Tuberculosis in Belarus
Tuberculosis in Belarus
In Belarus a thousand of people die from tuberculosis every year. In the 18th – beginning of the 20th centuries tuberculosis was a real medieval plague. At that time each seventh European died because of it. Belarus did not avoid it as well. The great Belarusian poet Maxim Bogdanovitch, whose 115-years anniversary will be celebrated at the end of this year, got this disease and died when he was 26 years old. Hundreds of thousands of little known at present Belorusians became infected by Koch's bacillus and died in the 19th – beginning of the 20th centuries during the Civil War and the Great Patriotic War.
During Soviet times this disease was not eradicated, but its extension was stopped and sickness rate (the number of primary detected patients per 100 thousand people) was considerably reduced. Before dissolution of the Soviet Union, in 1990, in Belarus this index was 20,8 cases per 100 thousand people. However in independent Belarus tuberculosis again has become a plague bringing death to a thousand of our countrymen every year. According to a death rate tuberculosis undoubtedly takes the first place among infectious diseases.
AnamnesisAlready in 1992 tuberculosis sickness rate amounted to 33,7 per 100 thousand people. In 1998 this index reached 54,7, and in 2004 it was observed though not high, but still increase – 55,4. But even this generally accepted index does not reflect the actual picture of tuberculosis sickness rate increase in Belarus. It does not account relapse cases, when cured people again have symptoms of the disease. Ministry of Health Protection registers these people as “re-treated”. Data about this category of patients is not a subject of broad discussion. That’s why it is difficult to imagine a full picture with relapse cases. Nevertheless even in quite safe against a background of general Republic indexes Minsk (index of newly detected patients in 2004 was 41,7 cases per 100 thousand people), the number of patients suffering relapse amounted last year to almost one third of total patients listed in official statistic reporting.
Furthermore in analysis of general dynamics the data about tuberculosis within penal system are not accounted. Meantime, according to the latest investigations of penal systems Belarus takes a stable place among five countries with the largest number of convicts per capita in the world. And data about consumptive patients in institutions of confinement are listed in a separate statistics. In 2004, for example, official index of sickness rate within Penitentiary Department of the Ministry of Internal Affairs amounted to 623,8 cases per 100 thousand of convicts. If sum up statistic data from the Ministry of Health Protection, Departmental Institutions, penal system and add to these data the number of patients suffering relapse – situation with tuberculosis growth in Belarus looks really horrifying. By the way in the developed countries like USA, Canada, Japan, Australia, where consumptive patients among convicts are included into common statistics the level of sickness rate is not more than 10 cases per 100 thousand people. Experts note that since 1991 in Belarus there have been recorded the increase of the number and specific weight of patients with complicated in treatment forms of tuberculosis, first of all those fraught with lethal outcome growing progressively worse and destructive forms. Including caseous pneumonia – consumption, forgotten during Soviet times. In 1992 it was excluded from clinical classification of tuberculosis at all. However in post-Soviet Belarus they had to include in into classification under the name “Acute progressive form of pulmonary tuberculosis”(ОФТЛ) again.
Specialists also note the increase of the number of remedy resistant forms of tuberculosis. Since the beginning of 1990 evident is the increase in the number of cases of infantile and juvenile tuberculosis, which is an exceptional case for the developed countries. If in 1986 the index of sickness rate among children was 2,2 cases per 100 thousand children, in 1998 it has been increased up to 4,5. In the beginning of 2000 it looked as if situation was improved: in 2001 the level of sickness rate was decreased – 3,4 cases. But in 2004 according to official statistics the level was increased again and even exceeded the index of the “worst” 1998 year – 4,6 cases.
Analogous wavelike picture is observed for juvenile tuberculosis. In 1990 tuberculosis sickness rate among teenagers was 9,9 cases per 100 thousand people, in 1998 it was increased up to 17,3. In 2001 it was observed some decrease (12,1), but then again the level of sickness rate among youth was increased.
