Tuberculosis: A long lasting impact on Latin America

Tuberculosis has been a scourge of populations in Latin America for a long time -- but for how long, exactly? According to the conventional wisdom, European colonizers in the late fifteenth century brought TB, as well as other diseases, with them to the New World (López Campillay, 2015). However in 1973, this point of view shifted when a child’s remains dating back to 700 C.E. were found in southern Peru. The remnants of this child’s lungs were coated with lesions characteristic of tuberculosis (Allison et al., 1973). Although there is still speculation as to which came first, it is clear that Latin America has suffered at the hands of tuberculosis and the social implications that arose with it.

Tuberculosis as we know it is caused by the bacteria Mycobacterium tuberculosis and is the leading cause of death worldwide from a single infectious agent (World Health Organization, 2018). The Americas account for 3 percent of global TB cases, with 46.2 per 100,000 and 61.2 and 25.9 per 100,000 persons incidence rates in South America and Central America (including Mexico), respectively (Pan American Health Organization, 2018). TB is most commonly spread when someone infected with the pulmonary bacteria coughs which then releases the bacteria into the air (World Health Organization, 2018). The disease’s more evident symptoms include fatigue, depression, and chronic coughing (Woodman et al., 2019). At the beginning of the twentieth century, people began to notice the clear deterioration in health in those affected by TB to the point where everyone, regardless of class, gender, or race, began to fear the disease (Cueto & Palmer, 2014).

Urbanization was a key catalyst in the spread of tuberculosis. Today, Latin America is considered one of the most urbanized regions in the world, and most of this urban shift happened during the twentieth century, coinciding with the increasing burden from TB especially among the working class (Urbanization in Latin America, 2014). It is believed that the high population density, overcrowded living and working conditions, and unhealthy lifestyle changes that came with urban life were key in the spread of TB (Lönnroth et al., 2009). According to historian Diego Armus, Dr. Clemente Álvarez told the story of a working class man from Buenos Aires, Argentina who unknowingly contracted TB in the early 1900s. The patient believed it was simply a cough for a few months until he began to cough up blood. A trip to the doctor revealed it was TB; however, the treatment at the time required plenty of rest, a healthy diet, fresh air, and good hygiene. But, for a working-class husband and father, the prospect of quitting his job to recuperate made the doctor’s prescription a luxury he could not afford. The patient continued to work to support his family, making compromises along the way to receive minimal rest from everyday stressors. This worked temporarily until his TB relapsed with an equal if not greater intensity. Eventually, he wound up in an overcrowded inner-city hospital to await death (Armus, 2011). This was the unfortunate and deadly reality of much of the lower and working class Latin Americans at the time.

However, Latin American women were also part of the working class and were directly impacted by TB in additional and slightly different ways. Towards the beginning of the twentieth century, TB was used to redefine and enforce gender roles, most evident in Argentina (Cueto & Palmer, 2014). Around that time period, the presence of the milonguita, a cabaret girl, emerged in the media of the quickly urbanizing city of Buenos Aires. In movies, literature, and tango lyrics, the milonguita was typically a young woman with dreams to break out of her quotidian life and live freely in the inner city (Armus, 2003). The most notable characteristic of all these women was that they had tuberculosis. These milonguitas were thus portrayed as small, frail, sickly women who would do anything to leave the safety of their homes for the inner city for more exciting lives, even if it lead to prostitution (Armus, 2003). In many cases, these women contracted TB as a result of their new lifestyle, creating the narrative that these milonguitas and the cities in which they contracted the disease were one. Although TB affected mostly men, it was still perceived as a woman’s disease filled with passion that ultimately lead to the same outcomes. An infected woman could expect either dishonor and death, or she could settle for men and living conditions of a lower status because having TB inherently made you lesser than (Armus, 2011). Either way, tuberculosis created a damaging narrative for young women that outlined a predetermined path that cannot end well unless they hid in the safety of their home, thus enforcing constraining gender roles.

Not long after that, a cure for TB was discovered by researcher Albert Schatz and Selman Waksmanl in 1943, leading to what we know as the antibiotic era (López Campillay, 2015). It was evident that the antibiotics were working, as TB rates plummeted to an all time low across Latin America. Over the following years, researchers worked tirelessly to perfect the anti-TB drugs to make them more effective and less toxic (López Campillay, 2015). However, doctors began to notice that the rate of TB incidence was declining at a much slower rate, indicative of something new arising. Chilean doctor Victorino Farga noted that his patients seemed to respond well to the antibiotics, but as soon as he would send them home, they would stop taking the rest of the prescribed medicine (López Campillay, 2015). Without the proper knowledge about antibiotics, this might not seem problematic. However, the reality is that the small amount of harmful bacteria that remain can gain a resistance towards the medication, making any chance for curing TB in the future much more difficult and continuing the transmission cycle.

