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Memórias do Instituto Oswaldo Cruz
Fundação Oswaldo Cruz, Fiocruz
ISSN: 1678-8060 EISSN: 1678-8060
Vol. 102, Num. s1, 2007, pp. 109-112
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Memórias
do
Instituto
Oswaldo
Cruz,
Vol.
102,
No.
Suppl.
I,
2007,
pp.
109-112
The
social
determinants
of
Chagas
disease
and
the
transformations
of
Latin
America
Roberto
Briceño-León/+, Jorge Méndez Galván*
Laboratorio de Ciencias Sociales, Av. Codazzi, Quinta Lacso, Santa Monica, Caracas 1040, Venezuela *Secretaría
de
Salud,
Mexico
D.F.
+
Corresponding
author:
bricenoleon@cantv.net
Received
4
July
2007
Accepted
3
September
2007
Code
Number:
oc07141
"It has been said that Chagas disease is a forgotten disease", stated Dr JC Pinto Dias in the initial conference of the seminar. "But, what really exists", he added, "is a forgotten population". It is not the disease that was neglected, but rather the people who suffer it or who are at risk of contracting it who have been abandoned by governments and health policies. These words marked the tone of the discussion on the current situation of Chagas disease, because the social determinants of the disease were discussed throughout the entire workshop, since it was not possible to encompass them in one or another topic, because when each one of the speakers or participants referred to the vectors, houses, blood transfusions, programs of control, at the same time people, poverty, migrations, companies, changes in government appeared. And it has to be so, because the process of transmission of Chagas disease, as well as its prevention, control or treatment, are social and political processes that occur or change with the fluctuations of the contemporary history of Latin America.
THE
RURAL AND URBAN FACES OF THE DISEASE
For
many decades Chagas disease was a strictly rural illness, existing
only in specific zones of the countryside marked by poverty and
exclusion. The disease was symbolized by the peasant family and
the rural hut full of triatomines. Nevertheless, changes in the
rural areas, migrations to the cities, increase of poverty in the
urban areas, has transformed the disease into an equally urban phenomenon.
The symbol is no longer the rural hut, but blood banks, immigrants,
and patients in hospitals seeking help and attention. When at the
beginning of the past century Carlos Chagas (1909) described the
disease, 90% of the population of Latin America lived in rural areas
and the disease was there; at this time, at the beginning of the
XXI century, in all countries there are more people in the cities
than in the countryside and altogether more than 70% of the population
is urban (Celade 2004), therefore it is to be expected that the
disease has moved there.
The
rural population in Latin America has decreased in relative terms,
but has remained stable in absolute numbers, what has occurred is
a notable increase of the urban population and also an increase
of the poverty of the cities. In 1980, according to the calculation
of the Economic Commission for Latin America and the Caribbean (Cepal
2004), "moderate" poverty, that is, those who could meet
their needs for food but not much more, was represented by a total
of 73 million people in the rural areas and 136 million in the urban
areas. Two decades later, that is in 2002, the number of people
who lived in moderate poverty in rural areas had hardly increased
by 1.8 million, to approximate 75 million, while in the urban area
it had increased by 85 million new urban poor to reach 221 million.
The
situation with extreme poverty was different at the beginning, but
later the same change is produced and in an accentuated manner.
"Extreme" poverty refers to family groups that do not
even manage to meet their food needs and in 1980 it was made up
of 40 million people in rural areas and 22.5 million in urban areas,
that is, there were more people in that situation in rural areas
than in urban areas. But, 22 years later, the number of people in
extreme poverty in the countryside had increased by only 6 million
and in the cities by 29 million, so that the number of people in
extreme poverty in the cities reached 51.6 million, exceeding in
the new century those that exist in the countryside: 45.8 million
(Cepal 2004).
These
data reflect the changes and the faces of Chagas disease, because
the poor of the countryside continue having the conditions in their
houses and environment for the vectorial transmission of the disease,
while the urban poor represent the increasing face of the disease,
because in some cases they transport the vectors to their new residencies,
but many carry with them the infection to the cities that are not
totally prepared for their attention and care.
SPRAYING
PROGRAMS AND RURAL HOUSES
The
seminar recognized the noteworthy effort that is being made in the
region for the vectorial control of the disease through different
regional initiatives, such as that of the Southern Cone, Central
America and Mexico, Andean region, and recently the Amazon forest.
