TUBERCULOSIS REMAINS UNDER-REPORTED PROBLEM IN NORTH

UNCLAS SECTION 01 OF 02 MOSCOW 000809

DEPARTMENT FOR PRM/ECA AND OES/IHB JEHAN JONES

SENSITIVE
SIPDIS

E.O. 12958: N/A
TAGS: PGOV PHUM EAID TBIO RS
SUBJECT: TUBERCULOSIS REMAINS UNDER-REPORTED PROBLEM IN NORTH
CAUCASUS

1. (SBU) Summary: The International Medical Corps (IMC) Acting
Russia Country Director warned of the continuing spread of
tuberculosis (TB) in the Russian republics of Chechnya and
Ingushetia at a meeting of post's Refugee Assistance

Roundtable/Forum on March 24, World Tuberculosis Day. While the
disease has a high prevalence throughout Russia, IMC's efforts are
focused in the North Caucasus. There are serious impediments to
stopping the disease's proliferation: absence of TB specialists in
the region, non-adherence to standard treatment protocols, low early
detection and registration of the illness, prohibitive drug prices,
and the social stigma of acknowledging infection. IMC wants to
tackle this major public health challenge and has been in
discussions with the principle Russian recipient of the Global Fund
to Fight AIDS, Tuberculosis and Malaria (GFATM) about obtaining
funding for training of health care workers. End Summary.

ALARMING STATISTICS
--------------

2. (U) Representatives of the Finnish Embassy, USAID, and French NGO
Samusocial Moskva met at Refcoord's invitation March 24 to hear from
Simon Rasin, MD MPH, International Medical Corps (IMC) Russia's
Acting Country Director. Rasin shared alarming World Health
Organization tuberculosis statistics regarding the prevalence of the
disease in the Russian Federation, which ranks 12th on the list of
high-burden TB countries. The proportion of cases cured and treated
in Russia is among the lowest worldwide. Rasin acknowledged that
some countries, such as Tajikistan, may actually have higher rates
than Russia of TB infection but do not have the public health
capacity to provide full statistics.


3. (U) In the Chechen Republic, 925 new TB cases were registered in

2008. Some 554, or 60 percent, of these cases were already in the
last stages of TB, when death is imminent. There is a total of
4,100 active TB cases in Chechnya - or .34 percent of the
population, compared to the Russian Federation average of .22
percent. In general, Rasin averred, the numbers are greatly
underestimated, and health officials lack the means to track those
who are ill. Rasin reckoned that the actual number of TB cases is
likely more than three times the number of officially registered
cases.


4. (U) The situation in Ingushetia, while similar to that in
Chechnya, is all the more appalling to Rasin because there was no
war there. In 2008, there were 1,195 individuals registered in the
Ingush Republic with an active form of TB. Unfortunately, Rasin
noted, many of these individuals are registered as chronic, which in
actuality means they have developed a multidrug-resistant (MDR)
tuberculosis. Some 47 percent of all TB patients are women, while
the average country rate is 30-35 percent. TB progression from
infection to disease is reportedly much faster for women of
reproductive age than it is for men. In 2001, only three people
were documented as having tuberculosis and HIV; by 2008, there was
an increase of 38 cases. The tuberculosis problem in Ingushetia is
exacerbated by inadequate health care facilities. HIV-positive
individuals are accommodated in the same hospital as those with MDR
and extensively drug-resistant (XDR) TB, increasing the risk of
infection for all.

OBSTACLES TO TREATMENT
--------------


5. (SBU) One of the greatest barriers to proper TB care in the
region, particularly in Chechnya, is the amount of official
corruption, according to Rasin. The republic has one regional TB
center, located in Groznyy, with 140 beds. Rasin believes that this
is only a fifth of the number needed. Funds have been allocated
five separate times by the federal government for the construction
of a new TB center, but each time the money has "disappeared."
Existing facilities have modern equipment but suffer from lack of
connections to basic services, including sewage and water. Staff
shortages are common, particularly in rural areas, due to poor
living conditions and compensation. Rasin contended that the local
physicians are intellectually able but need guidance and support "in
terms of everything."


6. (U) Ingushetia's system of addressing TB is also deficient.
Poverty and poor living conditions, particularly among IDPs,
insufficient early detection, and scant public awareness all pose
challenges to Ingush public health officials. In the Nazran TB
treatment center, the sewage and water systems are in a constant
state of disrepair. In addition, the Ingush center is severely
understaffed, Rasin estimates by up to 60 percent. In the health
care system at large, some nurses refuse to care for TB patients,
for - not unrealistic, in this environment -- fear of themselves
developing TB. Clinic staff turnover is high.


