Determinants of tuberculosis in Indigenous people worldwide
Authors: Paulo Cesar Basta, Paulo Victor de Sousa Viana
Journal: The Lancet Global Health (2018)

Tuberculosis remains one of the main health concerns affecting Indigenous populations worldwide. Several studies present evidence that the incidence of active tuberculosis and prevalence of latent tuberculosis are substantially higher in Indigenous groups than in non-Indigenous populations.1Tollefson D Bloss E Fanning A Redd JT Barker K McCray E Burden of tuberculosis in indigenous peoples globally: a systematic review.Int J Tuberc Lung Dis. 2013; 17: 1139-1150Crossref PubMed Scopus (56) Google Scholar According to Lönnroth and colleagues,2Lonnroth K Jaramillo E Williams BG Dye C Raviglione M Drivers of tuberculosis epidemics: the role of risk factors and social determinants.Soc Sci Med. 2009; 68: 2240-2246Crossref PubMed Scopus (629) Google Scholar this scenario might reflect proximate determinants such as overcrowding, tobacco, and alcohol use, as well as clinical conditions; and upstream social determinants such as poverty, food insecurity, housing conditions, insufficient work opportunities, ethnic prejudice, and poor access to education and health care. In The Lancet Global Health, Maxime Cormier and colleagues3Cormier M Schwartzman K N'Diaye DS et al.Proximate determinants of tuberculosis in Indigenous people worldwide: a systematic review.Lancet Glob Health. 2019; 7: e68-e80Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar present an overview of the prevalence of proximate determinants of tuberculosis in Indigenous populations worldwide. This review included a highly comprehensive and sensitive systematic search strategy as well as eligibility criteria that were standardised and rigorous for the studies, considering the past four decades. The authors identified 34 255 articles, of which 475 were included. Most of the studies confirmed a higher prevalence of the proximate determinants among Indigenous populations. Illicit drug use, food insecurity, and tobacco use were the predominant risk factors in Indigenous people worldwide. Diabetes and alcohol binging were more prevalent in Indigenous people from high-income countries than in those from low-income countries. According to the authors, given the dearth of the literature, it was not possible draw reliable conclusions on HIV, crowding, and housing conditions. Since Cormier and colleagues3Cormier M Schwartzman K N'Diaye DS et al.Proximate determinants of tuberculosis in Indigenous people worldwide: a systematic review.Lancet Glob Health. 2019; 7: e68-e80Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar used the UN4UNState of the world's indigenous peoples. United Nations Department of Economic and Social Affairs, Division for Social Policy and Development, Secretariat of the Permanent Forum on Indigenous Issues, New York2009Google Scholar definition of Indigenous people—mainly characterised by self-identification—the articles included in the review addressed an enormous diversity of ethnic groups. These groups comprised native people of Latin and North America, Australian Aboriginals, Roma and Iranian Gypsy people, Cameroon Baka people, San people in Namibia, Nigeria Andibila, Scheduled Tribes of India, people from Taiwan, Malaysia, and Bangladesh, among others. We believe that the UN's definition of Indigenous people is the best way for Native people to claim their rights (human, social, political), to struggle for inclusion in mainstream societies, to valorise their culture, their language, and other aspects of traditional knowledge. Nevertheless, we should be cautious in the interpretation of the findings because this huge diversity might have introduced a great level of heterogeneity in the data and, at least hypothetically, might have biased the results. For example, the concept of food insecurity, as well patterns of alcohol and tobacco consumption, can vary greatly between different cultures and regions. Although supported by the UN declaration on the Rights of Indigenous Peoples,4UNState of the world's indigenous peoples. United Nations Department of Economic and Social Affairs, Division for Social Policy and Development, Secretariat of the Permanent Forum on Indigenous Issues, New York2009Google Scholar Indigenous people remain at the margins of society. This exclusion has serious consequences and results in large disadvantages, which are especially reflected in health indicators. As mentioned by some authors,5Anderson I Robson B Connolly M et al.Indigenous and tribal peoples' health (The Lancet–Lowitja Institute Global Collaboration): a population study.Lancet. 2016; 388: 131-157Summary Full Text Full Text PDF PubMed Scopus (536) Google Scholar, 6Gracey M King M Indigenous health part 1: determinants and disease patterns.Lancet. 