A Turning Point in the Fight Against Tuberculosis in Russia

Novosibirsk, Russia -

“I knew how it all finishes. I was surrounded by death,” she says three years later.

Today, Stepanova, a chirpy 46-year old carefully attired against the autumn chill, is alive and well. Her first grand-child was born recently, she has resumed her hospital work and she is confident that the rigorous anti-TB treatment she followed has rid her body of the debilitating disease.

Her victory is one that health specialists working here are hoping to replicate on a massive scale -- not only in Novosibirsk but all over a country affected by a virulent resurgence of tuberculosis, an age-old condition known to the Greeks as phthisis or consumption. The challenge is enormous -- a simple sneeze can transmit the disease -- and further complicated both by the spread of multiple-drug resistant (MDR) tuberculosis strains, and the increasing number of people whose immune systems are compromised by HIV/AIDS.

In the past, Russian anti-TB practices were heavily centralized and relied on mass x-ray screenings. Treatment included lengthy hospitalizations and allowed for variations in the drug regimens followed by patients. This arsenal, however time-tested, was no match for the doubling of tuberculosis cases which coincided with the economic hardship and stress of the 1990s. (1.1 million people, or almost 1 percent of Russia’s population, developed TB in 1995-2004.) Nor were decrepit Soviet-era medical facilities, neglected in the turbulent years of post-Communist transition, in any shape to fight the airborne disease.

Spurred by a TB and HIV/AIDS Control Project conceived by the World Bank and supported by a $150-million loan, Russia’s health care system recently adopted a more rigorous strategy for the diagnosis  and treatment of tuberculosis.

TB patient taking drugs under  observation in Vladimir.

This strategy, developed and promoted with technical assistance from the World Health Organization, represents a momentous “paradigm shift for Russia,” according to the World Bank project’s team leader Patricio Marquez.

Although Russian TB doctors and health authorities were initially wary of DOTS, the approach has gradually won over skeptics and is now the law of the land: Federal orders No. 109 and No.50, issued by the Russian Ministry of Health in 2003 and 2004, set guidelines for detection, therapy and reporting of TB cases which conform to international standards. The strategy which was applied in just three regions 10 years ago, now covers Russia's 86 regions.

“I believe we’ve reached a turning point,” says Vladimir Krasnov, director of the Novosibirk Research Institute of Tuberculosis, an institution that leads and monitors TB efforts in Russia’s immense Siberian territory. “We needed time to prepare doctors and change people’s mentalities but implementation is going ahead.”

So far, 358 trainers have been trained under the World Bank project, and more than 7,000 units of medical equipment have been shipped to the four corners of the Russian Federation.

“Help came just at the right time,” recalls Dr. Svetlana Kruglova, a physician at the main tuberculosis hospital for the region of Vladimir, 190 km east of Moscow -- a time when “economic and social conditions were very difficult,” she says.

Dr. Kruglova has seen the profile of TB patients move away from older alcoholic men (the disease’s usual contingent) towards “younger, more female and more active patients.” Her patients Denis, a 21-year old tourism student, and Liudmila, a 51-year old factory worker and mother of five children, are representative of this new wave and a sign that the epidemic is still in a threatening phase.

TB is a so-called "social disease" that appears at  the crossroads of health and living standards.

Nationwide, the 1990s, which combined a deep socio-economic crisis with a health care system in tatters, provided fertile ground for the spread of TB. Following the financial crisis of 1998, “people who were already living very precariously saw their real incomes drop by 25 to 30 percent at a time when government spending was also falling,” explains John Litwack, the World Bank’s chief economist in Moscow.

The TB facility where Dr. Kruglova works moved three years ago from a small dilapidated location in the center of Vladimir to a multi-storied building, equipped with proper ventilation and modern laboratory equipment provided in part under the World Bank project. Staff at the new dispensary is better able to separate patients according to their level of infectiousness and implement WHO recommendations.

A network of 170 low-quality labs in the Vladimir region is being pared down to 22 quality centers. There, equipment and training financed by the World Bank project, WHO and other donors such as USAID, is already making an impact. “The quality of diagnostics has improved and the risk to the personnel has decreased,” says Dr. Grigory Volchenkov, chief TB physician for the Vladimir region and head of the regional TB dispensary.

Dr. G. Volchenkov is leading anti-TB efforts in the Vladimir region, where DOTS was first introduced in 2000.

Nationwide, this type of comprehensive approach is yielding higher numbers of notified tuberculosis cases among previously unscreened or misdiagnosed groups, including patients in the late phase of tuberculosis who are harder to cure. As a result, Russia’s TB morbidity and mortality rates remain uncommonly high. But improved diagnosis and care hold the promise for better treatment success rates over time.

TB incidence in prisons is decreasing but drug resistance is on the rise.

Laboratory equipment and an adequate supply of drugs are still crucial to ensure further progress. “We can not fight TB with bare hands,” says Anatoly Byrgazov, director of Novosibirsk’s regional hospital-prison. He is thankful, in this regard, for the material support provided both by the World Bank and the Global Fund.

The challenge is to ensure that prisoners continue to follow a strict drug regimen once they are discharged. In Novosibirsk, only 28 percent of freed TB prisoner-patients find their way to TB dispensaries according to Dr. Maxim Dubin, chief TB specialist of the region's correctional services. One of the World Bank project’s aims is to reinforce the coordination between the penitentiary and civilian health sectors so that ex-prisoners, who are often homeless or social out-casts, are kept in the medical loop.

First published October 20, 2006