Phthisis. Tabes. Schachepheth. Consumption. A disease that has cycled through many
names and one that has wrecked humanity for many centuries, tuberculosis is a condition in
which the illness-causing bacteria, Mycobacterium tuberculosis, destroy the body, primarily
affecting the lungs [1]. The progression of the illness starts as the bacteria enter the body through
inhalation, immediately reaching the lungs, where macrophages, white blood cells that comprise
the immune system, attempt to destroy the foreign objects [2]. If the macrophages suppress the
bacteria, it results in latent tuberculosis where the person is asymptomatic and cannot spread the
infection [2]. However, if the macrophages are unable to perform their duty, the bacteria multiply
within these macrophages, and spread throughout the body, causing active tuberculosis where the
person experiences symptoms and can infect others [2].
Presently, Lineage 4 Tuberculosis (TB) is the most dispersed type of tuberculosis globally,
with its origins tracing back to Europe [3]. In investigating the strain’s spread over time,
researchers discovered that Lineage 4 TB reached regions in Africa, America, and Southeast Asia
in the same period as European colonizers, indicating that the spread of tuberculosis occurred
through colonization [3]. Currently, tuberculosis is one of the leading causes of death in
developing countries found within these regions; over 95% of deaths due to TB occur in low and
middle income countries, especially in Sub-Saharan Africa and Southeast Asia.
In addition to colonialism directly introducing widespread tuberculosis to these nations, it
affected other factors which stimulated TB’s spread and prevalence. During colonization,
colonizers split up land haphazardly, disregarding ethnic and racial tensions present among
populations of those regions – decisions that ruined the “political structures” of these areas due to
instability in governance caused by these increased tensions [4]. Instability itself led to weak,
sometimes corrupt governments that resisted change and prioritized the wealth of politicians over
growth of the country – a key factor causing decreased public services, including a lack of
healthcare due to absence of regulation and resources provided by the government [4]. However,
decreased public services and economic crises increase rates of tuberculosis through more than
just inaccessible healthcare – poverty, which has a positive linear association with tuberculosis,
occurs at an increased rate due to a lack of resources allocated towards infrastructure, education,
housing, etc [5].
With an airborne illness such as tuberculosis, the external environment, specifically
working conditions and living conditions, play a prominent role in the spread and prevalence of
the illness. Working and living conditions in developing countries can be quite poor, with a
multitude of factors leading to acute and chronic health stressors. Considering the workspace,
individuals work under terrible conditions, excessive hours, and abuse, while receiving pay that
does not cover living expenses [6]. These conditions heavily contribute to higher tuberculosis
rates due to increased susceptibility – since the bacteria is airborne, working in poorly ventilated
and overcrowded areas can spread infection at a very rapid rate, with workers being unable to
receive enough pay or time off to seek out healthcare services when sick. Considering living
situations, which are very similar to working conditions, such spaces can also have poor
ventilation, overcrowding, and a lack of sanitation systems, putting individuals at risk for
environmental toxins, other infections, and other ramifications aforementioned [7]. Furthermore,
the strenuous conditions can contribute to chronic exhaustion and stress, which can decrease
immune responses – a deadly consequence. A weakened immune system causes weaker
lymphocytes, decreasing macrophages’ ability to fight off tuberculosis bacteria [1]. These
situations can be further exacerbated by high rates of malnutrition; developing nations have
prevalent types of nutrition issues, such as marasmus and kwashiorkor (protein-energy
malnutrition), iron deficiency, iodine deficiency, vitamin A deficiency, and zinc deficiencies, due
to poor diets and high rates of infectious diets [8]. Such issues have a disastrous effect on a
person’s health, serving to increase susceptibility and severity of infections, thus increasing TB
infection and mortality rates. However, individuals aren’t always able to receive care – although
developing nations account for 90% of the global burden of disease, they only make up 12% of
spending on healthcare services, with most of the money being out-of-pocket spending due to
lack of welfare [9]. In addition to affordability issues, developing nations often face issues with
access itself; they have a much lower density of healthcare providers, services, and facilities –
creating a huge inequality in use of health services as only those with substantial resources are
able to receive any type of care [9]. Increasingly, there are further opportunity costs affecting
accessibility – patients have to sacrifice time and money for transportation, food, and lodging to
receive healthcare, as there is a high possibility an individual would need to travel long distances
in order to obtain services [9]. Even when they are able to receive services, they may face limited
physician time, extended waiting periods, lack of healthcare workers and medicinal supplies [9].
