StephenShenfield.NET

Special Issue No. 21. January 2004. Tuberculosis in the post-Soviet region

Introduction 
1. Background briefing: TB; history of TB; MDR TB; DOTS and DOTS-PLUS; DOTS and Russian physicians; note on sources 
ASSESSMENTS BY RUSSIAN SPECIALISTS 
2. O.V. Govor, Tuberculosis Infection in the Russian Federation, 1955--2010 
3. O.M. Tsvetkova, V.B. Turkutiukov, and L.A. Frolova, A Study of the Incidence of Tuberculosis in the Primorsky Territory 
4. O.V. Govor and V.B. Turkutiukov, The Trend in Basic Epidemiological Indicators for Tuberculosis in Primorye Over the Period 1992--2002 EDITOR'S ASSESSMENT 
5. Tuberculosis in Russia: past, present, and future trends
THE WORK OF WESTERN NGO'S IN THE REGION 
6. Donna J. Barry, NP MPH, Treating Multi-Drug Resistant Tuberculosis in Russia: The Experience of Partners in Health 
7. Central Asia: Tuberculosis in the Aral Sea region 
TB IN THE CAUCASUS 
8. Notes on TB in Chechnya, Ingushetia, Dagestan, Georgia, Azerbaijan, and Armenia 
RUSSIAN BOOKS ON TUBERCULOSIS 
9. TB in Russia's penal system 
10. The doctor's advice 
TUNERCULOSIS AND CULTURE 
11. Chekhov and tuberculosis

INTRODUCTION

In the postwar period, humanity came close to vanquishing the ancient disease that Bunyan dubbed "the captain of the men of death" -- tuberculosis or TB. Now TB is again resurgent. What is more, new strains have emerged that are resistant to many of the anti-TB drugs in common use: multi-drug-resistant TB or MDR TB. This process may spawn a new TB that will resemble the TB of the past in being fatal and effectively incurable.

I believe that MDR TB is one of the two most urgent threats to human health. The other, of course, is AIDS. And AIDS in turn fuels the further spread of TB, including MDR TB, because TB is one of the main opportunistic infections that attacks AIDS sufferers.

TB and AIDS threaten the whole world, including the United States. But Russia and most of the other post-Soviet states are affected especially acutely -- and disease does not respect international borders. As AIDS has received much more public attention than its twin scourge, I am devoting this special issue of the RAS to tuberculosis in Russia and the post-Soviet region.

I apologize for the long delay in preparing this issue. It is due in part to the pressure of other work, but in part also to my feeling that I was not coping adequately with the enormity of the subject. I had trouble getting hold of much of the information I wanted and making sense of some of the information I had. As a statistician by training, I was unhappy at being unable to put together a coherent and reliable statistical picture. I managed to obtain only two relevant books from Russia.

Finally I resolved that I must do my best with what I have. If the statistics are not usable, I can at least explain why and offer a broad qualitative assessment. Perhaps others will be inspired to do a more thorough job.

I set the scene with a background briefing on TB and MDR TB in relation to the post-Soviet region (item 1). There follow epidemiological assessments of the TB situation in Russia as a whole (item 2) and the Russian Far East in particular (items 3 and 4), written specially for the RAS by Olga Govor and her colleagues at the Vladivostok State Medical University. Item 5 is my own attempt at a qualitative assessment of TB trends in Russia.

Then I turn to the work of Western NGOs engaged in investigating and fighting the spread of TB, and above all MDR TB, in the region. Donna Barry, who I would like to thank for all her help, describes the work that the organization "Partners in Health" has been doing in Russia (item 6). Next I summarize a report, kindly sent me by Helen Cox, of the work being carried out in the Aral Sea region of Central Asia by "Médecins Sans Frontières" (item 7).

Item 8 consists of notes from various sources on the situation in different parts of the Caucasus.

The next two items are based on the two books I got from Russia -- a collection of articles on medicine in the Russian penal system (item 9) and a book offering "the doctor's advice" to people suffering from TB (item 10). Finally, item 11 considers the hidden influence of TB on the creative work of the famous 19th-century Russian playwright Anton Chekhov.

Stephen D. Shenfield

1. BACKGROUND BRIEFING

TB

Tuberculosis (TB) is a fatal wasting disease caused by a rod-shaped bacillus (bacterium) that was discovered in 1882 by the German physician and scientist Robert Koch. The bacillus has a hard waxy exterior that impedes the action of anti-TB drugs, which did not become available until the mid-1940s.

People usually identify TB with its most common form, tuberculosis of the lungs or pulmonary TB. This is the disease that used to be called consumption or phthisis. Its most obvious symptoms are fever and the coughing up of blood. I too concentrate on this form of TB. There are other forms that attack many other parts of the body, such as the skin, bones and joints, bladder and kidneys, intestines, brain, eye, inner ear, and Fallopian tubes.

TB can be active or latent. An outbreak of active TB can result from a new infection or from the activation of latent TB. Active TB can take an acute galloping form, leading to rapid death or recovery, or a chronic form that stretches, often with temporary remissions, over many years.

History of TB

TB was a common fatal disease from the dawn of recorded history until the late 1940s. There were TB epidemics in the Roman empire. The TB bacillus has even been found in ancient Egyptian mummies.

Historians believe (there are no statistics before the 1840s) that the first phase of the industrial revolution brought an explosive increase in TB. In England this phase corresponds to the period 1790-1840; in other countries it came later. The cause was the terrible working and living conditions of industrial workers, especially poor diet and overcrowded, unhygienic housing. In Lancashire it was said that "the beds never get cold" -- workers on day and night shift slept in the same beds. They probably never got free of TB either. TB was even more endemic in such institutions as prisons, convents, and boarding schools (Dormandy, pp. 74, 79-81; see note on sources below).

The following period, up to World War One, was marked by a gradual decline in the prevalence of TB, though the disease remained very common. (When the decline began and just how great it was are matters of controversy.) Although there were some medical advances in the later part of this period -- the discovery of the TB bacillus in 1882 and X-rays in 1895 -- they were of little practical help, and most of the "treatments" imposed by doctors were useless or harmful (e.g. bloodletting and starvation). The decline is therefore attributed to improvement in working and living conditions, especially housing, and -- toward the end of the period -- in public hygiene. Some good was also done by the rising sanatorium movement, which stressed the recuperative power of nutritious diet, fresh sea or mountain air, sunshine, rest, and graduated exercise.

TB rates rose during the economic depression of the inter-war years. By this time a vaccine was available -- Bacille Camille Guérin (BCG), invented in 1921 -- but its safety and effectiveness were uncertain and it was not widely used. In this period TB was often treated by means of complex and painful but sometimes effective surgical procedures. The most common was pneumothorax or collapse therapy, in which an infected lung (or parts of one or both lungs) was immobilized to halt the spread of TB to other parts of the body.

The breakthrough came in the middle and late 1940s, when effective anti-TB drugs such as streptomycin and isoniazid were at last discovered. As resistant strains of TB soon began to emerge, a consensus formed by 1955 that three drugs should be used simultaneously. The appearance in the 1960s of new anti-TB drugs such as rifampicin made it possible to cure TB more quickly (in nine months) and at lower cost.

Within a few years, in those countries where these drugs were available on a sufficiently large scale (and that did NOT include the Soviet Union), TB had became a rare disease. The postwar rise in the standard of living and the creation in many countries of welfare states and national health services must also have contributed to this historically unprecedented state of affairs. With the help of the World Health Organization (WHO), developing countries also made substantial though less dramatic progress in controlling TB.

TB was almost vanquished. Almost, but not quite. The disease retained a foothold and so was able to make a comeback later. Some authors argue that if the necessary resources had been allocated TB could have been eradicated for good. But the dramatic progress already made bred complacency and resources were diverted prematurely to politically more "sexy" uses. Another pertinent point: TB has always been a disease of poverty and poverty remained widespread, both in the Third World and in quite a few developed countries, especially but not only in those like the US that lacked welfare states.

