Tough Measures in Russian Prisons Slow Spread of TB: Nearly a Decade after Starting Work with the Russian Federation to Stem a Tuberculosis (TB) Epidemic, WHO Is Reporting Slow but Steady Progress. the WHO-Recommended DOTS Treatment Strategy Is Gradually Taking Hold across World's Largest Country, but Its Vast Network of Prisons and Labour Camps Remains a Hotbed of the Disease

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When Russian billionaire Mikhail Khodorkovsky was sent last October to a remote Siberian labour camp near a uranium mine to serve an eight-year fraud and tax evasion sentence, friends and relatives accused the Kremlin of trying to ruin his health.

Yet Anatoly Rusin, who was released from prison last year, told the Bulletin that Khodorkovsky had better worry about a far less exotic threat to his health.

"I have not heard of inmates dying of radiation, but I have seen them die of TB," Rusin said.

Until the 1990s, Soviet authorities kept tuberculosis (TB) under control. With the collapse of the Soviet Union, falling living standards, mass migration and a crumbling health system contributed to a 7.5% annual increase in new cases from 1991 to 1999.

Professor Margarita Shilova, Head of the Tuberculosis Epidemiology Department at Moscow's Phthisiopulmonology Research Institute, recalls those days with horror.

"Suddenly, the money stopped. There were no drugs, communication with local hospitals broke down as telephones were cut off over unpaid bills, there were no stamps or envelopes to send letters, doctors could not use a car to see their patients, it was impossible to transport patients to hospitals, the system broke down," Shilova said.

"Discipline among patients and doctors--which is key to treating the disease--was no longer there," she told the Bulletin.

By the end of the 1990s, tuberculosis had reached alarming proportions, particularly in the country's vast penal system.

Virtually every prisoner was exposed to tuberculosis. Many became sick, many died, and thousands of infected ex-convicts were being released into the general population every year.

It was not until 1995 that tuberculosis cases among prisoners were included in official statistics, revealing a concentration in the penal system.

While prisoners account for 0.5% of the 143-million population--there were 765 000 prisoners at the end of 2004--about 12% of cases are detected in prisons alone compared with 27% in 1995, Shilova said.

In recent years tuberculosis cases and deaths have fallen slightly across the country, largely due to this decline of the disease in prisons, but also improved control and general health improvements, according to WHO's Global Tuberculosis Report 2005: Global Tuberculosis Control--Surveillance, Planning, Financing.

WHO experts started working with the ministries of health and justice to revise the national tuberculosis strategy in 1999. WHO's help was timely and welcome, but the first pilot projects were difficult because of a diversity of approach.

"Russia has a very rich history of TB control," said Dr Wieslaw Jakubowiak, WHO's Tuberculosis Control Programme Coordinator in Moscow.

"But the Russian school took a different approach to WHO and, at first, it was not easy to talk the same language and establish the same definitions," Jakubowiak said.

"Since then, we have been able to sit down around one table and to reach a consensus," Jakubowiak said.

WHO reckoned that the country's unwieldy X-ray machines were too expensive and exposed patients to unhealthy doses of radiation. In response, Shilova said the Russians dropped their old methods and switched to the WHO-recommended DOTS strategy.

DOTS once stood for Directly Observed Treatment (Short Course). Now the acronym refers to a five-element treatment strategy encompassing: government commitment, diagnosis through sputum microscopy, regular drug supply, 6-8 months of regularly supervised treatment including direct observation of drug-taking for at least two months; and reporting systems to monitor treatment progress and programme performance.

DOTS was first introduced in the Russian Federation in 1994. Initially it encountered resistance from some Russian tuberculosis experts, but WHO experts say it was often misinterpreted. …


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