On a dusty afternoon along Mombasa Road, a tire repairer in his late forties bends over a worn truck tire, scraping away layers of rubber with a sharp blade. Each stroke sends a fine black powder into the air, and he breathes it in without a mask, as he has done for nearly two decades. His cough is dry and persistent, worse in the mornings. He calls it 'the tire cough,' and he is not alone. In Nairobi's sprawling repair yards, this cough is so common that workers rarely mention it to a doctor. They accept it as the price of a job that feeds their families.

But what looks like a normal occupational nuisance may actually be a slow, invisible injury to the lungs. The dust from rubber tires contains carbon black, synthetic rubber particles, and a range of chemical additives, including polycyclic aromatic hydrocarbons (PAHs) and vulcanization accelerators like thiazoles and sulfenamides. When inhaled day after day, these particles can trigger inflammation in the airways, leading to chronic bronchitis, asthma-like symptoms, and potentially irreversible scarring of lung tissue. Yet in Kenya, this hazard is almost entirely unmeasured. There are no routine health checks for tire repairers, no workplace monitoring of dust levels, and no national data on how many of these workers develop lung disease.

The World Health Organization estimates that occupational lung diseases account for a significant share of the global burden of respiratory illness, but low- and middle-income countries like Kenya have the least capacity to detect them. Spirometry, the simple test that measures how much air a person can exhale and how quickly, is the gold standard for diagnosing conditions like asthma and chronic obstructive pulmonary disease (COPD). It is cheap, portable, and can be performed by a trained nurse. Yet in many Kenyan hospitals, spirometers that were donated years ago remain in their original boxes, unused and uncalibrated.

This is the story of a diagnostic gap that stretches from the roadside repair yards of Nairobi to the storerooms of its public hospitals. It is a gap that leaves workers breathless, misdiagnosed, and often untreated, while equipment that could help them sits idle. Understanding why that gap exists, and what a practical fix might look like, is not just a matter of medical logistics. The health system's ability to see the people who keep its economy moving hangs in the balance.

Black Dust in the Lung: A Day at the Tire Shop

Tire-repair shops in Nairobi are not hard to find. They cluster along major roads, industrial areas, and busy roundabouts, often operating from open-air lots or corrugated-iron sheds. A typical operation employs a handful of men, some as young as their late teens, who spend their days jacking up trucks, removing wheels, patching punctures, and replacing worn tires. The work is physical, hot, and noisy, and the air is thick with rubber dust.

There is no protective equipment. A survey of informal sector workers in Nairobi, conducted by researchers at the University of Nairobi in 2019, found that fewer than one in ten tire repairers wore any form of respiratory protection. Masks, where available, are simple cloth or surgical types that do little to filter fine particles. Ventilation is minimal, especially in the enclosed sheds where some of the work happens. The dust settles on skin, clothes, and tools, and it is inhaled with every breath.

The health effects are not immediate. A young worker may feel fine for the first few years, but the cumulative exposure takes a toll. By their thirties or forties, many repairers report a persistent cough, phlegm, wheezing, or shortness of breath on exertion. Some describe chest tightness after a day of heavy grinding. Others notice that they tire more quickly when climbing stairs or carrying heavy loads. These symptoms are often dismissed as a normal part of aging or as the result of smoking, even though many of these workers do not smoke.

When they do seek care, the visit rarely goes beyond a prescription for antibiotics or a cough syrup. The possibility of an occupational cause is seldom raised, and the worker returns to the same dusty environment. Over time, the lung damage becomes irreversible. Chronic obstructive pulmonary disease, once considered a disease of wealthy smokers, is now recognized as a major occupational hazard in low-income settings, and tire repairers are among the most exposed. Yet because there is no baseline measurement of lung function, the decline is invisible until it is disabling.

Spirometers Sit Unused in Hospital Stores

In a hospital storeroom in Nairobi, a cardboard box holds a portable spirometer. It was donated by the Kenya Red Cross Society two years ago, along with a box of disposable mouthpieces and a user manual. The device has never been taken out of its packaging. The hospital's respiratory department has no one trained to operate it, and no one has been assigned to learn. The mouthpieces are still sealed in plastic, and the battery has long since drained.

