INT J TUBERC LUNG DIS 15(6):S6–S8
© 2011 The Union
doi:10.5588/ijtld.11.0158
Tuberculosis: still a social disease
RUDOLF VIRCHOW, contemplating the fact that
tuberculosis (TB) was causing more than one in five
deaths in mid-nineteenth century Germany, told a
1860 meeting of German scientists and physicians
that ‘it shows that disturbances exist in the develop-
ment of our populations, disturbances which arise
from political and social institutions, and are there-
fore preventable’.1 Virchow, the Berlin-based physi-
cian, scientist and politician, was the main figure of
the social medicine movement in Germany, a move-
ment that surely influenced Robert Koch as well.
Koch, in his 1905 Nobel Prize Lecture on ‘The cur-
rent state of the struggle against tuberculosis’, identi-
fied ‘one of the most powerful weapons, if not the
most powerful, which we can bring into use against
TB’. He was talking about the growing network of
‘social welfare centres’ for TB patients in Germany,
and explained: ‘The sick person is visited in his home,
and he and his relations are given instruction and ad-
vice concerning cleanliness and how to deal with ex-
pectorations. If living conditions are bad, then money
is granted (. . .). In addition, poor families are sup-
ported by granting them appropriate food, fuel, etc’.
He went on to talk about the responsibility of the
State both to invest in health services for TB and to
improve upon unfavourable living conditions, argu-
ing that ‘Private action is virtually powerless against
this nuisance, while the State can easily remedy the
situation with suitable laws’.2
This and other observations of the link between
health and societal factors helped shape both preven-
tive public health interventions and the emerging
welfare state. Countries that experienced welfare im-
provements saw a dramatic decline in TB rates in the
first half of the twentieth century, well before the in-
troduction of chemotherapy. The notion of TB as a
social disease was by then well developed. Brock
Chisholm, the first Director General of the World
Health Organization, asserted in 1949 that ‘the death
rate from pulmonary tuberculosis is now everywhere
accepted as a sensitive index to the social state of a
community’.3
Just before that statement was made, the first anti-
tuberculosis medicine that could effectively cure TB
had become available, resulting in a further accelera-
tion of the decline. This innovation gradually shifted
the focus from prevention through development to pre-
vention through cure of infectious cases. A short-cut
for TB control had been discovered, and hopes were
high that TB could be eliminated through medical in-
terventions alone. One landmark study in the early
1960s on the applicability of ambulatory TB treat-
ment among the poorest people in low-income coun-
EDITORIAL
tries concluded that ‘successful treatment of patients
in their home in developing countries need not await
an increase in the standard of living’.4 The scale-up of
health care services for TB diagnosis and cure were out
of their starting blocks, and the race has since been
on to ensure universal access to quality TB care.
More than a century after Koch’s Nobel speech,
we are again contemplating the ‘current state of the
struggle against TB’. We have witnessed both remark-
able successes and considerable deficiencies. Com-
pared to performance before 1995, with the scale-up
of the DOTS strategy and later the Stop TB Strategy,
41 million people have been cured from TB, much
human suffering has been prevented and an estimated
6 million deaths have been averted. Prevalence and
death rates have fallen, especially where health serv-
ices have been strong enough to deliver high quality
TB diagnosis and treatment. The global TB incidence
rate has started to fall very slowly, at less than 1%
per year, since 2004. Yet the total number of TB cases
globally continues to increase year after year, as de-
mographic factors are offsetting the slow decline in
rates. With the current rate of decline, therefore, the
TB elimination target set for 2050 will be missed by a
huge margin: in fact, the best estimate is that the glo-
bal TB rate will be at least 100 times higher than the
1 case per million hoped for.5
The challenges to be faced for an accelerated de-
cline are formidable. First, an estimated 37% of TB
cases are still missed by National TB Programmes
(NTPs) and are potentially exposed to poor quality
care or no care at all. Second, treatment results are
suboptimal in many settings, especially in Africa and
in Eastern Europe, where human immunodeficiency
virus (HIV) infection and multidrug-resistant TB
(MDR-TB), respectively, are frequent. Third, weak
and inequitable health systems and services are fail-
ing to exploit the available medical technologies to
the full, and the poorest and most marginalised are
worst hit due to socially determined access barriers.
Finally, the available diagnostic and treatment tools
are imperfect, and there is no effective pre- and post-
exposure vaccine in the pipeline. Failure to control
TB is thus in part a medical failure, but it is as much
a failure of the broader health system and social and
economic development. TB is maintained in a com-
munity by sustained and widespread poverty, igno-
rance, social injustice, dismal living and working con-
ditions, socially determined unhealthy behaviours and
inequitable health care access.
