said Destiny Brown, whose kids alsoattend P.S. 130.
The principal didn’t respond to a request for comment. But Helen Aguila, the Office of School Health pulmonologist, said it’s not up to the schools to educate parents on asthma. “We don’t really have a program for outreach,” she said. Open Airways workshops are designed for school personnel and students; they usually don’t include parent education.
The Riveras feel that if it hadn’t been for their own initiative in managing Benjamin’s crisis last fall, they would have been lost.
“If you don’t know what to do, if you don’t know where to ask, what happens?” said Richard.
Physicians agree that preventative care and medication adherence can reduce asthmatics’ trips to the ER.
A $10 million state grant will enable Montefiore Hospital to build 21 in-school health centers with full-time doctors in public and charter schools in the Bronx. The centers, which should open by 2021, would be in addition to the 26 school health centers already in place in the borough.
According to Dr. David Appel, director of the Montefiore School Health Program, schools with a health center generate 30 percent fewer 911 calls for asthma than those without a health center.
But not all schools have one — indeed, Benjamin’s doesn’t. School-based health centers can open only in schools with 1,500 or more students, according to the Department of Education’s website.
In lower-income neighborhoods, where insurance issues can limit access to health care, public clinics are especially important. Some of them employ health educators who help fight the asthma epidemic.
On an average day at the Urban Health Plan clinic near Simpson Street in the South Bronx, as many as 30 asthmatic children and their parents see an energetic woman named Gabi Gutierrez. She makes sure that parents are up to date on their children’s asthma, that they administer medication regularly, and that school forms are filled out and brought back to the schools.
On a recent Monday morning, a smiling 8-year-old boy and his mother walked into Gutierrez’s door-less cubicle. First, Gutierrez measured the boy’s lung inflammation levels.
As the boy breathed into a plastic cylinder and an animated cartoon on the machine’s display moved to his breath, Gutierrez asked the mom when the boy had last had symptoms.
“It was just recently, one month? I don’t … Sorry, I’m kinda lost in my time,” the mother said.
“No, no, no, don’t worry,” Gutierrez replied. “Remember when he’s like that to use the machine or the pump every four hours for a good three to five days. As soon as you see that he’s better, don’t just stop the medication, because then it’s gonna come right back.”
The boy’s lung inflammation hadn’t worsened since last year, the last time he was tested. “So you see, it’s pretty good,” said Gutierrez after the boy left. “You have a lot of patients that come in and they’re like, ‘Thank you so much for explaining this to me.’ ”
Gutierrez’s mission also includes giving special attention to immigrants. The South Bronx is “not the same as living in a country where maybe you lived in the countryside and there wasn’t so much pollution,” she said.
And hospitals, which ought to be the last stop for asthmatics, have been developing outreach programs.
In 2017, children visited Lincoln Hospital’s Emergency Department for asthma 2,600 times, according to Tomas Jimenez, an asthma-care manager at Lincoln. The hospital asked the families of those who visited more than once to enroll in a series of home visits to assess the triggers and make sure preventative care is followed. But only about 50 people a year are enrolled in the program, and there are only two community health workers.
Another state program refers asthmatic children to community health workers. The program, managed by NYC Health+Hospitals — the company that oversees public hospitals in the city — employs one community health worker and followed 129 Bronx children in 2017.
More is needed, physicians say.
“If you look at the volume that we get in the Emergency Department, it just scratches the surface,” said Jimenez.
Part of Lincoln’s outreach efforts is to get general practitioners more involved in prevention and education. But without a streamlined record-sharing system between hospitals and clinics, this has proven hard as well, Jimenez said.
New York City ranks 35th in the Asthma and Allergy Foundation of America’s ranking of the 100 most challenging places to live with asthma. The worst city, Memphis, Tenn., recently established outreach initiatives similar to those put in New York City.
LeBonheur Children Hospital in Memphis currently enrolls 587 children in a program to provide asthma education. Memphis’ initiatives involve schools deeply, which has helped reduce emergency room visits by 36 percent and cost of care by 50 percent.
