New Center to Reinforce Battle against TB in Peru

Partners In Health laid the first stone yesterday for the Center for Global Health Delivery, a three-story facility on the northern outskirts of Lima, Peru, that will be a hub for treating patients with multidrug- and extensively drug-resistant tuberculosis (or MDR- and XDR-TB). The center, which may be complete by the end of 2017, will also serve as a training site for health professionals interested in learning the nuances of TB care, as well as a research base for infectious disease experts.

The first floor will house exam rooms and a state-of-the-art laboratory, and the second will house rooms for patients who require hospitalization. The third floor is dedicated to administrative space and may eventually include a suite of operating rooms to handle extreme cases.

“The idea is to make this great complex where we can provide the best standard of care using all of our combined experience,” says Dr. Leonid Lecca, a renowned tuberculosis expert and executive director of Socios En Salud, as PIH is known in Peru. “We can then say to the world, ‘Here, all TB patients are cured. Here no patient abandons treatment.’”

The center’s construction couldn’t come at a better time. In 2014, TB outpaced HIV as the most deadly infectious disease worldwide—that despite the fact it is completely curable.

PIH staff in Peru know this, and have been battling the disease for years with impressive success. Since the mid-1990s, in collaboration with the Ministry of Health, they have treated more than 10,500 patients for MDR-TB with cure rates of greater than 75 percent—well above the global benchmark. Meanwhile, researchers have conducted dozens of rigorous studies and expanded the body of knowledge surrounding TB diagnosis, treatment, and prevention. All of this has been accomplished on a shoestring budget out of a small office in Carabayllo, with support from colleagues at Harvard Medical School and Brigham and Women’s Hospital in Boston.

Yet Lecca knows that much more needs to be done and has been talking with PIH leaders for years about building such a center in Peru. There are simply not enough hospital beds to meet demand among the sickest of the sick, those with XDR-TB. “Patients wait for weeks to begin treatment,” he says.

There are more cases and more need all the time.

Three years ago, Lecca spoke with colleagues at the Ministry of Health and they agreed to have PIH begin treating XDR-TB patients in their homes, the same way PIH staff revolutionized care for MDR-TB patients in the 1990s. Community nurses began making daily visits to XDR-TB patients to ensure they took their medication and had all other needs met. While this freed up hospital beds and put more patients on lifesaving treatment, it also gave PIH staff a glimpse of the epidemic’s severity.

“Ultimately, it wasn’t enough,” Lecca says. “There are more cases and more need all the time.” And so he started dreaming of a center where PIH could offer hospitalization to XDR-TB patients just beginning treatment.

Exam rooms and hospitalization services are key for another reason. As Lecca explains, Peru’s public health care system has begun to refer patients to private third party clinics for specialized care of anything from diabetes to heart disease. Because of stigma surrounding TB and clinicians’ fear of contagion, no private clinic has emerged with a focus in the disease. With no other alternative, patients visit public clinics where there are long waits or limitations in providing care.

“There are many patients now who are not receiving the best treatment,” Lecca says.  

PIH can offer that alternative while partnering with the Ministry of Health. Peru staff know what it means to deliver TB care in the community, collect samples and arrive at accurate diagnoses, select and follow rigorous treatment regimens, and provide all the supporting care patients need. They have achieved all this while caring for the most complex cases, such as drug-resistant TB in children, in HIV-positive adults, and in patients who live on the margins of society.

Thanks to an anonymous donor, Dr. Courtney Yuen (far left), a Harvard and Brigham and Women's Hospital-based epidemiologist, cuts the ribbon to lay the first stone of the Center for Global Health Delivery, while PIH CEO Dr. Gary Gottlieb (from left), PIH Co-founder Ophelia Dahl, Lecca, Carabayllo Mayor Rafael Álvarez, and the Ministry of Health's Dr. Martín Clendenes take part in the ceremony.

If he can manage it, Lecca would like to add surgery to the slate of services available to truly sick patients visiting the center. Roughly 10 to 15 percent of MDR- and XDR-TB patients need to have part of their lungs removed if they have hope for a cure. But for the past two years, not a single patient in Peru has been allowed under the knife. Health workers refused to perform TB-related pulmonary surgery after public hospital staff became infected while operating on a positive patient. The operating room’s negative pressure system, which is supposed to maintain a constant supply of fresh air, was broken and the deadly bacteria easily spread.

Following the incident, hospital staff insisted that proper ventilation systems be installed in all public operating rooms before any further surgeries are performed on positive TB patients. It’s a good idea. But that would require at least $1 million, a sum that simply doesn’t exist in government coffers.

And so many patients are stuck on a waiting list, Lecca says. A third, he fears, have already missed the window of opportunity for a lifesaving procedure.

“It’s not because there aren’t surgeons, because there are,” says Lecca. “The problem is this question of air circulation and infection control that isn’t being resolved.”

And so Lecca dreams of a surgical ward in the new center. “There are a lot of people who need it,” he says. “We can have the key to the operating room and no one can tell me that we can’t operate, because it will be ours.” That same space, he says, can also be used to train the next generation of thoracic surgeons.  

We would have the opportunity to save many more lives.

Beyond serving as a home for TB care and training, the center would also further PIH’s research agenda in Peru. Harvard investigators and Lima-based staff have partnered for years on studies that expanded the medical community’s knowledge of TB prevention, transmission, and treatment in low-resource communities like Carabayllo.

EPI was the biggest such example, having followed 18,500 patients over three years to determine whether MDR-TB is as easily transmitted as drug-sensitive TB. And the latest example is endTB, a project PIH is leading in collaboration with Médecins Sans Frontières, Interactive Research & Development, and financial partner UNITAID in 15 countries with a high TB burden. Patients who have battled drug-resistant TB for years are taking new drugs—the first developed in 50 years—with astounding results. PIH in Peru has already invited 50 patients into the project, with a goal of 420 over the next three years.

Lecca and his colleagues would like to continue conducting cutting-edge TB research in Peru, including testing vaccines and studying transmission. They see the new center as a perfect base of operations for local and international investigators.

Clearly, Lecca is not short on dreams for the new center, and he readily admits it. But who could blame him for dreaming when the stakes are so high?

“We would have the opportunity,” he says, “to save many more lives.”