While at the beginning they involved an effort of multinational
coordination to reduce costs in purchases, especially of insecticides,
they were later transformed into a true agreement for scientific,
technical, and administrative cooperation.
The
oldest and most successful experience is that of the Southern Cone
which has achieved important advances in the eradication of Triatoma
infestans through spraying of houses. Nevertheless, the success
attained shows a new situation of risk from the presence of secondary
species and the existence of residual foci in the peridomicile.
The
continuity of programs of control requires political agreements,
but the sustainability implies a permanent oversight and the transformation
of the material conditions of the house and the peridomicile to
make the colonization or reinfestation of the houses by the vector
insect of the disease difficult. The challenge of a healthy and
decent house for the population covers much more than the interruption
of the transmission of Chagas disease, it implies and favors other
aspects of health and even more of the social welfare of families.
For that reason, the actions involving improvement or modification
of housing are very relevant when policies change their focus of
attention from the disease to the health of the population.
In Latin
America there have been diverse programs for improvement of the
house in different countries such as Argentina, Bolivia, Paraguay,
Honduras, Venezuela, El Salvador. Some of these programs have had
a direct orientation toward Chagas disease, in other cases this
has not occurred; in some community participation has been stimulated
or required, in others not, but altogether they have proven to be
of great importance in the sustainability of the control of the
disease. Two very distinct examples of interventions in housing
and their effect on the vectors of Chagas disease are represented
by Venezuela and El Salvador. In both countries R. prolixus has been an important vector in the transmission of the disease,
but in Venezuela it is autochthonous while in El Salvador it was
introduced (Zeledón 2004). In Venezuela, for several decades,
a rural housing program was carried out that permitted building
more than 400,000 houses, it was a program of the central government,
in which a part of the petroleum income that entered the country
was invested. At the beginning of the program in the 1950s, a complete
community participation was promoted, later in the 1960s the role
of the family in the building of the house was reduced until participation
fully disappeared at the beginning of the 1970s when the price of
petroleum and government income tripled (Briceño-León
1990). The situation in El Salvador has been different, because
it is a small and poor country that experienced a painful internal
war producing a strong migratory wave to the United States, Canada,
and Australia. In El Salvador there were two types of vectors, Rhodnius
prolixus and T. dimidiata, that colonized peasant houses
made of mud walls and roofs of plant material, but at this time,
Dr C Ponce reported in the seminar that R. prolixus does
not exist any more, because the houses where they lived were transformed
by the population itself and they no longer have conditions for
their colonization (Proyecto SSA-EC 2005). The situation of El Salvador
is very interesting, because starting from the peace agreements,
a process of agrarian reform was initiated that allowed giving ownership
of the land to the peasants and at the same time emigrants began
to send important amounts of money that today are the principal
source of foreign exchange of the country and that families invested
in the improvement and construction of houses of good quality. In
this manner families on their own, without direct intervention of
the government, managed to eliminate one of the vectors of the disease.
The paths can be dissimilar, but the improvement of the house continues
to be a fundamental challenge in the sustainability of the control
of the disease.
STIGMA
AND CULTURE OF THE DISEASE
Chagas
disease has a dual situation in the culture of societies, on one
hand it can be ignored, it is a nonexistent disease because the
political or sanitary authorities ignore or neglect it, because
it occurs among distant populations and without immediate lethal
or political consequences because it is a chronic disease. On the
other hand, in many places the diagnosis is not reported to patients,
and as was pointed out in the seminar, it is paradoxical that even
though it bears the classification of disease in its name, people
do not consider it as such because they do not see people becoming
sick or dying from it.
But
together with that situation of ignorance and silence, there is
another equally dramatic one that is given by the stigma from suffering
the disease. The stigma may have social consequences, because it
can lead to a social rejection on evoking a poor and rural past,
or it can mean a labor restriction, because it is supposed that
it will lead to some type of limitation or difficulty at the time
of performing a job or financial consequences for the employing
firm. In a paradoxical manner, some measures such as National Law
of Argentina No. 22360 of December 23, 1980, that obligates presenting
a serology of Chagas to "the candidates for permanent or transitory
jobs", have created an undesired effect, because although it
is assumed that it is designed to protect the Chagas patient, in
practice it has become a discriminatory mechanism since employers
reject the seropositive and the patient is obligated to accept another
type of employment with a precarious type of labor contract because
it is the only one that is available to him.
