This webinar was recorded on May 26, 2022
Quality care is vital for those with asthma and people who are a part of underserved communities live with distinct barriers to care. We will look at ways to reduce barriers and provide the best asthma care for each and every person.
Speaker:
- Dr. Bridgette Jones
CME is available through ACAAI for this webinar.
CNE is available through Allergy & Asthma Network’s Online Learning HQ
Transcript: This transcript is automatically generated. While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
00:04
Welcome to today’s webinar on Access and Equity in Asthma care. This webinar series is sponsored by the American College of Allergy, Asthma and Immunology and we work to share the latest information and advances in allergy and asthma with you. This is Sally Schoessler, director of education for allergy and Asthma network. Today’s webinar helps allergy and asthma network live out our mission to end the needless death and suffering due to asthma, allergies and related conditions through outreach, education, advocacy and research today. We are pleased to welcome today’s speaker, doctor Bridgette Jones. Doctor Jones holds a faculty appointment as an associate professor of Pediatrics in the divisions of pediatric clinical pharmacology, toxicology and therapeutic innovation, and allergy and asthma and immunology at Children’s Mercy Hospital.
00:58
If you can move the slide forward, everyone can see you. She is an NIH funded clinical scientist with a focus on therapeutics and interventions to improve the lives of children with allergic disease and asthma. She’s also Co principal investigator of the Sunflower Pediatric Clinical Trials Research extension as part of the National Institutes of Health ideas states pediatric clinical trial network. She’s the former medical director of the Office of Equity and Diversity. At Children’s Mercy, where she developed the student training and academic research 2 0 program. She continues to lead this program, which provides an opportunity for high school students who are from backgrounds underrepresented in medicine and science and gives them exposure to medical and science careers.
01:47
She’s also led work to develop and maintain a pipeline of diverse and successful trainees and physicians and medicine to ensure their career development. She has also been a national advocate for diversity. And equity for women in medicine. Doctor Jones is active on a national leadership level as well. She currently serves as chair of the American Academy of Pediatrics Committee on Drugs, Immediate past president of the American Academy of Allergy, Asthma and Immunology, asthma and cough diagnosis and Treatment Committee, and serves as a member of the Food and Drug Administration Pediatric Advisory Committee. She was appointed by the United States Secretary of Health to serve on the National Institutes of Health Task Force on research specific to pregnant women and lactating women.
02:35
She’s wife, and mother to Lola and Nora. Thank you for being with us today, Doctor Jones, and for sharing your insight into this important and timely topic.
Thank you so much for that wonderful introduction and thank you for inviting me to speak today. I’m very excited to discuss the topic of access and equity in asthma care and to provide this presentation and to also have a little bit of discussion hopefully at the end. So here are my disclosures. And here are the objectives today. So the objectives are to understand the current asthma related health disparities landscape, the underlying structural drivers and individual and system level interventions needed to close health disparity gaps, to utilize an appropriate lens when considering health disparities, and to improve consideration of contributors to health disparities in clinical practice.
03:39
So as we all likely know who’s on this call today that there are deep and long standing disparities in asthma within the United States. These have been well described for decades if not even longer, where in children and in adults we see that asthma prevalence rates. So whether or not someone has an asthma diagnosis or not, those rates are much higher in certain racial and ethnic groups. Particularly they’re higher in patients who identify as black and or Hispanic. And within the Hispanic community, asthma is highly prevalent within those who identify as Puerto Rican. We also see from the figure, the blue figure here on the right is that this is a longstanding disparity where you have this gap between.
04:40
People who identify as black and or Hispanic and people who identify as white in the United States and this healthcare, this health disparity is persistent. You see some fluctuations there in some of the data but the gap still remains and so despite all of the technology and science that we now have in asthma care and asthma management, we still have not been able to close these racial and ethnic disparity gaps. And so it’s not only just asthma prevalence or asthma diagnosis that differs by race and ethnicity, but also the impact of asthma in these populations. So patients who identify as black and or Hispanic are impacted more significantly when it comes to having emergency department visits for asthma hospitalizations for asthma urgent care.
