DISPATCHES

Wealth Inequality out after the resurgence of TB in the late 1980s in North
America and in Europe indicated that, along with HIV in-
and Tuberculosis fection and drug resistance, socioeconomic factors were a
major determinant in acquiring TB (8,9). The 27 EU mem-
Elimination in ber states, with a wide distribution of TB notification rates

Europe
(4–138/100,000 population/year) as well as diverse levels
of wealth as measured by gross domestic product (GDP) in
purchasing power standards (PPS) per capita (8,600–63,100)
Jonathan E. Suk, Davide Manissero, (Eurostat; http://epp.eurostat.ec.europa.eu), represent an op-
Guido Büscher, and Jan C. Semenza timal setting in which to analyze whether a correlation can
be detected between wealth, social cohesion, and TB.
In Europe, wealth inequality is directly related to tu-
berculosis (TB) notification (R2 = 0.69), while in countries The Study
with lower TB rates, higher proportions of TB cases occur
In this ecologic study, distribution of TB prevalence
in foreign-born persons. Particularly during times of finan-
cial upheaval, efforts to eliminate TB must address social
rates (all forms, per 100,000 population per year, 2006)
inequality. (10) for each EU member state was plotted against 2 mea-
sures of income distribution to examine the most descrip-
tive indicator of how socioeconomic setting relates to TB

T he current global financial crisis may be expected to

exacerbate health inequalities (1), which in turn lead to
differential health outcomes (2,3). In Europe, for example,
prevalence in Europe: 1) the Gini coefficient, a common
measure of inequality of income distribution within a coun-
try (11); and 2) Eurostat’s inequality of income distribution
discrepancies between those living in lower and higher so- ratio, which measures the ratio of total income received
cioeconomic positions are manifested through differential by the 20% of the population with the highest income (top
death rates from chronic diseases, such as cardiovascular quintile) to that received by the 20% of the population with
and cerebrovascular diseases, as well as alcohol- and smok- the lowest income (lowest quintile). The Gini coefficient
ing-related diseases (4). was not strongly associated with TB prevalence in Europe
Similar discrepancies also exist for communicable (R2 = 0.22), nor was Eurostat’s inequality of income distri-
diseases. A comprehensive literature review demonstrated bution ratio (R2 = 0.34).
that in every European Union (EU) member state, vulner- Hypothesizing that the quantification of a country’s
able groups (those with low educational or income levels, wealth (i.e., GDP), along with its distribution, would cor-
migrants, persons engaged in high-risk lifestyles) have a relate better than either indicator separately, we computed
disproportionately higher incidence of communicable dis- an indicator called the public wealth index (PWI). This
eases (5). However, because the overall effect of commu- index divides a nation’s economic wealth (using Eurostat
nicable diseases is currently estimated to be 9% of total data on GDP in PPS per capita) by its level of social cohe-
diseases in Europe, such differences are difficult to quan- sion (using the Eurostat inequality of income distribution
tify (6). Furthermore, surveillance systems do not system- ratio). Effectively, this metric takes the relative high level
atically capture indicators of socioeconomic status (such as of wealth in Europe into account while also controlling for
education, occupation, ethnicity, or housing tenure) or link its distribution. It favors wealthy countries with low ratios
those indicators to specific persons. of income inequality: the top 5 scores on the public wealth
Tuberculosis (TB) provides a good case study for fur- index were generated by Luxembourg, Norway, Denmark,
ther analyzing correlations between communicable diseases Sweden, and the Netherlands.
and wealth distribution. Historically, the decline of TB in- Using the PWI, we then developed a simple regres-
cidence in Europe preceded the advent of anti-TB drugs sion model to explain TB prevalence rates. Because of the
and coincided with rapid improvement of quality of life structure of the data, we used a log-log transformation in R
(7). Whether this link continues to be valid for high-income version 2.8 (12). The explanatory variable (PWI) and the
countries remains an open question. Earlier studies carried dependent variable (TB prevalence rates), were log-trans-
formed. We analyzed all 27 EU member states as well as
Author affiliations: European Centre for Disease Prevention and
Norway and Iceland. The model yielded a strong inverse
Control Scientific Advice Unit, Stockholm, Sweden (J.E. Suk, D.
relationship between PWI and TB rates with a correlation
Manissero, G. Büscher, J.C. Semenza); and University of Cologne
coefficient of R2 = 0.69. The differences when using the
Institute of Health Economics and Clinical Epidemiology, Cologne,
estimator for the intercept parameter in the model (14.36,
Germany (G. Büscher)
p<0.001) and when using the estimated regression param-
DOI: 10.3201/eid1511.090916 eter for the logarithmic PWI (–1.39, p<0.001) were both

