MODESTO, Calif. – The students filing into Bret Harte Elementary School every morning barely notice the flags fluttering by the school’s main entrance. There is the American flag, the California state flag and the color-coded asthma flag – green when the air is clear, red when it is a respiratory nightmare, as it so often is here.

“Asthma pretty much rules our medicine cabinet,” said school nurse Diana Connacher, revealing a stockpile of inhalers belonging to the school’s youngest students, at least one or two per classroom. “We have a lot of ‘frequent fliers’ around here.”

School nurses like Connacher are on the front lines of a public health war to combat childhood asthma. Although asthma rates nationally for adults and children are on the rise, youngsters in the Central Valley face a particular set of challenges, experts say, growing up in a place that is “a cooking pot for asthma,” in the words of Dr. Esteban Burchard, a professor at the University of California, San Francisco who studies asthma in underserved communities.

Earlier this year, the American Lung Association released its lists of the 10 most polluted cities in the country – six with the most year-round particle pollution, including Modesto, are in the Central Valley. In the Fresno Unified School District, 17 percent of students are known to have asthma; in response, Kaiser Permanente recently donated $20,000 to help the district buy more than 2,000 “spacers,” tubes that attach to inhalers to help medication reach the lungs.

“Fall is a bad time of year,” said Mary Ellen Basmarjian, school nurse at Jane Addams Elementary in Fresno, where the diesel-infused conduit of California agriculture, Highway 99, is visible from the playground. “Children will start coughing, not able to concentrate. They get fatigued easily.”

The region’s pick-your-poison air is the result of a complex web of factors, exacerbated by the area’s climate, weather patterns and geography. Ozone and particulate matter, the two pollutants most heavily linked to asthma, become trapped in the vast basin between the Coast Range and the Sierra Nevada. The particulate matter is a dangerous mix produced by car exhaust, diesel fuel, road dust and a variety of emissions from agricultural operations. In autumn, air inversion from tule fog, a dense ground fog that occurs after heavy rainfall, adds to students’ asthma woes by holding defoliants and pesticides in place, Basmarjian said.

At Bret Harte and other Central Valley schools this year, the first weeks of school coincided with the massive Rim wildfire, its smoky haze stretching from Yosemite National Park to Modesto, some 60 miles away.

Maria Arviso rushed to school one day with grandson Orlando’s nebulizer and dinosaur-themed pediatric nebulizer mask – the fire, she said, was a trigger for his asthma.

Orlando, a first-grader, had been absent all the previous week. At age 4, he was hospitalized twice for asthma. It can be hard on a rambunctious child, his grandmother said.

“If he jumps or runs, he gets really short of breath,” she explained while tapping Orlando’s nebulizer tube to make sure the whole dose reached his lungs. “He needs to calm down.”

The sight of Orlando, mist emanating from his dinosaur mask, is all too familiar to Steven Hurst, the school’s principal. His 50-year-old wife, Brenda, and 23-year-old daughter, Nicole, both were diagnosed with asthma two years ago.

He ticked off a list of autumnal asthma triggers: “crop spraying, dust, silage corn cutting, pollen, leaf blowers kicking up leaves and dirt and blowing them into the air and streets.”

“I look at that and I’m thinking, ‘How many kids are out there?’ ” he said. Many of the 930 children at Bret Harte do not get diagnosed due to lack of medical care. “You could easily double the number,” he said of his 71 students with asthma.

Children are prone to colds and respiratory viruses, which also can be asthma triggers. Youngsters are vulnerable because their lungs still are developing. The diameter of a child’s airway – the area of the throat in which air passes to and from the lungs – is narrower than an adult’s “and thus more susceptible to contraction, or closure, during an asthma attack,” said Dr. Arlaine Gutierrez, a pediatrician in Modesto.

“It feels scary,” said Karyna Rios, a Bret Harte fifth-grader who carries a rescue inhaler in her backpack along with Gatorade, colored pencils, glue, a Hello Kitty pencil box and other paraphernalia. “When you can’t breathe, it feels like you’re going to die.”

