By Mick Dumke Twelve-year-old Hiram Moss is in the back of the Mobile C.A.R.E. Foundation's Asthma Van one morning, insisting to several skeptics that he has been taking his medication.
Glancing at a laptop computer, nurse Becky Blasé looks over the readings from his last breathing test. She doesn't find his claims persuasive, so she tries a different tack. "All right, well, how is basketball?" "Good."
Sitting nearby, Hiram's aunt, Loretta Mitchell, shakes her head as her 1-year-old daughter, London, tries to squirm out of her grasp. "He's saying ‘good' because he likes to play," Mitchell says. "But how are you breathing?"
Hiram nods. His basketball jersey hangs from his wiry frame like a flag. He knows he has to take care of himself; he wants to get even better at basketball, win a scholarship to Duke or Notre Dame, and make the NBA, and maybe someday he will become a lawyer. Right now, though, he is jumpy, anxious, ready to be outside doing something, playing ball, whatever. "Good," he says.
Blasé is patient but unyielding. "Are you taking all your medications?"
"In the morning?"
Hiram pauses. His voice softens as he makes his confession: "Sometimes I don't in the morning. You know, in the morning sometimes I'm in a rush." But it happens no more than once or twice a week, he insists.
Dr. Karen Malamut, the van's director, appears behind him. She is a little shorter than him-maybe 5-foot-2-with full cheeks, intense brown eyes and an eagerness to kiss, cajole or chastise her patients, depending on what is needed.
This time, embracing Hiram in a playful headlock, Malamut cries out: "It takes 40 seconds! You puff and breathe in for 10 seconds, then you puff and breathe in for 10 seconds-four times! That's it!" She pulls out her stethoscope and asks him to breathe deeply. She is disappointed. "Oh Hiram, Hiram."
Going to the need Mobile C.A.R.E., which runs the 34-foot Asthma Van and another asthma clinic on wheels known as the Breathmobile, is one of several privately run, privately funded medical programs that do what experts say the area's public health programs should be doing a whole lot more of: Trying to find and treat some of the thousands of area children with asthma who aren't getting the medical attention they need-before they end up in the hospital emergency room, or worse.
The programs aren't lacking patients. Every month, the Mobile C.A.R.E. Foundation's two vans make stops outside 43 different schools on Chicago's South and West sides, seeing students and other neighborhood children. Operating with an annual budget of about $850,000, the program has screened more than 20,000 children in its first five years, and currently more than 2,600 are active patients.
Most come from families with no or poor medical insurance, Malamut says. But even those who have adequate coverage complain doctors don't give them enough education and treatment for asthma. Malamut, Blasé and other van staff may spend 30 or more minutes with each patient, giving exams, prescribing medications, demonstrating how to use inhalers, going over what the medications do and explaining the biology behind asthma and asthma attacks.
"We explain with lots of illustrations: The lungs are like trees. They have lots of branches. Having a normal lung is like breathing through a Burger King straw. Breathing bleach-that's what it's like when you have an attack," Malamut says.
Listening is also a key part of the job, since asthma can be triggered by everything from cat dander to old carpeting, dust mites, outdoor air pollution, poor use of medication and neighborhood crime that keeps children cooped up.
"I can't change where they live and all they're up against, but I can try to help them control their asthma," says Malamut, who formerly worked as a pediatrician in a more conventional North Shore office.
Not everyone responds, though. Malamut is still haunted by the boy who wouldn't take his medicine. His mother let him miss appointments and didn't take his asthma seriously. "We did everything we could but live with her," Malamut says. "And the child was out playing and had an asthma attack and died. And there was no reason for it."
The message has reached Loretta Mitchell and her sister, Yvette. Hiram was 4 when he suffered his first asthma attack: While playing with a friend, his laughter turned to a relentless cough and then breathing trouble. Yvette Mitchell, a clinical social worker, whisked him to a west suburban hospital, where, she says, "They never did explain to me what was going on. Their treatment of asthma really wasn't treatment of asthma. They never gave me any education on it."
She learned more a couple of years later, when Hiram's oxygen levels dropped and he was admitted to Cook County Hospital for three days. But she says the Asthma Van, which she heard about through Hiram's West Side school, has been the most helpful. In addition to explaining Hiram's condition and treatment, the van staff provided Hiram with free medications when the family was without insurance for a time.
It's not just about treatment Last summer, Loretta's daughter, London, had an asthma attack. "Her breathing slowed down. It was really scary-she wasn't even 6 months old," Mitchell says. "I was going crazy. I was like, ‘Oh, my god, my baby, what's wrong with her?'"
The doctors who treated London weren't any more helpful than those Hiram had first seen. After getting the little girl through her immediate crisis, the doctors released her without offering any advice on preventing another attack. Loretta took London to the Asthma Van along with Hiram, where she was given an inhaler.
So Hiram-and, to a lesser extent, London-knew what to expect during this recent checkup in the Asthma Van. As one of the van's regular patients, Hiram knows he will be examined, badgered and mothered during his checkup until he again acknowledges that he absolutely must take care of his asthma.
At this point, he plops down in an easy chair and scoops London onto his lap. Only for a second, though-Malamut summons him to the front and shows him a new adult-sized inhaler. He doesn't need the extension for kids anymore. "You've graduated, Big Man," Malamut tells him.
London is up next. Hiram watches carefully as Malamut examines the little girl's tongue, mouth and ears, and listens to her breathing. Blasé updates London's patient history with Loretta Mitchell. "Is she active?"
As if on cue, London darts across the van, little lights in her tennis shoes flashing red. Mitchell laughs and Blase joins her. "Hey, I have to ask the question," Blase says.
Of more concern, Mitchell says her daughter has been up coughing twice that week. She hasn't been exposed to smoke, carpeting, cats, mice or roaches, so it's unclear what caused it. Malamut prescribes a new medication and hands Mitchell an inhaler. "This will not hype her up any more." London smiles, showing lots of teeth, runs to the easy chair, dives in and sprawls out.
Pointing to a diagram on the wall, Blasé explains how the drugs should open London's lungs. Malamut hands Mitchell a sheet summarizing the medications for both Hiram and London. The ones to be taken in the morning are shaded in pink and the evening ones are in yellow.
As the Mitchells prepare to leave, with Hiram begging his aunt to hurry so he can make basketball practice, Malamut tells Hiram she likes his hair. "It looks great," she says.
"Hiram has always been a good-looking man," Blasé says.
Hiram looks down, embarrassed and trying to hide his smile.