Asthma in the U.S.
Uncontrolled Asthma and Racial Disparities
Soka University of America
Professor Danielle Denardo
Adv. Sociology: Health Inequalities
November 26, 2019
Asthma is a chronic non-communicable disease in which recurrent attacks of breathlessness, wheezing and inflammation of the lung airways occur. The severity of asthma varies individually; for instance, asthma attacks can occur up to several times a day in extreme cases and in mild cases a few times a week. Asthma symptoms include having asthma attacks which occurs when the lining of the bronchial tubes swell, causing the airways to narrow impairing one’s ability to breathe (CDC 2019). The fundamental causes of asthma vary and are not always identifiable. There are numerous triggers including indoor allergens (ie. dust mites, pet dander, mold) and environmental allergens (ie. air pollution, smoke, pollen, chemicals). Additionally, triggers such as cold air, extreme emotional arousal (ie anger, distress), physical exercise and certain medications can contribute to an onset of an asthma attack (WHO 2017). Environmental exposure in combination with a genetic predisposition are linked to asthma development as well as urbanization and have been associated with increased asthma prevalence (WHO 2017).
There is no cure for asthma, however, there are management strategies that can help relieve symptoms and attacks (WHO 2017). Two classifications of asthma include uncontrolled and controlled. Controlled asthma is when the individual experiences very few symptoms and are able to carry out day-to-day activity without restraint. Uncontrolled asthma is considered an indicator of treatment adherence and consistent asthma care which results in less severe asthma. Uncontrolled asthma includes poor symptom control indicated by frequent symptoms immediate relief medication use, limited life activity, frequent exacerbations and inconsistent or nonexistent adherence to a treatment plan. Controlled asthma has a minimal impact on everyday living. Uncontrolled asthma is associated with significant cost to families and society because it may relate to an increased risk of an emergency department visit, hospitalization, and work and school absenteeism (CDC 2019).
In terms of medication treatments, both short term and long term medications exist. For people who have persistent chronic asthma, long term medication is required to control bronchial inflammation and associated symptoms. Additionally, inhalers are used to administer asthma medicines directly to the lungs. There are two types of inhalers, metered dose inhalers and dry powder inhalers (AAFA 2019). Long term control medicines prevent and control asthma symptoms while quick relief medicines relieve immediate symptoms and are used when attacks are active. Avoiding asthma triggers is a management strategy that medical providers can help those who suffer from asthma identify with diaries. Asthma diaries track peak airflow, triggers, symptoms, medications and side effects (CDC 2019). These diaries can help those with asthma to understand their condition and make decisions on whether or not to use short term vs. long term medication. Persons with asthma can be severely affected because they may not be able to enjoy daily activities due to fear of having an asthma attack or coming into contact with a potential trigger. Though asthma has a low fatality rate compared to other chronic diseases if not treated or managed it can lead to death. Every day in the U.S. due to asthma: 30,000 people have an asthma attack, 5,000 people visit the emergency room, 1,000 people are admitted to the hospital and eleven people die (CDC 2019). According to the latest WHO estimates, there were 383,000 deaths from asthma in 2015 (WHO 2017). Asthma is a significant health burden to patients, their families and to society.
Asthma prevalence is an estimate of the percentage of the population with asthma and helps us understand the burden of asthma on the U.S. The total and overall prevalence of asthma in children under eighteen years of age is 8.4% while overall prevalence in adults (>18 yrs) is 7.7%. Currently, there are 6.2 million children under the age of eighteen who suffer from asthma (AAFA 2019). Although adolescents between eleven and twenty-one have the highest number of individuals with asthma, young teens twelve to fourteen have the highest rate of asthma. Asthma is the leading chronic disease in children and is more common in children than adults (AAFA 2019). Although the prevalence percent of children with asthma is high, they make up a smaller population than adults, therefore, more adults suffer from asthma than children overall despite having a lower average rate of asthma. For instance, children under 18 years have a prevalence percentage of 8.4 (6,182 persons) whereas, adults 35-64 have a prevalence rate of 8.1 (10,036 persons) which is lower in rate but higher in population count.
