Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Populations are often divided categorically into distinct racial/ethnic groups based on social rather than biological constructs. Genetic ancestry has been suggested as an alternative to this categorization. Herein, we typed over 450,000 CpG sites in whole blood of 573 individuals of diverse Hispanic origin who also had high-density genotype data. We found that both self-identified ethnicity and genetically determined ancestry were each significantly associated with methylation levels at 916 and 194 CpGs, respectively, and that shared genomic ancestry accounted for a median of 75.7% (IQR 45.8% to 92%) of the variance in methylation associated with ethnicity. There was a significant enrichment (p=4.2×10^-64) of ethnicity-associated sites amongst loci previously associated environmental exposures, particularly maternal smoking during pregnancy. We conclude that differential methylation between ethnic groups is partially explained by the shared genetic ancestry but that environmental factors not captured by ancestry significantly contribute to variation in methylation.

The Coronavirus infectious disease 2019 (COVID-19) pandemic has disproportionally impacted historically disadvantaged populations, with infection and mortality rates among Black and Latinx Americans far exceeding the proportion of the population that these groups represent. We, as researchers, educators, and critical care and pulmonary providers on the frontline of care for all individuals, believe it is important to reflect on the root causes for these striking disparities. Moreover, recent incidences of structural violence highlight the need to recognize the critical role of racism in causing and perpetuating health disparities. Without attention to the underlying causes, it is difficult to enact equitable action. Applying the World Health Organization Conceptual Framework for Action, we examine the social and structural determinants of health (SDOH) that contributed to disparities in the care and outcomes of patients with COVID-19. Applying this lens, we identify three potential critical targets for action: 1) increased exposure due to occupation and/or living circumstances that make social distancing and self-isolation more difficult, 2) limited access to accurate, up to date information regarding the health risks of COVID-19, and 3) limited and differential access to healthcare services, including coronavirus testing and care. In this perspective, we focus on action steps that we, as members of the American Thoracic Society, should take to actively change the status quo and influence policies that address root causes. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Purpose of Review: Using the WHO Conceptual Framework for Action on the Social Determinants of Health, this review provides a discussion of recent epidemiologic, mechanistic, and intervention studies of structural and social determinants of health and asthma outcomes covering the period from 2014 to 2019.Recent Findings: A majority of studies and interventions to date focus on the intermediary determinants of health (e.g., housing), which as the name suggests, exist between the patient and the upstream structural determinants of health (e.g., housing policy). Race/ethnicity remains a profound social driver of asthma disparities with cumulative risk from many overlapping determinants. A growing number of studies on asthma are beginning to elucidate the underlying mechanisms that connect social determinants to human disease. Several effective interventions have been developed, though a need for large-scale policy research and innovation remains.Summary: Strong evidence supports the key role of the structural determinants, which generate social stratification and inequity, in the development and progression of asthma; yet, interventions in this realm are challenging to develop and therefore infrequent. Proximal, intermediary determinants have provided a natural starting point for interventions, though structural interventions have the most potential for major impact on asthma outcomes. Further research to investigate the interactive effect of multiple determinants, as well as intervention studies, specifically those that are cross-sector and propose innovative strategies to target structural determinants, are needed to address asthma morbidities, and more importantly, close the asthma disparity gap.

Rationale: The burden of asthma is highest among socioeconomically disadvantaged populations; however, its impact is differentially distributed among racial and ethnic groups. Objectives: To assess the collective effect of maternal educational attainment, annual household income, and insurance type on childhood asthma among minority, urban youth. Methods: We included Mexican American (n = 485), other Latino (n = 217), and African American (n = 1,141) children (aged 8–21 yr) with and without asthma from the San Francisco Bay Area. An index was derived from maternal educational attainment, annual household income, and insurance type to assess the collective effect of socioeconomic status on predicting asthma. Logistic regression stratified by racial and ethnic group was used to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (CI). We further examined whether acculturation explained the socioeconomic-asthma association in our Latino population. Measurements and Main Results: In the adjusted analyses, African American children had 23% greater odds of asthma with each decrease in the socioeconomic index (aOR, 1.23; 95% CI, 1.09–1.38). Conversely, Mexican American children have 17% reduced odds of asthma with each decrease in the socioeconomic index (aOR, 0.83; 95% CI, 0.72–0.96) and this relationship was not fully explained by acculturation. This association was not observed in the other Latino group. Conclusions: Socioeconomic status plays an important role in predicting asthma, but has different effects depending on race and ethnicity. Further steps are necessary to better understand the risk factors through which socioeconomic status could operate in these populations to prevent asthma.

Adverse Childhood Experiences (ACEs) are associated with behavioral, mental, and clinical outcomes in children. Tools that are easy to incorporate into pediatric practice, effectively screen for adversities, and identify children at high risk for poor outcomes are lacking. To examine the relationship between caregiver-reported child ACEs and related life events with health outcomes. Participants (0–11 years) were recruited from the University of California San Francisco Benioff’s Children Hospital Oakland Primary Care Clinic. There were 367 participants randomized. Participants were randomized 1:1:1 to item-level (item response), aggregate-level (total number of exposures), or no screening for ACEs (control arm) with the PEdiatric ACEs and Related Life Event Screener (PEARLS). We assessed 10 ACE categories capturing abuse, neglect, and household challenges, as well as 7 additional categories. Multivariable regression models were conducted. Participants reported a median of 2 (IQR 1–5) adversities with 76% (n=279) reporting at least one adversity; participants in the aggregate-level screening arm, on average, disclosed 1 additional adversity compared to item-level screening (p=0.01). Higher PEARLS scores were associated with poorer perceived child general health (adjusted B = −0.94, 95%CI: −1.26, −0.62) and Global Executive Functioning (adjusted B = 1.99, 95%CI: 1.51, 2.46), and greater odds of stomachaches (aOR 1.14; 95%CI: 1.04–1.25) and asthma (aOR 1.08; 95%CI 1.00, 1.17). Associations did not differ by screening arm. In a high-risk pediatric population, ACEs and other childhood adversities remain an independent predictor of poor health. Increased efforts to screen and address early-life adversity are necessary.