[Note: This is an excerpt from my 2009 global health research project and presentation. Here’s the entire article w/footnotes. Keep in mind that statistics and research were the latest at the time of this project, around 2000-2004 or so. Since that time, conditions and the prevalence of multidrug-resistant tuberculosis have improved.]
Tuberculosis in Politically Vulnerable Places
Tuberculosis is one of the world’s top infectious diseases, second only to AIDS. The numbers are staggering: One-third of the world – two billion – is infected and nearly nine million become infected each year; each year more than 1.6 million die.
The World Health Organization estimates that one actively contagious person infects 10 to 15 people a year. Tuberculosis (TB) is an air-borne, infectious bacterial disease transmitted by bacilli when an infected person talks, sneezes, or coughs. It decays the lungs, and can spread to other organs. The appearance of tuberculosis often reflects the destruction of a country’s infrastructure through political and economic instability, deteriorating health systems and health conditions and, ultimately, through poverty.
Nowhere is this more dramatic than in the former Soviet Union since the break-up of that nation in 1991. Within the former Soviet Union, nowhere is the appearance of tuberculosis more dramatic than the former Soviet republics in Central Asia of Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. Within this region, nowhere has TB more dramatically appeared than in an area bordering the now-dried up Aral Sea in the autonomous republic of Karakalpakstan, Uzbekistan.
Here is a microcosm of all that goes wrong in a society: environmental, political, and economical. This instability leads to poverty, and poverty helps incubates the appearance of tuberculosis. Its new ‘ground zero’ for infection is Karakalpakstan, Uzbekistan, where the multi-drug resistant (MDR) tuberculosis rate is one of the highest in the world. Given these prevailing conditions, it is imperative that funds, programs and training, and first-line drugs be available to keep this MDR-TB epidemic from exploding throughout Uzbekistan and beyond its borders to the rest of the world.
A Soviet History Lesson
For thousands of years this northwestern area of Uzbekistan – known as Karakalpastan, the name of the ‘Black Hat’ nomadic tribe – was a prosperous, heavily populated oasis for fishing as well as a fertile delta for simple irrigation-based agriculture. Water came from two main rivers, Syr Darya and Amu Darya, which fed into the Aral Sea. At one time, this sea was the fourth-largest in the world, and one river – the Amu Darya – was wider than the Nile.
However, in 1918 the Soviet government diverted water from the two rivers in massive projects to irrigate the desert for crops such as fruits, grains, and rice and—most importantly—for cotton as Uzbekistan’s top export. Over the years the Aral Sea began losing its water supply and gradually began drying up. Pesticides and fertilizers leeched into the water: as the water dried so did the salt and chemicals, spread by winds and dust storms.
Additionally, for many years the Soviet government used an island in the Aral Sea to develop and test biological warfare – weapons-grade bacteria and viruses such as anthrax and bubonic plague – which contaminated the water, land, animals and vegetation. As the Aral Sea dried, that island transformed into a peninsula, making its contaminated area more accessible to humans and animals.
Against this environmental and political backdrop, the ‘desertification’ of the Aral Sea diminished to just 10% of its original size, leaving a wasteland of 19,000 square miles – about twice the size of Massachusetts.
The once-thriving seaport of Muynak, Karakalpakstan is now 93 miles away from water. The salinity of the Aral Sea’s remaining water increased five-fold, killing off fish, the fishing industry, and most of the area’s natural vegetation. As the Aral Sea died, so did the region of Karakalpakstan, Uzbekistan. The United Nations calls this the ‘largest man-made environmental disaster in the world.’ It is, indeed, an environment ripe for disease.
The Relentless Fallout
This politically-based ecological disaster of the Aral Sea has many ramifications for health. After the break-up of the Soviet Union in 1991 – and no longer supported with subsidies from Moscow – Uzbekistan plunged into poverty. Since fishing and related industries dried up with the sea, unemployment in Karakalpakstan has skyrocketed to over 70 percent. Those who do have jobs, such as health care workers, are poorly paid: about $12/month for nurses and $24 for doctors. Many have left the area, seeking more lucrative work; many of those who remain can’t afford to heat their homes, so they crowd together into smaller places, creating unsanitary conditions.
Moreover, with little money it is difficult to buy healthy food, and when they do purchase meat and produce, it may be contaminated from dirty water used in irrigation or from the soil itself.
Additionally, salinized soil makes it nearly impossible to grow nutritious vegetables with essential micro-nutrients. Water is unsafe and contaminated with salts, DDT, and pesticides; high groundwater tables make sanitation inadequate, and diarrhea is widespread.