Source: Centers for Disease Control, National Data on Asthma. 2017 Data includes U.S. population Accessed at https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm
Disparities Inequalities & New Incidence
The number of individuals with asthma in the U.S. grew 75% between 1980 and 1994, making asthma one of the few diseases whose incidence and death rates continued to increase, despite medical advancements in asthma control and treatment (Brown et al. 2004).
Source: Centers for Disease Control Asthma Surveillance Data. 2019 Accessed at https://www.cdc.gov/asthma/asthmadata.htm
The graph above demonstrates that asthma disparities exist based on age, gender and race/ethnicity. The largest disparity exists between men and women and between white and black populations. National data reports that many disparities exist in uncontrolled asthma. For instance, African Americans with asthma experience higher rates of emergency department visits and inpatient hospitalizations, coupled with lower rates of long-term control medication use when compared to other racial/ethnic groups (Anarella et al 2017). According to the graph shown above, African Americans have the highest rates of asthma prevalence which correlates with reported data that African-americans die from asthma at a higher rate than people of other races or ethnicities (AAFA 2019).
Centers for Disease Control Uncontrolled Asthma in Children. 2019 (NH = non-hispanic) Accessed https://www.cdc.gov/asthma/asthma_stats/uncontrolled-asthma-children.htm
The disparity between white and non-hispanic black populations of uncontrolled asthma is greater than that of age and gender. This graph specifically shows data on uncontrolled asthma which excludes controlled asthma prevalence. Rates of uncontrolled asthma differ from prevalence because prevalence includes anyone who has ever had asthma and those with a controlled asthma status. Note: there are other racial/ethnic groups that may have a more severe disparity but due to a lack of data on those populations they may not be represented in national data and conclusive graphs. In both categories (asthma prevalence & uncontrolled asthma) African Americans are reported to be at high risk for asthma and particularly for uncontrolled asthma.
There is an intersection of race and age in asthma prevalence. About 13.4 percent of African-American children have asthma compared to about 7.4 percent of white children with asthma (AAFA 2019). Children have a higher rate of asthma than adults and asthma is the number one reason for school absenteeism. In the United States, children with asthma who are under 4 yrs old have higher rates of asthma and the rate is more rapid than other groups who are at risk for asthma (Koenig et al. 2004). Children are at high risk for asthma in comparison to other groups and more prevently experience asthma despite making up a small portion of the population. In the graph above from the CDC, uncontrolled asthma for African American children exceeds all other racial and age groups. Meaning, Black children are at high risk for uncontrolled asthma.
Source: Centers for Disease Control Uncontrolled Asthma among children. Shows rate of prevalence among children populations only. Accsessed at https://www.cdc.gov/asthma/asthma_stats/uncontrolled-asthma-children.htm note: NH stands for non-hispanic
Children are at an increased risk for asthma according to the graph above and statistical data (CDC 2019, WHO 2017). Black children have the highest rate of uncontrolled asthma with children 0-4 yrs old with the second highest rate. In some urban areas, it is possible to find a classroom where half of the students suffer from asthma (Brown et al. 2004). Fifty percent of children with current asthma had uncontrolled asthma between 20212-2014 (CDC 2019). Due to the increasing rates of asthma in children, schools and education departments are increasing asthma education amongst teachers, faculty and parents (Anarella et al. 2017).
Source: AAFA, Ethnic Disparities in the Burden and Treatment of Asthma. ED= Emergency Department 2005 Accessed at https://www.aafa.org/media/1633/ethnic-disparities-burden-treatment-asthma-report.pdf
More children die than adults from asthma despite having lower instances of hospitalizations, ED visits, and office visits in the U.S. This graph suggests that children are not getting the recommended and necessary asthma care needed to prevent mortality.
