If you’re a Black American, you’re about 1.5 times more likely to have asthma than people of most other races and ethnicities. And it’s likely to affect you more seriously. Black people are five times more likely than White people to go to the emergency room for asthma symptoms, and three times more likely to die from asthma complications.
Many of the reasons Black people experience asthma differently than those of other racial and ethnic backgrounds can be linked to socioeconomic status, which is defined as a combination of social and economic factors that affect a person or group. They include:
- Income and employment
- Education
- Community safety
- Social support
- Power and prestige
More than 22% of Black people in the U.S. have incomes below the federal poverty level, compared to 9% of White people, 19% of Hispanic people and 11% of Asian people. Only Indigenous Americans have a higher poverty rate, at nearly 24%.
Asthma is more common among people in lower-income groups, and they tend to have worse outcomes. Studies show that asthma affects 11.8% of people with family incomes below the poverty level, compared to 8.5% of those who earn up to 2.5 times the poverty level and 5.9% of those making 4.5 times the poverty level. For adults with household incomes of less than $50,000, asthma treatment is 1.6 times more likely to fail than for those with higher incomes.
These differences aren’t just in the U.S. Disparities in who gets asthma, and how seriously, exist around the world, says Geoffrey Chupp, MD, director of the Yale Center for Asthma and Airways Disease in New Haven, Connecticut.
According to the World Health Organization, more than 80% of all deaths from asthma happen in low- or lower-middle-income countries where asthma is less likely to be diagnosed and properly treated.
How Do Socioeconomic Factors Drive Asthma Disparities?
Income and things related to it are linked to asthma for a number of reasons, experts say.
Environment and air quality
Living in less-healthy neighborhoods is one reason for higher rates of asthma in Black people. Poor outdoor and indoor air quality can trigger and worsen asthma. And if you live in a low-income area, especially an urban one, you’re more likely to face high levels of allergy triggers.
Studies have shown that Black people and other minorities are exposed to more air pollution than White people. Because of a history of discriminatory housing policies, heavy industry and busy highways tend to be concentrated in minority communities.
Run-down housing in low-income areas also makes asthma worse. Homes that need repair are more likely to contain asthma triggers like dust, mold, pests, and unvented cooking fumes.
Also, living in “food deserts” – areas where there’s limited access to affordable, healthy foods – contributes to how widespread and severe asthma is. Anti-inflammatory diets rich in vegetables and fruits are thought to help protect against asthma.
“There is strong evidence that the high burden of asthma among Black people is mostly due to where this population tends to live,” says Elizabeth C. Matsui, MD, a professor of population health and pediatrics at the University of Texas at Austin.
“We have created neighborhoods that are causing and perpetuating a high burden of asthma while also having a health system that is failing those living in these neighborhoods,” she says. “It is a ‘perfect storm.’ … If neighborhoods were healthy, there would be less need for intensive asthma management.”
Access to health care
Minorities are more likely to live in poorer areas that lack asthma specialists and even primary care doctors. They may not have reliable transportation to reach a doctor’s office or clinic. Many also have jobs that make it hard to take time off work or don’t offer paid time off.
If you can’t physically get to a doctor, diagnosis and treatment are delayed and you’re likely to have worse outcomes, studies show
Quality of care
Your income affects whether you can afford health insurance and what kind. When you have no or limited health insurance, it’s harder to get good medical care. Research shows that Black and Hispanic people are more likely to lack health insurance than White people. High copays can be a barrier to treatment even for those who do have insurance.
Studies have found that people with public insurance such as Medicaid are less likely to be prescribed biologic drugs to treat their asthma. They’re also less likely to be referred to a specialist (an allergist or pulmonologist), which is known to improve outcomes.
Lack of good-quality care leads to a lack of trust in health care providers, which further affects asthma treatment and outcomes. Research has found that Black caregivers of children with asthma tend to be unsatisfied with their health care providers, and less likely to contact them before an emergency room visit.
Discrimination
Another reason for substandard care and the resulting lack of trust of health care providers is bias and racism within the health care system. That’s thought to be one reason minorities with asthma are less likely to properly use asthma medication than non-Latino White people.
“The impact of systemic racism is probably the biggest issue [driving disparities], as it has led to limited access to primary care providers and asthma education programs,” says Maryum Merchant, MD, a pulmonologist at UCLA Health.
Racism contributes to the under-prescription of essential medications, high copays, and fewer medication options, says Merchant, who’s also lead doctor of the Adult Asthma Program at UCLA Health Thousand Oaks Hampshire Primary & Specialty Care.
