**4. Prevalence**

**10.** WHO programs of NCD, PEN, and PAL have been introduces in PHC dispensaries in many developing countries including Syria, and training for those programs was done at pilot sites, but the humanitarian crisis in Syria and other conflict zones discontinued

**11.** Conferences and World Asthma Days as recommended by GINA are improving asthma care: Make health workers in PHC familiar with asthma control, peak flow meter, and corticoid inhalers, but there is a great need for more education, which can also be provided

**12.** Patient organizations are playing a role on patient education and providing free medica‐

**13.** According to the GARD Survey results, training sessions for the essential on asthma and COPD are needed for health workers at primary care level. This needs to adapt educational

**14.** The list of essential medications for asthma, especially inhaled corticosteroids [24], is not available in all countries; in Sudan, a survey pointed this issue [25]. In a general review, researchers reported [26]: Another issue is in some developing countries, the essential medication as listed by WHO is not available. Health services in low-resource countries are poorly adapted to treating chronic diseases. Designed to respond episodically to acute disease, almost all historical investment has focused on infectious diseases. Crucial to the successful management of chronic diseases is an infrastructure designed to support proactive management, providing not only an accurate diagnosis, but also a secure supply of cost-effective drugs at an affordable price. When in very poor health systems, ICS are not available, a variety or a phenotype of severe asthma prevails (defined by WHO as the non-treated severe asthma) [27], while the ATS/ERS definition for severe asthma is asthma

**15.** The WHO issued a guide on prevention and control of non-communicable diseases in: Guidelines for primary healthcare in low-resource settings: 2012, and urged developing

Inner city asthma is a variant of asthma that afflicts patients who reside in some of the poorest neighborhoods of some urban localities [29]. These patients frequently have economic and financial difficulties and reside in housing projects that are environmentally poor with increased likelihood of pollution [30]. Several studies have demonstrated that these factors coupled to barriers to appropriate asthma care, as well as reliance on emergency care, poor medication compliance, limited availability of primary and specialty asthma care and poor communication between patient and physicians are responsible for the unique nature of this entity [31–33]. Because of these factors, the character of inner city asthma may be different from

countries to follow the directives for chronic respiratory disease as well [28].

progress. Effort should be done to continue [3, 4].

192 Asthma - From Childhood Asthma to ACOS Phenotypes

online.

tions [11].

materials.

refractory to ICS.

**3. Inner city asthma - Introduction**

Over the past several decades, a gradual increase in the prevalence of asthma has been noted in several industrialized countries [29]. Although some of this increase may be related to changes in health insurance policies resulting in better coverage and increased access to care and improvements in diagnostic testing, other factors may be involved. Some of the increase is attributed, in part, to a gradual increase in prevalence of asthma in individuals of lower socioeconomic status who reside in inner cities [29, 34]. For example, statistical analysis shows that between the years 2001 and 2010, rates of asthma in adolescents in the United States of America have increased at a rate of around 1.4% reaching 9.5% in 2010 [34]. Careful analysis of this phenomenon indicates that this increase was most realized among various minority groups including African-Americans and Hispanics.

African-American children are reported to have a rate of asthma per population that is 1.6 times the level observed in white children [34, 35]. Some Hispanic groups, like children originally from Puerto Ricco, have been reported to have asthma prevalence that is almost 2.4 times that of white children [35, 36]. The prevalence of asthma among children in some Chicago neighborhoods is estimated to be as high as 44%, with the highest rate observed and reported in neighborhoods with a higher proportion of residents of African-American and Hispanic ancestry [37]. In one district of New York City, asthma prevalence was reported 13.2% for Puerto Ricans [38]. Racial background is not the only factor responsible for this disparity. Asthma prevalence varies among various localities with those localities with low income levels manifesting an increase in prevalence irrespective or racial and ethnic mix [29, 33].