05:45
Visits and mortality rates are also significantly higher, particularly among people who identify as black, whereas described that in the black population mortality rates are two to three times higher than those who identify as white. So again, these are persistent disparities that have been around for some time. And so again, as I mentioned, despite all that we now know about asthma, we still haven’t been able to close these gaps. And so part of that reason is due to the significant complexity of what’s contributing to these health disparity gaps. So I thought that a good way to exhibit today the complexities involved in the these disparities and what patients are dealing with on a day-to-day basis and those of us who are trying to manage their asthma to kind of give a real life picture.
06:45
So this is a case, this is a case of an actual real patient of a colleague of mine. This patient actually doesn’t have asthma, but they have another chronic condition. But when I heard them tell this story in a presentation they gave on health disparities, it sounds, the story, sounded just like a culmination of many of the patients that I see. So we’ll go through this case and then as I give my presentation, I would like you to kind of think back to this case and some of the things that we’ll discuss as potential drivers for asthma.
07:22
So TD is an 11 year old boy with severe persistent asthma who’s been in the hospital frequently, including ICU stays. He lives in the city with his mother and three of his four brothers and a cousin. His mother is not able to work steadily due to her son’s health because he’s in and out of the hospital and she’s having to take off quite a bit with him being sick. She also has her own medical concerns. She has a mental health diagnosis and sees a therapist and is on medications.
07:54
She has limited social support from her extended family because they’re also dealing with complexities with their own lives. There’s a significant family history of lot loss. A younger brother died 10 years ago at age 8 months from SIDS. A younger brother was also born prematurely at 26 weeks and has developmental delay. And after a recent hospitalization for asthma, TD had two family members who were murdered and one murder was witnessed by his brother. Td has become extremely withdrawn. So when he visits you and comes to his office visits, it’s very difficult for him to open up.
08:34
He won’t really talk to you. He’s been diagnosed with conversion disorder due to the stressful situations that he’s experienced. His mother’s boyfriend is a strong support for the family emotionally and financially. And has lived with them, but was recently arrested for unpaid parking tickets and has not been able to be released from jail due to not being able to pay the bail cost. They had a home that had mold inside and when a team went out and did an environmental inspection mold was found and it didn’t pass.
09:10
There are safe home inspections and so the mother was able to find a new home in her price range, but it’s in a more dangerous neighborhood. They comment that they hear gunshots every night. He’s not allowed to go out into the local park to play because it’s too dangerous. Td is starting to miss school quite a bit and also had to change schools due to the new home. His mother is concerned that the new school does not have the necessary support to help him in the way that’s needed.
09:42
He used to be an A student, but now he has poor grades and is behind. He’s started to not show up for appointments. You’ve contacted the mother about medical transportation and tried to set that up, but she’s canceled and says that she can drive but they still have no shows so the family has.ended up being hotline by another clinic who’s called Children Services for medical neglect due to no shows and inability to follow up. So how do you manage asthma in this patient? I think that’s the real difficulty that many of us face when trying to manage asthma with so many complexities socially and emotionally.
10:29
And so this leads into the topic, the specific topic that I was asked to talk about is access and equity. And so I think it’s important for us to start in a baseline of understanding definitions, particularly definition of equity. So this is terminology that you have likely seen in equality, equality, equity and justice. So inequality basically means that things are not equal, there’s an unequal access to what you need. Are unequal access to opportunities. And so in this case, we’re thinking about access to the opportunity for health and well-being. So equality would mean that we’re making things equal.
11:12
We’re giving each side the same thing. And so as you can see here with the figure, if your opportunity that you’re trying to reach is the apples on the tree, giving someone the same size ladder as the other person may not be able to help that person achieve that same opportunity so equity means providing custom tools that will give someone else the boost up to achieve that goal or achieve that opportunity that they need. And so, but what we’re really trying to strive and what we really need to do is yes, you know, giving the tools that are necessary. Giving someone a taller ladder is 1 important step. That the real goal is justice.
12:02
And justice occurs when you’re actually modifying the system itself. So not having to modify the person so much, but modify the system and change the system and fix the system so that each person can reach the apples on the tree and the same number of apples so each person can reach that opportunity and that opportunity for health and well-being And so in thinking about access, you know, access can mean a lot of things. I think when you initially think about it, I mean, does access mean that you’re able to get an appointment with a physician in a timely manner? That’s one way to think about access.
