For many people in San Antonio, a hot, smoggy afternoon or a cold winter morning loaded with pollen might only lead to a wheeze or a sneeze.
For a child with uncontrolled asthma, a day like that may mean a trip to the hospital or worse.
State health data show that compared to other Texas cities, San Antonio has a relatively high rate of children getting sent to hospitals or urgent-care clinics due to asthma attacks.
In 2015, 14.7 out of 10,000 children ages 17 or under were hospitalized for asthma, above the Texas average of 8.3 per 10,000. Bexar County and Travis County, home to Austin, were tied for most childhood asthma hospitalizations out of all of Texas’ urban counties that year, the latest year for which such numbers were available.
“That tells us there’s something else wrong in the equation,” San Antonio Metropolitan Health District Director Colleen Bridger said. “Someone who has asthma, especially a child who is being appropriately medically managed … shouldn’t have to end up in a hospital.”
Like most public health matters, the issue is complex. Health experts say these high rates are tied to triggers floating in the air – ozone and pollen outdoors, and cigarette smoke and pet dander indoors – as well as education and access to health care.
Asthma is a lung disease characterized by inflammation of the lung tissue. Parents who have asthma have a significant chance of passing it on to their children, but environmental factors like poor air quality also play a role.
Those who have asthma are sensitive to the air they breathe in ways most people aren’t. A cloud of mountain cedar pollen, a chest cold, wisps of cigarette smoke, fumes from a bus exhaust pipe, or a house full of dogs and cats all can trigger an attack, when lung inflammation increases and airways constrict enough to cause chest tightness and difficulty breathing.
Air pollution is the only trigger that’s currently a matter of public policy debate. From March through November, when weather conditions are right, San Antonio experiences spikes of ozone, tied to pollution from power-plant stacks, engine exhausts, and outdoor chemical use. Ozone is a key component in smog.
Asked whether San Antonio’s ozone levels are sometimes high enough to trigger asthma attacks, Bridger responded, “Unequivocally, yes.”
Ozone is one of the pollutants regulated under the Clean Air Act, first passed by Congress in 1963 to help control the acrid air choking U.S. cities.
Urban air across the U.S. has improved greatly since then, but many urban areas, including Houston and Dallas-Fort Worth, are still considered out of compliance with some health standards.
San Antonio is still waiting on the EPA to say whether its air is healthy. The issue is the subject of a political back-and-forth exchange, with Texas Gov. Greg Abbott lobbying the EPA against a designation of “nonattainment.” Last week, Abbott’s spokesman called a stricter ozone standard set in 2015 “draconian.”
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For local children, it’s not ozone but allergens that are the most significant trigger, said Dr. Erika Gonzalez-Reyes, an asthma and allergen specialist who has practiced in San Antonio since 2006. She served as chief of allergy, immunology, and rheumatology for the Children’s Hospital of San Antonio before focusing exclusively on private practice.
“The worst scenario for an asthmatic would be winter in Texas,” she said. “You’ve got cold air, you’ve got the mountain cedar out, and those act as very potent triggers.”
Viruses like influenza also are common triggers, she said, which in part explains an uptick in winter asthma attacks.
The problem is severe enough that one local school district has a full-time staff member solely dedicated to asthma.
Diane Rhodes, a San Antonio native, has been a respiratory therapist for more than 30 years. Since 2006, she’s been working for North East Independent School District.
In the district of 67,000 students, 7,300 to 8,500 students at any given time have asthma – around 10 to 12 percent, she said. Missing class for asthma attacks can have a big effect on a student’s education.
“It’s lost classroom time, it’s lost academic instruction,” Rhodes said. “It can really impact their ability to be successful academically.”
Rhodes spends her days making buildings and classrooms friendlier for asthmatic students and getting families to properly control the condition through medication.
She works with the facilities staff to remove asthma triggers like carpeting or stuffed animals that act as sponges for pollens, chemicals, and pollutant. So-called air fresheners, whether plug-ins or spray cans, also trigger attacks.
Rhodes’ job often involves some “detective work,” she said. Just last week, she traced one student’s asthma attack and seven others’ headaches at an NEISD elementary school to one boy who had doused himself in a cloud of scented body spray.
In another case, a father couldn’t understand what was triggering his daughter’s symptoms at home since he made sure to confine his cigarette smoking to the bedroom. Rhodes told him his central heating and cooling system was dispersing the smoke-filled air throughout the house.
Rhodes has become intimately familiar with managing asthma because of her own experiences with the illness. As a child, she remembers missing up to a month’s worth of school per year because of asthma attacks.
Her son, now 32, also had it, as did her father, who died from an asthma attack at the age of 60, she said. Among the items he left behind, she found an unused inhaler she had given to him to help him manage his symptoms.
“It’s heartbreaking, because it’s completely controllable,” she said. “In my dad’s case, he wasn’t controlling the inflammation.”
In 2017, asthma attacks led to the deaths of three children in San Antonio, Gonzalez-Reyes said.
“That news immediately makes it through the medical community in pediatrics and allergy and asthma because we know that those deaths are preventable,” she said. “It really hits home, because it should not be happening.”
Gonzalez-Reyes has worked in clinics all over San Antonio, often offering free medical care to those who can’t afford it. For her, the health disparities across different parts of the city are “a very big problem.”
Asthmatics require two inhalers – one for a dose of a controlling medication to be taken every day and one known as a rescue or relief inhaler to stop the attacks. Using them properly allows asthmatic children to live normal lives and be outside even on days with poor air quality, Rhodes said.
Out-of-pocket, each medication costs $300 to $500 a month, Gonzalez-Reyes said. Sometimes, certain medications are not covered by insurance plans. Drug companies sometimes offer coupons, reducing the costs to around $80 to $100 each, but even that’s too much for many families, she said.
Gonzalez-Reyes recalled treating an adolescent boy at a clinic on San Antonio’s Southside. The boy’s mother said she couldn’t afford both the control and the rescue medications, so she simply picked one of them.
Next time they came in, the boy was using all the right inhalers, Gonzalez-Reyes said. But the mother had stopped taking her diabetes and high blood pressure medications to afford medicine for her son.
“We need to do better,” Gonzalez-Reyes said. “A parent obviously is always going to put their child’s needs before their own, but we should not live in a community where people are having to choose whose health are we going to prioritize, whose medicines are more important.”
As far as stopping the triggers, no one can do much about mountain cedar pollen or the air quality inside other people’s homes. But everyone can do something about the ozone issue, Gonzalez-Reyes said.
That’s why so much of the advice of the City’s “Breathe Today, SA Tomorrow” campaign to improve local air quality takes the form of the mundane: walk, bike, or carpool whenever possible; refuel cars and trucks after 6 p.m. when the heat of the day is past; don’t idle vehicles for more than 10 seconds.
“Controlling air quality is a big thing that I think most of us can do things to help improve,” Gonzalez-Reyes said.