An Unobstructed View: Through Central Asia on a Wing and a Prayer
by Eve Jacobs
anuary is icy cold in Uzbekistan, Kazakhstan and Kyrgyzstan, where the
thermometer can plunge to minus 25 degrees C and snow is a dreary fact of life. Only the intrepid choose to go there when winter temperatures cause physical pain, the sun goes into hiding and skies are always gray.
On January 15, following a 16-hour flight stretching over two days from Newark to Amsterdam to Almaty, Kazakhstan, two tired, parka-clad women emerge from a plane. Nisha Ahamed, MPH, training and consultation specialist, and Bonita Mangura, MD, pulmonologist — both from the New Jersey Medical School Global Tuberculosis Institute — have traveled here from New Jersey to work, and extreme weather is not going to get in their way.
The women — tuberculosis experts — are here to wrestle with a horrific medical problem. While bird flu captures headlines on a daily basis, TB is almost silently spreading at the rate of one person per second (according to the World Health Organization), killing more people worldwide than any other infectious disease. Experts in the U.S. can feel proud that they are on their way to taming this killer in their own country, but they recognize a simple fact: TB has no respect for national boundaries, and jumps from continent to continent and across oceans using the very modes of transportation that our global economy depends upon. Currently two billion people — one third of the world’s population — are infected with Mycobacterium tuberculosis, the organism that causes TB disease. Each year nine million people become ill with new cases of TB disease and two million die. Experts predict that by 2020 nearly one billion additional people will be infected with TB and 70 million of those will die of the disease.
The irony of the situation is that TB is curable and the cure is relatively inexpensive. Antibiotics to successfully treat the disease have been available for decades.
Unfortunately, political upheaval often has a deleterious effect on the provision of healthcare, and the availability and affordability of medicines. The breakup of the former Soviet Union in late 1991 spawned 15 independent nations whose fledgling governments have had to grapple with such major challenges as inadequate public health infrastructures and a shaky economy. “Because of insufficient funding for public health programs and healthcare, and because of poverty and poor nutrition, the incidence of tuberculosis has been rising,” explains Ahamed, who graduated with an MPH from the UMDNJ School of Public Health in 2002.
Nisha Ahamed and Bonita Mangura in front of the National Tuberculosis Institute in Bishkek, Kyrgyzstan.
TB is called the disease of poverty because it most frequently sickens those who live in crowded spaces, have poor nutrition and already weakened immune systems. The WHO estimates that in 2003 there were more than 23,000 cases of tuberculosis in Kazakhstan, more than 7,000 in Kyrgyzstan and about 40,000 in Uzbekistan. Mangura says that not only has the incidence of TB been on the rise in these countries, but many new cases are resistant to one or more of the medicines used to treat the disease.
According to the WHO, TB patients in Eastern Europe and Central Asia are 10 times more likely to have multi-drug resistant tuberculosis (MDR-TB) than the rest of the world. MDR-TB is resistant to isoniazid and rifampin, the two most effective anti-TB drugs, and sometimes to other drugs as well. The WHO suggests that drug resistant strains are becoming more resistant, and reports that 79 percent of drug resistant cases are caused by “super strains”— germs that are unresponsive to at least three of the four primary drugs used to treat the disease.
The WHO has placed several countries that were part of the former Soviet Union among the world’s MDR-TB hotspots. It is estimated that in one region of Uzbekistan, where drug sensitivity testing is available, up to 13 percent of new tuberculosis cases are drug resistant and that 40 percent of re-treatment cases are drug resistant. (Data for the entire country are not available because there are few laboratories to test for drug resistance). How did Kazakhstan, Kyrgyzstan and Uzbekistan land in the “top 10” hotspots for MDR-TB? Experts point to several factors.
For one, “TB drugs must be taken daily over a six to eight month period to achieve a cure and they must be taken according to a standardized regimen. Inadequate treatment has been a big problem in this area of the world,” explains Mangura. When drugs are in short supply or not administered correctly, when people can’t afford the medicines, or when patients stop taking their pills and there are not enough trained healthcare workers to keep on top of the situation, TB incidence increases and resistant strains develop. These resistant strains are then passed directly to others — who have not had the garden variety of the disease. Tackling MDR-TB is a long and expensive proposition and the second-line drugs used to treat it are also more toxic and less effective.
Another major factor is the prison system in the countries of the former Soviet Union. Mangura says that neglect, overcrowding, poor sanitation and inadequate nutrition have made the jails breeding grounds for infectious diseases, particularly tuberculosis. Not only do many prisoners have weakened immune systems due to the conditions noted above, but their chances of being in close contact with someone infected with these diseases are very high. Prisoners who contract a drug resistant form of TB also spread that hard-to-treat form of the disease to visiting family members, prison staff, and to other family members and contacts when they are released.
“The emergence of HIV/AIDS in this part of the world is also a matter of concern,” says Ahamed. “As HIV weakens the immune system, an individual becomes far more prone to other infectious diseases, among them TB.” The two infections together can be devastating, each accelerating the progression of the other.
