1. Tribhuvan University, Nepal.

*             Correspondence: alonerakesh@gmail.com

Keywords: Nepal, tuberculosis (DR-TB), health, Health Insurance Program, DOTS

1. INTRODUCTION

Tuberculosis (TB) remains one of the leading causes of morbidity and mortality worldwide, despite being both curable and preventable. From a medical anthropological perspective, TB illustrates the complex interplay between biological processes, cultural interpretations, and structural inequalities. The disease continues to account for more than 10.6 million new cases and 1.3 million deaths each year, highlighting the importance of studying TB not only as a biomedical challenge but also as a deeply social and cultural phenomenon. TB is a contagious airborne infection caused by Mycobacterium tuberculosis. It primarily affects the lungs, though it may also spread to the kidneys, spine, and brain. Transmission occurs when an infected individual expels bacteria through coughing, sneezing, or speaking, releasing droplets into the air. While many people exposed to the bacteria develop latent tuberculosis infection (LTBI)—a silent, non-contagious state—others progress to active TB disease, particularly when immunocom promised by conditions such as HIV/AIDS, diabetes, or malnutrition. The clinical symptoms of active TB include persistent cough, chest pain, hemoptysis, weight loss, fever, and night sweats. The standard biomedical treatment for TB consists of a six-month drug regimen that includes isoniazid, rifampicin, pyrazinamide, and ethambutol. To ensure adherence, the World Health Organization (WHO) recommends the Directly Observed Treatment, Short-course (DOTS) strategy, which requires supervised administration of medications. Although DOTS has been widely implemented, the global rise of drug-resistant TB presents new challenges. Drug resistance, first observed in the mid-20th century, has evolved into multiple forms. Mono-resistance describes resistance to a single first-line drug, poly-resistance refers to resistance to several first-line drugs excluding both isoniazid and rifampicin, multidrug-resistant TB (MDR-TB) involves resistance to at least isoniazid and rifampicin, and extensively drug-resistant TB (XDR-TB) adds resistance to fluoroquinolones and at least one second-line injectable drug. Currently, drug resistance accounts for more than 4% of new TB cases and 16% of retreatment cases globally. In high-burden countries like Nepal, the rise of MDR-TB and XDR-TB poses an urgent public health threat. Historically, TB was interpreted through spiritual and cultural frameworks in Nepal, often regarded as punishment from the gods and treated through shamans and traditional healers. The biomedical response began with the Tokha Sanatorium in 1937, followed by the initiation of Nepal’s first national TB control program in 1965 in collaboration with WHO and UNICEF. The adoption of the DOTS strategy nationwide in 2001 accelerated progress, achieving an annual 3% reduction in TB incidence, which is above the global average. Despite these advances, stigma surrounding TB continues to deter individuals from seeking timely diagnosis and treatment, revealing the importance of cultural and anthropological perspectives in TB control. Social determinants play a critical role in sustaining both TB and drug-resistant TB. Poverty restricts access to adequate healthcare and nutrition, while food insecurity weakens the immune system, increasing susceptibility to infection and reducing the effectiveness of treatment. Social exclusion and stigma further discourage patients from pursuing diagnosis and care, perpetuating cycles of transmission. For patients with drug-resistant TB, the prolonged and costly nature of treatment imposes an additional economic burden, pushing households deeper into poverty and reinforcing marginalization. These dynamics form a vicious cycle: poverty leads to poor nutrition and weak immunity; TB infection worsens economic hardship; inadequate treatment fosters drug resistance; and drug-resistant TB intensifies stigma and impoverishment. Tuberculosis thus represents a biosocial disease, where microbial evolution, human behavior, and structural inequalities are intertwined. While biomedical interventions such as DOTS and molecular diagnostic tools are essential, they are insufficient on their own to halt the global TB epidemic. Sustainable solutions require integrated strategies that address not only medical treatment but also the social, economic, and cultural conditions that shape vulnerability. For medical anthropology, TB offers a crucial lens through which to understand the ways biology, behavior, and culture converge to influence health outcomes, underscoring the need for holistic and inclusive approaches to global health.

