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This chapter examines four ethical issues raised by clinical asthma research involving children subjects: (1) to what extent are clinical asthma trials designed as placebo-controlled trials as opposed to active-drug controlled trials?; (2) do placebo-controlled trials in a condition like asthma place the research subjects at increased risk of harm?; (3) are the new guidelines promoting increased access of children to research changing the enrollment pattern of children in research?; and (4) are the new guidelines achieving their goal of garnering useful information about medication safety, efficacy, and dosing for children as a class? It is argued that children are a vulnerable population in clinical research and need additional protection. This means that the former recommendations of the National Commission to perform research first on animals, second on adults, and only then on children should be maintained. It also means that when children are involved, highest scientific and ethical standards must be maintained.

Compliance has become a principal public health issue of the twenty-first century, and compliance posits a figure with a responsibility to continually work to discipline the self into a biomedical subject This chapter draws on fieldwork in the Caribbean and the United States on the science and medicine of the chronic diseases of asthma, diabetes, and obesity to explore this subject. Moving from scientists in the United States to health officials, doctors, and patients in Barbados and Trinidad and Tobago, it explores the ways in which biomedical science and global health become intertwined, creating particular forms of health intervention. It argues that the figure that inhabits biomedical compliance is not the familiar (neo)liberal individual found by recent social science analyses to be at the center of global science, markets, and governing.

This chapter explains how mold spores can cause allergies. Spores carry proteins on their surface, and those that act as antigens can cause a cascade of immune responses resulting in the miseries of allergic rhinitis or hay fever, allergic conjunctivitis, skin allergies, asthma, eczema or atopic dermatitis, and hypersensitivity pneumonitis. This chapter describes interactions between immune cells in allergies mediated by IgE and IgG, providing a primer on this complex field of medicine. The idea that allergy is a perversion of a response that evolved to combat parasitic infestations is discussed, along with the hygiene hypothesis that has been advanced as an explanation for the increasing prevalence of asthma.

The Sinai's Improving Community Health Survey found that Puerto Rican children had the highest asthma prevalence rate of all groups. Twenty-one percent of Puerto Rican children had diagnosed asthma while another 13% had a positive asthma screen for a potential total asthma burden of 34%. This chapter discusses the lack of specific interventions that target Puerto Rican children, establishment of the Greater Humboldt Park Community of Wellness, and the asthma experience in Humboldt Park as a model of community-based participatory research.

The development of respiratory disease epidemiology is relatively recent compared to other disease-oriented epidemiologies, such as those devoted to infectious diseases, cancer, or cardiovascular diseases. It should therefore not be surprising that respiratory disease epidemiology, with few exceptions, is not yet covered in most teaching programmes. This chapter aims to facilitate the establishment of introductory courses and sessions of respiratory epidemiology in a variety of teaching contexts. Because modern epidemiology is largely focused on cancer and cardiovascular diseases, it is necessary to understand the particularities of respiratory epidemiology. The chapter primarily refers to chronic obstructive respiratory disease and asthma.

This chapter discusses the role of genetic variation in modulating gene expression and how this can help resolve functionally important regulatory variants. The successful application of genetic mapping techniques to define expression quantitative trait loci in model organisms including yeast and mice is discussed, together with evidence from studies of human populations. The need to take into account transcript isoform diversity resulting from alternative splicing is highlighted, together with the value of analysis based on allele-specific gene expression and at the protein level. The synergy between genome-wide disease association studies and analysis of the genetics of gene expression, also at a genome-wide level in terms of markers and expression traits, is illustrated by review of recent studies in asthma. The context specificity of regulatory variants is demonstrated, noting the importance of analysis in primary cells or tissues in conditions relevant to the disease or other trait of interest.

Compared to other systems, little is known about the mechanisms of placebo and placebo-related effects in both the cardiovascular and the respiratory system. Side effects in placebo groups of cardiovascular clinical trials are common and might represent the basis of nocebo effects. Heart activity can be conditioned and can also be affected during a placebo analgesic response by the activation of the endogenous opioid systems. Not only may placebo-activated endogenous opioids act on pain transmission and the heart, but on the respiratory centres as well, inducing respiratory depression. Other conditions, like asthma and cough, are powerfully affected by placebos, but the underlying mechanisms are virtually unknown.

This chapter illustrates the application of the disease process model approach to discrete reversible disease processes. The process model approach is applied in five steps: (1) identifying and showing the relevance of a tentative process model; (2) identifying one or more markers of the key effect; (3) choosing an etiologic time interval; (4) selecting the hypothetical agent(s) and a measurable marker for exposure; and (5) defining a summary dose metric that represents our hypothesis about the agent and mechanism to be tested in an epidemiologic study.

Asthma is a chronic respiratory disease characterized by the swelling and narrowing of the lung airways. Although asthma can be a detrimental disease if not managed properly, it can be controlled via the proper use of medications, trigger avoidance, early recognition of symptoms, and appropriate and timely response to symptoms. When asthma is well-controlled, people with asthma and their families can live healthy and productive lives. This chapter discusses how local-level data pertaining to the prevalence and effects of paediatric asthma in six diverse Chicago communities led to culturally appropriate action to improve asthma outcomes among children living in some of the city's most affected communities.

Sleep has a significant impact on breathing through withdrawal of the wakefulness stimulus and alterations in muscle tone, ventilatory chemosensitivity, lung properties, and metabolic rate. Obstructive sleep apnea and sleep-related hypoventilation are highly prevalent and frequently unrecognized sleep breathing disorders, which have a significant impact on health. Among the many factors promoting their development, obesity represents the most important modifiable risk factor. There is increased recognition that a dual interaction between sleep/sleep disorders and chronic lung disease exists. On the one hand, there is increased prevalence of globally disturbed sleep, insomnia, and restless legs syndrome in chronic lung disease. On the other hand, sleep is a vulnerable time for these patients and there is data to suggest worse respiratory outcomes and quality of life in patients with coexistenting sleep disorders. Many gaps remain in our knowledge of the nature of these interactions, their underlying mechanisms, and implications for these already compromised populations.

