Violence: An Unrecognized Environmental Exposure That May Contribute to Greater Asthma Morbidity in High Risk Inner-City Populations. (Grand Rounds in Environmental Medicine)
Wright, Rosalind J., Steinbach, Suzanne F., Environmental Health Perspectives
In the United States, rising trends in asthma prevalence and severity, which disproportionately impact minorities and the urban poor, have not been fully explained by traditional physical environmental risk factors. Exigencies of inner-city living can increase psychosocial risk factors (e.g., stress) that confer increased asthma morbidity. In the United States, chronic exposure to violence is a unique stressor existing in many high-risk urban neighborhoods. In this paper, we describe a series of cases that exemplify a temporal association between exposure to violence and the precipitation of asthma exacerbations in four urban pediatric patients. In the first three cases, the nature of the exposure is characterized by the proximity to violence, which ranged from direct victimization (through either the threat of physical assault or actual assault) to learning of the death of a peer. The fourth case characterizes a scenario in which a child was exposed to severe parental conflict (i.e., domestic violence) in the hospital setting. Increasingly, studies have begun to explore the effect of living in a violent environment, with a chronic pervasive atmosphere of fear and the perceived or real threat of violence, on health outcomes in population-based studies. Violence exposure may contribute to environmental demands that tax both the individual and the communities in which they live to impact the inner-city asthma burden. At the individual level, intervention strategies aimed to reduce violence exposure, to reduce stress, or to counsel victims or witnesses to violence may be complementary to more traditional asthma treatment in these populations. Change in policies that address the social, economic, and political factors that contribute to crime and violence in urban America may have broader impact. Key words: asthma, case series, innercity, stress, violence. Environ Health Perspect 109:1085-1089 (2001). [Online 2 October 2001]
We present three cases encountered in the Boston City Hospital Pediatric Allergy--Immunology--Respiratory Clinic and a fourth case seen as an inpatient at Boston City Hospital in which exposure to violence seemed to be the asthma symptom precipitant.
Case 1. Case 1 is a 12-year-old African-American girl with lifelong asthma who has numerous recognized triggers that include pollen, cold air, and exercise. She had presented several times each year to her neighborhood clinic with acute wheezing that responded to nebulized bronchodilator treatment. On initial evaluation in July 1994, her physical exam was notable for allergic rhinitis. Pulmonary function testing showed a mild obstructive defect primarily affecting the small airways: forced vital capacity (FVC), 94%; forced expiratory volume in 1 sec (FE[V.sub.1]), 79%; and forced expiratory flow rate over the middle 50% of the FVC volume (FE[F.sub.25%-75%]), 51%. Oral antihistamines, nasal cromolyn, and inhaled steroids were added to her inhaled bronchodilator therapy. In the subsequent month, amoxicillin was begun for sinusitis, and nasal steroids were added to her treatment regimen. After a period of symptom stability she developed increased wheezing in October 1994. Oral prednisone was begun, resulting in rapid improvement to her baseline by the fifth day which was Halloween. On Halloween night, the patient heard gunshots outside of her home in a housing project and shortly thereafter became aware that one of her peers had been fatally shot. She quickly developed recurrent wheezing, slept poorly that night due to respiratory symptoms, and required an extended course of prednisone to control the recurrent asthma exacerbation. Following recovery from this episode, her asthma stabilized.
Case 2. Case 2 is a 15-year-old Hispanic gift who has had severe asthma since infancy and is now enrolled in a college preparatory course in an urban high school. Her history was remarkable because of her need for assisted ventilation with status asthmaticus at the age of 2 years and subsequent every-other-day prednisone therapy up to the age of 5 years. …