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India Cannot Eliminate TB By 2025 Without Also Tackling Poverty And Undernutrition

Poverty sustains TB and TB ensures poverty.

05/06/2017 9:20 AM IST | Updated 05/06/2017 9:20 AM IST
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At the recently concluded international meeting of the Stop TB Partnership coordination committee India's Health Minister made a bold declaration—that of eliminating TB in India by 2025, a decade ahead of the global target. This commitment was applauded and welcomed universally as India remains the epicentre of the global TB epidemic and progress to control the disease remains limited despite persistent efforts.

However, TB cannot be viewed in isolation—any plan to eliminate it would remain incomplete without simultaneously addressing poverty and nutrition. A well known though somewhat neglected fact is that TB thrives in poverty and hunger. The relationship is mutual and reinforcing. Yet not enough is said about the economics of TB and the consequent suffering.

It's baffling why the economics of TB remains neglected and often ignored by policymakers.

TB remains a severe health crisis but also a significant economic one. Indeed, it's an engine of poverty and debt. It's baffling then why the economics of TB remains neglected and often ignored by policymakers.

Consider some hard facts: TB costs India close to $ 24 billion each year. It mostly affects those in the 15-55 age group, affecting productivity and creating unemployment. It is a leading cause of debt, pushing families and communities into poverty and consequently financial desperation. In India a study established that the average period of loss of wages for an individual diagnosed with TB in India was three months. This has catastrophic consequences for those employed in the informal sector. As a result of TB-induced poverty, nutrition is affected and this impacts recovery and also the ability to complete treatment.

In the end, poverty sustains TB and TB ensures poverty. As a result, a large percentage of the TB affected end up financially desperate, under debt and often sicker. For those with multidrug resistant tuberculosis (MDR-TB), the costs associated with treatment and diagnoses are even higher. Hence the economic burden is greater and the consequences far more severe.

Imagine the journey of a poor family affected by TB. For the poor, the expense of health services creates barriers to prompt diagnosis and treatment which may lead to continuing transmission. As the poor cannot afford diagnosis and treatment, they just get sicker and in turn infect more people.

The government program though reliable is often difficult to access, there are stock-outs of drugs and long waiting times. Patients are often mistreated. For those in informal employment, all of these are disincentives to access treatment.

Even when diagnosed, expenses such as transportation, cost of food, and lost income push families further into debt and make it difficult to continue treatment. They also face discrimination and neglect within communities and families. Poor nutrition in the TB-infected leads to wasting, poor recovery and, often, unsuccessful treatment outcomes. For poor households, the cost for TB leads to cuts in consumption, sale of assets, and debt that often result in further impoverishment and often destitution.

For the poor, the expense of health services creates barriers to prompt diagnosis and treatment which may lead to continuing transmission.

The World Health Organisation's (WHO) End TB Strategy mandates that no TB-affected household should face catastrophic costs due to the disease. India's recent National Strategic Plan crafted for controlling and managing TB has begun to take into account the need for economic support. This is a welcome move.

Best practices from other countries can be incorporated in India's efforts at addressing TB, poverty and nutrition. A key way of doing so is to consider economic assistance programmes where direct transfers of money, such as cash, are paid as part of a social security system. Or there could transport reimbursements, treatment allowances, and the like that to affected individuals. Travel vouchers or support can be a great enabler for continuing treatment for poor individuals, households or families. This is especially true for areas where treatment centres are far and expensive to access.

India should consider investing in community-based systems of care. We forget that clinic-based treatment supervision poses a significant economic and psychological burden on the TB affected. Also, poor geographical and financial access to health services often prevents or delays health seeking among people with TB. The creation or strengthening of community-based treatment supervision programmes such as family DOTS would have the greatest potential impact on reducing patients' TB-related costs.

Best practices from other countries can be incorporated in India's efforts at addressing TB, poverty and nutrition. A key way of doing so is to consider economic assistance programmes...

Finally, we have to consider the life-altering impact of TB on those affected. Being cured from TB also comes at considerable physical cost. Hence we need to consider skill development and financial assistance post recovery. This includes training programmes or credit that helps individuals or families affected by TB to generate income post treatment. This is particularly relevant for those TB affected that work in the informal sector and lose employment due to the disease. This ensures that families and individuals are able to rebuild their lives and do not fall into poverty and increased debt due to TB.

It's time we recognise that a vast percentage of individuals affected by TB are poor and have unstable employment, and that India cannot eliminate or even control the disease until it addresses the economic aspects discussed above. In the long term, this will ensure early diagnosis, treatment adherence, improved outcomes and reduced transmission. The only way to end TB is to end is if every Indian affected by TB can recover and rebuild their lives without the fear of poverty.

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