Researchers Evaluate Racism as a Factor in Underestimation of Atopic Disease

Racial and ethnic populations may face a higher burden of atopic and allergic disease, including eosinophilic esophagitis (EoE), food allergies, and asthma, and accessing care for these illnesses appears complicated due to the impact of racism and oppression as contributing factors in social determinants of health (SDOH), according to researchers.

Focus on SDOH, including education, income, and neighborhoods, has broadened since 2020 to include systemic racism as a component of negative health outcomes. In The Journal of Allergy and Clinical Immunology: In Practice, researchers published results of a scoping review to explore what is known about health care for allergic disease in “structurally oppressed racial and ethnic populations.”

The authors said they conducted the review because they wanted to understand the impact of racism on allergic disease, which is prevalent in affluent Western countries with socioeconomic divisions, and the impact of disease in other groups may not be fully captured by existing literature.

The review, conducted according to scoping review guidelines, used 3 databases (Scopus, Ovid, and CINAHL) and 4 relevant gray literature sites (Canadian Paediatric Society; American Academy of Pediatrics; American Academy of Allergy, Asthma, and Immunology; and The Canadian Society of Allergy and Clinical Immunology). There were no restrictions on date or country of publication, study design, or age of participants. Searches used keywords commonly used in Canada and the United States for race and ethnicity.

From 1198 potentially relevant articles, 12 studies were included in the review; most were conducted in the United States. No relevant articles from the gray literature were found.

Of the 12, five were published on Black or African Americans, 3 on Indigenous Peoples of Canada, and 4 on a combination of both along with Hispanic/Latinx peoples.

None of the studies focused on Hispanic, Latinx, or Native American populations or identity alone.

Taken as a whole, the 12 studies point to an increased burden of allergic and atopic disease for Black Americans, the researchers said. These burdens include a greater number of emergency departments visits and hospitalizations, higher death rates, younger age of diagnosis, and/or greater severity of disease.

Of the 5 studies on Black patients, 1 was a retrospective chart review and 4 were cohort studies; all were from the United States and published between 2006 and 2021. Four focused on children and 1 study was conducted on adults. Two studies exclusively examined asthma, and 3 studies looked at EoE, food allergy, and allergic contact dermatitis.

In one of the first works on the topic, Gupta et al described the widening gap in hospitalizations and deaths between Black and White children. Between 1980 and 2002, the ratio of asthma hospitalizations between Black and White children increased by 50%. Between 1980 and 2001, the Black to White ratio of asthma deaths increased from 4.5 to 5.6.

In another study looking at food allergy outcomes, Black children, compared with White children, were 2.5 times more likely to be allergic to fin fish and about 3 times more likely to be allergic to shellfish or have asthma.

Looking specifically at EoE, Black children were more likely to have delayed diagnosis, symptoms appear at an earlier age, and comorbid atopic dermatitis.

Studies conducted in Canada on Indigenous Peoples found a lack of culturally appropriate asthma education, providers, and other resources that would make asthma a health priority.

Researchers also found a lack of published literature on atopic diseases in Native American populations.

“The complete lack of literature on this population is concerning,” the authors wrote. “It may reflect a greater distrust of organized systems including those that carry out health-related research. However, it may also reflect a more insidious and historically neglectful attitude toward this population that has resulted in inequitable access to health care, and culturally respectful education about allergic diseases, or inclusion in research studies."

Allergic and atopic disease is well studied and researched overall, but the authors noted that they did a scoping review rather than a systematic review because of the lack of literature in these populations, even though a scoping review is considered less rigorous.

“Given that structurally oppressed racial and ethnic populations face a variety of challenges accessing the health care system, as well as justified mistrust of the medical system and medical research, the existing literature on the burden of allergic disease among these populations almost certainly underestimates this burden,” they said.

Reference

Jafri S, Janze J, Kim R, Abrams EM, Gruber J, Protudjer JLP. Burden of allergic disease in racial and ethnic structurally oppressed communities within Canada and the United States: a scoping review. J Allergy Clin Immunol Pract. Published online August 19, 2022. doi.org/10.1016/j.jaip.2022.08.018