12:49
But when I think of access from an equitable lens, it includes much more than that. So these are some of the things that I think about on this check mark list. And I think about Equitable Access and all the factors that go into that. So I think about communities, neighborhoods and zip codes in general in this country we have healthcare deserts where there are some communities that have a significant lack of healthcare providers. They have a lack of pharmacists and pharmacies and quality Healthcare is lacking the healthcare infrastructure. Also is a big part of having access.
13:33
If you’re thinking about access to Equitable Care and the opportunity for health, our healthcare infrastructure currently is not very well equipped to address the needs of all patients, especially patients that have much complexity in their social and emotional lives. Social and economic opportunity is also an important aspect of access, so being able to take care of yourself. Economically, to be able to have work opportunities that can support you for sick leave, that can provide health insurance, that’s a big part of access to equitable health and care environment. Having the environment that you’re not disproportionately experienced to certain exposures versus other exposures, whether it’s pollution, whether it’s exposure to violence or crumbling neighborhoods.
14:32
That’s also important for access to health and well-being And then there’s intersection of institutions within our society. So if you think about medicine or the medical institution and how it intersects with things like our educational system, our judicial system, all of those things overlap to impact whether or not we have access to healthy opportunities. So this is another way to look at it as well that it’s a little bit more specific to asthma and what may lead to asthma health disparities.
15:11
So the big circle here, the big, the big yellow circle in from what you know, what I think about is kind of the starting point of where we start with thinking of systemic and structural barriers that lead to health disparities that overlap pretty much everything else. In this circle, so thinking about social disadvantage and intentional oppression of certain communities, which can lead to things like disproportionate environmental exposures, whether it’s pollution, stress or other exposures. And these can lead to changes within the body biologically.
15:50
So these can lead to changes in your DNA, where your DNA turns on or turns off certain genes that produce inflammatory markers. And that’s what we see when we see this varying what we call pathophysiology or what’s going on inside the body, what’s going on inside the lung that’s making this person more likely to have asthma or more likely to have more severe asthma or difficult to treat asthma. And so social determinants of health is another way to think about all of this. So I’m sure many of you have heard the term social determinants of health. And the World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work in age.
16:46
It’s influenced by economic, political, and social factors linked to health inequities and. It’s important here to think about and consider that social determinants of health are avoidable. They’re avoidable. Inequalities in health between groups of people within populations and also between countries. So things like poverty, housing insecurity, immigration status, early childhood adversity, these have all been types of social determinants of health that have been described. Healthequity addresses or. In order to achieve health equity you need to start at addressing social determinants of health because they are such a big driver and health equity means that everyone again has a fair and just opportunity to be as healthy as possible.
17:42
And so, as I mentioned, things like poverty have been described as a social determinant of health. And social determinants of health are the conditions where we work, live, and play. And so a few years ago, the American Academy of Pediatrics published a policy statement on the impact of racism in child and adolescent health. And in that policy statement, they describe racism as a core social determinant of health that is a driver of health inequities. In this policy statement, if you haven’t read it, I would strongly encourage you to read it because they talk about the definition of racism and in types of racism, and discuss racism from interpersonal to a structural level and how it impacts children.
18:30
Racism has also been described by the CDC as a serious public health threat that directly affects the well beings of Americans. And so again, to provide a definition so that everyone’s kind of on the same page here and understanding what we mean when we say that racism is a social determinant of health and how that functions, here’s a definition to consider. So racism is defined as a system of power and oppression that structures opportunities and assigns value based on race, leading to unfairly disadvantageing some people unfairly while advantaging other people. So again, it’s assigning value based on what we define as race or which is often related to the color of your skin. And I think it’s also important to understand and consider that race is not biologically defined. You know, we’ve completed the Human Genome project several decades ago and so we now know that we all, genetically and biologically are much more similar than we are different and so race is a social definition or a social construct that we have devised to categorize people based on the color of their skin.
19:54
And so when you’re assigning value to human life based on race and providing opportunities for some versus others, that’s what racism really is. And I think this quote from Cameron Phyllis, where she talks about how racism actually zaps the strength of the entire society, because you’re wasting human resources, so you’re discounting the contributions of some people in your society. And so I think that’s also really important to think about how it really impacts us all. And there’s different types of racism.
