Yet Another Ignored Scourge

Rarely discussed, and usually believed to be a minor malady, in fact asthma is a huge problem in the world, causing wheezing and difficulty breathing that can lead to complete debilitation. It is a common chronic disease and cause of disability affecting 334 million people of all ages in all parts of the world.

"Asthma is seriously neglected,” said Innes Asher, Department of Pediatrics, Child and Youth Health at the University of Auckland. “Asthma is invisible compared with obesity, which is easily seen, or stroke or cancer. Asthma causes disability – the 14th most important disorder in terms of global years lived with the disability."

As an indication of the lack of attention to asthma as a social problem, there has been no new study by the World Health Organization in 12 years so no new data exist. The most recent global asthma data which is now old came in 2003. However, new data is crucial because there is every indication that widespread pollution is exacerbating the problem in ways experts do not understand. Healthy children even in areas where traditional pollutants are relatively sparse are contracting the allergy.

“Economies suffer because of asthma - children miss school or preschool and adults are not able to work either due to asthma or while caring for a child with asthma, Asher continued. “Many people are not able to work effectively due to asthma causing serious loss of productivity. Economic cost of inaction due to asthma is huge! For example, Europe loses Euros 19 billion for 2011 due to asthma."

Deaths related to asthma are more common in low and middle income countries, with a disheartening 1,000 dying – per day.

A study by the International Society for Augmentative and Alternative Communication found that asthma occurs everywhere in the world, is more common than thought, and there are large variations. ISAAC had also found that asthma rates were overall increasing, but increases were more common in low and middle income countries," Asher said.

Common environment factors that have a positive association with asthma can potentially increase asthma prevalence or make its symptoms worse. They include tobacco smoke exposure, open fire cooking, farm animals, high intensity truck traffic exposure, dampness in homes, fast food intake, obesity, paracetamol/antibiotic use in first year of life, migration to higher prevalence country or greater family size (severe asthma).

Asthma also has an inverse association with fresh fruits and vegetables intake, and breastfeeding of the child (in first six months of life) in non-affluent countries.

Not surprisingly, with the long neglect asthma has faced from governments, national strategies exist in only 23 of 103 countries surveyed.

Steve Graham, Professor at Department of International Child Health, University of Melbourne, who has been advocating accelerating the response to childhood asthma said: "We know for fact that deaths due to asthma are much more common in resource-limited settings, as people are unable to get on inhaled steroids or preventer therapies. Asthma remains a very important but neglected non-communicable disease in children and adolescents in the world, there is no doubt about that."

Dr Karen Bissell, a senior consultant with The Union, said asthma is also prioritized in the WHO Global NCD Action Plan of 2013-2020. The Action Plan has listed a 25 reduction for premature mortality from NCDs and 80 percent coverage of essential NCD medicines and technologies - we need to look for asthma as well in these targets.

As the Millennium Development Goals are about to expire at the end this year and a new set are debated the UN General Assembly later this month for 2015-2030, the target 3.4 of draft SDGs aims to reduce premature mortality from common ailments through prevention and treatment and promoting mental health and wellbeing, by one-third. Target 3.8 aims to achieve universal health care (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all. The post 2015 development agenda does present a strong opportunity to push governments to act upon asthma related issues as well.

Access to asthma medicines relies on policy, procedures and communications all working well in a country. Dr Bissell enlisted few factors that directly influence the access to medicines:

• Procurement: Who sets the agenda when medicines get procured?

• Distribution: Public and private health services, other agencies?

• Prescription by doctors or nurses (is the medication right?)

• Education: Healthcare workers such as doctors, nurses, pharmacists, patients, etc. need to access training on how to educate patients, standard messaging, etc.

Few countries have a national program. Few countries have information system for asthma. Many have no real national consensus to implement asthma management guidelines, strategy or dedicated budgets. Some countries follow guidelines that are more for high-income countries. Essential medicines list (EML) often does not include inhaled cortico-steroids for asthma management, and if they do, then often these are not updated.

Speaking about challenges in health services, Bissell underlined that "few medical professionals understand the essential role of inhaled cortico-steroids in asthma management, rather they prescribe the reliever medication alone. Health services are often not organized for long term chronic care and health workers are not trained in asthma care. Procurement environment can effect access to medicines: market usually does not encourage rationale procurement. Nonessential medicines are often pushed by pharmaceutical companies and specialist physicians."

The Union and Global Asthma Network reports that asthma medicines were part of essential medicines listed in only 10 countries surveyed, and were available in 41 percent of private pharmacies surveyed, distressingly along with 17 percent of public hospitals surveyed.

Therefore, the Asthma Drug Facility was created by The Union to provide affordable access to quality-assured essential asthma medicines for low and middle income countries. Although critically needed in today's context, yet it is on hold since 2013 due to lack of funds and demand from countries.

The Asthma Drug Facility has mandated more than 50 percent reductions in annual costs for patients with severe asthma, said Dr Bissell. There were enormous cost savings for countries that were using standardized long-term management of asthma and helping avoid unnecessary hospitalization.

But is the cost of hospitalization for asthma patients significant? The cost of hospitalization for an asthma patient of 2 days 4 times a year was calculated to be €269 in Benin, €585 in Sudan, and €852 in El Salvador.

Are asthma medications expensive? Five days’ wages in Ethiopia, eight in Malawi, almost 14 days in Madagascar. Those with severe problems need as many as 16 inhalers a year.

Dr Bissell recommended that at the country level, national asthma management guidelines, based on standardized management of asthma (pro-equity) and essential medicines, are crucial. We also need to get WHO essential medicines on to the national EMLs. Countries must resist undue pharmaceutical influence in policy making particularly related to setting up EMLs. Countries must strengthen and monitor procurement, distribution, prescription and education practices on asthma.

Bobby Ramakant is editor of Citizen News Services (Follow him on Twitter: @CNS_Health and @bobbyramakant)