Asthma is not primarily a problem of tightness. It is a problem of inflammation.
Each year, World Asthma Day reminds us that the distance between a life-saving medicine and the person who needs it can be as vast as any ocean. South Africa finds itself in precisely this paradox: a country with guidelines, specialist centres, and available treatments that nonetheless scores among the lowest globally when it comes to patients actually reaching that care. For the more than 260 million people worldwide living with asthma — and the 450,000 who die from it annually — the crisis is rarely one of medical ignorance, but of the quiet, structural failures that keep healing out of reach.
- South Africa's care access score of 36 out of 100 — among the lowest of 43 countries surveyed — reveals a system where the medicine exists but the path to it remains blocked for many patients.
- Children bear a hidden cost: uncontrolled asthma does not merely disrupt school and sleep, it physically remodels developing airways, embedding damage that follows them into adulthood.
- The country has no formal national asthma strategy, meaning severe cases often go unrecognised, unreferrred, and untreated — patients cycling through crisis without ever reaching the specialist who could change their trajectory.
- Air pollution, poor indoor air quality, and vaccination gaps act as a relentless second front, worsening symptoms in the very communities least equipped to access care.
- The South African Thoracic Society's new Severe Asthma Registry and biologic therapy guidelines signal a turning point, but the infrastructure of referral, access, and environmental reform still lies largely ahead.
Every May 5th, World Asthma Day carries a deceptively simple message: people with asthma need access to anti-inflammatory inhalers. The simplicity is misleading. Asthma is not merely a tight chest or a sudden gasp — it is a disease of inflammation, where airways swell, muscles clench, and mucus accumulates until breathing becomes labour. Over 260 million people live with it globally, and more than 450,000 die from it each year.
For decades, treatment centred on the blue reliever inhaler — a fast-acting rescue device. But medicine has since learned that asthma is driven by underlying inflammation, not just acute tightness. The Global Initiative for Asthma now recommends a combined inhaler that addresses both the immediate crisis and the chronic fire beneath it, preventing attacks rather than merely responding to them.
South Africa, on the surface, appears equipped. National guidelines exist. Specialist centres like Groote Schuur Hospital operate. Medicines are available in the public sector, and the private system offers advanced biologic treatments for severe cases. In the 2025 Severe Asthma Index, the country scored 58 out of 100 overall — but only 36 out of 100 on care access, placing it among the lowest of 43 nations surveyed. The gap between what exists and who can reach it is stark.
Without a formal national asthma strategy, severe cases go unrecognised. Patients with uncontrolled symptoms — disrupted sleep, repeated steroid courses, persistent breathlessness — are rarely referred to specialists or assessed for advanced treatment. Children are especially vulnerable: uncontrolled childhood asthma does not just impair daily life, it permanently remodels the airways, carrying consequences into adulthood.
Environment deepens the crisis. South Africa carries a high environmental risk score, shaped by air pollution and poor indoor air quality that disproportionately burden already underserved communities. Vaccination gaps leave people exposed to respiratory infections that can trigger severe attacks.
Change is stirring. The South African Thoracic Society has launched a Severe Asthma Registry, and a new position statement on biologic therapies offers clinicians clearer guidance. But these are early steps. The harder work — building referral pathways, ensuring anti-inflammatory inhalers reach those who need them, addressing environmental risk — remains unfinished. For millions of South Africans, asthma is a controllable condition held just out of reach, not by the absence of medicine, but by the distance between the medicine and the patient.
Every May 5th, the world pauses to mark World Asthma Day. This year's message was straightforward: people with asthma need access to anti-inflammatory inhalers. It sounds simple. It is not.
Asthma is a global burden. More than 260 million people live with the condition worldwide, and it kills over 450,000 of them each year. The disease is not simply about a tight chest or the sudden gasp for air that most people imagine. What happens in an asthma attack is more complex. The muscles surrounding the airways become hyperresponsive and clench. The airway tissue swells and inflames. Mucus accumulates, sometimes plugging the passages entirely. Air becomes trapped. Breathing becomes work.
