Race, Racism, and Respiratory Health

Health Disparities in Pediatric Asthma

In the United States, minoritized and marginalized groups such as non-Hispanic Black children, Puerto Rican children, American Indian/Alaska Native children, and multiracial children share a disproportionate burden of asthma, largely because of greater exposure to environmental, lifestyle, and behavioral risk factors than white children. Such unequal exposure is due to racism and discriminatory policies that affect social determinants of health and, ultimately, area of residence and access to resources. In this focused article, I first review the epidemiology and selected risk factors for health disparities in asthma and then briefly discuss knowledge gaps and future directions in this field. Except for genetics, risk factors for disparities in asthma and poor asthma outcomes are potentially modifiable and co-exist at the individual or community level, including exposure to violence and related distress; indoor and outdoor pollutants; unhealthy dietary habits; overweight or obesity; and barriers to adequate health care, such as lack of health insurance and poor parental health literacy. Research plays an important role in advancing our knowledge of the determinants and prevention of health disparities in asthma but should not preclude the development and implementation of policies that foster funding of inclusive research studies and clinical trials, "environmental justice," and universal health care. Advocating for such policies requires concerted efforts by all key stakeholders to achieve better health outcomes for all children with asthma.

A Normal Forced Vital Capacity Does Not Reliably or Equitably Exclude Restriction

Background

European Respiratory Society and American Thoracic Society (ERS/ATS) guidelines for pulmonary function test (PFT) interpretation recommend the use of a normal forced vital capacity (FVC) to exclude restriction. However, this recommendation is based upon a single study from 1999, which was limited to White patients, and used race-specific reference equations that are no longer recommended by ERS/ATS. We sought to reassess the support for this recommendation by calculating the negative predictive value (NPV) of a normal FVC in a diverse, multicenter cohort using race-neutral reference equations.

Methods

We interpreted PFTs performed between 2000 and 2023 in two academic medical systems and in a national electronic health record (EHR) database. We calculated the NPV of a normal FVC to exclude restriction overall and among pre-specified racial and ethnic groups.

Results

We included PFTs from 85990 patients. The prevalence of restriction was 35.1%. The overall NPV of a normal FVC to exclude restriction was 80.5% (95% CI 80.1% to 80.8%), compared to an NPV of 97.6% cited in support of ERS/ATS guidelines. The NPV ranged from 65.2% (95% CI 64.4% to 66.0%) among non-Hispanic Black patients to 85.9% (95% CI 85.6% to 86.3%) among non-Hispanic White patients. This difference was largely attributable to lower FVC z-scores among non-Hispanic Black patients.

Conclusions

The NPV of a normal FVC is lower than has been previously reported and varies by race and ethnicity. The approach to PFT interpretation recommended by ERS/ATS guidelines results in the under-recognition of restriction, particularly among non-Hispanic Black patients.

Research Priorities in Pediatric Asthma Morbidity: Addressing the Impacts of Systemic Racism on Children with Asthma in the United States. An Official American Thoracic Society Workshop Report

Background: In the United States, Black and Latino children with asthma are more likely than White children with asthma to require emergency department visits or hospitalizations because of an asthma exacerbation. Although many cite patient-level socioeconomic status and access to health care as primary drivers of disparities, there is an emerging focus on a major root cause of disparities-systemic racism. Current conceptual models of asthma disparities depict the historical and current effects of systemic racism as the foundation for unequal exposures to social determinants of health, environmental exposures, epigenetic factors, and differential healthcare access and quality. These ultimately lead to biologic changes over the life course resulting in asthma morbidity and mortality. Methods: At the 2022 American Thoracic Society International Conference, a diverse panel of experts was assembled to identify gaps and opportunities to address systemic racism in childhood asthma research. Panelists found that to examine and address the impacts of systemic racism on children with asthma, researchers and medical systems that support biomedical research will need to 1) address the current gaps in our understanding of how to conceptualize and characterize the impacts of systemic racism on child health, 2) design research studies that leverage diverse disciplines and engage the communities affected by systemic racism in identifying and designing studies to evaluate interventions that address the racialized system that contributes to disparities in asthma health outcomes, and 3) address funding mechanisms and institutional research practices that will be needed to promote antiracism practices in research and its dissemination. Results: A thorough literature review and expert opinion discussion demonstrated that there are few studies in childhood asthma that identify systemic racism as a root cause of many of the disparities seen in children with asthma. Community engagement and participation in research studies is essential to design interventions to address the racialized system in which patients and families live. Dissemination and implementation studies with an equity lens will provide the multilevel evaluations required to understand the impacts of interventions to address systemic racism and the downstream impacts. To address the impacts of systemic racism and childhood asthma, there needs to be increased training for research teams, funding for studies addressing research that evaluates the impacts of racism, funding for diverse and multidisciplinary research teams including community members, and institutional and financial support of advocating for policy changes based on study findings. Conclusions: Innovative study design, new tools to identify the impacts of systemic racism, community engagement, and improved infrastructure and funding are all needed to support research that will address impacts of systemic racism on childhood asthma outcomes.