Figure 01:  Vicious Cycle of DR-TB Vulnerability

2. MATERIALS AND METHODS

This study investigated the social determinants of drug-resistant tuberculosis (DR-TB) within marginalized communities in rural Nepal, focusing on Jhapa district, which has a high TB prevalence, particularly among vulnerable groups. A mixed-methods, exploratory design was employed, combining quantitative surveys with qualitative approaches such as in-depth interviews, case studies, and direct observations. Quantitative data captured prevalence, treatment adherence, and demographic features (age, gender, ethnicity, occupation, and education), while qualitative methods explored cultural practices, lived experiences, and barriers influencing vulnerability to DR-TB. Case study selection considered diagnosis status, socioeconomic background, geographic distribution, treatment stage, and willingness to consent. The study population comprised all DR-TB patients in Jhapa facing poverty, inadequate housing, limited healthcare access, and social exclusion. A purposive sample of 35 patients receiving treatment under the DOTS PLUS program was recruited. Primary data were collected through structured surveys, interviews, and community observations, while secondary data came from treatment center records, the National Tuberculosis Control Program, and regional and national health reports. Triangulation was applied to ensure validity, alongside strategies to mitigate recall bias, social desirability bias, and measurement limitations. Data were analyzed using descriptive statistics and thematic analysis, identifying socioeconomic factors—poverty, education, and occupation—as key determinants of DR-TB risk. These factors shaped access to healthcare, adherence to treatment, and health outcomes, with pathways of influence mapped through both quantitative correlations and qualitative narratives. The analysis revealed clear disparities in exposure, treatment adherence, and socioeconomic impact between marginalized and privileged groups. Ethical standards were strictly upheld: informed consent was obtained, data anonymized, and cultural sensitivity prioritized to preserve participant dignity. Limitations included the study’s restricted geographic scope, small sample size, and inability to access some patient households. Nonetheless, the findings contribute to understanding the complex interplay of social determinants and DR-TB, providing practical insights for healthcare providers, policymakers, and organizations. The results underscore the need for targeted interventions and policy reforms that address socioeconomic inequities, improve treatment adherence, and strengthen healthcare delivery for marginalized populations.

3. RESULTS AND DISCUSSION

The study focused on Jhapa district, Nepal, covering 1,606 square kilometers in the fertile Terai plains. Demographic data of respondents—age, gender, education, job types, income, family dynamics, living situations, locations, marital status, and TB history—are crucial for understanding the social and economic environment where Drug-Resistant Tuberculosis (DR-TB) emerges and is managed. Jhapa connects the hilly districts of Taplejung, Panchthar, and Ilam to the Terai via a 57 km stretch of the East–West Highway, vital for mobility, trade, and services. With a population of 998,054, it faces demographic challenges due to high density and a sex ratio of 92.10 males per 100 females. Socio-economic indicators show major difficulties, with a poverty rate of 21.82% and diverse ethnic groups: Rajbanshi (29.1%), Hill Brahmins (23.8%), Chhetris (15.7%), Limbu (8.6%), Rai (4.5%), Satar/Santal (3.8%), Newar (3.3%), Musalman (3.0%), Kami (2.9%), Tamang (2.2%), Magar (1.9%), and Damai/Dholi (1.9%).

Figure 02:  Population of ethnic groups in Jhapa

The region’s population is diverse and socially ranked, with the privileged group holding significant power at 40%. The Rajbanshi, an indigenous caste, makes up 30%. Other key ethnic groups include Limbu (8.6%) and Rai (4.5%), with the remaining population spread across smaller castes.

Figure 03:  Religious distribution of Jhapa

The majority of the population in Jhapa practice Hinduism, with a literacy rate of 75%. However, a significant number of people lack basic education. The majority of the population is literate, with a small percentage following other religions. Jhapa is also linguistically diverse, with 55.7% speaking Nepali, 31.3% speaking Rajbanshi, and the rest speaking various ethnic languages. Despite this high literacy rate, a significant number of people still lack basic education.

Figure 04:  Literacy rate in Jhapa

Jhapa District is home to a diverse population of indigenous peoples, ethnic minorities, and marginalized groups, yet their socio-economic conditions remain inequitable, reflecting uneven distribution of resources and opportunities. The district hosts a range of health facilities, including one government hospital, 16 private hospitals, 6 primary health centers, 44 health posts, 7 urban health clinics, and 2 community health centers. It also has 3 GeneXpert testing centers for diagnosing drug-resistant tuberculosis (DR-TB), underscoring persistent disparities in access to healthcare resources.

