Structural Racism and the Social Determinants of Health in Asthma.

Asthma prevalence and morbidity are disproportionately higher among minoritized communities in the United States. Racial and ethnic disparities in asthma result from complex interactions across biological, environmental, and social factors. Asthma is considered a complex heterogeneous disease consisting of different phenotypes, some of which may be more common in individuals impacted by the downstream effects of structural racism and lack of access to the social determinants of health. Structural racism across generations has created and reinforced inequitable systems through policies and practices which are embedded in the economic, educational, health care, and justice systems (Bailey et al., N Engl J Med 384(8):768-773, 2021; Bailey et al., Lancet 389:1453-1463, 2017; Williams et al., Annu Rev Public Health 40:105-125, 2019). This manifests in an inequitable distribution of resources and the social determinants of health affecting an individual's physical and social environment (Bailey et al., Lancet 389:1453-1463, 2017; Thakur et al., Am J Respir Crit Care Med 202:943-949, 2020; Martinez et al., J Allergy Clin Immunol 148(5):1112-1120, 2021). In this chapter, we outline how inequity in housing, zoning laws, urban planning, education, employment, healthcare access, and healthcare delivery is linked to higher asthma prevalence and morbidity. We also describe the role that chronic physiologic stress has on asthma by enhancing neuroimmune and immunologic responses to environmental exposures. Interventions aimed at addressing the physical or social environment of an individual or community have been shown to improve asthma outcomes in patients at higher risk of severe disease.

Structural racism and its pathways to asthma and atopic dermatitis.

Black, Latinx, and Indigenous people in the United States experience a disproportionate burden of asthma and atopic dermatitis. The study of these disease disparities has focused on proximal socioenvironmental exposures and on the biomechanistic (including genetic) differences between racial and ethnic groups. Although biomedical research in allergy and immunology stands to benefit from the inclusion of diverse study populations, the narrow focus on biologic mechanisms disregards the complexity of interactions across biologic and structural factors, including the effects of structural racism. Structural racism is the totality of ways in which society fosters discrimination by creating and reinforcing inequitable systems through intentional policies and practices sanctioned by government and institutions. It is embedded across multiple levels, including the economic, educational, health care, and judicial systems, which are manifested in inequity in the physical and social environment. In this review, we present a conceptual framework and pull from the literature to demonstrate how structural racism is a root cause of atopic disease disparities by way of residential segregation, socioeconomic position, and mass incarceration, which may lead to aberrations in the innate and adaptive immune response and the augmentation of physiologic stress responses, contributing to a disproportionate disease burden for racial and ethnic populations.

Adverse Childhood Experiences and Related Events are Associated with Asthma Symptoms in Children.

OBJECTIVE: To examine the association between adverse childhood experiences (ACEs) and related events and asthma symptom burden in children. METHODS: This is a cross-sectional study of baseline data from 147 participants with asthma from a cohort of children enrolled in the Pediatric ACEs Screening and Resiliency Study. Participants completed the PEdiatric ACEs and Related Life Events Screener (PEARLS) tool, a 17-item questionnaire, capturing 3 domains of childhood adversity-child maltreatment, household challenges, and social context. Asthma symptom burden was assessed using the International Study of Asthma and Allergies in Childhood core questionnaire, which asks participants to identify the presence and frequency of severe wheezing that limits speech, wheezing with exercise, nocturnal wheezing, and nocturnal cough in the last 12 months. Using multivariable logistical regression models, we examined the relationship between reported PEARLS and asthma symptoms. RESULTS: Of children with asthma, 86% reported at least 1 adversity, with 48% reporting 4 or more. The odds of severe wheeze limiting speech increased by 19% with each additional reported adversity captured by the PEARLS tool (95% confidence intervals (CI) 1.01-1.41). Increasing PEARLS scores were also associated with 16% increased odds of reporting wheeze with exercise (95% CI 1.03-1.31). Wheezing with exercise was associated with the household challenges domain (odds ratio (OR) 1.34; 95% CI 1.05-1.72), while severe wheeze limiting speech was associated with the social context domain (OR 1.75; 95%CI 1.02-3.02). CONCLUSIONS: Childhood adversities are associated with increased asthma symptom burden, suggesting the tool may be helpful in identifying children at risk for poorly controlled asthma.