| Fall 2001;
Volume 2, Number 2|
Physicians’ Asthma Prescribing Habits: Challenges to Popular Therapeutic Narratives of Racial Disparities in Asthma MorbidityJennifer Clark
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Black children are three times as likely as whites to be hospitalized for treatment of asthma...blacks are rushed to emergency rooms for asthma attacks at more than four times the rate (19.1 visits per thousand population) than whites (4.5 per thousand) or those of other races (3.9 per thousand).1
In the early 1990’s, partly in response to increased media and political attention to public health and diversity, a series of unrelated epidemiological studies attempted to verify and quantify newly perceived disparities between black and white health outcomes. The results of several surveys demonstrated significant disparities in health outcomes of diseases that included kidney disease, cancer,3 heart disease,4 obesity,5 diabetes,6 and childhood asthma. Statistics on childhood asthma seemed to particularly capture the media’s interest. The medical community had witnessed a disturbing 61.2% increase in asthma prevalence since the early 1980’s and an almost two-fold increase in deaths due to asthma attacks.7 At the same time, the gap between the prevalence of asthma in whites and blacks widened, with blacks eventually making up only 12.7% of the population but 22% of asthma patients.8 At first, these compelling statistics alone made up the content of most media citations on asthma. But in the last few years journalists, health advocates, and medical researchers have taken a particular interest in explaining the sources of these health outcome disparities via paradigms that diverge from the purely biomedical. This paper examines the narratives that have been developed in such articles, and uses data from the 1998 National Ambulatory Medical Care Survey to challenge widely held beliefs about the source of racial discrepancies in asthma morbidity.9 Explanations of elevated black asthma morbidity take one of three forms. The least politically popular narrative seeks ethnic variation in genetic predisposition to or experience of asthma to portray asthma as a disease similar to sickle-cell anemia in its ethnically unequal distribution. Other accounts seek to correlate asthma morbidity to another condition or situation which is distributed unequally among blacks and whites accounts in this vein, in general, seek to explain a great degree of minority health disparities in one illness by pointing out that the difference actually reflects a disparity in another statistical reality or condition that has a nearly 1:1 comorbidity relation to asthma.
Accounts in the third vein identify culturally motivated patient noncompliance and/or physicians unwitting ethnic insensitivity as the source of discrepancies in the experience of asthma. The strategy of narratives in this category is to identify a particular cultural practice among black children or their parents that leads to noncompliance with therapy and then provide some judgment of how the cultural practice can be adjusted to be more in line with biomedical practice. Two oft-cited strategies are educational programs for minority families and cultural competency training for physicians. This latter narrative is capturing public imagination and discourse and gradually overshadowing earlier comorbidity and ethnic genetic variation narratives to become the focus of political and medical programs to eliminate racial health outcome disparities.
The popular explanation for differing rates of asthma morbidity focuses on cultural and social factors leading to disparate patient reactions to uniformly administered medical care. If this narrative accurately portrays the patient/doctor/society interaction that leads to increased asthma morbidity in black children, then statistical surveys from the late 1990s should show physicians providing relatively equal medical care to both black and white patients (especially when controlled for certain socioeconomic factors). Analysis of self-reported data on the prescribing habits of physicians who participated in the 1998 National Ambulatory Medical Care Survey, however, indicates large disparities in the primary drugs prescribed for asthma patients.10 Black asthma patients are routinely given fewer prescriptions that white asthma patients. Surveys previously interpreted to indicate patient non-compliance or voluntary underuse of medications may actually have been recording differences in the type and number of drugs prescribed to white and black asthma patients. The source of explanatory theories of these discrepancies that is, medical and public health researchers may be largely responsible for the failure to yet turn the statistical eye on physician behavior or consider the possibility that, even in the 1990s and today, medical care might be provided unequally to black and white asthma patients.
