The war against asthma

NZ worst in world rank­ings.

Element - - Contents - By So­phie Bar­clay

It must rank up there as one of mankind’s great­est med­i­cal mys­ter­ies: no one knows what causes asthma. De­spite the ef­forts of a multi bil­lion dol­lar phar­ma­ceu­ti­cals in­dus­try, the causes, and hence a cure, re­mains elu­sive. But some com­bi­na­tion of the causal fac­tors of asthma has meant that New Zealand has the high­est rates of suf­fer­ers of any coun­try in the world – both de­vel­oped and de­vel­op­ing. As asthma aware­ness week kicks off to­day, we ask why this dis­ease, which af­fects one in four New Zealand chil­dren, is so preva­lent here, and ex­am­ine the stag­ger­ing costs to the coun­try – both mon­e­tary (over $800m a year in health costs) and so­ci­etal. If we can’t find a cure, at least we can con­trol what is be­lieved to be the trig­gers – poor hous­ing stock which is poorly heated and ven­ti­lated, smok­ing rates, diet. We also meet the peo­ple fight­ing the good fight here in New Zealand, and see what can be achieved – like com­pet­ing in an Iron­man event like the bloke here on the right – through good man­age­ment of the dis­ease.

Asthma has been around since an­cient Egyp­tian times. In fact, the name de­rives from the Greek word for ‘pant­ing’. De­spite its long his­tory, no one is any closer to know­ing what causes it or why we have so many in­haler-tot­ing suf­fer­ers.

The Global Asthma Re­port put the num­ber of asth­mat­ics at 235 mil­lion world­wide and ris­ing. The in­crease in asthma over the last 30 years prompted the es­tab­lish­ment of the world’s big­gest epi­demi­o­log­i­cal re­search pro­gramme, the In­ter­na­tional Study of Asthma and Al­ler­gies in Child­hood (ISAAC). In 2004, ISAAC won Guin­ness Book of World Records’ recog­ni­tion for its large-scale epi­demi­o­log­i­cal re­search in­volv­ing more than 1.96 mil­lion kids in 105 coun­tries and 500 plus publi­ca­tions.

In 1998, ISAAC found that New Zealand, along with the UK, Australia and the Repub­lic of Ire­land, had the high­est preva­lence of asthma. A decade later, New Zealand came top of the ta­bles. One in six adults and one in four chil­dren are likely to suf­fer from it, some 600,000 ki­wis each year.

Cur­rent asthma trends point to an in­crease in low and mid­dlein­come coun­tries where symp­toms are likely to be more se­vere, and a plateau­ing of the dis­ease in high-in­come coun­tries where it is more com­mon. As coun­tries like Mex­ico and the Ukraine ‘ Western­ise’, there is a greater risk of de­vel­op­ing asthma; the seden­tary life­styles, fast food fads and ill-health of the West ev­i­dently come at a cost.

De­spite the dis­ease’s per­va­sive­ness, no one knows how it is caused, says Phillippa Ell­wood, se­nior project man­ager at ISAAC. “It’s the 64-mil­lion-dol­lar ques­tion. A lot of peo­ple get mud­dled be­tween trig­gers and causes. We know what the trig­gers are, things like privet and cig­a­rette smoke, but not the causes.”

Swathes of in­con­clu­sive re­search has been un­der­taken on how to re­duce the risk of ac­tu­ally ac­quir­ing the dis­ease. Ini­tially asthma was blamed on ge­net­ics. How­ever, stud­ies amongst iden­ti­cal twins re­vealed that only half of iden­ti­cal twins with one asth­matic twin had an asth­matic co-twin. Asthma can run in fam­i­lies, but this could be due to en­trenched fam­ily habits or the sur­round­ing en­vi­ron­ment. “When our ge­netic stud­ies didn’t come out strongly, we thought the causes could be en­vi­ron­men­tal. A fam­ily tends to eat the same things; it tends to be in the same, damp house. Fam­i­lies fol­low the same pat­tern be­cause of the en­vi­ron­men­tal link,” states Ell­wood.

