The easiest way to find a fantastic disease in Russia is to do a search of its prisons. Through unsustainable practices such as the failure to continue treatment of highly communicable diseases, such as tuberculosis, once an inmate has been released from prison, tuberculosis has spread in places where it can be easily treated.[1] In order for health in Russian prisons to improve, measures must be taken to ameliorate the inadequate living conditions that spread communicable diseases.[2]  The World Health Organization (WHO) created the Health in Prisons Programme (HIPP) in 1995 to fix the major issues of prison healthcare in Europe and create a more sustainable prison health care system. [3] Hopefully, with programs like these in place, Russia will develop a solution to the health care issues that have plagued its society for decades.  

Though the tuberculosis epidemic in Russia began in earnest in the 1990s, Russia’s new health minister, Dr. Evgenii Ivanovich Chazov re-evaluated Russia’s crumbling health care in 1987 and found it in need of drastic improvements.[4] According to Chazov, “The organization of our health protection is in a sad state.” [5] He spoke truly, as corruption, deficient medical training, poor quality of health care, insufficient equipment, and irresponsibility were all present in the Soviet health care system.[6] The majority of these problems can be traced back to the national budget. New equipment and practices were put into place to cure more diseases, but this new equipment and training cost more, resulting in an increase in the budget for health care. These demands put a strain on hospitals throughout Russia, as newer hospitals with better equipment opened and older hospitals fell to ruins.[7]  But with the cost so high, the health care often became underfunded and services suffered.[8]

Doctors’ lack of proper ethical and medical training led to many poor decisions, chief among them taking bribes, which Chazov claims was done in order to pass a student who had no comprehension of basic medical procedures, but the results were far worse.[9] This lack of trained doctors led to hospital administrations with no knowledge of how to respond to crises in the hospitals they were running.[10] Many of these incompetent doctors did more harm than good, making fatal errors because of their lack of schooling.[11] Moreover, the best trained doctors and most modern equipment went to clinics for the elite, leaving the middle class unable to afford life-saving antibiotics without resorting to black markets. [12] In the post World War II years, the Soviet Union attempted its first survey on how competent its doctors were and which doctors needed better training.[13] The results of this survey showed the incompetence of Soviet doctors was so drastic that the Ministry of Health required 40-45% of all Soviet surgeons to complete more training and some to be demoted or fired from their positions.[14] The majority of these untrained doctors had been taught medicine at the battlefront in 4-month courses on military medicine.[15] Some of the better-trained doctors were given 1-month courses under a Ministry of Health edict while the most incompetent doctors spent half a year in intensive on site training at hospitals throughout the Soviet Union.[16]

X-Ray of TB Patient Courtesy of WHO/ Europe

However, since 1990 health services have improved through laws implementing educational programs that have spread knowledge and awareness of major health issues in Russia and the importance of a clean environment, healthy diet, and unpolluted water. Some of these health issues have existed since the 1930s, when hospitals without baths or soap and filled with dirt and lice were not uncommon.[17] Now these issues are being resolved through improved practices. Historians Ruth Bonita and Robert Beaglehole explain that much of Russia needs help in raising awareness of new research studies and epidemiological methods that are commonly used in the West.[18] As Russian officials become more aware of how low birth rates and poor health affects its military and labor force, more policies are being considered and drafted as solutions to these issues.[19] More public health programs and schools of public health have been opened and drastically changed European health. Education is key to lowering the spread of diseases like tuberculosis that are easily treated by modern antibiotics.[20] While these programs and schools have improved public health practice in most of Europe, parts of the former USSR, such as Armenia and Georgia, still need developments to improve their practices.[21]

Russia has not often proven itself to be sustainable, but in order to counteract the communicable diseases that still plague its citizens, public health practices must be reformed. The Russian government has disregarded the development of public healthcare and modern, affordable hospitals for far too long. The health care budget in Russia has also been neglected, so in order for the public health workforce to modernize and be free from corruption, Russia has a lot of work to do. The World Health Organization has helped develop a Global Fund to Fight Tuberculosis, but with many countries suffering from similar problems, improving all of Europe’s public health practices will take time. Russia is just one piece of the puzzle and needs to fix some of these public health problems through an updated government by reducing the spread of communicable diseases.[22]

