Food Insecurity and Tuberculosis: Policy Urgently Needs To Play Catch-Up

D A. Cassidy1, L C. Ivers2

1School of Medicine and Medical Science, University College Dublin, Dublin 4, Ireland
2Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA.

Tuberculosis (TB) is a leading cause of death from infectious disease worldwide. In 2015, TB was responsible for 1.8 million deaths, over 95% of which were in low- and middle-income countries. Food insecurity is defined as insufficient availability of or access to food of sufficient quantity and quality for a healthy life. A complex, bidirectional relationship between TB and food insecurity exists in which the latter has a negative impact on TB treatment adherence and outcomes, and can also be the result of illness with TB through its impact on the livelihood and income of patients. Yet, the global health community has not adequately recognized the complexity of food insecurity’s association with TB in policy, and this hampers TB control. We review the current policy, as it relates to food security, of three key stakeholders in the global struggle against TB: World Health Organization (WHO), World Food Programme (WFP) and U.S. Agency for International Development (USAID), and make reference to Irish Aid’s stance on the issue.

Of the policies discussed, WHO provides the most comprehensive and forward-thinking policy relating to food insecurity and TB acknowledging that food insecurity (and poverty) are both causes and consequences of TB1. WHO policy also recognises that governments should be accountable for societal-level responses that can bolster TB prevention and control through, for example, food security initiatives targeted at regions of high risk, and that interventions addressing food insecurity can potentially enhance access and adherence to treatment and alleviate the financial and social consequences of TB1,2. However, clear guidance on what these interventions are and how to implement them are not offered. WHO reports that ministries of health are not fully availing of the opportunity to use the evidence of associations between ending TB and ending poverty to advocate for responses to relevant risk factors such as food insecurity2. Moreover, WHO acknowledges that determinants such as food insecurity are beyond the scope of authority of the health sector alone, and the health sector often does not have the skill base to address issues such as these3. Therefore, ministries of health must engage with sectors outside of their own when attempting to successfully control TB.

WFP policy presents a narrower view of the relationship between TB and food insecurity, focused on curing the disease and not sufficiently considering the potential impact that food security may have on prevention of TB. Many of WFP policy documents regarding TB are centered around its interaction with HIV and thus lack some clarity and independence4-7. The WFP approach to food and nutrition support for patients with HIV and/or TB is two-tiered; involving ‘curative support to the infected’, offering food products to those deemed malnourished until they are nutritionally recovered; and ‘enabling/preventative support to the affected’, offering income support to affected households, support to peers and community and HIV/TB safety nets. WFP policies acknowledge that it is ‘widely recognized’ that HIV, TB and food insecurity are closely related creating a vicious cycle, including an increase in the progression of TB from latent to active disease6,8. However, their written proposed interventions focus only on those who have TB and their households, and despite stating that there is ‘significant correlation’ between areas with elevated TB prevalence and elevated food insecurity, the concept of decreasing food insecurity as a means to prevent TB is not discussed8.

USAID does not make reference to pathways between food insecurity and TB in any of their key documents9-12. USAID was responsible for $1.2 billion of programs (of the $2.8 billion the U.S. Government invested to combat TB globally) between 2010 and 2014, therefore their policy on issues such as food insecurity and TB have far-reaching consequences. This is not to say that USAID policy underappreciates the importance of food insecurity in the context of global health. The first of the ‘Core Development Objectives’ in their most recent policy framework is increasing food security, and sustainable household food security is a key component of their ‘Multi-Sectoral Nutrition Conceptual Framework’10,11. However, USAID have yet to fully acknowledge the crucial associations between food insecurity and TB or provide specific guidance to programs on how it might be addressed.

Irish Aid acknowledges the importance of TB as a leading cause of death globally, and states that it is dedicated to supporting efforts to tackle TB13. Irish Aid also reports that integration of food security into their approach to improving global nutrition is crucial14. However, they have yet to make reference to the relationship between food insecurity and TB. There is a consensus by WHO and WFP that food insecurity is an important contributor to the global burden of TB. However, without more specific guidance on how to integrate food security interventions into public health programming, major public health institutions are missing an opportunity for large scale contribution to the crisis of global TB control. Further evidence and policy guidance is needed on how to address the critical associations between food insecurity and TB for effective treatment and prevention of TB to become a reality.

Conflicts of Interest
The authors declare no conflicts of interest.

Correspondence
Diarmuid Cassidy, School of Medicine and Medical Science, University College Dublin, Dublin 4
Phone: +353 85 842 2239
Email: Diarmuid.cassidy@ucdconnect.ie

References:
1. World Health Organization. Guideline: Nutritional Care and Support for Patients with Tuberculosis. Geneva: World Health Organization; 2013.
2. World Health Organization. Global Tuberculosis Report. Geneva: World Health Organization; 2016.
3. World Health Organization. Tuberculosis (TB) and Poverty in SEAR [Internet]. New Delhi: World Health Organization; 2017 [Accessed 2017 December 15]. Available from: http://www.searo.who.int/tb/topics/tb_poverty/en/#
4. World Food Programme. WFP’s HIV and TB Policy [Internet]. Rome: World Food Programme; 2017 [Accessed 2017 December 18]. Available from: https://www.wfp.org/hiv-aids/wfp-policy
5. World Food Programme. WFP HIV and AIDs Policy. Rome: World Food Programme; 2010.
6. World Food Programme. WFP’s Response to HIV, AIDs, and Tuberculosis [Internet]. Rome: World Food Programme; 2017 [Accessed 2017 December 10]. Available from: http://www.wfp.org/hiv-aids/
7. World Food Programme. HIV, AIDs, TB and Nutrition. Rome: World Food Programme; 2013.
8. World Food Programme. Tuberculosis and Nutrition [Internet]. Rome: World Food Programme; 2017 [Accessed 2017 December 13]. Available from: http://www.wfp.org/hiv-aids/tuberculosis-nutrition
9. U.S Government. United States Global Tuberculosis Strategy 2015-2019. Washington: U.S Government; 2015.
10. United States Agency for International Development. USAID Policy Framework 2011-2015. Washington: United States Agency for International Development; 2011.
11. United States Agency for International Development. Multi-Sectoral Nutrition Strategy 2014-2025. Washington: United States Agency for International Development; 2014.
12. United States Agency for International Development. Ending the Tuberculosis Epidemic: U.S. Agency for International Development FY 2015 Report on Foreign Assistance for Tuberculosis. Washington: United States Agency for International Development; 2016.
13. Irish Aid. Tackling Tuberculosis [Internet]. Dublin: Department of Foreign Affairs and Trade; 2013 [Accessed 2018 February 10]. Available from: https://www.irishaid.ie/news-publications/news/newsarchive/2013/march/tackling-tuberculosis/title-13528-en.html
14. Irish Aid. Leadership and Governance on Hunger and Under-nutrition [Internet]. Dublin. Department of Foreign Affairs and Trade; 2018 [Accessed 2018 February 10]. Available from: https://www.irishaid.ie/what-we-do/our-priority-areas/hunger/leadership-and-governance/

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