It wasn’t until the 1990’s that the WHO and company created and implemented the Directly Observed Treatment Shortcourse (DOTS) which aimed to reduce the rate of TB even further (Lönnroth et al., 2009). What helped make DOTS so effective was that health workers were required to check in on patients to make sure that they took the correct amount of medicine for the entire duration of the treatment. It was later found that community-based DOT programs as opposed to the clinic-based ones were more effective in keeping patients accountable for taking their medication (Zuñiga, 2015). But even this methodology encountered problems, specifically among poorer communities. The most evident issue was that simply creating health interventions in these communities were complex due to either a lack of resources or understanding. In other words, DOTS as a one-size-fits-all program was not going to be effective in marginalized regions. With this came the creation of the DOTS-Plus program that took the previous model to an entirely new intensity. In Peru, DOTS-Plus workers were trained with an emphasis on community patient care and made aware of socioeconomic elements that led to the higher prevalence of TB in poorer communities (Shin et al., 2004). The WHO was aware that not every country affected by TB had the adequate resources to combat it effectively, leading to the creation of DOTS. However, this was still not enough due to its inaccessibility to more marginalized groups in these already poor communities. This led to a more cost effective and accessible tool to combat TB in Latin America (Lönnroth et al., 2009).

There is no doubt that tuberculosis has rampaged through the world, greatly affecting those most vulnerable throughout class, race and gender. Despite much effort and progress, the presence of TB is still felt today as it remains the leading cause of death by a single infectious agent (World Health Organization, 2018). However, the fact of the matter is that tuberculosis is a curable disease. Ideally, a country would have the resources to accurately and rapidly diagnose TB along with efficient methods to complete all treatments. This is unfortunately more difficult to achieve for countries with fewer resources. However with additional, comprehensive education over TB prevention, improved TB diagnoses, and an overall improvement of international and domestic strategies for TB control, tuberculosis can become a disease of the past (Pelly et al., 2004).

Related Articles

• Ramón Carrillo, Argentine Minister of Health
• Pan American Health Organization
• Urbanization and Health: A Case Study of Rio de Janeiro

References

Allison M., Mendoza D., Pezzia A. (1973). Documentation of a case of tuberculosis in Precolumbian America. Am Rev Respir Dis;107:985-91.

Armus, D. (2003). Disease in the history of modern Latin America: From malaria to AIDS. Durham: Duke University Press.

Armus, Diego. (2011). The Ailing City: Health, Tuberculosis, and Culture in Buenos Aires, 1870-1950. Duke Univ. Press.

Cueto, M., & Palmer, S. (2014). Medical Innovation in the Twentieth Century. In Medicine and Public Health in Latin America: A History (A New Approach to Endemic Diseases, pp. 183-192). Cambridge: Cambridge University Press.

Lönnroth, K., Jaramillo, E., Williams, B. G., Dye, C., & Raviglione, M. (2009). Drivers of tuberculosis epidemics: The role of risk factors and social determinants. Social Science & Medicine,68(12), 2240-2246.

López Campillay, M. L. (2015). Medicina, política y bien común: 40 años de historia del programa de control de la tuberculosis (1973-2013). Santiago, Chile: Ministerio de Salud de Chile.

Pan American Health Organisation. (2018). Tuberculosis in the Americas 2018; Pan American Health Organisation: Washington, DC, USA. Available online: www.paho.org

Pelly, T., Moore, D. A., Gilman, R., & Evans, C. (2004). Recent tuberculosis advances in Latin America. Current opinion in infectious diseases, 17(5), 397–403.

Shin, S., Furin, J., Bayona, J., Mate, K., Kim, J. Y., & Farmer, P. (2004). Community-based treatment of multidrug-resistant tuberculosis in Lima, Peru: 7 years of experience. Social Science & Medicine, 59(7), 1529-1539.

Urbanization in Latin America. (2014). Retrieved from www.atlanticcouncil.org/publications/articles/urbanization-in-latin-america

Woodman, M., Haeusler, I., & Grandjean, L. (2019). Tuberculosis Genetic Epidemiology: A Latin American Perspective. Genes,10(1), 53.

World Health Organization. (2018). Global Tuberculosis Report 2018; WHO: Geneva, Switzerland. Available online: www.who.int/tb/publications/global_report/en/

Zuñiga, J. A. (2015). An Integrated Review of Directly Observed Therapy for Tuberculosis in Latin America. Hispanic Health Care International,13(1), 46-54.