Disease of the poor

A young man lies before me in the emergency room. In his late 20s, he weighs a mere 31kgs. Too weak and emaciated to converse, his concerned mother gives an account of his symptoms. A two-month history of fever, cough with sputum containing streaks of blood. A chest X-ray film hangs in my hand, showing numerous cavities tilting the diagnosis in favour of tuberculosis.

Digging further, some important risk factors were revealed. Prior to contracting the disease, he was part of the nursing staff in a public hospital’s TB ward. He lived with 14 family members, three of whom had TB in the past, who crammed a small mud house on the outskirts of Islamabad.

Every March 24^th, we observe World Tuberculosis Day. This year’s theme, ‘Wanted: Leaders for a TB free World’ aims at eliminating TB as a public health problem through unified global efforts of all heads of states, health ministers, non-governmental organisations and community leaders.

According to the WHO, TB is one of the top 10 causes of death globally. There are almost 1.7 million TB-related deaths each year. Seven countries make up for 64% of the total deaths, with India leading the count, and Pakistan at fifth.

In developing countries like Pakistan, poverty and TB are inseparable. The socioeconomically weak are more likely to live and work in poorly ventilated and overcrowded conditions which provide ideal conditions for TB bacteria to spread. This population segment also suffers from malnutrition and diseases, particularly HIV, which weakens the immune system. This reduces resistance to TB.

The unforgiving whirlpool of poverty does not end here. The economic status of the family spirals downwards as the patient either quits working or is told by the employer to stay at home which burdens the whole family. In Pakistan, unawareness and lack of access prevents patients from getting appropriate hospital treatment. Such patients end up being preyed on financially by so-called faith healers. Cost of travelling to the hospital and additional nutrition needs further intensify the struggle of patient with money.

Unfortunately, poverty has stunned our cognitive abilities too. Still many associate TB with witchcraft as it affects multiple generations of the same family. Medical science shatters this myth by offering a simple explanation that TB is an airborne illness, spread between people who share frequent close proximity through coughing, sneezing, spitting and laughing. Furthermore, in an uneducated society as ours women are always at the wrong side of the sword. They are either labelled as the source of this contagious disease or are considered unworthy of marriage.

Tuberculosis is as curable as it is preventable, provided both are exercised in their true sense. Prevention has failed to thrive in our society, so we are not left with much but to wait for a disease and then offer treatment. For TB, treatment is not that simple either. Anti-TB drugs in the market are either of low quality or are taken with interruptions. This chronic problem has led to the rise of superbugs which are impervious to first-line anti-TB medications. Multi-drug-resistant TB is a threat to our existence. It not only requires a longer than usual medication course but also greater expenses.

The WHO declared TB a global emergency in 1993. Twenty-five years on, we face more or less the same abysmal state, as is evident by 510,000 TB cases that were reported last year, owing to our benumbed political and social will. Eradicating TB is not a health issue alone but it is also a developmental challenge. There is a need more than ever to strengthen TB control programmes in poorest localities which are most at risk of being affected by tuberculosis while addressing the most important determinants of the disease, specifically low body mass index and indoor air pollution. Only then can we hope to contain the TB explosion.

Published in The Express Tribune, March 24^th, 2018.

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