How? Is not it eradicated?
The question is often heard.
Is this behind a good part of the society that considers it a head of the past, Tuberculosis is still ill and killingThere is no need to travel back in time or over long distances to see how the Ftize described by Hippocrates in Ancient Greece – also known as white plague – to which European Middle Aged monarchs believe they can heal with the "royal your touch ". – Opposes the passage of centuries: in Argentina provokes more than 11,000 cases per year and 700 deaths, Figures have been decreasing since 1980, but the trend has been reversed since 2013. Preventive and curable, the reasons for their survival exceed the biomedical aspect; its social dimension, its relation to material conditions of life and vulnerability strengthen it.
Last month, the deaths of a 38-year-old woman and an 18-year-old woman happened publicly.
"Two deaths caused by Tuberculosis in Quilmes!" How "is there tuberculosis?" Yes, there is a ", Domingo Palmero, a specialist in pneumotyology and infectious diseases who has been devoted to tuberculosis for 40 years, is joking about this widespread ignorance.
The second bulletin on tuberculosis in Argentina, presented this year, puts the problem in numbers. Figures correspond to 2017: 11,659 cases (among new, recurrent and previously treated). Although there were 99 messages more than the previous year, the percentage remains stable at 26.5 per 100,000 inhabitants. All regions have registered cases, but the distribution shows significant differences, as six jurisdictions have exceeded the country's average values: Zhuhai, Salta, Formosa, Buenos Aires, Coco and Buenos Aires. And almost six of the 10 notifications (57.4%) correspond to the AMBA (responding to CABA and 40 provincial municipalities).
The local epidemic model then fits into what the World Health Organization (WHO) defines as tuberculosis (TB) in major cities, "which happens when a large concentration of poor people crowded, which favors the transmission of the disease and that cases are heavier, "he commented. hunting horn Claudia Rodriguez, Director of AIDS, PDB, Hepatitis and Tuberculosis (DSETT) of the Ministry of Health and Social Development, a field on which the National Tuberculosis Control Program is based. Accelerated urbanization in these areas, as well as barriers to access to health care and the fragmentation of care, are other characteristics that attract the local profile.
In Casa Masantonio, the drug for various treatments of the disease. / Photo: Fernando de la Orden
Age distribution shows a disturbing reality: Tuberculosis particularly affects productive age populations. 18% of cases were seen in children under 20 and half of new cases (49.2%) were in people between 20 and 44 years of age, "And in the smallest, both in working age, the problem for the country is very important," says Rodriguez. He adds, "If a person who has a family has tuberculosis, he remains for a while without being able to work. In the smallest, the problem is different: they can learn, then there is an opportunity to transmit the infection to others, because, among other things, because of their youth, they have less control over the cough than they limit. in the studio. "
The bacillus in the air
Coughing is one of the characteristic symptoms of the disease, but it is also the outcome of Mycobacterium tuberculosis Coco bacillus, which mainly affects the lungs. In Argentina, 86% of cases are pulmonary localization: the most common and, against which the BCG vaccine does not protect, which greatly avoids the severe forms of the disease such as meningitis and osteomyelitis. Then, due to ignorance of the validity of the disease, widespread confusion is added.
"People often think my son is a cough eight months ago, but tuberculosis will not be because he's vaccinated: that's serious mistake that we do not know how to betray properly, "says Rodriguez.
The infection is produced by inhalation of the particles that contain the bacilli and the patients are thrown into the air by coughing, sneezing or spitting. When a sufficient number of bacilli invades a healthy person, three things can happen: that the disease develops that the immune system destroys the bacilli, or the infection remains dormant for years (which does not mean he is sick or infected).
