Treating Multidrug-Resistant Tuberculosis in Tomsk, Russia

Developing Programs That Address the Linkage between Poverty and Disease

Authors

  • S. Keshavjee,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
    3. Partners In Health, Boston, Massachusetts, USA
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  • I.Y. Gelmanova,

    1. Partners In Health, Boston, Massachusetts, USA
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  • A.D. Pasechnikov,

    1. Partners In Health Russia, Moscow, Russian Federation
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  • S.P. Mishustin,

    1. Tomsk Oblast Tuberculosis Services, Tomsk, Russian Federation
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  • Y.G. Andreev,

    1. Tomsk Penitentiary Services, Ministry of Justice, Tomsk, Russian Federation
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  • A. Yedilbayev,

    1. Partners In Health Russia, Moscow, Russian Federation
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  • J.J. Furin,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Partners In Health, Boston, Massachusetts, USA
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  • J.S. Mukherjee,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
    3. Partners In Health, Boston, Massachusetts, USA
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  • M.L. Rich,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Partners In Health, Boston, Massachusetts, USA
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  • E.A. Nardell,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
    3. Partners In Health, Boston, Massachusetts, USA
    4. Harvard School of Public Health, Boston, Massachusetts, USA
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  • P.E. Farmer,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
    3. Partners In Health, Boston, Massachusetts, USA
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  • J.Y. Kim,

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
    3. Partners In Health, Boston, Massachusetts, USA
    4. Harvard School of Public Health, Boston, Massachusetts, USA
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  • S.S. Shin

    1. Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA
    2. Partners In Health, Boston, Massachusetts, USA
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Address for correspondence: Salmaan Keshavjee, Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, FXB Bldg.—7th floor, 651 Huntington Ave., Boston, MA 02115. Voice: 617-432-3215; fax: 617-432-6958.
 skeshavjee@partners.org

Abstract

Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) are diseases of poverty. Because Mycobacterium tuberculosis exists predominantly in a social space often defined by poverty and its comorbidities—overcrowded or congregate living conditions, substance dependence or abuse, and lack of access to proper health services, to name a few—the biology of this organism and of TB drug resistance is intimately linked to the social world in which patients live. This association is demonstrated in Russia, where political changes in the 1990s resulted in increased socioeconomic inequality and a breakdown in health services. The effect on TB and MDR-TB is reflected both in terms of a rise in TB and MDR-TB incidence and increased morbidity and mortality associated with the disease. We present the case example of Tomsk Oblast to delineate how poverty contributed to a growing MDR-TB epidemic and increasing socioeconomic barriers to successful care, even when available. The MDR-TB pilot project implemented in Tomsk addressed both programmatic and socioeconomic factors associated with unfavorable outcomes. The result has been a strengthening of the overall TB control program in the region and improved case-holding for the most vulnerable patients. The model of MDR-TB care in Tomsk is applicable for other resource-poor settings facing challenges to TB and MDR-TB control.

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