Fighting Tuberculosis: Western Myths and Belarusian Reality

Last week, Mario Raviglione, director of WHO's Global TB Programme, singled out Belarus and parts of Russia as being part of a developing "disaster situation" due to the high rates of multi-drug resistant tuberculosis.

He warned that migrants from these countries pose a threat to Western Europe, where multi-drug resistant tuberculosis​ ​(MDR-TB) is exceedingly rare.

The good news is that these fears are exaggerated. Research indicates that post-Soviet migrants account for a mere 1.7% of TB incidence across the EU border.

What is more, Belarus may pose less risk to Europe than countries like Moldova, where overall TB rates (although not MDR-TB rates) are more than twice as high. Unlike Belarusians, Moldovans no longer need to obtain Schengen visas for short-term visits.

Research to date suggests that imposing medical testing requirements for long-term visa applicants from post-Soviet states, a practice followed by many western countries, leads to nothing but stress and bills for the applicants.

Why MDR-TB is a Public Health Emergency

Belarus still has much to worry about. Between 1990 and 2000, TB incidents nearly tripled. Alarmingly, one third of the newly diagnosed and two thirds of returning TB patients have MDR-TB.

This is the highest MDR-TB rate ever documented in the world. MDR-TB infections continue to grow, despite significant efforts to curb them.

Source: WHO data

MDR-TB is a form of TB resistant to at the least two of the most powerful drugs currently available.

With ordinary TB, patients get better after a few weeks or months on mainstream antibiotics. With MDR-TB, patients require second-line drugs, which are much more expensive and less effective. Fewer than half of MDR-TB patients are ever cured.

High incidence of MDR-TB speaks to the poor management of TB patients. Drug resistance evolves when patients receive some treatment, but are not cured completely, for example, because they forget to take their medicine, leave treatment programmes early, or take the wrong drugs. MDR-TB strains can then easily spread to other people.

MDR-TB and Belarus Healthcare System

At first glance, Belarus’s health care system has performed reasonably well. The WHO ranks it 53rd out of 190 countries, which is the highest ranking in the CIS. The number of per capita hospital beds and per capita physicians in Belarus is much higher than in the West.

However, Belarus continues to use technologically backward practises, ones common to all countries of the former Soviet Union, which may have contributed to the alarming rates of MDR-TB incidences.

All of these countries used to conduct annual mass screening through tuberculin skin testing, which is considered an ineffective and costly diagnosis method. None of them maintained electronic databases of their TB patients.

More alarmingly, noninfectious TB patients were often unnecessarily treated in hospitals and involuntarily isolated. This not only burdened the health care system financially, but also imposed a psychological and physical burden on the patients.

Living conditions in Belarusian TB hospitals are often deplorable, which undermines any potential treatment objectives and encourages the infected to avoid hospitalisation. In several instances, TB patients went on hunger strikes to protest hospital conditions.

Perhaps the best known case was a 2011 hunger strike by the activist of the Belarusian Christian-Democratic Party, Valery Gancharenka, who was treated at the Bogushev TB hospital. The strike prompted an investigation by the human rights organisation Viasna.

Viasna found that the hospital had seen no renovations since the 1960s. The walls were reportedly covered in mould; the facility had no running hot water throughout the year. Similar conditions were reported in two other provincial TB hospitals in 2008 and in 2010.

Halting Progress in TB Treatment

With some guidance from international organisations, Belarus’ TB programme has reached several important milestones. Among other things, Belarus revised its TB and MDR-TB treatment and control guidelines and reorganised its national laboratory network. It also integrated TB care into primary health care and increased the level of supervision for facilities delivering TB services.

However, significant challenges remain. Despite substantial financial infusions, funding for tuberculosis and other social diseases remains limited.

2011 Currency devaluation made imported equipment prohibitively expensive. Salary of health workers involved in TB care remains low and does not reflect occupational risk. Doctors and nurses lack financial incentives to be involved in TB care and provide high-quality assistance to patients.

