In a small manufactured home in south Phoenix, 6-year-old Jonathan Hendrix is hiding behind a chair, pretending to be shy.
"I don't want to go to the doctor," he mumbles to his mother, when a stranger arrives at his house to talk about his medical condition.
Jonathan has chronic asthma. He's intimately familiar with the doctor's office. What started as an attack that landed him in the hospital when he was 2 has led to years of breathing treatments, missed school days (despite his mother Jennifer's best attempts) and, too much of the time, shortness of breath.
This kid has an understanding of his disease that goes beyond his years. He can lay out all of the equipment that helps manage his asthma and demonstrate how to use each piece. His mother, who works more than 50 hours a week for the U.S. Postal Service, says Jonathan's asthma isn't as bad as she's seen in other kids, but still, they've had some scary moments.
She wishes her son didn't have to think about his next breath.
"When I see him breathing like that, I feel myself taking less breath. When he takes his inhaler and he holds it in and counts to 10, I hold it in," she says. "I'll never know what it feels like. Maybe like choking."
In Arizona, which has the second highest asthma rate after Maine, according to the American Lung Association, Jonathan's story is a familiar one for school-aged children especially in low-income school districts. Janet Napolitano got headlines in 2003, early in her administration, for talking about asthma and other environmentally triggered hazards to children, but as her first term comes to a close, the governor's done almost nothing to change public policy.
She's too late for one little girl.
Earlier this year, a fifth-grader at Rose Linda Elementary School in south Phoenix died of an asthma attack triggered by bad air while she played outside during recess. By all accounts, the school did what it was supposed to sent the 10-year-old home with strict instructions to her mother that she needed to go to the hospital. But because the mother is an undocumented immigrant, she kept her daughter home and tried to stop the attack herself.
The child was not taken to the emergency room until the next morning, and by then, it was too late.
Of course, not every child who has an asthma attack at school dies, but many are unable to sit through class. Mary Chick, head nurse for Roosevelt Elementary School District, which includes Rose Linda, says that in 2004 there were more than 10,000 missed school days in the Roosevelt district because of asthma. She estimates that she treats at least 12 asthmatic children a day, and that only counts those who come in for daily medication. Even more come in complaining that they can't breathe.
It took a death to create public policy, and even then it hasn't reached beyond a school district in this case. Roosevelt School District has implemented a flag program, modeled after a successful endeavor in California's San Joaquin Valley, that helps schools monitor air quality.
Each school flies an air quality flag: Green means the air is good, yellow is cautionary, and orange and red indicate poor to very poor air quality. Children are not supposed to play outside on orange and red days, and highly sensitive kids should stay inside on yellow days as well.
If the flag had flown the day of the fifth-grader's death, it would have been orange. The flag system may have prevented her asthma attack and saved her life, yet even now it's not mandated statewide, and it's up to individual Roosevelt principals and the superintendent to enforce it.
The state's not involved in such efforts at all.
As soon as she took office in 2003, Janet Napolitano gave Steve Owens, her newly appointed director of the state Department of Environmental Quality, an initiative to focus on children's health.
Owens and his staff at DEQ came up with the Children's Environmental Health Project. They kicked it off with a lot of hype at a press conference that April.
One month later, DEQ followed up with Arizona's first Children's Environmental Health forum, which pulled together policymakers, university researchers, private health advocates like the Arizona Asthma Coalition, parents, and teachers to talk about children's health and figure out what issues DEQ should focus on. There have since been two additional forums.
From the 2003 forum, DEQ developed four main goals: to fight environmental triggers of asthma, to improve air quality in and near schools, to address lead in drinking water, and to lower or eliminate the use of pesticides in schools.
Asthma was the Number 1 priority.
Lori Faeth, the governor's policy adviser for natural resources, agriculture and environment, says this is an issue Napolitano thinks is important.
"The governor is really committed to the children of Arizona, and obviously health issues with children has an impact on the ability to study, so she thought it was an important place to dig in," Faeth says. (Napolitano's deputy chief of staff Michael Haener said it wasn't necessary for New Times to talk to the governor about the issue, since Faeth had already been interviewed.)
