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Diseases Without Borders

September 15, 2009
by Frank Browning

Tuberculosis is easily treatable, but with millions of new cases each year—many of them drug-resistant—it remains a world-wide epidemic.

Should you happen to run into Marcos Espinal, MPH ’90, Ph.D. ’95, in an airport lounge—which could happen given how much of his life he spends girdling the earth to fight tuberculosis—be prepared for a shock. He’ll tell you that TB is today’s most widespread and deadly communicable disease. The scourge of the 19th century that left John Keats hacking blood on his death bed is resurgent in some of the world’s most prosperous cities, including New York, San Francisco, Los Angeles, London, and Paris. Espinal may even scare you off flying: “It has been shown that tuberculosis can be acquired in flights longer than six hours. I mean, you take a plane from London and six hours later, technically you can get TB if you are sitting two rows from a person who is infected.”

Espinal, recipient of the 2007 Elise and Walter A. Haas International Award, directs the World Health Organization’s Stop TB Partnership from Geneva, Switzerland. He spends a lot of his time lobbying, cajoling, sometimes even haranguing political leaders all over the world to invest in TB care and prevention. Espinal doesn’t consider himself an alarmist. TB, he stresses, can be treated for as little as $25 per patient—assuming the treatment is thorough and starts early. But when they’re not treated correctly, bacteria can persist in the lungs or lymph system and recur in more virulent forms that often require two years of costly, painful and nauseating treatment to cure. This is called MDR, (multidrug-resistant) TB. Worse is XDR (extensively drug-resistant) TB, for which there is no reliable cure.

As UCSF epidemiology Professor Emeritus Andrew Moss, Ph.D. ’79, once told me, the only reason most of us are here today is because our Asian and European ancestors survived TB when they were living in the same medieval huts as their cows and sheep, which were sneezing, spitting, and coughing up Mycobacterium tuberculosis into the air. When those ancestors migrated to congested, fetid urban slums, TB epidemics intensified due to poorly ventilated living quarters. Exposure to the bacteria is in most cases harmless. The body’s immune system quickly controls the bacteria without generally killing it, resulting in so-called latent TB infection. Active TB results when the body’s immune defences are compromised by other infections or from overall poor health and nutrition. Today’s additions to that list include HIV and, many physicians believe, prolonged stress.

To find the disease you needn’t go very far. California leads the nation in general TB cases with more than 38,000 diagnoses reported between 1994 and 2003, more than 400 of them drug-resistant TB. Perhaps more surprising, in 2006 the Golden State’s Silicon Valley had three times the national average of TB incidence with 12.8 cases per 100,000, including a handful of cases that proved resistant to drugs. The toll is worse in San Francisco, largely due to immigration from Asia (which has high rates of endemic TB). But, as drug resistant TB hotspots go, nothing compares to Romania and Ukraine, on Europe’s doorstep.

Armed with bacterial masks and antiseptic gels I flew to Bucharest last spring. Romania, Marcos Espinal’s colleagues told me, harbors the largest TB pool in the European Union, but with help from the WHO, the country has developed an acclaimed TB control campaign. If I wanted to grasp the enormity of the medical and social challenges posed by TB, they told me I had to visit Ukraine. Mindful of Espinal’s warnings about air travel, I decided to take the 27-hour train from Bucharest to Kiev instead.

What you see from the windows of the rickety, Soviet-era train is a metaphor for the panorama of disease and collapsing public health across the former Soviet Union. The land is rich, among the most fertile in the world, but most of the farmers tending the privatized strips of earth still dig weeds by hand or plod behind mule-drawn plows. The rest of the land is cultivated by men on enormous tractors in huge fields consolidated during the oligarchic land grab that replaced Communist collective farming. The contrast is not merely stark, it is surreal, punctuating the vast class and educational differences that divide Ukraine today. Those same social disparities are reflected in the notorious battles between former Soviet bureaucracies in Ukraine’s capital, Kiev, and the huckstering new elites whose commitment to raw, unregulated markets has encouraged state corruption.

If that characterization seems unfair, all you need do is talk to Katya Gamazina, a doctor with the Seattle-based non-profit PATH who is in Kiev trying to import Espinal’s WHO strategies into Ukraine. Involved in anti-TB campaigns since shortly after the Soviet collapse in 1991, Gamazina speaks bluntly about the threat: “Everybody in Ukraine, almost all adults, [are] infected with latent TB. That doesn’t mean they will get sick.” She estimates that at least 40,000 Ukrainians do develop full-fledged tuberculosis annually and that 300,000 have come down with TB in the last decade.

Ukraine’s most worrisome TB-related problem is the changing profile of those who are getting sick. Once a disease of poor people living in crowded conditions, TB has begun to climb the class ladder, hitting more and more young, tax-paying, middle-class professionals: businessmen, actors, government bureaucrats.

To see the situation first hand, I took a sunrise flight from Kiev to one of its easternmost cities, Donetsk, which, for most of the 20th century, was the industrial motor of Ukraine, a leading mining and metalworks center for the Soviet Union. Much of that industry has now closed, but the landscape on the drive from the airport is mottled with huge peeling cranes, antique power pylons, and mountainous slag heaps from the mostly abandoned coal mines. Closer in, shrouded by tall poplar groves, come the stark concrete housing blocks from the 1940s and ’50s and then the Donetsk TB Hospital.

