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© 2011 The Union


Tuberculosis: still a social disease

RUDOLF VIRCHOW, contemplating the fact that tries concluded that ‘successful treatment of patients
tuberculosis (TB) was causing more than one in five in their home in developing countries need not await
deaths in mid-nineteenth century Germany, told a an increase in the standard of living’.4 The scale-up of
1860 meeting of German scientists and physicians health care services for TB diagnosis and cure were out
that ‘it shows that disturbances exist in the develop- of their starting blocks, and the race has since been
ment of our populations, disturbances which arise on to ensure universal access to quality TB care.
from political and social institutions, and are there- More than a century after Koch’s Nobel speech,
fore preventable’.1 Virchow, the Berlin-based physi- we are again contemplating the ‘current state of the
cian, scientist and politician, was the main figure of struggle against TB’. We have witnessed both remark-
the social medicine movement in Germany, a move- able successes and considerable deficiencies. Com-
ment that surely influenced Robert Koch as well. pared to performance before 1995, with the scale-up
Koch, in his 1905 Nobel Prize Lecture on ‘The cur- of the DOTS strategy and later the Stop TB Strategy,
rent state of the struggle against tuberculosis’, identi- 41 million people have been cured from TB, much
fied ‘one of the most powerful weapons, if not the human suffering has been prevented and an estimated
most powerful, which we can bring into use against 6 million deaths have been averted. Prevalence and
TB’. He was talking about the growing network of death rates have fallen, especially where health serv-
‘social welfare centres’ for TB patients in Germany, ices have been strong enough to deliver high quality
and explained: ‘The sick person is visited in his home, TB diagnosis and treatment. The global TB incidence
and he and his relations are given instruction and ad- rate has started to fall very slowly, at less than 1%
vice concerning cleanliness and how to deal with ex- per year, since 2004. Yet the total number of TB cases
pectorations. If living conditions are bad, then money globally continues to increase year after year, as de-
is granted (. . .). In addition, poor families are sup- mographic factors are offsetting the slow decline in
ported by granting them appropriate food, fuel, etc’. rates. With the current rate of decline, therefore, the
He went on to talk about the responsibility of the TB elimination target set for 2050 will be missed by a
State both to invest in health services for TB and to huge margin: in fact, the best estimate is that the glo-
improve upon unfavourable living conditions, argu- bal TB rate will be at least 100 times higher than the
ing that ‘Private action is virtually powerless against 1 case per million hoped for.5
this nuisance, while the State can easily remedy the The challenges to be faced for an accelerated de-
situation with suitable laws’.2 cline are formidable. First, an estimated 37% of TB
This and other observations of the link between cases are still missed by National TB Programmes
health and societal factors helped shape both preven- (NTPs) and are potentially exposed to poor quality
tive public health interventions and the emerging care or no care at all. Second, treatment results are
welfare state. Countries that experienced welfare im- suboptimal in many settings, especially in Africa and
provements saw a dramatic decline in TB rates in the in Eastern Europe, where human immunodeficiency
first half of the twentieth century, well before the in- virus (HIV) infection and multidrug-resistant TB
troduction of chemotherapy. The notion of TB as a (MDR-TB), respectively, are frequent. Third, weak
social disease was by then well developed. Brock and inequitable health systems and services are fail-
Chisholm, the first Director General of the World ing to exploit the available medical technologies to
Health Organization, asserted in 1949 that ‘the death the full, and the poorest and most marginalised are
rate from pulmonary tuberculosis is now everywhere worst hit due to socially determined access barriers.
accepted as a sensitive index to the social state of a Finally, the available diagnostic and treatment tools
community’.3 are imperfect, and there is no effective pre- and post-
Just before that statement was made, the first anti- exposure vaccine in the pipeline. Failure to control
tuberculosis medicine that could effectively cure TB TB is thus in part a medical failure, but it is as much
had become available, resulting in a further accelera- a failure of the broader health system and social and
tion of the decline. This innovation gradually shifted economic development. TB is maintained in a com-
the focus from prevention through development to pre- munity by sustained and widespread poverty, igno-
vention through cure of infectious cases. A short-cut rance, social injustice, dismal living and working con-
for TB control had been discovered, and hopes were ditions, socially determined unhealthy behaviours and
high that TB could be eliminated through medical in- inequitable health care access.
terventions alone. One landmark study in the early Future TB control is not only going to be condi-
1960s on the applicability of ambulatory TB treat- tional on significant medical advances and health sys-
ment among the poorest people in low-income coun- tems strengthening, it will also depend upon efforts
Editorial: TB still a social disease S7

