Tuberculosis
Poverty's Penalty

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The association between poverty and health is well documented (1). In the nineteenth century, the founders of social medicine reestablished the powerful relationship of poverty and ill health that was attributed to the dire housing, crowding, sanitation, and working conditions of poor people. With brilliant public health initiatives, the incidence of infectious diseases such as tuberculosis, smallpox, diphtheria, measles, and syphilis declined dramatically. Not a single cure for any of these diseases was known at the time; nor was there effective therapy. Smallpox has been eliminated from the world by global public health measures, including vaccination, but a cure was never found. Yet, despite curative chemotherapy, tuberculosis persists; actually transiently increasing early in the 1990s in the United States. Today, tuberculosis remains a huge problem in the world. In 1996, eight million new cases, three million deaths, and projections indicating that one of every three of the world's population will be infected with tuberculosis.

In this journal, Cantwell and colleagues (2) further examined the relationship between tuberculosis and social economic status (SES). Combining information on the incidence of tuberculosis with data from the U.S. census, they begin to define the attributable risk for tuberculosis by various SES indicators, specifically, crowding, median household income, poverty, use of public assistance, unemployment, and high school completion. As might be expected from the literature on the relationship between SES and other conditions (3), much, but not all, of the large racial difference in these health indices can be eliminated. The methods of these investigators for this type of ecologic approach to risk-factor analysis are sound, and they also provide the reader with a clear reminder of the many limitations of this type of ecologic analysis.

Yet, upon reading this fine study, we are left with two central questions. First, although much of the effect of race on the incidence of tuberculosis can be attributed to SES, there are still very large differences in rates by race even when the rates are fully adjusted by available SES indicators. What accounts for the variation by race? The second, and perhaps more important question, is how can this new knowledge about the effect of SES factors on the incidence rates of tuberculosis be used to address the public health problem of reducing these rates? Cantwell and colleagues (2) begin to provide the reader with their insights into the former question, but they leave the larger issue unanswered.

It is the larger issue of how to tackle the problem of the incidence of tuberculosis using knowledge of SES risk factors that currently confronts the health care community. Most public health efforts remain focused on control of tuberculosis through treatment, not prevention. With most of the resources directed towards therapy, it is not surprising that cost-effective strategies such as directly observed therapy have emerged and to a large extent have been successful, even within populations of lower SES. However, the current predominantly treatment-based approach to tuberculosis control cannot be expected to lead to eradication of tuberculosis in the United States without matching efforts in prevention. Adequate funding is not available for the prevention of tuberculosis.

Innovative strategies for tuberculosis prevention exist: examples are directly observed preventive therapy and short-course preventive therapy with rifampin and pyrazinamide instead of longer courses of isoniazid. Although some of these strategies have been successful, most public health departments operate with limited budgets, and funds are easily consumed in supporting treatment of infectious cases, the correct first step in tuberculosis control. The study by Cantwell and colleagues reminds us that we have epidemiological methods that might improve our precision in targeting tuberculosis prevention programs. Indeed, the vast majority of the geographic areas identified by the investigators are known to be located in our country's largest cities.

The phrase "urban health penalty" is used to describe the ill health found in impoverished areas throughout the United States (4). When areas, especially in the inner cities, experience severe financial decline, few jobs, closed businesses, and no capital investment, the result is vacant buildings that come to be occupied by the homeless, used for drug sales, and often burned and looted. The "urban health penalty" includes increased rates of crime and violence, communicable diseases, and infant mortality. Tuberculosis definitely is an urban health penalty!

As the gap between rich and poor in the United States continues to grow (5) and public sector financial support of the poor is curtailed, the prevention and control of tuberculosis will be difficult to achieve. How ironic it is that though we possess curative chemotherapy and innovative delivery strategies such as directly observed therapy and prevention that could eliminate tuberculosis, federal, state, and municipal health care administrators lack the will to fund this effort adequately.

KEVIN B. WEISS

Associate Professor of Internal Medicine

Rush-Presbyterian-St. Luke's Medical Center

Chicago, Illinois

WHITNEY W. ADDINGTON

President, Chicago Board of Health

Chicago, Illinois

	References

TOP Article REFERENCES

1. Link, B. G., and J. Phelan. 1995. Social conditions as fundamental causes of diseases. J. Health Soc. Behav. Extra Issue:80-84.

2. Cantwell, M. F., M. T. McKenna, E. McCray, and I. M. Onorato. 1998. Tuberculosis and race/ethnicity in the United States: impact of socioeconomic status. Am. J. Respir. Crit. Care Med. 157: 1016-1020 [Abstract/Free Full Text].

3. Singh, G., and S. M. Yu. 1996. U.S. childhood mortality, 1950 through 1993: trends and socioeconomic differentials. Am. J. Public Health 86: 505-512 [Abstract/Free Full Text].

4. Greenberg, M.. 1991. American cities: good and bad news about public health. Bull. N.Y. Acad. Med. 67: 17-21 [Medline].

5. Pappas, G., S. Queen, W. Hadden, and G. Fisher. 1993. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986.  N. Engl. J. Med. 329: 103-109 [Abstract/Free Full Text].