Poverty increases vulnerability to TB

Photo by babasteveSo little attention has been given to the tuberculosis (TB) pandemic because it's a disease of the poor, Dr Nils Billo, executive director of the International Union Against Tuberculosis and Lung Disease told delegates towards the end of the 38th World Conference on Lung Health in Cape Town.

TB generally affects society’s most vulnerable – those who live in abject poverty, are marginalized or economically and socially isolated. Poverty significantly increases a person’s vulnerability to the disease.

Social and economic determinants at individual, household and community levels affect a person’s vulnerability to TB. Special situations such as massive population movements – the displacement of people and refugee flows – and living or working in particular conditions also increase the risk of a person contracting TB.

In developed countries, ethnic minorities and other marginalized communities are at a greater risk of contracting the disease. In Canada for instance, indigenous communities have a 20 to 30 times higher TB burden than majority ethnic groups, Dr Kim Barker and Dr Anne Fanning from Stop TB Canada said during the conference.

Factors such as social isolation, reduced access to health services, a lack of trust in the health system and lack of organized community voices exacerbate the risk of TB spreading. But by identifying these vulnerabilities to TB, control strategies can become more focussed on reaching the people most in need.

TB is transmitted more readily in conditions such as overcrowding, where there are inadequate ventilation and malnutrition. Improvements in socio-economic conditions will therefore lead to reductions in TB incidence. This should also lead to improvements in access to care, its rational use and quality of care.

“Poverty is so terrible” said Prisca Akelo, who completed TB treatment in Kenya and later founded a patients’ support group called the Coastal Organisation for Prevention and care of TB.

“If someone takes only black tea in the morning, and nothing during the day, by the end of the day the person is likely to default [on their treatment]” said Prischa. “TB drugs are strong, made me vomit. I lost lot of water due to vomiting and was so weak” she said.

“We need to come up with better drugs that are less toxic, have less side effects and have elements of food supplement.”

About one billion people live in urban slums and over the next 30 years that number is expected to double. In the poorest countries, about 80% of the urban population lives in slums. The poor socio-economic and environmental conditions that characterize the slums facilitate the transmission of many communicable diseases including TB. The burden of TB is often far greater in these urban settings than in rural areas.

There is also increasing recognition of the fact that TB reduces people’s ability to work and earn a living and that TB controls have the potential to reduce poverty.

Poor TB patients in developing countries are mainly dependent on daily wages or income from petty trading and have no security of income or employment. In many studies people with TB have been found to have borrowed money, used transfer payments or sold assets because of their illness.

“We have to create jobs, find income generation alternatives for those people who are on TB treatment and need financial support to sustain them through the entire treatment course,” said Prischa.

Even where Directly Observed Treatment – Short course (DOTS) programmes are well established, patients with TB face substantial costs prior to diagnosis. While aggregate costs for poor people tend to be lower than for those from a higher socio-economic position, the costs as a proportion of income are much higher for the poor.

Prischa also said that it was usually health-care volunteers that reached the most marginalized communities, providing them with TB and HIV care and treatment services.

“I haven’t heard anybody talking about remunerating community volunteers. Why do people expect us from poor countries to work for free? We end up volunteering 24 hours even taking sputum samples to the hospitals and bringing back the results. In Europe I have heard people volunteer for two hours!” Prischa said.

“I was down with TB for nine months. I know how it feels with no one to help you and no one to assist you or share or care. Mostly the care and support needs are met by community volunteer health-care workers – without these volunteer health-care workers TB will engulf you all,” she warned.

Bobby Ramakant-CNS