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Are Indians getting the right treatment for asthma?

Raj B. Singh

Inhaled medication is used by less than two per cent of the 50 million asthmatics in India.

THE SIMPLE answer to the question is `probably, not.' Asthma is a common and chronic respiratory disease that has been found to be increasing in prevalence throughout the world. Over the last 25 years, safe and effective treatment has been available which has the potential to allow asthmatics throughout the world to lead a normal life with well preserved lung function. Inhaled steroids have emerged as the mainstay of asthma treatment. Widespread use of inhaled medication in the developed countries has led to a reduction in the number of asthma deaths and days off work and off school; improved quality of life; and has resulted in a paradigm shift in the way an asthmatic considers his illness. Despite the increasing knowledge and understanding of asthma and its management, optimum treatment is apparently not reaching the vast majority of people in countries like India. A study published in the reputed British journal Thorax notes that doctors working in poorer countries are unable to use optimum treatment because of the high cost and lack of access to medication, although they may be fully aware of the advantages of such treatment.

The diagnosis of asthma is made mainly from the symptoms of cough, wheezy breathlessness, and chest tightness. Any unexplained cough, especially when chronic or recurrent, should alert one to the possibility of asthma. Confirmation is by a simple lung function test of `spirometry,' which involves blowing hard into an instrument that measures the speed and volume of the blow. Where spirometry is not available, a simple hand-held instrument called the peak flow meter has been found to be helpful. Allergy skin testing, which was once very popular, has now been found to be only occasionally of any use.

Avoiding some of the obvious aggravating factors like house dust, smoke, strong smells, fumes, pollen, and pets can be helpful. Other common aggravating factors are infection, high humidity, air pollution, and stress. Contrary to popular belief in India (often derived from traditional systems of medicine), food plays little role in asthma exacerbations. Dietary manipulations are therefore unnecessary apart from caloric restriction to treat or prevent obesity.

Asthma is estimated to affect 5 to10 per cent of the population in India. Inhaled medication is being used by less than 2 per cent of the 50 million asthma sufferers in India, whereas more than 90 per cent of asthmatics in the United Kingdom are on inhalers, mostly inhaled steroids. Although cost and availability are the major factors, there are also other reasons for the low utilisation of effective treatment in our country. One is the reluctance to accept the diagnosis, which means that a lot of inappropriate and often expensive medication like antibiotics and occasionally even anti-TB drugs are used in people with asthma. Secondly, short-term relieving medication like theophylline and salbutamol is more popular than inhaled steroids, which, though working more slowly, address the real problem of inflamed airways in asthma far more effectively. Therefore periodic injections and short courses of tablets are more commonly used, which give the asthmatic the illusion that his disease is not chronic but only an occasional `allergy' in an otherwise normal lung. This strategy, unfortunately, can give rise to sudden, severe and occasionally life-threatening attacks of asthma and can also lead to progressive deterioration of lung function over the years.

Regular use of inhaled steroids over prolonged periods is considered to be expensive. Inhaled medication is therefore not available from government hospitals and health centres. But, in fact, it has been shown that treatment given intermittently is more expensive in the long run when one includes the cost of periodic hospitalisation, not to mention the days lost from work. Moreover, the cost of the basic inhaler could come down further with government intervention and by larger volumes of manufacture and purchase.

To improve asthma management in India, the following points need consideration:

1. Awareness of asthma as a common and debilitating condition needs to be improved by government institutions as well as the NGOs.

2. Inhaled medication should be made available through government institutions.

3. Pharmaceutical companies should come forward to supply basic inhalers, particularly the earlier introduced but effective ones at a lower cost.

4. The safety, efficacy, and necessity of inhaled steroids should be widely disseminated among the general public.

5. Simple spirometers and peak flow meters should be made available in all government institutions.

6. Cost-effective and, if necessary, second-best options need to be worked out in situations where optimum treatment is not affordable or not possible for some other reason.

May 2 is observed this year as the World Asthma Day. Several programmes are being coordinated throughout the world today by the Global Initiative for Asthma (GINA). The Asthma Foundation of India is contributing to this effort in our country.

(Dr. Raj B. Singh, MD, FRCP, is a Consultant Respiratory Physician based in Chennai and Managing Trustee of the Asthma Foundation of India.)

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