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                                                                                COVER STORIES, Page 61

ASTHMA

Deadly . . . but Treatable


By CHRISTINE GORMAN -- Reported by Mary Cronin/New York


    You name it, and Olympic track star Jeanette Bolden, 32,
is probably allergic to it. Household dust, cats, seafood. Just
the smell of fish cooking on a grill is enough to make her eyes
puff up and start to water. But Bolden's allergies are linked to
a more serious problem. Like 15 million other Americans, she
suffers from asthma, a chronic affliction of the airways in the
lungs that can turn the simplest act of breathing into hard
labor and leave a person gasping, coughing and wheezing for air.
Last fall the gold medalist (100-m relay, 1984) was hospitalized
for a severe attack in which her airways closed off altogether.
"Imagine slicing an orange and squeezing all the juice out of
both halves," Bolden suggests. "That's how my lungs felt -- as
if someone or something was squeezing all the air out."

    Not long ago, Bolden's asthma might have kept her from
competing or even coaching. But asthma specialists have learned
so much in the past few years that they now believe they can
keep most potentially fatal attacks at bay. They have found that
allergies play a dual role in causing asthma to develop in the
first place as well as in triggering individual episodes of
wheezing. By studying families in which asthma appears to be
inherited, scientists hope one day to discover the genes that
predispose people to develop it. And by controlling the
underlying irritation and inflammation of the lungs, most asthma
patients should be able to enjoy a full and active life.

    Despite these advances in knowledge, both the incidence
and severity of asthma appear to be growing worldwide.
Epidemics have been reported in Britain, Australia and New
Zealand. In the U.S., the number of asthma cases rose 70% from
1980 to 1989. Even more alarming, the death rate, which had been
declining steadily during most of the 1970s, began inexplicably
increasing, and is now rising 8% a year. Asthma accounts for $5
billion in medical costs each year in the U.S.

    Acute attacks of asthma occur when the bronchial tubes of
the lungs become partly blocked. For reasons that are not
entirely clear, the lungs are overstimulated by viral
infections, allergens or pollutants. The body responds by
activating various defense cells from the immune system. Their
mobilization causes the airways to swell. At the same time, the
muscles surrounding the airways contract, cutting off airflow.
When that happens, asthmatics must inhale an adrenaline-like
substance to stop the muscle spasm and reopen their airways.

    If the attacks recur enough times, however, the lungs do
not return to normal. They continue to act as if they are being
invaded by parasites. This constant state of inflammatory alert
damages the bronchial walls, creating scar tissue. As a result,
the airways can no longer clear the mucus that forms deep in the
lungs. The ensuing buildup reduces the flow of air and sets the
stage for the next attack. "In olden times, which was only about
five or 10 years ago, we all concentrated on the bronchospasm
and assumed the patients were all right between episodes," says
Dr. Peter Konig of the University of Missouri. "Now we see that
inflammation is there from the beginning even in mild or
asymptomatic cases."

    Once asthma begins, it establishes a powerful feedback
loop that may not even need an allergen to trigger an attack.
General irritants such as cigarette smoke and urban smog can
cause the already inflamed airways to constrict. "It is my
opinion that parents or caregivers who smoke in the presence of
a child are guilty of child abuse," says Dr. Allan Luskin of the
Rush Medical Center in Illinois. "Smoke not only increases the
risk of a child getting asthma in the first place, it makes
asthma worse when it is there."

    Scientists have developed a number of plausible
explanations for the recent jump in asthma's prevalence and
severity. In the process, they have also generated a fair amount
of controversy and no little confusion. Certainly, some of the
growth in the caseload results from more accurate diagnosis. But
several researchers blame the increasing amounts of time that
human populations are spending in tightly sealed, air-conditioned
homes and workplaces, and the resulting exposure to concentrated
allergens and pollutants.

    After studying a group of 67 children with a family
history of asthma, Dr. Thomas Platts-Mills, head of the allergy
division at the University of Virginia, concluded that exposure
to a high concentration of dust mites in infancy was linked to
a greater chance of developing asthma. The children became
sensitized to the dust, and in many but not all cases their
initial allergic reaction led to a chronic inflammation of the
airways. "We spend 20 to 22 hours a day indoors," says
Platts-Mills. "And newborn babies spend almost all their time
inside for the first few months. It seems very likely that
indoor allergens are one of the primary causes of asthma."

    Other researchers blame the jump in asthma rates on gaps
in the availability of health care, particularly in the U.S. In
Chicago and New York City, the number of hospitalizations for
acute attacks in chil dren under age four has surged. "A black
child in the inner city has a 13- to 16-fold better chance of
dying from asthma than his white suburban counterpart," says Dr.
James Wedner, an allergist at Washington University in St.
Louis. Poor or uninsured asthmatics often get medical attention
only on a crash basis at the hospital emergency room. They
receive no treatment for the underlying condition, so their
lungs deteriorate.

    Indoor pollution can play a powerful role in urban
settings. Many city dwellers live in damp, humid apartments
where cockroaches and mold spores as well as dust mites can
trigger allergic responses. Even if these people realize that
such conditions are conducive to asthma, they may not be able
to change their circumstances.

    Most controversial of all is the suggestion that
physicians themselves have exacerbated the epidemic. Over the
years, doctors have come to rely on powerful adrenaline-like
substances called beta-agonists to treat asthma. When inhaled,
these drugs open airway blockages in the lungs. But in the past
18 months a couple of studies have indicated that beta-agonists
may be overprescribed. They are still the drug of choice during
an acute attack, but many specialists now contend that if
patients need to use beta-agonists four or more times a day,
their treatment should be changed because their underlying
condition is getting worse.

    Part of the reason may be that beta-agonists work too well
at providing relief. "If you're allergic to a cat, and a cat
walks into the room, you'll cough and wheeze," explains Dr.
Clive Page of the University of London. "What your body is
saying is `Leave the room or get rid of the cat.' What you
actually do is use your inhaler. You feel wonderful and sit
there watching the television with the cat." Meanwhile, the
inflammation gets worse because the lungs are still being
exposed to allergen. "By dampening down the symptoms, you feel
better, but you're deluding yourself into believing that you're
O.K."

    In addition, the majority of asthma patients are seen by
nonspecialists who still treat it as an intermittent problem
rather than on a continuous basis. For that reason, the National
Institutes of Health last year published a set of guidelines for
health-care workers that emphasize closer monitoring of lung
function and more comprehensive care for the underlying
condition. For any but the mildest cases of asthma, the nih
recommends that doctors reorganize their first line of defense
to include such anti-inflammatory agents as cromolyn sodium or
inhaled steroids. This strategy, the experts believe, should
lessen the number and severity of later complications.

    Just as important, asthma sufferers should learn all they
can about their condition and try to eliminate their exposure
to as many allergens as possible. Even if they cannot avoid
every single irritant in the indoor or outdoor environment, they
can certainly try to allergy-proof the bedroom. And with proper
treatment, their symptoms will be kept under control. "People
with asthma can live normal lives," Rush Medical's Luskin
declares. "They and their families should expect nothing less."