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Georgia: Official Says TB Epidemics Contained, But Warns Against Too Much Optimism

  • Jean-Christophe Peuch

Long believed to be a relic of a bygone era, tuberculosis has made a conspicuous comeback in Europe as degrading social conditions, interethnic conflicts, and uncontrolled migration flows followed the fall of the Soviet regime. Today, the infectious disease kills about 2 million people every year, most of them in Africa, Asia, and the former Soviet Union. Georgia's health officials say that, thanks to the international community, their country has taken the lead among ex-Soviet republics and managed to contain the epidemics.

Tbilisi, 29 October 2002 (RFE/RL) -- Since the collapse of the Eastern bloc, tuberculosis has emerged as a serious public-health problem in most former Soviet republics.

With a reported occurrence of about 200 cases per 100,000 inhabitants in the mid-1990s, the Southern Caucasus state of Georgia was said to be among the main sources of this infectious disease among CIS countries.

Two separatist conflicts, a civil war, uncontrolled migration flows, seasonal energy shortages, and persistent economic hardship have presided over Georgia's debut as an independent state.

Only after the political turmoil abated were local authorities able to address the tuberculosis issue.

First, the United Nations' World Health Organization, or WHO, helped launch a number of pilot projects in the capital Tbilisi and in the central cities of Rustavi and Gori.

Then, the German government stepped in, providing Georgia with antibiotics, microscopes, and other devices as part of an ambitious national program to contain the epidemics and screen the most vulnerable populations among the country's 4 million to 4.5 million inhabitants.

This program, which was launched seven years ago, now covers all of Georgia's regions, with the exception of the two separatist republics of Abkhazia and South Ossetia, which have been out of Tbilisi's control for the past decade or so.

Georgian health officials pride themselves on having reached some achievements. But they caution against too much optimism.

Giorgi Khechinashvili is the chief coordinator of Georgia's national tuberculosis program and runs a center that serves as a reference tuberculosis laboratory for the Southern Caucasus region. He told our correspondent that the disease is now under control: "In 1996, when our program really started functioning, we had 8,481 recorded cases of tuberculosis throughout the country. This indicator was catastrophic, or to say the least, very alarming. Last year, we recorded 5,594 cases, including among the penal population. So, yes, this is a progress. Yet, the fact remains that these indicators are still very menacing."

One of the main problems facing Georgian health officials is the development of multi-drug-resistant tuberculosis, or MDR, which does not respond to essential treatment.

MDR generally appears when standard drugs are not properly administered, when medical control is deficient, or when the course of treatment is disrupted. This form of tuberculosis can be treated by so-called second-line drugs which are much more expensive than essential antibiotics and, therefore, remain largely unaffordable for cash-starved Georgia.

WHO estimates the cost of a standard seven-month treatment against tuberculosis at about $20 per head, while second-line drugs cost several thousands dollars and necessitate up to two years of continuous treatment. MDR is particularly widespread among the officially recorded 7,500 prisoners and detainees who populate Georgia's 17 penal establishments.

Recent statistics show that approximately one-fourth of contaminated prisoners fails to respond to standard treatment.

The International Committee of the Red Cross (ICRC) has been screening Georgian prisoners for signs of tuberculosis for the past eight years or so. As part of Georgia's national tuberculosis program, the Geneva-headquartered organization four years ago launched a countrywide operation to treat inmates infected with mycobacterium tuberculosis, the bacteria responsible for the disease.

The ICRC operates a tuberculosis clinic at the Ksani detention facility, some 30 kilometers northwest of Tbilisi, where some 1,700 prisoners held in penal colonies have been treated since 1998 using the WHO-recommended Directly Observed Treatment Shortcourse (??DOTS??) method.

Inmates serving sentences in prisons and detainees held in pretrial detention isolators are being treated either on site or at the Tbilisi-based Republican Prison Hospital.

ICRC experts say they have free access to all penal facilities, including the so-called "red colony," in the western town of Khoni, which houses convicted policemen, security officers, and army officers.

ICRC Medical Tuberculosis Officer Levan Sharashidze told RFE/RL that the infection rate among prisoners currently stands at approximately 6 percent. He, too, sounded cautiously optimistic regarding the progress achieved in combating the disease in penal institutions: "It would be perhaps premature to say that we have succeeded in significantly lowering the percentage of infected prisoners. But we can say that we have managed to stem the epidemics. The disease has stopped spreading."

