Tuberculosis and Structural Poverty: What can be done? i Solomon R Benatar ii and Ross Upshur iii

Relative and absolute poverty have been constant characteristics of the human condition. Poverty in South Africa shares common causes and manifestations with poverty globally, and in this respect South Africa is a microcosm of the world. With rapid increases in the wealth of the elite over the past fifty years, relative poverty has become more pronounced. At the beginning of the twentieth century the wealthiest 20 per cent of the world's population were nine times richer than the poorest 20 per cent. This ratio has grown progressively - to thirty times by 1960, sixty times by 1990 and to well over 100 times by the early 2000s. 1 In South Africa 40% of the population live on less than R450 per month and are poorer than during apartheid. The number of extremely poor people in the world more than doubled between 1975 and 1995. Over half of the world's population live on less than $900 a year, and more than a quarter of the world's population live (on less than $1 a day) under conditions of absolute poverty. Of the 4.4 billion people in developing countries, over half lack access to sanitation, over 30 per cent lack access to clean water and essential drugs, and almost a quarter are inadequately nourished. The recent global economic crisis, with rapidly rising food prices, committed an additional 100 million people to poverty. Poverty directly accounts for almost one third of the global burden of disease, and a significant proportion of South Africa's burden of disease. Poverty leads to poor health, which in turn aggravates poverty and reduces human productivity and potential. Ninety- five per cent of TB cases and 98 per cent of TB deaths are in developing countries. Tuberculosis directly affects the economies of poor countries, as 17 per cent of those who die from TB are in the economically productive age group of 15-49 years. Four eras can be identified within the history and trajectory of tuberculosis in the world. In each of these eras different sets of circumstances have contributed to the amelioration or aggravation of the burden of this disease. In the eighteenth century TB killed about 500 people per 100 000 population every year in the United Kingdom. Improved living conditions associated with the industrial revolution, led to reduction in the annual death rate to 200/100 000 by 1882 (when Koch discovered the tubercle bacillus), and to 50/100 000 by the time the first anti-tuberculosis drugs were introduced in the 1940s. These trends made clear the social underpinnings of the disease—an insight that needs to be more consciously appreciated and acted upon today in South Africa and globally.