Asthma: beyond the blue and the brown

To breathe is a fundamental human right. Yet every day 235 million people around the world struggle to do just this. Asthma is one of the most significant non-communicable diseases of the 21st century. Combine asthma with other respiratory diseases, including chronic obstructive pulmonary disease (COPD), and it contributes to more than 4 million deaths every single year, a stagnated figure that has seen no decline since 2006. Although most asthma-related deaths occur in low- to middle-income countries, asthma is very much a First World problem. We in the UK have the highest rates in Europe, taking three lives every day. This is a shocking statistic.

The mayor of London, Sadiq Khan, revealed last year that he had recently begun suffering from asthma. He has since initiated plans to battle air pollution in the city, which he holds accountable for his disease. With asthma affecting 1 in 3 children in every classroom in the UK, Khan decided to launch his 50 ‘air quality’ audits for primary schools in the worst polluted areas in London; his goal: to ‘protect pupils from toxic air’. London has come under increasingly intense scrutiny in the media for its appalling levels of air pollution, a significant cause of which is road traffic. Labelled the Mayor Air Quality Audit, the recommendations include moving school entrances away from busy roads and improving walking initiatives. Khan’s audits, which were started in September, will be completed by the end of 2017 and the report will be available by March 2018.

Earlier this year, a PhD student who had just started at Imperial College London wrote an article in The Guardian in which she described how moving to London and cycling to her campus had triggered her first asthma attack in 10 years. She attributed her trigger to the air pollution. Feeling unsupported by the university’s reaction to her concerns, she decided that her health was not worth compromising for her degree. Imperial College London is ranked as the number one UK university in the respiratory, cardiovascular and gastroenterology fields, so it is sad and startling to discover such a huge disconnect between the teaching university support services and the academic research ethos.

The National Heart & Lung Institute (NHLI) at Imperial College is one of the largest heart and lung departments in the world and is the highest-ranking medical department of the university. The NHLI’s affiliation with the Royal Brompton and Harefield NHS Trust puts the NHLI in a unique position to carry out research in respiratory-related diseases. The research includes those diseases that are rare and neglected such as cystic fibrosis, a condition that has a devastating effect on patients, families and carers. One of Imperial College’s research ventures has culminated in the development of Circassia Pharmaceuticals, a spin-out biotech whose co-founders were at the time testing a prototype vaccine technology for prevention of cat and ragweed allergies. This year, Circassia established a commercial collaboration with AstraZeneca in the US for COPD.

For innovation in respiratory medicine to be meaningful in the real world, a more fundamental shift is needed. Andrew Bush, professor of paediatric respirology at Imperial College, and Ian Pavord, professor of respiratory medicine at Oxford, have called for a radical rethink around asthma. The two professors led The Lancet Clinical Commission, ‘After asthma: redefining airways diseases’ in 2015. In this, they set out the need to break asthma down into its individual components - definition, basic concepts, diagnosis, monitoring approaches, drug development, treatment, guideline development, life-course approach and current inadequate approaches to serious disease and severe attacks. The Commission conveyed a strong and urgent message that progress in this disease has been slow and unacceptable. Having convened a panel of 23 international asthma experts, the group published a paper on 11 September 2017 in The Lancet. It calls for a deconstruction of asthma in its current abstract terminology, moving towards true functional, pathological and molecular understanding and descriptions that can lead to individualised and effective treatment. Indeed, it challenges the validity of the term ‘asthma’ in the modern day medical lexicon at all.

To make progress in chronic airway diseases, we need to activate at a grass-roots level, and that includes patients who must challenge their ‘asthma’ diagnosis and demand more from their healthcare practitioners with regards to treatment and management. The medical communications industry is the linchpin that brings patients, clinicians, researchers and the pharmaceutical industry together. Working collaboratively, the future could look brighter and beyond the blue and brown.

Saira Silie is executive director of strategy and science at Virgo Health