Tuberculosis' deadly return to Europe

He's been in the Tomsk TB hospital undergoing treatment for a disease against which very few drugs work at all for four years now. He complains that four years is a long time for a hospital whose library doesn't have much of a selection, but he's happy his wife has not left him "as, you know, it happens a lot in Russia," and that she and his children come to visit.

But however bad he looks - there is a reason TB was once called consumption, or the wasting disease - his doctors say that he's actually on the mend and they are confident that in another two years he will be cured.

"He'll survive," says Dr Evgeny Nekrasov as he paints a picture of this very typical patient and his disease, proud of the work they are doing in Tomsk, Siberia's university town long forgotten, if it was ever known, by the rest of the world but a model region for Europe in combatting TB.

Multi-drug resistance

Vladimir has what is called XDR-TB, they say, or 'extensively multi-drug resistant TB', a form of the bacteria resistant to most drugs and that emerged in 2006 from the already robust MDR-TB, or plain old 'multi-drug resistant TB'.

TB is usually treated with a course of four standard, or first-line, anti-TB drugs over the course of six to nine months under the direct supervision of a healthcare worker. The full course can cost as little as $11. A patient is classified as MDR if he is resistant to the two most powerful of these. MDR takes longer to treat - up to 24 months - with second-line drugs that have more profound side-effects and that are much more expensive.

An XDR patient is resistant to almost all of these first-line drugs and some second-line drugs are also ineffective. XDR TB treatment can cost a thousand times what everyday TB costs. In the most extreme cases, strains are resistant to all existing TB antibiotics.

Vladimir, for his part, is resistant to eight first-line medicines and sensitive to just two of them. The doctors say that from the beginning, his TB developed in a very advanced manner. This was then compounded by the fact that he was not very compliant with his treatment, interrupting it to stay home. "There were periods of alcohol abuse," his surgeon explains.

It is this interruption that has been the major cause of the development of MDR and subsequently even more virulent XDR, in turn a product of deteriorating diagnostic facilities and healthcare systems that do not have the manpower or time to ensure at-risk patients continue to take their medicine. "Patients believe they are better, because after a short period of treatment, many symptoms go away, but they are not cured, and then the drugs have a limited effect."

Along with Africa, eastern Europe has the lowest success rate for TB treatment in the world. The breakdown of social safety nets, beyond just healthcare systems, growing HIV/Aids rates, alcoholism also contribute to the return of TB. And this before the onset of the economic crisis.

At the Tomsk TB Hospital, chief doctor Golina Yanova reads off the statistics about her patients. All are middle-aged men. Only 2.5 percent have regular jobs. Ninety-five percent are homeless; 50 percent are disabled; 57 percent are alcoholics; 37 percent are convicts.

"At the same time, anybody can contract it. So it's both a medical and a social problem at the same time," she says. "It's a litmus test for society as a awhile. I think we're going have many more patients here. There will be a lot more jobless and homeless as a result of the crisis."

Disease of the past

Still in many quarters considered a disease of the past - in the 1970s, like small pox, it was thought to be on the verge of eradication - even normal TB remains a killer. Roughly a third of the world's population carry a latent strain. The disease has returned in a novel form that is quietly stalking Europe, beneath the media's radar, most of the time marching a soldier's slow but steady stride westward, but at times moving as fast as it takes for a plane to travel from Tallinn's Lennart Meri airport to Heathrow.

Experts worry that Europe, which spent millions battling a Swine flu that killed 14,286 last year, is at a loss when dealing with the threat from the more mundane but far more lethal TB, which strikes down 1.77 million people annually worldwide.

"Just to give this some perspective in terms of international health scares," explains Lee Reichman, the director of the Global TB Institute at the University of Medicine and Dentistry of New Jersey, and one of the world's foremost authorities on the subject. "Sars killed 813 people; H1N1 has killed 3,917; the anthrax scare in the US after 9/11 - five; and mad cow disease - one."

"TB is the biggest single killer of any infection globally and has been neglected for very many years."

