The covid-19 pandemic is one of the greatest challenges experienced in the current context of globalization, taking many countries and their health systems by surprise. As fast as the means of transport that brought the disease to every continent on the planet, the disease has sparked a race to restructure healthcare systems.
We sought to build sanitary barriers that aimed to stop the circulation of the virus, as well as reallocating resources, health professionals and increasing the number of hospital beds for the sick. The pandemic affected not only the health sector, but went far beyond, causing crises wherever it went.
The high transmissibility of the virus, the inexistence of early treatment and the lack of vaccine at the beginning of the pandemic forced the health authorities to take isolation and social distance as a primordial measure for the control of the pandemic. The latter is a dilemma until today, it has become a national and international political dispute, with the economy and its consequences as the central debate.
The current covid-19 pandemic has also reinforced many differences existing in our country, one of the most striking ones was the deepening of socioeconomic inequalities. Data from the National Household Sample Survey (PNAD/IBGE) show that during the pandemic the poorest 40% of the population had their family income from work reduced by 30%.
The decrease in the income of Brazilian families has forced many people to submit to unhealthy working conditions and relationships, including working in the informal market, as street vendors, drivers and application delivery people, as an alternative to survive.
These forms of work do not provide many guarantees, such as unemployment insurance, 13th salary, vacations and a decent workload, and end up negatively affecting people’s health.
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In addition to the loss of part of the income, there was a significant increase in unemployment in society in general. According to the Brazilian Institute of Geography and Statistics (IBGE), 14.8 million people continue to look for a job throughout Brazil – the highest record since 2012. The social vulnerability that already existed was aggravated by the pandemic and the political crisis that Brazil is facing worsening housing and living conditions, especially for the poorest.
The sharing of houses between acquaintances and family members in an attempt to share residential costs such as rent, food and other expenses has become more frequent.
Community densifications (very close houses, alleys and alleys), which hinder the circulation of air, the entry of sunlight, and precarious water, sewage and garbage services also impact the living conditions of its residents.
The decrease in family income, in turn, makes adequate food increasingly scarce as unemployment and the informal labor market gain space. This scenario favors the manifestation not only of chronic diseases, such as hypertension and diabetes, but also of biopsychosocial diseases such as depression and anxiety, in addition to drug use.
This entire scenario, existing in thousands of communities and slums, hinders the population’s access to healthcare and favors the occurrence of other diseases, such as tuberculosis. In addition to the development of covid-19 being a risk factor for tuberculosis and vice versa, patients with tuberculosis and covid-19 are 25% less likely to recover from covid (SY, HAW and UY, 2020). In addition, patients with pulmonary sequelae caused by covid-19 may be at increased risk of developing tuberculosis in the future.
Tuberculosis is an infectious contagious disease caused by a microorganism called Mycobacterium Tuberculosis, better known as Bacillus of Koch (BK), and has man as its main host. A person with the bacillus infects an average of ten to 15 people in a year, this in a context without a pandemic.
The disease, in most cases, is transmitted by air through the inhalation of droplets that have the bacilli expelled by the infected person in the airways (pulmonary or laryngeal) when talking, sneezing or even coughing. In practice, not all infected people become sick, as it is necessary for the individual to have their immunity weakened.
Therefore, individuals affected by the human immunodeficiency virus (HIV), who have unhealthy habits such as using drugs or who have other immunosuppressive diseases such as diabetes, silicosis and malnutrition are more likely to develop tuberculosis.
Tuberculosis is a disease commonly associated with social factors, as those most vulnerable to illness generally live in unhealthy housing and in poverty, which negatively reflect on the body’s autoimmune capacity.
The disease was once known as “the plague of the poor” and has had an impact in the country since colonial times, when the European brought the bacillus to the territory that today comprises Brazil and, by having contact with native populations, decimated thousands of lives. However, it gained prominence in public health when it was identified, in the late nineteenth and early twentieth centuries, as the main cause of death in the city of Rio de Janeiro.
Currently, it is a disease that, by law, it is mandatory to report cases to public health authorities throughout Brazil, that is, mandatory notification. The detection of cases of pulmonary tuberculosis is the main step in controlling the disease, since the faster it is diagnosed and treated, the easier it will be to break the transmission cycle of the bacillus.
during the pandemic
In the year 2020, with the pandemic taking place all over the world, it became extremely difficult to fight tuberculosis. Health systems turned their efforts to face the new coronavirus pandemic and other diseases were discovered.
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There was also a precariousness of health services, including in the aspect of family health, with delays in salaries for health professionals, high turnover of these and work overload for those who remained, which affected the assistance and care of other related activities to primary care.
All this situation had an impact on the fight against Tuberculosis, which had been conducted mainly by Primary Care and had as its main strategy the Directly Observed Treatment (DOT), popularly known by Community Health Agents as DOTS (acronym in English for Directly Observed Treatment Short Course).
DOT encourages the creation of a bond of humanized action between health professionals and patients, where observation of the patient’s medication intake is inserted in this treatment, under the supervision of a health professional at previously agreed upon locations and times.
Basic health units had to adapt to the new context, the professionals who work there have actively participated in the vaccination campaign to fight covid-19 and had to adapt their work processes due to social isolation; as a partial solution, many professionals started to use digital technologies to keep up with their users, many became ill and the teams were left out.
Notifications of new cases of tuberculosis also continued to occur, including concomitant infections of covid-19 and tuberculosis, being much more lethal. However, the decrease in tuberculosis notification in many states compared to previous years was remarkable. Experts believe that the reduced demand for diagnosis and treatment will influence future rates of incidence and mortality, because even there is similarity between the symptoms of both diseases.
According to the National System of Notifiable Diseases/TABNET Rio de Janeiro, Cashew is one of the five neighborhoods most affected by tuberculosis in the city of Rio de Janeiro, and according to the 2010 Census, it is also one of the most slum in the city – where 4 each 5 residents live in communities. Tuberculosis in Cashew remained with the average number of notifications in the last 10 years.
While the average cure in the last ten years was 72.4%, in 2020, the outcome as cure represented only 47.3% of cases, according to data from the city of Rio de Janeiro.
These numbers help to understand part of the context that the neighborhood and the health professionals who work there experience, but underreporting should be considered (since the professionals are carrying out other activities related to the fight against the pandemic that, at the moment, are understood as priority).
Thus, the debate about tuberculosis and covid-19 is much deeper and undoubtedly goes beyond the health sector. Confronting tuberculosis requires the adoption of measures such as awareness campaigns among the population about it, but it must go further and incorporate actions that reduce socioeconomic inequalities and an effective housing and urbanization policy capable of providing decent living conditions for all.
*The article was originally published in the 13th edition of Radar Covid-19 Favela, produced by the Oswaldo Cruz Foundation (Fiocruz).
**Reinaldo Dantas Lopes, professor of geography at the Center for Studies and Solidarity Actions of Maré (Ceasm) and PVCSA, geographer at the Information and Registration Laboratory of the Joaquim Venâncio Polytechnic School of Health (EPSJV/Fiocruz), master’s degree in the program in Epidemiology in Public Health of the Sérgio Arouca National School of Public Health (ENSP/Fiocruz).
**Felippe de Oliveira Cezário – Coordinator of the Health Surveillance Service of Rocinha, taking a master’s degree in epidemiology and public health from ENSP/Fiocruz.
Source: BoF Rio de Janeiro
Edition: Mariana Pitasse