摘要：Growing consensus indicates that progress in tuberculosis control in the low- and middle-income world will require not only investment in strengthening tuberculosis control programs, diagnostics, and treatment but also action on the social determinants of tuberculosis. However, practical ideas for action are scarcer than is notional support for this idea. We developed a framework based on the recent World Health Organization Commission on Social Determinants of Health and on current understanding of the social determinants of tuberculosis. Interventions from outside the health sector—specifically, in social protection and urban planning—have the potential to strengthen tuberculosis control. In December 2009, at the International Union Against Tuberculosis (TB) and Lung Disease's World Conference in Cancun, Mexico, Mario Raviglione, director of the World Health Organization (WHO) Stop TB Department, made a clear commitment to “moving beyond the TB box .” 1 His remarks echoed an emerging shift within the TB sector toward recognizing the importance of social and economic development policies and interventions in supporting TB control. 2 The 5 Elements of Directly Observed Therapy—Short Course (DOTS) and 6 Components of the Stop Tuberculosis (TB) Strategy The 5 Elements of DOTS 12 Political commitment with increased and sustained financing, Case detection through quality-assured bacteriology, Standardized treatment with supervision and patient support, An effective drug supply and management system, and Monitoring and evaluation system and impact measurement. The 6 Components of the Stop TB Strategy 14b Pursue high-quality DOTS expansion and enhancement. Address TB and HIV, multidrug-resistant TB, and the needs of poor and vulnerable populations. Scale up collaborative TB and HIV activities. Scale up prevention and management of multidrug-resistant TB. Address the needs of TB contacts and of poor and vulnerable populations. Contribute to health system strengthening based on primary health care. Help improve health policies, human resource development, financing, supplies, service delivery, and information. Strengthen infection control in health services, other congregate settings, and households. Upgrade laboratory networks and implement the Practical Approach to Lung Health. Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health. Engage all care providers. Involve all public, voluntary, corporate, and private providers through public–private mix approaches. Promote use of the International Standards for Tuberculosis Care. Empower people with TB and communities through partnership. Pursue advocacy, communication, and social mobilization. Foster community participation in TB care. Promote use of the Patients’ Charter for Tuberculosis Care. Enable and promote research. We welcome this timely shift in emphasis but recognize too that practical ideas for action are scarcer than is notional support for the idea. In this article, we briefly described why we think this shift occurred. We developed a framework informed by the recent WHO Commission on Social Determinants of Health (CSDH) 3 and WHO work on the social determinants of TB 2 that guided our ideas for action in this area. We also described 2 non–health-sector domains in which we think program and policy action is feasible and could reduce the public health burden caused by TB in key settings. Finally, we call for a new era of research, action, and evaluation in this field.