Figure 05:  Health facilities in Jhapa

The socio-cultural and economic landscape of Jhapa, Nepal, is central to understanding public health challenges, particularly the high incidence of Drug-Resistant Tuberculosis (DR-TB). Poverty, inadequate healthcare, substandard living conditions, and high population density collectively exacerbate the DR-TB crisis. According to the National TB Prevalence Survey (2018–19), 46% of 4,160 new TB cases in Jhapa were notified in 2018, leaving 54% undetected. WHO data from the same year indicate that 4.33% of DR-TB cases were reported, suggesting that approximately 83 new DR-TB cases are notified annually in the district. Prevalence varies by geography, with higher rates in the Terai compared to hilly regions, yet overall the district demonstrates an average prevalence, reflecting a comparatively high TB burden.

Figure 06:  TB case finding status in Jhapa

The ‘Respondent’s Background’ section provides insights into survey participants’ social and demographic characteristics, including age, gender, education, occupation, income, and marital status. This data is crucial for understanding the role of social determinants in shaping health outcomes and resource access. Data collection took place from August to September 2024, laying the groundwork for analyzing respondents’ health and social conditions.

Table 01:  Percentage Distribution of Respondents by Gender Age

Gender	Age group			Grand total
	0-14 years	15-60 years	60 years & above
Male	0	27	4	31
Female	0	3	1	4
Total	0	30	5	35

Analysis of the data shows that the largest proportion of respondents, 85% (30 individuals), were aged 50–60 years, making this the most represented age group. In contrast, 15% (5 individuals) were 60 years and above, while no respondents fell below 15 years, indicating that the survey primarily captured older adults. As illustrated in the line diagram, males constituted the majority of participants (88.5%), compared to females (11.4%). Generational differences were also noted, with 85.7% of responses from the new generation and 14.2% from the older generation. Caste and ethnicity played a significant role in shaping cultural values and practices related to DR-TB. Beliefs, stigma, and treatment-seeking behaviors varied across communities, influencing both health management and access to care. The study included participants from diverse caste and ethnic backgrounds, encompassing higher castes, ethnic groups, and scheduled castes, ensuring that the cultural perspectives represented a broad spectrum of community experiences and practices.

Table 02:  Percentage Distribution of Respondents by Caste and Ethnicity

Cast	Number	Percentage
Brahmin/Chhetri	11	31.4%
janajati(Rai,Limbu,Magar,Tamang,Gurung,Newar, Kumal,Dhimal,Santhal,Rajbanshi etc)	19	54.2%
Madhesi(Mandal,Dev, Shah etc)	1	2.85%
Dalit(Kami,Damai,Sarki,Paswan etc)	4	11.4%

The study’s respondents varied in education levels, from primary to college, highlighting the diverse educational landscape in the communities studied, highlighting potential changes in awareness and views on DR-TB.

Table 03: Education level of respondents

	Female	Male	Percentage
No formal education	1	6	20%
Primary Level education	1	7	22.85%
Secondary Level education	1	12	37.14%
Higher education	1	6	20%

Table 04: Income level of respondents

Income Level (Monthly)	No. of Respondents	Percentage
Below 6,075(Below poverty line)	08	25.7%
6,075-15,000 (Low income)	14	37.15%
16000-25000 (Middle income)	10	37.15%
>25000 (Higher income)	03	8.5%

Most respondents were in the low-income group, reflecting the economic hardships that hinder access to DR-TB treatment and worsen its impact, as shown in the diagram below. Housing conditions ranged from poor to well-constructed, with overcrowding, inadequate ventilation, and poor sanitation in deficient homes fostering DR-TB transmission. Improving housing quality is essential to reduce spread and improve health outcomes.

Table 05:  Data on respondents housing condition

Type of Housing	Percentage of  Respondents living
Poor Housing Condition (Simple structures made from mud or other temporary materials, often small and lacking basic amenities, such as sanitation, electricity,  proper roofing and ventilation.)	13 (37.14%)
Moderate Housing Condition (Semi-permanent houses made from a mix of materials like brick, stone, or partially concrete, offering basic amenities but with limited space and infrastructure.)	17 (48.5%)
Well Housing Condition: Permanent, well-constructed homes made from durable materials like brick, stone, or concrete, featuring multiple rooms, modern amenities, and good infrastructure.	05 (14.2%)

Housing conditions showed clear disparities between vulnerable and privileged groups. Poor housing without basic facilities was reported by 37.14% (13) of respondents, 48.5% (17) lived in moderately equipped homes, and only 14.2% (5) resided in well-maintained houses with adequate facilities. These patterns highlight stark socio-economic inequalities, as vulnerable populations disproportionately endure poor conditions while privileged groups benefit from better housing. Occupation also plays a critical role, shaping exposure to DR-TB, access to healthcare, and economic resilience. Those in low-paying or informal jobs face higher risks due to unsafe workplaces and limited medical access, illustrating how employment patterns compound the burden of DR-TB.

