Lessons from Tomsk

Russian health authorities have managed to devise a model strategy, hailed internationally, to treat TB and they believe Namibia can learn from mutual cooperation in this regard.
Staff Reporter
The Russian Federation in cooperation with the World Health Organisation (WHO), last month hosted the first-ever WHO Global Ministerial Conference under the theme 'Ending TB in the Sustainable Development Era: A multisectoral approach', in Moscow. The two-day conference, which was attended by ministers from across the globe, including Namibian health minister Bernard Haufiku, led to the Moscow Declaration.

The declaration undertakes to end TB by 2030, primarily through a multisectoral approach which includes political will, financing of projects, research and development, the advancement of universal health coverage and minimising the spread of drug-resistant tuberculosis across the world.

At the conference, Russia announced a donation of US$15 million to WHO in 2018-2020 for the fight against TB.

“Cooperation between Russia and WHO will not only benefit Russian citizens, but all the citizens of UN member states,” President Vladimir Putin said.

TB remains a global problem, particularly in poorer communities across the world, and in prisons. High levels of alcohol use and drug abuse also correlate with a high incidence of TB. Due to its infectious nature, TB is notoriously difficult to combat. Russia has the world's 11th highest burden of tuberculosis and WHO figures indicate that around 120 000 Russian citizens suffer from TB.

The country has battled TB for decades but, following the collapse of the Soviet Union in 1990, the disease took on epidemic proportions. Healthcare practitioners, and researchers alike, report that support systems all but collapsed. Drug shortages, and a lack of finance and infrastructure made adequate healthcare for TB, including monitoring patients, all but impossible. Prior to 1990, the Soviet government had managed to reduce infection levels and keep the disease under control through effective monitoring and medication. Rates of TB were quite low in 1990 with roughly 30 cases per 100 000.

The disease peaked a decade later, in 2000, with up to 90 cases per 100 000 citizens and a mortality rate in the region of 20 to 25 patients per 100 000.

In cooperation with WHO, the Russian authorities took control. In 2001, a new law making TB testing mandatory, was effected. Testing was done through radiography but this was later, in 2002, changed to the DOTS treatment endorsed by WHO. DOTS originally stood for Directly Observed Treatment, Short course but now, it is set to include a five element strategy including political commitment, case detection, standardised treatment with supervision and patient support, effective drug supply and management, and systems to treat progress and evaluate the programme's performance.

A little more than a decade later, programmes launched in Russia have become a model for TB treatment across the world.

“It was not easy. Russia, classified as a high-income country, receives less aid in certain sectors, so funds had to be mobilised from State resources to effectively deal with TB in the country,” the Russian deputy health minister Dr Dmitry Kostennikov said.

Oksana Ponomarenko, Russia's country director for Partners in Health, has been working on TB programmes for more than 15 years.

The treatment strategy in the city of Tomsk, in the east of Western Siberia, is one such a programme. According to Ponomarenko, the TB explosion in 1990 followed as crime rates increased, coupled with increased incarceration, and funding dried up.

“High rates of penal incarceration due to increased poverty and crime rates resulted in the spread of drug-sensitive and drug-resistant TB.”

Primary challenges that had to be faced included adequate infection control measures, including in prisons, and outpatient care in the ambulatory sector.

In Tomsk, Ponomarenko explained, an innovative programme has shown great success, becoming a global example due to the model of ambulatory, or outpatient care that has been developed and implemented.

The programme in Tomsk combined different health services allowing them to work in partnership. This includes psychiatric services, HIV care, drug addiction services and TB care. These were combined into a package serving as a holistic approach for TB care.

“For example, a patient can travel to one dispensary to receive both HIV and TB care. This interconnectedness has been the foundation of our success.”

To add further impetus, in 2006, Sputnik, a care programme for the most vulnerable members of society, was launched. This programme serves the homeless, those suffering from chronic alcoholism, drug addiction and behavioural challenges. Twice a day, Sputnik staff must find each patient in the programme, deliver the correct medication, ensuring it is taken properly and distribute food parcels. The cure rates in 2013 were as high as 90% and the programme is being rolled out to other regions in Russia.

The Tomsk project has been a pioneer for TB treatment and research based on this specific project has prevented future mistakes in other programmes.

Based on successes achieved at Tomsk, a new regulation took effect in Russia in 2012. This regulation controls the organisation and treatment of TB patients and it places specific emphasis on the model of ambulatory care. This includes the distribution of food parcels, public transportation subsidies so patients can reach the clinics, the use of community health workers who go out and see the patients, and increased monitoring.

Essentially, what has been done in Tomsk is now the official policy of the Russian health ministry in combating TB.

What has been learnt from the Tomsk successes is that the traditional model of keeping a TB patient in a facility and providing in-patient care for months is unsuccessful. Not only is efficient out-patient care significantly cheaper, it is also easier for the patient. Policymakers with regard to TB treatment and care, have come to realise this and Tomsk has been a WHO-recognised model for the world in this regard.

Namibia and Russia have much common ground in the fight against TB. According to Dr Kostennikov, both countries battle a high incidence of TB in adult males and in prisons and both countries have isolated far-off communities that need to be served. The excessive use of alcohol, correlated with high rates of TB, also occurs in both countries.

“We have managed to devise a strategy that works with outreaches and an out-patient system which is cheaper and very effective. It takes some coordination but I think Namibia can learn a lot from the way Russia has, and is, dealing with its TB patients,” Kostennikov said.

Russia and Namibia have good bilateral relations although the primary focus is on military cooperation and education.

The Russian government has expressed its desire for enhanced cooperation and trade and the field of healthcare is one of the focal points for the Putin administration.

RUSSIAN EMBASSY

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