Untreated and poorly managed asthma diminishes the ability to learn, earn and contribute to family and community life.

ACCESS TO HEALTHCARE

For many people living with asthma, it is a chronic disease that they have to cope with throughout their lives. For those with severe asthma, the effort simply to breathe can be an all-consuming challenge.

Fortunately, the regular use of medications – and particularly the use of inhaled corticosteroids – can provide relief from asthma symptoms, substantially for most and entirely for some.

Asthma can be a matter of breath or death

For people with severe persistent asthma, their condition dominates their lives. The disability is costly – both in terms of the health care required and the loss of income it can entail. Frequent crises in their clinical condition force them to seek urgent care, which is costly both for them and the health care systems that serve them. Without appropriate long-term treatment, they are at substantial risk of dying of the disease.

For patients with moderate or mild persistent asthma, effective treatment can mean the difference between living a life curtailed by disability and taking a full active part in their work, families and communities. Ensuring regular, unobstructed access to appropriate care is therefore crucial to relieving the suffering and restoring the health of all patients with asthma.

Challenges to receiving care for asthma

In spite of the critical need for effective asthma care, numerous studies have shown substantial challenges to accessing appropriate treatment for patients across the spectrum from high-income to low-income countries.

Asthma often goes undiagnosed

The first challenge is the knowledge and practice of the health services personnel providing care for such patients. A recent study in Canada surveyed medical practices to identify the extent to which practitioners routinely diagnosed people living with chronic lung disease. The results showed that a high proportion of such patients were never diagnosed by their health practitioner, even when they attended the health service regularly.

The most effective medicines are not prescribed

Clearly when patients are not diagnosed, they cannot benefit from the medications that would be able to help them. But patients who are diagnosed face obstacles too. Surveys undertaken by The Union among chest specialists have shown that, even though the practitioners surveyed were specialists, and they had access to literature on what constitutes good-quality care for asthma patients, many of them did not prescribe the inhaled corticosteroids so vital to the care of a patient with persistent asthma.

The gap between rich and poor is wide – and gets wider

A number of studies in the United States of America showed, more than 10 years ago, that obstacles to appropriate care for asthma included family income, social status, access to health insurance and race. Even in a wealthy country such as the United States, many who desperately need such care are unable to access it. This leads to poor people becoming steadily poorer due to the cost of care and to the disabling effect of their chronic disease.

In some regions, essential medicines are completely unavailable

Surveys of many countries around the world undertaken by The Union assessed the affordability of aerosol medicines used routinely in the treatment of asthma. The results indicated that the essential medicines were completely unavailable in some locations.

In others, medicines are available –at prices out of reach for most people

In some of the poorest countries of the world, the cost of essential asthma medicines was found to be so high that paying for them would consume a substantial proportion of the income of a professional person. As a result, these life-saving medicines were completely out of reach for many patients, especially the poorest.

Emergency rooms are full of people with asthma

In an effort to improve access to high-quality care in poor communities, The Union and partners in China, Sudan and Benin worked together with funding from the World Bank. The pilot projects they carried out revealed that, while asthma was essentially unrecognised by the practitioners in some communities, the emergency rooms were full of asthma patients in crisis. In some locations, this was due to the fact that emergency care was free of charge, while ambulatory care was not. Consequently, patients sought care in the emergency rooms to get temporary relief, but continued to suffer from the ongoing disability caused by their asthma, since they could not access the long-term care they needed.

When health services don’t help

In some locations, The Union and its partners learned that patients resorted to finding solutions for their asthma through the ‘grapevine’. One such notion was that taking corticosteroid tablets by mouth could help them.

The tragic results of this inappropriate treatment are illustrated by the case of a woman, an elderly farmer. She took corticosteroid tablets for several years to try to control her asthma, but her asthma had not improved. She became virtually house-bound, unable to farm her land, and consequently, desperately poor. When inhaled corticosteroids were finally made available to her, she regained her strength, her breathing improved, and she was able to resume farming. However, her bones had become extremely thin and brittle as an adverse effect of taking corticosteroid tablets, and when she fell one day, she had a severe fracture and died of the complications. For her, the health-restoring inhaled corticosteroids had come too late.

Stopping the cycle of poverty and disease

Asthma is a frequent and, in some cases, debilitating disease whose effects can be avoided or improved in most cases. However, this depends on access to good-quality care, including the proper recognition of the disease, an understanding of the correct way to treat it and regular access to the medications needed to improve health. Unfortunately, although there is excellent evidence to show that, given the systematic application of good practice in the care of people living with asthma, the worst effects of the disease can be avoided, it is clear that many people do not have access to this care. This is worst amongst those who most need it, causing poor people to become even poorer and forever condemning them to a vicious cycle of poverty and disease.

- Donald A Enarson

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