CHILDREN AND ASTHMA
"A Light Saraf-Evans Production"

Mom: She woke up with major differences: "uhhh, uhhhh" [imitates hard breathing]. So I went and I got cough medicine, and I thought, "Hmm, you know, it's a common cold." But by noon, we were on, you know, on our way to a friend's house É but by noon, she was just laboring to breathe É and that's when we came to the hospital.

Dr. Landrigan: The major problem in children's environmental health today is asthma. The Centers for Disease Control estimate that 15 million children are predisposed to asthma. Rates of acute asthmatic attacks among American children have doubled in the past decade. The group within the American population who are at highest risk are children, and within the broad population of children, it is poor children of color living in inner cities who are clearly at the very highest risk.

[Veronica Lightfoot and kindergarten class at Carver School]

Kids: Good morning, Ms. Lightfoot. I'm here and ready to learn.

Lightfoot: You look like you're ready to learn today. Today, I came to your class because I want to share some information with you about asthma. Can anyone spell that word?

Kids: A-S-T-H-M-A.

Lightfoot: Raise your hand if you have asthma. OK, raise your hand if somebody who lives in your house has asthma.

Boy 1: My auntie has asthma.

Girl 1: My mommy has asthma.

Lightfoot: Yes.

Boy 2: My brother has asthma.

Lightfoot: Your brother has asthma. Yes.

Girl 2: My sister has asthma.

Lightfoot: Your sister has asthma. Yes.

Boy 3: My cousin has asthma.

Lightfoot: We are concerned here in Bayview-Hunter's Point because we are a very toxic area. We have a very high percentage of children with asthma. And we formed what is called the Asthma Task Force. The Asthma Task Force started here at Carver, and our primary purpose was to educate our children.

Lightfoot: Can you show me where your lungs are? Right here. Are your lungs here?

Kids: No. Lightfoot: Are you sure? Are your lungs here?

Kids: No.

Lightfoot: Where are your lungs?

Kids: Right here!

Lightfoot: Show me! OK, how many lungs do you have? One?

Kids: Two!

Lightfoot: You sure it's not three?

Kids: No.

Lightfoot: OK, ready? One, two, three ... blow. Now put your hand there. You feel the air coming through the straw? [Teacher: Yes.] That's how your lungs feel when you are not sick with asthma. Now, pinch your straw. Pinch it. Pinch. Now blow. Put your hand there. [Teacher: Now blow.] Do you feel any air? No, just maybe a little, right? Well, that's how a person feels when he or she has asthma.

Dr. German: Asthma's an inflammatory disease. There's inflammation in the bronchial tree, and that inflammation, that inflammation is something that, once it starts, it's very difficult to turn off.

Dr. Sharek: Recognizing that the prevalence of asthma has, you know, skyrocketed over the last 20 years and particularly in populations such as the Bayview's -- lower socioeconomic populations -- at San Francisco General, I helped set up an asthma clinic to cater to this population in terms of access and education and medication distribution and testing.

Arthur Hill: Take a good inhalation breath, like this. É

Father [to son]: Mira, Juan, nota las saques de la boca [demonstrates] a la sida ... y lo que tiene doctora, bastaba absorber fuerte para dentro, todo que puedes absorber, y cuando lo es solamente para afuera sida ...

Arthur Hill: Deep breath, deep breath, deep breath, deep breath, deep ... blow, blow, blow, blow, blow, blow, blow, blow, blow, blow ... blow, blow. ...

Very good ... we're gonna, we're gonna save that! OK.

Dr. Sharek: We know that children can be predisposed to getting asthma if they are exposed to certain what we call "sanitizers" in their environment from early on: such things as cockroach, dust mites, cat dander, molds, cigarette smoke, uh, and very likely other chemicals as well.

Female Nurse: OK, so if you ... OK, turn this arm. OK. You can't move, though, Ôcause I might scratch you. OK, here we go. Let's sit.

Wendell's Sister: Did it hurt, Wendell?

Wendell: Not that much.

Female Nurse: There you go. See? Wasn't that bad, huh? Now we gotta just put a line through it so we know which one you're a ... you're allergic to. That's one, two, three, four ...

OK, you're done! In twenty minutes, we should know.

[To sister]: It's OK, relax your arm! Nothing's gonna hurt. There. How's that? I just have to move it; that's all. That's over. Now I'm gonna put the line again, just like I ... just said with your brother.

Wendell's Sister: That tickles!

Female Doctor: That tickles!

Dr. Thyne: What I want to do is take her in [Mom: OK.], examine her, set her up for a treatment if she needs it, and then listen to her again afterward. OK, you ready, Fati? OK, let's go. So how long were you in Mexico? Two weeks?

Let's wait for your mom, OK?

All right. I'm not gonna take it off; I'm just going to pull it down so I can listen better. Then I'm gonna check your lungs, OK?