The trend line for TB in the period from 1945 to the present has been U-shaped. In the late 1970s its decline slowed down and from the 1980s it began to rise, first slowly and then more quickly. "Globally TB was once again by far the biggest killer among infections, accounting for 7 percent of deaths and 26 percent of avoidable deaths" (Dormandy, ch. 33).

Why? There were two reasons. One was the emergence of HIV and AIDS, the immune-deficient victims of which were at least 40 times more likely than other people to get TB and 20 times more likely to die of it. The other reason was the emergence of multi-drug resistance (MDR).

MDR TB

MDR TB was recognized as a public health problem in 1991, when several small outbreaks were reported in the US, mostly in New York. The origin was traced to homeless tramps and a prisoner. Screening showed that the MDR strain was present in at least 23 prisons in the state of New York. One organism tested was found to be insensitive to seven of the most commonly used anti-TB drugs. "The disease caused by such a bacillus was as untreatable as it had been when [the English poet] Keats had his first hemorrhage [in 1818]" (Dormandy, p. 387).

The shock at this development prompted the revival of the defunct federal TB program. MDR was blamed on monotherapy (use of a single drug instead of a combination) and incomplete treatment.

There are two ways you can get MDR TB. You can catch it from someone else who has it, even if you never had TB before, or you can develop it as a result of inconsistent, incomplete or incompetent treatment of ordinary TB in the past.

We have no clear idea of how widespread MDR TB is in much of the world, only scattered studies of the situation in various areas. These studies suggest that "hot spots" -- areas in which MDR TB is already common -- are numerous in both the Second World of communist and post-communist countries and the Third World of developing and underdeveloped countries.

Here are the data that we have for the former Soviet Union. They suggest that much of the region may consist of "hot spots."

MDR Rates in Areas of the Post-Soviet Region (2001-02)

Percentage of Percentage of New Cases Re-Treatment Cases

Estonia 14 38

Latvia 9 24

Russian provinces

Arkhangelsk 13.5 60

Ivanovo 9 26

Tomsk 6.5 27

Kazakhstan

Almaty province 7 36

Uzbekistan

Karakalpakstan 13 40

Turkmenistan

Dashoguz province 4 19

DOTS and DOTS-PLUS

In order to halt the generation of MDR, a treatment program called DOTS was worked out, standing for "Direct Observation Therapy (Shortened Course)." A combination of five commonly used ("first-line") anti-TB drugs is administered on an outpatient basis over a period of 6--8 months. As many patients cannot be trusted to take medication regularly by themselves, medical personnel or community health workers must directly observe them taking it. DOTS remains the basis of the anti-TB strategy of the WHO and most governments and NGOs.

DOTS is a suitable program to treat TB and prevent the emergence of MDR TB in populations that have NOT YET been affected significantly by MDR TB. However, the realization has gradually spread that its use is ineffective and counterproductive in populations that have already been so affected. The old first-line drugs do not cure patients with MDR TB; their resistance to them is merely amplified.

New "second-line" drugs have been developed to treat MDR TB. However, they have several drawbacks:

* They are less effective than first-line drugs.

* They have serious side effects.

* They may need to be taken for up to two years.

* They are MUCH more expensive than first-line drugs.

For these reasons, but above all due to the cost factor, the previously dominant view in government, WHO, and NGO circles was that large-scale treatment of MDR TB is impractical and cost-ineffective. Stick to DOTS regardless!

Certain MGOs -- in particular, Partners in Health and Médecins Sans Frontières (MSF) [Physicians Without Borders] -- have worked hard to weaken the hold of this view, which they consider shortsighted as well as inhumane (items 6 and 7). A new program making use of second-line drugs, known as DOTS-PLUS, has now been introduced to treat TB in populations known to be affected by MDR TB.

But where are the resources to come from to make second-line as well as first-line anti-TB drugs available on the necessary scale? To what extent can drug prices be brought down? And how can the generation of further drug resistance through the irregular, intermittent, and incompetent use of all these drugs be prevented?

The main danger, as I see it, is that more resources will -- belatedly -- be channeled into the fight against TB, but not on a scale sufficient to resolve the problem. As a result, second-line drugs will become more widely available to the increasing number of people with MDR TB, but not on a reliable and regular basis. This will cause yet more drug resistance, creating a need for new and even more expensive third-line drugs. And so on until TB has finally become incurable again.

DOTS and Russian physicians

DOTS has encountered considerable resistance from part of the Russian medical establishment as well as from many rank-and-file physicians. (The same is true to varying degrees of other post-Soviet states.) Such resistance from officials in the Ministry of Health was the reason (or one of the reasons) why the Russian government refused for two years to accept a $150m World Bank loan for the treatment of AIDS and TB. (The loan was finally accepted in April 2003.)

What accounts for this dislike of DOTS? For decades Soviet physicians were isolated from their professional colleagues abroad and embedded in a system that resisted innovation even on technical matters. As in many other fields, this resulted in the preservation of archaic methods and ideas that had been left behind in the West. Thus ideas about TB and methods of treatment that predominated between the wars (e.g., the pneumothorax surgical procedure) are still common in the FSU. Problems associated with anti-TB drugs -- in particular, the problem of drug-resistant strains -- are not very widely understood (see item 10).

One old idea that was preserved in the USSR was the traditional ideal of the right of the individual physician to his or her autonomous judgement. The standardization of the treatment regime in DOTS flies in the face of this ideal. A neat reversal of ideological stereotypes, don't you think?

Many Russian physicians feel that they are heirs to a worthy national medical tradition and resent being patronized by arrogant Western experts. Western experts are accused of placing Russia on the same level as Third World countries like Haiti and Peru (by recommending methods originally devised for the Third World) and of being unfamiliar with Russian conditions. For example, Western experts say that long hospital stays are a wasteful use of resources, not understanding that many patients do not live in housing conditions conducive to recovery -- if they have homes at all.

These misunderstandings are gradually being overcome as Western experts adapt their approach to Russian conditions and Russian physicians gain familiarity with foreign experience. But will "gradually" be fast enough to meet the demands of the situation?

Note on sources

The literature on tuberculosis is enormous. Here I list only the six books that I have found most useful in my research for this issue of the RAS.

The best general history of TB that I found is one written by a British physician -- Thomas Dormandy, The White Death: A History of Tuberculosis (New York University Press, 2000). Also of great interest is the shorter classic by a famous microbiologist and his tubercular wife -- René and Jean Dubos, The White Plague: Tuberculosis, Man, and Society (New Brunswick, NJ: Rutgers University Press, 1987).

Unfortunately, it seems that all the books on the history of TB focus on Europe and the US to the exclusion of the rest of the world. I have not located any work that deals specifically with the history of TB in Russia and the Soviet Union (even in Russian). Someone should write one.

For discussion of the recent resurgence of TB in the US, see Frank Ryan, MD, The Forgotten Plague: How the Battle Against Tuberculosis was Won -- and Lost (Boston and New York: Little, Brown and Company, 1992). Also a challenging book by another British physician -- Richard J. Coker, From Chaos to Coercion: Detention and the Control of Tuberculosis (New York: St. Martin's Press 2000).

Specifically on the rise of MDR TB, see Harvard Medical School / Open Society Institute, The Global Impact of Drug-Resistant Tuberculosis (Boston: Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, 1999). A more popular account that deals with the situation in Russia at some length is Lee B. Reichman, MD, MPH with Janice Hopkins Tanne, Timebomb: The Global Epidemic of Multi-Drug-Resistant Tuberculosis (New York: McGraw-Hill, 2002).

ASSESSMENTS BY RUSSIAN SPECIALISTS

Note on authors

The authors of these articles work in the epidemiology department of Vladivostok State Medical University. My translations of the articles have been checked by the authors.

Note on terminology

The "incidence" of a disease is the number of newly registered cases per 100,000 population (including cases of relapse of people who had the disease earlier but were regarded as cured). Incidence is the best indicator of the rate at which an epidemic is spreading.

The "prevalence" of a disease is the total number of cases of the disease per 100,000 population. Prevalence is the best indicator of the proportion of a population affected by a disease.

"Morbidity" is a general term for the degree to which a population is affected by a disease. It can refer either to incidence or to prevalence.

