NY Times, December 5, 2000
FREEDOM'S TOLL
Infectious Diseases Rising Again in Russia
By ABIGAIL ZUGER
VORONEZH, Russia - Natalia Kostina lay flat on her back on a metal
examining table in this city's tuberculosis hospital, staring impassively
at the ceiling. In an instant, a doctor jabbed into her abdomen a thick
needle attached to a syringe and pushed in a few cubic inches of air.
A moment later the needle was withdrawn and Ms. Kostina, silent and stoic,
got off the table and returned to her room. Her treatment was over for
another week.
Injecting air into the abdomen is a painful, archaic, last-ditch way to
battle tuberculosis when medications are scarce or can no longer help. It
has not been used in the West for decades.
But this is Russia, where TB, once nearly under control, has become
epidemic since the collapse of the Soviet Union. Doctors often use air
injections to fight TB strains that resist the most commonly used drugs.
The technique compresses infected lungs, giving them time to rest and heal.
Ms. Kostina, 24, was healthy until two years ago, working as a nurse at the
local prison, just a mile down the road from this hospital. There, as in
most of Russia's overcrowded prisons, tuberculosis has been spiraling out
of control. When she fell ill with fever and a cough, doctors quickly
ascertained that she had caught tuberculosis from one of her inmate patients.
Despite months of treatment, her disease got worse. All four of the
antituberculosis drugs she tried were powerless against it. Moreover,
during the year she spent traveling from work to home, then into the
hospital, then to a convalescent home, then back to the hospital, she had
undoubtedly exposed dozens of others to her drug-resistant germs.
Russia's political turmoil, its economic crisis and its new freedoms have
been accompanied by a wave of old diseases. Tuberculosis is flooding the
country, producing what some authorities are calling the world's largest
outbreak of the drug-resistant variety, one of medicine's most ominous
problems.
Rates of other infections, including hepatitis, syphilis and AIDS, are
skyrocketing. An epidemic of diphtheria swept through in the mid-1990's.
Reports of smaller, regional outbreaks of encephalitis, typhoid fever,
malaria, polio, pneumonia and influenza pepper the nightly news.
Health experts describe Russia's prison system as an "epidemiologic pump,"
continuously seeding the country with pockets of tuberculosis that can
spread on their own. Increasingly, TB cases of Russian origin are turning
up in the Baltic countries and even farther afield - for instance, Germany
and Israel.
Specialists worry that if the rising rates of infectious diseases in Russia
continue unabated, the country itself may turn into an epidemiologic pump,
sending infectious diseases into the rest of the world.
"It's not surprising to see a case here," said Barry N. Kreiswirth, a
tuberculosis expert at the Public Health Research Institute in New York
City, "but it's a good reminder that it doesn't take much for one person to
be a vector and start an epidemic."
An Old Scourge Made New
Tuberculosis is hardly new in Russia. It ravaged the country in the 19th
century and the first half of the 20th. But before the Soviet Union fell it
was finally being brought under control, through major government effort
and expense. Infection rates, though roughly three times higher than in the
United States, were falling in parallel with those in Europe and developed
countries elsewhere.
This victory bred "a tremendous pride on the Russian side," said Dr. Mario
Raviglione, coordinator for TB activities at the World Health Organization
in Geneva.
That has changed.
With thin budgets, government health programs are no match for infections
given new momentum by increasing poverty, stress, alcoholism, overcrowding
and intravenous drug use.
Mortality from infectious diseases has not reached third world rates here.
Last year, infections were estimated to account for 2 percent of all deaths.
But that is still four times higher than in most developed nations. "The
total cost of infectious diseases in Russia is not that great," said Martin
McKee, an expert in Russian public health at the London School of Hygiene
and Tropical Medicine, "but the important thing is that it is going up and
up and up." As AIDS becomes more firmly entrenched, that cost is expected
to rise even faster. Deaths due to tuberculosis alone rose 30 percent in
1999.
In the days of the Soviet Union, the powerful Sanitation and Epidemiology
Service, or "SanEp," sought out infectious diseases and stamped them out
with compulsory vaccinations and annual disease screenings: chest X-rays
for tuberculosis, blood tests for syphilis. People suspected of harboring
infection were removed from society for as long as it took to guarantee
that they were no longer contagious. The SanEp tactics were brutal - people
were often taken from their families and hometowns for months to years -
but they were effective.
"Now, instead, we have human rights," said Alla Loseva, the Voronezh
tuberculosis hospital's deputy chief doctor, rolling her eyes. SanEp is but
a poorly funded shell of its former self. Its job has fallen instead to
doctors like Ms. Loseva, struggling to contain the epidemic with minuscule
budgets and skeletal staffs.
A colleague, Dr. Galina Chervanova, said that when she arrived at the
hospital in 1987, "there was even talk of eliminating TB completely."
"Now we are not even close to that anymore," added Dr. Chervanova, the
hospital's deputy chief superintendent. "The number of sick people has
risen, and we are seeing many, many difficult, chronic cases."
Full article at: http://www.nytimes.com/2000/12/05/science/05INFE.html
Louis Proyect
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