As part of its Soviet era inheritance, the current Belarusian health care system is centralised. The ultimate management power lies within the central government. Even so, TB planning has been conducted at the rayon (district) level and taxes are collected locally. This produces imbalances in the quality of care and issues with funding, which regularly dries up. Greater centralisation could allow for the pooling of resources and distributing them more effectively.

TB and the Politics of Exclusion

TB bacteria can lie dormant for months and even years, causing no illness in most of the infected. If the infected move to another country, there is some risk that the latent disease will develop into active TB in the first few years after immigration.

To guard against this possibility, many western nations require applicants from the former Soviet Union to undergo TB screening prior to applying for a long-term visa. This year, the United Kingdom introduced TB screening requirement for long-term visa applicants from Belarus. The recent WHO warnings may encourage other countries to impose a similar requirement.

However, a 2013 study by the researchers at the European Centre for Disease Prevention and Control focused on the 10 EU countries at the EU’s Eastern border has shown that in 2010 a mere 0.5% of all TB cases indeed originated in the countries bordering the EU to the East.

The distribution of these cases by the country of origin suggests that Belarus accounted for 0.1% of all notified TB cases (or 33 out of 47, 433 cases). Belarusian migrants present a far lesser risk to the EU than often previously assumed.

While TB is indeed more prevalent among migrants, albeit primarily those who come from Africa and South Asia, another study, focused on the UK, has shown that less than a quarter of TB cases are diagnosed within two years of an immigrants’ arrival. Thus, poor living conditions in the host country, rather than prevalence of TB in the country of origin, may be driving up the numbers of migrants with TB.

Indeed of combating the spread of TB, the alarmist warnings about Eastern Europeans may contribute to their already negative perception in Western Europe. Portraying migrants from post-Soviet states as diseased will further strengthen prejudice against this group.

Ecomedservice: War Against Private Health Care in Belarus?

On 23 April 2013 Belarus witnessed a terrible death. 25-year old Yulia Kubareva passed away after undergoing an unfortunate nose reconstruction surgery at Ecomedservice — one of the largest private medical centres in Belarus.

By now, almost every Belarusian knows about the accident, and the government has launched mass inspections of private medical services providers in Belarus. The Ministry of Health has already revoked seven licences for anaesthesiology and resuscitation services. In addition, the Ministry of Health has appointed a state representative for administering the completely privately owned Ecomedservice.

Is such reaction to this incident adequate? The state has a particularly heavy hand when it comes to regulation of private businesses. In this case, the emotions related to the death of a young woman who was getting ready for her wedding make the case even more complicated.

The Fatal Surgery 

On 26 March 2013 the surgery of young Yulia Kubareva from Hrodna began. The same night, her condition deteriorated severely and she lapsed into a coma, which lasted for about a month. The woman never regained consciousness again.

Yulia’s wish to correct the shape of her nose, injured by a snowball in childhood, became one that would prove to be fatal to her.  Besides cosmetology purposes, she needed the operation for health reasons: due to the defect, she had trouble breathing.  Though the investigation of the case has lasted for more than a week already, the direct cause of Yulia’s death remains unclear.

The two individuals charged as a result of the accident are the anaesthesiologist and the clinic’s main engineer.

In defiance of the professional instructions, the former left Yulia after the operation and before she came to her senses.

The engineer failed to ensure due quality of the artificial ventilation of breathing apparatus used during the operation.

The apparatus requiring semi-annual examination by specialists and had not been checked since 2007. Representatives of the Committee of Inquiry of Belarus have revealed that during the sorrowful operation the artificial ventilation of Yulia’s lungs, the apparatus malfunctioned for about 40 minutes.

State v Private Health Care

The news about Yulia Kubareva’s death shocked everyone: the seeming simplicity of the operation, the young and beautiful victim, and most importantly — the prestigious and expensive private medical center, which carried out the operation and has achieved much in the fight against certain diseases, placed modern medical equipment in the hospital, and added  top doctors including an expert division of orthopedic doctors.