Source: Centers for Disease Control, Asthma Mortality. CDC 2019. Note: U.S. national Data represented. Accsessed at https://www.cdc.gov/asthma/data-visualizations/mortality-data.htm#anchor_1569600149691
Women are more likely to die from asthma. At a rate per million 16.4% of women die from asthma versus 10.3% of men which is indicative that uncontrolled asthma may be more common among women. Death is relatively low for asthma overall and in general across all demographics, however, it is particularly high for women.
Source: (Milet 2017) Asthma Prevalence in California: A surveillance Report. Accsessed at https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/EHIB/CPE/CDPH%20Document%20Library/Asthma_Surveillance_in_CA_Report_2017.pdf
Note: Poverty level is based on family income and family size and categorized using the U.S. Census Bureau’s poverty thresholds. “Poor” persons are defined as those below the poverty threshold; “near poor” persons have incomes of 100% to less than 200% of the poverty threshold; and “not poor” persons have incomes of 200% of the poverty threshold or greater.
Of national data in the U.S. there is little to no association between income level and asthma prevalence. According to this graph, individuals who are not poor are at a higher risk for asthma than persons who are of near-poor status. Meaning, there are other factors at play that are more powerful than poverty. Some studies have shown that particularly in California low-income individuals are more at risk of experiencing asthma symptoms, use the emergency room for asthma care, miss more school due to asthma, and are more likely to encounter asthma risk factors.
Source: AAFA, Ethnic Disparities in the Burden and Treatment of Asthma. 2005 Accessed at https://www.aafa.org/media/1633/ethnic-disparities-burden-treatment-asthma-report.pdf
As shown in the graph above, Black inner-city children are more at risk for asthma than children whose family makes under $15,000 a year. Meaning, the demographic of a black child is a greater indicator of asthma risk than being severely poor.
Racial Disparities of Asthma
Given the national data, African Americans experience a greater degree of prevalence than white’s of uncontrolled asthma. There are significant comparative differences in national uncontrolled asthma prevalence, asthma mortality and health care use between Black and White populations. Collectively, national data reports racial disparities between Black and White populations in terms of hospitalizations & emergency room use for asthma, lower long-term medication use, asthma mortality, and uncontrolled asthma prevalence. Because of the evident racial disparity between Blacks and Whites, there has been a considerable amount of research done to explain the causal factors in racial disparities particularly among Black and White populations with asthma.
For most of the studies conducted on asthma racial disparity in the U.S., racial classification of Black and African American are often used interchangeably. Although there are distinctions between the terms Black and African Amerian, the research is not consistent across the board with the definitions of Black and African American. Though, puerto ricans do show the most significant disparities in uncontrolled asthma prevalence there is a lack of research on puerto ricans, however, there is a considerable amount of research that focuses on disparities between Black and White populations which also present significant disparities. Thus far, research on racial disparity in the U.S. for asthma shows that black and white children in particular show the greatest disparity in terms of emergency care use for asthma and rates of uncontrolled asthma when compared to adults. Overall, the research does not always distinguish age within control groups of race. There is significant research on asthma care and management as causal factors for racial disparity, however, the research with more of a focus on racism as a fundamental cause theory focuses on neighborhood and housing conditions. The main causal factors for racial disparities that have been identified include, asthma care, asthma management, Socioeconomic influences and poverty, environmental pollution, as well as neighborhood and housing conditions.
