Why Ebonie Can't Breathe

Thirteen-year-old Antonio O'Bryant knew the drill by heart. A lifelong asthma sufferer, he never left for school without an inhaler full of medicine to open his airways. But whhen Antonio went to his gym class last Dec. 18, he apparently left his g ear behind. When he felt an attack coming on, a substitute teacher sent someone to fetch the nurse. Unfortunatly, the nurse had stepped away from her desk. By the time she and an assistant principal reached the gym with medication, the boy wasn't breathi ng well enough to get it into his lungs. The nearest hospital was only a mile away, but Antonio was unconcious when he arrived by ambulance. He hung on in a coma for several days and once managed to squeeze his brother's hand. But when his brain started to swell, his prospects for recovery faded. "They finally had to turn off the ventilator," his mother recalls. "My baby died on Christmas Day."

Tragedies like Antonio O'Bryant's are still mercifully rare. But as anyone with school-age kids can attest, his daily life was exceedingly common. In the course of a few decades, what was once an obscure allergic syndrome has emerged as one of the nation's most vexing health problems. Asthma now afflicts about 14.6 million Americans, including 5 million children. The number of sufferers has jumped by 61 percent since the early 1980s, according to the American Lung Association-- and the death toll has nearly doubled, to 5,000 a year. Fifth graders now monitor their air-flow rates in liters per minute, while their parents swap information and moral support on the Internet. And none of this is unique to America. Throughout the developed world, people are suffering asthmatic reactions to a range of allergens that once caused little trouble. And though scientists are learning more about asthma, the explosion is still largely a mystery. "Why are we becoming more allergic?" asks James Wedner of the Washington University School of Medicine in St. Louis. "Ten allergists will give you 10 different answers-maybe 15 or 20. No one really knows."

The dynamics of asthma are no mystery. The trouble starts when the immune system becomes sensitized to some allergen, usually through heavy exposure in early life, and starts treating it as a threat. Whenever the irritant enters the body, the immune system's B cells start churning out antibody molecules known as IgE. The antibodies then attach themselves to mast cells, which respond by spewing out histamine and other inflammatory chemicals. If this cascade is confined to the upper airways, the victim may suffer no more than a runny, itchy nose. The real trouble starts when the reaction extends down into the lungs. When small airways called bronchioles get doused with histamine, they swell and fill with mucus (chart). And as those passages narrow, the consequences can range from a tightness in the chest to suffocation. "Try running in place for two minutes," says Nancy Sander, president of the Allergy and Asthma Network/Mothers of Asthmatics in Fairfax, Va. "Then hold your nose and try breathing through a straw in your mouth. That's what an asthma attack feels like."

Almost anything can act as an irritant. Toddlers who live with at least one smoker are nearly three times as likely to wheeze as kids in smoke-free homes, but nonsmokers' children also suffer. Dust mites, those tiny creatures that thrive in bedding, upholstery and carpets, spike their droppings with a highly allergenic protein. So do cockroaches. Molds and pollens cause a lot of asthma in humid environments. But people who flee the Everglades for Arizona don't end up suffering less asthma. They just find something else to react to, like the dander from their pets. Liz Aplin, a 47-year-old art teacher in Chattanooga, Tenn., is so sensitive to the dust from her pastels that she wears a mask to class. "Show me the dust from 100 houses in a community," says Dr. Thomas Platts-Mills of the University of Virginia's Asthma and Allergic Diseases Center, "and I'll tell you what people are allergic to."

With THE RIGHT MEDIcines, even a severe asthmatic can make the condition manageable (page 62). But the greater challenge is to prevent it. Clearly, something is making us ever more sensitive to allergens. The question is, what? Genes clearly play a role in the disease. Children with one asthmatic parent contract asthma at three to six times the rate of other kids,says Dr. Fernando Martinez of the University of Arizona's Respiratory Sciences Center. Those with two asthmatic parents have 10 times the risk. And identical twins are more likely than fraternal twins to share allergies. But the gene pool hasn't changed dramatically in the past few decades. And as Wedner observes, "there is no gene that says, 'If you have this, you will wheeze.' Something in the environment must have changed."

Asthma isn't usually a problem in pre-industrial societies, regardless of their natural surroundings. But when development sets in, asthma quickly follows. Dr. Hal Nelson of Denver's National Jewish Medical Center cites a 1991 study of children in Zimbabwe. Only one in 1,000 of those living in rural villages suffered from obstructed airways. Yet asthma plagued one in 17 (5.8 percent) of those in a prosperous section of the capital, Harare. Researchers have documented the same pattern among Aboriginal people in Kenya, South Africa,Papua New Guinea, New Zealand and Australia. Even within Western societies, increasing urbanization seems to make people more and more vulnerable. The United States has an overall asthma rate of about 5 percent, says Dr. Irwin Redlener of New York's Montefiore Medical Center. But the rate is 8.4 percent in New York City, and it can reach 25 percent among kids in the poorest urban neighborhoods.

If asthma is a disease of civilization, the question becomes: what aspects of modern life are to blame? Air pollution might seem an obvious suspect. As Dr. Norman Edelman notes in the American Lung Association's new "Family Guide to Asthma and Allergies" (238 pages. Little, Brown. $19.95), ozone, diesel fumes and exhaust particles can all irritate the airways. Hospital admissions for asthma often rise 20 to 80 percent during periods of severe air pollution. But outdoor air pollution can't be driving the asthma pandemic, because it has improved in recent decades. Londoners suffered horribly from bronchitis during the 1950s, when the city was blanketed by noxious industrial fog. But asthma arrived after the worst of the pollution was gone. And Martinez has found that east German children enjoy lower asthma rates than west Germans, despite pollution levels that are often 10 times as high.