Genetic Variation NarrativesThe number of studies which have seemed to show statistically significant variations in genetic predisposition to asthma are few, although such studies continue to be scientifically popular to the present despite their politically incorrect implications. Notably, a May 2000 study in Chest concluded, based on a variety of genetic tests, that black children could be genetically predisposed to develop asthma.11 A recent study by Xu et al. supports this data, demonstrating small but statistically significant differences in asthma susceptibility across families and ethnic groups.12 In general, however, politically popular scientific narratives that seek to show greater genetic variation within, rather than across, racial groups are fairly successful in demonstrating that genetic differences between races can account at most for only a fraction of disparities in health outcomes.
Comorbidity NarrativesComorbidity is a medical term that refers to certain illness contributing to or being partially caused by other illness for example, diabetes, heart disease and obesity are all considered comorbid conditions. In the case of racial disparities in asthma morbidity, the comorbid conditions may be either medical or socioeconomic/geopolitical conditions. Arruda et al., in their review of cockroach allergens and asthma, ascribe heightened asthma morbidity to cockroach allergen exposure within the first three months of life, postulating that poorer housing conditions among African Americans is the true source of discrepancies in asthma morbidity.13 Brooks et al. report a strong correlation between very low birth weight and severe asthma symptoms, pointing to a greater prevalence of very low birth weight babies among blacks as a major determinant of disparity.14
Popular media coverage often exaggerates the extent to which such studies invalidate discrimination or substandard care hypotheses. For example, studies throughout the 1990s, including an early study by Weitzman et al.15 and a recent study by Fagan et al.16 , have reduced or eliminated racial disparities in asthma prevalence by controlling for socioeconomic status. A May 1999 survey published in The Journal of Asthma examined the distribution of asthma hospitalizations in New York state by zip code and concluded that rates of hospitalization because of asthma were generally higher in the zip codes with higher proportions of poverty, unemployment, poorly educated residents, African-Americans, and Hispanics.17 The New York Times take on this study, however, places the authors in opposition to the earlier literature cited in their article and suggests that the authors are dismissing earlier theories on substandard minority care, lack of access to care, and environmental factors due to lack of evidence.18 The concentration of hospitalizations in poor zip codes of New York City is presented as data that explains away the results of earlier studies, rather than as data that contributes to a more complete understanding of the dynamic of asthma morbidity (the authors stated intent).
Similarly, in a fall 2000 study with similar methodology, lead author Andrew Aligne specifically stated that he hoped to challenge public perceptions that asthma is something thats related to race, in the way sickle cell anemia is19 but the lead-in of the same article in which this comment appeared gave a much more simplified view of the dynamic:
Federal studies have found a 20 percent higher incidence of         asthma in black children than in whites. But a new study               suggests that this may be missing the point.20
Again, the purpose of the study moves from clarifying and        enhancing earlier studies of race and asthma to dismissing             them as beside the point.
Studies on asthma prevalence by zip code led to hypotheses that location of residence was a greater risk factor for asthma than socioeconomic status. A September 2000 study by Aligne et al. revealed that both urban poor and urban non-poor children were at a greater risk of developing asthma than were non-urban poor children.21 Data from Lamphear et al.s March 2001 Pediatrics article seems to support Alignes theory.22 It is important to note that these studies all focus on eliminating racial disparities in prevalence by controlling for socioeconomic or geopolitical factors. However, equalizing prevalence does not necessarily equalize the burden of disease. Within socioeconomic and geopolitical groups, blacks are more likely to have acute asthma attacks, more likely to be hospitalized for asthma, and more likely to die from a severe asthma episode. In order to account for this unequal burden of disease, explanatory narratives must move beyond simple comorbidity explanations of disparities in prevalence.
