The importance for tuberculosis of mitigating economic crises

Abstract

Economic crises are among the most impactful and frequent complex events of modern societies, and have been shown to be detrimental for a wide range of diseases and health conditions, especially in low-income and middle-income countries (LMICs).1Backhaus I Hoven H Di Tecco C Iavicoli S Conte A Dragano N Economic change and population health: lessons learnt from an umbrella review on the Great Recession.BMJ Open. 2022; 12: e060710Crossref PubMed Scopus (1) Google Scholar The most frequent consequences of economic crises are sharp increases in poverty rates, income inequalities, and unemployment, which are among the strongest social determinants of health with the potential to influence population morbidity and mortality rates.2WHOClosing the gap in a generation: health equity through action on the social determinants of health: commission on social determinants of health. Final report. Aug 27, 2008.https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1Date accessed: August 21, 2022Google Scholar Tuberculosis is one of the infectious diseases most affected by poverty and socioeconomic vulnerabilities,3Carter DJ Glaziou P Lönnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar and it is expected that large economic recessions, such as the one that Brazil suffered in 2015–16, affect the burden of tuberculosis. Although Brazil technically ended its economic recession in 2017—after more than 2 years of decreasing gross domestic product—its poverty rates continued to increase until the beginning of the COVID-19 pandemic in 2020, demonstrating how economic shocks could have more prolonged effects on the most vulnerable groups than previously thought. This phenomenon reflects also on the temporality from the economic crises to the observed impacts on health, resulting in short-term and long-term increases in the incidence of diseases and their consequences.To our knowledge, the multi-level regression modelling study by Yunfei Li and colleagues published in The Lancet Global Health,4Li Y de Macedo Couto R Pelissari DM et al.Excess tuberculosis cases and deaths following an economic recession in Brazil: an analysis of nationally representative disease registry data.Lancet Glob Health. 2022; (published online Aug 29.)https://doi.org/10.1016/S2214-109X(22)00320-5Summary Full Text Full Text PDF Google Scholar is the first to estimate, with nationally representative data and a robust statistical methodology, the impact of the Brazilian economic crisis on the increase in tuberculosis incidence. The authors extracted tuberculosis case notifications from Brazil's National Notifiable Disease Information System, and data on tuberculosis deaths from the Mortality Information System, to compare excess cases and deaths between the pre-recession period and the recession period. This subpopulation analysis showed that the recession had a stronger effect on young adults, who are more sensitive to changes in unemployment and poverty rates.During this recession in Brazil, increases in poverty and income inequalities were not followed by a corresponding expansion of social protection and health-care services, which could have covered the growing number of vulnerable individuals and thus mitigated the impact of the crisis on health outcomes.5Rasella D Basu S Hone T Paes-Sousa R Ocké-Reis CO Millett C Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study.PLoS Med. 2018; 15: e1002570Crossref PubMed Scopus (100) Google Scholar On the contrary, structural measures of fiscal austerity were implemented, and the welfare state suffered substantial funding restrictions.6de Souza LEPF de Barros RD Barreto ML et al.The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil.BMJ Glob Health. 2019; 4: e001661Crossref PubMed Scopus (31) Google Scholar As shown in a longitudinal analysis of 5565 Brazilian municipalities, only municipalities with higher coverage of health care and social protection were able to mitigate the impact of the economic crisis on adult mortality.7Hone T Mirelman AJ Rasella D et al.Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalities.Lancet Glob Health. 2019; 7: e1575-e1583Summary Full Text Full Text PDF PubMed Scopus (74) Google ScholarThe increase in tuberculosis case notifications seen in Brazil has been observed in several countries in Latin America during the same period.8Ranzani OT Pescarini JM Martinez L Garcia-Basteiro AL Increasing tuberculosis burden in Latin America: an alarming trend for global control efforts.BMJ Glob Health. 2021; 6: e005639Crossref PubMed Scopus (5) Google Scholar The region has been facing political as well as economic crises, thus magnifying the impact of the economic recessions on tuberculosis. Although Li and colleagues report the relative proportion of tuberculosis cases from incarcerated population to be 9% (81 371 of 902 743 adults) in Brazil, the literature points towards prisons being one of the main drivers of tuberculosis in the Latin America population.9Walter KS Martinez L Arakaki-Sanchez D et al.The escalating tuberculosis crisis in central and South American prisons.Lancet. 