“When I took this job in 2024, the only mention of chronic obstructive pulmonary disease (COPD) I could find in the New York Times was an obituary of [the Irish singer] Sinéad O’Connor. In that year, nearly four million people died of asthma and COPD, but there wasn’t a single major story about it.”
José Luis Castro, the World Health Organization’s director general special envoy for chronic respiratory diseases (CRDs), spoke to The BMJ as global ministers assemble in New York for a high level meeting on non-communicable diseases (NCDs). Castro’s mandate is to raise the profile of the respiratory diseases that kill millions but rarely make headlines. COPD is the deadliest—now the third leading cause of death worldwide, outside pandemic years.
The meeting will test governments’ commitment to reduce premature mortality from NCDs by a third by 2030—a goal widely acknowledged to be off track.
“One of the biggest challenges is that CRDs aren’t infectious diseases; you cannot catch any of these diseases from your neighbour,” he says. “And when there isn’t a fear, it’s very hard to get it as a priority for politicians, who are constantly dealing with the emergency of the day. The conversations up to now have been in scientific and medical circles, there hasn’t been much outreach to the mainstream media to tell the human stories.”
That lack of visibility translates into a lack of money and political will. “CRDs are under-resourced, under-prioritised, and under-reported across the board,” says Castro.
Air pollution is a leading risk factor for asthma and COPD, yet remains under-addressed in health strategies. “No health system can treat its way out of the CRD epidemic if the air people breathe continues to make them sick,” Castro says. “Even before they’re born, children are having their lungs compromised.”
But the things polluting the air are “beyond the control of the ministry of health alone,” he emphasises. “Ministers of finance, economy, and transport are the people who have to be at the table to tackle the problem of emissions. We have to work with them and with advocates in civil society who work on air pollution.”
Tobacco use is the most recognised cause of COPD, but the regulation of newer products such as e-cigarettes and heated tobacco is proving difficult.
“At the World Conference on Tobacco Control in Dublin, delegates raised vaping and these new products as a major concern,” Castro says. “We’re dealing with interference from an industry that is very well financed, organised, and very aggressive at pushing back and slowing down the implementation of tobacco control policies. They’re developing new products that are more addictive, more attractive, and targeted at young people.”
Access to medicines
WHO’s essential medicines list includes inhaled corticosteroids, but access is patchy in low and middle income countries. Steroid inhalers are available in fewer than half of primary care facilities.
“There are too many countries that lack affordable, quality inhalers—and patients are forced to choose between being treated and going broke,” says Castro. “We need to make these medicines affordable, to have procurement networks to ensure prices that the system can afford, and to have supply chains for the production of quality inhalers in these countries. It needs to be done now.”
Castro says pharmaceutical companies must also do more. “There is the matter of pricing and sharing their technology with countries,” he says. “In the past 50 years, there really hasn’t been a major breakthrough in treatment for CRDs, mainly because of a lack of resources to conduct research.
“If you look at diseases like HIV/AIDS, prioritisation and resources for research don’t come about by chance. It’s because of activism. The same can be done for NCDs.”
Another barrier is the lack of integration into health systems. “We need to better integrate CRD diagnosis and treatment into primary healthcare,” he tells The BMJ. “Most people with asthma or COPD never see a specialist, they rely on primary care. This needs to be well equipped with a trained workforce to manage these diseases.”
Even middle income countries are struggling. “In China, for example, which has more resources, primary healthcare systems still need improvement.”
A year in post
Castro has been in post for a year, at which point he remembers being “hardly invited to many of the global discussions.” That’s changed, he says, pointing to the World Health Assembly resolution this year on integrated lung health.
In July the Economic and Social Council of the United Nations called for stronger multisectoral action for the prevention and control of CRDs. And this week at the UN General Assembly meeting COPD and asthma will be explicitly referenced for the first time in the new political declaration that member states are expected to endorse—an effort aimed at getting global goals for the control and prevention of NCDs back on track.
But policy commitments must be followed by implementation. “We do have to strengthen advocacy, otherwise you won’t get the attention and the resources,” he says, adding that they have been working with the media to “tell people’s stories, to give patients a voice, because they are the most effective ambassadors.”
For now, Castro is part of a small team. “At WHO, we advocate for the disease that affects 650 million people and causes nearly four million deaths. But there is only one medical person leading on CRDs. There needs to be a department to be able to provide technical assistance to countries adequately.
“It’s only through multi-sectoral partnership—tackling tobacco control, air pollution, housing problems—that you can translate that political declaration into meaningful results.”
Footnotes
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Commissioned, not externally peer reviewed.
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I have read and understood BMJ policy on declaration of interests and declare the following interests: None.