Table 06:  Data respondent’s occupation

Type of employment or primary occupation	No. of Respondents	Percentage
Farmer	8	22.85
Laborer	8	22.85
Business owner	5	14.28
Foreign employee	9	25.71
Unemployed	5	14.28

Occupational distribution showed varied livelihoods. Farming and labor each accounted for 22.85%, reflecting dependence on manual and agricultural work. Foreign employment was the largest share at 25.71%, highlighting its role in sustaining households. Both unemployment and self-employment were reported at 14.28%, indicating unstable income sources and small-scale entrepreneurship. These patterns reveal diverse economic activities but also the vulnerability of those lacking steady jobs, as illustrated in the pie chart below. Family size further influences DR-TB risk, with larger households facing higher transmission due to close living arrangements and greater financial and caregiving burdens when illness occurs.

Table 07:  Family size of respondents

Size of Family	No. of Respondents	Percentage
1	0	0
2	3	8.57%
3	4	11.42%
4	11	31.42%
5	9	25.71%
More than 5	8	22.85%

Access to safe drinking water is crucial for health and hygiene, directly influencing control of drug-resistant tuberculosis (DR-TB). Respondents with reliable clean water sources are more likely to maintain better health, while reliance on tube-wells or insecure options increases vulnerability. Assessing water access helps identify communities at higher risk for diseases associated with inadequate water availability. 

Table 08: Drinking water sources of respondents

Water source	No. of Respondents	Percentage
Supplied drinking water	15	42.85%
Tube-well	20	57.14%
Other (River, well etc.)	0	0%
Total	35	100%

Among respondents, 42.85% reported having piped drinking water, while 57.14% relied on tube wells. Dependence on tube wells, often linked to unhygienic practices, increases vulnerability to waterborne diseases and weakens immunity, reducing the body’s ability to fight infections. Nutritional intake also plays a critical role in DR-TB outcomes, as inadequate diets compromise immunity, heighten susceptibility to TB, and lower treatment success. The data below illustrates the frequency of respondents’ nutritional intake.

Table 09:  Nutritional diet consumption data

Frequency of nutritional diet consumption (i.e. Meat, egg, milk, fruits etc.)	Number of respondents	Percentage
Daily	3	8.57%
Twice a week	10	28.57%
Thrice a week	6	17.14%
Once a week	8	22.85%
Less than once a week	8	22.85%

Nutritional intake patterns revealed clear disparities. Only 8.57% of respondents reported daily consumption, 28.57% twice a week, 17.14% thrice a week, 22.85% once a week, and 22.85% less than once a week. A stark divide exists between privileged and marginalized groups, with above-average households consuming nutritious diets more regularly. These findings underscore structural inequities shaping the health and socioeconomic impacts of DR-TB, influencing disease burden, access to care, economic security, and quality of life. Access to healthcare—particularly financial capacity and distance from services—was also found to be crucial for treatment adherence and overall outcomes.

Table 10:  Healthcare access data of respondents

Distance of DR-TB treatment health facility	No. of respondents	Percentage
Up to 1km	8	22.8%
2-3 km	11	31.42%
4-5 km	3	8.57%
>5km	13	37.14%

This data is further classified between two communities that are vulnerable and privileged.

Table 11:  Classified healthcare distance

Distance of healthcare facility	Respondents no. from vulnerable community (24)	Respondents no. from privileged community(11)
Up to 1km	3	5
2-5 km	9	3
>5km	14	1

Data indicate that privileged communities enjoy better access to healthcare, while vulnerable groups often live farther from facilities, resulting in poorer outcomes. To address such disparities, the Nepal Government introduced a Health Insurance Program, offering up to NPR 100,000 in coverage for an annual fee, enabling wider access to health institutions.

