Tuberculosis (TB) and Poverty in SEAR

Globally, one billion people – one sixth of humanity – live on less than a dollar a day. Two billion people live in urban slums and other difficult habitats. Their lives are characterized by harsh environmental conditions, overcrowding, poor ventilation, and poor nutrition. . Under these circumstances they are more vulnerable to tuberculosis, resulting in further financial and social insecurity. Presently, 95 %of the TB-related deaths occur in the developing world

Poverty is both a cause and consequence of TB. When a poor person has TB, he/she spends his money and time to get well. This could lead to the loss of livelihood because of having to spend excessive time absent from work, resulting in less money earned and less spent on food and nutrition. Consequently, nutritional deficiency further erodes health, and increases the potential for re-infection. Other opportunistic infections then invade the body. Other diseases also can bring on TB. HIV/AIDS is a classic example that invites TB into an immune compromised body

The barriers to effectively address the issues of TB of the poor are several and severe in many of our countries. On the side of treatment, access is of paramount difficulty. Finding the poor and providing the treatment poses both cultural and logistical concerns for TB programmes. This requires persuasion, and awareness creation. But this may not be enough. The first step – the mere logistics of getting to the places where the patient resides is often a major impediment

The determinants of TB are both biological and environmental. While the role of environment is generally understood, it is difficult however, to mainstream into the TB programme action. This is because determinants often lie outside the parameters of the health sector, and the health sector has traditionally been reticent about dealing with factors beyond health. Housing, overcrowding, social habits, sanitation and personal hygiene with respect to respiratory disease prevention, and nutrition and food security are both beyond the authority purview of the health sector and also often alien to its communication and negotiation skill base. The key to getting other sectors to be involved is by working assiduously with the policy makers and programme managers of these sectors to instill the necessity and importance of a coordinated multi-faceted approach in order to manage the spread of TB. This is major shift in the working of health sector staff, yet a necessary one for succeeding in TB control.

In seeking solutions, the first step must be good analysis to identify how the population below poverty are distributed within our communities so that we can make focussed input in future programme implementation. We must address the barriers mentioned above with innovative solutions to access the unreached, the poor and getting the other development sectors involved in a cooperative program on TB control – with the private medical sector also effectively brought into this engagement. Programmatically, the poor needs to be focused on, not merely for diagnosis and treatment, but with attempts to address the related social determinants also such as housing, livelihoods, risk behaviour, nutrition, and food security. This will require the health sectors to move beyond their regular realms of action.

So far there has been low emphasis on the above aspects in the ongoing TB programmes in most of our countries. Perhaps a stronger inter-sectoral emphasis needs to be made in the planning of TB programmes, and more regular programme progress analysis would need to be carried out with more enthusiasm and emphasis on this aspect. Such assessments will contribute to future iterations of programme cycles that will make for success. This is also a way for assessing the effectiveness of how the social determinants of TB are being undertaken within an integrated program structure. The medical practitioners involvement must also be strengthened into this fold of integrated program concept for future success.

Some of the essential components towards addressing poverty in the context of disease prevention and control are

  • Community empowerment through the primary healthcare approach. Strengthened health systems through the PHC approach will ensure community participation so that all aspects of tuberculosis can be addressed in a holistic manner.
  • Donors also need to be shown good examples of intersectoral and multi-disciplinary programs so that they may be convinced to direct their policy towards scaling up funding for such efforts.
  • Actively seeking common objectives linking the MDGs and social determinants of health in a programmatically integrated way will also help the streamlining the process.
  • Highlighting the economic benefits of an integrated approach. This argument may resonate with policy makers and politicians. But more research and analyses of the work of national health sectors from the health economics perspective is needed. Having other disciplines incorporated into the fold of health sector expertise, and learning to work effectively with other sectors will be transform the future of the health sector, and the effectiveness of our programmes
  • The necessity to promote an integrated approach. There needs to be greater effort on the part of the health sector in working in partnership with others. National health authorities and even WHO need to work more holistically. The example of the WHO programme on drugs harm reduction working with the police is cited as an example of health and other sectors working successfully together