Archive for the ‘global respiratory health’ Category

Respiratory epidemiology review (February 9, 2010)

Work-related respiratory diseases in the EU [Sigsgaard et al – ERJ]
New European Respiratory Society report surveys the epidemiology of the major occupational respiratory diseases in the EU, with a look at historic and contemporary risk factors, and an update on regulation. Highlights the emerging burden of occupational lung disease in “newer professions, such as public administration, education and occupational cleaning,” as well as the continued prevalence in traditional high-risk occupations, such as mining, farming, manufacturing and service work.

Social determinants of asthma [Cruz et al. – ERJ]
Editorial accompanying a report in ERJ by Sembajwe et al. on the relationship between gross national income, the prevalence of symptoms and doctor diagnosis of asthma. Cruz et al. review the interesting bimodal association between socioeconomic status and asthma and offer some thoughts on the puzzle, and the important distinction between risk of asthma ever and current symptoms: “Gross national product per capita is generally associated with both an increasing prevalence of wheezing ever and wheezing in the last 12 months. However, the prevalence of current symptoms is modifiable by current exposures (to allergens and environmental pollution,as well as other factors) and by effective treatment. Thus,even where prevalence is low, the burden of disease may be high, and poverty emerges as an important risk factor for current symptoms of asthma.”

What Genes Tell us about the Pathogenesis of Asthma and COPD [Weiss – AJRCCM]
“Recently a series of Genome Wide Association Study manuscripts (GWAS) in asthma and COPD have been published. These papers suggest that, in part, asthma and COPD have a common genetic origin, and that this common origin, is due to polymorphisms in genes that are involved with the development of the lung.”

Hygiene Hypothesis wanted: Dead or Alive [Linneberg letter and Douwes and Pearce reply – IJE]
This month IJE has published an interesting exchange between Allan Linneberg ( and Douwes and Pearce (, who suggest that “detailed exposure assessment strategies for both allergens and other potentially protective co-exposures are likely to shed new light on the roles of these exposures in the development of asthma and the validity of the hygiene and allergen tolerance hypotheses more generally.”

Follow up discussion to an editorial (PDF) published in 2008 by Jeroen Douwes and Neal Pearce, called, “The end of the hygiene hypothesis?” which concluded that “New aetiological theories of global asthma prevalence are, therefore, required that are more consistent with the epidemiological evidence and which take into account factors affecting the time trends for both allergic and non-allergic asthma.”

Asthma epidemiology reports – February 2, 2010

Reduction in Asthma Hospitalizations, Definitions of Childhood Asthma; Confirmation of Asthma; Adult Asthma Trends

Rapid reduction in hospitalizations after an intervention to manage severe asthma (ERJ – Souza-Machado et al.) – Evaluation of the Programme for Control of Asthma in Bahia (ProAR) which focused on providing free management of severe asthma. Achieved an 82% decline in asthma hospital admissions between 1998-2006, and report an “inverse correlation between provision of medication for asthma and hospitalization.”

Different definitions in childhood asthma: how dependable is the dependent variable? (ERJ – van Wonderen et al.) – Amazing review of 122 papers yielded 60 different definitions of asthma. “Prevalence estimates varied between 15.1% and 51.1% depending on the asthma definition used. The percentage of children whose posterior asthma probability was in the area of clinical indecision varied from 14.9% to 65.3%.” Conclusion – “Variation in definitions and its effect on the performance of prediction models may be another source of otherwise inexplicable variation in daily clinical decision making.”

Confirmation of Asthma in an Era of Overdiagnosis (ERJ – Luks et al.) – Following up on their recent report that 30% of adults with a physician diagnosis of asthma did not have asthma when objectively assessed, this article demonstrates that, “For the majority with a previous physician diagnosis of asthma only pre- and post- bronchodilator spirometry and a single methacholine challenge test are required to confirm asthma.”

