Wanda Hernandez points to her four children and explains in Spanish how she noticed the same physical similarity in each. They all had "dents" in their necks when they breathed. Her neighbors eventually told her what that means. All four have asthma, they said, just like Javier, their father.
Wanda's oldest, 7-year-old Christian, has the most severe case. He heaves so violently during his attacks that he loses control of his urinary function and is deeply embarrassed.
Today, an asthma educator named Annie Rodriguez pays a return visit to the Hernandez family's three-room apartment in North Philadelphia. In Spanish, Rodriguez quizzes Wanda to see how much knowledge she has retained from the first visit.
Wanda responds well. She recalls the need to wash bedding at least once a week in hot water, to cover bed mattresses and pillows in dust-proof zippered covers, to wash clothes and hair if it's exposed to cigarette smoke, and more.
Still, it's hard to keep a household allergen-free when cockroaches and mice from the apartment next door wander over in search of food.
Puerto Rican Hispanics like the Hernandez family belong to the minority population hit hardest of all by America's rising asthma rates. Puerto Rican asthma prevalence even eclipses that of blacks.
Theories abound as to why the restrictive airway .disease afflicts so many Hispanics, particularly Puerto Ricans:
- They may have a genetic predisposition to it.
- The stress of moving to a new land, of grappling with a foreign language, and of adapting to a new diet alters their immune response to allergens.
- Poverty and lack of insurance condemn them to sub-standard medical care.
- Cultural beliefs and home remedies cause them to stray from prescribed drug regimens.
- They have a heightened sensitivity to airway tightness, so they're frequently misdiagnosed.
The task of teasing out which of these factors are valid and significant and then launching a counterattack has barely begun. Well, the medical community should get a move on, experts warn.
At 32.8 million strong, Hispanics (or Latinos, the two designations appear to be interchangeable) comprise roughly 12 percent of the U.S. population, according to the 2000 U.S. Census. They are growing faster than any minority group.
"It's time to bring Hispanics into asthma studies," declared Gregory Fritz, MD, a child psychiatrist engaged in asthma research in Puerto Rico.
One huge factor complicates the problem of tracking asthma rates among Hispanics. They all share a common culture and language but, unlike blacks, Hispanics are racially heterogeneous. Some Hispanics are white; some are black. Some hail from Puerto Rico, some from South America. Most have Spanish blood.
Mexican-Americans, at 60 percent, constitute the largest slice of the U.S. Hispanic population, according to the census. Then come Hispanics from Puerto Rico, then from Central/South America, Cuba and, lastly, "other," a small fraction who failed to identify their national origin on census forms.
"Too often, Hispanics are considered a homogenous racial group," Dr. Fritz said. "Most of the world finds this complicated. We ask Hispanic kids what ethnic background they are. They say 'Hispanic' is not a race, it's a culture."
Asthma prevalence appears related to this variability in national origin, according to David Mannino, MD, of the pulmonary and critical care division at Emory University School of Medicine, Atlanta.
"Clinicians have documented four- and even fivefold differences in asthma morbidity and mortality among Latinos of different origins," Dr. Mannino explained at a seminar for pulmonologists last year.
More Investigators Needed
Dr. Mannino and colleagues analyzed national statistics from 1990 through 1995 on national and regional age-adjusted asthma mortality rates for U.S. Hispanics of Mexican, Cuban and Puerto Rican heritage.
They found that Puerto Ricans had an age-adjusted annual asthma mortality rate of 40.9 per million, the highest of any U.S. population, with blacks second at 38.1 per million. By contrast, Mexican-Americans had a rate of 9.2 per million, which is lower even than Caucasians at 14.7 per million.1
"The time has come to stop having papers published in the United States that do not distinguish among different Latino subgroups," declared Juan Celedon, MD, DrPH, assistant professor of medicine at Brigham and Women's Hospital, Boston. "We need to train more people of Latino origin to do good clinical work. There is an incredibly low proportion of them in the pulmonary community."
Dr. Celedon is one of the few. He served as lead investigator of a study published in Chest.