The in­flu­ence of en­vi­ron­men­tal con­di­tions on asthma – where you live, diet, med­i­ca­tion – has also been in­ves­ti­gated with vary­ing re­sults. One study il­lus­trated a link be­tween fre­quent parac­eta­mol use in ba­bies less than one year old and asthma preva­lence in school-age chil­dren. Re­search also found that those liv­ing on farms had lower asthma rates cou­pled with fewer al­ler­gies. New Zealand’s air qual­ity is pos­i­tively pris­tine com­pared to other coun­tries such as China, so the ‘poor air qual­ity’ the­ory is out too.

Ac­cord­ing to res­pi­ra­tory spe­cial­ist and NZ Asthma Foun­da­tion med­i­cal di­rec­tor, Dr Bob Han­cox, what is clear is that obese and

over­weight women have higher chances of de­vel­op­ing asthma as adults and, if al­ready an asth­matic, more likely to have se­vere symp­toms. The ef­fect is strong for women, says Dr Han­cox, and prob­a­bly true for men. A Fin­nish study in 2011 re­ported that over­weight women were also more likely to have ado­les­cent chil­dren with asthma.

In 2009, re­search from the Univer­sity of Not­ting­ham em­pha­sised a high vi­ta­min in­take kept asthma at bay. Leanne Male, as­sis­tant di­rec­tor of re­search at Asthma UK, says that although the jury is still out, in­creas­ing vi­ta­min in­take by eat­ing a bal­anced diet is a good pre­cau­tion­ary step, es­pe­cially if there is a fam­ily his­tory of asthma or dur­ing preg­nancy.

Diet does seem to play a key role, says Ell­wood. “From our ISAAC re­search we found that the higher the in­take of fresh fruit, green veg­eta­bles, fish, ce­re­als, pulses and grains, the less asthma and al­ler­gies were ap­par­ent. Con­versely, the less of those food groups they ate, the higher the asthma al­ler­gies”. Chil­dren on the so-called ‘burger diet’ (three or more burg­ers a week) dis­played an in­creased asthma risk. Ir­re­spon­si­ble par­ent­ing? Or could this diet be just an­other in­di­ca­tor of hard­ship?

Pro­fes­sor Innes Asher, pe­di­a­tri­cian and global au­thor­ity on asthma, says New Zealand faces a triple jeop­ardy which im­pacts on asthma rates: “Poverty, poor qual­ity hous­ing which is cold, damp and over­crowded and poor ac­cess to pri­mary health care.” One in four chil­dren grow up in poverty, around 270,000 chil­dren; a fright­en­ing statis­tic for a coun­try we con­sider to be ‘de­vel­oped’. If you look closer, the fig­ure re­veals en­trenched eth­nic in­equal­i­ties – one in six Pakeha chil­dren ver­sus one in four Pa­cific, and one in three M ori chil­dren. Maori chil­dren are also more likely to have more se­vere asthma and are twice as likely to be hos­pi­talised for asthma. Adults have a higher rate of the dis­ease, one in four com­pared to one in seven for non-maori pop­u­la­tions.

Asthma Foun­da­tion Maori health man­ager, Sharon Ca­vanagh, points out that so­cial in­equal­ity un­der­pins the in­equal­i­ties of health. “If peo­ple are liv­ing in a state of poverty their homes may be over­crowded, they could lack ad­e­quate heat­ing, or lack in­come to pro­vide heat­ing. Many live in ar­eas where it is dif­fi­cult to ac­cess a range of health ser­vices. Then there’s the whole is­sue of in­suf­fi­cient nu­tri­tion.”

There should be Maori-spe­cific ini­tia­tives in place, says Ca­vanagh, and pro­grammes like ‘Whanau ora’ are on the right track. “My per­sonal view is that if we get it right for Maori, we will get it right for ev­ery­one.”

One of the big­gest is­sues for Maori is smok­ing, says Ca­vanagh. Smok­ing in adults could have links to adult-on­set of asthma, whilst sec­ond­hand smoke is as­so­ci­ated with a risk in child­hood and adult­hood asthma. Pre-natal ex­po­sure to cig­a­rettes may also be a fac­tor in caus­ing the dis­ease. A re­cent press re­lease from Ac­tion on Smok­ing and Health (ASH) showed that in 2011, 14 to 15-year-old Maori had the high­est re­duc­tion in smok­ing rates. “Young Maori are tak­ing a lead­er­ship role by say­ing, ‘we don’t want to do this – this isn’t our fu­ture,” she re­flects.

