Social determinants of tuberculosis: context, framework, and the way forward to ending TB in India

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 – centered care inclusive of nutritional, psycho-social and financial support, universal health coverage, and social protection; and convergence with multi-sectoral efforts to address poverty, undernutrition, unsafe housing, and indoor pollution.

KEYWORDS:

• Tuberculosis
• social determinants
• end TB
• poverty
• universal health coverage
• malnutrition
• equity
• paradigm shift

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 the United Kingdom 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.

Acknowledgments

The authors wish to thank Dr. R. Srivatsan, formerly Senior Fellow at the Anveshi Research Centre for Women’s studies, Hyderabad and Prof. Rakhal Gaitonde, of the Achutha Menon Center for Health Science Studies, Trivandrum, for their critical comments on the drafts of the manuscript.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.