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Asthma Attack
When "zero tolerance" collides with children's health.
Just before the beginning of this school year, the Bristol Township School Board in Pennsylvania decided that students with asthma must keep their emergency inhalers in the school office, rather than on hand.
On September 7, the board received a letter from Nancy Sander, executive director of the Allergy and Asthma Network/Mothers of Asthmatics (AANMA), a national asthma support and education group based in Fairfax, Virginia. Sander's letter neatly encapsulated the all-too-common frustration of parents when their doctor's advice about how to care for an asthmatic child encounters a school with an entrenched hall-monitor mentality. The letter read, in part:
"The decision to accommodate and facilitate a child's needs with asthma is far easier than pretending their needs do not exist or that restricting student access to medications is for the safety of all students. To do so places your students with asthma at greater risk of death or missed school days, their classmates at risk of witnessing their death, and your school board at risk of lawsuits....
"If a student placed a plastic bag over a teacher's head for a brief moment, the student would be charged with assault. But a school board voting to restrict a child's access to his life-saving asthma medication is no less guilty of a crime. Is Bristol Township School Board really ready to accept responsibility for violating a child's right to breathe? Are you prepared to breach the provisions of the Americans with Disabilities Act?"
Three days later, the school board held a hearing and reversed its original decision. Students in Bristol Township are now allowed to retain control of their asthma inhalers.
There are a couple of remarkable things about Nancy Sander's letter. The first is that it was necessary at all. Although school officials have often taken zero-tolerance laws against drugs in schools to mean that even asthma medicine must be kept locked in the office -- which obviously defeats the purpose of rescue inhalers like quick-acting bronchodilators -- in the past few years many states passed bills specifically exempting inhalers from such rigidly interpreted rules. Pennsylvania become one of them, to a fair amount of publicity, almost a full year before the Bristol Township School Board decided to deny asthmatic students easy access to their own medicine. On September 27, 2000, the state's House Education Committee voted unanimously to require its public school districts to let students carry asthma inhalers. This was partly in response to "The Flagpole Mom" (as the media dubbed her), a Pennsylvania mother who chained her lawn chair to her son's elementary school flagpole for 19 days to protest the school's asthma inhaler policy.
Similar laws are in place in Delaware, Florida, Illinois, Indiana, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Virginia, and Wisconsin. But ignorance and obstinacy among school officials often trump even their own local laws. In August, the Chicago Asthma Consortium succeeded in getting Illinois to pass a bill allowing students to keep asthma inhalers on hand; the group had previously persuaded Chicago's public schools to pass a local version of the law in 1997. And yet a survey of Chicago school nurses, sponsored by a local chapter of the American Lung Association in May of 2000, revealed that only 30 percent of asthmatic students carried their inhalers at school. "We have better control," one nurse told the Chicago Sun-Times.
The second remarkable thing about Nancy Sander's letter was its gloves-off tone. Heads of 10,000-member nonprofit groups who present their case to Capitol Hill every year are generally more circumspect in official communications. But Sander began her organization in 1985 as a simple support group called Mothers of Asthmatics (three of her four children have asthma), and I know from experience that when a mother of an asthmatic encounters school stupidity that threatens the health of her child, the result can be murderous rage.
My daughter, who is now in the seventh grade, attended one of the better Los Angeles public schools, Ivanhoe Elementary, through the middle of fifth grade. She has mild-to-moderate asthma and rarely needs to use her emergency inhaler. But when she did, the elementary school's involvement ranged from OK to inept. (Her current private school is better about the inhalers, but far from glitch-free.) In first grade, one of the after-school counselors helped my daughter, who'd been wheezing, take her inhalers. At the time, her doctor had prescribed two to three puffs of Proventil, a fast-acting bronchodilator, followed by three puffs of a slower-acting one called Atrovent, which takes about 20 minutes to work. It turned out the counselor had only given her the Atrovent; apparently he'd failed to read the written instructions and had just grabbed the first inhaler handy. Luckily, her breathing improved anyway. Or at least it had by the time I picked her up, about 20 minutes later.
This is just the sort of situation that University of Iowa nursing professor Anne Marie McCarthy found two years ago, in a survey she conducted of 649 school nurses: Almost half reported medication errors in their school the previous year, and three-quarters said that medication was dispensed not by nurses but by other school employees, such as office clerks or playground aides. That's not surprising, considering that the national ratio of school nurse to student is 1 to 1,500 at best and 1 to 2,500 at worst, depending on who's estimating the figures.
Ellie Goldberg of Newton, Massachusetts, advises parents of children with various medical problems how to deal with schools. She gets calls about asthma inhalers every day. One of the most memorable: "A person from Louisiana called and told me about a teacher who pulled a drawer out, spilled all the medicine out of the cups, refilled them randomly and said, 'Gee, I hope this doesn't hurt anybody.'" When Goldberg's own asthmatic daughter was in the second grade, the school secretary mistakenly gave her Ritalin instead of her inhaler.
My daughter always keeps emergency inhalers with instructions in her backpack, a fact kept on file in the school's office. Despite that, no one in charge had been quite aware of this when she had that asthma attack in the first grade; apparently, she'd been wheezing too badly to speak. "Jasmine knew where the medicine was," a teacher later explained, referring to another first grader who was often in trouble for digging around in other student's backpacks. Considering how the adults at the school had handled the situation, I probably would have been just as well off leaving them out of the loop and going over the instructions with the enterprising Jasmine.
I was relieved when my daughter learned to read and proved she knew how to take her medicine by herself. Plus, unlike most adults, she was careful not to leave it locked in a hot car or sitting in the sun. One day when in the fifth grade, however, she was in tears when I picked her up from school. The teacher had yelled at her when she'd used the inhaler in class, claiming that she didn't really need it.
I spoke to Ivanhoe's then-principal, Kevin Baker. He said I'd been "breaking the law" for five years by keeping the inhaler in the backpack instead of in the office, and that he would "confiscate" it if he found it there in the future. If the school had allowed this before, he said, it was an oversight. "So now what we need to do," he explained, in a sing-songy, Romper Room voice, "is set up a series of intervention meetings to help you understand our concerns about you breaking the law." My arguments about doctor's orders went nowhere. "When your daughter is at school," Principal Baker said, "I am the ultimate authority concerning her health."
That Robert De Niro soundbite from The Untouchables that Howard Stern likes to play -- "I want him dead! I want his family dead!" -- kept echoing in my head as I left the school office. But I'd heard enough misinformed pronouncements over the years from that school -- a jellyfish is a mollusk, "Indian" should be spelled with a small i -- to consider the possibility that the principal didn't know what he was talking about. So I went home and called the Los Angeles Unified School District's director of nursing. Within an hour, I had a fax on Principal Baker's desk saying that district policy (Bulletin Z-19, Attachment F) does allow students to keep medicine on hand with a note from their doctor. I sent a copy to his supervisor, and he backed down quickly.
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