Catching their breath: Communities take on tuberculosis in Latin America

Catching their breath: Communities take on tuberculosis in Latin America
By Eliza Barclay

The odds of staying healthy were against 27-year-old Richard Huaricacha after his brother, Angel, contracted tuberculosis (TB), probably during a visit to a crowded public hospital in Lima, Peru.

Poverty and poor nutrition, a lethal pairing that sets the stage for TB transmission, reign in the Huaricacha household in the San Juan de Lurigacho shantytown. The two brothers share a tiny, dim, one-room house with six other family members. The house’s windows are thin panes of glass that do not open, creating an ideal environment for TB to flourish and spread from person to person through the air.

When Angel’s diagnosis was confirmed, the doctors realized he had contracted a strain of TB resistant to the normal regimen of medications, known as multi-drug resistant TB (MDR-TB). Richard was soon infected with the same strain.

Had the brothers contracted the disease 15 years ago, their chances of survival would not have been good. That’s because treatment for MDR-TB once cost about $25,000 a person, an exorbitant sum, particularly in a low-income country like Peru. But thanks largely to the work of Partners in Health, a US-based public health advocacy and service organization, the price of treating MDR-TB has come down to $1,500 a person. MDR-TB patients in Peru can now count on receiving free drugs through the combined effort of international organizations and the Peruvian health ministry.

Today, the Huaricacha brothers are nearing the end of their treatment under the scrupulous attention of a health promoter named Rosario Yupanqui, who visits their house once a week to check on them and make sure they have the medications they need and that they are taking them properly. The community-based model of TB treatment and care, with community health workers like Yupanqui at its core, is gaining increasing traction in Latin America as an effective way to treat the disease and prevent new cases.

Tuberculosis in Latin America

While few Americans or Europeans even think about TB, the disease still kills nearly 2 million people a year worldwide. Most of those deaths are concentrated among the world’s poorest and most vulnerable communities.

Although only 6 percent of all TB cases worldwide are found in Latin America, it is still far from vanquished in the region. About 50 percent of the region’s cases are clustered in Peru and Brazil. Both countries have recently made it a priority and are implementing the internationally recommended TB control strategy of directly observed short-course chemotherapy, known as DOTS.

According to Disease Control Priorities in Developing Countries, 2nd ed. (DCP2), a comprehensive public health guide launched in April 2006, one of the advantages of DOTS is that it can be carried out conveniently and relatively cheaply in the community, rather than requiring hospitalization. “We know that DOTS, is, in principle, very cost effective,” said Christopher Dye, coordinator for tuberculosis monitoring and evaluation for the World Health Organization’s (WHO) Stop TB Partnership and DCP2 author.

In fact, both Peru and Brazil are developing effective models of community-based TB services in the poorest communities through a decentralized health service model. Partners in Health’s sister organization in Peru, Socios en Salud (SES), works at the community level specifically with MDR-TB. In Brazil, the state of Rio de Janeiro has set up a community-based health center in the Rocinha favela, which the state hopes will serve as a model for poor communities throughout the state.

Yet TB experts in both countries say a major hurdle remains, which is the widespread implementation of DOTS at the local level. Because both countries are in the midst of decentralizing their health systems, TB treatment and prevention is increasingly in the hands of local leaders.

Progress in Peru

Peru is often hailed as a success story among countries with high TB incidence in the developing world. According to DCP2, the DOTS program in Peru has generated a 6 to 7 percent annual reduction in the rate of new cases of pulmonary TB.

In 2004, three percent of new TB cases in Peru were multi-drug resistant. “There has been an enormous change since 1996, when people with MDR-TB were only being treated with first-line drugs,” said Dr. Jaime Bayona, director of SES in Peru. First-line drugs are those most appropriate for treating pulmonary TB but are largely ineffective on MDR-TB. “We now have an established scheme for treating MDR-TB…” and each patient receives the most appropriate drugs from the moment they are diagnosed. In fact, Peru has now achieved an exceptionally high cure rate of 85 percent, which meets the norm set by the World Health Organization.

Dr. Bayona says that the number of MDR-TB cases is now stable and should begin to fall in a couple of years, due to a more effective national TB program and the success of SES’s interventions in treating the disease. SES’s community-based model of TB treatment and care administers DOTS through health promoters who routinely visit patients’ homes to enable and ensure compliance to treatment.