20:32
So there’s internalized, interpersonal, institutional, and structural. So internalized racism involves when people of minoritized identities are often people of color within the United States take on some of those negative feelings or thoughts about their own race within themselves. So one famous description of this and sometimes I’ll show. A video of this, but I don’t have time to do that today. But if any of you have ever seen the doll test where they take where in early in the nineteen sixties they did this experiment. And then again in the in the nineties they did the experiment again where they took early elementary age children and gave them dolls.
21:20
They gave them a black doll and a white doll and they asked them which doll was good, which doll was bad, which doll was smart, which doll was not. And overwhelmingly, the majority of the children chose the white doll versus the black doll as good versus bad. And so this is a stark example of how things that are picked up as cues within society become ingrained in young children early on. So that’s internalized racism. Interpersonal racism is the more common type of racism that I think most people think about, which is between. People are directed toward an individual. So things like racial slurs or racist acts, that’s inner interpersonal racism. And so institutional and structural racism are really the things that we’re talking about when we talk about it being a social determinant of health and impacting health and opportunity for health and leading to health disparities.
22:25
And so as institutional racism occurs within and between institutions. So again, if you’re thinking about the institution of medicine, the institution of law enforcement, our immigration system, so when there are biases that have been baked into and written into policies that impact people in an inequitable way, this is what again, divides opportunities based on race within entire institutions and then structural racism. Is when you have these institutions that are linked again linking the medical institution to that of the educational system. So when you have these structures that are linked, that doubly reinforces this inequity across society. So here is an example of institutional and subsequently systemic racism. So many of you may have heard of the federal policy of redlining within the United States that was put in place during the Great Depression.
23:43
The federal government passed the Homeowners Loan Corporation Act, and that act created standards to where cities and neighborhoods define creditworthiness for neighborhoods and zip codes based on whether they were a desirable area, so they find some areas as the best areas for investment, in other areas for hazardous areas for an for investment. And so across the United States, in major cities, these communities were divided up to where generally the majority black. Neighborhoods were considered hazardous versus the majority of white neighborhoods were considered best for investment.
24:30
And so that’s exactly what happened. The black neighborhoods, there were no investments, didn’t invest in them. Business just didn’t want to invest in those areas. And also banks did not want to invest, meaning they didn’t did not want to give mortgages or home loans to people that lived in those neighborhoods. So even though a neighborhood. And in predominantly black, many times those families were not able to own that home.
24:56
They were renting that home. And so we can see now today the continued impacts of that. So even though redlining is now technically illegal, it’s no longer actually a part of a federal policy. We can still see how that has left a legacy still of disinvestment in this area. And we can also tie it specifically to asthma. So this is a redlining map of Kansas City where I live. And just an aside here, the concept of redlining was actually started in Kansas City by a man named JC Nichols and he helped to disseminate this concept and get it into federal policy.
25:45
But this is the redlining map here in Kansas City. So you can see the red areas here and then this is a more recent. Map and depiction that shows all of these little red dots. And so each little red dot represents a child who has been hospitalized for asthma more than four times in one year between the dates of 2016 and 2018 And so as you can see here, these dots from current day patients having asthma, frequent asthma flare ups overlap directly with Red line. Historically red lined areas, because I know because I live in Kansas City, these are still areas where there’s disinvestment in these areas. There is dilapidated housing, there’s housing that has environmental concerns like mold.
26:41
There’s actually a major US highway that divides this east side and West side within Kansas City where you have these big diesel trucks going up along right aside homes, these areas are also food deserts and they’re also healthcare deserts as well. So this is a stark example of continued systemic and structural racism within our society that’s directly linked to asthma health disparities. Another important aspect to think about in regards to this inequitable opportunity as a result of redlining is the impact that it had along with other policies and the opportunity for wealth in our country.
27:33
So we know that there is a long standing wealth gap within our country between white households and black and Hispanic households. And you can see here from this bar graph, it’s present. This is huge and it’s very persistent. And so when we think about wealth, we’re not really thinking about just the income, the amount your paycheck is that you bring home every day, but money that’s able to be passed down. From within families, within generations. So many times that’s through property or actual funds and other assets. And so with redlining, the lack of opportunity for people who identify as black in the United States has made it for owning homes early on has made a lasting impact in the lack of opportunity for generating wealth we also saw.
