International Federation of Red Cross and Red Cresent Societies - 13 April 2004
John Sparrow in Tajikistan

Today he is desperate. The remaining five are ill as well. So is he. So is his wife. Unless something dramatic changes soon the whole family will perish. The cause: tuberculosis.

The Alimovs are not the first impoverished family to be decimated by TB in the Kulyab region of southern Tajikistan. Deserted and boarded up houses show the disease's progression through a string of villages in Vose district. Their owners and tenants died poor and abandoned, deprived of treatment because they couldn't afford it.

That is how it is in much of the country. Out of sight, out of control, TB is ravaging the most vulnerable.

Tuberculosis is a global disaster with a third of the world's population thought to be infected and two to three million people dying annually.

TB's hold on Central Asia strengthened after the break-up of the Soviet Union, and both incidence and mortality rates have increased alarmingly since the mid-1990s. A shortage of drugs and trained medical staff, and inadequate detection and diagnosis has contributed, along with poverty, poor living standards, poor nutrition and immune defences brought low by a general poor standard of health.

Beset by civil war for much of the 1990s, Tajikistan has suffered abominably. The World Health Organization put the incidence at 127 per 100,000 in 2001 and anticipated it would rise to 170 by 2004, one of the highest rates in the world.

In the Vose villages they calculate differently. Tajikistan Red Crescent district chairman, Gaphur Mirzoev, says simply, "Every third house has it." It is a figure of speech. Sometimes it is house after house. Next door to Abdualim, his brother's family are all infected.

The Alimovs' story leaves no doubt as to why this should be. Abdualim is 43, a subsistence farmer in the village of Nonjemas, which is no stranger to TB. The district was known for it back in the Soviet Union, only then it was treated. There were drugs enough, and a sanatorium. Good nutrition - essential in the recovery process - was assured, and people were cured. All was provided by the state which, in today's penurious circumstances, is impossible.

Wife Idigul holds a hand to her face and stares at the ground as the farmer names their dead children. Abdukodir was 28, Faizali 26, Nuridin 24, Mushkinisso 19, Tojinisso 17. All were diagnosed, he says, but there was no real medical assistance.

Mirzoev confirms. "It is easy to discover who is sick. There is the equipment here. The authorities know, the hospitals know but they cannot provide the drugs to assist them. Somebody has to pay." The authorities report 355 cases in the district.

As he got more and more sick and unable to work, Abdualim did put himself in hospital. When the breadwinner is ill, small children suffer more in Kulyab. He borrowed 120 somonis (about US $40) from relatives and stayed in hospital for as long as it lasted. Then he was obliged to go home. He does feel better and can work, but he isn't cured. Before too long he will be sick again, and there could be other consequences.

Breaking off treatment, or the inconsistent use of it, fuels multi-drug resistance, a serious and growing problem that faces the whole of Central Asia.

In fact, Abdualim is worse off than ever. Now he is in debt. How will he repay his relatives? He hangs his head. "I don't know," he says.

And where will the food come from? He grows onions, and some wheat that he sells for other vegetables, but this will sustain no one. Today Idigul is feeding the family only onions and bread. There isn't even any milk. They have sold all their animals as poverty has overwhelmed them. The Alimovs will drink water taken from a nearby stream.

Tragic irony

It is cold comfort but they do have a roof over their heads. Gulbahor Rahimova, a 34-year-old mother of three, lost her home after tuberculosis swept through her family.

With nowhere to go she moved into Nonjemas's deserted and derelict children's TB sanatorium. By the greatest of tragic ironies a breakdown of health care provided her with sanctuary.

The sanatorium, closed soon after the Soviet Union's dissolution for want of funds, today houses four, otherwise homeless, TB families. They asked no one's permission to move in but the authorities are understanding and a nurse turns up from time to time to check how they are and offer advice if she can.

Gulbahor, her husband and children lived with relatives in the village. As TB moved into a house, they would move on and eventually ran out of options. Those who could have assisted them were dead, and anyway running hadn't helped.

Her eldest son, now 12, is infected, and probably her husband as well. Again treatment has been interrupted. The couple found money to buy the boy drugs for a while but not long enough to cure him. A poor diet and unsanitary conditions worsen their situation.

The woman's neighbour in the former sanatorium, Lutphiya Rahmatuloeva, tells a similar horror story. She has TB, as does her husband, who was treated for several months. Sick again, he should return to hospital but he does not have the cash to do it.

Lutphiya is counting her blessings, though. Daughter Umeda, aged two, and five-year-old son Radjaboly have so far escaped infection. She has lost two other children to the disease.

Why the plight of the Vose villages has been allowed to endure for so long is as disturbing as their ordeal. A tendency to dismiss them as a pocket must also raise questions about the commitment to counter TB.

The villages may be a microcosm, they may show extremes that are the consequence of a specific history. But they reflect basic health care problems to be found the length and breadth of Central Asia. Poor people are in trouble and far too little is done to assist them.

Dr Rahmon Khaphizov is far from a disused sanatorium in a rural backwater. He heads the children's department of Kulyab's regional TB hospital, and loses sleep over the shortage of drugs. His nightmare is that children will die because he is unable to treat them.

It hasn't happened yet but, according to the doctor, it is a real threat. In 2003, his department received enough medication for only two months, he says. "It was enough for 15 children." The department has 30 beds.

What about the rest? "We have to ask parents to buy the drugs," he says. What if parents cannot afford them? "The children could die. A large number of people die from TB in this country."

