**5. The patchwork: What do these findings mean? Are they useful?**

TB, far from being under control, as was believed at the end of the decade of the 1990s, continues to cause many deaths, disability, and health expenditure; indeed, it has been recognized that the situation may be worsening due to an accumulation of structural condi‐ tions favoring its appearance and development: increased poverty in important population nuclei (which are the most susceptible to the disease), migratory movements (whether due to economic, work, political or even environmental issues), higher incidence of other immuno‐ suppressive diseases (mainly HIV/AIDS and diabetes), or weakening of health of certain individuals (such as due to malnutrition, and chronic pneumopathies), the increasingly more common appearance of forms of MDR, and the shortage of health resources to cope with TB, mainly in areas of greater socioeconomic exclusion. In this sense, the so-called developed countries have also felt the impacts of the disease, largely due the appearance of HIV/AIDS and to cases among immigrants who, whether legally or illegally, settle in foreign territories seeking to improve on the conditions which caused them to leave their places of origin.4 These populations are generally speaking the most socioeconomically disadvantaged groups.

This type of planning and programming of objectives apparently does not take account of the particular situations affecting the population, above all those aspects which are notably different from the global mean values. In fact the few population based studies available, some involving Latin American countries, likewise fail to treat marginal populations specially. For example, if it was not for international support, few governments would have sufficient resources to conduct national health surveys, which are usually carried out through household interviews, based on self-perceived morbidity, and which hardly ever include laboratory tests to identify diseased individuals (TB in our case). Generally, the level of disaggregation of surveys of this type goes no further than large geographical regions (north, south, east, etc), tending to disguise inter- and intra-regional heterogenei‐ ty, and the data are analyzed based on artificially created convenience categories, not based

Pulmonary Tuberculosis in Latin America: Patchwork Studies Reveal Inequalities in Its Control – The Cases of Chiapas

(Mexico), Chine (Ecuador) and Lima (Peru) http://dx.doi.org/10.5772/54950 453

In other words, it is usual that global policies emanating from the international agencies and institutions ignore the true situation, applying criteria of homogeneity in the calculation of targets, costs of equipment and supplies and staffing levels, among other aspects. Curiously, despite it being well known that social factors are related with TB, they are not taken into

In order to identify, analyze and ideally contribute alternative solutions to the problem of unmet needs of socioeconomically excluded populations, means working with samples which are not representative of the general population, but rather focused on these sub-populations, biased precisely due to their conditions. In this sense, our team has been employing the patchwork approach, involving studies focusing on marginal or susceptible populations, those with the worst socioeconomic and health conditions. In the case of TB, these circumstances (poverty, social vulnerability, and shortage of health facilities) are well recognized as one of the basic determinants of the presence and spread of the disease, but its characterization

For example, in marginalized rural areas, in the best case, active TB case finding is limited in practice, to identifying chronic coughers among users who seek health care. This results in at least three possible situations: a) there may be delays in the TB diagnosis (patients arrive in an

symptoms, TB may not even be detected;6 and, c) that a certain proportion of patients do not use the health services (due to accessibility barriers which may be geographical, economic or

5 Several studies have shown that groups living in conditions of greater socioeconomic margination present longer delays

7 Political conflicts (belonging to a particular organization), religious conflicts (not belonging to the religion predominant in the community), administrative barriers (nearest clinic not the one assigned officially), and conflicts deriving from access to and utilization of natural resources (water, timber, etcetera) can mean that certain individuals are denied access

6 In several studies we found that PTB status is not associated with the reason for visiting health services [10].

if the medical consultation is for reasons other than respiratory

on observed patterns of disease or deaths.

advanced stage of the disease);5

in seeking care for health problems [26,27].

cultural)7

consideration in order to improve the quality of plans to control it.

usually is not considered by health systems in their solution proposals [24].

and hence are not even diagnosed [10].

to health services, or they are denied medical care or drugs [6].

There is no doubt that TB is an outcome indicator of the socioeconomic, cultural and political structure of a population. TB is a historical reflection of the forms of social construction, particularly of the post-industrial revolution era experienced in capitalist countries. TB in this sense feeds, to a greater or lesser degree, depending on circumstances, on the social context in order to reproduce, and this fact finds expression, as documented in the present studies, in various gradients of exposure and susceptibility to the disease, in which the more socioeco‐ nomically disadvantaged groups are the ones most affected by the disease, but the ones which, paradoxically, usually receive least attention, whether in terms of prevention, diagnosis, or treatment, and hence cure rates are low.