As many as half a million TB cases identified each year are resistant to multiple drugs, 40,000 of them XDR. This latter form has so far turned up in some 50 countries. Of the 27 countries most affected by MDR, 15 are in the WHO European region, with Estonia, Latvia, Lithuania and the Russian Federation having some of the highest rates of drug resistance amongst new patients. Across the east, 14 percent of MDR patients have been diagnosed with XDR. This proportion ranges from range from four percent in Armenia to almost 24 percent in Estonia, according to the World Health Organisation (WHO).

Most European countries have been able to slightly reduce overall TB infection, but rates of drug-resistant TB have taken off. Cases resistant to one or more first-line anti-TB drugs were reported by all EU states in 2007, the most recent year for which data is confirmed. In 2005, the WHO declared TB a European region-wide emergency.

Paul Nunn of the WHO says XDR "is raising the spectre of something that we have been worried might happen for a decade - the possibility of virtually untreatable TB."

But citizens and policymakers should not think that the problem is isolated to Russia, EU neighbourhood countries and new member states, particularly the Baltics. Spain, Portugal, Cyprus, the UK and Belgium have seen a growth in cases, particularly in large cities, which have seen previous declines in TB infection rates slow down or reverse.

"TB is a very real and growing threat to the whole continent," concluded a 2008 UK cross-party report.

Patient compliance

There is however no great mystery to solving the problem. Some new drugs would be helpful - the anti-TB vaccine was developed in the 1920s. Frontline workers like Dr Yanova worry that the bacili are becoming more and more resistant to second-line drugs. "If this continues, we could lose a whole range of drugs."

But fundamentally the problem is two-fold: a political commitment to tackling the problem - the first element of the WHO-recommended treatment strategy for detection and cure of TB, Directly Observed Treatment, Short-course, or Dots, is "Political commitment with increased and sustained financing" - and just ensuring patients take their drugs.

Tomsk, which is a pioneer in Russian treatment of the disease, enjoys some of the best numbers for the whole of the Russian Federation, with a 9.4 percent morbidity rate and a one to fourteen death-to-cure ratio.

The region offers social support to all of its patients, support that includes food packages, hot meals, day care centres, travel vouchers - and, crucially, monitoring. Someone who stands there and watches while you take your medicine.

"Look, even I, a TB specialist, with how busy I am, would from time to time forget to take my medicine if I were infected. And if I would, how can we expect anyone else not to?" asks Dr Reichman.

Orwell, Kafka, Chopin

The list of the great European writers, poets, artists and composers afflicted or struck down by ‘consumption' is long, including Kafka, Moliere, all the Brontes, Voltaire, Orwell, Gauguin (although he was finished off by syphillis), Modigliani, Chopin, and Stravinsky. While the disease was endemic of the urban poor, there was such an association between TB and art that some even thought the disease to endow artists with greater energy and creativity, delivering a kind of euphoria.

Today, as before, the disease can in principle strike anyone but remains a malady foremost of the poor. However, in 2010, there is no artistic romance at all associated with TB. It is not John Keats, dead at 25 and the author of When I have fears that I may cease to be, who is the face of modern TB, but rather 25-year-old Maxim, a homeless young man from Tomsk.

Maxim, too old now despite his still adolescent face to be described as a delinquent, has seen more days in jail than days in work. He reckons it was there where he caught MDR TB. It was also there where he was twice treated for the disease. Both times he broke off the treatment - the first time after two months of medication, the second time after four months.

"I felt better. I didn't like the side-effects and I felt cured," he explains sitting in the Tomsk TB Day Clinic. He's there now giving it a go for the third time.

But what makes this time any different? Won't he just give up once again? Right now, he seems the opposite of Vladimir from the hospital. He appears as fit as any young man. One would never know he was sick from looking at him. "I want to be completely cured now. I've had enough of getting sick again and again."

His mother died of TB and his father died from alcoholism. He says he lives in the town's underground heating system, which he enters via a duct on Rosa Luxembourg Street, but the nurses say he exaggerates. It's been months since he was living in the heating system, one says, adding that he has an apartment now he shares with his mates. "It's warm in wintertime," he insists.

