Welcome back everyone! GlobeMed’s fall rummage sale is happening next week! You can drop off your (clean, gently used) clothes in any of our donation boxes in Reynolds, Cobb, and Harper until 10/15.
Check out the Facebook event to stay updated!
To wrap up the year, we made a movie! Thank you for your continuous support throughout the year. We had a lot of fun selling bubble tea, doing the rummage sale, and hosting our educational events, Film Fest and Global Getdown. To learn more about us, please check out our website
Thank you all once again for making bubble tea sales a massive success! We hope to see you all back again for more bubble tea and many more exciting events GlobeMed has planned for the rest of the year :)
Bubble Tea is back! Come out to the Reynolds Club on Tuesday and Thursday and Cobb on Wednesday to satisfy your bubble tea craving! For $4 each or 2 for $7 try peach, lavender, taro, or honeydew, and all of the profits go to ASPAT Peru!
GlobeMed is hosting a Global Getdown!
Our theme this year is “Innovations in Targeted Healthcare Delivery: A Multidisciplinary Approach” and the event will feature speakers from the fields of: socio-cultural anthropology, medicine, health economics, and human rights.
The speakers include: Eric Hirsch, Evan Lyon, MD, Rena Conti, PhD, and Allison Arwady, MD
Buy tickets in the Reynolds Club 1/27-1/29 10:30-12:30pm
Get ready for a fun night of experienced panelists, discussion, food, and raffles!
On behalf of our team, we would like to thank you for your interest and desire to attend our Laser tag event. Unfortunately, due to scheduling conflicts, we have decided to reschedule Laser Tag. It will now be hosted during Winter Quarter. Please stay tuned and we are so sorry again. We hope to see you during Winter Quarter but for now, good luck on finals!
P.S. For any refunds, please message us directly.
GlobeMed is hosting a Star Wars themed laser tag event December 4th! To get a reduced price for your team, come to the registration event **
November 30th, 11am at the Reynolds Club. Get ready for tons of tun, courtesy of GlobeMed :)
**The registration event has been moved to Tuesday, December 1st! See you all there!**
Thanks for coming out to the Reynolds Club yesterday to buy bubble tea! You made our first day of sales a success, so much that we sold out! The bubble tea sales will resume Wednesday, November 18th at 10:30 in the Reynolds Club, hope to see you all there :)
GlobeMed is having another fall fundraiser, and this time we are selling bubble tea! Find us at the Reynolds Club Monday, November 16th through Wednesday, November 18th from 10:30am to 1:30pm to buy some delicious bubble tea :)
Lots of great finds and fun on the first day of the Rummage Sale! If you love thrifting be sure to check us out Thursday and Friday from 11am-5pm at the Reynolds Club :)
The tuberculosis epidemic here in Peru represents a puzzling paradox of sorts: although the disease itself is curable and medication is subsidized, the high incidence rate persists and drug-resistant cases (MDR TB) continue on the rise. The problem is not a lack of breakthrough medical advancement or sophisticated technology. Accessible drugs exist, but it is getting patients to take them and to continue taking them that can be especially challenging. A day spent shadowing Magali, a community health worker, helped me better understand the constellation of factors that influence treatment outcomes.
PS Medalla Milagrosa is a health center located at the foothills of the cerros, the mountainous region in Lima known for its high TB transmission rates. Because TB is an airborne disease that can infect people who share an enclosed air space, the TB ward is housed apart from the rest of the facility and specially designed to circulate air flow. Patients waiting to receive care are seated outside, where a dainty row of chairs are carefully lined up.
With Magali’s help, we were able to get clearance from the medical jefe to interview the patients and staff at the center. The first patient we spoke with was just 13 years old. She was there to begin her 6 month long treatment regimen, and her father was with her for moral support. Anxious and slightly reserved, she told us how she likely contracted the disease at school and that she knew very little about TB and its transmission prior to her diagnosis just a few weeks ago.
We then spoke with a patient in her late 20s. Already 3 months into her treatment regimen, she recounted how difficult it was when she first started the medication: she lost her energy and her appetite. It was a challenge just keeping food down during that initial month of treatment. Had not been for her two young girls, she said, she would have never continued with the grueling treatment process. Listening to her experience, we learned a lot about the cause for the high treatment abandonment rates here in Peru. The first step to containing the spread of TB is to get patients into treatment. But that treatment can often take months—if not years—to complete and can be so debilitating, so disruptive that people often leave school or quit their jobs for it. Nausea, fever, rash, and lethargy are just a few of the common side affects of the cocktail of pills that patients must to take to recover. It’s easy to see that without a proper support network—a source of strength and motivation—many patients default on their treatment and develop MDR TB.
Apoyo familiar. Again and again this term came up in our conversations with patients and healthcare workers alike. Google it and images of happy families linking hands will be the first result that shows up. Corny as it may seem, family/social support is critical to a timely recovery. Here, treatment is not seen as something you merely do for yourself, but as an obligation to all those who cherish and support you. The truth is TB, like any other disease, is hard to flight alone. Our emotional investment in others strengthens the web of accountability, and having proper psycho-social support is so important that MINSA (the Peruvian Ministry of Health) recently mandated that all TB patients see a psychologist as part of their treatment.
In understanding TB treatment outcomes as a property of the interactions between individuals and the social and environmental forces that inevitably shape their choices, it is clear that there is a critical need for a holistic approach to medicine that is not only attentive to patients’ physical health but also to their emotional needs as well. Now more than ever, I feel the urgency behind ASPAT’s work and the unique role they play in the fight against TB. Founded in 2007 by TB survivors, ASPAT was created to help patients regain their health through psychosocial support, education on treatment and prevention, and advocacy for patient rights. By offering indirect patient care that addresses the social dimensions of the disease, ASPAT’s work supplements and fortifies the direct treatment provided in the health centers. At the end of the day, the fight against TB is not a solitary effort, but one in which everyone must endeavor in together.
Magali, a community health worker, and Adela walk to a Centros de Salud
I have been very inspired by some aspects of the healthcare system here in Peru, especially the unique existence of the promotoras, who aid in care by delivering medicine to patients and ensuring that they take it. In addition to this, the Peruvian government mandated two years ago that TB patients see a psychologist in addition to their treatment and medicines that they are prescribed by their physician. This means that a TB patient is supported by a team of many healthcare workers, and a physician´s role is minimized greatly.
As a Comparative Human Development major, it was quite fulfilling and exciting to watch some of the readings I have studied for my major being put into action in Peru’s healthcare system. I have struggled greatly in trying to reconcile Kleinman’s trichotomy of illness, disease, and sickness that he writes about in his Illness Narratives in relation to a patient’s identity. To me, the gap between illness and disease is akin to the gap between diagnosis and identity. Kleinman says that an illness is the “human experience of symptoms and suffering”(3) and disease is “what the practitioner creates in the recasting of illness in terms of theories of disorder”(5). In addition to one’s culture and relationships with their family members, a patient’s identity is shaped by the gap between “illness” and “disease”, and their relationship with their label. It’s no secret that support from friends and family can often be extremely beneficial for a recovering patient.