Take a deep breath through your mouth! Blow it out! Good. Perfect! OK, again. OK, you sound pretty good, but I think what I'm gonna do is -- you've got a little bit of wheezing right back here -- so I'm going to give you a treatment, OK? And we'll see if it sounds a little better when we're done. You remember the treatments, right? The special mask.

Why don't you adjust that mask so it fits on your head? Perfect.

Here goes the medicine!

Fati's Mom: There's the medicine!

Dr. Thyne: You want to take nice, slow, deep breaths, OK? Perfect! So it'll take about five minutes, all right? And then, when it's done, I'm going to check you again.

Female Nurse: Number one. You've got a little allergy, looks like.

Wendell: What happens if, like, we try to pop them or something?

Female Nurse: Uh, it won't ... nothing will come out.

Another Doctor: What about over here? Let's have a look at him.

Another Female Nurse [about another patient]: He's got a lot of allergies, you know that? Yeah ... it looks to me like number two is pretty positive, like he's really positive to dust mites. Number three is cat hair, so he looks pretty positive to the cat hair. Um, number four, cockroach, just a little bit. Um, number five is mold.

Dr. Thyne: Quiet, huh? So how do you feel?

Fati: Fine.

Dr. Thyne: Do you feel any better? A little bit?

Fati's Mom: How does this feel?

Fati: Fine.

Fati's Mom: Feels good now? OK.

Dr. Thyne: Deep breath. Ohh, you're breathing much more deeply; that's perfect. OK, now blow out through your mouth, like candles. OK, I'm going to let you rest.

Fati's Mom: I have noticed that a lot of families do have kids with asthma, but they won't come because ... first of all, Ôcause they're illegal. They think that they're going to be in trouble, or, you know, like that. But it's not about that, you know ... I mean, they should worry more about their baby-self. You know, I didn't know if my daughter was going to die. A lot of people told me different things. They're like, "Oh, kids die from that."

Fati: My heart is doing like this.

Fati's Mom: If she starts feeling short of breath, she'll come to me, or she'll come to her grandmother.

When she first became sick, she was actually about ... espera aqua [agua? aquel?] ... she was maybe, like, about 2 months old, and we actually took her to the hospital, and that's where they told us that she had the symptoms of asthma. And from there on, it was like every other week.

We have heard about asthma, but, you know, we weren't, like ... how can I say? ... very educated, myself and my mother. Um, I can show you her room, now, how it is compared to how it was before. She has more open space. She used to have stuffed animals everywhere. Once we learned about asthma, we put everything, like, in pla ... plastic containers. So there's no stuffed animals here in this room any more. And before we got, like, plastic containers, she was always sick, so that's one thing that I noticed. She has her inhalers at home.

Fati: This one. And I have two blue ones, and I take off the top, and I put it right here. So I open the thing, and that's when I ... I press ... when I press it, it goes in, the medicine, and then I've got to breathe two times with the pink one. And the white one, just one time.

Fati's Mom: Like, she's telling me another way that we also find out is, like, when we travel. You know, when we go into a hotel, we go into the room, we can tell if it bothers her because she starts getting wheezing from her nose, her chest, and we, right away, we can tell, you know, either they had animals in that room or they were smoking. One thing that really affects her is the smoke of cigarettes. She'll tell me, "Ooh, that bothers me, Mom. You know, tell them to stop smoking; it's not good."

Dr. Hunninghake: The very worst exposure for a child is second-hand smoke, no question about it. It is almost impossible to control a child's asthma if someone smokes in the home.

Veronica Lightfoot: How many of you know what this is?

Kids: Cigarette.

Lightfoot: This is a cigarette. And if you're around cigarette smoke, sometimes you might get an asthma attack.

Girl: Just like my daddy kept smoking, and now he's got asthma.

Another Girl: When I was a little baby, my mama used to smoke around me, and that's how come I got asthma.

Lightfoot: And that's how you got asthma, you think? We're saying, smoking sometimes will make you feel sick. Sometimes it will make your chest feel tight if you have asthma. If somebody is smoking, and there's smoke around, what can you do? What would you do?

Girl: Have an asthma attack.

You'll have an asthma attack if you're around cigarette smoke. But some ... one thing that you can do is, if somebody is smoking in the room, you can go to another? ...

Kids: Room.

Lightfoot: Room. You don't have to stay there to smell the smoke all the time. Another one is mold. How many of you have you ever seen mold before? Know how mold looks? See the mold? Who wants to hold it? [Kids: Me.] Pass it around. [Kid: I want to hold it.] This is mold. Sometimes we have mold in our house. Sometimes you have mold and mildew around your windows or anywhere where it gets really wet. And sometimes the mold will cause you to have an asthma attack.

