Tuberculosis has been a pervasive, intractable public health problem in Latin America, and for decades, nowhere was the problem worse than in Peru. National programs and legislation had made little headway against the disease. In the 1980s, less than half of the people who even received treatments were being cured. When Partners in Health arrived in 1994, beating multi-drug-resistant strains of TB was costing $250,000 per case in the hospital-based system of the United States. In the slums and shanty towns swelling the desert hillsides outside Peru’s capital city of Lima, where 700,000 people lived in unheated shacks without basic services of electricity, sewage, and water, relief from the epidemic seemed hopeless. “Obviously,” says Dr. Jaime Bayona, a local physician who was brought on to direct the effort, “we had to do things differently.”
While others in the organization worked at the international level to reduce the high cost of drugs, Bayona and his team went into the settlements of Carabayllo, Comas, and Independencia and went about replicating a community-based approach that had worked surprisingly well in rural Haiti. Turning away from the standard physician- and hospital-driven model, the Partners in Health team turned, instead, to the nurses, social workers, and community members who interacted daily with the patients. They asked questions, became familiar with the culture, came to understand the circumstances and constraints of the families afflicted by the disease. They created extensive interview questionnaires, and developed a rich data set of behaviors and conditions that gave them insight about how best to get people to commit to a drug regimen and remain on it. Over time, they built 16 botiquines (small health posts) in the shantytowns to serve patients who would otherwise have no access to primary care. They trained local women to serve as health promoters, manage supplies, and coordinate appointments. They helped develop a social support network that included sharing and donations of food baskets, transportation, and lodging. The patients and their families felt empowered, and — for the first time in their lives — they took control of their own health.
The community-based approach has been a remarkable success. The cost-per-case has been driven below one-tenth of the cost in the U.S., and some 10,500 people have been successfully treated. The cure rates for multi-drug-resistant tuberculosis in the slums around Peru have reached 75 percent – higher than anywhere else on the planet.
“At some point,” recalls Jaime Bayona, “when you’re working in a place like Peru and struggling with so many difficult issues, and you start to understand how those problems can be solved, you realize that there are families suffering everywhere who might also be helped. Tuberculosis was the excuse for me to learn about the importance of systems. I came to TDC because I wanted to take what we learned in Peru and extend it. Not just to people suffering from Tuberculosis or HIV, but all kinds of health problems. And not just people in Peru, but all over the world.”