But according to Cesar Bonilla, coordinator of Peru’s National TB Prevention and Control Strategy in the Health Ministry, the prize awarded to Peru in 2000 by WHO for successfully implementing DOTS may inadvertently have caused the country to shift focus away from the disease. For this reason, the number of new cases still has not dropped as dramatically as it could have, and the disease continues to spread among the poor.

SES is working with the Ministry of Health to widen community-based DOTS for all TB patients nationwide—pulmonary TB patients, MDR-TB patients, and TB patients infected with HIV.

But while Peru remains committed to controlling TB on a national level, the country is still struggling to roll out and implement community-based programs. “Municipal leaders are now responsible for implementing DOTS,” said Bayona. “But stigma and discrimination against TB patients remains a major barrier to treating and preventing the disease.”

A Spark of Hope in Brazil

Despite having made progress in implementing DOTS, Brazil is still on WHO’s list of high TB burden countries. According to WHO’s 2004 figures, Brazil was number 16 on the list of 22 countries, with 110,000 new cases. DOTS coverage has also been low until recently; it increased from 7 percent coverage in 2000 to 52 percent coverage in 2004.

The state of Rio de Janeiro has the highest TB incidence in the country with 87 cases per 100,000 people. More than a third of Rio’s 10 million residents live in favelas, and most TB cases are concentrated there.

TB has thrived in Rio’s favelas in part because of the city’s density, according to Lisia Freitas, coordinator of the state’s TB control program. Rio is one of the densest cities in the world with an average of 12,500 people living in every square kilometer, and many poor favela residents live crammed together in tiny spaces. Providing health services in Rio’s favelas has proved very difficult because of the rampant violence there and the unwillingness of health workers to venture into the communities.

According to a 2006 report entitled “TB Policy in Brazil: A Civil Society Perspective” by the Soros Foundation, Brazil has failed to include the participation of communities most affected by TB in the analysis of government TB control efforts, namely the impoverished people living in the favelas, or shantytowns.

The state has managed, however, to set up one successful DOTS treatment center in the Rocinha favela, a large shantytown of nearly 150,000 people, which has spawned satellite health centers of its own. “Rocinha has a good center with good medical attention. We are working with several other favela communities and hope they will initiate similar efforts,” said Freitas.

The Rocinha treatment center provides a spark of hope for TB treatment advocates and health care providers. But Brazil’s decentralized health system means that each of the 32 municipalities inside the state must take the initiative to develop localized community DOTS programs, under the guidance of the state and the federal TB programs.

Despite the need for continuing progress, there are still very few people trained as community health workers in Rio, according to Carlos Basilia, secretary of the Brazilian Stop-TB Partnership. “Rio’s TB program is lacking in many other things as well, including food assistance for patients, good detection strategies, and information for patients on where to seek treatment,” said Basilia.

“TB now is a priority of the federal government and the state is also committed to the issue,” said Eduardo Bethlem, a technical advisor to the state TB program and a professor at the State University of Rio de Janeiro. “The challenge is getting the municipalities to make it a priority.”

TB experts in Brazil are optimistic that more municipalities will follow the lead of the Rocinha favela and will build community-based treatment facilities.

Drug Logistics a Challenge to Community Programs

According to Dye of WHO, while MDR-TB and co-infection with HIV remain significant concerns in Latin America, countries should focus primarily on finding people with TB and treating them appropriately and completely. This will not only cure most TB patients, but will also avoid the development of more MDR-TB.

Unfortunately, many of the first-line drugs are not reaching patients because of distribution problems, according to Bonilla. “We have all the drugs to treat TB, but some are not reaching the patients,” said Bonilla. “The drugs aren’t arriving and that is our biggest weakness.”

But Bonilla expects that eventually the kinks in the distribution system will get worked out, and Peru can reach its goal of being in control of its TB epidemic in the next few years.

Though Peru and Brazil have demonstrated that with political will, community-based DOTS programs can be established, some countries in Latin America still lack national DOTS programs altogether, according to Edith Alarcon, the Lima-based regional representative for The International Union Against Tuberculosis and Lung Disease. “The priority is to have DOTS in every country, have support via community agents, and get DOTS in place at the community level,” said Alarcon.

Thanks to the diligent attention of SES community health workers in Peru, Richard Huaricacha has nearly beaten his MDR-TB. “I’ve been sick for a long time, but I am almost finished with my treatment, and I’m ready to go back to work.”

As community-based DOTS programs grow, more and more TB patients will be able to access treatment and ultimately join the Huaricacha brothers on the road to health.


Eliza Barclay is a freelance journalist based in Mexico City. She can be reached at elizabarclay@gmail.com.