Running head: TUBERCULOSIS AWARENESS

Populations Threatened by Tuberculosis

Ronda Mott
Ferris State University

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Populations Threatened by Tuberculosis

One of the most medically vulnerable populations in both the United States and globally,
is the community of persons at risk for new tuberculosis (TB) infections. Although the disease
was known to prehistoric human cultures and manifested in ancient Egyptian and early European
civilization, TB remains a worldwide infectious threat even today. According to the World
Health Organization (2010) TB plagued over two billion with latent infections and killed 1.7
million internationally in 2009 alone, alongside some 9.4 million distinct new and 14 million
ongoing illnesses in the same year (World Health Organization, 2010). Despite generally
decreasing overall TB rates in the United States, TB remains one of the most important
infectious diseases listed among the thirty-six Nationally Notifiable Infectious Conditions in the
United States for 2011 (Veenema, 2013, p. 236) and is actually on the rise in many vulnerable
geographic pockets of the country and of the world.
Prior to studying this vulnerable demographic, I have typically assumed, when
considered worldwide, that the populations at risk for TB were ordinarily those who were
predisposed due to endemic disease risk factors and naturally followed from the comparative
global shortfall of healthcare access, infrastructure, personnel and resources common to nonwestern countries and territories. As such, I typically viewed the populations at risk for TB in the
U.S. as products of those environments and likely to be immigrant, non-white,
socioeconomically deprived, non-English speaking, new to the United States, victims of
predisposing illnesses such as HIV and likely to have spent time in high risk infectious settings
such as prisons, mental health institutions or even reservations (Verma, EG-Upshur, Rea, &
Benatar, 2004).

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However, a review of the literature paints a different picture as to who is constituent in

this susceptible group. For example, contrary to my initial assumptions, according to Herchline
(2014), although the genetics of TB are complex, compelling evidence suggests many immune
system chromosomes and genetic variances dictate either protection from or susceptibility to TB.
These genetic tendencies may explain the almost ten-fold greater proclivity for the disease in
Blacks, Native Americans, Pacific Islanders and Hispanics when compared to Caucasians
(Herchline, 2014). However, consistent with my initial bias, is the fact that vulnerability to TB is
predictable among the economically disadvantaged, including homeless and indigent persons,
inner city residents, persons of color, foreign-born individuals from high TB incidence countries,
HIV seropositive persons, immigrants, persons with substance abuse problems, injection drug
and alcohol abusers, smokers, residents in institutional settings such as corrections and long term
care facilities, persons with certain chronic diseases, including diabetes, renal failure, cancer and
other debilitating conditions (Parr, Leonard, & Blumberg, 2013). New to my understanding
however, according to Herchline (2014) age and sex related TB risk demographics in the U.S.
include increasing disease in younger persons in general, however, an inclination toward
increased disease in older men and a declining incidence in older women, regardless of the
aforementioned risks.
As an extension of my prior view of what traits defined the populations threatened by TB,
social conditions that predispose to TB disease and its spread are well understood: overcrowding, inadequate housing, malnutrition, lack of timely access to medical care and
medication inordinately plague the typecast risk groups. Tuberculosis remains a scourge of
marginalized populations that continue to live in conditions that increase their vulnerability to

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TB and have difficulty accessing comprehensive treatment and following it through to

