India’s silent lung crisis persists even as the world breathes easier

In much of the world, fewer people are dying from chronic lung diseases than three decades ago. Advances in treatment, tobacco control and early diagnosis have steadily pushed global death rates downward, even through the disruption of the COVID-19 pandemic.

But India tells a more troubling story.

According to a new analysis¹, South Asia — led largely by India — remains one of the most burdened regions in the world for chronic respiratory diseases, despite having lower overall prevalence than many high-income countries. The contrast points to a persistent gap between disease detection and survival, and to structural failures that continue to put Indian lungs at risk.

The study, part of the Global Burden of Disease (GBD) 2023 collaboration, tracked chronic respiratory diseases — including chronic obstructive pulmonary disease (COPD), asthma, pneumoconiosis and interstitial lung diseases — across 204 countries from 1990 to 2023. Globally, it estimates that these conditions affected nearly 570 million people and caused 4.2 million deaths in 2023.

Worldwide, age-standardized death rates from chronic respiratory diseases have fallen by about 26% since 1990. In India and its neighbours, that decline has been far smaller — and in absolute terms, the death toll remains staggering, according to the analysis.

High mortality, lower prevalence

India’s paradox mirrors a broader South Asian pattern. While countries like Australia, New Zealand and the United Kingdom report some of the world’s highest prevalence of asthma and other chronic lung conditions, their mortality rates are comparatively low, reflecting robust primary care, widespread spirometry, and access to long-term inhaled therapies.

South Asia, by contrast, shows much higher death rates despite lower reported prevalence. In 2023, South Asia’s age-standardized mortality rate from chronic respiratory diseases was more than double the global average, according to the analysis.

“This gap between prevalence and mortality is telling us something very important,” said Anurag Agrawal, Dean of BioSciences and Health Research at Trivedi School of Biosciences, Ashoka University. “It points to late diagnosis, under-treatment, and the cumulative impact of environmental exposures that healthcare systems are not equipped to manage early,” he said.

COPD — a progressive disease most often caused by smoking and air pollution — remains the dominant driver of deaths in India, accounting for most of the chronic respiratory mortality. Asthma, while highly prevalent, contributes a smaller share of deaths but continues to cause avoidable fatalities, particularly among children and older adults.

Air pollution and older lungs

Globally, smoking remains the single largest risk factor for COPD, especially among men. But the study highlights that ambient particulate air pollution — fine particles known as PM2.5 — is the leading COPD risk factor for women in several regions, and a major contributor for both sexes in South Asia.

India is home to many of the world’s most polluted cities, and exposure begins early and lasts a lifetime. Household air pollution from solid fuels — still widely used in poorer households — compounds the risk, particularly for women.

The researchers point out that by the time patients come to clinics in their 50s or 60s, the lung damage reflects decades of exposure — from cooking smoke, traffic pollution, construction dust, and infections.

The study also finds a sharp rise globally in deaths from interstitial lung disease and pulmonary sarcoidosis, particularly among people over 75. India is part of this trend, although underdiagnosis likely masks the true scale.

“These are conditions that require imaging, specialist interpretation and long-term follow-up,” said Pankaj Bhardwaj at the School of Public Health, All India Institute of Medical Sciences, Jodhpur. “In South East Asian countries, they are often missed or mislabelled as tuberculosis or generic ‘lung fibrosis’ until very late.”

COVID’s paradoxical imprint

One of the study’s more surprising findings is what happened during the COVID-19 pandemic. While the incidence of chronic respiratory diseases rose modestly worldwide between 2020 and 2023, mortality declined faster than before.

The authors suggest several explanations: reduced circulation of other respiratory infections due to masking and distancing, better adherence to inhalers, and heightened medical attention to respiratory symptoms.

India followed this global pattern in part — but with caveats.

During the pandemic years, access to routine care was disrupted for millions of Indians with chronic lung disease, particularly in rural areas. Many patients missed follow-up visits or struggled to obtain medicines. At the same time, heightened attention to breathlessness and widespread CT scanning led to incidental detection of previously undiagnosed conditions.

“The pandemic forced a reckoning with respiratory health,” Agrawal said. “But the systems that emerged stronger in some countries did not uniformly do so in India.”

A global contrast

The study underscores how sharply respiratory outcomes diverge by income and health-system capacity. Australasia recorded the highest prevalence of chronic respiratory diseases in 2023, driven largely by asthma — yet ranked far lower in mortality. Western Europe and East Asia saw steep declines in deaths over three decades, reflecting successful tobacco control and stronger chronic care.

India and Pakistan, the authors note, “rank higher in age-standardized mortality rates despite lower prevalence,” a pattern they attribute to limited access to early diagnosis and timely treatment.

That gap persists even as global science advances. Over the past two decades, targeted biologic therapies for severe asthma and improved combination inhalers for COPD have transformed outcomes in high-income countries. In India, such treatments remain inaccessible to most patients.

“There is a widening innovation divide,” said Chandrakant Lahariya at the Foundation for People-Centric Health Systems in Delhi. “The science has moved ahead, but it has not reached the population that needs it most.”

A lot of burden of respiratory illnesses is on poor and marginalised individuals and households. “That is a bigger call for urgent policy and programmatic interventions,” he added.

What the numbers can, and cannot, capture

As with all GBD studies, the estimates rely on complex modeling to compensate for gaps in national data. In India, where lung function testing is uncommon and cause-of-death certification remains uneven, uncertainty intervals are wide.

Yet independent Indian studies broadly support the study’s conclusions: chronic respiratory diseases remain among the country’s top killers, particularly among older adults and the urban poor.

Public health experts say the findings strengthen the case for treating respiratory disease as a development issue, not merely a medical one.

“Air quality, housing, energy policy, occupational safety — these are lung health policies,” Lahariya said. “You cannot solve India’s respiratory burden with inhalers alone.”

A lot of burden of respiratory illnesses is on poor and marginalised individuals and households. “That is a bigger call for urgent policy and programmatic interventions,” he added.

An unfinished transition

Globally, the decline in respiratory deaths is a public-health success of the past generation. It reflects decades of anti-smoking policies, cleaner fuels and better chronic care.

India, the new analysis suggests, is stuck in the middle of that transition — burdened by the risks of rapid industrialization, but without the protections that richer nations built along the way. Unless air pollution falls sharply, early diagnosis becomes routine, and affordable long-term treatment is integrated into primary care, the country’s lung crisis is unlikely to ease soon.

“The good news from the global data is that progress is possible,” Agrawal said. “The bad news is that India has not yet made respiratory health a national priority on the scale the numbers demand.”