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(Chest. 1999;116:132S-134S.)
© 1999 American College of Chest Physicians

Chicago's Response to the Public Health Challenge of Urban Asthma*

Whitney W. Addington, MD, FCCP and Kevin B. Weiss, MD

* From the Rush Primary Care Institute (Drs. Addington and Weiss), Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.

Correspondence to: Kevin B. Weiss, MD, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612


   Introduction
TOP
 Introduction
Strategies of Individual Health...
 Community-Based Strategies
 Chicago's Response to the...
 References
 
It is difficult to discern exactly when asthma switched from being a common medical concern to a major public health epidemic in our urban environments. As early as the 1970s, articles suggested that asthma mortality rates were disproportionately high in a few areas of the United States, including the Bronx, NY1 and New Orleans, LA.2 However, this phenomenon was easily considered a localized problem until the publication of a study that examined variations in asthma mortality rates across the United States. This study found asthma mortality to be disproportionately high in urban environments throughout the country.3 Subsequent studies of asthma mortality and hospitalizations for a number of US cities have explored this problem in greater detail.4 5 6 7 8 Asthma prevalence also appears to be increasing.9 Independently, these two phenomena are cause for concern; together, they create a modern public health dilemma of paramount importance.

Throughout the course of this decade, much has been learned about the problem of urban asthma. One of the principal findings is that much, if not most, of the disproportionate morbidity appears to be explained by the socioeconomic status of the affected individuals. Specifically, several epidemiologic studies have found an inverse relationship between low socioeconomic status and higher asthma morbidity and mortality.4 5 10 In response to this finding, the National Institutes of Health launched the National Cooperative Inner-City Asthma Study.11 The National Cooperative Inner-City Asthma Study, along with other studies, has brought to light some of the unique social, environmental, and medical care factors that appear to be contributing to this urban health problem.12 13 14 15

During this same period, a number of investigators contributed to our understanding of intervention strategies that are potentially useful in combating the problems associated with urban asthma. The majority of these studies describe the strategies of individual health-care organizations. More recently, community-based interventions involving the collaboration of two or more health-care groups or organizations are beginning to emerge in the literature. Since, at present, there are no primary prevention strategies proven to reduce asthma prevalence, most studies have focused on reducing asthma morbidity as their primary goal.


   Strategies of Individual Health-Care Sectors/Organizations
TOP
 Introduction
 Strategies of Individual Health...
Community-Based Strategies
 Chicago's Response to the...
 References
 
There have been a number of studies that have addressed the problem of asthma morbidity among urban populations of lower social economic status. One common feature of these studies is that they are based in a single organization, or they examine one particular sector of care (eg, a study conducted in one hospital, or a study of asthma care in emergency departments).

A study by Mayo et al16 demonstrated that a program of facilitated referral of patients to transitional specialty care reduced the number of asthma hospitalizations and length of stay at Bellevue Hospital in New York City. Using a very different strategy, Evans et al17 demonstrated that efforts to reeducate primary care providers in a public health clinic setting can lead to enhanced disease recognition and continuity of care of children with asthma. Other efforts to improve clinical outcomes for these high-risk inner-city patients have focused on models of asthma education.18 The National Cooperative Inner-City Asthma Study demonstrated that additional social services support can also be an effective mechanism for reducing asthma morbidity.19

Thus, there are many examples of possible strategies that might be used to address the public health problem of urban asthma. However, these studies all represent isolated solutions as opposed to integrative, community-based solutions.


   Community-Based Strategies
TOP
 Introduction
 Strategies of Individual Health...
 Community-Based Strategies
Chicago's Response to the...
 References
 
There are only a few studies that describe community-based strategies to addressing the problem of urban asthma. Butz et al20 reported on the use of community health workers in a pilot project conducted in the Baltimore-Washington area. In this study, community health workers, visiting the homes of African-American families of children with asthma, were effective in providing asthma education, as well as obtaining medical information on asthma symptoms, health-care utilization, medication use, and environmental exposures. Fisher et al21 reported on a community asthma coalition focused on improving asthma morbidity in an inner-city neighborhood in St. Louis, MO.

Given the magnitude of urban asthma morbidity, and the likely need to use many different intervention strategies across various health-care sectors and organizations, the concept of building a community coalition appears promising. At a recent meeting sponsored by the National Asthma Education and Prevention Program in Washington, DC, it was reported that, as of October 1998, they had identified 44 asthma coalitions throughout the country, a third of which were targeting local reductions in asthma morbidity.22


   Chicago's Response to the Public Health Challenge of Urban Asthma
TOP
 Introduction
 Strategies of Individual Health...
 Community-Based Strategies
 Chicago's Response to the...
References
 
Perhaps it is not surprising that the Chicago community has recognized and accepted the challenge of addressing the major public health problem of urban asthma. During the past few years, members of the medical-care community, public health agencies (such as the Chicago Board of Health and the Cook County Department of Public Health), academic medical centers, voluntary health organizations, and members of the general public have all put forth efforts to reduce asthma morbidity in the Chicago community. At first, these efforts were independent and isolated from each other. Metaphorically, the organizations and their asthma programs were operating within silos. However, in 1996, with the assistance of civic leadership and the support of a local foundation, organizations and individuals were given the opportunity to break through their silos and begin working together as a community to address the issues of asthma in Chicago. Thus was the start of the Chicago Asthma Consortium (CAC).

This journal supplement describes the many efforts to combat the public health dilemma of asthma in Chicago. Some of these efforts are the attempts of the CAC to catalyze new and innovative asthma care improvement strategies, others are formal clinical studies, and still others are descriptions of asthma programs without the benefit of formal evaluation.

