Europe's Bad Lungs

Respiratory disease is the world's leading killer, and it is on the rise. According to the World Health Organization, of all 50.5 million deaths recorded in 1990, 9.4 million were due to respiratory diseases. By 2020, of 68 million deaths, 11.9 million will be caused by Chronic Obstructive Pulmonary Disease (COPD), pneumonia, lung cancer, or tuberculosis.

Europe performs little better than the rest of the world. Respiratory diseases rank second (after cardiovascular diseases) in terms of mortality, incidence, prevalence, and costs. In some countries, such as the United Kingdom, they are already the leading killer.

The European White Book on Lung Disease, published in 2003 by the European Respiratory Society and the European Lung Foundation, produced epidemiological data for the full spectrum of lung diseases collected from all European countries for the first time. It provides a detailed overview of the evolution of lung diseases in Europe, including data on morbidity, mortality, and costs.

We have learned a great deal from the White Book . For example, lung cancer mortality rates for males fell slightly between 1960 and 1989 in some Western European countries, such as Norway and Switzerland, but are still rising for females in almost all European countries. The prevalence of COPD, which is diagnosed mainly in smokers and former smokers, ranges from 2,000 per 100,000 inhabitants to more than 10,000, with mortality rates varying between 25 and 75 per 100,000.

Lung diseases are not just related to smoking. Genetic influences, along with nutritional, environmental, and poverty-related factors, play key roles. But COPD is predicted to increase as a cause of death, along with lung cancer and TB.

Epidemiological data for TB are the most complete, due to a surveillance system developed for all European countries. Whereas TB's incidence and mortality rates in Western and Central Europe are stable or declining, they have increased in Eastern Europe during the last decade, due to deteriorating health systems.

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Pneumonia will remain an important cause of death in Europe, with incidence currently ranging from 250 to more than 1,000 per 100,000 and mortality from 15 to 45 per 100,000.

Asthma has become increasingly prevalent in recent decades, affecting 2-20 % of children in Europe, and between 5 % and 10 % of adults in Western Europe. Reported mortality rates vary widely, the highest being more than eight per 100,000 in Portugal.

Data for other respiratory diseases are scarce. Interstitial lung diseases vary considerably in incidence and prevalence. The prevalence of sleep-related diseases, for which data are available only from some of the Western European countries, is less than 1,000 per 100,000 inhabitants in France, but more than 5,000 per 100,000 in Sweden. Available data on the incidence of cystic fibrosis, the most important hereditary lung disease, indicate a range of between five and ten per 100,000.

Where does respiratory disease kill most often? According to the data collected in the White Book , the age-standardized mortality rate per 100,000 inhabitants is highest in Kyrgyzstan, at 165, and lowest in Austria (30). The European average stands at 65, while the European Union average is 57. Ireland and the UK suffer some of the highest rates - 120 and 105, respectively - whereas other Western European and most Central European countries remain below the average.

As the incidence of lung disease rises, so will its costs. The total annual financial burden of respiratory diseases in Europe is currently approximately €100 billion, with COPD accounting for almost half of the total, followed by asthma, pneumonia, lung cancer, and TB.

Inpatient care is just the tip of the iceberg, amounting to €17.8 billion annually. Surprisingly, the annual number of hospital days is higher in Western Europe than in Central and Eastern Europe (11.1 versus 7.2 per 100,000 population), while average daily hospital costs in Western Europe are almost ten times higher (€310 versus €32). Other costs include ambulatory care (€9.2 billion), drug supplies (€6.7 billion), and mortality and rehabilitation (€20 billion).

The largest single cost by far, estimated at €48.3 billion, is indirect: lost productivity. The total number of workdays lost due to respiratory diseases was 66.2 per 100,000 inhabitants in Western Europe - more than four times higher than the rate of 15.4 in Central and Eastern Europe. As with hospital stays, so with workdays: higher productivity in Western Europe compounds the cost.

Because lung diseases are so important, preventive measures, early detection and treatment must be reinforced. This will necessitate not only improvements in direct patient care, but also in basic and clinical research as well as in teaching and training.

Across Europe, there are huge differences in the number of specialists in respiratory medicine, as well as in the number of researchers at the university level. The number of chest physicians per 100,000 inhabitants is only 0.8 in the UK, but 10.4 in Greece, with a European average of 3.2. The same is true of respiratory medicine at the university level, where the European average is 0.06 per 100,000 inhabitants, but varies from 0.04 per 100,000 in Poland, Russia, Romania, Austria, Germany, and the UK to more than 0.08 per 100,000 in Norway, Finland, and Ireland.

Given the scale of their human and economic costs, managing lung diseases should become a high priority for all European countries in the twenty-first century.

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