From smoking and nerve gas to poor quality air: How the act of breathing became political

The lungs are life’s bookends. A baby cries and we welcome them into the world. A loved one draws their last breath and we know they’ve gone forever. But our organs of respiration are also political. If you want to know how free someone is, just check out the quality of their breathing. 

At the extreme end, breathlessness hits those in war zones, with chemical weapons designed to target the respiratory system employed since early history. Peloponnesian forces released sulphur fumes in the town of Platea in 479 BC, and the army of Leo IX of Byzantium threw vases filled with quicklime, overpowering their enemy when they smashed. Chlorine, phosgene and mustard gas were used by both sides in the First World War, killing around one million.

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Even today, more than 50 different chemicals are stockpiled, with various sinister mechanisms for damaging the lungs. Nerve agents like sarin, tabun and soman cause respiratory muscles to stop working by interfering with normal signals at the neuromuscular junction. Choking agents cause pulmonary oedema, a process in which fluid leaves the lung tissue and enters the air spaces, effectively drowning its victims.

International laws to prohibit their use have been ineffectual, and perhaps it’s no wonder. What more terrifying assault could there be than one which threatens a person’s ability to breathe. 

In peacetime too, there’s a clear apartheid between those who breathe easily and those who can’t. Just look at chronic obstructive pulmonary disease (COPD), the commonest cause of breathlessness globally. Ninety percent of fatalities from this inflammatory condition occur in low-income countries. And in the UK, where it affects 3.7 million, COPD is concentrated disproportionately among ethnic minorities and lower socioeconomic groups.

As doctors, we’re taught to think about symptoms along strictly pathological lines, as if it’s our organs’ fault when we get sick. But what about the environmental circumstances that give rise to these bodily symptoms? It’s starkly clear, not just in the case of COPD but also asthma, lung cancer, heart failure and Covid, that lung diseases aren’t randomly allocated across society, and neither are the conditions which give rise to them. 

Smoking remains the main risk factor for breathlessness, and it’s worth thinking about why this toxic habit remains so much more prevalent among the disadvantaged, cigarettes perhaps providing an easy hit to those with more life stressors and few alternatives for pleasure. But the other big cause, poor quality air, is harder to swerve.

We should have learned our lesson from the Great Smog of 1952, when a deadly combination of windless weather and a rise in coal emissions resulted in the death from asphyxiation of 12,000 people in London. No such luck. There are still 40,000 preventable deaths from air pollution every year in the UK. Traffic fumes may be the chief culprit but poor people bear the brunt, since they’re more likely than the wealthy to live and work in uncongenial areas.  

But breathlessness isn’t just the literal consequence of inhaling bad air. A startling number of the world’s crises are manifested in this organ. Another group of migrants dies in the back of a lorry from asphyxiation. A boy washes up dead on a beach, his lungs waterlogged. A man lies on a road suffocating, with a policeman kneeling on his neck while he begs, “I can’t breathe.” Respiration is a political as well as a physiological act, our capacity to perform it not just a sign of life, but of freedom. 

The lungs bring some of our most intense personal experiences. The tight anxious breathing of madness and grief. The deep lungful of air that gives succour at the end of a long period of confinement. The gulping of a sob, the paroxysm of laughter. The mounting breaths of sex, the sustained exhalation against a closed glottis that pushes a baby into the world. But these organs also connect us to each other, at the most basic atomic level, via the air we breathe.

What does the Hippocratic Oath amount to if all it demands of a doctor is an intention to do no harm? Our duty should include bearing witness to the often-intolerable lives our patients describe, lives they must return to, as well as holding our government to account for condemning some citizens to languish while others prosper. With a problem as big as breathlessness, we’re going to need to start thinking outside the box.

Alive: An Alternative Anatomy by Gabriel Weston is out now (Vintage, £20). You can buy it from the Big Issue shop on bookshop.org, which helps to support Big Issue and independent bookshops.

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