For decades, asthma treatment relied on a single tool: the reliever inhaler—the blue rescue device that opens airways fast when an attack strikes. But medicine has learned something crucial. Asthma is not primarily a problem of tightness. It is a problem of inflammation. The Global Initiative for Asthma now recommends that most people use a single inhaler combining quick relief with anti-inflammatory medication, treating the immediate crisis while also dampening the underlying fire that drives the disease. This approach prevents attacks before they start. It keeps asthma controlled.
South Africa has the pieces in place. The country maintains national asthma guidelines. Specialist centres like Groote Schuur Hospital exist. Medicines are available in the public sector. The private system offers advanced options, including biologic treatments for the most severe cases. On paper, the infrastructure looks reasonable. In the 2025 Severe Asthma Index, South Africa scored 58 out of 100 overall. But the score masks a troubling gap. When researchers measured access to care—the ability of patients to actually reach specialists, get diagnostic tests, and obtain advanced treatments—South Africa scored only 36 out of 100. Among 43 countries surveyed, this was among the lowest. A person with severe asthma in South Africa faces real barriers to the care they need.
The country lacks a formal national asthma strategy. Severe asthma is not formally embedded in broader respiratory or non-communicable disease plans. Patients with uncontrolled symptoms, those needing repeated courses of oral steroids, those whose asthma disrupts sleep and work despite treatment—these people often go unrecognized. They do not get referred to specialists. They do not receive the assessment that might reveal what type of asthma they have or whether advanced treatment could help. Children are particularly vulnerable. Uncontrolled asthma in childhood damages more than daily life. It remodels the airways themselves, leaving lasting impaired lung function that persists into adulthood.
Environment compounds the problem. South Africa carries a high environmental risk score for asthma, driven by air pollution and poor indoor air quality. These factors worsen symptoms, especially in communities already struggling to access healthcare. Respiratory infections—whooping cough, flu, respiratory syncytial virus—can trigger attacks. Vaccination gaps leave people exposed.
Change is beginning. The South African Thoracic Society has launched a Severe Asthma Registry to measure the true scale of the problem and identify gaps. A new position statement on biologic therapies aims to guide clinicians toward evidence-based treatment. These steps matter. But they are early. The real work—building the referral systems, ensuring anti-inflammatory inhalers reach those who need them, cleaning the air, closing the access gap—remains ahead. For now, millions of South Africans with asthma are managing a condition that should be controllable but often is not, held back not by lack of medicine but by the distance between the medicine and the patient.
Citações Notáveis
Asthma is driven by swelling and inflammation in the airways, not only tightness in the chest, and people with asthma need treatment that helps manage the inflammation behind the condition.— Dr Dwayne Koot, medical manager, Sanofi South Africa
Improving asthma care means looking at the whole patient journey, including access to the right inhalers, earlier diagnosis, stronger referral systems, patient education, cleaner air, and advanced care for people with severe asthma.— Dr Dwayne Koot, medical manager, Sanofi South Africa
A Conversa do Hearth Outra perspectiva sobre a história
Why does it matter whether someone uses a reliever inhaler versus one that also treats inflammation?
Because a reliever only buys time. It opens the airways when they're already closing. But the inflammation that caused the closing is still there, waiting. So the next trigger comes, and the airways close again. You're always in crisis mode. With anti-inflammatory treatment, you're actually healing the underlying problem.
South Africa has guidelines and specialist hospitals. Why is access still so poor?
Having the thing and being able to reach it are different. A specialist centre in Cape Town doesn't help someone in a township without transport money or time off work. And if your local clinic doesn't know to refer you, you never even know the specialist exists.
The article mentions children's airways being "remodeled." What does that mean?
Chronic inflammation changes the structure of the airway tissue itself. It thickens, it scars. A child who grows up with uncontrolled asthma may have permanently reduced lung capacity as an adult, even if their asthma improves later. The damage is done.
Is this a problem unique to South Africa?
No. But South Africa's score of 36 out of 100 on access puts it in the bottom tier globally. The infrastructure exists. The gap is in the system connecting patients to it.
What would actually change things?
A national strategy that names severe asthma as a priority. Training more clinicians to recognize it. Making sure anti-inflammatory inhalers are available and affordable at primary care level, not just in private practice. And honestly, cleaner air. You can't control asthma in a polluted environment.