Tuberculosis and the Indian Poor: The present and the future

Co-Written by K Rajasekharan Nayar; Arathi P Rao; Lekha D Bhat; Anant Kumar and Parul Malik

Tuberculosis TB

The World Health Organization has recently published the latest World Tuberculosis Report (2020) and there are many trends which are of serious concern regarding elimination of this age-old disease from the world (1). At one time, the Tuberculosis did not even spare some very famous people like John Keats, Emile Bronte, George Orwell, Anton Chekhov, Albert Camus etc. apart from many well-known artists. Emile Bronte who wrote ‘The Wuthering Heights’ died of TB at the age of 30. Many political figures also were inflicted with TB which include, Ho chi Minh, Nelson Mandela, Desmond Tutu and it did not spare even kings, queens and priests. Considerable improvements in socio-economic conditions  and improvements in nutrition helped many countries to eliminate the disease. Tuberculosis is now considered as one of the diseases of the poor as it is widely prevalent in many poor countries.

Tuberculosis is one of the highly prevalent diseases in India which is still inhumanly ravaging lives. According to WHO, ninety percent of those who fall sick with the disease each year live in just 30 countries . Globally, an estimated 10.0 million (range, 8.9–11.0 mil-lion) people fell ill with TB in 2019, a number that has been declining very slowly in recent years. Most people who develop the disease are adults, and there are more cases among men than women. WHO also reports that in 2019, approximately 1.2 million people died from TB-related illnesses, and of the estimated 10 million people who developed the disease that year, some 3 million were not diagnosed or were not officially reported to national authorities.

According to World Tuberculosis Report 2020,  most people who developed TB in 2019 were in the WHO regions of South-East Asia (44%), Africa (25%) and the Western Pacific (18%), with smaller percent-ages in the Eastern Mediterranean (8.2%), the Americas (2.9%) and Europe (2.5%). Eight countries accounted for two thirds of the global total: India (26%), Indonesia (8.5%), China (8.4%), the Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh (3.6%) and South Africa (3.6%). The present pandemic has also seriously affected case detection and treatment of TB.  WHO has warned that most likely, the global targets for prevention and treatment will be missed (1).

It is likely that Kerala might eliminate the disease by 2020. Kerala’s TB incidence rate is just 67 per 100,000 population as against the all-India rate of 138 per 100,000. The state has detected only 352 new cases in 2018 in a population of 38 million. This is a sign that the end of TB is in sight. It is possible that an active case finding strategy may not be the only cause for this achievement. In Kerala, socio-economic improvements in combination with better availability and accessibility of health care could have influenced this sharp decline. The impact of higher private sector participation also could have contributed to the decline to some extent. The Kerala example proves useful for developing future TB elimination strategies in other states in India. According to reports in February 2020, nine states- Assam, Bihar, Karnataka, Madhya Pradesh, Maharashtra, Rajasthan, Tamil Nadu, Uttar Pradesh, and West Bengal accounted for 65% of the total net tuberculosis (TB) cases in India.(2). The Central Government decided to step up measures in these states to eliminate TB by 2025, ahead of the SDG target of 2030.

The problem of TB in the neighbouring states of Tamil Nadu and Karnataka are not as favourable as in Kerala. According to India TB report of 2020,  there are 110845 net notified cases in Tamil Nadu. The state also has higher HIV/ AIDS prevalence and hence cases with TB-HIV are also more in the state. This makes elimination a real challenge in the state. According to the Annual TB Reports of 2019 (3) and 2020 (4), Karnataka notified a total of 83094 cases of TB in 2018 and this number increased to 91703, with the annual total TB notification rate of 135 cases/lakh/year in 2019. Due to high prevalence of TB-HIV co-infection, Karnataka had recorded the highest TB death rate in the country in 2018, at 6.2%, higher than the national TB death rate of 4% in public sector.

With respect to other vulnerable states in India, the total number of TB notified patients that are currently in the facility/District/State give an indication of the extent of problem of TB. In 2019, Assam notified 48669 cases, whereas Bihar stood at 122671. Madhya Pradesh notified 187407 cases while cases notified in other states are Maharashtra (227348), Rajasthan (175218), Uttar Pradesh (486385) and West Bengal (110668) (4). It is also possible that there is considerable under reporting of cases in many vulnerable states like Jharkhand, Chhattisgarh etc.

The conditions are still unfavourable in many states in India, where the socio-economic and living conditions are unfavourable for the eradication of many diseases including TB. The major hurdles are related to overcrowding, childhood exposure and poor nutrition. Other factors are migration, TB comorbidity with HIV and Diabetes and migration of vulnerable sections of population to crowded slums/cities for livelihood. As many scholars had suggested,  improvements in socio-economic conditions played an important role in improvements in health status in the past (5). Certainly, this is the main constraint in the elimination of Tuberculosis from the world which means that technological solutions can only partially help in addressing the problem. Therefore, what is required is a multi-sectoral approach using Health in All Policy (HiP) as suggested by the WHO especially since TB is closely linked to conditions of living.

Prof. K Rajasekharan Nayar is affiliated to Global Institute of Public Health and Santhigiri Research Foundation, Thiruvananthapuram, Kerala. [email protected]

Dr. Arathi P Rao is the Coordinator of MPH Programme and the Head of Manipal Health Literacy Unit at the Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, India. [email protected]

Dr. Lekha D. Bhat is Assistant Professor in the Department of Epidemiology and Public Health at Central University of Tamil Nadu, India. [email protected]

Dr. Anant Kumar is an Associate Professor at Xavier Institute of Social Service, Ranchi, India. [email protected]

Dr. Parul Malik is a medical doctor with a Master of Public Health (Global Health) degree from Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, India. [email protected]


  1. WHO, Global Tuberculosis Report 2020.
  2. Karnataka is among nine States that accounts for 65% of tuberculosis cases. The Hindu [Internet]. 2020 Feb 24 [cited 2020 Oct 17] Available from:
  3. India TB Report 2019. RNTCP Annual Report [Internet] [cited 2020 Oct 17]. Available from:
  4. India TB Report 2020. RNTCP Annual Report [Internet] [cited 2020 Oct 17]. Available from:
  5. Rajasekharan Nayar. To Be or Not to Be: Is TB Elimination Possible in India Through a Humanistic Approach? BMJ Medical Humanities, May 13, 2019




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