Two million people die every year from TB, the majority of them in the "under-developed countries". The Global Plan to Stop TB 2006-2015 aims to treat 50 million people, save 14 million lives, and expand equitable access to quality diagnosis and treatment. According to this Global Plan, by 2010 it was expected "to be using diagnostic test that allow rapid, sensitive and inexpensive detection of active TB… and introduce the first new TB drug in 40 years. It also expects to see a new, safe, effective and affordable vaccine available by 2015" [21]. However, the World Health Organization, Pan-American Health Organization and Governments in general, establishing targets for TB control programs, take as their basis the reports they receive from the countries themselves, with the result that programs elaborated are eminently political, whose objectives and information basis constitute a kind of feedback system which rapidly departs from reality.

TB control programs thus planned are designed as though the social structure of the countries was homogeneous, and this impedes acting in such a way as to take account of the particu‐ larities of marginal populations, which are the ones presenting the highest rates of prevalence of this disease. The usual ways of working lead to government planning and actions being based on central estimates and tackling of global objectives. For example, the global mediumterm goal for TB control is to halve TB prevalence and death rates by 2015 as compared to 1990 levels, and to achieve a reduction in its incidence, as part of the Millennium Development Goals (number six) [22,23].

<sup>4</sup> The first report of a rise in cases of HIV/AIDS was published in 1991, affecting New York City, and the status of TB was changed to that of an AIDS-defining disease, although it has been calculated that currently 50% of new TB cases in the European Union occur among immigrants.

This type of planning and programming of objectives apparently does not take account of the particular situations affecting the population, above all those aspects which are notably different from the global mean values. In fact the few population based studies available, some involving Latin American countries, likewise fail to treat marginal populations specially. For example, if it was not for international support, few governments would have sufficient resources to conduct national health surveys, which are usually carried out through household interviews, based on self-perceived morbidity, and which hardly ever include laboratory tests to identify diseased individuals (TB in our case). Generally, the level of disaggregation of surveys of this type goes no further than large geographical regions (north, south, east, etc), tending to disguise inter- and intra-regional heterogenei‐ ty, and the data are analyzed based on artificially created convenience categories, not based on observed patterns of disease or deaths.

tions favoring its appearance and development: increased poverty in important population nuclei (which are the most susceptible to the disease), migratory movements (whether due to economic, work, political or even environmental issues), higher incidence of other immuno‐ suppressive diseases (mainly HIV/AIDS and diabetes), or weakening of health of certain individuals (such as due to malnutrition, and chronic pneumopathies), the increasingly more common appearance of forms of MDR, and the shortage of health resources to cope with TB, mainly in areas of greater socioeconomic exclusion. In this sense, the so-called developed countries have also felt the impacts of the disease, largely due the appearance of HIV/AIDS and to cases among immigrants who, whether legally or illegally, settle in foreign territories seeking to improve on the conditions which caused them to leave their places of origin.4 These populations are generally speaking the most socioeconomically disadvantaged groups.

There is no doubt that TB is an outcome indicator of the socioeconomic, cultural and political structure of a population. TB is a historical reflection of the forms of social construction, particularly of the post-industrial revolution era experienced in capitalist countries. TB in this sense feeds, to a greater or lesser degree, depending on circumstances, on the social context in order to reproduce, and this fact finds expression, as documented in the present studies, in various gradients of exposure and susceptibility to the disease, in which the more socioeco‐ nomically disadvantaged groups are the ones most affected by the disease, but the ones which, paradoxically, usually receive least attention, whether in terms of prevention, diagnosis, or

Two million people die every year from TB, the majority of them in the "under-developed countries". The Global Plan to Stop TB 2006-2015 aims to treat 50 million people, save 14 million lives, and expand equitable access to quality diagnosis and treatment. According to this Global Plan, by 2010 it was expected "to be using diagnostic test that allow rapid, sensitive and inexpensive detection of active TB… and introduce the first new TB drug in 40 years. It also expects to see a new, safe, effective and affordable vaccine available by 2015" [21]. However, the World Health Organization, Pan-American Health Organization and Governments in general, establishing targets for TB control programs, take as their basis the reports they receive from the countries themselves, with the result that programs elaborated are eminently political, whose objectives and information basis constitute a kind of feedback system which rapidly

TB control programs thus planned are designed as though the social structure of the countries was homogeneous, and this impedes acting in such a way as to take account of the particu‐ larities of marginal populations, which are the ones presenting the highest rates of prevalence of this disease. The usual ways of working lead to government planning and actions being based on central estimates and tackling of global objectives. For example, the global mediumterm goal for TB control is to halve TB prevalence and death rates by 2015 as compared to 1990 levels, and to achieve a reduction in its incidence, as part of the Millennium Development

4 The first report of a rise in cases of HIV/AIDS was published in 1991, affecting New York City, and the status of TB was changed to that of an AIDS-defining disease, although it has been calculated that currently 50% of new TB cases in the

treatment, and hence cure rates are low.

