Science / Medicine : Apparent Increase in Asthma Deaths Generates Concern

A curious and disturbing medical trend has caught the attention of physicians who treat and study asthma: Despite dramatically improved understanding and treatment of the disease, deaths from asthma appear to be rising.

There is little agreement on what might be causing the increase, which comes at a time when the death rate for most diseases is dropping. Undertreatment, overtreatment, emotional turmoil, even smog are among the possible influences being studied.

But some researchers suspect that asthma is becoming more deadly simply because doctors and patients are failing to take it seriously. They say that physicians have treated asthma lightly and that patients have put off treatment in some cases until it is too late.

“The reason there is so much concern is we believe deaths from asthma are preventable,” said Dr. Homer Boushey, a professor of medicine and specialist in asthma at UC San Francisco. “ . . . We need to change the way we think about asthma.”

Especially perplexing to some experts are the figures among blacks.

Higher Rate

Blacks are nearly three times more likely than whites to die of asthma, even though asthma itself is only slightly more prevalent among blacks, researchers say. According to one researcher, the death rate is seven times as high as among comparable whites.

Some scientists believe that the disparity reflects inequities in access to the kind of steady medical attention often needed to keep asthma under control. Because there is no reason to believe that the disease is significantly more severe or more prevalent among blacks, they say the reasons appear to be socioeconomic.

“I think it certainly raises questions about whether people have greater access to medical care now than they did eight or 10 years ago,” said Dr. Floyd J. Malveaux of Johns Hopkins University. “ . . . Certainly those with chronic diseases may be worse off.”

Asthma is a chronic breathing disorder often triggered by exposure to pollen, dust or other allergens. It may affect as much as 5% of the population in the United States. In more than half of all cases, it is diagnosed before the age of 17.

Death from asthma remains relatively rare in the United States: Just 3,670 people died of it in 1986, according to federal figures. But with hospitalizations also rising, some experts wonder if the death rate suggests asthma is becoming more common and more severe.

According to the National Center for Health Statistics, the asthma death rate rose from 0.9 per 100,000 population in 1976 to 1.5 in 1986. The most recent figures available show the rate among blacks rose from 1.5 in 1976 to 2.8 in 1985.

Increased deaths have also been reported in New Zealand, France, Sweden and Great Britain.

An asthma attack is believed to occur because a person’s airways become unusually sensitive to stimuli. When triggered, they respond by narrowing and secreting mucus. That constriction, in turn, provokes wheezing, coughing and a suffocating sensation.

Initial attacks tend to be treated with the use of inhalers--devices that deliver medication that dilates the airways by calming bronchial muscle spasms. Most attacks last less than an hour. But in serious cases, they can recur with increasing severity over many weeks.

Over time, inhalers may become less and less effective. So a common treatment for severe and chronic asthma is steroids to reduce inflammation of the breathing passages. Without treatment, a severe attack can lead to death by suffocation.

Asthma is the leading cause of absenteeism among schoolchildren, researchers say. Its economic consequences include lost work time among parents. One study found that caring for an asthmatic child can consume up to a quarter of the income of a low-income family.

“People think that asthma is a very mild disease,” said Dr. Erwin Gelfand, chairman of pediatrics at the National Jewish Center for Immunology and Respiratory Medicine in Denver. “In fact, it is a very serious disease in terms of potential mortality and loss of work and school.”

The most common explanation for the apparent rise in deaths is undertreatment resulting from the failure to recognize the potential severity of asthma. Patients, as well as doctors, are to blame, researchers say.

Physicians, they say, sometimes fail to recognize asthma. There is no easy diagnostic test, and the condition can be mistaken for others. Some physicians also fail to refer patients to specialists for reasons, one researcher said, “of ego or economics.”

For example, some health plans without specialists on staff may delay referring a patient to an outside specialist if it will cost the health plan money, Malveaux said. He said he believes that the denial of access to specialists “has made a tremendous difference.”

Patients, meanwhile, have delayed seeking care. Some are unprepared for severe attacks. The proliferation of inhalers to dilate the bronchial airways has created a false sense of security, leaving patients uncertain about what to do when an inhaler no longer works.

Boushey of UC San Francisco blames “our collective mythology” about asthma.”

“Americans think of asthma as a psychosomatic disease,” Boushey said. “ . . . People are reluctant to bring their children to medical attention. Others believe it’s a sign of character weakness that they shouldn’t acknowledge.”

Emotional factors may, in fact, play a role in some asthma deaths, researchers suspect.

Dr. Bruce D. Miller, a psychiatrist at the National Jewish Center, became interested in asthma deaths after a number of his patients died. So he and others compared the lives of 12 children who had died of asthma and 12 who had a “near-death experience” but lived.

