TB belies Russia's claim to modernity


ST. PETERSBURG, Russia -- Dr. Tatyana Suprun apologized while walking along the tree-filled grounds of this city's largest tuberculosis hospital and then inside, as if the shabbiness of the brick buildings and the sagging metal-frame beds inside were her fault.

"This is, unfortunately, our reality," said Suprun, the head physician, pointing to a plaster ceiling damaged by water.

The crumbling infrastructure is not her most pressing problem. Her institution, Tuberculosis Hospital No. 2, can't afford to stock the costly medications and X-ray and ultrasound machines it needs to replace the material on hand, equipment that she says would be unacceptable for a hospital in the United States.

She welcomes the fact that Russia has made infectious disease, including TB, a priority at the Group of Eight summit being held here this weekend with Russia's President Vladimir V. Putin as host - but questions the impact it will have on her own hospital.

"I doubt it will help us," she said of the three-day gathering of world leaders. To improve the country's preventive medicine and patient care, "the federal government must work with such problems every day."

Critics have raised doubts about Russia's fitness for membership in the G-8, noting that Russia is neither one of the world's leading industrialized economies nor committed to democratic reforms, criticisms Russia has vigorously challenged.

But one measure highlighting how unlike the nation is to its G-8 partners Russia does not dispute: the high rate of tuberculosis.

Nearly 32,000 people here died last year of TB, a death rate more than 40 times higher than in the United States. The fatality rate is nearly six times higher than in the country that ranks second among G-8 nations, Japan.

"TB is a curable and preventable disease," said Dr. Wieslaw Jakubowiak, coordinator of the World Health Organization's TB-control program in Russia. "This is a killer that shouldn't be a killer."

The number of TB cases in Russia increased during the 1990s after the breakup of the Soviet Union and the near-collapse of the health care system but has leveled off in recent years, a sign that government-backed efforts to stem the epidemic are beginning to yield results.

But there are major challenges to continued progress. Multidrug-resistant TB - a more dangerous variant because it doesn't respond to ordinary treatment - is a significant public health threat, in part because the nation doesn't have enough second-line drugs to treat it.

And the more than a million people believed to be infected with HIV in Russia make especially vulnerable targets, as they are more likely to develop TB or suffer a relapse from earlier bouts with the disease.

In the late 19th century, tuberculosis - a bacterial infection that is spread through the air - killed one of every seven people in the United States and Europe. It was brought under control in large part because of the advent of antibiotics. TB still kills about 1.7 million people a year, the majority in developing nations.

Russia ranks 12th on the WHO's list of "high burden" nations, in the company of India, China, Nigeria and Cambodia.

When Suprun announced her intention to specialize in TB after graduating in 1975 from the medical institute, colleagues urged her to seek another specialty. "I was told, 'It's not interesting. In five years it will not exist,'" she said.

Her hospital now doesn't have enough beds to meet the need.

The vast majority of her hospital's 500 patients are men. Most are of prime working age - 30 to 40 - but half are unemployed. More than a third are alcoholics. Some are drug addicts, former prisoners or both.

Along with TB, almost all have other medical problems, such as hepatitis B and C, diabetes, cardiovascular disease or HIV. The hospital in 2000 opened a ward for patients with both TB and HIV, a dangerous combination; tuberculosis is the leading cause of death among those infected with HIV.

The rooms in the TB-HIV ward are bright but cramped, the beds covered with old wool blankets. There are modest decorations and furnishings - calendars and stuffed animals, electric kettles and small TV sets - attempts to make the place homey.

A man named Pavel, 25 and with a goatee, sits in a wheelchair because his TB infection caused paralysis in his feet. Angela, 30, lies on her stomach in bed, covered by a thin blanket that accentuates her skeletal frame; she has TB meningitis, an infection of the membrane surrounding the brain and spinal cord. Maxim, a brown-eyed 24-year-old who did construction work before contracting HIV, has multidrug-resistant, or MDR, tuberculosis.

Between 8 percent and 12 percent of new TB cases in Russia - and more than 20 percent of previously treated cases - are multidrug-resistant, according to the WHO's Jakubowiak. The percentage of MDR cases among prisoners is considerably higher. Resistance is a result of poorly managed programs and erratic treatment or patients failing to take their medications properly.

Jakubowiak said Russia has demonstrated a growing commitment to fighting tuberculosis, adopting new treatment programs that meet international standards, improving reporting and making drugs more widely available.

"Russia is gradually improving," he said. "Tuberculosis is not a disease that can be eradicated from one day to another."

What makes fighting TB so hard is that it is more than just a medical problem. The infected here are often homeless, jobless and poor, and unable to reach health facilities.

"Tuberculosis is a social disease," said Suprun, the hospital chief in St. Petersburg. "It's a reflection, to a certain extent, of the social situation in the country."

Suprun and her staff of 65 physicians will continue to do what they can. The hospital received a grant from the WHO that helped purchase needed medications, but the $45,000 only went so far.

"We are grateful," she said, "but still, it doesn't solve the problem."


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