The breath India keeps losing

She was forty-seven, a schoolteacher from Kanpur, and by the time her story reached me, she had been prescribed three different inhalers in two years and had never once used any of them correctly. Nobody had shown her how. The first device a general physician handed across the table with a prescription and a reassuring nod; she pressed it, swallowed reflexively, tasted nothing, and concluded it did not work. The second she kept in a kitchen drawer because using it in the staff room felt like a confession. The third she rationed — two puffs only when she could no longer climb the stairs to her classroom — because somewhere she had absorbed the belief that an inhaler is addictive and that needing one every day meant she had already reached the end. In those two years, she was hospitalised twice for a condition that, managed properly, should never have put her in a bed at all.

I have spent twenty-six years in Indian pharmaceuticals, and I can name every link in the chain that failed her. The GP who wrote the prescription but never demonstrated the device. The medical representative who called on that doctor for years and never once asked whether the patients could actually use what they were being prescribed, because his target was prescription share, and the technique was not a line on his report. The brand manager in a head office a thousand kilometres away, whose quarterly numbers rose every time that doctor’s pen produced a script, and who was entirely indifferent to whether the medicine ever reached a lung. And the regulator who can tell you how many units we sold last year but has never, in any meaningful way, measured whether one patient is breathing more easily as a result. Everyone in that chain did their job. The patient still nearly died. That gap — between everyone doing their job and the patient still losing — is the subject I want to write about, and it is far larger than one woman in Kanpur.

A failure that the strongest players cannot explain away

Here is a fact that should unsettle anyone who runs a pharmaceutical company in this country. In the Indian inhalation therapy market, you can count the genuinely successful firms on one hand — realistically, three. The rest are laggards, strugglers, or quiet retreats dressed up as portfolio rationalisation. What makes this remarkable is who the failures are. They are not small companies. Many are giants with deep pockets, world-class factories, distribution that reaches the last pharmacy in the last town, and field forces thousands strong. They win in cardiology. They win in diabetes. They dominate neuro-psychiatry and antibiotics. They hold every structural advantage a market can offer — and in respiratory inhalation they launched, they spent, and they failed.

When the strongest players in an industry repeatedly fail at one specific thing while succeeding at everything else, the explanation is not bad luck or poor execution. It is that the thing is different, and they never grasped how. The respiratory inhaled market cannot be won with the instruments most of our leadership has spent careers perfecting: gifting, brand-reminder activity, relationship management, and the gentle and not-so-gentle craft of pressure selling. Those tools move a tablet. A tablet is forgiving — swallow it any way you like, and the molecule still enters the bloodstream. An inhaler is unforgiving. The device is half the prescription. If the technique is wrong, the most sophisticated molecule in the world settles on the back of the throat and does nothing. You are therefore not selling a chemical; you are selling correct behaviour, repeated daily, by a frightened patient, taught by a hurried doctor, reinforced by a representative. Most of our industry has no idea how to sell behaviour, because it has never had to.

What the numbers actually say

Consider what that failure costs. India carries roughly thirteen per cent of the world’s asthma cases but somewhere close to forty-two per cent of the world’s asthma deaths — a small share of the disease and a staggering share of the dying. We have an estimated thirty-four to thirty-five million asthmatics, and chronic respiratory disease is the second-largest contributor to mortality in this country, behind only cardiovascular disease. The studies that look hardest at the ground are the most damning. Among Indians with current wheeze, somewhere between three-quarters and four-fifths have never been clinically diagnosed at all; and of those, fewer than one in a hundred is on the daily inhaled corticosteroid that is the cornerstone of asthma control.

Even among the diagnosed, far too many are parked on short-acting bronchodilators — the reliever that makes you feel better for an hour and does nothing for the inflammation quietly scarring the airways — while adherence to the controller that actually changes outcomes is poor enough to be tragic. People in India die of asthma. In 2026, with effective inhaled therapy available and genuinely affordable, that sentence should be unwritable. It is not.

Why this market punishes everything Indian pharma is good at

So why is this market so much harder than the others, and why do deep pockets fail to solve it? Because the difficulty lives at three levels at once, and you have to win all three or you win none.

At the doctor’s end, the prescription is only the beginning. A cardiologist who writes a statin has, for practical purposes, finished the job. A physician who writes an inhaler has done perhaps half of it; the other half is a two-minute demonstration of the device, a check that the patient can actually perform it, and a willingness to revisit technique at the next visit. In a high-volume Indian outpatient clinic, that two minutes is the first casualty. Layer onto this a persistent, irrational fear of inhaled steroids among prescribers who would not hesitate to reach for far more aggressive systemic drugs elsewhere, and you get chronic under-prescription of the controller and habitual over-reliance on the reliever.

