The right to breathe: how policymakers can tackle severe asthma

Asthma impacts over 330 million people worldwide. While severe asthma makes up only 5-10 percent of cases, it is accountable for over half of asthma-related costs globally.[1] It profoundly affects patients’ lives, undermining their physical, mental and economic well-being, and increasing the risk of preventable deaths. Despite its significance, severe asthma is often overshadowed by other health priorities, leading to inadequate resource allocation and substandard care, further straining already pressured health systems.

Severe asthma outcomes, like many other chronic diseases, are deeply entangled with a wide range of environmental and socio-economic factors. Therefore, addressing it is not merely about medical intervention, but about creating and implementing comprehensive, holistic strategies.

The challenges presented by severe asthma are not beyond our capabilities. Around the globe, there is a wide range of best practices, treatments, and approaches to asthma management. Yet, the path to transformation demands a unified commitment from a broad set of stakeholders, from policymakers to medical professionals, industry, patients and beyond. While the blueprint for a future unburdened by severe asthma exists, it is up to decision-makers to realize it together.

While the blueprint for a future unburdened by severe asthma exists, it is up to decision-makers to realize it together.

And the good news is that progress is already underway. Since autumn 2022, we have collaborated as an international expert group to support the development of the Copenhagen Institute for Futures Studies’ (CIFS) Severe Asthma Index. This tool assesses how 29 OECD countries manage severe asthma across various indicators, such as national strategies, treatment access, hospitalizations, societal costs and air quality, among others.

While the Severe Asthma Index is an important stride in tackling severe asthma, the true test lies in how its insights are applied in practice. Among the many actions needed to be taken to improve severe asthma care, the most pressing concern is policy change.

We have identified three actions, derived from the work we have conducted to date, for policymakers to kickstart strengthening health systems’ approaches to and management of severe asthma:

  1. Development and implementation of national asthma plans and strategies

The Severe Asthma Index has found that less than half of the countries analyzed have a national strategy for asthma, prevention, and management. There is, therefore, a need to formulate and actively implement dedicated national asthma programs, tailored to the unique challenges of individual health systems. These programs should not only emphasize prevention, early detection and diagnosis but also adapt best practices to specific national and local contexts.

Importantly, plans should be situated in the context of long-term strategies for improving population health outcomes.

“In England, work around respiratory illness is gaining traction,” notes Sir David Behan, chair of Health Education England, NHS, and expert group member. “Part of the initiative being developed [is] to ease pressure on the emergency care pathways and hospitals.”  

All approaches should promote awareness on respiratory diseases, support personalized care plans, empower patients and improve training and opportunities for training health care professionals working in respiratory care.

2. Coordination and harmonization of policies and care guidelines

There is a patchwork of country approaches to severe asthma, illustrated by the observation that more than two-thirds of the country guidelines assessed in the Severe Asthma Index do not fully align with the Global Initiative for Asthma’s (GINA) guide for Difficult-to-treat and Severe Asthma in Adolescence And Adult Patients. Policymakers must strive to coordinate their approaches to severe asthma by harmonizing policies and guidelines for asthma care to the greatest possible extent, with the aim of reducing outcome disparities, bolstering equity and promoting health system sustainability.

In doing so, there should be an emphasis on identifying and scaling best practices, promoting cross-border collaboration, and championing holistic solutions informed by the widely-acclaimed Health in All Policies approach.

The Australian National Asthma Council’s Australian Asthma Handbook is a strong example of a best practice in this area that policymakers could draw inspiration from in acting on this point.

3. Supporting improved data collection and the development of a more robust evidence base for severe asthma

Policymakers should incentivize and ultimately mandate improved production, recording and utilization of asthma- and severe asthma-specific data, as well as identifier data such as prescription data, adherence to treatment regimes, lung function analysis and demographic and socioeconomic indicators, following a set of common standards.

Currently, despite the existence of clinical codes for severe asthma, the condition remains significantly underreported in clinical settings due in large part to inconsistent coding practices, leading to an increased probability of patients receiving inadequate care and suboptimal allocation of health system resources. The dearth of severe asthma data and barriers to accessing the few datasets that do exist render it difficult to develop a comprehensive and consistent understanding of the full impact of severe asthma.

