The silent tormentor

Asthma, a non-communicable respiratory disease, has not received in India the attention it deserves.

ASTHMA, or Status asthmaticus, defies the general pattern of incidence of diseases. Unlike in the case of most other diseases, the prevalence of asthma is the highest in developed countries such as the United States, the United Kingdom, Australia and New Zealand, and the least in India and China. Again, its prevalence is higher in urban areas than in rural areas.

Over 300 million people around the world suffer from this non-communicable respiratory disease. Asthma affects 3.5 per cent to over 20 per cent of the population in any country. While the causes of asthma are still unclear, its pathogenic mechanism appears to be the same for all those suffering from it.

Respiratory diseases, classified broadly into infective and non-infective, cause more deaths in India than in any other country. In low-income countries, infective respiratory diseases, caused mainly by TB, pneumonia and childhood infections, have been a major problem. Closely behind are the non-communicable or non-infective respiratory diseases such as asthma, which most often do not even get recognised. During the course of the diagnosis and management of diseases, asthma is not treated independently but fitted into the general spectrum of respiratory diseases. So much so that even though medicines that treat asthma effectively are available at affordable costs (Rs.5 to Rs.10 a day), it hardly reaches 1 per cent of those who need it.

According to Dr. Martyn Partridge, Professor, Respiratory Medicine, Charing Cross Hospital, London, not much data are available on the prevalence of asthma. But a 1998 study (part of an international study on "Asthma and Allergies in Childhood", done in 100 countries) confirmed that the incidence of asthma varies from country to country, with a strong urban bias.

According to Dr. Raj B. Singh, respiratory physician, Apollo Hospitals, Chennai, there are different theories about the low prevalence of asthma in low-income countries. One theory revolves around the genetic background of the patients. But the prevalence of asthma has increased rapidly over the last few years and genetic changes cannot happen so quickly. Therefore, the cause is less likely to be genetic factors. Changes in the environment are probably the cause. But it is also well established that pollution, including that from allergens, smoke and toxins, does not cause asthma, though it may worsen a pre-existing condition.

Another theory gaining ground is the hygiene hypothesis. Our immune system has evolved over millions of years to fight infection. So, if a child is born and brought up in a sterile environment, then there is a subversion of the whole immune mechanism into a hyper-reactive allergic mechanism. So, in a society where infection is low, one expects a high incidence of asthma. This is a very elegant and intellectually appealing concept. But, according to Dr. Raj Singh, there are not enough data to support a generalisation like this because there is no reason for the incidence of infection to be low in rural areas. Yet, the prevalence of asthma is low in the rural areas. Citing the example of Chennai slums, he says that though one expects to find high levels of infection there and hence low prevalence of asthma according to this theory, there is, in fact, high prevalence of the latter.

Changes in lifestyle are thought to be another reason for the increase in the prevalence of asthma. For instance, in rural Africa, where the entire population has moved from a traditional to a more affluent lifestyle, the prevalence of asthma has increased. There could be something in the rural, or traditional, lifestyle that has protected people, or something in the urban lifestyle that causes asthma.

It is not enough to recognise and diagnose asthma, what is more important is to manage it with optimum medication. The development of inhaled corticosteroids has revolutionised asthma treatment, which has moved away from treating the symptoms to controlling the underlying inflammation of bronchial airways. Inhalation of the asthma medicine is the most effective treatment as it delivers medicine right to the place where it is meant to work, and is also devoid of any side effects.

For people suffering from mild asthma (infrequent attacks), the use of inhalers can be need-based, while those having significant asthma (symptoms occurring every week) must be treated with anti-inflammatory medication, preferably inhaled corticosteroids and bronchodilators. Acute or severe asthma attacks may require hospitalisation, administration of oxygen and intravenous medication. Hospitalisation and such other emergency situations can be prevented by the sustained use of inhaled medicines.

Inhaled medication has led to a dramatic fall in the morbidity and mortality rates of asthma patients in the U.K., Sweden, Australia and New Zealand, and led to the development of guidelines for asthma management. But in many countries, including India, it has not been possible to implement these guidelines.

In India, only approximately 1 per cent of the people with asthma use inhalers of any sort. According to Dr. Raj Singh, this means that 99 per cent of the people with asthma use medication that is sub-optimal. He says: "Although most doctors in India are aware of the inhaled steroids, only a small number of them prescribe them for a number of social, cultural and economic reasons, apart from the illiteracy of the patients." According to the National Asthma Foundation of India, the perception, causes and management of the disease are greatly influenced by the cultural background of the people. People in India mostly prefer traditional treatment for asthma.

According to Dr. Raj Singh, there are several reasons for the poor use of the inhalation method of medication. Among them, the most important are the lack of acceptance among patients and doctors and the overwhelming influence of alternative or traditional systems of medicine, which focus on diet changes unlike in the allopathic form of treatment. For instance, the traditional method prohibits asthma patients from taking phlegm-causing fruits and vegetables, while the allopathic method recommends all fresh fruits and vegetables. Sometimes, complications develop when people take allopathic and traditional forms of medicine simultaneously. Educating people about the simple methods of treatment and the complications arising from not adhering to one regimen is very important.

The other major problem with asthma management is the cost of medicines, as this chronic disease requires sustained administration of drugs. Dr. Raj Singh says that the difference between the disease and its symptoms has to be recognised. There is a tendency to treat the symptoms of asthma thinking that only when a patient has the symptoms can he/she have the disease and that if asymptomatic the disease does not exist. But the current understanding is that it is the constant state of inflammation that needs to be treated and not just the symptoms. This means the treatment has to be given every day and that adds to the patient's expenses.

Asthma medication is cheap; yet, as it costs Rs.5 to Rs.10 a day and has to be taken every day, year after year, it may strain the budget of a lower middle-class family. Developing low-cost alternatives that would also work reasonably well must be explored. But the government may need to be involved in this process; it can get asthma covered under the public health system.

Recognising the need to improve the management of asthma in India, some medical and non-medical professionals started the Asthma Foundation in 1998 with help from Prof. Martyn Partridge. From propagating the knowledge of asthma and encouraging newer ways of managing the disease, the Foundation is now looking at ways of fitting asthma into the spectrum of respiratory diseases and evolving simple strategies for its management at the primary-care level without much investment. The Foundation is focussing on rural areas where healthcare facilities, in general, are poorer than in the urban areas. The management methods are being tailored to the availability, accessibility and cost of infrastructure.