An Asthma Epidemic in the African American Community

In spite of increased understanding of asthma and excellent treatment available, black Americans are three times as likely as white Americans to die of asthma. “Prior authorization” is one contributing factor.

America is facing a new epidemic. It is not the deadly HIV virus or even cancer. The condition is asthma. In this country, 5,000 people die each year from asthma-related illness.1 In 2001, the National Medical Association declared asthma to be a public health crisis within the African American community. President George W. Bush has targeted asthma as a top national health priority. African Americans represent 12% of the US population, and they experience more than 21% of all asthma deaths.2 They are three times more likely than white Americans to be hospitalized from asthma and three times as likely to die from the disease. African-American women, among all adult asthmatics in America, have the highest mortality rates.3

Urban Communities
Asthma is underdiagnosed and inappropriately treated in poor urban communities. Interventions are commonly incomplete or misdiagnosed. Despite the excellent available treatment for asthma, the number of people in poor urban populations who die from this condition has not declined. High concentrations of pollutants are suspected contributing factors. According to the Air of Injustice report from 2002, 71% of African Americans compared to 58% of white Americans live in counties that violate federal air pollution standards. In 2002, 90% percent of African Americans in Illinois lived in communities with air pollution levels exceeding federal health standards compared with 66% of white Americans.4

Contributing to this epidemic is the quality of care provided to African Americans and other minorities. Guidelines have not been sufficiently adhered to. African Americans are under-referred to specialists. Asthma is frequently diagnosed late, resulting in treatment delays. This contributes to the higher morbidity and mortality of African American asthma patients. There is belief in the African American community that asthma is a one-time event and not a chronic inflammatory lung disease.

A significant percentage of those who live in depressed economic environments receive governmental assistance from Medicaid or similar programs. As a result, many of the physicians tending those patients are pressed for time, limiting time during patient encounters, which contributes to delays in the correct diagnosis and decreases the likelihood that adequate patient education will transpire during office visits. The unfortunate outcome is ineffective education of the African American patient and suboptimal accessibility to ideal treatment options.

Prior Authorization
For more than a decade, the governmental procedure of “prior authorization” increasingly has separated physicians from their ability to control the treatment of their patients. Today, many states are implementing a system that threatens to limit a physician’s ability to prescribe the best medicines for patients covered by Medicaid. These decisions are being made by lawmakers and not by medical professionals.

Prior authorization requires physicians to order from a fixed list of generic medications for Medicaid patients, often not allowing the best therapy possible. In cases involving medical emergencies, the prior approval process is labor intensive and expensive, ultimately leading to higher costs to the patient and the state. Many asthma-related hospitalizations can be prevented by managing the disease with proper chronic and acute “rescue” medications.

No chronic disease expresses itself the same way at all times; therefore, the heterogeneity of the disease, the variability of expression of the disease, and the circumstances that environmentally surround and impact the disease all require individualization of therapy. To restrict the best medications available on the basis of pharmacoeconomics and geopolitical circumstances is ineffective.

Professional groups including the National Medical Association and the American College of Asthma, Allergy & Immunology have staked out positions opposing prior authorization legislation. Patient advocacy group the Allergy & Asthma Network/ Mothers of Asthmatics has also spoken out against it. b

Michael B. Foggs, MD, is chief of allergy and immunology at Advocate Heath Care, Chicago.

References
1. Table 6. Monthly Vital Statistics Report. August 14, 1997;46(1).
2. American Lung Association. Available at: www.lungusa.org.
3. Foggs MB. The growing asthma problem in the inner city. Presented at: American College of Allergy, Asthma & Immunology Annual Meeting; November 2003; New Orleans.