ORONEZH, 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A moment later the needle was withdrawn and Ms.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."
Prisons as Incubators
When it comes to TB, this faded industrial city 300 miles south of Moscow mirrors the
nation. As elsewhere, the number of TB patients has almost doubled since 1993 — and
the source of most of the local epidemic is the prison down the road.
After the Soviet Union collapsed, prison populations soared in Russia, which now shares
with the United States the highest per capita rates of incarceration in the world. From
overcrowding and weak health programs came breeding grounds for tuberculosis, which is
transmitted by particles coughed or sneezed into crowded spaces.
Without a steady supply of the right medications, TB becomes resistant to drugs and
much harder to treat. This was the case in the prisons, where anti-TB medications are
continually running short, and prisoners still in need of treatments are released or
transferred.
An epidemic-within-an-epidemic of drug-resistant disease soon arose and began
percolating out of the prisons, carried by workers, like Ms. Kostina, or by released
prisoners. Periodic prison amnesties also flooded the country with prison-bred TB —
last year, Dr. Chernova said, more than 1,000 prisoners with active tuberculosis were
released into the Voronezh area.
"In Russia at one point," said Dr. Paul E. Farmer, a TB authority, "80
percent of the index cases of drug- resistant disease in the community could be traced to
the prisons." Dr. Farmer is a Harvard anthropologist and infectious disease
physician.
As many as 10 percent of Russia's million prisoners now have active tuberculosis, Dr.
Farmer and his colleagues estimated in a report issued last year by Harvard University and
the Open Society Institute at the Soros Foundation. More than half of those cases are
resistant to at least one anti-TB drug, and 20 percent to 30 percent of them are resistant
to several.
The Cost of Drug Resistance
Treating drug-resistant tuberculosis is among the greatest of medical challenges. It
requires expensive, "second-line" drugs, which must be taken for years instead
of months, and which have many side effects.
Dr. Raviglione of the World Health Organization estimated that drugs to treat an
ordinary case of TB in Russia would cost $20. But he put the bill for a drug-resistant
case at $13,000.
In Voronezh, Ms. Kostina has been luckier than most. To supplement the painful weekly
injections of air into her abdomen, which let her infected lung rest, doctors found her a
last- ditch pair of medications: a spray she inhales directly into the lung, and expensive
American pills imported by the Russian government and doled out in tiny quantities to
outlying hospitals.
With this concoction of archaic and cutting-edge treatments, she has gotten better. Her
fever is gone. She has gained weight, and the cavities in her lungs have shrunk. She left
the hospital last September to convalesce at home. So far none of her family has come down
with TB.
But the expensive pills she takes twice a day use up her hospital's entire allotment.
As long as she needs the medication, the hospital has none for anyone else.
In the face of desperate medicine shortages, nearly a dozen private and public
international health organizations are now collaborating with Russian experts to regain
control of the disease.
Although they represent an international investment of hundreds of millions of dollars,
these efforts involve only about a dozen of the country's 70 provinces, Dr. Raviglione
said, reaching a "pretty small percentage" of the population.
Nor is it very clear how best to use the money. The W.H.O. prefers to treat TB with a
carefully monitored combination of standard first-line drugs. But that method is at best
ineffective in treating drug-resistant TB. At worst, it risks increasing levels of drug
resistance.
Yet freer use of the longer-term drugs has perils, too.
"We are terribly afraid of liberal use of second-line drugs," Dr. Farmer
said.
Some experts fear that without close monitoring, such an approach would breed a form of
disease resistant even to those drugs and essentially untreatable.
Sex, Drugs and Disease
Further, an epidemic in one disease could easily ignite epidemics in others. Infection
with H.I.V., the virus that causes AIDS, is rising faster in Russia than almost anywhere
else, according to estimates from the Joint United Nations Program on H.I.V./AIDS. And
syphilis and hepatitis B cases skyrocketed during the 1990's.
This is an explosive combination: syphilis enhances the sexual transmission of H.I.V.,
and tuberculosis can worsen the immune deficiency caused by H.I.V. An H.I.V. infection, in
turn, can cause syphilis and tuberculosis to take unusual forms, making them both harder
to diagnose and harder to treat.
