Tuberculosis is a major and still neglected cause of death and disability in low-income and middle-income countries. Although the disease is treatable, and even preventable, it has limited political backing and little interest from the private sector. This neglect is partly because the greatest burden of disease is among those who are poor or economically and socially excluded. But also, until the early 1990s, there was a firm belief that tuberculosis had been conquered (at least in the economically developed world), and that the disease no longer justified priority status. The reality is quite different. In the past year alone there have been 2 million deaths from tuberculosis and 9 million new infections.1 There is more tuberculosis today than at any other time in history. The emergence of drug-resistant strains and the confluence with the HIV epidemic, as reviewed by Neel Gandhi and colleagues2 and Anthony Harries and colleagues3 in our Series today, has turned tuberculosis into a global public health crisis.
For too long, control of tuberculosis has been approached as a medical or public health problem only. Despite the inclusion of tuberculosis in the Millennium Development Goals (MDGs), tackling this infection as a wider development problem has hardly begun. One difficulty is that the central development issue for tuberculosis is its complex intersection with poverty. On the one hand, tuberculosis is an issue that affects development through its effect on the health of individuals and families. The disease has a devastating economic impact. On the other hand, lack of economic development hinders efforts to control tuberculosis—overcrowding, lack of ventilation in households, and poor nutrition all provide environments for the spread of tuberculosis. Worse, in the current fragile economic climate, affordability of food and medicines has put additional pressure on individuals. The decline in tuberculosis notification rates at the turn of the past century reflects the fact that economic and social development is important in addition to the availability of treatment.4
Efforts to control tuberculosis should therefore include more than just ministries of health. Policy and practice must also include ministries responsible for finance, housing, social development, and education. Indeed, our Series concludes that treatment-related actions will be insufficient to reach global goals. There is an urgent need to assess interventions for social and economic determinants, such as malnutrition, alcohol use, poor housing, indoor air pollution, and poverty.
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