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Tuberculosis: The Challenge Facing Peru

Millions of Peruvians have moved from inland towns and villages to Lima, the country’s urban area, over the past several decades. Since 1980, Lima’s population has doubled, going from 4.8 to 10 million in 2015. This migration to urban areas has encouraged political stability in the country and the improvement of education and healthcare systems. Despite these positive changes brought about by urbanization, Peru still faces severe problems even in the realms of these newly improved systems, especially healthcare.

Figure 1: Between 2006 and 2016, the percentage of Peru’s total population living in urban areas has increased.
Figure 1: Between 2006 and 2016, the percentage of Peru’s total population living in urban areas has increased.

This urbanization has driven great economic growth. Peru has become one of the best-performing Latin American countries. Peru’s economic scenario is optimistic as inflation is low and investment rates are high. As a result of this situation, Peru’s middle class is flourishing and urban areas are expanding. However, rural areas continue to struggle. Although the poverty rate in Peru has dropped, it remains at more than 55% in rural areas.

Figure 2: Percentage of Peruvians below the poverty line
Figure 2: Percentage of Peruvians below the poverty line

The number of Peruvians making a middle-class income has increased greatly, though income inequality remains an issue in the country. Although urban and rural populations are about equal, only 15% of non-urban citizens are middle class.

Despite the economic achievements that Peru has made, the country still struggles to reconcile the disparity between rural and urban citizens. This is most prominent in regard to healthcare. Peru established a comprehensive health system in 2002 that succeeded in increasing enrollment in health insurance (from 41.7% in 2003 to 54.1% in 2008). However, this system was aimed primarily at women and children under 18 years old, and while it did reduce maternal and child mortality, it did not provide care to the adult population as a whole. A new healthcare policy was introduced in 2009, though there has been little progress in its implementation. Information on health insurance is not available in rural areas, particularly among the indigenous Amazonian people who live in those areas. The inadequacy of the country’s healthcare system is demonstrated by its struggle to face its severe tuberculosis (TB) problem.

Peru contains 3.1% of the population of the Americas but reports 13.6% of TB cases and 41% of cases of multi-drug resistant TB (MDR-TB) in Latin America. When compared to Latin American countries with similar or lower GDPs, its poor performance becomes significant, as those other countries have lower incidence rates of TB.

Figure 3: Gross National Income compared to TB incidence rate
Figure 3: Gross National Income compared to TB incidence rate

In Peru, tuberculosis affects 33,000 people and kills 4,000 every year. In the recent past, Peru has had the highest number of cases of drug-resistant tuberculosis in the Americas. Although the number of deaths due to tuberculosis has decreased in recent years, TB cases are on the rise in impoverished districts.

Figure 4: The number per 100,000 people in Peru with TB has decreased over the years.
Figure 4: The number per 100,000 people in Peru with TB has decreased over the years.

Oil exploration and logging in rural Amazon territories, which comprise 60.9% of national territory, have exposed the indigenous people there to new diseases, including TB, causing them to develop rapidly and aggressively. The geographic accessibility of health facilities in rural areas such as these is a major challenge to the treatment of TB throughout the country. Primary health clinics may be many hours away on foot from rural areas, making it difficult for patients who are undergoing treatment that are required to visit health clinics daily. There is also a major gap in access to accurate information on TB, as well as its management and treatment.

Tuberculosis is not limited to rural areas. The living conditions brought about by mass migration to urban areas have caused the disease to proliferate. Because of the great number of arrivals in cities, migrants have had to create informal settlements to live in. These slums are breeding grounds for tuberculosis due to overcrowded, poorly-ventilated, and often damp living spaces.

It must be noted that although Peru has the greatest number of TB cases in the Americas, it also has some of the world’s highest cure rates for the disease (87% for new cases and 66% for a multi-drug resistant strain).

The DOTS (Directly observed treatment, short-course) program was implemented in Peru in 1990. It is the tuberculosis control strategy implemented and recommended by the World Health Organization. Patients were eager to participate through the promise of food packages, employment training, and free transportation. The program has increased the case detection in the country and has decreased the number of deaths due to TB in Peru.

Figure 5: The morbidity and incidence rates of TB in Peru after the implementation of DOTS.
Figure 5: The morbidity and incidence rates of TB in Peru after the implementation of DOTS.
Figure 6: Enrollment of patients in Multi-Drug Resistant Tuberculosis (MDR-TB) treatment programs has been successful.
Figure 6: Enrollment of patients in Multi-Drug Resistant Tuberculosis (MDR-TB) treatment programs has been successful.

The implementation of DOTS has caused positive results, including the decrease in the number of TB cases and the maintenance of a high percentage of cured patients. However, the number of cases of multidrug-resistant TB (MDR-TB) has grown in recent years, and the emergence of extensively drug-resistant TB (XDR-TB) in Peru is a great threat to the country.

The newest development to the TB treatment approach in Peru is a training program for community volunteers that teaches them how to tend to TB patients at their homes. A Boston-based non-profit, Partners in Health, works with Peru’s health ministry to train people to ensure that patients take their medicine daily and to help these patients navigate the country’s public health service.

One in four Peruvian TB patients drops out of treatment because the medicine prescribed has such harrowing side effects, including changes of skin color and occasional bouts of psychosis. Patients need accompaniment and personal support in the treatment process, which is why the current treatment program in the country is successful.