Since the collapse of the Soviet Union, tuberculosis has made a strong resurgence. Particularly worrying is the rise of the drug-resistant forms of the disease. Dr Andrei Slavuckij explains.The former Soviet Union is one of the regions in the world worst hit by tuberculosis (TB). According to the World Health Organisation, the former Soviet Union countries also face significant levels of multidrug-resistant tuberculosis (MDR-TB), which accounts for a record high of 28 percent among new TB cases in some of the affected areas. MSF treated TB patients in Siberian prisons from 1995 to 2003 and has been working in Kyrgyzstan’s prisons providing support to TB patients since 2006.
Dr Andrei Slavuckij has been following the evolution of the disease in the former Soviet Union for the past dozen years.
He trained as a doctor in Lithuania and joined MSF’s emergency response teams in 1991. In 2000 he became a medical coordinator for MSF in Russia, where he supervised the TB project in Siberia, and he then went on to become Programmes’ responsible for MSF mission in Kyrgyzstan among others. Andrei recently joined the medical department of MSF in Geneva as deputy director.
Why are former Soviet Union’s states are so badly hit by tuberculosis?
Following the collapse of the Soviet Union in 1991, the healthcare system deteriorated and the population became much poorer. TB thrives in conditions of poverty. It’s a disease that primarily affects the most vulnerable layers of society: the unemployed, the homeless, drug addicts and, of course, prisoners. However, once a certain level of epidemic has been reached, the transmission of TB escalates and anyone, regardless of his or her social class, can contract the disease.
In Soviet times, the fight against TB was largely financed by the state. This disease as a mirror reflects the state of social well-being and was therefore viewed as unacceptable in a socialist country that claimed to be developed. Patients remained in hospital for the duration of their treatment; they were able to visit sanatoriums, received compensation and were guaranteed the right to return to their jobs. Those who were chronically ill were even provided with an apartment. After 1991, when financing dried out, health care managers failed to adapt the TB control system to the new environment; they kept the expensive infrastructure intact instead of choosing priorities, as for example, assuring uninterrupted supply of quality TB drugs.
Why does MSF provide care to prisoners rather than to the wider population?
In countries of the former Soviet Union, prisoners are one of the most vulnerable groups of population. TB is one of the most prevalent diseases in prisons. The lack of private space, poor hygiene and nutrition, overcrowding and stress all contribute to the spread of the disease.
After the collapse of the Soviet Union, the prison population grew significantly: a decrease in the general standard of living led to a rise in crime, and since simple theft was punishable by several years in prison, prisons quickly became overcrowded breeding grounds for TB.
Another knock-on effect of the collapse of the Soviet Union was drugs shortages due to the slow-down of industrial production. This impacted not just the prison system but also the wider population. Without adequate treatment, TB sufferers developed extraordinarily high levels of drug resistance. And because they were no longer followed up after their release, they contributed to the spread of the disease, including its most drug-resistant forms.
What are the achievements of the MSF programme in Kyrgyz prisons?
In 2010, in collaboration with the prison healthcare system, MSF helped to detect over 300 cases of TB, a drop from more than 700 in 2006. This decrease in the number of patients reflects both the intervention of MSF in treating patients and also the overall reduction of the prison population: a consequence of penal and prison reforms undertaken by the Kyrgyz authorities.
Unfortunately, the cases that we are faced with are becoming increasingly complicated and difficult to treat. Just like antibiotics become ineffective when taken irregularly, resistant strains of the disease they’re supposed to cure develop. Two-thirds of new patients are resistant to at least one of the first-line drugs used, and a third are infected with MDR-TB.
TB sensitive to first-line drugs requires six to eight months’ treatment and has a 98% cure rate. Multidrug-resistant forms of the disease on the other hand take two years to treat, and the chance of recovery can drop to below 70 percent. We are also seeing an increasing number of patients directly contract MDR-TB, having never suffered from TB before.
The precise data for the whole of Kyrgyzstan are unavailable, but we estimate that 20 percent of new cases of TB are multidrug-resistant. This “epidemic within an epidemic” is a cause for great concern, and the problem is equally worrying in other post-Soviet states.
What are the main challenges faced by MSF in Kyrgyzstan?
The greatest challenge we face is the fight against MDR-TB. 14% of TB patients are also infected with HIV/AIDS and the majority are also suffering from a form of hepatitis, which further complicates treatment. In prisons there are many cases of drug addiction and also violence. MSF is still searching the best ways to take in charge these multiple pathologies.
The extended TB treatment course requires two years of medication which is difficult to complete: two years is a long time and the treatment produces heavy side-effects. In prisons, the risks of interrupted treatment are increased when prisoners are transferred for investigation, to attend a hearing, for example – or when they are released.
Then, once they have returned to civilian life, TB patients require social support. Without it, continuing their treatment would become impossible. We go to a great deal of effort to find and organise follow up for TB sufferers released from jails. We hope to begin collaboration with a Kyrgyz non-governmental organisation to which we can gradually transfer these follow up activities.
What is the future for the tuberculosis programme in Kyrgyzstan?
We are going to set up a TB care programme for the civilian population in the south of the country, which we hope to start next summer. At the same time, MSF will gradually transfer its activities in one prison in the North to the ICRC, which is already active in another prison for treatment of MDR-TB cases. We aim to concentrate principally on peripheral prisons, where there is still a lot to do in implementing a system of early TB detection. Finally, we will continue follow-up activities of TB patients who have been released from prisons.
MSF and tuberculosis
In 2010, MSF treated close to 30,000 people with TB in 29 countries, and 1,000 patients with DR-TB. Projects where MSF treats DR-TB range from prisons in Kyrgyzstan to urban contexts in India and HIV-endemic settings such as Swaziland and South Africa. MSF has developed treatment strategies that are adapted to individual contexts, often providing treatment in the community through ambulatory care models so as to reduce the burden on patients and boost adherence to treatment. Given regional specificities of the epidemic, MSF will strengthen differential approaches. From April 14 to 16, MSF will host a symposium in Tashkent (Uzbekistan). The objective is to call for better attention to the growing challenge of TB and MDR-TB in former Soviet Union and to increase collaboration between different partners in the region.