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Tuberculosis, Poverty
The Return of the White Plague: Global Poverty and the "New Tuberculosis"
edited by Matthew Gandy and Alimuddin Zumla, 330 pp, with illus, $35, ISBN 1-85984-669-6, New York, NY, Verso, 2003.
JAMA. 2004;291:2646-2647.
There are many reasons to read this book about tuberculosis, one of the major infectious diseases in the world. It has become clear that, despite a century of control efforts, infectious diseases remain an important global public health problem most affecting the disenfranchised. But, even the rich are not immune, and the authors believe that tuberculosis has recently received more attention because of the perceived threat of its spread to the wealthiest cities and regions of the world.
Throughout the book, the doctrine of epidemiologic transition is questioned, since infectious diseases remain a public health problem in many countries. In the developed world, mortality from infectious diseases has decreased, but, unfortunately, the developing world has not had the same success. Two billion people are infected with Mycobacterium tuberculosis, representing nearly one third of the global population, and every year 8 million people develop active disease. Out of these, 2 million die every year. Shamefully, 95% of the total tuberculosis burden and 98% of death occur in the developing world. The economically most productive age group (15-54 years of age) is also the most vulnerable group. These and other important epidemiological aspects of tuberculosis and its association with social determinants are presented in many chapters.
Owing to changing patterns of infectious diseases, new infections have emerged, and old infections have reappeared. Their reappearance is sometimes attributed to higher virulence or antibiotic resistance. Every chapter is a desperate cry for attention to the devastating disease of tuberculosis in the face of its reemergence, increasing rate, association with HIV, and multidrug resistance. The tuberculosis and HIV coepidemic is growing and will continue to fuel the devastating impact of tuberculosis. Worldwide, more than 11 million people are coinfected. Sub-Saharan Africa bears the major burden of these infections, which threaten to destroy its societies. In that region, the first manifestation of infection with HIV in one third of infected patients is tuberculosis, and for about one third of patients with HIV who have died, tuberculosis was the principal cause of death. The spread of multidrug resistant tuberculosis has outpaced our ability to respond appropriately. As the end of Soviet Communism brought poverty and massive social disruption in the former Soviet republics, a new epidemic of tuberculosis occurred. In many cases, multidrug resistant tuberculosis was the predominant type, following upon a dismantled public health system and more frequently seen in Soviet prisons.
The authors discuss the impact of structural violence—which they describe as the denial of economic opportunity, access to decent health care, housing, and education—on people living in resource-poor settings. Such individuals become sick with tuberculosis and other infectious diseases. Furthermore, all these factors act together to predispose these populations to economic and social underdevelopment and, subsequently, to poverty and illness, a never-ending vicious cycle. It is calculated that 3 to 4 months of work time are lost if an adult is affected by tuberculosis in the developing world, resulting in the loss of 20% to 30% of annual household income and, if the patient dies, 15 years' income. Tuberculosis is the commonest cause of death in young women in the developing world. Every year, in India, more than 300 000 children leave school because of their parents' tuberculosis. As correctly stated in the book, "Tuberculosis impoverishes, and poverty attracts tuberculosis."
This book does an excellent job of reviewing the historical, epidemiological, sociological, and anthropological aspects of tuberculosis. Most chapter authors conclude that, in order to control tuberculosis and perhaps other diseases such as malaria and HIV, it is extremely important to consider all disciplines of public health. It is necessary to rethink the influence of social context on infectious diseases, to understand transmission patterns, to provide insight into management issues, and to incorporate results of operational research into tuberculosis national programs. A few chapters look at the impact of tuberculosis in terms of gender, race, and ethnicity and argue that national tuberculosis control programs should take these factors into account when designing control strategies.
The last chapter, by a professor of bioethics from South Africa, examines tuberculosis in terms of ethics and human rights. Just as ridding South Africa of apartheid and its dehumanizing disparities was a priority, the author argues, it is urgent that the gross disparities created by global, economic, and social apartheid, which lead to diseases of poverty such as tuberculosis, be eliminated. It is important to move ethical considerations from the micro level of interpersonal relationships to the meso and macro levels of a broader view of the responsibility of health professionals. At these levels, considerations of community order and justice, international relations, and the interdependence of all forms of life become priorities.
In the discussion on social and economic inequalities, the authors suggest that tuberculosis is a barometer of social justice and equity. One chapter discusses tuberculosis during wartime as an example of how the miserable social, physical, and environmental circumstances of displaced populations are conducive to increasing rates of tuberculosis and other infectious diseases, with ensuing elevated mortality. During World War I, 1.7 million Russian soldiers were killed while 2 million civilians died from tuberculosis during the same period.
This book's main contribution is to call attention to the commitment needed from the developed world to drastically improve social and economic conditions in resource-poor settings. Without changing these structural factors, strategies such as widespread implementation of Directly Observed Therapy, Short Course (DOTS) will not succeed as expected in controlling the resurgent tuberculosis pandemic. Finally, this book reminds us that we are all morally obligated at a global level to promote respect for the dignity of all populations and redress the widespread inequity in health and development.
Carlos Franco-Paredes, MD, MPH, Reviewer
Emory University School of Medicine
Centro Nacional para la Salud de la Infancia y Adolescencia
Ministry of Health/Secretaria de Salud
Colonia Merced Gomez, Mexico
cfranco{at}sph.emory.edu
Books, Journals, New Media Section Editor: Harriet S. Meyer, MD, Contributing Editor, JAMA; David H. Morse, MS, University of Southern California, Norris Medical Library, Journal Review Editor.
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