A Public Health emergency — Chronic Obstructive Pulmonary Disease

Chronic respiratory disease, of which COPD is the most common, is oft regarded as a self-inflicted disease whose prevalence is waning due to declining rates of both smoking and occupational exposure to dusts and fumes. The reality is the opposite.

The Lancet highlights (“Towards the elimination of Chronic Obstructive Pulmonary Disease — a Lancet Commission, 17 September 2022), that despite the identification of cigarette smoking as a major risk factor some 50 years ago and substantial progress in reducing the global impact of many non-communicable diseases such as heart disease and cancer, “morbidity and mortality due to chronic respiratory diseases continues to increase”.

Measured between 1990 and 2017, rates have increased by 40 %, with chronic respiratory disease now the third leading cause of death globally. COPD affects over 300 million people around the world and is responsible for 3.3 million deaths annually.

The Health and Safety Executive (HSE) Summary Statistics published in December 2021, link past occupational exposures to dust and fumes with an estimated 12,000 deaths each year in the UK.

The Commission Report describes many factors which they say have contributed to a “Public Health Emergency” which include a failure to limit the sale/consumption of tobacco, exposure to occupational and environmental pollution and an ageing global population.

Diagnosis and treatment unchanged

Describing diagnostic approaches as “unchanged for decades” the Commission criticises the (over) reliance on spirometry as too insensitive to detect early pathological changes — meaning by the time the condition has been diagnosed, it has become irreversible. 

The Report also highlights how research into COPD is underfunded compared to other diseases (120 million dollars, compared to 338 million dollars for asthma) and concludes that treatment therapies are often the same for all patients regardless of the pathology.

COPD — causes and symptoms

COPD is caused by multiple risk factors which will interact and co-exist throughout life. While cigarette smoking is a primary cause, not all smokers develop COPD and between 20% and 30% of all COPD patients are “never smokers”.

Other causes include occupational exposures to dust, gases and fume, air pollution and respiratory incidents which have occurred early in life leading to compromised respiratory function. 

Common symptoms include dyspnoea (shortness of breath), chronic cough, exercise intolerance and episodic flare-ups of respiratory symptoms (exacerbations). Not only does COPD cause direct physical and financial cost to the patient in compromised/lost employment, but it imposes on others the need to care for those with the greatest respiratory disability.

The Commission; it's objectives and recommendations

The Commission sets its aim to eliminate the disease by challenging “the accepted dogma and the general debate” as “wholesale rethinking of COPD is needed”.

They propose to do this by:

• Gaining a better understanding of risk factors.
• Avoiding future cases by identifying pathological changes earlier by a more inclusive diagnosis.
• Banning smoking in all its forms.
• Categorising COPD into five main risk factors: genetics, early life events, pulmonary infections. tobacco smoke exposure and pollution
• Personalising prevention and treatment strategies.
• Investing in curative and regenerative therapies.
• Launching public health strategies around smoking and clean air.

Conclusions

Whilst the continuing decline in adult smoking rates will help reduce the burden of COPD, it will be insufficient on its own to eliminate the disease. It is perhaps surprising given the advances we have seen in other areas of medicine, that both diagnosis (through spirometry) and treatment strategies have remained largely unchanged for several decades. 

The Commission’s emphasis and recommendations — which have parallels with the approach taken to tackling hypertension during the 1970’s -represent a holistic solution to the problem — prevention, early diagnosis and personalised treatment strategies to sit alongside public health campaigns.

The call for all forms of smoking to be outlawed — to follow the recent example set by New Zealand — may be seen as ‘extreme’, or an attack on personal freedom. However in the context of the global impact of Chronic Respiratory Conditions, it may in time, be viewed as both necessary and proportionate.