Breathing Easy: Closing the Gap On Asthma

By Scott Kearnan - Sue Ponte isn’t just a nurse; she’s a part of the community.

“The kids identify with me, they go home and imitate me,” laughs Ponte. In her work as director of the Asian Pediatric and Adolescent Clinical Services Program at Tufts Medical Center, Ponte forms relationships with every child she treats. Walking down the hallway of the pediatrics department, where 47 percent of patients are of Asian ethnicity, Ponte hears a 12 year-old patient call out her name and quickly responds in Cantonese. “They recognize that I look like them, identify with them, and can speak to them in their language,” she says.

Recognition of culture is paramount to the program’s work, and the evidence is everywhere. “Notice a difference?” smiles May Chin, program manager of Tuft’s Asthma Prevention and Management Initiative (APMI). This effort, funded by a three-year grant given through the Blue Cross Blue Shield of Massachusetts Foundation’s Closing the Gap on Health Care Disparities program area, is designed to coordinate care, promote self management, and develop educational tools to address disparities around asthma rates in young patients in nearby Chinatown. To her right, Chin motions to a hallway decorated with cartoon pictures of American fairy tale characters like Cinderella and Sleeping Beauty; to her left, another hallway is filled with Asian-inspired art featuring dragons, bamboo, chrysanthemums, and a series of murals depicting the Chinese horoscope.

These small markers of cultural competency are purely symbolic, compared to the Initiative’s very practical intent to address high rates of asthma in the Asian community. Health issues related to asthma constitute 20 percent of the pediatric department’s visits, and in local Chinatown schools, Asians are disproportionately represented among those with asthma. The reasons are many and not always clear, though Ponte and Chin can indicate a few that bear significant weight: air quality in an extremely congested, downtown environment; and old, urban housing that can be rife with asthma triggers.

“One issue in Chinatown and other immigrant communities is that you may not have one family [living in a unit],” says Chin. “You may have 15 people living under the same roof. It’s old housing—dusty, mildewy and moldy.” Chin recalls the story of one young asthma patient who was adhering to treatment quite well, but kept coming back with breathing issues that wouldn’t dissipate. “We couldn’t figure out why this kid kept cycling through the door,” says Chin.

Then a home visit from the Boston Public Health Commission’s Healthy Homes initiative uncovered “mold all across the ceiling,” says Chin. “And there was a leak in the roof, so the mold would come right back again.” When the mold was cleaned up, the young patient’s asthma improved.

Education is vital to helping parents identify triggers like this, eradicating stigma and alleviating fear so that children and families feel comfortable seeking service. Under the Foundation grant, APMI collaborated with two local schools neighborhood centers, and street fairs to provide outreach, conduct forums, and teach asthma classes. These were also opportunities to disseminate bilingual educational materials developed by AMPI: Jimmy's Asthma Diary, a bilingual illustrated children’s book and a DVD with language options in English, Cantonese, Mandarin, and Vietnamese. Research with parents and students helped identify the kind of information that was needed, including the need to demystify asthma as a condition. For example, in a 2008 phone survey of parent and child participants, 50 percent of respondents stated that they did not have asthma despite having at least two asthma-related hospital visits in the last 12 months.

“At first when you say the word asthma, [parents] get frightened,” says Ponte. For many in the community, the diagnosis can feel culturally charged, and parents don’t want to label their children. By focusing terminology on asthma symptoms, like coughing and wheezing, the door to conversations about the condition is opened. Young people, meanwhile, are resistant to the stigma associated with asthma. “Teenagers are embarrassed,” she says. “I would give them inhalers to use at school … they would balk at the idea of [using them] and suffer.”

Despite these challenges, AMPI yielded tangible results: over the three years of the program, days absent from school by students with asthma decreased even as overall average absent days increased; documented patients with prescribed asthma controllers increased from 47 percent to 78 percent; and Chin says that the number of children now coming to the emergency room for asthma has been dramatically reduced to well below state averages.

Moving forward, these clinicians hope that more attention will be paid to the prevalence of asthma in the Asian community. They say there is precious little literature available.

“At a gut clinician level, you say, ‘Something is going on here,’” says Chin.

“But there isn’t a lot of data out there,” adds Sherry Dong, associate director of Community Health Programs. “When it comes to [examining] health disparities, wherever I look it’s white, black — [studies] add Latinos, and very few add Asian. … People don’t want to take the extra step to get that data.”

Back in the pediatrics department, Ponte proves that these clinicians have no problem going the extra mile.

“They have my phone number, they can call me anytime,” she says of her patients. And for that, most of them will breathe much easier.