2021; 397: 1591-1596Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar Specific actions can be taken to mitigate tuberculosis in prisons (such as improvements in air ventilation and active tuberculosis screening and diagnosis); however, these actions must be implemented together with social and economic protection at the community level.Li and colleagues' study is particularly relevant in this post-pandemic period. One of the main consequences of the COVID-19 pandemic has been the increase in poverty rates and socioeconomic vulnerabilities worldwide, which—together with the current effects of the war in Ukraine and the probable incoming global economic recession—have the potential to substantially increase the burden of tuberculosis, especially in LMICs.To act on the source of the problem, a substantial and prompt increase in the coverage of social protection interventions3Carter DJ Glaziou P Lönnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar (such as cash transfers) and of universal health care programmes (such as primary health care)10Jesus GS Pescarini JM Silva AF et al.The effect of primary health care on tuberculosis in a nationwide cohort of 7·3 million Brazilian people: a quasi-experimental study.Lancet Glob Health. 2022; 10: e390-e397Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar is essential. These actions, together with other interventions identified in the end tuberculosis strategy, such as integrated patient-centred care and prevention, could spare thousands of excess cases and deaths from tuberculosis worldwide over the next decade.Unfortunately, the escalation of poverty and increase in vulnerable populations, which results in high tuberculosis burden, will not end soon. Tuberculosis is hard to control due to its respiratory transmission, long lead times between infections and disease, and potential delays in diagnosis and treatment. Even in an optimistic scenario where all relevant stakeholders take seriously the implementation of mitigation interventions for tuberculosis, the next decade will require tuberculosis to be a public health priority worldwide if the tuberculosis-related Sustainable Development Goal 3.3 is to be achieved. Without firm policy responses to the effects of the current and incoming global economic crises, there is the real possibility of large increases of the tuberculosis burden in LMICs over the next decade. Economic crises are among the most impactful and frequent complex events of modern societies, and have been shown to be detrimental for a wide range of diseases and health conditions, especially in low-income and middle-income countries (LMICs).1Backhaus I Hoven H Di Tecco C Iavicoli S Conte A Dragano N Economic change and population health: lessons learnt from an umbrella review on the Great Recession.BMJ Open. 2022; 12: e060710Crossref PubMed Scopus (1) Google Scholar The most frequent consequences of economic crises are sharp increases in poverty rates, income inequalities, and unemployment, which are among the strongest social determinants of health with the potential to influence population morbidity and mortality rates.2WHOClosing the gap in a generation: health equity through action on the social determinants of health: commission on social determinants of health. Final report. Aug 27, 2008.https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1Date accessed: August 21, 2022Google Scholar Tuberculosis is one of the infectious diseases most affected by poverty and socioeconomic vulnerabilities,3Carter DJ Glaziou P Lönnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar and it is expected that large economic recessions, such as the one that Brazil suffered in 2015–16, affect the burden of tuberculosis. Although Brazil technically ended its economic recession in 2017—after more than 2 years of decreasing gross domestic product—its poverty rates continued to increase until the beginning of the COVID-19 pandemic in 2020, demonstrating how economic shocks could have more prolonged effects on the most vulnerable groups than previously thought. This phenomenon reflects also on the temporality from the economic crises to the observed impacts on health, resulting in short-term and long-term increases in the incidence of diseases and their consequences. To our knowledge, the multi-level regression modelling study by Yunfei Li and colleagues published in The Lancet Global Health,4Li Y de Macedo Couto R Pelissari DM et al.Excess tuberculosis cases and deaths following an economic recession in Brazil: an analysis of nationally representative disease registry data.Lancet Glob Health. 2022; (published online Aug 29.)https://doi.org/10.1016/S2214-109X(22)00320-5Summary Full Text Full Text PDF Google Scholar is the first to estimate, with nationally representative data and a robust statistical methodology, the impact of the Brazilian economic crisis on the increase in tuberculosis incidence. The authors extracted tuberculosis case notifications from Brazil's National Notifiable Disease Information System, and data on tuberculosis deaths from the Mortality Information System, to compare excess cases and deaths between the pre-recession period and the recession period. This subpopulation analysis showed that the recession had a stronger effect on young adults, who are more sensitive to changes in unemployment and poverty rates. During this recession in Brazil, increases in poverty and income inequalities were not followed by a corresponding expansion of social protection and health-care services, which could have covered the growing number of vulnerable individuals and thus mitigated the impact of the crisis on health outcomes.5Rasella D Basu S Hone T Paes-Sousa R Ocké-Reis CO Millett C Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study.PLoS Med. 2018; 15: e1002570Crossref PubMed Scopus (100) Google Scholar On the contrary, structural measures of fiscal austerity were implemented, and the welfare state suffered substantial funding restrictions.6de Souza LEPF de Barros RD Barreto ML et al.The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil.BMJ Glob Health. 