Why India Is Struggling To Tackle Its Lung Disease Crisis
Mangal Lal, 70, a farmer from Achalpura village, Chittorgarh, Rajasthan suffers from COPD. Lal was a beedi smoker all his life but quit three years ago. “I cook my own food on the chulha,” he says.
New Delhi, Pune, Bengaluru, Mysuru: In 2014, one of India’s foremost researchers on respiratory diseases went to meet the union health secretary to apprise her of the spurt in chronic obstructive pulmonary disease (COPD) in India and the need for a strategy to screen and manage patients. The specialist, who collaborates frequently with the Indian government, did not wish to be named.
At the meeting, the health secretary, who seemed unfamiliar with the disease, asked her technical advisor to brief her. “COPD, wahi bimari jo bachon mein hoti hai, (that disease which affects children),” said the advisor, a medical doctor.
His “explanation” reflected how unaware India was of the gravity of India’s COPD crisis--the disease is the second most common cause of death in the country after heart disease. COPD takes years of exposure to smoke from tobacco or coal, wood or cow-dung and other irritants to manifest and its patients are usually above the age of 40.
Five years since the anecdote, there is improved awareness about the disease but India has yet to evolve a strategy to deal with its spread. There were 28.1 million cases of COPD in India in 1990, this increased to 55.3 million in 2016, showed a September 2018 study published in The Lancet Global Health. India has 18% of the world’s population but 32% of its COPD burden, it further showed.
COPD is responsible for nearly a million deaths every year, as IndiaSpend reported in March 2019, in the first part of this series. The second part explained the contribution of traditional stoves burning coal, wood and cow-dung to COPD in India. The third part was the story of a nation’s toxic air, a dangerous habit and a man being slowly claimed by a disease killing more Indians than ever before.
In this fourth part, we look at why India is not responding fast enough to the challenge of containing COPD. In our investigations we found a number of reasons: Spirometry--the gold standard test to diagnose COPD--is not commonly used by doctors because they do not know how to read the results. Further, the national non-communicable disease programme does not screen patients for COPD. Also more than half of India’s COPD burden is due to air pollution, a problem that India has been struggling to resolve.
Due to frequent hospitalisation, COPD drains patients of financial resources. Annually, India spends Rs 32,000 crore on treating the disease, as per a 2005 report published by the National Commission for Macroeconomics and Health and commissioned by the ministry of health and family welfare (MOHFW). This is close to the amount the health ministry has allocated for the National Health Mission for 2019-20 (Rs 33,651 crore); it is a little less than the allocations for National Education Mission (Rs 38,547 crore) and a little more than what is set aside for the national housing scheme for the urban and rural poor, the Pradhan Mantri Awas Yojana (Rs 25,953 crore).
COPD not a part of national screening mission
The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was launched in 2010 in 100 districts across 21 states in India to prevent and control the major non-communicable diseases (NCDs). The main focus of the programme was health promotion, early diagnosis, management and referral of cases, besides strengthening the infrastructure and capacity building.
At the time the major cause of death and illness was not communicable diseases like diarrhoea, malaria and pneumonia but NCDs like diabetes, heart disease, stroke and cancer. Six out of ten deaths in 2016 were due to NCDs, IndiaSpend reported in November 2017.
But between 1990 and 2016, COPD moved up from being the eighth biggest cause of disease burden to the second but found no mention in NPCDCS in 2010. It, along with chronic kidney disease guidelines, was included in the programme in 2016 but there has been no effort to screen or manage more patients for the disease in the public health system.
In 2018, India launched Pradhan Mantri Jan Arogya Yojana, commonly knowns as Ayushmaan Bharat. Along with providing 500 million with a health cover, it also aimed to transform 150,000 sub-centres and primary health centres into health and wellness centres (HWCs). These centres were supposed to provide comprehensive primary care along with health promotion at the community level. To this end, a programme for mass screening, prevention and management of common non-communicable diseases has been rolled out across the country.
