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Canada (158,426)
Geography (140)
GGRB28H3 (32)
Chapter 8

Chapter 8

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University of Toronto Scarborough
Mark Hunter

Optimism and Pessimism in Tuberculosis ControlChapter 8 Lessons from Rural Health y We know most things about it but TB still kills more people than any other pathogen far more than alcoholism AIDS malaria tropical diseases and Ebola combined and nobody seems to care Lee Reichman 1997 y Murray and Lopez show that tuberculosis alone among infectious pathologies will hold its unenviable place for the next thirty years with the exception of HIV disease all other infectious diseases are projected to drop in rank over the coming three decades y According to a baseline projection tuberculosis will be the fourth leading cause of death overall in developing countries by the year 2020 y Because effective therapy for tuberculosis has existed for decades it is necessary to explainand sometimes to explain awayour failure to treat it Such explanations are contested terrain and the literature contains striking divergences of opinion Although patient noncompliance generally heads the list of favored explanations the vast majority of tuberculosis deaths are registered in settings of great poverty with abysmal tuberculosis services In such venues noncompliance is often outweighed by massive numbers of dropouts from treatment the results in no small part of prohibitively high treatment costs Visitors to programs in such settings also report substandard care a failure to keep accurate records a neartotal lack of followup and high mortality One review noted that the proportion of patients with active disease who complete therapy under standard conditions ranges from as little as 2040 percent in developing countries And these are the patients who are brought to medical attention in 1991 the WHO estimated that only about half of all tuberculosis cases are ever diagnosed as such In short too few tuberculosis patients have access to care and those who do often do not receive appropriate care y Haiti the nation in the Western hemisphere most affected by tuberculosis offers a good deal of support for the more pessimistic assessment How Tuberculosis Risks are Structured Over Time y The experience of tuberculosis in rural Haiti is one strongly condition by historical contingencies and material constraintsy The slaves brought from Africa to Haiti carried with them the remnants of their cultural systems yellow fever yaws and malaria y Moreau de SaintMry noted in the late eighteenth century that the rainy season was particularly hard on the colonys poitrinaires a term still commonly used in reference to tuberculosis in rural Haiti y A later observer estimated that les tubercules were after dysentery the most common chronic illness y The major causes of childhood deaths are diarrhea pneumonia and tetanus tuberculosis is the leading cause of death among adults y In sanatoriums in urban Haiti during the mid1980s some 45 percent of all tuberculosis patients reportedly were coinfected with HIV In a more recent
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