She points out that when the borders opened between the former Soviet Union and such drug-producing giants as Afghanistan (directly to the south of Uzbekistan), illegal drugs began to flow through these countries on their way to Russia, and intravenous drug use became more prevalent. Contaminated syringes are an avenue for the spread of HIV, and in these countries, disposable products are not readily available. Shared needles mean an increase in HIV infection, and with it the chance of more TB.
Ahamed says the WHO recommended a new plan earlier this year called the “STOP TB Strategy” or Global Plan II, advocating expansion and enhancement of the six key elements of its earlier DOTS strategy, which includes: political commitment; case detection through quality-assured bacteriology; short course chemotherapy ensuring patient adherence to treatment; an adequate drug supply; and sound recording and reporting systems. It also addresses TB/HIV and MDR-TB.
One of the key elements of the DOTS strategy is based on a simple technique called “directly observed treatment.” It involves no technology, no expensive equipment and no hospitalization —just someone “in the know” watching the patient take the
appropriate medicines every day until the course of treatment is completed. Directly observed treatment is responsible for the continuing decline of TB in Newark and its environs. It’s the staff of the New Jersey Medical School Global Tuberculosis Institute who can take credit for this success and who now “lend” their expertise around the globe.
The two UMDNJ specialists have come to this part of the world to collaborate with Project HOPE and plan what can be accomplished in the upcoming year. So far, in the Central Asia republics, international teams have trained several thousand
medical professionals in DOTS, provided treatment for more than 93,000 people with TB (thereby preventing many new infections, too) and have equipped laboratories and trained lab workers on diagnosing TB.
But there is still much to do. Ahamed observes that in the countries that were once part of the Soviet Union, there is little standardization of practice. “Doctors treat the disease in different ways. There is also a wide availability of second line drugs through small drug stores that are springing up. This is an encouraging sign for the economy,” she says, “but it makes it difficult for the government to regulate the medicines.” She comments that health clinics are also vastly under-funded and often have a hard time getting staff.
Mangura points out that many TB patients need social support rather than medical care. “These are the chronic cases,” she says. “Once you have TB in the old Soviet system, even if you’ve been effectively treated, you are marked for life. You probably won’t be able to get a job. The hospital often becomes a hotel for these patients.”
Both experts observe that the TB problem in Central Asia is “tremendous” and that trying to get a handle on it can be quite overwhelming. The lack of funding for even basic infection control measures in hospitals, the small number of labs equipped to test for drug-resistance, the shortage of drugs and the numbers of “chronic cases,” sometimes hospitalized for years, are major impediments to progress.
In Kazakhstan, mortality from tuberculosis more than tripled from 1991 to 1997 largely due to delayed diagnosis, inadequate treatment regimens, and chronic shortages of antibiotics. When the disease is found at a late stage, it is far more difficult to cure and more infectious. Without treatment, someone with active pulmonary TB can infect between 10 and 15 others in a year.
Ahamed says that when you see “the dark, crumbling hospital buildings, the poverty, the constant cold and snow, it can feel horrifyingly depressing.”
But things are starting to happen, she continues. “Work on pilot projects in these countries is going forward and WHO’s Green Light Committee is working to provide second-line drugs (to treat MDR-TB) to pilot projects at reduced rates.” A WHO Center of Excellence on MDR-TB for the area has recently been established in Riga, Latvia, to train workers on administration of TB drugs and to conduct research. The UMDNJ tuberculosis experts say they were particularly impressed with the dedication of the local healthcare staff to gain access to whatever knowledge and resources can better serve their patients.
Ahamed came back to New Jersey alone. After Central Asia, Mangura went on to Geneva to join the WHO TB Strategy and Health Systems general meeting and get together with WHO’s Green Light Committee to discuss quality control and training in the labs, the potential of rapid diagnostics in the region, and her impressions of what she had seen. “Some TB patients may not have major medical needs, but they do need food and shelter for themselves and their families,” she states. “If the bread winner is in prison or spends months in a TB hospital, the family needs support.”
She also points out that often prisoners are part way through their treatment for TB when they are released. “They may be desperately ill but there is no follow-up for treatment,” she says. “There is no mechanism for coordinating care.”
The two women did extensive tours of hospital wards, clinics, dispensaries and labs, and met with physicians. Now back in the U.S, they are working on their trip reports and making recommendations for future actions.
Remembering the region from her office in Newark, Ahamed says, “The mountains and foothills of this region are quite beautiful, especially when viewing them from the air.” But Mangura chimes in to remind her traveling companion of the underbelly of working in out-of-the-way places.
The two were airborne — on their way from Tashkent, Uzbekistan to Bishkek, Kyrgyzstan via a noisy, drafty Uzbek Air propeller-driven 15-seater — when Mangura noticed that her traveling companion was unusually quiet. She looked at her and seeing the expression on Ahamed’s face asked, “Are you OK? Why are you so silent?”
“I’m writing our obituary,” Ahamed admitted.
Fortunately, the old Uzbek plane brought the UMDNJ duo safely to their destination and they completed their tour of duty in Central Asia.
“You have to go on site,” says Ahamed. “You have to really see and feel what’s going on to understand the scope of the problem, and the potential solutions.”
It is that sense of determination and pioneering spirit that will fuel the engines when this UMDNJ team takes off again for the same region in June.