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

Ecuador), and Lima (Peru), and whose results have been published in journals of medi‐

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

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

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

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‐

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

continue to severely affect the most marginalized sectors of society:

vaccines and better chemotherapy for preventive treatment [22].

um and high impact factor.

458 Tuberculosis - Current Issues in Diagnosis and Management

ing of results) [10,35].

anti-TB treatment difficult.

changes.

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 analysis of the distribution of TB among different population groups.

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 social vulnerability [39].

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

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

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

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

In contrast, despite the fact that TB has been accompanying humans for thousands of years, and that the etiological agent was first described in 1882, it is the disease which has alone caused the greatest numbers of deaths in the adult population worldwide, and for which the resources currently dedicated are insufficient to lead us to expect, in the foreseeable short or medium term, the appearance of more effective measures for its control. Perhaps this is because it is considered a disease of the poor, and thus there is no incentive to "invest" in it? As some of our colleagues have pointed out: "even if the Global Plan to Stop TB is successfully imple‐ mented and results in the expected rate of reduction in incidence of about 6%, the global incidence rate in 2050 would still be of the order of 100 per million of inhabitants, i.e. about 100 times greater than the elimination target" [22].

orientation, among others. A violation occurs when there is the intention or effect of nullifying

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 461

Second, physical accessibility, meaning that health facilities, goods and services must be within safe physical reach for all groups, specially the vulnerable or marginalized ones, such as ethnic

Third, economic accessibility requires that health facilities, goods and services must be affordable for all, including socially disadvantaged groups. It points out that poorer persons should not be disproportionately burdened with health expenses, and those individuals (e.g. peasants) who through not having access to cash face particular difficulties, need to be

Fourth, the right to seek, receive and impart information and ideas concerning health issues,

With regard to acceptability, it is understood that "health facilities, goods and services must be respectful of medical ethics and culturally appropriate… [and] requires respect for tradi‐ tional medicines and practices which have not been shown to be harmful to human health"

For adequate quality, it requires that health facilities, goods and services must be scientif‐ ically and medically appropriate and of good quality (skilled medical personnel, scientifi‐ cally approved and unexpired drugs, and hospital equipment, among other aspects) [43,

Unfortunately, the findings of our studies indicate that health care is not sufficiently available or accessible (in either quantity or quality) to more disadvantaged social groups, creating mistrust among them of the government health services, something that is reflected in the relatively high percentage of people that do not use these services, even for vaccinations. This situation is more marked when health services are not culturally adapted, when people perceive mistreatment on the basis of their ethnicity or social conditions and health personnel

**•** Failure to improve the level of health in a population. The fact that health indicators, in our case indicators of TB do not improve in a population, even though they do not worsen, constitutes a violation of human rights (specifically of the right to "Non-retrogression and

**•** The presence of inequalities in access to quality and coverage of health services (in the case

**•** The lack of meaningful popular participation, in regard to the making of decisions which involve the design, organization and functioning of health services. It is common to find that local health services nominate a "health promoter", charged with various activities such as vaccination, routine pediatric checkups, etcetera, but this does not necessarily mean the community has a voice or participates in the definition of its own priorities, decision-making

or impairing the equal enjoyment or exercise of the right to health [43, paragraph 18].

and indigenous populations.

[43, paragraph 12 (c)].

paragraph 12 (d)].

Adequate Progress").

considered in governmental policy and practice.

which includes health information in indigenous languages.

make disparaging remarks about their habits and demeanor [6]. Other indicators of violation of human rights in TB patients are:

of TB affecting aspects from prevention to cure).

From the viewpoint of international human rights law, by providing woefully substandard health services to marginalized populations, and failing to assure prevention of disease through appropriate public health measures, governments violate their obligations in human rights [6].

In this sense, high rates of TB constitute a reflection of the fact that certain populations face important obstacles in their exercise of the right to health, and other economic, social and cultural rights, due to the main social determinants of this disease being associated to social exclusion and poverty [31]. The presence of TB constitutes a violation of the right to the highest attainable standard of physical and mental health ("the right to health protection") which is inextricably related to the right to life and other human rights that allow an individual to live with dignity [6,42].

The International Covenant on Economic, Social and Cultural Rights (ICESCR) in its Article 12, Paragraph 2, sets out the steps states should take in order to fulfill the highest attainable standard of health, and includes "the prevention, treatment and control of epidemic, endemic, occupational and other diseases, as well as the creation of conditions which would assure to all medical service and medical attention in the event of sickness".