The biggest benefit to TB patients that psychologists provide is mental and emotional support. Treatment for people with tuberculosis can be incredibly rough and is notorious for making patients feel worse that the disease itself. Because of this, retention in treatment is a huge issue that healthcare workers and organizations such as ASPAT are trying to combat. Many of the patients that we talked to said that their reasons for staying in treatment were their children, husbands, wives, or parents. For patients that don’t have family members, seeing a psychologist can work as a form of motivation and support. The psychologist we spoke to said that a lot of patients walk into the office, and say “I want to die” when they are first undergoing treatment, and she asks them “why? Why do you want to die? It matters to me whether you live or die.” ASPAT can add something incredibly unique and powerful to the mix by offering counseling for patients undergoing treatment from people who have survived TB and TB treatment. My hope is that the team of clinicians and healthcare workers that are involved in the care of TB patients here in Peru will be able to remind patients how precious and valuable their lives are, causing them to continue their treatments and survive TB.
because strategic planning is better with jello #happyfriYAY
Happy Friday from the ASPAT office! Today the GROW team is presenting their initial recommendations for the organization’s strategic plan and discussing how they can best help ASPAT in the fight to end TB!
Though TB is no longer an issue in the US, there were a staggering 1.5 million TB-related deaths worldwide in 2013. Peru continues to struggle with TB today, a burden that falls on the country’s poorest and most vulnerable. ASPAT-Peru represents something special: former TB patients banding together to eradicate the disease.
What are you even doing, exactly?
Conducting an organizational assessment of ASPAT and working with ASPAT on a strategic plan to address these gaps.
So, basically, we’re finding out what ASPAT’s good at and what it needs to work on, and deciding together what ASPAT needs to do next.
So, do you need any specific background?
No one needs a specific skill set coming in. The focus of each GROW trip changes from year to year, but we make sure that everyone develops all the right skills before we get here. This year, we had to do extensive research on nonprofit capacity assessment and the strategic planning process before coming.
What’s up with SisBioTB anyways?
SisBioTB is a pilot project funded by Grand Challenges Canada. We wrote the application with ASPAT and secured funding for it in September 2014. It’s essentially an electronic patient record system that tracks adherence to the DOTS TB treatment regimen by logging clinic attendance and medicine dosage.
After a year of difficult negotiations with MINSA (Peru’s Ministry of Health) and the 30 MINSA health centers, prototyping the biometric technology and database, project implementation is now in full-swing. ASPAT, with the assistance of 2 Metcalf interns from UChicago, has been installing the system in the 30 health centers and training the staff on how to use it. Everything should be installed and running by the end of September.
Tze: The language barrier. All of us speak Spanish to varying degrees, but the conversations we’ve had with ASPAT would be complicated even in English. Thankfully, Melecio speaks slowly and things have become smoother as Melecio has gotten more comfortable with us and vice versa. We’re getting better, but it’s still difficult.
Chiara: ASPAT is so small and they are running a ton of important projects at the same time, so it has at times been difficult to get the face time and the materials that we need to be able to develop a strategic plan for ASPAT.
Nick: The most challenging, yet truly rewarding aspect of our work here has been the dialogue with Melecio. The potential for the organization’s growth is really quite exciting, but there are, naturally, significant capacity and funding constraints that we have to consider and plan for.
Priya: Crossing Javier Prado. To make our morning bus to Callao, we have to cross a street entirely unadorned with luxurious stoplights and pedestrian walk signs. The “crossing” has become a ritual in our daily routines, and it’s so scary that we have to cheer each other on for moral and emotional support! Who thought something as simple as crossing the street would make me feel so connected to the rest of the team?
Victoria: The restaurants here don’t seem to serve vegetables? At all??? (Tze: I am totally okay with this.)
What is a defining moment of the trip so far?
Chiara: The public transportation here is one of the strangest I’ve ever seen. There are these small vans called micros, and you only know their routes when men and women hanging out of the buses shout their various destinations at you as the bus zooms by. We are now experts at getting to ASPAT, but not much else. Even then, earlier this week we tried to get there from a different starting-point and, despite triple-checking the route with the driver, we ended up in a totally unknown part of Callao and had to cab back to retrace our steps.
Victoria: We ordered cuy (guinea pig) and alpaca at a restaurant in Cusco (why?? I don’t even know. Blame it on blind curiosity. Or the altitude sickness.) ANYWAYS, the cuy came served to us whole and was wearing a tomato hat.
It was okay until our tour led us to a farm in the mountains with cute little guinea pigs just scurrying about. I just couldn’t after that.
Tze: Nick, our best Spanish speaker, was sidelined with food poisoning yesterday, so we were a little nervous heading into work given the difficulties we’ve had with language and complex subjects. However, our conversations with Melecio yesterday felt like a breakthrough. The mood was light, and though sometimes we still struggled to say what we wanted to, conversation was easy. I learnt yesterday that a desire to engage with each other can be more important than knowing all the right words. We need grammar to make sense, but we need human connection to make sense to one another.
Priya: Spending time with Magali yesterday, a promotora (community health worker), was one of the most inspirational experiences I have had so far, giving me hope in both the Peruvian healthcare system and the ways that ASPAT can augment it. The Peruvian government requires TB patients see a psychologist in addition to their treatment, something that can ideally remind patients that there is a whole team of people who care very deeply about whether they attend treatment. Counseling from ASPAT can provide additional support, as TB survivors can provide a level of emotional understanding that is both unique and beneficial.
Nick: Meeting Melecio in person, for sure - made everything more real for me. The amount of time, energy, and heart he and other members of ASPAT put into their work, which is almost entirely uncompensated financially and not appropriately recognized, is truly significant and inspiring. Not only does being on the ground make the picture of what is being/needs to be done more apparent, it also motivates me more and more to figure out how we can help facilitate ASPAT’s work.
What’s the best thing you’ve eaten in Peru?
Chiara: Despite the annoying made-up song that Tze and Nick keep singing, Lomo Saltado. And quinoa ice cream–I DIED.
Nick: Lomo saltaGROWWW~
Victoria: Octopus mushame from Costazul for sure. Heck, I didn’t even know I liked octopus.
Priya: Same, the octopus thingy!
Tze: I don’t like seafood, but I’m d with Arroz con Mariscos.
I love hospitals. A place of sickness probably seems like a strange place to love. While seeing people struggle with an illness is difficult, I am always inspired by the dedication and commitment I find in the hospital staff, and am often impressed by the willingness and excitement that patients show for receiving treatment and improving their health. Hospitals are filled with resilience, found in both the staff and the patients they house. This quality is one I have found in every hospital I have been in, and my experience shadowing Adela, one of ASPAT’s Metcalf interns at Peru III Zona was no different.
I watched as the head nurse at centros de Salud de Peru III Zona crouched over a monitor while Adela taught her how to go to the Yahoo.com website: “hay un espacio entre W e Y.” It had not hit me before that moment that SisBioTB will be installed in many hospitals and health centers in which the nurses and staff have never used, or sometimes, even seen, a computer. A system like SisBioTB could be seen as an annoyance or a waste of time, requiring nurses to input the same patient information into the system as well as on paper, at least for the time being (though MINSA`s goal is for all paper patient records to be replaced with electronic ones). However, the nurses at Peru III Zona are willing to incorporate new technology into their daily routines in order to achieve more comprehensive care for their TB patients. The nurses struck me as incredibly hardworking and friendly, their priority being the health of their patients.
I left Peru III Zona feeling incredibly inspired by the commitment to providing the best possible care for their patients I found in the members of the nursing staff, and felt my own desire to enter the field of medicine grow to a level it had never reached before. I find a great deal of happiness in helping others to take care of themselves, something that I believe SisBioTB will achieve. I was inspired by the excitement it sparked within the nurses at Peru III Zona as well as the emotion it caused in me, rekindling my desire to be a physician. I want to enter the field of healthcare because of its ultimate purpose to eliminate diseases like tuberculosis, and watching the operations of SisBioTB at Peru III Zona made me feel closer to that.
On Friday, we joined Melecio for the installation of the SisBioTB System at the Infantas health center in San Martin de Porros, just outside of Callao. Once there, we met Marilu, former TB patient, close friend of Melecio’s, and currently paid part-time volunteer for ASPAT as well as Jaime, the technician who had recently been hired part-time to help with the installation process.