Dr. Sharek: Now, one of the other major things that's ... that's a concern in the inner city, especially in a ... a relatively humid area like San Francisco with its fog, is, uh, mold, uh, and fungus and, um, children who live in cramped and damp housing with, uh, maybe a lot of water leakage and certainly a lot of moisture. ... And we have found a tremendous amount of grow ... growth of mold within sort of the concrete walls and floors that we tend to see in ... in some of the projects.

Michelle Phillips, African-American mom [on the phone]: So what I'm asking for is another copy of the latest inspection that you all did. Um, the doctor wrote a letter to relocate me and my children.

Michelle [sitting]: At the time I, I knew very little about mold. I ... I wasn't sure. I didn't even tell the doctors at the time that I had mold because I just didn't think that was the problem with my baby.

So the mold started getting worse, and one Sunday afternoon, he stopped breathing; it seemed like he just, he just start grasping for air, breath, you know; he couldn't. ... And I immediately told my daughter; I said, "Oh, we got to get him to the hospital."

This is his T-shirt as an infant, and what is here is the mold that was in this apartment ... started to eat away into not only Ronald's clothing but all our clothing.

Dr. Sharek: It's very difficult to eradicate mold from these houses. It really requires essentially complete reconstruction of the homes. This is what I've heard from the Department of Public Health folks who are looking into this.

Dr. Hunninghake: Allergy to cats and dogs is really very common. We recommend, if it's possible, that if a child that has asthma due to an allergy to a pet, that the pet be removed from the home, but we also recognize that pets are often ... an integral part of the family. If the pets are bathed on a regular basis, that really can cut down on the amount of exposure that the children get.

Cats don't go outside very much, but a dog, when it goes outside, rolls in the grass and dirt, and they also can bring nonspecific irritants that are really bad for asthma. Although children are more likely to develop allergy to cats, really, dogs can make asthma worse.

Kid [to dogs]: Stop it ... stop eating that disgusting water. Dr. Hunnighake: Not only is it on the fur, but it can then be on the floor of the house, too.

We have to remember where children play. They tend to play on the floor. They play the most in the family room or the kitchen; those areas in particular need to be kept clean. I always start by saying, "Let's try to reduce all the environment exposures we can to make this the mildest possible asthma that we can for the child."

Lois Gibbs: The Center for Health, Environment and Justice is working specifically on children and health around schools. Most schools, um, use pesticides on a routine basis. It's not even as a result of, like, an ant sighting or a cockroach sighting. They just do it every single month, and these pesticides are neurotoxins that can affect their abilities to learn, um. ... They cause cancer. They, again, are a respiratory irritant, and they spray them around the foot of most classrooms, around the baseboards, and then when you think about kindergartners or first graders who sit on the floor all the time to learn and play, um ... they are in the breathing space of this buildup of month after month after month of very toxic chemicals. People don't think about the fact that pesticides are meant to kill, and little children are just as susceptible as the ant or the cockroach or whatever pest they're trying to take care of.

Landrigan: We know on the basis of very careful studies that pollutants in the air, in the ambient air, can cause asthma. We know that ozone, oxidizer, nitrogen, fine particulates, all contribute to asthma.

Peters: Ah, "smog" is a word that combines smoke and, and fog, uh, originally and, uh, was recognized shortly after the public transportation system in Southern California was dismantled, and, uh, large number of cars began to occupy the roads.

Smog consists of particles and gases, and the main ones that we measure and worry about are ozone as a gas, nitrogen dioxide as a gas, and particles from wearing-out tires, from smoke coming out of stacks, tail pipe emissions, pollens ... there are hundreds of things in the smoggy air in Southern California.

McConnell: The Children's Health Study is, um, a 10-year study of, uh, children, following them from, uh, from fourth grade through the end of high school. We are looking at children in 12 different communities inside and outside the air basin for Los Angeles, the large pool of air that we're all exposed to here.

There are a variety of reasons to look at children as a study population for air pollution. They are less likely to be smoking; they are less likely to be in a job where they might be exposed to some chemical that might be harmful for their lungs.

Peters: Children are outdoors more, so they're exercising, so they're breathing heavily and taking in more pollution.

McConnell: Children's lungs are, uh, still growing, um, and they are growing fairly rapidly. Those lungs may be more susceptible to the effect of air pollution.

Almost 6,000 children, uh, total are participating, or have, have participated in the, uh, in, in the study, and we found that, in the communities with higher levels of particles and higher levels of nitrogen dioxide, that the children's lungs grew more slowly. They grew about 10 percent slower in the dirtier communities than in the cleaner communities.

Peters: If we divided the population into asthmatics and nonasthmatics, we saw a clear relationship in the asthmatics, that the more particles or the more NO2 that the asthmatics were exposed to, the higher the rates of chronic cough and, and phlegm.

McConnell: Children who played three or more team sports, they were three to four times more likely to develop asthma if they lived in a high-ozone community than children who played no team sports.

