Elsevier

The Lancet

Volume 397, Issue 10277, 6–12 March 2021, Pages 928-940
The Lancet

Review
Improving lung health in low-income and middle-income countries: from challenges to solutions

https://doi.org/10.1016/S0140-6736(21)00458-XGet rights and content

Summary

Low-income and middle-income countries (LMICs) bear a disproportionately high burden of the global morbidity and mortality caused by chronic respiratory diseases (CRDs), including asthma, chronic obstructive pulmonary disease, bronchiectasis, and post-tuberculosis lung disease. CRDs are strongly associated with poverty, infectious diseases, and other non-communicable diseases (NCDs), and contribute to complex multi-morbidity, with major consequences for the lives and livelihoods of those affected. The relevance of CRDs to health and socioeconomic wellbeing is expected to increase in the decades ahead, as life expectancies rise and the competing risks of early childhood mortality and infectious diseases plateau. As such, the World Health Organization has identified the prevention and control of NCDs as an urgent development issue and essential to the achievement of the Sustainable Development Goals by 2030. In this Review, we focus on CRDs in LMICs. We discuss the early life origins of CRDs; challenges in their prevention, diagnosis, and management in LMICs; and pathways to solutions to achieve true universal health coverage.

Introduction

Non-communicable diseases (NCDs) are a major cause of morbidity and mortality, accounting for approximately 70% of global deaths, with the highest risks of dying from NCDs observed in low-income and middle-income countries (LMICs).1 The United Nations' Sustainable Development Goals (SDGs) aim to reduce the risk of premature mortality from NCDs by a third by 2030.2 Chronic respiratory diseases (CRDs), such as asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, and post-tuberculosis lung disease (PTLD) are common and frequently neglected NCDs that span the life course. They are frequently associated with high levels of patient and health care costs, morbidity, and risk of mortality due to persistent symptoms, activity limitation, and intermittent exacerbations requiring acute care. They disproportionately affect poor people in all countries, but especially in LMICs where resources for research, prevention, and management are scarce.3 The recent Lancet Commission on NCDs and Injuries has helped to highlight and frame this issue as a matter of justice and equity for the world's poor.4

This Review focuses on CRDs in LMICs. Although we recognise that poverty and social deprivation are global issues, people living in LMICs face a particularly difficult combination of damaging early life and environmental exposures, challenging social and political contexts, and poor access to high-quality health services. We discuss the early life origins of CRDs in LMICs, and potential approaches to the prevention of disease. We address the clinical and health system challenges faced in the management of established disease. We suggest strategies for research and clinical capacity strengthening, for both the prevention and management of CRDs, and propose pathways to solutions that would contribute to achieving international targets for health, including reducing morbidity and premature mortality, and achieving universal health coverage.

Section snippets

Early life origins of chronic respiratory disease

Evidence that has mainly been acquired in high-income countries (HICs) indicates that the in-utero, infant, child, and adolescent environment is crucial for lung development, with pre-school lung function tracking and predicting early adult lung function, into at least the seventh decade of life.5, 6 Although comparable data from LMICs are scarce, the same association probably holds true in these countries.7 Common to both settings are detrimental in utero and early childhood exposures, which

Asthma

Asthma is the most common CRD globally, affecting 262·4 million people in 2019,47 with LMICs contributing 96% of global asthma-related deaths and 84% of global disability-adjusted life-years (DALYs; figure 1).47 However, morbidity and mortality from asthma is largely preventable.48

COPD

Global burden of disease estimates suggest that 212·3 million adults were affected by COPD in 2019.47 However, primary data on the global burden of disease show widespread variability in the prevalence, causes, clinical presentation, and mortality between and within LMICs.64 These differences are mainly related to poor access to spirometry and scarce epidemiological data, but are compounded by controversy in the definition of COPD—for example, it is unclear whether fixed ratios and percent

Bronchiectasis

The reported population prevalence of non-cystic fibrosis bronchiectasis in HICs has increased in recent years to 566 per 100 000,87 with disease prevalence and severity associated with increasing age88 and female gender. Epidemiological data on bronchiectasis in LMICs are scarce,89 but the few data that are available suggest that the prevalence, causes, and risk factors for bronchiectasis might differ substantially to those in most HICs, with more post-infectious disease, an association with

Post-tuberculosis lung disease

Pulmonary tuberculosis survivors, estimated at 58 million globally so far,31 have two-to-four fold odds of persistently abnormal spirometry (airway obstruction and low FVC patterns) after completion of tuberculosis treatment, compared to those who have never had tuberculosis disease. Bronchiectasis, parenchymal cavitation and destruction, and fibrotic change are widely seen on imaging.94, 95, 96, 97 Much heterogeneity exists in the prevalence, patterns, and severity of residual pathology, but

Health systems strengthening

Strong health systems that are capable of providing effective and efficient services across the life-course will be key to the prevention and management of CRDs and NCDs in LMICs, and must include the provision of comprehensive maternal care. Development of these systems will require attention to the six key building blocks specified by the WHO: service delivery; health workforce; health information systems; access to essential medicines and vaccines; financing; and leadership or governance (

Research priorities and research capacity strengthening

This Review has highlighted several areas of uncertainty that we have formulated into research priorities for CRDs in LMICs (panel 2). However, these issues cannot be addressed without a thriving critical mass of LMIC investigators. The Structured Operational Research Training Initiative (SORT-IT) course, and the American Thoracic Society/Pan African Thoracic Society's Methods in Epidemiological, Clinical and Operational Research (PATS-MECOR) course are examples of successful

Conclusions

CRDs contribute substantially to the burden of disease in LMICs. Achieving the SDGs will require action to address this burden of disease through improvements in prevention and care. Poverty reduction measures must be at the core of efforts for prevention, with a specific focus on improving maternal nutrition and health, reducing exposure to airborne contaminants (tobacco smoke, household and atmospheric air pollution, and occupational exposures), and improving the prevention and management of

Search strategy and selection criteria

We did not do a formal literature search for this Review. Studies included in this Review were identified by the authors based on their knowledge of non-communicable respiratory disease in low-income and middle-income countries; the studies referenced were selected by the authors, as most relevant to this field.

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