When I visited the facility there were more than 140 TB-stricken children, from babies to teens, living there. One child, a 6-year-old, had been there for six months. She sat, scared, with her mother in a room with kindergarten desks and a dozen other kids. The two have lived at the hospital since the child began treatment. No one could say how the girl got TB. Most Ukrainian children, like most European kids, are inoculated against the disease. Some parents blamed the vaccine, while others just shrugged.

The children at Donetsk TB Hospital are relatively lucky. It will soon be a showcase in a new $20 million project to eliminate TB from the Donetsk region. The money is not coming from the Ukrainian government, but from Renat Akhmetov, among the nation’s richest citizens—a shady figure whose resume includes a brief stint on an organized crime list. He is the owner of the Donetsk football club—Ukraine’s top soccer team. Eager to enhance his public image and to boost his direct influence in the Ukrainian Parliament, Akhmetov created what is now the country’s leading foundation dedicated to education, cultural programs, and public health. One of the foundation’s top priorities is a total renovation of Donetsk’s two TB hospitals, which will be done through Akhmetov’s Foundation for Development of Ukraine, rather than the health ministry. “If you provide money to the state, you risk to lose half of money—from 10 to 40 percent,” said Anatoliy Zabolotny, a former Siberian public health officer who directs the foundation.

Possibly worse than the corruption is what both Zabolotny and Gamazina describe as the chaos of Ukrainian health records, an issue confirmed in February 2008 by a damning WHO analysis. “There is no [TB] registration system now,” Zabolotny says. “We create this system to get the real numbers: how many sick people there are, how many are treated, how many get healthy, how many died. This information doesn’t exist, which is critical.”

The Soviet system effectively reduced TB incidence, Gamazina says but it was by operating independently of other public health programs and through a system that permitted Russian authorities to quarantine or imprison patients who failed to follow treatment rules. Remnants of that old structure remain and have resisted active collaboration with the rest of the country’s public health system, most importantly programs to control the spread of HIV.

Add to that the continual shuffle of governments that rise and fall through parliamentary alliances, and the chaos grows even worse. “I could not even tell you how many ministers of health [there have been] during my 13 years at PATH—15 or more,” Gamazina says. The latest deputy minister in charge of TB was forced to resign three days before I spoke to her last spring; then in September the entire government collapsed.

While health planning has gone from bedlam to shambles, a new AIDS epidemic has also been growing. And because HIV attacks the immune system, this, in turn, promotes multidrug-resistant TB. Most cases of tuberculosis respond quickly to a cocktail of fairly standard antibiotics. MDR TB, and its even more virulent variant, XDR, do not respond to the standard drugs and many patients simply die.

Of the 40,000 new TB cases in Ukraine each year, 16 percent are drug-resistant TB, and that number may be rising. It’s difficult to know given the lack of reliable data and the remnants of a Soviet system that counted anyone ever infected with TB bacillus as still sick—even years after effective treatment. Because of this and other irregularities, Ukraine’s national TB program has not yet qualified for subsidized low-cost drugs provided by the Global Fund to Fight AIDS, TB, and Malaria.

Back in Geneva in the sleek steel and glass cube that houses WHO headquarters, Espinal is alternately angry and depressed when he talks about Ukraine. “TB,” he says patiently, “is not a medical problem.” That’s a provocative line Espinal uses when trying to get the attention of political and business leaders. TB is clearly a medical problem; a global health crisis that claims between 2 million and 3 million lives a year. But because early, consistent treatment is relatively easy and inexpensive, he argues that the medical dimension is less important than the social and economic consequences of the disease. “[TB] is a development problem—an economic problem,” he says. “TB infects people between the ages of 19 and 55 years of age, the years that are economically productive. If we don’t put that in the minds of the political leaders the problem will not be solved. It’s not a problem of the past.”

Creation of public education programs in countries like Ukraine, Espinal insists, only happens when political leaders realize the full cost of TB. “We estimate that one third of the world’s population is infected,” he says, then shakes his head, amazed that those statistics—including the 9 million new cases that develop each year—don’t in themselves change public concern or political will. It’s only, he says, when leaders realize how TB (like other diseases) throws a roadblock in national development that change happens.

For the moment, Ukraine’s political leaders appear to have other matters on their minds—how to deal with the fragile internal political alliances and staggering levels of public corruption, what to do about the fact that half the country’s economic output runs through the black market, and whether to yield to pressure to join the NATO alliance and risk having Russia cut off its energy supplies. Yet all of these social and political tensions also amplify the mounting dangers posed by TB, which are not confined by Ukrainian boundaries.

Between 5 million and 7 million Ukrainians are working outside their own country, the majority of them illegally and without access to health care. By Gamazina’s estimate, nearly all of them are infected with TB. Most are in Western Europe, but not all. They also go to New York, to Poland, to Turkey. “TB is a respiratory disease,” Gamazina says. “It is not like HIV where you really need to do something to contract the virus. You just breathe in a church, in the museum, in an airport, in a plane,” and you can contract it. “It’s a geometrical progression, going out and out and out and growing.”

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