Asthma Program Starts After Incinerator Fails
By Francie Scott
Call it a case of the punishment fitting the crime. A hospital with a faulty infectious waste incinerator agreed to launch an asthma program in local schools to settle a violation with the United States Environmental Protection Agency (EPA).
This happened in Pennsylvania last year when Crozer-Chester Medical Center in Upland launched an asthma treatment program in the Chester Upland Schools. Although staff at the medical center declined to discuss the program, a school nurse told ADVANCE that someone from the medical center comes frequently to the schools to work with asthma patients.
“A school is a wonderful place to identify problems,” said Jill P. Karpel, MD, director of clinical pulmonary research at Montefiore Medical Center in the Bronx, N.Y. School-based programs can offer asthma screening and refer their “captive audience” to care centers. School nurses see the children frequently and can spot undiagnosed and badly managed asthma.
The Chester/Upland community service project has been funded to the tune of $250,000 by Standoil Energy Power Corp., a utility company that formerly operated the incinerator. The program is termed a Supplemental Environmental Project (SEP). EPA regulations define such ventures as “an environmentally beneficial project which a violator voluntarily agrees to perform as part of the settlement of an enforcement action.” Supplementary projects must “improve, protect or reduce risks to public health or the environment at large.” They must be voluntary and related to the violation.
EPA officials first identified the incinerator’s violation of the Clean Air Act in 1992, when they found unacceptable levels of acid gases, mercury, arsenic, lead and ash in the atmosphere. When inspectors from the EPA and the Department of Environmental Protection (DEP) visited the site, they found holes and leaks in the incinerator’s air pollution control equipment. DEP officials threatened to rescind the operating license for the incinerator. After negotiations with the utility company failed, the EPA and the U.S. Attorney’s office then filed a suit against the medical center and Standoil.
According to an account in The Philadelphia Inquirer, the medical center proposed the asthma program in lieu of a fine at that time. The newspaper account described goals of the proposed program as identifying children with asthma and teaching children how to manage the disease.
The proposed asthma program met the goals of a public health SEP, which is expected to provide diagnostic, preventative or remedial aspects of human health care related to actual or potential damage caused by the violation.
Asthma represents a serious public health problem in the United States, where approximately 15 million residents are diagnosed with the disease. Asthma accounts for 100 million days of restricted activity, 470,000 hospitalizations and more than 5,000 deaths per year. Costs related to asthma care exceed $6 billion annually. These sobering statistics, supplied by the National Institutes of Health (NIH), underscore the severity of the disease.
Karpel recently heard horror stories from one of her patients who said high school students shared inhalers in the playground and used medication prescribed for other family members or friends. The recent asthma-related death of a 12-year-old boy in the Bronx underscores the need for disease management in economically stressed urban communities.
Self-management asthma programs such as the one being overseen by Crozer-Chester have long been shown to reduce morbidity and costs associated with asthma. Investigators led by Robert J. McDonald, MD, of Williamsville, N.Y., showed that a similar asthma management program based in a physician office helped 50 asthmatics cut their school absences from 310 days to 73 days during a 12-month period. Sick visits to the doctor’s office dropped from 132 to 43, emergency room visits dropped from 45 to 7, and hospitalizations dropped from seven days to one day. Overall, the quality of life score reported by the patients jumped significantly.
In that study, doctors, based at Buffalo Cardiopulmonary Associates, used the NIH asthma guidelines to develop care plans for their patients. They refined medication schedules and spent time educating patients about self-management. The team presented its study during a poster session at the annual meeting of the American College of Chest Physicians in Chicago last year. Members concluded that “an organized approach to asthma management can significantly improve asthma outcomes.”
Another asthma study presented at that meeting showed that children from urban communities, like Chester, Pa., are vulnerable to asthma. Investigators of that study, conducted in neighboring Philadelphia, concluded that urban children experience a higher degree of asthma prevalence than previously thought, and many do not know they have asthma.
Researchers in that study surveyed students attending 12 Philadelphia middle schools serving poor and minority communities. Of the 3,247 5th and 6th graders who completed a test administered by clinicians, only 22.7 percent acknowledged having asthma. However, 31.8 percent of the children reported wheezing at rest, 35.5 percent reported wheezing during exercise and 27.7 percent said they had experienced severe dyspnea at rest.
Children are not the only asthmatics who do not know how to manage their disease. Karpel discovered that many asthmatics over 18 did not understand how to use their medication when she surveyed 250 doctor-diagnosed patients in April 1998. While 65 percent of the patients knew prophylactic drugs existed, only slightly more than half of that group used beta agonists and only 10 percent took inhaled steroids.
In addition, 28 percent of the sample group said they did not know that inhaled steroids helped prevent asthma attacks. *
Francie Scott is an ADVANCE senior editor.