Socioeconomic impact of tuberculosis on patients: Further study needed.

Sir,

I read with interest the recently published article by Ananthakrishnan et al. in your journal.[1] The authors’ observation that the social impact of tuberculosis (TB) was perceived by 69% of patients, economic impact by 30%, and both types of impact by 24% of the patients is very interesting. Despite the implementation of directly observed treatment short course (DOTS) strategy, the high socioeconomic impact of tuberculosis care to patients and their families is a major challenge to delivery of TB services in developing countries.[2] In India, previous studies have demonstrated high socioeconomic impact of TB care to patients even with the implementation of the DOTS strategy.[34] The authors’ conclusion suggests that the decentralisation of DOTS services was associated with reduction of the economic impact of TB to patients in Chennai.

I wish to present some further points that the study did not address. Patients’ perception of social or economic impact may actually differ from the real socio-economic impact of TB care faced. It is not clear what economic roles families play in supporting care-seeking for TB patients. However, patients from extended family setting perceived more economic impact.[1] It might have been better to present the total, prediagnostic and postdiagnostic costs incurred by patients who perceived or did not perceive economic impact due to TB in the study. This would have suggested if there are particular thresholds of spending which when exceeded patient perceive economic impact due to TB. Also, it would have allowed us to compare patient costs of TB during the early period of DOTS compared to the current period where there is full DOTS coverage.

Similarly, perceived social impact may differ from the real social impact faced due to TB. It was very informative that more than two-thirds of the perceived social impact was because of fear,[1] this lead to failure of disclosure to family members and indeed disease transmission to some (children). Additional information which would have been very important was to inquire from the patients if they lost their job, dropped from school, had separation/divorce from spouse, or had disruption of sexual life. However, their finding points to a valuable policy implication. There is need to adjust patient/community education and counselling against fear of disclosure following TB diagnosis.

Finally, I wish to thank the authors for such an important study. I hope their findings would attract the attention of health policymakers for better control of TB in India and other developing countries.