ODESSA, Ukraine — In the Ukrainian tourist destination of Odessa, a port on the Black Sea, holidaymakers mingle with internally displaced people from the country’s war-torn east, local Roma, students, and economic migrants from Central Asia and the Caucasus, Africa and Asia.
Yet the air carries something less healthy than sea breezes: tuberculosis.
Odessa has the highest rate of TB in Ukraine, with 110 cases per 100,000 people in 2016, and rising fast. Closely linked with migration, instability and poverty, controlling this airborne disease takes on additional urgency this year as Ukraine seeks to integrate into Europe thanks to a new visa-free regime. Part of a migration corridor from Central Asia and the Caucasus to Russia and Western Europe, Ukraine has at least 5 million citizens working abroad, according to its foreign ministry: in Poland, Italy, Spain, Portugal, the Czech Republic, Russia and Germany. Another 1.5 million people have been internally displaced by the war in the east of the country.
“Ukraine should pay special attention to TB because it’s a very sensitive topic for Europe” — Alexey Bobrik, World Health Organization’s technical officer
Tuberculosis was largely wiped out in Western Europe in the early 20th century through treatment, improved health monitoring and awareness, and higher living standards. Since the Soviet Union collapsed the disease has returned with a vengeance in former Soviet states. Ukraine declared a TB epidemic in 1995.
Since then, the country has received huge amounts of international aid to tackle TB and its twin epidemic, HIV. But weak political will and chronic distrust of the country’s corrupt health system has held back progress. While overall TB rates are gradually falling, in places like Odessa they continue to rise. More worryingly, Ukraine is one of the leading countries in the world for multi-drug resistant (MDR) forms of TB, which do not respond to traditional treatment.
A quarter of newly diagnosed cases of TB in Ukraine in 2016 were MDR-TB, according to WHO. Cure rates for resistant forms are the lowest among all MDR-TB burden countries: 38 percent. In Odessa, where TB-HIV co-infection is rife, the overall TB cure rate last year was just 43 percent. “That basically shows you how effective the health system is here, which is a shame for a European country,” Bobrik said.
Ukraine’s TB system has changed little since Soviet times. It’s based on in-patient treatment lasting months or even years in TB clinics and sanatoriums, often located in once-beautiful historical buildings that are in disrepair and unsuited to modern infectious disease control and patient needs.
“We can’t provide proper treatment conditions,” said Dr. Oksana Leonenko-Brodetskaya, who heads Odessa city’s TB clinic. It’s housed in a peeling pink classical building in the city center. “We’ve no individual isolated wards, and no phasing system of existing wards, and so cross-infection occurs.”
According to modern international standards, isolated in-patient treatment is not the answer to TB anyway — early and accurate diagnosis, early treatment and retention of patients on an ambulatory basis is. Most patients stop being infectious within days or weeks of starting treatment. In a country with no job or social security, and in a city like Odessa with a large migrant population, expecting patients to stay for months in poorly equipped hospitals is unrealistic, unnecessary and hugely expensive.
“Ukraine can’t afford it,” Bobrik said. “You can spend your funding on TB dispensaries and a lot of health workers who sit in these dispensaries and don’t go to patients. Or instead of that, you can create an out-patient model.”
Retaining out-patients requires a change of approach. More than 20 percent of newly diagnosed patients in Odessa in 2016 were migrants and non-residents of the city. Many — although far from all — are among the most disadvantaged members of society: the homeless, drug users, former prisoners. The stigma around TB is another reason patients try not to be associated with TB treatment centers.
“They all try to disappear,” Leonenko-Brodetskaya said of her patients, claiming many register with false addresses and fall off the grid as soon as they start to feel better.
Everyone concerned with TB in Odessa speaks about a taxi driver or a market trader still working with active TB and a fake health certificate, because they can’t afford to stop. The stories may be apocryphal but Maria Kochetova, who spent three months in a TB ward earlier this year, recalled patients there who stopped taking medication, checked out early or simply disappeared. Even among patients, there’s an instinct to blame other patients for spread of the disease.
Kochetova also recalled several patients dying of a disease which, if caught early enough, should be treatable. Kochetova’s doctors didn’t expect her to survive either. The 34-year-old called an ambulance only after weeks of what she told herself was flu. She’d never considered herself at risk from TB: She wasn’t homeless; she didn’t use drugs; she had a regular job as a cleaner.