Sacking of DOTS opponent good news in Russia
Still lots of work to be done in the provinces
The Russian government's conservative minister of tuberculosis control, Alexei Priymak, has been dismissed. The move pleasantly surprised international TB experts, who hope it signals that Moscow finally has committed itself to modernizing and strengthening its much-maligned TB control program.
Priymak's successor is reported to be Mikhail Perelman, head of the department of lung diseases at the Moscow Medical Academy.
"He's very good, very progressive, but it's not really a question of personalities," say Alexander Goldfarb, PhD, associate director of the Public Health Research Institute (PHRI) in New York City. "What is significant is the change."
In addition, the country's national health ministry has been promised $240 million for a new TB control program. The new program will take effect when (and some would add, "if") it is approved by the Communist-led State Duma. The promised sum is expected to fund a program that will run through the year 2,004.
The particulars of Priymak's dismissal were scarce in Russian press accounts; as of TB Monitor's press time, Priymak was still on record as denying he had been fired. His dismissal reportedly took place in a closed-door, heated exchange with First Deputy Prime Minister Anatoly Chubais. In recent months, Priymak had become an outspoken defender of the Russian method of TB control, an approach heavily weighted toward long and costly hospitalizations, diagnosis by X-ray, and invasive treatment. He lashed out at appeals for change from the World Health Organization (WHO) and other international experts.
Directly observed treatment, short-course (DOTS), is nothing more than "the recommendations of foreigners . . . not adapted to Russian conditions," he once wrote; for that reason, DOTS "will not save Russia from tuberculosis."
In Russia, physicians who work in TB are among the eldest of the medical profession, with many having reached their professional zenith between 1970 and 1990, when TB rates were falling, says Malgorzata Grzemska, a medical officer with WHO's Global TB Program. Like Priymak, many of these elderly men and women long for the return of a strong, centralized system of TB control and believe that returning to the old days would solve Russia's TB problems.
In a sense, they're right, says Goldfarb: The demise of the Soviet Union and the attendant social breakdown, coupled with an increase in immigration, have fueled the TB epidemic like dry kindling on a bonfire. "But things can't be put back the way they were," Goldfarb adds. "Plus, there isn't the money."
A decade-long campaign of lobbying on the part of international health experts was capped by a transnational venture led by American TB experts and financier/philanthropist George Soros, working with PHRI; but Goldfarb, though he played a huge role in bringing Soros and his wealth to Russia, denies the campaign alone has been responsible for the shift in Russian attitudes toward Western ways.
"The major factor here isn't political influence or lobbying but the fact that the TB epidemic is worsening," says Goldfarb.
TB rates in Russia have increased fivefold since 1991, with an incidence rate of 168/100,000, putting Russia on a par with developing nations including Pakistan, India, and Chad. One in five cases is drug-resistant. At present, only 5% of all TB patients are being treated with DOTS.
But will the provinces get on board?
Despite hopeful developments in Moscow, there is some question as to how fast the new philosophy will take hold in the country. Decision-making authority for TB control is strongly regionalized, says Goldfarb; the changing of the guard signals only that the National Health Ministry is committed to change, not that change will actually happen, he says.
"The decision of how the new money will be spent will be made mostly by local TB controllers under the authority of regional Departments of Health," he adds. "Each region and local authority has its own opinion. It will take a lot of education and work on the part of people in Moscow to move this around."
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