Respiratory health issues in the Asia-Pacific region: An epilogue

During 2011, Respirology—the official journal of the Asian Pacific Society of Respirology (APSR)—published a series of review articles on ‘Respiratory Health Issues in the Asia-Pacific Region’. The articles focused on respiratory health issues considered to be of particular importance to the Asia-Pacific region, which is comprised of vastly diverse cultures and where escalating modernization confronts some of the oldest civilizations in the world.¹

Lung health is unavoidably linked to the air we breathe. Both outdoor and indoor air quality pose immense attributable burdens of disease. The Asia-Pacific region boasts a number of emerging economies, including populous countries such as China and India; however, rapid economic growth comes at a cost, and environmental pollution, especially air pollution, has become an obvious threat to health.² Growing industrial development and increasing traffic have created additional pressures on energy consumption and the production of related waste products, far beyond usual domestic levels. Atmospheric air pollution is not only causally related to acute worsening of chronic respiratory diseases, such as asthma and COPD but may also lead to impairment of lung growth, as well as the development of chronic respiratory problems, including mucus hypersecretion, airflow obstruction and lung malignancies. Successfully curbing the relentless and widespread deterioration in air quality requires public policy interventions—which are unlikely to come about spontaneously. The medical profession plays a pivotal role in researching, confirming and publicizing the treacherous effects of air pollution on health-related quality of life, and raising awareness in the wider community, which is still enjoying the many obvious benefits of a growing economy. Adding to the ongoing man-made environmental pollution is the occurrence of natural disasters, to which Asia is certainly no stranger. Intense episodes of air pollution due to smoke and toxins from bushfires, such as those in Indonesia in 1997, are not uncommon ‘regular’ occurrences in Australia.³ Volcanic eruptions, earthquakes and tsunamis, which have continued to strike different areas in the Asia-Pacific region in the past two decades, have caused various forms of lung injury, either directly through inhalation or aspiration,⁴ or indirectly, as in the recent nuclear power plant disaster.⁵ These health consequences of natural disasters pose huge challenges, not only clinically, but even more so in terms of public health, as they impose acute strains on healthcare resources, which must be delivered under difficult conditions.

It cannot be understated that smoking, which is an acquired habit, remains the dominant culprit in poor respiratory health, particularly in the Asia-Pacific region, which produces and consumes over one third of the world's tobacco, and where the prevalence of smoking is as high as 50–70% among men and women in some countries.⁶ Smoking-related respiratory diseases such as COPD and lung cancer comprise a large proportion of the conditions we manage as clinicians. However, the tobacco problem certainly goes beyond that of treatment of disease or even smoking cessation measures; the public health battle against smoking should be part of the remit of pulmonologists and should not be delegated to public health personnel alone.

Given the combination of increasing longevity, a high prevalence of smoking and increasing production of industrial carcinogens due to lack of regulation of industrial modernization, malignancies such as lung cancer will continue to impose a major disease burden in the Asia-Pacific region.⁷ In some localities, occupational and unintended exposure to inhaled carcinogenic substances may pose a specific threat.⁸ Sadly, the use of asbestos has increased in Asia since the 1970s, contrasting with declining use in some Western countries. Asian populations, especially the female segment, are further afflicted by a unique predisposition to lung adenocarcinoma despite the low prevalence of smoking in this group. However, there is a ray of hope in this unique misfortune; recent medical advances have led to the discovery of a ‘target’ genetic mutation in the epidermal growth factor receptor (EGFR) in lung cancer tissues of these patients, which was much more frequently observed than in other ethnic groups.⁷ The availability of the relevant ‘targeted therapy’, with improved response rates compared with chemotherapy, heralds the start of fulfilling the promise of personalized therapy for this dreaded disease.

