In a small mining town in rural Kenya, a 52-year-old man named Joseph has coughed for ten years. He calls it "the miner's cough" and considers it normal, a cost of earning a living. His clinic visits are rare, and spirometry, the test that could measure his lung function, is a two-day journey away. In Nairobi, a 30-year-old teacher named Grace has an asthma diagnosis, but her public clinic has referred her to a private lab for a breathing test she cannot afford. Both live with chronic respiratory disease, but their paths could not be more different.

The Same Breath, Two Different Lungs

Joseph and Grace represent the two poles of respiratory illness in low- and middle-income countries. Joseph's disease is occupational and slow, driven by decades of silica dust inhaled in small-scale mines. Grace's is urban and acute, triggered by traffic fumes and poorly ventilated housing. The wealth gradient shapes every step of their care: how they are diagnosed, what treatments they receive, and who pays.

For Joseph, the diagnosis is often missed until the disease is advanced. There is no compensation scheme for informal miners, and his symptoms are normalized as an expected part of the job. For Grace, the diagnosis is clear, but the treatment is rationed. Her clinic's referral to a private lab is a de facto denial of care, a way of shifting costs onto the patient.

Both experiences are shaped by payer rules. Occupational lung disease is under-coded and under-claimed, leaving the burden on workers and their families. Urban asthma is over-referred, bouncing patients between facilities that cannot or will not provide the full package of care. The result is a system that treats the same category of illness very differently depending on where you live and what you do.

This is not a story about a single country. It is a pattern that repeats across Africa, Asia, and Latin America, where health systems are fragmented and out-of-pocket costs dominate. The WHO and the African Union recently renewed their partnership to strengthen health systems and move toward universal health coverage, but the gap between policy and practice remains wide.

Mine Dust: A Slow, Unclaimed Burden

Small-scale mining is a major source of livelihood in many rural areas, but it comes with a hidden cost. Workers inhale silica dust, which can cause silicosis, a progressive and irreversible lung disease. Spirometry, the test that could detect early changes, is rarely available on site. In a survey of artisanal mines in Tanzania, fewer than one in ten workers had ever had their lungs tested.

Even when symptoms appear, clinic visits are often too costly and too late. A consultation may cost a day's wages, and the nearest health facility may be hours away. As a result, many miners continue working until they are too breathless to climb a ladder. By then, the disease is advanced and the treatment options are limited.

Compensation is almost unheard of. Informal workers are not covered by occupational health regulations, and they have no union to advocate for them. The burden falls on families, who lose income and face mounting medical bills. A study in Ghana found that miners with silicosis spent, on average, more than half their monthly income on treatment.

Some governments have tried to address this. South Africa has a compensation system for former mineworkers, but it is slow and bureaucratic, and many claims are rejected. In other countries, there is no system at all. The data gap is enormous: most cases of occupational lung disease in low-income settings are never officially counted.

The human cost extends beyond the worker. In Zimbabwe, where artisanal gold mining employs an estimated one million people, a miner's disability often forces children out of school to supplement the household income. A 2019 study in the country's Mashonaland Central province found that nearly half of miners interviewed reported respiratory symptoms, yet fewer than a tenth had ever undergone any form of lung function testing. The local health center, staffed by a single clinical officer, had no spirometer and no training to interpret one. Instead, miners were treated for tuberculosis repeatedly, even when sputum tests came back negative, because the symptoms of silicosis mimic TB. This misdiagnosis not only delays proper care but also exposes patients to the side effects of unnecessary antibiotics.

Even when occupational health services exist, they often focus on formal sector workers. In India, the National Programme for Control, Treatment and Rehabilitation of Silicosis was launched in 2016, but its reach is limited. A 2020 assessment in the state of Rajasthan, a hub for sandstone mining, found that only a fraction of affected workers had been identified, and fewer still had received compensation. The program relies on district-level hospitals to conduct spirometry, but these are often several hours away from remote mining sites. Community health workers, who could screen for symptoms, lack the tools to measure lung function and the authority to refer directly to specialists. As a result, the program's ambitious targets remain unmet.

City Asthma: Referrals That Redirect Care

In cities, the problem is different. Asthma is a common diagnosis, but the care is often fragmented. Public clinics in Nairobi, Dhaka, and other cities have limited access to specialists and diagnostic tools. When a patient needs a spirometry test or an allergy assessment, the clinic often refers them to a private lab, hoping the patient can pay out of pocket.

This referral is a way of managing scarce resources, but it also creates a barrier. Many patients cannot afford the test, so they return to the clinic with unresolved symptoms. Others bounce between facilities, trying to find a doctor who can prescribe the right inhaler. The follow-up is often lost in the transition.

Payer rules make this worse. In some public insurance schemes, asthma medications are only covered if the diagnosis is confirmed by a specialist, but specialist appointments are few and far between. This creates a catch-22: you need the test to get the drug, but you cannot get the test without the referral, and the referral leads to a private lab you cannot afford.

The result is that many urban asthmatics are undertreated. They use short-acting relievers, which are cheap and widely available, but they rarely receive the controller medications that could prevent attacks. A study in Kenya found that less than a third of asthma patients in public clinics had a controller inhaler, and most relied on oral salbutamol tablets, which are less effective and have more side effects.