2019; 4: e001661Crossref PubMed Scopus (31) Google Scholar As shown in a longitudinal analysis of 5565 Brazilian municipalities, only municipalities with higher coverage of health care and social protection were able to mitigate the impact of the economic crisis on adult mortality.7Hone T Mirelman AJ Rasella D et al.Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalities.Lancet Glob Health. 2019; 7: e1575-e1583Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar The increase in tuberculosis case notifications seen in Brazil has been observed in several countries in Latin America during the same period.8Ranzani OT Pescarini JM Martinez L Garcia-Basteiro AL Increasing tuberculosis burden in Latin America: an alarming trend for global control efforts.BMJ Glob Health. 2021; 6: e005639Crossref PubMed Scopus (5) Google Scholar The region has been facing political as well as economic crises, thus magnifying the impact of the economic recessions on tuberculosis. Although Li and colleagues report the relative proportion of tuberculosis cases from incarcerated population to be 9% (81 371 of 902 743 adults) in Brazil, the literature points towards prisons being one of the main drivers of tuberculosis in the Latin America population.9Walter KS Martinez L Arakaki-Sanchez D et al.The escalating tuberculosis crisis in central and South American prisons.Lancet. 2021; 397: 1591-1596Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar Specific actions can be taken to mitigate tuberculosis in prisons (such as improvements in air ventilation and active tuberculosis screening and diagnosis); however, these actions must be implemented together with social and economic protection at the community level. Li and colleagues' study is particularly relevant in this post-pandemic period. One of the main consequences of the COVID-19 pandemic has been the increase in poverty rates and socioeconomic vulnerabilities worldwide, which—together with the current effects of the war in Ukraine and the probable incoming global economic recession—have the potential to substantially increase the burden of tuberculosis, especially in LMICs. To act on the source of the problem, a substantial and prompt increase in the coverage of social protection interventions3Carter DJ Glaziou P Lönnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar (such as cash transfers) and of universal health care programmes (such as primary health care)10Jesus GS Pescarini JM Silva AF et al.The effect of primary health care on tuberculosis in a nationwide cohort of 7·3 million Brazilian people: a quasi-experimental study.Lancet Glob Health. 2022; 10: e390-e397Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar is essential. These actions, together with other interventions identified in the end tuberculosis strategy, such as integrated patient-centred care and prevention, could spare thousands of excess cases and deaths from tuberculosis worldwide over the next decade. Unfortunately, the escalation of poverty and increase in vulnerable populations, which results in high tuberculosis burden, will not end soon. Tuberculosis is hard to control due to its respiratory transmission, long lead times between infections and disease, and potential delays in diagnosis and treatment. Even in an optimistic scenario where all relevant stakeholders take seriously the implementation of mitigation interventions for tuberculosis, the next decade will require tuberculosis to be a public health priority worldwide if the tuberculosis-related Sustainable Development Goal 3.3 is to be achieved. Without firm policy responses to the effects of the current and incoming global economic crises, there is the real possibility of large increases of the tuberculosis burden in LMICs over the next decade. OTR reports funding via the Sara Borrell fellowship (CD19/00110) from the Instituto de Salud Carlos III. DR and OTR report financial support from the Spanish Ministry of Science and Innovation and State Research Agency through the Centro de Excelencia Severo Ochoa 2019-2023 programme (CEX2018-000806-S), and financial support from the Generalitat de Catalunya through the Centres de Recerca de Catalunya programme. Excess tuberculosis cases and deaths following an economic recession in Brazil: an analysis of nationally representative disease registry dataTuberculosis cases in Brazil rose substantially in 2015–19 during the recession, largely affecting young men. This increase seems to be linked to increasing tuberculosis transmission among incarcerated populations. Rising tuberculosis case rates threaten tuberculosis control in Brazil, and highlight the threat posed by prison-based tuberculosis transmission. Full-Text PDF Open Access