It'd be unfortunate if people went away from this study thinking that children shouldn't exercise, because in terms of weighing, weighing the risks, there is no question but that there are so many benefits to, uh, to exercise that, when there are high levels of air pollution, we can restrict children's outside activity.

Most air pollution in Southern California is caused by moving vehicles.

Diesel differs from, uh, gasoline in that it's a more complex mixture of fuel, and in general it's a dirtier fuel than gasoline. When diesel burns, it creates large quantities of nitrogen dioxide. It also creates, uh, large quantities of particles.

If we want to reduce exposure to air pollution, then we need better mileage standards, and we need to reduce people's reliance on automobiles, encouraging better mass transit.

Dr. Jackson: Outdoor air pollution is bad for people with asthma. During the Olympics, uh, the Olympic Games in Atlanta in 1996, everyone was asked to take public transport. And we did. And the city was twice the population, it was filled with people, very few cars in the streets -- air pollution levels dropped dramatically. And during that same period of time, despite the doubling in population, we had 40 percent less people visiting emergency rooms and seeking care for their asthma.

Dr. Sue Jane Quon: I was never really told outright that he had asthma, but when he was a little baby and he would get a cold, um, he had to go in and get and get, uh, albuterol treatments. So I suspected that maybe he might have asthma because my grandfather had had it, and my sister's child had had it, and I ... I worried a little bit about it, uh ...

We were staying at Curry Village in the hotel rooms, and the kids like to jump on top of the beds whenever we're in any hotel room. And I've always wondered if that stirs up dust mites. And Tony was really stuffy. So I gave him some ... I think Benadryl or something. You know, I thought, well, that'll do it.

Tony: And it didn't work.

Quon: It didn't. You woke up in the middle of the night, remember?

Tony: I start coughing a lot, sneezing a little. My throat kind of hurts.

Quon: We were in the middle of, uh, nowhere, it felt like. And, and I was worried, because he just, uh, had never reacted quite so badly. So, uh, we didn't know what to do. And we had been camping with Dr. Owen, and her son has asthma, and we borrowed her inhaler. She has an aero chamber, which is a lot easier if your child is, is younger and doesn't, you know, time the, the inhaling well with the medicine. So, uh, she knew what to do.

I think it's important to ask more questions than I did ... of your doctor. Um, I don't know if I was just too busy, or I was hoping he'd grow out of it. I was wondering if, if asthma might run in our family, or if maybe there were triggers in my house like the cat or, uh, the rug or dust mites.

Dr. Schwartz: There's a balance between genetic susceptibility and environmental stress. So some people that are especially susceptible can develop asthmatic reactions with minimal environmental stress. People that are genetically resistant might require a tremendous amount of environmental stress to have an asthmatic-like reaction.

Asthma is a really difficult disease for children to have. I have a child who has asthma. My child is limited in terms of his ability to go to school sometimes, to do homework, to participate in sports.

People think of asthma as a disease. It's not really a simple disease. Asthma is a series of different types of disease that all affect the airway in the same way.

Dr. Kline: There's a hygiene hypothesis of asthma, which states briefly that in olden times, children were exposed to lots of pathogens, bacterias, viruses and parasites. It turns out that aspects of infection may be, in fact, protective against asthma and allergy. Nowadays, we keep our children locked up in little airtight boxes. We don't allow them to get any infection. Anytime a child gets an infection he ... he or she is treated immediately with antibiotics. In Third World, in unindustrialized countries, asthma and allergy have not been increasing.

Dr. Schwartz: The level of infections that children have in developed countries versus developing countries is much different. So that individuals in developed countries, children in developed countries, have a much lower rate of infection. It appears that that low rate of infection is beneficial to a child because it prevents them from getting pneumonias and ear infections, but it puts them at higher risk of developing asthma.

Dr. Kline: Here at the University of Iowa, we have the Childhood Asthma Center, and one of the important studies that I'm involved in is looking at some of the reasons why we think children today are getting more asthma than they were a decade ago or 25 years ago. And we're seeing, uh, a 50 percent increase over 25 years, which is really not possible, uh, from a genetic explanation, so it's probably an environmental cause for the increased amount of asthma.

Dr. Hanninghake: Our studies are indicating that as many as a fifth, maybe even as high as a fourth, of the children in the rural communities in Iowa may have asthma, and in over ... half of the cases, we are estimating that asthma is in the moderate to severe category. The primary problem is exposure to grain dust and endotoxins that contaminate a lot of grain and get into the air.

So, if you travel in the rural communities, you don't see smog like you see in Los Angeles, but you can see clouds of dust in the air, and these can be very irritating to the air tubes of the lung for the children with asthma.

Merchant: Uh, Kiacut County is a small, uh, southeastern Iowa county, typically rural, typically agricultural, and, uh, we have been studying this county for about six years. Uh, the first round of 1000 families, uh, um, revealed something surprising to us, which was a rather high rate of childhood asthma.