452 Tuberculosis - Current Issues in Diagnosis and Management

departs from reality.

Goals (number six) [22,23].

European Union occur among immigrants.

In other words, it is usual that global policies emanating from the international agencies and institutions ignore the true situation, applying criteria of homogeneity in the calculation of targets, costs of equipment and supplies and staffing levels, among other aspects. Curiously, despite it being well known that social factors are related with TB, they are not taken into consideration in order to improve the quality of plans to control it.

In order to identify, analyze and ideally contribute alternative solutions to the problem of unmet needs of socioeconomically excluded populations, means working with samples which are not representative of the general population, but rather focused on these sub-populations, biased precisely due to their conditions. In this sense, our team has been employing the patchwork approach, involving studies focusing on marginal or susceptible populations, those with the worst socioeconomic and health conditions. In the case of TB, these circumstances (poverty, social vulnerability, and shortage of health facilities) are well recognized as one of the basic determinants of the presence and spread of the disease, but its characterization usually is not considered by health systems in their solution proposals [24].

For example, in marginalized rural areas, in the best case, active TB case finding is limited in practice, to identifying chronic coughers among users who seek health care. This results in at least three possible situations: a) there may be delays in the TB diagnosis (patients arrive in an advanced stage of the disease);5 if the medical consultation is for reasons other than respiratory symptoms, TB may not even be detected;6 and, c) that a certain proportion of patients do not use the health services (due to accessibility barriers which may be geographical, economic or cultural)7 and hence are not even diagnosed [10].

<sup>5</sup> Several studies have shown that groups living in conditions of greater socioeconomic margination present longer delays in seeking care for health problems [26,27].

<sup>6</sup> In several studies we found that PTB status is not associated with the reason for visiting health services [10].

<sup>7</sup> Political conflicts (belonging to a particular organization), religious conflicts (not belonging to the religion predominant in the community), administrative barriers (nearest clinic not the one assigned officially), and conflicts deriving from access to and utilization of natural resources (water, timber, etcetera) can mean that certain individuals are denied access to health services, or they are denied medical care or drugs [6].

In this context, women living in remote and marginalized regions, have a more pronounced lack of access to health services due to gender reasons: there are differences in the process of seeking medical care, and in the quality of the care received between women and men [25].

appropriately and application of the DOTS strategy is very deficient: even if TB patients are diagnosed, in many cases they begin, but do not complete their anti-TB treatment. In this sense,

Pulmonary Tuberculosis in Latin America: Patchwork Studies Reveal Inequalities in Its Control – The Cases of Chiapas

(Mexico), Chine (Ecuador) and Lima (Peru) http://dx.doi.org/10.5772/54950 455

**a.** It is extremely difficult to perform culture analysis, in order to determine MDR status, in a patient with less than six months of treatment, due to poor quality sputum samples. The main obstacles to obtaining good quality sputum samples are: barriers in communication with indigenous people, distance of the communities from the centers where samples are processed, unsuitable transport conditions of samples (risk of exposure to sunlight or lack

**b.** It is very plausible that in indigenous populations, due to their having less contact with health services, there are more undiagnosed TB cases and that, among non-indigenous patients, more TB cases are diagnosed but not necessarily treated adequately [12].

**c.** A patient confirmed with MDR condition, is practically impossible to treat, given the high cost of the secondary treatment, and because if the health system is incapable of guaran‐ teeing the follow up of a patient sensitive to the four primary drugs during six months, it is probably even less able to follow up a MDR patient not only in terms of the time required (from 6 months to 1.5 or 2 years) but also in terms of level of patient care, due to the possible secondary effects of the "second line drugs" employed. In this sense, if a program cannot guarantee appropriate follow up and compliance with treatment among TB patients, it should not initiate their treatment, thus condemning them to a situation of no hope of cure, with all that this implies, not only for the patient, but also for his family, who apart from watching their family member suffer, are also exposed to the possibility of their

With regard to mortality due to TB, we have found unacceptably high rates. In addition, a considerable proportion of TB patients die without having received any medical care.8 We found that 55% of patients whose death was related to TB, had died within two years of being diagnosed, possibly due to delays in diagnosis, and the poor quality of the followup in their anti-TB treatment. Whereas the life expectancy in Chiapas is 72.2 years [29], the average age of deceased patients was 47.4 years, representing an average of at least 24 potential years of life lost [13]. We believe that the accumulation of unfavorable living conditions such as malnutrition, poverty, as well as deficient and/or lack of health services, makes them an especially vulnerable group. According to official statistics, while in 2009 the PTB mortality for the country was 1.7/100,000 inhabitants in Chiapas it was 3.79 with

Our findings have provided evidence that in the area studied, patients being aged 45 years and over, not having completed the established six months of treatment, and not having been treated via the DOTS strategy, are all associated with a higher risk of the patient

8 Eighteen percent of patients traced to their homes, in a study carried out in Chiapas, had died. Of the 40 deaths

presumed to have been associated with PTB, 33 died without having received medical care [13]

we must emphasize the following aspects:

refrigeration), among others.

catching the disease.

the same denominator [14].

dying from PTB.

