Michel Kazatchkine: Tuberculosis and poverty in Europe

michel_kazatchkineAfter recently returning from a ministerial conference on tuberculosis (TB) and multi-drug resistant TB held on the initiative of the Latvian Presidency of the European Union, I am encouraged that our political elites are eventually deciding to commit to eradicate—rather than to only “control”—TB, the world biggest killing curable disease.

Tuberculosis has always been a disease of the poor and the vulnerable.

Today, despite TB being curable for most who are diagnosed with it, the fact remains that globally and here in Europe, it is still poor people who die from the disease. Some 1.5 million people annually. [1] The economic recession in Eastern and Central Europe in the nineties is a case in point: the then noted increase in morbidity from TB was directly correlated with the relative decrease in GDP experienced by countries. [2] It was also shown that a 1 per cent increase in GDP levels corresponds with a 0.38 per cent reduction in TB incidence. [3]

Different pathways, including poor and crowded conditions of living, contribute to the strong positive correlation that exists between poverty and the incidence of TB. Three highly vulnerable populations are particularly affected: incarcerated people, people who inject drugs, and migrants, all three groups of relevance to Europe today.

There are an estimated 3.7 million people who inject drugs (PWID) in Europe. [4] Among risk factors examined, injection drug use was found to be the highest risk for acquiring MDR TB in the European region. [5] People living with HIV who inject drugs have a two to six fold increased risk of developing TB, as compared to non-injectors. [6]

In prisons, there is an average 23 times higher incidence of TB than in the general population. [7] A study in 2008 showed a direct log relationship between average TB incidence and incarceration rates in Eastern Europe and Central Asia, a region, where incarceration rates rank amongst the highest in the world. [8]

Migration, both within and between countries, has increased in Europe and worldwide in recent years. A significant proportion (20-70 per cent) of TB cases notified in Europe are among people of foreign origin or citizenship in countries across Europe. [9] Migrants often face barriers to care in a new country as a result of inadequate knowledge of, or coverage by, the health care services, differences in culture and language, lack of money, co-morbidity with HIV, and concern about discrimination and fear of expulsion.

We’ve long had at our disposal countless sets of grim statistics demonstrating the TB burden amongst the poor and vulnerable. The statistics themselves are not new, but they are worth reiterating to remind us that in 2015, so many people in Europe just do not access the basic human right that is access to healthcare.

I would argue that we’ve long known what to do to ensure the poor are not burdened with TB. Early detection, treatment, and care for TB are key elements of the WHO-UNAIDS-UNODC jointly recommended package of interventions for people who inject drugs. The International Union against Tuberculosis and Lung Diseases has issued a statement, urging health authorities to prioritize TB prevention and control in penitentiary settings. WHO Europe has developed a minimum package of cross-border control and care to address TB issues among migrants such as the continuity of care, information during migration and the availability of and access to health services in the new country.

We will not win the fight against TB, however, unless equity and human rights are at the centre of what we do. The response to the TB crisis among the vulnerable requires a “whole of government,” multi-sectorial commitment, that extends beyond the health sector. It also requires committed and proactive leadership so it is cause for optimism that the Latvian Presidency of the European Union has made TB a priority during its term and that the signs are there that Slovakia will consolidate this priority when they assume the next Presidency.

Michel Kazatchkine is the UN Secretary General’s Special Envoy for HIV/AIDS in Eastern Europe and Central Asia.

Competing interests: None declared.

1. Global tuberculosis control: WHO report 2013. Geneva: WHO, 2013 (WHO/HTM/TB/2013.11).
2. Arinaminpathy N, & Dye C. Health in financial crises: economic recession and tuberculosis in Central and Eastern Europe. J. R. Soc. Interface 2010 doi:10.1098/rsif.2010.0072.
3. David Stuckler et al. PNAS 2008;105:13280-13285.
4. Harm Reduction International (2012) ‘ The Global State of Harm Reduction 2012: Towards an Integrated Response’.
5. Post et al, Journal of Infection (2014) 68, 259-263, (Belarus, Latvia, Romania, Russia & Ukraine).
6. ECDC/WHO-Europe. Tuberculosis surveillance and monitoring in Europe 2014 Stockholm, ECDC, 2014.
7. Baussano I. et al, (2010); Tuberculosis Incidence in Prisons: A Systematic Review PLoS Med 7(12): e1000381. doi:10.1371/journal.pmed.1000381.
8. David Stuckler et al. PNAS 2008;105:13280-13285.
9. ECDC/WHO-Europe. Tuberculosis surveillance and monitoring in Europe 2014 Stockholm, ECDC, 2014.