A dangerous habit, man with oxygen tank and the story of India's toxic air

Over 34 years, as India’s economy expanded and flourished, Raj Iyer was on the move, travelling at least 14 days a month as a consultant with nonprofit and government agencies.

His itinerant, fulfilling life changed 11 years ago when he repeatedly felt short of breath and was eventually diagnosed with chronic obstructive pulmonary disease (COPD), which had debilitated his lungs and his ability to breathe.

Smoking 60 cigarettes a day for 40 years was probably the immediate cause, although worsening air pollution may have played a role. “I knew my symptoms were of a respiratory disease but I didn’t know it was COPD,” said Iyer. “I certainly didn’t know how bad it gets or that it is incurable.”

Today, Iyer is 69, and his once expansive life has shrunk to a room in his house in Bengaluru’s eastern Pai Layout, where he lives with his primary caregivers, his 34-year-old son and 27-year-old daughter-in-law, whose lives, as we explain later, are circumscribed by his illness.

“When I first got married (in 2012), his COPD was not as bad, and he didn’t need continuous oxygen support,” said Antara Karthikeyan, Iyer’s daughter-in-law and a kindergarten teacher.

As the COPD progressed, Iyer needed oxygen support, multiple hospitalisations because of breathlessness caused by high levels of carbon dioxide--which is toxic to the body and accumulates when COPD affects ability of the lungs to expel carbon dioxide--and fell frequently due to his weakening bones.

Iyer’s room is taken over by the paraphernalia of his life-support system. A “BiPAP machine”, which is a respirator that steadies his breathing. A portable oxygen concentrator to take along while travelling. A larger oxygen concentrator, a machine that scrubs nitrogen from the air and give him a stream of pure oxygen through a 7-m-long plastic tube that allows him to move around the house. And to keep the life-giving gas flowing even when the electricity cuts out in India’s IT capital, notorious for its shaky power grid, the oxygen concentrator is connected to an inverter.

If Iyer’s professional and personal life followed India’s physical and economic transformation, so did the trajectory of the little-known, ill-managed disease that ravages his body--and is killing more Indians than ever before in a country with growing air pollution, more smoking among young people and an ageing, vulnerable population.

An incurable and progressive disease, COPD moved up from eighth spot to second on the list of leading ways to die in India, over 26 years to 2016 (the year for which the latest data are available). COPD claimed more victims than either road accidents or suicides in 2016. It claimed more lives than diabetes, malaria, tuberculosis and breast cancer combined in 2016. It only trails heart disease in the number of Indians it kills.

COPD is responsible for nearly a million deaths every year, as IndiaSpend reported in March 2019, in the first part of this series. The second part explained the contribution of traditional stoves burning coal, wood and cow-dung to COPD in India. In this, the third part, we bring you the story of a nation’s toxic air, a dangerous habit and a man being slowly claimed by a disease killing more Indians than ever before.

The fourth part will explain how India is unprepared for its COPD crisis.

Air pollution, smoking and ageing

Tobacco smoking is the primary cause of COPD worldwide, and it is responsible for a fourth of all cases in India. But air pollution--including ambient and household pollution due to biomass burning--is the primary cause of COPD in India and is responsible for more than half (53%) of all cases.

The ambient particulate pollution in India rose 12.5% over 27 years to 2017, from 80 μg/m3 (microgram per cubic metre) in 1990 to 90 μg/m3 in 2017, whereas China reduced its ambient particulate pollution from 58 μg/m3 to 53 μg/m3 over the same period.

These are “population weighted annual means” measuring fine particles, either dust or smoke, that penetrate the innermost recesses of the lungs. Averaged across the country, these data give weight to areas in proportion to their population, so that greater weight is given to areas where more people live. But these averages mask local concentrations of toxic air that may be many times more than the average.