In 2018, over 10,000 HWCs were functional and 13 million people were screened for NCDs like diabetes, hypertension and oral, breast and cervix cancer. But COPD was not part of the screening programme. This despite the fact that in 2016, COPD killed more than diabetes, tuberculosis, malaria and breast cancer combined, as IndiaSpend reported in July 2019.
India does not have a structured programme to combat COPD like it has for hypertension, diabetes and cancer, says Sundeep Salvi, director of Chest Research Foundation, Pune.
“Although there is a mention about COPD in the NCD policy statement, there is still no structured programme yet to combat COPD like there is for hypertension, diabetes and cancer,” said Sundeep Salvi, director of Chest Research Foundation, Pune, a research institute that focuses on lung health. “I believe this is because officials in charge of NCDs do not know how to prevent, screen, diagnose and manage COPD patients.”
COPD does find a mention in NPCDCS guidelines (2013-17), but only twice, while diabetes is mentioned 87 times.
“We give each state a budget of Rs 150,000 for equipment and Rs 250,000 for medicines under NPCDCS,” said Rajeev Kumar, director, NCD, at the union health ministry. “States can use this budget for treating COPD by either getting spirometry or for getting ventilators or oxygen supply.”
The government is coming up with new clinical guidelines for COPD which will be issued soon, he added. “All new AIIMS [All India Institute of Medical Science] centres will have a pulmonology department which can treat COPD cases,” he said.
Why do the new HWCs not screen patients for COPD? “We cannot screen all diseases at once, we have just started, give us time,” Kumar said. Patients being screened for TB were asked about their smoking habits and the use of biomass for fuel in their homes, he pointed out, and these were also factors in COPD prevalence.
The difficulty lies in diagnosing COPD
It is not surprising that COPD is not present in the NPCDCS guidelines because its diagnosis is challenging. It requires a test called spirometry, which is not commonly available in India’s clinics, hospitals or public health facilities. The patient is required to blow into a tube connected to a rectangular apparatus which yields a graph-like report that has to be interpreted by a trained technician.
Without spirometry, and using only history and clinical symptoms to diagnose the disease, almost 60% of patients escape detection, including 44% with severe disease, showed a 2003 study conducted in the US on patient data.
The overall use of spirometry has been low in India. Almost 30% of chest physicians, 70% of general physicians, 90% of general practitioners and 80% of paediatricians did not use spirometry to diagnose obstructive airway disease like asthma and COPD in 2013, found a survey conducted by Chest Research Foundation. While this proportion increased for all groups as compared to 2005, it is still low considering the high burden of the disease.
The reasons for not using spirometry by doctors were: lack of time (32%), lack of affordability for patients (29%), equipment expenses (28%) and difficulty in performing (10%) and interpreting the diagnosis (8%).
The root of the problem is that respiratory medicine is often neglected in medical college, said B V Murali Mohan, pulmonologist at Narayana Health, Bengaluru. “When I used to teach MBBS [Bachelor of Medicine, Bachelor of Surgery] at a medical college, the exam was very heavily focussed on cardiology and neurology,” he said.
For example, in the course conducted for MD or Doctor of Medicine, the long case---where a student is given a case for an hour to examine and diagnose--was usually related to neurology and only a few times did it involve respiratory medicine, and even then, it would be TB, and never asthma or COPD, Mohan added.
"At MD level, most students are expected to read an ECG from day one, and frankly the quality of ECG reading is very good,” he pointed out. “But most of them cannot interpret and even recognise a spirogram.” This is despite the fact that it is easier to read an ECG than a spirogram, he added.
Is there an alternative to spirometry? “No, spirometry is the only way to diagnose COPD at the moment,” said Salvi.
The government is also planning to use peak flow metres--an inexpensive handheld device that can give an estimate of the lung function of the person--in primary and secondary level for identifying patients with impaired lung function for referrals to tertiary centres, said health ministry’s Rajeev Kumar.
“It will take a series of peak flow metre tests and many weeks of follow-up for it to work to diagnose COPD,” countered P A Mahesh department head, TB and respiratory medicine, JSS Medical college, Mysuru. “There have been no tests to test their efficacy against spirometry.”