Lifetime asthma rates in the Central Valley are higher than the state average, according to the 2009 California Health Interview Survey, taking a particular toll on low-income children.

A 2013 state asthma surveillance report found that 19.4 percent of adults and 4.7 percent of children were uninsured at some point in the past year. Children from low-income families, including those at Bret Harte and Jane Addams, are more likely to be living near freeways and more exposed to bioallergens like pollen and airborne pollutants from agricultural and industrial operations, said Tim Tyner, president of the Central California Asthma Collaborative and associate director of the Center for Clinical and Translational Research at UCSF Fresno.

They also are more apt to live in deteriorating housing. Statewide, about 40 percent of people with asthma are renters, which can limit their ability to alter their environment to address mold, dust mites, rodents, cockroaches and secondhand smoke, said Meredith Milet, an epidemiologist with California Breathing, the state Department of Public Health’s asthma program. Moisture-producing swamp coolers, common in many low-income neighborhoods, can harbor mold, said John Moore, a respiratory therapist in Dinuba.

Cultural and language barriers can contribute to many youngsters not receiving proper care, said Tyner, co-author of a 2011 study of children with asthma in Bakersfield, Fresno/Clovis and Modesto. The study found a correlation between annual emergency room visits – 1,830 additional visits a year, at an average cost of $1,500 each – and even moderately elevated levels of fine particulate matter.

In a different study published this year, UCSF’s Burchard and his team found that the rate of hospitalizations and emergency room visits was four times higher for people in areas where the median annual household income was $20,000 or less.

Basmarjian, of Addams Elementary, said poverty means that many children are not diagnosed and do not learn how to manage their asthma. “Everything is left to crisis mode,” she said. “So families wait until there’s a big stimulus, such as a child becoming ill.”

Even children who are well-versed in their disease will continue to have asthma attacks if they live in substandard housing or attend schools where the indoor air quality is poor, said Anne Kelsey Lamb, director of the Regional Asthma Management and Prevention program for the Public Health Institute, a nonprofit organization based in Oakland. Outdated school heating, cooling and ventilation systems can be potentially hazardous for asthmatic children, she said, as can a lot of cleaning products.

“Bleach is really bad,” she said. “It’s used by well-meaning staff to control the spread of germs, but bleach can lead to the onset of asthma.” 

Environmental triggers are a complex affair, Lamb added, requiring a major rethinking of housing, land-use and transportation policies. “Asthma is a social justice issue in which certain communities have suffered more than others,” she said.

Statewide, asthma represents 1.2 million missed days of school a year, according to the public health department. “Literally millions of children are missing school,” said Aurora Licudine, chairwoman of school nurses for Modesto City Schools. “If kids are not healthy, they cannot learn.”

Anelle Medina, now 7, missed 57 days of school last year. This fall, she already has been absent for a week, with a fever of 102 and her lungs filled with mucus. Her family lives in a rented apartment near Highway 99, a landscape of asthma triggers. Anelle, a student at Jane Addams, has had asthma since she was 3.

“She has had a rough childhood,” said her mother, Alexxandria Bottoms. “She can’t go out and play like her 2-year-old brother. She wants to do sports and ballet, and she can’t.”

Anelle was misdiagnosed for years, with doctors assuming she had a cold. “They kept telling us it was bronchitis,” Bottoms, 24, recalled. “But no child gets bronchitis every other week.”

This story was edited by Robert Salladay and copy edited by Pam Hogle and Nikki Frick.

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Patricia Leigh Brown is a long-time writer for The New York Times and a contributor to California Watch. For 13 years she was a staff feature writer in New York, and since 2000 has been a contributor based in the San Francisco Bureau. She began her newspaper career as a staff writer for The Philadelphia Inquirer. In 2009-10, she was a Loeb Fellow at the Harvard Graduate School of Design. Her work has been published in numerous book collections as well as many national magazines. Brown has been a visiting lecturer at the UC Berkeley School of Journalism, and is the Barach Teaching Fellow in Non-Fiction at the forthcoming Wesleyan University Writers Conference. She grew up in Highland Park, Ill.