On the day he spoke, eight children in his care did not have medication, among them sisters aged three and eight. Their mother, a single parent, was herself in hospital. The doctor leads the way to where the children are watching a Red Crescent puppet show set around hygiene messages.

"They are here and we do our best," he says. "We may get some drugs from somewhere. Sometime I use money from the food budget. Right now, though, they are living on air." The food is insufficient as well, the doctor insists. "The children don't get enough calories."

The situation, he agrees, is appalling, and asked if he feels abandoned, answers, "For a long time now. I am frightened."

Death warrant

These are common sentiments. The other side of Tajikistan, in the Pamir mountains, doctors are even unsure of the figures. Dr Maxzur Metarshoev, director of Gorno Badakhshan's anti-TB efforts, says there is no active state detection or prevention campaign. Until people are ill and report to a doctor, no one knows about them.

The Tajikistan Red Crescent and NGOs respond by spreading public information. Supported by the International Federation and the Netherlands Red Cross, the Red Crescent runs health education campaigns in most parts of the country. A fast-growing network of health volunteers will also bring better monitoring.

Dr Imomalibek Kiyobekov, the Red Crescent's chairman in Badakhshan, says prevention and detection must be strengthened. "TB is spreading wider and wider. We have to stop that and detecting it in time is an essential part of the process. Sadly, the health authorities do not have the resources to get out and about and do it."

What he wants to see is mobile detection units travelling the province. He is angered by procrastination. "Yes, of course the state is responsible, but so it is for this" he blasts, banging his hand on his office phone. "The line has been down for a week. The electricity's been off for days. Everything is the responsibility of the state but we can't just sit down and do nothing."

His point is underlined in the villages. Barodj, a community of 900 people above Badakhshan's River Gunt, is typical. People are poor here. They grow vegetables on small family plots and keep a few animals. Men migrate to Russia in the hope of making a living. TB is endemic but, says village leader Parpisho Silimonshoev, people frequently forgo treatment.

"We should go to the TB hospital in Khorog but it's not free," he comments. "No one treats you for free anymore. They'll test you. They'll give you a prescription. But if you want treatment you must pay. You need to sell a sheep to go there. Don't get me wrong. We do have great doctors but if you don't have money you don't bother going to them."

The hospital in Khorog, the provincial capital, is hard pressed. It diagnoses, prescribes, treats and observes but patients must buy the drugs. It cannot provide sufficient food, either. Most must come from the patients' families.

Yet this is a hospital other hospitals depend upon. In the northwest of the province, the Vanj central district hospital is one of them. It has no TB department, just a dedicated room in its policlinic. It refers patients on to Khorog.

"TB is a major problem in this district," says chief doctor Rahmon Radjabov. "I think each family has it. Khorog does provide us with drugs but what we get in a year is only enough to cover our needs for a month."

A start was made in 1998 on implementing World Health Organization (WHO) strategy for TB control. The Directly Observed Treatment Short Course, known the world over as DOTS, is the most effective methodology yet developed, and cures TB easily and inexpensively.

A routine DOTS course costs around US$11 per patient and, statistics show, permanently cures more than nine of every ten people who complete it. The cost of treating a person infected with multi-drug resistant TB - the strain nurtured by partial and irresponsible treatment such as is common in Tajikistan - is at least 100 times greater, and a death warrant to the poor of poor nations.

DOTS scored success in Badakhshan but stopped because of insufficient medication and general lack of support. For years the Aga Khan Foundation provided the drugs but its resources were finite and no sustainable alternative has been found.

Much of the DOTS hope in Tajikistan now lies with Project Hope. With USAID funding, it is working to improve TB control in all five Central Asian republics. Pilot efforts in Dushanbe and nearby Leninskiy district have produced promising results with good cure rates, and programme manager Thomas Mohr says Hope aims to spread the initiative throughout the country.

Plans to expand DOTS are being worked on with the Red Crescent and the International Federation. Says Mohr, "The government and WHO want DOTS nationwide by the end of 2005. We will see how realistic that is. It will not be easy."

Red Crescent roles

Red Crescent National Societies in Kazakhstan, Kyrgyzstan, Uzbekistan and Turkmenistan, as well as Tajikistan, have long supported DOTS intervention.

* Social and nutritional support has a major role. Around the Aral Sea the American Red Cross sustained a major food programme. Soup kitchens and food parcels are indispensable.

* Adherence to DOTS treatment is prioritised. Red Crescent workers visit the homes of discharged patients to ensure they continue with prescribed medication and to check on their general welfare.

* Public health education is universal, encouraging healthy lifestyles, preventing disease, prompting early recourse to health care among those who may have TB.

* Advice is given to affected families.

* Stigma and discrimination, a hindrance to detection and diagnosis, is countered.

Stopping the escalating spread of a preventable and treatable infectious disease, and mitigating the suffering, is in itself a preoccupation. What bothers the Red Crescent more is the increase of multi-drug resistant TB, and a hideous alliance with HIV.

The magnitude of both are unknown. TB is the most common opportunistic infection and the leading cause of death among people living with HIV/AIDS. A person with HIV/AIDS is ten times more likely to develop TB, and the presence of TB may allow HIV to progress more quickly.

By 2005, WHO's Stop TB Partnership, a global movement to accelerate social and political action, wants to detect 70 per cent of people with active TB, successfully treat 85 per cent of those detected, and scale up effective responses to TB/HIV and the multi-drug resistant disease.

Nowhere is the challenge greater than in the cauldron of Central Asia.
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