Table 12:  Involvement in Health Insurance Program

Title	Vulnerable popn (26)	Privileged popn(9)
No. of people enrolled in health insurance program	7 (26.92%)	8 (88.8%)
No. of people not enrolled in health insurance program	19 (73%)	1 (11/1%)

The study reveals a significant disparity in Nepal’s government health insurance scheme participation between privileged and disadvantaged groups. Despite 88.8% of privileged individuals participating, only 26.9% of vulnerable individuals participate. Financial difficulties are a constant reason for enrollment difficulties, highlighting limited healthcare access and increased mental stress among vulnerable populations.

Table 13:  Financial difficulty in accessing healthcare

Population group                                                   A=(B+C)	Not experienced financial difficulties in accessing healthcare (%)        B	Experienced financial difficulties in accessing healthcare (%)                     C (D+E)	Reported burden during treatment (%)                         D	Mental stress due to financial strain (%)          E
Vulnerable population(26)	23% (6)	76.9% (20)	38.4% (10)	30.7% (8)
Privileged population (9)	88.8% (8)	11.1% (1)	0	0

The data shows a significant disparity in financial difficulties for healthcare access between vulnerable and privileged communities. 83% of vulnerable individuals face financial burdens during treatment and mental stress, while privileged individuals have minimal financial difficulties. Early detection is crucial for successful treatment and reducing disease spread, but late diagnoses prolong suffering and increase vulnerability to infection.

Table 14:  Data on delay diagnosis

	Vulnerable population(26)	Privileged population(9)
Experienced delay in diagnosis	8	0
No experience of delays	18	09

The study underscored the difficulties underprivileged communities face in accessing timely healthcare, particularly for drug-resistant TB. A case from Gaurignj-4, Jhapa, involving a 43-year-old male, illustrates how socioeconomic constraints shape health outcomes. His prolonged and inadequate initial treatment adversely affected both physical and mental health, while dissatisfaction with healthcare services and financial hardship compounded the burden. The absence of support mechanisms and the requirement for daily visits to health facilities during the intensive phase of first-line treatment further intensified the economic strain.

Table 15: Challenges in visiting healthcare facility

Experiences of visiting healthcare facility daily	Vulnerable population             (Total 6)	Privileged population         (Total 1)
Difficult	4 (66.6%)	0
Somewhat difficult	1(16.6%)	0
No difficult at all	1(16.6%)	1(100%)

The study found that most vulnerable individuals (66.6% of 6) struggled to visit healthcare facilities daily for two months during treatment, compared to 16.6% of privileged respondents. Socioeconomic and psychological effects of DR-TB—such as stigma, job loss, and employment difficulties—were evident. Differences in willingness to disclose DR-TB status were also observed, with disadvantaged groups facing greater challenges.

 Table 16: Disclosing DR-TB Status

Comfortableness in disclosing DR-TB status with others

Vulnerable community (26)

 Privileged community
(9)Very comfortable2(7.69%)5 (55.55%)Somewhat comfortable14(53.84%)3(33.33%)Not comfortable10(38.46%)1(11.11%)

Findings show clear disparities in disclosing DR-TB status. Among the privileged, 55.5% were comfortable, 33.3% somewhat, and 11.1% not comfortable. In contrast, 53.8% of the vulnerable found disclosure difficult, 38.4% not comfortable, and only 7.7% comfortable. This indicates stronger stigma among disadvantaged groups, which hinders treatment adherence as many avoid care to hide their condition.

Table 17: Stigma associated with DR-TB

Community group	Total respondents	Faced stigma (%)	Not faced stigma (%)
Vulnerable population	26	46.15% (12)	53.8% (14)
-Low income	2	50% (1)	50% (1)
-Underprivileged community	24	45.8% (11)	54.16% (13)
Privileged community	9	11.1% (1)	88.8% (8)
-Middle income	5	40% (2)	60% (3)
-Higher income	4	0	100% (4)

The survey shows stigma is far more common among vulnerable groups. Of 26 respondents (24 underprivileged, 2 poor), 46.15% reported stigmatization, compared to only 11.1% of the privileged group (9 respondents: 5 middle-income, 4 higher-income). This gap indicates stigma strongly affects vulnerable people, hampering treatment outcomes. Job loss due to DR-TB status also reflects stigma’s social impact. Among 17 employed before diagnosis (8 laborers, 8 foreign workers), 13 lost jobs after disclosure. Vulnerable respondents faced higher losses—80% compared to 50% in the privileged group—showing stronger job-related stigma among marginalized populations.

