TB Treatment From Soviet Era Hinders Healing

By CAROL J. WILLIAMS

Nov. 28, 1997 12 AM PT

TIMES STAFF WRITER

ALMATY, Kazakhstan —

With its broken windows, crumbling staircases and sagging perimeter fence, the National Tuberculosis Center on tree-shaded Gorodskaya Street stands as a fitting monument to the lofty and elusive goals of the Soviet medical system.

Tuberculosis is epidemic in this and other former Soviet republics, but the costly and ineffectual treatment regime bequeathed by Communist-era planners is proving more hindrance than help in efforts to check the disease’s spread.

For the record:

12:00 a.m. Dec. 6, 1997 For the Record
Los Angeles Times Saturday December 6, 1997 Home Edition Part A Page 4 Foreign Desk 1 inches; 35 words Type of Material: Correction
TB patients--In a Nov. 28 article on the spread of tuberculosis throughout the former Soviet republics, an incorrect figure was given for the number of patients in a treatment program underwritten by Chevron. The program treats 2,000 people a year.

With more than 1,000 special tuberculosis hospitals, clinics and rest homes built throughout the former Soviet Union, the struggling successor states can ill afford to maintain them or pay salaries for tens of thousands of medical workers clinging to antiquated methods of diagnosis and treatment.

The TB epidemic in Russia, Central Asia and the Caucasus nations might have been brushed off by Western neighbors as just another hard-luck side effect of a region broadly beset by crises.

But with tuberculosis also on the rebound in many developed nations, health care officials have come to the conclusion that the burden of combating the disease here falls to the international community, if only in the interest of self-preservation.

The World Health Organization, the U.S. Centers for Disease Control and Prevention, the World Bank and a host of humanitarian organizations are pooling resources to develop a regional battle plan against a disease that already kills 3 million worldwide a year and poses a growing threat to the planet.

“This has traditionally been a sickness of the poor, but the most recent tendencies have been toward infection of average working people, those outside the usually vulnerable social groups like prisoners, drug addicts and the homeless,” said Aman Zhangireyev, director of the National Tuberculosis Center here. “The tuberculosis bacillus fails to recognize social boundaries.”

It also transcends territorial boundaries. Early this month, Israeli authorities ordered TB testing for all 160 passengers on an Oct. 27 flight from Almaty to Jerusalem after one man was found, days after emigrating, to be seriously ill with the disease.

The risk of an epidemic spread by the millions from the former Soviet Union who are now free to travel abroad is considered minimal, international health authorities say. But with the shocking increase in drug-resistant TB strains here, they concede that the dangers are significant enough to spur aid and action on a global level.

Tuberculosis is soaring here because of a general breakdown in health care due to lack of state funding and simultaneous drops in living standards, leading to malnutrition, alcoholism, drug abuse and unemployment.

The tuberculosis notification rate--the number of cases that have been brought to the attention of authorities--this year in Kazakhstan is at least 82 for each 100,000 people, Zhangireyev said.

Russians last year reported nearly 75 for each 100,000 people, and the small Central Asian republic of Kyrgyzstan suffered the highest rate of the ravaged region with 92 for each 100,000.

By contrast, the notification rate in the United States is eight for each 100,000 people, according to figures from the CDC in Atlanta.

“We refer to this as a notification rate, rather than the incidence of tuberculosis, because we recognize that many cases go undetected, perhaps many more than are brought in for treatment,” said Margorzata Grzemska, in charge of TB national program support for the World Health Organization.

WHO has recently added Kazakhstan to its “hot spot” watch list, joining Russia, India and parts of Africa as areas where tuberculosis has been deemed out of control.

The Soviet health system treated tuberculosis as a social problem more than a medical condition, compelling all workers to undergo regular chest X-rays and sending those who tested positive to isolated clinics and rest homes for as long as two years of state-funded treatment.

But since the breakup of the Soviet Union into its 15 constituent republics six years ago, none of the new governments has been able or willing to invest the considerable sums that would be needed to continue the fluoroscopic screenings or to keep patients hospitalized for months.

