Conquering COPD: A collective effort

Dr Sundeep Salvi

Chronic obstructive pulmonary disease or COPD is the third leading cause of death in the world and the second leading cause of death in India. It costs the Indian economy more than Rs 35,000 crores every year, which is more than the annual budget allotted to the Ministry of Health and Family Welfare, Government of India. Half a million people die due to COPD every year in India. COPD causes more deaths than those due to tuberculosis , malaria and diabetes, all combined. According to the WHO, deaths due to COPD are estimated to increase by 160 per cent by the year 2030. Despite this enormous health burden, COPD remains an unknown disease in India.

COPD is a chronic, progressive disease of the lungs associated with airways obstruction and destruction of the air sacs in the lung. The factors associated with damage to the lungs spill into the blood and subsequently cause damage to the heart, skeletal muscles, bones, kidneys and brain. In fact, over two thirds of patients with COPD die due to ischemic heart disease, congestive heart failure, hypertension, skeletal muscle dysfunction, weight loss, osteoporosis and kidney failure. The Western world taught us that COPD is caused predominantly by tobacco smoking, and because it was thought to be a self inflicted disease, it remained a neglected disease in India for several decades. It is only recently that we have realised that there are several risk factors other than tobacco smoking that are responsible for the development of COPD in India. In fact, more than 50 per cent of the COPD in India occurs in non-smokers. Chronic exposure to indoor air pollution due to the burning of biomass fuels in poorly ventilated homes and high levels of ambient air pollution, largely due to motor vehicular and industrial exhausts seem to be the major risk factors for COPD in India. Other risk factors are also not uncommon – occupational exposures (farming, mining, building and construction, stone cutting, leather industry and others), a previous lung tuberculosis, poorly treated chronic asthma, poor nutrition and poor socio-economic status. The prevalence of smoking is growing in India, especially among women in metropolitan cities. Among tobacco smokers, although cigarettes have been shown to be harmful beyond doubt for causing COPD, other forms of smoking such as bidis and chillums, which are very common in India, are even more harmful. Hookahs are thought to be safe because of the belief that the smoke passing through water cleans up the impurities. Little do people know that hookahs are even more harmful than bidis and cigarettes.

Indians have lung function values that are 30 per cent lower than Europeans, when corrected for age, gender and height. Already weakened lungs and a huge population exposed to myriad risk factors for COPD are believed to be largely responsible for the growing prevalence of this ailment in India. There are very few good quality studies that have studied the prevalence of COPD in India. Based on some of the recent data, an estimated 5-10 per cent of the adult population in India suffer from COPD.

Despite the huge and growing burden of COPD in India, it remains poorly diagnosed in clinical practice. Spirometry is the gold standard diagnostic tool for COPD, but it is not available in most clinics, hospitals and diagnostic centres. Lack of use of spirometry contributes to over 50 per cent of COPD patients being undiagnosed. It is not the cost of the tool that is responsible, but the lack of knowledge about its usefulness and the lack of knowledge about how to perform the test and interpret the test. Apart from this, the symptoms of progressive breathlessness and cough are usually insidious in onset and are often perceived by patients as age-related symptoms. Physicians too label them as symptoms of bronchitis and treat them symptomatically with antibiotics, coughs syrups and bronchodilators. The overall lack of awareness of COPD, both among patients as well as physicians, further contributes to the under-diagnosis of COPD in India.

CAUSES OF DEATHS IN SOUTH – EAST ASIAN REGION

Current and future predictions for mortality rates due to common diseases affecting the South East Asian Region

Annual mortality rates due to different diseases in India covered under the National Control Programmes by the Ministry of Health and Family Welfare, Government of India. COPD is not yet covered under the National Control Programmes

Even when diagnosed, it remains a poorly treated disease in India. As of now, there are no magic drugs that can reverse the damage that has already occurred in the COPD lungs, but there are good drugs that can significantly improve survival and improve the quality of life for COPD patients. Unfortunately, many of these drugs are not available in most government hospitals and many doctors don’t have the knowledge about how to use these drugs effectively. According to national and international guidelines, inhaled medications are the preferred routes of drug delivery because they are more effective and safe, yet many patients of COPD receive oral drugs in India that are not only poorly effective, but also more harmful. Earlier, there were not many useful drugs that could be offered to patients of COPD, but with huge investments in drug research, especially in the Western world, there are now a variety of drugs that can bring about a significant change in the quality of life and symptom relief for patients with COPD. Unfortunately, the overall nihilistic attitude towards the disease and lack of updated knowledge among primary as well as secondary care physicians still exists, and this contributes in a major way to poor quality of care being offered to patients with COPD.

Acute exacerbations of COPD are the greatest cause of concern for these patients, because each of these episodes significantly deteriorates lung health, worsens quality of life and drains them of their finances. Treating these episodes and more importantly, preventing these episodes is a challenge, which many physicians do not know how to handle. There is a need for more knowledge generation and knowledge dissemination in this area of COPD management that remains badly neglected.

Until recently, tuberculosis, malaria, HIV-AIDS, leprosy, filaria and dengue killed several thousands of people every year in India. With the introduction of the National Control Programmes for each of these diseases by the Ministry of Health and Family Welfare, the mortality rates have declined markedly. There are currently nine National Control Programmes that are ongoing in India, and each one has contributed immensely to reducing deaths and sufferings due to these diseases. Despite the fact that COPD is a leading cause of death and suffering in India, it has not attracted the need for a National Prevention and Control Programme. It still remains a neglected Cinderella disease.

India needs a National COPD Prevention and Control Programme before the disease gets out of hand. The three key areas where major thrust will be required are (a) setting up appropriate healthcare services infrastructure in India for early and accurate diagnosis, appropriate treatment and rehabilitation programmes, (b) generating new knowledge in COPD that will be relevant to India’s needs through properly designed and funded research studies and (c) dissemination of knowledge regarding prevention, diagnosis, treatment and rehabilitation to healthcare providers in India so that they can improve the quality of care of patients with COPD. For this, physicians, researchers, policy makers, medical educators and healthcare providers will need to come together, devise and implement strategies that will be effective and sustainable. In a resource poor country like India, it will be a challenge to tackle the growing burden of COPD but nonetheless we will have to stand up and face the challenge. Preventing the development of COPD will probably be the most viable long-term solution and that is where major public health initiatives will be required. But in the meantime, we will need to diagnose existing patients of COPD in India and treat them effectively with the best available drugs and care.