By Brooke Weiner
Published 6:44 EST, Weds October 6th, 2021
Throughout the COVID-19 pandemic, the term “pre-existing condition” has been anything but unfamiliar to us all. This heightened focus on individuals at increased risk for contracting COVID-19 or experiencing it more severely has brought long-standing racial disparities in healthcare to light.
One notable risk factor for COVID-19 is asthma, a chronic condition that narrows and inflames the airways of the lungs. According to the Centers for Disease Control (CDC), one in thirteen people have asthma [1], and it is caused by hypersensitivity or overreaction of the immune system. This sensitivity causes inflammation in the lungs, which makes it extremely difficult for those diagnosed to breathe at certain times or during an asthma attack [2], making individuals more vulnerable to COVID-19.
Financial burden is one aspect of asthma care subject to cause inequity. The most common treatment for an asthma attack is an albuterol inhaler, which contains a medication that relaxes the muscles in the lungs and opens the airway to allow for airflow. In circumstances that necessitate a hospital visit, treatment includes other medications with a breathing tube to be used in life-threatening circumstances [3]. In 2018, the annual medical cost of asthma was $3,266 per person [4]; in the same year, the mean yearly salary of an American individual was around $50,000 [5]. Essentially, those diagnosed with asthma must set-aside 6% of their salary to breathe, to perform an innate human function necessary for survival.
However, there are other aspects of asthma that create deeper disparities. Data from 2019 shows that in the United States, 11.2% of Black Americans were diagnosed with asthma, in comparison to the respective 7.6% and 6.8% of white and Hispanic populations [6]. Many questions stem from these statistics, such as why this noticeable gap exists. Where does it come from? Why does this resemble another disproportionate statistic from n the spring of 2021, stating that Black Americans were twice as likely to have died from COVID-19 than White Americans [7]?
According to the Asthma and Allergy Foundation of America (AAFA), disparities in asthma are driven mostly by “structural determinants such as systemic racism, segregation, and discriminatory policies,” and by “social determinants such as socioeconomic status…neighborhood and physical environment… social support networks, and access to health care” [8]. Although asthma has genetic associations, its hereditary nature is not specific to Black Americans alone. Therefore, a supposed difference in Black Americans’ genetics is no justification for asthma’s disproportionate affliction upon that community in particular; instead, environmental factors are the main determinant in obtaining this condition.
In the United States, both historically and presently, Black individuals have been and are more physically segregated than any other racial or ethnic group [9]. Today, when researchers studied 171 of the largest urban areas in the United States, the resulting data showed that the area with White individuals of the lowest socioeconomic status still had more resources than a comparable area in which Black Americans reside [10]. For example, the areas in which Black Americans live are less likely to have recreational facilities, such as playgrounds and swimming pools, for exercise [11].
Unsurprisingly, where an individual lives and the quality of the air in that location are the biggest determinants in having asthma. Poor residential conditions, like overcrowding, may predispose individuals to viral illnesses or indoor allergens [11]. In addition, these impoverished areas have difficulty with trash removal and are more likely to have landfills nearby. For example, landfills in Alabama, which are mostly located in areas with substantial Black populations and residents below the poverty line, are filled with waste from all across the US [12]. These landfills release methane and carbon dioxide [13], and as a result, “research reveals that segregated, inner-city areas have higher rates of air pollution,…which can exacerbate asthma symptoms” [11]. The living conditions in these segregated areas may negatively impact the resident’s practice of healthy behaviors, encouraging poor health habits that increase one’s morbidity and risk for developing asthma [11]. For these reasons, not only are Black Americans 40% more likely to have asthma than their White counterparts [14], they are also three times more likely to die from asthma than any other group [15].
As of September 9th, 2021, Black Americans faced 2.8x the COVID-19 hospitalization rate and 2.0x the COVID-19 death rate in comparison to White individuals, yet only encountered a 1.1x increase in COVID-19 cases [16]. The lower magnitude of cases among Black Americans may be due to a limited availability of testing, with the greater magnitude of hospitalization and death rates likely being attributed to the previously aforementioned prevalence of asthma. In addition, this could also be due to the fact that, prior to the current wide availability of vaccines, Black Americans made up a small percentage of the total number of Americans vaccinated [17]. These low vaccination rates stemmed from personal concern of the COVID-19 vaccine itself, originating from a long history of racial inequities and injustice in healthcare in the United States, in addition to limited environmental access.