If outdoor air isn't to blame, could indoor air be playing a role? There's no question that modern urban life entails large doses of the stuff. Most Americans now spend at least 90 percent of their time indoors, according to the Environmental Protection Agency--and when we're not locked in buildings, we're usually sealed in vehicles. During the 1960s, American kids spent an average of three hours a day playing out-doors. But that was before kickball gave way to PCs, VCRs and videogames. Today's children average only two hours outside. That's biologically abnormal behavior, says Platts-Mills, and it brings an array of medical consequences. "In every community where asthma has increased," he says, "there has been a decrease in overall exercise that correlates strongly with the rise of indoor entertainment."

While spending more time indoors, we have turned our dwellings into havens for dust mites and other allergens. Until World War II, most homes had wood floors with scatter rugs. "If your family got a carpet, you thought that was upscale," says Linda Ford, president-elect of the American Lung Association. "Now carpets are common and wood floors are upscale." Laying down carpets was just the beginning. We also invited our pets inside to shed on them--a practice that prewar Americans would have found strange. And just as the mix was getting rich, we installed airtight windows to save energy. "The number of air changes per hour has plummeted since the 1970s," says Dr. Daniel Rotrosen of the National Institute of Allergy and Infectious Diseases.

The homes in asthma-plagued inner-city neighborhoods aren't known for their plush carpets or draft-free windows, but they have an even greater disadvantage: the cockroach. An exterminator can usually banish cockroaches from a freestanding single-family home, but the pests are virtually inescapable if you live in a poorly maintained and densely populated high rise. In a study published this month, researchers led by Dr. David Rosenstreich of New York's Albert Einstein College of Medicine examined 476 asthmatic kids from eight impoverished neighborhoods and found that cockroach allergies were the leading cause of attacks. Skin tests showed that different children were sensitive to different allergens, such as cat, cockroach and dust mite. But when the researchers looked at household environments, cockroaches emerged as the key. Kids whose bedrooms harbored cockroach proteins wheezed the most, missed the most school and spent the most time in hospitals.

The indoor environment isn't all that has changed since the middle of the century. With the rise of vaccines and antibiotics, people in developed countries have experienced fewer serious childhood infections than ever before. And despite the obvious benefits, some scientists suspect that an immune system with no serious work to do is more likely to become a renegade army, attacking whatever irritant it encounters. This is still a hunch, but there is evidence to support it. Recent studies suggest that children who contract measles are less likely to develop allergies or asthma. So are those with positive skin tests for tuberculosis. And allergic conditions are rare among the Hiwi people of Venezuela, who often carry hookworm and other parasites. "We have an immune system that evolved to fight parasites," says Dr. Scott Weiss of Harvard Medical School. "Instead it finds dust mites."

A HUNTER-GATHERER LIFEstyle, complete with fresh air and rampant infections, might save us all from asthma. But researchers are looking for easier ways to tame this modern scourge. The hope is that if kids encounter fewer allergens early in life, they'll be less likely to develop allergic responses. Next year the National Institute of Environmental Health Sciences will launch an elaborate, eight-year study to see if that strategy works. In the first phase, researchers will study 120 households to determine the best ways to reduce allergen levels. They'll cover mattresses, steam carpets, trap roaches and apply tannic acid to any suspect surface. And once they perfect their technique, they'll enroll 500 high-risk newborns in a trial to gauge the effects. Half of the babies will be raised in allergen-free zones while the other half will serve as controls, and the scientists will track the kids' asthma rates. "Will we be able to reduce the prevalence of asthma in the community?" asks Dr. Darryl Zeldin, the NIEHS official overseeing the project. "We don't know. Even with our best reducing agents, we may not be able to get the allergen levels low enough that kids aren't sensitized."

Even if allergen-busting can't prevent asthma entirely, there's no question it can help control the condition (chart). Just ask Margarita Nieves, a $1-year-old South Bronx mother. When her son Jonathan developed asthma at the age of 5, his doctor mistook it for a persistent cold and suggested removing the child's tonsils. He had the surgery, but he got no relief until he visited an asthma-savvy community clinic. Besides prescribing proper medications, the doctors there taught the family how to reduce the allergen load in their apartment. "He's got no teddy bears in his room, no rugs, no curtains, no lampshades," says Nieves. "We even got rid of the cat." That may seem a lot to ask of a child, but it's a small price to pay for a pair of working lungs.

Asthma in young children is not always easy for parents to identify--or even for doctors to diagnose--since it can masquarade as a cold or respitory infection. Some possible red flags:

This seems like an obvious tip-off, but two thirds of infants under 1 year old who wheeze with respitory infections do not become asthmat

Coughing is an inescapable part of life, but persistant hacking--particularly accompanied by wheezing--is a clear warning. Croup can be another signal if the child has it more than once.

If exercise or playing hard typically brings on a fit of coughing, tightness in the chest or more than the usual panting, asthma mat be to blame.

It's not only bad dreams that spook asthmatic kids. If shortness of breath awakens them at night, suspect asthma

If one parent has asthma, the child is at least three times more likely to have inherited the disease. A strong family history of hay fever and eczema may be another tip-off.

When the respiratory system is working properly, the air we breathe passes in and out of the lungs through a network of airways. But for people with asthma, even a minor irritant will set off an immune response that can shot down the airways.

Asthma rates have increased in every age group, but kids have seen one of the largest jumps--73 percent from '82 to '94.