Since 1948 there have been numerous documented cases of drug resistant tuberculosis (TB), yet today less than 0.5% of people diagnosed worldwide with multidrug resistant tuberculosis receive the standard of care expected here in the United States. There are a number of conditions that enhance vulnerability to TB-poverty, homelessness, substance abuse, psychological stress, poor nutritional status, and crowded living conditions (WHO, 2001: 1). Looking at the rise of MDR-TB in the Carabayllo slum in Lima Peru, as well as the response to the epidemic and the outcomes of the response, gives us insight into how we can better approach the problem in the future. We must take into account the factors listed above while examining the roles social medicine and structural violence, the relationship between poor health and disadvantage, and the impact of the Alma Ata decision.
Rosen (1947: 681) believed that, “epidemics are signs of warning”, which is directly applicable to what happened in Peru in alerting us to the issue of the rise of MDR-TB and the impact of not properly treating it. Looking at the two principles of social medicine-that the health of the people is a matter of direct social concern and that social and economic conditions have an important effect on health and disease (Rosen, 1947: 678)-should drive the decision to treat MDR-TB using second line drugs. Social and domestic factors should be defined and taken into account (Rosen, 1947: 725), and in settings where TB is prevalent compliance is limited by forces outside of the patients control (Farmer, 1997: 351). One of the largest failings in Peru was the lack of prevention, and the significance of a disease is often based on frequency, form, etiology, social factors and viewpoints (Rosen, 1947). In the case of Peru, hundreds of deaths resulted from the lack of commitment to testing for MDR strains, understanding the social factors that spread TB amongst the poor in Carabayllo and the way that TB is viewed by the community. The value of health is defined differently by different social groups (Rosen, 1947: 731), as evidenced by the suggestion of the WHO and other international health authorities to adopt a low-cost, standardised regimen for the treatment of MDR TB. The poor community in Carabayllo has the right to health, like any other community, but lacks the financial means and social mobility to obtain the desired level of health. The way to overcome this would be to address the individual as part of an economic social group that exposes them to health problems linked to their social group (Rosen, 1947: 732).
Poor health is inexplicably linked to disadvantage and even in well developed nations like the US, the majority of cases have been noted among the inner city poor, prisons, homeless shelters and public hospitals (Farmer, 1997: 348). In Carabayllo, Peru the overcrowded, poorly ventilated and damp homes in the slum are a breeding ground for TB (Collyns, 2017), and a series of studies in India have strongly correlated income with TB (WHO, 2001: 9). Specifically in urban areas, the prevalence among those with no schooling was four times that of tertiary graduates (WHO, 2001: 9). Here we have three social factors-income, education and access to housing-that structured who would contract TB, and all three can be correlated with the people living in Carabayllo and the spread of TB there. Gutierrez, a liberation theologist, believed that disease makes a preferential option for the poor so the poor are sicker than the non-poor. Poverty is not a condition, but a result of society, which can be addressed. There is also the preferential option for the poor which includes creating a space to assess the lifestyles, policies and social institutions that directly impact the poor. In the slum in Peru, poverty is strongly correlated to the preferential option of the people to contract MDR-TB, which gives us as a health institution the opportunity to assess the impact of the social institutions on the response to the TB outbreak.
Structural violence is simply defined as the institutionalized inequalities in wealth and power that place people in harm’s way. Galtung (1969: 168) defined it as the cause of the difference between the potential and the actual. He used the example that if someone died of TB back in the 1800’s it was unavoidable, but today we would have to take into account violence (Galtung, 1969: 168). Knowing that the Peruvian government was advised to adopt a low-cost, standardised regimen rather than protocols based on the results of drug-susceptibility, we can assume that violence is in place. In Mountains Beyond Mountains, Tracy Kidder chronicled the work of Paul Farmer and Partners In Health (PIH), especially their work in Peru, during the outbreak of MDR-TB. The decision on how to respond by the WHO and other organisations prevented an efficient, effective and appropriate response. The decision to only use smear microscopy resulted in Dr. Farmer having to fly back TB samples to be tested at the Brigham, as he knew that the only clinic there was doing its job, meaning there was a natural resistance to the drugs (Kidder, 2003). The smear microscopy decision knowingly placed the already disadvantaged people in Carabayllo in harm’s way, therefore subjecting them to structural violence. Another issue with the decision to use the standard regimen is that taking ineffective TB drugs can actually cause new MDR-TB cases rather than wiping them out, what Farmer calls amplification (Kidder, 2003). Mycobacterium is known to build resistance to certain antibiotics, and by using first line drugs to treat a mutated strain, the problem is not solved and allows for the communicable period to be extended. It also helps to build a resistance within someone’s body to an antibiotic, making the antibiotic ineffective in treating other diseases the same individual may be exposed to due to their living in the slum. Finally, Farmer argues that the costs of treating individual cases of MDR-TB are small compared to the costs of allowing TB to thrive in the third world due to the ability of the MDR strain to spread to the US (Kidder, 2003). Here we are not only subjecting the people of Carabayllo to structural violence, but those around the world who are disadvantaged as well as ourselves, especially in the face of globalisation.
The Alma Ata decision, while broad and idealistic, offers some key decisions that could be helpful in approaching MDR-TB in the future. The second key decision at Alma Ata included training lay health personnel and community participation (Cueto, 2004: 1868), which PIH has sought to do, with success, in the case of Carabayllo (Collyns, 2017). One of the largest downfalls of Alma Ata in the case of the TB outbreak in Carabayllo is in the decision relating to appropriate technology, which was deemed too sophisticated, expensive or irrelevant for the needs of the poor (Cueto, 2004: 1867). The ultimate decision was that technology should be relevant, scientifically sound and financially feasible, but the poor in Carabayllo could have greatly benefitted from a lab that could test for MDR-TB as well as the access to second line drugs, and modern hospitals where they would have had the needed break from the slum to begin their recuperation. It is important to keep in mind that TB controls failed because we relinquished our commitment to the destitute sick; the people of Carabayllo.
In the future it would be more appropriate to adopt a horizontal approach-one that seeks to treat all the underlying issues of a population that cause various diseases and health problems. Paul Farmer (1997), noted that when care is taken care of, compliance and outcome are then correlated to access to food and income, and that patients often list structural barriers like inconvenient hours, proximity to clinic and lack of treating families as a unit kept patients from full recovery. This could be solved by increasing access to clinics that are open past the normal working hours, as well as being paired with a supplemental nutrition programme. The PIH strategy in Peru has been search, treat and prevent, and another breakthrough came with building a TB lab within the community (Collyns, 2017). Starting off right and getting the right diagnosis can be one of the best ways to help the patient. Other studies have shown that public health education contributes to the success of TB programmes, especially when peers and family members are involved (WHO, 2001: 8). By organising the community in Peru and educating them about the causes of TB, and advising people to get help as soon as they suspect a problem, while also making care obtainable, will make driving down the rate of TB infection an attainable goal. Jim Kim of PIH argues that money for TB treatment should come from private donors, rather than government programs because government programs are often unreliable and frequently subject to corruption (Kidder, 2003). This is proven by the difference in outcomes as seen by the push for the Peruvian government to adopt standard measures in contrast to the work of PIH in Peru. Finally, when it comes to the actual access to the drugs Gupta et al (2001: 1050), puts it simply that we must increase access to quality assured drugs by decreasing costs and maintain standards. This can be done by having supply outstrip demand, and the coordination of the drug companies to work solely with approved WHO projects. Implemented all together, and with care and a better understanding of the social structures in Carabayllo, a more effective response can be coordinated, not only if it were to arise again in Peru, but in similar instances around the world.