Projected Cost Savings of a Community Health Worker Model for Asthma Home Visits in the Massachusetts Pediatric Medicaid Population

Introduction

The community health worker-led asthma home visiting model (CHW model) improved asthma outcomes and reduced health care costs among Massachusetts children with asthma. We projected cost savings associated with the expansion of the CHW model among pediatric Massachusetts Medicaid (MassHealth)-eligible patients with uncontrolled asthma (≥2 asthma-related emergency department visits per year).

Methods

We estimated 2019 costs associated with asthma-related hospitalizations and emergency department visits for MassHealth pediatric patients with uncontrolled asthma who also had 365 days of Medicaid eligibility in 2019. We based estimated cost savings on previously published results from a study of a comparable patient population.

Results

The projected asthma-related cost savings from expansion of the CHW model were $566.58 per patient, or $774,514.86 total, for the 1,367 MassHealth-eligible children with uncontrolled asthma in our analysis.

Conclusion

Expansion of the CHW model is an effective way to increase asthma services and reduce Medicaid costs for MassHealth patients, a population made up disproportionately of Black and Hispanic residents with low incomes.

Race Adjustment of Pulmonary Function Tests in the Diagnosis and Management of COPD: A Scoping Review

Aim

Increasing evidence suggests that the inclusion of self-identified race in clinical decision algorithms may perpetuate longstanding inequities. Until recently, most pulmonary function tests utilized separate reference equations that are race/ethnicity based.

Purpose

We assess the magnitude and scope of the available literature on the negative impact of race-based pulmonary function prediction equations on relevant outcomes in African Americans with COPD.

Methods

We performed a scoping review utilizing an English language search on PubMed/Medline, Embase, Scopus, and Web of Science in September 2022 and updated it in December 2023. We searched for publications regarding the effect of race-specific vs race-neutral, race-free, or race-reversed lung function testing algorithms on the diagnosis of COPD and COPD-related physiologic and functional measures. Joanna Briggs Institute (JBI) guidelines were utilized for this scoping review. Eligibility criteria: The search was restricted to adults with COPD. We excluded publications on other lung disorders, non-English language publications, or studies that did not include African Americans. The search identified publications. Ultimately, six peer-reviewed publications and four conference abstracts were selected for this review.

Results

Removal of race from lung function prediction equations often had opposite effects in African Americans and Whites, specifically regarding the severity of lung function impairment. Symptoms and objective findings were better aligned when race-specific reference values were not used. Race-neutral prediction algorithms uniformly resulted in reclassifying severity in the African Americans studied.

Conclusion

The limited literature does not support the use of race-based lung function prediction equations. However, this assertion does not provide guidance for every specific clinical situation. For African Americans with COPD, the use of race-based prediction equations appears to fall short in enhancing diagnostic accuracy, classifying severity of impairment, or predicting subsequent clinical events. We do not have information comparing race-neutral vs race-based algorithms on prediction of progression of COPD. We conclude that the elimination of race-based reference values potentially reduces underestimation of disease severity in African Americans with COPD.

Counter-stories in the way of caste: towards an anti-casteist public health praxis in contemporary India

How can ethnographic methods track implicit & explicit forms of structural casteism in Indian public health policy and praxis? How can a critical attention to ordinary stories and subjectivities of casted lives reveal the underlying Brahmanical moralities, assumptions and imaginations of public health but equally also unravel anti-caste counter-framings/counter-theorizations of symptoms, afflictions, injuries and chronic wounds wrought by caste? How, in other words, can the horizons of anti-colonial theory-making be expanded to capaciously conceptualize casteism as a core determinant of community health outcomes and life-chances in India? By mobilizing 'counter-storytelling' as a concept and method for critical medical anthropology from the Global South, and case studies from longitudinal ethnography in northern India, this paper provides a dual critique of: 1. Public health praxis in relation to questions of caste, addiction, respiratory debilitation, air pollution and TB. And, 2. Epistemologies of health policy making pertaining to wellness for 'the poor' and the gendered and casted labour of community care workers like ASHAs and non-institutionalized health actors.