Harvesting Asthma

Vol. 16 •Issue 9 • Page 20
Allergy and Asthma

Harvesting Asthma

Childhood asthma in rural America poses unique challenges.

While many city dwellers consider the country air a refreshing alternative to city smog, it may contain just as many respiratory irritants that trigger asthma. Tilling the field, bailing the hay, and spreading manure may produce asthma flare-ups in addition to a good crop.

A vast “under”-world exists in pediatric asthma in all geographic locations, but under-diagnosis, under-treatment, and under-referral to specialists are especially problematic in rural settings.

  • Under-diagnosis: Families and physicians are much more likely to attribute asthma symptoms to hay fever, cough, or sinus problems, than asthma. It makes sense that a person working with hay would have “hay fever,” right? Wrong.
  • Under-treatment: Patients must get the right medicines for the right length of time. Doctors who have trained long ago tend not to realize the crucial role inhaled steroids play for these patients and the absolute need for long-term care. Families, too, want to limit the duration of treatment if the drugs are expensive and inconvenient to get.
  • Under-referral to specialists: This is especially true if a children’s asthma specialist isn’t available immediately. It may be inconvenient for the family, so the doctor may hesitate recommending such a referral unless the child is really sick. The family may choose not to follow up on the doctor’s suggestion for a referral. The distance to the specialist, the busyness and chaos for the whole family, and the potential cost are all disincentives for the patient to get care from an asthma expert. If the doctor has cared for the whole family for a long time, the family may feel they don’t need anyone else.

    Rural lifestyle

    A variety of conditions in rural America can hinder a child with asthma from getting optimal care. Rural youth may have more physical labor to do around the house than children in the cities. Because the children are out in the field, families may mislabel their respiratory distress from asthma simply as allergies or hay fever. Such work often is in a dusty environment, which can be laden with animal dander, pollen, manure, and farm chemicals. Exposure to such irritants also can contribute to more frequent flare-ups of acute asthma symptoms.

    There may be limited availability of physicians (especially specialists) who are comfortable diagnosing or caring for the child with asthma. Physicians in small towns often have been there for many years and may not have current understanding of asthma and its therapy.

    Patients with asthma who need acute care might not have access to an urgent care center, an emergency department, or a children’s hospital nearby. Compounding this problem, the family may be reluctant to drive an extended time or distance to seek care unless the child is experiencing an asthma exacerbation.

    In addition, pharmacies may not be readily available for families in rural areas. While most can get whatever medicines are prescribed, some pharmacists’ patient education skills may lack knowledge of the newer drugs.

    Health care coverage also can pose a problem for many self-employed farmers and business owners in rural America. Health insurance with adequate pharmacy and urgent care benefits may seem expensive. When coupled with distance from health care professionals, it may contribute to inadequate asthma care and control.

    Finally, smaller rural schools are less likely to have nurses on the premises every day. School nurses play an important role in the initial recognition, long-term monitoring, and administration of medications for children with asthma.

    Rural schools also might have fewer physical education teachers who know to look out for asthma symptoms. These educators may be the first to identify the signs of asthma and explain to the family that their child doesn’t have to feel breathless when he does physical activity.


    It’s crucial that families, educators, coaches, doctors, and nurses recognize the child with asthma and label the condition appropriately. The family must understand the diagnosis, the disease, and how it can affect their child before any real intervention can be made.

    The child who gets a tight chest with exercise may be thought to be lazy. Parents will often say “he likes to play video games” or “she likes to play with dolls” or “he’s a pretty lazy kid — just likes to sit around.” In some cases, it takes a few months of asthma therapy before the family will report: “She’s so much better. We didn’t realize all the problems she was having.”

    Also, the ability to perform pulmonary function testing will show the parents and child visually what’s happening to the airways. When symptoms occur at isolated times, the ability to monitor peak expiratory flow rates may provide crucial information for the caregiver.

    Although every family practitioner and pediatrician knows how to care for patients with asthma in general, the subtle points of diagnosis and newest therapies may be unfamiliar to them. Families need to be urged to request referrals to asthma specialists, for diagnosis, education, recognition of the patient’s individual triggers, and for excellent care and control.

    In most cases, successful asthma care truly is a team effort. It requires cooperation and effective management between the child, the family, the primary caregiver, and the asthma specialists, along with the child’s classroom and physical education teachers, coaches, and any other health care providers involved with the patient and family. Asthma may not be curable, but with the proper education, resources, and medication, it’s most definitely treatable.

    C. Michael Bowman, PhD, MD, is professor of pediatrics at the Medical University of South Carolina, Charleston.