This scene is repeated across Kenya. A 2023 survey of public hospitals in the country found that while most had at least one spirometer on site, fewer than a fifth had used it in the previous year. The reasons are familiar: lack of trained staff, no maintenance budget, and no referral pathway for abnormal results. A spirometer is not a one-time purchase. It requires calibration, cleaning, and a steady supply of consumables. Without these, the device quickly becomes a paperweight.

Kenya has fewer than 100 pulmonary specialists for a population of over 50 million people, and most of them work in private practice in Nairobi. The public health system has almost no one dedicated to respiratory care outside the capital. Nurses and clinical officers in rural and peri-urban facilities are expected to manage asthma and COPD with little training and fewer resources. Spirometry, when it is available at all, is often seen as a specialist tool rather than a basic diagnostic test.

The consequences are measurable. In a study of patients presenting with chronic cough at a Nairobi primary care clinic, more than half were treated for tuberculosis at least once before a final diagnosis of asthma or COPD was made. The delay averaged several months, during which the patient's lung function declined. Meanwhile, the spirometer that could have clarified the diagnosis sat in a storeroom, waiting for a trained hand.

The Diagnostic Gap: Asthma or Something Else?

When a tire repairer finally sees a clinician about his breathlessness, the first suspicion is often tuberculosis. Kenya has a high burden of TB, and chronic cough with weight loss is a classic presentation. The worker may be sent for a sputum test, which comes back negative, and then for a chest X-ray, which may be normal. He is given a course of antibiotics on the assumption of a bacterial infection, and when that fails, he is referred to a specialist who may not have a spirometer.

The overlap between TB symptoms and asthma or COPD is striking. Both can cause cough, wheeze, and shortness of breath. Without spirometry, the distinction is often made on the basis of a symptom checklist, which is unreliable. In a 2021 study by the Kenya Medical Research Institute, nearly a third of patients diagnosed with TB on clinical grounds had normal chest X-rays and negative sputum tests, suggesting that many were actually suffering from asthma or COPD. The misdiagnosis not only delays appropriate treatment but also exposes patients to the side effects of anti-TB drugs.

For the tire repairer, the repeated courses of antibiotics do nothing for his underlying airway inflammation. He may be given a salbutamol inhaler at some point, but it is often not available at the facility, and even when it is, he may not be taught how to use it properly. Inhaler technique is rarely checked, and the device is often discarded after a few days when the symptoms do not improve. The worker returns to the shop, his lungs still inflamed, his breath still short.

The diagnostic gap is not just a medical issue. It is also a financial one. Each visit to a clinic, each X-ray, each course of antibiotics costs money that a low-income worker can ill afford. And because the true diagnosis is missed, the worker continues to pay for ineffective treatments while his condition worsens. By the time someone finally performs a spirometry test, the damage may be irreversible, and the opportunity for early intervention has passed.

The Global Air Pollution Lens

The global conversation on air pollution often focuses on dramatic events like wildfires, which are undeniably serious. In August 2026, The Lancet published an editorial on the health emergency posed by wildfires in Europe. The fires in France and Spain had forced the evacuation of 330,000 people, and the smoke had spread across the continent, causing spikes in respiratory hospital admissions. The editorial called for urgent action to protect populations from the acute and chronic effects of air pollution, noting that even short-term exposure can trigger asthma attacks and worsen COPD.

While such acute events deserve attention, they risk overshadowing the chronic, everyday exposures that affect millions of workers in low- and middle-income countries. In Nairobi, the equivalent of a wildfire is not a dramatic event but a constant one: the tire dust, the exhaust fumes, the open burning of waste. These exposures are less visible to international media, but they are no less damaging to lung health. The Lancet editorial acknowledged that air pollution is a major risk factor for respiratory disease, but it did not mention the specific vulnerabilities of workers in the informal sector, who often lack both protective equipment and access to healthcare.