The supplement is organized into four sections. The first section focuses on assessing and characterizing the magnitude of the problem of asthma in Chicago. The Department of Public Health provides the basic epidemiology of the burden of asthma as seen through its vital records and state-based hospitalization records. Since 1996, the Chicago Asthma Surveillance Initiative has been conducting surveys to characterize asthma care as delivered by the various components of the health-care system. This section presents the findings of many of the Chicago Asthma Surveillance Initiative surveys to date.

The second section of this supplement describes the efforts of the CAC. Naureckas et al23 provide an introduction to the CAC and its various committees. This is followed by several detailed narratives describing the efforts of the CAC School Committee, an evaluation process developed by the Public/Patient Education Committee, and the Chicago Emergency Department Asthma Collaborative initiated by the Access to Care Committee.

The third section presents a series of short narratives under the title "Community Stories." Although the CAC has been an active and crucial element in catalyzing activities around the issues of asthma in Chicago, there are many other exciting projects occurring throughout the Chicago area that are targeting many of the same objectives. These projects are not formal academic studies, and most would not meet the criteria of peer review. However, they are a tribute to the hands-on work of many individuals and groups that have a true commitment to improving the quality of care for persons with asthma in their community.

The fourth section presents traditional, peer-reviewed manuscripts of original research conducted at several of the large health-care institutions in Chicago. This section is not inclusive of all the asthma research in the Chicago area; rather, the manuscripts were selected because they represent the types of research projects that are vital to understanding and eventually solving this important public health problem.

Collectively, the sections of this supplement provide a broad overview of the actions of one community in attempting to reduce morbidity and improve care for persons with asthma. It is, of course, too soon to know just how successful these efforts will be in achieving these goals. However, the reports in this supplement provide substantive evidence that the Chicago community is hard at work trying to identify solutions to this serious public health concern.


   Acknowledgements
 
In assembling this supplement, we would like to express our appreciation to several individuals. The concept of this publication was, in part, due to the insights of Sydney Parker, PhD, Vice President, Division of Health and Science Policy of the American College of Chest Physicians. We would also like to thank Ms. Robin Wagner for her editorial assistance. Finally, we would like to extend a special note of appreciation to the members of the Board of the Otho S. A. Sprague Memorial Institute for funding the publication of this supplement. In particular, we would like to thank Mr. Charles Haffner, III, and Mr. James Alexander for their support of this endeavor.


   Footnotes
 
Abbreviation: CAC = Chicago Asthma Consortium


   References
TOP
 Introduction
 Strategies of Individual Health...
 Community-Based Strategies
 Chicago's Response to the...
 References
 

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  4. Wissow, L, Gittelshon, AM, Szklo, M, et al (1988) Poverty, race and hospitalization for childhood asthma. Am J Public Health 78,777-782[Abstract/Free Full Text]
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  7. Lang, DM, Polansky, M (1994) Patterns of asthma mortality in Philadelphia from 1969 to 1991. N Engl J Med 331,1542-1546[Abstract/Free Full Text]
  8. Gottlieb, DJ, Beiser, AS, O'Connor, GT (1995) Poverty, race, and medication use are correlates of asthma hospitalization rates: a small area analysis in Boston. Chest 108,28-35[Abstract/Free Full Text]
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  10. Weiss, KB, Gergen, PJ, Wagener, DK (1993) Breathing better or wheezing worse? The changing pattern of asthma morbidity. Ann Rev Public Health 14,491-513[ISI][Medline]
  11. Mitchell, H, Senturia, Y, Gergen, P, et al (1997) Design and methods of the National Cooperative Inner-City Asthma Study. Pediatr Pulmonol 24,237-252[CrossRef][ISI][Medline]
  12. Kattan, M, Mitchell, H, Eggelston, P, et al (1997) Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study. Pediatr Pulmonol 24,253-262[CrossRef][ISI][Medline]
  13. Rosenstreich, DL, Eggleston, P, Kattan, M, et al (1997) The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med 336,1356-1363[Abstract/Free Full Text]
  14. Crain, EF, Mortimer, KM, Bauman, LJ, et al (1999) Pediatric asthma care in the emergency department: measuring the quality of history-taking and discharge planning. J Asthma 36,129-138[ISI][Medline]
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  16. Mayo, PH, Richman, J, Harris, HW (1990) Results of a program to reduce admissions for adult asthma. Ann Intern Med 112,864-871
  17. Evans, D, Mellins, R, Lobach, K, et al (1997) Improving care for minority children with asthma: professional education in public health clinics. Pediatrics 99,252-254[Free Full Text]
  18. Clark, NM, Feldman, CH, Evans, D, et al (1986) The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 78,108-115[CrossRef][ISI][Medline]
  19. Evans R, Gergen PJ, Mitchell H, et al. A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study (NCICAS). Pediatrics; In press
  20. Butz, AM, Malveaux, FJ, Eggleston, P, et al (1994) Use of community health workers with inner city children who have asthma. Clin Pediatr 33,135-141
  21. Fisher, EB, Jr, Strunk, RC, Sussman, LK, et al (1996) Acceptability and feasibility of a community approach to asthma management: the Neighborhood Asthma Coalition (NAC). J Asthma 33,367-383[ISI][Medline]
  22. Schmidt, DK, Fulwood, RF, Lenfant, C (1999) The National Asthma Education and Prevention Program: partnering with local asthma coalitions to implement the guidelines. Chest 116,235S[Free Full Text]
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