Future TB control is not only going to be condi-
tional on significant medical advances and health sys-
tems strengthening, it will also depend upon efforts

to address the social determinants of TB, as well as
the direct risk factors that mediate the effect of socio-
economic conditions on TB. These include mal- or
under-nutrition, crowded living conditions, HIV in-
fection, smoking, abuse of alcohol and other drugs,
diabetes, and mental illness. As a result, beyond bet-
ter diagnosis and treatment, TB control and elimina-
tion will depend much on broad public health actions
on communicable and non-communicable diseases,
as well as on interventions outside the health sector.
The traditional roles and responsibilities of NTPs do
not incorporate such actions. Should they? And if so,
how? Or should the NTPs just advocate for these
conditions to be addressed so that others may act? Is
this lack of action on the known causes of TB mor-
ally and ethically tenable?
These are questions addressed in this theme issue
on ‘Ethics and social determinants’. Rasanathan et al.
review the social determinants of TB, identify entry
points for intervention, and suggest actions that NTPs
should pursue and actions that other stakeholders
must implement to achieve results.6 Guidance on how
to move forward with the social determinants agenda
is somewhat hampered by weak evidence on the so-
cial determinants of TB and ways to address them ef-
fectively, especially in high TB burden countries. A
fundamental step for any action is therefore to gather
national and subnational level information on the
burden and distribution of TB in a given population,
identify the most important determinants and map
out high-risk populations. Community surveys are
one important tool for this, and van Leth et al. review
how the socio-economic gradient of TB has been as-
sessed in four recent TB prevalence surveys.7 Better
epidemiological data will allow both targeted action
at country level, as well as more precise modelling of
the impact of changing determinants on the TB bur-
den. Murray et al. discuss approaches and data re-
quirements for mathematical modelling of impact on
TB of social determinants and risk factors.8
A key element and common denominator is to
tackle poverty as an underlying cause of TB. While
more evidence about the effectiveness of interven-
tions is being produced in this area, urgent action is
warranted, using the evidence available. Broader pov-
erty alleviation per se is beyond the scope of NTPs
and the health sector as a whole. However, reducing
the poverty impact of TB on poor people can be
achieved by the health services through a reduction
of the direct and indirect costs of care, and by the
provision or the channelling of social and financial
support to TB-affected families. Such interventions
could also potentially enable TB patients to access
and complete TB treatment more easily. Boccia et al.
review how conditional cash transfers and micro-
credit schemes have helped improve the financial sit-
uation as well as treatment uptake and adherence for
people with conditions other than TB.9 They also iden-
Editorial: TB still a social disease S7
tify lessons relevant for NTPs that consider such inter-
ventions. While emphasising the great potential for
TB control, this review also highlights the fact that
there is very little research on such interventions spe-
cifically focusing on TB. Rochas et al. provide a rare
exception, reporting interim results from a social in-
tervention among TB-affected families in Peru.10 They
conclude that a set of concrete social interventions
can have a rapid, positive impact on several key TB
control indicators.
More than a century after Virchow’s and Koch’s
documentation of the causes of TB, we are still strug-
gling to act effectively on the knowledge they gener-
ated. However, there are now, at last, ample opportu-
nities for change. The Commission on the Social
Determinants of Health have provided a framework
for action,11 and the WHO’s Stop TB Department has
been actively engaged in the work of the Commis-
sion, to the extent that an assessment has been made
about the potential impact of a variety of determi-
nants.5 At the same time, unprecedented resources
are now available for countries through innovative
financial mechanisms that can also allow action on
determinants and risk factors. This is a matter of
mapping needs, focusing on the existing and feasible
measures and boldly implementing them. We are at a
crossroads, and 2011 is a year of great expectation in
this field. The World Conference on Social Determi-
nants of Health in Rio de Janeiro in October will be
an important milestone where we will be able to fur-
ther link the social determinants of TB to the broader
work on health determinants. This could be an op-
portunity to take stock of the ‘current state of the
struggle against TB’, and make key decisions that
will impact on the future of TB. The global Stop TB
community should show the way to improve health
through both core medical interventions and broad
advocacy for those who are responsibility of other re-
quired actions, within and beyond ministries of health.
Mario Raviglione*
Rüdiger Krech†
*Stop TB Department
† Department of Ethics, Equity,
Trade and Human Rights
World Health Organization
Geneva, Switzerland
e-mail: raviglionem@who.int
Disclaimer: Mario Raviglione and Rüdiger Krech are staff mem-
bers of the World Health Organization (WHO). The authors alone
are responsible for the views expressed in this publication and they
do not necessarily represent the decisions or policies of the WHO.
References
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