**Pulmonary Tuberculosis in Latin America: Patchwork Studies Reveal Inequalities in Its Control – The Cases of Chiapas (Mexico), Chine (Ecuador) and Lima (Peru)**

Héctor Javier Sánchez-Pérez, Olivia Horna–Campos, Natalia Romero-Sandoval, Ezequiel Consiglio and Miguel Martín Mateo

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54950

**1. Introduction**

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Tuberculosis (TB) has been present in Latin America since pre-historical times. Paleopatho‐ logical studies have found signs of TB in mummies from many parts of the world. In fact, whenever human mummies have been found, signs of TB have been observed in bones, lungs or skin [1].

Although TB may be considered as nearly as old as humankind, the current epidemiological profile of this disease must not be considered as the natural or expected one, given the large numbers of prevalent and newly occurring cases. The main questions related with the persistence and rise of TB in many regions of Latin America, have to do with social processes and inequalities. In this sense, the different processes usually resulting in TB disease are directly related with social and economic behavior of human communities [1].

TB constitutes one of the most complex situations in the health field. This complexity both makes visible, and raises questions about the existing inequities in the political and sociocultural structure and in class relations, as it is the result of the health-illness-care process. Among the main elements permitting operationalization of an analysis of this situation, we find social vulnerability and accessibility to a whole spectrum of health services (in geograph‐ ical, cultural and economic terms), from opportunistic diagnosis to effective treatment (meaning cure).

© 2013 Sánchez-Pérez et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In this sense, we understand as social vulnerability that set of economic, political, social and cultural conditions which determine that some individuals become infected by the TB bacillus while others do not, depending on the structural conditions which favor or hinder exposure to the disease,1 as well as those differential aspects by which, among those infected, some get TB disease while others do not, and among those with TB disease some are cured (whether spontaneously or as a result of anti-TB treatment), others remain chronically ill (possibly with multi-drug resistance) while others die (generally those presenting the worst socioeconomic conditions and poorer health in general).

considered in the design of programmes for their prevention and control, so that TB continues to cause high rates of disease, death and ever-rising health costs in these groups, something which represents a violation of their human rights a consequence of governments having been

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 445

Furthermore, the effectiveness of programs of TB Prevention and Control has been questioned because of their complexity. In this sense, a therapeutic intervention such as the Directly Observed Therapy – Short Course (DOTS) strategy, and socioeconomic and structural factors have been topics of discussion with regard the possible impact of one and the other, due to the decline of TB observed prior the use of antibiotics, as well as the goals met at present by DOTS strategy. In this regard, a correlation has been documented in Latin America between the early diagnosis of smear positive TB cases and improved cure rates [5]. So, one of the main emphasis of strategies to reduce the transmission of *Mycobacterium tuberculosis*, should be the identifi‐

The Africa and Latin America Research Groups Network (*Grups de Recerca d'America i Africa LLatines* -GRAAL) has conducted studies in marginal populations which reveal the conditions of patients, as well as the extent of the disease, of multi-drug resistance (MDR) and of mortality in these populations, producing figures which differ widely from the official average values. The main mechanism for tackling these aspects has been through doctoral theses. In this chapter we give examples of research undertaken in three different contexts of high poverty

Chiapas is one of the poorest states in Mexico, and has one of the highest rates of indigenous margination as well as an acute lack of health care resources. According to official government statistics, Chiapas ranks almost last among all Mexican states in terms of health and socioe‐ conomic indicators [6]. It is precisely in Chiapas where, due to the conditions of social exclusion, poverty, malnutrition and high mortality from infectious contagious diseases, the Zapatista National Liberation Army (EZLN) initiated an armed rising against the Mexican government in 1994, which drew attention, both nationally and internationally, to the preca‐ rious living and health conditions of the indigenous and peasant populations, not only in

Several studies have been carried out by our team in areas of high levels of poverty in Chiapas: Our first attempt to analyze the pulmonary tuberculosis (PTB) situation arose out of the discovery that in the only hospital (Comitán General Hospital, Ministry of Health) in the region of the border with Guatemala for patients not covered by insurance (the majority of whom are indigenous),2 there was empirical evidence of a high prevalence of PTB cases. In 1994, active case finding of patients with chronic cough (15 days or more) was carried out among all patients aged over 14 years seeking care in the hospital for whatever reason [7]. In this study

cation of active TB cases, particularly in deprived and highly exposed populations.

incapable of preventing this situation.

and social exclusion in Mexico, Ecuador and Peru.