Anemia is high in women and children, with air-borne chemicals, salts and contaminated dust increasing the incidence of skin and lung diseases. Throat cancer is the highest in the world – up to 80% of cancer patients in Karakalpastan have this disease, which may be attributed to DNA damage. Contaminated air – especially in the capital of – is twice the international standard that is considered polluted. Karakalpakstan’s child mortality rate is the highest in all the former Soviet republics.
Perhaps the most disturbing statistic is that GDP total spending on healthcare is just $6.50 – low even by developing world standards such as Uzbekistan’s $177.12 By comparison, the United State is $6,700.
Compare: Karkalpakstan: $6.50
Tuberculosis Magnified: Multidrug-Resistant Strains
In such conditions of poverty, poor diet, and lowered immunity, tuberculosis thrives. Tuberculosis may live dormant for years before it presents itself – and when it does, treatment can be relatively cheap and easy: about $20 per person taking drugs for six to twelve months.
However, if treatment is stopped, or if the TB is a more virulent strain, the cost jumps and treatment grows much more complex: $500-$3,000, with multi-drug treatments lasting up to two years. This can occur when tuberculosis becomes resistant to first-line drugs when treatment is not completed.
In this environment, the tuberculosis mortality rate increased by 20 percent in Uzbekistan between 1995 and 2003. Since 1998, the international medical aid agency, Medecins Sans Frontieres (MSF), worked in Uzbekistan with local tuberculosis services to implement DOTS (directly observed treatment, short course). Unfortunately, only 7% of Uzbek TB patients were treated using this method; 93% were not, relying instead on local markets and bazaars to supplement their intermittent supply of TB drugs, often of questionable quality.
Additionally, at the end of the Soviet era in the early 1990s, the supply of medicine became unreliable – devastating for TB patients who then became multidrug-resistant, infecting others with such virulent strains of the disease. This interruption in drug treatment and questionable quality of drugs are the very conditions that can lead to multidrug TB resistance, and it did. In an old Soviet-style healthcare system of low-paid, poorly trained, and unmotivated staff, it has been difficult to carry out the DOTS strategy for TB.
In Karakalpakstan, Uzbekistan, Medecins Sans Frontieres (MSF), reported in 2002 that TB rates in this region were twice as high as those in Uzbekistan – and Uzbekistan’s rates at that time were the worst in the former Soviet Union. This was partially attributed to extreme poverty; environmental desecration from the Aral Sea disaster; and a poor healthcare system with overcrowded and unsanitary hospital conditions for TB patients. In one former seaside town, Muynak, MSF reported that in just one year alone – from 2001 to 2002 – the number of tuberculosis cases increased by nearly 70 percent.
MSF conducted a 2003 study of Karakalpakstan and discovered drug-resistant strains of TB in 13% of new cases and 40% in previously treated patients. The World Health Organization (WHO) has established the lower limits for a TB epidemic at 50-70 infected people per 100,000. In Karakalpakstan, those rates ranged from 220 to 300 per 100,00026 – unquestionably an epidemic.
Tuberculosis: Discouragement and Hope
As a result of this disturbing information, in 2003 MSF began an MDR-TB DOTS-Plus treatment pilot program. They chose Nukus, a city of 260,000 and capital of the autonomous republic, as well as the Chimbay rural district of 97,000 which was less populated, more difficult to access, and farther away. The goal was to compare results between an urban and rural setting using standard first-line drug treatments and sputum smear microscopy for diagnosis, as recommended by WHO.
Because of the number of patients who developed XDR-TB (extreme drug-resistant TB) in the Karakalpakstan study, researchers cautioned against scaling up DOTS-Plus internationally, fearing that if staff, resources, support, and a simpler regimen aren’t available, this could increase the risk of XDR-TB worldwide.
Despite such caution and concern, there is hope that TB, MDR-TB, and XDR-TB will be more widely treated in Karakalpakstan, and throughout Uzbekistan and Central Asia. In 2008, USAID spent about $1.5 million on TB projects in Uzbekistan, with $50 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria earmarked to purchase anti-TB drugs and provide services to treat TB in Uzbekistan over the next five years. Medecins Sans Frontiers recently began a massive information campaign in Karakalpakstan; its goal is to increase public awareness about tuberculosis and reduce the stigma related to this disease of poverty.
The prevalence and death rate of tuberculosis in all its virulent forms in Uzbekistan – and especially in the environmentally desecrated autonomous republic of Karakalpakstan—are warnings for the need to improve treatment regimens, provide greater access to drugs and health services, and to develop better, simpler strategies to combat the explosion of this highly contagious disease.
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