The General Comment issued by the Economic, Social and Cultural Rights Committee [43], establishes that "the underlying determinants of health, such as including adequate sanitation facilities, hospitals, clinics and other health related buildings, trained medical and professional personnel" have to be available in sufficient quantity with the States parties, and specifies that health facilities, goods and services must be available, accessible, acceptable and of adequate quality.

In this General Comment, accessibility has four overlapping dimensions [43, paragraph 12 (b)]:

First, the principle of non-discrimination,10 on the grounds of sex (poorer quality of care among women than men), ethnic group (patients from indigenous communities receive poorer care), color, political filiation (belonging or not to the dominant political party in a region can affect access to care and to medication), religion (care may be denied to community members not belonging to the dominant religion), physical or mental disability, health status, sexual

<sup>10</sup> Non-discrimination is a core principle for the full realization of the right to health, as for all human rights [6]

orientation, among others. A violation occurs when there is the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health [43, paragraph 18].

In contrast, despite the fact that TB has been accompanying humans for thousands of years, and that the etiological agent was first described in 1882, it is the disease which has alone caused the greatest numbers of deaths in the adult population worldwide, and for which the resources currently dedicated are insufficient to lead us to expect, in the foreseeable short or medium term, the appearance of more effective measures for its control. Perhaps this is because it is considered a disease of the poor, and thus there is no incentive to "invest" in it? As some of our colleagues have pointed out: "even if the Global Plan to Stop TB is successfully imple‐ mented and results in the expected rate of reduction in incidence of about 6%, the global incidence rate in 2050 would still be of the order of 100 per million of inhabitants, i.e. about

From the viewpoint of international human rights law, by providing woefully substandard health services to marginalized populations, and failing to assure prevention of disease through appropriate public health measures, governments violate their obligations in human

In this sense, high rates of TB constitute a reflection of the fact that certain populations face important obstacles in their exercise of the right to health, and other economic, social and cultural rights, due to the main social determinants of this disease being associated to social exclusion and poverty [31]. The presence of TB constitutes a violation of the right to the highest attainable standard of physical and mental health ("the right to health protection") which is inextricably related to the right to life and other human rights that allow an individual to live

The International Covenant on Economic, Social and Cultural Rights (ICESCR) in its Article 12, Paragraph 2, sets out the steps states should take in order to fulfill the highest attainable standard of health, and includes "the prevention, treatment and control of epidemic, endemic, occupational and other diseases, as well as the creation of conditions which would assure to

The General Comment issued by the Economic, Social and Cultural Rights Committee [43], establishes that "the underlying determinants of health, such as including adequate sanitation facilities, hospitals, clinics and other health related buildings, trained medical and professional personnel" have to be available in sufficient quantity with the States parties, and specifies that health facilities, goods and services must be available, accessible, acceptable and of adequate

In this General Comment, accessibility has four overlapping dimensions [43, paragraph 12 (b)]:

First, the principle of non-discrimination,10 on the grounds of sex (poorer quality of care among women than men), ethnic group (patients from indigenous communities receive poorer care), color, political filiation (belonging or not to the dominant political party in a region can affect access to care and to medication), religion (care may be denied to community members not belonging to the dominant religion), physical or mental disability, health status, sexual

10 Non-discrimination is a core principle for the full realization of the right to health, as for all human rights [6]

all medical service and medical attention in the event of sickness".

100 times greater than the elimination target" [22].

460 Tuberculosis - Current Issues in Diagnosis and Management

rights [6].

quality.

with dignity [6,42].

Second, physical accessibility, meaning that health facilities, goods and services must be within safe physical reach for all groups, specially the vulnerable or marginalized ones, such as ethnic and indigenous populations.

Third, economic accessibility requires that health facilities, goods and services must be affordable for all, including socially disadvantaged groups. It points out that poorer persons should not be disproportionately burdened with health expenses, and those individuals (e.g. peasants) who through not having access to cash face particular difficulties, need to be considered in governmental policy and practice.

Fourth, the right to seek, receive and impart information and ideas concerning health issues, which includes health information in indigenous languages.

With regard to acceptability, it is understood that "health facilities, goods and services must be respectful of medical ethics and culturally appropriate… [and] requires respect for tradi‐ tional medicines and practices which have not been shown to be harmful to human health" [43, paragraph 12 (c)].

For adequate quality, it requires that health facilities, goods and services must be scientif‐ ically and medically appropriate and of good quality (skilled medical personnel, scientifi‐ cally approved and unexpired drugs, and hospital equipment, among other aspects) [43, paragraph 12 (d)].