The
symbolic representations of the vector and of the disease are very
varied and change from one area to the other, in the same manner
that the multiplicity of names with which they designate them in
some cases can symbolize good luck, while in others it is death.
What would seem to be a general rule is that there is no culture
or systematic protection that allows combating the vectors and avoiding
the disease (Briceño-León 1998). This same situation
described above, simultaneously of silence and stigma, has not contributed
to the creation of the cultural mechanisms of protection of the
population.
GLOBALIZATION
AND CHAGAS DISEASE
Changes
in the form or production, commerce and finance in the world are
affecting the presence of Chagas disease, and this can be clearly
seen in two processes that occur in completely different spaces,
on one hand the presence of Chagas disease in the United States
and Europe from the increasing arrival of Latin American immigrants,
and on the other, from the novel and increasing presence of Chagas
disease in the Amazon jungle.
Communications
have been facilitated and increased in a surprising manner in the
globalized world and that has made local problems expand to global
spaces and to global forces intervening in local decisions. Dr R
Zeledón reported how a cactus flower that appears in semi-desert
areas of Central America has had great success among flower lovers
and this has led them to be sold throughout the region, but even
their export to North America, with the particularity that in the
bromelia there are specimens of R. rickmani what are transported
together with the flower to distant destinations with the probability
of the dispersion of triatomines. And in origin this is what is
happening with the occupation of the Amazon jungle and with Latin
migrants who donate blood in the US, global forces that have repercussions
in the dispersion of the disease.
In the
Amazon jungle in spite of finding a large quantity of vectors and
of animals that are reservoirs of the parasite, it was only recently
that autochthonous cases were found and a notable increase of them
can be anticipated through the process of human migration and deforestation
that occurs in the region (Coura et al. 2002, Junquera et al. 2005).
But it is necessary to understand these processes in the changes
of the patterns of territorial occupation of the Amazon jungle and
the forces involved there. In the 1950s and 1960s, plans for use
of the Amazon jungle were in the policies that were called growth
toward the interior, that is, development of the society occupying
the internal frontiers in order to guarantee an economic activity
that could meet the demands of the internal market and strengthen
the process of national industrialization. Nevertheless, what is
observed starting from the 1980s, when there is the great occupation
of the Amazon jungle in Brazil or in Ecuador, is a different process,
because it is oriented to the external market (cattle for export,
soybean for the Asian market, wood and petroleum for the world market),
a process leading to some important changes such as deforestation,
eliminating the sources of wild nourishment of the vectors; a process
of occupation of new territories; the increased sedentary nature
of the population; the diffusion of a new type of house and the
incorporation of the presence of domestic animals in the home (Coimbra
& Santos 1994, Coimbra et al. 2004), all of which produces an
attractive habitat that can be visited and colonized by the vectors
of the disease.
A distinct
force acts in the case of the migrations, now not involving the
disease occupying new spaces of Latin America itself, as occurs
in the Amazon jungle, but rather moving to non-endemic areas and
without the vectorial presence from the movement of people, whether
for reasons of expulsion poverty, violence from their own countries,
the attraction of a better life in other countries, they move to
distant lands. In the United States it is calculated that there
are 40 million hispanics, 16 million of them born abroad, the great
majority Mexicans, some 10.6 million, and then there are 2.1 million
Central Americans and 1.4 million natives of South America (Census
Bureau 2004). In Spain at the end of 2005 there were close to two
million foreigners with residence permits, almost half of them from
Hispanic America: 826,000 persons. Of them, 348,000 are Ecuadorians,
172,000 Colombians, 73,000 Peruvians, 50,000 Argentines, 49,000
Bolivians, 17,000 Brazilians (Ministerio del Trabajo y Asuntos Sociales
2006). A good part of those immigrants comes from areas where Chagas
disease is endemic and they may be seropositive, the new reality
of the disease shows a population that can become a blood donor
in areas where screening for the disease is not performed, they
can bear children with the infection and they can seek health attention
at the time that the disease develops, without finding an adequate
response from the health system. This in some way already occurs
with internal migrations in many cities of Latin America, although
the response of medical attention is very slight and with little
information and knowledge about the disease, at least there is the
obligation in all countries to carry out blood screening (Schmuniz
2005). But the situation in countries receiving immigrants from
the endemic zones of Latin America is very different and is going
to require important responses from the health systems of those
countries in forthcoming years.
