Cause and effect... How much does it matter what we believe about what causes disease? And what are the implications of not making correct connections between causes and effects? The paper by van Gemert *et al.*^[@bib1]^ in this issue of the *PCRJ* provides interesting insights into the ways in which knowledge, beliefs, and understandings about COPD and its cause and consequences determine the health and wellbeing of individuals and communities.

Chronic obstructive pulmonary disease is a major public health problem globally and a major cause of morbidity and mortality.^[@bib2],[@bib3]^ Currently the fifth leading cause of death globally,^[@bib4]^ by 2025 it is projected to become the fourth leading cause, severely affecting those living in low and middle income countries. Increasingly poverty is identified as a risk factor for COPD, but its association with other risk factors for COPD remains unclear.^[@bib3]^ Tobacco smoking is the well-established risk factor for development of COPD globally, with an estimated 80--90% risk.^[@bib5],[@bib6]^ The decline in lung function of susceptible smokers is twice that of non-smokers, and the pattern of cigarette smoking has changed globally, rising at a rate of 2% in low income countries.^[@bib7]^ However, a significant number of patients with COPD, especially in low income countries in Africa, do not smoke, and the main risk factor for COPD in rural areas in Asia, South America and Africa is biomass smoke, where 90% of the rural population rely on biomass fuels for cooking.^[@bib8; @bib9; @bib10]^ Other risk factors include previous tuberculosis (TB) infection and other respiratory infections in childhood.^[@bib11]^

However, COPD is under-recognised in low and middle income countries by both patients and health professionals.^[@bib3]^ This is partly due to lack of diagnostic tools,^[@bib12]^ but it is also due to a lack of knowledge about the nature and the prognosis of the disease, and culturally-influenced attitudes towards the risk factors causing the disease and the symptoms of illness.

In one of the first studies of its kind, van Gemert *et al.*^[@bib1]^ report the views about COPD in a rural district of Uganda, a low income country. Through 10 focus group discussions of groups of women, groups of men, and mixed groups, beliefs, attitudes and understanding of respiratory illness, the use of biomass fuels, tobacco smoking, the influence of gender on health, and the use of health services were explored. Almost all households were exposed to biomass fuel through indoor cooking with inadequate ventilation. Women and children were particularly affected: children under 5 stay close to their mothers for care, and traditions expect young girls to learn early how to cook. Few understood the consequences of this early exposure.

The authors found that the participants recognised 'asthma' and TB but had not heard the term 'COPD' despite cough being common among smoking men and non- smoking women and children.^[@bib1]^ Some related smoking to breathing problems, and some of the women in the focus groups identified that firewood smoke might be the cause of breathing problems. But the strong message emerging from the focus groups was that women were expected to cook with wood even if they had chronic cough; cooking was the work of women --- it was their role to provide food.

A stark difference emerged between those living in tobacco growing areas and those in non-tobacco areas. Among the nonsmoking communities chronic cough was often associated with TB and was stigmatised. Wheezing and shortness of breath were considered serious and contagious and patients did not want to be identified with these symptoms. This delayed their seeking of health care. But in tobacco growing areas chronic cough was not even considered a health problem because it had become so much part of normal life. Most men and elderly women smoked tobacco; many believed smoking cigarettes was safe but associated smoking tobacco leaves with danger. Men smoked anywhere they wanted and smoked indoors in the presence of children, exposing their families to tobacco smoke every night; women had no decision-making power.

Treatment for COPD was minimal.^[@bib1]^ Participants reported that both traditional (local herbs) and modern treatment had poor results and often lack of finance prevented families accessing drugs. There was a lack of understanding of what needed to be treated and what treatments would and could do. Trust in health centres was low, especially as drugs for chronic respiratory symptoms were often out of stock.

The tragedy for sub-Saharan Africa is that this small study in this one region in Uganda is unlikely to be unique. Anecdotally we know that stigma and fear of TB leads to hidden illness. We know that men make behavioural decisions that negatively influence the health of the whole household, though these decisions are often made not from intent but from habit, from cultural and social traditions and lack of knowledge about cause and effect. We know that even when communities are aware of the danger of behaviours --- e.g. cooking indoors with biomass fuels --- the options for adopting alternative behaviors are simply not available. And not cooking food is not an option. We know that in most African countries there are no standard protocols for assessing and managing chronic respiratory diseases, and the services that exist do not reach most of the population affected by poverty. Treatments are sparse. Essential drugs are unavailable or inaccessible because of cost. A study in Ethiopia reported that many traditional asthma treatments such as ingestion of raw beaten eggs or smoking dry excreta of elephants are used.^[@bib13]^

A major public education initiative is needed to address the knowledge gap about COPD. Given that the dominant risk factors for COPD cannot easily be removed or avoided (as they are such an integral part of many people\'s lives) a new approach is needed. Two factors dominate: tobacco smoking, and the use of biomass fuels. Few in sub-Saharan Africa are aware of the role played by tobacco smoking as a cause of chronic respiratory diseases. Making connections between cause and effect --- exposing the link between smoking and disease, between indoor biomass fuel smoke and chronic symptoms --- is essential, but this sensitisation to the dangers of smoke must be supported by empowerment measures. Therefore new multidisciplinary approaches towards prevention must not only involve health professionals but also policy makers and cultural leaders. Issues of poverty, unhelpful cultural practices, women\'s lack of decision-making power and control, and the vulnerability of households, all need to be addressed simultaneously if there is to be adequate risk reduction. Health systems need to be strengthened to be able to diagnose, treat and manage COPD correctly in order to improve patients\' confidence in their health care and to provide essential drugs such as inhaled corticosteroids and bronchodilators that are essential for the treatment of airway diseases. And, as demonstrated by both this study and the authors\' previous study,^[@bib14]^ there is enormous value in using qualitative methods to analyse social systems and to elicit patients\' views on decision-making processes within households.

The authors declare that they have no conflicts of interest in relation to this article.