Non-smokers in India at risk
Lakshamma, 48, was cooking on a traditional stove for 30 years before she shifted to LPG. She has been detected with COPD but has not yet sought medical care.
Lakshamma, 48, starts her day at 4 am, milking her cows and delivering milk to houses across Belavadi, a village 15 km from Mysuru city. She walks slowly, taking small breaks during her 5-km trudge across the village but never fails to deliver milk. Lakshamma was detected with COPD when a group of researchers from the JSS Medical college in Mysuru conducted a lung function test on her and a group of 1,084 others from 16 villagers in the region for a lung health project named MUDHRA.
Lakshamma cooked on an earthen stove or chulha for 30 years before shifting to LPG a few years ago. Smoke from chulhas from burning wood, coal or cow dung, is a major risk factor for COPD in India, much more than tobacco smoking. More people in India are exposed to ambient and household air pollution than those who are smokers.
Source: The Lancet Global Health
This is because 70% of Indian houses use biomass fuel for cooking and heating purposes in poorly ventilated kitchens. In her lifetime, cooking for 2-3 hours every day, an average woman breathes 25 million litres of very polluted air, according to this 2012 paper.
In a 2016 study where 2,068 women with more than 10 years of biomass cooking were screened, almost one-fifth (18%) was diagnosed with COPD. The average age of the women with undiagnosed COPD who featured in the study was 47 years. Diagnosis was poor because of low education, poor knowledge about the hazards of biomass burning and the ignorance of health providers.
Lakshamma has not been to a doctor though she has known about her condition for six years now. “I started feeling breathless two to three years ago,” she said when the team from the hospital, along with this reporter, met her at her home. In its initial stages, COPD generally does not cause severe chest discomfort but with age, Lakshamma will feel its impact. Her husband Sivanna, who is a bidi smoker, has been diagnosed with COPD in 2006 but he has not consulted a doctor either.
Critical levels of exposure to pollutants
The MUDHRA project was undertaken to estimate the real prevalence of COPD and examine risk factors in rural areas between 2006 and 2010. Those tested were followed up again in five years for a repeat lung function test. This study was conducted because most earlier studies on COPD were based on questionnaire and not spirometry and did not explore the dose response relationship between the disease and biomass fuel exposure.
The study found that of 1,085 people, only 1% of men and 0.6% women had COPD according to the prescribed definition, but nearly half of them had poor lung function. Women less than 40 years exposed to wood fuels for cooking were disproportionately affected as compared to men of the same age.
After the follow up, 12.6% of those who suffered coughs at least three months a year for at least two years died as compared to 5.7% of those who didn’t. The study highlighted the fact that having a cough for even a few months a year needs to be tested.
“Chronic bronchitis is a part of COPD and it can be detected with a simple medical history and risk assessment,” says P A Mahesh, department head, TB and respiratory medicine, JSS Medical College.
“Chronic bronchitis is a part of COPD and it can be detected with a simple medical history and risk assessment,” said P A Mahesh, department head, TB and respiratory medicine, JSS Medical College and the brain behind the project. Identifying chronic bronchitis in the community is important even if access to spirometry isn’t available. “Many of these cases progress to develop COPD and have a higher risk of dying even without developing COPD,” he said.
The MUDHRA cohort was also responsible for establishing the link between exposure to biomass cooking and COPD. Earlier studies had shown that the minimum exposure of cigarette smoking that was necessary to cause disease is 10 pack years or 20 cigarettes a day for 10 years. Though biomass exposure was accepted to cause COPD, the minimum exposure that increased risk of disease was not clear. The quantification of exposure to biomass was first described by D Behera from the Postgraduate Institute of Education and Medical Research, Chandigarh and the exposure index can be understood as the product of number of hours of exposure per day and the number of years of exposure.