From the body of research, one of the potential causes of higher rates of uncontrolled asthma in African Americans can potentially be explained by differences in asthma care. For example, studies have shown that African Americans with asthma have higher rates of emergency department visits, inpatient hospitalizations and lower rates of long-term control medication use when compared to other racial/ethnic groups (Anarella et al. 2017, ). Emergency care does not provide preventative visits, long-term medication use, timely follow up appointments or post hospitalization visits which are essential to proper asthma care. Poor asthma outcomes such as emergency room visits, hospitalizations and overuse of quick medications demonstrate the severity of asthma, lack of consistent care or undiagnosed patients (Anarella et al. 2017). One of the reasons African Americans may have higher rates of emergency department visits is because they may not have a primary care physician or doctor which has been associated with inaccessibility due to poverty. In the case of an asthmatic attack the use of urgent care clinics and emergency care may be a constrained choice and only foreseeable option.
For instance, in a study conducted by (Koenig et al 2004) of low income African American families with an asthmatic family member, all but two families used the emergency room or urgent care to treat their asthma symptoms. In situations of poverty, maintaining consistent medical care for asthma can be difficult because of life circumstances and lack of insurance or financial stability. For instance, families from the study were unable to continue consistent care with a specialist because of the expense, difficulty with transportation, responsibility to caretake their other children, and work schedule. These are just some of the reasons why those in poverty, particularly African Americans, may turn to emergency room care. Insurance is another obstacle for poor African Americans despite the existence of medicaid. In the Koenig et al. study, one of the mothers using medicaid struggled with the copayments for specialist care and hospital fees. Additionally, the medicaid regulations of prescription refills made it difficult for the mother to administer consistent medication because accessing necessary medication for her asthmatic child was too difficult. Asthma care is the process of seeking medical support for asthma and to control asthma medical providers prescribe an asthma management plan which is one of the most important outcomes of asthma care.
Since asthma does not have a cure, asthma management is critical to a controlled asthma status. Asthma management is noted as a potential cause of disparity between Black’s and White populations and as an opportunity to reduce disparities. In attempts to explain racial disparity related to asthma researchers analyzed the patterns of interaction between providers, parental figures and patients to determine whether or not management plans are effective or adhered to.
One notable difference among Black and White patient groups is the language used in describing asthmatic symptoms to providers. For instance, “African Americans use more upper-airway word descriptors, whereas Whites used words that described lower airway or chest wall” (Boyle et al. 2004). Upper-airway descriptions can be interpreted by medical providers as a short term condition rather than as uncontrolled asthma which can lead to misdiagnosis or prescription of only short term medications. When providers underestimate the presence of asthma in their patients or severity of their condition it results in misdiagnosis which affects the patient’s ability to obtain a proper asthma management plan.
The concept of adherence is important in asthma care because adherence is one’s ability or willingness to complete the care plan which may include physican visits, medication use, and other treatments. The study suggests that caregivers’ demonstrated a lack of adherence to long-term control medications when the child seemed asymptomatic or when concerns of side effects was present. However, patient education is indeed important for any asthma health care program, however, patient education alone cannot counteract the trend of poor adherence and treatment failure in high-risk asthmatic children (Boyle et al. 2004).
Additionally research from Anarella et al. documents that low control of asthma is associated with distrust of medical professionals among African Americans which may influence parental doubts about medication use. Consequently, failure of medication adherence and consistent care from physicians is predictive of asthma morbidity and for African Americans asthma morbidity is at a higher rate. Fundamental differences between African American patients and their health care providers in terms of language, family roles and support, spirituality, socioeconomic status, and cultural experiences with prejudice may cause health care providers to miss subtle clues that would enable them to make an appropriate diagnosis (Boyle et al. 2004). Socioeconomic influences and poverty are associated with uncontrolled asthma and lack of asthma management, thus, analyzing all potential causal factors is important.