Furthermore, in Chiapas, Ecuador and Peru, as in many other regions of Latin America, TB cases notified to the information systems of the health sector, and from which inci‐ dence rates are estimated, correspond to cases detected in health services by acid-fast bacilli. We have documented that in rural and marginalized areas, its sensitivity is around 50%. This is an important aspect to consider because health system detection of TB cases is based on smear testing, meaning that in marginalized communities many cases are not detected. In consequence, the target of detecting at least 75% of cases is far from being reached, implying the presence of a not unappreciable risk of transmission of TB [9]. Indeed, the detection rate in hospitals studied in Chiapas is below this figure of 75%. The suboptimal case detection rate reflects an inadequate of quality medical care, probably health personnel are often overwhelmed by daily activities, as well as insufficiently trained, motivated, aware, and remunerated [10].

In order to increase detection rates, as it was demonstrated, the health system must take into account the considerable difficulties involved in obtaining and analyzing sputum samples in marginalized areas: cultural barriers (language spoken, world view) and economic barriers, as well as technical problems to be overcome in order to obtain adequate quantity and quality of sputum samples. It is therefore necessary to reduce the cultural and socioeconomic barriers between health care providers and people [10]. Not surprisingly, some results of our investi‐ gations show that apart from cultural barriers, there are also structural barriers [11].

In the same way, we have found that a very low proportion of patients eligible for anti-TB treatment effectively receive such treatment, and very high proportions of treatment failures and incomplete follow-up [10].

Two further aspects deserve special attention in the context of the studies conducted in Chiapas, Mexico, as well as in Peru: the problem of MDR, and the high mortality among patients diagnosed of PTB. Both indicators constitute expressions of the complete failure of the health system which, for whatever reason, did not manage to adequately treat these people, who consequently either died of TB, or were left as chronic MDR cases (which would lead to their death also, sooner or later).

In the case of MDR, it is well documented that the vast majority of cases of this type result from inappropriate treatment and follow up by the health system. According to official statistics, worldwide, the rates of MDR recorded in 2009 and 2010 were the highest ever, and trends in MDR rates are unclear in the majority of countries [28]. The observed rates of MDR in Chiapas suggest that in marginalized and excluded regions, it is a serious public health problem of alarming proportions. While the MDR rates calculated for the country as a whole are 1-3% for primary, and 20% for secondary MDR, in our studies these rates were 4.6% and 29%, respectively [12].

Although our results were made known to the health authorities, there are no signs to suggest that the TB situation has improved: the health system continues failing to diagnose cases appropriately and application of the DOTS strategy is very deficient: even if TB patients are diagnosed, in many cases they begin, but do not complete their anti-TB treatment. In this sense, we must emphasize the following aspects:

In this context, women living in remote and marginalized regions, have a more pronounced lack of access to health services due to gender reasons: there are differences in the process of seeking medical care, and in the quality of the care received between women and men [25]. Furthermore, in Chiapas, Ecuador and Peru, as in many other regions of Latin America, TB cases notified to the information systems of the health sector, and from which inci‐ dence rates are estimated, correspond to cases detected in health services by acid-fast bacilli. We have documented that in rural and marginalized areas, its sensitivity is around 50%. This is an important aspect to consider because health system detection of TB cases is based on smear testing, meaning that in marginalized communities many cases are not detected. In consequence, the target of detecting at least 75% of cases is far from being reached, implying the presence of a not unappreciable risk of transmission of TB [9]. Indeed, the detection rate in hospitals studied in Chiapas is below this figure of 75%. The suboptimal case detection rate reflects an inadequate of quality medical care, probably health personnel are often overwhelmed by daily activities, as well as insufficiently trained,

In order to increase detection rates, as it was demonstrated, the health system must take into account the considerable difficulties involved in obtaining and analyzing sputum samples in marginalized areas: cultural barriers (language spoken, world view) and economic barriers, as well as technical problems to be overcome in order to obtain adequate quantity and quality of sputum samples. It is therefore necessary to reduce the cultural and socioeconomic barriers between health care providers and people [10]. Not surprisingly, some results of our investi‐