2. TUBERCULOSIS INFECTION IN THE RUSSIAN FEDERATION, 1955--2010

O.V. Govor (Vladivostok State Medical University)

Despite the progress of medical science, mankind enters the new century with high morbidity and mortality from tuberculosis.

According to the classification of B.L. Cherkasskii, tuberculosis belongs to the category of formerly known diseases that have "re-emerged" with new characteristics. [1]

Tuberculosis is not simply an infectious disease. It is rightly considered the classical social disease. It owes its re-emergence to the following basic causes:

* deterioration of the socio-economic conditions of life

* military operations, both on Russia's territory and in the former union republics

* migration processes, including those triggered by military operations

* growth in size of socially maladapted population groups (drug addicts, alcoholics, the homeless) and of population of the penitentiary system

* reduced funding of measures to prevent and treat tuberculosis

* disorganization of the anti-tuberculosis service [5]

The trend in tuberculosis incidence (per 100,000 population) in Russia for the period 1955--2000 with forecasts for 2005 and 2010 is as follows:

1955 118.2

1960 99.5

1970 72.0

1975 56.8

1985 47.4

1990 34.2

1996 67.5

1997 73.9

1999 84.7

2000 86.5

2005 132.2 (forecast)

2010 190.7 (forecast)

Between 1955 and 1990 the trend in incidence was downward. However, the apparent reduction between 1986 and 1991 in part reflects a decline in the scale of population screening for tuberculosis.

The falling rate of decline in registered incidence in the 1980s corresponds to the deceleration of the country's economic development and the parallel slowdown in the growth of national income.

Thus, between 1950 and 1970 the country's gross social product grew by 5.2 times to 637 billion rubles. By 1980 it had reached 1,061 billion rubles: that is, in the 1970s it increased by only 66.5 percent. National income shows a similar pattern: in the 1950s and 1960s it rose fourfold, while in the 1970s it grew by only 55 percent (from 282 to 437 billion rubles). [2]

During perestroika, this slowdown was officially regarded as a reflection of the "period of stagnation."

The 1990s have seen a sharp and continuous rise in the incidence of tuberculosis. Between 1991 and 2000 it increased by 2.5 times.

If the existing unfavorable trend is maintained, the incidence of tuberculosis will reach 132.2 per 100,000 in 2005 and an alarming 190.7 per 100,000 in 2010.

Moreover, it must be kept in mind that the incidence indicator reflects only reported cases of tuberculosis. Several studies show that the ratio of unreported cases to reported new cases in a given year may reach 40 percent. This figure is made up of the following components:

actively infectious according to microscopic examination = 19.7 percent

chronically ill with fibrous-cavity tuberculosis = 3.2 percent

self-recovered with residual changes = 11.6 percent

dead within a year of observation = 4.1 percent

diagnosed after death = 2.2 percent [3]

The current situation with regard to tuberculosis is marked by a negative trend not only in incidence but also in other key epidemiological indicators such as mortality, prevalence, and infectiousness.

Mortality rose from 8.1 per 100,000 in 1991 to 20.0 per 100,000 in 1999. Today tuberculosis occupies the leading place among causes of death from infectious disease (over 80 percent of cases).

Prevalence in 1992 was 172 per 100,000 (255,900 persons). From 1993 on, the number of people with tuberculosis increased markedly and within three years had grown by 85.4 percent (actively infectious cases by 83.3 percent).

In recent decades, exogenous infection and super-infection have played increasing roles in the spread of tuberculosis. This is inevitable in view of the yearly expansion of the so-called bacillary core.

In the clinical structure of tuberculosis incidence, there are an increasing number of acute, destructive, and disseminated forms (caseous pneumonia, total cavity infection of the lungs, tuberculosis of the intestines, pancreas, and mammary glands). [4]

The age structure of those suffering from this infection has grown younger. The 20--39 year old age group (people of working age) predominates.

Of special concern is the spread of drug-resistant strains of the bacillus. This sharply limits the possibilities for treatment and has a negative impact on the prognosis of treatment. In the final reckoning, a certain proportion of those with primary, and especially of those with multiple, drug resistance makes up the indicator of mortality and prevalence -- that is, of the bacillary core that leads to exogenous and super-infection.

Conclusion

The situation with regard to tuberculosis is unfavorable now in many countries of the world, but for different reasons. Abroad the main reason is the HIV epidemic, in Russia the deep economic crisis.

It is necessary to set priorities for epidemiological monitoring in concrete situations, and in the Russian Federation in particular to focus attention on those population groups that have the greatest prevalence of tuberculosis and concentrate prophylactic and counter-epidemic measures on those groups.

References

[1] B.L. Cherkasskii, Rukovodstvo po obshchei epidemiologii (Moscow: Meditsina, 2001)

[2] I.G. Ursov, Epidemiologiia tuberkuleza (Novosibirsk: Izd-vo Instituta teplofiziki SO RAN, 1997)

[3] M.V. Shilova, Problemy tuberkuleza, 2001, no. 5, pp. 8-12

[4] V.V. Punga and L.P. Kapkov, Problemy tuberkuleza, 1999, no. 1, pp. 14-16

[5] A.G. Khomenko, Problemy tuberkuleza, 1997, no. 6, pp. 9-11

3. A STUDY OF THE INCIDENCE OF TUBERCULOSIS IN THE PRIMORSKY TERRITORY

O.M. Tsvetkova, V.B. Turkutiukov, and L.A. Frolova

In the period 1997--2000, the incidence of tuberculosis in the Primorsky Territory increased by 90 percent, and mortality from tuberculosis by 160 percent. According to data from the territorial center of the State Sanitary-Epidemiological Inspection, the indicator of the incidence of active forms of tuberculosis exceeded the corresponding indicator for the country as a whole by 60 percent (91.8 per 100,000 compared to 58.4), while for microbial forms of tuberculosis this figure was 50 percent (35.3 compared to 23.2).

We studied morbidity in the Primorsky Territory for active and microbial forms of tuberculosis over the period from 1995 to 1999. Over this period we observed a sharp rise in the incidence of active forms of the infection with a mean rate of growth of 8.5 percent a year. In 1995 incidence in the territory was 72.7 per 100,000 population, while in 1999 it had reached 101.1 per 100,000. Growth in the incidence of microbial forms began later and continued in subsequent years, with a mean rate of growth of 6.1 percent a year.

We found wide variation in the incidence of active and microbial forms of tuberculosis among the towns and rural districts of the territory. For the purpose of comparative analysis of incidence in various parts of the territory, we calculated average indicators. The average indicator of the incidence of active forms of tuberculosis in the territory was 83.4 per 100,000. The range of variation was from 37.9 to 133.6 among the rural districts and from 69.4 to 126.0 among the towns. The average incidence of microbial forms of tuberculosis in the territory over this period was 33.6 per 100,000 with variations by town from 26.5 to 34.2 and by rural district from 14.3 to 63.3.

The highest incidence of active forms of tuberculosis recorded in the Spassk-Dal'nii, Anuchinskii, and Nadezhdinskii rural districts; the lowest was in the Olginskii district. High incidence was observed in the town of Lesozavodsk and in the Dal'negorskii, Mikhailovskii, Chuguyevskii, and Oktiabrskii districts, while low incidence characterized the towns of Vladivostok, Shkotovo-17, Dal'negorsk, and Luchegorsk and the Lazovskii, Chernigovskii, Partizanskii, Terneiskii, Khankaiskii, and Khorol'skii districts.

4. THE TREND IN BASIC EPIDEMIOLOGICAL INDICATORS FOR TUBERCULOSIS IN PRIMORYE OVER THE PERIOD 1992--2002

O.V. Govor and V.B. Turkutiukov

Despite the expectations of the world community, efforts substantially to reduce tuberculosis morbidity and the consequent socio-economic damage by the end of the twentieth century were unsuccessful. What is more, it has become clear that in the 1980s and 1990s tuberculosis manifested itself in the new guise of a re-emerging infection. [6]

A rise in incidence has been recorded both in developing countries, where it can be attributed to the social nature of tuberculosis, and in economically prosperous states, due to the HIV epidemic and a decline in vigilance regarding tuberculosis.

