Ten things you should know about TB in Ukraine

Ten things you should know about TB in Ukraine

Did you know Friday is World Tuberculosis Day? You do now.

Ukrainian? In Ukraine? A Ukraine-watcher, whatever that means? Here’s a list of ten things you should know about TB in Ukraine:

  1. The TB incidence rate in Ukraine in 2016 was 67.6 per 100,000 persons – which, for perspective, is anywhere from ten to twenty times the rate in countries like the US, the UK or Canada (to say nothing of the absurdly high rates among First Nations and Inuit in Canada, but I digress).
  1. Fewer Ukrainians were diagnosed with TB in 2016 than in 2015 – a 4.3% decrease in the number of new diagnoses. Good.
  1. Ukraine has, alongside Russia, a spot on the World Health Organization’s (WHO) list of 20 countries with the highest estimated burdens of multidrug-resistant tuberculosis (MDR-TB). There’s more than 8,000 new cases of MDR-TB registered in Ukraine every year, and it’s increasing. That’s bad.
  1. Anyone can get TB in Ukraine, including children – especially if you don’t vaccinate them. OMFG BCG vaccine pls FFS.
  1. TB’s still a disease concentrated in at-risk groups in Ukraine. According to stats from Ukraine’s Public Health Center (thankfully renamed from the unwieldy “Ukrainian Center for Social Disease Control of the Ministry of Healthcare of Ukraine”), around 70% of new TB cases in 2014 were in so-called “socially vulnerable groups” like unemployed people of working age and drug/alcohol abusers. (NB. these are the most recent breakdowns they seem to have but I don’t see any reason why these would’ve changed at all over 2015/16).
  1. One the major groups of people at risk of TB, particularly MDR-TB, are people with HIV/AIDS. As I wrote about earlier this week, more than half (52%) of deaths from AIDS-related causes in Ukraine last year were from TB – much higher than the one-third of deaths globally from TB in people with AIDS.
  1. HIV/TB co-infection is increasing in Ukraine – a “noticeable increase” according to the Public Health Center, increasing year-on-year from 2013. All this “[reflects] the increasing burden of HIV infection in the country.”
  1. There aren’t any numbers on TB, HIV or anything coming out of the non-Ukrainian-government-controlled parts of Donetsk and Luhansk oblasts (“DNR”/”LNR”), but everyone assumes the TB situation there is pretty bad. One senior international official I spoke to last month told me “we hear about used needles, terrible conditions there” with the at-risk population in the east – largely in and around Donetsk, which has long been an HIV hotspot in Ukraine. “I’d say of course HIV is growing there, TB is growing there, because the conditions in which they are spending time in is terrible,” this official told me.
  1. As Oksana Grytsenko reported in the Kyiv Post a few days ago, Ukraine struggles to provide effective TB treatment. Read her piece. No point in me rehashing it here, other than to add this quote from the Public Health Center: “Especially dangerous is the untimely addresses for medical assistance, late TB diagnostics, and HIV/TB co-infection, which causes a high level of mortality due to TB and results from the lack of a comprehensive approach to the combination of preventive and treatment programs at the national and regional levels into a single system of counteraction”
  1. There’s cause for some cautious optimism, I think. To plug again what I wrote about HIV earlier this week, state funding for TB treatment is being increased in 2017 and activists I spoke to seemed confident that the Ministry of Health and the government as a whole is (re)recognizing HIV/TB as a priority. Still, we’ll see.
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Russia’s HIV epidemic dismissed as part of Western ‘information war’

Russia’s HIV epidemic dismissed as part of Western ‘information war’

(latest in Sydney Morning Herald)

Even as a UN conference began last week in New York, taking up the subject of ending AIDS, a Kremlin-backed research institute claimed the West is using HIV and AIDS as part of an “information war” against Russia.

The Russian Institute for Strategic Research (RISR) presented a report to the Moscow City Council last week on HIV in Russia where, unlike almost everywhere else in the world, rates of HIV infection are on the rise.

