Ramesh, a 55-year-old factory supervisor in Pune, thought his persistent cough was just part of getting older. "I figured it was something seasonal," he recalls. "Everyone around me coughs in winter. I didn't think it was serious." By the time he finally visited a doctor, his lungs had already deteriorated significantly. He was diagnosed with advanced COPD—chronic obstructive pulmonary disease—a condition he didn't know he had while years of damage accumulated silently inside his chest.
Ramesh's story is far from unique. It is, in fact, a pattern that repeats across India with heartbreaking regularity. Millions of people breathe with compromised lungs for years without knowing it, losing their health, their productivity, and their quality of life—not because they ignored warning signs, but because those signs were never recognized as warnings at all.
A Silent Epidemic: The Scope of Undiagnosed Lung Disease in India
India is home to an estimated 55.3 million people with COPD and approximately 34 million with asthma—making these two conditions among the nation's leading causes of illness and disability. Yet here is the troubling reality: fewer than 20% of these cases have been formally diagnosed. In some estimates, the underdiagnosis rate reaches as high as 95% in certain populations.
Consider the implications of these numbers. If 1 in 5 Indians with COPD or asthma are aware of their condition, then 4 in 5 are living with a progressive disease, watching their lungs weaken year after year, never knowing why they cannot climb stairs, why their productivity at work has declined, or why their children worry when they struggle to catch their breath.
The burden of these undiagnosed conditions is measured not just in health statistics but in disability-adjusted life years (DALYs)—a metric that captures both lost years of life and years lived with reduced health and function. India's burden from respiratory diseases is 1.7 to 2.4 times higher per person than the global average, despite similar levels of economic development. This disparity reflects not greater disease prevalence alone, but the compounding effect of late detection and missed treatment opportunities.
Why Symptoms Become Invisible: The Psychology of Normalizing Illness
The biggest barrier to diagnosis is not lack of medical technology, but lack of awareness—both among patients and, often, among healthcare providers. In communities across India, breathlessness and persistent cough are frequently understood not as warning signs but as normal consequences of aging.
"I am getting older, this is natural," many people tell themselves when a persistent cough develops. Or: "Maybe I'm just weak today" when climbing a flight of stairs becomes difficult. These are not signs of denial or lack of concern. Rather, they reflect deeply held cultural beliefs about aging and health that position breathlessness as inevitable rather than treatable.
Research from a comprehensive review studying breathlessness in India found that respiratory symptoms are often perceived within families and communities as hereditary ("my mother had this too"), linked to occupation ("I worked in a dusty environment for decades"), or consequences of past infections. In environments where multiple family members share the same risk factors—cooking over biomass fires, living in polluted areas, working in factories—breathlessness becomes normalized across generations as "just how we are".
Another layer of underdiagnosis comes from stigma. Some patients, particularly smokers, feel shame about respiratory symptoms and delay or avoid seeking care. Others worry that a cough signals infection and fear being isolated by their communities. The COVID-19 pandemic intensified these stigmas, creating a landscape where respiratory symptoms became associated with fear and isolation rather than treatable disease.
There is also a simple truth: approximately only 1% of Indians have ever heard of COPD, and most who have heard of it understand it primarily as a "smoker's disease". This misconception is profoundly damaging, because it causes non-smokers—who actually account for 56% of India's COPD cases—to never consider that their symptoms might indicate this condition. They attribute their breathlessness to other causes and thus never seek the diagnosis that could change the course of their illness.
The Healthcare System Gaps: Access to Diagnosis
Even when patients recognize that their symptoms warrant medical attention, they often encounter barriers within the healthcare system. Spirometry—the gold-standard test for diagnosing COPD and asthma—remains severely underutilized in India, particularly in primary care settings where most patients first seek help.
The reasons are practical and systemic. Spirometry equipment is expensive to purchase and maintain. Many government and private clinics lack even one spirometer, forcing patients to travel to tertiary care facilities for basic diagnostic testing. When spirometers are available, they often sit unused because many healthcare providers lack training in how to conduct and interpret the tests. Additionally, patients themselves face affordability challenges—the cost of spirometry testing, combined with travel time and lost wages, represents a genuine barrier for many.
In some regions, general practitioners—the first point of contact for most patients—lack adequate training to recognize and diagnose respiratory diseases, often defaulting to oral medications that address symptoms without targeting the underlying condition. Only 36% of Indian asthma patients use inhalers, the mainstay of treatment, with many relying instead on ineffective oral medications that do not manage the disease adequately.
The consequence is that when patients finally do reach a pulmonologist, they often present with moderate to severe disease after years of progressive damage. More than 50% of people with undiagnosed COPD found during screening studies had moderate to severe disease—meaning they could have benefited from treatment for years but never received it.
The Ripple Effect: How Undiagnosed Disease Steals Productivity and Quality of Life
The human cost of undiagnosed respiratory disease extends far beyond individual suffering. It ripples through families, workplaces, and entire communities.
In terms of work productivity, patients with undiagnosed or poorly controlled COPD and asthma experience significant impact. Studies show that respiratory disease patients have substantially higher rates of work absence compared to the general population—15.2% versus 8.9% respectively. COPD patients who do report to work often experience "presenteeism"—working while unwell, with reduced capacity and focus. The median work absence duration for COPD patients is 39 days per episode, compared to 15 days for asthma patients.