These factors, combined with what the American Public Health Association calls “bad
infrastructure, bad information systems, more inequality and discrimination” all deter individuals
from seeking healthcare, continually worsening tuberculosis rates in these countries.
Considering the widespread scope of this public health issue, various worldwide
organizations provide funding to developing countries to help populations recover. However, this
sector highlights the numerous issues in the ethics of public health interventions, specifically
regarding the type of help provided. Organizations focus on providing immediate treatment to
populations to help with recovery [10]; however, there are countless problems with such an
approach. Immediate treatment doesn’t help everyone as, in most circumstances, it is still only
available to those who have better access to healthcare, further failing to decrease the rates of
illness due to possibility of relapse and continued presence of other infected individuals [10].
Additionally, such an approach increases the prevalence of drug-resistant strains – limited
treatment allows for exposure of medication to previous strains, which allows the strain to mutate
and create a new strain of the illness [11]. Furthermore, such treatment doesn’t provide
continuation of care to people infected with a new strain of tuberculosis due to increased costs as
such strains require other forms of care, such as chemotherapy, which is considerably expensive
[11]. Considering this, current efforts to help ameliorate tuberculosis are violating the ethics of
equity, nonmaleficence, and responsiveness to population needs. By superficially providing care
rather than focusing on systemic changes to improve overall accessibility to healthcare, public
health measures are worsening the inequality gap present by only giving those of higher
socioeconomic status more accessibility and disregarding those who don’t fall into such a
category. In terms of nonmaleficence and responsiveness to population needs, such superficial
help has worsened the general health of the population. By increasing rates of new strains of
tuberculosis and then abandoning any efforts to care for people infected, the prevalence of
tuberculosis and mortality rates are projected to increase, with public health systems directly
doing harm and neglecting the ramifications of their actions. Such actions have the possibility of
setting a dangerous precedent for future measures in the global public health sector, leading to
the intensification of the ethical issues aforementioned.
Overall, tuberculosis has a deep, multi-faceted history among developing countries, with
its effects still rampant within populations. The tuberculosis burden in developing countries is
much higher in comparison to the rates of the illness in developed countries, with the
encompassing factor being structural issues caused by colonialism. Aside from individuals in
these countries who have substantial resources, a demographic which is a considerably small
percentage of these nations, many others may be subjected to poverty, malnutrition,
environmental toxins, and more elements that wreck their health and make them more susceptible
to tuberculosis. Furthermore, due to the lack of healthcare accessibility and affordability due to
absent or ineffective government welfare programs and low wages, many are unable to receive
care. These conditions are further worsened by global public health measures, with the ethics of
such programs called into question due to the long-term ramifications, such as worsening disease
rates and introducing drug resistant tuberculosis strands, they instill upon populations. In order to
address these ethical issues and prevent such unethical public health measures from further
aggravating a worldwide health crisis, long-term systemic change, rather than short-term
superficial solutions, are necessary.
References
1. Center for Disease Control and Prevention. 2016. “Basic TB Facts.” Center for Disease Control
and Prevention: Tuberculosis (TB).
2. Muller, Alex. 2016. “How TB Infects the Body: The Tubercle.” Global Tuberculosis
Community Advisory Board.
3. Brynildsrud, Ola B. et al. 2018. “Global Expansion of Mycobacterium tuberculosis Lineage 4
Shaped by Colonial Migration and Local Adaptation.” ScienceAdvances 4-10.
4. Robinson, James and Leander Heldring. 2013. “Colonialism and Development in Africa.”
VOXEU Column.
5. Rodrigues, Laura C. and Peter G. Smith. 1990. “Tuberculosis in Developing Countries and
Methods for its Control.” ScienceDirect 84-5.
6. Robertson, Raymond. 2016. “Working Conditions, Work Outcomes, and Policy in Asian
Developing Countries.” Asian Development Bank 497.
7. McKeown, Robert E. 2010. “The Epidemiologic Transition: Changing Patterns of Mortality
and Population Dynamics.” Am J Lifestyle Med 19S-26S.
8. Muller, Olaf and Michael Krawinkel. 2005. “Malnutrition and Health in Developing
Countries.” Canadian Medical Association Journal 173(3):279-286.
9. Peters, David H. et al. 2008. “Poverty and Access to Health Care in Developing Countries.”
The New York Academy of Sciences 1136-1
10. Hanefelt, Johanna. 2014. “The Global Fund to Fight AIDS, Tuberculosis and Malaria: 10
Years On.” Royal College of Physicians Clinical Medicine 14(1): 54-57.
11. World Health Organization. 2022. “Tuberculosis.” World Health Organization Newsroom.