The 2024 American Academy of Asthma Allergy and Immunology (AAAAI) conference in Washington, D.C., underscored the intricate nature of asthma, emphasizing the multifactorial determinants of its development and treatment access. While genetic susceptibility plays a role, epigenetic, environmental, socioeconomic, racial, dietary/nutritional, and emotional factors also significantly influence asthma susceptibility and medication accessibility. Notably, of the four plenary sessions, there was one dedicated to asthma: “New Insights into the Development and Treatment of Asthma.”
Two key presentations of this plenary session addressed the impact of social disparities, race, and ethnicity on asthma outcomes and therapeutic access.
Dr. Elizabeth Matsui, professor of Population Health and Pediatrics at the University of Texas, presented “Recent Advances in Non-Pharmacologic Therapies for Asthma.” Dr. Matsui focused her conference on a non-pharmacological intervention to treat asthma and referenced that there is a large body of evidence that shows psychosocial and socioeconomic factors as key players in the development or exacerbation of asthma in children. She referenced a study about neighborhoods and caregivers' stress as exacerbating factors in children’s asthma symptoms.
Dr. Matsui highlighted the interplay between environmental, socioeconomic, and racial variables in childhood asthma, particularly emphasizing the detrimental effects of poverty and racism on vulnerable populations, such as African American and Latinx children. Her research revealed a non-random spatial distribution of asthma ED visits, closely correlated with neighborhood poverty and racial demographics. One of the most impactful data presented by Dr. Matsui in this conference is the almost perfect overlap between the neighborhoods that back in 1910 and 1930–1960 had race segregation and housing discrimination patterns. The ED visits are from children who live in these impoverished neighborhoods that overlap with this geographical area and have been for decades part of a racial segregation pattern. These old segregated areas are found in cities such as Austin, Texas, Washington D.C., Baltimore, New York City, and Cincinnati, among others.
She states there has been a shift from centering individual interventions to neighborhood mobility interventions. An essential meta-analysis of multiple studies on the effects of reducing indoor allergens in inner-city homes (without any other change) led to the conclusion that lowering indoor allergens by itself, without changing anything else in this patient's home, would not achieve significant asthma reduction. If the reduction of allergens in the homes was not helping the allergic asthmatics, then there had to be other factors that induced the asthma phenotype of these patients. This question prompted the design of a prospective study of children with asthma. As is well known, African American children have 2–3 times the prevalence of asthma as compared to white children, and — among those with asthma —African American children have more than twice the risk for emergency department visits and hospitalizations compared with white children. Pollack and collaborators, with Dr. Matsui and Dr. Keet as senior authors, published an outstanding study on the Association of a Housing Mobility Program with Childhood Asthma Symptoms and Exacerbations published in JAMA in 2023 as a non-pharmacological intervention, a study done in conjunction with the Baltimore Regional Housing Partnership housing mobility program. This time, the patient would move to better housing in low-poverty neighborhoods. Patients would undergo evaluation after one year of the move. The main outcome was Caregiver-reported asthma exacerbations and symptoms. The majority of the children were African American (97.6%).
The results were a significant improvement in their asthma symptoms. There was a 50% reduction in the odds of an exacerbation and a 60% reduction in the odds of a symptom day. There was no racial change, no medication change, and very few allergens change. Indoor allergens did not change in cats, dogs, or dust mites. Cockroaches and mice decreased but did not explain the improvement. Pollution and cigarette smoke decreased but did not explain the changes either. What was more impactful was the reduction of neighborhood stressors. Families felt more social cohesion and safety and decreased urban stress. These changes explained 29% and 35% of the association between moving and lowering asthma exacerbations. There were no changes in Parents' caregiver stress, depression, or discrimination perception. This study underscores the importance not only of the impact of a positive and safe environment for the children but also the impact on the decreased stressor levels in the parents that significantly impacted their childrens’ asthma. Other non-pharmacological interventions that continue to be active areas of research are dietary/nutritional interventions and continue advancing in environmental interventions, where the reduction of psychological stress in the family appears to play an essential role in the asthma outcome, consistent with other studies that support this finding.
Dr. Matsui's study on a housing mobility program demonstrated a significant reduction in asthma symptoms and exacerbations following improvements in neighborhood conditions, emphasizing the critical role of addressing social stressors in asthma management.
Ayobami Akenroye, MBChB MPH PhD, Physician-Scientist, Assistant professor of Medicine, Allergist-Immunologist, Division of Allergy & Clinical Immunology at the Brigham and Women’s Hospital, Harvard Medical School, presented a conference “The Pharmacoequity in Eligibility for Biologics in Patient in Allergic Disease” Dr. Akenroye underscored the impact of racial disparities on the access to important biological asthma therapies in adults that we know are helping thousands of asthma patients but according to her research and those of others referenced in her conference, does not reach equally to all patients. Dr. Akenroye analyzed the real access of biological drugs that are well known to be effective in asthma patients. The assumption is that pharmacoequity means that there should be in clinical trials an equal or proportional representation of different genders, ethnic and racial subgroups to evaluate the treatment effects by patient characteristics, helping to evaluate the eligibility criteria for biological drugs (monoclonal antibodies) to treat asthma. Safety and therapeutic effects may vary depending on the subgroup of patients. On the other hand, there should be equity on the insurance coverage and support to ensure any patient has access for funding to get their treatment. Pharmacoequity is defined by Dr. Essien as “ensuring that all individuals, regardless of race and ethnicity, socioeconomic status or availability of resources, have access to the highest-quality medications required to manage their health needs.” Dr. Akenroye shares in her conference her findings that could be qualified as ‘pharmacoinequity’ where in reality the composition of the patients in the trials, the use of an access of the biologicals in the real world, do not always include minorities or include them but are underrepresented. This could potentially affect the assessment of the effectiveness of a particular drug that may vary according to race (or not). In addition, Dr. Ankenroy mentioned access to good insurance is different depending on the socioeconomic status of the patients. Their insurance coverage and quality of coverage may vary. It’s been found that there are some ethnic groups and races that are underrepresented in some clinical trials. There continues to be a challenge to have a complete representation of minorities in clinical trials. However, there is an increased awareness of this issue as mentioned by Dr. Akenroye in the field of multi-omics studies. The authors of these studies are working on more inclusive cohorts of classically underrepresented populations.
In summary, these presentations at the AAAAI conference emphasized the importance of addressing social determinants of health, particularly race and socioeconomic status, in asthma management. They underscored the need for equality, inclusion, and social justice in clinical trial design and medication accessibility to alleviate asthma-associated health disparities.
Dr. Lara-Marquez is the Past Chair of the Integrative Medicine Committee of the AAAAI, a volunteer position. Her views are her own.
Image by Angelina Bambina / Getty