2009; 374: 65-75Summary Full Text Full Text PDF PubMed Scopus (795) Google Scholar Indigenous people present higher rates of illness, especially because of a high burden of infectious diseases, as well injuries, disability, mental, and emotional disorders, and higher rates of mortality, when with to their non-Indigenous counterparts. Tuberculosis is no exception. Dehghani and colleagues7Dehghani K Lan Z Li P et al.Determinants of tuberculosis trends in six Indigenous populations of the USA, Canada, and Greenland from 1960 to 2014: a population-based study.Lancet Public Health. 2018; 3: e133-e142Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar did a population-based study among six indigenous populations of the USA, Canada, and Greenland from 1960 to 2014. That study aimed to investigate whether interventions specific to tuberculosis were associated with changes in tuberculosis notification rates. BCG vaccination and screening and treatment for latent tuberculosis were associated with decreases in reports of tuberculosis and the authors concluded that these interventions should be reinforced in populations still affected by the disease, while also addressing the persistent health and socioeconomic disparities. During analyses of the ethnic and racial inequalities in notified cases of tuberculosis in Brazil during 2008–11, Viana and colleagues8Viana PV Gonçalves MJ Basta PC Ethnic and racial inequalities in notified cases of tuberculosis in Brazil.PLoS One. 2016; 11: e0154658Crossref PubMed Scopus (22) Google Scholar showed that, apart from the distribution of tuberculosis being heterogenous among the Brazilian regions, ethnic and racial inequalities persist, revealing that the highest rates of the disease were reported among Indigenous populations. To achieve the UN Sustainable Development Goals, especially the goal that recommends the end of the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases by 2030, we believe that it is essential that Indigenous community members are directly involved in the conception and development of any kind of intervention. Similarly, the Global Plan to End TB and key populations from the Stop TB initiative9Stop TB PartnershipKey Populations Brief: Indigenous Peoples.http://www.stoptb.org/assets/documents/resources/publications/acsm/6_27-unops-kpb-indigenous-web.pdfDate accessed: November 2, 2018Google Scholar recommend that Indigenous groups are consulted at all levels of policy and intervention design for tuberculosis before programme implementation. To illustrate the potential of this intervention technique, Cormier and colleagues3Cormier M Schwartzman K N'Diaye DS et al.Proximate determinants of tuberculosis in Indigenous people worldwide: a systematic review.Lancet Glob Health. 2019; 7: e68-e80Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar identified 55 articles in their review that addressed culturally appropriate preventive programmes. According to the authors, the programmes yielded improved acceptability if the community was directly involved in its conception. Likewise, a well designed initiative done in 32 contiguous shanty towns in Callao, Peru, produced strong evidence that a socioeconomic support intervention that was specific to tuberculosis increased the uptake of tuberculosis preventive therapy and treatment success.10Wingfield T Tovar MA Huff D et al.A randomized controlled study of socioeconomic support to enhance tuberculosis prevention and treatment, Peru.Bull World Health Organ. 2017; 95: 270-280Crossref PubMed Scopus (52) Google Scholar Furthermore, Malacarne and colleagues11Malacarne J Kolte IV Freitas LP et al.Factors associated with TB in an indigenous population in Brazil: the effect of a cash transfer program.Rev Inst Med Trop S Paulo. 2018; 60: e63Crossref PubMed Google Scholar have studied risk factors associated with active tuberculosis in the second-largest Indigenous population in Brazil and showed that the Brazilian cash transfer programme (family allowance) was the main predictor in the prevention of tuberculosis in that region. Finally, as recommended by WHO's End TB Strategy,12WHOThe End TB strategy. World Health Organization, Geneva2015http://www.who.int/tb/End_TB_brochure.pdf?ua=1Date accessed: November 2, 2018Google Scholar we believe that to address the proximate determinants of tuberculosis it is necessary to consider not only bold policies and supportive systems, but also action on social protection and poverty alleviation. This combination can work towards reducing health inequalities and the burden of tuberculosis in Indigenous people worldwide. We declare no competing interests. Proximate determinants of tuberculosis in Indigenous peoples worldwide: a systematic reviewIndigenous peoples were generally reported to have a higher prevalence of several proximate determinants of tuberculosis than non-Indigenous peoples, with wide variation across Indigenous communities. These findings emphasise the need for community-led, culturally appropriate strategies to address smoking, food insecurity, and diabetes in Indigenous populations as important public health goals in their own right, and also to reduce the burden of tuberculosis. Full-Text PDF Open Access