TB burden in Indonesia shifts with socioeconomic conditions, study finds

Tuberculosis remains one of Indonesia's most stubborn public health problems, yet how it spreads across districts and why some places bear heavier burdens than others has remained largely unmapped. A new study of South Sulawesi, a region on Indonesia's eastern flank, reveals that TB incidence does not cluster in fixed geographic hotspots the way researchers might expect. Instead, the disease's footprint shifts constantly across the province's 24 districts, moving in tandem with changes in local economic and social conditions.

Researchers tracked reported TB cases from 2018 through 2023, watching how incidence rates rose and fell across districts and which neighborhoods climbed into high-burden categories. The overall trend pointed upward—more cases reported as the years passed—but the geography of that burden was unstable. Districts that ranked among the worst in one year might improve the next, while others that had seemed manageable suddenly spiked. This pattern of constant reclassification suggested that TB in South Sulawesi is not rooted in permanent structural features of particular places, but rather in conditions that shift and change.

When researchers examined what socioeconomic factors correlated most strongly with TB incidence, three stood out consistently: years of schooling in the population, the rate of open unemployment, and the human development index—a composite measure of income, health, and education. Counterintuitively, all three showed positive associations with TB cases. Higher unemployment, lower education levels, and lower development indices all linked to higher TB burdens. The relationship was not uniform across space or time, however. A statistical technique called nonparametric geographically and temporally weighted regression revealed that these socioeconomic factors did not exert the same influence everywhere or in the same way. Some districts showed strong associations between all three factors and TB incidence; others showed none. Over the study period, the number of districts where all three factors simultaneously predicted TB cases climbed from six to eighteen, suggesting that socioeconomic conditions were becoming increasingly important drivers of the disease's distribution.

The study found no evidence of global spatial clustering—TB cases were not concentrated in one corner of the province that could be targeted with a single intervention. Instead, spatial heterogeneity was strong, meaning each district's TB situation was shaped by its own local conditions. This finding has direct implications for how public health officials might respond. A one-size-fits-all approach to TB control is unlikely to work across South Sulawesi. Instead, the research suggests that districts need tailored strategies that address their specific educational, economic, and development challenges.

South Sulawesi has seen gradual improvements in development indicators over recent years, yet epidemiological disparities persist. The new analysis suggests why: TB is not simply a disease of poverty that will fade as development advances uniformly. Rather, it appears to track closely with localized economic disruption and educational gaps. A district with high unemployment but improving schools might face different TB pressures than one with stable employment but limited access to education. Public health planners in South Sulawesi now have evidence that controlling TB will require understanding these district-specific vulnerabilities and designing interventions that address the particular mix of educational, economic, and development challenges each area faces.