Expert Review of Respiratory Medicine ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierx20 Social determinants of tuberculosis: context, framework and the way forward to ending TB in India Anurag Bhargava , Madhavi Bhargava & Anika Juneja To cite this article: Anurag Bhargava , Madhavi Bhargava & Anika Juneja (2020): Social determinants of tuberculosis: context, framework and the way forward to ending TB in India, Expert Review of Respiratory Medicine, DOI: 10.1080/17476348.2021.1832469 To link to this article: https://doi.org/10.1080/17476348.2021.1832469 Accepted author version posted online: 05 Oct 2020. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ierx20 Publisher: Taylor & Francis & Informa UK Limited, trading as Taylor & Francis Group Journal: Expert Review of Respiratory Medicine DOI: 10.1080/17476348.2021.1832469 Article type: Review Social determinants of tuberculosis: context, framework and the way forward to ending TB in India Anurag Bhargava1,2,4*, Madhavi Bhargava2,3, Anika Juneja2 1 Department of General Medicine, Yenepoya Medical College, (Yenepoya Deemed to be University), University Road, Deralakatte, Mangalore, Karnataka, India. 575018. 2 Center for Nutrition Studies, (Yenepoya Deemed to be University), University Road, Deralakatte, Mangalore, Karnataka, India. 575018. 3 Department of Community Medicine, (Yenepoya Deemed to be University), University Road, Deralakatte, Mangalore, Karnataka, India. 575018. 4 Department of Medicine, McGill University, Montreal,Canada * Corresponding author: Anurag Bhargava Department of General Medicine, Yenepoya Medical College University Road Deralakatte, Mangalore, Karnataka 575018 Email:[email protected] MANUSCRIPT Abstract Introduction: Social determinants are involved in the causation of TB and its adverse outcomes. This review was conducted to evolve a framework for action on social determinants with special reference to India in the context of the new END TB strategy. Areas covered: We reviewed the social context of TB in India as a neglected disease of the poor, its emergence in epidemic form in the colonial period, and the factors that resulted in its perpetuation and expansion in post-independence India. We examined the role of social determinants in two key pathways – the pathway of TB causation and its outcomes, and the care cascade for patients with TB, and its consequences. We reviewed the most important social determinants of TB including poverty, membership of certain castes and indigenous population, undernutrition and poor access to healthcare, especially in rural areas. Expert opinion: We suggest that TB elimination will require an optimal mix of enhanced biomedical and social interventions. TB elimination strategy in India needs a pro-poor model of patient –centred care inclusive of nutritional, psycho-social and financial support, universal health coverage and social protection; and convergence with multi-sectoral efforts to address poverty, under-nutrition, unsafe housing and indoor pollution. Keywords: Tuberculosis , social determinants, End TB, poverty, universal health coverage, malnutrition, equity, paradigm shift ACCEPTED MANUSCRIPT Article highlights • TB continues to exact a high toll of disease and deaths in India, where it was a neglected disease of the poor being addressed with a poorly funded TB programme till the 1990s. • The decline of TB in UK occurred in parallel with the increase of TB in India and both were linked to the colonial enterprise. • A social determinants of health (SDH) framework explains the differentials in exposure, vulnerability, care and outcomes in TB. Access to care is an important social determinant. • It is important to understand the role played by social determinants in the pathways of TB causation and cascade of TB care. • Malnutrition, membership of certain ‘castes’ and indigenous communities, gender, stigma and discrimination are social determinants particularly relevant in India. • An optimal mix of biological and social interventions could represent a paradigm shift in TB care and control, especially in India. • India requires a pro-poor model of patient –centred care and prevention with nutritional, financial and psycho-social support, to address gaps in universal health coverage and social protection, and to launch multi-sectoral efforts to address poverty, undernutrition, unsafe housing and indoor pollution ACCEPTED MANUSCRIPT ‘‘Tuberculosis is a social disease, its understanding demands that the impact of social and economic factors on the individual be considered as much as the mechanisms by which tubercle bacilli cause damage to the human body. Rene.J. Dubos[1] Tuberculosis is a social disease with a medical aspect Sir William Osler [2] There is a rich man’s tuberculosis and a poor man’s tuberculosis. The rich man recovers and the poor man dies. Edward L.Trudeau[3] The quotes by an eminent microbiologist who ushered in the era of