Changes in the Prevalence of Asthma in Adults since 1966: The Busselton Health Study (ERJ – James et al.) – Cross-sectional respiratory health surveys of Busselton adults conducted in 1966, 1969, 1972, 1975, 1981, 1990 and in 2005-07 indicate that increased rates of doctor-diagnosed asthma are “partly explained by increased symptoms and atopy”; however, “factors such as diagnostic transfer and increased awareness of asthma have also contributed to the rise in prevalence.”

Missing populations in global health

I spent last week in the United Arab Emirates, attending a great conference sponsored by UAE University in Al-Ain to raise awareness of global health problems in the Middle East and neighboring Asia, and to draw attention to the region and its populations and health problems among the global health community.

As a result, I’ve been thinking about the scope of attention in global health, and about populations and settings that are, for some reason, out of focus right now; one group in particular came to mind.

Between sessions I wrote a short piece on the topic – It’s up now over at Pulse + Signal.

IDD meeting – Overview of the respiratory generic market

Last week in London I gave a presentation on the Spiroscout GPS inhaler device at the Inhaled Drug Delivery conference. It was a great meeting and I thought well worth writing up a few words on some of the presentations over the course of the next couple of weeks.

One of my favorites was a talk by Peter Wittner, of consulting group Interpharm, who gave a very interesting talk on the evolution of the respiratory (inhaled) generic market and the dissolving boundary between the traditional innovators and the generic manufacturers.

A recent article in the Economist – “Generically Challenged,” from the World in 2010 issue – lays out the growing interest of the major innovators in the generics drug companies, prompted in part by the “looming patent cliff.” According to EvaluatePharma, the total sales of prescription drugs at risk from patent expiry is set to more than double from 2010 to 2011. Vijay Vaitheeswaran argues that government attempts to control prices are propelling generics in high income countries, while in low income countries it is the growing middle classes. In fact, emerging economies already make up more than half of total global pharmaceutical sales.

Back in London, Wittner drew attention to the appeal of the branded generics approach. These are products made of off-patent formulations but sold for premium price. By his account, one company (Norton) was able to recognize that a lengthy generic name (sodium cromoglycate, rather than Intal) was hindering physicians from writing a prescription. In response, they adopted a branded generic approach, raised the price of their product, and labeled it Cromolyn. The Economist predicts that the major drugs firms are set to aggressively enter the branded generics market next year. It highlights a number of recent acquisitions and alliances between the big drugs firms and Asian generics firms like Ranbaxy.

Wittner also outlined the barriers facing the generics companies (such as proving bioequivalence) and some of the complicated struggles around patents in the respiratory drug market. There are several examples that illustrate how skilled generics companies have become at attacking weak patents; he discussed the recent European challenges to the Seretide and Symbicort patents in particular.

Finally, Wittner offered great bit on the lateral thinking and agility of generics companies, who are developing and protecting innovative new respiratory delivery devices and active pharmaceutical ingredients (API). He closed with some observations on the uncertainty around the potential competitors set to emerge from the Asian market and outlined some of the competitive advantages that Asian companies have, including a favorable regulatory environment.

India’s fury of frugal innovation

A recent article in the Economist surveys the drive toward frugal innovations in the Indian health care marketplace. This brief, compelling review describes the strategies and entrepreneurial activity being applied to identify and develop affordable approaches to a range of businesses in the health sector – from the delivery of advanced surgical care, to medicines, to insurance, and services.

The article notes how major India health companies, like Ranbaxy and Apollo – long focused on the upper classes – are now racing down the pyramid and helping stir up a powerful mix of cheap, innovative and radical solutions that will leapfrog the rich world. Not surprisingly, consulting firm Technopak Healthcare estimates that spending on health care in India is expected to rise from $40 billion last year to $323 billion in 2023.

Successful firms are rejecting technology whose costs don’t justify the benefits, and focusing on tools and techniques that spare resources and improve outcomes. The head of Fortis, a Delhi-based hospital chain, told the magazine, “We got out of this arms race a few years ago.”