Figure 07:  Job loss due to DR-TB status

 

A 23-year-old married woman from a marginalized community in Kuwait returned to Nepal with severe cough and partial paralysis. High treatment costs caused job and financial loss, and she was diagnosed with MDR-TB, reflecting the dual health and economic struggles of marginalized individuals.

Table 18:  People Involved In Physically Demanding Job

	Vulnerable population	Privileged population
People involved in physically demanding job	16 (61.5%)	2 (22.2%)
People not involved in physically demanding job	10 (38.4%)	7 (77.7%)

61.5% of vulnerable individuals worked in strenuous jobs versus 22.2% of the privileged, reflecting inequities that raise DR-TB risk. A 37-year-old unmarried male with DR-TB showed psychosocial and economic impacts, including stress, anxiety, and income loss. Stress after diagnosis was higher in the vulnerable group (over half) than the privileged (11.1%). Moderate stress was reported by 38.4% of vulnerable and 55% of privileged respondents. Only 7.6% of the at-risk group reported no stress, compared to 33.3% of the protected, underscoring the heavier emotional burden on disadvantaged populations.

Table 19:  Social Support Network

Social support network	Vulnerable population	Privileged population
Yes	6 (23%)	7 (77.7%)
No	20 (76.9%)	2 (22.2%)

Data show a sharp disparity in social support: 77.7% of the privileged group had networks, compared to only 23% of the vulnerable. Conversely, 77% of the vulnerable lacked support, versus 22% of the privileged. This gap strongly affects treatment adherence and outcomes. Income reduction from DR-TB is another major issue, often linked with stigma, stress, and anxiety, which hinder recovery. Loss occurs through reduced work hours, business decline, or job changes due to stigma. The data illustrate income loss among DR-TB patients after infection.

Table 20:  Income reduction due to DR-TB

Reduced income due to DR-TB infection	Vulnerable population (26)	Privileged population (9)
Yes	24 (92.3%)	3 (33.3%)
No	2 (7.6%)	6 (66.6%)

A study showed marked income loss from DR-TB, with 92.3% of the privileged group reporting cuts. Meanwhile, 66.6% of dominant and 7.6% of oppressed respondents saw no reduction. A case study of a 27-year-old single man in Nepal with MDR Gland TB illustrates the economic struggles of marginalized groups. The study also compared treatment success, TB-to-DR-TB conversion, relapse, and mortality rates, stressing the need for stronger healthcare systems and social safety nets.

Table 21: TB-DR-TB comparative conversions

Population group	DR-TB cases	TB-to-DR-TB Cases
Vulnerable population	26	8(30.7%)
Privileged population	9	1(11.1%)

The data shows a significant difference in TB-DR-TB conversion rates between vulnerable and privileged groups. Vulnerable populations have 30.7% of DR-TB cases starting with first-line TB treatment, indicating challenges in managing and preventing drug resistance. Only 11.1% of privileged individuals see TB-DR-TB conversion, highlighting the need for tailored public health strategies and addressing social and healthcare inequalities.

Table 22:  MDR-TB treatment success rate

Population category	Total MDR-TB cases	Successfully treated cases	Treatment success rate (%)
Vulnerable popn	26	18	69.2%
Privileged popn	9	8	88.8%
Overall	35	26	74.28%

The study revealed a significant disparity in treatment success rates for MDR-TB between marginalized and privileged populations, with 88.8% of privileged patients succeeding, highlighting the need for interventions addressing healthcare access and adherence disparities among vulnerable populations.

Table 23:  Mortality rate due to DR-TB

	No of DR-TB patients	Death rate
Vulnerable population	26	11.5% (3)
Privileged population	9	0

Data show a stark mortality gap: 11.5% of vulnerable DR-TB patients (3 of 26) died, while no deaths occurred among 9 privileged patients. This highlights the role of socioeconomic and healthcare inequities and the need for targeted interventions. A case of a 76-year-old man from Jhapa with MDR-TB illustrates these challenges—poor living conditions, poverty, and systemic barriers hindered recovery. He abandoned treatment after a family funeral, worsening symptoms and revealing how poverty, cultural pressures, and weak healthcare systems compound vulnerability.