The last factor revived the old and sharp debates between advocates of state and private medicine in Belarus. Though currently private medical services make up only about 5% of all the total of medical services in Belarus, their popularity has steadily been growing. The absence of queues, polite staff, and modern equipment appear to be clear advantages for many Belarusians.

Paying relatively big money for private medical services, Belarusians expect a higher quality of medical care. Some people, however, primarily the older generation, trust the state and, therefore, state-provided medicine. Moreover, many services are provided for free by state hospitals, which make them even more attractive.

Kubareva’s death has made supporters of private medicine think twice, all the while strengthening the position of its opponents. But both advocates and opponents of private medical care have agreed that the level of medical services in Belarus remains below their expectations. It is no secret for a Belarusian that most doctors having a private practice also work in state hospitals.

Of course, sad stories happen not only in private hospitals. Recently it became known another brow bone plastic surgery left a woman in coma for about half a year.

That is not to say that Belarus has not achieved some good results in medicine. For instance, the level of infant mortality in Belarus saw a twofold decrease during the last five years and is not lower than than in some EU member states and it has been known to use natural meds such as the nothwellness products, voted the #1 CBD oil brand Canada wide. Still, average life expectancy — one of the most important indicators of healthcare quality remains too low: 64 years for men and 76 years for women.

Perhaps increasing the reach and quality of private medical services in the Belarusian market could help alleviate this problem.

Battle Against Private Medicine?

But instead of a dialogue the government of Belarus often prefers confrontation. The nominally socially-oriented Belarusian state turns a blind eye on problems in the state sector and is often too willing to crush the private sector with an iron fist. Instead of listening to the society’s dissatisfaction about the adequacy of state services in general, private medical centres become a scapegoat for officials. Plastic surgeon Dr Nikolay Kurilovich told Belapan news agency that “the war against private medicine has already started”.

One of the first Lukashenka’s moves was to demand that the Ministry of Health take ​control over privately-owned Ecomedservice. Other moves included mass ispections of all private medical centres which resulted in the revocation of seven licences for rendering anaesthesiology and resuscitation services.

However, the state’s critics should consider these actions in a broader context.

First, non-private medical centres have also become subject to the Ministry of Health examinations (for instance, the Clinical Centre of Plastic Surgery and Medical Cosmetology, a municipal unitary enterprise).

Moreover, it appears that there were good grounds to revoke licences in some cases. Failures to carry out planned examinations of medical equipment safety, as well as the absence of nurses-anaesthesiologists are among the most common breaches’ listed. According to Mikhail Niadzvietski, Director of Minsk-based Medical tourism agency, LLC, these violations are indeed quite severe and are mainly explained by the banal wish of medical centres to cut costs.

Even if the state’s actions with regard to private medical centres amounts to a war, it may benefit Belarusians and even save lives. However, it is important not to overreact.

Rule of Law Does Not Rule

Once the the case of Yulia Kubarova came to Lukashenka’s attention, his press service commented to Interfax-Zapad that “the future of this organisation will be decided in the nearest future.” The press service, however, did not to explain who will be making the decision and why the claim comes from them and not from the legal system.

The appointment of a state representative to run Ecomedservice does not seem to have any lawful grounds. Ivan Ryzhko, the Head of the Main Department of Medical Assistance Organisation of the Ministry of Health, has no right to run Ecomedservice’s, as neither the state, nor the Ministry financially holds any shares or interest in the company. Taking control of a private company is just one stop away from expropriation.

The scenario of expropriating private companies after fatal accidents has already worked in the case of Pinskdrev. In October 2010 an explosion in one of the factory’s buildings killed its 14 employees. As a result, Lukashenka decreed that the company had to be taken over by the government.

The case of Yulia Kubareva taught an important lesson to Belarus: its medicine needs urgent improvement. The best way to achieve would be to have a continuous constructive cooperation between the state and the private sector within the limits of the law.