Vol. 15 •Issue 8 • Page 18
Allergy and Asthma
Asthma Doesn’t Discriminate
The reasons why racial disparities occur aren’t always black and white.
Asthma is a devastating disease that takes its toll in health care dollars, work and school days, and quality of life. In 2002, 30.8 million people in the U.S. reported having been told they had asthma in their lifetime.1
Blacks, however, are disproportionately affected by asthma. The lifetime prevalence rate of asthma is 29 percent higher in blacks than in whites.2 Blacks are more than three times more likely than whites to be hospitalized for asthma, and blacks are three times more likely than whites to die from asthma.2,3
The reason for these disparities is multifactorial and often elusive. While this article will attempt to address several of these factors, in the end, it’s most important to remember each patient is an individual.
It’s true that asthma runs in families. A person is three to six times more likely to develop asthma if a parent has asthma.4 This may be due in part to genetic makeup and predisposition to atopy (allergic responses), or to sharing a common environment.
Newer studies suggest that blacks may require higher doses of glucocorticosteroids used to treat and control asthma symptoms. Due to genetic T-lymphocyte differences, they may be more resistant to these medications.5
Genetic factors related to asthma have become an increasingly provocative area of research. A statistical analysis of mortality data from the U.S. controlling for socioeconomic status (SES) factors and education found race is independently associated with mortality for asthma.6
The field of medical genetics has opened entirely new areas of research regarding racial disparities in health. We’re finding it’s not the color of a person’s skin that defines how he will respond to certain medications, risk of disease, or resistance to disease — it’s his genetic makeup.
It’s now possible to genetically map ancestral backgrounds and origins using buccal swabs. Some blacks who have had this testing done are astounded to find they’re of European descent. However, this new technology has met with some resistance from the black community.
Blacks are less likely to have genetic testing done even when they see it as a potential benefit. Atrocities like the Tuskegee syphilis study, conducted from 1932-1972, when black men went untreated to observe the progression of disease, aren’t so far behind us. These men underwent tests believing them to be treatment and weren’t informed of their true condition.7
As a result, fears of discrimination, recrimination, and mistrust of the medical community are deeply embedded in the fabric of blacks’ health care relationship.8
Access to care
Asthma affects the black community as a whole, but those who lack resources are most affected. The official poverty rate for 2004 in the U.S. was 12.7 percent. The poverty rate for blacks was 24.7 percent compared to a rate of 8.6 percent for whites. Almost 20 percent of blacks were uninsured versus 11.3 percent of whites.9
Some studies suggest fears of discrimination and their perception of how they’re viewed by the health care system are keeping uninsured blacks from seeking care until absolutely necessary.10 This delay may contribute to worsened outcomes. Blacks have nearly four times the asthma-related emergency room visits than whites.3
A study looked at the medical management of patients with asthma in the emergency department and found all were managed approximately the same regardless of race, ethnicity, or SES. The researchers also found blacks were more likely to present to the emergency department in more acute distress and were more likely to be admitted.12
Where medication coverage is concerned, the landscape is difficult to navigate. Asthma treatment is primarily about prevention. Government subsidized programs such as Medicaid cover many of the medications to control asthma, yet often there are co-pays. No matter how small, co-pays can be difficult for someone struggling to make ends meet. He or she may be forced to prioritize medication filling.
Patients don’t perceive immediate relief with controller medications as they do with their fast-acting beta-agonists. If you had a co-pay of $2, and that was all the money you had, which prescription would you fill — the controller or the reliever? Most will opt for the least expensive route, if they’re uneducated about the value of controller meds.
Medicare doesn’t pay for metered dose inhalers or for dry powder inhalers but will pay for nebulizer medications, which further reinforces the practice of using only rescue medications.
Several pharmaceutical companies have patient assistance programs, and these have been a great resource; however, if patients are covered under any form of insurance or government medical assistance, they don’t qualify for these programs.
Environmental factors contribute to asthma disparities. Large urban centers with high pollution rates, crowded living conditions, and rental units make environmental interventions difficult.
A study of white and black pregnant women with asthma, participating in the same state Medicaid program, with the same access to health care, found that black women have significantly higher morbidity.14 An interesting divergence in the data set for this study was urban versus non-urban populations. The vast majority of the black women lived in the urban setting.
Fifty-two percent of all blacks live within an urban core of a metropolitan area in contrast to 21 percent of whites, so it’s not surprising that asthma, an environmentally triggered disease, would affect the black population more.15 For those who live in urban centers and use mass transportation, the walk to the bus stop or subway may be just enough exposure to ground-level ozone to trigger an attack.
Indoor triggers such as dust, dust mites, cockroaches, rodents, mold, and mildew can be difficult to control. When one is living in a rental property or low-income housing, getting rid of triggers becomes even more difficult. Negotiating with property owners for remediation is necessary and not easy.
Perception and communication
When it comes to describing asthma symptoms, it’s important to recognize blacks and whites may not be using the same language.
For example, researchers found whites tended to use phrases like deep breath, out of air, aware of breathing, hurts to breathe, and light-headed to describe breathlessness during a methacholine challenge.16 Blacks used terms such as tight throat, voice tight, tough breath, itchy throat, or scared and agitated. If we’re not aware of these differences in expressing shortness of air, those symptoms may not be assessed properly.
Some studies found black patients rate their overall health as excellent to good when asked, yet they score low in overall quality of life measures.12,17,18 These studies suggest a substandard quality-of-life might be accepted as good to excellent health for a black patient with asthma. What level would it have to be to bring him or her to the hospital or to the emergency department? This apparent disconnect between overall well-being and asthma quality-of-life scores is an area that warrants further study.
It’s not uncommon for us to ask one of our black patients how his asthma is doing, and the response is “just fine.” Prior to us understanding the perception and communication differences between racial groups, that answer would not have signaled a problem.
Yet when we dig a little deeper into the patient’s medical history and scrutinize the frequency of symptoms, we discover the same patient who’s doing “just fine” has to use rescue medicine five or six times a day — not fine.
Open and honest discussions about his actual quality of life open the door to solutions for an asthma patient with limited resources. We often ask patients, “What is it you used to do that you can’t do anymore because of your asthma?” Maybe the answer is playing sports, jogging, or going up a flight of stairs without having to stop and rest. For some, it’s not having to go to the emergency room twice a month. Setting achievable goals and implementing an asthma action plan is the best way to put a patient on the path to self-management.
In addition, talk with families about how they afford their medications, their living situation, stressors, and environmental triggers. This demonstrates you genuinely care about them and how they manage their asthma. Mutual respect is the key to understanding and overcoming racial disparities.
For a list of references, look under the “From Print” toolbar on the left side of our home page at www.advanceweb.com/respmanager.
Rita A. Mangold, RN, BSN, RRT, AE-C, is asthma clinical program coordinator, Truman Medical Center, Kansas City, Mo. Gary A. Salzman, MD, FACP, FCCP, is a pulmonologist at the same facility.