While people of all races and backgrounds can develop asthma, the evidence shows sharp disparities when it comes to who gets diagnosed and who is most adversely affected by the chronic respiratory condition.
The new report is an update to a 2005 report AAFA coauthored on the same topic, and it isn’t the first to document disparities for racial and ethnic minorities in asthma incidence and care.
“Over the last 15 years, given advances in healthcare, new asthma therapies, and an increased safety net through the Affordable Care Act, I would expect there to be improvements in overall rates for better asthma care of minorities,” says Kenneth Mendez, the president and CEO of the AAFA. “However, we are disappointed to see the disparities gap remains the same.”
The data in the report show 24.7 million Americans — 8 percent of the overall population — have asthma. But for people in Black, Indigenous, and People of Color (BIPOC) communities, the rate is significantly higher than among white people. People of Puerto Rican descent have asthma at the rate of 14.9 percent; it's 10.6 percent for Black Americans, 10.2 percent for American Indians and Alaska Natives, and 7.6 percent for white Americans, according to the report.
The report highlighted some other disparities in asthma care utilization and outcomes:
- Among Black Americans, emergency room (ER) visits for asthma were five times higher than for white Americans in 2017. ER visits can be a sign that asthma is not well-controlled or that access to a physician who can help a patient with routine asthma management is limited.
- Rates of death linked to asthma are much higher for Black Americans compared with white Americans: There are 23.9 asthma deaths per 1 million people among Black Americans and 7.4 deaths per 1 million people for white Americans.
- The report finds Puerto Ricans bear a very disproportionate burden when it comes to asthma. Puerto Ricans get asthma at twice the rate of other Hispanics (6 percent for Hispanics overall versus 14.9 percent for Puerto Ricans), and the death rate for Puerto Ricans is nearly triple that of white Americans (21.8 percent versus 7.4 percent for white Americans).
New Report Cites Poverty and Systemic Racism as Drivers of Inequities in Asthma Care
Poverty and systemic racism are major reasons for disparities in asthma rate, control, and care, says Payel Gupta, MD, an allergist-immunologist in private practice in New York City who is a spokesperson for the American Lung Association (and who was not involved in the development of the new AAFA report).
“Unfortunately, one of the things that has not changed over time is that Black, Hispanic, and Indigenous populations are still living in poorer conditions than their white counterparts,” Dr. Gupta says. It means racial and ethnic minority groups experience more exposure to asthma triggers, as well as less access to asthma specialists familiar with (or who have access to) newer treatment options, she says.
Likewise, the AAFA report points to poverty and systemic racism as underlying the inequities in asthma care. More specifically, the report identifies lower income, poor housing conditions, environmental exposures, more limited access to healthcare, and, particularly, limited access to asthma specialists as some of the significant factors driving disparities in asthma incidence, care, and outcomes.
“A long history of social and economic policies driven by systemic racism have denied racial and ethnic minorities access to the same wealth and resources as white populations,” Mendez says. “Discriminatory housing policies, for example, caused long-lasting residential segregation where poverty is concentrated in Black and Hispanic communities. Residential segregation then perpetuates a cycle of limited access to education, employment, and quality healthcare services.”
Here's a closer look at some of these factors.
Lower Incomes and Poor Housing Conditions
Low income plus poor housing conditions can mean more exposure to triggers for developing and worsening asthma, including mold, dust, and mouse and cockroach droppings, Gupta explains.
Unequal Access to Healthcare
Researchers tracked 579 people with severe asthma for a year; Black participants were 43 percent less likely to see a doctor outside the ER (such as a primary care doctor or allergist) for asthma care compared with white participants.
Because good asthma care involves working out a plan with a doctor for using controller and emergency medications, reducing exposure to asthma triggers, and staying aware of how well your lungs are functioning, not having a doctor is an enormous problem that will likely affect people with this condition in a negative way, Gupta says.
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While genetic differences among racial and ethnic minorities are certainly not the only factor driving disparities in asthma, a lack of BIPOC participants in studies of asthma drugs and of asthma pathology in the past has been problematic and needs to be addressed, says Sanaz Eftekahri, the AAFA’s vice president of research and a co-principal investigator of the AAFA report. “Not only are we generalizing data from primarily white populations when it comes to identifying genes implicated in asthma, but we’re also generalizing responsiveness to treatments,” Eftekhari says.
Treatment decisions based on research that involves too few participants from BIPOC communities can lead to ineffective care for the most vulnerable people with asthma, she notes.
Solutions, Now and in the Future
Outreach programs across the United States for years have sought to address racial disparities in asthma, through government policies, medical intervention programs, and research. But, according to the AAFA report and the researchers who worked on it, more work is needed.
“Within the last 15 years, we’ve seen improvements in access to medical care, including the establishment of the Affordable Care Act and expansion of Medicaid and the Children’s Health Insurance Program (CHIP),” says Melanie Carver, AAFA’s chief mission officer and a co-principal investigator for the new disparities report. Those policy changes have helped expand access to healthcare for some, but those steps alone will not fix the disparities.
Additional efforts need to be made to address the unequal environmental exposures that contribute to asthma disparities and the lack of specialist care for minority populations, she says.
The AAFA report recommends 69 different strategies to address the disparities: improvements in housing to addressing pollution exposure, an increased minimum wage, additional training for healthcare workers on the social determinants of health, more school-based and home-based asthma programs, and other measures. The recommendations require effort from stakeholders at all levels, including local and national policymakers, hospitals, healthcare workers, nonprofits, schools, and others.
Some of the state, local, and community-based programs across the United States currently working to address asthma health disparities include:
- Hospital programs, such as Boston Children’s Hospital’s Community Asthma Initiative, send healthcare practitioners into the homes of kids with asthma to provide education about asthma care and help identify ways to reduce asthma triggers like dust and mold for kids and teens with poorly controlled asthma.
The program was developed to address disparities in asthma for racial and ethnic minorities, according to its website; kids who are seen in the ER for asthma get referred to the program.
- Mobile asthma clinics Breathmobile vans rolling through the streets of Los Angeles bring asthma specialty care to inner-city kids at no cost to their families.
The Breathmobile program was designed to improve outcomes for children from low-income families and reduce barriers to them getting asthma care. Among kids who used the program for at least a year the services reduced emergency-room visits for asthma by 66 percent, reduced extensive school absences (five days or more per year) by 78 percent, and brought 80 percent of kids’ asthma cases under control within three visits, according to a 2011 study published in the Journal of Allergy and Clinical Immunology.
- Community asthma programs Breathe DC, a Washington, DC, nonprofit community group, tackles all aspects of lung health for communities affected by health disparities, providing home visits for kids with asthma, linking expectant mothers who smoke to smoking cessation programs, and advocating to make local university campuses and public housing communities smoke-free.
The program has taught more than 800 kids how to better manage their asthma through public school and summer camp programming.
- Government health department programs Available in five Minnesota counties, home asthma care (via Minnesota Department of Health’s Asthma Home-Based Services) is usually recommended by the doctor of a child or teenager with asthma.
Such care includes visits by a nurse, certified asthma educator, community paramedic, community pharmacist, or respiratory therapist to help improve asthma treatment and long-term management, and to assess asthma triggers in a person’s home. According to the Minnesota Department of Health, such programs reduce emergency room visits and hospital stays, improve asthma control, and reduce school sick days for asthma by 2.4 days over three months. The program centers on the counties that include and surround Minneapolis–St. Paul, an area with some of the state’s highest rates of hospitalization for asthma
— and are also home to 40 percent of Minnesota’s Black residents.