28:32
Similar things happen in regards to the opportunity for education, which we also know is linked to wealth and opportunity for wealth. So this is another example where you have all of these institutions that are aligned again through policy had bias and racism embedded with them that have very long standing effects. This is a really neat figure that I was able to find from researchers from Harvard that showed the likelihood if a child is born at the bottom 20 percentile of a wealth distribution, the likelihood of them to reach the top twentieth percentile by the time that they’re an adult.
29:18
And so the proportion of white children versus black children to be able to get out of this lower bottom twentieth percentile again shows how significant this persistent health or this persistent wealth disparity gap is, and again I mentioned that opportunity for wealth is directly tied to health as well. When you think about, you know where you’re able to live, what types of jobs you’re able to have, what types of health supports you’re able to have, those things are all linked. This is another study that was published.
29:58
So you know my kind of poor man study where I just showed the red lining maps for Kansas City and the number of asthma. Hospitalizations and emergency department visits, well other researchers have done more formal study where they looked at the impact of historical red lining and emergency department visits. So this study was done in eight cities in California and so they showed here ZIP codes that were the predominantly red line areas both versus ZIP codes that were predominantly non red line areas.
30:38
Historically, they show a strong association between red lining having increased emergency department visits for asthma. So this is just kind of backing up statistically what I showed you in that earlier map comparison. We also know that inequities within neighborhoods and how neighborhoods are treated as far as redlining and exposure to things like major highways that also impacts the likelihood of being exposed to climate change, the negative impacts of climate change. And so it’s described that black and African American individuals are 40 % more likely than non black and non African American individuals who currently live in areas with the highest projected increases in mortality rates due to climate driven changes in extreme temperatures. So they’re more likely to live in areas of the country where climate change is having a more significant impact, where you have more warming as well as things like more ozone as well. It’s also been shown that in neighborhoods, particularly historically redlined neighborhoods, the temperature in those neighborhoods. They’re actually higher than other areas because you have less green space, you have less parks, you have less trees, you have more concrete and so there’s higher temperatures there is as well, which also leads to increased ozone exposure and so those types of exposures have been linked to impacts on things like lung function. So in this study, they actually looked at two types of exposure, your typical environmental exposure of pollution compounded with other exposures that may occur in these neighborhoods and communities of stress and chronic stress. And we’ll talk a little bit more about that more deeply in the next few slides, but there’s an interaction here where. In areas where there was higher ozone and pollution on top of parental stress, you had more significant impacts on decreasing lung function.
32:59
And so here we will get into talking more about chronic and toxic stress. So there’s a lot that’s been written about and described about the impact of chronic and toxic stress on health and on health outcomes. So the ACEs study or adverse childhood experiences study was done in the early nineteen eighties. And So what this study was is that it looked at significant adverse stressful experiences.
33:30
That occurred in childhood. So things like a child witnessing abuse, a child witnessing you know, or being exposed to a drug or alcohol addicted parent. And so the more number of ACEs the child had, the more likely when they grew up they would have certain chronic diseases such as heart disease such as hypertension, diabetes. But of course asthma is one of these diseases that’s been linked to aces. And so aces is a type of very significant stressor that may occur in a lifetime, but there’s also a concept of chronic stress. So many times within communities there may be day-to-day just chronic stressors. So poverty may not be this one Sentinel event, but I’m living through poverty and all the challenges that go through go with that on a day-to-day basis is a chronic stressor.
34:30
So several studies have shown that chronic stress and toxic stress and anxious leads to increased risk of asthma and poor asthma outcomes. So in one study, they described that having four more ACEs leads to two times more likelihood of having asthma and other allergic conditions. And you’re also more likely to have other comorbidities, such as obesity, learning and behavior problems, and depression, which these compound on top of having asthma. To likely lead to increase asthma morbidity. And so we did a study to look at ACEs and their impact on early childhood.
