Sargam Choudhury

Tuberculosis in Urban Slum-Dwelling Men in Bangladesh

Sargam Choudhury
Introduction
Bangladesh is one of several countries wherein the population is heavily at risk for tuberculosis, and is
categorized as a “high tuberculosis burden” country by the World Health Organization (Tuberculosis, 2023).
Even though the national government has implemented several programs that have the potential to treat and
prevent tuberculosis cases, like the NTP, the number of cases that continue to arise is alarming and has resulted
in a public health crisis in the country. There are many subpopulations that are at higher risk for being affected
with tuberculosis, but we are specifically looking to target Bangladeshi men living in urban slums. This
population is at a higher risk compared to the general population of Bangladesh specifically because urban
slums, with as compact as they are with large numbers of people, lead to high rates of transmission of
tuberculosis. Given that nearly half of Bangladesh’s urban population lives in slums, this is a matter of grave
importance.
In order to begin working on a permanent solution to this public health crisis, we must first look at the
causes of tuberculosis infection, as well as the factors that put urban slum residents at risk. The purpose of this
paper is to meticulously outline the causes and consequences of tuberculosis infection, highlight key statistics of
the crisis in both the general population and in urban slum-dwelling men, and provide context for how our
target population is at higher risk compared to the general population. Epidemiological models such as the
Social-Ecological Model and Cross-Cutting Themes will be utilized in order to outline the factors that increase
risk in urban slum-dwelling men. Essentially, we will set the foundation upon which the necessary actions to
eradicate the tuberculosis crisis in urban slum-dwelling men can be developed.

The Problem
Tuberculosis is a disease that is both preventable and curable, but it has an incredibly high transmission rate
and can be lethal if not treated rapidly and properly, mainly affecting the respiratory system. While it is found
all over the world and can infect anyone, the tuberculosis bacteria, also known as Mycobacterium tuberculosis,
affects certain populations at a much higher rate. People with comorbidities and/or weakened immune systems
caused by comorbidities, such as diabetes, HIV/AIDS, kidney disease, cancer, and drug abuse, are more likely
to get infected. Tuberculosis infection is also more likely to be found in areas of large gatherings, whether that
is a stadium full of people or a crowded residential community (Tuberculosis - Symptoms & Causes - Mayo
Clinic, 2023).
1
Sargam Choudhury

According to the Mayo Clinic’s overview of tuberculosis, the bacteria spreads primarily through respiratory
droplets; when someone speaks, coughs, or sneezes, respiratory droplets are released into the environment, after
which another person can breathe in the droplets, opening themselves up to infection as the bacteria enters the
lungs. There are three stages to a tuberculosis infection – primary infection, latent infection, and active disease.
In the primary infection stage, some people may have flu-like symptoms, but the majority of people have no
symptoms at all. The latent infection stage occurs if the immune system is able to keep the tuberculosis bacteria
under control, even though the bacteria survive. People with a latent tuberculosis infection experience no
symptoms of the disease at all. The active infection stage can occur either right after a primary infection or after
a latent infection and usually comes about because the immune system cannot control the infection, allowing
the bacteria to exponentially multiply. Symptoms for an active tuberculosis infection range from mild to severe,
and they usually worsen over several weeks. Beyond the lungs, active infection can be present in the kidneys,
liver, cerebrospinal fluid around the brain and spinal cord, heart, genitals, lymph nodes, skin, blood vessels, and
bones and joints. Symptoms of active infection requiring emergency care include sudden headache, chest pain,
seizures, confusion, difficulty breathing, coughing up blood, or blood in the stool.
Without proper and rapid treatment of tuberculosis, symptoms can worsen until the infection becomes
lethal. In countries with a high tuberculosis burden, like Bangladesh, high transmission and high fatality rates
are a common occurrence. A study performed in 2015-2016 concluded that the incidence of tuberculosis and
prevalence of sputum smear-positive tuberculosis among the general population was 221 per 100,000 people
and 113 per 100,000 people, respectively. The survey found that prevalence was higher among men as
compared to women, and higher in urban settings as compared to rural settings, although further research was
required at the time to confirm this (National Strategic Plan for TB Control 2021-2025, 2020). For a country
with a population above 164 million, this is an incredibly large incidence and prevalence rate already, but a later
study found that the prevalence of sputum smear-positive tuberculosis in urban slums was twice that of the
prevalence in the general population, at 253 per 100,000 people, placing urban slum dwellers at a much higher
risk of contracting and dying from tuberculosis than the general population (Banu et al., 2013).
In order to understand what puts urban slum-dwelling men at a higher risk, we can approach this problem
with the tried and true social-ecological model. The social-ecological model identifies and breaks down the
individual, interpersonal, community/institutional, and societal/political levels of this problem, and how it has
been developed and exacerbated over time. Epidemiological data of tuberculosis infection in urban slums
showed that “a higher likelihood of developing active tuberculosis was associated with smoking, previous
history of anti-tuberculosis treatment, and low BMI,” (Banu et al., 2013). Supporting this analysis, likely
individual factors that can increase risk of tuberculosis infection include malnutrition, past medical history, and
2
Sargam Choudhury