In addition, more than 266 million Indians use tobacco, according to a 2018 World Health Organisation factsheet, and while the most common way to die of tobacco is from cardiovascular disease (48%), the next is chronic respiratory disease (23%), which includes COPD.

Although the proportion of any smoking among men aged 15 to 69 in India fell 27% over 12 years to 2010, cigarette smoking rose two fold in that age group and four fold in the 15-29 age group, according to a 2016 paper in BMJ Global Health, a journal.

“Despite modest decreases in smoking prevalence, the absolute numbers of male smokers aged 15-69 years has increased substantially over the last 15 years,” said the paper. Iyer started smoking when he was 17 and did not quit until a year before he was diagnosed with COPD.

A compounding factor in COPD’s rise in India is its ageing population, since there is growing evidence that susceptibility rises with age.

Over 21 years to 2011, the number of Indians above the age of 60 rose 93% from 53.7 million to 103.8 million. The decadal growth in elderly population between 2001 and 2011 was 35.5%, compared to 17.7% growth in the general population.

As the country ages and air pollution rises, COPD is likely to be increasingly common in India, experts told IndiaSpend.

India now accounts for a third (32%) of all disability adjusted life years (DALYs)--an indicator of overall disease burden--for COPD worldwide. Over 26 years to 2016, there was a 54% rise in the share of COPD in India’s total disease burden, as COPD moved up from being the eighth-leading cause of death to the second, according to the 2017 India: Health of the Nation’s States report by the Public Health Foundation of India (PHFI), a think tank, and the Indian Council for Medical Research, a government-run network of research laboratories.

Within this rise of COPD, there are medical nuances that explain why the disease is poorly understood, even by doctors, and poorly managed, claiming more Indian lives than it should.

Why so many Indians die of COPD

When Iyer felt the first shortness of breath, constant cough and tiredness in 2006, he went to a cardiologist who suspected it to be respiratory and cardiac related. The doctor prescribed medicines for both and despite symptoms getting worse, Iyer continued to work and travel.

Two years later, when he was alone, Iyer’s blood sugar levels dropped and he asked his driver to take him to a hospital. There, a number of tests later, his condition was correctly diagnosed as COPD.

It should not have taken two years for a diagnosis because Iyer has been a smoker since he was 17 and smoked, as we said, up to 60 cigarettes a day for 40 years.

As in Iyer’s case, a classic COPD symptom is shortness of breath, although other symptoms can include fatigue, cough and tightness of the chest. Patients feel short of breath because the tubes carrying oxygen to air sacs in the lungs are inflamed--chronic bronchitis--or because smoke damages these sacs, which is emphysema.

Either way, the lungs do not expel carbon dioxide or absorb oxygen as they should, even as airways are inflamed, making breathing difficult. This is especially difficult for older patients.

“At the age of 25, our lungs are at their optimum efficiency [taking in] around four to six litres [of air with every breath]; from then on, it gradually declines about 25-30 ml per year,” said H B Chandrashekar, director of the Jain Institute of Pulmonology and Sleep Medicine at the Bhagwan Mahaveer Jain Hospital, Bengaluru. “For smokers, this is two or three times faster, so about 80-90 ml decline each year,” said H B Chandrashekar.

So, by the time a smoker reaches the age of 45, the lung capacity is equivalent to a 75-year old’s, he said. Iyer, as we said, was 58 when diagnosed.

All his adult life, Iyer’s mother and friends told him to quit smoking. In 2007, he finally did. A year later, he was diagnosed with COPD. By then, he was in the second stage of the disease, meaning his COPD was moderate with symptoms worsening on exertion.

COPD patients say they are perfectly normal before but the fact is that lung function has been on decline that hey noticed because of aging, said Rajani Bhat, consultant physician, pulmonologist and critical-care-medicine specialist, who treated Iyer for eight years. Credit: Rajani Bhat

“Usually patients come to COPD as an exacerbation of a bad lung infection,” said Rajani Bhat, consultant physician, pulmonologist and critical-care-medicine specialist, who treated Iyer for eight years. “They say that they were perfectly normal before, but the fact is that their lung function has been on a decline for sometime, but they felt it only later because of aging.”