National policymakers need to prioritize financial and logistical support for country-level asthma research. Research activities should aim to produce a solid evidence base that will offer a nuanced understanding of each country’s needs, challenges and opportunities regarding asthma care. Support for research activities granted over the long term will enable longitudinal studies so that national trends and progress can be accurately tracked.

Only 3 percent of the European Union’s budget for health [is] spent on lung health, although 13 percent of Europeans have lung disease.

“Only 3 percent of the European Union’s budget for health [is] spent on lung health, although 13 percent of Europeans have lung disease,” says Susanna Palkonen, director of the European Federation of Allergy & Airways Diseases Patients’ Associations (EFA) and expert group member.

The International Severe Asthma Registry (ISAR) initiative provides a strong basis for continued work in this area.

The path ahead requires that these actions evolve in tandem with the latest advancements in respiratory care and approaches to the management and prevention of noncommunicable diseases. This is not simply about updating and developing new policies — it’s about crafting robust and well-rounded solutions that proactively address a health challenge that is both global and local and supporting a much-needed vision for improved respiratory health outcomes.

As we look forward, we cannot just treat asthma. We must transform our approach to ensure that every patient’s right to breathe becomes a global reality.


Author(s):
Patrick Henry Gallen, senior advisor and futurist at Copenhagen Institute for Futures Studies

Bogi Eliasen, director of health at Copenhagen Institute for Futures Studies

Professor Dr. Vibeke Backer, MD, DMSci, chief respiratory physician at Department of ENT and Centre for Physical Activity Research (CFAS), Rigshospitalet, Copenhagen, Denmark

Sir David Behan, chair Health Education England, National Health System (NHS), U.K.​

Dr. Mark Levy, board member, Global Initiative for Asthma (GINA), U.K.​

Mikaela Odemyr, chair European Lung Foundation (ELF) Patient Advisory Committee; chair Swedish Asthma and Allergy Association, Sweden

Susanna Palkonen, director, European Federation of Allergy and Airways Diseases Patients’ Associations (EFA)  

Professor Dr. Arzu Yorgancıoğlu, chair European Respiratory Society (ERS) Advocacy Council; member of Global Initiative on Asthma (GINA) Board; chair of GINA Dissemination and Implementation Committee; chair of the WHO GARD Executive Committee Turkey 


References:
[1] Al Efraij K, FitzGerald JM. Current and emerging treatments for severe asthma. J Thorac Dis 2015;7(11):E522-E525



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Serbia’s far right seizes on Putin’s war to push retaking Kosovo

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BELGRADE — Serbia’s ultra-nationalists are using Russia’s invasion of Ukraine to galvanize their campaign against Kosovo’s independence — and anti-war activists are getting caught in the crossfire.

Politicians on Serbian President Aleksandar Vučić’s right flank have sniffed out an opportunity to tie Russia’s war on Ukraine to their desire to swallow up Kosovo, even as Vučić engages in EU-brokered negotiations to partially normalize relations with Kosovo, the independence of which neither Belgrade nor Moscow recognize.

A victory for Russian President Vladimir Putin in Ukraine is a stepping stone to Serbia regaining Kosovo, according to Miša Vacić, the leader of the highly nationalistic, pro-Kremlin Serbian Right political party.

“We must be patient and must wait to finish in Ukraine, and after that we will have enough time,” he told POLITICO.

More than 200,000 Russians have arrived in Serbia since the beginning of the invasion. As one of just a handful of European countries offering visa-free entry to Russian passport-holders, it provides safe harbor for those seeking an exit for reasons ranging from economic to ideological.

Vacić, who in September traveled to Russian-occupied Donetsk to observe the so-called referendum to join Russia that was widely slammed by Western governments as a sham, claims Russian liberal activists in Serbia are a threat to realizing his ideal society, if they join forces with their local counterparts. 

“It is a real revolution of liberals,” Vacić said, adding that even if only 10 percent of the new Russian arrivals were committed liberal activists, Serbia would still be flooded with at least 20,000 of his political enemies. “They think they must liberate Serbia from Serbs, from traditional Serbian values.”

