By Nabi Abdullaev
According to medical standards, one lethal case of the tubercular meningitis marks the downfall of epidemiological services in a given region. In 1999, ten children with this diagnosis died in the Russian southern republic of North Ossetia. Experts believe the situation is even worse in other republics adjacent to the breakaway Chechnya is even worse.
During the last ten years the population of the Russia’s provinces, many of them mired in poverty and, in the south, torn by armed conflicts, lost access to basic health care. The overall collapse of social infrastructure worsened the problem, resulting in Russia placing eleventh on the list of the world’s high-burden TB countries in 1999, with newly detected TB cases increasing by 8.3 percent (123,403 cases). Russia’s rate is ten times higher than the average for Western Europe, and the figures for Russia do not reflect the full picture, given that data on TB situation in Chechnya have not been available for years. According to the Russian Federation’s Ministry of Health, TB morbidity in the Northern Caucasus is 20-35 percent higher than the average for the country as a whole.
Experts say that the official statistics provided by Republic of Ingushetia’s state medical institutions, which indicate that the republic’s TB morbidity rate has reached eighty-four per 100,000 of the population, are not reliable, given that far less than half the population was examined. Dagestan’s Ministry of Health estimates the republic’s TB caseload at roughly 30,000 (10,000 of whom are children). This comes to ninety cases per 100,000 people. In the areas bordering Chechnya, which are flooded with refugees, this ratio jumps to 150 per 100,000. Six thousand five hundred of those infected with TB suffer from its active form. Ten percent of the republic’s children are potentially chronic patients because there is no possibility of isolating them from their sick parents. Over the last five years the TB caseload in Ingushetia has increased 42.4 percent while the mortality figures have risen 37 percent. Only 50 percent of those cases detected can be cured (the overall Russian rate is around 80 percent). More than one-third of those cured soon contract TB again. In 70 percent of the cases detected, the patients have suffered decay of the lung tissues.
By the end of 1998 the main TB hospital in Makhachkala, the capital of Dagestan, was destroyed by the residents of the neighboring district. They justified their actions by pointing to the absence of a proper sewage system in the hospital and the fact that wastewater from the hospital had flowed into the streets and thus threatened the health of people living nearby. Two hundred patients from the clinic suffering from the active form of TB now live in Makhachkala without proper treatment.
“The epidemiological institutional structures were practically absent in Chechnya,” said Doctor Nana Gvetadze, Northern Caucasus coordinator of the World Health Organization’s (WHO) TB program. “In the surrounding republics, anti-TB services are in a very poor condition–often they even don’t have the film for a fluorographic examination. The population’s high level of migration aggravates the situation by hindering access to impartial statistic epidemiological data.”
Elizaveta Dzaranova, the head of TB-dispensary in Ingushetia, reported that 2,800 refugees who had arrived from Chechnya with acute TB had applied for medical help in the last six months. Officials from Ingushetia’s Health Ministry examined 16,860 refugees who had arrived from Chechnya in March, and found that 215 of them had TB, seventy-one of them in its active form. No treatment had been available to them Chechnya for years.
Since the international relief agencies established an effective presence in the North Caucasus in the mid-1990s, they have mainly concentrated on distributing medical and food supplies. WHO chose a more long-term approach, focusing on developing diagnostics and introducing DOTS, the Directly Observed Treatment System for tuberculosis, which has already proved successful in other parts of the world. The main impact of DOTS is that it has introduced microscopic examination and out-patient procedures in which medical personnel regularly visit the patient and control the treatment’s course in parallel with the X-ray examination and in-patient treatment that is traditional in Russia. Direct microscopy analysis of the patient’s sputum for early case-detection is an easier and cheaper alternative to the traditional X-ray check up. This method allows the quick identification of TB at any medical station.
Since March 1, 2000, 120 physicians from Stavropol region have been training in microscopy analysis in Moscow on a WHO-sponsored program. In addition, twenty-five binocular microscopes were handed over to medical institutions in Stavropol krai, thus leaving the region fully equipped for effective TB-control of the population. One hundred and twenty specialists from Northern Ossetia have also been trained by specialists sponsored invited by WHO, and 30 doctors from Dagestan underwent the advanced training courses in May 2000. WHO also plans to help provide the republics of Northern Ossetia, Ingushetia and Dagestan with centralized epidemiological laboratories and to equip existing ones with the binocular microscopes.
In introducing DOTS, the WHO has met often meets resistance from Russian health workers. “The method of TB-diagnostics proposed by the WHO is applicable mainly to bacilli-excreting patients,” explained Raisa Ekazheva, Ingushetia’s Deputy Minister of Health. “But very often we encounter with locked centers of infection in the lungs. Such sick people don’t excrete bacilli. These cases can be identified only with the help of X-ray or fluorographic examinations.”
Dagestan’s Ministry of Health is very interested in cooperating with the WHO, but the prevailing opinion among the republic’s health workers is that introducing DOTS corresponds with social conditions that are more ideal than reality offers.
“We accept everything positive and applicable that DOTS offers, but we cannot refuse X-ray examination,” said Abdurazak Adziev, the head of the Anti-TB Dispensary in Makhachkala. “It is also impossible to refuse in-patient treatment and to observe the patients at home. We just don’t have enough personnel for this, and those we have need additional training.”
