It’s often difficult to reflect on success in the world of public health. The challenges are tremendous, and resources limited. But when the International Union Against Tuberculosis and Lung Disease awarded the Karel Styblo Public Health Prize to the Tomsk TB Program, a long-standing partnership between PIH and Russia’s Tomsk TB Services, it seemed appropriate to step back and take a brief inventory of our shared accomplishments in a daunting environment.
When PIH began working in Tomsk, Russia, the oblast was facing an epidemic of drug-resistant tuberculosis. The efforts initially focused on curbing transmission of TB among prisoners. As author Tracy Kidder documented in Mountains Beyond Mountains, “In most places, prisoners contract TB at higher rates than civilians. In Russia’s prisons, though, the incidence was forty to fifty times higher. Moreover, the majority of sick inmates had strains resistant to at least one drug, while nearly a third in some of the jails had full-fledged MDR. Tuberculosis had become the leading cause of death in the prisons, but not all were dying there. Many inmates were surviving long enough to get released and bring the drug-resistant strains of TB back into civilian society. And when they get out, most of those who were sick didn’t get treated, mainly because Russia’s huge civilian TB system was itself in shambles.”
Between 2000 and 2012, the TB incidence rate fell from 116.1 per 100,000, to 62.5 per 100,000—lower than the national average.
Working closely with Russian Ministry of Health, the World Health Organization (WHO), and the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Tomsk Oblast in close partnership with PIH/Russia have achieved significant progress over the past decade. Between 2000 and 2012, the TB incidence rate fell from 116.1 per 100,000, to 62.5 per 100,000—lower than the national average. Meanwhile, the TB mortality rate in Tomsk dropped from 21.9 per 100,000 to 6.1 per 100,000, the lowest TB mortality rate in Siberia and far-east Russia.
PIH’s work in Russia fuses research and trainings with clinical accompaniment and psychosocial support. For instance, the Sputnik program, a model of comprehensive accompaniment designed specifically for vulnerable patients with socio-behavioral challenges, ensures that patients have enough food to take their medications, enough money to afford public transportation to health care facilities, and enough encouragement to stick to their treatment regimen, which can lead to brutal side effects, including deafness, psychosis, and liver damage.
The success and evidence-based approach of PIH/Russia, which has long been supported by the Eli Lilly & Co. Foundation, has helped inform tuberculosis programs throughout Russia and around the world. Clinicians and researchers have published more than 30 peer-reviewed journal articles on lessons from Tomsk and have led dozens of workshops to disseminate their expertise.
“Evidence-based research is truly important because it can facilitate appropriate policy and decision making,” Oksana Ponomarenko, country director for PIH/Russia, said in a recent interview. “Essentially, what we have done in Tomsk has now been adopted as official policy by Russia’s Ministry of Health.”
Even today Tomsk is a challenging setting. Between 2006 and 2010, up to 40 percent of TB and MDR-TB patients enrolled in the Sputnik program were co-infected with hepatitis B and/or C. Chronic alcoholism and drug addiction threaten to derail some patients from their treatment course.
Yet everyone involved with the program, from the driver to the nurses to monitoring and evaluation team, are committed to building on successes and accompanying our patients into the future.