In the same way, we have found that a very low proportion of patients eligible for anti-TB treatment effectively receive such treatment, and very high proportions of treatment failures

Two further aspects deserve special attention in the context of the studies conducted in Chiapas, Mexico, as well as in Peru: the problem of MDR, and the high mortality among patients diagnosed of PTB. Both indicators constitute expressions of the complete failure of the health system which, for whatever reason, did not manage to adequately treat these people, who consequently either died of TB, or were left as chronic MDR cases (which would lead to

In the case of MDR, it is well documented that the vast majority of cases of this type result from inappropriate treatment and follow up by the health system. According to official statistics, worldwide, the rates of MDR recorded in 2009 and 2010 were the highest ever, and trends in MDR rates are unclear in the majority of countries [28]. The observed rates of MDR in Chiapas suggest that in marginalized and excluded regions, it is a serious public health problem of alarming proportions. While the MDR rates calculated for the country as a whole are 1-3% for primary, and 20% for secondary MDR, in our studies these rates were 4.6% and

Although our results were made known to the health authorities, there are no signs to suggest that the TB situation has improved: the health system continues failing to diagnose cases

gations show that apart from cultural barriers, there are also structural barriers [11].

motivated, aware, and remunerated [10].

454 Tuberculosis - Current Issues in Diagnosis and Management

and incomplete follow-up [10].

their death also, sooner or later).

29%, respectively [12].


With regard to mortality due to TB, we have found unacceptably high rates. In addition, a considerable proportion of TB patients die without having received any medical care.8 We found that 55% of patients whose death was related to TB, had died within two years of being diagnosed, possibly due to delays in diagnosis, and the poor quality of the followup in their anti-TB treatment. Whereas the life expectancy in Chiapas is 72.2 years [29], the average age of deceased patients was 47.4 years, representing an average of at least 24 potential years of life lost [13]. We believe that the accumulation of unfavorable living conditions such as malnutrition, poverty, as well as deficient and/or lack of health services, makes them an especially vulnerable group. According to official statistics, while in 2009 the PTB mortality for the country was 1.7/100,000 inhabitants in Chiapas it was 3.79 with the same denominator [14].

Our findings have provided evidence that in the area studied, patients being aged 45 years and over, not having completed the established six months of treatment, and not having been treated via the DOTS strategy, are all associated with a higher risk of the patient dying from PTB.

<sup>8</sup> Eighteen percent of patients traced to their homes, in a study carried out in Chiapas, had died. Of the 40 deaths presumed to have been associated with PTB, 33 died without having received medical care [13]

Based on our findings, we can say that people from rural and indigenous communities suffer mistreatment by the health services [30], meaning, among other aspects, deficient application of the DOTS strategy (sometimes due to shortages in the supply of anti-TB drugs [31], or poor follow up), leading to higher mortality and increasing their chances of becoming MDR cases [12,13].

In our view, to remain with the idea that TB is decreasing in Latin America, tends to conceal the failure which the rise in MDR patients represents. In any case, countries are alarmed by the rise in MDR because of the cost of treatment and its inefficiency, not necessarily for the health and welfare of TB patients, particularly if they are poor, as our studies suggest.

Pulmonary Tuberculosis in Latin America: Patchwork Studies Reveal Inequalities in Its Control – The Cases of Chiapas

(Mexico), Chine (Ecuador) and Lima (Peru) http://dx.doi.org/10.5772/54950 457

One discussion point is clear. Objective-oriented programs which attribute to the entire country the same values of incidence and detection rates present a problem known as "trim‐ med estimation", meaning that when the established objectives are reached, case finding and detection are relaxed, or the resources to permit continuing with case finding and/or provision

If, together with these data we take into account cases in areas enjoying lower TB incidence, and if this total was the true number of existing cases, the result would necessarily be a systematic reduction in incidence rates, leading to false optimism, whose historical cost has been a relaxation of efforts to prevent and control TB worldwide during the decade of the 1980s

Imagine the simple case that we have an incidence rate of X, in a given country. This figure conditions the work plan for the coming year in terms of supplies, staff, anti-TB treatment drugs, etcetera. Later on, 70% of the reporting areas indicate a rate of 0.9X, another 15% of areas a rate of X, and the remaining 15% provide no data on rates, but their population is taken into account in the denominator. The final rate for this country, based on these hypothetical figures, would be 0.78X. In other words, not receiving reports from the areas with the worst

Unfortunately, even without questioning the figures declared, we know that areas which do not report (or report, but at best with high levels of under-notification) are the ones with the poorest conditions, both in terms of the socioeconomic conditions of the population which theoretically must be cared for, and in terms of the lack of resources and other failures in the organization and functioning of the program. Thus, by apparently having fewer cases, the resources dedicated to the TB prevention and control program are also cut back, and this creates a vicious circle which is difficult to break, so that program outcomes may be false, i.e.

