The death rate from asthma has more than doubled in the United States since 1978. And worried officials of the National Institutes of Health attribute the trend in part to the lack of education and training of the primary-care doctors who treat the vast majority of asthmatics.
Dr. Michael A. Kaliner, chief of the allergy section at the National Institute of Allergy and Infectious Diseases, did not mince words in criticizing the medical care that most asthmatics receive and the lack of understanding by many doctors about new treatments.
At a news conference sponsored by the American Medical Association last month and in an interview this weekend, Dr. Kaliner said there was too wide a discrepancy between the care delivered by the 3,000 allergy and asthma specialists and that provided by the more than 210,000 primary-care doctors, like pediatricians, family doctors and internal medicine specialists in the United States.
"No asthmatic should die, and if properly treated very, very few asthmatics would die," Dr. Kaliner said.
Primary-care doctors tend to underuse the specific treatments that allergists regard as the first line of attack against asthma, Dr. Kaliner said. He added that primary-care doctors tend to rely on drugs that provide only symptomatic relief for asthma and do not address the underlying triggers, thus leaving asthmatics at greater risk for death.
Rarely has a representative of the institutes so directly scolded a group of practitioners or medical educators as Dr. Kaliner did.
Yet even the American Medical Association, which is the largest organization of doctors in the country and which shares responsibility for overseeing the education and training of young doctors with several other organizations, said there might be something to the criticism.
The Association of American Medical Colleges agreed that the institutes were correct in calling attention to the growing asthma problem, but disputed the criticism of medical education. "It's a false indictment," said Dr. Edward J. Stemmler, the association's executive vice president.
The medical association and federal health officials say asthma is the only chronic disease, except for AIDS and tuberculosis, that is on the rise throughout the world. Deaths from asthma have increased to nearly 5,000 a year in the United States, with an increase particularly among blacks and the elderly. For unknown reasons, more elderly women than men die from asthma. But with a death rate of 1.9 per 100,000 per year, according the National Center for Health Statistics, Americans still have one of the lowest death rates from asthma in the world.
The number of American asthmatics has risen sharply, to more than 15 million, a 66 percent rise since 1980, federal health officials said. Blacks are hit hardest, and are three times as likely as whites to die from the disease. Asthma is the leading cause of admission of children to hospitals in this country and the leading cause of absenteeism from American schools.
Allergy is the most common underlying cause of asthma. But, Dr. Kaliner said, only half the medical schools in this country have an allergist on staff and most doctors are taught little about the diagnosis and treatment of allergies in medical school and in residency training.
Dr. Stemmler said it was an exaggeration to assert that medical schools did not teach about asthma because allergists might be based in divisions with other names.
But Dr. M. Roy Schwarz, senior vice president of the American Medical Association, said, "The allegation that physicians are not as well as trained in managing asthma as would be desirable probably has some merit."
Young doctors are taught much about asthma, but the instruction is often disjointed. "You could safely conclude that even with limited knowledge, we still do not do as good a job on it as we should," Dr. Schwarz said.
Asthma is a chronic inflammatory disease characterized by periodic attacks ranging from mild shortness of breath to terrifying wheezing, and in the worst case, sudden death.
One important recent advance in asthma therapy is the use of inhaled steroids, not to be confused with inhaled bronchodilators that offer symptomatic relief.
Because the inhaled steroids act only on the lungs and are not absorbed to any extent, they do not have the potential for the serious side effects that can result when they are taken systemically, as they may be for severe arthritis or other conditions. But "many patients who die from asthma, die without the advantage of having been treated with inhaled steroids" because too many doctors still fear prescribing them, Dr. Kaliner said.
"The U.S. was late in getting inhaled steroids and even later in adopting their use," Dr. Kaliner said. He added, "The major problem we have in asthma therapy today is that primary-care physicians use too little inhaled steroids."
The increasing number of asthmatics has implications for future health care because experts are learning that many children do not outgrow asthma, as once believed.
About half of those who develop asthma before the age of 16 will continue to have attacks, while the remaining half will go on to a quiescent period until about age 25.
Also, a child who develops asthma between the ages of 2 and 8 years has about a 50 percent chance of having a remission during the teen-age years. But 50 percent of children who stop having attacks at that time get their asthma back in their 30s.