Russia's Tuberculosis Catastrophe

TOMSK, SIBERIA: Europe ignores Russia’s public health problems at its peril. So do the other industrialized countries who cheered the Soviet Union’s fall but have failed to respond to the collapse of Russia’s health and social-service infrastructure. For out of a confused swirl of economic ideology and sometimes insensitive advice has emerged a new form of drug-resistant tuberculosis that is proving hard to contain. Much has been made of Russia’s plummeting life expectancies – its "mortality crisis." Although that grim trend appears to be being slowly reversed, another problem is spiraling out of control: tuberculosis. In several regions of Russia, young men fall ill and die from tuberculosis at rates well in excess of ten times those documented a mere decade ago; in some non-Russian areas of the former USSR, the story is even worse.

A confluence of events is to blame, including the collapse of Russia’s social safety net at the very moment when petty crime, and thus imprisonment, was reaching new heights. Russia and the United States have long been world leaders in rates of imprisonment. In the context of wars and economic disruption, Russia has pulled ahead. Tuberculosis is now epidemic within Russia’s prisons and jails. One in ten prisoners is sick with the disease. Victims of tuberculosis, especially drug-resistant tuberculosis, are likely to have served time in prison or to have a close relative who has gone through the Russian justice system. Like other airborne plagues, drug-resistant tuberculosis cannot be stopped by either prison walls or national boundaries. In the state of Massachusetts, where I practice medicine, close to 70% of all tuberculosis cases are diagnosed in people born abroad. The proportion is much the same throughout Western Europe.

The epidemics of recent years are fundamentally “transnational” in character, as befits the global era. As infecting organisms easily cross frontiers, solidarity and generosity usually get tied up in customs. So far, Russian health specialists have received much haughty advice but little practical assistance from their colleagues abroad.

Of course Russia must update its approach to tuberculosis control, as physicians in other nations are doing. Chiding Russian doctors for their failure to contain tuberculosis, however, makes little sense when they are not responsible for slashing the health budgets under which they operate. And, of course our colleagues in Russia need to set clear goals and must seek to avoid waste, just as we do in the West. But to decrease health expenditures on grounds of “cost-effectiveness” makes little sense in the midst of an epidemic. When your house is on fire, do you suddenly decide to conserve water? Russian politicians need to support penal reform and seek alternatives to incarceration, just as we do here. But to amnesty sick prisoners while making no provisions for their care after release is a favor to no one; it only invites a more rapid spread of drug-resistant tuberculosis. After a long silence, we are at last beginning to hear arguments in Europe and America to support Russian health care. Some of these arguments are self-serving. We read that it is in our “enlightened self-interest” to assist the former Soviet Union with this epidemic. Some political leaders now cast tuberculosis as a key national security issue. That, however, is an approach which puts physicians and public-health personnel in the position of border guards. Only a brave few speak of solidarity and mutual support. Regardless of justification, it is essential that the countries of North America, the European Community, Scandinavia, Japan, Australia – indeed all those who care about stopping a senseless, avoidable and devastating epidemic – come together to lend real support to those seeking to control tuberculosis in Russia and elsewhere in the former Soviet Union. The global community needs to follow a number of principles if this initiative is to prove effective.