Socioeconomic Influences & Poverty
Studies have correlated poverty in asthmatic African Americans with two factors: 1) less access to asthma care 2) lack of information about management practices. However, some studies show that even middle class children with private health insurance still have high rates of emergency care (Tanne 2001, AAFA 2005). Though there are slight correlations, socioeconomic inequalities do not entirely explain the disparity among black and white populations in terms of uncontrolled asthma. Poverty in African Americans may cause them to focus on day-to-day concerns rather than asthma care or management (Boyle et al. 2004). Because poor African Americans naturally have less access to health care services due to limited finances, poverty may lead to a lack of or consistent asthma care in some cases. Poverty is often associated with stress, lack of medical support/knowledge, and inability to seek appropriate care of uncontrolled asthma. It is clear that inconsistent care is coupled with uncontrolled asthma however, the studies on asthma management and care did not focus poverty as fundamental cause of uncontrolled asthma. The Anarella et al. (2017) study offers another perspective on uncontrolled asthma in African Americans, stating that more financial support must be allocated to asthma care and management services as opposed to increasing financial support for African Americans. The study states that specialized funding for improving asthma care and management can help decrease racial disparities of uncontrolled asthma. As both researchers have shown there are some associations between poverty and low SES with quality of asthma care attained by Blacks/African Americans which affects adherence and consistency of asthma management. (Anarella et al. 2017, Boyle et al. 2004).
A racial status of Black or African American proved to be a greater indicator of asthma risk than low-income (CDC 2019). Some studies and reports show that even Black families who are middle class or can afford private insurance, still have higher rates of self-reported uncontrolled asthma than whites (Tanne 2001, AAFA 2005). Still, the association between poverty and low SES is unclear and there is not enough consistency to state that poverty is a fundamental cause of uncontrolled asthma in African Americans.
Neighborhood and Housing Conditions
While some researchers associate poverty with uncontrolled asthma, several studies show that housing and neighborhood conditions are factors that more accurately explain observed racial disparities in asthma. Neighborhood conditions are linked to high concentrations of poverty and are connected risk factors for asthma; however, the most important risk factor is neighborhood conditions. The high concentration of above average asthma rates in minority inner city residents is linked to low quality of housing and neighborhoods. For instance, researchers Rosenbaum 2008, Boardman et al. 2001, and Williams et al. 2009 have found that socioeconomic status is assocaiated with the occupancy of inadequate housing, which is a direct affect of housing discrimination that has led to racially segregated neighborhoods. In the U.S., the history of racism including slavery, convict leasing, lynching, jim crow laws, the war on drugs have all lead to racially segregated neighborhoods and multigenerational burdens from racism. Racially segregated neighborhoods now are the product of the history in the U.S. of racism and segregation laws.
Uncontrolled asthma rates in Black populations is related to differential exposure, stress and health-related behaviors in which all take place within neighborhoods. For instance, affluent families who are mostly white experience less exposure to asthma triggers than do black families who live in substandard housing. Indoor triggers include but are not limited to dust mites, cockroaches and mice feces, lead based paint, and mold (Rosenbaum 2008). Additionally, Indoor triggers are a product of substandard housing conditions and may reflect poor implementation of housing regulations (Rosenbaum 2008). Both indoor and outdoor triggers contribute to uncontrolled asthma and due to housing conditions in Black neighborhoods, trigger exposure is high.
High asthma prevalence among black families correlates with high-poverty neighborhoods whereas, higher-quality housing has the opposite effect. For example, children who moved from public housing in high-poverty neighborhoods to high-quality housing in a different neighborhood had a 50 percent drop in asthma attacks (Rosenbaum 2008). Neighborhood characterization plays a large role in asthma risk factors. Housing and neighborhood conditions are partially independent of socioeconomic conditions which suggests that structural factors such as housing discrimination, racism, and disporptiate housing standards may be a major contributor to racial disparities of asthma between white and black populations.