This tendency worries experts not only because of quite high level of sickness rate, but also because indexes are in progress. These indexes are progressive even in conditions of common (if trust official propaganda and statistics) “economic growth and improvement of living standards of the population”. The point is that tuberculosis is actually a social - biological phenomenon, which respond to social cataclysms, economic recession, lowering of living standards. Because of these reasons the number of diseased increases greatly during wars and in post-war period. But at present in Belarus the situation is quite different – social stability, economic growth, well-being of people is increased fifty-hundred dollars per year. And at the same time the number of patients and those who died is also increasing even according to official statistics. What is the explanation for this?
At a front lineBelarusian phthisiatricians not sparing themselves undertake considerable efforts in order to stop the spread of the infection and to achieve positive dynamics in treatment. However the number of specialists is not sufficient. In 2002, for example, the staffing of two Minsk T.B. prophylactic centers (note: not oblast centers and not T.B. consulting rooms in rayons) was at the level 60,4%. According to our interlocutors nowadays the situation with T.B. prophylactic centers staffing is not better.
Average salary of metropolitan T.B. prophylactic center employer is about EUR 90, including EUR 20 for harmfulness. This amount hardly corresponds to the value of medical duty, where conditions resemble a battle. Staff of these centers gets EUR 20 for daily contacts with potential source of infection, for visiting at home registered patients, who insult doctors and sometimes even threaten them (in some cases doctors have to visit patients accompanied by militiamen). Even 42-days vacation and shortened working day (7 hours) can’t compensate these working “delights” of an average T.B. prophylactic center employer.
In addition they don’t trust doctors – they say doctors steal money and remedies. Otherwise it is impossible to explain a new method to distribute remedies among registered patients, which was introduced in the middle of 2004. If earlier remedies were distributed in a centralized way through prophylactic centers, now patients have to buy medicine themselves in definite pharmacies and based on prescription (there are only three such pharmacies in the capital). But necessary remedies are not always available and very often pharmacy is far away from patient’s home. It makes it necessary for patients to take municipal transport 3 times per month and to go first to a prophylactic center for getting prescriptions and after that to a pharmacy and back, being a potential source of infection for the people. By this decision authorities, trying to extirpate corruption from a health protection system only contribute to infection spread.
In village area phthisiatricians get smaller salary than in the capital and oblast centers. This often results in a formal approach to patients at different stages – from making a diagnosis to treatment. We learned one of such stories, which unfortunately ended with a lethal outcome, from the staff of one of Minsk prophylactic centers.
Children were anxious about the health of their elderly mother who lived in Grodnensky oblast and organized her movement to their place. The woman had complained of pain in the chest and children insisted that she had to make roentgenofluorographic examination, which showed not only advanced and progressive form of tuberculosis, but also, simultaneously, pneumonia – “mixture” in medical terminology. At that the woman told, that recently she had passed X-ray examination. She said, that a mobile X-ray room was in their village and she visited it and was examined without taking off her dress.
Another case happened in a military unit, which was stationed at the border with Smolenschina. Doctors were examining fresh forces and paid attention to exhausted appearance of one of inductees. They immediately got an idea about tuberculosis and at a stage far from initial. But in inductee’s personal file there was included roentgenogram bearing a date two months before conscription. Doctors had no reasons to call the medical certificate in question. However the soldier was visibly pining and month later tuberculosis squeezed the first grume out of his lungs. He was urgently taken to tuberculosis hospital and service investigation started in his unit. Medical officers requested about the results of the last roentgenogram in T.B. prophylactic center. In response they got a request for inductee’s medical file. Not expecting any dirty trick medical officers sent a file.
In the result: initial conclusion “healthy” was replaced by a reference with a record, that the last roentgenogram had been done 2 years before conscription. Medical officers decided not try to strive for truth. In the Ministry of Defense the conflict was hushed up and the soldier was discharged. In a similar way the Military Department acted in a case with an officer of the same military unit. His tuberculosis the same “imperceptible” way reached the last stage. He was saved by a miracle. Physicians affirm, that 2-3 months of military service more would result in inevitable death. The officer underwent a long treatment and had a rest in sanatoriums at the expense of the Ministry of Defense. After that a small tuberculoma left in his lungs, which any moment may provoke recurrent acute attack.
