India carries about a tenth of the world’s asthma but more than two-fifths of its asthma deaths. The reckoning begins in childhood—with a diagnosis that arrives years too late, and a treatment that sits, cheap and proven, on the pharmacy shelf.
The script has the worn smoothness of liturgy. “Doctor, it’s just recurrent bronchitis.” A cough that returns every fortnight; a chest that rattles after every cold; a child who cannot finish a game of gully cricket without stopping to catch her breath. The clinician’s reply is equally rehearsed: a course of antibiotics, a bottle of cough syrup, perhaps an oral bronchodilator. No spirometry. No inhaled steroid. No follow-up. The ritual repeats—ten times, fifteen times, twenty—until, somewhere around the age of eleven, the child is finally sent to a chest physician who says aloud the word everyone has spent a decade avoiding: asthma.
By then a good deal of the damage is done, and it is the kind that does not fully undo itself.
India is, by the cold arithmetic of epidemiology, the epicentre of the world’s asthma problem. It is home to roughly 13% of global asthma cases—some 34m people—yet it accounts for a staggering 42% of the world’s asthma deaths, according to the 2019 Global Burden of Disease study. Indians lose about 4.8m disability-adjusted life-years to the disease each year, four times the toll borne by China, the country in second place. Put plainly, a condition that in 2026 is eminently controllable kills Indians at roughly three times the global rate. The figures permit only one conclusion. The problem is not the asthma; it is what is, and is not, done about it. And the gap between the two opens in childhood.
The cost is not paid all at once but compounds, like a debt, across a life. Each untreated year of inflammation nudges the airways towards remodelling—a thickening of the bronchial walls that can fix a portion of the lung impairment permanently in place. Each needless antibiotic course adds to a rising national tide of resistance and disturbs a child’s developing microbiome. The softer costs accrue in parallel: the games declined, the stairs climbed slowly, the sleepovers missed, the parent who keeps the child indoors “for her chest.” A diagnosis deferred is not a diagnosis avoided. It is merely one whose bill arrives later, with interest, in the shape of a wheezier, more anxious and less capable adult.
There is a supply side to the scandal, too. Inhaled steroids are cheap, off-patent and listed as essential medicines, and yet India buys only a fraction of what its patients need: one analysis put national ICS sales at barely 7% of the volume the disease burden implies. Walk into a crowded public facility and the inhaler is often simply not on the shelf; walk into a private pharmacy and the family is steered instead towards a nebuliser and a drawerful of syrups. Fewer than a third of India’s asthmatics use an inhaler at all, while close to nine in ten have swallowed a course of oral steroids in the past year—the crude, side-effect-laden substitute for the targeted dose they were never offered. The economics quietly reinforce the clinical inertia, because there is more money in treating attacks, over and over, than in preventing them once.
A diagnosis that should not exist
Consider the phrase “wheezy bronchitis,” along with its cousins “recurrent chest infection,” “allergic cough” and “low immunity.” These are not diagnoses. They are descriptions wearing the costume of diagnoses, and the costume does real harm. “Bronchitis” implies infection, infection implies a germ, and a germ implies an antibiotic—which is precisely how a child accumulates six or eight needless courses of amoxicillin before her seventh birthday. Yet a child who wheezes every few weeks, coughs in the small hours, improves with a bronchodilator and flares in cold air or beside the neighbour’s cat does not have a string of unrelated infections. She has asthma, presenting in the manner described on the first page of every textbook.
The Indian evidence on how routinely this is missed is sobering. In surveys using the international ISAAC protocol, around 82% of children with current wheeze, and 70% of those reporting symptoms of severe asthma, had never received a clinical diagnosis of asthma. In Delhi, 88% of the children found to have asthma did not know they had it, and a mere 0.3% were using any kind of inhaler. Measured against spirometry, the questionnaire itself underestimated asthma in the capital by more than a third. The disease is not rare in Indian children—prevalence estimates range from 4% to 19% depending on the city—it is simply unnamed.
Why the word goes unsaid
There are three reasons the word goes unsaid, and not one of them is ignorance.
The first is fear of steroids—corticophobia. To many Indian parents, “steroid” conjures the bodybuilder’s syringe and the cricketer’s ban, not a microgram dose delivered to the airway and largely broken down before it reaches the bloodstream. A doctor who reaches for an inhaled corticosteroid must therefore also reach for twenty minutes of counselling—and twenty minutes is the one thing a clinic seeing eighty patients a day does not have.
The second is the absence of tools. Reliable spirometry in a six-year-old is genuinely difficult; it demands coaching, patience and a cooperative child, and a great deal of Indian primary care operates without a working spirometer at all. Faced with a wheezing toddler and no objective test, the path of least resistance is to treat the symptom in front of you and send the family home.
