Lung health for life: putting a spotlight on global respiratory inequalities

Chronic respiratory diseases

CRDs and health inequalities

Title

Lung health for life: putting a spotlight on global respiratory inequalities

?

Body text:

?

Last week was the World Health Summit in Berlin, and one of the topics was ‘The Climate-Health Nexus: Pathways to Action for Equity’. The intersection of these factors – health, climate change and equity – may not seem obvious to some. But for respiratory medicine specialists like me it is a growing reality, particularly as it relates to chronic respiratory diseases (CRDs).

?

CRDs are intrinsically linked to social inequalities

CRDs are a collection of conditions that affect the airways and other structures of the lungs. They include chronic obstructive pulmonary disease (COPD) – also known as emphysema or chronic bronchitis – asthma, occupational lung diseases and pulmonary hypertension. In 2019, together these conditions affected an estimated 455 million people around the world, causing 4 million deaths. And their prevalence is growing.

People at the lowest socioeconomic levels are up to 14 times more likely to develop respiratory diseases than people at the highest levels; and people who have a lower household income are at greater risk of developing asthma than those with a higher household income. Children who experience poverty are also at increased risk of asthma exacerbations. The number of people who die from COPD is also higher among people of low socioeconomic position, and data from England suggest that CRDs are one of the major causes of the observed gap in life expectancy between the most affluent and most deprived communities.

Unsurprisingly, the main risk factors for CRDs also follow a social gradient, disproportionately impacting the most vulnerable in society. Smoking, for instance, is probably the most widely recognised risk factor common to all CRDs, and research from England and Wales, China, and the US demonstrates that smoking rates are highest among traditionally underserved communities. However, the causes of CRDs are not just behavioural; research from Sweden found that they can be the result of a combination of physiological and environmental factors and exposures throughout an individual’s lifetime, some of which have roots in early life (e.g. being born prematurely, childhood respiratory infections, exposure to second-hand smoke, and air pollution) and can lead to premature death.?Exposure to air pollution is also particularly important at an international level because it disproportionately impacts people living in low- and middle-income countries (LMICs).

?

Lung health sits at the interface of climate change, air pollution and social inequalities

In 2019, more than 4 million premature deaths were caused around the world by outdoor air pollution, including emissions from power stations and vehicles, and burning waste and crops. Climate change is contributing to this due to the development of warmer temperatures that are increasing the frequency, severity and duration of wildfires globally. These wildfires are releasing hazardous air pollutants which in high enough doses can aggravate asthma, trigger lung disease, cause heart attacks and lead to premature death. Taking action on climate change and reducing the rising levels of these harmful pollutants is thus vital for better lung health.

Tackling indoor air pollution is also important to address inequalities in lung health; globally, approximately 2.3 billion people are exposed to harmful fumes resulting from cooking indoors with open fires or heating homes with stoves that use biomass fuels, kerosene and coal. Most of these people live in LMICs, where data show that up to 23% of COPD deaths are associated with exposure to household air pollution. These inequalities are compounded by gender and age; women and children experience higher levels of exposure to these pollutants because they tend to spend more time in the home.

?

Ensuring equitable access to proactive diagnosis and care is an integral part of the solution

Preventive approaches alone are insufficient. Ensuring proactive detection and access to appropriate treatment for everyone at risk of CRDs must also be prioritised, with targeted approaches for more vulnerable communities. Integrating lung function testing into general health checks can encourage more people to seek diagnoses for their respiratory symptoms, and dedicated programmes for communities most at risk of CRDs could be run in collaboration with local schools, community centres, religious institutions or workplaces. Lung health checks could also provide a window of opportunity to intervene with health promotion and disease prevention activities, particularly in childhood. Fully utilising community health workers is essential to this approach as, with appropriate training and resources, they can deliver primary care, support underserved communities and provide educational outreach, acting as a liaison between people with CRDs and the health system.

Targeted interventions are also needed to provide broader access to high-quality respiratory care. Regional studies suggest that people with CRDs who live in areas of greater deprivation have a higher risk of hospitalisation, unplanned emergency admissions and death. Data from the US also demonstrate that Black Americans with asthma are twice as likely to be hospitalised, five times as likely to require emergency care and three times as likely to die from asthma as their White counterparts. It is crucial to have a better understanding of such disparities, and the reasons behind them, to develop targeted interventions for underserved communities and improve their access to care.

?

Comprehensive policies are needed to tackle this multifaceted problem

Governments need to invest in comprehensive strategic lung health strategies to reduce the impact of CRDs on society – tackling their root causes with an equity lens. Some promising initiatives already exist, but more needs to be done. The Framework Convention for Tobacco Control is a key example that helped set a blueprint for countries to implement effective anti-tobacco actions. Yet only 18% of low-income countries provide financial support towards smoking cessation programmes, despite the fact that approximately 80% of the world’s tobacco users live in LMICs. Initiatives to tackle CRDs have been set up in low-resource settings, and they could be scaled up and emulated elsewhere. For example, the burden and impact of respiratory disease in Africa is on the rise; however, access to appropriate diagnostic tools, such as spirometry, is lacking. To address this problem, the Pan African Thoracic Society runs a programme that provides free access to spirometry training and educational materials, enabling healthcare professionals to qualify for certification to conduct testing. If initiatives such as these were applied more widely among the world’s most vulnerable communities, there could be real opportunities to drive equitable change in CRDs.

Better lung health for all is something every country should strive for. The report Lung Health for Lifeoffers governments, respiratory clinicians and patient organisations a helpful starting point to tackle one of the deadliest chronic conditions in the world. ?