4. CONCLUSION

Tuberculosis continues to represent a significant public health challenge in Nepal, disproportionately affecting vulnerable and socially excluded populations. Despite the nationwide implementation of the Directly Observed Treatment, Short-course (DOTS) strategy in 1996, more than half of cases remain undiagnosed or untreated, perpetuating transmission and increasing the risk of drug-resistant tuberculosis (DR-TB). Multidrug-resistant tuberculosis (MDR-TB) is of particular concern, with recent data indicating resistance in 2.2% of new cases and 15.4% of retreatment cases. The phenomenon of DR-TB functions as an “invisible illness,” disproportionately burdening marginalized communities who already face barriers such as limited healthcare access, financial constraints, malnutrition, and poor living conditions. This issue has been investigated through a mixed-methods approach combining quantitative and qualitative evidence. Primary data were gathered through surveys, interviews, and case studies with affected patients, while secondary sources included national and global TB statistics alongside health office records. The integration of numerical data with lived experiences revealed profound inequities in healthcare access, treatment success, and socio-economic stability. Quantitative findings demonstrated lower treatment adherence, higher rates of TB-to-DR-TB conversion, and greater community transmission among disadvantaged groups. Qualitative accounts underscored the compounded effects of delayed diagnosis, financial hardship, and stigma. Only 7.6% of vulnerable individuals expressed comfort in disclosing their condition compared to more than half of privileged patients, illustrating the pervasive role of social exclusion. The economic consequences were equally stark, with approximately 80% of vulnerable patients losing employment and more than 90% reporting drastic income reductions. The persistence of these disparities highlights the need for a multi-faceted response that transcends biomedical interventions. Health system strengthening must be prioritized, including decentralization of TB services to community levels through programs such as Community DOTS, which bring medicines directly to patients’ homes, thereby reducing financial and logistical barriers. Nutritional support is equally critical, as food insecurity undermines recovery and heightens vulnerability; free distribution of nutritional supplements could improve treatment outcomes. Financial assistance programs should also be institutionalized to alleviate the economic strain associated with prolonged illness. In addition, mass TB and DR-TB screening initiatives targeted at high-burden areas could reduce undetected cases and community transmission. Social interventions are essential, including legal frameworks to protect workers from discrimination and stigma, ensuring that infection does not automatically result in job loss. The study reaffirms that the burden of TB and DR-TB is significantly greater among marginalized groups than among privileged populations, driven by structural inequalities. The main source of DR-TB remains the conversion of drug-susceptible TB due to incomplete or abandoned treatment, underscoring the importance of improving treatment adherence and continuity of care. Addressing these challenges requires a comprehensive strategy that integrates biomedical treatment with socio-economic interventions. By strengthening community-based care, providing nutritional and financial support, conducting widespread screening, and addressing stigma through legal and cultural reforms, Nepal can make significant strides in reducing the burden of drug-resistant tuberculosis, improving health outcomes, and interrupting transmission cycles. 