**2. Patch 1: Chiapas, Mexico**

Chiapas, but throughout the entire country.

2 In Chiapas, over 80% of population is not covered by social security [6]

Nevertheless, TB prevention and control programmes are designed as if the disease behaved in a homogeneous way in all countries and regions, based almost solely on biological and medical factors, without taking into account socio-cultural, economic and political factors, such as poverty, malnutrition, health services accessibility and quality, as well as intra and intercommunity political conflicts, among others.

This approach impedes acting on the particularities of marginal populations, which are precisely the ones presenting the highest rates of morbidity and mortality of this disease, manifesting various gradients of exposure and susceptibility. This leads governments to act on the basis of global estimates, even when their interpretation of these is limited and partial, because the differential exposures and true extent of TB are unknown.

Furthermore, this way of tackling TB does not reflect the reality of the different regions within a given country, because local or regional variations in rates of morbidity and mortality are disguised. Such variability could easily be quantified by, at the very least, providing the standard deviation corresponding to the global values of these rates for each country. Conse‐ quently, areas which should be given priority, paradoxically receive only limited resources for interventions.

In this sense, it is important to point out that TB, like HIV/AIDS, is one of the diseases for which estimations of impact in terms of incidence and prevalence are frequently based only on the registered cases. While it is true that published national and international figures often include estimates of sub-notification, they do not usually include gradients of the magnitude of the disease, or of the intra- or inter-regional under-notification rates, nor the differential rates between different population groups. According to several authors, calculation of the number of cases of TB disease is possible based on the expected evolution of cases of infection [2] or through linear regression modeling involving age-specific prevalence values across a range of differently aged populations [3]. Although this calculation technique for the frequency of TB and HIV status has been considered [4], there are currently no models in which population impact has been measured in terms of social factors.

In summary, in general terms, national and international policies to cope with TB ignore this reality, applying criteria of homogeneity in the calculation of objectives, materials, costs and logistics, among other aspects. While it is well known that marginal groups are the ones presenting the highest TB morbidity and mortality rates, their characterisation is not usually

<sup>1</sup> According to World Health Organization calculations, one third to the human population is infected with TB bacillus

considered in the design of programmes for their prevention and control, so that TB continues to cause high rates of disease, death and ever-rising health costs in these groups, something which represents a violation of their human rights a consequence of governments having been incapable of preventing this situation.

Furthermore, the effectiveness of programs of TB Prevention and Control has been questioned because of their complexity. In this sense, a therapeutic intervention such as the Directly Observed Therapy – Short Course (DOTS) strategy, and socioeconomic and structural factors have been topics of discussion with regard the possible impact of one and the other, due to the decline of TB observed prior the use of antibiotics, as well as the goals met at present by DOTS strategy. In this regard, a correlation has been documented in Latin America between the early diagnosis of smear positive TB cases and improved cure rates [5]. So, one of the main emphasis of strategies to reduce the transmission of *Mycobacterium tuberculosis*, should be the identifi‐ cation of active TB cases, particularly in deprived and highly exposed populations.

The Africa and Latin America Research Groups Network (*Grups de Recerca d'America i Africa LLatines* -GRAAL) has conducted studies in marginal populations which reveal the conditions of patients, as well as the extent of the disease, of multi-drug resistance (MDR) and of mortality in these populations, producing figures which differ widely from the official average values. The main mechanism for tackling these aspects has been through doctoral theses. In this chapter we give examples of research undertaken in three different contexts of high poverty and social exclusion in Mexico, Ecuador and Peru.
