How air pollution is doubling COPD: Expert warns of lung crisis growing faster than heart disease

Unlike the West, where smoking remains the dominant driver, India’s COPD burden is shaped by pollution, says Dr Anurag Agrawal

When fine particles of PM2.5 penetrate deep into the lungs, they aggravate the inflammation, build up oxidative stress and damage lung tissue. (File Photo)

As pollution levels spiral, Chronic Obstructive Pulmonary Disease (COPD) has emerged as a public health emergency hiding in plain sight. This is a condition that blocks airflow — making it difficult to breathe — inflames airways and mucus and damages air sacs.

When fine particles of PM2.5 penetrate deep into the lungs, they aggravate the inflammation, build up oxidative stress and damage lung tissue. Some pollutants can impair the function of mitochondria, the powerhouses of cells, leading to cell damage and death. Women are particularly vulnerable as they have smaller lungs and airways than men, so a given amount of exposure to smoke or irritants can lead to a greater concentration in the airways. Besides, hormones play a role, too.

“COPD ranks second only to heart disease in terms of disability and death and unfortunately there is typically long disability. Sudden cardiac death grabs headlines and attention because the risk is easy for the public to comprehend. People fear it and the medical system prepares for it. But while the nation fixates on the heart, the urgent call of poor lung health across India proceeds almost unnoticed,” says Dr Anurag Agrawal, Dean, BioSciences and Health Research, Trivedi School of Biosciences, Ashoka University.

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Why should COPD be treated at par with heart disease?

Unlike ischemic heart disease (IHD), COPD has no real cure. For heart disease, we have decades of investment that have genuinely improved survival via statins, acute interventions, stents and bypass surgeries. For COPD, 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 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.

Why are Indians vulnerable to COPD?

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 some cases may be genetic, most are likely due to the adverse environment. 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. So, 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.

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What is the biggest trigger of COPD 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. Their lungs have paid the price. The fact that they have never smoked a day in their lives offers no protection. Now, access to cleaner cooking fuels has expanded, albeit unevenly. Behavioural norms are shifting.

But the outdoor environment is moving in the opposite direction. Air quality in many Indian cities is worsening, not improving. 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. Progress indoors is being offset and, in some regions, entirely negated, by deterioration outdoors.

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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 rather than rising. 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. Given the lifelong burden of poor lung function, as they get old enough, COPD will catch up.

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.

How can we prevent COPD?

Prevention via clean air, addressing early-life lung health issues, reduction of indoor and outdoor pollutants can be 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.