However, thirteen countries account for three-quarters of all cases of tuberculosis: South Africa, Ethiopia, Zaire, Brazil, Mexico, China, India, Pakistan, Thailand, Bangladesh, the Philippines, Indonesia, and Russia. [1, 2]

It is an interesting fact that on the most reliable statistical indicator, mortality from tuberculosis, Russia at the start of the twentieth century was at about the same level as the developing capitalist countries. But by the end of the century mortality from tuberculosis in Russia was 20.9 times greater than in Britain, 41.7 times greater than in Germany, and 50.2 times higher than in the USA. [3]

In order to trace the development of the tuberculosis infection in the Primorskii Territory, we carried out a retrospective analysis of the epidemiological situation over the period 1992--2002. We studied the level and trend of basic indicators as shown by data from official statistical forms nos. 8 and 33.

Even in earlier years, tuberculosis was always more prevalent in the Primorskii Territory than in European Russia. One reason is the unfavorable conditions of the monsoon climate. [5]

The Primorskii Territory is a large region, 165,900 square kilometers in area -- about 1 percent of the territory of Russia and 3 percent of the territory of the Far East. The territory has today 12 towns and 24 rural districts. It is the most densely populated part of the Far East (13.2 persons per square kilometer), with 30 percent of the Far East's total population. The highest population density is recorded in the towns of Arsen'ev, Spassk-Dal'nii, Vladivostok, and Ussuriisk (944--1,658 persons per square kilometer). At the same time, the density of settlement in the rural districts does not exceed 26.8 persons per square kilometer (in Nadezhdinskii district). [4] The permanently resident population of the territory as of the beginning of 2002 was 2,127,000, of which the urban population was 1,677,800 (79 percent) and the rural population 449,200 (21 percent).

The epidemiological situation in the Primorskii Territory regarding tuberculosis has deteriorated significantly over the last ten years. Tuberculosis of the respiratory organs continues to predominate, accounting for 95--97 percent of all active cases throughout the period of study with little fluctuation. In 2002 the number of first registered cases of active tuberculosis of the respiratory organs was over 80 percent greater than in 1992 (2,361 persons compared to 1,270), and incidence was 141 per 100,000 population. However, while in the period 1992--2000 incidence grew rapidly (from 59 to 139 per 100,000), since 2000 it has grown much more slowly (2001 -- 140 per 100,000; 2002 -- 141 per 100,000).

Incidence in Primorye is significantly higher than in the Russian Federation as a whole (88.2 per 100,000 in 2001). Moreover, Primorye also has a large population of temporary residents (15 percent of the total population); this means that many cases of tuberculosis are not recorded. The highest incidence was recorded in 2002 in the Khorol'skii (244) and Spasskii (202) rural districts and in the towns of Dal'nerechensk (164), Spasske-Dal'nii (127), and Ussuriisk (117).

Among first registered cases there was a significant preponderance of men, the multiyear average proportion being 73 percent. Young adults were the most susceptible age group: in 1992--98 the mean proportion of 20-39 year olds was 46 percent, while in 1999--2002 the 25-34 year age group accounted for 26 percent and the 35-44 year age group for 23 percent of new cases. Thus tuberculosis strikes at the most able-bodied section of the population, thereby inflicting great socio-economic damage.

The incidence of bacillary forms of tuberculosis also rose over the period studied by 80 percent; the intensive indicator for 2002 was 44.1 per 100,000. The proportion of bacillary cases with multi-drug resistance over the last four years (when such data became available from form no. 33) fluctuated between 2.9 percent in 1999 and 15.1 percent in 2001. The high incidence among children -- 27.4 per 100,000 in 2002 -- indirectly indicates the substantial size of the bacillary core in the population. [Relatively high: tuberculosis is in general much less widespread among children than among adults -- ed.]

On the other hand, such an intensive epidemic process, with a constantly increasing number of sources of infection, has a negative impact on incidence among child and adolescents. Thus, incidence among child and adolescents in Primorye in 2002 was 27.4 and 75.3 per 100,000 respectively -- again, significantly higher than the corresponding figures for Russia as a whole (18.6 and 36.3 per 100,000 respectively). However, over the period studied incidence among child and adolescents did not undergo significant change, especially against the background of the continuing rise in the absolute number of persons with tuberculosis. On average, children constituted 4.9 percent and adolescents 2.6 percent of all persons with tuberculosis.

The indicator of the incidence of fibrous-cavity tuberculosis (FCT) bears witness to the late diagnosis of tuberculosis cases and is one sign of the spread of the epidemic in Primorye. In 1992 FCT incidence in the territory was 4.5 per 100,000; since then it has risen continuously, more than doubling to 9.4 per 100,000. The proportion of FCT among adolescents and adults first registered as having tuberculosis of the lungs was 9.5 percent in 2002.

Given such high indicators of the incidence of tuberculosis in all age groups and the growth in FCT, the decrease in the proportion of bacillary cases (from 45.3 percent in 1992 to 40.6 percent in 2002) and of cases with disintegration of lung tissue (from 46.1 percent in 1992 to 43.4 percent in 2002) points to deficiencies in the diagnosis of tuberculosis rather than to an improvement in the epidemiological situation. Further evidence of the low level of bacteriological diagnosis is the ratio between bacillary cases and cases with disintegration of lung tissue, which over the whole decade did not exceed 1 in Primorye and had an average value of 0.9, while a favorable ratio is considered to be 1.5.

In the structure of clinical forms of tuberculosis of the respiratory organs, infiltrative tuberculosis continues to predominate, accounting for 59.4 percent of cases. Threshold forms constitute only 17.5 percent. Disseminated tuberculosis accounted on average for 6.8 percent of all active cases of tuberculosis of the respiratory organs over the period studied, with insignificant fluctuations.

An indicator of the spread of tuberculosis infection is prevalence, which encompasses all persons with active forms registered in groups I, II, VA, and VB. In Primorye the prevalence of tuberculosis is quite high -- 417.3 per 100,000 in 2001, compared to 268.6 per 100,000 for the Russian Federation as a whole; 440.2 per 100,000 in 2002. The prevalence of active tuberculosis in the whole population of the territory increased by 70 percent between 1992 and 2002. The rate of growth was 5.7 percent, indicating a clear growth trend.

Moreover, the rise in prevalence among children was almost 100 percent, and among adolescents 120 percent -- an extremely unfavorable prognostic sign that bears witness to deterioration in the epidemiological situation regarding tuberculosis. The indicator of FCT prevalence also has a tendency to increase (from 43.7 per 100,000 in 1992 to 62.6 per 100,000 in 2002). A cause of this trend may be the poor organization of observation of persons with chronic tuberculosis.

The indicator of mortality increased by 140 percent over the period studied, reaching 34.7 per 100,000 in 2002. The level of mortality among those who have been registered as tuberculous at clinics for less than one year is also high -- on average 9.7 percent. This bears witness to the untimely implementation and poor coverage of planned measures to screen the population for tuberculosis.

Taking into account the fact that in 2002 the coverage of fluorographic screening in the population due for screening was 63.9 percent, the real epidemiological situation must be even more acute.

Analysis of the main statistical indicators for tuberculosis (general, child, and adolescent incidence, prevalence, mortality, the bacillary core, coverage by fluorographic examination) did not reveal any substantial differences between the urban and rural populations of the Primorskii Territory over the period 1992--2002. Thus, multi-year mean indicators of the incidence of active tuberculosis of the respiratory organs were 88.5 per 100,000 for the urban and 86.1 per 100,000 for the rural population. Incidence among children was 17.6 per 100,000 in the towns and 16.5 per 100,000 in the countryside, while urban adolescents get tuberculosis only a little more frequently than their rural counterparts (51.9 as against 49.7 per 100,000). The sole significant urban-rural difference was in the coverage of fluorographic screening: 57.1 percent among urban and 47.8 percent among rural dwellers on average for the period studied.

