Asthma morbidity is disproportionately high in low-income, inner-city communities. According to the Asthma and Allergy Foundation of America, African Americans are three times more likely to die from asthma, and African-American women have the highest asthma mortality rate of all groups.
Studies have shown that exposure to community violence has been associated with asthma morbidity of children living in inner-city neighborhoods, and a recent Penn Medicine study has found a correlation between exposure to violence and hospitalizations and emergency room visits in adults, as well.

Andrea Apter, chief of the Section of Allergy and Immunology in the Division of Pulmonary, Allergy, and Critical Care Medicine at Penn Medicine and lead author of the study, says she was interested in the effects of community violence on adults with asthma in part because of the association found with children, but also because of her experiences as a doctor and time she spent working as a secondary school teacher.

“As a doctor, you see patients who are poor and patients who are very sick and you want to do something about it,” she says. “I have been interested in health disparities for a long time. Patients who are minorities or poor are vulnerable to these sorts of things.”

Apter’s study, published in the September issue of The Journal of Allergy & Clinical Immunology, examined with prospective longitudinal data whether exposure to community violence is independently associated with asthma-related health outcomes in adults. Partial funding came from the National Institutes of Health.

For their research, Apter and colleagues surveyed 397 adults from the Philadelphia area, most of whom were African-American women with moderate to severe asthma and earning less than $30,000 per year. More than half had an asthma-related emergency department visit in the year before enrolling in the study, and about a third had been hospitalized for asthma in that interval.

Patients were asked if they had witnessed any violence in their neighborhoods in the past six months. If they answered, “Yes,” they were further questioned about whether the violence involved a fight in which a weapon was used, a violent argument between neighbors, a gang fight, a sexual assault or rape, a robbery or mugging, or “other.” Patients were then followed for 26 weeks.

Ninety-one participants reported exposure to community violence, with 39 respondents reporting observing at least two types of violence. Fifty witnessed a fight in which a weapon was used, 43 saw a violent argument between neighbors, 11 witnessed a gang fight, two witnessed a sexual assault or rape, 21 witnessed a robbery or mugging and 33 checked “other,” which ranged from murder to shootings to vandalism of cars to domestic and drug-related violence.

The study concluded that asthma-related quality of life was lower in participants exposed to violence. While Apter says the research does not show cause and effect—meaning exposure to community violence did not cause a severe asthmatic reaction—she finds it alarming how living in violent communities can impact all aspects of life.

“It’s speculated, because we don’t know, that exposure to violence causes stress, and we know that stress impacts on health, but we don’t know how,” she says. Low-income neighborhoods also often have inadequate housing, schools, transportation, access to grocery stores and pharmacies and high pollution rates, which could also contribute to asthmatic reactions.

Apter says solutions lie in improving patient care to eliminate health disparities, increasing education, fighting segregation in low-income communities and neighborhoods dichotomized by income levels and providing more jobs.

From a medical standpoint, she says physicians could be more aware about the living environments of their patients.

“We need to take into account the context of people’s lives,” she says.