Tuberculosis in Argentina causes more than 11,000 cases a year and 700 deaths. / Photo: Fernando de la Orden
"The disease requires prolonged contact with the patient for a cough that is bacillary and, on the other hand, an individual predisposition: immunopressurizing diseases have a major impact," Palmero explains. "Accidental contact is very contagious," he explains. What does a long contact mean? Shrinking, 4 to 6 hours a day, most of the days, with the infected person, says the director of the Vaccarpse Institute, which is dependent on the Faculty of Medicine of the UBA and is the reference center of tuberculosis for university and one of the most recognized in country. Sharing property with the hospital Muni, where the doctor is the head of the Pneumotiology department. Both institutions function as a public-public union, the highest number of cases,
"Tuberculosis is much more common in diseases that clearly change protection, such as HIV, there is a specific change that facilitates not only tuberculosis but is more serious and can be fatal," says Rodriguez. In the 35-49 age group, one-third of TB deaths are HIV-related, says the latest newsletter. Diabetes, obesity and genetic factors can also act as predisposing, experts say. And among the vulnerable groups of the population are children and adolescents, communities of indigenous peoples, people deprived of their libertymigrants, closed communities and people in situations of problem use of substances.
Disease related to social
Weak immune system and close contact are conditions that are common (but not only) in the worst position; in which poverty, overcrowding, eating poorly and badly are a common occurrence, and sets the ideal scenario for spreading bacillus.
"The greater the cluster, the greater the ability to transmit," Palmero says. / Reuters / Mariana Basso
"The more clutter there is, the greater the transmission capacity", says Palmero. – If I have not worked for 10 hours without stopping, opening the windows, sleeping well, eating well … if I meet all these conditions, we probably will not get sick. If I do not have them, yes. This is why tuberculosis is absolutely related to material conditions of existence. In fact, a large number of cases have been registered in clandestine textile shops. Many people who have or have had a disease work or work in an illegal workshop: they are closed, window-free, with very little space between one person and another, who do not eat well or have enough rest because they can sleep a little, – says Virginia Culzello, a social worker at Pinero Hospital, the second in patient care in the city. It belongs to municipality 4, which together with 1, 7, 8 and 9 are the ones with the highest number of cases, all in southern Buenos Aires.
Gustavo Barreiro is one of the coordinators of the Casa Masantonio project that serves people with complex illnesses (tuberculosis, HIV, among others) within the AUPA cooperative, which provides comprehensive assistance to Pako users at the Parque Patricios border with barracks. The Little Brother, as they call it, knows very well how the problem use of substances has recently been added as a risk factor of particular complexity. "For 10-15 years, many people who are in use have made it possible bacillus is distributed to the young population, which is the growing band. A tuberculosis attendant goes to sleep with two or three in a closed place, a little randhad. He coughs all night with people beside him who are malnourished, perhaps immunosuppressed. While under other conditions, the bacillus will hardly enter – if healthy – it is easy in this situation, he says.
Palmero shares statistics on the dynamics of disease transmission: about one person with pulmonary tuberculosis, 20 are infected, two of whom get sick. "The problem, he says, is all the time before he connects with the diagnosis. The average patient was infected for six months and was assisted at least three times until he was diagnosed with tuberculosisThe health system, as well as many people, believes that tuberculosis does not exist, which is a rare disease.
In the same way, the social worker says: "Sometimes patients transmit it as "I allowed myself to be" and this is not the case. In general, they slow down counseling because they are symptoms that do not mean urgency, and their daily lives have many difficulties. How difficult it is to keep the job, especially if it is informal and more in the conditions of slavery, to go out to control yourself because you have back pain for a while because you cough for more than 15 days, feel desperation or no appetite is complex because they are common symptoms and can be related to other things. Many times go to the guards and tell them it's nothing, cough, come back. The possibility of tuberculosis is made not only invisible by the person suffering from it but also by the health system".
"Of all cases of tuberculosis reported annually in Argentina, less than 2% have drug resistance." / Photo: Fernando de la Orden
And as a logical consequence of what you do not see (or do not want to see): stigma. "Not everywhere they take people the same way," says the doctor. We have patients traveling 40 kilometers and there is no way to get them back to their place of origin to continue treatment because they face administrative obstacles: shifts, treatment is not always the most appropriate. Not all health centers are equally patient-friendly. There is also fear of tuberculosis, which is even visible at the hospital level: "Go directly to Mounis". The patient experiences this rejection and is very cruel".