The center consisted of two floors. The first floor had a general waiting area, a few consultation rooms, and a storage room where files and supplies were kept. The second floor had three rooms: a waiting area where patients lined up to receive their medication, a treatment area where nurses worked, and enclosed behind that, an office where the computer was located. We found it unusual that the computer was carefully hidden from the patient window, such that the nurses had to walk into a separate room every time they needed to record and access patient information. Later, we found out this unintuitive design was deliberately chosen to prevent theft. The nurses were especially cautious with their computer because it was issued by MINSA. Because of budget constraints, MINSA would potentially be unwilling to entrust new computers if anything were to happen to the existing one.
Setting up the SisBioTB system required configuring the router, running the ethernet cable from the router to computer, and linking the biometric scanner from the patient window all the way to the computer in the back office. With our help, Jaime finished set-up, Melecio installed the system onto the computer and trained the team of nurses in how to operate it. It was so crammed that all we could was poke our heads through the window to participate. What we saw was striking: Melecio and seven nurses huddled around the computer, in a room not much larger than an elevator.
As we looked on, we realized something that was indicative of an increasingly significant concern of ours: namely the role of MINSA in the implementation of SisBioTB. We have been told that SisBioTB is a top priority for MINSA; however, apart from program approval, we have not yet seen any direct contributions on the behalf of MINSA. Despite ASPAT’s limited organizational capacities, ASPAT is not only responsible for installing the system and training the nurses, but also for maintaining the system, ensuring fidelity, and analyzing results. We hope to make more sense of this informational gap over this next week.
Lima, like Chicago, is a city where crossing a block can transform your surroundings. We arrived at Surquillo at 9:30 am to a main street lined by shops and teeming with people, but walking two blocks east made the neighborhood unrecognizable. Gone were most of the shops and people, replaced by barred windows, stray dogs, and dust.
The TB clinic was a few paces away from the main health center, comprising a small room and a window that sectioned away the alcove where patients waited to receive their medication. Two staff members manned the clinic: a nurse and a technical assistant.
Although the SisBioTB system had been fully set up, the staff did not yet know how to record patient attendance using the software and the biometric scanner. Julia, a Metcalf Intern who had been working with ASPAT for the last two months, was there to train the staff in how to do so.
Though we were there to observe, our presence felt a little disruptive. It was clear that the nurses had a lot on their plate, and it was a while before they had the time to sit through the training. Eventually, there was a lull, and we got to see SisBioTB in action for the first time. An overview of how the system works: for unregistered patients, the nurses record their medical and personal information as well as their fingerprint. With subsequent visits, patients scan their fingerprint, which logs their attendance in the system and tracks their adherence to their treatment regimen.
We were impressed by the speed of the system, but we also had a few concerns. The system still seemed to contain bugs. It also made life difficult for the nurses. Though MINSA’s goal is to replace all paper records with electronic ones, in the interim, nurses have to concurrently maintain both paper and SisBioTB’s electronic records.
However, what we saw at the center reminded us why SisBioTB is needed. All of the clinic’s records were done on paper, which could be easily lost and/or fudged. Tracking patient adherence required sifting through piles of manila folders brimming with patient records. A fully functioning SisBioTB would not only make the process more efficient, but less prone to errors. There is work to be done, but this work is important.
In order to more fully understand ASPAT’s needs and capabilities for the strategic planning process, the GROW Team has identified several key areas we needed to delve into more deeply:
We began last week with a discussion centered around ASPAT’s vision, mission and objectives, which we learned had not been formally revisited since 2011. This led us into a conversation about how Melecio saw ASPAT’s vision, mission, and objectives evolving to fit the organization’s new profile and ambitions. Declaring that ASPAT’s grand vision was to create a future without tuberculosis in Peru, Melecio expressed his desire for ASPAT to maintain and strengthen its unique position of leadership and trust within the local and regional communities. He hoped that ASPAT would continue to combat TB by supporting patient treatment at the individual level, while advocating for change at the systemic level through continual political and social advocacy as well as innovative solutions such as SisBioTB.
To see ASPAT in action for ourselves, we split up into teams and joined Melecio and the two Metcalf interns, Adela and Julia, on Friday on trips to three of the centros de salud (health centers) with the highest treatment default rates in Peru - Surquillo, Infantas, and Peru III Zona. These centers are part of the pilot program for SisBioTB that is scheduled to be fully implemented by the end of September.
Hola from Lima! Yesterday the 2015 GROW trip kicked off, and we met with Melecio, ASPAT’s founder and executive director, to review our respective goals and expectations for this three-week long internship.
As many of you know, GlobeMed at the University of Chicago and ASPAT-Peru made a lot of progress in the fight against tuberculosis this year. Together, we secured a US$100,000 grant to implement a biometric patient tracking system called SisBioTB which, according to Melecio, is being rolled out in 20 health clinics across the Lima/Callao area. For us GlobeMedders, this marks an exciting transition in our work with ASPAT, as we are becoming more involved with our partner and more strategic with our plans for the future. Given this, our primary objective for these coming weeks is to conduct an assessment of ASPAT’s needs/capabilities, and more importantly, to work together with ASPAT to lay the foundations for a long-term strategic plan that will maximize impact.
Ciao for now! Follow us on Instagram and Tumblr @globemedatuchicago for more updates!
- Victoria (at Callao, Peru)
On Tuesday morning of our last week with ASPAT, we accompanied Melecio and two clinical psychologists – Lucero and Liz – to the San Cosme Community Health Center, the largest in Lima. We were to attend a “charla educativa” – one of the potential projects in consideration for this year’s Partnership Action Framework – and meet with doctors and patients, all of which we were very excited for. We were warned that it would be different from the health center we had previously visited in Barrio Altos, but what stood out more to us at first was not so much the bigger structure or higher patient intake, but rather what we observed passing through the neighborhoods and communities surrounding the health center.
We met up with Melecio, Lucero and Liz near the Lima Museum of Art, and jumped into a microbus to cross the freeway into La Victoria/San Cosme. The Lima Museum of Art is located in the Parque de Exposiciones in the city’s historic center, near the Peruvian Supreme Court, and other governmental buildings. It’s a busy, touristic, and relatively clean area; we stood between many professionals in suits and ties as we waited to change buses on the street corner. After just ten minutes on the microbus, it was as if we had crossed an unmarked, but very salient border. We entered San Cosme near the “estacion”, where trains and buses leave for towns on the outskirts of Lima. Beyond the estacion was a huge depot building, outside and inside of which people were laying out second-hand items to be sold. The scene was very different than a thrift store or used car dealer district in the US, though. Here, men and women were seated in uncovered areas off the side of the road outside of often abandoned buildings and had, laid out in front of them, everything from worn pair of shoes to old kitchen appliances, including dolls with missing limbs or stained dresses, and fruits and vegetables, which ranged from familiar celery to unidentifiable tropical offerings. Seeing this from the bus window, we understood what a different world we had just entered – one where poverty drove an informal economy where many people on the streets bought, sold, used, and reused items that others would have thrown away. This market scene went on for several blocks, until we got off by a gas station where a narrow lane allowed cars to come in and out for fuel, but which was also occupied by heaps of unbagged trash. Getting off the bus, we could only see grey and brown; and the pungent smell of an environment clearly beyond the reaches of effective municipal infrastructure for street cleaning overcame us: Lima’s shantytown.
