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Asthma afflicts 9% of Michigan residents, up 15% from late 1980s
Sharnay Duncan: The 4-year-old uses a mask for her daily nebulizer treatment. Her mother, Shari Duncan, 45, of Detroit and her six children all have asthma. "I usually have to choose between medication for my kids or for me," Shari Duncan says.Related report
Common asthma triggers
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Since Eric Brandau, 7, began taking inhaled steroids, his asthma condition has significantly improved.
Cynthia Babcock of Clio has her lung capacity measured at the Royal Oak office of Dr. Michael Harbut. Experts say asthma is aggravated in Michigan by high soot and smog levels, the few bans on smoking in public places and naturally occurring factors such as pollen.
Kate Safford lives by obsessing about her disease.
To eliminate dust mites that might trigger a life-threatening asthma attack, Safford's house makes clean seem like a dirty word.
She has spent $40,000 on special air filters, buys expensive hypoallergenic sheets and covers for her pillows and mattresses, and has opted for hardwood floors instead of carpeting. Her husband knows that a tap on his shoulder while he is driving means he needs to close the car vents to block exhaust from other vehicles.
"I look at the weather reports every day just to see what kind of day it is going to be for me," said Safford, of Birmingham. "I am always thinking before I go outside: Do I have my inhaler? Do I have all of my meds? It keeps you from dying, actually."
Nearly 870,000 people in Michigan have asthma -- about 9 percent of the state's population. That's a 15 percent increase from the late 1980s, according to 2003 figures from the Centers for Disease Control and Prevention, the latest data available. Michigan ranks fourth in the nation in the prevalence of asthma. Nearly half the cases are in Wayne, Oakland, Macomb and Livingston counties: about 290,000 adults and 100,000 children.
The cause of the disease is not known; doctors are exploring genetic links. But experts say the condition is aggravated in Michigan by high levels of soot and smog, the absence of bans on smoking in public places and naturally occurring factors such as pollen. Critics say the lack of a concerted approach to dealing with the disease is costing the state millions of dollars in expensive emergency room visits, lost productivity and absences from school.
Asthma costs the state $460 million per year -- $270 million in direct health care costs and $190 million in indirect costs, according to the state Department of Community Health. Adults miss an average of 10.1 workdays per year because of the disease, and asthma is the leading cause of preventable absences in schools.
"Asthma presents a significant burden and challenge in Michigan," state epidemiologist Sarah Lyon-Callo said, adding that racial and geographic disparities in care are increasing.
"Asthma affects almost 10 percent of the population," said Dr. Ken Rosenman, a professor of medicine at Michigan State University. "I don't know of many other medical conditions that are as common ... in terms of improved quality of life and reducing health care costs, this is certainly significant."
The state does not track emergency room admissions for asthma, however, meaning it is difficult to target specific areas of the state for prevention and management strategies. The emergency room information allows other states to determine where asthma patients are underserved by doctors and where public information programs can be directed.
"Michigan is backwards in terms of keeping track of rates," Rosenman said. "A majority of states do this."
Chronic problem
Asthma is a chronic inflammatory disease of the airways in the lungs. Symptoms include coughing, wheezing, shortness of breath and tightness in the chest.
The city of Detroit accounts for a significant number of cases, according to the state health department, though exact figures are not available. Efforts to thwart the worst effects of the disease are lagging, particularly among African-Americans and low-income people, who make up a disproportionate segment of the city.
A study by the School of Public Health at the University of Michigan in 2001 determined that children with private health care plans are three times more likely to see an asthma specialist than poor children on Medicaid.
The lack of care is driving many asthmatics to emergency rooms, where treatment can be expensive, adding to the taxpayers' tab. And tight cost controls on Medicaid make it more difficult for the poor and working poor to obtain the level of care they need, said Safford's doctor, Michael Harbut of the Center for Occupational & Environmental Medicine in Royal Oak.
"There is a definite lack of physicians who treat (asthma) in the city," Harbut said. "Part of the reason is a lack of insurance."
But asthma is a growing problem in suburban areas also, driven in part by high levels of pollution from industry.
"In places like Metro Detroit and Baltimore, we still find problems with smokestack pollution," said Dr. Jonathan Samet, chairman of the Department of Epidemiology at Johns Hopkins University in Baltimore and an expert on how dirty air and smoking affect health.