By ordering the towns and rural districts of Primorye according to the severity of the epidemiological situation, we were able to identify those that are in the most unfavorable situation -- namely, the towns of Spassk-Dal'nii, Partizansk, and Dal'nerechensk and the Anuchinskii, Mikhailovskii, and Chuguyevskii districts. They are distinguished by an aggregate of unfavorable epidemiological indicators, with incidence rates ranging from 94 up to 122, prevalence from 396 up to 555, bacillary contingents from 115 up to 274, and high mortality -- from 34.7 up to 57.4 per 100,000 population.

The results obtained from retrospective analysis confirm that the epidemiological situation in the Primorskii Territory regarding tuberculosis remains unfavorable and that it is necessary constantly to monitor its development.

References

[1] A.A. Vizel' and M.E. Guryleva, Tuberkulez (Moscow: GEOTAR MEDITSINA, 1999)

[2] F. Drobniewski et al., "Rifampin- and Multidrug-Resistant Tuberculosis in Russian Civilians and Prison Inmates: Dominance of the Beijing Strain Family," Emerging Infectious Diseases, 2002, v. 8, no. 11, pp. 1320--26

[3] K.V. Pomel'tsov, Voprosy tuberkuleza, 1925, no. 5, pp. 112-26

[4] Primorskii krai na rubezhe tret'ego tysiacheletiia: Statisticheskii sbornik (Vladivostok: Primkraistat, 2001)

[5] O.M. Tsvetkova et al., "Epidemicheskaia situatsiia po tuberkulezu v Primorskom krae v 1995-2000 godakh," pp. 199-200 in Dostizheniia otechestvennoi epidemiologii v XX veke. Vzgliad v budushchee. Trudy konferentsii, posv. 80-letiiu so dnia rozhd. akad. V.D. Beliakova (St. Petersburg, 2001)

[6] B.L. Cherkasskii, , Rukovodstvo po obshchei epidemiologii (Moscow: Meditsina, 2001)

EDITOR'S ASSESSMENT

5. TUBERCULOSIS IN RUSSIA: PAST, PRESENT, AND FUTURE TRENDS

There are major inconsistencies that I have been unable to resolve between the figures given for the incidence and prevalence of tuberculosis in different sources at different times, so I shall restrict myself to a broad qualitative assessment.

Although data are not available, we can safely assume that in Russia as in other countries tuberculosis was rife during the early stages of industrialization. The social conditions were basically the same: overcrowding, poor hygiene, malnutrition, etc. This applies to Stalinist no less than to tsarist industrialization.

It is widely agreed that TB rates fell sharply, though not to western postwar levels, in the 1950s and 1960s. (1) This may be attributable primarily to improved diet and housing conditions, as methods of medical treatment remained out of date. As in the inter-war period, physicians relied heavily on not very effective methods such as vaccination, surgery, and long stays in hospitals and sanatoria. Effective anti-TB drugs were in short supply.

Whether the situation continued to improve in the 1970s and 1980s is less clear. The official figures suggest that it did, but the downward trend may have been produced (at least in part) by the curtailment of mass screening programs. (2) This would be consistent with the stagnation in living standards in the late Soviet period.

Even if TB rates were somewhat higher at the end of the Soviet period than the figures indicate, it cannot reasonably be doubted that rates rose sharply through most of the 1990s. These were years of the impoverishment of most of the population and near-collapse of the public health system.

Moreover, TB has been especially rife among the predominantly new "marginal" population of refugees and other homeless people. St. Petersburg Nochlezhka [Shelter], Russia's leading NGO working with the homeless, estimate that 70 percent of the homeless are infected with TB. (3) However, these cases are not diagnosed, treated, or registered and so do not enter the official statistics. A major reservoir of untreated and unregistered tuberculosis is Chechnya (item 8). World Health Organization specialists recommend that official figures be increased by one third to take account of unregistered cases; a study published in 2001 suggests increasing them by 40 percent (item 2).

At the other end of the social scale, people who can afford to do so increasingly use private medical services. As the providers of these services guarantee confidentiality, these cases too are not counted in the statistics. (4)

Another area of statistical uncertainty is the coverage of inmates in institutions of various kinds. In the past the penal system was excluded from the general statistics. Now it is included, though perhaps not consistently; this may be one source of confusion in the figures. The question arises of whether other kinds of institution are included, such as orphanages, mental hospitals, and institutions for the mentally retarded. The abysmal conditions in all these places are certainly conducive to the spread of TB.

Official figures indicate that incidence (though not yet prevalence) rates have stopped rising in recent years. Apparently their growth slowed down in 1999-2000 and in 2001 they began to decline. How much credence can we place in this? It seems consistent with the modest improvement in the standard of living since the 1998 crisis.

However, is it consistent with the continued spread of TB from still very large marginal strata into the general population? The large-scale release of prisoners must have accelerated this process. It can also be assumed that refugees, migrant workers, and also police and soldiers serving in Chechnya, carry TB, including MDR TB, from Chechnya to other parts of Russia.

Even if overall TB rates are leveling off, this by no means excludes the likelihood that MDR TB rates continue to rise -- and this is by far the most serious threat.

In any case, arguing about this point is rather like arguing about whether a storm at sea is showing signs of abating when a tsunami (tidal wave) is fast approaching. The tsunami is AIDS. TB is one of the main opportunistic infections that attack people with AIDS; AIDS also often activates latent TB. Thus whatever the trend may be for TB at present or in the immediate future, it will not be many years before the AIDS epidemic expands to a point at which TB will again follow a sharp upward trend.

Notes

(1) See Gordon Hyde, The Soviet Health Service: A Historical and Comparative Study (London: Lawrence and Wishart, 1974), pp. 206-7, 227

(2) A critical view of the TB situation in this period is given by Sarah Helmstadter, TB or not TB, Post-Soviet Prospects (Center for Strategic and International Studies), No. 13, May 1992

(3) John Varoli, The Problem of Homelessness is Growing in Russia, Prism, vol. 3, no. 2, December 5, 1997

(4) See RAS No. 4 item 7 for a discussion of this point in the context of sexually transmitted diseases. People have motives to keep TB secret too. In particular, they are afraid that if their condition is known they will lose their jobs.

THE WORK OF WESTERN NGO'S IN THE REGION

6. TREATING MULTI-DRUG RESISTANT TUBERCULOSIS (MDR TB) IN RUSSIA: THE EXPERIENCE OF PARTNERS IN HEALTH

Donna J. Barry, NP MPH < This email address is being protected from spambots. You need JavaScript enabled to view it. > Program Director for the Russia Project at Partners in Health

Partners In Health (PIH) is a Boston-based public charity. Our mission is to provide a preferential option for the poor in health care. PIH attempts to achieve two goals in all settings in which we work: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair. PIH and its sister organizations in Haiti, Peru, Russia, and Boston have implemented effective TB and HIV therapy programs in resource-poor and logistically challenging settings. PIH is a consortium of health professionals and community health workers with close ties to a premier research university and teaching hospital ­ Harvard University and Brigham and Women’s Hospital.

PIH has over twenty years of experience implementing these programs in a variety of physical and clinical settings, including rural Haiti, the urban slums of Peru, the prisons of Siberia and the ghettos of Boston. All of these settings have disenfranchised populations of individuals suffering from poverty, disease, and lack of access to health care. All have faced major epidemics of inequality and infection, particularly with regard to HIV and TB, including multi-drug resistant TB (MDR TB). And all have successful, community based interventions for managing these diseases implemented by PIH and her local partners with excellent patient outcomes.

PIH began working in the central plateau in Cange, Haiti in 1984 with a team of anthropologists and physicians as well as a group of local religious and lay community leaders. Working with a team of community members, a survey was carried out of the region’s residents to determine their health care needs. Nearly all those who took part in the survey stated that the region needed a hospital where the area’s poor could receive free health care. In 1995, PIH began treating MDR TB after noting that DOTS was not curing many patients with TB. It was here that DOTS-Plus first began. Since 1996 we have been providing HIV education and in 1998 we began treating HIV with highly active anti-retroviral therapy (HAART). PIH and our local partner, Zanmi Lasante, are now treating over 400 patients with HIV and following 3,000 more HIV+ clients. In addition, basic primary health care services are now provided for over 200,000 patients per year as well as a variety of medical and surgical subspecialties, including infectious diseases, pediatrics, and women’s health.