Walking down just one block, we arrived at the San Cosme Health Center, where we immediately found the stairs which led us to the second floor: an open-air TB treatment center. The health center, which had views of the surrounding slum-covered hills, seemed like a welcoming place: staff was very friendly, benches and plants created an inviting atmosphere for patients, and colorful painted walls and poster boards gave patients information on resources and statistics (from the demography of TB patients the center sees, to tools for undocumented patients seeking treatment). The upper level was an outdoor hallway with, like in the other center we visited, with separate treatment rooms for drug-susceptible TB and MDR-TB patients. Plastic tiles, on which several stray cats slept, covered the walkway below, and metal gates demarcated the first-floor ceilingless waiting room, where mothers and children sat among wheelchairs made of plastic garden chairs and bicycle tires.
Seated with Lucero and Liz and soon joined by two doctors, two simultaneous and interesting conversations ensued. Liz and Lucero, were at first very curious about where we came from and what we had enjoyed so far in Lima, and shared with us that they had known each other for the past six years – from psychology school and working together. Both clinical psychologists working for the municipality, they divide their time between schools, health centers, and home visits (although they do not administer medication, they help the most vulnerable patients stay motivated through home psychosocial support).
The doctors that welcomed us were also fascinating to listen to. The first man to approach Melecio was Dr. Maldonado, a lively doctor who has been working at the San Cosme health center for 6 months and seemed to know the patients very well. The second, Dr. Anthony Byrne, wore a Socios en Salud lanyard around his neck, and after several exchanges in fluent Spanish, switched to English for our ease much more than his. Dr. Byrne is an Australian pulmonologist, who, having recently completed the MD portion of his education on the other side of the Pacific Ocean, was just starting his research here in Peru for his PhD from the University of Sydney. Married to a Peruvian and the father of three, he has been volunteering for Socios en Salud at the health center for the past five months, time to adjust to this new environment, fill out all the paperwork, and lay the foundation for the next year of research that awaits him here. Melecio later told us that Dr. Byrne was planning on leading clinical trials and researching alternative drugs. Dr. Byrne didn’t tell us much about himself, but was instead interested in hearing about our work and experiences so far. He introduced us to the work of this health center by stating that while the rest of Lima generally sees an incidence of 100 new TB cases per 100,000 people, the neighborhoods of La Victoria and San Cosme that this health center serves has quadruple that rate: incidence here is 400-500 cases per 100,000 people. This, he said, is in large part due to the barriers in maintaining hygienic living conditions for the people he serves: his patients are poor and live in crowded homes and neighborhoods with little ventilation. Furthermore, the rates of prostitution and/or drug-use are high due to the lack of economic opportunities, which only worsens the state of public health.
We soon had to end our English conversation when Melecio called us over from the laboratory, where his lab technician friend, Juan Martin, had agreed to give us a tour. The two-room facility, albeit equipped with well-worn instruments (a microscope, hood, fridge, and sink), was clean and orderly. Martin briefly explained the TB-test procedure (coloration of the bacilli) and how to recognize the positive samples (red strands) and negative ones (only blue) in the microscope. He had a pile of forms neatly stacked up, and trays of samples to test. He told us that nowadays, he only detects two to three new TB cases a week. Three years ago, it was two to three a day. He conducts about 100 of these tests, called “Baciloscopia” or “Tincion de los frotis de BAAR”, per week (between 400-500 a month).
Back from our tour of the laboratory, Melecio, Lucero and Liz had regrouped patients to start the day’s “charla educativa” (or educational conversation). Three benches were pulled together in a U-shape, with Melecio, Liz and Lucero standing on the fourth side, facilitating the conversation. Thirteen people were seated on the benches – eleven patients, and two women here to support a husband and a son. Of the eleven patients, only two were women. Three were under twenty years old, six were 20-50, and three older than 50. The youngest attendee was a seventeen-year old boy (accompanied by his mother), and the oldest a 68 year old woman, whose body clearly showed the signs of the challenges it had faced before this point, with a hunchback and missing teeth. After signing everybody in and making sure that this group had never participated in this activity before, Lucero signaled to Melecio that the charla could start.
The first phase of the charla was introductions – everyone in the circle went around and shared their name, how long they had been on treatment, and how they were feeling. Squatting down to speak at level of his seated companions, Melecio initiated a short applause after every single person’s introduction, and asked follow-questions (“how are you feeling?”) if he sensed a sadder tone in someone’s voice. Melecio then concisely explained the importance of staying on treatment, keeping hope alive, and not giving up on one’s dreams – indeed, while six months might seem like a long time, it is nothing next to the risk of incurring 18+ months treatment if you develop a resistance to first-line TB drugs. Melecio went on to explain how he had found himself in their shoes 15 years prior, at a time when he hoped to become a pilot and could not imagine himself working on public health for the rest of his life, and how he had watched many of his now close friends undergo this difficult experience as well. Throughout his speech, Melecio was calm, made eye contact, and was very encouraging, stating multiple times that they should “sigue adelante” (continue moving forward).
The second phase of the charla, following Melecio’s personal testimony about shattered air pilot dreams and the rise of a new vocation to serving TB patients, was another pass around the circle during which each patient was asked to share their hopes, goals, and dreams. Almost all patients said their dream was to go back to work again; the younger patients wished to finish school. After everyone shared, Melecio insisted that TB should not come to interfere, and that TB would not prevent them from going back to school or work soon, or from having a career and family later. Although everyone’s personal battle must go on, Melecio also stressed the importance of having someone to talk to, and of sharing one’s fears and feelings.
The third and most touching phase of the charla started with Melecio giving everyone 10-15 minutes to write two anonymous messages of support that would then be randomly distributed to someone else in the group, and that they could keep and look at again in difficult times. The four of us wrote motivational messages along the following lines: “Don’t give up, continue fighting and stay on treatment”, “Harness your inner strength, stay strong!”, “You are more than your disease”, “Six months of treatment is worth a lifetime of health”, “Never forget that someone out there loves and cares for you deeply. You can get through this.” When Melecio re-distributed the messages to other participants, he also gave out brochures on municipality-sponsored employment for TB patients, and other resources for patients, such as psychosocial services, and legal help. Before dismissing participants, granola bars and peach juices were distributed as a snack to take along with their daily dose of medication. Melecio wished them all well, and promised that he would be available for consultations at this health center at the same time next week.
After the charla was over, the GROW team regrouped to talk about two patients who had caught our attention in particular. The first was the 68 year old lady. She had shared that although she lived with her two sons, she receives very little help and support at home. “Everyone is just living their own life,” she said, speaking of the fact that she has to do all her cleaning and cooking on her own. The second patient whom we were all worried about, whom we will refer to as Alfonso, had problems of a different nature. During the charla, he was on the verge of tears and lightly shaking when he had shared that this was his second round of TB treatment, and that he was depressed and experiencing debilitating fears. He talked about not being able to endure his current state. To all of us, he appeared very alone and in serious need of professional support. Luckily, as soon as the talk was over, he came to sit by Melecio, Liz, and Lucero and talked to them for the next half hour.
