Short of breath
Today is the eighth annual World COPD Day, an event held each November to raise awareness of chronic obstructive pulmonary disease (COPD) worldwide. COPD is a largely preventable long-term serious respiratory disease with a high level of disability, particularly in the elderly, with patients suffering from cough, excessive sputum and increasing shortness of breath. The disease develops gradually and symptoms vary among individuals from mild shortness of breath to severe disabling breathlessness on minimal exertion. It is a major public health problem, causing significant morbidity and mortality. According to the World Health Organization (WHO), COPD is the fourth leading cause of death worldwide causing more than 3 million deaths every year. Moreover, recent studies indicate that 25 to 50 percent of the people with clinically significant COPD don’t know they have the disease.3 The early stages of COPD often go unrecognised, and many COPD patients do not receive a diagnosis until their disease is relatively advanced.
Worldwide, the most commonly encountered risk factor for COPD is tobacco smoking including cigarette and other forms of tobacco contributing to about 85 percent of the risk of developing COPD. Other important risk factors include smoke from biomass fuels (such as coal, wood and animal dung) burned for cooking and heating in poorly ventilated dwellings, especially in the developing countries, and dust and chemicals encountered on the job.
The current disease burden of COPD represents an enormous problem for Nepal and demands immediate attention. COPD affects nearly 10 to 15 percent of older people who are smokers and exposed to indoor air pollution by the use of biomass fuels and working in dusty workplaces. The economic burden associated with COPD is substantial, mainly related to medication, repeated hospital visits and hospitalisation. Indirect costs are substantial due to the significant degree of disability of COPD patients. They experience progressive disability associated with the decline in lung function. A majority of the people are incapable of productive work within a few years of diagnosis of COPD. COPD has no cure, and treatment options are still relatively limited. Long-term home oxygen therapy is one of the more costly interventions for COPD.
On average, people with the disease die 10 to 12 years earlier than the age-adjusted average rate of death, with death rates increasing significantly for people from 60 years of age and with other associated diseases. If current trends persist, chronic respiratory diseases like COPD would kill much more people in the next decade in Nepal. Patients suffering from COPD have long received less than due attention from health professionals in contrast to the enormous effort that has been made both nationally and internationally for other diseases like tuberculosis and HIV/AIDS, whereas COPD presents a much greater burden to the health care system — more people die in Nepal because of COPD than HIV/AIDS.
The World COPD Day theme, “Breathless Not Helpless!” emphasizes that effective treatments are available for people who have been diagnosed with COPD, and raises awareness that — for people who have not been diagnosed — breathlessness is a signal that they should see their doctor. A concerted effort is required for making COPD as a national health priority and to develop specific strategies for reducing the future burden of COPD in Nepal. There is also a pressing need to educate healthcare providers and health professionals and public on measures which can be taken to improve the health and economic outcomes for COPD. There is an urgent requirement for reliable prevalence data for COPD for the prediction of current and future healthcare needs and to monitor trends. There is a need to review the policies and action plans of the government against the background of the increasing magnitude of chronic respiratory diseases like COPD in Nepal.
The ideal way to prevent or reduce the health impacts of COPD is withdrawal or reduction of the exposure to tobacco smoke, indoor air pollution and occupational dust. However, selection of the strategies to achieve this aim is very complex. The tobacco epidemic is shifting from older age groups to younger age groups, from rich to poor and from cities to peri-urban and rural areas. The key reasons for increased consumption and shifting pattern of consumption are the marketing strategies of the tobacco industry and ineffective implementation of tobacco control policies and lack of political will among planners and policy makers.
The public must also demand to know the truth, the whole truth, about the dangers of tobacco use. Tobacco is the leading preventable cause of death in Nepal. It is the only legal consumer product that kills when used exactly as the manufacturer intends. Civic society must persuade governments to ban tobacco advertising and promotion, and to make cultural and sports events tobacco-free. Each single youth should help educate the population on the harm of tobacco use and exposure to second-hand smoke, boycott sports and cultural events sponsored by tobacco companies and ensure that their voices are heard across a vast range of social, economic and political arenas.
The next logical step in Nepal is to develop projects to define local resources and capacities to offer widespread and sustainable improvements in household energy. Local conditions and strategies to adopt massive interventions related to cleaner and alternative energy (fuels and stoves) to reduce exposure must also be explored. Interventions to suppress or reduce indoor exposure include behaviour changes, improvements of household ventilation, improvements of stoves, and, outstandingly, transitions to better and cleaner fuels. Greater involvement of academic health institutions, the commitment and active participation of the government, scientific societies, non-governmental organizations, and the general community is required.
The growing COPD epidemic in the country calls for a review of the existing health policy. The current health system in Nepal is poorly equipped and under-funded to implement comprehensive care for chronic respiratory diseases. There are large "unmet" clinical needs for people with COPD in Nepal The Ministry of Health and Population should establish coordination mechanisms between academic medical institutions and reap the benefits from the researches carried out there for developing technical and operational policies for providing effective care to patients with COPD.
The adult chest clinic at the Department of Internal Medicine at the B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan is the only clinical service that provides comprehensive care to patients with COPD. Strong integration between academic medical institutions and the government health sector will go a long way in offering cost-effective management and better outcomes for people with COPD in Nepal. A clinically recognized focal point, chest clinics at university teaching hospitals, should be strengthened to provide comprehensive care to patients with COPD. All the national poverty reduction strategies should address the issue of chronic respiratory diseases, and they should be given appropriate priority alongside reproductive, nutritional and communicable diseases.
(The author is additional professor and in-charge of the Respiratory Critical Care and Bronchoscopy Services, Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan)
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