His study of 791 children in Hartford, Conn., found that Puerto Rican children with mild to severe asthma were three times more likely to be allergic to cockroaches and twice as likely to be allergic to weed mix and mugwort/sage than white children with asthma. Black children had rates almost as high.2
When compared with white children, Puerto Rican and black children in Hartford were more likely to live in an urban area, to be insured by Medicaid, to have severe persistent asthma, to have eczema, and to be exposed frequently to cockroaches and rodents in their homes.
No explanation has emerged as to why Mexican-Americans have far lower incidence of asthma than Puerto Ricans, noted Roberto Cruz-Gervis, MD.
"I could hypothesize that their genetic backgrounds may be different," offered Dr. Cruz-Gervis, co-director of the Meharry-Vanderbilt Center for Reducing Asthma Disparities at Vanderbilt University and Meharry Medical College, Nashville, Tenn.
"Mexican Hispanics, as well as Hispanics from other Central and South American countries, have a genetic background that predominantly originates from white Europeans and American Indians, creating what we call the 'mestizo' race. Puerto Rican Hispanics, on the other hand, have a genetic background that includes the mestizo and black races, creating what some call 'castizo.' If it ever gets proven that genetic factors play a role in the higher incidence of asthma seen in blacks, this could help explain why Puerto Rican Hispanics have more asthma than Mexican Hispanics."
Environmental and social factors also could play important roles, he said. The fact that many Mexican Hispanics from Mexico work on farms and live in rural areas as opposed to inner cities may also explain the difference. "But this has not been proven yet," he stressed.
What is clear is that Hispanics as a whole, more than any group, struggle to communicate effectively with health care providers due to a lack of bilingual caregivers, Dr. Cruz-Gervis said.
"Without a good history, you can't diagnose asthma," he pointed out. "You can't do good PFTs if you can't tell the patient how to perform the test, and asthma can't be managed if you can't educate patients about MDI use and peak flow monitoring."
Without education, patients depend only on quick-relief inhalers rather than seeking more long-term relief from inhaled corticosteroids, a choice that can "lead to negative consequences," he said.
Providers must accept some blame too, Dr. Cruz-Gervis added. "There's been a mismanagement of asthma across the board, across all races and ethnic groups," he charged. "Over the last 10 years, the situation has improved. Increasingly, health care providers are using the NIH asthma guidelines, but it will take several more years for them to propagate.
"Language is a big barrier. We must have information available for patients. Spanish asthma literature has been published by the ACCP and the NIH, but there is also a problem of literacy among Hispanic patients. So even with the available Spanish literature, having enough bilingual providers would help."
Lastly, lack of insurance prevents many Hispanics from getting regular health maintenance visits and asthma management visits.
"They tend to go more to the emergency rooms, but ER physicians are too busy, and perhaps lacking in expertise as well, to sit down and teach asthma patients about the pathophysiology of their asthma and how to self-medicate," Dr. Cruz-Gervis said.
That's why community asthma educators like Rodriguez are needed to fill the knowledge gaps.
She questions Wanda intently about each child. Try to recall where most asthma attacks occur, she coaches. If it's the bedroom, wash the curtains and drapes twice a week. What foods did they eat before an attack? Do they struggle to breathe when it's very cold?
Then, Rodriguez reviews nebulizer technique. "The baby, he doesn't like it," Javier says of the treatment. "He sees the mask, and he starts to cry," Wanda adds.
Later, driving back to her office at the Asociacion de Puertorriqueos en Marcha (Association of Puerto Ricans on the March), part of a consortium of health services aimed at the city's Hispanic population, Rodriguez seems satisfied with her progress.
"I feel good about this family," she says. "When I first went there, they didn't know some of the triggers getting them sick. They are very responsible for their kids. They're always trying to find a way to help the children more. I would love to do more, but I try to do the best I can."
What more would she do if she could? "I'd try to help them with the roaches," she replies.
1. Homa D, Mannino D, Lara M. Asthma .mortality in U.S. Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990-1995. AJRCCM. 2000;161:504-9.
2. Celedon J, Sredl D, Weiss S, et al. Ethnicity and skin test reactivity to aeroallergens among asthmatic children in Connecticut. Chest. 2004;125:85-92.
Michael Gibbons is senior associate editor of ADVANCE.