The Silent Killer

The Silent Killer

Following a decade of social and economic upheaval, Russia’s tuberculosis rate has surged. The number of infected persons has doubled since 1991, from 34 cases per 100,000 to 78 per 100,000 in 1998, according to the US Centers for Disease Control. Last year alone, about 120,000 new cases of TB were diagnosed, according to the Russian Health Ministry. 

TB also now counts as one of the country’s leading killers. Though curable in 95% of cases, some 25,000 Russians die each year from TB, according to the state statistics agency (of the 8 million persons worldwide who get TB each year, 2 million die, according to the US CDC). That works out to a per capita mortality rate for TB of 17 per 100,000, far greater than the U.S. rate of 0.5. The reason for the problem is simple: Russian doctors, through little fault of their own, are not treating the disease properly and in time.

Most of the victims of TB are from the lower classes and those on the edge of society—prisoners and the homeless. As an airborne disease, it flourishes in areas of social and economic crisis, where there is poverty, overcrowding, alcoholism, and drug abuse. Yet TB is not as infectious as commonly believed. According to Vladimir Zhemkov, chief physician at the St. Petersburg Tuberculosis Center (SPbGTTs), if a person infected with TB comes into contact with 100 persons every day for a year (i.e. 36,500 people), just 12-16 of those persons will contract the disease. 

While 80% of TB cases affect the lungs, the infectious disease can attack almost any part of the body. Doctor Svetlana Sanayeva, head of the eye department at SPbGTTs, says many people do not realize that TB can infect eyes, skin, genitals, etc. 

The most disturbing news, however, is the rapid spread of a multi-drug resistant form of the disease, known simply as MDR TB. Even though the first case was diagnosed about 30 years ago, the United Nations only labeled it a public health threat five years ago. Today, about 20,000 Russians are infected with MDR TB, most of them prisoners. And the numbers are growing rapidly.

The spread of MDR TB is primarily due to the incorrect use of TB medicine. At a minimum, a TB patient should be simultaneously treated with four types of medicines. But because many hospitals do not have enough money, said Tine Demeulaere, former director of Medecins Sans Frontiere (MSF) in Russia, they only treat patients with one or two medicines. Russian doctors cannot stand by and watch patients die, and most think that it is better to administer at least some medicine, rather than none at all. But half the treatment cannot kill off all the TB bacteria—those which remain multiply and mutate into the more virulent MDR TB. “Either you treat patients properly, or don’t do it at all,” said Demeulaere. 

Demeulaere predicted that, as a result of this ineffective treatment in Russia, MDR TB will start to appear on western shores with greater frequency. “The potential is enormous for an outbreak in the West, and people are not waking up to the threat,” she said.

There is a rather simple solution, however. For the past two years and up until recently, Demeulaere headed up MSF’s program treating about 1000 TB patients in a prison hospital in the Kemerovo region, where she spent one week every month. That program has helped bring the prison’s mortality rate down from 80 a month in the early 1990s, to four a month today. MDR TB, Demeulaere said, is curable within six to nine months, and it can be done for about $8,000 per patient in Russia. While this price may be prohibitive for Russia’s impoverished health care system, it would be a small price for Western governments to pay. In New York, which had an outbreak of MDR TB in 1991, treatment costs $200,000 per case. 

Siberia is Russia’s most blighted TB territory, due to poverty and its high ex-convict population. In fact, the prison system harbors the vast majority of the country’s cases. Ten percent of Russia’s 1.3 million prison inmates have the disease. But prison officials protest when prisons are labeled as incubators of the disease. “Prisons are a sponge that society uses to wipe its face clean of social dirt,” said Mikhail Perin, chief medical officer for Russia’s prison system. “Those who end up in prison are often the dregs of society, various alcoholics and drug addicts, and other people who have lost their family and societal ties. It is precisely they who are infected with TB.”

Yet, there is no denying the role that deplorable prison conditions play in fostering the disease. Prisons have infection rates 32 to 100 times higher than in civil society, primarily because less treatment is available. Other factors include the overcrowding so typical of Russian prisons, poor food, and the high stress of prison life. That Russia can afford to ignore this problem only at its peril is underlined by the fact that some 300,000 prisoners are released back into society every year, many of them carriers of TB.

— John Varoli

In the photo: A few dozen prisoners from the Caucasus—all either HIV-positive or TB patients—have been isolated in a special colony near Dvukhbratsy village. As seen, special precautions are taken during all innoculations.