The researchers found several factors more common among the children that died, Miller said in a telephone interview. They included a condition of hopelessness or despair, severe family disturbance and an extreme sensitivity to separation or loss.

Miller then considered why depression or despair might contribute to a child’s death: Had those children given up and stopped taking the precautions needed to control their asthma? Was it “a passive form of inflicting self-harm,” a kind of small suicide?

Miller also wonders whether the children’s emotional state might have triggered physiological changes. They may have become more sensitive and less resistant to factors that trigger asthma, Miller said, though he pointed out that such explanations are speculative.

“It doesn’t take much imagination to look around today at increases in teen-age suicide and the stresses children are being asked to endure,” Miller said, referring to such things as the high divorce rate and peer pressures. “ . . . It’s understood that our society . . . is really under a great deal of pressure.”

Other Explanations

Other researchers have explored additional explanations for the death rate.

Dr. Eugene D. Robin, a professor of medicine at the Stanford University School of Medicine, suspects that the use of multiple prescription drugs to treat asthma in a single individual may be blamed in part for the high percentage of asthma deaths among older people.

Some of those combinations may be toxic, Robin suggested, acknowledging that his theory is difficult to prove. He also suggested that the medications administered through inhalers can, at high doses, cause a rapid or irregular heartbeat that may eventually prove fatal.

Another researcher, Peter Guarnaccia, a medical anthropologist on the faculty of Cook College at Rutgers University, has examined asthma rates among Puerto Ricans in the Northeast and has concluded that they too appear to have a disproportionately high number of cases.

Guarnaccia said one explanation may be the effect of migrating from rural areas in the tropics to urban areas in the often-frigid Northeast. He is also interested in the influence of cockroach dust and other allergens in deteriorating housing and the effects of crowding.

Ozone Examined

Canadian researchers have examined concentrations of ozone and particulate matter in summer haze in midwestern and eastern Canada and the United States and have raised the question of whether there might be a link between ozone levels and hospitalizations for asthma.

Dr. Michael Kaliner, head of allergic diseases for the National Institutes of Health, said, “We seem to be getting a more allergic population than in the past.”

If true, that may partially explain the rise in asthma deaths, he said.

A few researchers said they have yet to be convinced that asthma deaths are truly rising. They and others pointed out that the rise may in part be a statistical fluke caused by a change in 1979 in the international code used to classify asthma for record-keeping purposes.

It is possible that conditions that previously were classified as other respiratory diseases are now being classified as asthma, some said. Asthma also may be listed as the cause of death in elderly people who in fact die of other respiratory conditions, some said.

“I don’t think the data in this country are sufficient to be confident that there is a real increase in asthma mortality,” said Dr. Benjamin Burrows, a professor of internal medicine at the University of Arizona.

“I think what’s fair to say is that people are disturbed that with all the new ways we have of treating asthma, there has not been a gross decline,” Burrows said. “And there may have been an increase, though it’s not very convincing.”

Late last year, a task force on asthma mortality convened by the National Heart, Lung and Blood Institute; the Food and Drug Administration, and the American Academy of Allergy and Immunology issued a series of recommendations to legislators, researchers and physicians.

The recommendations included a call for improved information on the extent and severity of the disease worldwide, postmortems in the case of all asthma-related deaths and new studies into the use of asthma medications and the most effective treatments.

The group also called for improved education about asthma for medical professionals--from medical students and family physicians to medical examiners and pathologists.

ASTHMA DEATHS ON THE RISE

The death rate for asthma has risen slightly in the last 10 years, but alarmingly so for non-whites. Blacks are nearly three times more likely than whites to die of asthma, even though asthma itself is only slightly more prevalent among blacks. Death rates, shown in parenthesis, are calculated per 100,000 population.

1985:

Total deaths 3,880 (1.2%)

Whites 3026 (1.0%)

Blacks 778 (2.8)

Other 76 1975

Total deaths 1,961 (0.9%)

Whites 1,515 (0.8%)

Blacks 446 (1.6%)

1965

Total deaths 4,137 (2.1%)

Whites 3,499 (2.0%)

Blacks 738 (3.1%) Source: National Center for Health Statistics DEATHS BY YEAR

Per Year Deaths 100,000 1976 174 .79 ’77 165 .74 ’78 187 .82 ’79 275 1.18 ’80 348 1.46 ’81 349 1.44 ’82 386 1.57 ’83 486 1.87

DEATHS BY SEX MALE

1976: .53 (per 100,000)

1983: 1.54

FEMALE

1976: 1.03 (per 100,000)

1983: 2.30

(Statistics compiled from statewide death certificates by Dr. Gary Rachelefsky, Dr. Charles E. Lewis and Mary Ann Lewis of the UCLA faculty.)