We're also looking at what exposures the kids have on the farm. There are a number of organo-phosphate pesticides that have been, uh, identified as causes of asthma. The rite of passage in Iowa and every other rural community in America is that, uh, children begin to work at a very young age, so they're out there in the barn, around animals, getting exposed to farm chemicals, uh, ammonia, hydrogen sulfide that, uh, arises from animal manure. In Iowa, there's a lot of livestock raised in confinement, so-called concentrated animal feeding operations, or "ca-foes."

We have the organic dusts themselves, which is common to agriculture. The animals, uh, are fed grain dust primary [?], corn and soy beans. And then the detergents that are used to clean these units cause asthma. Then there's the whole area of, uh, endotoxins that live in the guts of the animals and, uh, they get aerosolized, uh, in these livestock facilities.

Kline: Endotoxin is the product of certain kinds of bacteria, and it's extremely hardy; it stays around for years or decades. It's difficult to get rid of even in the laboratory situation ... and we've done studies here showing that endotoxin inhalation can cause bronchial spasm, or narrowing of the airways, after you inhale it, even in nonasthmatic, normal individuals.

Merchant: Endotoxin is tracked into the homes by farmers. Uh, they typically wear their work clothes and their work boots into the homes.

Chrischillis: About 30 percent of the families in the parent study live on farms. We are really focusing our efforts to improve the child's indoor environment, um, realizing that a lot of exposures out on the farm or, uh, out in the community get tracked into the home.

Pat: We take our shoes off when we walk in the house so it doesn't track dirt through the carpets to keep the dust down.

Chrischillis: We meet with the family in their home; we walk around with a checklist identifying particular issues that might be, uh, a problem for a child with asthma.

Technician: Hi. Let's see where the heavy traffic area is and where I can get my sweeper in. I'll be doing the main sample area right here, one square meter. What's in here is, uh, could be anything, uh, that's on their feet -- lint from the carpet, tracking dirt -- whatever they bring in from the outside is on the floor in here. So we'll go down here and check out the furnace.

Chrischillis: We have several families who have wood-burning furnaces. Now, smoke is a direct irritant to any child with asthma.

Kline: Chronic asthma is a disease which has many different presentations. So there's a range of severity. Children may have intermittent asthma chronically, meaning that they periodically get into trouble but they have long periods of time where they don't have any trouble at all. But increasingly we're recognizing that a lot of asthma is what we call persistent, and that means that they have symptoms every week, maybe several times a week, that they wake up at night, that they're coughing, wheezing and have chest tightness.

Adolescent Girl: You just can't breathe, and it feels like you're getting smaller, and it's, like, all congested, and [sighs] you can't talk and you can't breathe, and it's, like, hard.

Dr. Ahrens: When an acute attack of asthma starts, one of the most common initial symptoms is, uh, is coughing. While we think of wheezing as being, uh, a hallmark of asthma, uh, coughing is actually probably the most common symptom of asthma.

[Ben coughs.]

Ahrens [to Ben]: The cough came back first?

Ben: Yeah.

Ahrens: And then you started, uh, what? Having a runny nose?

Ben: Yeah, stuffed nose, and my throat started to hurt a little bit.

Ahrens: I see.

A little bit deeper.

Ahrens: First of all, you've got to make the diagnosis and make sure that you're really dealing with asthma and not some other respiratory disease. The second thing that you would do is to classify the disease. Is this intermittent asthma? Or is this chronic persistent asthma?

Technician: OK, Ben, what we're going to do is take a measurement of your lung capacity. OK. Big breath in. Really big, go! Nice job. Hang in there. Don't let up on it. And ... breathe in big and fast. Very nice ... now stop.

Ahrens: We as pediatricians usually drop the term "mild" because, while it can be intermittent, it can be extremely severe -- sometimes even putting children in the intensive care unit, you know, potentially even being life threatening at its worst.

Children are just a great group of people to work with. The most delightful characteristics that kids have is their ability to recover and their ability to go on and live normal lives.

Linda Pierson: Up you go ... there you go ... there you go.

Both of the girls were in 4-H, and we've always lived on a farm, and they're both asthmatic. But they were asthmatic, like, from birth, too, I mean, and there's a lot of grain dust in corn. So they've always been around dust.

Uh, Sarah, the youngest one, like we help unload hay in, in the summer, and she can't be in the hay mound.

Sarah: I'll start coughing, and ... [cow sound] tightness in my chest. Um, it almost feels like I try to breathe in real deep and I cannot take a deep breath. I mean, you don't know how bad it's going to be.

Linda: When she was under a year old she'd have asthma attacks, and we'd rush her to the doctor because we were afraid she was taking her last breath, and as she got older it seemed to get a little better. The one thing the doctor used to tell me was to try and make her, make her relax, and I [cow sound] could remember spending hours tickling her back or rubbing her forehead, you know, trying to help relax the, the lungs and, and breathe more easily.

