The unbearable cost of severe asthma in underprivileged populations

The prevalence of asthma is increasing in many countries following trends of urbanization and westernized lifestyle (1). In various regions, these characteristics of modern societies follow an improvement in socioeconomic status. As a chronic illness, asthma has a major impact on the life of the individual as well as the family, and the economic burden of asthma is high (2), in particular among uncontrolled asthmatics (3–5). Most studies on the cost of asthma focused on direct and indirect costs to the health system (6). However, direct expenditures incurred by the families of subjects with asthma are often overwhelming. Asthma prevalence and severity increase everywhere in the world, and particularly in underprivileged populations (3). There are underserved individuals living in large urban centres of high-income countries with limited access to health care (7). In various mega cities of lowand middle-income countries, asthma prevalence is very high and most of the population cannot afford paying for the proper treatment of persistent asthma (8, 9). These unfavourable scenarios generate a situation in which dozens of millions of human beings suffering from asthma cannot afford to breathe well (10). Social inequities may not be addressed fully by regular welfare and employment policies. Major noncommunicable diseases (NCD) such as cardiovascular disease, diabetes, chronic respiratory disease and cancer pose a major barrier to development in lowand middleincome countries, as well as among excluded populations in affluent societies (11). It requires broad health promotion – disease prevention strategies and a coherent health system response, combining a strong primary health care with proper support of secondary and tertiary levels. The successful efforts to reduce NCD in highincome countries reflect adequate use of these principles. Recent trends to revive primary health care in countries such as Brazil, India, China, Thailand, Spain and New Zealand, are mostly driven by inadequate health system response to NCD and the need to improve assess to health care (12). Nevertheless, many countries continue to focus only on a narrow range of conditions, with a priority to communicable diseases. Despite significant progress in health outcomes over the last 30 years, inequities continue to increase and there are gross disparities between countries at all levels of health expenditure (13). The Commission of Social Determinants of Health of the World Health Organization has recently stated: Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to A. A. Cruz, P. J. Bousquet ProAR, Faculdade de Medicina da Bahia, and CNPq, Brazil; D partement d Epid miologie Clinique, Biostatistique, Sant Publique et Information M dicale, Groupe Hospitalo, Universtaire Car meau, N mes, France