to address the social determinants of TB, as well as tify lessons relevant for NTPs that consider such inter-
the direct risk factors that mediate the effect of socio- ventions. While emphasising the great potential for
economic conditions on TB. These include mal- or TB control, this review also highlights the fact that
under-nutrition, crowded living conditions, HIV in- there is very little research on such interventions spe-
fection, smoking, abuse of alcohol and other drugs, cifically focusing on TB. Rochas et al. provide a rare
diabetes, and mental illness. As a result, beyond bet- exception, reporting interim results from a social in-
ter diagnosis and treatment, TB control and elimina- tervention among TB-affected families in Peru.10 They
tion will depend much on broad public health actions conclude that a set of concrete social interventions
on communicable and non-communicable diseases, can have a rapid, positive impact on several key TB
as well as on interventions outside the health sector. control indicators.
The traditional roles and responsibilities of NTPs do More than a century after Virchow’s and Koch’s
not incorporate such actions. Should they? And if so, documentation of the causes of TB, we are still strug-
how? Or should the NTPs just advocate for these gling to act effectively on the knowledge they gener-
conditions to be addressed so that others may act? Is ated. However, there are now, at last, ample opportu-
this lack of action on the known causes of TB mor- nities for change. The Commission on the Social
ally and ethically tenable? Determinants of Health have provided a framework
These are questions addressed in this theme issue for action,11 and the WHO’s Stop TB Department has
on ‘Ethics and social determinants’. Rasanathan et al. been actively engaged in the work of the Commis-
review the social determinants of TB, identify entry sion, to the extent that an assessment has been made
points for intervention, and suggest actions that NTPs about the potential impact of a variety of determi-
should pursue and actions that other stakeholders nants.5 At the same time, unprecedented resources
must implement to achieve results.6 Guidance on how are now available for countries through innovative
to move forward with the social determinants agenda financial mechanisms that can also allow action on
is somewhat hampered by weak evidence on the so- determinants and risk factors. This is a matter of
cial determinants of TB and ways to address them ef- mapping needs, focusing on the existing and feasible
fectively, especially in high TB burden countries. A measures and boldly implementing them. We are at a
fundamental step for any action is therefore to gather crossroads, and 2011 is a year of great expectation in
national and subnational level information on the this field. The World Conference on Social Determi-
burden and distribution of TB in a given population, nants of Health in Rio de Janeiro in October will be
identify the most important determinants and map an important milestone where we will be able to fur-
out high-risk populations. Community surveys are ther link the social determinants of TB to the broader
one important tool for this, and van Leth et al. review work on health determinants. This could be an op-
how the socio-economic gradient of TB has been as- portunity to take stock of the ‘current state of the
sessed in four recent TB prevalence surveys.7 Better struggle against TB’, and make key decisions that
epidemiological data will allow both targeted action will impact on the future of TB. The global Stop TB
at country level, as well as more precise modelling of community should show the way to improve health
the impact of changing determinants on the TB bur- through both core medical interventions and broad
den. Murray et al. discuss approaches and data re- advocacy for those who are responsibility of other re-
quirements for mathematical modelling of impact on quired actions, within and beyond ministries of health.
TB of social determinants and risk factors.8
Mario Raviglione*
A key element and common denominator is to
Rüdiger Krech†
tackle poverty as an underlying cause of TB. While
*Stop TB Department
more evidence about the effectiveness of interven- † Department of Ethics, Equity,
tions is being produced in this area, urgent action is
Trade and Human Rights
warranted, using the evidence available. Broader pov-
World Health Organization
erty alleviation per se is beyond the scope of NTPs
Geneva, Switzerland
and the health sector as a whole. However, reducing
the poverty impact of TB on poor people can be
achieved by the health services through a reduction Disclaimer: Mario Raviglione and Rüdiger Krech are staff mem-
of the direct and indirect costs of care, and by the bers of the World Health Organization (WHO). The authors alone
provision or the channelling of social and financial are responsible for the views expressed in this publication and they
do not necessarily represent the decisions or policies of the WHO.
support to TB-affected families. Such interventions
could also potentially enable TB patients to access
and complete TB treatment more easily. Boccia et al. References
review how conditional cash transfers and micro-
1 Sudhoff K. Rudolf Virchow und die Deutche Naturforscher-
credit schemes have helped improve the financial sit- versammlungen. Leipzig, Deutschland: Akademische Verlags-
uation as well as treatment uptake and adherence for gesellschaft, 1922. [German]
people with conditions other than TB.9 They also iden- 2 Koch R. The current state of the struggle against tuberculosis.
S8 The International Journal of Tuberculosis and Lung Disease

Robert Koch’s Nobel lecture. In: Nobel lectures, physiology or economic data in tuberculosis prevalence surveys. Int J Tuberc
medicine 1901–1921. Amsterdam, The Netherlands: Elsevier, Lung Dis 2011; 15 (Suppl 2): S58–S63.
1967. 8 Murray M, Oxlade O, Lin H-H. Modeling social, environmen-
3 Chisholm B. Social medicine. Sci Am 1949; 180: 11–15. tal and biological determinants of tuberculosis. Int J Tuberc
4 Ramakrishnan C V, Andrews R H, Devadatta S, Fox W, et al. Lung Dis 2011; 15 (Suppl 2): S64–S70.
The role of diet in the treatment of pulmonary tuberculosis: an 9 Boccia D, Hargreaves J, Lönnroth K, et al. Cash transfer and
evaluation in a controlled chemotherapy study in home and microfinance interventions for tuberculosis control: review of
sanatorium patients in South India. Bull World Health Organ the impact evidence and policy implications. Int J Tuberc Lung
1961; 25: 339–359. Dis 2011; 15 (Suppl 2): S37–S49.
5 Lönnroth K, Jaramillo E, Williams B G, Dye C, Raviglione M. 10 Rocha C, Montoya R, Zevallos K, et al. The Innovative Socio-
Expanding the global tuberculosis control paradigm—the role economic Interventions Against Tuberculosis (ISIAT) project:
of TB risk factors and social determinants. In: Blas E, Sivasan- an operational assessment. Int J Tuberc Lung Dis 2011; 15
kara Kurup A, eds. Priority public health conditions: from (Suppl 2): S50–S57.
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6 Rasanathan K, Sivasankara Kurup A, Jaramillo E, Lönnroth K. cial Determinants of Health interim statement. Geneva, Swit-
The social determinants of health: key to global tuberculosis zerland: World Health Organization, 2007. http://www.who.
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7 van Leth F, Guilatco R S, Hossain S, et al. Measuring socio- statement_final_07.pdf Accessed March 2011.