Q&A: Providers can do more to reduce racial disparities in food allergy care

PHOENIX — Racial disparities touch every aspect of clinical care for food allergies, from prevention and diagnosis to insurance coverage and to the diversity of the workforce providing treatment.

The Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD) study has published multiple papers exploring where these disparities come from and how they best can be addressed.

Andrea Pappalardo, MD, FAAAAI, assistant professor of medicine and pediatrics at University of Illinois at Chicago, discussed these findings as well as her own experience as the asthma director of Coordination of Healthcare for Complex Kids (CHECK) community outreach program during the American Academy of Allergy, Asthma & Immunology Annual Meeting.

Healio spoke with Pappalardo, who also is director of Mobile Care Chicago, to find out more.

Healio: What are the primary racial disparities in food allergy care?

Pappalardo: There’s many. First, there’s a higher prevalence of food allergy in people of color, especially Black and African American children, as well as in comorbidities, especially regarding asthma. There also is a discrepancy in that Black individuals are more likely to die of an allergic reaction.

Andrea Pappalardo

Overall, individuals of color do not only have an increased likelihood of having a food allergy and of additional factors in their atopic disease milieu, but they are also more likely to die or have a worse and severe reaction.

Another aspect of these disparities relates to the knowledge and understanding of access to care and to subspecialists. There is a lot of interplay in multiple layers of disparities that make the overall experience more difficult for people of color.

Healio: Do these disparities impact food allergies more than other allergies?

Pappalardo: Yes. There’s an increased rate of various food allergens, typically like shellfish, in African Americans and Blacks, that could be a problem. But I don’t believe anything is in isolation, because children don’t get just one thing. It’s all on a spectrum.

Healio: What are the biggest factors driving these disparities?

Pappalardo: One would be racism, and it unfortunately interacts with all these other factors, such as food security. The social determinants of health would be another. A third would be the ability to access education and the provider that’s right for you, and that can mean many different things.

Healio: Is insurance coverage one of barriers in access to care?

Pappalardo: Absolutely, and that interplays not only with race and ethnicity but also with socioeconomic status. Previous research has compared whether the same patient would get to see the same specialist whether they had private insurance vs. Medicaid or state insurance, and there was a significant difference.

We see this in the ivory towers. We work with the academic institutions, and we accept a lot of state insurance. But it’s really hard for families to access. That’s why I like the model of taking one provider and giving families access to care where they live, work and play, because that is a beautiful concept of helping overcome some of these issues.

Healio: What do allergists need to do to start reducing these disparities?

Pappalardo: Physician advocacy can help providers understand, first of all, that there’s a problem. I think this is starting to occur, which is fantastic, but this is a relatively new area in food allergy.

You recognize where things are not equal, and you try to look into yourself and your practice and how you live every day and what you can potentially do. Just open your eyes to what’s happening in front of you, and potentially find your comfort zone in what you feel OK doing to take that next step toward equity.

Healio: Primary care physicians are the first point of contact for many of these families. What can they do to improve care?

Pappalardo: It really starts with primary care. A lot of what we’re doing in the FORWARD study is beautiful work, but these are children who have already accessed the specialist. So, we really need to work on primary care.

What are the early introduction practices that they’re talking about? How can we prevent food allergy? When children first develop a food allergy, how can we get them to the subspecialist that they need and deserve?

Perhaps a patient navigator, a community health worker or some sort of care coordination model within primary care that can help these patients from the beginning to the end of their life within the food allergy and allergic disease spectrum might potentially help.

Healio: Another first point of contact for many families would be the school nurse. What kinds of school policies would help improve these disparities?

Pappalardo: This is right up my alley, because I do school-based work in both asthma and allergy. The National Association of School Nurses and I would say that we need a school nurse in every school. When one school nurse might be spending only a few hours a week within a school that they are assigned to, and they have several schools at once, how could they possibly know enough information to help adequately take care of an emergency when they’re not physically there?

So, number one, we need advocacy within schools. We need to have a school nurse within every single school, and they need to have access to a stock of relievers as well as epinephrine that is in code and accessible without a person’s name attached to them.

We need to understand the latest in what’s going on in the recommendations for food allergy, asthma and other atopic diseases within the school setting — and the school nurse is the ambassador to that. Otherwise, we cannot make a meaningful change within the school-based approach to care.

Healio: How can providers engage in community partnerships?

Pappalardo: There are many ways. Food Allergy Research & Education, the Food Equality Initiative and various other groups offer ways that we can start thinking about how we can connect the dots and start working altogether. But they’re not the only ones.

Working within your communities, your own advocacy organizations within your own towns, your school districts — grassroots from the beginning in your own location — you can do a lot more than you think you can.

Healio: Should doctors reach out to schools in their town and local chapters of their professional organizations?

Pappalardo: Absolutely, and I found that to be very successful in my own work. Talk to regional superintendents. Speak with school districts, with nurses who are on the ground, with families. This can really help you understand what’s going on in your own specific area.

What a lot of these groups like the Allergy and Asthma Foundation of America and others are doing is fantastic. But then we get down to how this child is going through the school system by himself or herself. Working with the families within the community context that our children live in and that you work in is going to be the first, easiest way to connect.

Healio: Where do you go for the funding to support these programs?

Pappalardo: There’s not enough, so it has to be an investment that is considered worthy, and we believe that everyone who does this work is extraordinarily worthy. This work is a necessity. To help health outcomes and reach health equity in all populations, we must pay attention to it.

Put your money where your mouth is. If you want to have a more diverse clinician workforce, if you want more diverse representation in clinical trials, you need to invest the communities in which you live and in the communities in which you’re practicing. I do believe that is one of the main areas that we want to focus on.

Healio: Previously, you discussed the need for a more diverse clinician workforce as well as more diversity in academics and research to help eliminate these disparities. What are the keys to achieving this diversity?

Pappalardo: It’s a pipeline. I’m an allergist and immunologist, but I spend a good portion of my time working within the medical school. I took on a teaching role for exactly this. Get allergy and immunology in the minds of medical students from the beginning. There’s more diversity in medical schools now than we’ve seen before.

There also are people who spend significant time reaching out to students in high schools. I’m doing that with the children who I’m seeing in our mobile clinic. Recognize that there’s potential there and put it in the minds of these young people that anyone can do this, that you could do this, that you could be successful.

References:

• Food allergy outcomes related to white and African American racial differences. https://www.nal.usda.gov/research-tools/food-safety-research-projects/food-allergy-outcomes-related-white-and-african. Accessed: February 25, 2022.
• Pappalardo A. Racial and ethnic disparities in diverse populations with food allergy. Presented at: AAAAI Annual Meeting; Feb. 25-28, 2022; Phoenix (hybrid meting).