According to scholar Donald Filtzer, Russia’s serious health care problems date back to the 1950s, when access to good food, clean water, and a sewage system was not universal. Diseases in that period not only included tuberculosis but also pneumonia and dysentery. In some parts of Russia in the 1940s, not even every hospital had a sewage system or water treatment system. At one point, only 16 out of 67 hospitals through Russia, the Ukraine, and Belarus had a sewage system. [23] Needless to say, this poor health infrastructure led to many unnecessary deaths, especially among infants. Between 1946-1947, the percentages of infants who died of tuberculosis increased from 3.6 percent to 3.9 percent and pneumonia and other respiratory diseases killed up to 30 percent of infants in those years.[24]  In order to downplay the severity of their infant mortality rates, sometimes the dates of when newborns died was falsified in the hospitals to make it look like the child had at least survived one year of life.[25] But tuberculosis also affected many adults. In the famine years 1946-1947, adults between 30 and 49 years old were most likely to die of tuberculosis. In fact, the number of adults in the age range who died in those two years went up from approximately 12,000 to 14,000.[26] Tuberculosis was not the leading cause of the death in those (starvation was far more common in the years of food shortage during and after the war), but it did consistently kill middle-aged men.[27]

Important factors in Russia’s medical history include the theories of European sanitarians, experts in public health, from the nineteenth century, whose misguided beliefs were the foundation of many countries’ medical systems.[28] In the centuries before germ theory, many doctors attributed the cause and spread of diseases to environmental factors that were also a byproduct of poverty such as “bad air” and the slums of Europe.[29]  Soviet sanitarians believed that changes in the economic standard of living would improve the health of their citizens and their susceptibility to infectious diseases, much like their French contemporaries, who believed that “tuberculosis [was] a side effect of industrial capitalism”. [30]

NPR Interview with Corey Flintoff

Diseases still have links to socioeconomic factors to this day, as prisons with high recidivist rates of unemployed criminals are more likely to have higher rates of multidrug resistant tuberculosis (MDR-TB) within their population.[31] While tuberculosis and HIV are infections that often occur concurrently, the rise of tuberculosis in Russia is more attributed to the social issues of homelessness and alcoholism than to HIV incidence.[32] As criminals with alcohol or drug addictions succumb to tuberculosis infections and spread their disease to other prisoners, the problem worsens.[33]

Courtesy of Andrei Shukshin, Bulletin of the World Health Organization

According to scholars Jerry G. Pankhurst and Michael Paul Sacks, since the 1960s’ these criminals often have had less education than employed Soviets, which is one possibility for their foray into crime and lack of knowledge about proper hygienic practices.[34] In a study done in 2002 in two St. Petersburg remand prisons, none of the prisoners who had completed a higher level of education developed TB.[35] These uneducated and sick ex-convicts return to cramped apartment buildings and spread tuberculosis to neighbors and family members. [36] While recidivists return to prisons, leaving sick family members behind, the spread of MDR-TB continues and medications become less effective.

The pattern of infection among prisoners has led to programs by the World Health Organization (WHO) and Partners in Health (PIH), such as the DOTS and DOTS-plus programs as methods to fight TB. [37] The DOTS regimen stands for Directly Observed Therapy, Short Course, but its name is a misnomer as the 4 antibiotics used in DOTS (isoniazid, rifampin, ethambutol, and pyrazinamide) must be taken for two months, and 2 of those antibiotics (isoniazid and rifampin) must be continued for four months more to complete the treatment.[38] DOTS-plus treats MDR-TB and takes almost 2 years to complete treatment.[39] The DOTS program is ineffective in treating MDR-TB, so PIH developed DOTS-Plus to treat all cases of MDR-TB in Russia, which can take up to 2 years per patient and over 6 medications. [40]

In at least one Russian hospital, the PIH, the WHO, several non for profits, and pharmaceutical firms founded the DOTS-plus program and the number of patients to die from tuberculosis has gone down from 60-0 in four years. [41] This improvement has greatly affected the tubercular mortality rates in prisons, because the grants from organizations like PIH allowed Russian prisons to afford the antibiotics their inmates with TB and MDR-TB needed.[42]  In Archangel prison in 2000 there were as many as 3,174 cases and 171 deaths due to tuberculosis per 100,000 prisoners.[43] Even though Archangel prison had seen a decrease in tuberculosis cases until 1991, when the incidence increased steadily from 55.6 cases in 1991 to 104.0 cases in 2000 within its 100,000 prisoners. Archangel prison has such a large epidemic because its imprisoned population, including prisoners who do not have tuberculosis, is more than double Russia’s entire prison population.[44]

