Introduction
Tuberculosis (TB) remains one of the world’s most deadly infectious diseases, causing immense human suffering and death, particularly in the world’s most vulnerable populations. Despite significant global efforts to combat TB, the disease continues to wreak havoc, especially in regions afflicted by conflict and instability. The complex interplay between TB and conflict exacerbates the challenges of prevention, diagnosis, and treatment, leading to a disproportionate impact on populations in these areas. This article explores the global burden of TB, the challenges posed by conflict, and the international efforts to address this ongoing crisis.
Historical Context and Global Burden of Tuberculosis
Tuberculosis is an ancient disease, with evidence of its presence found in the remains of prehistoric humans. Known as “consumption” in the 19th century due to the severe wasting it caused, TB was once the leading cause of death in Europe and North America. The development of antibiotics in the 20th century, particularly streptomycin in the 1940s, led to significant reductions in TB cases in the developed world. However, TB never disappeared; instead, it became concentrated in low- and middle-income countries, where it remains a major public health issue.
Today, TB is the second leading infectious killer worldwide, after COVID-19. According to the World Health Organization (WHO), an estimated 10.6 million people fell ill with TB in 2021, and 1.6 million people died from the disease, including 187,000 people with HIV. The disease disproportionately affects impoverished and marginalized communities, particularly in regions of sub-Saharan Africa, Southeast Asia, and the Western Pacific, where healthcare systems are often under-resourced.
TB in Conflict-Affected Areas
Conflict zones represent some of the most challenging environments for TB control. The impact of conflict on TB is multifaceted, as wars and political instability lead to the destruction of healthcare infrastructure, displacement of populations, and the disruption of social and public health services. These conditions create an environment where TB can spread unchecked, and where access to diagnosis and treatment is severely limited.
The relationship between TB and conflict is a vicious cycle that further entrenches the disease within affected populations. In conflict zones, the breakdown of governance and law enforcement exacerbates the challenges of TB control. Public health campaigns that might otherwise educate communities about TB prevention and encourage individuals to seek early diagnosis are often halted due to security concerns.
Moreover, healthcare workers, who are vital in the fight against TB, face significant risks, including attacks, kidnappings, and lack of resources, which further undermines TB control efforts. The result is an environment where TB spreads more easily, and those infected are less likely to receive timely and effective treatment, leading to higher mortality rates and the potential for drug-resistant strains to develop.
Displacement and Overcrowded Living Conditions
One of the most significant challenges in conflict-affected areas is the displacement of large populations. Wars and conflicts force millions of people to flee their homes, often ending up in overcrowded and unsanitary refugee camps or informal settlements. These conditions are ideal for the transmission of TB, which spreads through the air when an infected person coughs or sneezes. In these settings, the disease can quickly become endemic, with many people remaining undiagnosed and untreated.
For example, in countries like Syria, Yemen, and South Sudan, years of conflict have led to massive displacement. Refugee camps in these regions are often overcrowded, with limited access to clean water, adequate nutrition, and healthcare services. The spread of TB in such environments is almost inevitable, as people with weakened immune systems, including those suffering from malnutrition or other diseases, are more susceptible to infection.
Disruption of Healthcare Services
The destruction of healthcare infrastructure is another critical factor that exacerbates the spread of TB in conflict zones. Hospitals, clinics, and laboratories are often targeted or collateral damage in conflicts, leaving vast areas without any functioning healthcare services. Even where healthcare facilities remain operational, the supply chains for essential medicines, including TB drugs, are often disrupted. This leads to shortages of medications, forcing patients to interrupt their treatment, which can cause the disease to become drug-resistant.
In Afghanistan, where decades of conflict have ravaged the country, the healthcare system struggles to provide even basic services. The prevalence of multidrug-resistant TB (MDR-TB) is particularly high, with the WHO estimating that around 11% of new TB cases in Afghanistan are drug-resistant. The situation is further complicated by the ongoing violence, which makes it difficult for healthcare workers to reach those in need, and for patients to travel to healthcare facilities.
Stigma, Discrimination, and Social Isolation
Stigma and discrimination associated with TB also play a significant role in the spread of the disease, particularly in conflict zones. In many parts of the world, TB is associated with poverty, poor hygiene, and even moral failings. People with TB are often ostracized by their communities, which can prevent them from seeking diagnosis and treatment. This stigma is compounded in conflict zones, where fear and mistrust are already high.
