The Right to Inhalation

A 58-year-old auto-rickshaw driver walks into a clinic in his sixth decade of life, breathless after climbing a single flight of stairs. He has been wheezing for fifteen years. He has never had a spirometry test. He has never used a controller inhaler. By the time someone listens to his lungs, the damage is the work of decades — and it is irreversible.

This man is not an outlier. He is the median Indian respiratory patient. And he is the reason a new analysis in Nature Medicine, summarised this January by Nature India, should be read not as an academic update but as an indictment.

The paradox we keep ignoring

The global picture is, for once, encouraging. As part of the Global Burden of Disease (GBD) 2023 collaboration, researchers tracked chronic respiratory diseases — COPD, asthma, pneumoconiosis and interstitial lung disease — across 204 countries from 1990 to 2023. Worldwide, these conditions affected nearly 570 million people and caused 4.2 million deaths in 2023. The heartening part: age-standardised death rates have fallen by about 26% since 1990. Better treatment, tobacco control and earlier diagnosis are steadily pulling the world’s lungs back from the brink.

India is the exception that should keep us awake at night.

South Asia — led largely by India — remains one of the most burdened regions on earth for chronic respiratory disease, despite having lower overall prevalence than many high-income countries. In 2023, South Asia’s age-standardised mortality from chronic respiratory disease was more than double the global average. Read that again. We have fewer people reporting these diseases than Australia or the United Kingdom, yet far more of our patients die from them.

This is the paradox at the heart of the crisis: high mortality, lower prevalence. And it is not a mystery. As Dr Anurag Agrawal of Ashoka University put it in Nature India, the gap “points to late diagnosis, under-treatment, and the cumulative impact of environmental exposures that healthcare systems are not equipped to manage early.”

In plain terms: in rich countries, people get the disease and live with it. In India, people get the disease and die of it. The difference is not the air alone. It is what happens — or fails to happen — between the first wheeze and the last breath.

What separates a managed disease from a fatal one

Countries that have driven respiratory mortality down did not discover a cure. They built a system. Robust primary care. Widespread spirometry, so disease is caught while lungs are still salvageable. And — critically — routine, affordable, lifelong access to inhaled therapies.

That last pillar is the one we treat as optional. Inhaled corticosteroids and bronchodilators are not luxury medicine. They are, for asthma and COPD, the equivalent of insulin for diabetes: the difference between a chronic condition and a terminal one. Delivered directly to the airway, they control inflammation, open obstructed passages, prevent the exacerbations that scar lungs and fill ICU beds, and let people keep working and breathing. The science is settled and the molecules are old enough to be cheap.

Yet in India, inhalation therapy reaches a fraction of those who need it. Some patients are never diagnosed because spirometry is uncommon and breathlessness is dismissed as ageing or “weakness.” Some are diagnosed but handed tablets and syrups instead of inhalers, because a stubborn myth persists — among patients and prescribers alike — that an inhaler signals a “last stage” or causes “dependence.” Many who are correctly prescribed simply cannot sustain the monthly cost, or live too far from a pharmacy that reliably stocks the device. The newest combination inhalers and biologic therapies that have transformed severe asthma and COPD in high-income settings, the Nature India piece notes, “remain inaccessible to most patients” here. Dr Chandrakant Lahariya of the Foundation for People-Centric Health Systems calls it “a widening innovation divide” — the science has moved ahead, but it has not reached the population that needs it most.

The burden falls hardest, predictably, on the poor and marginalised — the households already breathing the worst air from cooking smoke, traffic and construction dust, and least able to absorb the cost of treating the damage it causes.

Naming the solution: a Right to Inhalation

You cannot fix what you have not named. So let me name it: #RTI — the Right to Inhalation.

The Right to Inhalation is the principle that every person diagnosed with asthma or COPD should have guaranteed, affordable, uninterrupted access to the inhaled therapy and the diagnostic test that makes that therapy rational. Not as charity. Not as a premium add-on for those who can pay. As a standard of care to which a patient is entitled.

This is not a slogan in search of a policy. It is a concrete, four-part agenda.

Diagnose before you treat — make spirometry routine. A bronchodilator prescribed without confirmed airflow obstruction is a guess. Spirometry should be available at every district hospital and equipped primary health centre, with trained technicians and a referral pathway, so that the interstitial lung diseases now too often “missed or mislabelled as tuberculosis,” in the words of AIIMS Jodhpur’s Dr Pankaj Bhardwaj, are caught correctly and early.

Put inhalers on the essential-access list — and keep them in stock. Controller and reliever inhalers, and spacer devices for children and the elderly, belong in the free or subsidised public drug supply, available at the primary care level. A right that the supply chain cannot honour is not a right.

Treat the inhaler as first-line, not last resort. This is as much a campaign against a myth as a matter of procurement. Frontline prescribers and patients need clear, repeated messaging that inhaled therapy is the correct early treatment — the thing that prevents the breathless 60-year-old, not the thing you reach for once he arrives.

Integrate respiratory care into primary care. Diagnosis, dispensing, inhaler-technique coaching and follow-up should live at the health centre nearest the patient, not three bus rides away in a tertiary hospital they reach only in crisis.

The caveat

The Right to Inhalation is necessary. It is not sufficient. As Dr Lahariya rightly cautions, “You cannot solve India’s respiratory burden with inhalers alone.” Air quality, housing, clean cooking fuel, occupational safety — these are lung-health policies too, and PM2.5 is now a leading COPD risk factor for women across South Asia. The damage being treated in clinics today began in kitchens and on roadsides decades ago.

But here is the asymmetry that makes #RTI urgent. Cleaning India’s air is the work of a generation. Guaranteeing that a diagnosed patient can breathe with a two-dollar inhaler is the work of this budget cycle. One is a marathon we must run regardless. The other is a life we can save next month.

The GBD data carries, as Dr Agrawal noted, both good news and bad. The good news is that progress is possible — the rest of the world is proof. The bad news is that India “has not yet made respiratory health a national priority on the scale the numbers demand.”

A right reframes that priority. It turns inhaled therapy from a product some patients are lucky enough to afford into a standard every patient is owed. India recognised a Right to Education and a Right to Food because we decided some things were too fundamental to ration. For 570 million pairs of lungs and counting, breath belongs on that list.

It is time we recognised the Right to Inhalation.