When Alfonso, seemingly reassured and in a more composed state, walked back into the office to receive his medication, we took his place by Melecio and were joined by Dr. Maldonado. Melecio and the doctor shared that Alfonso, a former cook, had been quite optimistic about his treatment following his initial diagnosis. It was only a few months into his treatment, when the results of his drug-susceptibility tests came in, that he began feeling so bleak. Receiving the news that he had MDR-TB and that his treatment regimen would therefore be at least 14 months longer than initially projected crushed him. Following this news, he had become extremely depressed and suicidal – to the point where he experienced a serious hallucination, the exact psychiatric cause of which is still unknown. His mother, who Dr. Maldonado labeled quite supportive, helped Alfonso get hospitalized. But, even in the hospital, TB patients can face discrimination. Alfonso was kicked out of the psychiatric ward and the hospital at large, on the pretenses of being rapidly ready for discharge, when the healthcare professionals realized he had MDR-TB. Let me stress that point again: he was kicked out of a hospital for being sick. I doesn’t get more mind-blowing than this. Luckily, Alfonso has now also been prescribed drugs to stabilize his psychological condition. Though it was unclear whether or not Alfonso was in fact seeking mental health care, Dr. Maldonado commented on how much Melecio’s chat with him had calmed him today. Liz also shared that while many patients theoretically have access to these services, few are able to find the schedule regularity, mobility, and motivation to follow the frequent meetings or counselling sessions. In today’s conversation, although the topic was centered around Alfonso looking for employment, it was a good opportunity to also share information about other services available to him.
Visibly distraught by Alfonso’s situation, Dr. Maldonado shared with us his indignance at society’s discrimination against TB patients – both within families when patients are “quarantined” in their own homes and made to feel dangerous and alienated (some individuals do not interact with their family members, or are not allowed to use the same kitchen utensils at meals) – and within communities. Indeed, regardless of whether or not TB patients wear a mask, they are subject to discrimination (social isolation, loss of employment, etc.). Dr. Maldonado believes these social ills can be cured, just like the disease, but that it will take time. In the meantime, TB patients must find resilience within themselves, and find support from family members; (for example, some male patients who must stop working to stay on treatment but cannot afford to lose their job can ask employers to replace them with their wife or oldest child for a six-month recovery period).
This last point touched on some of the medical ethical dilemmas that Dr. Maldonado faces every day. In many cases, he wants to tell patients they must stop work to stay healthy, rest, and take their daily medication, but the difficult truth (which he empathizes with), is that giving up the job that pays for all a family’s expenses is not something that many patients can realistically comply with. These dilemmas seemed to really dismay Dr. Maldonado, who let us in on some of his frustrations and values. After discussing these in the context of the incident of Alfonso being kicked out of a hospital, Melecio told us that few doctors were like him. And unfortunately, we all agree. Many doctors distance themselves from TB patients, which only furthers their feelings of hopelessness, and in some cases, lack of self-esteem. If even the doctors, whom to many patients are their only allies in the fight against TB, turn against them, who is there to help them through this difficult time? Dr. Maldonado strongly believes in the importance of doctor-patient relationships, which he envisions as horizontal, not vertical. “Just touching a patient – putting a hand on their lap or shoulder, reassuring them with physical contact– can make a huge difference in your relationship. It instills trust, and lets them know you are here to care and support them through this rough journey. The problem is that not enough doctors are doing this simple human act.”
At the end of a week that flew by in the flurry of translating a grant proposal for ASPAT and helping them prepare a budget on a tight timeline, Melecio told us to meet him downtown Lima for a meeting on Friday. We were excited to spend the day with him and discover a new side and setting of ASPAT’s work, but we did not expect to be treated to such an incredible experience. Much to our surprise, we were invited to sit in on a meeting of the Multi-sector Committee for the Prevention of Tuberculosis, which was run of the Ministry of Health for the municipality of Lima.
Our meeting spot was to be in front of the Palacio del Gobierno on the Plaza Mayor de Lima, which we thought was just an easy-to-find meeting spot conveniently located near the Ministry of Health’s office building. Getting into the Plaza de Armas, where the Peruvian President’s house, Lima’s main cathedral, and the Municipality are located, required talking our way past policemen who had the nearby streets blocked off for a strike. We successfully convinced them that us “rubios” did in fact have business to do at the Municipal Palace other than just taking tourists’ pictures, and we made our way to Melecio, who was unphased by our delayed arrival. Instead of greeting each other and starting to walk in another direction, we were led inside of the ornately decorated building, away from the bright yellow exterior and hustle-bustle of the street into a white glass-roofed lobby. Inside, a table with folders, documents, a banner printed for the occasion, a photographer and several administrators were there to greet us and sign us in.
After introducing us to a couple of his colleagues from the municipality, Melecio escorted us to the Salon Azul where a few promotores were already seated. Once there we met Jose, another ASPAT volunteer, and then Melecio proceeded to disappear for an hour. In proper Peruvian style, we were in fact among the first to arrive to the meeting, which we were 20 minutes late to. In the hour interim before the meeting actually started, various participants from the Lima city government and MINSA trickled in, and we had the time to compare and contrast our surroundings in a colonial palace complete with velvet chairs, stained glass ceilings, and centuries old paintings, with their counterparts in various city governments in the US. Our conclusion: we were thoroughly impressed by the elegance, and interested in the cultural differences this embrace of the colonial elements of Peruvian heritage represents. It was a pleasant surprise for us to see the two supposedly divided worlds of elite government officials and low-paid promotores united in this official venue.
About fifteen minutes before Melecio came back with the presenting MD, the deputy mayor opened the meeting by talking about the importance of intra-governmental collaboration between the national level Ministry of Health and the local Lima municipal government. This was followed by an awards presentation that honored some of the city’s most committed promotores, including Grace whom we met last week, and whom we applauded wholeheartedly.
In the subsequent presentations, we learned that Lima now has over 800 trained promotores, community health workers who work on an entirely volunteer basis to follow up with patients and assure that they are receiving the emotional support they need to stick with their treatment regimens. Not all volunteers stay on for a long time- it is a large time commitment, and many are unable to work long hours without compensation. But, like Grace, there are a good number who stick with it and, in the words of many of the promotores we heard from, their patients “become like family”.
The importance of non-medical interventions such as nutritional care and psychological support was stressed throughout the meeting. It was really encouraging to hear municipal officials and medical experts talking about the fight against TB in such broad terms, with an emphasis on training all their peers to treat TB patients as holistic people and not just attack the biology of the bacteria.
The doctor reminded the audience that treatment abandonment is the most common way that patients develop MDR- and XDR-TB. In addition to the importance of genotyping all samples to identify and closely monitor mono-resistant cases, he said that increased contact and social support of patients is to be at the heart of Peru’s fight to reduce TB. In order to reduce abandonment, there must be systematic attention paid to a patient’s lifestyle, wellbeing, and access to opportunities, which include: education (about TB and generally, as an opportunity to increase their social mobility), family and community support (which contrasts with the discrimination that patients often face due to misinformation about the way TB spreads), and psychosocial support (including access to psychologists and consistent contact with community health workers, who listen to patients explain the non-medical obstacles they face, give them tools to remedy these problems, and keep them motivated to get better). Furthermore, access to social services programs and the DOTS-mandated direct supervision of treatment are also channels through which patients receive support from peers and professionals, which enables them to keep providing for their families and not lose sight of their goals throughout treatment.
Between 2011 (when the first collaborative policy plan against TB was rolled out by MINSA, the Ministries of Housing and of Work, and the Lima Municipal government) and 2014, the government has educated 189,000 people of various social backgrounds about TB in regional parks and trained 824 promotores. In 2013, MINSA also created a new manual of official treatment guidelines that mandates that patients who test positive for TB get tested for other chronic diseases including HIV and diabetes. It also advises healthcare providers to inform their patients about all social services programs that they might qualify for and reiterates the importance of moral support. Access to the 72-hour genotyping test has been increased – there are now four in the Lima-Callao area. Concluding his presentation, the doctor also confirmed that MINSA has promised to implement increased food baskets in the near future.
When we discussed the presentation, the usually calm, cool, and collected Melecio was almost beaming. To have MINSA officials labeling as essential the emotional support consultations and increased food basket programs that ASPAT pioneered is a huge triumph for TB patient quality of care, and rightfully a source of pride and motivation for our partner.