Although smoking is the major aetiology for COPD in Asia, indoor air pollution as a by-product from the burning of fossil fuels may account for a substantial proportion of COPD cases in some rural districts. However, the populations of emerging countries are not the only casualties of the ever-growing demand for energy. The recent earthquake and nuclear power plant disaster in Fukushima have once again sent an alarm signal regarding the safety of nuclear energy, which has been progressively installed as a source of ‘clean’ energy in many Asian Pacific countries, as well as globally. Radiation damage to the lungs has become not only an individual or professional concern with respect to the use of radiation in disease diagnosis and treatment but also a potentially serious threat to workers and even inhabitants of the disaster zones, increasing the pressing need for more effective treatment.⁵

Genetic factors, in combination with socioeconomic and environmental factors, have led to some unique patterns of diseases in the diverse, multi-ethnic Asia-Pacific region. In this context, diffuse panbronchiolitis occurs almost exclusively among East Asians, especially Japanese, and to a lesser extent Koreans and Chinese.⁹ The Middle East, which is geographically located between the ‘east’ and the ‘west’, manifests an amazing and challenging spectrum of respiratory conditions.¹⁰ Sickle cell lungs, Behcet's syndrome and warfare-related afflictions are specific to this region, in which cystic fibrosis is also prevalent, whereas it otherwise occurs only among the Caucasian populations of Australia and New Zealand but not in other Asian-Pacific populations. Furthermore, the region has increasing health problems relating to the ‘modern’ lifestyle, including sleep apnoea, which is now recognized as having a surprisingly high prevalence among Asians due to the global epidemic of obesity despite Asians generally having a lower BMI compared with Caucasians.

Transmissible infectious diseases are still a major cause of morbidity and mortality globally and even more so in the Asia Pacific region where old and new social structures coexist alongside each other. We are hopefully begetting the best of both worlds in the future, but we may still be having the worst of both worlds in terms of respiratory infections. Whilst the ancient curse of tuberculosis, although considered to be ‘controlled’, still thrives relatively well in Asia, the region has also been fertile ground for, or even the source of, some epidemic or pandemic outbreaks, including avian influenza, severe acute respiratory distress syndrome (SARS) and most recently, H1N1 influenza (swine flu).¹¹ Asia will continue to be a major battlefield in this never-ending struggle between man and microbes.

Although lung function testing cannot be used as the sole indicator of respiratory health or disease, its utilization does reflect a recognition of the importance of the airways and lungs in overall physical well-being.¹² In an effort to champion the cause of lung health, the Forum of International Respiratory Societies (FIRS),¹ of which the APSR is a member, launched World Spirometry Day in 2010, and this will take place again in association with the Olympic Games in 2012. We appeal to respiratory healthcare professionals in the Asia-Pacific region to use this event as an opportunity to promote lung health in their respective communities.

Heathcare practitioners tend to focus on treating diseases of individuals, and there is no doubt that this is the day-to-day job and major responsibility for the vast majority of practitioners. However, we must not lose sight of the fact that each of us is capable of, and has a responsibility to play, an active role in promoting lung health and mitigating the burden of disease, be it in our daily clinical practice or through our engagement with professional medical organizations or voluntary agencies. The World Health Organization has listed respiratory disease as one of the four major non-communicable health afflictions for the coming decade, signifying recognition of the serious impact of respiratory diseases. It is critical that the respiratory community continues to champion the cause, and every healthcare professional is expected to play a role in their various capacities as clinicians, researchers and advocates. Accurate scientific knowledge and competence in clinical skills are not the only prerequisites to effective management of disease but also form the cornerstones for enhancing public awareness, which is the ultimate driver of translation to policy interventions. We hope this series of articles in Respirology has offered an overview of major contemporary respiratory health issues facing the Asia-Pacific region in a global context, and will be a wake-up call for us to join the campaign for a healthier tomorrow for everyone.

Footnotes

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  FIRS is the Forum of International Respiratory Societies and its members are the American Thoracic Society, American College of Chest Physicians, European Respiratory Society, Asian Pacific Society of Respirology, Asociacion Latinoamericana de Torax, International Union Against Tuberculosis and Lung Disease and Pan African Thoracic Society.