Is Saving Millions from TB Realistic or Wise?

I saw a tweet the other day from Bill Gates about TG. He says we can save the population of Paris each year if we eradicate TB. He’s statistically correct. I think there is much more to the story, however, something that really bothers me at a more basic level. It’s another one of those discourses where I am very, very likely to get some people yelling and some people screaming, and the bleeding heart “think about the children” types will probably go off the deep end. However, it’s a discussion that must be had, needs to be had, and dammit, I want to have. The concept is pretty simple, if we do in fact save 1 plus million people from dying of TB and keep another 8 million or so from contracting the illness, what happens then?

A little background first before we discuss anything. The World Health Organization has a wonderful interactive map of where TB occurs, where people die, and the like. One look at the map will tell you where this discussion is going, and why it will be uncomfortable for some people. The TB map is almost a perfect overlay for human development and human advancement, as well as a map of the difference between stable governments (of the people) and less stable / communist countries. It is also a fairly good overlay for population growth rate maps such as this one, with the exception basically that Russia’s population is pretty stagnant. Otherwise, it’s all there.

So you can combine these three known items and draw some interesting conclusions. Stable, generally democratic countries have lower population growth and much lower instances of TB. In countries with higher birth rates and either unstable governments or governments not of (and for) the people, you have higher instances of TB and generally higher population growth. Let’s consider that very carefully and think about the implications there before I move forward. TB (and many other so called “curable” diseases) tend to thrive in certain areas because the governments aren’t working to care for the people, and where the increases in population are a heavy burden on society.

The proof in the pudding on this one is China. China has a strong central government but until the late 1990 was not one that took much consideration of the “for the people” concept. in 1990, their TB rate was 19 per 100,000, and with better government, increased wealth for the people, and better levels of information and protection, that rate is now down to 3 per 100,000. China’s government has spent strongly to improve the medical infrastructure, and with increases in personal income, more of it’s citizens are able to take care of themselves. Better communication about disease control and better coordination on the ground has contributed greatly to resolving the issue. It could also be said that China’s one child policy during the time frame has helped to slow population growth and make it possible for both the government and individual families to get ahead of the curve on many diseases. It’s not perfect, but an 84% reduction is certainly a marked improvement.

There is the second key component in all of this, population. While the change in China has certainly saved millions of lives, it has happened at the same time as lower population growth, lower birth rate, and a better understanding overall that we as a people cannot continue to reproduce like rabbits and hope to have enough food, water, and space to go around.

The true problem spots are the poorest countries, the weakest governments, and populations that are either uneducated or who live with superstitious fears that impede the spread of disease. The situation of HIV is a perfect example, Africa has 10 times the prevalence of HIV infected people 18 to 49 than anywhere else in the world. It is also slow going to try to get it down from it’s peak, this map of reduction in HIV since 2010 is pretty telling. The countries of central Africa are having a very hard time to change the course of HIV. That gets back to the problem of weak governments, weak social spending, weak medical care, and a population that is ill informed and often follows exactly the wrong advice passed down through the generations. HIV in Africa has ravaged a region where unprotected sex in the norm, promiscious behavior (particularly by men) is significant, rates of rape are high, and many consider anal intercourse as a valid method of birth control or retaining one’s virginity for marriage. All of those things provide solid vectors for the disease to riddle the population, and that is just what it’s done.

The point here is that all the medication, all of the help, all of the contributions, and all of the knowledge cannot and will not fix the problems in those regions most affected because there are much bigger underlying issues that drive the spread of disease. While we know how to minimize the risks of HIV and to cut back the spread, it’s very hard to accomplish this when the majority of the people in an area act exactly in ways that increase the spread.

it applies especially to TB because TB is very easily spread. According the the US center for Disease Control,

TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected.

In countries where people live close together, who don’t have access to medical help, who absolutely need to work and be out every day to obtain their sustenance level living, or where there is significant human interaction (such as over crowded buses, trains, and the like) the spread of TB is hard to check. It is incredibly doubtful that any agency or group (even that lead by Bill Gates himself) has enough manpower, time, and skill to change the course of a society as a whole. In the long fight against HIV, we continue to see that the stubborn ignorance of the population and the lack of strong governments to work thwart that ignorance is the key contributor to the problem. It is perhaps not realistic to think that you can truly “save” people until the people can save themselves. HIV in Africa will not go away until there are significant cultural and economic changes that help to stop the ignorant actions of many. TB (and many other diseases) fall into the same set of problems: People who don’t know how to protect themselves, who don’t know how to protect others when they get sick, and people who’s economic life is such that they cannot and will not remove themselves from society when sick, because they need to feed themselves and their families.

So it may not be realistic to think you can fix the problem of TB, and even if you vaccinate the entire population. Even with 100% success rate, you still will get some cases, and more over, you failed to fix the true underlying issues at hand. That brings on the risk: What’s next?

The problem here is that saving a million people a year from TB deaths many only mean that you get a million more of something else, because the people are still ignorant about spreading disease, still unaware or unable to stop behaviors that will cause disease to spread, and more over you add additional population strain to areas that already have high birth rates and high population increases. The governments and the land cannot adequately support there people that are there now, saving another 10 million people and adding in their offspring to the game makes it even worse. These are societies where the cultural norms of family size and birth rates come from the ingrained knowledge that many of the children will die before adulthood, and that the adults will not live as long. You can look at maps of infant birth rates and life expectancy maps to understand the reality that many of these places live with.

My point is simple: if you want to change the courses of disease, you must address the underlying issues. Improving lifespan without dealing with the social and economic issues of explosive population growth, the land being unable to support that population, and weak central governments unable to care for their people is going to lead to bigger and further disasters down the road. The risk we face in saving a million people from TB deaths a year is an economic or health disaster just down the road waiting to take them out again. It’s a vicious cycle, and unless the underlying causes are addressed and dealt with, all the prevention in the world will just shift the problem and create new and perhaps larger problems that will be even harder to fix.

So Mr Gates, perhaps ever dose of vaccine should be equaled with a dose of reality and social intervention as well. The true disease for most of these cases isn’t the TB or the HIV or anything like that, it’s the ignorance and lack of education and information getting to the people. Perhaps better educating the people about the spread of TB (and disease in general) and trying to overcome the superstitions and old wives tales that guide many of the people would go much further to fixing the problem.

That’s what China did. It’s working.