All I Want Is Clean And Safe Air

Shobha Shukla *

Breath is life, and yet the importance of lung health is under-recognised, especially in women. No wonder then that lung disease (including respiratory infections, chronic obstructive pulmonary disease (COPD), tuberculosis, lung cancer and asthma) accounts for more than 16% deaths among women worldwide. Exposure to tobacco smoke and indoor air pollution, from using solid fuels for cooking and heating, are the two leading risk factors that impact women's lung health much more than that of men, especially in low/middle income countries. Each of these pollutants kills over 1.5 million women worldwide every year.

Although asthma affects 235 million people and is responsible for just 0.5% of all deaths among women worldwide, it is a highly debilitating disease, making the simple act of breathing a real challenge at times. Dr Chen-Yuan Chiang, Director, Department of Lung Health and NCDs, International Union Against Tuberculosis and Lung Disease (The Union), avers that, "Asthma is under diagnosed and poorly managed in resource limited settings. Unfortunately, in developing countries, many women (and also men) living with asthma have limited or no access to affordable inhaled corticosteroids, which are essential in asthma control."

My first brush with the severity of this disease was several years ago, when during a Physics Practical Examination of Class 12, one of my students suddenly started gasping for breath in the middle of doing her experiment. She was in obvious distress and unable to speak and breathe properly. We were clueless about the cause of her sudden affliction.

Other than making her sit in the open air and force her to drink water, we did not know what to do. Even before any medical aid could be given, I phoned her doctor parents who said that it was an attack of asthma and she had forgotten her inhaler at home. The college authorities were not even aware of her medical problem and this could have had serious consequences. Thankfully she normalized after a while. But the memory of those agonizing 15 minutes still remains etched in my mind. What if something untoward had happened because of her carelessness and our ignorance?

Asthma is a non-communicable, chronic respiratory disease of the bronchial tubes that is characterized by recurrent attacks of breathlessness and wheezing. During an asthma attack, the lining of the bronchial tubes swell, narrowing the airways and reducing the flow of air into and out of the lungs. The risk factors for developing asthma could be genetic predisposition, lowered immunity levels, cold air, physical exercise and exposure to tobacco smoke, pet fur, mould spores, dust mites, pollen, some medications and chemical irritants that may trigger allergic reactions or irritate the airways. The trigger stimulates Immunoglobulin E antibodies to produce histamine and other chemical mediators which swell the lung's lining and tighten the muscles of the airways.

Dr Amita Pandey, Associate Professor of Obstetrics and Gynaecology, King George's Medical University said to Citizen News Service - CNS that, "Over the past 20 years the burden of asthma has been steadily increasing, affecting around 10% of the general population (but more women than men) in our setting. Women are more likely to show acute exacerbations of the disease. Pregnant women need to take some special precautions to keep their asthma under control—keep house humidity low, avoid outdoor activity between 5am and 10am when pollen and pollutant effect is maximum, take inhalation therapy and avoid allergic foods like peanuts and eggs."

Rashmi (name changed) is 25 years old and has been suffering from asthma for the last 5 years. Incidentally that was the time when she got married into a family which uses solid fuel stove (chulha) for cooking purposes. When I spoke to her a few days ago she was in an advanced stage of her second pregnancy and admitted in a government hospital because of acute breathlessness. She told me that, "I have been on oral medication since December 2012, but for the last one week my breathlessness has increased. Earlier I used to take a nasal spray. Change of weather triggers an attack or when I eat something cold."

The doctor on duty in Rashmi's ward informed that, "We have to take some precautions with asthmatic women at delivery time as we cannot give such patients utero tonic injections for controlling postpartum haemorrhage as they can cause broncho spasm. So we have to be careful of that."

Biomass and solid fuels are a major source of indoor air pollution, but their health effects are poorly understood in developing countries like India. A study published in November 2012 examined the effect of cooking smoke produced by biomass and solid fuel combustion on the reported prevalence of asthma among 56,742 adult men and 99,574 adult women in India. The results showed that adult women living in households using biomass and solid fuels have a significantly higher risk of asthma than those living in households using cleaner fuels. Interestingly, this effect was not found among men. However, tobacco smoking was associated with higher asthma prevalence among both women and men. Combined effects of biomass and solid fuel use and tobacco smoke on the risk of asthma were greater and more significant in women than they were in men.

A guide book on -lung-health-consequences-of-exposure-to-smoke-from-domestic-use-of-solid-fuels- refers to another study from India which showed an increase of 22% to 30% in symptoms of asthma in nonsmoking women living with asthma and exposed to biomass or liquefied fuel smoke.

Dr Chiang rightly avers that, "Passive exposure to tobacco smoke and indoor air pollution due to domestic use of solid fuel for cooking and heating are the two main factors that contribute to asthma in women."

It would be worthwhile to mention here a study published in 2012 in the American Journal of Respiratory and Critical Care Medicine which found that women's asthma symptoms became more severe when they were menstruating. The lead author of the study, Ferenc Macsali of Norway's Haukeland University Hospital, informed that, "In a cohort of nearly 4,000 women, we found large and consistent changes in respiratory symptoms according to menstrual cycle phase, and these patterns also varied according to body mass index, asthma, and smoking status. Our results point to the potential for individualizing therapy for respiratory diseases according to individual symptom patterns. Adjusting asthma medication, for example, according to a woman's menstrual cycle might improve its efficacy and help reduce disability and the costs of care."

According to Professor Dr Surya Kant, Head of the Pulmonary Medicine Department, King George's Medical University, "If one of the parents has asthma then there are 25% chances of the child having it too. If both parents are asthmatic then this increases to 50%. If the mother is asthmatic then she should become more cautious about her asthma and more regular with the inhaler during pregnancy. Her environment should be clean and not harbour dust mites hidden in carpets, soft toys and cobwebs. The house in which she is living should not be painted/ white washed during the period of pregnancy; else an asthma attack is sure to follow. Smoking by or before a pregnant lady is a crime."

Says Professor Innes Asher, Chair of the Global Asthma Network: "Millions of women in the world struggle to breathe because of asthma, and this affects their ability to look after their families and to stay in paid work. The environment within the home may be a contributing factor – especially tobacco smoke, but also other pollutants like open fire cooking may be a factor. Policies need to support women having clean air to breathe in all situations. We know that asthma can be treated by effective medicines, but many women miss out because these medicines are not available or too expensive."

So on this International Women's Day on 8th March 2013, let us all resolve to do our little bit in making the air we breathe safer by saying no to smoking; making non-polluting cooking fuels available in all homes; and practising simple hygiene methods (no spitting or coughing in the open, washing hands, no littering).

Shared air has to be safe air, because unless we breathe well, we cannot live well!