Asthma is the most common chronic disease of childhood and the incidence is increasing. This chapter reviews published health economic studies of asthma interventions and medical technology with a focus on pediatric and adolescent populations. It begins with descriptions of the etiology, epidemiology, and management of asthma, followed by the economic burden of illness. A detailed literature review and a quality appraisal are presented, scrutinizing asthma outcome measures, the analytic framework and handling of uncertainty. The discussion evaluates how well the current health economic recommendations in pediatric asthma have been reflected in clinical guidelines and suggests avenues for future improvement.

Occupational diseases are illnesses that are associated with a particular occupational or industry and result from hazards in the workplace. They are entirely preventable if hazards in the workplace are eliminated or controlled. Many occupational diseases are unique to the hazards encountered in certain workplaces and do not, or rarely, exist apart from workers. Silicosis, for example, simply does not occur unless the patient has been exposed to silica dust and this almost never occurs except in the workplace. Other occupational diseases are familiar diseases, seen in the general population, that have an occupational cause in the particular case. For example, occupational lung cancer is identical to lung cancer from smoking but may be caused by many occupational exposures, including asbestos, arsenic and polycyclic aromatic hydrocarbons. Occupational skin disorders can be broadly divided into three groups: dermatitis, skin damage, and skin cancers. Occupational lung diseases are also varied. They include occupational asthma, airway irritation, toxic inhalation, infections, hypersensitivity pneumonitis, fume fevers, pneumoconiosis, and cancer. Noise-induced hearing loss is a form of progressive deafness caused by exposure to noise. Reproductive disorders include many causes of infertility, most of which affect men more than women. Because of concern for the fetus, pregnant women should be protected from many physical and chemical exposures but are generally otherwise able to do what work they have been doing until late in the pregnancy.

Chapter 1 begins by stressing the severity of climate change (CC) and showing how, contrary to popular belief, atomic energy is not a viable solution to CC. Many scientists and most market proponents agree that renewable energy and energy efficiencies are better options. The chapter also shows that government subsidies for oil and nuclear power are the result of flawed science, poor ethics, short-term thinking, and special-interest influence. The chapter has 7 sections, the first of which surveys four major components of the energy crisis. These are oil addiction, non-CC-related deaths from fossil-fuel pollution, nuclear-weapons proliferation, and catastrophic CC. The second section summarizes some of the powerful evidence for global CC. The third section uses historical, ahistorical, Rawlsian, and utilitarian ethical principles to show how developed nations, especially the US, are most responsible for human-caused CC. The fourth section shows why climate-change skeptics, such as “deniers” who doubt CC is real, and “delayers” who say that it should not yet be addressed, have no valid objections. Instead, they all err scientifically and ethically. The fifth section illustrates that all modern scientific methods—and scientific consensus since at least 1995—confirm the reality of global CC. Essentially all expert-scientific analyses published in refereed, scientific-professional journals confirm the reality of global CC. The sixth section of the chapter shows how fossil-fuel special interests have contributed to the continued CC debate largely by paying non-experts to deny or challenge CC. The seventh section of the chapter provides an outline of each chapter in the book, noting that this book makes use of both scientific and ethical analyses to show why nuclear proponents’ arguments err, why CC deniers are wrong, and how scientific-methodological understanding can advance sound energy policy—including conservation, renewable energy, and energy efficiencies.

The increasing burden of asthma in developing countries has emerged as an important challenge to global public health. While international organizations have emphasized the role of guidelines in improving the diagnosis and management of asthma, very little is known about how practicing clinicians in these settings have responded to the rising prevalence and growing public health importance of these diseases. This chapter presents a case study from India that examines the changing social and epidemiological profile of asthma, and the evolution of allopathic clinical practices in the context of a pluralistic medical marketplace. Through ethnographic research among physicians, it identifies day-to-day determinants of diagnosis and treatment of patients in a variety of clinics, and examines the factors limiting their implementation of asthma guidelines.

This chapter presents an example of the application of the scheme for critical appraisal: a prospective cohort study entitled ‘Long-term relation between breastfeeding and development of atopy and asthma in children and young adults: a longitudinal study’, published in The Lancet, in 2002. Working through this, critical appraisal shows that this is a substantial and carefully performed prospective cohort study, in which the information on outcome, asthma at the age of nine years, is very clear, and the information on breastfeeding is almost equally clear.

This chapter examines the contextual factors related to the occurrence and risk of asthma, health behaviors, access to health care, and the design of effective interventions to reduce the burden of asthma. The latter is exemplified through the discussion of a specific community-based approach to asthma management: the Neighborhood Asthma Coalition.

Pregnancy is characterized by profound metabolic and physiological alterations involving virtually every organ system. Among apparently healthy women, the metabolic challenges, or “stress test” of pregnancy may contribute to adverse perinatal and neonatal outcomes, and may also unmask susceptibility for maternal chronic disorders. Available clinical and epidemiologic data are supportive of the hypothesis that common medical complications of pregnancy including gestational diabetes mellitus, and hypertensive disorders of pregnancy may represent, at least for some women, their underlying risk for developing related chronic medical conditions as they age. This chapter first provides a brief overview of maternal metabolic, physiological, and anatomical changes during pregnancy. These are followed by a review of selected maternal pre-gestational chronic medical conditions and those arising during pregnancy. The chapter closes with a discussion of the influence of other factors, including intimate partner violence, on maternal physical and mental well-being.