“When everyone worked together in huge factories, it made sense to conduct massive testing with fluorography,” said the doctor responsible for tuberculosis programs in Russia, Anatoly Vyalkov of the federal Health Ministry. “But this is no longer effective, with so many factories closed down and people more likely to be working in small private enterprises.”

Chest X-rays detected TB in only 40% of those referred for treatment in the Soviet era, Grzemska noted; the rest appealed to doctors on their own after noticing symptoms. Mass screening by fluoroscopy has ceased because governments no longer fund it, and self-referrals have also fallen sharply because few can afford to pay for their own treatment.

Drug supplies have also been erratic because of high import costs and the hurdles of a corrupt network of procurement and distribution. That irregular supply is blamed for the sharp growth in antibiotic-resistant tuberculosis.

WHO guidelines for treating tuberculosis recommend a battery of five different medications, but most of those who appealed for help over the past few years were provided with only one or two because of the costs and shortages. The half-measures allowed bacilli to mutate and develop immunities, resulting in a staggering rise in cases resistant to medication.

The multi-drug-resistant strains now account for as much as half the cases in Kazakhstan and about 30% of those reported in Russia.

That rise in resistance is worsening the mortality rate, which health officials here and in Russia estimate to be as high as one-third of active cases.

As the tuberculosis epidemic has intensified, humanitarian aid groups and philanthropic organizations have stepped in to help, and in this oil-rich state, private business concerns are also pitching in to cure a community from which they will draw their future employees.

Chevron, which has made the single biggest investment in Kazakhstan with its Tengiz oil projects, is underwriting a program to treat 200 tuberculosis patients a year within the broader health-care aid being provided by Project HOPE.

“The only way to prevent the spread of TB is to cure those infected, but the task is so big that it’s going to take years to bring under control,” said Lara Frazier, tuberculosis program director for Project HOPE in Almaty.

Frazier and other foreign aid workers note that authorities throughout the region continue to waste their limited resources trying to revive the costly and inefficient infrastructure of the Communist era. Microscope analysis of sputum samples, for instance, is far less expensive than X-ray diagnosis, they point out, and hospitalization can be shortened to two or three months if patients are supplied with sufficient medicines to take at home.

With the full-court press of aid workers and medical experts pushing for more local government funding and philanthropy, “some money is bound to come into the system to deal with this--it’s just a matter of making sure it gets used appropriately,” said Bruce Ross, in Kazakhstan on a CDC monitoring project funded by the U.S. Agency for International Development.

“The challenge we face at the CDC is dealing with [tuberculosis] domestically, but we can’t do that unless we deal with it internationally as well,” said Ross, noting that a resurgence of TB cases in the United States at the start of this decade was due in part to health authorities having let down their guard on the global problem.

Much of the foreign activity has been focused on getting local governments to recognize the severity of the problem and avoid actions that could make it worse, such as amnesties to rid crowded prisons of inmates who are infected.

Both Russian and Kazakh interior ministry officials are considering sizable releases of inmates in January to reduce overcrowding, which will include thousands of tuberculosis sufferers.

“We are very worried about this plan because if the infected are allowed to go into the public, travel on crowded trains and take shelter in dormitories and railway stations, there will undoubtedly be a devastating spread of the illness,” warned Vladislav Yerokhin, deputy director of the Russian Federation’s Central Tuberculosis Institute in Moscow.

Those fighting tuberculosis are now scrambling to target the problem in prisons by deploying resources and specialists to the gulag zone. A pilot project to be funded by U.S. philanthropist George Soros is expected to be underway next month in Siberia’s Tomsk region, and a similar project aimed at the Ivanovo region, which suffers exceptionally high unemployment, is also a priority for Soros funding, Yerokhin said.

“Many fear that this is just a drop in the ocean and that it will make little difference,” the doctor said from his office at the institute, which, like its counterpart in Almaty, stands almost forgotten in suburban woods. “But we have to believe that something positive will result from even modest action because we know what the consequences will be if we do nothing.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

TB Rates

Notification rates of tuberculosis cases per 100,000 population:

Former Soviet Union

Armenia 25.5

Azerbaijan 32.7

Belarus 54.1

Estonia 35.4

Georgia 98.7

Kazakhstan 82.9

Kyrgyzstan 91.6

Latvia 70.3