In fact, several examples illustrate how new outfits are providing basic approaches, embracing economies of scale, and enthusiastically adopting health information technology and reshaping their services around it, increasing efficiency and cutting errors and costs at the same time. (LifeSpring Hospitals – an increasingly well known and funded chain of maternal and child health hospitals is given as an example). The article also describes the tendency for innovative new firms to leverage the sliding scale – subsidizing care for the poor by charging affluent customers more.

I witnessed this type of pricing a number of years ago among Indian pharmaceutical companies. At the time, most offered lines of asthma medications targeting different socioeconomic segments of the population. It is a business model that brings to mind durable goods, but was (and remains) largely unfamiliar to people in high income countries. In India, old oral medications, such as theophylline, are still widely used by practitioners who prescribe them specifically to patients at the lower end of the market; expensive newer drugs never reach the public hospitals or the bulk of the population. Cipla, for example, manufactures an inhaled combination of beclomethasone and salbutamol. Neither of these are the most efficacious medications currently available in their classes but they are both generic, low-cost compounds. Cipla representatives call the combination – sold under the trade name Aerocort – “the poor man’s Seroflo,” in reference to the company’s top of the line fluticasone and salmeterol combination product. As one executive told me: “Aerocort is much cheaper and it’s the same type of combination. So, a lot of people use that.”

Paul Yock, head of the bio-design laboratory of Stanford University, is quoted in the Economist piece as saying that the international med-tech giants have so far “looked at need, but been blind to cost,” and argues that the industry will find inspiration in India.

Perhaps GE already has. The company recently launched their Healthymagination campaign, a US$6 billion effort to re-strategize how the organization develops medical technology in order to emphasize the delivery of affordable equipment. A full post on that to come.

Global affordability and availability of asthma medication

In my chapter in Anthropology and Public Health I noted that global respiratory health activities and guidelines tend to assume the affordability of asthma medications. I wrote a bit about the lack of affordable antiasthma medications in India and other low income settings, and how questions of affordability figure into the day-to-day decisions of physicians. I cited a handful of studies which reported that in many countries, when they are even available, essential asthma medicines and appropriate preventive asthma therapy remain unaffordable for the majority of the populations (see, for example Ait-Khaled et al 2000 and 2001; Watson and Lewis 1997; and Mendis et al 2007). For example, in one study of doctors in 24 developing countries, 83 percent reported that they would prescribe more inhaled corticosteroids if they were cheaper (Watson and Lewis 1997).

On the airplane yesterday I read a great article from the Lancet – Medicine prices, availability, and affordability in 36 developing and middle-income countries – that I’d been carrying around for a while but never gotten to. It describes the development of a standardized method by WHO and Health Action International to routinely measure medicine prices, availability and affordability and make international comparisons. The full-text of the article and an accompanying editorial are available online for free. 

The paper presents the results of 45 surveys done in 36 countries, and notes that more than 50 surveys have now been done – with results available here

The article has a handful of striking statistics. For example, they report that medicines account for 20-60 percent of health spending in developing and transitional countries, compared with 18 percent in OECD countries. In addition, up to 90 percent of the populations in developing countries pay for medicines out of pocket, making, them “the largest family expenditure after food.”

In a nutshell, the project involved a multistage clustered sample of health care facilities in urban centers and outlying areas. Surveys examined a standard list of 30 core medicines that indicate a range of treatments for common acute and chronic conditions. The core medicines are “recommended, usually as first-line courses of treatment, in global, regional, and national treatment guidelines…Most are on the WHO Model List of Essential Medicines.” Up to 20 supplemental locally-relevant medicines were also included. A complete manual (and much more) is available online.  

While there are interesting findings regarding antibiotics used for respiratory infections, I’m going to limit my notes and comments to antiasthma medications.

Two drugs for asthma were included in the basket of 15 medicines that were represented in at least 80 percent of the surveys:

  • Beclomethasone (0.05mg/dose) inhaler
  • Salbutamol (0.1mg/dose) inhaler

However, specific data for beclomethasone was not included in the report, so I’m focusing on the results for salbutamol.

Availability – Low public and private sector availability

Overall, public sector availability of surveyed generics ranged from 29 to 54 percent across WHO regions.