There is therefore a clear need to promote studies specifically aiming to analyze the population groups most vulnerable to TB, and in this way ascertain more precisely their situation, even when they are not representative of what happens in a given country. Continuing to carry out representative population based studies can only yield the probably already known rate for the country as a whole, and the situation of marginal groups will not be reflected in such rate. In this sense, the patchwork studies contribute very valuable elements which help to make more visible and understandable the situation of population groups which go unnoticed in the global rates utilized in public health. We would encourage potentiating studies which break with the classical schemes, and use methods appropriate for the analysis of samples considered too small by classical approaches, but without renouncing the maximum of scientific rigor, as demonstrated by the doctoral theses developed in projects conducted in the three settings we have dealt with, Chiapas (Mexico), Chine (Cotopaxi,

conditions provokes an apparent reduction in the global rate.

underestimates of the numbers of cases.

of treatment, are cut short.

of last century.

Another fact that reduces the chances of successfully carrying out patient follow up, is migratory movements. Migration in the region is mainly due to economic factors, but can also be for health reasons. Sometimes patients are registered by health services as urban patients when in fact they are not, or they give a false address in order to obtain the first consultation, but subsequently return to their rural communities or find another place to live without notifying the health services.

In addition, health services give little consideration to socio-cultural and anthropological aspects. For example, in indigenous medicine the process of health and illness involves their world view, their personal and community histories, in an atmosphere of trust in which supernatural intervention, transgression of social norms, culpability, or malice on the part of enemies, are all admissible possible causes of the disease [16,32,33]. In this sense, patients may seek care from traditional medicine practitioners, who attend them in accordance with their age-old diagnostic and therapeutic rituals.

On the other hand, the use of public transport is a risk factor of TB not only among users, but also among minibus drivers and fare-collectors, and hence may be considered an occupational disease in these workers, who work in conditions such that not only do they have precarious employment, with all its implications (temporary contract, no social security or medical insurance, among other aspects) but also their job places them in a position of greater vulnerability to TB, since if they don't work, they don't get paid, and hence it is very probable that many of them go to work despite their illness, if they are able to do so, only seeking care when the disease really makes it impossible for them to continue working. In this sense, a worker with active PTB is a source of infection not only for co-workers but also for passengers. In countries where TB is endemic with increased circulation of resistant mycobacteria, the situation could be even worse. In a situation of this kind, the health system should be implementing, at very least, home-based DOTS to avoid exposure as far as possible, as well as implementing specifically designed occupation‐ al health programs [19,20,34].9

Observation of the particular facts which determine the appearance of TB and its prognosis, shows that the diagnosis and treatment strategies employed by the health services are just that, strategies, rather than ends in themselves, something which, unfortunately, is frequently emphasized. If more clearly focused measures are not taken, TB will not disappear in margi‐ nalized areas, despite the fact that trends in the ecological indices suggest that TB is tending to decline in Latin American countries; rather, it will persist as a greater public health problem for years to come.

<sup>9</sup> In fact, the authors believe that more attention ought to be given to the risk of infection, by any aerially transmitted disease that utilization of public transport represents, for both passengers and the workers.

In our view, to remain with the idea that TB is decreasing in Latin America, tends to conceal the failure which the rise in MDR patients represents. In any case, countries are alarmed by the rise in MDR because of the cost of treatment and its inefficiency, not necessarily for the health and welfare of TB patients, particularly if they are poor, as our studies suggest.

Based on our findings, we can say that people from rural and indigenous communities suffer mistreatment by the health services [30], meaning, among other aspects, deficient application of the DOTS strategy (sometimes due to shortages in the supply of anti-TB drugs [31], or poor follow up), leading to higher mortality and increasing their chances of

Another fact that reduces the chances of successfully carrying out patient follow up, is migratory movements. Migration in the region is mainly due to economic factors, but can also be for health reasons. Sometimes patients are registered by health services as urban patients when in fact they are not, or they give a false address in order to obtain the first consultation, but subsequently return to their rural communities or find another place to live without

In addition, health services give little consideration to socio-cultural and anthropological aspects. For example, in indigenous medicine the process of health and illness involves their world view, their personal and community histories, in an atmosphere of trust in which supernatural intervention, transgression of social norms, culpability, or malice on the part of enemies, are all admissible possible causes of the disease [16,32,33]. In this sense, patients may seek care from traditional medicine practitioners, who attend them in accordance with their

