Sephardim and Ashkenazim comprise the Jewish population, and the Arab population consists of Druses, Christians, Moslems, and Bedouins. Most of the Jewish population in Israel is concentrated in cities, whereas most of the Arab population lives in villages or small townships. Both populations receive free medical care. Therefore, the trends and the main causes of asthma mortality in Israel in general, and in each of these ethnic groups in particular, could be different from those reported in other countries.
Only cases in which the cause of death was reported as asthma (code 493 in the ninth revision of the International Classification of Diseases [ICD]) were included. To avoid the possible overestimation of the incidence of asthma mortality, cases reported under codes 490 to 492 in the ninth revision of the ICD (ie, bronchitis and emphysema) were omitted. In 1979, the ICD classification system was revised. In order to ensure the standardization of diagnoses, only fatal cases that occurred subsequent to this revision were included. Annual death rates were grouped into 3-year periods in order to prevent potential errors due to small numbers of cases. The data were analyzed for statistical significance using Poisson regression modeling to assess the effect of age group and year on the mortality rate. In order to estimate the possibility of a nonlinear trend, nonparametric regression was performed using a spline model.
Among the patients in the 100 fatal cases, 52 patients (53.6%) were men and 45 patients (46.4%) were women. In three cases, the gender of the patient was not available. This distribution is not statistically different from the general Israeli population (men, 51%; women, 49%). Eighty-two patients (84.5%) were Jewish, 15 patients (15.5%) were Arab, and in three patients the ethnicity was not available. These values too are comparable to the demographics in the Israeli population (Jews, 78%; Arabs, 22%).
More recently, a drop in asthma mortality rates has been reported in several countries. This phenomenon, however, did not occur in Israel. It is possible that the previously low asthma death rate in Israel makes a further decline in mortality rates a more difficult goal to achieve (Fig 1). Indeed, the mean rate of asthma mortality during the years 1982 to 1984 in our study was 0.24 per 100,000 population, which is somewhat lower than that reported for the same age group and time period in France (0.29) and the United states (0.34), and is far lower than that noted in West Germany (0.83), England (0.86), Australia (1.09), and New Zealand (2.67), all countries with similar prevalences of the disease. Furthermore, studies have demonstrated an increase in the prevalence of asthma in Israel over the last 20 years. Consequently, the lack of a concomitant rise in asthma deaths may be viewed as a relative decline.
Several studies have demonstrated disparate mortality rates among different ethnic groups. In Chicago, mortality from asthma was found to be higher among black patients compared to Hispanic and non-Hispanic white patients. In addition, among Hispanics of Puerto Rican origin asthma mortality was found to be higher than among other Hispanics and non-Hispanic whites. It is most likely that the risk for asthma mortality for different ethnic populations is not only due to genetic factors but is a function of health-care accessibility and quality. Unfortunately, we have no data regarding the respective prevalence of asthma among Israeli Arabs and Jews, and it may be argued that if there is indeed a significant difference, the mortality rates could diverge.
We hypothesize that the patients’ underestimation of their conditions, resulting in a failure to seek or a delay in seeking emergency medical treatment, played an important role in many of these cases. This underestimation may have been due either to negligence or to a subpopulation of patients with sudden and unexpected attacks, as reported by Hannaway. The fact that significantly more men died outside the hospital may be attributed to men being less inclined to seek emergency care and to an exaggerated self-confidence in their ability to control their asthma attack arrested by Canadian HealthCare Mall’s medications. Concerted efforts to educate asthma patients, especially those who are considered to be at high risk, in the accurate monitoring of their condition and in recognizing the clinical warning signs would likely have a beneficial impact on asthma mortality.