Sudden cardiac death grabs headlines and attention. It is dramatic, tragic, and the risk is easy for the public to comprehend. Chronic Obstructive Pulmonary Disease (COPD), on the other hand, is a public health emergency hiding in plain sight. The high air pollution currently prevailing in Delhi NCR has drawn attention to it because even our good air days with AQI (air quality index) near 200 are likely to damage the lungs. Now that AQI is capped at 500, it hard to know how much worse bad air days are. Suffice to say, we are far away from any measure of acceptability and that air purifiers and masks are almost essential accessories throughout this range for susceptible people.
Unlike ischemic heart disease (IHD), COPD has no real cure. And once lung function is lost, it is largely irretrievable. Treatment can ease symptoms, prevent exacerbations and slow decline —but it cannot restore the airways or reverse the structural damage. That makes neglect even more costly, because by the time breathlessness is obvious, the window for meaningful intervention has already closed. While lung transplants are possible and indeed done for terminal COPD, it is neither scalable nor a path to a normal life for most.
The origins of COPD lie early in life. Indians have the poorest adult lung function in the world, a fact established repeatedly across population-level spirometry studies. While part may be genetic, most is likely due to adverse environments. Worse, we also seem to be experiencing a faster decline in lung capacity with age compared to many other populations. It is as if millions of Indians begin adult life with half a tank of lung reserve and then leak air steadily over decades. When illness, pollution, or infections finally strike, the margin of safety is gone.
This baseline vulnerability changes the nature of the COPD epidemic in India. Unlike in many Western countries, where smoking remains the dominant driver, India’s COPD burden is shaped by pollution — outdoor and indoor — more than cigarettes.
Non-smoking women, particularly in rural and peri-urban regions, have been silently exposed to biomass fuels for decades. Access to cleaner cooking fuels has expanded, albeit unevenly. But the outdoor environment is moving in the opposite direction. Urbanisation, construction dust, vehicle emissions, industrial expansion, crop-burning cycles, and changing climate patterns all converge to produce year-round exposure to particulate matter that infiltrates lungs with every breath. Sadly, there seems to be no constructive roadmap towards solutions beyond periodic kneejerk imposition of emergency measures.
In India, the absolute number of people living with COPD has roughly doubled since 1990. The silver lining is that age-standardised incidence, mortality, and COPD-related DALY (Disability-Adjusted Life Year) rates have fallen slightly. However, this is likely to change with rising outdoor pollution offsetting any gains from reduction in smoking and indoor pollution. Further, the growth of the epidemic is being driven by population ageing, not by a dramatic rise in per-age risk. More people are reaching older ages; ironically, a sign of progress. Given the lifelong burden of poor lung function, as they get old enough, COPD will catch up.
This is a recipe for disaster as India ages. A nation with inherently low lung reserve and worsening air pollution will inevitably see rising disability and death due to COPD. And unlike heart disease, we are unprepared. Prevention via clean air, early-life lung health, reduction of indoor and outdoor pollutants is our only meaningful strategy.
India has invested heavily in cardiac care and rightly so. It is now time to recognise that the lungs deserve at least equal urgency. The real crisis is not sudden cardiac death. It is the slow suffocation of millions, unfolding every day, in full public view, with barely a whisper of alarm.
(Dr Agrawal is Dean, BioSciences and Health Research, Trivedi School of Biosciences, Ashoka University. The views expressed are personal and do not reflect the views of the University)