PIH began working in Carabayllo, Northern Lima in 1995. We had been contacted by a parish priest living in Carabayllo who knew of our work in Haiti. During a large community-based survey to uncover the health problems in the community, a large number of individuals with “incurable TB” were found and in this way it became clear that MDR TB was a major problem. In addition, the parish priest had returned to the US for medical treatment of what was thought to be drug-susceptible TB. To our great sadness, he died soon after initiating treatment. It was subsequently discovered that he too had been infected with MDR TB.

While PIH first started treating MDR TB in Haiti, we became international advocates for appropriate treatment based on our experience in Peru. In the 1990s, the health care system of Peru was decimated by privatization and mismanagement. In this setting, a deadly new epidemic of tuberculosis took root and flourished, most often striking the most vulnerable citizens. On the outskirts of Lima in a dusty shantytown, a strain of TB that was resistant to many of the drugs commonly used to treat it became entrenched. People in the prime years of their lives were dying from MDR TB. The disease had already been encountered in many countries throughout the world, but had been deemed by public health experts as being too costly and too difficult to treat outside hospital settings in the rich countries of the world. Those living in resource-poor settings were simply left to die. MDR TB is spread through the air, thus posing a threat to the lives and health not only of those who suffer from the disease but also to their families, friends, and contacts, especially those in health care settings. Without proper treatment, not only does the individual patient die, but he or she also infects many more people, some of whom will become sick and continue the cycle of infection and death.

Working with a team of international MDR TB experts, the young members of the Carabayllo community elaborated a plan to begin treating the patients suffering from MDR TB in their area. Treatment of MDR TB in the community had not before been attempted and public health experts warned that failure was inevitable. Not surprisingly, when treated appropriately, the patients improved. Although once a small program, treating only ten patients in Carabayllo, through the generosity of the Bill and Melinda Gates Foundation, it has now expanded to treat more than 1,400 patients from all over the country. The results of the project have been excellent, with a cure rate of over 80 percent, higher than those achieved in much wealthier countries.

When the Soviet Union collapsed in the late 1980s, so too did the strong public health system that cared for the basic health needs of its citizens. Poverty and illness skyrocketed. In this setting of economic strife, petty crimes perpetrated for survival and drug addiction became a way of life for many Russians and the prison population exploded. In addition, national resources devoted to keeping TB in check in both the prison and civilian populations were greatly decreased. What was once an internationally known system of controlling TB, collapsed into a disorganized, underfinanced system of care and treatment. Although doctors were well trained and knowledgeable about appropriate TB treatment, they were forced to treat patients with inadequate medication regimens due to national shortages, all the time knowing that they risked increasing resistance among the population.

PIH developed a “several spigot theory" to explain the development of MDR TB in Russia, especially in the over-crowded prisons. The spigots include:

* High rates of transmission in pretrial detention facilities

* Drug resistance acquired though intermittent therapy and/or inadvertent monotherapy. If a patient is already resistant to two or three drugs in a four-drug regimen and is retreated over and over with the same drugs, it is likely that s/he will become resistant to the remaining drugs (inadvertent monotherapy leading to amplification)

* Transmission of drug-resistant strains in prisons and now, more often, in the civilian populations

* High rates of progressive TB due to poor prison conditions and deteriorating conditions related to poverty in civilian areas

* Patients with drug-resistant TB remain smear positive and infectious during and after treatment with first-line drugs and are likely to infect more persons

This deadly combination of factors led to a burgeoning health crisis in the Russian prison system, and subsequently in the civilian sector ­ that of an outbreak of MDR TB. The MDR TB problem in Russia was so daunting that public health experts began to come together to seek a plan of containment and treatment. In addition, after a DOTS program was initiated in Tomsk Province, it very soon became clear that patients were failing DOTS regimens instead of being cured and that MDR TB also needed to be addressed through adequate treatment regimens. Based on our experience in Peru and in advocating in the international arena for improved treatment of MDR TB, PIH was asked by the British NGO, Merlin and the Public Health Research Institute (PHRI) to step in and provide consultation and services for prisoners and civilians with MDR TB. PIH began collaborating with Merlin, PHRI, the Tomsk Province TB Service (TOTBS) and the Tomsk Department of Corrections on a DOTS-Plus project in September 2000. We provide technical and financial support for the use of second-line anti-tuberculosis agents. We have also started to examine methods to manage other health problems including HIV and alcohol abuse.

To date, 394 patients have been enrolled in the Tomsk DOTS-Plus treatment program. Although the setting of Siberia is quite different from that of Lima, Peru, many of the same MDR TB treatment principles have been applied. Patients are treated with 4--6 medications over a period of 18--24 months. Much of the treatment now takes place in out-patient settings, thus lowering costs and easing the burden of treatment for many patients. The program in Russia relies more on health care professionals (doctors, nurses, and feldshers [assistant doctors]) than on community health workers. (Community health work is not a well-developed profession in the former Soviet Union.) Initial results of the program, especially in the prison, based on smear conversion and treatment completion are very encouraging. Preliminary analysis of the patients with less than 6 months of treatment reveals projected cure rates between 80 and 90 percent.

The positive aspects of the program include:

* Deep commitment by Tomsk health professionals to treating MDR TB appropriately

* Extremely strong political and general program support from the local prison system and federal system, including high levels at the Ministry of Justice

* Political support at all levels in the province

* Well-trained staff

* Social support of patients including nutritional support, free transport to health care facilities, counseling by trained psych professionals and social workers

* Patients who are willing to be treated for up to two years

The problems the project is contending with include:

* Improving directly observed therapy of patients taking medications, in many cases twice a day; this is especially difficult when patients are treated in rural communities

* Decreased health budgets from the federal level due to federal deficits and the fact that international funding is available through our project

* Lack of strong political support at the Ministry of Health, although tacit support has been generated as a result of positive outcomes

* Continuation of economic problems in the area: more poverty means more TB

* Inconsistent drug supply of key medications needed to treat MDR as a result of worldwide shortages of certain medications and registration difficulties in Russia

* Low salaries for health professionals in Russia

PIH has committed to funding the treatment of 630 MDR TB patients in Tomsk Province. Unfortunately, due to steady rates of transmission, this is only about half of the patients needing treatment today. Tomsk Province has successfully applied to the Global Fund for AIDS, TB and Malaria (GFATM) for additional funding to treat the remaining patients. On October 17, we learned that the proposal was approved, paving the way for the Tomsk services to continue the program and build upon its successes. One enormous project success has been noted in the prison setting in Russia. In 2001, the case fatality rate of prisoners from TB was 144 per 100,000 prisoners. Since implementing DOTS-Plus, this number has decreased to zero in Tomsk Province.

While working in the projects in Peru, Haiti and Russia, on the international level, PIH still has two great battles to fight:

* The international community must be convinced that treating MDR TB is appropriate and possible in resource-poor settings.

* The cost of the medications needed to treat the disease must be reduced.

The first battle has nearly been won. The World Health Organization, with strong guidance from PIH, formed the Green Light Committee (GLC), which approves and assists projects treating MDR TB. Programs that are approved by the GLC can obtain second-line TB agents at concessional prices. Based on the programmatic and treatment successes of GLC projects, the WHO has officially accepted DOTS-Plus as an appropriate treatment methodology for treating MDR TB in settings where there are moderately high levels of MDR TB. Also, through the GLC mechanism, the costs of medications to treat one patient with MDR TB have decreased from $15,000 to just under $3,000. However, even this amount is prohibitively expensive for many TB programs.

The new Decree No. 109 issued by the Ministry of Health on March 21, 2003 to treat tuberculosis in Russia is based on the DOTS strategy and also allows for DOTS-Plus treatment strategies. However, it still relies on initially re-treating patients that fail DOTS regimens with inadequate regimens which may increase amplification of drug resistance. We are hopeful that once more evidence is available regarding the program successes in Tomsk and other GLC-approved projects in Russia it will become a national strategy. The Tomsk treatment model has been adopted by the Ministry of Justice and the Department of Corrections (GUIN) and they sent participants to our first national training course in November 2003.

