San José, Costa Rica, since 1956

Cause of Tuberculosis Increase Unclear

JUDGING by the numbers, tuberculosis has run rampant in Costa Rica in the last decade. But the numbers themselves are under scrutiny by medical professionals.

The number of diagnosed tuberculosis patients has increased steadily from at least 261 in 1995 to at least 972 in 2001, a fact that has caused some finger pointing among professionals in the medical community.

Dr. John Marín, retired from the former Department of Pneumology and Tuberculosis Control of the Ministry of Health, blames the rising levels of tuberculosis on the change in management that marked his last year of service with that department.

In 1999, the Ministry of Health’s “Fight Against Tuberculosis” program and Marín’s department were discontinued with a restructuring of the socialized health-care system.

Tuberculosis diagnosis and treatment passed from the Ministry to the Social Security System (Caja), and consequently each hospital and clinic in the country began to manage its own program of treatment.

“NOW, there is no central authority that regulates and controls the treatment,” Marín recently told The Tico Times.

When Marín worked for the Health Ministry, doctors and nurses visited the homes of patients and ensured they followed their regimens of pills and shots, he said.

Now, patients are expected to visit the hospital for follow-up treatment – and many patients do not have the means or the will to do so, he added.

“The poor patients stay here for treatment. Those with money leave the country to avoid the stigma,” he said, of undergoing treatments for a potentially lethal and misunderstood disease.

He said he believes the rise in the number of cases is a result of the lack of organization and an inattention to the severity of an epidemic.

“In past years there was much more control and many fewer cases,” he said.

THE World Health Organization declared tuberculosis a global emergency in 1993, when cases began to rise in Europe and the United States.

Now, Marín said, it is ignored because people believe it has been largely eradicated.

But Jorge Obando, a social worker with the Ministry of Health, offers another explanation for the high numbers of tuberculosis patients.

His theory also begins with the restructuring of the health-care system in 1999, but he said the new system has allowed the Ministry to test more people and compile more accurate statistics.

The disease is under the most thorough control today than ever before, he said –which makes the numbers look higher because more people have access to testing and treatment.

While Marín criticized the Ministry for not allocating the resources to pay professionals to leave their desks and visit patients to make sure that they finish their treatments, Obando praised the new policy of issuing tuberculosis tests to every patient who enters a clinic with a cough.

Symptoms of the disease include a persistent cough, tiredness, thoracic pain and weight loss. In advanced stages, victims can cough blood.

“IT looks like there are more cases lately because we are looking for infected people,” he said, explaining there is a more active process of diagnosis than ever before.

Dr. Leonardo Mata, an epidemiologist with the Institute of Health Research at the University of Costa Rica, agreed with Marín that the new system is a result of a lack of funds and not a novel approach to health care.

“There is almost no research in the Ministry of Health now,” he said. “It’s full of bureaucrats.”

He, however, attributed the increase in tuberculosis patients in part to the burgeoning number of AIDS victims in Costa Rica. People with weakened immune systems are more likely to become sick with tuberculosis, he said.

Of the 861 tuberculosis patients in 2000, 42 of them also had AIDS, and of the 972 tuberculosis patients in 2001, 47 had AIDS, which, in both cases, is about 5% of tuberculosis patients.

ACCORDING to the Ministry, fewer people than ever are dying from tuberculosis, a result of the early diagnosis and treatment programs.

In the last four years, the state has vaccinated 90% of newborns, 92% since 2002.

Most forms of tuberculosis are curable, according to Marín. Medical treatment involves daily antibiotic injections and pills for two months, then pills taken daily for four more months. In some cases, a good diet and healthy lifestyle can overcome the disease, he said.

“It’s an opportunistic disease,” he said. “Healthy people can contract it and nothing will happen to them. I’ve worked around it for nearly 40 years… but it only affects people with weakened defense systems.”

The disease will flex its muscle in bodies that are malnourished, that suffer from emphysema (not just a smoker’s disease – it also shows up in the lungs of people who regularly cook over wood-fired stoves, for example, which is not uncommon in rural areas), and those who are weakened by other diseases, including AIDS.

One of the myths about tuberculosis Marín said he would hear when working with uninformed patients is that it can be contracted from cow milk, but he points out that tuberculosis bacilli is most often airborne, and never contracted through the digestive system.

OTHER diseases in Costa Rica, which, like tuberculosis, were commonly thought to have gone the way of the dinosaurs, are still around, although apparently on the wane.

Approximately 5,150 cases of malaria were reported in 1998 and only 1,400 cases in 2001. Leishmaniasis, a disease carried by the sand fly that affects rural populations near wooded areas in Costa Rica, dropped from 625 in 1995 to 425 in 2001.

In Costa Rica, according to the Ministry’s figures, there are no cases of leprosy – although Mata said that statement troubles him.

In 1999 and before there were from 11 to 20 cases reported annually, while from 2000 on there are none. Mata said he suspects a reporting problem, which indicates a dangerous lack of knowledge of who is infected, where they are, and who else is at risk, he said.


Number of diagnosed cases (rate per 100,000)

1995                1997 1             998                  1999                2000                2001

261 (7.8)          633 (18.0)        627 (16.6)        853 (17.5)        861 (24)           972 (24.15)


(Compiled by Dr. Leonardo Mata, INISA, University of Costa Rica, from annual records of the Ministry of Health)

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