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Ukraine’s reversal of fortunes in health care

by Cesar Chelala

NEW YORK — Once called the breadbasket of the Soviet Union because of its rich soil and favorable climate, Ukraine is now experiencing a rapid increase in cases of tuberculosis (TB), a disease often associated with poor living conditions.

What makes this epidemic particularly serious is that the infection is resistant to several medications (Multiple Drug Resistant or MDR), and its increase parallels the spread of HIV in the country. Because of its impact, tuberculosis in the Ukraine is not only a medical problem but also a social and economic one.

According to Ivan Vasiunik, Ukraine’s vice prime minister, TB rates in the country are 10 to 12 times higher than in developed countries. He stressed concern about the rate at which the disease is spreading in prisons and detention centers. By 2004, it was estimated that there were 40,000 new cases per year.

TB is the world’s greatest infectious killer of women of reproductive age. It is also the leading cause of death among people infected with HIV. The rate of new TB cases can vary widely, even among neighboring countries, reflecting differences in development and the quality and availability of health-care systems.

In Ukraine, following the move toward a more private system of health care, many physicians have become indifferent to the threat posed by TB. Dr. Marcos Espinal, executive secretary of the Stop TB Partnership, has stated, “Even though TB is one of the three major killers in the world, it has been so neglected that it is an embarrassment for the international community.”

Among the factors that make people more susceptible to TB, the most important is being HIV-infected. The rise in HIV infections and the neglect of TB control programs explain the resurgence of tuberculosis. It is estimated that 2 million people die from this disease worldwide annually.

The emergence of drug-resistance strains has contributed significantly to the spread of the epidemic. In both Russia and the Ukraine, it is estimated that between 10 and 20 percent of new cases may be multidrug resistant.

MDR-TB is resistant to two of the first-line drugs: rifampicin and isoniazid. Drug-resistant tuberculosis has been a particular concern in the countries of the former Soviet Union due to drastic changes in their health-care system and out-of-date control methods. Evidence collected from the Baltic states of Latvia, Lithuania and Estonia, as well as from Central Asian countries, has pointed to increasing rates of MDR-TB.

Many TB patients experience discrimination, because the disease is often associated with poverty, homelessness, drug use and being in prison. In the Ukraine, the main risk factor for being co-infected with HIV is injection drug use.

As Dr. Jack Chow, assistant director general of HIV/AIDS, TB and Malaria for the World Health Organization, says, “We cannot control one without controlling the other, and we must begin to scale up TB/HIV collaborative activities to provide a synergy of prevention, treatment and care for co-infected patients.”

One key strategy for controlling TB is “DOTS,” a series of measures that include a regular supply of anti-TB drugs, a strong political commitment to sustained TB control, laboratory control for diagnosis, and free treatment of patients with high-quality drugs. When followed accurately, DOTS allows treatment of TB with nearly a 99 percent success rate.

DOTS application in Ukraine is already having a positive impact in the country and its extensive use will allow better control of the epidemic.

As Dr. Mario Raviglione, director of WHO’s Stop TB Department has stated: “Ukraine has the capacity to rapidly scale up and modernize TB control. But for this to happen, the political will must be in place.”

Cesar Chelala, M.D., is an international public health consultant.