Unfortunately, the findings of our studies indicate that health care is not sufficiently available or accessible (in either quantity or quality) to more disadvantaged social groups, creating mistrust among them of the government health services, something that is reflected in the relatively high percentage of people that do not use these services, even for vaccinations. This situation is more marked when health services are not culturally adapted, when people perceive mistreatment on the basis of their ethnicity or social conditions and health personnel make disparaging remarks about their habits and demeanor [6].

Other indicators of violation of human rights in TB patients are:


in regard to planning of activities or elaboration and evaluation of health programs for the community. Veneklasen and colleagues have said [44]: "True rights-based participation requires programs that enable people to be active, informed and critical agents and citizens, rather than objects of charity". In this sense, the International Labor Organization, Conven‐ tion 169 [45] stresses that health services shall, to the extent possible be, "planned and administered in co-operation with the peoples concerned and take into account their economic, geographical, social and cultural conditions as well as their traditional preventive care healing practices and medicines".

the health authorities in order to provide all people (especially the more socially vulnerable groups) with: effective prevention programs, a reliable and timely diagnosis, adequate anti-TB treatment and follow-up, clear and appropriate information and counseling about TB (what

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

In consequence it is necessary change the dysfunctional health system that contributes to the persistence and intensification of exclusion, voicelessness, and inequity, while simultaneously defaulting on its potential and obligation to fulfill human rights and contribute to the building of more equitable, egalitarian and democratic societies. The history of TB teaches us that the improvement of social justice led to increase the global health conditions and thus, it avoids the called "social diseases", including TB. The academic community has much to say and actively contribute in these aspects. The first step is to do research in order to make visible excluded people. To analyze, sensitize and lead to better socioeconomic conditions is an

1 Society, Culture and Health Academic Area, The College of the Southern Border (ECO‐ SUR), San Cristóbal de Las Casas, Chiapas, The Africa and Latin America Research Groups

2 The Africa and Latin America Research Groups Network (GRAAL). Faculty of Medicine,

4 School of Medicine, Pontificia Universidad Católica del Ecuador, Quito, The Africa and

5 University Institute of Health, National University of La Matanza, San Justo, Buenos Aires,

, Olivia Horna–Campos2,3, Natalia Romero-Sandoval4

,

(Mexico), Chine (Ecuador) and Lima (Peru) http://dx.doi.org/10.5772/54950 463

it is, mechanisms of transmission and possibility of infecting others, etcetera).

assignment for all of us.

Héctor Javier Sánchez-Pérez1

Ezequiel Consiglio1,5 and Miguel Martín Mateo2

\*Address all correspondence to: hsanchez@ecosur.mx

\*Address all correspondence to: natalia.romero.15@gmail.com

\*Address all correspondence to: econsiglio\_ar@hotmail.com

Biostatistics Unit, Barcelona Autonomous University, Bellaterra, Spain

3 Barcelona Public Health Agency, Epidemiology Service, Barcelona, Spain

Latin America Research Groups Network - GRAAL-ECUADOR, Ecuador

\*Address all correspondence to: miquel.martin@uab.es

Network (GRAAL)-ECOSUR, Mexico

Argentina

\*Address all correspondence to: ohornac@yahoo.es

**Author details**


The performance of patchwork studies has allowed us to identify, evaluate and measure the situation of marginalized population groups in three different contexts (Chiapas, Mexico; Chine, Cotopaxi, Ecuador and Lima, Peru). Our findings revealed the poor quality of diagnosis and treatment of TB patients. Our data can be useful not only in the studied regions, but also in other countries with similar socioeconomic inequalities, if they are taken into account by the health authorities in order to provide all people (especially the more socially vulnerable groups) with: effective prevention programs, a reliable and timely diagnosis, adequate anti-TB treatment and follow-up, clear and appropriate information and counseling about TB (what it is, mechanisms of transmission and possibility of infecting others, etcetera).

In consequence it is necessary change the dysfunctional health system that contributes to the persistence and intensification of exclusion, voicelessness, and inequity, while simultaneously defaulting on its potential and obligation to fulfill human rights and contribute to the building of more equitable, egalitarian and democratic societies. The history of TB teaches us that the improvement of social justice led to increase the global health conditions and thus, it avoids the called "social diseases", including TB. The academic community has much to say and actively contribute in these aspects. The first step is to do research in order to make visible excluded people. To analyze, sensitize and lead to better socioeconomic conditions is an assignment for all of us.