Sarah: Usually it happens in ... at night is usually [cow sound] when I have them the most, um, when I'm sleeping, when I'm laying flat; um, I would say the [cow sound] summer months are probably the worse months for me.

The last couple of years, I've had more troubles with my asthma. I'm not sure why, and I know that I didn't take good control of my asthma either, and now I have special inhalers that I'm taking regularly.

Dr. Ahrens [with inhalers]: I've just got a few examples here of the many different kinds of inhalers. One category is the quick relief inhaler. Those are inhalers you take for asthma symptoms that you want to relieve over the next five to 15 minutes. These are inhalers that contain drugs that prevent asthma. They're extremely effective if you take them over the next few weeks to months to bring your asthma under better control.

The drug comes flying out of there at about 30 miles an hour, and it wants to stick on whatever it runs into, and if you assist that speed by taking a fast breath, it goes right to the back of the throat and the majority of it sticks right in the back of the throat. So, if you inhale slowly, it allows a little more time for it to slow down and more of it to make the turn into your lungs.

Uh, another alternative is a chamber device like this, either for a little bit older child, one who can understand to put their lips around it and seal it properly, a mouthpiece like that, uh, or a mask, where you can put it over the child's nose and mouth, and these are meant to be used, uh, with ... meter dose inhalers like this. You shake it, you put it in the back there ... then you puff it, and now, at least for a few seconds, the drug remains suspended here waiting for the child to inhale.

Zeke's Father: Push it harder. É

Zeke: When I breathe, it, um, it goes into my lungs.

Irving: And when do you use it?

Zeke: When I feel like I have asthma.

Patricia [sarcastically]: I always have to carry around an inhaler with me, so before I do gym or before I do sports, I have to take two puffs off of it, and I think it's a waste because I don't think I'm getting anything from it.

Patricia's Mom: I was worried more about the, the steroids that she kept having to take, because all the literature that we had said that it would stunt your growth, and ...

Patricia: Well, it hasn't done that, I'll tell you that. ...

Dr. Hanninghake: When we use, uh, corticosteroids in children, we like to use inhaled corticosteroids because wh ... what you're doing there is to deliver the medication right onto their airways so that it has more of a local effect, and although most studies suggest that the risk of inhaled steroids is small in terms of growth and development to children, we should never substitute more and more powerful medications for environmental control of asthma.

Yolanda: We have 200,000 trucks coming in a day and the same 200,000 have to go out. We are the mainland, which means every truck coming in through the city of New York c ... crosses our borders and into where they're going. And this brings in an extreme burden. The air is saturated, polluted, and we have the highest rates of asthma in the United States and in the world. This is the poorest congressional district in the whole entire United States, and it's done that way by design. Because it's the Bronx, it's been forgotten, and we don't get our fair share of the good things, but we get an overabundance of everything that's harmful.

Buses in New York run on diesel, and the children, they wait for them on the street, and children's noses are very low, so that means they're closer to the ground than anybody else. And as the buses pass by, and they have diesel particulates left behind, they're breathing it. So by the time they go to school, they're already using their pumps on a daily basis.

We also have a constriction of open space here. We have less than an acre per 1,000, which is very little, so children are confined in a space where not too much circulation of air happens. You have buildings that have been imploded; they knocked them down instead of carting them away; they just put them down into the ground, and that covered the holes of the basements. So you have there what's called asbestos -- because it's before '75 -- you have gypsum, they had to bring in pesticides to kill whatever vermin was there, so you have, um, lead because the paint used to contain lead -- so when the wind comes and swirls this around, you have a perfect cocktail for not only asthma but for cancer. There are solutions to the problems. The thing is that nobody's looking at them because it's just children. We have to find out what's killing our youth.

Dr. Perrera: We're doing a study in northern Manhattan and the Bronx aimed at understanding early-life exposures in the womb and learning about what role they may play later on in that child's life in terms of asthma and respiratory illness. Um, so to do that, we're enrolling over 600 pregnant women, we're monitoring them during pregnancy, we're collecting a small air sample using a portable backpack which they keep with them for two days during their pregnancy, and we're also monitoring the air inside and outside their homes, and a sample of dust is taken from the home before the baby is born. And then at birth we collect, uh, s ... s ... small samples of blood from the mother and from the umbilical cord blood. This blood would otherwise be discarded. And then we do a very careful clinical evaluation of each child, and the child comes in at 6 months, a year, 2 years, 3 years.

Dayshell Bullock: Both my kids have asthma, and my daughter had asthma since she was a newborn, and she was hospitalized for it. She stayed in the hospital, um, a week.

I had my prenatal visits at Harlem Hospital, and I was pregnant with my son when I was introduced to the program. That's when I met Di Di.

Di Di: Christopher, come here.