If caught early, ideally in full body health checks that include lung-function tests, COPD can be treated and managed through inhalers, usually bronchodilators, that open airways and make breathing easier, even though there is no direct cure.

There are several reasons why COPD is not diagnosed early by most Indian doctors:

• It is often confused with asthma because it has some similar symptoms: shortness of breath, wheezing, cough and chest tightness.
• Diagnosis is confirmed with a test called spirometry--measuring how much and how fast the lungs exhale--which is not commonly available in India.
• Most doctors assume only smokers are at risk, thus underestimating the risk to non-smokers who contract it due to biomass burning and occupational hazards like working in mining, textiles, welding, foundry and farming.
• COPD patients are often misdiagnosed as having asthma and are given inhalers for asthma that is corticosteroid inhalers which do not work.
• COPD often progresses into heart disease, which may be treated but the underlying lung disease remains undiagnosed.

“In our own study, we found that 25% of patients admitted with myocardial infarction [heart attack] had an underlying lung disease which was not known,” said B V Murali Mohan, Consultant, Pulmonology and Internal Medicine, at Narayana Health, Bengaluru.

Unlike heightened general awareness of India’s number one killer--cardiovascular disease--COPD is seldom written about in the popular media.

“It (COPD) is not considered of reader or viewer interest,” said Srinath Reddy, PHFI president. Coupled with poor diagnosis in primary care, confusion with other respiratory diseases and “low self referrals” by patients, COPD is an ill-understood disease, said Reddy.

Living with COPD

Iyer has watched COPD gradually take over his life.

From stage two in 2008, the disease within him has progressed to stage four, which means it is now in very severe stage where hospitalisations are frequent and lung function is limited.

Over the last four years, he has been hospitalised 10 times, mostly with a lung infection or low oxygen saturation in the blood.

In 2019, Iyer has only been hospitalised in January.

“They say if you have not been hospitalised for more than six months, you are doing well,” said Iyer. He has become adept at managing his disease at home, adjusting his BiPAP machine, running his nebuliser, which deliver medication to open his airway in a fine mist, and has avoided going to the hospital.

“Most patients, especially women, do not want to burden their children and family (and) hence wait till it is too late to see a doctor,” said Bhat, Iyer’s doctor. This is being penny wise, pound foolish, she said, since regular follow-ups ensure patients do not need to be hospitalised frequently.

Since most COPD cases in India are detected late and in stage 2 and beyond, they need frequent hospitalisation, especially in winter.

Iyer spends between Rs 10,000-15,000 every month on managing COPD, but each hospitalisation that usually lasts a week can cost between Rs 60,000-100,000.

Apart from the medical paraphernalia that keeps him alive, opposite his bed is a blackboard, on which daughter-in-law Antara Karthikeyan has written a list of medicines he needs to take every day and in case of an emergency.

Raj Iyer’s COPD was first thought to be a cardio-respiratory problem. By the time he was diagnosed with COPD, two years later--a year after he quit smoking--the disease was in its second stage, at which point there were moderate symptoms that worsened on exertion.

Given his research background--he has a master of philosophy degree in social anthropology--Iyer has studied the disease’s mechanism extensively and answered questions on treatment and medicines with ease.

“To treat COPD, doctors prescribed steroids, which in-turn bring on diabetes and osteoporosis,” said Iyer. “Because COPD makes you breathless, you are less active, which further weakens bones and muscles.”

Inhalers do not cause these side-effects; only the oral steroids, said Bhat, his doctor. “Iyer has to take oral steroids for his exacerbations and he has had to take them over a long period of time” she added. “However he wouldn’t be alive, if not for those medications.”

Yet, COPD detected early can be managed, and patients can hope for better quality of life.