The third, and most corrosive, is the antibiotic reflex. Acute respiratory infection is the daily bread of Indian paediatrics, and the antibiotic is its reflexive seasoning. Doctors prescribe under pressure from anxious parents, in the absence of diagnostics, and against the fear that a child sent home without a “strong medicine” will simply be taken elsewhere. The parents, for their part, are often unaware of the harm: in recent Indian surveys roughly 73% did not know that misusing antibiotics breeds resistance. The result is a system that medicates the symptom enthusiastically and names the disease reluctantly.
A centimetre of height
On the central fear, the evidence has been reassuring for more than a decade. The worry that inhaled steroids stunt a child’s growth contains a kernel of truth wrapped in a great deal of exaggeration. The landmark CAMP trial, whose long-term results appeared in the New England Journal of Medicine in 2012, followed children on inhaled budesonide into adulthood. They ended up, on average, 1.2 cm shorter than their peers on placebo—171.1 cm against 172.3 cm. That is the whole of the harm, and three features of it matter. The effect was small. It was not cumulative: almost all of the difference appeared in the first one to two years and did not widen across years of further treatment. And it must be weighed against the alternative.
The alternative is not a taller, healthier child. It is uncontrolled asthma: airway inflammation that, left to smoulder, can drive remodelling and a permanent loss of lung function; nights broken by coughing; sport quietly abandoned; school days lost; and the small but real risk of a fatal attack that helps explain India’s grim share of the world’s asthma deaths. The modern consensus, codified in the Global Initiative for Asthma (GINA) guidance, no longer even endorses treating asthma with a reliever inhaler alone, precisely because the anti-inflammatory steroid is what prevents attacks and death. A centimetre of height is a poor reason to forgo it.
Three children, three failures
The abstractions acquire faces in any Indian clinic. Take Riya (the names are changed), ten, the daughter of an educated, upper-middle-class family in a large city. She has had a cough-and-cold “episode” roughly every fortnight since the age of two, treated by turns with antibiotics, oral bronchodilators and, when those failed, a homeopath’s sweet pills. At seven a severe attack put her on a hospital nebuliser; she was discharged with a bronchodilator inhaler that the family largely ignored in favour of the sweet pills. Only later did a paediatric pulmonologist diagnose asthma and prescribe inhaled budesonide—which now sits on a shelf while Riya endures a regime of “torturous” dietary and lifestyle restrictions in its place. The bleakest detail is that her mother is herself asthmatic, well controlled on a LABA-ICS inhaler. The treatment that works for the mother is withheld from the child.
Reba, eight, from a smaller town and a middle-class home, illustrates the opposite failure. After years of wheeze and the usual antibiotics, a newer doctor moved her to nebulised bronchodilators and montelukast, then to a reliever-plus-steroid nebuliser. The trouble is that Reba now self-medicates with that nebuliser whenever symptoms strike, which is often, and takes nothing as a regular controller. She is spared Riya’s dietary prison, but her asthma is quietly worsening for want of steady, preventive treatment. She is being rescued, repeatedly, instead of being protected.
Raman is the cautionary tale that doubles as a prospectus. Now 21 and from a lower-middle-class family in a small city, he was treated with oral bronchodilators by a succession of GPs throughout a childhood of symptoms—until he wandered into a “Right to Inhalation” camp and was started, with proper education, on an ICS-LABA inhaler. At follow-up his symptoms had vanished and his lung function had climbed. He left with one unanswerable question: who is to account for the 21 years he spent breathing at half capacity, when he might have lived a normal life all along?
A protocol for Monday morning
The remedy requires no new drug, no new machine and no new guideline—only the will to apply the old ones. A general practitioner or paediatrician could adopt the following on Monday morning.
1. Name the pattern. Recurrent wheeze, nocturnal cough, exercise limitation and a clear response to bronchodilators is asthma until proved otherwise. Write the word in the notes—and say it to the parent.
2. Trial the treatment. Where spirometry is unavailable, a supervised trial of low-dose inhaled corticosteroid over two to three months is both treatment and diagnostic test; unmistakable improvement confirms the diagnosis.
3. Demote the antibiotic. Reserve antibiotics for genuine bacterial infection. A wheezing child without fever or focal signs almost never needs one.
4. Counsel the fear directly. Spend the minutes. Explain that inhaled steroids act locally, in microgram doses, and that the height “cost” is about a centimetre weighed against a lifetime of controlled breathing.
5. Teach the device, then follow up. Demonstrate the inhaler and spacer, watch the child use it, and book a review. Asthma is managed over time, not cured in a single visit.
The uncomfortable truth
None of this is unknown to the doctors who fail to do it. That is the uncomfortable truth at the centre of India’s paediatric asthma problem: most clinicians can recite the guidance and still prescribe the antibiotic, because the parent expects it, because the steroid frightens the parent, and because nobody—least of all an industry that earns more from a lifetime of nebuliser refills than from a patient educated into independence—has done the dull, unprofitable work of changing the parent’s mind. The fix is almost free. It costs a sentence said out loud, early, and the patience to say it well. India’s children have waited long enough to hear it.