35:16
And so we did a study where we worked with operation breakthrough here in Kansas City. It which is a Community Center and help and head start program that serves underserved children and families here in Kansas City. And so this is a community of children and families who were known to. Be dealing with lots of aces. So this shows the distribution of aces within this operation breakthrough community of children and Family. So a large group of these families are dealing with many aces in their lives. And so we looked at the association between ACEs and other chronic stressors as well and asthma control.
36:09
That’s defined by the asthma control test questionnaire and the association between having these chronic stressors and whether or not the child’s asthma was controlled or not controlled. So we looked at things like housing insecurity, food insecurity. We also included a questionnaire called the Crisis Questionnaire which looked at lots of day-to-day stressors. So whether or not you had a job or not, or whether you lost a job or gained a job, just kind of the day-to-day stressors.
36:41
But one of the things that. Add it to the study when working with their parent Community Advisory Board was we added measures of racism within the life experiences of the parents. And this really came out of discussions with the Community Advisory Board about their day-to-day life and the things that they were dealing with. And so one of the striking things that kept coming up in the conversation was racism that they were dealing with in various ways and how that was. Impacting them as a chronic stressor. So we included a questionnaire assessment of experiences of racism within the parents lives.
37:24
And what we found was this was the chronic stressor that was most associated with poor asthma control. So in parents who described frequent and significant experiences of racism as a stressor, their children were more likely to have. For asthma control, we’re actually following this study up and we’re doing a larger study in children that are coming into our emergency department for asthma flare ups and looking at how this stressor may impact them biologically. So what are some of the changes that may occur from a DNA and an RNA level and how that may make them more likely for viral illnesses, which we know is a is a big driver of asthma in children. This is another study that we did kind of getting away from thinking about chronic stress so much. But another structural driver is access in general. So whether or not you have healthcare in your community. So this is a study where we looked at the association between COVID-19 rates across the country and whether or not there was access to primary care, so is everyone, you know, likely knows and heard on the news when COVID-19 first started that there was a big disparity in between racially and ethnically, with people who identify as black and Hispanic more likely to get COVID, more likely to have severe COVID and die from COVID.
39:06
And so lots of factors were discussed. And like I’ve mentioned before, there is no biological reason, baseline biological reason, those disparities exist. And so people started thinking about more. That the structural drivers there, so one of the things we didn’t want to look at was actual access were these populations living in neighborhoods that were healthcare deserts. And so that’s exactly what we found. So we looked at ZIP codes and we define them as racially or ethnically advantage versus disadvantage based on the racial makeup. So racial and ethnically advantaged neighborhoods were predominantly white neighborhoods and so what we found were that racially and ethnically advantaged ZIP codes had on average 108 more primary healthcare provider providers available than those in disadvantaged neighborhoods.
40:02
And we also show that when primary healthcare provider number decrease COVID-19 incident ratio increase. So there was a direct correlation or association between the number of healthcare providers and having COVID-19 and I think this can apply for you know certainly. For a thing like COVID and a pandemic, but certainly for our chronic conditions like asthma. So if you live in a neighborhood where there’s lack of access you’re not able to seek care appropriately and many times the healthcare there may not be adequate to treat that entire population. And I think a big part of this and in thinking about you know OK, what are you know we’re thinking about the health disparities, what are the drivers.
40:50
We know we have these healthcare deserts within our community. What are some of the reasons we have these healthcare deserts. So we talked about redlining as one of them and the disinvestment in communities, but also we need to think about our healthcare workforce as well. So this yellow and. Blue bar graph here shows the representation of physicians within the United States compared to the general population. So the blue is your general population then, and the yellow is the percentage of physicians.
41:28
And so you can see here that again there’s stark disparities where people who identify as Black and Hispanic as well as other racial groups such as Native American and Alaskan natives, they’re sorely. Underrepresented, especially for black and Hispanic when compared to the general population. And so the reason that this is important is because people that are from those communities who grew up in those communities that are now healthcare deserts, they’re much more likely to go back to those communities and provide care there.
42:05
So this is one way that we could help to close at least some of the access gaps, and looking at specifically the allergy immunology workforce. It reflects the same thing where again, people identify as Black and Hispanic are sorely underrepresented within allergy specialists in the United States. And you know, we have trainees that are coming along, but that gap is still not closing. So it was reported in a recent article published in JACII in practice that in 2019 and 2020 of the 278 New Fellows.
