August 3, 2001

Tuberculosis, a disease that demands very strict controls

By Norma de la Vega

Everyday, Carlos López makes his way prowling through Tijuana neighborhoods in his old but well-used car. His trips are part of his work - personally delivering medicine to people stricken by tuberculosis and making sure that they take it.

Jesús (who did not give his last name) waits with a glass of water as Carlos López arrives with daily medication. Jesús discovered he had developed tuberculosis at an early stage. “I feels much better already, but I know I need to finish the whole treatment to totally cure me of this disease,” he said.

He is a community health worker (CHW) in a program known as DOT (Directly Observed Therapy.) The program, which is used around the world has been recently implemented by the Baja California Department of Public Health.

Dr. Paris Cerecer, program coordinator, said an average of 600 cases of tuberculosis are detected annually in Tijuana and that Tijuana is among the top five of cities in Mexico with a high incidence of tuberculosis.

"That is somewhat amazing, don't you think?" he said.

Because of this, local authorities have adopted new strategies to strengthen the tuberculosis program. Part of that push involves taking the medicine to patients who, because of lack of resources, cannot go to the city's health centers. Tuberculosis patients under treatment must take medicine daily and the process can last 6-12 months.

The health department provides treatment for free at all health centers, with one condition: that patients go to the centers and take their medicine in front of a supervisor.

Dr. Cerecer said that for several years, it was believed tuberculosis was under control. But during the 1990s, the world saw a resurgence of TB, mostly because of a greater susceptibility among AIDS patients and also because people with TB often abandoned treatment before completing it, which can allow the bacteria to develop a resistance to the medication.

He said tuberculosis is a disease based on social contact. Many cases are found among poor people who live in highly populated areas. There is also a high incidence of TB among drug addicts.

Dr. Norma Molina, also with the TB program, said chronic coughing and phlegm, (which can mean that active TB has been developing for at least two weeks,) are signs that help identify the disease early on. "When this occurs it is time to go to your doctor," she warned.

Dr. Molina also said that people who have tuberculosis and cough can spread the bacteria through the air, but becoming infected requires very close contact. People who are infected start feeling fever, loss of appetite and weight, and nocturnal sweating.

The good news, said health officials, is that there are very few children afflicted with TB. Dr. Cerecer said children in Mexico are vaccinated against TB, which offers certain protection against more serious forms of the disease. He said the percentage of children under the age of 15 with tuberculosis is below eight percent.



Carlos López personally visits 21 patients daily because they cannot afford to take the bus to any of the health centers.

The home-visit program started two months ago, and is an important task because, López said, if the patient stops the treatment, there is a risk that the TB bacteria will return even stronger and/or develop a resistance to the treatment. Also, when a patient takes the medicine properly, the risks of contagion are lessened. That is why López tells his patients to be wise and take their medicine on time.

Lupe, 32, has been sick with TB for several months.

She lives in a small shack with her four children and her American boyfriend. López said that as part of the program, which also includes educational and preventive aspects, the four children and the boyfriend are examined regularly to make sure they are not infected.

In Lupe's case, her boyfriend said she has lost a lot of weight. "She used to weigh 135 pounds. If she weighs 60 pounds today, that would seem too much," he said. She is extremely weak, which makes it impossible for her to stand up and she's been in bed for several months now.

For her, the visits are an enormous help. She said the program has been a blessing for her, and her biggest wish is for the treatment to end and for her to get better.

Dr. Molina said the biggest problem for medical authorities is caused by patients dropping their treatment. "When they're three months into the treatment, they feel fine, then they abandon the treatment and have a relapse," she said.

López knows this all too well. When his patients tell him they are tired of taking so many pills, he reminds them: "That may be so, but the best thing is to make sure that you are completely well, so let's finish the treatment."

López visits patient after patient. One of them, Jesús, a man of about 50, was waiting for Lopéz with a bottle of water in his hands. Several other patients welcomed Lopéz with visible gratitude. That is López' daily routine. His patients know they must take their pills in front of him.

Howver, López is overwhelmed and many TB patients go without getting treatment.

Dr. Cerecer said there are just too many patients. "There should be one community health worker for every five to ten TB patients because (the treatment) includes time to teach people about TB and how to prevent it.

Dr. Cerecer said he's talking to private-practice doctors to get them to report cases of TB they might detect. A lack of coordination between private and public health servers represents an enormous obstacle for controlling TB, he said.

Moreover, it is indispensable to expand the program to reinforce medical supervision among drug addicts and alcoholics. Also, the jail is one place that requires special supervision because of the high number of inmates infected with TB and the close quarters that they live in.

Dr. Cerecer says health department personnel conduct educational sessions about TB at the jail because TB was detected among numerous inmates. "The sessions took place because we had found six TB patients at the jail, but when we started explaining about the symptoms and we conducted TB tests, we found 21 patients in all."

López knows the challenges of his work but carries on because of his personal convictions. He knows the risks, but knows his work is making a difference.

"I believe that the way we're working at it, we will control tuberculosis," he says.

Reprinted from "Border Reflections - Profiles on Community Health" June / July 2001, Issue 30. Published by The Border Health Initiative 148 E 30th St., National City. 619-791-2601.

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