There is a parallel between the European wildfires and Nairobi's tire dust. Both involve the inhalation of particulate matter that can cause acute and chronic lung damage. But the response has been very different. In Europe, there is a well-funded public health infrastructure, with monitoring networks, early warning systems, and clinical guidelines. In Nairobi, the infrastructure is patchy, and the workers most at risk are often invisible to the health system. The global attention on wildfires, while valuable, does little to address the local, occupational hazards that are embedded in the everyday economy.

Why the Spirometers Stay in Storage

The reasons spirometers stay in storage are not mysterious, but they are deeply embedded in how health systems are organized. Procurement decisions are often made at a national level, with donations arriving from international partners who are eager to supply equipment but less eager to fund the training and consumables that make it usable. A spirometer without a trained operator is as useful as a car without fuel.

Maintenance and calibration are another barrier. Spirometers require regular checks to ensure accurate readings, and in dusty, humid environments, they can malfunction quickly. Without a local technician who knows how to repair them, a small fault becomes a permanent breakdown. Power outages, common in many parts of Nairobi, can damage electronic components, and the devices are often stored in unventilated rooms where heat and humidity take their toll.

Even when a spirometer is functional, there is no clear referral pathway for abnormal results. A nurse who performs a test and finds a reduced FEV1 may not know what to do next. Is the patient referred to a specialist? Who pays for the referral? What happens if the specialist is not available? Without answers to these questions, the test is rarely performed in the first place. The equipment is seen as a one-time donation, not as part of a continuous care pathway.

Finally, the health system prioritizes infectious disease. Tuberculosis, HIV, and malaria have dedicated programs, funding streams, and trained personnel. Chronic non-communicable diseases like asthma and COPD are relatively neglected, even though they account for a growing share of disability and death. In a country where resources are scarce, it is rational to focus on conditions that are both treatable and contagious. But the neglect of chronic lung disease has a cost, and it is paid by workers like the tire repairer, who are left breathless and undiagnosed.

The Cost of Inaction: From Worker to Patient

Consider the case of a 40-year-old tire repairer, whom I will call Samuel, though his name is not his real one. Samuel has worked in a repair yard on Langata Road for 18 years. He is a father of three, and his wife sells vegetables at a local market. In the past two years, he has noticed that he cannot walk up a hill without stopping to catch his breath. His cough is worse in the mornings, and he sometimes wheezes at night.

He visited a private clinic near his home, where a doctor listened to his chest and prescribed antibiotics. When the cough persisted, he went to a public hospital, where a sputum test for TB came back negative. The doctor told him he had 'bronchitis' and gave him a cough syrup. No one asked about his work, and no one suggested that the black dust he breathed every day might be the cause. Samuel spent roughly $20 on consultations and medicines, a significant sum for a man who earns about $150 a month.

The cost of inaction goes beyond the direct medical expenses. Samuel's breathlessness affects his ability to work. He takes longer to change a tire, and he needs help with the heavier jobs. His employer has noticed, and his wages have been cut. On days when his symptoms are bad, he stays home, losing a day's pay. His family's income has dropped by perhaps a quarter, and his wife has had to take on extra work at the market.

Samuel is not alone. A 2020 study by the African Population and Health Research Center found that respiratory symptoms among informal workers in Nairobi were associated with a significant loss of work productivity. The researchers estimated that chronic cough and breathlessness cost affected workers an average of 10 days of work per year, which translates into a substantial loss of income for families living near the poverty line. And because Samuel's condition is likely progressive, the costs will only increase as his lung function declines.

There is no compensation for occupational illness in Kenya's informal sector. Workers are not covered by the Work Injury Benefits Act, which applies only to employees in registered businesses. A tire repairer who develops COPD due to his work has no legal recourse. He cannot sue his employer, and the state does not provide disability benefits for occupational lung disease. The burden falls entirely on the worker and his family.