But four years later, the only asthma prevention programs in the state are voluntary, pesticides are still used freely in schools, and no substantial attention has been paid to lead in drinking water.
To a lot of people, the forum goals and the governor's attention to children's health sounded great. At first, there was a lot of momentum around the project.
And yet, virtually nothing has happened. Attention for the program dropped off, after that first big press conference and forum. No legislation has been passed as a direct result of the project. No departmental mandates have been given to school districts to improve student health.
Sandy Bahr, conservation outreach coordinator for the Sierra Club, says the lack of attention to the program is disappointing.
"The governor has made child's issues and education a big deal," she says. "But they can't learn if they can't breathe."
One of the best asthma programs in the state, the Breathmobile, has nothing to do with Napolitano. The mobile asthma unit, operated by Phoenix Children's Hospital and funded by corporate sponsorship, serves families in the Roosevelt, Creighton and Phoenix Elementary school districts. According to Judy Harris, director of the Breathmobile program, the mobile provides complete treatment, including pulmonary function testing, medication and asthma education, for areas of Phoenix that are medically underserved and underinsured.
It does more for parents like Jennifer Hendrix than any DEQ program. Hendrix says she was delighted to discover the free service the care and information provided to her from Breathmobile staffers and nurses has made a big difference in Jonathan's life. She'd like to see a similar program made available to more schools and families.
"Napolitano, I would say if she's talking about people's health and asthma and poor quality of air, maybe she should start a program just for asthma. Even start something like that [the Breathmobile]," says Hendrix, who adds that she did vote for Napolitano in the last election and probably will this time as well.
One of the Breathmobile's greatest virtues is that it's free for the families that use its service. Still, it currently is only able to serve 19 schools, and many parents in areas with high asthma rates do not have access to health insurance. Financial disparity between high- and low-income school districts places asthmatic kids on some very uneven ground.
Without funding, many low-income schools can't implement the program. And it's the poorest schools, like the ones in Roosevelt School District, that have the highest asthma rate. Many low-income schools sit near industrial sites and freeways and are exposed to high levels of pollution. Nurse Mary Chick feels that while more money for schools would be nice, it's not the only answer. And she'd rather not wait around for money that probably won't be coming from the Capitol any time soon. She says that what is really needed is stronger enforcement of environmental policies, and mandatory, not voluntary, programs.
"I don't think the state is doing their part at all," says Chick. "There's no enforcement. Unlike California, where they have laws mandating certain things helping asthmatics, Arizona doesn't have any laws (although Arizona's asthma rate is higher). It took something like a child dying to say, hey, we've got to do something. Make it mandatory, not voluntary, that these children are not sent outside when the air is bad."
Mandatory regulations and strict enforcement won't cure Jonathan's asthma, and they might not have saved the Rose Linda fifth-grader's life, but they would cut down on asthma attacks in schools and certainly would decrease the number of school days missed.
The Sierra Club's Sandy Bahr has worked on environmental issues like air quality and pesticide exposure for a long time, through several gubernatorial administrations. This past legislative session she helped to get a bill passed that will regulate pesticides in schools. She was at the Children's Environmental Health project's kickoff forum, and was encouraged at the time, though she says the buzz has disappeared.
"In the beginning, there was excitement about this opportunity to make a difference," she says. "Interest has waned, and I'm not sure why. People get discouraged. They think, 'The Legislature stinks so there's nothing we can do.' This is when we have to get creative."
The project's one significant success is a voluntary school-bus-idling program that requires school buses to turn off their engines rather than idling outside schools pumping exhaust into the air children are breathing. The program started with just seven schools and has increased to 144.
Not bad for a voluntary program, but that still leaves more than 1,500 schools not participating.
DEQ has also implemented a voluntary program to cut down on pesticide use. Working with University of Arizona entomologist Dawn Gouge, the department is trying to educate schools about integrative pest management an exterminating approach that avoids mass spraying of pesticides. Often, when dealing with a pest problem, schools will just contract with the least expensive extermination company. Gouge says this is an ineffective practice that ultimately winds up costing a lot of money (because the pests don't go away) and can harm kids.