antibiotics, and two great physicians of the pre-chemotherapy era draw our attention to the fact that social factors are fundamental to the prevention, care and control of tuberculosis. These factors explain why when nearly a quarter of the world’s population is infected with M.tuberculosis, the disease occurs in only a minority, around 10 million people in 2018, mostly in the poor in low and middle-income countries[4]. We may have modern molecular tools for diagnosis which probe the genome of M.tuberculosis in minutes but inequities in access produce months of delays in diagnosis in people living with TB in low-middle income countries. We have therapies with potential for 95% cure rate for tuberculosis (TB) within 6 months in patients with drug- susceptibleACCEPTED TB (DS-TB), yet we had 1.2 million TB-deathsMANUSCRIPT in HIV negative individuals in the year 2018[4]. While there are raising rates of drug resistant TB (DR-TB) which threaten the treatment success, only 1 in 3 of the estimated patients with MDR-TB could access therapy in 2018 [4]. This article focuses on the social determinants of TB with a special focus on India, the country with the largest burden of TB. The first section of the article discusses the context for addressing the social determinants of TB: the relationship between TB and poverty, the neglect of TB as a disease of the poor, and the renewed global and national TB control efforts over the last nearly three decades which have improved case-finding, cure rates but failed to have a desired epidemiologic impact at the population level. The new END TB strategy and its targets are discussed with the need for a synthesis of biomedical and social interventions. We highlight the social origins of the TB epidemic in India in the nineteenth century, juxtaposing it against the decline in UK with improving socio-economic conditions. The second section uses the social determinants of health (SDH) framework to examine and understand two key pathways- the pathway of TB causation and its outcomes, the care cascade for patients with TB, from a SDH perspective. We then briefly review some of the most important social determinants of TB in India. In the final section we discuss the way forward and highlight action points for the National TB elimination programme (NTEP), using the SDH framework. 1. The Context 1.1. Poverty as a cause and effect of TB. Poverty creates an ecology where TB becomes more ACCEPTEDprevalent, more lethal and more difficult MANUSCRIPTto treat. Poverty and its related factors in an individual affect the probability of getting infected with M.tuberculosis, the probability of further progression to active disease and its severity, the access to health care and its quality, and the ability to adhere and complete treatment. The difference in TB incidence between the low, middle and high-income countries (LMICs and HICs) according to 2018 is 19 fold (206/100,000 vs. 11/100,000 in LMICs vs. HICs respectively); 95% of TB cases and 98% of TB-deaths also occur in the LMIC[5]. Patients and their households incur catastrophic costs due to the direct medical costs, indirect costs of lost income, wage loss for accompanying member, travel and food costs. 1.2. TB as a neglected disease of the poor, globally and in India: The massive burden of disease and deaths in the high TB burden countries is related to the historical neglect of the disease and the diseased by health ministries, international health organisations and aid agencies, who had “ virtually ignored TB” for decades [6]. The global TB control unit in WHO declined to a situation where it had only two people in Geneva in 1988[7]. Earlier in the 1980s, a highly influential article even advised against launching national TB programmes (NTP) in LMIC, because TB required prolonged treatment and even longer follow-ups[8]. The worsening of poverty and neglect of TB programs in HIC had disastrous consequences as well. In New York City between 1984 and 1991, the TB incidence rose from 23 to 50/100, 000[9]. Treatment completion rates were as low as 11% in some. In black men in the age group of 35-44 years in central Harlem, the TB incidence was 469/100,000, 45 times the national average[9]. The TB program was a low priority program in India with poor funding, low levels of case- ACCEPTEDfinding, sub-optimal regimes and supervision MANUSCRIPT with low cure rates and high death rates. For an estimated 1.5 million patients, had an allocation of INR 20 million in 1981 (USD 2.6 million, then), which rose only up to INR 120 million in 1990,(USD 7 million, then)[10].The only communicable disease program with a lower allocation was guinea-worm eradication [11]. The case finding efficiency was only 30% of the potential,most of it based on radiologic grounds [12]. The shortage of drugs was common, isoniazid and thiacetazone combination for 18 months was often used till early 1990s, with completion rates of only 30%[12].