This story was produced as a project for The California Endowment Health Journalism Fellowship, a program of the University of Southern California's Annenberg School for Communcation & Journalism.
FIREBAUGH -- Carmina Ramos vividly recalls the night her son, Francisco, then age 2, was in his car seat suffering from an asthma attack and gasping for air as her boyfriend barreled 80 miles an hour on a two-lane, country road to Children's Hospital of Central California, about 45 miles away.
Police stopped the car, and drew their guns as they shouted instructions.
Francisco eventually made it to the hospital emergency room that night.
That frightening scene -- minus the police stop -- has become too common for Latinos in the San Joaquín Valley.
Latino children in Fresno County are hospitalized at a rate of 289 per 100,000 residents, according to the state Department of Health.
In California, asthma affects approximately 2.1 million residents, including 614,000.
From 2001 to 2009, asthma cases grew by 4.3 million, according to the Centers for Disease Control and Prevention. In 2007, nearly 200 kids and 3,300 adults died from the disease.
About 17 percent of non-Hispanic black children had asthma in 2009, which makes it the highest rate among racially/ethnic groups.
Nationally, 7 million of the 25 million asthma sufferers are children. According to the American Lung Association, asthma ranks third among causes for hospitalizations among children under 15.
The bigger problem, according to health care providers, is the lack of information among Latino parents.
Carmina's family physicians, Drs. Óscar and Marcia Sablán, have operated the Sablán Medical Clinic in Firebaugh for more than 25 years. Because of the clinic location, the husband-and-wife team has been the first responders to hundreds of patients suffering an asthma flare-up.
The Sabláns believe too many families need more education on the disease, which is caused by an inflammation and constriction of the airways.
Early signs of asthma are shortness of breath, coughing and wheezing, and chest pain. Triggers for asthma vary among sufferers, but include allergens like pollens, animal dander, mere changes in weather, and exposure to respiratory irritants like smoke and smog.
Too often, parents rely on humidifiers and Primatene mist and don't realize it is just a short-term fix. A doctor's examination is necessary.
"Basically people would not treat asthma; just opt for an ER visit," said Marcia Sablán.
"They would put a lot of Vicks (vapor rub) on their chest. For someone who has not seen a physician, those are the things they do. They don't realize they could feel better, and actually have a lot more energy when their asthma is controlled," adds Óscar Sablán.
"If you're not aggressive in treating the asthma, then the asthma persists into adulthood, and in a more malignant form."
Not facing the exacerbations of asthma, another term for asthma attack, could lead to more frequent attacks, if early treatment is not sought.
"If you have a lot of attacks, you are at risk to have another one, but if you can get it under control for an extended period of time, then you have less of a chance of recurrence," said Óscar Sablán.
Ramos began educating herself on the disease shortly after the first scare about 30 minutes after Francisco was born at Fresno Community Medical Center. He was soon transferred to Children's Hospital, where he was diagnosed with a collapsed lung.
Doctors told Ramos that Francisco would live his life as a chronic asthmatic.
Families living in rural communities are not likely to have regular visits to a doctor. Therefore demographics and socioeconomic status play a major part in the disparity in the health care.
Francisco's family has learned to follow a stringent protocol in his care. Ramos makes sure everyone is aware of the signs.
"I listen to my son's breathing," said Ramos, a Head Start teacher in Fresno who is working on becoming a lawyer, "and if I hear that he's beginning to have trouble breathing, I'm doing something about it."
She has three back-up doses of emergency medication for Francisco. That amount of medication, she said, is not overboard.
Ramos said any parent who has been in tears and frightened because their child cannot breathe is reason enough to have the medication in such large numbers.
"I remember when we were at Children's Hospital. Francisco was in the playroom next to a little girl," said Ramos. "Her room was down the hall from Francisco's. On another day, we were in the playroom again, and I asked the nurse about her. She said she didn't make it."
The 6-year-old girl died on the operating table from cancer.
On a recent day in May, Francisco, an avid soccer player who, his mother says, spends too much time sprawled on the family's couch playing video games, was walking home from school and became ill.
