Asthma: the silent killer who persecutes selectively 

Written By Liya Kamran

Your chest tightens. Suddenly each breath is a battle. What felt like breathing seconds ago feels more like gasping. Your hand hovers over your inhaler. You take one pump and then another. The panic is replaced by instant relief. 

But, what if the ordeal continues and your inhaler is no longer your saviour? You're rushed to hospital. In an ambulance, medical professionals run to you with tubes, ventilators, nebulisers and everything necessary for survival. A sense of security comforts you as you watch your oxygen saturation climb back up. It's passed.The battle against your own lungs feels easier now. You no longer feel like you're fighting for every breath. This is your reality, a battle that can be fought with the weapons of modern medicine. But what about those who have no inhalers, no ambulances and most unfortunately, a diminishing hope for survival?

Asthma affects around 262 million people globally and was responsible for 455,000 deaths in 2019 alone. It's a silent killer which can manifest in symptoms ranging from occasional breathlessness and difficulty breathing to deadly asthma attacks that escalate rapidly. Despite its volatile nature, asthma fatality is highly preventable with lifesaving treatment such as inhaled medication.

However, this is a wishful outcome which is contradicted by the fact that asthma mortality is significantly high in lower-middle income countries. In fact, such countries contribute to 80% of total asthma mortality globally. Asthma management varies drastically between Western and lower-middle income countries and the disparity is evident when comparing prevalence and mortality rates. Australia has the highest prevalence of asthma yet one of the lowest mortality rates in comparison to South Africa, which is ranked 25th in the world for prevalence but 5th for mortality. Asthma deaths are rife in developing countries in comparison to Western societies, where receiving an inhaler and long term asthma medication is simpler.

There is a huge divide in how asthma is diagnosed and treated in different parts of the world. This is due to a range of factors, including a lack of diagnosis and therefore adequate treatment, socioeconomic deprivation and a lack of patient education. The issues caused by socioeconomic deprivation that have a direct impact on asthma management are multifaceted. For example, high smoking rates often correlate with deprived areas, purchasing asthma medication can be expensive or scarcely available, and it might be difficult to arrange frequent doctor visits to discuss and devise asthma plans. Socioeconomic deprivation can also mean poor housing, which can be a hotbed for certain asthma triggers like air pollution, dust mites, and mould.. There are also more complex and deep-rooted issues such as the inaccessibility to affordable healthcare itself. We are privileged to live in a society where healthcare is free at point of use and seeing a doctor is not a constant battle. 

Patient Education 

Socioeconomic deprivation is not the only barrier to adequate asthma care; the underdiagnosis of asthma leads to its undertreatment which can accelerate mortality. Underdiagnosis of asthma is not solely due to a lack of doctor visits or limited healthcare access. 

A widespread misconception is that asthma primarily affects children when, in reality, asthma is a chronic condition that can develop at any stage of life. Furthermore, In South Asia, Africa and the Middle East, there is a growing fear that inhalers are addictive, leading to less acknowledgement of their life-saving role. Inhalers do not contain addictive compounds. Rather, they contain bronchodilators to open up the airways and corticosteroids to reduce inflammation. In parts of East and South Asia, some people may turn to herbal treatments and, while these remedies may provide temporary symptom relief, they’re not a substitute for long term asthma management by prescribed medication.

Patient education is imperative for the distribution of asthma medication into areas where it is needed. Without the necessary guidance and knowledge on how to use inhalers correctly and when to use them, increasing accessibility alone will be a futile attempt to curb mortality. In the UK, there are many initiatives aimed at increasing awareness on asthma from a young age, an example of this would be the UCL Medical School Year 1 Self selected component ‘Speaking up for Asthma’, where the assessment is to inform primary school children on what asthma is and how it is treated. A message echoed repeatedly during the presentations to the children is the differentiation between brown and blue inhalers. However, if we focus on Latin America, Africa and South Asia, there are fewer - if any - initiatives on asthma education in younger children.

