How Vulnerable Populations Tackle Tuberculosis in Colombia

Karen Rivas, 29, was born in Chocó, a department in northwest Colombia which was most affected by the armed conflict.

In 2009, after presenting symptoms which included weight loss, loss of appetite, fever and diarrhoea, Karen was diagnosed with bacilliferous pulmonary tuberculosis, a contagious and drug-resistant strain also known as Multi-Drug Resistant TB (MDR). As her home region did not have adequate medical infrastructures, she was forced to migrate to Medellin, one of Colombia’s largest cities.

Beginning in 2010, Karen started her battle against this particularly tough strain of TB. In addition to leaving her family, she had to confront a difficult economic situation. Being alone and sick in a strange city, without financial resources, at one point, she survived by eating leftover food. 

Although still very ill and desperate, Karen started helping other people in similar circumstances. She started supporting other sick people and became a leader in patient support for those with TB and HIV-related TB, not just in Medellin but throughout the country.

During all this time, she continued with her treatment until 2012 when, after many difficulties including the removal of part of her lungs, she was finally cured.  

In 2014, at the start of the second phase of the TB Project supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria, Karen became a Community Health Promoter for TB in Medellin working in the TB Directly Observed Treatment, Short-course (DOTS) control strategy led by IOM Colombia and the Colombian Anti-tuberculosis and Respiratory Disease League (LAC). 

In her role as health promoter, Karen accompanied people with these afflictions and their families in overcoming the difficulties created by the diseases, such as social stigma, discrimination and low self-esteem.

“From my personal experience, when I was diagnosed, I found myself filled with feelings of guilt and felt that I had done something bad to deserve this disease. It is more than just a physical illness, as it also affects your emotional state and makes you feel embarrassed as a person. That is why I want to help others who are in the situation I was in,” says Karen.

IOM Colombia has worked in the last few years with 40 community health promoters, like Karen, in different parts of the country to coordinate and improve relationships between patients, their communities, and national health services. Karen is one of the 13,000 people in the country diagnosed annually with TB and is one of the 62 per cent who have been successfully treated.

Because of the long 50-year internal conflict that affected Colombia, there are many vulnerable populations in the country: a high number of internally displaced people, alarming rates of recruitment of child soldiers in illegal armed groups, and ex-combatants starting their process of reintegration in society. These populations and other groups are frequently subjected to forced internal migration and uprooting which exposes them to the risk of contracting HIV, TB, and other diseases.

The IOM Mission in Colombia, through its Migration and Health Programme, focuses efforts on the priority issues such as the prevention and addressing of emerging diseases like TB and HIV, where demographic movements and internal migrations play a determinant role.

Between 2015 and 2016, and within the framework of the agreement between IOM and the Colombian Ministry of Health and Social Protection, IOM managed activities with officials from the Ministry’s General System for Social Security that focused on patients, especially those with both TB and HIV infections that were drug resistant and in conditions of vulnerability. Thus, IOM liaised with local authorities, health care providers and academics to promote the harmonization of coordinated actions that focused on TB/HIV in both annual planning and regular management.

Since 2012, IOM has been one of the main partners of the Global Fund to implement the project, “Strengthening STOP TB strategy in priority municipalities in Colombia”. The first phase was carried out in 46 municipalities along the Colombian Pacific Coast. Together with the efforts and commitments of community actors, results were achieved that had never yet been attained in this country. 

In this region, IOM contributed to the detection of BK+ (transmitter of TB) in cardiac patients found in 10 per cent and 14 per cent of new cases in 2012 and 2013 respectively. Additionally, IOM supported the implementation of a new strategy for supervising patients using a network of community agents, which is credited for the 20 per cent improvement in treatment success in 30 of Chocó’s 46 municipalities – from 68 per cent in 2011 to 88 per cent in 2012.

In its second phase (2014-2016), the project was expanded to eight priority cities in Colombia, registering nearly 60 per cent of the TB cases in areas where the incidence of TB/HIV co-infection was clear. Thanks to the experience gained in the project for attending to these patients, it has been possible to impact and improve primary project indicators that measure reductions in national rates of morbidity and mortality due to tuberculosis.

In 2017, the project was extended to ensure the effective transfer of materials, methods, instruments and strategies to the Anti-Tuberculosis League of Colombia (ALC), which has been a partner of IOM since the beginning of this initiative. This was done to ensure the sustainability of the community actions and related strategies so that they would be adopted by organized civil society, represented by the ALC, and by the National and Territorial Program for Prevention and Control of Tuberculosis.

“Once civil society adopts the transfer of IOM processes, it will be able to look for its own means of sustainability through public-private partnerships that guarantee the sustainability of these activities and the prevention and control of TB in Colombia, with a tailored approach to vulnerable groups, which include children, migrants, transient populations, the homeless and the incarcerated, among others,” explained Beatriz Gutiérrez, Migration and Health Programme Director in IOM Colombia.

Thus, under this initiative, it has also been possible to facilitate planning, coordination and creation of synergies among activities financed by the Global Fund, IOM and the Ministry of Health that help to provide comprehensive assistance to patients with TB and TB/HIV, especially to those living in the streets and in prisons.

Global Fund, IOM, and ALC funding, together with resources from the Colombian Ministry of Health and Social Protection, and the Baylor College of Medicine (USA) were used to develop an international training on TB in early March for vulnerable populations.

This training attracted the attention of national and international participants, including Dr. Poonam Dhavan, IOM Migration Health Division in Geneva, who provided an overview of the current situation of tuberculosis in Colombia, including information about the global experience of managing the disease, as well as the drug-resistant cases.

The training process also incorporated a discussion about key aspects such as prevention, diagnosis, and treatment options, as well as monitoring and contact management. A panel discussion also took place on clinical perspectives and programming used in the Baylor Centres of Excellence in Africa.

Additionally, within the bounds of international cooperation for the development of the country’s capacity for operational research, IOM Colombia led a training course in tropical disease research and special programmes (TDR). This course was oriented towards strengthening health services and systems (HSS), and was intended to train researchers and form research networks through events in the public health sector and in environments with limited resources.  

“TB does not recognize borders but it does recognize poverty and marginality,” explained Gutiérrez. “TB affects all ethnic groups and all ages; the difference is in access to treatment and opportunities for diagnosis. TB is not acquired through a lack of hygiene. It is particularly present among vulnerable populations who live in conditions of misery, overcrowding, malnutrition and, as a result, immunological suppression.” She added, “We need to understand the mobility of our populations throughout their life cycles to reduce the risk of contagion and becoming sick so that we might move towards the elimination of tuberculosis by 2030.”