completion or education about their illness.
The fact in sharpest contrast to my previous bias according to Ellner (2012) reveals that
despite traditional risks for increased infection susceptibility, the U.S. and western countries see
increased TB rates in patients who have been the beneficiaries of other western medical marvels.
In the last two decades, TB risk is climbing in solid organ transplant recipients, renal
hemodialysis patients, gastrectomy, jejunoileal bypass and weight loss bariatric surgery patients,
cancer survivors of leukemia, head and neck, lung, lymphoma and other solid organ
malignancies and a new generation of U.S. patients being increasingly treated with
immunosuppressive therapies including immune modulators, tumor necrosis factor inhibitor and
monoclonal antibody therapy for inflammatory diseases and arthritis. Despite the cutting edge
gains made in the lives of these patients, an unfortunate byproduct of their treatment successes
now include increasing TB incidence and mortality (Ellner, 2012, p. 1940).
After research into the TB vulnerable population, I was glad to find that many of my
previously held conclusions and training was reinforced and supported by the literature. More
revealing, however, was my discovery of risk demographics and conditions that predispose to
TB, including genetic and iatrogenic factors that were heretofore unknown to me and have
completely reshaped my thinking about what constitutes TB risk. Most interesting and sobering
for me is the fact that the populations who have benefitted from medical breakthroughs are
commonly the new face of TB risk, who are in many cases disproportionately represented in my
radiation oncology practice. Such a revelation immediately impacts how I will risk assess these
patients for continuity care and treatment in the future.

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Inherent in the biases that health care professionals harbor toward certain patient
populations is the risk of the disparities they may create or contribute to in terms of disease
recognition and burden, timeliness, quality and comprehensiveness of the delivery of health care
and the utilization of resources toward specific populations. Sadly, such clinical bias is the
byproduct of incomplete and dated information, limited clinical experiences, geographic
variations and both institutional and individual proclivities of the persons caring for at risk
populations. Further, diseases like TB raise several issues including stigmatization of infected
individuals, including cultural and economic fallout from acquiring TB, that shape perceptions,
ingrain certain biases and strain ethical standards while subsequently effecting care. As an
example, according to Verma, EG-Upshur, Rea, and Benatar (2004) one central ethical divide
concerning TB control consists of balancing the patient's rights and autonomy with the protection
of the public's health. Given the disease consequences, TB is indeed a serious threat to
communities, which deserve protection from exposure to TB and attention to the means to curtail
its spread. Simultaneously, individuals in liberal democracies maintain the right to personal
autonomy and privacy. Interventions such as directly observed TB therapy, detention and
mandatory treatment entail a substantial reduction of patient autonomy not customarily found in
other areas in clinical medicine. On a larger scale, TB can be viewed as a human rights issue,
raising important questions about equity regarding who suffers the most from the disease and the
global imbalance with regard to disease burden and the implied social compact that the health
care complex and public policy have to alleviate suffering (Verma et al., 2004). Knowledge of
these kinds of misinformation, perceptions, controversies, ethical dilemmas and the individual
and institutional predispositions that flavor the response to and treatment of a disease in such a

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vulnerable population are essential to crafting accurate and responsive public health policy as
well as my own individual standards for private practice.

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7
References

Eller, J. J. (2012). Tuberculosis. In L. Goldman & A. Schafer (Eds.), Goldman's Cecil Textbook
of Medicine (24th ed., pp. 1939-1947). Philadelphia, PA: Elsevier Publishing.
Herchline, T. E. (2014). Tuberculosis. Retrieved from http://www.medscape.com
Parr, J. B., Leonard, M. K., & Blumberg, H. M. (2013). Scientific American Medicine. Hamilton,
ON: Decker Intellectual Properties. Retrieved from http://www.sciammedicine.com
Veenema, T. G. (2013). Disaster Nursing and Emergency Preparedness (3 ed.). New York, NY:
Springer Publishing Company, LLC.
Verma, G., EG-Upshur, R., Rea, E., & Benatar, S. R. (2004). Critical reflections on evidence,
ethics and effectiveness in the management of Tuberculosis: Public health and global
perspectives. BMC Medical Ethics, 5(2), . doi:10.1186/1472-6939-5-2
World Health Organization (2010). Global Tuberculosis Control 2010. Retrieved from
http://www.who.int/tb/publications/global_report/en/
World Health Organization (2013). Countdown to 2015 global Tuberculosis report 2013
supplement. Retrieved from http://www.WHO_HTM_TB_2013.13_eng.pdf