The resulting cyclone of mutually enhancing infections can tax medical ingenuity and
budgets everywhere. In New York City in the early 90's, for instance, an outbreak of
tuberculosis among H.I.V.-infected people and their contacts — involving about 1,000
cases of drug-resistant disease — cost more than $1 billion to squelch, by some
estimates.
In Russia, H.I.V. is largely confined to intravenous drug users. An estimated three
million Russians use such drugs, with H.I.V. infection rates among them in some areas as
high as 30 percent. Public health authorities know that H.I.V. will soon begin to spread
among this population's sexual partners.
Pavel Ryabov, 21, works in a Moscow candy factory and has used intravenous drugs for
the last two years.
He has hepatitis B and C, which are usually contracted through sharing needles with
infected people, and he was admitted to a Moscow hospital over the summer with meningitis.
From his hospital bed, Mr. Ryabov expressed fear of AIDS, but said he nonetheless
routinely shared needles with drug-using friends and did not use condoms with his two
girlfriends.
"Yes, so maybe I'll stop using drugs," he said. "I've already begun to
drink instead."
Risk of disease increases drastically, of course, where drugs and sex intersect. Recent
studies have shown, for example, that in some groups of drug-using prostitutes here,
H.I.V. infection rates have exceeded 50 percent. And prostitution, in turn, has been
driven up by deepening levels of poverty.
Dr. Olga Loseva, chief of the venereal diseases department at the Central Research
Institute for Skin and Venereal Diseases in Moscow, called sex "a new form of
currency here."
"We really have had a sexual revolution here," she said. "People have
earlier sexual relationships, more partners, more one-night stands, more children born out
of wedlock."
In Soviet times, a system of screening and treatment, in combination with fines,
unemployment and even imprisonment for some patients, kept syphilis and other venereal
diseases in check.
While the punishments have been eliminated, the stigma of syphilis lingers. In Moscow
and other cities where rates are particularly high, there are underground clinics that,
for a price, guarantee anonymity. But they frequently fail to treat patients effectively
and do not reliably keep track of the number of infections they see.
Thus, although figures over the last three years show a 30 percent drop in syphilis
cases, public health authorities are skeptical.
"We're hopeful these figures really reflect a decrease in disease," said Dr.
Caroline Ryan, associate director for international activities in the division of sexually
transmitted disease prevention in the Centers for Disease Control and Prevention in
Atlanta. But the decrease may merely reflect underdiagnosis or underreporting of cases,
she said.
The worry is that the stigma factor may drive the young H.I.V. epidemic partly
underground too, making it even more difficult to control.
Looming Infection
Here in Voronezh, as in most of Russia, these brewing infections seem invisible.
Doctors say they have seen only a single case of AIDS, in an Ethiopian woman who got sick
while visiting five years ago. Syphilis rates are low and stable, according to the city
health commissioner, Dr. Michael V. Ivanov, and no cases of H.I.V. infection have
surfaced.
But at the edge of the city, within the complex of infectious disease hospitals where
pear and apricot trees separate the tuberculosis hospital from the region's largest
infectious disease hospital for children, the doctors can hear the hoofbeats of trouble
ahead.
The city's pediatricians are now seeing about 50 cases of congenital syphilis a year, a
disease they only used to read about, said the hospital's pediatric epidemiologist, Dr.
Emilia Bashenova.
And a steep increase in hepatitis B, which is far more contagious than H.I.V., has been
ascribed to increasing intravenous drug use and sexual transmission of the infection.
Diphtheria cases soared nationwide in the early 90's, the combined result of declining
childhood vaccination rates and the vulnerability of adults who had received shoddy Soviet
vaccines as children. Since a new vaccination campaign backed by international aid,
diphtheria is now rare again.
But the low numbers don't tell an accurate story, Dr. Bashenova said. "Even though
numerically they are not up," she explained, "the cases of infections are more
serious, and we see more complications from each. Immunity is down among our children
here. It comes from poverty, from too little food, not enough vitamins, from more
difficult access to health care — the children are sick more often, and more
seriously sick."
This city lies halfway between Moscow and Chechnya, and already Chechen refugees have
turned up with TB. Doctors have been alerted that cholera, polio and the plague from that
region may soon start showing up as well.
Dr. Bashenova shook her head doubtfully. "We're prepared," she said.
