Tuberculosis, a contagious and airborne disease is a major public health problem in India. It has the highest number of TB cases in the world and accounts for the one fifth of the global TB burden in the world. Each year, more than 2 million people in India get TB. It also has the greatest number of new cases of MDR-TB, with an estimated 99,000 cases in 2014. Despite the fact that the total number of death by TB has fallen by 22% over last 5 years, over 300,000 people die from it annually (two in every three minutes). Case fatality ratio is 20% in India compared to 5% in developed country. The variation in the percentages suggests that there are critical socioeconomic determinants of TB that aggravate the situation and makes population in developing more vulnerable to TB. This essay aims to illustrate how social determinants of Tuberculosis such as low income, food insecurity, weak infrastructure and religion and culture make certain populations more vulnerable to Tuberculosis.
Food Insecurity and malnutrition
Food insecurity is a significant factor that causes disadvantaged groups to be risk averse to Tuberculosis infection. Despite impressive economic growth, India has not been able to maneuver around the problem of food insecurity. According to the International Food Policy Research Institute, 21% of the whole population is malnourished, and 60 million children in India are underweight (Food Security Portal). Studies done in India showed discrepancy between economic levels; prevalence of TB was three times higher among low-income households than high-income households (Thomas, 2012). In low-income households, populations do not receive adequate nutrition because of food insecurity, which results in malnourished people. Malnourished people often have weakened immune system; as a result, they have higher chances of getting infected by the tuberculosis bacteria (Thomas, 2012). Additionally, weak immune system can also lead to secondary immunodeficiency that increases the TB patient’s vulnerability to other infections. Lastly, weakened immune systems also leads to other health complications such as loss of appetite, altered metabolism, and mal-absorption of nutrients, which further increases the chances of getting infected by the TB bacteria (Thomas, 2012).
Religion and Culture
Religion and Culture are factors that strongly influence one’s attitudes towards health and treatment methods. India being a country that values religious and traditional beliefs, has significant population that believe that diseases are the manifestation of god’s wrath and are curable solely by prayer (Ghose, 2014). It is generally perceived that religious people have a strong sense of guilt and are opposed to taking medication because medication is perceived as an attack on their faith (Ghose, 2014). These beliefs although significant can deter population from receiving the required healthcare assistance. This can be illustrated by a research that was conducted by Babiarz in Bihar, India. This research set out to investigate the effectiveness of India’s TB control programs; however, it was found that 24% of the patients discontinued their treatment 25 weeks prior to the treatment completion (Babiarz, 2011). Symptoms persisted in 42% of patients discontinuing treatment within 5 weeks and symptoms persisted in 28% after completing 25 weeks of treatment (Babiarz, 2011). The reason behind discontinuation of treatment was largely based around religious reasons; 84.2% of the patients who discontinued their treatment were religious (Hindu) versus 30.80% who were Hindus out of all the patients who completed their treatment (Babiarz, 2011). This clearly depicts the fact that religious and cultural beliefs play a significant role with regards to discontinuation of TB treatment in India. No treatment of discontinuation of treatment due to religious beliefs increases the risk of getting the TB infection because the untreated population is contagious and put lives of other who they interact with at risk.
Prevalence of TB is greatly influenced by individuals’ income status especially in India. Research shows that TB is prevalent in the poorest and most marginalized communities such as migrant groups, homeless or ones with minimal shelter, and prisoners (TB Alert) . Statistics from Indian Council of Medical Research iterates that globally, the highest burden of TB (80%) is found in poorest countries among which India is the largest bearer of TB patients (Muniyandi, 2008). As mentioned before, 1.8 million Indians develop tuberculosis annually (Muniyandi, 2008). Another research conducted by World Health Organization revealed that TB prevalence is higher among people living below the poverty line (242/100,000) compared to those above the poverty line (149/100,000). Additionally, TB cases were 1.5 times higher among marginalized crowd. Underprivileged populations are more exposed to TB bacteria (and get infected) because they live in poorly ventilated and overcrowded conditions, which provide ideal conditions for TB bacteria to spread (Tuberculosis and Poverty). Further, underprivileged populations suffer from malnutrition and disease, which reduces resistance to TB. They also have limited access to healthcare which also puts other at risk – statistics depict that just one person with untreated infectious TB can pass the illness on to 10-15 people annually (Muniyandi, 2008).
Crowded and poorly ventilated living and working environments are often factors that risk transmission of tuberculosis in India. A UN-HABITAT report revealed that 40% of TB cases were of people living in slums in India. Slums are living conditions that have inadequate sanitation and therefore underprivileged populations living in slums unfortunately have poor hygiene (Schmidt, 2008). Unhygienic conditions not only puts people at risk of getting infected it also makes it difficult to stop the infection from spreading (Schmidt, 2008). Poor ventilation provides ideal conditions for TB bacteria to spread. Additionally, slums are over crowded as slum dwellers all live in the same vicinity and each household in a slum on average have six family members (Gupta, 2009). Hence, people living in slums are in regular contact with people who are ill which increases chances of exposure to TB bacteria (Gupta, 2009). According to the Global Health Strategies report on India, annual risk of TB infection was 69% higher in rural areas than urban areas. Another research done by The Tuberculosis Research Centre (TRC) disclosed that TB prevalence was 2.5 times higher among people living in houses made out of mud or thatch – houses that were ranked low on the Standard of Living Index (SLI) (Jadhav, 2014). These facts illustrate that people living in crowded and poorly ventilated conditions are more vulnerable to getting infected with TB.
A lot of policy recommendations revolve around reducing poverty, improving food security, developing better working conditions, and promoting healthy lifestyles. Despite the fact that they are great recommendations, they are much harder to implement in a developing country. Governments in developing countries are unlikely to focus on healthcare, an aspect where there is little or no chance for economic return. That being said, social determinants such as low income, food insecurity, weak infrastructure and religion and culture can be addressed by advocacy especially because they are multidisciplinary in nature – because solutions come in joint collaboration, improvement in one aspect usually leads to development of other aspects. Health policies have shifted their focus to equity; accelerating health progress in poor and socially excluded groups. This is essential to achieving health-related Millennium Development Goals. World Health Organization, a dominant health related organization in India, is committed to ensuring equitable access to quality TB care for all people with TB, especially the poor and the vulnerable. The Indian government is also intensifying action on TB control by eliminating physical, financial and social barriers that affect the underprivileged and vulnerable populations. The Indian government has strengthened public private partnerships, which is a breakthrough in TB care in India. The Ministry of Health and Family Welfare and private partners together launched a pilot project, which provides free treatment as well as free medication to first line TB patients. Under this program, the patient only has to pay the doctor’s consultation fee. So far, this scheme has only been successful in two states, Mumbai and Nagpur. This is a feasible preliminary step taken by the government to cure TB patients, and with logistical and financial from development and welfare organizations and private sector, the government will soon be able to control the spread of TB in India.