by Gennady POROSHENKO, Dr. Sc. (Biol.), Institute of Reanimatology, Russian Academy of Medical Sciences
Recently a young ambitious woman consulted at the Institute of Pulmonology, I. M. Sechenov Moscow Medical Academy, asked the doctor with horror: "Can I really have tuberculosis? Why, it is the disease of degenerated people!" "Not at all", she heard in response, "La Traviata and Anton Chekhov suffered from consumption, too" - "Are tuberculosis and consumption one and the same thing then?!" the patient wondered and, it seemed, even felt a little proud.
Back in the 19th century this severe disease became a global problem, all the more so that there was no proper treatment of it. ТВ did not spare people of any rank (even the Russian tsar's family), but was predominantly the lot of the poor, and was often considered a social malaise of the "rank and file" of society. Its name was consumption: the infected people were slowly, but inevitably consumed by the disease.
Advanced countries, in their attempts to check the progress of the disease and help its victims, organized a Tuberculosis Control League. Many of its active members appeared in Russia, and they had the widest strata of the population face the problem. At first the movement was restricted to private donations (from the tsarist family and aristocracy) and social charity, with three-thirds of donations being allotted to the creation and support of ТВ sanatoria (later they were organized by the zemstvos-elected organs of local self-administration). These institutions worked up ТВ cases. Simultaneously, specialized outpatient health centers were opened; this practice was copied from France. Also, one took care of weak patients (mainly children) from poor families and of relatives of patients, who were in permanent contact with them. By 1911 there had been more than 100 organizations running rest camps (colonies) in which more than 15,000 boys and girls improved their health in summer.
At the end of the 19th century societies for control of this, heretofore incurable, disease appeared in our country; small and scattered along its huge territory, they were known only to the few. In 1903 came an idea to unite these societies, but the turbulent events of the 1905 revolution delayed this intention, and the All-Russian Tuberculosis Control League appeared only 4 years later. There were not enough means for its activities, and, following the example of the Scandinavian countries, White Daisy Days were established: on those days in the most crowded city places and streets active members sold white flowers, natural or hand-made, bringing every kopeck into a common fund for the organization and maintenance of specialized medical institutions.
On April 20, 1911, the first action of this kind was held in Moscow, St. Petersburg, Kiev, Revel (now Tallinn, Estonia), Kronstadt, Nikolaev, Saratov, Simferopol, Tula, Ufa, and Yalta, then in about 100 more towns. The sum collected only in Moscow amounted to 67,214 roubles 7 kopecks. This precise sum means that it was always known, how much and where the money was donated and how it was spent. In order to give the modern reader a proper idea of this sum, let us note that in those years it was possible to buy a ship for 15,000 roubles.
Such broad campaigns involved many prominent persons. For example, on one of these days daisies in Yalta were sold by children of the Tsar, Nicholas II (HM family was on vacation there). The Tsar and his family donated large sums. The population at large also made their contributions, everyone-from businessmen to paupers. For example, the Lyutov family of merchants donated 200,000 roubles to their native town Vyazma (Smolensk province) on condition that one-quarter of this sum be spent for setting up a hospital for ТВ patients and the rest, for the construction of a water pipe; the profit gained from its exploitation was to be spent for the maintenance of the hospital. And the vagabonds from the Yaroslavl doss-house, who knew well what con-
sumption was from their own experience, collected 5 roubles 19 kopecks!
The Tuberculosis Institute was founded in Moscow in 1919 (now Institute of Pulmonology, I.M. Sechenov Moscow Medical Academy), then Central Recearch Institute of Tuberculosis, Russian Academy of Medical Sciences, was founded. It is noteworthy that the former institution occupies the complex of buildings of the Mariinsky Hospital for Poor People, built on donations of Maria Fyodorovna (1759 - 1828), dowager of Emperor Paul I. Fyodor Dostoevsky's father worked as a doctor there, and the great writer was born in one of the outbuildings of this hospital. The latter of these institutions is located on the grounds of the sanatorium opened on the money collected on a White Daisy Day.
In time a network of ТВ outpatient centers and hospitals spread all over Russia; great efforts were made to improve the social conditions of patients. Such efforts produced good results, for one, a decrease in ТВ incidence; but treatment of ТВ cases still remained ineffective by and large. The discovery of streptomycin, an antibiotic produced by microorganisms of the Actinomycetes group, came as a breakthrough. It was discovered in 1944 by Alexander Fleming, an English microbiologist and Nobel Prize Winner of 1945. While at the beginning of the 1940s the diagnosis of tuberculous meningitis in children was tantamount to a death sentence (infected babies died within several weeks), such cases could be cured with the new drug.
