Every 20th of November since 2002 we mark the World chronic obstructive pulmonary disease (COPD) day to raise awareness about this top-four cause of death globally. Chronic Obstructive Pulmonary Disease is an incurable condition resulting from irreversible damage of the airways and the air sacs of the lungs. Often, this is caused by long term smoking of tobacco including shisha and vaping, and sustained breathing of other organic or inorganic pollutants. Further to being incurable and irreversible, this damage is progressive with continued exposure to the noxious agents.
There is increasing awareness that tuberculosis of the lung, even when completely and effectively treated, results in COPD and other lung diseases amongst some survivors. COPD causes narrowing and clogging of the airways, hence a cough that never goes way, and which may produce mucoid phlegm or sputum. There may be breathlessness, initially with significant exertion, but that may insidiously worsen over time to eventually cause disability. Chest infections, which usually represent flare-ups of this lung disease, feature repeatedly over time as the lungs become increasingly vulnerable. There may be wheeze or other types of noisy breathing, and eventually patients waste away and develop many different complications affecting the heart and other vital bodily functions. It is the eighth biggest cause of poor health in the world. The occurrence of two or more of these symptoms in people who have had consistent exposure to cigarette smoke, even passively, or other causes usually increases suspicion of COPD. Definite diagnosis requires measurement of specific parameters of air flow during forceful breathing using a test called spirometry, by trained healthcare professionals.
It is estimated that about 64 million people in the World currently suffer from this devastating disease. A recent review of COPD in Ethiopia, Sudan, Malawi, Kenya, Uganda and Tanzania found that it affects between seven to nineteen percent of East Africans and is as frequent as 11.3% in Kenya. In high income countries, more than 70% of COPD is caused by smoking of tobacco whilst this number drops to between 30 and 40 percent in Low and Middle Income countries where pollution from burning biomass fuels like firewood, charcoal and kerosene has been postulated as an important cause. Tuberculosis and poor air quality amongst quarry workers, miners and other occupational exposures to organic and inorganic air pollutants contribute to COPD.
At the height of the Covid pandemic, COPD was the fourth biggest cause of death in the world behind heart disease, stroke and Covid-19, accounting for 3.5 million or 5% of all deaths. This magnitude of mortality has been consistent and increasing in the past decade with expectations that COPD shall be the third biggest cause of death in the next 6 years. Sadly, almost ninety percent of these deaths amongst people aged less than 70 years occur in Low- and Middle-Income Countries of the World.
Management of COPD must of necessity begin with a clean break from exposure to the causative exposures. Important lifestyle changes beyond this include healthy diets and regular exercise to improve fitness and breathing, and to retain muscle strength. Specific treatment involves consistent use of treatments that dilate the clogged airways to reduce cough and breathlessness. Steroids, in appropriate doses, have an important but niche role in managing flare ups and reducing infections. This role is significantly less than the central role they play in management of asthma. There are other medicines that reduce the tenacity and amount of sputum production, hence cough, vulnerability to infections and breathlessness. Some medicines reduce airway and lung inflammation. Antibiotics may be prescribed when bacterial infections are responsible for a flare-up. Vulnerability to infections is further reduced with vaccinations against influenza, and against the commonest bacterial cause for respiratory infections. Most of these medicines are delivered into the body using inhalers which are rather smart and easy to use devices. They deliver miniscule doses of medication using the breath as a courier, hence efficiently and effectively depositing the drug to most of the diseased airway and lung tissue whilst minimizing side effects. It is important to point out that these treatments are necessary when prescribed but are not addictive at all, and hence development of dependence is never an issue.
Given the prevalence of COPD in Kenya and its importance as a major cause of death and poor health, it is concerning that public awareness of this disease is appallingly low. Definite diagnosis requires the use of spirometry equipment by specially trained personnel, both of which are not readily accessible to the majority of Kenyans. Further, most of the effective treatments are out of reach to those who need them most. We must do more to increase correct diagnosis of COPD in Kenya, and increase the affordability and accessibility of effective treatments to all Kenyans.
By Dr Jumaa Bwika, Consultant Pulmonologist at Aga Khan University Hospital, Nairobi