Yesterday was a comparatively unadventurous, yet nonetheless rather exciting, day spent reveling in the beauty of in-person communication at the ASPAT office in Callao.
Our first achievement of the day was proving our recent mastery of the Lima public transit system, a sprawling, decentralized tangle of privately-managed vans and buses that run along the city’s main thoroughfares. In fact, many of the ubiquitous posters for mayoral candidates tout platforms of transit reform, reassuring us that we are not the only ones who find the system chaotic. We were more or less mentally prepared for a distinctly non-Western commuting experience when we realized about a month before leaving that there is no such thing as a map of Lima’s public transit system in existence. Indeed, the difficulty of creating one is perceived to outweigh the potential profit of selling it to thousands of tourists (especially since most of them travel by foot, city tour bus, or Lima’s cheap taxis). We have yet to have encountered other tourists on our bus trips. Yet, we have been pleasantly surprised at how relatively quick the buses actually are, at least in contrast to how deteriorated they feel, though they are not particularly speedy compared to how long it would take to travel that distance in the U.S. Their speed seems to be in large part due their barely stopping to pick up passengers, and being able to swerve among cars. Thus the upside of the transit system is that it has led us to an important new theory in the scientific understanding of time: time slows down at a rate equal to the square of the amount of pressure that the other bodies you are crammed between exert on you, multiplied by the number of transfers you have to make. We’ve now got the route to ASPAT’s office perfectly timed and perfectly planned, with the motive of maximizing morning sleep, of course.
ASPAT’s office itself is very modest; no exterior indications or signs: you knock on a house front door and enter one room divided by a wall. The back area is Melecio’s office: a central desk, a few cabinet, and bare walls. The front part of the room is the ASPAT common working space, made up of a desk with PC, a large table seating up to six people, a few book shelves, and piles of empty hardback binders. ASPAT’s humble quarters (protected by several locks and out of sight from passer-bys thanks to window shades) are located on the bottom floor of Melecio and Judy’s small two-story purple house, which they share with their five year old son, Sebastian, and Judy’s mother and sister. The first floor includes another bedroom and bathroom, and the upper floor common living quarters, as well as an open-air terrace which where clothes are hung to dry. Below, the street is dusty and dirty: garbage is strewn on the sidewalk, there are no plants or grassy areas, and stray dogs watch the come-and-go of cycle rickshaws. This means there is largely no hard and fast separation between work and home life for Melecio, which seems to have both its pros and cons. We’ve learned that Melecio often works on Saturdays, especially since that’s the only day that some of ASPAT’s volunteers are available, yet, even during the week, he also needs to be available for Sebastian when he gets off school to meet him for lunch at Judy’s mother’s restaurant around the corner. We are immensely impressed by what ASPAT is able to achieve with such modest human, spatial, and financial resources.
In that vein, we were able to get a lot of substantial updates from ASPAT about many of the projects our partnership with them has touched on over the past 4 years:
1. Canastas: A couple of years ago, GlobeMed at UChicago’s Memorandum of Understanding (MOU) funded the delivery of food baskets to low-income patients receiving TB treatment at some of the clinics that ASPAT regularly works with, and the positive results of that project are finally trickling through the government bureaucracy and beginning to influence the Peruvian Health Ministry’s (MINSA) policy proposals. MINSA currently gives some very basic food supplies to low-income patients who have lost their jobs as a result of starting daily TB treatment, but not enough to prevent malnourishment. Melecio says that MINSA is currently discussing increasing the food baskets they provide to be much more similar to the ones that ASPAT was delivering, increasing their investment per basket per month from a cost of 50 nuevos soles (about 18 USD) to 300 soles (about 110 USD). This comes probably in part as a response to an analysis of government policy by some low-income Peruvians that Melecio encapsulated as, “the national economy has improved recently but that has not translated into better social services and policies.”
2. Desayunos nutritional guide: While the UChicago chapter is working on raising the last of our funds for our previous MOU, ASPAT is working on getting everything lined up to begin the implementation of the Desayunos pilot program we are funding. One of the final steps in that process is finalizing the recipes and beginning the creation of the nutritional guide. We learned today that the initial nutritionist who was supposed to work with ASPAT on refining a menu tailored to the needs of TB patients has virtually dropped out of the project and no longer answers Melecio’s emails. But we got the good news that Judy has found two young nutritional consultants with a wide breadth of experience and expertise between them, who are now collaborating on the recipes. A draft is expected in about a week, meaning that Desayunos is finally almost ready to get up and running.
3. Micro-Business Seminar: Workforce discrimination is a huge barrier faced by many TB patients, exacerbating the financial strains that are often a large contributing factor in creating the conditions that lead to their contraction of TB in the first place. In response, GlobeMed and ASPAT collaborated last year on the development and execution of micro-business training seminars for fifteen TB patients so that they could start their own small businesses to give them a flexible source of income while they continued to comply with treatment. Melecio let us know today that, despite initial difficulties in finding interested candidates who had the initiative to follow through and run a business, ASPAT was able to identify and train fifteen patients, all of whom successfully started their businesses in the beginning of 2014. Some of the patients have returned to higher paying employment since finishing their six month regimens, or have moved back to provinces outside of Lima to rejoin their families, but a number of them are still running their businesses. We are hoping to meet some of them in the days to come.
4. STOP-TB grant: ASPAT was recently awarded a new grant from the international organization STOP-TB giving them funding to start a leadership training program for patient advocates from other provinces outside Lima. True to their title (the Associacion de Personas Afectadas por Tuberculosis), the heart of ASPAT’s mission is enabling and amplifying the voices of TB patients themselves in Peru’s conversation about public health and policy. This new program will allow them to take big steps towards that goal.
On Friday, September 5, we met with Melecio in downtown Lima to visit the Juan Perez Carranza clinic. This open-air facility welcomes hundreds of out-patients everyday, and serves as an information, diagnosis, and treatment center for people living in Barrios Altos. Around a central atrium, which is made up of a outdoor waiting room and shrine to the Virgin Mary, wards branch out on all sides. Services offered here include HIV and TB diagnosis and treatment, OB/GYN appointments, a dentist, a radiology center, a pharmacy, a laboratory, and a children’s ward. We were led to the “Neumologia”, or pulmonary ward, where 100 patients come in every day from 8am-2pm to take their free medication, supervised by a nurse. In the Neumologia ward, composed of an open-air courtyard and two offices (one for MDR patients, the other for regular TB patients), we find patients and their families, nurses, doctors, reporters, and promotores (community health workers). We had the pleasure of meeting two individuals in particular, one patient and one promotora, who told us their stories. Each painted a different picture of strength and hope in the face of vulnerability and the realized threat of TB.