At the patient’s end, the barrier is rarely the medicine and almost always its meaning. An inhaler in India still signals serious, final, the stage before oxygen. Patients believe it is addictive. They are ashamed to use it in public, so it ends up in a drawer. And because well-controlled asthma feels like no asthma at all, the patient who finally starts a controller and feels well concludes the medicine is no longer needed and stops — and the disease, which never left, returns. The very success of the therapy becomes the reason it is abandoned.

At the public level, all of this is amplified by a society that has never been taught to take the breath seriously. Steroid phobia, the addiction myth, the visible stigma of the device, the assumption that breathlessness is merely age or pollution or weakness — these are not individual failings. They are an information vacuum, and the industry that profits from inhalers has done remarkably little to fill it.

Three uncomfortable truths

Twenty-six years have taught me three uncomfortable things that I intend to keep saying, in this essay and the ones that follow. The first is that most patients started on chronic therapy in India fail it within months — not because the science is wrong, but because no one owns what happens after the prescription. The second is that most medical representatives are sent into the field undertrained, which, in a tablet business, is merely inefficient, but in an inhaler business is something nearer to negligence, because the representative is precisely the person who could carry device training into thousands of clinics and does not. The third is that most young doctors in this country learn India-specific prescribing — the steroid fear, the device technique, the adherence reality — only after they have already harmed patients by not knowing it.

Beneath those three sits the truth the industry least wants stated plainly: the primary driver of poor chronic-care outcomes in India is not the patient’s behaviour. It is our own incentive system. We reward prescription share, not patient outcomes. We pay for the script, not the result. We have built an elaborate machine optimised for the instant a doctor’s pen touches paper and indifferent to everything that happens to the human being afterwards. The schoolteacher in Kanpur did not fail her treatment. The system did exactly what it was designed to do, and she was the externality.

Credit where it is owed, and a harder question

None of this is to say the picture is hopeless, and it would be dishonest not to name the work that has been done. Pulmonologists and respiratory physicians in India have, over decades, dragged inhalation therapy from the margins to the standard of care, often against the grain of their own profession’s habits. And among companies, Cipla’s contribution has been pioneering and, in my view, unmatched — building devices, widening access, driving affordability, and patiently educating a market that did not want to be educated. That work is the reason we have a respiratory inhaled market worth arguing about at all.

But here is the harder reframing. Three successful companies is not a success story; it is a market failure. A therapy area this large, this lethal, and this underserved should have a dozen serious players competing to do it well. The scarcity of winners is not proof that the market is hard and only the worthy survive — it is proof that an entire industry looked at thirty-five million patients and decided the behaviour-change work was not worth learning. More good companies in this space would mean more patients diagnosed, more devices taught, more controllers prescribed, more lives held intact. The patient does not benefit from our exclusivity. The patient benefits from competence, and we have rationed it.

What I am asking of each of you

I am writing this here, on my own site, rather than in a journal, and on purpose. The journal is where we describe the problem to one another in language engineered to be unfalsifiable and unread. The field — the outpatient clinic in Lucknow, the chemist in Indore, the patient in Kochi who has stopped her controller because she feels fine — is where the problem actually lives, and where the people who can fix it spend their days. I would rather reach the brand manager, the regulator, and the third-year resident than the citation index.

To the leaders running these companies: change what you measure. A field force rewarded for adherence and correct technique would transform this market in a single cycle; a field force rewarded only for scripts will keep manufacturing the Kanpur patient indefinitely. To the doctors: the demonstration is not an optional courtesy; it is the other half of the prescription, and the fear of inhaled steroids costs far more lives than the steroids ever will. To the policymakers and regulators: you cannot manage what you refuse to measure, and as long as we count units sold instead of patients controlled, we will keep mistaking a sales figure for a health outcome.

The schoolteacher in Kanpur is, as far as I know, still alive, still teaching, and — I hope — finally on the right inhaler, used the right way. She should never have been the exception. On this site, over the coming months, I am going to write about the parts of this business I spent a career inside, including the parts the industry would prefer I leave in the drawer beside her unused inhaler. I will name dysfunctions, not individuals. I will offer fixes, not merely diagnoses. And I will lean on evidence rather than anecdote wherever the evidence exists.

I also want to hear back. If you are a doctor who sees this every week, a representative who was sent in undertrained, a patient who has lived the stigma, a founder who thinks I am wrong, or a regulator who thinks I am unfair — write to me, disagree with me, send me the field stories I cannot see from where I stand. We have spent twenty-six years becoming very good at manufacturing the medicine and very bad at delivering the breath. It is long past time we told ourselves the truth about the difference — because someone is always paying for the lies we tell ourselves, and it is never us.