Dayshell: She introduced herself to me, and she explained to me that she was in, uh, Mother and Child Newborn Study.

Di Di: We asked her a series of questions about, um, her health, her family health, what she was exposed to. She was a nonsmoker, but perhaps someone in the family was constantly smoking around her. We also collect, um, a sample of urine to find out if she might have been exposed to lead during pregnancy, and then we go and visit her, um, upon delivery.

Dayshell: I think by next week somebody's going to come and put a thermometer, some type of thermometer, in my house and, um, like just monitor the, the air.

I know that I have active kids, so I know when they get asthma attacks. I knew, like, if he starts wheezing, what to do. I wouldn't panic. He's, he cried a lot. He cried all the time. Um, he always had, um, like phlegm in his chest, and basically, I just had to keep him in the house and just every three to six hours put him back on a, on a, um, the machine. They haven't been getting sick, having colds. They have a little minor cough, but attacks just don't come up any more.

Dr. Rachel Miller: After, um, the baby's born and the blood sample's collected, we take it to the laboratory, where we grow these white cells in culture. We incubate the cells in the presence of cockroach proteins, two different dust mite proteins, mouse proteins. In fact, there is some evidence of these baby cells showing some sort of memory response or an immune response to these proteins in the air that the mother, uh, breathes in.

[About technician in footage] She's isolating her white blood cells, uh, from a blood specimen.

Patch ... do you see the little patch there, at about one o'clock?

Technician: Mm-hmm.

Dr. Miller: Why don't you go for that, and then you're done.

Dr. Miller: We were surprised at how common it was for the cells to respond to the cockroach proteins, for example, which occurred in over half the cases.

Dr. Jean Ford: It's well known that cockroach, uh, allergen can, in fact, make the airways, the bronchial tubes, sensitive and that cockroach exposures are associated with a more severe form of asthma.

Dr. Ginger Chew: My main job is to, to identify which allergens are associated with cockroach allergy and then which exposures are associated with developing the disease of asthma.

For the Mothers and Newborns Study, we go into the houses and we collect dust samples. Like, for instance, this dust sample is collected from a bedroom, and it's primarily composed of skin scales, lint, and in here's a mixture of cockroach allergens and most likely some cat allergen and some dust mite allergen.

The allergens are proteins produced by the digestive tract of the cockroach. They come out in fecal pellets, and when a cockroach dies, as it starts to decay, the dried pieces start flaking off, and you have to worry about dried pieces of coc ... cockroach carcasses getting into the air and being inhaled.

Cockroaches like to be touched on all sides; that's why they like cracks and crevices. We include, in each of these containers, tubes where the cockroaches can socialize, and they also like to, to congregate around the food watering holes, sort of like humans.

We're growing the cockroaches in order to determine if change in diet or application of pesticide influences their allergen production. If they produce more concentrated allergen or different types of allergens, it might be associated with childhood asthma.

The results as they apply to the Mothers and Newborns Study are such that we might have some, some say in what kind of pesticides we'll use in the homes that have cockroach allergens and where the children have asthma.

Nadine: I have roaches, but I don't have as many as, you know, some people [laughs] have. I can't stand Ôem [laughs]! Uh, my thing is, I put Combat down because you can't use a spray, because the spray's another thing that triggers them off, and, me, I have live fish in my fish tank and I want my fish to live, so if I use the spray it'll kill them off too. So, what I do is I use Combat or chalk and mark in front of my door, but I see a few. I might see maybe two a night, two a day, if not some days, I don't see any. I just try to keep my house clean, you know, even though they say roaches like clean. I know they don't like filth; they go through the filth, they eat, and then they come to the clean to ... to live [laughs]!

When I was going to prenatal care for my 2-1/2-year-old, I went into the studies when I was six months. When I hit seven, eight months, they put a bag on me to carry to breathe the air that I breathe to see if it was the pollution of the air or the tar or the pollution of the trains and the buses ... or of cars, or was it the pollution in my house. As of today, he's still in the studies; he's going on 3 ... and he was diagnosed with asthma. And I know bed bugs, I know roaches, I know rats, I know mice, I know all these things cause Ôem, so anything you can do to stop them, you stop Ôem. Like when I moved here, I had mice and I couldn't believe it, and the man, the landlord, told me to get a cat. I told him, what would I do with a cat with two children with asthma?

This is the nebulizer that I have for both of my children. When they stole my car, they stole the other one out of it. And you prepare it, when you prepare it, you put it together when your kid has an asthma attack. [To Leslie: Flip it over.] It snaps together; it's battery operated and it also is plug adapted.

[To Leslie]: Snap it.

Leslie: I can snap it.

Nadine: It snaps. It snaps together. The medicine goes in this little boat right here.

Leslie: You put this ... fits here, then you put this back on, and then you turn it on like this.

Nadine: Press it on.