For most parents in the Koenig et al. study (2004), managing asthma was only one of the many serious life concerns their family had to deal with due to chronic stress. The level of physical and social disorder in poorer and segregated neighborhoods is high in comparison to white affluent neighborhoods. For instance, chronic stress can lead to lower immunity and may be a result of stressful circumstances in the home or neighborhood. Stressful neighborhood or in home circumstances include high rates of drug abuse, living with a drug abuser, drug dealing spouse, drive-by shootings, alcohol abuse, credit debt, unstable living situation, house arrest, jailed family members and sexual/physical abuse (Anarella et al. 2004, Rosenbaum 2008). The aforementioned conditions create and environment in which asthma may develop as a response to high stress in or outside the home. Asthamtic response can be triggered by extreme emotional arousal, therefore, children who are disproportionately exposed to violence or stress can experience increased asthmatic response (Anarella et al. 2004, Rosenbaum 2008,Williams et al 2009). Uncontrolled asthma prevalence in black populations and families is connected to underdiagnosis, low accessibility to health services, and inconsistent asthma management which is influenced by neighborhood risk factors. Consistent asthma management may be difficult for black populations who live in racially segregated communities where life circumstances are extreme and their communities are burdened by poverty and disproportionate exposure to environmental triggers. Researchers have associated the lack of asthma management adherence in Black populations to neighborhood conditions and segregated housing.
Blacks are disproportionately likely to live in substandard housing and neighborhoods of low social cohesion which directly increases their exposure to asthma triggers and is positively correlated with the prevalence of uncontrolled asthma (Rosenbaum 2008). Poverty, SES, lack of quality of asthma care & management do contribute in part to asthma racial disparities, however, several studies have confirmed that housing discrimination and neighborhood conditions are the main causal factors of asthma racial disparities. The root of housing discrimination is racism, therefore, racism is the main causal factor of racial disparity in asthma prevelance.
Asthma is an illness that is a result of environmental factors disrupting the respiratory processes, therefore, studies have attempted to demonstrate associations between particulate matter and specific chemicals in the air with asthma prevalence. Research of environmental pollution as a causal factor for uncontrolled asthma states that in order to reduce asthma prevalence, air quality must improve. Exposure to various environmental factors, including allergens,particulate matter as well as indoor and outdoor pollutants, only partially explain increased incidence of asthma in African Americans (Ostro et al. 2001). Ostro et al. hypothesized that environmental factors compounded by socioeconomic factors are responsible for asthma racial disparities. In African-American children with asthma in Los Angeles the impact of air pollution was noted as clinically meaningful, however, no consistent correlation between environmental pollution and asthma emerged.
Environmental context is directly dependent on neighborhood conditions, therefore, it is inconclusive to attribute racial disparities in asthma to solely environmental factors independent of housing and neighborhood characterization. However, studies that focus on how environmental pollution, air quality and triggers affect asthmatic symptoms contribute valuable information for understanding how the level of indoor/outdoor pollution characterizes neighborhoods. Exposure to triggers and sources of air pollution such as automobile traffic, industrial emissions, bus depots and waste storage facilities are predominantly located in poor and minority communities. (Brown et al. 2004).Additionally, “the fear and stress associated with neighborhood crime and violence may increase people’s tendency to smoke” and because tobacco smoke is an environmental trigger, it can create an increased risk of exposure to asthma triggers for members of the community (Rosenbaum 2008). Although studies conducted by Ostro et al. (2001) report that air pollution, increased particulate matter, and mold counts are associated with asthma exacerbation confirming that both indoor and outdoor pollution are important factors in uncontrolled asthma prevalence it does not provide the explanation for understanding why African Americans are being disproportionately exposed to pollution.
Conclusion & Analysis
Existing research on racial disparities in asthma is vast and covers an array of different causal factors in detail. Researchers have dedicated many years to uncovering the potential causes of asthma racial disparities. However, most of the research focuses on asthma care and management solutions which are often downstream and microlevel approaches. Additionally, the research narrowly focuses on individual causal factors rather than using a multidisciplinary and integrated analysis. Researchers must also distinguish between the terms African American and Black to provide more clarity on population categorization.