Georgia has been long pressed by the Council of Europe and the UN to improve detention conditions in its unhealthy jails. Overcrowded cells or barracks, poor diet, lack of hygiene, and a high drug-consumption rate are all factors responsible for the spread of infectious diseases among inmates.

In a report published in May of last year, experts from the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) said that in prisons and colonies they had visited during a two-week fact-finding mission in Georgia, the detention conditions of prisoners with tuberculosis were inadequate and could only favor the spread of infection.

Consequently, CPT experts noted, the success of the treatment that was being provided faced the risk of being "jeopardized."

Citing a customary clause of confidentiality, ICRC officials declined to detail detention conditions in Georgian prisons.

Nana Kakabadze chairs a Tbilisi-based nongovernmental organization known as Former Political Prisoners for Human Rights. She sees the fact that infected detainees held in prisons and detention isolators are not allowed to be transferred to the so-called "tuberculosis colony" in Ksani and therefore remain confined in unhealthy cells as a major impediment to the ICRC program.

"The [International] Red Cross is working very actively. They have transformed a penal colony into a hospital where so-called 'beta-positive' detainees -- that is, those who have developed an open form of tuberculosis -- are being transferred. Living conditions there are more or less normal for detainees. But this [transfer] program does not apply to all detention places. Therefore, one can say that the problem has been only partially removed. On the whole, the [tuberculosis] problem remains."

The ICRC's Sharashidze agrees that now that all detainees have access to treatment, the main problem is to improve living conditions in prisons. To the medical officer's view, the risk of contamination in penal institutions is 60 times higher than outside prisons and colonies, which in Georgia and most former Soviet republics constitute the main source of tuberculosis infection.

Hence the problem posed by beta-positive prisoners when they are released from jail and return to their hometowns or villages, sometimes in hardly accessible mountainous places.

National tuberculosis program coordinator Khechinashvili: "Our main concern is the follow-up, which remains the weakest link of our work. We are currently in a position to control something like 35 or 40 percent of former prisoners. This is very few and, of course, this indicator is not satisfactory, although compared to other indicators, this one is encouraging. [Nevertheless,] it remains a very serious problem [because] infected prisoners who are not being followed simply vanish; they are outside our field of vision. This is precisely one of the reasons that explains why the achievements [of our program] do not appear that clearly."

Follow-up procedures for infected prisoners are not the only source of concern for Georgian health authorities. Decades-long prejudices, which see tuberculosis as a sign of social deprivation, often lead community members to disrupt their treatment for fear of being considered an outcast.

Khechinashvili says the rate of disrupted treatments among non-former convicts in ambulatory regime currently stands at around 20 percent, whereas the threshold of tolerance is generally put at 10 percent.

Georgia's tuberculosis medical officers are also confronted with contamination from neighboring countries, notably from Russia where up to 75,000 prisoners are believed to be infected with MDR and where Khechinashvili says antituberculosis measures do not match international health standards.

"Last year, 70 patients came in our [Tbilisi-based] national tuberculosis center to get treatment. Among them, 36 -- that is, more than 50 percent -- were Georgian citizens who had spent some time in Russian or Ukrainian prisons. It means that our country is getting multi-drug-resistant forms of tuberculosis that have developed in neighboring countries. In other words, trying to solve the [tuberculosis] problem on a strictly national scale is not the [only] problem. This is why our national program and our Health Ministry have proposed that measures be taken on a [regional,] all-Caucasian, scale."

In their concern to optimize the efficiency of their combat against the disease, Georgia's tuberculosis officials have been consulting since the late 1990s with Armenia and Azerbaijan, which have already started developing antituberculosis programs of their own.

International workshops and seminars attended by medical experts from all three Southern Caucasus republics have been regularly organized since 1997, and Georgia is now considering coordinating actions with all countries from the Black Sea basin -- Russia, Ukraine, Bulgaria, Romania, Moldova, and Turkey.

But, for Georgian health authorities, fighting the disease at home through on-site treatment, training of medical personnel and information campaigns remains an immediate priority. "We think that our national tuberculosis program should continue forever. At least until tuberculosis is eradicated on a world level," says Khechinashvili.