Nadine: And that's what gives him his oxygen.

Younger Child: Mommy, get mine.

Nadine: You want your nebulizer? Yeah, it's yours; here, it's yours. I have four boys, one girl. My daughter's 16 years old, going on 17. I have a 9-year-old boy that's living with asthma, and I have a 2-1/2-year-old living with asthma. I also have an 8-year-old that lives with seizures and a son that has disabilities in speech therapy. As far as when my son has asthma attacks, I know it's triggered by colds. I have to keep him warm; I have to keep my house warm.

My son Leslie catches them from nail polish, stuffed animals, the dirty carpet, the dust and whatever.

Leslie: When I'm Ôbout to have a heart attack ...

Nadine: Not a hear ... a heart, uh, the tightening of the heart ... an asthma attack.

Leslie: An asthma attack, ... my hea ... my heart starts beepin' hard. I start coughin' a little bit. And my chest starts getting tight.

Nadine: I mop my floors constantly, one to two times a day.

The trigger is carpet, the trigger is stuffed animals, the trigger is dirty clothes. You know, it's hard, but it's, it's a struggle, because I'd rather do that than sit in that emergency room four or five hours, but I can sit at home four or five hours and clean my house.

So, you learn [child sound] ... it's, it's, it's nice to have knowledge on anything, any disease, going from AIDS to asthma to bronchitis to hepatitis to whatever. It's not nice to be ignorant. Nobody gets educated overnight [child sound]; cut it out, I'm talking ... [child sound]. I'm talking. Shhh.

Mothers going to always teach mothers.

Young Woman on Street: Boy ... Come on, Ibo. Come on, Ibo ... Wait, wait, wait -- take it off, take it off, take it off. ...]

Nadine: That's my godbaby right there. That's my godbaby. We're waiting for her to be in Mothers and Newborns, too.

Yolanda: My son had asthma, and he had asthma as a very young child. I had moved away for a few years to Puerto Rico. He became better. We moved back here because my family's here. Well, he died of asthma, and saying a young man at 25, dying of asthma and leaving a small child behind, is a horrible way. ... And the way that he suffered with asthma was very difficult.

We became involved because we had the Bronx, living on a medical waste incinerator that was spewing junk into the air. So when we closed it down, I said, wow, this is good; you know, we've struck the big note, and a lot of kids are going to be safe. Two months after we closed it, three months after we closed it, my son died because what we didn't know was that they were cleaning the place so they wouldn't be fined, and it was spewing all this stuff into the air.

We only have so much power as a community, and if EPA had been in there doing what they're supposed to be doing ... people would've probably been alive today.

Dr. Lois Gibbs: The only way children are going to be protected is if the community stands up. This is not a matter of, do they need to be involved or not; they absolutely need to be involved, and the way they need to be involved is to begin by looking at their community. What does their school use? Go in and talk to the principal or talk to the maintenance folks. Just get in the car and become a, a detective and drive around your neighborhood. What's being released? Where is it being released? Uh, many of the schools are built on or near either garbage dumps or hazardous waste dumps, if you can believe that, um, next to incinerators or plants that release chemicals into the air.

Eric Mar: We are at George Washington Carver Elementary School, one of three schools within a half a mile of the naval shipyard here in the Hunter's PointÐBayview area of San Francisco, a toxic site cited by the federal government. It's not just the naval shipyard and the toxic site, but it's also the PG&E power plant and other, um, pollutants in the air that impact on students' learning environment when they have asthma and other health problems.

It's no coincidence that the students are low-income African-American, Asian and Latino students.

Veronica Lightfoot: You brought your medication today? OK, you want to show your medication? What's your name?

Damar: Damar.

Lightfoot: Damar, you want to show your medication? OK, let's see your medication. Shake it up! All right ... very good. [Class applauds.]

Teacher [in background]: OK. All right. ... Very good ... very good ... very good.

Lightfoot: It frightens you, as an educator, when you see such a little person, you know, having an asthma spasm and an asthma attack, and maybe the medication is not here. We try to keep as much medication here as we possibly can, but, if not, then we have to call 911.

END OF PROGRAM

BACKGROUND FOR END CREDITS

Lightfoot [to Damar]: OK, why don't you turn around? What are these? These?

Kids: Your lungs.

Lightfoot: Are you sure?

Kids: Yes.

Lightfoot: OK, what is this?

Kids: Heart!

Lightfoot: Your heart! So now you know where your lungs are, right? OK, so you want to come and touch the lungs? You want to touch the lungs? This is ... what?

Kids: Your stomach?

Lightfoot: What about this one?

Kids: Your liver.

Lightfoot: Your liver! This is a kinde ... you sure this is a kindergarten class? Sounds like you guys are in second grade, you're so smart.

OK. Yeah, you were excellent. You did an excellent job. Give yourselves a hand. [Kids clap and cheer.] All right.

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