REFERENCES

1. Sushma, K., Kaiwar, S., Selvarajan, C., Mascrenhas, A. A., Flynn, A., Yadav, R. K., … & Siribaddana, A. SAARC.
2. Acharya, P., Bhattarai, N., Kunwar, B. R., Sharma, K. R., Khanal, V. K., & Yadav, B. K. (2024). Risk Factors of Multi-Drug Resistant Tuberculosis among Tuberculosis Patients in Province 3, Nepal: A case-control study. medRxiv, 2024-06.
3. Najafizada, M., Rahman, A., Taufique, Q., & Sarkar, A. (2021). Social determinants of multidrug-resistant tuberculosis: a scoping review and research gaps. Indian Journal of Tuberculosis, 68(1), 99-105.
4. Gilmour, B., & Alene, K. A. (2024). Ending tuberculosis: challenges and opportunities. Frontiers in Tuberculosis, 2, 1487518.
5. Madhuha, E. (2024). The Persistent Health Burden: Understanding Black South African Working-Class Men’s Experiences of Living with Tuberculosis(Doctoral dissertation, University of the Witwatersrand, Johannesburg).
6. Ntuli, T. T. (2022). Socio-Economic Risk Factors for Acquired Multi Drug-Resistant Tuberculosis Among Tuberculosis Patients in South Africa, Tshwane Health District: A Retrospective Study. University of Johannesburg (South Africa).
7. Bhargava, A., Bhargava, M., & Juneja, A. (2021). Social determinants of tuberculosis: context, framework, and the way forward to ending TB in India. Expert Review of Respiratory Medicine, 15(7), 867-883.
8. Santos, F. L. D., Souza, L. L. L., Bruce, A. T. I., Crispim, J. D. A., Arroyo, L. H., Ramos, A. C. V., … & Arcêncio, R. A. (2021). Patients’ perceptions regarding multidrug-resistant tuberculosis and barriers to seeking care in a priority city in Brazil during COVID-19 pandemic: a qualitative study. PloS one, 16(4), e0249822.
9. Chakraborty, A., & Jayawickrama, J. (2024). History of tuberculosis and contemporary challenges. In A Brief Social History of Tuberculosis(pp. 10-24). Routledge.
10. Mohindra, K. S., Haseen, F., & Adams, M. (2025). The social determinants of superbugs: antimicrobial resistance in South Asia. In Handbook on the Social Determinants of Health(pp. 278-292). Edward Elgar Publishing.
11. Yanga, N. (2025). Missed Nuances in Tuberculosis Research: Reflections from a Tibetan Scholar. International Journal of Social Determinants of Health and Health Services, 27551938251314654.
12. Liebenberg, D., Gordhan, B. G., & Kana, B. D. (2022). Drug resistant tuberculosis: Implications for transmission, diagnosis, and disease management. Frontiers in cellular and infection microbiology, 12, 943545.
13. Abubakar, A. (2024). Evaluation of determinants, acceptability and effectiveness of community-based management of multidrug-resistant tuberculosis (MDR-TB) in Nigeria(Doctoral dissertation, Anglia Ruskin Research Online (ARRO)).
14. Deshpande, A., Likhar, R., Khan, T., & Omri, A. (2024). Decoding drug resistance in mycobacterium tuberculosis complex: genetic insights and future challenges. Expert Review of Anti-infective Therapy, 22(7), 511-527.
15. Almeida, C. P., Andom, A. T., Casseus, A., Do, J. M., Gelin, A., Lecca, L., … & Tzelios, C. (2024). Revealing disparities in representation in knowledge generation and guideline development. BMC Health Services Research, 24(1), 1516.
16. Annisa, S. N. (2023). The Missing Link: Unravelling Household Welfare Dynamics in Tuberculosis.
17. Yahaya, J. Y. (2022). Assessment of Multidrug Resistance Among Tuberculosis Patients in Lesotho(Doctoral dissertation, Walden University).
18. Oga-Omenka, C. (2021). Timely treatment initiation of free drug-resistant tuberculosis care in Nigeria? a mixed methods study of patient experience, socio-demographic characteristics and health system factors.
19. Jiang, W. X., Li, Z. P., Zhao, Q., Gao, M. Q., Long, Q., Wang, W. B., … & Tang, S. L. (2021). Impacts of a comprehensive tuberculosis control model on the quality of clinical services and the financial burden of treatment for patients with drug-resistant tuberculosis in China: a mixed-methods evaluation. Infectious diseases of poverty, 10, 1-13.
20. Gona, P. N., Estrada-Martinez, L. M., Zhang, L., Gona, C. M., Mody, A., Rao, S. R., … & GBD 2019 TB Racial Disparity. (2024). Racial disparity in mortality from tuberculosis in the US between states with and without a history of Jim-Crow laws: an analysis of the Global Burden of Disease (GBD) and risk factors study, 1990 to 2019. BMC Public Health, 24(1), 3075.
21. Siswanto, M., Kusnadi, A. L., Armevia, N. Z., & Agustin, R. (2025). Investigating the types and mechanisms of Mycobacterium tuberculosis resistance: why Indonesia continues to experience high case rates compared to other nations. Current Research on Biosciences and Biotechnology, 6(2), 8-14.
22. Mason, P. H. Borderland tuberculosis: The social, economic, and geopolitical contours of disease care and prevention on Daru Island, Papua New Guinea. In A Brief Social History of Tuberculosis(pp. 25-39). Routledge.
23. Steuernagel, C. R., Lillehagen, I., & Seeberg, J. (2024). The invisible pandemic of antimicrobial resistance and its possible endings. Global Public Health, 19(1), 2355318.
24. Zhou, C., Li, T., Du, J., Yin, D., Li, X., & Li, S. (2024). Toward tuberculosis elimination by understanding epidemiologic characteristics and risk factors in Hainan Province, China. Infectious Diseases of Poverty, 13(1), 20.
25. Shaw, E. S., Stoker, N. G., Potter, J. L., Claassen, H., Leslie, A., Tweed, C. D., … & Lipman, M. (2024). Bedaquiline: what might the future hold? The Lancet Microbe, 5(12).