Making Change: Air Conditioning

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In the grim emergency wards of hospitals throughout the Bronx and Manhattan, Kimberly Negron has spent countless agonizing hours with her two asthmatic kids, 4-year-old Ashly and 9-year-old Francisco. Each time she rushed her breathless kids to the hospital, doctors treated the asthma episode, but within months or even weeks, her children’s symptoms would recur. “Believe me,” the 27-year-old Negron says with a laugh, “my kids got records in every hospital in New York.”

Now, after years of crisscrossing the boroughs searching for a doctor who could explain how to keep her kids out of the ER, Negron believes she has found her ideal doctor. A pediatrician at Bronx Lebanon Hospital, her new doctor prescribes “control medications,” drugs that diminish symptoms over time.

Just as important as her conscientious new doctor, however, is another key part of her kids’ asthma treatment plan: the place where she buys her kids’ medication, De Franco Pharmacy.

If the city’s asthma epidemic ever inspires its own movie–a gritty Erin Brockovich, say, set in the South Bronx–it will need a glamorous hero to battle the lung-tightening forces of evil and help kids fight the asthma monster. Mild-mannered, graying James De Franco may not have Erin’s wardrobe, but, like her, he’s practicing grassroots activism in a most unlikely setting.

De Franco’s pharmacy could never be mistaken for a doctor’s office, and his staff certainly isn’t being paid doctors’ salaries. But while the city and state spend millions fighting asthma, funneling money to community groups, working with schools and creating public service ad campaigns, De Franco has launched his own effort to combat the disease with no money. He’s turning a small businessman’s trade association into a public health organizing network that attacks one of asthma’s most intractable features: patients’ ignorance of how to treat it properly.

De Franco’s bustling, family-owned pharmacy is located on Randall Avenue in the Soundview section of the Bronx. A modest neighborhood of low-rise homes in the shadow of the Bruckner Expressway, it happens to be the asthma capital of America: In 1997, the disease landed nearly 5,000 Bronx children in the hospital.

His pharmacy sees a steady stream of asthmatic children and adults ordering the pills and inhalers they need to breathe freely. In the mid-1990s, alarmed by the local prevalence of the disease, De Franco started counseling customers on how to control their asthma. He has trained his pharmacist colleagues to call asthmatics at home to make sure they’re taking their medication regularly and correctly, ask if the disease has landed them in the emergency room and send notes to their doctors when their patients’ disease flares up. “He’s doing as much education [of] practitioners as of patients,” says Marian Feinberg, health coordinator with the South Bronx Clean Air Coalition.

The fact that pharmacists can be found in easily accessible storefronts–not crowded clinics–makes them well placed to counsel patients about taking medications correctly, says De Franco, who calls pharmacists “the missing link between patients and practitioners.” Dr. David Rosenstreich, an asthma and allergy specialist at Albert Einstein College of Medicine in the Bronx, agrees. “It’s where the patients are being given the medication,” he says. “If they have time, they can be shown what to do, and that’s the ideal time to do it.”

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It’s practically a cliché among asthma experts that treatments are now so effective that no one should ever die of the disease. Yet in New York City, about 200 people die from asthma every year.

Ideally, patients should treat asthma by taking control drugs, which lessen the airway constriction and inflammation of asthma over time. Doctors and public health practitioners call this “managing asthma.”

But many poor families don’t have doctors who can explain the remedies to them. So instead of “managing” the disease, many asthmatics simply treat their symptoms with quick-fix, so-called “rescue” medications, drugs that keep airways open temporarily but don’t provide any long-term benefit. Before long, their shortness of breath, wheezing and coughing fits reach a crisis point. Then they rush to an emergency room and wait hours to get treatment that will let them breathe freely again. In 1997, asthma resulted in $141 million in Medicaid hospitalizations statewide.

For many patients with Medicaid or without insurance, an emergency room doc is the only physician they see, and those doctors are often too frazzled to prescribe control drugs and explain their importance. “Their focus is on the attack,” Rosenstreich says. “They don’t have time to sit down and show patients how to use their inhalers, and make sure they know how to use them correctly. They’re going on to the next emergency.”