The first individual we met, Grace, is a transgender promotor. We never asked for preferred pronouns, but we will use the feminine form because she introduced herself using a female name (all names have been changed). Grace is tall, wears a long, untidy black wig, and thick eye makeup around her eyes. Besides from a long sweater with faux-fur cuffs and collar, the rest of her clothing (blue jeans, closed-toe shoes, and a patterned shirt) are quite ordinary. Grace is most likely in her late-30s, but is already missing several teeth. Grace was diagnosed with TB in 2009, at which point she underwent the 6-8 months drug treatment, and met Melecio. She is now cured, and has since then been working as a promotor – she acts as a community health worker and liaison between the clinic and the patient’s home by delivering and supervising daily medication for patients. She sees about 4 patients a day, but most of the time her work does not stop there. In many cases, she visits the homes of patients unable to travel to the clinic themselves. Traveling from home to home takes up much of her time, and she also often ends up cooking meals or caring for the children of the house whose parents do not have the energy to look after them. Outside of patient visits, Grace spends time at the clinic, counseling patients who come in and seem to have lost hope, or who are having a hard time taking their medication regularly. She says TB patients who have drug addiction problems are the most difficult to work with because of the dual stigma associated with their condition. She mentioned one particular young woman who came to the clinic because of severe back pains and was quickly diagnosed with TB. The woman initially refused to admit that the pain she was feeling was due to TB and left the clinic; it was difficult for Grace and other clinic staff to persuade her to start treatment. After giving us an extensive tour of the clinic and chatting for a while, Grace accompanied Melecio and the GROW team to lunch, and then made sure we made it safely back to the bus home. On the way to the bus, I couldn’t help but notice several instances of people turning around to stare at Grace: people in cars, pedestrians, or store-owners on the sidewalk. Most of these gazes seemed derisive or laden with shock. Either way, it made me feel uncomfortable and sad, but Grace stood her ground – not once did she look back in their direction, flinch, or say anything back. She was definitely owning her appearance and her pride was admirable, but it still hurt me to see that, despite dedicating so much of her time to help others, she herself remained so vulnerable. On the bus trip home, Jeanne L. and I chatted about Grace and her generosity, but also how her appearance and situation made her not only vulnerable in the streets, but also in the job market – although she might enjoy what she does, she may not really have a chance of trying a different line of work and permanently leaving behind her dark TB days.
The second portrait I would like to draw is Gabriela’s. We found her sitting on a bench outside the TB ward, a mask over her mouth, looking down at her lap. Gabriela is 19-23 years old, a young beautiful girl with long hair, an obvious sense of style, and a meticulous French manicure. Three days ago, she was diagnosed with TB. For the past two months, she was been feeling down, tired, and was spending less time with her friends. Because she lives only five blocks away, she came to the clinic to be diagnosed, fearing the worst. Yet, learning about her infected status was not the worse news to befall her: she had to quit her job, and most important, she had to interrupt her studies. Her class cycle started just days ago, all her friends are back at school, but she is forced to spend all day inside watching TV and cooking in her tiny, stuffy, windowless apartment. Although she agrees with Melecio that her health must come before everything else and knows she can resume her psychology studies when the next cycle starts in January, she still feels bored, depressed, and lonely. Following her diagnosis, her parents accompanied her back to the clinic to make sure neither they nor her three younger brothers (ages 5, 6 and 15) had been infected, and to learn about the precautions they should take. Upon returning home, Gabriela (who presumably shared a room with her 15-year old brother) moved into a room of her own in order to protect her family. The good news in all of this is that Gabriela seems to be receiving the support she needs in this difficult time, and has easy access and the will to take her medications. She has also learned that in a month, she will no longer be contagious, so although she will not be able to resume school yet, she will be able to spend time with friends again and maybe take up a job for a couple months. This will also ease up the situation at home. Until then, though, she must wear her mouth mask whenever she speaks and cover her cough and sneezes. After our conversation with Gabriela, Melecio shared his own story of having been in her shoes just a decade ago, when his dream of become an airline pilot were dashed by a TB diagnosis.Though her future may currently look bleak and uncertain, Gabriela is young, healthy, and driven. TB is an early obstacle in her career and life, but she will be able to overcome it and beat the disease. Her vulnerability will diminish as long as she continues treatment- in this sense it is more transient than that which Grace must endure. However, unlike that of Grace, Gabriela’s vulnerability is contagious: with three young siblings breathing the same air she does everyday, she feels a great deal of responsibility to avoid infecting them, which surely weighs heavily on her shoulders.
In 2013 in Peru, 31,000 new cases of TB were diagnosed.1,600 of those were MDR-TB, and 275 with XDR, of which only 40 are currently receiving treatment.
Experts contracted by the Peruvian Ministry of Health estimate that 56% of MDR cases are not detected, so it is difficult to know how many vulnerable people are being exposed to MDR/XDR and how many are carrying the disease, or getting the wrong treatment
Peru is the leading TB-afflicted country in South America, in front of Brasil, Ecuador, Bolivia, Honduras and others. For instance, there were 68 recorded cases of XDR-TB patients in the first trimester of 2013 in Peru, vs. 18 in Brazil. Of course, Peru’s 30 Million population does not rival with Brazil’s which is close to 200 million. This makes the figures, in proportion, even more alarming.
The highest number of new cases of TB in Peru was recorded in 1995; (4,200 for 100,000 people vs 1700 for 2013). Melecio says that this most likely has to do with the economic situation of the time produced by the switch to the Nuevo Sol (the current currency system), which caused many people to hit on hard times.
Age breakdown of TB cases in Peru by percent:
37% are adults ages 30-59
34% are young adults ages 18-29
15% are older adults ages 60+
9% are teens ages 12-17
3.4% are kids 0-11 years old
Seeing that Peru’s population is largely very young (29% of the population is under 14 years old), TB affects in large part a working age population that is already quite small. TB thus not only affects the economically active, but also their family’s ability to make ends meet. In addition, TB mostly affects men, who are detected with 61% of new cases every year. Luckily, the HIV-TB incidence is quite low, with only 4% of TB cases being HIV co-infections.
Peru region who are leading the nation in TB caseload are (% of the nationwide load):
Lima Ciudad 24%, East Lima 18%, South Lima 8%, Callao 7%
Already, we see 57% of Peruvian TB cases in the Lima Metropolitan Area (8.4M people, about one third of Peru’s 30 Million people total). In fact, the coastal areas of Peru, which make up only 11% of the country’s territory, host 55% of the population.
Furthermore, another scary indicator is that 4% of people who are given general medical exams should be diagnosed with TB according to expert estimates, but only 2% are… Many medical professionals aren’t looking hard enough for the symptoms when the disease is in its earlier stages, and thus compromises the health of hundreds of families.
Although most TB is found in Lima, and XDR largely concentrated in Lima (with 557 recorded between 1997 and 2013, of which 40 only were being treated – and only 21 in hospitals), East Peru is also very affected. Indigenous practices replace western medicine, and these populations have very little access to drugs, tests, hospitals, or other health services.
Currently, Peru has largely sped up the screening and testing process by introducing the genotype test in 2011. Before this new test, the 1990 DOTS program, and the 2007 STOP TB were the only government-sponsored testing programs, which, with only one working lab in the country, were not as efficient in delivering results and getting patients on treatment fast.
ASPAT-Peru’s work has a lot of breadth, ranging from prevention and outreach in schools, to check in on patients about the quality of their day-to-day care, to giving policy suggestions to almost every level of local and national government. Yet, though it might seem slightly ironic, Melecio spent much of our first morning together explaining the Peruvian TB diagnosis and treatment process in-depth, as it is extremely important that we understand the context for their advocacy and the experiences of the patients we will be meeting.
Despite having one of the most well developed diagnostic processes in South America for identifying MRD- and XDR-TB, it still takes over four months for most Peruvian health centers to identify drug resistance in patients already diagnosed with TB. And that is only when they are tested for in the first place. Although the Peruvian Ministry of Public Health (MINSA) guidelines dictate that all patients diagnosed with TB should be immediately given a drug susceptibility test, Melecio and public health experts estimate this only happens for 40-50 percent of such patients. Peru’s lack of health infrastructure and easily accessible medical technology has historically made widespread and efficient susceptibility testing difficult- as recently as fifteen years ago, all samples had to be sent to Massachusetts for processing. However, in the past decade, MINSA has made considerable strides to improve health care systems for TB care, including building their own labs capable of performing susceptibility tests.