1812 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009
 Wealth Inequality and Tuberculosis, Europe

significant. The observed values and the regression line

with no log transformation are shown in the Figure.
Finally, to demonstrate the differences in the composi-
tion of TB populations between countries, we plotted the
percentage of foreign-born TB case-patients within a coun-
try (a surveillance proxy for immigrant populations, which
is typically defined as place of birth, except in Austria, Bel-
gium, Bulgaria, Malta, and Poland, where it is defined as
place of citizenship as reported in 2006) (10). As countries
rank higher on the PWI, the proportion of TB case-patients
that are foreign-born generally increased (Figure). With in-
creasing PWI status, TB rates dropped, but the proportion
of foreign-born TB case-patients increased.

Conclusions
We demonstrate a strong inverse relationship between
PWI scores and TB rates. The data presented here are, how-
ever, subject to important limitations. First, aggregation Figure. Public wealth index and tuberculosis (TB) prevalence rates
bias is inherent in all ecologic studies, which are not able to in the 27 European Union member states plus Norway and Iceland,
disaggregate individual level risk factors important in TB 2006.
transmission. Second, national-level surveillance informa-
tion consists of few socioeconomic indicators. One of the
indicators, foreign born, is perhaps an unfortunate proxy turning jobless migrants might also be particularly vulner-
term for migrant populations, but it is the only one avail- able if they are no longer able to access their country’s so-
able. The term is further limiting because definitions of cial insurance systems. Thus, particularly for countries with
foreign born vary between countries, as discussed earlier. high incidences of TB, advancing social equalities is fully
Third, inconsistencies in TB reporting likely occur across compatible with the aim of lowering TB prevalence rates.
the European Union, although this would in any case bias Indeed, addressing social and environmental determinants
the results away from the null hypothesis. (such as social inclusion, education and training, crowding,
Nevertheless, given the strong correlation between the and indoor air pollution) could pay dividends in the fight
PWI and TB rates across Europe, as well as the strong trend against TB during difficult economic times.
linking high PWI with higher rates of TB among foreign- Data related to the financial crisis and its effects on
born populations, our data lend support to the notion of en- public health will need to be carefully scrutinized as they
suring equality, both within and between nations, as an im- become available. In the meantime, the public health com-
portant building block for effective TB control. Yet, as the munity must continue to both defend and act upon the in-
Figure suggests, especially for countries with higher scores sights from the World Health Organization Commission
on the PWI, emphasis must also be placed on directly en- on the Social Determinants of Health, which has so elo-
gaging specific vulnerable groups for public health action, quently inserted discussion of social inequalities into pub-
whether these groups consist of foreign-born persons, HIV- lic health discourse (3). Addressing TB among vulnerable
positive persons, Roma people (http://web.worldbank.org/ populations and tailoring services to these groups (14) will
WBSITE/EXTERNAL/COUNTRIES/ECAEXT/EXTRO also be an essential component of any strategy aiming at
MA/0,,contentMDK:20341647~menuPK:648308~pagePK progressing towards TB elimination, as the action plan by
:64168445~piPK:64168309~theSitePK:615987,00.html), the European Centre for Disease Prevention and Control
or others. suggests (15).
The current financial crisis could exacerbate the condi-
tions of existing vulnerable groups as well as create new
Mr Suk currently works at the European Centre for Disease
ones. For example, the EU Directorate for Employment,
Prevention and Control in the Scientific Advice Unit’s Section
Social Affairs and Equal Opportunities estimates that 16%
on Future Threats and Determinants. He has a background in the
of Europe’s population currently lives below the poverty
social sciences and biology, and his research focuses on social
line (13). Rising unemployment rates could push this rate
determinants of infectious diseases.
even higher, with implications for factors that drive TB
spread such as the quality of housing and sanitation. Re-

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009 1813
DISPATCHES

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1814 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009