THE WORK OF WESTERN NGO'S IN THE REGION

7. CENTRAL ASIA: TUBERCULOSIS IN THE ARAL SEA REGION

SOURCE. Helen Cox et al., High Rates of Resistance to First-Line Anti-Tuberculosis Drugs Among Patients from a DOTS Programme in the Aral Sea Area of Central Asia [Unpublished Report] (1)

The French NGO Médecins Sans Frontières initiated the Aral Sea Area (ASA) tuberculosis program in collaboration with the tuberculosis service of the Uzbekistan government in 1998. The DOTS strategy was introduced at two pilot sites (Muynak and Kungrad) in the formally autonomous Republic of Karakalpakstan in western Uzbekistan. These places are among those worst affected by the environmental degradation caused by the dessication of the Aral Sea.

In late 1998 it was decided to expand the program over five years to cover a larger part of Karakalpakstan and the contiguous provinces of Khorezm (also in Uzbekistan) and Dashoguz (in northern Turkmenistan). DOTS now covers 58 percent of the population in Karakalpakstan, 73 percent of the population in Khorezm, and the whole population in Dashoguz -- close to three million people in all. In 2002 almost 8,000 patients were treated under the program.

High initial failure rates -- 10 percent of new cases and 13 percent of re-treatment cases in 2000 -- suggested the presence of MDR TB. (2) It was therefore decided to conduct a drug susceptibility testing survey to assess the prevalence of MDR TB in the region, using three alternative definitions of MDR.

Between July 2001 and March 2002, 441 patients -- 76 percent of those eligible -- were recruited for the survey in Karakalpakstan and Dashoguz. Sputum samples were cultured and sent to a lab in Borstel, Germany to be tested for resistance to five first-line and three second-line anti-TB drugs. The TB bacillus was detected in 416 samples.

The rates of resistance to the first-line drugs for Karakalpakstan -- 13 percent of new cases and 40 percent of re-treatment cases -- were among the highest yet recorded for the world. The corresponding rates for Dashoguz -- 4 and 19 percent respectively -- were less extreme. Significant resistance was also found to one of the second-line drugs.

Logistic regression analysis was used to determine which factors might be associated with MDR. They found only two such factors: previous treatment for TB and female gender (women TB patients being somewhat more likely than men to have MDR TB). Surprisingly, neither previous imprisonment nor reported contact with other known TB patients in or outside the home was found to be a significant factor.

Why should MDR TB be so prevalent in Uzbekistan? The authors point out that during the 1990s the proportion of GDP, itself a declining quantity, spent on healthcare fell from 6 to 3 percent. Increasingly TB patients have had to pay for their drugs, especially after leaving hospital, often leading to premature termination of treatment. About half of TB patients have had their treatment interrupted by intermittent shortages of first-line drugs.

The authors suggest an economic explanation for the lower MDR rates in Dashoguz. Although Turkmenistan has also had problems, thanks to its wealth of natural resources (above all gas) it has been hit less hard. In particular, drug shortages are less severe.

In 2003 MSF initiated a pilot DOTS-PLUS program in Karakalpakstan to treat MDR TB with second-line drugs. Despite the high cost of these drugs, the authors conclude, the cost to everyone of not treating MDR TB is much greater than the cost of treating it.

NOTES

(1) The following is a full list of the authors of the report and their institutional affiliations:

Helen Cox, Juan Daniel Orozco, Dennis Falzon, and Roy Male (Médecins Sans Frontières, Aral Sea Area Programme)

Sabine Ruesch-Gerdes ( National Reference Center for Mycobacteria, Borstel, Germany)

Ian Small (University of Toronto, Canada)

Darebay Doshetov (Ministry of Health, Nukus, Karakalpakistan, Uzbekistan)

Yared Kebede (Médecins Sans Frontières , Amsterdam, Holland)

Mohammed Aziz (World Health Organization, Geneva, Switzerland)

(2) The presence of MDR is suspected whenever failure rates exceed 5 percent.

TB IN THE CAUCASUS

8. NOTES ON TB IN CHECHNYA, INGUSHETIA, DAGESTAN, GEORGIA, AZERBAIJAN, AND ARMENIA

CHECHNYA

Source. Natalya Estemirova, Chechnya Stricken by TB, IWPR Caucasus Reporting Service, No. 180, May 22, 2003

Conditions in Chechnya are ideal for the spread of TB. According to the republic's health ministry, 3 percent of the population is infected. Treatment facilities are on a miniscule scale because almost all hospitals are in ruins or have been taken over for military or police use. The World Health Organization operates an anti-TB program in neighboring Ingushetia, but not in Chechnya itself due to security concerns. Thus few people get drugs free and few people can afford to buy them. Most of those who do obtain drugs must be taking them on an inadequate and inconsistent regimen, thereby becoming foci for the spread of MDR TB.

INGUSHETIA

The rate of TB in neighboring Ingushetia is also very high due to the presence of a very large number of Chechen refugees living in overcrowded conditions. Medical facilities are somewhat better than in Chechnya itself.

DAGESTAN

Source. Polina Sanaeva, Novoe delo (Makhachkala), reported in Russian Regional Report Internet Edition, April 30, 1998

According to the author, the TB rate in Dagestan is four times the national average (seven times in districts bordering on Chechnya). Almost 10 percent of children are infected and will develop chronic TB. Existing TB clinics have the capacity to handle only one fifth of active cases.

GEORGIA

Source. Chris Bird, Impoverished Georgia fosters fatal form of TB, The Guardian Weekly, August 14-20, 2003, p. 3

The author reports that conditions in Georgia are perfect for the spread of MDR TB. Inconsistent and episodic use of anti-TB drugs results from the following factors:

* There is no regulation of the sale of anti-TB drugs on the open market.

* Patients cannot afford a steady and adequate supply of drugs. Even where treatment is supposed to be free of charge, with drugs provided free by foreign aid donors, in practice people have to pay -- and far more than the actual cost of treatment.

* Outdated ideas about TB remain widespread. Thus many physicians still take the traditional Soviet negative view of standard treatment regimens like DOTS. Georgians still believe in "the myth of fresh mountain air" as a cure for TB.

AZERBAIJAN

Source. Namik Ibragimov , Death stalks Azeri prisons, IWPR Caucasus Reporting Service, No. 184, June 19 2003

The author reports that 49 percent of Azerbaijan's 18,000 prisoners have TB. Jails are overcrowded and rations are meager and of poor quality. TB accounts for three-quarters of deaths in detention. Due to corruption sick prisoners have to pay for treatment, generating MDR TB.

ARMENIA

In Armenia the rate of incidence of TB has been reduced to a relatively low level by an effective TB control program run by the Health Ministry and backed by the highest levels of government.

RUSSIAN BOOKS ON TUBERCULOSIS

9. TB IN RUSSIA'S PENAL SYSTEM

Source. Meditsina v penitentsiarnoi sisteme Rossii (sbornik) [Medicine in Russia's Penal System (Handbook)] (Moscow: Prava cheloveka, 2001)

This book was produced by the NGO "Novyi Dom" [New Home] in collaboration with the Main Penal Administration (GUIN) of the Ministry of Justice (1) with the support of the European Commission under the aegis of the European Initiative for Democracy and Human Rights. Intended mainly for medical personnel working in Russia's penal institutions, it contains material of various kinds, including information about European and international practice, such as a document of the World Health Organization about the DOTS strategy. Our interest here is in the articles about the problem of TB in the Russian penal system.

E. Khromova (New York Institute of Health) gives some basic figures. Out of roughly a million prisoners, some 10 percent have active TB and about a third of these have MDR TB. The rapid turnover of the prison population -- each year about 300,000 enter the system and a similar number are released -- spreads TB and MDR TB throughout the rest of the community. She forecasts that by 2010 at least two and a half million Russians will have MDR TB.

Colonel V. G. Borodullin, deputy head of the medical administration of GUIN, surveys the TB treatment facilities within the penal system. There are 36 hospitals solely for TB, while 50 of the GUIN's remaining 94 hospitals have special divisions for TB. These TB hospitals and divisions contain 13,530 beds. Nevertheless, many of the other 14,610 beds in GUIN's hospitals also hold TB patients. Therefore TB patients occupy a majority of all beds.

