Tuberculosis, long ago subdued by Western doctors, is not only rampant in Russia but increasingly mutating into terrifying new forms that even the most powerful new medicines cannot kill.
It is spreading among the country’s most vulnerable groups: around one in 10 prisoners in Russia’s jails has it, and among homeless people the rate is broadly similar.
And post-Soviet medical mismanagement, many doctors say, has already allowed the contagious, air-borne disease to mutate into strains that cannot be killed by even the most modern medicines.
'Impossible to treat'
“The reservoirs of super-resistance will be huge; it will be impossible to treat,” said Andrei Slavutsky of the medical charity Medecins Sans Frontieres. MSF was so disgusted by official refusal to adopt treatment techniques backed by the World Health Organization that it ended its tuberculosis program in Siberian prisons.
The Soviet Union developed an effective if cumbersome anti-TB program using mass tests to catch the disease early. The totalitarian system ensured that the population did what health authorities wanted.
But the fall of communism starved the system of cash and robbed it of its ability to control patients, and an explosive epidemic followed its failure to adapt.
The WHO estimates that TB in Russia has risen threefold since 1991 and predicts an epidemic among HIV-positive Russians whose immune systems are hit by the virus that causes AIDS.
WHO figures put TB prevalence in Russia at 134 cases per 100,000 people compared with six per 100,000 in Norway, 12 in Britain and five in the United States.
“People need good living conditions, to be well fed and to work. The problem is 85 percent social and only 15 percent medical,” said Mikhail Perelman, Russia’s top TB expert.
Authorities slow in fighting epidemic
Some doctors think medical authorities have not only been slow in fighting the epidemic, but that action has been so inappropriate as to be harmful.
Multi-drug-resistant (MDR) TB can be treated only with expensive modern drugs and is often caused by not ensuring that patients finish a course of treatment. MDR-TB drugs need to be used for longer, are less effective and have more harmful side effects than traditional treatment.
“Lack of resources in the 1990s also led to late diagnosis and ineffective treatment. Insufficient supervision, poor management and low treatment effectiveness led to the growth of MDR-TB,” said Wieslaw Jakubowiak, the WHO’s TB control program coordinator in Russia.
WHO figures show MDR-TB running as high as one in 10 new TB cases among the general population in some regions and almost as high as one in five in the prisons. “This situation needs to be immediately addressed,” said Jakubowiak.
Many doctors say Russia is now incorrectly using modern drugs -- the last line of defense against MDR-TB -- allowing the disease to mutate to survive those as well.
Zulfira Kornilova, deputy director of an institute in a forest outside Moscow which treats Russia’s most serious TB cases, said her experts were picking up terrifying rates of super-resistant strains.
“There is now a group of patients who do not respond to any medicine. It is maybe 15-20 percent of all those who have MDR-TB,” she said.
“But there are no exact figures for super-resistant forms, because the laboratories do not have the right equipment and are not clean enough.”
Resistance to foreign aid
Partly to improve these diagnosis rates, the World Bank is lending Russia $150 million. Like many foreign initiatives the agreement was held up for years by Russian reluctance to modify tried and tested practices.
Perelman said that despite the growth of MDR-TB, he resented interference, adding that the Russian system was best suited to the country.
“Imagine what would happen if I came to the United States or England and started to work whatever way I wanted? They would put me in prison,” he said.
The WHO says Russia is now closely approaching internationally acknowledged standards and has put the disease at the top of its agenda, but for many doctors the change is coming far too late.
“There is already massive supply of second-line drugs going on, but without clear guidelines explaining how to use them efficiently this is absolutely criminal,” said MSF’s Slavutsky.
“Use of second-line drugs in this situation will stimulate the creation and spread of super-resistance.”