"It was the air. It was something in the air. Sometimes that happens," said Francisco. "So I have to come home and take some of my inhaler."
In 2006, Oxnard resident Lydia Rojas rushed to the hospital where she found her husband in tears leaning against a corridor wall. Their 15-year-old daughter, Stephanie, was pronounced dead.
Stephanie suffered an asthma attack at Oxnard High School while swimming in her physical education class. Emergency personnel told Lydia that her daughter was already beyond the point of resuscitation after classmates pulled her out of the swimming pool.
Rojas said seeing a doctor is crucial, but not enough to prevent a fatal asthma attack. Rojas wants to make sure teachers, coaches, teammates, friends, other parents know the signs of an asthma attack.
"All of her friends told me they were scrambling looking for her backpack and running to her locker room. They knew she needed her inhaler," she said.
"We thought we were doing everything we were supposed to be doing. I had all the proper forms filled out at the school."
Rojas wants parents of children with asthma to have a one-on-one conversation with teachers and care givers in the hope of preventing further tragedies.
Rojas, who now lives in Fresno, has joined Carmina Ramos in promoting asthma education among Latino parents.
Both found that disparities in health care exist between children living in rural communities against those kids living in cities. Children in the cities are more likely to have regular visits with a doctor.
More than 90 percent of people with asthma live in counties with a failing grade for air quality, which can trigger an asthma attack. According to a study by the non-profit RAND Corporation, cleaner air would save about $193 million and about 30,000 fewer visits to the hospital.
The American Lung Association published 'Luchando Por El Aire' (Fighting for Air), a report that explores the burden of asthma on Latinos. Asthma costs the U.S. $50 billion and an additional $6 billion in indirect costs, according to the report. One-third of the cost comes from urgent care fees.
María Elena Avilá-Toledo, a health promotion specialist with Cal-Viva Health, helps families in Madera, Fresno and Kings counties with education on a variety of health topics, including asthma.
"There are many misconceptions (about asthma). When I'm out in the community, I hear, 'Asthma is a kid disease,' and 'I'm too old to have asthma,'" said Avilá-Toledo.
"I don't think that everyone knows that asthma can be fatal. And I don't think that everybody knows that it is also manageable."
She agrees with Rojas and Ramos that parents still need to become more proactive in the education of the disease.
She believes there is a need for more education, and offered the Asthma Action Plan: Ideally create the plan with the advice of a health care provider.
"Try to find triggers in the home. We encourage families to wipe down areas to avoid the buildup of mold. If there is someone in the family who smokes, we encourage them to get help to quit because second-hand smoke does impact others," added Avila-Toledo.
In the San Joaquín Valley, bad air quality can become a major problem for asthma sufferers.
The most recent State of the Air report released in April by the American Lung Association ranked numerous Valley cities among the top 15 in either ozone, year-round particle pollution or short-term pollutants. Areas that made the top 15 included Visalia-Porterville, Fresno-Madera, Hanford-Corcoran, Merced, Modesto, and Bakersfield-Delano.
"What we breathe matters greatly to our health," said Dr. Kari Nadeau, a specialist on asthma and immunology at Stanford Medical Center and a board member of the American Lung Association in California.
"California continues to have some of the worst air quality in our nation," added Jane Warner, president and chief executive officer for the American Lung Association.
The Central Valley had nearly 60 days through last November without a drop of rain and result was devastating for asthma sufferers.
"Every day we see a variety of chronic problems. It's much more common in the farmworker population than the literature would let us know," said Marcia Sablán.
"We're seeing air quality degradation and along with that comes asthma. Probably in the last couple of weeks (as of March), we have seen as many as 40 patients a day with asthma, asthmatic bronchitis or some variety of that," said Óscar Sablán.
Ramos and Rojas believe a proactive approach starts with education in the home.
"I remember my son being intubated. I don't want to see that again," said Ramos.
"Without clean air, you can't breathe, if you can't breathe, you die," said Rojas. "Know what to do."