CARMEL, Calif. — The fall of the Soviet Union left the newly formed Russian Federation with more than economic problems and political difficulties. As unemployment, poverty and crime increased in post-Soviet Russia, tuberculosis took advantage of the new vulnerable populations and rose to dangerously high levels. The disease continues to plague the country today with only limited success in its prevention or treatment.
Russia is ranked 11th in the world for the highest struggle with tuberculosis (TB) and third of the 28 countries with a high incidence of multi-drug resistant TB (MDR TB,) according to the World Health Organization. About 30.3 percent of TB cases are drug resistant, making them much more difficult and more expensive to treat. To make matters worse, although TB overall is slightly decreasing, MDR TB is increasing, meaning more of the remaining cases are drug resistant. Today, almost 50,000 cases do not respond to the two common and potent drugs.
Tuberculosis affects different regions of Russia at different levels. The eastern part of the country, closer to Mongolia and China, has nearly 10 times the incidence of TB as Moscow in the western region. This is partly because the western region is more developed and less impoverished, but the fact remains that TB anywhere is a risk to everyone.
The groups that are most at risk for developing TB are the same candidates for other similar virulent diseases. In fact, a large portion of patients have a co-infection of TB and AIDS. These risk groups include heavy alcoholics, drug addicts and the homeless. Unfortunately, these are also the hardest patients to track down and treat. One of the greatest flaws of Russian programs to prevent TB is their ineffectiveness at keeping the disease from spreading in risk groups.
One of the biggest risk factors for tuberculosis is poverty. The World Bank considers Russia a high-income nation, but a significant portion of the country lives in crippling poverty. This strongly affects the rates of TB. Of new TB cases, 40 percent to 70 percent are in poverty. On top of this, the prevalence among the unemployed is 750 cases per every 100,000 people, which is much higher than the 45 cases per 100,000 people among employed. The reason the disease is much more common in impoverished populations centers around a lower standard of living, less hygiene and less education on health habits and the disease itself. All of this makes impoverished regions much more vulnerable to the large-scale spread of TB.
In addition to the common risk groups, tuberculosis in Russia is particularly famous for infecting prisons at an unfathomable rate. While cases have decreased from 4,347 per 100,000 prisoners in 1999 to 1,308 in 2008 and deaths have decreased from 238 to 80 in the same time period, prisons still struggle significantly to keep TB in check among inmates. MDR TB has a particularly high rate in prisons because inmates often fail to finish treatment before release or contract the disease multiple times in transport between facilities. In addition, TB is incredibly infectious and spreads quickly in close, unsanitary quarters. All of this allows the disease to come become more aggressive and less responsive to treatment.
Tuberculosis in prisons endangers the entire community. Prisons act as a reservoir for MDR TB, meaning that these facilities keep the disease alive in the population. Lowering the prevalence of TB in prisons is key to decreasing its presence in the entire community.
Luckily, Partners in Health, an American organization, operates the Medical and Penal Institution Number One clinic in a Siberian prison. Prisoners in the area infected with TB are sent to this secure treatment center for part of their sentence until they recover. Because of this program, infection rate is down nearly seven percent and the death rate has dropped. Evidence shows that prisoners who have successfully gone through the treatment process have a better chance of reintegrating fluidly into society and staying out of prison in the future.
Partners in Health also runs successful programs to target other at risk groups. Sputnik, one of their most successful practices, is a mobile clinic that has been operation in the Tomsk region since 2006. The program sends nurses around the city twice a day, locating patients with MDR TB and administering medication. It is often difficult to keep track of patients, but Sputnik has cure rates of up to 90 percent, showing that while unconventional, it is an incredibly effective program.
However, while these Partners in Health programs are showing great success in their target regions, in order for TB to decrease significantly across the country, more needs to be done over a wider area. Russia needs to take steps to revamp its early detection and prevention program that started in 2010, as well as implement new structures that will help keep tuberculosis out of at risk neighborhoods and prisons. Successful programs could look like Partners in Health’s ideas, but these practices need to be spread across the country. Russia is too developed a nation to struggle so significantly with tuberculosis, and it is time it steps up to tackle its public health.