But these numbers obscure a deeper challenge. When workers with undiagnosed disease miss work, they often attribute their absences to other causes, not recognizing that their respiratory condition is driving their inability to function. This means they do not seek diagnosis or treatment, creating a cycle where productivity loss continues unchecked.
The economic burden is staggering. In India, the annualized direct and indirect costs for patients with respiratory diseases average USD $637 per patient annually, with lost productivity accounting for 62.2% of total costs. For COPD specifically, the average productivity loss cost per patient is USD $650 per year—representing lost wages, lost opportunities, and reduced family income in an economy where many households live close to the margin.
Children with undiagnosed asthma face a different but equally concerning trajectory. School absenteeism increases, academic performance declines, and the condition often worsens because the child is not receiving preventive treatment. Parents, unaware that their child has treatable asthma, may interpret school absences or poor grades as behavioral issues rather than health problems.
The measure of disability-adjusted life years captures this comprehensively. Every year of delay in diagnosis represents years of life lived with reduced function, reduced income-earning capacity, increased healthcare costs, and reduced quality of life. For respiratory diseases in India, this burden is 1.7 to 2.4 times higher than what would be expected based on disease prevalence alone. That gap represents the cost of delayed diagnosis.
A Missed Opportunity: When Early Detection Could Change Everything
Here is what makes this crisis particularly painful: these diseases are treatable. Early detection and appropriate management can dramatically improve outcomes and quality of life.
A patient diagnosed with mild COPD can use inhalers to slow disease progression and maintain lung function. A child diagnosed with asthma can access controller inhalers that prevent attacks and allow normal childhood activity. An adult with newly diagnosed asthma can return to work without days missed, provided they receive the right medication.
Early detection can mean the difference between losing 2–5 years of life expectancy and living substantially longer with good quality of life. It can mean staying employed, staying active, and staying independent. Yet because of the diagnostic gaps, most patients in India meet their physician only when they are already in moderate to severe stages of disease.
Studies explicitly document this lost opportunity: more than 50% of people with undiagnosed COPD identified during screening programs had moderate to severe disease—disease that could have been managed far more effectively had diagnosis occurred years earlier. These individuals represent a massive pool of treatable patients whose health is deteriorating unnecessarily.
Innovation in Diagnosis: Vocal Biomarkers and Accessible Screening
Recognizing these barriers, new diagnostic approaches are emerging that promise to democratize early detection. One of the most promising is vocal biomarker technology—AI-powered voice analysis that can detect respiratory disease patterns through simple voice or cough recordings.
The science behind this approach is compelling. Research shows that COPD, asthma, and other respiratory conditions alter voice characteristics in detectable ways. Patients with COPD often have characteristic cough sounds and vocal patterns that AI algorithms can recognize with 66–77% sensitivity—comparable to or exceeding traditional screening methods. What makes this approach revolutionary is its accessibility: it requires only a smartphone, needs no expensive equipment, takes minutes, and can be deployed in community settings, clinics, or even homes.
The PinkTree Foundation has been pioneering this approach in India. During community lung health camps in Mumbai's neighborhoods like Govandi, Deonar, and Versova, PinkTree introduced vocal biomarker analysis as a screening tool. Instead of requiring patients to travel to hospitals or afford spirometry tests, residents could have their respiratory status assessed through a simple voice analysis right in their community.
The advantage is profound: vocal biomarkers lower the barrier to screening, making early detection accessible to populations that traditional healthcare systems have not yet reached. This is particularly valuable in India, where the gap between available diagnostic capacity and population need is so vast.
The Path Forward: Breaking the Silence
Addressing India's silent epidemic of undiagnosed lung disease requires action on multiple fronts.
Awareness campaigns must reframe respiratory symptoms—particularly persistent cough and breathlessness—as potentially serious conditions worthy of medical evaluation, not inevitable features of aging. Communities need to understand that COPD affects non-smokers, that asthma is treatable, and that early diagnosis changes outcomes.
Healthcare system strengthening must include spirometry training programs for primary care physicians, equipment provision to government clinics, and task-sharing approaches where trained nurses and respiratory technicians perform spirometry under physician supervision, expanding access significantly.
Innovative diagnostic tools—like vocal biomarker technology—must be integrated into screening programs in high-burden communities, workplaces, and clinics, making early detection practical and affordable.
Policy support is essential. Inclusion of respiratory disease screening in government health programs, coverage of inhalers and medications under insurance schemes, and integration of respiratory care into primary health centers would dramatically expand access to diagnosis and treatment.
Community engagement remains foundational. When communities understand that breathlessness is not inevitable, when they see neighbors who were once struggling now working productively after receiving treatment, attitudes shift and people seek care earlier.
The PinkTree Foundation's work—bringing screening camps to communities, introducing innovative diagnostic technologies, and advocating for policy change—represents this multifaceted approach. The foundation's mission recognizes that the illness we don't talk about remains an illness nonetheless. It progresses silently, stealing years of productivity, quality of life, and health from millions who could be helped if only their condition were recognized.
Breaking this silence begins with awareness: knowing that a persistent cough is worth investigating, that breathlessness at middle age is not normal aging, and that diagnosis and treatment are available. It continues with action: seeking care, pushing healthcare systems to invest in diagnosis, and building a culture where respiratory health is understood as something everyone deserves to protect.
Ramesh's advanced COPD diagnosis could have been prevented with earlier recognition. How many others are following his path right now? That question should move us to act.