Lack of Political Commitment Impedes Efforts to Control Tuberculosis in Brazil

SAO PAULO, Brazil—Brazil's failure to control tuberculosis is shameful, especially given the country's fine universal health care system and its proud record of success in the fight against AIDS. Brazil ranks among the top twenty countries in the world in cases of TB—a disease too many Brazilians assume was eradicated decades ago. Today in Sao Paulo, health policymakers are gathering at the Brazilian National Conference on Tuberculosis. They will hear a prominent TB and AIDS activist, Ezio Távora dos Santos Filho, a man who has lived with HIV for more than 20 years and has survived TB twice, present a new report that analyzes Brazil's failed approach to TB and insists that Brazil can and must do better.

Published by the Open Society Institute's Public Health Watch project, Santos-Filho's report, TB Policy in Brazil: A Civil Society Perspective, takes note of a number of indications that the Brazilian federal government has taken steps toward correcting the current situation. The National Tuberculosis Control Program, for example, adopted clear policy guidelines and targets in 2004, which provide much-needed leadership and technical assistance to state and municipal TB authorities. The government has also fostered the creation of the Brazilian Partnership to Fight TB.

The Santos-Filho report, however, insists that much more needs to be done. The report draws upon extensive field research and interviews with a wide range of patients, health care workers, and policymakers and highlights a range of continuing challenges. First, Santos-Filho insists that access to high-quality TB services is not guaranteed in practice. “At present, only an individual with good connections and access to top-quality medical assistance, including rapid TB diagnostic tests, can survive a complex TB/HIV co-infection in Brazil,” he writes, adding that many persons affected by TB are from Brazil’s poorest and most marginalized communities.

The report notes that public awareness of TB's symptoms and its treatment options is shockingly low, even among people living with HIV and other groups at high risk of infection. Stigmatization and self-stigmatization of TB patients are serious issues. Santos says, “People find it very strange when I speak openly about having TB—they would feel ashamed of having the disease. I have known well-educated, professional people who have died rather than seek treatment.” The absence of strongly articulated public demands for better TB services is striking, especially given Brazil's high level of social mobilization on AIDS.

With no strong public outcry, the Brazilian government has so far not backed up its rhetorical commitment to TB control with sufficient allocations of funding from federal, state, or municipal budgets. The consequences have been disastrous. Compensation for health workers is so low that many of them must work two or even three jobs to make ends meet. Recruiting and retaining talented medical professionals for TB work is difficult. Lack of staffing makes it difficult for TB control units to meet the demand for laboratory and diagnostic services; as a result, many TB patients die without ever being diagnosed. The Rio de Janeiro State TB Control Program estimates that 20 percent of all TB victims are not diagnosed at an early stage, which enables the disease to spread. According to Margareth Dalcomo, Coordinator of the Outpatient Clinic at the National TB Reference Center Prof. Helio Fraga, “patients arrive at the emergency room, dying of TB without ever having accessed diagnostic services.”

Lacking sufficient funding and staff, state and municipal TB programs are struggling to ensure the level of patient supervision required by national policy. Federal agencies seem to be unable to supervise the quality of TB control services at the state and municipal levels. Most states and municipalities do not provide the incentives that many patients from disadvantaged backgrounds need to adhere to the demands of TB treatment, like bus tickets and food coupons.

Drawing upon his long experience in Brazil’s highly effective AIDS movement, Ezio Távora dos Santos Filho insists that social mobilization is the only way to turn the tide of the TB epidemic. “From a civil society standpoint," Santos says, "the Brazilian government has simply not been held accountable for effective implementation of its stated TB policy, due in part to the absence of mechanisms to allow for public scrutiny of government efforts in this area, including by the people and communities most directly affected by TB.”

The report combines its critiques with a number of constructive policy recommendations for the Brazilian government, including the following:

• Ensure opportunities and mechanisms for the people and communities affected by TB to engage substantively in TB policy development and implementation.
• Empower and support community leadership by providing community groups appropriate technical support and training.
• Redouble efforts to raise public awareness about the magnitude of the TB problem in Brazil and to publicize the availability of TB services.

Science magazine quotes Brazilian Public Health Watch TB researcher Ezio Tavora dos Santos Filho, noting the report he authored on TB and TB/HIV policy in Brazil. See www.sciencemag.org/cgi/content/full/313/5786/486.

Tavora is also quoted in a related Science piece, “Brazil: Ten Years After”: www.sciencemag.org/cgi/content/full/sci;313/5786/484b.

A Portuguese-language version of this press release is available for download.