Deep pockets, shallow breaths

Here is a puzzle I keep coming back to. India’s largest pharmaceutical companies — the same firms that dominate cardiology, diabetes, neuro-psychiatry and antibiotics — have repeatedly walked into the respiratory inhalation market with deep pockets, large field forces, modern factories and national distribution, and walked out defeated. Many launched inhalation portfolios with confidence. Most quietly retreated.

Today, you could count the companies that have genuinely succeeded in India’s inhaled respiratory market on the fingers of one hand. Just a handful. Everyone else is a laggard, or struggling to stay relevant.

That should stop us in our tracks. When a company that wins in five therapeutic areas loses in the sixth, the problem is not the company. It is that the sixth market plays by different rules — and most boardrooms have never bothered to learn them.

The wrong playbook

The standard pharma growth engine in India runs on three cylinders: gifting and freebies, brand-reminder activity, and pressure selling through an army of representatives. In many therapy areas, this is enough. Push hard enough, remind often enough, and the prescriptions follow.

The inhaled respiratory market is where this engine stalls. You cannot freebie your way to a patient using their inhaler correctly. You cannot brand-remind a family out of the belief that “steroids are dangerous” or that “inhalers are addictive.” You cannot pressure-sell a pulmonologist who has seen what happens when a patient is put on the wrong device. This is not a market you can buy. It is a market you have to understand — which is precisely why so few have managed it.

Three audiences, three sets of problems

Success in inhalation therapy means solving problems at three levels at once, and most companies are equipped to solve none of them.

At the doctor’s end, inhalation therapy is technical and unforgiving. Device selection, inhaler technique, step-up and step-down decisions, distinguishing asthma from COPD — these demand genuine scientific partnership, not a reminder card and a desk calendar.

At the patient’s end, the barriers are behavioural and deeply emotional. In one survey, more than 84% of non-asthmatic respondents viewed inhalers as a social stigma. Patients fear addiction, fear steroids, fear being seen using a device in public — so they never start, or they stop the moment they feel better.

At the level of the general public, decades of myth have hardened into common sense. Until that shifts, every patient a company reaches has already been taught to resist the very therapy that could save their life.

The cost of getting this wrong

This is not an abstract commercial puzzle. The human stakes are staggering.

India has roughly 34 million asthma patients — about 13% of the world’s cases — yet accounts for an estimated 42% of the world’s asthma deaths. Our asthma mortality rate runs around three times the global average. People are dying of a disease we have known how to control for decades.

Look at how the medicine is actually used. Analysis of national sales data suggests inhaled corticosteroids — the cornerstone of asthma control — are dispensed at roughly 6.8% of the level the patient population actually needs. In one well-known multi-city survey, not a single one of the 400 asthmatics assessed had well-controlled asthma; fewer than a third were using inhalers at all, while 89% had taken oral steroids in the previous year. State by state, the more inhaled corticosteroid is sold, the fewer people die — the correlation is real and statistically strong.

COPD tells the same story from another angle: it is now the second-leading cause of death in India. So when I say most companies fail in this market, I am not only describing lost revenue. I am describing a market failure with a body count.

Why three winners is a problem

Some will say a concentrated market is fine — the leaders are doing good work, and one Indian pioneer in particular built this category almost single-handedly. I am grateful for that work. But a handful of serious players cannot diagnose, educate and treat 34 million asthmatics and tens of millions more with COPD. A category this large and this under-served needs many capable companies competing to do it well. More serious players is not a threat to patients. It is the best thing that could happen to them.

That is the uncomfortable conclusion: in inhalation therapy, the shortage of successful companies is itself a public-health problem.

In the essays that follow, I will get specific — about what the winners understand that the laggards do not, and how a company that is serious can build a respiratory inhaled franchise that lasts. Failure here is not destiny. But it will keep repeating until we are honest about why it happens.