42:42
And in allergy training only 1 8 % identified as black and 6 8 % identified as Hispanic. So we need to do a much better job at diversifying our pathway of allergists and other specialists so to rid us of these health deserts. Another thing that goes along with that is also clinical trial inclusion. So we know that participating in a clinical trial actually does improve health outcomes many times, but also it’s important to make sure that we are creating data that’s informative for our general population, especially creating data that is addressing the populations that are often most. Impacted by acute and chronic disease. So clinical trials and translational research are the things that give us medicine.
43:43
They give us new diagnostics, new tests and new therapies. And so it’s widely known that there’s a lack of inclusion of people who identify as racial or ethnic minorities within NIH funded research and also industry research. So this is data from Esteban Richard that talks about the fewer than. 5 % of lung disease studies funded by the NIH over the past two decades have included statistically meaningful number of participants from racial and ethnic minorities. So there may have been a few in the study, but there really wasn’t enough in the study to make any conclusions about whether a certain tool or intervention works in that population.
44:30
These are just some studies that we’ve done to kind of show some of the same things. So this is a study we did where we looked at the new biologics that had come out to treat asthma and looked at representation within those studies. So you can see people who identified as black or Hispanic or sorely represented or sometimes not represented at all in these trials.
44:55
The same thing, we recently presented this abstract at the American Academy of Allergy Immunology meeting where we looked at the clinical trials that informed the new NHLBI asthma guideline update and again show here that overwhelmingly the majority of these clinical trials included people who identified as white as the majority group. We also looked at US trials only initially when we looked at this we said. Ok. Well, there’s half representation of people identify as black within the six US trials. But this was really driven by one study that enrolled a significant amount of black or African American participants because that was the focus of the study.
45:40
So they enrolled a thousand participants. So that skewed those results. And so if you take that away again there’s a disparity and then we broke down the studies of whether there were pediatric studies, adult only studies or combined pediatric and adult studies and. Again, people identified as white were predominantly. Represented within clinical trials and some groups such as Hispanic populations were not represented hardly at all, particularly in our pediatric and pediatric and adult combined studies.
46:18
We’re at about 10 minutes to the top of the hour. We do have questions. So if OK, sooner we can get to those the better, OK, I will try to speed through. So this is the same thing pretty much. We looked at food allergy immunotherapy trials and so i did want to talk a little bit also about the concept of race based medicine as well. So you know it’s important to have racial diversity and clinical trials, but we cannot think of race as a biological.
46:47
Construct and it should not be used as a variable to actually predict treatment because race is not biologic, it’s a, it’s a social term. And so within algae immunology we have this issue that we have yet to deal with is with spirometry, which is one of the mainstays of how we diagnose and follow asthma where race is built in as a factor. When you measure spirometry, so if you do spirometry measurements, you have to put in a race.
47:23
And if you put in the race of black, that automatically leads to a lower prediction for FEV1 and for lung function. And this has been baked into this historically, and it’s been baked in historically due to dehumanization of black people to justify enslavement. And we’ve yet to remove this from our current diagnostic tools. And so again, this is another example of how there is baked in bias within our institutions within the way that we practice medicine. That again leads to the health disparities that we see.
48:07
So this is just kind of going back to the case of TD. I hope you’ve been able to kind of think about some of the things and how those things might apply to his case. I’m not going to go through this. I’ll just skip this one here. You know there’s, this is a lot. So really they kind of get to like what can we do about this. I think it comes from many levels. It can come from the patient oriented level, community level, the system and policy level. I think we could pick any level and start at them or start at them at all at the same time.
48:40
It’s really what we need to do and I think that what we really need to do is recognize and grain legacy of inequity and address systemic and institutional racism. On an individual level, whether it’s thinking about what our healthcare workforce looks like, our research workforce, individual bias that may occur within providers systems, our medical system, our educational systems and other systems and then where is it built, built into steel policy that leads to inequity and opportunity. So with that here are my conclusions. So these disparities are striking. The gaps are not closing, the disparities are not due to inherent biological or individual factors and they exist due to long standing historical and current structures and system of oppression in equitable opportunity and racism.