On the other hand, the use of public transport is a risk factor of TB not only among users, but also among minibus drivers and fare-collectors, and hence may be considered an occupational disease in these workers, who work in conditions such that not only do they have precarious employment, with all its implications (temporary contract, no social security or medical insurance, among other aspects) but also their job places them in a position of greater vulnerability to TB, since if they don't work, they don't get paid, and hence it is very probable that many of them go to work despite their illness, if they are able to do so, only seeking care when the disease really makes it impossible for them to continue working. In this sense, a worker with active PTB is a source of infection not only for co-workers but also for passengers. In countries where TB is endemic with increased circulation of resistant mycobacteria, the situation could be even worse. In a situation of this kind, the health system should be implementing, at very least, home-based DOTS to avoid exposure as far as possible, as well as implementing specifically designed occupation‐

Observation of the particular facts which determine the appearance of TB and its prognosis, shows that the diagnosis and treatment strategies employed by the health services are just that, strategies, rather than ends in themselves, something which, unfortunately, is frequently emphasized. If more clearly focused measures are not taken, TB will not disappear in margi‐ nalized areas, despite the fact that trends in the ecological indices suggest that TB is tending to decline in Latin American countries; rather, it will persist as a greater public health problem

9 In fact, the authors believe that more attention ought to be given to the risk of infection, by any aerially

transmitted disease that utilization of public transport represents, for both passengers and the workers.

becoming MDR cases [12,13].

456 Tuberculosis - Current Issues in Diagnosis and Management

notifying the health services.

age-old diagnostic and therapeutic rituals.

al health programs [19,20,34].9

for years to come.

One discussion point is clear. Objective-oriented programs which attribute to the entire country the same values of incidence and detection rates present a problem known as "trim‐ med estimation", meaning that when the established objectives are reached, case finding and detection are relaxed, or the resources to permit continuing with case finding and/or provision of treatment, are cut short.

If, together with these data we take into account cases in areas enjoying lower TB incidence, and if this total was the true number of existing cases, the result would necessarily be a systematic reduction in incidence rates, leading to false optimism, whose historical cost has been a relaxation of efforts to prevent and control TB worldwide during the decade of the 1980s of last century.

Imagine the simple case that we have an incidence rate of X, in a given country. This figure conditions the work plan for the coming year in terms of supplies, staff, anti-TB treatment drugs, etcetera. Later on, 70% of the reporting areas indicate a rate of 0.9X, another 15% of areas a rate of X, and the remaining 15% provide no data on rates, but their population is taken into account in the denominator. The final rate for this country, based on these hypothetical figures, would be 0.78X. In other words, not receiving reports from the areas with the worst conditions provokes an apparent reduction in the global rate.

Unfortunately, even without questioning the figures declared, we know that areas which do not report (or report, but at best with high levels of under-notification) are the ones with the poorest conditions, both in terms of the socioeconomic conditions of the population which theoretically must be cared for, and in terms of the lack of resources and other failures in the organization and functioning of the program. Thus, by apparently having fewer cases, the resources dedicated to the TB prevention and control program are also cut back, and this creates a vicious circle which is difficult to break, so that program outcomes may be false, i.e. underestimates of the numbers of cases.

There is therefore a clear need to promote studies specifically aiming to analyze the population groups most vulnerable to TB, and in this way ascertain more precisely their situation, even when they are not representative of what happens in a given country. Continuing to carry out representative population based studies can only yield the probably already known rate for the country as a whole, and the situation of marginal groups will not be reflected in such rate.

In this sense, the patchwork studies contribute very valuable elements which help to make more visible and understandable the situation of population groups which go unnoticed in the global rates utilized in public health. We would encourage potentiating studies which break with the classical schemes, and use methods appropriate for the analysis of samples considered too small by classical approaches, but without renouncing the maximum of scientific rigor, as demonstrated by the doctoral theses developed in projects conducted in the three settings we have dealt with, Chiapas (Mexico), Chine (Cotopaxi, Ecuador), and Lima (Peru), and whose results have been published in journals of medi‐ um and high impact factor.

**6. Conclusions: Tuberculosis as indicator of structural violence and**

analysis of the distribution of TB among different population groups.