Public section availability of salbutamol was very poor – only 29 percent (the lowest) overall. It ranged from 5 percent in Southeast Asia, 14 percent in Africa, 35 percent in Eastern Mediterranean, 42 percent in Europe, 48 percent in Western Pacific, to 88 percent in the Americas.

Private sector availability was a bit better overall (61 percent) – still the lowest of the target medications – with availability ranging from a low of 47 percent in Africa to a high of 79 in southeast Asia.

Price – Below the international reference price across most regions

Overall, private sector patients paid 9-25 times international reference prices for generic products and over 20 times international reference prices for originator products across WHO regions.

Surprisingly, however, the median price ratio for salbutamol inhalers was below the international reference price in all WHO regions except for the Americas; in a couple of regions (Africa, Southeast Asia) it was substantially lower.

Affordability – Not enough info to judge affordability of real-world asthma treatment

The report estimates affordability using the salary of the lowest-paid unskilled government worker to establish the number of day’s wages needed to purchase a course of treatment (30 day supply) for a variety of acute and chronic conditions (respiratory infection, diabetes, asthma and ulcer).

Unfortunately, the course of treatment for asthma only refers to a salbutamol inhaler; even though data on beclomethasone were collected, they are not included or reported (nor is any other anti-inflammatory).

Nevertheless, the authors report affordability for a month of inhaled salbutamol of 1.2-4.4 days in the private sector (originator brands) across regions, 0.6-5 days for private sector lowest priced generics; and 0.6-15 days for public sector lowest priced generics.

They note another shortcoming in the evaluation of affordability: That a substantial portion of the populations in many of these regions may earn less than the daily wage of the lowest-paid government worker. And they suggest that “further work is underway to identify alternative measures of affordability that could be included in the WHO/HAI methodology.”

The Indian setting

One other thing about the report that I found interesting. India – with its pricing regulations and vigorous domestic pharmaceutical industry (large number of generic manufacturers)  – appears to be have several lessons for efforts to improve the availability and affordability of medicines. In fact, the situation there is so unique that the manuscript reports the results from India separately.

For example, the availability of private sector generics was higher in India than in upper middle-income countries, while the median price ratios were much lower in India compared to other low income, lower-middle income and upper-middle income countries.

Moreover, median price differences between originator brands and lowest-priced generics in the private sector were also much lower in India (6% compared to over 300% in other low and lower-middle income countries).


With increasing demand for treatment of chronic respiratory disease in many low and lower-middle income countries, the value and timeliness of this report and methodology can’t be overstated. A more detailed analysis of typical asthma regimens – and some possible low-cost alternatives – should be at the center of global respiratory health efforts; improved public sector support for chronic respiratory disease medications is needed too.

As the authors write, “Increased emphasis should be placed on reducing the cost of these medicines in light of the high burden of non-communicable diseases. The affordability of chronic disease treatment is further constrained by the frequent need for more costly combination therapies and by the ongoing nature of treatment.”

News that El Salvador has recently become the first country to order from the Global Asthma Drug Facility hopefully indicates some progress, at last, “to increase availability, lower prices, and improve affordability of [asthma] medicine in all regions and at all levels of country development.”

Low-cost, open-source spirometry

Chronic respiratory disease is a serious and growing threat to global health. The WHO estimates that 300 million people worldwide have asthma or chronic obstructive pulmonary disease, already one of the top killers. 

Having worked in clinical settings in low and lower-middle income countries, I’ve always been struck by the absence of basic equipment like spirometers and pulse oximeters. One physician after another in India complained about the very high cost of spirometers, if he or she could even get one at all. 

Part of the problem with efforts to improve global respiratory health is their limited focus on clinical practice guidelines, which take for granted that asthma medications and tools like spirometers are available and affordable. When they’re not, we develop separate algorithms for these settings that use simple, readily available indicators, such as symptoms or basic clinical signs. But without basic tools, practitioners are flying blind, making important decisions about treatment and medications without essential information. The consequences are unnecessary morbidity and mortality. 

