‘I want you to be able to breathe’

^{Coverage is proud to publish columns featuring the perspectives of Black women physicians who belong to the Diva Docs network in Greater Boston. Today, Dr. Margee Louisias, a Brigham and Women’s Hospital allergist-immunologist and a researcher in community-based interventions to reduce racial disparities, shares her thoughts with Dr. Philomena Asante, leader of Diva Docs Boston and creator of the Digital Health Award-winning Diva Docs series for Coverage.}

I was inspired to be a physician by my love for Haiti. My parents are Haitian immigrants, and I grew up hearing stories of what things were like back home, particularly how much medical care was needed.

As I grew older and researched and studied in Ethiopia, Ghana, and South Africa during college and medical school, I realized Haiti is not the only country plagued with infrastructure and disparities issues, and I began to see how these issues were linked to colonization and globalization.

In residency, I began to understand the extent of racial disparities in the United States too. I did my residency in internal medicine and pediatrics at Mount Sinai Medical Center, which has a campus spanning the largely high-income, White Upper East Side of Manhattan neighborhood as well as the largely low-income, Black and Latinx East Harlem neighborhood with one of the highest prevalence rates of asthma in New York State.

I realized that if I became a specialist in allergy and immunology, I could provide expert, in-depth care that could not be provided in primary care. I saw an opportunity to serve communities that needed this kind of care -- there was very limited access to allergist-immunologists in upper Manhattan and the Bronx. And I was encouraged by Dr. Anne Maitland, one of the first Black attendings I met in residency, who became one of my mentors.

With Dr. Maitland’s guidance, I learned the role of our field in addressing disparities, and that if you are passionate about equity work, there is opportunity across every field in medicine.

What do allergist-immunologists do?

Allergist-immunologists take care of children and adults. We are trained to care for people with conditions including eczema, asthma, environmental allergies, food and drug allergies, vaccine allergies, insect allergies, and disorders of the immune system, such as immunodeficiencies and mast cell disorders.

Mostly, our clinical care focuses on outpatients, but we also do inpatient consultation work. At the Brigham, we have one of the busiest inpatient consult services in the country. Allergist-Immunologists perform skin testing, patch testing, and food and drug challenges to determine allergies. We also do desensitizations, where we administer a drug or food in incremental doses to provide a temporary tolerance to it. For example, an oncology patient may be allergic to their chemotherapy but will need it as part of their cancer treatment plan. I really love this part of the job – being able to provide a patient with a first-line, life-saving treatment that would not be able to receive under normal circumstances.

I spend a lot of time talking with patients and I spend a good portion of that time answering questions.

What is asthma? What are the symptoms? What should I expect? How does this medication work? Will there be side effects? What are allergies?

For example, I take time to explain the differences between food allergies and food intolerances/sensitivities. Patients with food allergies typically develop hives, swelling, shortness of breath, vomiting, and a drop in blood pressure immediately after ingestion of that food. When symptoms are severe, they need immediate medical attention, or they may risk death. People with sensitivities or intolerances may not like how certain foods like gluten or milk make them feel, but they do not have these severe symptoms.

I also take time to discuss the meaning of asthma with my patients. The medical definition entails reversible bronchoconstriction, which means you have symptoms of chest tightness or coughing that feel better when you take albuterol. But there is a spectrum of asthma activity. You may have asthma that triggers occasionally and rarely requires use of albuterol. Or you may have shortness of breath daily and need to be on a preventative inhaler and/or even an injectable medication.

Racism and asthma

We see disproportionately high rates of asthma among Black Americans – and disproportionately high rates of hospitalization and death from asthma too. Those rates don’t stem from genetics or biology.

Higher rates of asthma can be traced to the decades-long practice of redlining, the systemic denial of mortgages, insurance, investments and loans to neighborhoods that were predominately Black.

Deprived of investment, many of these neighborhoods became heat islands, sites for dumping industrial waste, and were divided by interstate highways, leading to disproportionate pollution exposure.

Even today, data shows, Black and Brown communities are exposed to higher concentrations of pollution, particularly PM_2.5, which are fine particles that travel very easily into the deep airways. Pollutants are believed to have an exponential impact on allergens: they can affect the timing of pollen release and the amount of pollen that is released, and they appear to augment the immune response to allergens.

Taking action

Patients who are well-informed can take control of their own treatment plan. There are five steps you can take during your first visit with your allergist.

• Prepare for your visit. Ask if you will have skin testing, and if so, make sure you don’t take antihistamines for at least three to seven days before that visit. Also ask if you should pause any of your other usual medications before your visit.
  
• Make sure you discuss any childhood allergies. Your doctor can evaluate whether you still have an allergy or whether you have outgrown it. Also ask about new allergies you may have developed as an adult.
  
• If you are concerned about a particular product or food that may have caused a rash or another allergic reaction, bring it or take a picture of the label; the list of ingredients will help your doctor evaluate what you may be allergic to.
  
• If you or your child are given an epinephrine autoinjector, ask your doctor to explain clearly how and when to use it. When a person is having a severe allergic reaction, the leading cause of death is not using an epinephrine autoinjector in time. Know the signs of a severe allergic reaction: not being able to breathe, feeling like you’re going to pass out, or sudden swelling of your face, tongue, or throat. When that happens, use the epinephrine autoinjector immediately, call 911 and go to the ER for evaluation. Make sure when you use your epinephrine autoinjector that you get a new one to replace it.
  
• If you are concerned about potential allergic reactions to COVID vaccines, ask your doctor. These reactions are extremely rare, but it’s important to have trustworthy places to get your questions answered. As allergists-immunologists, we are experts in the immune system and we know how vaccines work and what their side effects are. If you are concerned, do not Google or look for answers on YouTube or Facebook. Instead, you can reach out to an allergist-immunologist. We will take the time to talk to you about any side effect you may be worried about.
  

Societal strategies to address disparities

We face steep challenges in addressing health inequities, but not insurmountable obstacles. Four major strategies are successful in addressing disparities in asthma in underserved Black and Brown communities.

Addressing bias in medicine

The medical field has a big role to play in addressing inequities in health care too. For example, we know implicit bias can impact medical care and health outcomes in a wide range of ways. One study examined the association between bias and nonverbal communication in a simulated end-of-life care setting and found less or poorer nonverbal communication like eye contact with Black patients compared to White patients. Lack of communication, even nonverbal, can lead to less trust between patients and physicians.

One way to address bias is by making our field more diverse. More minority physicians may not only improve outcomes and the health care experience for Black and Brown patients, but also can affect the way in which their White colleagues interact with their minority patients. We can provide more opportunities for White physicians to understand Black and Brown communities

Diversity can be increased in our field in part by doing holistic reviews of fellowship applications, rather than screening out applicants purely based on board scores or which lab they worked in. It is important to review applications with the goal of seeking out characteristics that are in alignment with the mission of the fellowship program.

Diversity is also important in clinical trials that shape medical care. We need Black and Brown patients to participate in these trials because their data will tell us which treatment options lead to the best outcomes for patients before they reach the market.

A message of hope

If you have asthma or allergies, know there are ways we can make you better.

Some patients may feel, “This is my life. It’s normal for me to be symptomatic and have my ability to work or exercise be compromised. This is a normal way of living.”

I spend a lot of time of dispelling that and talking to my patients about a better future.

^{PHOTOS OF Dr. MARGEE LOUISIAS AND Dr. ASANTE BY FAITH NINIVAGGI.}