According to RISR deputy director Tatyana Guzenkova and her colleagues, the real goal of the West’s fights against HIV “is the implementation of the economic and political interests of US-led global structures, relying on an extensive network of international and quasi-NGOs.”

But none of this comes as a shock to Anya Sarang, head of the Andrey Rylkov Foundation.

“We’re not surprised at these kinds of statements anymore,” she tells me from Moscow, where she works with drug users and sees the scale of Russia’s growing HIV epidemic firsthand.

“It’s the usual thing in Russia now to discard science for ideology.”

There are two models for fighting HIV, according to the RISR report. The Western model, it says, is made of “neoliberal ideological content, insensitivity towards national sensitivities and over-focus of certain at-risk groups such as drug addicts and LGBT people.”

The Russian model, on the other hand, “takes into account the cultural, historical, and psychological characteristics of the Russian population, and is based on a conservative ideology and traditional values.”

The Russian model

The science says the Russian model isn’t working.

Approximately 93,000 new HIV cases were reported in Russia in 2015 – a per-capita rate almost fifteen times that of Australia. A million people in Russia have HIV, including almost one percent of all pregnant women – the threshold for a generalised epidemic.
Dr Vadim Pokrovsky heads up Russia’s federal AIDS research centre and is a longtime critic of the Kremlin’s HIV policies.

“The last five years of the conservative approach have led to the doubling of the number of HIV-infected people” Pokrovsky told AFP last year.

The arch-conservative head of Moscow City Council’s health committee, Lyudmila Stebenkova, described Dr Pokrovsky last year as a “typical agent working against the national interests of Russia.”

Not surprisingly, Pokrovsky doesn’t think much of RISR’s report.

“They use some questionable sources of information and incorrectly interpret the data they present,” he tells me from Moscow.

“Their arguments are not convincing.”

The Western contraceptive industry

According to Igor Beloborodov, one of the RISR report’s co-authors, attitudes to condom use is one of the main factors behind Russia’s HIV epidemic.

“The [Western] contraceptive industry is interested in selling their products and encouraging underage people to engage in sex,” he told Moscow City Council.

He and his RISR colleagues argue in the report that condoms “create the illusion of the safety of sex” and should not be “gratuitously distributed” in Russian schools. The solution, they say, is to completely abstain from sex outside of (heterosexual) marriage.

Dr Pokrovsky is dismissive of arguments like these.

“This is traditional rhetoric that was used thirty years ago and still used in conservative circles throughout the world. It is not particularly troubling evidence.”

Pokrovsky also takes issue with the report’s argument that “risk elimination” – in other words, completely giving up drugs and extramarital sex – is superior to harm reduction approaches.

He stresses that “risk elimination” is actually impossible. “The experts who understand this know that people cannot just give up extramarital sex,” he says, “and people dependent on drugs cannot just stop using them.”

‘AIDS and drugs will solve each other’

Even though 60 per cent of HIV-positive Russians are injection drug users, methadone replacement therapy remains illegal in Russia despite clear evidence of its effectiveness.

It’s an approach that has led some commentators to question if the Kremlin is even that interested in the fight against HIV at all.

“I have had conversations with Russian government officials who have said things like ‘AIDS and drugs will solve each other,'” Daniel Wolfe, director of the International Harm Reduction Program at the Open Society Foundations (an organisation funded by frequent Kremlin target George Soros), told The Verge.

“So I think there’s some question about whether or not Russia is actually committed to protecting the lives of everyone, or whether drug users fall into the category of ‘socially unproductive citizens’ the state might just as well do without.”

In Moscow, Anya Sarang worries about the impact the “information war” rhetoric from the Kremlin and its allies might have on Russian with HIV.

“It send the completely wrong message,” she says of the RISR report. “Basically this report is saying that the HIV problem is something made up by western media.”

“The Russian population is really psyched up now with this whole anti-Western ideology and discourse,” she warns. “People might take this seriously and think ‘oh, HIV isn’t a Russian problem – it’s just a part of the information war.'”