7. (U) Beyond the systemic challenges to TB patient care are
unhelpful underlying social norms in the region. There is great
social stigma associated with TB. Cases of TB are often concealed

MOSCOW 00000809 002 OF 002


1. (SBU) Summary: The International Medical Corps (IMC) Acting
Russia Country Director warned of the continuing spread of
tuberculosis (TB) in the Russian republics of Chechnya and
Ingushetia at a meeting of post's Refugee Assistance
Roundtable/Forum on March 24, World Tuberculosis Day. While the
disease has a high prevalence throughout Russia, IMC's efforts are
focused in the North Caucasus. There are serious impediments to
stopping the disease's proliferation: absence of TB specialists in
the region, non-adherence to standard treatment protocols, low early
detection and registration of the illness, prohibitive drug prices,
and the social stigma of acknowledging infection. IMC wants to
tackle this major public health challenge and has been in
discussions with the principle Russian recipient of the Global Fund
to Fight AIDS, Tuberculosis and Malaria (GFATM) about obtaining
funding for training of health care workers. End Summary.

due to the shame the condition can bring to a family. The refusal
of a family to acknowledge that a member may have the illness can
lead to the spread of the disease. For example, elders are held in
high esteem in Caucasian culture. Family members will still give
babies to a grandparent to kiss, even if the elder has been showing
signs of pulmonary infection; to do otherwise would be considered
disrespectful.

OVERCOMING OBSTACLES
--------------


8. (U) IMC is working to increase prevention and early detection of
TB. The organization is waging a public awareness campaign to
combat stigmatization. IMC currently has State/PRM-funded mobile
medical teams comprised of physicians and nurses that travel to
rural areas and IDP settlements in Chechnya and Ingushetia. The
teams work at outpatient centers and give public lectures to
increase public awareness four days a week. On the fifth day, the
teams conduct trainings for local health care personnel and health
classes in schools with IDP populations (note: the disease is more
prevalent among IDPs and recent returnees living in dormitories; end
note). During these classes, the medical team uses games to
demonstrate normal lung capacity and identify children who may be
infected. Rasin says that the IMC has seen positive results from
these classes. For example, a child who discovers he cannot blow
out a candle from three feet away may later attend the
organization's mobile clinic for follow-up diagnosis and treatment.
The team also works with community volunteers to train and develop
prevention messages. It meets with religious leaders and community
elders in order to develop a culture of awareness and to reduce the
stigma associated with TB infection. Rasin argued that these
measures are important but not enough.


9. (SBU) For the future, IMC hopes to conduct skin tests in Chechnya
- none were performed there in 2008 due to a lack of tuberculin.
There is also a need to train village health facility staff. Groznyy
has benefited from a great deal of NGO-provided training, but
villages have had far fewer opportunities. IMC hopes to close the
gap. It would like to partner with the Global Fund to Fight AIDS,
Tuberculosis and Malaria, but it is not a member of the Russian
Country Coordinating Mechanism Against Aids, Tuberculosis and
Malaria (CCM),which selects the GFATM grant recipients. (Note: USAID
sources tell us that IMC only recently began to attend the CCM
meetings as an observer, and did not submit an application to GFATM
or participate in the working groups that developed proposals. If
IMC hopes to receive money from the GFATM, it may only do so as a
sub-recipient of the Russian Health Care Foundation (RHCF),which
was selected as the principal national recipient. End note.)
Speaking to the roundtable, Rasin simply said that GFATM money would
not be available until 2010. He affirmed that IMC is actively
working to identify other donors to improve TB prevention and
treatment in the intervening months.

Comment
--------------


10. (SBU) Although the quality of official TB epidemiological data
in the North Caucasus is no worse - and in some instances better -
than in other Russian regions, the real extent of infection is still
not apparent. Weak political commitment from local governments,
graft, poor infrastructure, an unstable economic environment, and
the prejudices of the local population all hamper TB control.
Inadequate public health response by federal and local officials to
the high TB infection rate in the North Caucasus is sadly emblematic
of the sloppiness and corruption that render the Chechen and Ingush
republics miniature failed states. U.S. assistance programs should
continue to target the health sector as part of a broader protection
strategy for the society's most vulnerable, including its IDPs.