The cost of the problemIt is difficult and expensive to treat tuberculosis when it is untimely detected. For newly detected patients the course of minimum therapy during 6 months costs in average from 600 to 1000 dollars per month. For a patient with a relapse both the period of treatment is longer and expenses are almost twice higher. It is known, that the Ministry of Health Protection in its budget items of expenditure does not occupy the first place. That’s why they try to save money. And the necessity to introduce from the 1st of January 2003 a new methodology for tuberculosis diagnostics (to use selective examination of risk groups, which amounts to 50% of the population instead of general prophylactic roentgenofluorographic examinations) is grounded in the corresponding Order by “application of more economically efficient method for tuberculosis detection”. Strategy for fight against tuberculosis DOTS (Directly Observed Treatment Short-course) recommended by the World Health Protection Organization and introduced in the Republic is aimed, according to our interlocutors, also for savings. It reduces expenses for treatment and the period of treatment. Experts say, that DOTS is approved and introduced in many countries, where it illustrates efficiency (however this issue is still disputable). But the point is that DONS is assigned first of all for developing countries of Africa, Latin America and Asia, where indexes of tuberculosis sickness rate are much higher than in general in the world. In Africa, for example, this index is 200 cases per 100 thousand people, in South-Western Asia – 240. At the same time the greatest part of European countries continue follow their national methods.
The way we treat tuberculosis may be assessed on the basis of observed during the last time increase in the number of relapse cases, which are not included into general statistics. According to the definition of the Ministry of Health Protection relapse is “a case, when tuberculosis patient whose recovery was certified by a doctor gets this disease again. A patient who starts treatment because of tuberculosis relapse is called re-treated”.
Relapse statistics is collected only at a local level and is available exclusively at the highest level of the Ministry of Health Protection. We have only some figures from Frunzensky district of Minsk city, which confirm that the number of relapse cased is increasing. In 2003 there were initially detected 88 tuberculosis patients and it was 9 relapse cases; in 2004 these figures changed correspondingly to 93 and 25. In 2005 the situation was practically the same – 78 newly detected patients and 23 relapse cases.
Not long ago in Vitebsk oblast there happened an incident, which shocked medical circles. The event took place in ordinary tuberculosis hospital, in a room where there were kept patients before the discharge from the hospital. A doctor on duty has found one of the patients on the floor dying in a puddle of his own blood. It appeared impossible to save his life. A blood flooding through a throat from lungs took away the life of 30 years old patient. The event has become the subject of service investigation. The doctor in charge of the case insisted that the treatment was correct and the death was a consequence of deep emotions. The incident was hushed up by making guilty a bride of the patient, who carelessly visited him two hours before his death.
Dangerous zoneTuberculosis in institutions of confinement is a separate subject for investigation. According to official statistics the level of tuberculosis sickness rate is decreasing, but according to the same statistics it is still quite high. And once convicts, serving their sentence in investigative cells and jail, both sick and treated will be released. As it was during amnesty dated for the 60th anniversary of the victory in the Great Patriotic War, when about 4 thousand convicts were released, including those, carrying Koch's bacillus.
In a single tuberculosis hospital of penitentiary institution УЖ 15\12 there are about 2 thousand patients. More than a half of them have a serious stage. As noted one of prison hospital doctors initial stage of tuberculosis is detected quite rarely among convicts. To his mind the reason is in poor diagnostics and medical care in colonies. As a rule medical staff pays attention to a patient only when infection starts “corrode” lungs and the first symptom of the disease – hemoptysis - appears.
By the way five years ago bloody sputum was regarded as one of tuberculosis initial symptoms.
Doctors, working in prisons assure, that tuberculosis was and still remains a scourge of all colonies. The main reason is that prisons are overcrowded. Nowadays more than 140 thousand people serve their sentence in prison. This figure exceeds the designed capacity by 30 thousand. In order to manage with this number of people you have to neglect many medical norms. Including those related to tuberculosis prophylaxis.