Also, clinical trials for new treatments often don’t include enough minority people. That means these trials don’t take into account how asthma and medications for it might affect people of various races and ethnicities differently.
“Health care workers need to be educated on inherent biases in the health care system,” says Chupp, a professor of pulmonology at Yale School of Medicine.
“Patients need to be educated as well on how to advocate for themselves and properly handle medical discrimination,” he says.
Education and health literacy
People who live in areas with concentrated poverty and lower home values tend to be less well-educated than those in higher-income areas, studies have shown.
Not only does this educational inequality influence job opportunities and income, it also affects health literacy. Health literacy is how well you’re able to find and understand information that helps you make good decisions about your health.
Research has shown that caregivers for children with asthma who have low levels of health literacy are less likely to understand asthma or use medications when needed. Their children:
- Had worse asthma control
- Missed more school
- Were less likely to be treated by a specialist
- Were more likely to go to a hospital for asthma
School-based programs have helped to better inform some children and parents about asthma. But data from 2019 showed that just 12.1% of people with asthma got education about the disease from their health care providers.
Reducing Asthma Disparities
We’ve made some progress toward addressing inequities in asthma. Since the Affordable Care Act was signed into law in 2010, 18.6 million people have gained health insurance coverage – including 2.7 million Black people.
Experts are speaking out about the need for training for health care workers to help them understand and address health care biases. The health care industry has recognized the need to increase diversity in its workforce. And there are many community intervention and education programs, such as those funded by the Asthma and Allergy Foundation of America through its Health Equity Advancement and Leadership (HEAL) program.
But much more needs to be done, experts say.
To ease disparities, both the public and private sectors must reduce air pollution, improve housing quality, and enhance access to medical care, says Scott Bickel, MD, a pulmonologist and medical director of respiratory therapy at Norton Children's Hospital in Louisville, Kentucky.
“Certainly there is always room for greater awareness, but to really have an effect, we need to act,” Matsui says.
Show Sources
Photo Credit: Tetra Images/Getty Images
SOURCES:
Elizabeth C. Matsui, MD, professor of population health and pediatrics, University of Texas at Austin.
Geoffrey Chupp, MD, professor of pulmonology, Yale School of Medicine; director, Yale Center for Asthma and Airways Disease.
Scott Bickel, MD, pulmonologist and medical director of respiratory therapy, Norton Children's Hospital.
Maryum Merchant, MD, pulmonologist, UCLA Health; lead doctor, Adult Asthma Program, UCLA Health Thousand Oaks Hampshire Primary & Specialty Care.
Asthma and Allergy Foundation of America: “Asthma Disparities in America,” “Asthma Facts,” “Health Equity.”
American Lung Association: “Current Asthma Demographics,” “The Unequal Burden of Asthma on the Black Community,” “Disparities in the Impact of Air Pollution.”
U.S. Department of Health and Human Services: “Asthma and African Americans.”
Cureus: “Epidemiology of Current Asthma in Children Under 18: A Two-Decade Overview Using National Center for Health Statistics (NCHS) Data,” “Geographic Disparity in Asthma Hospitalizations: The Role of Race/Ethnicity, Socioeconomic Status, and Other Factors.”
Current Opinion in Allergy and Immunology: “Asthma and Ethnic Minorities: Socioeconomic Status and Beyond.”
Science Advances: “PM2.5 polluters disproportionately and systemically affect people of color in the United States.”
The Journal of Allergy and Clinical Immunology: “Housing and Asthma Disparities,” “Racial disparities in asthma-related healthcare utilization in the National Heart, Lung and Blood Institute’s Severe Asthma Research Program,” “The Racial and Ethnic Makeup of the Asthma Clinical Trials informing the 2020 NHLBI asthma guidelines update.”
Yale Journal of Biology and Medicine: “An Overview of Health Disparities in Asthma.”
Chest: “The Relationship Between Insurance Status and the Affordable Care Act on Asthma Outcomes Among Low-Income US Adults.”
Journal of Community Health: “Traveling Towards Disease: Transportation Barriers to Health Care Access.”
BMC Pulmonary Medicine: “Student knowledge gains among first-time and repeat attendees of school-based asthma education program.”
U.S. Pharmacist: “Health Disparities in Educational Aspects of Asthma Care.”
Clinical Pulmonary Medicine: “Disparities in Asthma Care, Management, and Education Among Children With Asthma.”
World Health Organization: “Asthma.”
CDC: “Socioeconomic Factors.”
Annals of Allergy, Asthma, & Immunology: “Asthma and the social determinants of health.”
