Siberian Jail Is a Champion in Fight Against TB

ReutersAn inmate sitting in a TB ward in a Tomsk prison, where doctors halved the deaths from the disease in eight years.
TOMSK — Alexander Pushkarev, head doctor at the 1,000-bed hospital in a Soviet-era prison nestling at the edge of Siberia, flashed a row of metal teeth with his smile.

"Welcome to Tomsk Correctional Facility No. 1," he said. "This is the best treatment for TB in Russia."

In the mid-1990s, virulent tuberculosis was killing prisoners here every week, but with the help of a group of U.S. doctors, the jail near one of the world's biggest swamps has set an example to others worldwide dealing with drug-resistant TB.

Following an initiative from the U.S. Public Health Research Institute, which was funded by George Soros, the Tomsk project now run by Boston-based doctors' group Partners in Health has overturned conventional medical thinking that drug-resistant TB strains are extremely difficult and expensive to treat.

"Without the Tomsk project, drug-resistant TB treatment would be years behind where it is now," said Jussi Saukkonen, a doctor from Boston who was in Tomsk to inspect the project.

"It's been an important benchmark in dealing with this problem."

Under the project, which has now extended beyond the prison to the general population in the region, deaths from TB in Tomsk have nearly halved in eight years to around 12 per 100,000 people — a third of the average in Siberia.

Its main thrust is simple: ensure that existing treatment is adhered to properly rather than introducing new high-tech solutions or expensive drugs.

About 2 million people die each year from TB, a rate that is accelerating, making it one of the world's biggest killers: There are around 3 million deaths a year from AIDS and 1 million from malaria.

Drug-resistant TB emerged over the last couple of decades, mainly because patients failed to complete courses of medication. So the Tomsk correction facility is an appropriate place for this project: One of its core weapons has been discipline.

The most effective response was produced by rigorously enforcing a series of existing measures, including improving ventilation, ensuring that the medical staff have proper training, paying for essential drugs and establishing a strict monitoring system to make sure patients complete their treatments.

Among the nonprison population, doctors do rounds and physically watch their patients take their TB medicine. State benefits are withdrawn if the patient skips their treatment, while testing and education about TB have improved.

Doctors use a range of antibiotics and are ready to switch patients between treatments if they do not respond.

Thomas Peter / Reuters
Inmates entering a tuberculosis ward in the Tomsk Correctional Facility No. 1.

The World Health Organization now promotes such a strategy, called the DOTS (Directly Observed Treatment, Short-course) program.

Previously known as consumption, TB killed millions, including the 19th-century Polish composer Frederik Chopin, Scottish author Robert Louis Stevenson and 20th-century English writer George Orwell.

Rising living standards and antibiotics virtually wiped out TB — bacteria spread via droplets that commonly attack the lungs, invoking a bloody cough and sapping energy — in the developed world during the second half of the 20th century.

But it still stalks poorer countries, where people infected with HIV are most vulnerable, and figures show that there are more people with the disease now than ever.

The WHO estimates that nearly half a million people a year worldwide become infected with a form of TB that is resistant to two or more of the primary drugs used to treat it.

Parts of the former Soviet Union are among the worst affected areas: Around 15 percent of new cases in Tomsk are drug resistant, against a world average of just over 5 percent. Baku, Azerbaijan, has the world's highest rate of drug resistance in new cases at 22 percent.

But Partners in Health, the Boston-based doctors' group, says it has achieved nearly an 80 percent cure rate for drug-resistant TB. The group, founded to provide medical care to the poor, is using the experience from Tomsk to set up projects to treat drug-resistant TB in the African countries of Rwanda and Malawi, as well as other former Soviet states.

Since the group took it over, the Tomsk project has also been funded by the Bill & Melinda Gates Foundation and pharmaceutical group Eli Lilly, and in 2004 it received a grant worth $10.8 million over five years from the Global Fund to Fights AIDS, Tuberculosis and Malaria, set up by the world's wealthiest countries.

The Federal Prison Service now sends inmates from other regions to the jail to receive treatment, and the regional authorities plan to set up a global TB research unit there this year.

In a wing of the prison cordoned off from the rest of the hospital, a few dozen inmates infected with drug-resistant TB have been locked away. People only enter wearing protective clothing — plastic hats, overalls and face masks.

Before the U.S. doctors launched their project here, few inmates could expect to leave this wing alive.

"Maybe that's why Tomsk was so receptive," said Ed Nardell, another of the group's doctors. "They were literally counting the bodies and knew that something had to be done."

Groups of men dressed in black overalls stared out from behind high wire fences that segregate courtyards or peered through mucky, barred dormitory windows. Their heads were shaved, their expressions blank, their faces gaunt and hollow.

A prisoner who gave his name as Rakhid said life in the hospital prison had vastly improved: "I've been here eight years," he said and then chuckled. "And I'll be here a while longer."