Cultural beliefs and Traditions 

Deeply rooted traditions and beliefs may influence the perception of asthma in many parts of the world. Cultural practices and alternative treatments take precedence over inhaled medication in some parts of the world. While some of these traditions are harmless, others pose potential risks. For instance, in Hyderabad, India, a longstanding ritual involves swallowing a live murrel fish coated in herbal paste for asthma relief. However, this practice carries risks such as infections and choking and there is no scientific evidence to support whether it is a viable treatment option. Similarly, in parts of West Africa and rural Latin America, asthma is sometimes linked to supernatural causes which leads individuals to seek treatment from spiritual healers and shamans rather than medical professionals.In Indonesia and Filipino villages, some believe that drying and consuming a flying lizard can cure asthma, but this practice carries risk of introducing parasites and bacteria into the body. In China, Vietnam and parts of Africa, consuming snake or frog soup is associated with improving lung health and curing asthma although there is little scientific evidence to support this claim.Meanwhile in Eastern Europe and Russia, walking barefoot on morning dew is believed to strengthen lungs, yet exposure to cold air can actually trigger asthma rather than provide relief. There are some traditions that can be more dangerous than beneficial, such as placing a live spider in the mouth for a few seconds in parts of South America.These beliefs persist and highlight the importance of culturally sensitive education on asthma management. Misinformation and alternative treatments should not be dismissed outright but rather addressed through awareness and accessibility to proper care. Understanding why people turn to these practices is crucial in order to bridge the gap between traditional beliefs and modern medicine. 

Cost of medication

The price of asthma medications in lower and middle income countries is an instigator for the deadly misconception that inhalers are only to be used in severe cases. This is a natural reaction considering that the price of an inhaler in some of these places is unreasonably high and so people tend to turn to medication only when they deem it to be extremely necessary. This misunderstanding is dangerous and puts the lives of asthma patients in jeopardy. There must be initiatives that give people a realistic picture of asthma so they understand that the thousands of deaths that occur by asthma globally are preventable.

The ‘Lancet Global Health’ published a study in which they analysed the different prices of inhalers globally. Affordability of long acting muscarinic antagonists (which are inhalers used for chronic obstructive pulmonary disorder and asthma) ranged from four days worth of wages in Jordan, a third of the monthly income in Brazil, up to 75 days in Nigeria and 95 days of wages in Gambia. Even when considering just the availability of inhaled corticosteroids (brown inhalers), a map presented by the ‘Lancet Global Health’ showed availability as being less than 80% in 10 countries located in Africa, the Middle East and South Asia. 

The standard availability of inhaled corticosteroids globally should be above 80% in both public and private healthcare settings according to the World Health Organisation (WHO). There are two initiatives, the “universal Health coverage” and “global action plan for non communicable Diseases, which are put in place by WHO to ensure universal access to essential medicines: inhaled corticosteroids being one of them. However, as shown by the study, lower income and lower-middle income countries are falling short of the 80% target, which is limiting access to asthma care. 

Access to care 

The issue is not that we don’t have solutions.The problem lies in how these solutions are implemented and the fact that they do not have a global reach. There are a plethora of organisations and NGOs that aim to tackle the disparity in asthma treatment but they are not as widely implemented as they should be.

The first step to end selective prevention and management of asthma and to standardise the quality of asthma care globally is to acknowledge that there is disparity and divide. Inhalers are  imperative for so many, yet so overlooked in such communities where ancient myths and ideologies that contradict modern asthma care remain. The WHO called for increased asthma education on World Asthma Day, as they highlighted one of the key issues is that health facilities in lower and middle income countries have a lack of inhalers, which are transformative to the lung health of asthma patients. However, with increased education comes the need for increased funding for programmes to help people navigate how to manage their disease. For example, if communities in which asthma is less recognised are targeted and informed about effective asthma care and management, they would then need to be able to access the care that they are informed about. Education is futile without action to follow it; providing knowledge on asthma treatment in order to urge these communities to recognise it as a chronic lung condition is not enough. 

Currently, developing countries like Pakistan have begun spreading more awareness around asthma despite rural areas still being deprived of any impactful programmes to increase public health education. While teaching people about asthma and inhalers is a crucial first step, the next challenge is to ensure inhalers are actually accessible. Additionally, affordability persists as a major barrier for those who can access healthcare facilities but not afford medication. A way to address this is by liaising with governments to implement policies which ensure low-income families are not deprived of life saving treatment. Such initiative was taken in Pakistan, with the invention of the ‘sehat’ card (or ‘health’ card) and it targeted the people who needed it the most: rural communities. The card allowed free healthcare such as hospitalisation, surgeries and diagnostic tests for people suffering from a wide range of conditions in the Khyber Pakhtunkhwa area, which is known to be one in which healthcare is scarcely available. However, with a shift in political policy, this initiative has lost its grounding and is now not functioning as efficiently, which is why it is important for us to constantly raise awareness for asthma in order to stop preventable deaths from becoming normalised. 

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The next time you gasp for air after a run and find relief in your inhaler, imagine if it was absent. Then, think about those who have no choice but to fight for every breath, caught in the cruel divide of the unequal burden of asthma. Life saving treatment is a fundamental right, not a privilege determined by where you live. Understanding this can help us raise a voice for the thousands who have fallen victim to the impact of the disparity in asthma care, management and treatment around the world. 

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