The translator warns against sympathising with Maxim. "He's a criminal," he says, "You must not feel sorry for him."

Maxim was jailed for two and a half years for assault, his second sentence. He assaulted another man because he "was drunk and he had led me to that point. I like drinking, and anything that comes my way," he declares with a bravado belied by his fidgety hands.

But he wants to get a job now. "Maybe a journalist, in Europe!" His two mates, who've come with him to the clinic either for moral support or just for something to do, fall apart with laughter. He laughs along, but goes on to say he took some schooling while in prison.

'Mind-bogglingly stupid'

Whether Maxim migrates westward or not, TB in Europe is increasingly being associated not with the old artistic stereotype, whatever the fate that befell Satine, in Moulin Rouge. In tabloids and the minds of conservative policymakers, it is not the starving artist but the starving immigrant that is the face of TB. There is a danger even from articles such as this that readers conclude that a wave of TB is set to consume Europe, infesting it from the undersides of lorries and the insides of shipping containers.

Frontline workers are scornful of this sort of thinking. Sergey Mishustin, the day clinic's chief doctor, says anti-immigrant policies have the perverse result of spreading the disease rather than preventing it.

"Last year in the Tomsk region, we detected TB cases amongst migrants from other regions. Our laws say they are supposed to be deported, but fully understand, by doing that, we will help to disperse the disease, in buses, aircraft. That is why we took them under treatment. We try to provide healthcare to all immigrants that come to the Tomsk region."

Dr Reichman fears how the disease will play out with rising anti-immigrant sentiment in Europe: "Russia's feeding eastern Europe; eastern Europe is feeding the rest of Europe, without even showing a passport and it's got a lot of the western countries really worried. Portugal was the highest in Europe, but then they got their act together and they lowered it down, but it was people coming from Angola, Sao Tome - high-incidence areas. It builds a stigma, and will lead to some ticklish situations."

"But recognising where it's coming from is really a double-edged sword, because the minute you say, ooh, we have to think about people coming from these areas, the first thing the right-wing will say is: ‘Keep ‘em out!' But you can't keep them out. You shouldn't want to keep them out in the first place, but even if you want to keep them out, you can't keep them out."

He is scathing about Italy's recent ‘security package', which requires that doctors report irregular immigrants to the police. "It's very obvious what will happen - it happened in the US - when an illegal immigrant is not able to access healthcare.

"He'll get sicker and he'll spread his disease. These are airborne diseases. Someone's coughing and sick but he thinks: ‘If I go to the doctor, my God, they'll deport me.' So he gets worse and worse and worse until they have to carry him in and how many has he infected in the meantime? It's actually a health benefit for everyone if they access healthcare."

"It's mind-bogglingly stupid this sort of politics."

Berlin Declaration

We have yet to see which way the European Union as a whole goes. In 2007, Portugal's turn at the bloc's rotating presidency dovetailed with its newly aggressive approach to the disease, borne of its realisation that it was amongst the worst hit sites in Europe to produce a new desire at the European level to tackle the problem.

With TB a real example of how one country's weakness in healthcare undermines even excellent healthcare provision in its neighbours, that year saw the bloc as a whole commit to greater European engagement on the issue, with EU Health Ministers signing the Berlin Declaration, which called for greater action to combat TB and specifically MDR-TB.

In June 2009, the World Health Organisation and the European Commission's health department met to discuss ways to better engage Europe in TB control and to re-invigorate the Berlin process.

"It's an airborne disease, You can't have a great health system really tackling the problem next to a country where it's lousy," reminds Dr Reichman. "It has to be tackled internationally."

He is guardedly optimistic now that the disease is beginning to get some of the attention it deserves.

"Five years ago, there was no interest at all in Europe. It wasn't sexy enough. It's beginning to get a bit sexier in Europe now, or, rather, I don't know if sexy is the right word yet. Acknowledged is perhaps better."

The travel and research for this article was funded by the Lilly MDR-TB Partnership, a public-private initiative led by pharmaceutical firm Eli Lilly.

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