Imperial County leads state in treatment of children with asthma

By Anna Gorman, Los Angeles Times

July 16, 2012 12 AM PT

CALEXICO, CALIF. — As the relentless wind stirs up piles of dust and dirt and creates a gigantic funnel of haze in the vast, sweltering Imperial Valley, children like Marco Cisneros battle to breathe.

Marco wheezes and coughs and reaches desperately for his inhaler, but the medication doesn’t always give him the relief he needs. Often, his mother has to call 911.

Since being diagnosed with severe asthma six years ago, Marco, who lives in this border town east of San Diego, has visited the hospital nearly 50 times. He has been airlifted on several occasions. The illness has affected much of his childhood, preventing him from playing sports, going to friends’ houses and attending school for days at a time. Blowing out the candles on his 8th-birthday cake earlier this year, Marco had just one wish: “I just want to run.”

PHOTOS: High asthma rates in the Imperial Valley

For children with asthma in California, there is no place worse than Imperial County. They are far more likely than children in any other county to end up in the emergency room or hospitalized. Kids go the ER for asthma at a rate three times higher than the state’s average, according to the Department of Public Health.

“Imperial stands out,” said Meredith Milet, an epidemiologist with the department. “There is obviously a disparity.... There is just a need for something to change. It should be possible for it to be different for the kids of Imperial.”

Severe childhood asthma is also a major problem elsewhere in California, including the smog-filled Central Valley. Heavily agricultural Fresno, Merced and Bakersfield, for example, all rank high in the nation for the worst cities for asthmatics. Imperial County is different because it leads the state for asthmatic children going to the ER and being hospitalized, but experts are unable to pinpoint the cause.

Doctors and public health officials said that a combination of whipping winds, pesticide-tinged farmland dust and large numbers of low-income families lacking health insurance contribute to high rates of asthma hospitalizations and ER visits. Whatever the reason, uncontrolled asthma and frequent hospital visits aren’t just an issue for those with the disease; many children are covered by Medi-Cal, meaning taxpayers often pay the tab for care.

In Imperial County, about 63% of asthma-related ER visits and 67% of the hospitalizations, for both children and adults, are paid through Medicare and Medi-Cal. Each hospitalization costs, on average, about $16,600.

The county spans nearly 4,600 square miles of mostly desert in the southeastern corner of California, just north of Mexico and west of Arizona. The county is hot and dry and depends largely on agriculture. About 20% of the 177,000 residents live in poverty.

One in five of Imperial County’s children ages 5 to 17 has been diagnosed with the chronic respiratory disease, which cannot be cured but can be managed with medication. Uncontrolled asthma can lead to hospitalization and in rare cases, death. In 2009, a 16-year-old girl died after an asthma attack.

Asthma is so prevalent among the students at Barbara Worth Junior High School in Brawley that the principal sends air quality alerts to his teachers and regularly cancels outdoor activities. Students keep inhalers in multiple locations on campus, and paramedics respond to asthma attacks several times each year.

“It impacts everything,” Principal Luis Panduro said. “It is a major issue.”

One student, Joseph Leon, 13, who has been to the hospital numerous times and misses several weeks of school each year, started an effort to have youths with severe asthma wear identifying bracelets and to get more training for both teachers and students.

At El Centro Regional Medical Center, nurses look outside and know immediately how busy their pediatric unit will be. Is it cold? Are the farmers burning their fields? Is it windy? Of every 10 patients, nurse Jessica Ruiz estimated that seven are being treated for asthma.

Imperial County is known for its poor air quality, in part because of its unpaved roads, agricultural tilling and industrial pollution from Mexico. The county’s air pollution control district has made progress in improving the air quality, but it still far exceeds federal health standards for airborne particulates. And that, according to the EPA, can increase the number and severity of asthma attacks among residents.

Kimberly Calderon, a nurse practitioner, said the valley is like a giant bowl, filled with a hazardous stew of pesticides, fertilizer and dust. “All that smoke and air lingers and doesn’t go anywhere,” she said.

In addition to the bad air, youths also frequently end up in the hospital because of asthma triggers such as cigarette smoke, mold or pets, or because they don’t know how to correctly manage the disease, said Luz Tristan, a physician in Calexico.

“They don’t think a daily medication is needed, so they will stop taking it as soon as they feel well,” she said. “It’s denial and poor compliance.”

Some patients also don’t have insurance or regular doctors so they use the ER as a way into the healthcare system and to get to specialists, said Afshan Baig, chief medical officer of the Brawley-based Clinicas de Salud del Pueblo, where a third of the pediatric patients have asthma.

The hospital isn’t the best place to treat asthma, she said. “It’s like any other chronic disease — the better we can manage it in an outpatient setting the better it is for the patient.”

County public health department officials said they are consistently working to reduce hospitalization rates from asthma. “It is a health issue that has been ... a concern to our community for some time now,” said Paula Kriner, an epidemiologist with the department. “It has a cost in terms of hospitalization. It has a cost in terms of medical care and quality of life.”

One of the county efforts is run by Aide Fulton, a nurse who visits families at the hospitals and their homes to educate them about the disease and keep them out of the ER. Fulton has spent years working with Marco Cisneros’ family, even helping the family move to subsidized public housing with fewer asthma triggers. Nevertheless, Marco’s asthma continues unabated.

Marco, who is covered by Medi-Cal, regularly sees doctors and specialists and has shelves full of medications. The family lives in fear of the next asthma attack, and his mother said she wishes she could make his childhood more normal. Last year, she and her husband bought him a bicycle, but he is afraid to ride it. He tried to play soccer, but he could only run a few seconds before needing his medication.

“He asks me, ‘When am I going to be cured?’ ” said Susana Tolentino. “I would like a doctor who is magic, that they would tell him that he wouldn’t have any more asthma crises.”

Norma Valenzuela, who lives in El Centro, knows about asthma crises too. Three of her four children have the disease.

Valenzuela said she does her best to avoid going to the hospital, but it doesn’t always work. She keeps her sons indoors as much as possible and when they do go outside, she first hoses down the yard. When they have trouble breathing, they don’t go to school. Esteban, 13, missed about one-third of last school year.

Esteban said having asthma is “kind of normal” for him, even though he sometimes gets scared of all the doctors, nurses and medications. He knows that as long as he lives in Imperial County, his asthma won’t improve. “The environment here is dusty and dirty and bad for us,” he said.

But Valenzuela said the family lives in subsidized housing and can’t afford to move. So she just carefully monitors the boys’ medication and watches for signs of an asthma attack.

“I’m trying not to go to the ER too much,” she said. “It’s less traumatizing to them if I can try to control them at home.”

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