For example, Koenig et al. (2004) and Anarella et al. (2017) both focus on asthma management and care while neglecting upstream influences such as racism, segregated housing, and environmental pollution. Moving forward, researchers must study whether racism is a fundamental cause theory for uncontrolled asthma racial disparities. The research hints that all causal factors are interconnected, however, research must actively and clearly address all causal factors in relation to each other and particularly in relation to neighborhood conditions where asthma incidence develops. Most of the research across a larger timespan focuses on asthma care and management; however, other studies have uncovered that while asthma care and management are factors to consider, the most important factor is neighborhood and housing conditions. To begin reducing racial disparities in uncontrolled asthma, research must focus on identifying racism as the fundamental cause theory. In the U.S. Black and African American populations are affected disproportionately by uncontrolled asthma, research must also acknowledge and study disparities among other racial groups such as Puerto Ricans and Latinos.
In the disease of asthma, the macro includes the healthcare system and the micro includes individuals as well as family units. Solutions cannot only be tailored to the micro and macro spheres, solutions must target the meso level which includes neighborhood and housing conditions. Meso Level is where asthma development occurs; therefore, the solutions must integrate the research and practicum of medical professionals, environmental health scientists, sociologists and urban planners to respond adequately to racial disparities in uncontrolled asthma.
Environmental health specialists, physicians and sociologists can take action by completing a full community environmental health assessment (CEHA) on Black neighborhoods with high rates of asthma, to report on the most critical areas that need improvement. A CEHA can create a practical action plan that addresses the most important environmental health issues within a target population. A community environmental health assessment includes environmental toxicology, epidemiology, child health, occupational health and risk assessment, water, air, and soil quality control, as well as remediation methodology (Sanchez 2008). A CEHA aims to determine the physiological and psychosocial interactions between individuals and the physical, chemical, biological and social factors of the environment (Sanchez 2008). A CEHA of black neighborhoods with high asthma rates can help connect research to practical solutions by creating a report on the most important causal factors within neighborhood environments, which can be used to combat triggers of asthma in Black Neighborhoods particularly. Efforts to eliminate indoor triggers arising from housing deterioration have great potential to not only reduce asthma rates generally but also reduce excess morbidity in Black households, which is the result of uncontrolled asthma. The CEHA can be the basis for initiating a state or government funded housing project that responds to the causal factors of asthma in that area. Because a CEHA includes social factors, reducing social stressors would also be an aim of the project. Some improvements would include replacing lead based paint, reconstructing buildings, bringing in experts of indoor pollution, ensuring that industrial environmental pollution is properly regulated and installing high quality indoor air filtration systems. Additionally, implementation of improving neighborhoods must aim to prevent gentrification displacement.
Community members must be involved in the CEHA process because they have valuable contributions of their local knowledge about environmental health risks and their own asthma triggers (Cornburn 2002, Sanchez 2008). They can also advocate for themselves and be represented in the process if they are involved. A CEHA would be the most appropriate first step towards decreasing racial disparities in asthma; however, other solutions are still needed such as improved asthma care and management. Strengthening both the laws regarding housing code violations is essential. Additionally, programs that help landlords to make structural improvements can help prevent housing deterioration and maintain housing standards. Uncontrolled asthma in the U.S. must be met with adequate research, public health funding, housing regulations and thorough community environmental health assessments.
Fair housing laws must strengthen in order to make safe and desirable housing accessible to Black and African American populations. The fundamental nature of race/ethnicity as a cause of disease is at play in asthma racial disparities and intervention must focus on more than the biological or physical aspects of the disease. Intervention must address the environmental and social factors to be truly effective (Link and Phelan 1995, Rosenbaum 2008). Social, economic and political efforts as well as regulation to reduce housing discrimination is necessary to decrease uncontrolled asthma prevelance in Black populations. The disporportiante exposure of Black households to such conditions stem not from poverty alone but from their constrained choice in housing and low quality of neighborhoods, which is due to racism and housing discrimination. Therefore, housing discrimination must be adressed in conjunction with improving the neighborhoods themselves.
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