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Some social remarks concerning the control of HCD

Many years ago, a PAHO scientific group, which took place in Caracas and was organized by Jorge Rabinovich and Robert Tonn, put into an ancient computer thousands of pieces of data concerning the available strategies for HCD control in a typical Latin American rural situation. Considering a projection for 20 years, the results showed that the adequate and sustainable triatomine chemical control would provide the best shortterm impact, reaching the interruption of vector transmission in the first 4 or 5 years and sustaining this situation for the rest of the prospective period. House betterment came in second place, reaching considerable reduction of transmission in the medium term. An ideal vaccine and patient-specific treatment did not work.12

The only alternative would be social development, which provided similar results to insecticide, over the long term. Regarding this theoretical approach, 28 years later, we can confirm absolutely the projection made in 1979. In several areas of endemic countries, in which regular chemical programs were undertaken, not only was the incidence of HCD stopped, but the degrees of prevalence, morbidity, and mortality are also falling down. , , , Naturally, in the scope of such results, there is a clear association between the chemical strategy and the social and economic development.

Regular insecticide spraying and the sustained entomological surveillance produced naturally the first and more bruising impact, cutting down dramatically the indoors population of Triatoma infestans and Rhodnius prolixus. This impact can be particularly certified in very poor and underdeveloped communities of Argentina, Bolivia, Brazil, Honduras, Paraguay, and even Venezuela, where social development did not arrive in the last decades.16,24 On the other side, it is unquestionable that the social improvement of several Latin American communities, a consequence of the regional economical development, is also contributing with house improvement, better local health services, reduction of rural density, etc. Some examples can be easily observed in the State of Sao Paulo, Brazil, where industry and extensive crops of sugarcane and soybean rapidly improved the social status of the whole population. Thus, the challenge for the future will necessarily involve the social and the political affairs, side by side with insecticides, and medical attention. In both areas of the question (transmission control and medical attention), the problems concerning sustainability, access, expertise, and public health systems will be crucial to consolidate the overcoming of HCD in Latin America. All of these goals are absolutely attainable, according to current observations, but all of them are dependent on political will.14,16,24

Since 1990, a new social and political figure appeared in the scenery of HCD control, the so-called “Intergovernmental Initiatives,” sharing resources, expertise, policies, and political reinforcement among the countries of different regions (Southern Cone, Andean, Central America and Mexico, and Amazon, the latter being added as the “nonendemic” countries).12,25 With the involvement of the WHO and PAHO, a schedule of continuous supervision, operational and epidemiological criteria homogenization, rationality of costs and prices, general research, and intensive communication was implemented and regularly reviewed, generating significant impacts, mainly in terms of vector and blood banks control. Additionally, new aspects of disease management have been incorporated, such as congenital transmission, diagnosis, clinical management, and specific treatment.14,23 In spite of natural problems, chiefly in terms of financial constraints, human resources turnover, and the evolution of the programs to decentralized models, the Initiatives remain active and can be considered as an exceptional advance in terms of the macropolicies required to face neglected diseases.14

 
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