The deadly mix: TB, tobacco, diabetes and poverty

Today we are more likely to work in silos, but the diseases and conditions like poverty - collaborate in a deadly manner increasing manifold the impact of each other on people's lives. Working collaboratively is surely what makes sense.

34% of the global TB burden is in the South-East Asian region. 3 million new TB cases and 600,000 TB deaths annually every year occur in this region, said Dr Nevin Wilson, Regional Director, South-East Asia office of the International Union Against Tuberculosis and Lung Disease (The Union). Dr Wilson was addressing the consultative workshop of the TB and poverty sub-working group held recently in India (29-30 October 2010). Nearly 3 million TB-HIV co-infected people are in this region. Although data on drug-resistant forms of TB is emerging, India is estimated to have 100,000 incident cases of multi-drug resistant TB (MDR-TB) annually. Read more

Poorer populations are two times more likely to have TB, three times less likely to access TB care, four times less likely to complete anti-TB treatment and many times more likely to incur impoverishing payments for TB care, highlighted Dr Wilson.

The ongoing 41st Union World Conference on Lung Health in Berlin, Germany (11-15 November 2010) shall also address these issues.

Dr Wilson outlined how the vicious cycle of poverty and TB impacts the lives of people, particularly poor people. As a result of some of the obvious and more likely impacts of poverty and TB, people suffer from loss of income, stigmatisation, and homelessness, to name a few. The impact on women and children is more severe. To cope with this adverse impact of poverty and TB, they cope by decreased food intake, selling assets, borrowing money, withdrawing children from school, leaving their families or delaying seeking care.

Presenting an interesting 1999 study, Dr Wilson said in 1990, communicable diseases caused 59% of death and disability among the world's poorest 20%. Among the world's richest 20%, on the other hand, non-communicable diseases (NCDs) caused 85% of death and disability. A raised baseline rate of communicable disease decline between 1990 and 2020 would increase life-expectancy among the world's poorest 20% around ten times as much as it would the richest 20% (4.1 vs 0.4 years). However, the poorest 20% would gain only around a quarter to a third as much as the richest 20% from a similar increase in non-communicable diseases (1.4 vs 5.3 years). As a result, a faster decline in communicable diseases would decrease the poor-rich gap in 2020, but under an accelerated rate of overall decline in non-communicable diseases, the poor-rich gap would widen. There was a response to this study by Professor (Dr) K Srinath Reddy which was published in The Lancet (23 October 1999) ‘A manipulated dichotomy in global health policy.’

More recently, the researchers calculate that a 1% reduction in the number of people infected with HIV or a 10% reduction in rate of deaths from NCDs in a population would have a similar impact on progress toward the tuberculosis millennium development goals (MDG) target as a rise in gross national product (GDP) corresponding to at least a decade of growth in low-income countries.

Dr Nevin Wilson was right on spot in bringing out the dangerous synergies between TB and other non-communicable diseases or conditions – like diabetes, diseases attributed to tobacco use among others. 

Tobacco is now the world’s leading single agent of death, said Dr Wilson. There is a significant burden of tobacco use in South Asia. India accounts for about 128 million smokers (11% of the world’s total number of smokers), whereas in India, tobacco consumption in form of smoking is less than 20% and major ways to consume tobacco are leaf-rolled tobacco (beedi) or chewing tobacco (gutkha).

According to a 2008 study, 38% of deaths among male smokers in India were due to TB, 31% due to other respiratory diseases, 20% due to heart diseases/ stroke, and 32% due to tobacco-related cancers. Clearly TB was the biggest cause of death among male smokers in this study.

According to another 2007 study, smokers who had TB were about 2 to 3 times more likely to die due to TB. The mortality risk was most high among ‘beedi’ (leaf rolled tobacco) users.

Diabetes makes a substantial contribution to the burden of incident TB in India, and the association is particularly strong for the infectious form of TB. Calculations suggest that diabetes accounts for 14.8% (uncertainty range 7.1% to 23.8%) of pulmonary TB and 20.2% (8.3% to 41.9%) of smear-positive (i.e. infectious) TB, said Dr Wilson.

Let's hope that the different programmes on TB, diabetes, tobacco and poverty work more collaboratively and synergistically than the conditions.

Bobby Ramakant - CNS