Over the past 15 years, there have been moderate advances in U.S. public policy, healthcare, and research, but racial gaps in asthma outcomes have not changed.
Melanie Carver
Chief Mission Officer, Asthma and Allergy Foundation of America
In the United States, the burden of asthma falls disproportionately on Black, Hispanic, and Indigenous populations. Years of research and public health data have identified disparities in asthma prevalence, mortality, and emergency healthcare use along racial and ethnic lines.
Black individuals are nearly three times as likely to die from asthma than white individuals, and asthma-related emergency department visits are nearly five times as high for Black patients compared to white patients. Although the gaps in health outcomes between various populations have begun to narrow as access to healthcare has generally improved, stark inequities in asthma persist.
Barriers to care
Racial and ethnic disparities in asthma are the result of complex interactions between varying levels of social, structural, biological, and behavioral determinants. While all four aspects play a role, social determinants of health (related to the built environment around us, where people are born, grow, live, work, and age) and structural determinants of health (the wider forces and systems shaping the conditions of daily life, including policy, governance, and culture) have led to persistent systematic disadvantages and gaps in care for Black Americans.
The link between social disadvantage and poorer health is especially well-documented in asthma: poverty plays a major role. People with low income and wealth are more likely to have poor quality of housing, live near highways and other highly polluted areas, and struggle to pay for asthma treatment.
Research shows that asthma disparities are highly driven by socio-environmental and economic conditions, and that structural injustices over time have led to accumulated disadvantages for Black populations in the United States.
In addition, structural racism — which alone is a significant driver of asthma disparities — is intertwined with and amplifies socioeconomic disadvantages, such as poverty, poor housing, and lack of access to healthcare. The cumulative risk from these overlapping determinants intensifies disparities in asthma.
Case study
The association between social disadvantage and poorer health can be seen clearly in Los Angeles. L.A. has a poverty rate of 13.4 percent, higher than the national average of 12.3 percent. The poverty rate for Black Angelenos is even higher at 19.2 percent. Black Angelenos are more than two times more likely to live below the poverty threshold than their white counterparts.
The prevalence of asthma among Black populations in California is 10.7 percent, compared to 9.9 percent in white populations and the 9 percent national average. In Los Angeles County, Black individuals are nearly three times more likely to die from asthma than white individuals.
While health insurance can cover the needed cost of medication and lead to better health outcomes, in Los Angeles, 10.2 percent of individuals are uninsured, which is higher than the national average of 9.2 percent. When stratified by race, 6.6 percent of Black individuals are uninsured, compared to 4.7 percent of white individuals.
Further, air pollution, such as high ozone and small particle pollution, can irritate the lungs and airways, and worsen asthma. According to AirNow data from the Environmental Protection Agency, the Los Angeles region experiences some of the worst air quality in the country, with a high number of days with elevated ozone or particulate pollution (from haze or wildfires). In a 2019 analysis, it was found that fine particulate matter (PM2.5) was disproportionately experienced by Black and Hispanic populations, but emissions were disproportionately caused by white populations.
More progress is needed
Over the past fifteen years, there have been moderate advances in U.S. public policy, healthcare, and research, but gaps in asthma outcomes between Black and white populations continue. While policies and interventions that directly relate to healthcare are essential in reducing asthma disparities, they are not enough.
Promising solutions will require partnerships across many sectors, including health, education, labor, housing, social services, and city planning. The Asthma and Allergy Foundation of America published a comprehensive report on “Asthma Disparities in America” and proposed nearly 70 strategies to improve asthma health for people at highest risk.
To improve the health of Black people with asthma, we must fix the structural and social inequities that continue to overburden Black communities.