Violent threats

Among the Russians who have arrived in Belgrade since Putin launched his full-scale invasion last year is Ilya Zernov. The 19-year-old political activist from Tolyatti in southwestern Russia sought sanctuary in Belgrade last March — his anti-war protests prompted a police search of his student dormitory in Kazan.

“I realized that I would not be able to continue my studies, and would not be able to be in Russia for a long time,” Zernov told POLITICOadding that the police who searched his dorm threatened him with violence and imprisonment.

Zernov is an active participant in the Russian Democratic Society (RDS), an anti-war organization founded last year in Belgrade with the stated goal of supporting Ukrainian victory. It has since emerged as one of the most visible pro-Ukraine advocacy groups in Serbia, regularly organizing protests in the streets.

But in a country where Putin enjoys significant support amid an increasingly assertive ultra-nationalist movement, anti-war activists are a target.

A Russian Democratic Society (RDS) event on February 24, 2023 | Bennett Murray for POLITICO

Zernov reported to the police last month that Vacić had assaulted him. The attack, which Zernov said occurred after he attempted to paint over anti-Ukrainian graffiti on the side of a Belgrade apartment block, left him with a perforated eardrum. Vacić denies assaulting Zernov.

Threats of violence also overshadowed plans to hold two anti-war rallies on the first anniversary of Russia’s invasion.

“The police warned us that they had information that some kind of violent provocations were being planned by these extreme-right people,” said RDS co-founder Peter Nikitin, whose group organized one of the protests.

Nikitin also rejected Vacić’s claims that his group, and those like it, are seeking to campaign on social issues in Serbia.

“Our only purpose is to show the world and the Serbian public what is happening, and to mobilize public opinion for Ukraine,” he said, adding that it is Vacić who wants to make Serbia subservient to foreign interests. “[Vacić] is pushing Russian interests and Putin’s interests in Serbia very directly, and he’s the one trying to turn Serbia into Russia.”

Rallying around ‘Z’

As the anniversary of Russia’s invasion of Ukraine approached last month, tensions simmered in Belgrade.

A far-right rally in mid-February ended with participants attempting to break into President Vučić’s office. Damjan Knezevic, the leader of the People’s Patrol far-right network, gave a fiery speech to a crowd of around 1,000 calling for Vučić to be overthrown, amid a heated national debate over the proposal to resolve the Serbia-Kosovo dispute.

Many in attendance waved Russian flags or sported pro-war symbols, including the letter “Z” used by the Russian military to mark its vehicles in Ukraine, and the skull and crosshairs logo of the Wagner Group, a private mercenary force that has been backing Moscow’s military in the war.

Police arrested Knezevic and two other associates the following day on charges of inciting violence. On the day of the rally, another People’s Patrol member was also arrested in Serbia’s second city Novi Sad on weapons charges after being discovered with a rifle, optic sight and ammunition. 

The arrests spurred yet more outrage among People’s Patrol followers, who doubled down on plans to hold a pro-war rally on February 24, adjacent to RDS’ anti-war protest. While authorities refused to issue a permit for the People’s Patrol rally, officials feared riots would ensue.

When the first year anniversary of the invasion arrived, RDS held a scaled-back version of its planned events, per police advice. It proceeded without incident.

A man wearing a patch with a “Z” on it at a rally on February 15, 2023 | Bennett Murray for POLITICO

Natalia Taranushchenko, an organizer for Belgrade-based Ukrainian association Cini Dobro who is originally from Ukraine’s Vinnytsia region, told POLITICO that while Serbia is generally welcoming, “There are still symbols of Russian aggression, letter Z on the streets of Belgrade, and we still hear that Ukrainians are ‘Nazis’ and a lot of other Russian propaganda.”

Still, there’s some hope for the Ukrainians and anti-war Russians seeking safety in Serbia: Putin’s stalled offensive has also deflated the ultra-nationalists here.

“Serbs were very passionate because they were expecting that Putin would overthrow Ukraine in three days, and after that they thought he would say that we need to get back Kosovo for Serbia,” said Čedomir Stojković, a Belgrade-based lawyer who investigates covert Russian influence in his country. 

“But over time, as the war did not happen the way people expected, those expectations started to change, and now because there is cognitive dissonance, there is no passion,” he said.



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