TB in Russia

Your average TB-infected Muscovite. Photo by Christopher Cole

Tuberculosis is a contagious disease that spreads through the air just like the common cold. Someone with TB can cough or sneeze and infect others (10 to 15 people a year on average) with the bacteria known as bacilli. Getting the bacilli does not necessarily mean getting the disease, however. It is estimated that over a third of the planet’s 6.5 billion people currently have the bacilli. It’s not until the immune system is weakened or compromised that tuberculosis sets in. This is the reason that TB and HIV/AIDS is such a common tandem. According to the World Health Organization, tuberculosis is the most common cause of death worldwide for people who are HIV positive. Tuberculosis is not a disease that you can just throw money at and expect to go away. It is actually better to leave a person infected with tuberculosis rather than risk improperly administering antibiotics and treatment, but this requires a stable and attentive medical infrastructure. If the drugs are taken for too short a time or erratically, the bacteria evolve into a condition know as MDR(Multidrug-Resistant)-TB, which is more contagious and incredibly difficult, if possible, to treat. So far the most effective strategy for preventing the spread of MDR-TB is a program implemented by the WHO called DOTS (Directly Observed Treatment with Short-Course Chemotherapy). The man responsible for the most comprehensive TB and MDR-TB treatment models is Paul Farmer. His work as both a doctor and anthropologist is unparalleled in terms of producing large-scale results in areas of the world where TB runs rampant amidst little to no health care. Through coordination with the DOTS program, his organization Partners In Health (PIH) has facilitated huge leaps forward in how TB is addressed around the world, in particular emphasizing the need to assess medical infrastructure as well as social conditions. As Farmer said in a speech before the TIME Global Health Summit in 2005,
"Treatment that is supervised and community-based is simply better care for chronic disease. This model of care, tuberculosis experts will tell you, is the first line of defense against acquired resistance to many antibiotics. Good, supervised care will slow the acquisition of drug resistance; trying to keep medications from the poor will not. And community-based care isn't some sort of proprietary model, but one that we should adopt simply because it works. In the poorer reaches of the world, I don't believe any other model will be as effective. We need tools that will come only from basic science; we need to invest in health care delivery." (Paul Farmer speech entitled "The case for optimism", Time Global Health Summit) Post-Soviet Russia was in many ways an ideal breeding ground for tuberculosis and MDR-TB. The collapse of the USSR led to a severe decrease in health care quality and translated into many incomplete antibiotic courses. The high rate of unemployment and poverty catalyzed a dramatic increase in crime, which the state reacted to with a firm crackdown. The result is overcrowded prisons rampant with TB, an incredibly high percentage of which are MDR-TB. When you add other factors, like the prevalence of malnutrition, HIV/AIDS, poor ventilation, and limited access to medical care, the active development of bacilli and the fruition and transmission of the disease within prisons increase dramatically. Even outside of prisons, alcoholism, crowded urban housing, and inadequate nutrition continue to provide a medium for tuberculosis to flourish. Conservative estimates put the rates of contracting tuberculosis within Russian prisons at 40 to 50 times higher than in the civilian population, which are already among some of the highest of the world. And the situation only continues to get worse as a revolving traffic of visitors, staff members, and former inmates allows the prison to act as a sort of epidemiological reservoir and pump. Old Soviet pride doesn’t want Russia's mismanagement of health problems on display for the world. Similarly, paranoid rumors that TB-fighting pioneers like Farmer were actually spies using patients as their front haven’t helped the situation. As a result, PIH and other likeminded organizations have encountered stiff resistance to their efforts within Russia. The Putin administration has taken unusual steps in the last six months to rein in foreign organizations that have involved themselves in these kind of issues. Several new laws were passed this fall that allow the government to expel any foreign NGO operating in Russia without justification. The absence of openness and the rule of law there has been a severe impediment to attempts to address the worsening public health conditions. Russia represents a unique and interesting case in that it is the only industrialized country with a PIH chapter. The economic reforms that followed the collapse of the Soviet Union left whole segments of Russian society in destitution. One of the principal conditions of the structural adjustment loans the IMF provided Russia in the early 90s was that it cut spending on social programs. The infrastructure of the national healthcare system was already badly under-funded, and structural adjustment left it in shambles. The economic turmoil of the post-Soviet period has eroded the social fabric of the nation. Despite the fact that they represent an educated and highly-skilled population, most Russians live in a state of ridiculous poverty. Money extended to fighting the TB epidemic in Russia will be more than a worthwhile investment. All morality aside, this is a situation that will affect Russia and the world in a massive way if mishandled or left alone. It will become an exponentially heavier burden and more and more difficult to address the longer it is allowed to metastasize. Tuberculosis is a social and economical disease. There is no clearer example of this than Russia and the fact is that the path that this disease takes within its borders and beyond will be almost entirely dictated by international aid and infrastructural health care reform. JOHN JAMES