While it will not happen overnight, increasing focus in two areas, environmental justice in communities with poor residential conditions and racial justice in healthcare and governmental policy, combats the very root of these inequities. Healthcare is so much more than having access to high-quality medical care or a hospital nearby; environmental factors are much more at play than most realize. It is critical to educate the public and governmental officials on the intersection of environmental justice and racial justice, advocating for the protection of both the people and the planet, directly helping communities to address climate injustices.
However, the complete elimination of these inequities must come from “political will and commitment to implement new strategies to…dismantl[e] the structures of racism…that can counteract the pervasive negative effects of institutional discrimination on health” [11]. It is important to note the strides being made on a larger scale within the World Health Organization (WHO), the CDC, and the United States Environmental Protection Agency (EPA) who are working to reduce, prevent, and control the burden of disparities in asthma and asthma care.
COVID-19 and asthma are only two of many conditions that disproportionately affect the population based on racial and social determinants. While the media did cover disparities in COVID-19 hospitalization and death rates, racial inequities in healthcare did not materialize with the pandemic. Affecting the care of millions of individuals on a daily basis, they have occurred on a large scale since the foundation of our nation, spanning wide ranges of health conditions and concerns. If there is any time to make a change, it is now, as we recover and rebuild from the loss our community has faced.
Brooke Weiner Youth Medical Journal 2021
References
[1] 2019 National Health Interview Survey (NHIS) Data | CDC. 11 Jan. 2021, https://www.cdc.gov/asthma/nhis/2019/data.htm.
[2] Asthma | NHLBI, NIH. https://www.nhlbi.nih.gov/health-topics/asthma.
[3] “Hospital Stay for Asthma Attack: Treatments and More.” Healthline, 30 Mar. 2020, https://www.healthline.com/health/severe-asthma/hospital-after-asthma-attack.
[4] Nurmagambetov, Tursynbek, et al. “The Economic Burden of Asthma in the United States, 2008-2013.” Annals of the American Thoracic Society, vol. 15, no. 3, Mar. 2018, pp. 348–56. PubMed, doi:10.1513/AnnalsATS.201703-259OC.
[5] National Average Wage Index. https://www.ssa.gov/oact/cola/AWI.html.
[6] CDC. “Asthma’s Effect on the Nation.” Centers for Disease Control and Prevention, 14 Jan. 2021, https://www.cdc.gov/asthma/asthmadata.htm.
[7] “Color of Coronavirus: COVID-19 Deaths Analyzed by Race and Ethnicity.” APM Research Lab, https://www.apmresearchlab.org/covid/deaths-by-race.
[8] Asthma Disparities – Reducing Burden on Racial and Ethnic Minorities | AAFA.Org. https://www.aafa.org/asthma-disparities-burden-on-minorities.aspx.
[9] Massey D, Denton N. American Apartheid: Segregation and the Making of the American Underclass. Cambridge, MA: Harvard University Press; 1993
[10] Sampson RJ, Wilson WJ, Hagan J, Peterson RD. Toward a theory of race, crime, and urban inequality. In: Hagan J, Peterson R, eds. Crime and Inequality. Stanford, CA: Stanford University Press; 1995:37–54
[11] Williams DR, Sternthal M, Wright RJ. Social determinants: taking the social context of asthma seriously. Pediatrics. 2009 Mar;123 Suppl 3(Suppl 3):S174-84. doi: 10.1542/peds.2008-2233H. PMID: 19221161; PMCID: PMC3489274.
[12] “‘We’re Not a Dump’ – Poor Alabama Towns Struggle under the Stench of Toxic Landfills.” The Guardian, 15 Apr. 2019, http://www.theguardian.com/us-news/2019/apr/15/were-not-a-dump-poor-alabama-towns-struggle-under-the-stench-of-toxic-landfills
[13] “Basic Information About Landfill Gas | US EPA”. US EPA, 2021, https://www.epa.gov/lmop/basic-information-about-landfill-gas#methane.
[14] CDC. “Asthma’s Effect on the Nation.” Centers for Disease Control and Prevention, 14 Jan. 2021, https://www.cdc.gov/asthma/asthmadata.htm.
[15] Asthma and African Americans – The Office of Minority Health. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=15.
[16] CDC. “Cases, Data, and Surveillance.” Centers for Disease Control and Prevention, 11 Feb. 2020, https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html.
[17] Pham, Olivia, et al. “Latest Data on COVID-19 Vaccinations by Race/Ethnicity.” KFF, 8 July 2021, https://www.kff.org/coronavirus-COVID-19/issue-brief/latest-data-on-COVID-19-vaccinations-
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