In his book ‘The Strat­egy of Pre­ven­tive Medicine’, Pro­fes­sor Sir Ge­of­frey Rose wrote, “the pri­mary de­ter­mi­nants of dis­ease are mainly eco­nomic and so­cial, and there­fore its reme­dies must also be eco­nomic and so­cial. Medicine and pol­i­tics can­not and should not be kept apart.” Re­cent re­search from the Univer­sity of Otago em­pha­sizes that in­creas­ing so­cial in­equal­i­ties are cre­at­ing in­equal­i­ties of health and in­creas­ing hospi­tal ad­mis­sions for in­fec­tious dis­eases, in­clud­ing res­pi­ra­tory in­fec­tions. In 2011 the OECD re­port ‘Di­vided we Rise’ high­lighted that chasm be­tween the wealthy and the de­prived is in­creas­ing in Aotearoa, and fast. In 2010 The Chil­dren’s Com­mis­sioner Re­port ob­served a link be­tween poverty, in­suf­fi­cient hous­ing con­di­tions and poor health in­clud­ing res­pi­ra­tory in­fec­tions, asthma and de­pres­sion. The ‘Grow­ing Up in New Zealand’ study found that one fifth of homes are of­ten or al­ways damp. 30.6% of houses in lower so­cio-eco­nomic ar­eas were more likely to be damp, and even in wealth­ier sub­urbs the num­ber was high at 11.9%. In­cred­i­bly, 20% of fam­i­lies in de­prived ar­eas had no form of heat­ing at all.

Dr Ju­lian Crane, co-di­rec­tor of He Kainga Oranga (Hous­ing and Health Re­search Pro­gramme) says that in­creas­ing the in­su­la­tion of a house can help in the fight against asthma. A snugly in­su­lated house means fewer days off school and doc­tors vis­its for asthma suf­fer­ers. He Kainga Oranga re­search also showed that un­flued gas heaters, which give off asthma-in­duc­ing ni­tro­gen ox­ides, should be swapped for flued gas heaters (that vent air pol­lu­tants and water vapour out­side the home), pel­let burn­ers or heat pumps. In houses where un­flued gas heaters were re­moved, the sever­ity of asthma de­creased and the heat­ing of the house im­proved. Many houses have bed­rooms well be­low the World Health Or­gan­i­sa­tion rec­om­mended tem­per­a­ture of 18˚c.

These types of sta­tis­tics paint a bleak picture for the fu­ture of New Zealand, where asthma will con­tinue to thrive in con­di­tions of poverty

“Young Maori are tak­ing a lead­er­ship role by say­ing, ‘we don’t want to do this [smok­ing] – this isn’t our fu­ture.”

and in­ad­e­quacy. Known as the ‘cin­derella’ of dis­eases, asthma has never ac­tu­ally been a pri­or­ity for the Min­istry of Health and its lack of spe­cific causes make it hard to be tack­led head on. It’s per­haps this lack of pri­or­ity, and there­fore lack of funded re­search, that ex­plains why we know so lit­tle about the dis­ease.

Un­til a break­through is made, asthma will con­tinue to bur­den the coun­try by well over $800 mil­lion each year.

Per­sonal and fi­nan­cial costs such as hospi­tal ad­mis­sions and ab­sen­teeism costs could be avoided with bet­ter treat­ment in the com­mu­nity, says chief ex­ec­u­tive of the Asthma Foun­da­tion An­gela Fran­cis. “This would re­quire im­proved ac­cess to asthma ed­u­ca­tion and health care to pro­vide bet­ter long-term con­trol of asthma and prompt treat­ment of de­te­ri­o­rat­ing symp­toms. We need to make this a pri­or­ity.”

Photo: Woolf pho­tog­ra­phy.

Above right: Asthma Foun­da­tion Maori health man­ager, Sharon Ca­vanagh.

Photo: Woolf pho­tog­ra­phy.

Be­low: An­gela Fran­cis, chief ex­ec­u­tive of the Asthma Foun­da­tion and Teresa Demetriou, na­tional ed­u­ca­tion ser­vices man­ager, Asthma Foun­da­tion, are declar­ing war on asthma.

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