Addressing Structural Racism with Asthma Research

Neeta Thakur, MD, MPH

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Current research demonstrated the neighborhood conditions experienced by Black and Indigenous communities in the US are a result of historical policies rooted in structural racism and oppression.

Neeta Thakur, MD, MPH, and Adali Martinez, MD, MPH, from the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, wrote an editorial reflecting on the investigation led by Craig Evan Pollack, MD, MPH, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health.

Despite a growing body of evidence linking asthma disparities to structural racism, a recent editorial highlights the limited number of studies explicitly naming or intervening in this root cause to improve asthma outcomes. Thakur et al. emphasize the crucial importance of identifying and addressing racism and its associated policies and practices as the underlying factors contributing to these disparities.

However, there has been limited guidance on how to target meaningful interventions and develop or evaluate them effectively. When considering structural racism interventions, investigators stressed the specificity in identifying the most impactful changes.

These policies have shaped physical and social environments, leading to negative health outcomes, including a higher prevalence of asthma in these communities. One example of discriminatory practice is residential redlining, which marked predominantly Black neighborhoods as hazardous investment areas.

These practices have intensified asthma disparities by exacerbating the concentration of poverty, heightened exposure to environmental hazards, and substandard housing quality in these communities.

Addressing the Racism that Accompanies Asthma

In Pollack et al., investigators examined whether participation in a housing mobility program could lead to reduced asthma morbidity among children living in predominantly Black low-income neighborhoods in Baltimore, Maryland. The study focused on participants enrolled in the Baltimore Regional Housing Program, which aimed to counter discriminatory housing practices by providing residents with housing vouchers to move to more resourced neighborhoods.

The prospective cohort analyzed 123 children with persistent asthma enrolled in the housing program. With the assistance of vouchers, most participants moved to higher-income neighborhoods with fewer Black residents and increased opportunities.

Pre-post analysis revealed a significant 54% reduction in the odds of asthma exacerbation, along with a similar reduction in symptom days. These main findings were further strengthened through a propensity-matched cohort analysis, enhancing the internal validity of the results.

Mediators of Asthma

The investigation also assessed several indoor environmental factors as potential mediators of the association between moving and improved asthma outcomes. While indoor particulate matter concentrations did not significantly change, median concentrations of mouse and cockroach allergens decreased after the move.

However, these changes were not found to mediate the observed decrease in exacerbations and symptoms. Psychosocial stress factors such as perceived social cohesion, daytime and nighttime safety, and urban stress were identified as the primary drivers of improved asthma outcomes.

The success and limitations of the Baltimore Regional Housing Program as a structural racism intervention for asthma can be analyzed using 2 conceptual frameworks. The editorial stated Camara Jones' approach to anti-racism emphasized the naming of racism, understanding how it operates, and organizing and strategizing to address it.

Additionally, the Racism as a Root Cause (RRC) framework developed by Malawa et al. provided guidance on intervention design, prioritization of racialized groups, a focus on policy and system changes, institutionalization and sustainability, and redressing historical injustices by reallocating resources, power, and opportunities to marginalized groups.

“Researchers can best work to reduce or eliminate health disparities by taking a step beyond identifying associations between race and health outcomes,” Thakur wrote. “They can move the field forward by acknowledging the pervasiveness of racism in causing adverse health outcomes and addressing the root cause.”

References:

1. Thakur N, Martinez A. Housing Reparations as an Avenue to Counter the Impact of Structural Racism on Asthma. JAMA. 2023;329(19):1645–1647. doi:10.1001/jama.2023.7242
2. Grossi G. Housing Mobility Program Transforms Asthma Management in Children. HCPLive. May 17, 2023. https://www.hcplive.com/view/housing-mobility-program-transforms-asthma-management-in-children