Management of colonies tries to overcome overcrowding by arrangement of additional places. In УЖ 15\8 – the greatest colony in Europe – in barracks there is placed a third tier of beds for new comers. Prisoners call those who sleep under the ceiling “condemned to death”. At night there is accumulated so much condensate from breathing at a ceiling, that it drips to faces of people sleeping at the third tier. It’s impossible to get rid of moisture and tubercle bacillus in it. As a result many prisoners are infected. However, when prisoners feel bad they are not in a hurry to ask for a doctor: they are waiting when the disease will be more serious and they will be taken to tuberculosis “sanatorium”, as they call the prison hospital. Republic tuberculosis hospital of Penitentiary Department is located within city Orsha boundaries. It is a prison as well but with wider medical unit and separate rooms for those seriously ill, to whom belong patients with reproduction and discharge of tubercle bacillus. The rest are in mass rooms. In day-to-day life doctors call these rooms the “hell”. During the last two years the “fire of this hell” burnt several tens of people. Medical staff refuses to provide statistic data, but do not deny, that two-three corpses are taken from the hospital per month. In most cases those patients die who has tuberculosis simultaneously with some other chronic disease. Also treatment methods in this close institution are not the best ones. It should be noted that provision of medical supplies in УЖ 15\12 corresponds to modern requirements. For treatment of one convict from tuberculosis the state honestly allocates about 9 thousand dollars. The problem is that tuberculosis little by little becomes resistant to the existing medicaments. Perhaps this is the reason why not only convicts, but also staff of the colony suffers from tuberculosis. Recently in Orsha there happened an event, which Penitentiary Departments does not disclose. During prophylactic fluorographic examination (in УЖ 15/12 fluorographic examination is carried out once in half a year or before a long vacation) it was determined that the Deputy Chief of the colony had tuberculosis. We should note, that he didn’t have any contacts with the diseased, but only with those whose diagnosis was “healthy”. And according to our information this is not a single case. From time to time tuberculosis attacks also medical staff. At that they usually suffer very serious forms. As staff of the colony says the point is in medical fumes, which medical staff breaths in. These fumes make tubercle bacillus resistant to usual remedies, requiring specific non-standard approach.
In the nineties physicians actively used for tuberculosis treatment a needle and an oxygen caddy. The treatment was called “lungs blowing” and it allowed join edges of holes in pulmonary pleura, which had been torn by tubercle bacillus. This method was quite effective and saved a lot of human lives. The only one problem was accuracy of needle sticking. In order to “blow” lungs a doctor had to touch a two-millimeter zone by a needle. Not everybody managed to do this. Perhaps that’s why the Ministry of Health Protection was quite skeptical to blowing oxygen into abdominal cavity. This method was forbidden and only “heavy medicaments artillery” was left at infectious front. However every day it looses its efficiency.
The Ministry of Health Protection tries not to disseminate much information about the fact, that remedies do not have the supposed effect -such information may cause panic among the population. At the same time truth could save a lot of lives. With educational purposes the Ministry of Health Protection distributes posters and brochures. To definite extent the Ministry contributes to spread of infection. For example, in public clinics doctors have the right to keep patients until their final curing. But in closed prison clinics Penitentiary Departments based on connivance of the Ministry of Health Protection does not support keeping extra months to feed by high-calorie diet. And some patients are discharged from prison hospitals before they are cured when their stretch is over.
Management of the colony doesn’t care much where patients go. Of course before the escape from a prison all patients of prison hospital get referral to tuberculosis centers and public hospitals, where they should be registered. However former prisoners rarely follow prescriptions of medical staff. And during the last ten years in Vitebsk oblast none criminal case was brought to a court against intentional infection of people by tuberculosis.
Militiamen do not undertake any visible steps for protection of the population. Medical staff explains this by a long incubation period of the disease. If symptoms (fever, high temperature, pain in a chest and hemoptysis) were evident immediately or, for example, in a week it would be possible to accuse those, who had spread the infection. But the nature gives former prisoners carte blanche for paying the society back. And don’t doubt, they use this chance.
Material is prepared by “Journalistic Investigation Agency” Creative Studio under assistance of Danish Journalists-Investigators Association.
Thursday 08 Jun 2006 (Source - SCOOP Project website / www.i-scoop.org)