Although the pathophysiology of asthma is increasingly understood, asthma deaths continue to increase, especially among non-Caucasians in inner-city urban areas including East Harlem, which has the highest mortality rate in the United States. The cause for this increase is uncertain, but several factors, including poor access to appropriate medical management, the overuse of beta agonists, environmental precipitants, or more severe disease, have been proposed as contributng factors. The Mount Sinai Hospital is a 1300-bed, tertiary care university hospital located at the juncture of East Harlem, an inner-city, predominantly Hispanic and African-American neighborhood, and Carnegie Hill, an affluent, predominantly Caucasian residential area. We examined asthma deaths (13) and near-deaths (20) at the Mount Sinai Hospital from 1986 to 1992 to determine risk factors and compared them to an age-and demographically matched control group. All of the information was based on retrospective patient chart reviews, and the parameters considered included ethnicity, insurance status, poverty level, and medications including the use of beta agonists. All of the asthma deaths and near-deaths except 1 occurred in low-income African-American and Hispanic patients (x = 16.9) However, steroid and beta-agonist usage were comparable in the adverse outcome group compared to the control group. Our results confirm that adverse outcome asthma in East Harlem occurred predominantly among non-Caucasians of low socioeconomic status. We conclude that ethnicity and socioeconomic status play an important role in asthma death and near-death at our institution. Patients were followed for asthma at the same institution, which may imply equivalent care, but it is also possible that some aspects of health care, such as follow-up, access, or reliance on emergency room visits, differed between the two groups. Alternatively, the disease may be more severe in African-American and Hispanic patient populations. Attempts to reduce asthma mortality have to address these issues.