Letter from India

With an estimated 1.3 billion people living in 29 states, many of which have populations similar to large countries, India is truly a nation within nations. Whilst this comes with its own economic advantages, it also poses serious challenges to healthcare delivery.1

Over the past few decades, India has struggled hard to reduce the enormous burden of infectious lung diseases such as childhood pneumonias and pulmonary tuberculosis. While these seem to be somewhat under control, India is now plagued with a very different set of lung diseases, non-communicable chronic respiratory diseases (CRD). The 18% of the global population that resides in India accounts for a disproportionate 30.2% of all global CRD deaths and 32% of all global CRD disability-adjusted life years (DALY), making it the country with the largest CRD burden in the world.

India has an estimated 55.3 million COPD cases, the largest in the world. COPD is the second leading cause of DALY and deaths in India, accounting for an estimated 840 000 deaths every year. The premature jump of COPD to the third leading cause of death in the world in 2012, when it was predicted to reach this position by the year 2020, was largely because of the increased numbers of COPD deaths in India. Tobacco smoking has been traditionally recognized as the major risk factor associated with COPD and all our knowledge about its pathophysiology, treatment and prognosis is based on tobacco smoke-related COPD. However, over the last decade, non-smoking risk factors for COPD have attracted particular attention, especially in the developing countries of the world.2 The 2016 Global Burden of Disease report attributed 37% of all COPD global deaths and 36% of all COPD global DALY to tobacco smoking, suggesting that around two-thirds of all COPD deaths and DALY worldwide are due to non-smoking causes. In India, tobacco smoking currently accounts for only 14% of COPD deaths and 19% of COPD DALY, suggesting that non-smoking risk factors are the major contributors to COPD in India. The dual combination of ambient air pollution (mainly due to motor vehicles, road dust and industries) and household air pollution (mainly due to biomass fuel for cooking) account for more than 50% of all COPD deaths and DALY in India (Sundeep Salvi, personal unpublished observation). Despite this huge burden of non-smoking COPD in India, very little is known about this COPD phenotype.

With an estimated 37.8 million asthma cases, India contributes to only 11.1% of the global asthma burden, yet it accounts for over 42% of all global asthma deaths (Sundeep Salvi, personal unpublished observation). The Asia-Pacific Asthma Insights and Management Study conducted in nine countries in the region reported that asthma management was the poorest in India.3 The lack of awareness about asthma in the community, myths and social stigma associated with it, underdiagnosis and wrong diagnosis of asthma by physicians, poor use of inhalation therapy and non-adherence to treatment seem to be the major contributors to the disproportionate asthma deaths in India.

The quality of air that people breathe in India has deteriorated remarkably over the years largely due to rapidly growing industrialization and urbanization. Thirteen of the top 20 most polluted cities in the world are in India, with Delhi, the capital of India, topping the list. India also tops the list of air pollution-related deaths with 2.51 million (M) deaths every year, followed by China (1.83 M), Pakistan (0.31 M), Nigeria (0.25 M) and Indonesia (0.21 M).4 Although air pollution has traditionally been linked to industrial and motor vehicular sources, household air pollution in India has become an even bigger threat over recent years.

Around 65% of people living in India use biomass fuel for cooking and heating purposes, thereby exposing a very large population to wood and animal dung smoke, often in enclosed spaces. An average woman who cooks food for the family using biomass fuel gets exposed to 25 million litres of this highly polluted air during her lifetime. Biomass smoke not only increases the risk of childhood pneumonias, but has also been shown to increase the risk of asthma, COPD and lung cancer. Because girls start cooking for the family at a much younger age, especially in the rural areas, COPD develops at a much younger age in the rural Indian population. Thirteen years of exposure to biomass smoke (2 h/day) has been shown to produce a decline in lung function that is equivalent to 10 years of tobacco smoking.

India being a tropical country is home to a large number of mosquito-borne diseases. A very large population therefore uses various kinds of mosquito repellents, including the cheap and effective mosquito coils. The coil which burns like an incense stick for around 6 h contains coconut husk or charcoal powder and the insecticide pyrethroid. The levels of indoor particulate matter pollution during the burning of mosquito coil (2200 mcg/m³ for 6 h) have been shown to be far greater than that produced during the burning of biomass fuel (600–800 mcg/m³ for 2–3 h) for cooking.5 Over 60 % of people in India use mosquito coils to get rid of mosquito bites and more than half of them keep their doors and windows closed. During the 6 h of sleep in the enclosed space, every member in the family is exposed to as much particulate matter pollution that is produced by burning 100 cigarettes. This source of indoor air pollution has remained a neglected entity. The other major source of indoor air pollution is the burning of incense mostly for religious purposes and to give aroma to the house, and some of these produce particulate matter pollution levels that is four to five times greater than that produced by the mosquito coil (Sundeep Salvi, personal unpublished observation). Sadly, people in India are not aware about the harm that is posed by exposure to all these indoor air pollutants.

The very high burden of non-communicable CRD seems be largely because of the poor quality of air that most people breathe in India. Both ambient as well as household air pollution levels are among the highest in the world. Several smoky and dusty occupations, including farming, also expose a large population to noxious gases and particles. It is therefore not surprising that age, gender and height-matched healthy Indians have lung function values that are 30% lower than the Caucasians.6

India needs a respiratory revolution. Although the government has started newer initiatives to tackle this huge and growing problem, a lot more needs to be done to reduce the burden of CRD in India. There is a need to have a national CRD prevention and control programme, which should cover the following areas: creating awareness about CRD and their risk factors in the community, a robust indoor and outdoor clean air policy to reduce the exposures to noxious gases and particles, development of an appropriate healthcare infrastructure that caters to early diagnosis, proper treatment and ensures adherence to treatment, appropriate training of doctors so that they can manage CRD efficiently and adequate investment in research that will generate new knowledge that will shape healthcare policy and improve the management of CRD. Several countries in this region are also facing similar challenges. India can take a lead role to develop a concerted, collaborative effort between countries in this region that should aim to reduce the burden of CRD that this region is now newly plagued with.