The Compliance NarrativeCompliance narratives generally take the forms of inquiries into cultural or ethnic differences that may serve as barriers to appropriate medical care. In medical literature, this quest has often taken the form of discussion of cultural competence, the underlying idea of which is that noncompliance is largely motivated by cultural differences between physicians (and biomedicine in general) and patients. The idea of cultural differences affecting the way patients react to the self-care demands of biomedicine is a theme that seems to have captured public and professional imagination recently. Anne Fadimans The Spirit Catches You And You Fall Down, a text chronicling the epilepsy experienced by a Hmong child constantly slipping through what Harvard professor Mary Jo Good has called the biomedical embrace and perhaps one the first and longest media investigations into cultural competency has enjoyed widespread popularity and is in large part responsible for bringing issues of cultural barriers in medical care to public attention. Medical societies, medical schools and hospitals across the country have been rushing to establish committees on cultural competency and to investigate and inform the extent to which physicians are delivering culturally competent care. The AMAs extensive investigations and reports on cultural competency clearly attest to this popularity. The purpose of these committees, however, is not to advise physicians on how to better or more equitably deliver biomedical care, but how to structure their dialogue with patients to elicit desired reactions and compliance. In other words, the patients are portrayed as mixed up or chronically misinformed and physicians are trained in how to mediate this issue.23
As early as 1993, researchers were investigating potential ways that black patients attitudes toward asthma might contribute to their increased rates of acute asthma episodes.24 Although the study in question was more interested in correlating attitudes with socioeconomic and other factors, later studies became more specifically focused on identifying black patients (and their parents, in the case of children) misperceptions as the source of asthma disparities. An early 2000 study sought to explain higher functionality morbidity in black asthma patients in terms of caretakers [overestimating] the level of adolescent involvement in asthma self care.25 In this study, and in an earlier study on perceived control of asthma, black patients were portrayed as ignorant of or unable to adhere to the advice and information physicians had clearly provided.26
The attitudes toward racial disparities presented in these studies carry over into the media investigations of disparities in health outcomes. Articles constantly stress the difficulty of teaching black patients how to manage asthma:
Two years ago, federal health officials recommended the              daily use of inhaled corticosteroids to control asthma in                people with moderate or severe disease. Experts say the              medicines can reduce emergency room visits,                               hospitalizations and deaths. But only half the eligible                     patients use them.27
The implication here is that all eligible patients are being prescribed inhaled corticosteroids, but that not all carry through the physicians orders to fill the prescription or use the medicines regularly. Although the article goes on to briefly suggest that not all physicians may have accepted the idea of long-term asthma management (and thus may in general prescribe short term over long term therapies), the remainder of examples cited portray black parents who, for a variety of imputed reasons, did not buy recommended medicines and continue to treat their childrens asthma through acute care and hospitalization.
Other articles on recent increases in asthma point to the slow adoption of new standards expressed in a 1997 federal document on asthma management which portray the disease as chronic rather than as a string of acute episodes: what we dont want is for families to have to go to the emergency room and hospital.28 Some articles focus on success stories - tales of individual parents whose children once had their asthma treated through emergency room visits but who were educated on the correct way to manage asthma. These accounts seem to suggest a sort of stubbornness or latent skepticism in the patients and their guardians. A mid-1999 Washington Post article cites one recommendation of such an educational program, and then proceeds to describe the parent in question clearly ignoring this recommendation, sending her child outside on a bad air day.29
The most recent in a spate of similarly veined articles was published in the New York Times on May 13, 2001. The article, Breathless, touches on a variety of potential triggers for asthma - including indoor pollution, cockroaches, and the stress of inner-city living - before settling on its most important issue: compliance.
All too often, parents treat asthma as an acute, not a chronic, problem. Children gasp, parents want to help, and an emergency room visit works...How to make sure patients keep taking their anti-inflammatories comes up often in talking to doctors in East Harlem. If they would take their medicine, they wouldnt need to go to emergency rooms, and they wouldnt get sick.30
The attitudes expressed in this article may have been due in part to a mid-2000 study of medication use among asthmatics in East Harlem.31 The study surveyed parents of asthmatic children (as identified through school programs) regarding the medications their children took on a regular basis. Not surprisingly, the study found that black patients were more likely to be hospitalized for acute asthma episodes and less likely to use anti-inflammatory medicine on a regular basis. The explanation for this difference, however, was that social and cultural factors were preventing these patients either from getting to a physician for regular asthma care or from taking anti-inflammatory medications on a regular basis.
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