Imagine Siberia, swamps, snows and mosquitos, the dark heart of Russian history- prisons and camps and starving farmers. It might be surprising to you that I left Moscow on a midnight flight disheartened about the Russian health system and 24 hours later I am inspired by a Siberian prison doctor.
The TB rate in Russia more than doubled 1990-2000 and now multidrug resistance is rampant. From Moscow it appears the Russian public health system is a failure. There are public health books that scare people about global pandemics that originate in Russia. The litany of problems we heard about in this country are striking: almost half of Russian TB drugs are poor quality, diagnostics lack the reagents to actually be used, there is no budget for prevention. We visited patients, kids, held in hospitals for six months or longer (much could be outpatient for a fraction of the cost), often with outdated methods of aging, poorly paid and poorly respected TB doctors. Some believe as many as 100,000 people now have multi-drug resistant (MDR) -TB and most are fated to either suffer, remain on failing treatment for a long time, switch to painful treatments with horrible side effects, or die.
Who do you turn to? There is no TB department and the new “head TB doctor” in the country has no background in TB – but the feeling is that he can’t be worse than the last one. The government purchase of this year’s TB drugs hadn’t been announced as of the end of May and last year the government only spent 7% of a central part of the TB budget. Russia refused to sign the latest application to the Global Fund for $150M, (proudly believing that Russia is a donor country, not a recipient) so the Paul Farmer’s group Partners in Health went ahead and submitted nonetheless.
As in many developing countries the answer is to go around the federal system as much as possible, and so we go far away from Moscow. Last year the only requests from Russia to the WHO for high quality second-line drugs came from Partners in Health for a project in Siberia, where about 1,000 patients are treated. That’s right- about 1% of people who need treatment are receiving high-quality medicine. This glimmer of hope comes from a collaboration between NGOs, State government, universities, companies and prisons to address TB. And on a hot summer day a Siberian prison doctor told me “The most important thing we can do for prisoners is give them hope, and a path to a life without TB.”
While there are some good folks out in the field, I am still grappling with the reality that little has changed in the 30 years since the height of the cold war, when my dad came from the US to help treat the lung failure of a young woman in Moscow. Once in Moscow he realized he had to set up a separate supply chain to bring antibiotics from Boston for those few short weeks. The Moscow doctors had proposed a dilute red wine enema (Stalin’s favorite) to cure the infection. Its still a problem of antibiotics- in fact the same one he had hand-imported. 30 years from now will my children be coming back to deliver antibiotics to Russia? Can the big ideas we have bout social change – like collective impact, be applied here? It has been exciting to discuss these ideas in Moscow offices and in the shtetls of Siberia- and while my optimism is challenged, it is not overwhelmed.