"You need to know what pesticide to use on which organism, and that's not what usually happens when you contract with a low-bid pest management company," she says. "Integrated pest management is about resolving the reasons why pests are there in the first place as well as giving sensible remediation."
But because integrated pest management is more involved than blanket pesticide spraying, it's also more expensive. Currently, 14 school districts in Arizona are able to participate in the program. There are others, like Roosevelt School District, that have shown an interest, but do not have financial resources to implement IPM strategies. Gouge says DEQ does a good job supporting the program on a voluntary basis, but the program will need monetary support from the state if it's going to expand.
"They [DEQ] should be supported better than they have been in the past," she says. "We are at our limit. For us to expand, we're going to require new resources."
And while Gouge and her co-workers never ask the schools they work with to pay for their expert advice that's taken care of by a grant from the Environmental Protection Agency schools are responsible for remediation costs to fix any problems.
"For some schools," Gouge says, "that's just not possible."
California has laws in place to protect children's health, including the aptly named Children's Environmental Health Protection Act of 1999. California is also the only state in the Environmental Protection Agency's region nine (including Arizona, California, Nevada and Hawaii) that has a strategic asthma plan.
DEQ's Steve Owens says mandates and regulations for schools were never the goal of the project. Part of the problem would be enforcement his office is already understaffed.
"If you have a mandatory program, you have to get into the question of how you would enforce it," Owens says. "It's one of those things that are tough to enforce from a regulatory perspective. For a lot of schools, one of the most useful things we do is give them the tools they need to do this stuff themselves."
Another problem is funding. DEQ and the Legislature are far from compatible in 2004, the Joint Legislative Audit Committee actually tried to sunset the agency and getting any funding through the Legislature, let alone passing an actual environmental bill, is tough. The funding DEQ tried to pass this year, part of which would have gone toward retrofits for diesel school buses for cleaner engines, was not approved. A 2005 bill that focused on air quality in school buildings (Senate Bill 1009) was passed but virtually gutted when provisions for air quality inspections in schools were removed. This year's Senate Bill 1350, which forces schools and child-care facilities to notify parents when pesticides are going to be sprayed and give them the option to keep their children home, made it through the Legislature, but only because Bahr and other environmental lobbyists fought hard.
Barbara Burkholder, the policy and advocacy committee chair for the Arizona Asthma Coalition, has worked with the Children's Environmental Health Project since its inception and understands the reasons for the funding and lack of implementation beyond volunteering.
"The legislators are really keeping DEQ on a short leash," she says. "It's a revolving door the agency can be criticized for not carrying out its function, but if you . . . don't give them enough money, it says, 'We don't appreciate everything you do.'"
A common sentiment throughout environmental and public health circles is that, as far as children and the environment go, Napolitano is "better than the alternative."
But the Sierra Club's Sandy Bahr says that's not a good standard. If Napolitano could rally some of her political capital and make environmental health a top priority, Bahr is certain she could get bipartisan support in the Legislature and really begin to make a difference.
"Right now we're at crisis management. That's how we do everything," Bahr says. "The governor could be nudging agencies to do more: Draft legislation. Look into putting some funds for preventative maintenance and invest in better equipment up front. Look for opportunities for cooperation on legislation and help highlight new information. What would the people of Arizona rather have healthier kids or some little tax cuts? I think most people would rather have healthy kids."
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But the governor's office agrees with Owens that there is not a need to create and enforce any new regulations.
"There's no need to mandate issues associated with these programs," says Faeth, the governor's environmental adviser. "The bigger focus is coordination of the agencies that have to do with children's health."
Bahr and others working on the ground disagree. While cooperation and dialogue between agencies is essential, Bahr says it's just not enough.
"I think if one child dies because of bad air quality, it's too much. The fact that we accept it is so wrong," she says. "Industry people try and turn things around, and they love the cost-benefit analysis. But if it's your kid that dies from asthma, how do you do a cost-benefit analysis on that? The fact is we're not doing a good job."