smoking practices, as well as inadequate hygiene and sanitation practices and a lack of knowledge regarding
infection prevention (Ferdous et al., 2022; Mahmud et al., 2022). Without further analysis, some possible
solutions to these individual factors may include the adoption of safer and cleaner hygiene practices, increased
health seeking practices, and the management of comorbidities (Bam et al., 2014; Hossain et al., 2014).
Interpersonal factors that potentially exacerbate tuberculosis transmission include expensive and unreliable
transportation to medical centers and very little emphasis on housing and nutritional support. Possible solutions
for these factors may include increased engagement between local healthcare providers and patients and
increased public housing endeavors (Arulchelvan & Elangovan, 2017; Lee et al., 2022). Community and
institutional factors that may have an effect on tuberculosis transmission includes limited availability to
adequate medical care (specifically insufficient utilization of tuberculosis screening), lack of knowledge
regarding tuberculosis, and clustered patients in areas with high population densities, for which possible
solutions may be peer-led tuberculosis screening and social media/mass media campaigns advocating for
tuberculosis prevention and treatment (Arulchelvan & Elangovan, 2017; Bam et al., 2014; Hossain et al., 2014;
Mahmud et al., 2022). Finally, societal and policy factors that can lead to the development and exacerbation of
tuberculosis are poverty, social stigma towards disease, and a lack of universal health insurance. Solutions for
these factors require government involvement, including federal support for urban slum dwellers, tightened
regulation of tuberculosis screening programs, communication regarding active cases within communities, and
increased access to health insurance options (Hasib et al., 2013). Although there has been a considerable
amount of work accomplished by the Bangladeshi government, especially through the establishment of the
National Tuberculosis Control Programme (NTP) and its plans to reduce the rate of tuberculosis transmission
and infection by 2025, the many factors that contribute to this public health crisis require further analysis and
detailed solutions.

Cross-Cutting Themes
Cross-cutting themes play an important role in how perspectives on public health crises can be developed.
There are three themes in this model that offer a holistic view of how a public health crisis is developed: Rights
and Social Justice, Lifecourse, and Environmental. Once we have an outline for each of these themes, we will
gain a better understanding of what issues persist and require more attention in our analysis.
First, we will dissect how social inequalities and racism impede on health and create challenges to achieving
health equity through the lens of Rights and Social Justice. The theme of Rights and Social Justice can help us
understand which populations are disproportionately affected due to structural discrimination, and how this
structural discrimination affects the spread of tuberculosis. Some possible factors that have led to the
3
Sargam Choudhury

development of this crisis in urban slum-dwelling Bangladeshi men may be the lack of rights for the
homeless/urban slum residents, poor access to healthcare, and the underutilization of social justice frameworks
in medicine in Bangladesh (Zwerling et al., 2017). Many urban slum dwellers are unable to break
socioeconomic barriers due to the discrimination they face, both socially and structurally. Because of this, they
are left to face issues like inadequate access to healthcare, which leads to an increase in tuberculosis cases.
Next, we will view how the health problem develops and is either maintained or eliminated over the course
of one’s life. This can be done through the Lifecourse theme, which can help us understand how tuberculosis
continues to be spread throughout high-risk populations. High-risk populations are primarily made up of those
who have lived in poverty and/or are residents of urban slums for most of their lives. If they choose to have
families, then the cycle continues. Developing on this, some possible factors that have maintained the
development of the tuberculosis crisis in our target population are life-long poverty, sustained malnutrition, lack
of educational opportunities, impaired immune system, and underlying medical conditions.
Finally, we will consider what factors in the physical and social environment influence health and create
challenges to achieving good health through the Environmental theme. This theme can help us understand how
the environment, as well as a lack of environmental justice, can lead to exposure to tuberculosis and an increase
in cases for our target population. Crowded living environments, poor ventilation, unsafe and unclean living
spaces, indoor air pollution, and active tuberculosis cases within the community are all factors that place urban
slum dwellers in a terrible position when it comes to tuberculosis prevention, as living in heavily polluted areas
with low ventilation increases the risk of exposure immensely.