CHANGING
HEALTH POLICIES
The
seminar discussed two aspects that have affected programs of control:
on one side, the instability of programs in the provision of resources
and execution, due to the presence of other new infectious diseases.
And on the other, processes of decentralization of health programs
that have taken place in the continent.
The
programs of control of Chagas disease have been from the beginning
to be subject to the successes and urgencies of other diseases,
in particular of what has occurred over time with malaria and dengue
fever. In Venezuela the launch of the Chagas program at the end
of the 1950s was a consequence of the notable success that had been
attained in the campaign against malaria. The campaign had been
initiated at the end of the Second World War and a decade later
the government of Venezuela had managed to declare the eradication
of malaria in a vast territory, but it maintained personnel and
human resources that it could not waste, the program for the control
of Chagas disease was founded, and those resources fed it for several
years until new outbreaks of malaria appear first at the beginning
of the 1980s, and then of hemorrhagic dengue fever at the beginning
of the 1990s. Starting from this, the Chagas program lost resources
and relevancy until it almost disappeared, but not because the epidemiological
situation had notably improved, but because competition from other
diseases detracted from its importance (Añez et al. 2004).
Something similar, although in different magnitudes, occurred in
several countries and still marks the current instability.
Another
aspect that was broadly discussed corresponds to the decentralization
process that accompanies the processes of state reform in Latin
America after the 1980s. Endemic disease control programs, traditionally
vertical and centralized, were dismantled or transferred to the
regional or local authorities without the corresponding preparation
or transfer of resources and training. In some cases, such as Colombia,
the Chagas program that had been created at the end of the 1990s
disappeared with decentralization; in other cases, local authorities
that did not grant it importance or did not know how to carry them
out assumed it (Guhl et al. 2005) The policy of decentralization,
while it is an adequate response to bring the actions of government
closer to the people and communities, has had very contradictory
effects, because it has not achieved a true participation of people
or communities. Decentralization and participation must go together
in a decentralized and horizontal program, and this is important
above all at the time when there has been a significant reduction
of the number of domiciliary vectors, but where the disease still
persists, because traditional programs lose their effectiveness
where there are a small number of vectors, since it is required
that specific measures be applied that demand the participation
of families and local authorities for their sustainability.
In addition,
the importance of the participation of Chagas patients and the relevance
of organizations constituted by them was emphasized as a manner
to combat the stigma and fatalism that in the absence of cure attack
many of the seropositive patients.
Moreover,
an innovative approximation is required in the environmental management
for the control of the disease, with transformations in the habitat:
the house and the peridomicile and the ecological environment. The
experiences of Mexico in malaria and dengue programs and of Central
America with Chagas disease itself were discussed with interest,
because they reflect a process of social and environmental transformation
that is slow and complex, but with more lasting effects because
they imply the participation of communities at risk.
CONCLUSION
Chagas
disease is a profoundly social disease, therefore changes in the
society, positive or negative, are reflected in the situation of
the disease and in programs of control. The scientific community
has greatly advanced in the comprehension of the disease, its prevention
and treatment, but a process of continuous adaptation to new realities
in the countryside and the city and to the process of internationalization
of the illness is required. This need for continuous adaptation
involves both research centers and programs of control, because
the problem has become more complex given that the need for vectorial
programs in rural areas persists, but new epidemiological situations
derived from the globalization process and the need for attention
to patients in zones where the disease is unknown have been created.
The response that at the beginning of the XXI century must be given
to Chagas disease as a neglected disease cannot be exclusively entomological
or medical (Ehrengerg & Ault 2005, Briceño-León
2005) it must be given in a broader social and sanitary context
that involves distinct levels of the government and of the civil
society, it must be a holistic approach that is oriented not to
avoiding the disease but to promoting the health of the population
as a means to achieve development.
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Copyright
2007
Instituto
Oswaldo
Cruz
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Fiocruz
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