Trouble in the air
Despite gains in reducing emissions, Wayne, Oakland, Macomb and Livingston counties are among 474 counties in 31 states that are under orders by the Environmental Protection Agency to cut ozone-causing pollution because they fail to meet federal standards for reducing health risks from smog.
Sites in Wayne County regularly test just above the 15 micrograms per cubic meter standard for soot in the air, for example. They sometimes test as high as 10 percent to 25 percent above the limit.
Automobile emissions also contribute to the problem. Diesel engines, in particular, still produce significant amounts of microscopic airborne particles.
But many experts credit automakers with significant strides in producing cleaner-burning engines. "Auto emissions remain a problem, but there are more gains to be made in the area of industrial emissions," said David Gard, policy specialist for the Michigan Environmental Council.
The Southeast Michigan Council of Governments projects that while the number of vehicle miles traveled in Metro Detroit will increase from 136 million in 2002 to 160 million in 2030, the total emissions will actually decline by 50 percent because autos are burning cleaner.
Besides pollution, factors exacerbating conditions for asthmatics include few stringent bans on smoking in public places, according to the Asthma and Allergy Foundation of America, which ranks Detroit and Grand Rapids among the top 20 "asthma capitals" in the country.
Only 10 counties in Michigan have adopted bans on smoking in public places; all exempt bars and restaurants. In Metro Detroit, Wayne County and the city of Detroit have a ban on smoking in the workplace, but both exempt bars, restaurants and casinos.
Most deaths are preventable
Health experts say most, if not all, of the 150 to 200 asthma deaths in Michigan per year are avoidable. So are the thousands of expensive emergency room visits and hospital admissions that add to the state's health care costs.
"Many people do not take asthma seriously," said Harbut, the Royal Oak doctor. "There's data that shows over 50 percent of the people who die of an asthma attack have not had one in three years. They stopped taking their medication, or they've left it at home."
Health experts say a more concerted approach would include:
• Increasing the awareness of the triggers that spur asthma attacks.
• Controlling air pollution, especially sources of soot and ozone.
• Wider use of inhaled steroids.
• Better diagnosis and disease management.
• Tracking emergency room visits attributable to asthma so more effective management programs can be developed.
"If we had more dollars in the budget, we would invest in asthma prevention," said T.J. Bucholz, a spokesman for the state health department. "We work very hard to maintain funding, but we have not been able to put in any new dollars. That is true of a lot of health prevention issues."
Setting it off
Shari Duncan, 45, of Detroit didn't even know for years that she had the disease. Doctors didn't tell her that her chronic health problems resulted from asthma.
Once it was diagnosed, she learned that many everyday triggers were aggravating her condition. So the simple act of cleaning her house helps make the disease more manageable.
"I put a mask on when I do it," said Duncan, a single mother who has had asthma for 20 years. "But the children can't be there."
Common household dirt can spur the sort of asthma attack that can drive Duncan and her six children -- all of whom have asthma -- to the hospital. She says dealing with the chronic ailment takes "a real effort."
Many other triggers occur outside the home.
"Most of mine are chemical sensitivities; car exhaust and smoking are very challenging," Safford said. "I refuse to go into an establishment where people are smoking at the door. Even at a company where I worked, I insisted that they have a restroom that did not have one of those little scent emitters. Those are killers."
Schools are a fertile environment for many of the same triggers, including dust, dust mites and mold. In public middle and high schools in Michigan, 17 percent of students have asthma, but school officials are rarely trained in dealing with the problem.
The EPA has ordered the state to develop a plan by 2007 to reduce ozone levels by 2010. The agency also has ordered the state to submit a plan by April 2008 to begin reducing soot.
And by September 2006, the state must have a plan to reduce pollutants such as sulfur dioxide and nitrogen oxide that also aggravate asthma.
Stopping the soot
Yasser Maisari, whose son Ramsey, 15, has asthma, believes the poor air quality in Metro Detroit is the leading cause of his child's suffering. An air quality monitor in the Maisaris' south Dearborn neighborhood regularly registers some of the highest readings for soot in Michigan.
"When we leave town for vacation or to visit friends, his asthma is much better controlled," Maisari said.
