Uzbekistan - Tuberculosis – a public health emergency in Uzbekistan

Citation

(2005), "Uzbekistan - Tuberculosis – a public health emergency in Uzbekistan", International Journal of Health Care Quality Assurance, Vol. 18 No. 2. https://doi.org/10.1108/ijhcqa.2005.06218bab.005

Uzbekistan - Tuberculosis – a public health emergency in Uzbekistan

Uzbekistan - Tuberculosis – a public health emergency in Uzbekistan

Keywords: Public health, Diseases, Uzbekistan

There are a number of reasons for the high incidence of tuberculosis in Karakalpakstan. A lack of funding generally for health-care services in Karakalpakstan, and indeed the rest of Uzbekistan, is felt acutely within tuberculosis treatment services.

A disease associated mostly with poor and marginalised members of society, tuberculosis is commonly a neglected disease in many resource-poor settings.

In Karakalpakstan, although the authorities are increasingly committed to fighting tuberculosis services since MSF started lobbying for these patients, they just lack the resources to do so. The total health-care budget for 2002 in Karakalpakstan was only US$6.5 per capita, of which 9 per cent was spent on tuberculosis services. Basic items like paracetamol, syringes, or some car petrol to do supervisory visits, are often unavailable despite the fact that almost all other items needed for a DOTS programme are provided by donors. Support from international organisations is therefore crucial for improving all health services in Karakalpakstan in order to improve the health of the population.

Health-care staff are poorly paid (a doctor can expect to earn around $US24 per month, and nurse and a laboratory technician around $US12). Often this money is not paid on time or is paid in the form of credit for food from a certain shop. They therefore have to save time and energy to make money in other ways. Since the DOTS treatment programme requires extra efforts from several health-care professionals compared with the Soviet treatment system, many are not motivated to take on this extra work without additional rewards. Unlike in other poor countries, in Africa for example, in Karakalpakstan living expenses are relatively high. The winters in Karakalpakstan are bitterly cold (minus 20°C is normal), for which you need a well built and heated house and good clothes. Many health-care professionals are known to have moved from the region in search of better salaries in Kazakhstan and Russia.

The epidemic of tuberculosis is fuelled by poor living standards. That gas pressure goes down with the temperature in Karakalpakstan is commonly acknowledged, and many families survive throughout the winter with no gas at all. As a result, families and groups tend to huddle together in one room for much of the time, conditions that may increase transmission. Poor nutrition is an issue in Karakalpakstan and is known to be associated with increased risk of acquiring tuberculosis. Tuberculosis patients are a particularly vulnerable group, and hospitals provide little food for their patients.

The International Federation of Red Cross and Red Crescent Societies is currently working in Karakalpakstan, providing food parcels to all patients with active tuberculosis and their families.

“The International Federation of the Red Cross and Red Crescent are currently in their fourth year of a supplement food relief programme in Karakalpakstan. There is clearly a nutritional problem throughout the population In Karakalpakstan, but we decided to focus on the most vulnerable – tuberculosis patients. We found that tuberculosis patients are often the main money earner in the family, so we support the entire family with extra food supplies.

Although I wouldn’t say there is a food shortage here in Karakalpakstan, there has been a drought so it is harder for people to grow crops. Also, there are barriers to Karakalpaks to getting certain key nutrients – often they can’t afford certain foods, much of the food here is poor quality, and there are cultural issues that may impact on their poor nutritional status”, stated: Kristen Donnelly, International Federation of Red Cross and Red Crescent Societies, Aral Sea Program Coordinator, Karakalpakstan.

A huge stigma is attached to tuberculosis in Karakalpakstan. As a result, many are reluctant to come forward for testing and treatment, and MSF has noted high failure and high death rates partly caused by patients presenting late to the tuberculosis service. Many local people in Karakalpakstan see tuberculosis as a disease of the poor, associated with poor diet and poor hygiene. Such a stigma contributes to the fact that some people are more likely to go to the local bazaar when they have symptoms than present to the tuberculosis facility. Anti-tuberculosis drugs are widely available on bazaars in Karakalpakstan.

MSF carries out a programme of health education, to encourage people to come forward to testing, but the task is enormous. On World Tuberculosis Day in March 2003, MSF could not find one ex-patient in Karakalpakstan who was willing to stand up in front of an audience and discuss his/her disease history, which well highlights the situation at this time.

Multi-drug resistant tuberculosis (MDR-TB) is emerging as a major threat to tuberculosis control in many parts of the world. Throughout MSF’s work in the Aral Sea area, MSF has observed that a consistently high number of patients are not fully cured after a course of DOTS treatment and MSF has suspected that resistance to these “first-line” drugs is the reason. In Karakalpakstan in 2002, a survey was carried out into the drug resistance profile of the tuberculosis that is infecting patients in the community. Results show some of the highest rates of MDR-TB yet recorded globally to date. Thirteen per cent of new patients presenting to tuberculosis clinics in Karakalpakstan have MDR-TB. According to WHO, countries with MDR-TB resistance levels above 5 per cent represent an international public health emergency.

From June 2003 the DOTS programme will have expanded to cover the whole of Karakalpakstan. MSF has ensured a continuous supply of anti-tuberculosis drugs and laboratory supplies to the region (since January 2003 this has been provided by the German bank KfW), has trained health-care workers in internationally approved protocols, upgraded laboratory facilities, built waste-compounds and latrines, carried out supervisory visits, and successfully lobbied for local authorities to renovate existing health-care facilities. However, the process has not been an easy one.

MSF has encountered many problems and obstacles along the way. MSF wants to share these experiences with other international and national organisations that might be interested in the future to expand the DOTS programme in other parts of Uzbekistan and in similar settings. Only 7 per cent of Uzbekistan’s population is covered by the WHO recommended DOTS treatment programme at this time, and MSF hopes that our experiences in Karakalpakstan will encourage others organisations to take up this challenge. Attempts by other interested organisations to access prison populations inKarakalpakstan should also be encouraged with utmost urgency.

Furthermore, many of MSF’s experiences gained in improving tuberculosis treatment in Karakalpakstan can be applied to other diseases and health-care issues facing the population. Basic primary health care, public-health interventions, disease prevention activities, cancer services, emergency health care, sexual health services, to name but some, are all in need of support. The extensive health-care infrastructure that exists, built during the Soviet era, is struggling to meet current challenges. Urgent assistance is needed to upgrade and maintain its capacity.

Through MSF’s positive experiences in Karakalpakstan, we hope to encourage interested parties to initiate pilot health-related projects in the region and then work to expand them accordingly. Emphasis should be placed on working collaboratively with society, international non-governmental organisations (NGOs), donors, and local and national government.