Conclusion
Tuberculosis is already an incredibly dangerous disease to contract, but with added risk factors and lack
of rapid treatment, it can be deadly. For our target population of urban slum-dwelling Bangladeshi men, it is just
that. In a country that is already considered a “high tuberculosis burden” country by the World Health
Organization, the public health crisis that men in urban slums face is quickly spiraling out of control, even with
all of the labor that the Bangladeshi government has given to this cause. In order to approach this problem, we
first have outlined the causes and consequences of contracting tuberculosis, allowing us to comprehend the
importance of the task at hand. We then brainstormed factors that potentially put urban slum dwelling-
Bangladeshi men at a higher risk of contracting tuberculosis, using key statistics and popular epidemiological
models to guide our thought process as we move forward in developing an analysis of these determinants.

4
Sargam Choudhury

References

Arulchelvan, S., & Elangovan, R. (2017, October 1). Effective communication approaches in tuberculosis
control: Health workers’ perceptions and experiences. Indian Journal of Tuberculosis; Elsevier BV.
https://doi.org/10.1016/j.ijtb.2016.11.017.

Bam, K., Bhatt, L. P., Thapa, R., Dossajee, H., & Angdembe, M. R. (2014, August 27). Illness perception of
tuberculosis (TB) and health seeking practice among urban slum residents of Bangladesh: a qualitative
study. BMC Research Notes; BioMed Central. https://doi.org/10.1186/1756-0500-7-572.

Banu, S., Rahman, M. T., Uddin, M. K. M., Khatun, R., Ahmed, T., Rahman, M. M., Husain, M. A., & Van
Leth, F. (2013, October 21). Epidemiology of Tuberculosis in an Urban Slum of Dhaka City,
Bangladesh. PLOS ONE; Public Library of Science. https://doi.org/10.1371/journal.pone.0077721.

Ferdous, S., Chowdhury, F. N., Ali, M. L., Bodrud-Doza, M., & Rahman, M. M. (2022, October 20).
Assessment of urban sanitation status and management gaps in a metropolitan city, Bangladesh:
Potential challenges to achieve SDG 6. Frontiers in Water; Frontiers Media.
https://doi.org/10.3389/frwa.2022.950887.

Hasib, E., Khan, T. U. H., Sarker, M., Islam, S., Islam, A., Husain, A., & Rashid, S. F. (2013, January
1). Exploring the Roles, Practices and Service Delivery Mechanism of Health Service Providers
Regarding TB in Two Urban Slums of Dhaka. Current Urban Studies; Scientific Research Publishing.
https://doi.org/10.4236/cus.2013.14015

Hossain, S., Zaman, K., Quaiyum, A., Banu, S., Husain, A., Islam, A., Borgdorff, M. W., & Van Leth, F. (2014,
May 1). Care seeking in tuberculosis: results from a countrywide cluster randomised survey in
Bangladesh. BMJ Open; BMJ. https://doi.org/10.1136/bmjopen-2013-004766.

Lee, J. Y., Kwon, N., Goo, G. Y., & Cho, S. I. (2022, March 30). Inadequate housing and pulmonary
tuberculosis: a systematic review. BMC Public Health, 22(1). https://doi.org/10.1186/s12889-022-
12879-6.

Mahmud, S., Maqbool, M., Irfan, S. H., Muyeed, A., & Islam, A. (2022, October 11). Knowledge, attitude,
practices, and determinants of them toward tuberculosis among social media users in Bangladesh: A
cross-sectional study. PLOS ONE; Public Library of Science.
https://doi.org/10.1371/journal.pone.0275344.

National Strategic Plan for TB Control 2021-2025. (2020, March 13). National TB Control Programme.
https://www.ntp.gov.bd/wp-content/uploads/2022/03/Clear_FINAL_NSP-Bangladesh-2021-2025.pdf.

Tuberculosis - Symptoms & causes - Mayo Clinic. (2023, March 22). Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250.

Tuberculosis. (2023, April 21). www.who.int. https://www.who.int/news-room/fact-sheets/detail/tuberculosis.

Zwerling, A., Dowdy, D. W., Von Delft, A., Taylor, H. A., & Merritt, M. W. (2017, November 1).
Incorporating social justice and stigma in cost-effectiveness analysis: drug-resistant tuberculosis
5
Sargam Choudhury

treatment. International Journal of Tuberculosis and Lung Disease; International Union Against
Tuberculosis and Lung Disease. https://doi.org/10.5588/ijtld.16.0839.