In response to the pattern of underutilization of medical care and “poor day-to-day management of asthma” among African American children, the authors of this paper describe a program designed to address the difficulties attached to routine asthma care and management. The Neighborhood Asthma Coalition, which serves four low-income predominantly black neighborhoods in St. Louis, seeks to promote the following 1.) ongoing vs episodic care; 2.) reduced exposure to triggers; 3.) sensitivity to signs of attacks; 4.) attack management; and 5.) improved communication with caregivers, professionals and teachers. The programs also targets a disturbing trend of “inappropriate or insufficient treatment” among low-income African American children in the St. Louis area. The authors note that there were “ five cases of asthma-related deaths in 1987 in the St. Louis area, all [of which] were African American and of low socioeconomic status. Lack of prescribed corticosteroids in two decedents with known severe asthma and markedly subtherapeutic or zero serum theophylline levels at the time of fatal episodes in four of the five dramatize the need to promote adequate basic care as well as co-management to those who may be unaware of its importance or unsupported in its pursuit.”

Several reasons for the deficits in basic care are suggested. In essence, “working with the neighborhood asthma coalition has revealed numerous, concrete barriers to treatment which, unless pointed out by neighborhood residents, would have gone unnoticed. For instance, pharmacies are not open 24 hours a day in low-income neighborhoods, and residents do not have transportation to find outlets that are. We wonder how many times frustrated clinicians have attributed to lack of interest rather than to lack of an open pharmacy the failure of an overwhelmed mother to fill a prescription written in the emergency department on a weekend evening.” In addition, the lack of awareness by physicians of the social and environmental barriers may augment a hazardous pattern of care for the asthmatic patients. By anecdotal accounts, this article suggests that professionals “report the futility of scheduling routine follow-up visits and have come to accept a pattern of urgent and emergency care as the standard.”

Furthermore, although physicians may encourage continual and timely care, there may be institutional barriers—coupled with the personal barriers evident from the physicians’ personal assumptions about patient care seeking behavior—to achieving this goal. The initial program planning of the Neighborhood Asthma Coalition, therefore, focused on increasing access to care for asthmatic children and their caregivers. The program developers found that “in practice,” there was a “substantial lack of availability of routine, preventive asthma care as opposed to episodic, acute care.” Data on the frequency of cases receiving different numbers of routine follow-up visits over a 1-year period indicated that 77.23% of asthmatic children received no such care and only 0.99% had received the recommended 5 routine asthma-related visits in a one year period. This program sought to ensure continual care by collaborating with the ED of the St. Louis Children’s Hospital, and most importantly, by implementing “regular meetings with physicians from the community in order to address access to care and review the physicians’ perceptions of problems with asthma care and barriers within target neighborhoods.”

During office visits, a doctor’s past experiences with patients who have been unable to adhere to treatment or return for a follow-up visit may affect the way the current patient is treated. And, as pointed out by the authors, the physicians could be so far removed from the patients’ daily reality—burdened by the daily struggles of survival—that the patient-physician interaction is compromised and the patient is rendered suboptimal treatment.