Policymakers offer strategy to curb asthma rates

Asthma experts see a federal action plan and debate as encouraging signals in the fight against what some say is an epidemic.

By Stephanie Stapleton, amednews staff. June 12, 2000.

Washington -- In response to increases in asthma incidence rates -- especially among young children -- policymakers and public health experts are wrestling with how best to marshal federal resources to respond to the problem.

Over the past 15 years, the number of Americans with asthma doubled to about 15 million, according to Dept. of Health and Human Services statistics. Between 1980 and 1994, the overall incidence increased by 75%, with rates for children under age 4 increasing 160%. In addition, a May Pew Environmental Health Commission report estimated that new cases could total as many as 29 million by 2020. All the while, the fact that asthma's grasp is tightest among the very young, very old and very poor holds steady.

"There is an increase in asthma over the years," said Martha White, MD, the director of research at the Washington, D.C.-based Institute of Asthma and Allergy. "There is also an increase in mortality. That's real." Part of the reason why, she said, is that asthma is very undertreated -- both in terms of medical attention and the public resources.

"It's an incredibly common disease," she said. But the danger with common diseases is that they are not always taken seriously enough. "The fact that people die of asthma is personally frustrating to me" -- as are the facts that many patients are undertreated, not being referred and not being recognized for how ill they are.

To this end, HHS Secretary Donna Shalala, PhD, unveiled the federal Action Against Asthma plan May 3. It places a priority on determining the causes of asthma and developing preventive interventions, reducing the disease's burden, eliminating the disproportionate health burden among minorities and the poor, and tracking incidence. Dr. Shalala also pointed out the expanding administration investment -- from $157 million in fiscal 1999 to a proposed $193 million in the president's budget for fiscal 2001.

Too little too late?

The Pew commission's report, however, sharply criticized the action plan as coming 15 years into the epidemic. Researchers at Johns Hopkins University in Baltimore associated with the commission also found that both the amount and direction of resources were inadequate. They concluded that in fiscal year 1999, less than 10% of federal asthma research spending -- approximately $14 million -- was directed at monitoring or preventing the disease. This year, asthma will cost the U.S. economy at least $11 billion.

The report offered several recommendations: the creation of a national asthma tracking system within five years, the development of a plan to coordinate federal agencies' response, more investment in asthma prevention research, and implementation of a comprehensive public education campaign for the public and health care professionals.

To Dr. White and other asthma experts, both the federal strategy and the Pew report are positive because they signal raised awareness.

"If doctors and patients were better educated -- if more were known -- we could turn a lot of these statistics around," Dr. White said.

Severe problems now often go underestimated, agreed Richard Wasserman, MD, PhD, the director of the immunology clinic at the Children's Medical Center of Dallas. In one week, he saw three children whose parents had no idea of their child's condition. In each case, the exam began with reports of only "subtle problems." When the child was tested, the results showed dramatically compromised lung function.

Additionally, experts agree that placing more emphasis on data collection and surveillance is an important step. But it is also not the only answer. "In my own experience, we know where the worst pockets are occurring. That's not the hard problem to solve," Dr. Wasserman said. It is intervention that is challenging, he said. And the public health care system often contributes to the barriers.

His example: The most important asthma susceptibility factor after genetics is exposure to dust mites. This can be controlled by using special bed coverings. But Medicaid does not cover this expense, which totals about $100. Instead, the program pays only for medications that cost hundreds of dollars per month. "A better match between needs and the health care system would help," he said.