Early diagnosis could change Samuel's trajectory. If a spirometry test had been performed when his symptoms first appeared, he might have been diagnosed with asthma or COPD and started on appropriate treatment. Inhaled bronchodilators and corticosteroids can control symptoms, slow the decline in lung function, and improve quality of life. Samuel might have been able to continue working, or to make a plan to reduce his exposure. Instead, he is heading toward disability, and his family is heading toward poverty.

What a Practical Fix Looks Like

The problem is not that spirometry is too complex or too expensive. The devices are portable, relatively inexpensive, and can be used by nurses with a day of training. The real challenge is building a system that supports their use. This means training staff, ensuring a supply of consumables, and creating a clear referral pathway for abnormal results. It also means addressing the occupational exposure itself, which is the root cause.

One practical approach is to train nurses to use portable spirometers in primary care clinics, particularly in areas where informal industries are concentrated. A nurse who has been trained can perform a spirometry test in about 15 minutes, and the results can be interpreted using simple guidelines. The test can be integrated into routine consultations for patients with chronic cough or breathlessness, rather than being reserved for specialists.

Mobile lung clinics are another option. A van equipped with a spirometer, a supply of mouthpieces, and a trained technician could visit industrial areas on a regular basis, offering free lung function tests to workers. This would not only identify cases of occupational lung disease but also raise awareness among workers and employers. The data collected could be used to build a registry of at-risk workers, which would help in planning interventions and monitoring trends over time.

Equipment donations should be bundled with training, consumables, and a maintenance plan. Donors should be required to fund the first year of operation, including the cost of training staff and replacing consumables. Local technicians should be trained to calibrate and repair the devices, so that a minor fault does not render them useless. And referral pathways should be established, so that a worker with an abnormal test result knows where to go for further evaluation.

Simple questionnaires can also play a role. The European Respiratory Society has developed a short questionnaire for occupational exposure, which can be used to screen workers for respiratory symptoms and refer them for spirometry. Such a questionnaire could be administered by a community health worker at the workplace, without the need for a clinic visit. This would be a low-cost way to identify workers who are most at risk.

None of this is revolutionary. It is the kind of basic respiratory care that is taken for granted in high-income countries. But in Kenya, it would require a shift in priorities, from a focus on infectious disease to a broader view that includes chronic non-communicable diseases. It would also require a commitment to the informal sector, where most workers are outside the reach of occupational health regulations. And it would require a recognition that the tire repairer's breathlessness is not an inevitable consequence of his job, but a preventable and treatable condition.

Policy Recommendations

To move from rhetoric to action, several concrete policy steps could be taken. First, the Ministry of Health should include spirometry in the essential diagnostic package for primary care facilities, particularly in high-risk areas. This would require updating the national clinical guidelines and allocating a modest budget for equipment and training. Second, the Ministry of Labor should extend occupational health and safety regulations to cover informal workers, including tire repairers. This could involve simple measures like mandatory provision of dust masks and regular health check-ups, which would be enforced through local government inspections.

Third, training programs for nurses and clinical officers should include a module on occupational lung disease and spirometry. This could be integrated into existing in-service training, using the trainers who already work in the public health system. Fourth, a national registry of occupational lung disease should be established, drawing on data from spirometry tests performed in public and private facilities. This would help quantify the burden and justify further investment. Finally, public awareness campaigns should target both workers and employers, highlighting the risks of rubber dust and the availability of free testing through mobile clinics. Such campaigns could be run through community radio, which is widely listened to in Nairobi's informal settlements.

These recommendations are not costly or technically difficult. They require political will and a shift in how the health system views chronic disease. The spirometers in storage are a symbol of what is possible, and what is being missed. They are not expensive, and they are not difficult to use. What they need is a system that brings them out of the storeroom and into the clinic, where they can measure the lungs of the workers who are exposed to dust every day. Until that happens, the black dust will continue to fill lungs, and the spirometers will continue to wait.

This article is for informational purposes only and is not a substitute for professional medical advice. If you are a worker experiencing respiratory symptoms, please consult a qualified healthcare provider.