The unmet global burden of COPD

Chronic respiratory diseases receive little attention and funding in comparison with other major causes of global morbidity and mortality [1]. Chronic obstructive pulmonary disease (COPD) is a major public health problem. COPD is the end result of a susceptible lung being exposed to sufficient environmental stimulus. Caused principally by tobacco smoking and household air pollution (HAP), COPD is a silent killer in lowand middle-income countries (LMICs): an estimated 328 million people have COPD worldwide [2], and in 15 years, COPD is expected to become the leading cause of death [3]. The relentless decline in lung function that characterises COPD is associated with progressive symptoms and functional impairment, with susceptibility to respiratory infections called ‘exacerbations’. Exacerbations are responsible for much of the morbidity and mortality. COPD has a significant impact on quality of life for those living with the condition, and on local economies for those affected, those caring for the affected and health services. A population literally struggling for breath is, in consequence, unproductive. The majority of cases of chronic lung disease are preventable. Exposure reduction initiatives must focus on tobacco control, and cook-stove interventions: either cleaner fuel (ideally), or better ventilation (at the least). Awareness campaigns and health programmes have the potential to revolutionise the diagnosis and management of COPD and COPD exacerbations, improving quality of life and health service cost and burden. LMICs face unique challenges in managing COPD, including sub-optimal and diverse primary care systems which present challenges with diagnosis and management, especially during exacerbations. A better understanding of how to prevent, diagnose and manage COPD in both rural and urban settings would make a real difference in countries of need. Two important aspects to consider when addressing the global economic burden of COPD are that of underdiagnosis and comorbidities [4]. Firstly, COPD remains underdiagnosed in many jurisdictions [5]. Studies included in reviews focusing on the global economic burden of COPD are all based on diagnosed COPD, and a simple multiplication of these values by the number of COPD patients to calculate the overall economic burden of COPD will underestimate the contribution of undiagnosed COPD [5]. Secondly, COPD is known to be associated with a significant number of comorbid conditions, and estimating costs that are directly attributable to COPD fails to consider the burden of such comorbidities [4]. Adjusting for comorbidities by calculating excess costs with an appropriate comparison group can provide a better opportunity, but even this results in an underestimation of the costs of the comorbidities [6–8].