In addition, there are 57 prison colonies especially for tubercular prisoners, with a total capacity of 57,546. Nevertheless, these colonies were filled well in excess of capacity and there was still a shortage of places until a large-scale amnesty relieved the pressure.

Besides overcrowding, Borodullin complains about the following problems:

* Living conditions for prisoners with TB do not meet sanitary norms.

* 30 percent of posts for medical personnel are unfilled.

* Funding from the federal budget is grossly inadequate. It hardly suffices to pay staff and feed patients standard rations. They do NOT get the special rations to which they are theoretically entitled and nothing is left to buy drugs or equipment.

* Shortages of equipment and medicines make treatment ineffective and generate MDR TB.

* Some regions refuse to set up facilities for their tubercular prisoners, whom they dump unfairly on other regions. For instance, St. Petersburg and other northwestern regions send all their tubercular prisoners to the salubrious surroundings of Karelia in the far north.

* An increasing number of people with TB are entering the investigative isolators (SIZOs), the prisons where newly arrested individuals await trial. (2)

S. V. Sidorova and S. G. Safonova, senior physicians in the GUIN medical administration, discuss the treatment of TB in the penal system at greater depth. They estimate that 40 percent of tubercular prisoners are resistant to at least one basic drug and 10 percent have MDR TB. However, due to a lack of diagnostic lab facilities almost half the patients receive treatment that takes no account of drug resistance. As a result of intermittent drug supplies and for various other reasons, courses of treatment are continually being interrupted.

There is often no follow-up on release. A patient's documents are sent to the TB service of his region of previous residence, but about half of released prisoners do not return to that region.

Two articles are devoted to an experimental project in Tomsk province using DOTS and DOTS-PLUS strategies with support from the British NGO Merlin and the New York Institute of Health. One aspect of the project was improved coordination between the GUIN medical administration and the local medical service for the non-prison population.

The second of these two articles focuses on the inadequacy of the prison diet -- in particular, lack of protein and vitamins. After three months of treatment on the DOTS-PLUS program, 37 patients with MDR TB had lost on average 16 percent of their body weight. Half of them regained their initial weight thanks to supplementary food paid for by the New York Institute of Health (beef stew, eggs, milk, curds, yogurt, sugar, and dried fruit) (pp. 102-3). According to official norms, tubercular patients are supposed to receive rations of these foods. (3)

Notes

(1) GUIN used to be subordinate to the Ministry of Internal Affairs (MVD) but a few years ago was transferred to the Ministry of Justice. It is hard to imagine that it would have cooperated in producing a book such as this when it was under the MVD.

(2) The Ministry of Justice proposes limiting the time that a person can be held in a SIZO to one year (or six months for adolescents). Still long enough to catch TB!

(3) The food norms for various categories of prisoner are tabulated at the end of the book. Norm No. 7 states that prisoners with TB should get 150 grams of meat a day, 40 grams of butter, 45 grams of sugar, 350 grams of vegetables, 500 grams of milk, 50 grams of curds, 15 grams of fruit, and half an egg. Corresponding daily norms for ordinary prisoners are 80 grams meat, 30 grams sugar, and 250 grams vegetables; they get no butter, milk, curds, fruit or eggs.

RUSSIAN BOOKS ON TUBERCULOSIS

10. THE DOCTOR'S ADVICE

Source. K. A. Sergeyev, Tuberkulez: reshenie nabolevshei problemy [Tuberculosis: Solution of an Urgent Problem] (St. Petersburg: Nevskii prospekt, 2002)

This booklet is part of a popular series entitled "The Doctor Advises" addressed to people suffering from various diseases. Much of the information and advice that it contains is similar to what one might find in a Western publication of the same kind. However, the differences in tone and content are also very striking, and I focus on these.

Any modern (i.e., postwar) Western work on the treatment of TB will be primarily about the use of anti-TB drugs. This author too discusses drugs, but only as one element of a "many-sided" approach to treatment that also includes:

* "collapse therapy" (of a single infected lung) and other surgical procedures;

* tuberculin therapy and immunotherapy;

* natural therapy (fresh air, sunshine, water, rest and sleep);

* physiotherapy (electroflorescence, ultrasound, aerosol therapy, X-ray therapy, massage); and

* popular remedies such as honey, herbal teas, and koumiss (fermented mare's milk, and also aromatherapy, using lemon, fir, or juniper.

The author also emphasizes repeatedly that it is essential to abstain from alcohol, keep regular habits, and in general lead a healthy way of life.

Well, what's wrong with all that? Many of these things may do some good or at least harmless. For instance, the circulation of fresh air helps the patient breath more easily and reduces the risk of infection for others living with her. But to get fresh air a window must be kept open even in the depth of winter, so the patient is advised to inure herself to cold (p. 80). That is perhaps less beneficial. In any case, fresh air, massage, and lemon aroma do not kill bacilli, so it seems strange to attach the same importance to them as to proper medication.

The problem of the TB bacillus acquiring resistance to a specific drug is discussed, but the impression is conveyed that it is an inevitable process (pp. 59-60). No mention is made of the simultaneous use of several drugs to minimize the development of resistance. It is mainly the reliance on monotherapy (use of one drug at a time) that makes drug treatment so unreliable and thereby stimulates the continued use of outdated methods and the endless search for exotic therapies.

TUBERCULOSIS AND CULTURE

11. CHEKHOV AND TUBERCULOSIS

SOURCE. Thomas Dormandy, The White Death: A History of Tuberculosis (New York: New York University Press, 2000), Chapter 17

A galaxy of famous and not so famous writers, poets, artists, and musicians of the eighteenth, nineteenth, and early twentieth century suffered and died from tuberculosis. (1) Thomas Dormandy -- a consultant pathologist as well as a historian of medicine -- tells the story of several of these tragic figures: Keats, the Bronte sisters, Chopin, Schiller, Thoreau, Modigliani, Kafka, D. H. Lawrence, Orwell. Here I focus on his study of the nineteenth-century Russian playwright Anton Chekhov.

The author demonstrates the enormous, albeit largely hidden, influence that tuberculosis had not only on the lives of its victims but also on their creative work, and thereby on the whole classical culture of modern Europe to which we are heirs. (2) Chekhov's last plays, the ones for which he is best known -- The Seagull, Uncle Vanya, The Three Sisters, The Cherry Orchard -- provide a good example.

These plays have a timeless appeal despite the fact that they meet none of the standard dramatic or socio-political criteria. They are not exciting, funny, morally instructive or politically relevant. Perhaps they could be considered tragic, but their tragic quality is a low-key undertone, not the high-strung display of tragedy as a genre of classical drama.

In Dormandy's view, the plays "are unique insider studies of the tuberculous destiny without once mentioning the illness." Tuberculosis is the secret presence in the world of the young characters that "does not stop them from speaking, feeling, thinking and dreaming but stops them from trying to enact any of their thoughts, feelings and dreams" (pp. 189-90). The reticence too reflected real life: the tuberculous rarely referred to their disease in conversation with the healthy, and if they did so they resorted to euphemisms. (3)

The tuberculous interpretation of Chekhov's last plays also has a bearing on the style in which they should be performed, which from the start was a matter of dispute between the rival theatrical directors Stanislavsky and Meyerhold. Chekhov himself felt that Stanislavsky overdramatized the plays, "serving up a suet pudding" when what he had in mind was "a soufflé." (4)

NOTES

(1) Many famous scientists and physicians shared the same fate.

(2) He is not the only historian of tuberculosis to take this view. See, for instance, René and Jean Dubos, The White Plague: Tuberculosis, Man, and Society (New Brunswick, NJ: Rutgers University Press, 1992 -- first published 1952), especially chapter 5 on "consumption and the Romantic Age."

(3) There is one play, Ivanov, in which tuberculosis is mentioned by name, but Chekhov wrote it before he got the disease.

(4) The Soviet censorship suppressed evidence of conflict between Chekhov and Stanislavsky.

JRL Special Issue No. 21. January 2004. Tuberculosis in the Post-Soviet Region

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