To summarize the diagnostic process here in Peru:
Step 1: A patient goes to a doctor’s visit because they are having symptoms of a serious illness. (90 percent of the time these are respiratory for patients with TB since only about 10 percent of TB cases are extra-pulmonary). The doctor takes two samples of mucus from the lungs and sends them to the lab for a TB test.
Step 2: If the TB test is negative, the doctor must continue to look for other possible illnesses. If the TB test is positive, another mucus sample should be taken from the patient and sent for the drug sensitivity test. Peruvian labs now have genotyping capabilities, which detect MDR resistance within 72 hours. A TB case is only labeled MDR if resistances to both of the primary first line drugs (rifampicin and isoniazid) are picked up by the genotyping test. If a strain of TB is resistant to one drug, it is known as mono-resistant and treated with the other first line medicine. If a strain is resistant to two drugs other than rifampicin and isoniazid, it is poly-resistant, but can be treated with a normal regimen.
Also of note, Peru has greatly improved its infrastructure for diagnosing MDR TB over the last ten years; at one time there was only one lab in the country that could do these tests and the 72 hour genotype test is quite new, having been introduced into the medical infrastructure here only in 2011. The quick turn around time is important because failure to receive the right treatment can result in the development of increasingly serious resistance and a loss of hope for the patient who will not see improvement despite taking their drug regimen regularly.
Step 3: If the patient does not have MDR-TB, they are given a doctor’s order for a first line drug regimen and are directed to a clinic to immediately start their six month treatment. If the patient is diagnosed with MDR-TB, the doctor must collect more samples and send them for two more extensive drug sensitivity tests, which check for all first- and second- line drug resistances. A case will be labeled XDR if it is resistant to the two primary first line drugs, as well as either Capreomycin or Kanamycin, which are the primary second line drugs, as well as one other second line therapy. Patients must wait 3 to 4 months to receive answers.
Step 4: Meanwhile the patient must also undergo an in depth medical examination. A physician records their full clinical history, do x-rays of their lungs, test for HIV and diabetes, and run a battery of other general tests (which even include hearing and seeing tests). They also see a psychologist and a social worker to receive an assessment of the social factors contributing to poor health and/or barriers to treatment access.
Step 5: All of the information from the medical tests and assessments is passed on to a local committee of medical experts, along with the results of the drug susceptibility tests. This committee is charged with drawing up the patient’s treatment regimen. This committee plays a continued, crucial role in the patient’s wellbeing, as they are the only ones that can alter the drug regimen or prescribe new drugs were the patient to have a bad reaction to certain drug or experience any other difficulties or resistances. The treatment plan the committee draws up is then taken to a regular health clinic where the patient will receive their medication multiple times a day for a year and a half or more.
Thus though the process for getting all TB patients onto an efficacious
ASPAT has also played a crucial role in increasing the efficacy of this infrastructure in Peru by providing transportation services for many sputum samples within the municipality of Lima. Since Lima’s public transit system is highly chaotic and unstandardized, samples often sit for days before arriving at the requisite lab facilities when it is left up to busy general public health workers to deliver them. ASPAT’s service has made a considerable increase in the number of samples that get to labs without being contaminated or spoiled.
ASPAT believes that one of the most important elements in assuring that Peru’s TB treatment infrastructure continues to improve has to do with informing citizens about TB and reducing the stigma of talking about it
, and other communicable diseases in Peruvian society. Melecio thoroughly explained the current structure of the government and
However, there is a long way to go. Melecio says health rarely even makes the government’s priority list, and even when it does, it falls far below other issues such as citizen security, education, and public works improvements. But, this switch in governance structure allowed ASPAT to make many positive changes in Callao, as they received ownership of a number of dilapidated wooden health clinics and were then able to make much needed sanitary and hospitality improvements. Their work continues to raise the profile of social factors that contribute to poor health outcomes, such as malnutrition and over-crowded housing conditions.
Hello from Lima, Peru!
The 2014 GROW team from the University of Chicago’s GlobeMed chapter has assembled and is reporting for duty. Our goal is to assist our partner ASPAT-PERU to implement the Desayunos pilot study, developed collaboratively with our chapter. For those unfamiliar with this project, our excellent Elena Hadjimichael has written a poignant and reflective blog post that captures its practical, intellectual, and emotional dimensions. To briefly summarize, the project aims to demonstrate that tuberculosis (TB) patients can benefit greatly from nutritional supplementation to bolster their ability to fight the disease. Desayunos will provide free, nutritionist-designed breakfasts to patients already receiving care at public clinics. We hope this will alleviate the debilitating side effects of tuberculosis medication, which are often exacerbated by malnutrition, and will keep patients on their medication more consistently and prevent the development of drug-resistant TB.
For the past year, our GlobeMed chapter has been working to develop this project with ASPAT, and has campaigned to fund the pilot program during the 2013-14 academic year. We not only hope that it will be successful for ASPAT’s participating patients, but that it will also lay the groundwork for similar programs in Peruvian health clinics in the future. Tuberculosis is highly stigmatized in many countries, including Peru, which impedes eradication of this very preventable and unnecessary disease. Poverty complicates the issue further because patients must often choose between either keeping a job to support their families or taking time off to recover and medicate. We aim to show that this disease must be treated not just with antibiotics, but with time, nutrition, and social support.
As Elena so eloquently put it,
“Sometimes, improving health in a community isn’t about the grand gestures, like a new hospital, a fleet of ambulances, or a six-figure donation. Sometimes, it’s about the smaller things. In this case, it’s about breakfast.”
Beyond the Desayunos project, the GROW experience is one that many of us have been looking forward to after having spent 2-3 years working with ASPAT from a distance in Chicago. It’s a way for us to concretize a partnership, give a human form to what used to be a signature in an email and a voice over Skype. GROW is also a way to tangibly and realistically understand the realities of our partner’s work in order to not only educate our chapter, but build a concrete MOU and ensure that our partnership is rooted in a dialogue of mutual, responsive understanding. For many of us, GROW is also a unique pre-professional on-the-ground public health experience, facilitated by previous connections and and project we deeply care about. All in all, GROW is learning about the second half of the equation for social change that we fundraise for all year long, and propelling forward our dedication to global health equity.
Our GROW team mission is to work on-the-ground with ASPAT to make this project a success. Follow us on this blog and our Facebook page, or by using #uchicaGROW2014.
It is, says the World Health Organization, “an extraordinary event.” Polio is spreading to a degree that constitutes a public health emergency.
The global drive to wipe out the virus had driven the number of polio cases down from 300,000 in the late 1980s to just 417 cases last year. The World Health Organization has set a goal of wiping out polio by 2018.
But this year, polio has been reported in 10 countries, and there are fears the number could rise. Bruce Aylward, the head of WHO’s polio program, says if the international spread isn’t halted, the virus could easily re-establish itself, particularly in conflict-torn countries like the Central African Republic and South Sudan. The unrest makes it difficult to sustain vaccination efforts, and poor sanitary conditions cause the disease to spread.
Although polio mainly afflicts children under 6, a WHO emergency committee has stated that adults are to blame. The committee noted that there is “increasing evidence that adult travelers [from Pakistan, Syria and Cameroon] contributed” to the polio surge.
As a result, the World Health Organization has taken the unusual step of ordering these three countries to vaccinate any resident who travels internationally. In addition, WHO is calling for the three countries to continue efforts to inoculate their children. The mandate was issued by the director-general’s Emergency Committee on International Health Regulations.
Aylward says this focus on travelers is critical to stem the virus, which causes paralysis and can be fatal
Photo: A health worker administers polio vaccine drops to a child at Karachi International Airport in Pakistan. The country’s government has set up immunization points at airports to help stop its polio outbreak from spreading abroad. (Rizwan Tabassum/AFP/Getty Images)