If you had flown in like a bat
and banged around,
all search and disappointment,
I might have fled the room,
afraid of your confusion.
But you moved in slowly,
unconcerned and steady,
so heavy with your age
that I walked out to meet you
impatient and unafraid.
ROXANNE LANIER
Greenbrae, California
Phillip Kennedy woke up later than usual on Monday, January 27, 1997. He had a headache and fever, and he planned to stay home from work. I awoke at 5:45 AM, tired after a weekend on call. As I dressed in the dark winter dawn, I looked forward to coming home early. But, Phillip Kennedy was to die that day, and I was destined to share in his death.
Phillip was 54 years old with diet-controlled diabetes and alcoholism in recovery. I had cared for him in my internal medicine practice for seven years. Phillip usually saw me three times a year for routine visits and his annual physical. He was a gregarious, affable man with red hair and a ruddy complexion. Our interactions were friendly, natural, affectionate, and at times, playful.
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Phillip came to see me for his annual physical on Wednesday, January 22. He felt good and had no specific complaints. Phillip told me that, over Christmas, he had married June, the woman he had been living with for the past 12 years. June was 20 years his junior. Phillip said that there were parties surrounding the wedding and that he had started to drink again. He said that he was just celebrating with friends, not drinking excessively. Everything was under control.
Basic research questions regarding the relative contributions, possible interactions, and mutability of the multiple risk factors discussed above undoubtedly remain unanswered. Regardless of the cause of asthma, however, a gap exists between the current capacity to treat the condition and the availability of medical therapies in real world settings, particularly among under-served populations. Clinicians and public health officials can take steps to reduce this avoidable gap in the morbidity of asthma between Latino and non-Latino children.
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The individual clinician can be aware of the increased morbidity among Puerto Rican children and of the environmental risk factors associated with increased morbidity in both these and other children. He or she can make a special effort to keep up-to-date on high quality asthma medical management. The clinician can take additional steps when treating high-risk patients, such as monitoring changes in clinical status, modifying medical therapy more frequently, and facilitating the elimination of detrimental home exposures.
This paper has examined what is known about why children of Latino backgrounds have different prevalences of asthma. This review raises two questions. Why do Puerto Rican children have the highest prevalence of asthma among all Latino and non-Latino children in the United States? Why do Mexican American children, in spite of poverty and lack of access to care, appear to have a lower prevalence of asthma than Puerto Rican children?
Table 2 presents a conceptual summary of the possible risk and prognostic factors for asthma prevalence and morbidity that we have identified through a review of the scientific literature and clinical experience. For the purposes of this discussion, we distinguish between risk and prognostic factors. Causal risk factors are positively associated with incidence of disease, protective risk factors are negatively associated with incidence of disease, and prognostic factors affect the disease’s morbidity and remission, once it has occurred. Research to date, however, has not completely clarified whether certain factors are risk factors, prognostic factors, or both.
Research indicates that asthma prevalence rates vary among subgroups of Latino children, but little is known about differences in morbidity. Table 1 summarizes key studies indicating that mainland and island Puerto Rican children have the highest asthma prevalence of all Latino and non-Latino children in the United States.
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Using data from HHANES, Carter-Pokras and Gergen estimated a point prevalence of asthma for Mexican American children (2.7%) similar to that of non-Hispanic white children (3.3%), but much lower than that of mainland Puerto Rican children (11.2%), non-Hispanic black children (5.9%), and Cuban American сЫШгеп (5.2%). Lifetime prevalence of asthma was 20.1% among mainland Puerto Rican, 8.8% among Cuban American, and 4.5% among Mexican American children.
Latino children represent a significant proportion of all US children, and asthma is the most common chronic illness affecting them. Previous research has revealed surprising differences in health among Latino children with asthma of varying countries of family origin. For instance, Puerto Rican children have a higher prevalence of asthma than Mexican American or Cuban American children. In addition, there are important differences in family structure and socioeconomic status among these Latino populations: Cuban Americans have higher levels of education and family income than Mexican-Americans and Puerto Ricans; mainland Puerto Rican children have the highest proportion of households led by a single mother. Our review of past research documents differences in asthma outcomes among Latino children and identifies the possible genetic, environmental, and health care factors associated with these differences. Based on this review, we propose research studies designed to differentiate between mutable and immutable risk and prognostic factors. We also propose that the sociocultural milieus of Latino subgroups of different ethnic and geographic origin are associated with varying patterns of risk factors that in turn lead to different morbidity patterns. Our analysis provides a blueprint for future research, policy development, and the evaluation of multifactorial interventions involving the collaboration of multiple social sectors, such as health care, public health, education, and public and private agencies. Viagra Professional 100 mg