One of the main aspects we want to stress in the present work is the fact that analyzing TB through the measurement of global indicators conceals the situation of vulnerability to the disease suffered by socioeconomically disadvantaged population groups. The data obtained in the different studies we have presented show that there is a need for methodological approaches (such as that known as patchwork studies) which allow the measurement and

Pulmonary Tuberculosis in Latin America: Patchwork Studies Reveal Inequalities in Its Control – The Cases of Chiapas

(Mexico), Chine (Ecuador) and Lima (Peru) http://dx.doi.org/10.5772/54950 459

It is well known that TB is one of the infectious diseases which has caused the most deaths among humans [36], above all among the socioeconomically most vulnerable groups [37]. These groups, apart from having higher risks of infection, developing active disease, and dying due to TB, are also the ones facing the greatest barriers (including information barriers) to access health services [38]. In this sense, and given that nowadays the medical resources to cure the disease are available, the fact that even today TB continues to cause deaths may be considered as an indicator of the violation of human rights in excluded and marginalized populations, as well as an indicator of "structural violence", given that it is precisely the social, economic, cultural and political structures which do not allow certain social groups to achieve their full potential, while other groups do so, due to the unequal distribution of power and available resources, placing some in conditions of social privilege and others in situations of

The social context of TB is strongly related with social justice. The history of TB teaches us that the improvement of social conditions, work conditions ant the access to better quality food

Taking as a starting point that the appearance, development and distribution of TB is largely influenced by social determinants, and that public health achievements will depend on actions outside the health care sector [41], two forms of interventions are necessary: a) those reducing peoples' vulnerability, such as poor living and working conditions, and improving nutrition, among other aspects (such as structural and socioeconomic conditions), and b) by seeking

Two clear examples that help to visualize health related inequalities in respect to TB are firstly, the so-called "10/90 gap", in reference to the fact that only 10% of worldwide expenditure on health research and development is devoted to the problems primarily affect the poorest 90% of the world's population, and that 90% of worldwide expenditure is devoted to the problems

The second example is the comparison between HIV-AIDS and TB. Whereas the first cases of HIV-AIDS were described during the decade of the 1980s of the last century, today it is one of the diseases which have received the most resources for its prevention and treatment, and notable advances have been achieved in these aspects, and in improving survival of patients. At the end of the last century, it was practically a death sentence, and yet today we have a

alternatives that promote higher levels of prevention, diagnosis and cure of TB.

series of drugs which increase both survival and quality of life of these patients.

**violations of human rights**

social vulnerability [39].

decreased its mortality in the pre-microbial stage [40].

that affect the richest 10% of the world's population.

On the other hand, Ecuador and Peru present changes in their control program strategies: active case finding, incorporation of economic incentives, strategies to reduce stigma among patients, citizens' observatories and integration of TB research in academic circles, among other aspects. It will be fundamental to perform studies which evaluate possible effects of such changes.

As the studies have shown, a failure to introduce changes in the structure and functioning of TB prevention and control programs would have as a consequence that this disease will continue to severely affect the most marginalized sectors of society:

In the field of TB prevention, several authors recognize that effective efforts have not yet been fully considered, and that it is necessary to improve this issue, for example through better vaccines and better chemotherapy for preventive treatment [22].

In the field of TB diagnosis, efforts must be made to reinforce active case finding of coughers, as for example, incorporating other diagnostic tests which allow better detec‐ tion of the disease (from the use of cultures, and conducting molecular tests, to the search for faster diagnostic methods, such as biosensors). Epidemiological surveillance systems rely on smear testing, failing to take into account that in marginalized and rural areas these tests with only around 50% sensitivity, leave large numbers of cases undetected by the health services, or who will only be captured in advanced stages of the disease [12-14]. It is not unusual to find, within a given Latin American country, that while highly devel‐ oped regions have advanced technologies available for TB diagnosis, in others the only possibility for diagnosis is the smear test. Nor is it unusual in regions of this type to find that smear testing is done badly, both in numerical terms (hardly ever obtaining three samples from a given patient), and in terms of quality (for reasons attributable to the poor quality of samples, such as errors in collection, storage, transport, processing and read‐ ing of results) [10,35].

In regard to anti-TB treatment, while the DOTS strategy has achieved a certain level of effectiveness in curing patients and saving lives, the epidemiological impact has so far been less than predicted [22], perhaps among other reasons, because treatment programs do not find patients soon enough to significantly reduce transmission [5]. Thus it is necessary to ensure: a) training, awareness and supervision of health personnel about the importance of avoiding patients defaulting from treatment, as well as guaranteeing the appropriate supply of medication; b) when necessary to adapt the DOTS strategy, both socially and culturally, taking into account the community health agents, community world view, and implementing the scheme in the patient's homes, supporting them and their families economically during their treatment; and c) that patients and their family are accompanied during the six months of treatment, in order to cope with possible secondary effects and to overcome possible barriers (alcoholism, religion, gender issues, seasonal migration, etcetera) which make compliance with anti-TB treatment difficult.
