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Infectious Diseases Rising Again In RussiaBy: Abigail Zuger VORONEZH, Russia — Russia's political turmoil, its economic crisis and its new freedoms have been accompanied by a wave of old diseases. Tuberculosis is flooding the country, producing what some authorities are calling the world's largest outbreak of the drug-resistant variety, one of medicine's most ominous problems. Rates of other infections, including hepatitis, syphilis and AIDS, are skyrocketing. An epidemic of diphtheria swept through in the mid-1990's. Reports of smaller, regional outbreaks of encephalitis, typhoid fever, malaria, polio, pneumonia and influenza pepper the nightly news. Health experts describe Russia's prison system as an "epidemiologic pump," continuously seeding the country with pockets of tuberculosis that can spread on their own. Increasingly, TB cases of Russian origin are turning up in the Baltic countries and even farther afield — for instance, Germany and Israel. Specialists worry that if the rising rates of infectious diseases in Russia continue unabated, the country itself may turn into an epidemiologic pump, sending infectious diseases into the rest of the world. "It's not surprising to see a case here," said Barry N. Kreiswirth, a tuberculosis expert at the Public Health Research Institute in New York City, "but it's a good reminder that it doesn't take much for one person to be a vector and start an epidemic." An Old Scourge Made New Tuberculosis is hardly new in Russia. It ravaged the country in the 19th century and the first half of the 20th. But before the Soviet Union fell it was finally being brought under control, through major government effort and expense. Infection rates, though roughly three times higher than in the United States, were falling in parallel with those in Europe and developed countries elsewhere. This victory bred "a tremendous pride on the Russian side," said Dr. Mario Raviglione, coordinator for TB activities at the World Health Organization in Geneva. That has changed. With thin budgets, government health programs are no match for infections given new momentum by increasing poverty, stress, alcoholism, overcrowding and intravenous drug use. Mortality from infectious diseases has not reached third world rates here. Last year, infections were estimated to account for 2 percent of all deaths. But that is still four times higher than in most developed nations. "The total cost of infectious diseases in Russia is not that great," said Martin McKee, an expert in Russian public health at the London School of Hygiene and Tropical Medicine, "but the important thing is that it is going up and up and up." As AIDS becomes more firmly entrenched, that cost is expected to rise even faster. Deaths due to tuberculosis alone rose 30 percent in 1999. The Cost of Drug Resistance Treating drug-resistant tuberculosis is among the greatest of medical challenges. It requires expensive, "second-line" drugs, which must be taken for years instead of months, and which have many side effects. Sex, Drugs and Disease Further, an epidemic in one disease could easily ignite epidemics in others. Infection with H.I.V., the virus that causes AIDS, is rising faster in Russia than almost anywhere else, according to estimates from the Joint United Nations Program on H.I.V./AIDS. And syphilis and hepatitis B cases skyrocketed during the 1990's. This is an explosive combination: syphilis enhances the sexual transmission of H.I.V., and tuberculosis can worsen the immune deficiency caused by H.I.V. An H.I.V. infection, in turn, can cause syphilis and tuberculosis to take unusual forms, making them both harder to diagnose and harder to treat. The resulting cyclone of mutually enhancing infections can tax medical ingenuity and budgets everywhere. In New York City in the early 90's, for instance, an outbreak of tuberculosis among H.I.V.-infected people and their contacts — involving about 1,000 cases of drug-resistant disease — cost more than $1 billion to squelch, by some estimates. Looming Infection Diphtheria cases soared nationwide in the early 90's, the combined result of declining childhood vaccination rates and the vulnerability of adults who had received shoddy Soviet vaccines as children. Since a new vaccination campaign backed by international aid, diphtheria is now rare again. |