There are tens of thousands of private physicians in places like India who run small private fee-for-service clinics that want and need basic medical technology. But since they can’t pass on the high costs to their patients, who are often poor, they don’t purchase it. Nevertheless, these practitioners realize that spirometers or oximeters would mean much better outcomes for their patients (and that would help them compete with the many other practitioners). 

After some discussions with Julian Crane last year, I’ve decided to organize a group to design, develop and test a low-cost, open-source spirometer. I’m also hoping to simplify and improve the quality of measurement by delivering coaching through standardized audiovisual materials. 

As of January, development is underway. A team of four undergraduate engineering students here in Madison has decided to work on the project for their applied design course. We’ve set up a basic website with a forum and wiki, where we’re putting all of our notes, drawings, background research, and everything else we generate.

This is a challenging – if exciting – undertaking, and we really need your help. We hope and intend to grow an online community for the project, and want to interact with other interested designers, engineers, respiratory physicians, and scientists around the world. Please visit and explore the site, spread the word, and contribute your skills and knowledge.

New edition of Anthropology and Public Health published

The first edition of Anthropology and Public Health, which was edited by Robert Hahn, is one of my favorite books of medical anthropology – full of great pieces like Dorothy Mull’s report on acute respiratory infections in Pakistan (I’ve written about it here).

Last year, Marcia Inhorn and Robert Hahn asked me to write a chapter for the new, updated edition. It was a pleasure to work with them and I’m grateful to have been included in the project. 

My chapter looks at the diagnosis and management of asthma in India, and considers why the clinical practices of physicians there diverge from the recommendations of international guidelines. I illustrate that a lack of knowledge about appropriate asthma therapy is not one of the main obstacles, and that guidelines like GINA are an incomplete strategy to improve the quality of care.

Overall, there are another 23 or so chapters in the book, which weighs in at 752 pages. I’m really looking forward to reading the work of Vinay Kamat, Mimi Nichter, and the other contributors. The book has just been published by Oxford University Press and is available at Amazon.

Here’s the summary from Oxford University Press:


Many serious public health problems confront the world in the new millennium. Anthropology and Public Health examines the critical role of anthropology in four crucial public health domains: (1) anthropological understandings of public health problems such as malaria, HIV/AIDS, and diabetes; (2) anthropological design of public health interventions in areas such as tobacco control and elder care; (3) anthropological evaluations of public health initiatives such as Safe Motherhood and polio eradication; and (4) anthropological critiques of public health policies, including neoliberal health care reforms. As the volume demonstrates, anthropologists provide crucial understandings of public health problems from the perspectives of the populations in which the problems occur. On the basis of such understandings, anthropologists may develop and implement interventions to address particular public health problems, often working in collaboration with local participants. Anthropologists also work as evaluators, examining the activities of public health institutions and the successes and failures of public health programs. Anthropological critiques may focus on major international public health agencies and their workings, as well as public health responses to the threats of infectious disease and other disasters. Through twenty-four compelling case studies from around the world, the volume provides a powerful argument for the imperative of anthropological perspectives, methods, information, and collaboration in the understanding and practice of public health. Written in plain English, with significant attention to anthropological methodology, the book should be required reading for public health practitioners, medical anthropologists, and health policy makers. It should also be of interest to those in the behavioral and allied health sciences, as well as programs of public health administration, planning, and management. As the single most comprehensive and up-to-date analysis of anthropology’s role in public health, this volume will inform debates about how to solve the world’s most pressing public health problems at a critical moment in human history.

Product Details

752 pages; 15 halftones, 10 lines; 6 1/8 X 9 1/4;

ISBN13: 978-0-19-537464-3

ISBN10: 0-19-537464-9

How do physicians in India treat asthma exacerbations?

Raj B. Singh MD (Apollo Hospital – Chennai) and I recently published a paper in the Clinical Respiratory Journal describing the management of asthma exacerbations by physicians in India. We used a well-known epidemiological instrument, the ISAAC video questionnaire, to simulate five presentations of asthma. For more details, please take a look: [abstract] [pdf]