But it is not only in areas with heavy industry in Metro Detroit where pollution aggravates asthma. Smog and soot know few boundaries, traveling widely in the wind so that Wayne, Oakland and Macomb counties all have air dirty enough to be affected by the federal cleanup orders.
Kate Safford said she breathes in smog and soot in Birmingham, too. "Weather combined with the poor air quality is just torture for me, particularly on humid days," Safford said.
Maisari has led organizing efforts to rid the air in south Dearborn of the soot that often coats automobiles parked on the street and even the floors inside of homes. Residents of the area have sued Severstal North America, the new owners of the old Rouge Steel plant in south Dearborn, seeking a court order to force it to clean its soot-producing operation. Company officials say they are cooperating with the state Department of Environmental Quality to address the problem.
Others have organized to oppose a truck depot in Detroit, the Detroit Intermodal Freight Terminal, asserting that diesel exhausts from trucks in the heavily traveled area near the Ambassador Bridge already impose significant health risks. The EPA is raising similar concerns about the project.
"We are seeing a lot more asthma and tougher cases of asthma even in the suburbs, and I think the environment has a lot to do with it," said Dr. James Fordyce, a Dearborn allergist. Fordyce said he saw 4,716 patients with asthma in 2004, compared with 1,914 in 1994. Last year, he saw 2,572 new patients compared with 348 a decade before. "We struggle to deal with ozone and other things in the air, and yet we continue to use more fossil fuels."
Steroids can help
The condition is further aggravated by the fact that many asthma patients -- and some doctors -- resist one of the most effective means of controlling asthma: steroids.
Health experts say many asthmatics, especially those with persistent asthma, should use inhaled steroids to reduce inflammation of the lungs. But the stigma surrounding steroids is difficult to surmount because of publicity over their abuse.
The inhaled steroids -- called corticosteroids -- are unlike the anabolic steroids that several athletes have admitted to using. Anabolic steroids are synthetic substances related to the male sex hormones that promote growth. Corticosteroids are produced from a substance in the adrenal gland, and they block the body's production of inflammatory agents.
Like other steroids, the inhaled steroids have side effects. They can disrupt children's growth. They can cause faces to grow wider, in a more oval shape. Yeast infections of the tongue are also possible, and doctors often advise patients to brush their teeth immediately after using their inhaler to help avoid the complication.
But doctors say the risks are low and manageable, and the benefits to asthmatics are significant.
"We can deliver these steroids ... directly into the airwaves where the problem is," said Dr. Mohamad Tawila, who practices in Royal Oak and Sterling Heights.
"In essence, this bypasses the need to give the steroids by pill or in a shot, which would potentially have some serious side effects over the long term."
When a doctor told Tina Brandau of Brownstown Township to start giving steroids to her asthmatic 7-year-old son Eric, she said, "I absolutely freaked out."
Brandau, who nearly lost her son when he had an attack before dawn on Christmas 2002, now credits inhaled steroids with significantly improving his condition.
"We'll deal with the risks, which seem mostly unfounded," she said.
Getting proper care
While doctors emphasize the importance of proper health maintenance for asthmatics, data collected by the state health department show that only 9 percent of asthmatics in Michigan have a plan for managing their asthma from their doctor or other health care provider.
And 78 percent of asthmatics visit their doctor once or not at all each year. The minimum national standard for monitoring asthma is two doctor's visits per year.
"Asthma is very treatable and controllable, and yet the information does not get to enough people," Tawila said.
While not yet requiring mandatory reporting of emergency asthma treatment from hospitals -- a move fought by some hospital administrators -- the state health department is trying to determine whether such data can be gathered from other emergency room statistics hospitals report.
Critics say the data is easy to gather.
Within two weeks of requests for the information, hospitals in Detroit, including Detroit Receiving, Harper and Children's, produced data showing increases in emergency room visits ranging from about 400 percent to 700 percent between 1999 and 2004.
Beaumont Hospital in Royal Oak reported a decline in emergency room visits of more than 50 percent from 2002 to 2003, raising the question: Are doctors in Oakland County managing the disease better?
"The emergency room numbers would help to identify more effective strategies concerning treatment and define where public education efforts might have the most impact," Rosenman said.
"At this point, we don't know enough about asthma because we are
You can reach Gregg Krupa at (734) 462-2296 or gkrupa@detnews.com.
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