While these programs have had major affects in treating individuals with TB and MDR-TB, infection control is still an issue in Russian prisons, where 5 prisoners in a room is the norm. Some larger prisons, like Archangel prison, have anti-tuberculosis medical wards for prisoners with TB and MDR-TB and use treatment certified by the WHO. [45] Hopefully, DOTS-Plus will continue to lower the rates of MDR-TB, but more health improvements are necessary for the health care system.[46] Improvements in the Siberian capital of Tomsk included a diagnostics lab in 2008 that has shortened the diagnostic multidrug resistant tuberculosis period from 3 months to 3 weeks.[47] The faster MDR-TB can be diagnosed, the faster it can be treated and the likelihood of misdiagnosis decreases because lab results return sooner. Misdiagnosis of MDR-TB often leads to failed treatment, and with MDR-TB being 15% of all medical cases, diagnostic improvement was sorely needed.[48] This new lab should improve survival rates for patients with TB and MDR-TB because those who are resistant can be moved to separate rooms for treatment and thus minimize the amount of time TB patients spend with individuals with a more deadly form of the disease.[49]  Another diagnostic screen that should be implemented in Russian prisons is the sputum PCR test, which would improve TB and MDR-TB treatment by determining which treatment regimen is necessary for each patient.[50] Sputum PCR test takes mucus from the lower airways of a patient and analyzes the bacteria for respiratory infections.[51] Sputum PCR tests are quick and lead to faster isolation and treatment of tuberculosis-infected prisoners, but it’s the DOTS and DOTS-Plus programs that reduce the spread of TB in prisons. Persons infected with TB still need treatment after their release from prison so recidivists do not return to prisons infected with stronger strands of the disease.[52]

Fran Buntman discusses the work of Anton Oleinik on criminals who create links to Soviet society post-incarceration through illegal markets with ease because social structures are the same in a prison cell or an apartment if a prisoner is a “thief in law” or in a prison gang. Oleinik argues that Russian politicians abuse their power as much as criminals control the prison subculture, so prisoners never learn from their crimes and the recidivist rates increase.[53] Scholar Dominique Moran and her colleagues agree that the end of gang culture would lower recidivist rates (and MDR-TB rates as well) if prisons were reorganized geographically to prevent gangs from forming.[54] The different penal facilities in Russia have their own geographies because individuals are sent to the facility that fits the crime. Some detention centers are specifically for first-time offenders, juveniles, women, or TB sufferers but these specialized prisons are few in number.[55] Prisons that are not sectioned tend to have more problems, like men’s prisons where overcrowding is an issue.[56] One of the highest risk factors for developing tuberculosis in prison is overcrowding of bed space, followed by lack of personal bedding, and not enough time outdoors for exercise and health.[57] Overcrowding is made worse in older prisons, which have poor ventilation and sewage systems.[58] These building issues are why tuberculosis is the largest health problem in Russian prisons because TB incidence is larger in prison populations than the Russian population as a whole.[59] Russian prison officials also treat prisoners without appropriate medical training or follow up on prisoners after release. The lack of follow up usually leads to the patients withdrawing from the expensive treatment programs and developing MDR-TB.[60]

However, screening and treatment is not available yet through most of Russia, especially in the poorer regions, where rural clinics often do not have modern medical equipment or the ability to supply patients with expensive antibiotics used to treat tuberculosis.[61] One way to lower the cost would be to shorten the treatment length from 6 to 4 months, which is being tested in clinical trials in Africa.[62] Several drugs for treatment of TB and MDR-TB are in clinical trials and hopefully will become available by 2015 when the WHO hopes to have reached its goal of cutting the incidence of global TB in half.[63] Countries with the endemic TB, like Russia, must improve their health care systems and use of their antibiotics, and they also must reduce their poverty levels and reform institutions, where TB still flourishes.[64] To help tackle health issues in prisons, the WHO created the Health in Prisons Programme in 1995 to reduce the spread of communicable diseases in prisons.[65] In 2001, the WHO spoke of the need for the creation of national commissions to focus on health issues such as communicable diseases like HIV and TB in order to send resources and alert the public to the health issues in countries around the world.[66]