Chest X-ray and bacillus searches in the sputum sample (which the patient expects) are the most commonly used tools for diagnosing pulmonary tuberculosis. There are also rapid molecular methods that are already in use in our country, but are still on a small scale and are focused on people who suspect a case of resistant tuberculosis.
"Numerous studies have shown that resistant tuberculosis can occur when wrong medicines used or used to treat tuberculosis, including that treatment is discontinued without finalization"Said Clarin Juan Carlos Bossio, Head of Health Programs at the National Institute of Respiratory Diseases (INER) Emilio Coni, dependent on ANLIS-Malbrán." Of all cases of tuberculosis reported annually in Argentina, – less than 2% have resistance to first-line drugs, "he says.This places the country among those with a low incidence of this type of tuberculosis.In 2017, 112 cases of MDR-TB have been reported and in 2018 the number of these cases is 138. "
That the patient timely arrives at diagnosis costs. But this is only the first step from a thorny path: treatment that takes six months (in some cases nine times) daily doses of the drug and should not be interrupted to reach treatment. "This is one of the main reasons that make it difficult to maintain treatment because they are difficult to treat," says the social worker. Of all cases reported in 2016, the result of the 30% treatment is unknown and, of the remaining 70%, 77% completed successfully, says the latest newsletter.
Infectoctor of Casa Masantonio, Santiago Jimenez. / Photo: Fernando de la Orden
All figures come from the national vigilance that has been taking place since its inception, through Santa Fe, INER E. Coni. "The lack of detection of some cases or the discontinuation of treatment of open cases before finalizing leads to more sources of infection contributing to the notification of cases that do not reduce as much as they could reduce or increase "says Bossio.
One of the most important achievements to improve adherence, emphasizes Claudia Rodriguez, is the recent acquisition of the National Tuberculosis Control Program combined treatments that reduce the amount of pills a day what the patients should take In the initial stage (the first two months), the 12 tablets are replaced by four per day. The drug is available free of charge in hospitals and public health centers throughout the country. However, the investigated sources noted that the new quadruple presentation (Rifampin 150 mg, IIsoniazide 75 mg, Pyrazinamide 400 mg and Ethambutol 275 mg per tablet) is not yet available in all services.
Medical Bennen Spirita views Christian, one of the few interned in the "casinos" to cope with treatment. / Photo: Fernando de la Orden
The ideal treatment should be controlled: the patient goes to a health center every day to withdraw the medicine, says the specialist of Vacarezza and del Muñiz. "The strategy is that our country is performing the most, in 30% of cases, the rest is administered alone, the drug is given for one week or every 15 days, so there is a periodic visit to the treating physician. "Admission is limited to serious, social cases (those who have difficulties with outpatient treatment) and for short periods.
Adherence is a key determinant of the success of treatment. "In a patient who is addicted or lives in inhumane conditions, he is shifted, adherence is not expected to be good. They have so many problems that tuberculosis is a problem and not the most important– He says.
For the social worker "the health system should place emphasis on creating greater accessibilityand not just focus on adherence as an individual problem. Services that visit in limited hours, guards in which the disease is not detected in time, become obstacles. And if the causes that give rise to it are not resolved, it can not be solved by individual wills.
Santiago Jimenez, an infectious disease physician at Casa Massantonio, illustrates the problem and the need for a comprehensive approach: "The next day we treated a boy who did not want to go to the hospital because he had no shoes. he does not realize that there is a connection between the shoes and go to the studyThere are people who do not even have access to the basics, and this major effect has a real impact on their health.
The story of Christian
"I have this more or less than 2015. I started with the medication and cut it off. While the small kidney of the tuberculosis did not become very stable.