In the meantime the WHO’s proposal does not mean that traditional schemes of diagnostics and treatment must be abandoned. The main impact of DOTS lies in the sphere of public health care. The rapid identification of bacilli-excreting contagious patients with DOTS methods serves more to prevent the spread of the disease than to cure the individual patient.
“When the WHO tries to offer DOTS to the Russian health workers, we meet enormous resistance,” said Mikko Vienonen, the WHO Director General’s special representative Russia. “At the same time DOTS is as effective as the Russian method of treatment, and three times cheaper.”
The extremely poor condition of the health-care system in Russia’s regions makes any assistance significant. But while the WHO has been helping to fill the gap in controlling the spread of TB in the Northern Caucasus, the need for diagnostic equipment and personnel remains dire.
According to Ingushetian Deputy Minister of Health Raisa Ekazheva, until recently Ingushetia had only one stationary and several Mobile X-ray units to cover the needs of more than 500,000 people, one-third of them refugees from Chechnya. The equipment was quite old and was often not in working order. Since the republic has no means for repairing medical equipment, it takes weeks put the X-ray units back into action. Meanwhile, the system for training medical specialists and upgrading their qualifications collapsed many years ago.
“These kind of shortages–both [in terms of] equipment and the lack of the qualified personnel among the radiologists–preclude us from creating more or less secure system of TB-monitoring,” Ekazheva said. “We are collecting people from the remote areas to be examined, and they cannot wait for weeks until we try to repair our equipment.” Abdurazak Adziev, The head of Anti-TB dispensary in Makhachkala, Dagestan, supports this point of view. “The procurement of 3-4 mobile X-ray units would help us substantially,” he said. “Without them we cannot examine the residents of the remote mountainous areas of the republic.”
In Ingushetia, statistics from the republican Ministry of Health show that two thirds of the 150 beds at the republican Anti-TB Hospital are occupied by the refugees from Chechnya. The republican health-care structures, meanwhile, have been trying to increase their efforts in fighting TB. The republican Ministry of Health earlier this year approached President Ruslan Aushev with the request for additional help. Aushev ordered that the daily ration of food and medicine for the TB patients be doubled, and two additional stationary X-ray units were purchased. All the refugee children in Ingushetia–numbering 29,886, according to Minister of Health Kambulat Uzhakhov–were TB-vaccinated.
The direct distribution of medical supplies has not been sufficient to thwart the spread of TV. “Tuberculosis cannot be cured in a week, it takes six to twelve months of the therapy depending upon the case,” said Nana Gvetadze of the WHO. “Our statistics shows that 20 percent of the Russian patients drop even the therapy that is available to them. The relapse cases of TB, which make up as much as 30 percent of the total quantity, demand eighteen months of hospital therapy–usually an impossible option both for the patient and for the state-owned hospitals.” DOTS could make the problem less difficult.
Tuberculosis is closely related to social problems. The number of Russians disoriented by reforms continues to grow. While earlier prisoners, alcoholics and tramps were within the TB risk group, this category has widened to include the unemployed, divorced and lonely people, pensioners and invalids–in general, those who rely exclusively on state assistance and cannot afford proper nutrition and care. The situation is particularly acute in the Northern Caucasus, which is burdened by tens of thousands of refugees. The decline in living standards was followed by a decline in the health culture of the population. Many Russians are not able to visit medical institutions in time, and only members of the well-off elite can afford to attend sport clubs regularly. Under the Soviet system, patients with TB enjoyed a number of the social privileges. The main one was access to separate dwellings on preferential terms. Since 1991, according to the WHO, the number of privileges was reduced drastically, and sick people increasingly opted for self-treatment, which increased the number of patients with drug-resistant strands of TB. The latter fact brings to the therapist the patients with the resistant brands of TB. In the years of Chechnya’s de-facto independence, the local population was not properly vaccinated, which increased the risk of TB spreading in the area.
The statistics collected among migrants applying to medical institutions for TB treatment in the Northern Caucasus indicate that 44.4 percent of the newcomers have MDR–or multidrug resistance–a result of the uncontrolled and improper use of medicines.
The treatment of TB is a systematic process that cannot be interrupted. The refugee situation in the Northern Caucasus prevents the launch of a large-scale treatment campaign. Refugees currently being treated with medicine now risk to getting MDR as the result of interrupted treatment. This will only worsen their condition. This is why at the very beginning of the humanitarian operation aimed at refugees fleeing armed conflicts in the North Caucasus, the international relief agencies concurred with WHO’s decision not to distribute anti-TB drugs to the refugees. WHO was heavily criticized for this decision, given that international media outlets were very persistent in attracting the public attention to the TB situation in the region. Despite the public pressure, the WHO in Russia was firm in adhering to one of the basic principles of medicine: do no harm to the patient.
There are grounds for hope in the fight against TB in the Northern Caucasus. WHO experts cite the relatively high qualifications of the local medical personnel and the small distances between the settlements in the region. However, as the WHO’s Nana Gvetadze noted, long-term success will be possible only if the state structures join in the anti-TB effort and the local population is provided with jobs and a living wage.
Nabi Abdullaev is a journalist based in Makhachkala, Dagestan.