In Dhaka, Bangladesh, the situation is further complicated by the sheer volume of patients. The city's public hospitals see hundreds of asthma cases daily, and doctors have minutes to spend with each patient. Spirometry is available at a few tertiary centers, but the waiting list can stretch for weeks. A 2021 study in the city's slums found that over half of asthmatic residents had never seen a doctor for their condition, relying instead on over-the-counter remedies or traditional healers. When they do seek care, they often face informal payments that inflate the cost of a consultation. One woman, a garment worker, described how she was told to buy a peak flow meter from a pharmacy outside the hospital, at a price equal to two days' wages, because the hospital's own device was broken.

Even when patients manage to obtain a controller inhaler, adherence is poor. A study in Kenya found that less than a third of asthma patients in public clinics had a controller inhaler, and most relied on oral salbutamol tablets, which are less effective and have more side effects. The high cost of inhalers—often several dollars a month—forces many to ration their doses, using the medication only when symptoms flare. This pattern is not unique to Africa; in India, a 2018 survey of urban asthma patients found that nearly half had discontinued their controller medication within six months, citing cost and inconvenience as primary reasons. The result is a cycle of emergency visits and hospitalizations that could have been prevented with consistent, affordable preventive care.

Payer Rules Reshape the Same Diagnosis

The divergence between rural and urban respiratory care is not just about geography. It is about how health systems are financed. Reimbursement codes determine what treatments are available, and they often favor procedures over prevention. Occupational lung disease is under-coded because it is not recognized as a compensable condition in many informal settings.

Asthma drugs are costlier without insurance, and preventive care is deprioritized. A patient who could benefit from a cheap spacer device, which helps deliver the medication to the lungs, may not get one because it is not on the formulary. Instead, they are prescribed a more expensive inhaler they cannot afford, or they are referred to a specialist who can provide a more comprehensive package.

Data gaps hide the true prevalence of these conditions. Most surveillance systems rely on facility-based reporting, which misses the majority of cases that never reach a clinic. In rural areas, where spirometry is scarce, the diagnosis is often made on symptoms alone, leading to misclassification and under-treatment.

This is not a problem of insufficient resources alone. It is a problem of misaligned incentives. When payers reimburse for procedures but not for prevention, and when occupational health is treated as a separate, less important issue, the system will continue to fail the very people it is meant to serve.

Consider the case of a national health insurance program in a West African country that reimburses hospitals for inpatient asthma admissions but does not cover outpatient spirometry. A patient who has a severe attack is admitted, treated, and discharged with a prescription for an inhaler—but no follow-up appointment is scheduled. The hospital receives a fixed payment for the admission, which it can use for other services, so there is no incentive to reduce readmissions. Meanwhile, the patient's inhaler is not on the formulary, so they must pay full price at a private pharmacy. A simple change—covering spirometry and controller medications as an outpatient package—could reduce admissions by a third, but it would require the insurer to spend more upfront. The current system, which pays for the expensive end of the disease, is cheaper in the short term but costly in the long run.

Evidence from Two Continents, One Pattern

The pattern is visible beyond Kenya and Tanzania. In the Sahrawi refugee camps in Algeria, a 15-year-old boy with neck lumps and lethargy was eventually diagnosed with tuberculosis, a disease that is both treatable and preventable. The Lancet case study highlights how statelessness complicates access to care, as refugees are often excluded from national health systems.

In Dhaka, rickshaw pullers are exposed to diesel fumes all day, yet spirometry is out of reach for most. A previous article on this site documented how the city's air quality is among the worst in the world, and the health effects are borne by the poorest workers. The same story repeats in Kathmandu, where free asthma inhalers sit on shelves while private pharmacies sell the same dose at a markup.

These stories are not isolated. They are the predictable outcome of health systems that are designed for acute, episodic care, not for chronic, long-term conditions like respiratory disease. The WHO-AU partnership talks about universal health coverage, but the reality is that most people in low-income settings pay out of pocket and go without.

Climate change is adding another layer. Heatwaves can trigger asthma attacks, and air pollution is increasing. The Lancet recently described a musical about climate change that premiered during one of the hottest weeks in London, a reminder that the crisis is not just about temperature but about health. As global funding shifts tighten budgets, the risk is that respiratory care will be deprioritized even further.

What a Fair System Would Measure

To address this, a fair system would start by linking occupational exposure to outcomes. That means tracking workers in informal mines and quarries, and providing regular spirometry at the point of care. Portable spirometers are cheap and easy to use, and they could be deployed in rural clinics with minimal training.

It would also standardize referral pathways, so that a patient with asthma does not have to be bounced between facilities. A clear protocol for when to refer, and to whom, would reduce delays and out-of-pocket costs. And it would pay for prevention, not just procedures. This means reimbursing clinics for patient education, spacer devices, and follow-up visits, not just for diagnostic tests.

Finally, a fair system would track patients across clinics, so that their care is continuous and coordinated. This requires investment in health information systems, which are often neglected. In Kenya, a pilot project is using mobile phones to remind patients to refill their prescriptions, and early results are promising.

None of this is impossible. It requires political will and a shift in how we think about health financing. But the alternative is a world where Joseph continues to cough without a diagnosis, and Grace is referred to a lab she cannot afford. That is not a health system; it is a lottery.

This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.