Other and more effective drugs were developed in time. Thus, Russian medics created an optimal system of ТВ control: intensive treatment at hospitals was backed by financial support and up-to-date equipment, long (up to several months) paid sick-leaves, free-of-charge sanatorial rehabilitation at the best health resorts of the country, and early detection of contacts of the infection carriers. It seemed that very soon we would be able to do away with tuberculosis for good. Hence a phasedown of social care for ТВ cases. In addition, ТВ agents (Mycobacteria) acquired drug resistance.
There came the moment of truth-an unexpected sharp increase in tuberculosis morbidity was registered. In 1993 the World Health Organization proclaimed tuberculosis a global hazard. Although control of this disease requires more financial investments, they pay off. For example, an increase in appropriate allotments in the USA led to a 25 - 30 percent drop of ТВ incidence during 1993 - 1995. Besides, special attention should be paid to drug supply and provision of laboratories with equipment, devices, and reagents.
We should remember that Mycobacterium tuberculosis is highly resistant to external factors: the infective activity of this bacterium persists for as long as 3 months in the open air and even longer in water (bacteria are detected in rivers 5 km downstream from places of sewage discharge from hospitals). The most incident species, hazardous for humans, can be transmitted to humans from cows (Mycobacterium tuberculosis, Mycobacterium bovis) and from birds (Mycobacterium avium). The hazards are many, especially in town, what with close contacts among people. However, everything depends on the immune defenses of each individual; the victims are usually debilitated persons sensitive to these agents.
In this country attention to tuberculosis control has increased during recent years: financing, drug supply, and provision of diagnostic equipment for specialized service has improved, while the therapeutic process is carried out by the traditional protocol described above, which proved its efficiency more than once. The output of ТВ drugs developed by Russian and foreign pharmacologists is in progress; consequently, doctors can use a combined rational drug therapy with due consideration of drug sensitivity to mycobacteria. As a result, the lung involvement process is stabilized in 80 percent of cases, while some patients can be prepared for routine surgery.
However, mortality from tuberculosis in Russia increased in 2005 more than 2-fold compared with 1992
Tuberculosis incidence in Russia in 1992 - 2005.
Number of registered HIV-infected cases in 2000 - 2005.
(22.1 cases per 100,000 of population), and it still persists, remaining the highest in Europe. This sad situation, particularly grave for men aged 45 - 54 years, is caused by the gradual accumulation of people with chronic forms of the disease and increased incidence of acutely progressive diffuse processes. Moreover, the efficiency of antibacterial therapy is on the decrease: the drug resistance of the causative agent increases, while the number of patients with drug intolerance increases. Males are infected three times as often as females, though girls under 14 years of age show a 10 - 12 percent higher incidence rate than boys.
What are the causes of the comeback of this old, almost forgotten disease? The key cause is in looser prevention. In 1985 - 1987 the topmost population numbers underwent special examinations (75 percent), while in 1993 - 1995 almost half of ТВ cases escaped detection. Preventive measures were resumed only in 1997 and now cover more than 58 percent of the population.
The "resurgence" of tuberculosis in Russia at the turn of the 21st century can be divided into 2 stages. During the first stage (1992 - 2000) a 2.5-fold increase in the disease incidence was recorded (from 35.8 to 90.4 cases per 100,000 of population-by an average of 16.9 percent annually), while during the second stage (2001 - 2004) the morbidity decreased by 6 percent. By the present time mortality values, including those for children and for men of all age groups, have stabilized. In other words, there are signs that the epidemic process has been checked.
The acquired immunodeficiency syndrome (AIDS) is considered to be the main cause for ТВ renaissance in industrialized countries: the immune system is much suppressed in HIV-infected patients, which makes them an "easy catch" for mycobacteria. A similar picture is seen in our country. True, the increase in the number of HIV carriers has slowed down somewhat in recent years, though the increase in their number among females is fraught with new hazards; this is explained by the emergence of a considerable mobile working force in the gray sphere of the Russian economy, the greater part of this force being women, and the ongoing expansion of the sex industry sphere. This feminization of AIDS became obvious even among very young patients: in 2005 girls aged 15 - 17 years were infected much more often than boys of the same age. While formerly the population of HI V-infected subjects consisted mainly of intravenous drug users, today this population includes primarily those involved in the sex industry, clients and partners alike. Let us note that more than half of new cases in 2005 were caused by unprotected sexual intercourse.
In a word, the efficiency of ТВ control depends not only on progress in diagnosis and treatment, but also on the healing of the social malaises of mankind.
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