Richard R. MacMahon, Ph.D.
One aspect of the majority of science curricula that seems to be neglected or overlooked in school systems is the study of environmental health. And yet we are generally aware that we are all constantly subjected to environmental interactions with air, water and soil. We absorb an astonishing number of contaminants from the air and water we use, plus many other pollutants derived from soils, that we ingest in the plants and animals that we eat.
I have been interested, especially for the past four years, in the relationship between the city environment and asthma. In my forty years of teaching, I have seen the incidence of asthma increase steadily, especially in urban environments. Since I began teaching at High School in the Community, an urban regional magnet school, I have had a number of students who are severely asthmatic. This condition has detracted from their ability to fully participate in school and in social activities. Asthma has become a severe handicap to a fairly large number of my students.
What is the relationship between asthma, the urban environment in New Haven and socioeconomic status? A significantly higher rate of asthma in urban environments is well documented (Am. Thoracic Soc. Sym., 1996; Bernstein, 1999; Aligne, 1998; Augustine-Reaves and Augustine-Jefferson, 1996). It seems on the surface that most of my students who suffer with asthma live in older homes and mostly in poorer neighborhoods. What environmental factors cause asthma? How are the age of the home, diet, smoking of parents, and parental income related to asthma?
I see students barely passing in school because of excessive asthma-related absences. Poor performance and poor grades seem to be typical of most of my asthmatic students. But there are a number of them who simply refuse to let asthma stand in their way. They work hard to keep up, but they are in the minority (Taylor, 1997). For most of my asthmatic students, I feel this condition is a major negative factor in their lives. Many of them are angry, have low self-esteem and seem to lose hope, direction and conviction and thus fail to graduate from high school.
The reasons for this are fairly easy to understand, but are not often dealt with directly at school. Every time a student is absent, whether for a long or short period of time, they return to a class that has continued on, leaving the returning student behind. The more severe the asthma, the longer each absence lasts. If a student has mild persistent asthma (JAMA, 1997a), they may be absent two days per week. By the end of week three they have missed one week of school. It is very difficult for a student to get caught up in five or six subjects. Even if the student is able to make up the work, it is still not quite like being there in school. How good are someone else's notes? When do you make up labs? tests? Class discussions cannot be made up, the information developed here always remains second hand for the absent student. Being behind can be profoundly depressing.
Stress itself can cause an asthma attack. We recently had a bomb scare at school. We immediately evacuated the students to another school and held them there until our building was secured. Several students complained of breathing difficulties, and one girl had a full asthma attack complete with wheezing, shortness of breath and an EMS ambulance. If a student feels anxious and under stress because they have been absent and are behind, this may only exacerbate an already bad situation, and asthma symptoms may worsen. Thus students with many absences may inadvertently be bringing more troubles on themselves through stress.
We must remember that at this time of life our teenaged students are young adults and are distancing themselves from their parents as they grow up. They look more and more for support and companionship to their friends. The peer group becomes the dominant social force in the life of a teenager. How devastating it must be to be away (absent from school) from your friends.
Teens with asthma often seem to be on the fringes of social groups. It is hard to be an integral part of a group when you are constantly absent from school and the group. I have observed several students who seem to have a very hard time making friends. And their attendance records seem to indicate that those students who are constantly absent usually have a much harder time making friends. Frustration over social relations often seems to cause asthmatic students to act in a negative, aggressive manner. Asthmatic boys in particular seem prone to disciplinary problems in school, while asthmatic girls often exhibit low self-esteem.
Considering all of these factors together, it must be extremely depressing to be a teenaged asthmatic. And it is easy to become discouraged with yourself if you are asthmatic. This rather easily leads to a feeling of hopelessness. "What's the use? I'll just be absent again next week!" This attitude contributes greatly to low self-esteem and despair. If not encouraged and aided, the asthmatic student often fails to finish high school and does not graduate.
Two other factors come into play here. Asthmatics miss school more often than other students and most are on medications more often than other students. Both of these factors may contribute to a lower level of academic achievement. At what age does the asthmatic begin to think that they are not quite as bright as other students? I had one young woman student who several times referred to herself as "dummy"! If you think you are not very smart, why try at all? This is another negative aspect of being an asthmatic student.
From the perspective of the patient there are two vital physical issues involving effective medication. First the bronchioles must be relaxed and opened by a bronchodialator inhaler. But this gives only short-termed relief to asthma sufferers. In order to effectively control asthma the patient normally must also take an anti-inflammatory. These anti-inflammatories do not work immediately and need to be taken regularly for a period of weeks to be effective. (JAMA, 1997). Many children need to take an anti-inflammatory on a continuing basis until they are adults. This gives their lungs a chance to grow to adult size with the minimum amount of scarring and the maximum chance of outgrowing the asthmatic condition.
Unfortunately, many children seem to use mostly the bronchodialator and do not have the patience to continue long-term treatment with the anti-inflammatory medicines. This prevents a more complete remission of the asthma, and leads to further frequent attacks. Many inner city children are in charge of their own medication. In one study, over one half of the children nine years or older supervised their own medication, much of which turned out to be over-the-counter inhalers, such as Primatene Mist (Eggieston
et al
, 1998).
Medications taken by asthmatics have very definite side effects. The most common bronchodialator is albuterol. Its side effects may include tremors, nervousness, excitement, insomnia, hoarseness, cough, increased difficulty breathing, rapid heartbeat and palpitations. The anti-inflammatories in most common use are the corticosteroids.Their side effects include oral thrush, hoarseness, cough, impaired growth in children, adrenal suppression, impaired bone formation/resorption, cataracts, bruising, dermal thinning and behavioral disturbances. The most common non-steroidal anti-inflammatory is Cromolyn. It can prevent asthmatic bronchiole spasms, and help reduce inflammation. Its side effects include irritation of the throat and air passage, bad taste, hoarseness, cough, increased difficulty breathing, wheezing, sneezing,stuffy nose and lightheadedness.
Of course not all of these symptoms are present in each patient. Children under medication for asthma cannot help but feel sub-par or under the weather part of the time just from the effects of the medicines. If adrenal suppression occurs, the frequency of urination will change. Fluid retention usually leads to puffiness of the face and other body parts. Impaired growth is another serious concern for children taking corticosteroids.
Other bronchodialators have side effects very similar to albuterol. The main point is that all of these medicines may make patients, especially children, feel rather poorly. It is no wonder that children are often reluctant to keep on a regimen of medication, especially once they are past the initial asthma attack. My grandson gets "dull" when he is on constant anti-inflammatory medicines. He uses
Ginkgo biloba
extract at those times to combat this feeling of mental dullness.
This unit will explore this situation and attempt to offer some answers and encouragement to those afflicted students. Perhaps we will be able to explore what is known about dealing with asthma attacks, and in some small way this will allow these students better access to school and less time being incapacitated.
