The Journal of Asthma Research. Vol. 8, N o h a r c h , 1971
Guest Editorial
Statistics, Mortality, and Asthma
VINCENT J. FONTANA, M.D.”
The communication by Dr. Silverglade in this issue of The Journal of Asthma Research emphasizes once again the need for a more precise evaluation of statistics on mortality and asthma. An increase in the mortality from asthma, particularly in children, has been reported from Australia1, the United States2, Britain3, and exprcshed in several publications by clinicians4, B, who have been interested in the problem of childhood asthma. Whether asthmatic deaths are increasing or decreasing appears to be dependent on vital statistics as inter- preted by individual investigators. Gottlieb? in an article in The Journal of the American Medical Association indicated that the mortality rate from asthma appeared to be showing a downward trend in both sexes in all racial groups and all age groups. Almost simultaneously, in a meeting of the American Academy of Allergy, Dr. Warren Richards2 reported a definite marked increase in asthma mortality a t the Children’s Hospital of Los Angeles between 1937 and 1963. Palm, Murcek, Roberts, Mansman, Fireman8 have reported in their analysis of asthmatic deaths a definite decline in mortality rate.
These controversial reports by leading investigators serve to emphasize to the student of asthma that the true significance of mortality statistics dealing with bronchial asthma must be cautiously interpreted. The term asthma is a symptom complex and is more descriptive than definitive. The clinical features of wheezing, dyspnea, coughing and expectoration can denote diseases other than asthma. Many asthmatic deaths may be due to anaphylactic reactions, emphysema, infections, pneumothorax, atelectasis, and other cardiopulmonary complications. It is often difficult also for the physician filling out a death certificate to elicit the immediate cause of death and to relate this in terms acceptable to the Bureau of Vital Statistics. Periodic revisions of the interna- tional statistical classifications and coding practices only add to the many difficulties that are encountered in the study of deaths attributed to chronic pulmonary diseases. I n a personal communications from a member of the Na- tional Center of Health Statistics of the Department of Health, Education, and Welfare, i t was noted that coinparisons between the annual asthma death rates over the past 15 years are impossible due to changing coding practices. It is also apparent that accurate certification as to the cause of death is a t times difficult and dependent on physicians’ own arbitrary and often personal subjective criteria. The only valid statistics of asthma mortality are those based on au- t,opsy material.
of New York. Professor of Clinical Pediatrics, New York University College of Medicine. * Director of Pediatrics and Pediatric Allergy, St. Vincent’s Hospital and Medical Center
91
J A
sthm
a D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/20/
14Fo
r pe
rson
al u
se o
nly.
92 VINCENT FONTANA
Silverglade’s article mentions that the National Center for Health Statistics reported that an overall death rate from asthma has been declining progres- sively from 1960. In a very complete, intensive study of asth a mortality,
of the Department of Health, Education, and Welfare of the United States Public Health Services suggested a substantial increase in asthma deaths. From 1965 to 1966 the number of deaths attributed to asthma a t ages 1 to 14 years increased by 64% from 146 to 240. One can very well see the dilemma that one is faced with in evaluating the writings of leading investigators as well as the vital statistics released by various responsible agencies.
Therefore, should not more attention be paid to clinical observations and re- ports originating from pediatric allergists who have been treating asthmatic children in the pre-steroid as well as in the steroid era? I would agree with Silverglade in his comment that i t is time for the writers of a,rticles on the subject to review the reports from single institutions or based on individual physician’s experience in proper perspective. Personal observations of Peshkin5 and others4. who have been intimately involved in treating children for the past several decades have attested to the fact that asthma mortality in children has increased, and that asthma in childhood has been transformed from a benign to a malignant disease.
It remains for us as physicians treating asthmatic patients to recognize and consider an alleged decline or apparent increase in mortality of asthma in our pediatric population. I hope that Silverglade’s article in this issue of the Jour- nal will generate interest in the problem of asthmatic deaths and thereby ques- tion the effectiveness of present day therapeutics for this disease. If the rising death rate from chronic pulmonary diseases and bronchial asthma is found to be true, factors responsible for this change must be uncovered. Certain clinical impressions must be considered since some pediatric allergists have noted that the treatment of the asthmatic child was an easier task in the pre-steroid era than it is a t the present time. Statistics from residential asthmatic centers such as the Children’s Asthma Research Institute and Hospital will attest to the fact that the severity of asthma of almost all their applicants is now much increased and their dependence on medication particularly corticosteroids is well estab- lished and that the chances of complete rehabilitation rather than improving seem to be reduced with each passing year. There is no question that the per- centages of patients experiencing complete remission from asthma in these rehabilitation and residential centers seem to be steadily dropping.
Unless we address ourselves to and question the major medical advances made in the treatment of bronchial asthma during the past 25 years we will have abdicated our medical responsibilities to children. Major advances in the past 25 years have concerned therapeutics, particularly the use of antimicro- bial, steroid, and nebulization therapy. Within the terms of any drug usage there is the ever present danger of abuse. The possibility that the increased and promiscuous use of therapy, whether it be steroids, nebulization, or antimicro-
SpeizerlO in 1968 stated that data for 1966 from the Division of t ital Statistics
J A
sthm
a D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/20/
14Fo
r pe
rson
al u
se o
nly.
GUEST EDITORIAL ‘33
bial may be a contributing factor to an increase in the asthma mortality rate must be questioned and precisely studied. It would be wise to remember that therapeutic misadventures cannot be verified through the use of data available on death certificates which are the source material for the compilation of vital statistics for the United States.
J A
sthm
a D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/20/
14Fo
r pe
rson
al u
se o
nly.
