1940: Asthma death rate begins a gradual rise

The 1940's was a significant decade in the history of medicine, as advances in medicine resulted in declines of morbidity and mortality from some of histories deadliest diseases, such as consumption and influenza.  Our asthma history saw an opposite trend.  While asthma morbidity and mortality were negligible through the 1930, they started to gradually climb during the fourth decade of the 20th century.

Considering these other diseases were in the forefront of the general public, the spike in asthma deaths nearly went unnoticed. Some experts may have seen what was going on, although they had no way of even guessing at the cause.  The reason was because most of the public's attention remained on other diseases, with all public funds, therefore, not going for asthma research.  For this reason there was very limited data regarding asthma available to review.

That left researchers to reviewing death certificates.  However, many experts wondered if methods of certifying death certificates were even accurate.  There were probably times when asthma was misdiagnosed and under diagnosed.  A middle aged man with bronchitis may have been misdiagnosed with asthma.  A child with asthma may have been misdiagnosed with asthma. Likewise, a child with asthma may have gone unrecognized, and therefore un-diagnosed.

It actually wasn't until the 1960s when all eyes were opened to the rising death rates that death certificates were reviewed.  The experts decided to limit their research to asthmatics between the ages of 5 and 35.  The reason was that the likelihood of having pure asthma was greatest among this age group.  Those under five were hard to diagnose, and those over 35 had a a greater likelihood of having some other disease combined with asthma.  Figuring out which one resulted in death could sometimes be difficult to determine.

Data was collected from as far as 1900 for this age group.  According to Beasley, Pearce and Crane in 1968, here is what was learned:

Those Western countries in which relevant data have been published indicate that asthma mortality was uniformly low and relatively stable between 1900 and 1940.  The death rate began to increase gradually in the 1940s in a number of countries including New Zealand and Australia, in which a threefold increase over a 15-year period was observed.  Mortality declined again in the late 1950s in New Zealand, England, and Wales, but not Australia.  In contrast, little change in asthma mortality rates was observed in the United States during this period.  Although the interpretation of death rates over such an extended period is difficult, the historical data are likely to be acceptable accuracy in this age group." (1, page 14)

They also made one other observation:

It is interesting to note that isoprenaline was introduced in a nebulizer formulation during the 1940s when mortality began to increase, but whether this had a role in the increase in mortality was not examined in detail at the time. (1, page 14)

Trends in asthma related deaths were not significantly studied until the 1960s.  When this was done, one of the theories that arose for the rise of asthma deaths in the 1940s was the availability of nebulized isoprenaline at home.  Theorists sense this may have created a false sense of security among asthmatics, particularly children.  Where they once would have sought help, they now simply resorted to their rescue medicine.

Isoprenaline was a new line of sympaththeomimetic medicines, also known as beta adrenergic medicine, more recently as asthma rescue medicine.  Regardless of what it is called, it has the tendency to provide immediate relief from an asthma attack.  Having access to such medicine was a godsend for asthmatics, because it meant that they could get immediate relief in the convenience of their own homes.

While physicians were happy to provide such an opportunity to asthmatics, they were not ready for the potential consequences.  Allowing asthmatics to have quick access to such rescue medicine resulted in two things.

1. Overuse of isoprenaline may have resulted in cardiac arrest. This would have resulted in suden death from isoprenaline overdose secondary to asthma. 
2. Overuse of isoprenaline may have resulted in tolerence to the medicine. This would have made the asthma refractory to the isoprenaline, resulting in increased dosing. By the time the asthmatic gave up on the isoprenaline, it was too late. 

These were simply theories that were never proven.  It as impossible for researchers to question these asthmatics after they died, and therefore it was impossible to know how much isoprenaline they used, if any.  

However, in many instances, there were reports from family members and friends of these asthmatics using their rescue medicine prior to death.  

For these asthmatics, however, such theories were trivial and too late. Although data obtained from studying how they died may have resulted in safety precautions that saved the lives of many future asthmatics.  In this way, the experts made sure these asthmatics did not die in vane. 

Another good thing that came out of the rise in asthma deaths during the 1940s, and later in the 1960s, was better recognition of our disease by the medical community.  This ultimately resulted in better recognition by the public, and therefore better funding for future research.  

However, as morbidity and mortality from asthma still remained low in comparison to other diseases, the rise in public awareness continued to pale in comparison.  While it's sad to say, many asthmatics continued to suffer from their disease because the general public simply was not paying attention.  

References.

1. Beasley, Charles Richard William Beasley, Neil Edward Pearce, Julian Crane, authors of chapter two in the book "Fatal Asthma" edited by Albert L. Sheffer, 1998, New York, Hong Kong, Marcel Dekker, Inc. Chapter two is titled "Worldwide trends in asthma mortality during the twentieth century." 
2. Woolcock, Ann Janet, author of chapter 14 of the book, "Fatal Asthma," edited by Albert L. Sheffer, 1998, New York and Hong Kong, Marcel Dekker, Inc. Chapter 14 is titled "Natural Histor of Fatal Asthma." 
3. Sears, Malcolm R., "author of chapter 29 in the book "Fatal Asthma," edited by Albert L. Sheffer, 1998, New York and Hong Kong, Marcel Dekker, Inc. Chapter 29 is titled "Role of B-Agonists in Asthma Fatalities." 
4. Jackson, Mark, "Asthma: The Biography," 2009, New York, Oxford University Press 
5. Bisgaard, Hans, Chris O'Callaghan, Gerald S. Smaldone, editors, "Drug Delivery to the Lung," 2001, New York, Marcel Dekker, Inc 
6. Mittman, Gregg, "Breathing Space," 
7. Speizer, F.E., R. Doll, P. Heaf, "Observations on Recent Increase in Mortality from Asthma," British Medical Journal, February 10, 1968, 1, pages 335-339 
8. Altman, Lawrence K., "The Public Perception of Asthma," Chapter one of the book "Fatal Asthma," edited by Albert L. Sheffer, New York, Marcel Dekker, Inc, pages 3 and 11 
9. Speizer, F.E., R. Doll, P. Heaf, and B. Strang, "Investigation into use of drugs preceding death from asthma," British Medical Journal, 1968, 1, 339-343Sheffer, Albert L, "Partner Asthma Center's Grand Rounds," asthma.partners.org, http://www.asthma.partners.org/newfiles/ShefferFatalAsthma.html, accessed 10/5/13 
10. Bendy, Christine J., E.L-Fellah, R. Schneider, "Tolerance to sympathomimetic bronchodilators in guinea-pig isolated lungs following chronic administration in vivo," 1975, British Journal of Pharmacology, 55, pages 547-554 
11. Yarbrough, J., L.E. Lansfield, and S. Ting, "Metered dose inhaler induced bronchospasm in asthma patients," , Annals of Allergy, Asthma and Immunology," July, 1985, (55)1, pages 25-27 
12. Grant, Evalyn N., Kevin B. Weiss, "Socioeconomic risk factors for asthma mortality," chapter 17 of the book, Fatal Asthma," edited by Albert L. Sheffer, 1998, New York, Hong Kong, Marcel Dekker, Inc.