Dr. Monica Kraft, formerly of Duke University and the University of Arizona, is a healthcare educator and System Chair of the Department of Medicine at Icahn School of Medicine at Mount Sinai, and Mount Sinai Health System. In the following article, Dr. Kraft discusses from where the disparities in asthma treatment stem, and why there are such a large number of inconsistencies in individual treatment.
According to the Asthma and Allergy Foundation of America (AAFA), about 25 million people in the United States have asthma. This means that asthma affects 1 in every 13 people. The approach to asthma care can vary significantly which results in inequities in asthma care.
First, Dr. Monica Kraft, formerly of Duke University and the University of Arizona, explains that the AAFA defines asthma as a long-term disease that causes a person’s airways to become red and swollen, making it harder to breathe properly as the airways are narrowed. This results in less oxygen being carried from the nose and mouth to the lungs.
The most common asthma symptoms include shortness of breath, wheezing, coughing, and/or a tightness in the chest. Asthma currently cannot be cured and is especially worrisome because symptoms can be triggered by a variety of common everyday exposures such as dust, pets, stress, scents, exercise, and even cold air. All of these triggers can cause asthma attack.
Monica Kraft on Asthma Treatments
Dr. Monica Kraft, formerly of Duke University and the University of Arizona, explains that since there is no cure for asthma, physicians need to properly manage symptoms to make life as comfortable as possible for an individual suffering from this airway disease. The CDC recommends taking medications that are often inhaled through an inhaler or sometimes taken in pill form. Dr. Kraft, explains that there are two categories of asthma treatment: those that relieve symptoms quickly called “relievers” (such as albuterol) and the other category which do not work quickly but control symptoms long term called “controllers” (such as inhaled corticosteroids). A combination of controller and reliever medications are used to treat asthma. In severe asthma, specific treatment with medications called biologics are also used.
Why There are Disparities in Asthma and Asthma Care
Although asthma affects all ethnic groups, Dr. Monica Kraft, formerly of Duke University and the University of Arizona, explains the burden from this disease is disproportionately shared by certain minority groups and the economically disadvantaged. The prevalence of childhood asthma among Puerto Ricans (21.2%) or non-Hispanic blacks (14.5%) is higher than among non-Hispanic whites (8.2%) or Mexican Americans (7.5%). Ethnic disparities in asthma morbidity and mortality are even more pronounced. Asthma mortality rates in children and adults are nearly eightfold and threefold higher, respectively, in non-Hispanic blacks than in non-Hispanic whites (21.8 vs. 9.5 death rate per million).
How Society is Structured
Dr. Monica Kraft, formerly of Duke University and the University of Arizona, explains that there are multiple factors determining asthma disparities that are present at the individual and community levels. Poverty is a risk factor for asthma morbidity in the United States and related to ethncity. Ethnicity is linked with racial ancestry; racial ancestry may affect asthma independent of poverty through genetic variation. For example, The National Library of Medicine found that people of African ancestry have a specific locus in their chromosomes that is linked more strongly to asthma, which means that individuals with African ancestry could potentially have a greater risk of developing asthma.
Poverty can affect asthma independent of ethnicity through reduced access to healthcare. Often however, genetic variation and poverty are both present and have synergistic detrimental effects on asthma, which influence not only quality of care but also exposure to environmental and lifestyle risk factors. The latter includes indoor and outdoor air pollution, cigarette smoking, prematurity, obesity, poor nutrition and exposure to certain bacteria known to worsen asthma. People of color are more likely to live in heavily populated, urbanized areas with poorer air quality, which in turn aggravates conditions like asthma. Receiving appropriate treatment, especially for a disease like asthma, not only takes time to understand but is also expensive.
Inner-city residents and minority groups are often exposed to increased violence, and are thus more likely to experience stress, which has been shown to increase asthma morbidity in adults and their children. Depression and anxiety are more common in lower socioeconomic status (SES) groups. This situation can lead to altered perception and report of symptoms. In turn, psychosocial stress could lead to decreased adherence with prescribed controller medications, independently or in combination with other factors such family or community structure and support, cultural beliefs, inadequate communication from or with healthcare providers, and reduced health literacy. Lastly, there is a documented history of mistreatment of racial and ethnic minority patients in healthcare, including substandard clinical care and discriminatory practices. Consequently, racial and ethnic minority patients experience high levels of healthcare system mistrust, which is associated with lower satisfaction with the care received and undermines a healthy patient-provider relationship.
What can be done to stop these trends? The most important step would be to implement and enforce policies increasing access to healthcare for children and adults with asthma, regardless of their ethnicity or SES. However, increasing healthcare access is unlikely to suffice; additional steps must be taken to improve understanding of disease processes and therapeutic goals in patients with low literacy, ensure appropriate assessment of disease severity by physicians and patients, and increase prescription of and adherence with controller medications.
In conclusion, Dr. Monica Kraft, formerly of Duke University and the University of Arizona hopes that with continued clinical trials, we will one day find a cure for airway diseases, such as asthma, reducing the harmful damage caused by this disease. Observational and interventional research studies should try
to identify and expand our understanding of risk factors for asthma disparities. Dissecting the genetic and lifestyle factors underlying recently reported associations between racial ancestry and lung function or asthma is important and could help identify subpopulations at highest risk, ultimately help develop new means to disease prevention, diagnosis, and treatment. Beyond asthma itself, examining structural racism’s impact at the individual level as well as approaches to better understand its impact on healthcare policies and service delivery are necessary and required given its invisible yet ubiquitous nature.
1. Mario F. Pereza,* and Maria Teresa Coutinho An overview of disparities in asthma. Yale J Biol Med 2021;94:497-507
2.Forno E, Celedon JC. Health disparities in asthma. Am J Resp Crit Care Med 2012: 185:1033-1043