Tuberculosis (TB) is the leading cause of death among rural Haitian adults, and TB control in Haiti is widely acknowledged to be a failure. The causes of both the endemicity of TB and the failure of attempts to address it are briefly reviewed before data from a study conducted in rural, central Haiti are presented. Members of one group of patients with active TB were given free medical care; members of a second group were given free care as well as financial aid, incentives to attend a monthly clinic, and aggressive home follow-up by trained village health workers. Comparing the two groups shows significant differences in mortality, sputum positivity after 6 months of treatment, persistent pulmonary symptoms after 1 year of treatment, average amount of weight gained, ability to return to work, and cure rate. The roles of human immunodeficiency virus and cultural factors are also examined. When adequate nutrition and access to free care were assured, drug-dependent and patient-dependent factors were shown to be of secondary importance in determining treatment outcome. Based on these data from a small, community-based TB-control project, the authors conclude that high cure rates can be achieved if the primacy of economic causes of TB is acknowledged and addressed.
PIP: Between February 1989 and June 1990, village health workers with the Proje Veye Sante community health program in the central plateau of Haiti enrolled 30 adults with tuberculosis (TB) living around the reservoir in the Peligre basin (sector 1) and 30 TB patients living in villages and towns next to sector 1 (sector 2) to compare 2 TB treatment approaches. The cases (sector 1 patients) received free medical care, home visits, US$30/month for the 1st 3 months (financial aid), nutritional supplements, monthly reminders to visit the clinic, and travel expenses. The controls (sector 2 patients) received only free medical care. 1 case (3.3%) and 2 controls (6.7%) tested positive for HIV. By June 1991, all 30 cases were cured of TB compared with only 56.7% of controls. None of the cases died but 10% of controls died. None of the cases exhibited sputum positivity for acid fast bacilli 6 months after diagnosis yet 13.3% of controls did. 1 year after treatment only 2 cases (6.7%) still had pulmonary symptoms compared with 13 (43.3%) controls. Cases gained more weight on average than controls (10.4 lbs. vs. 1.7 lbs). All but 2 cases (93.3%) were able to return to work after 1 year of treatment while only 14 controls (46.7%) could. Cases made more trips to the clinic and experienced more home visits than the controls (11.4 vs. 5.8 and 37.9 vs. 1.1, respectively). 25 cases (83.3%) and 26 controls (86.7%) did not deny that sorcery may have been responsible for their illness. The results demonstrated that high cure rates can occur under extremely impoverished conditions where hospitals do not exist. The top priority under these conditions should be identification and treatment of patients with active pulmonary TB. TB programs should address nutrition and providing TB patients easy access to drugs. Direct financial aid provides an incentive for TB patients to follow through with treatment which the free treatment alone does not do.