For instance, in the Democratic Republic of the Congo (DRC), where conflict has raged for decades, TB patients often face severe stigma and discrimination. This, combined with the lack of healthcare infrastructure, makes it incredibly challenging to control the spread of the disease. The DRC is among the top 30 countries with the highest burden of TB, with the disease spreading rapidly in areas affected by conflict.
The Role of HIV in TB Epidemics
HIV/AIDS has significantly impacted the global TB epidemic, particularly in conflict-affected regions. People living with HIV are much more susceptible to TB due to their weakened immune systems. In sub-Saharan Africa, where both HIV and TB are highly prevalent, the co-epidemic of these diseases presents a severe public health challenge. Conflict exacerbates this situation by disrupting HIV treatment programs, further weakening the immune systems of those living with HIV and increasing their risk of contracting TB.
The intersection of TB and HIV presents a unique and deadly challenge in conflict-affected regions, where both diseases can spread unchecked due to the collapse of health services. Conflict often disrupts the continuous supply of antiretroviral therapy (ART) for HIV patients, which is crucial for keeping their immune systems strong enough to resist TB. The breakdown in ART services means that people living with HIV in these areas are not only more likely to develop TB but are also less able to recover from it.
Furthermore, the stigma surrounding both HIV and TB can be particularly intense in conflict settings, where misinformation and fear are rampant, leading to further social isolation and reluctance to seek treatment. This creates a dangerous cycle of increased vulnerability and infection, which is difficult to break without coordinated international intervention.
Global Initiatives and the Role of the United Nations
The international community, led by organizations like the WHO and the United Nations (UN), has recognized the urgent need to address TB, particularly in conflict-affected regions. The WHO’s End TB Strategy, launched in 2015, aims to reduce TB deaths by 95% and cut new cases by 90% by 2035, with a focus on reaching vulnerable populations, including those in conflict zones. This strategy emphasizes the need for universal health coverage, social protection, and addressing the social determinants of health, such as poverty and malnutrition, which are particularly relevant in conflict settings.
In addition to the WHO, the United Nations has been actively involved in the fight against TB through various initiatives. The UN General Assembly held its first-ever high-level meeting on TB in September 2018, where world leaders committed to accelerating efforts to end the TB epidemic by 2030, as part of the Sustainable Development Goals (SDGs). The meeting resulted in the adoption of a political declaration on TB, which includes commitments to increase funding for TB prevention, diagnosis, and treatment, particularly in high-burden and conflict-affected countries.
Humanitarian organizations such as Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC) also play a crucial role in providing TB care in conflict zones. These organizations often operate in areas where government services are non-existent or severely limited, offering diagnosis, treatment, and follow-up care for TB patients. However, their work is often hampered by insecurity, lack of funding, and the challenges of operating in conflict environments.
Challenges and the Way Forward
Despite the global initiatives and efforts, significant challenges remain in the fight against TB in conflict-affected regions. The ongoing violence in many of these areas makes it difficult to reach all those in need of care. Moreover, the COVID-19 pandemic has further strained healthcare systems, diverting resources away from TB programs and leading to a decline in TB diagnoses and treatment. According to the WHO’s Global Tuberculosis Report 2022, the pandemic reversed years of progress in the fight against TB, with TB deaths increasing for the first time in over a decade.
To effectively combat TB in conflict-affected regions, a multifaceted approach is needed. This includes strengthening healthcare systems, ensuring the consistent supply of TB medications, and addressing the social determinants of health, such as poverty, malnutrition, and overcrowding. Additionally, it is essential to combat the stigma associated with TB, encouraging individuals to seek care without fear of discrimination.
The global community must also focus on increasing funding for TB programs, particularly in conflict-affected regions. The WHO estimates that the global TB response is underfunded by nearly $8 billion annually. Bridging this funding gap is critical to scaling up TB prevention, diagnosis, and treatment services in high-burden countries, particularly those affected by conflict.
Conclusion
Tuberculosis remains a significant global health threat, particularly in conflict-affected areas where the disease can spread rapidly and is harder to treat. While international efforts have made progress in reducing the global burden of TB, much work remains to be done, particularly in reaching the most vulnerable populations. By addressing the unique challenges posed by conflict and instability, and by increasing global investments in TB control, the international community can make strides toward eliminating this deadly disease and saving millions of lives.