In order to keep asthma in check, the ratio of control meds to rescue meds should be about two to one in favor of control drugs. But drug company surveys show that Bronx patients get three times as many prescriptions for rescue drugs as for control drugs. That’s way too much emergency treatment and way too little prevention, says Rosenstreich. “When we see people refilling their albuterol [a rescue medication] twice a month, we warn them, because then they’re not using their control meds right,” says De Franco. “If they’re using too much of the albuterol and very little of the control meds, they’re not really controlling their asthma.”

Even with the right medications, treating asthma requires a complicated array of devices and the knowledge to use them properly. In 1999, De Franco found out that many Bronx pharmacies did not stock several of the medical devices asthmatics need, like chambers, which attach to asthmatics’ inhalers and slow down the delivery of inhaled medication. Though they’re essential for young children and certain older patients, many business owners refused to stock the attachments because outdated Medicaid rules forced them to sell the gadgets below cost.

Using the connections he’s developed over the years as executive director of the New York City Pharmacists Society, De Franco convinced manufacturers and wholesalers to sell bulk lots of chambers at a reduced rate, and he lobbied the state’s Pharmacy Advisory Committee, a liaison between pharmacists and the Department of Health. Within weeks, the state increased reimbursements, making it possible for pharmacists to make a small profit on the sales.

So that patients could know which pharmacies stocked the devices, De Franco got 50 pharmacies throughout the city–most of them in the Bronx–to join the Pharmacy Asthma Network (www.nycps.org/pan/pan.htm). The network’s members, nearly all mom-and-pop shops (De Franco says the big chain stores weren’t interested), also receive updates on the latest methods of treating the disease.

They also agree to explain to clients how to use asthma devices. Because many asthmatics mishandle their inhalers, the drug lands at the back of the throat, instead of in the lungs where it’s needed. It’s fairly simple to explain to a typical asthmatic how to keep symptoms at bay by using the devices correctly, and De Franco has bilingual staffers to help Spanish-speaking patients understand their treatments.

Among De Franco’s allies is Boris Mantell, owner of a chain of pharmacies throughout the city and president of the Pharmacists Society of the State of New York. Following De Franco’s model, Mantell has trained his own staff to educate asthmatics about controlling the disease.

But it’s hard for most pharmacists to drop what they’re doing and counsel one asthma sufferer while hordes of angry customers line up. “It’s a matter of finding the time to ask all those questions,” says Kathleen Carroll, De Franco’s daughter and colleague at the Bronx pharmacy. “I’m more concerned with making sure they get their medications.” De Franco suggested a Medicaid reimbursement for counseling to state health officials, only to be told tight budgets won’t allow it.

It could save thousands in medical costs, though. Take Asheville, North Carolina. The small, progressive city and its largest hospital, the private Mission St. Joseph’s Health System, have put in place a similar program, paying pharmacists about $20 to $60 each time they counsel a patient about controlling asthma. Most asthmatics–there are about 150 in the program–meet with their pharmacists about six times a year.

The result? The three-year-old investment has paid for itself many times over, saving $560 per patient annually in reduced medical costs and lower absenteeism, says Barry Bunting, a clinical pharmacy manager at St. Joseph’s. Certainly the local bean counters have enjoyed the boon: Sick days among asthmatics dropped by more than half, to two per month on average. But the most significant effect was on asthmatics’ health. After a year in the program, the average patient’s lung function rose from a bottom-of-the-barrel 61 percent of normal to 86 percent, which doctors consider healthy.

Hoping to achieve similar effects on a larger scale, states such as Mississippi have set aside Medicaid funds to pay pharmacists who counsel asthmatics, says Susan Winckler, policy director at the American Pharmaceutical Association.

The idea hasn’t caught on in New York, despite its sky-high asthma rates, but that doesn’t mean De Franco will stop trying. “I’m not giving up,” he insists. “After three years, something ought to break.”

Maura McDermott is a reporter at the Herald News in West Paterson, New Jersey.