Pulmonary rehabilitation

An intervention that works as effectively, if not better, than medication for COPD is pulmonary rehabilitation, which includes a 12-week programme of exercises for chronic lung patients under medical supervision, nutritional counselling and breathing techniques.

Exercise improves a patient’s breathing capacity by working muscles that become deconditioned due to disuse; it “empowers” patients and gives them confidence, so they can be independent, explained pulmonologist H B Chandrashekar of Bhagwan Mahaveer Jain Hospital who set up Bengaluru’s first, and one of India’s earliest, pulmonary rehabilitation centres in 2012 in the hospital.

“Exercise reduces chance of exacerbation, hospitalisation, improves symptoms and even may reduce mortality,” says pulmonologist H B Chandrashekar of Bhagwan Mahaveer Jain Hospital, Bengaluru. He set up the city’s first, and one of India’s earliest, pulmonary rehabilitation centres in 2012.

“Exercise reduces chance of exacerbation, hospitalisation, improves symptoms and even may reduce mortality,” said Chadrashekar. Most patients are reluctant to go into rehab, as they consider it unnecessary, and most hospitals do not have such a centre, since it does not bring in as much revenue as hospital beds do, he said.

Living in Bengaluru possibly took a greater toll on Iyer’s health. Pulmonologists explained how Bengaluru’s unique weather and geographical conditions make its residents especially prone to respiratory illness.

While air pollution is not as high as in New Delhi or in other northern cities--15 of which rank among 20 of the world’s most-polluted cities--Bengaluru’s altitude of 3,020 ft or 920 m above sea level and equable climate ensure pollutants do not rise, as they would in warmer weather, but stay close to the ground.

“The treeline in the city, with trees on both sides of the road, are the city’s lungs [but] also trap the pollutants close to the breathing zone,” said Bhat. The city’s high pollen concentration makes residents prone to allergies, asthma and COPD.

When Iyer was first recommended pulmonary rehabilitation in 2008, he didn’t take it seriously. In 2015 when his condition worsened, he went to Mahaveer Jain Hospital and accepted the rehabilitation.

He went to the hospital in a wheelchair with oxygen support; slowly he weaned himself off the wheelchair and constant oxygen support. In 2015, he felt better and was physically capable of doing more.

Iyer pointed out that insurance companies do not cover pulmonary rehabilitation. “They are willing to cover COPD and pay tonnes and tonnes of money, if you claim insurance,” he said. “But (they) will not pay for rehab that will prevent hospitalisation and save them money.”

The rehab costs Rs 1,000 a week, during which there are three one-hour sessions. Iyer paid for and continued rehab sessions for a year and was strong enough to achieve important milestones: his son’s wedding, buying property and travelling.

However, after a series of falls and injuries, he was not able to continue rehab after 2017. As his conditioned worsened, a greater burden is apparent on his family.

How families cope with COPD

COPD has altered the way Iyer’s family lives.

His son and daughter-in-law cannot, for instance, travel out of the city at the same time.

Daughter-in-law Antara Karthikeyan was once a retail manager with long working hours, but she was constantly worried about Iyer home alone.

“My number one concern was, what if he trips and falls,” said Antara Karthikeyan. “He cannot get up on his own. How will he call us?”

Her decision to become a kindergarten teacher, so she could return home by afternoon, was a personal choice, she said. She and her husband have hired help to look after their four-year-old daughter, Tanya, and be available in case Iyer needs assistance while Antara Karthikeyan is at work.

COPD does not affect only the lungs but causes wider systemic damage because of inflammation. The disease has brought gastritis, diabetes, oedema, sleep disturbance, anxiety and depression to Iyer, who uses music, reading books, watching documentaries and meditation as a way of making peace with his body’s slow degeneration.

This is the third of a four-part series. You can read the first part here and the second part here.

Republished with permission from IndiaSpend. You can read the original article here