“This the first study of its kind in the world,” Mahesh said of the group’s finding that a minimum biomass exposure index of 60 is necessary, to increase the risk of developing chronic lung disease. So a woman cooking for four hours will need 15 years of exposure to be at risk and a woman cooking for three hours will need 20 years of exposure.
Other hazards in rural areas
Due to high use of biomass fuel, rural areas have as much COPD prevalence as urban areas, if not more. States with low economic development that have fewer non-communicable diseases than communicable ones--which means a low epidemiological transition level (ETL)--have higher disease prevalence due to COPD, The Lancet Global Health paper found.
Uttar Pradesh and Rajasthan have high disease burden for COPD and asthma and the lowest reduction in number of cases compared to the states with high ETL such as Punjab, Kerala and Tamil Nadu.
R Devaraj, 68, was detected with COPD this year. He is not a smoker and works as a farmer in Mysuru district.
“I used to be very strong, doing so much work single-handedly. Now, look at me, I am so weak, I can’t even ride a bike,” said R Devaraj, 68 years, who was detected with COPD this year. R Devaraj is not a smoker and works as a farmer in a Mysuru district.
Farming is a known COPD risk due to dust and chemicals in pesticides, said Mahesh. Other occupational risks include working in mining, smelting, animal husbandry, chemical factories etc.
After air pollution (53.7%) and smoking (25.4%), occupational risks is the third leading risk factor for COPD in India.
“We cannot say with certainty about how much exposure to ambient air pollution will lead to disease,” said Mahesh. “We need more funding and research to find these answers.”
Mahesh has a simple message for those seeking to curb the disease: “Don’t ignore that cough.” Studies have shown those with a persistent cough that lasts more than three months a year have double the mortality than those who didn’t. We also know that switching from biomass to cleaner fuels will reduce a large number of COPD cases in rural areas. Quitting smoking will help as will screening of vulnerable populations.
Ultimately, it is increased awareness that will help India beat the disease, Mahesh said.
Switching from biomass fuels to LPG: Switching from biomass fuels to cleaner fuels like LPG will play an important role in reducing the COPD burden due to household air pollution. Pradhan Mantri Ujjwala Yojana--that provides support for LPG connection to poor families--has provided connection to 70 million households till date. “In the south, we have already seen the benefits of switching to LPG, in the north also we will see the impact soon,” said P A Mahesh of JSS medical college, Mysuru.
Improving ventilation: Poorly ventilated kitchens worsen the impact of smoke and adding even one more window can help ease the discomfort, said Sundeep Salvi, director of Chest Research Foundation of India. Adding chimneys and exhaust fans can also create better air quality in kitchens.
Trainings for physicians: Most patients go to primary healthcare physicians with early complaints. So, it is important to improve awareness and understanding of COPD among physicians. This is why Public Health Foundation of India (PHFI) and Narayana Health and Chest Research Foundation have began training doctors for a Certificate Course in Management of COPD and Asthma. The course is taught in 25 centres across the country by experts in chest medicine. So far, 600 doctors have been trained to conduct spirometry and good inhalation practices among other skills. “State governments of Gujarat, West Bengal, Orissa, Assam, Tripura and the municipal corporation of Kolkata have included the course for their medical officers,” said Sandeep Bhalla, director, training, PHFI.
Screening for at-risk groups: COPD takes many years to develop and by the time the patient experiences discomfort, a lot of irreversible damage would have occurred in the lungs. Patients over the age of 30 with risk factors like smoking and with exposure to biomass smoke and various occupational hazards should undergo screening once a year, said Mahesh of JSS medical college.
Exercise and pulmonary rehabilitation: For COPD patients, access to pulmonary rehabilitation can help improve the quality of life. “Exercise reduces chance of exacerbation, hospitalisation, improves symptoms and even may reduce mortality,” said H B Chandrashekar, heading the department of pulmonology at the Bhagwan Mahaveer Jain Hospital, Bengaluru.
Reporting for this article was supported by the REACH Lilly Media Fellowship Programme on Non-Communicable Diseases.
(Yadavar is a special correspondent with IndiaSpend.)
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