Seated in a plastic chair on the cement floor, Christian Molina, 26, sunbathing in the yard of the house (the so-called Casa Masantonio) who arrived three weeks ago from Muñiz where I was interned Closing my eyes to protect myself from the rays , which drain clothes hanging over a few meters, she says she realized something was wrong because He was very depressed, unable to get out of bed, and when he did, he would tremble"I went to the hospital in Lujan and they told me" tuberculosis ". Then my father, my mother and two brothers had it, "he says, adding that almost all of his family members, who usually visit him on Thursday, have already completed treatment.
Christian began treatment several times. Now he's trying to finish it at Casa Massantonio. / Photo: Fernando de la Orden
Patri (one of the coordinators) would see me in the hospital and talk to me about the house. Here as I feel better. It helps me finish the treatment. I took, smoked and cut off the medicine. Now I'm doing the right thing. I try to behave, to follow the treatment to heal– He says.
It has offices and hospitals for the most complex cases, but it is not the typical hospital smell it feels as soon as it enters the house (or the hospital as they know it). Ароматът на салсата идва от кухнята, която приветства заедно с привързаните поздрави, които се размножават при преминаване на вратата. И докато напредва, "Искаш ли другар?", "Нещо за пиене?", "Яде ли?", "Хайде, седни!", отбележете разликите, които правят това място Степента на адхезия по-голяма от 90% при лечението на туберкулоза на потребителите на пако, че може да се направи пряко наблюдаваното лечение и медицинските контроли, необходими за лечението. От споразумение, получава подкрепа от Националния здравен секретариат и работата му беше подчертана от Панамериканската здравна организация.
Casa Masantonio е част от мрежа, родена през 2008 г. от импулс на Bergoglio. / Снимка: Фернандо де ла Орден
Той принадлежи към "Familia Grande del Hogar de Cristo", мрежа от центрове за приобщаване, координирана от група свещеници, настанени в селища. Инициативата стартира през 2008 г. от тогавашния кардинал Хорхе Бергольо, пет години преди да бъде избран за папа.
Патриша Фигероа (Патри) казва, че първоначално те са били главоболие за болницата, защото ги отвеждат на сложни пациенти, докато не разберат, че всъщност са съюзници и сега работят в мрежа, в кръг, който стана добродетелен , "Много сложните пациенти в болницата, които имат много отпаднали (има деца с 12/15 отпаднали), които са хронични пациенти, приети от Масантонио, завършват лечението".
Мирта Баес, медицинска сестра и стълб на "малката къща". / Снимка: Фернандо де ла Орден
Masantonio започва работа през 2016 г. като специален център за грижи за пациенти със сложни заболявания като ТБ и ХИВ и техните семейства.
Какво ги отличава от официалната здравна система? Интегралният подход и "аморозида", които му поставят, потвърждава Мариано "Нано" Ретамозо. "Функцията на работа е да ги придружаваме в мелето на децата, тя е с прегръдка, с храна, с контакта и битието, сякаш сме семейство. В крайна сметка сме семейство. Болницата не може да работи от страна Постоянно и при лечение, което продължава шест, девет месеца, е много сложно да се работи с деца, които не ходят на болница всеки ден, защото един ден те могат да бъдат консумирани, може да са депресирани, затворници ”, казва той. Не само медицинската част се обслужва, но също така им помага да получат жилищни решения, да обработват документацията, наред с други въпроси.
Мариано Ретамосо, координатор на Casa Masantonio.
Снимка: Фернандо де ла Орден
Ролята на спътниците е ключова. Те търсят хора на лечение, знаят къде се намират, как да говорят с тях, намират правилните думи, за да ги насърчат, когато всичко изглежда загубено.
Седейки за масата за хранене, Мирта Баес се смее, заобиколена от няколко помощници? ¿Partners? ¿Другари? Както и да е, хора. В къщата няма йерархии. Няма гащеризон. Мирта е медицинска сестра и живее там. Докато някой го пита къде може да получи одеяло и друго, където да напусне пилетата, той осъзнава, че винаги е знаел, че иска да работи с трудни деца, с онези хора, които избягват очите им. Нейната задача превишава медицинската помощ, тя казва, че действа като майка, като готвач. Той е там за каквото е необходимо. С усмивка