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Asthma Attack
When "zero tolerance" collides with children's health.
(Page 2 of 3)
So it was with a sense of déjà vu that I read Nancy Sander's letter to the Bristol Township School Board. Just as my local school principal in Los Angeles should have known about his own district policies, so should those Pennsylvania school officials have known that state law allowed students access to their asthma inhalers. Why don't they know? Perhaps just because of how the school system tends to work.
"The nature of bureaucracy is you get these mailings with 57 pages that go out every two weeks and they go straight to the circular file," says Jura Scharf, executive director of the Chicago Asthma Consortium. "Anything that can carry risk, the short answer is going to be no. The paperwork gets to be cumbersome and so they fall behind."
"I think a large part of what happens," Scharf adds, "and this permeates all school situations, is the teacher and the school are petrified of being sued. They're almost afraid to admit they have children with asthma in the classroom, because then they have to do something about it."
It's when they don't do something about it, though, that schools end up on the losing side of lawsuits. In her letter to the Bristol Township School Board, Nancy Sander referred to the 1991 death of a New Orleans high school student, Catrina Lewis, who was delayed by security guards before being allowed to get her inhaler from the office. When it didn't help, she asked school staff to call an ambulance; instead they spent a half-hour trying to call her mother first. Catrina's sister, another student, finally called 911 herself, but emergency help arrived too late. In 1996, a New Orleans judge ordered Lawless High School's acting principal, a school counselor, and the school board to pay $1 million in damages to Catrina's family.
For school officials to be so obtuse about asthma now requires a certain amount of effort. The American Lung Association estimates that 7 to 10 percent of children have the condition, but for unclear reasons the incidence has increased dramatically in recent years -- almost doubling between 1982 and 1995, according to one study -- and some urban school districts now report initial asthma screening rates as high as 30 percent.
Rescue inhalers work by opening the bronchial passages, ideally to 100 percent of what they should normally be. It can't dilate them any further, so a non-asthmatic student who grabs another student's inhaler would feel no change in his breathing. The only likely side-effect might be a mild jitteriness. Inhalers aren't dangerous; asthma, which kills around 5,000 people a year, is. What's really frightening is how it can surprise you. I know children with severe asthma who have never been hospitalized; my daughter, who rarely wheezes badly, caught a simple, non-feverish cold when she was five that put her in the hospital for four days. Parents who've experienced such situations, who've been forced to acquire a certain level of expertise, can be impatient when school officials -- many of whom don't even know that asthma can be fatal -- dismiss their concerns as paranoia.
This doesn't mean that schools are unaware of the problem. "Everything about asthma, in the last two or three years, has come up more in every context," says Bruce Hunter, director of government relations for the American Association of School Administrators (AASA) in Arlington, Virginia. "We spend a fair amount of time on it." They'll probably spend even more time on it now that the Centers for Disease Control has just issued a special grant addressing school management of asthma in adolescents.
The AASA is no fan of zero-tolerance policies. Hunter notes that "the inhalers are an issue where, if you don't have some flexibility, you end up causing problems. Our view is people need to have common sense. But that being said, I don't think it'll be too long before someone finds some illicit use for inhalers. I've watched kids trade Ritalin. Kids just amaze me." Indeed, school nurses have reported students trying to use the devices to increase athletic performance or open the airways before sniffing glue. But the medical viewpoint that schools should let asthmatic students keep their inhalers is quite clear, and made even clearer whenever specialists talk to schools. Doctors don't worry about misuse; they worry about lack of access.
"The asthmatic should always have the inhaler on hand," says Dr. Robert Nathan, a clinical professor of medicine at the University of Colorado and a spokesman for the American Academy of Allergy, Asthma and Immunology. "The issue with schools, obviously, is that it's a drug. But it's kind of hard to overdose on an inhaler. Periodically, we will meet with school administrators, teachers, P.E. teachers. There are some who say, 'You can't use this inhaler and you have to run around the track with everyone else.' It's ludicrous."
Common sense would suggest that children are naturally reluctant to call attention to themselves by asking for permission to go to the office and use their inhaler, and clinical observation backs this up. Elizabeth McQuaid, a Rhode Island Hospital pediatric psychologist and Brown professor who studies human behavior and asthma, has surveyed focus groups about just that issue. "Particularly with early teenagers, it's embarrassing for them to take medication with people looking at them," she says. "They're hesitant to disrupt sports or other activities to go take the medicine in the office."
Not all school administrators have opportunities to meet with asthma experts. But a simple Internet search quickly reveals that medical opinion is clearly in favor of asthmatic students having access to their inhalers. Even school nurses, who straddle the two worlds of school employees and medicine, generally agree, with some caveats. The Ohio Association of School Nurses (OASN) lobbied hard for amendments to the state's 1999 asthma inhaler law. "We saw gaping inadequacies," says Sandra Gadsden, a Worthington, Ohio, school nurse. "Originally the law was just going to allow inhalers." Still, the OASN supported the law after legislators added requirements such as a doctor's certificate that the child is capable of self-medication, as well as a written procedure attached to the permission if the inhaler doesn't help.
The National Association of School Nurses (NASN) has a position statement on its Web site stating that they "support the self-management of asthma, including the use of prescribed, inhaled medications on a case-by-case basis." Nancy Sander reports that "I rarely run into a school nurse anymore who feels she needs to be in charge of the inhaler at all times." At my request, the NASN, to which around 11,000 of the nation's 40,000 school nurses belong, sent out an e-mail survey to board members asking what they thought about students carrying their own asthma inhalers. Of the 25 responses, only three were negative. Most members were aware of new state laws exempting inhalers from zero-tolerance rules and reported few or no problems, although some asked students to keep a spare inhaler in the office and demonstrate proper inhaler technique.
Go further up the ladder of experts -- to physicians specializing in asthma rather than school nurses -- and medical opinion is much firmer. "Information for School Personnel Regarding Treatment of Asthma" is a peer-reviewed paper on the Children's Virtual Hospital Web site. It was written by Dr. Miles Weinberger, a University of Iowa pediatrics professor and the director of the Children's Hospital of Iowa's pediatric allergy and pulmonary divisions. Dr. Weinberger states flatly that "it is essential that all students with sufficient maturity have their bronchodilator inhaler in their possession at all times," adding, "The inhalers pose no abuse potential or other danger to classmates. It therefore constitutes unreasonable interference with the student's medical care for school personnel to unilaterally restrict possession."
In an interview, Weinberger notes that "virtually all kids eight years and up, of normal intelligence, and in some cases six years and up, are capable of handling the inhaler." He deals with school administrators by handing out a preprinted form authorizing the child to keep the inhaler on hand. "Most go along with it," he says. "Others have Tight Rectal Sphincter Syndrome. But there are very few principals who are really going to argue with a note from the doctor."
"Around Iowa, at least, I gather they're pretty reasonable," Weinberger adds. "I rarely have to call up and say, look, you jackass, the kid's an asthmatic and needs his inhaler. But then, Iowa is a state of small towns, and we're also largely a middle-class state. People go in and talk to the principal. They probably already know the principal personally. I can see the problem with bigger school districts, in bigger cities."
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