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.