In Ukraine, mistrust of doctors remains high

In Ukraine, mistrust of doctors remains high

(latest in CMAJ)

Dr. Richard Styles was used to being trusted as a doctor in Britain, but that changed when he moved to Ukraine a decade ago, after working in a number of European Union-funded projects there.

“There is nearly no trust in doctors at all, even amongst doctors,” says the chief medical director at the American Medical Centre in Kyiv, Ukraine’s capital.

Indeed, a 2015 report by European Observatory on Health Systems and Policies, a partnership led by the World Health Organization (WHO), found that “popular mistrust of doctors [in Ukraine] is strikingly high,” and has been for many years.

Dr. Zoryana Chernenko, an assistant professor at the National University of Kyiv Mohyla Academy, points to Ukraine’s chronically low wages for doctors as one of the main culprits. This has forced doctors to supplement their incomes with informal out-of-pocket payments, despite the system supposedly being free at the point of service.

“Every day, doctors are just thinking about how to survive,” said Chernenko, who has worked on health system reform in Ukraine.

Wages for doctors in Ukraine have been low since before the 2014 Euromaidan Revolution, a series of violent events culminating in the ousting of the president. According to the European Observatory’s report, in 2013 the average monthly wage for a doctor in Ukraine was just over $400 a month, well behind that of professionals in many sectors of Ukraine’s economy.

More recent data on doctors’ wages in the Ukraine are not available, but an analysis published in October by the Ukrainian newspaper Komsomolskaya Pravda suggested that the average wage had fallen to less than $260 by mid-2015. Given that Ukraine’s currency has lost almost 20% of its value since the beginning of 2016, doctors’ wages are likely to drop even further.

Out-of-pocket payments have been a regular feature of Ukraine’s health care system since the 1990s following the collapse of the Soviet Union, according to the European Observatory’s report. During the subsequent severe economic downturn, doctors began levying informal payments to provide themselves with a more acceptable wage. Chronic government underfunding — including a 5% cut to health spending in 2016 — has contributed to these payments becoming an entrenched feature of the Ukraine’s health system.

“At the moment state funding covers only half of the financial needs of the system,” Konstantin Nadutyi, deputy chairman of the Ukrainian Medical Association, recently told The Lancet in a Feb. 20, 2016 article. “The rest is paid for by patients themselves.”

Patients in Ukraine usually give informal payments before a service is given. Sometimes these payments provide them with quicker access, other times with newer drugs and services.

This system of soliciting informal out-of-pocket payments, according to Chernenko, has led to Ukrainians feeling like their doctors are more concerned with their bottom lines than providing quality care.

This system of low wages and informal payments has also led to chronic overtreatment, which further erodes trust in doctors, says Styles.

“The problem is that people [in Ukraine] don’t get value for money.” Styles estimates that a substantial portion of Kyiv’s three million people is overtreated and prescribed drugs or forced to pay for services they do not need. “It’s rather strange in a health care budget that’s got its back to the wall.”

However, Styles is keen to point out that many of the Ukraine’s doctors, despite how they might be perceived, are hardworking, dedicated professionals. “I would be very careful not to denigrate Ukrainian doctors,” he stresses, pointing out the number of doctors who have risked life and limb in war-torn eastern Ukraine.

“In Ukraine, there are some very dedicated, very vocational doctors who are working for nearly nothing.”

Taskforce aims to bolster rural physicians

Taskforce aims to bolster rural physicians

(latest in CMAJ)

Having worked in the interior of British Columbia since 1989 Dr. John Soles life as a rural family physician has been nothing like his urban colleagues. He has done “the full spectrum,” he says, from delivering babies and treating colds to mentoring young physicians and managing the business side of his practice.

“It’s about how to work with fewer resources and always dealing with a degree of uncertainty,” says Soles, president of the Society of Rural Physicians of Canada (SRPC).

Although about 18% of Canadians live in rural or remote areas, only 14% of family physicians practise there. Adding to their stress is the fact that family physicians provide 85% of primary care needs. Continue reading “Taskforce aims to bolster rural physicians”