Russia has a very complex health care system. Following the collapse of the Soviet Union, the poverty rate in the Russian Federation rose dramatically. Depending on the measure used, somewhere between 35 and 60 percent of the population was living in poverty.
As unemployment rose throughout the 1990s, rates of TB rose as well, from a low of 34 per 100,000 in 1991 to a high of 90 per 100,000 in 2000. Russia also shares with the United States the distinction of having some of the highest rates of incarceration in the world, at close to 700 per 100,000 citizens, and the rate of incarceration in a country tracks with its TB incidence (Stuckler et al., 2008).
The cure rates from WHO’s DOTS approach in Russia were very low, observed Salmaan Keshavjee, Harvard Medical School. Instead of the 90+ percent that one would expect in a population of people where drugs were effective, cure rates were in the 60s, and as time went on, the cure rates for the DOTS regimen continued to decline. At the same time, the rate of MDR TB increased—from 6.7 percent in 1999 to 14.4 percent in 2010 among new cases of TB and from 10 percent to 30 percent among all cases of TB.2
The spread of MDR TB in Russia had several causes. The prevalence of drug resistance was already high; MDR TB was spreading in the air; HIV infections were increasing; incarceration rates were high; and patients were being treated in hospitals, leading to nosocomial transmission, especially during the intensive phase of treatment. In addition, the pharmaceutical supply systems had broken down, so drug supplies were limited, and drug regimens were inadequate; outpatient systems for observing therapy and managing side effects were lacking as well. More generally, this was happening in an environment characterized by considerable substance abuse, weakened family structures, and people feeling isolated from their communities and surroundings.
In 1998, Partners In Health began working in Tomsk Oblast at the invitation of the Russian Ministry of Justice and the Open Society Institute, which had a program to combat TB in the oblast’s prisons. Tomsk is in western Siberia and has a population of about 1 million spread over a
1 This section is based on the presentation by Salmaan Keshavjee, Director, Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School.
2 At the time that DOTS became a global program, international advisors were advising the Russians not to treat MDR TB. In 1996, WHO’s Groups at Risk wrote, “MDR TB is too expensive to treat in poor countries; it detracts attention and resources from treating drugsusceptible disease.” Later, it also was claimed that “best-practice short-course chemotherapy might even reduce the incidence of MDR TB where it had already become endemic” (Dye et al., 2002).