49:33
So closing health disparity gaps will take a multi prong institutional to individual level anti racist approach and justice. Is the goal. So with that, I will thank you so much. Appreciate all you had to say. I’m sorry, had to rush you a little bit at the end. You’ve got just great information to share. We do have several questions. One person first started out with a comment that said this topic is so on point as CVS recently closed in the area near our school, which is another way access is limited.
50:13
So and then our next question is what about equity in diagnostic excellence and shared decision making. These are things that clinicians and allergists can start doing today. So how do you see the inequities entering into that diagnostic process? Yeah, I think you know you know one part was the what I’ve mentioned with the spirometer of how that’s a problem in our field that we need to address but also you know when thinking about the individual level, patient level ways that you know we might contribute to in equity. So making sure that you staff are able to approach patients from a culturally aware level where you’re understanding or have some understanding of the background and the complexities that people may be dealing with, understanding of some of the experiences that they may have had within the healthcare system, which you know oftentimes are not positive. Some of the their own biases they may be bringing into that office when they see you.
51:21
And so I think you know being able to take the time to have a culturally aware approach for patients I think is a major step that you know any provider or healthcare worker can implement in their daily practice. Thank you so much. We have a question from Morgan who asks what ways do you recommend to help a patient that does not follow up with appointments? Yeah that’s the million dollar question because there could be multiple, you know, reasons why they don’t follow up and you know and I really, you know, it’s difficult you get annoyed because they’re not coming to their appointments.
52:04
But you know I’ve been surprised many times when you know I’ve looked out the window or driven by and seeing one of my patients leave and they’re getting on the bus you know, with their stroller and their three other kids. And so I think that you know screening for things like. Social determinants of health consistently within clinics is one way to maybe identify some of those barriers that may not be readily shared with you.
52:28
So making sure that they have transportation, making sure you know that they’re not, they’re not food insecure. You know, sometimes parents have to work if they have to choose between, you know, putting food on the table versus bringing their child in for an appointment, you know, that’s a tough, tough. Our decision to make. So I think that you know it’s usually multi pronged the reasons why that occurs and I think one way is making sure that we’re screening for social determinants of health and at least trying to meet those needs if we can. Thank you so much. The next question is what is being done to address the lack of mental health services for children’s adolescents and families in this country? Yeah, that’s also, you know I don’t think I have a good answer for that because you know i feel like even before the pandemic we were struggling with mental health and we know that you know in the case that I showed you know in many of my asthma patients especially patients with severe asthma, there’s always a mental health component and the resources that we currently have are not adequate.
53:40
Our workforce currently is not adequate. You know, with the pandemic we have been able to start to take advantage of some of the things that have come out of it, like telehealth, which can provide more access to mental health services. But we still don’t have enough providers. And even with having telehealth it that may not be the best way either to reach everyone. So solutions that you know have been discussed or starting to be discussed more or you know, embedding those types of things, especially for children and into schools.
54:14
And putting stronger mental health resources there. But you know, we’re currently within a, you know, an epidemic or a pandemic within a pandemic with what’s going on with children and mental health. Well, I think for so many years we’ve been so focused on physical health. Mental health has to, we have to make sure that gets caught up too. So our last comment, our last one isn’t a question, it’s a comment. And she says thank you for your courage in addressing topics no one wants to acknowledge.
54:49
So thank you so much to Doctor Jones today for joining us. Appreciate that so much and appreciate all of you who have tuned in today to listen. On our next slide, you’ll see that you can join us for our next. Advances in allergy and asthma webinar which will be on new treatments and atopic dermatitis. This will be on June 22nd at four o’clock PM. You can register on our website at allergyasthmanetwork.org Also at this time, please download the certificate attendance from your control panel.
55:26
If you have any difficulties, please email us using the link in your emails. Visit our website for quality guidelines based resources on allergy and asthma also. Access important medical information on allergies and asthma from our partners, the American College of Allergy, Asthma and Immunology and Allergy and asthmarelief.org Thank you again for joining us and we look forward to having you register to be with us next time on advances in allergy and asthma. This is Sally Schoessler for the staff at allergy and Asthma network. We’re glad you joined us today for an in-depth look at access and equity issues in asthma care, please join us next time.
56:06
Have a great day. Thank you.
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