Forms of tuberculosis are emerging that are costly, difficult and at times, nearly impossible to treat. This new, worldwide threat is called multidrug-resistant TB, and it occurs when the bacteria no longer respond to the most common TB medications. Doctors have to turn, instead, to older, less effective drugs that can have devastating side effects such as hearing loss, blindness, aches and severe depression.
Maria Smolnitcaia, a 52-year-old singer living on a TB ward in Balti, Moldova, says the drugs make her feel dizzy and uncomfortable. They also are damaging her hearing.
Curing an MDR-TB infection takes at least 18 to 24 months. And it's a challenge for patients of the communicable disease to endure.
Many patients become isolated from their community during the long treatment. When Igori Tian, 28, discovered he had TB, many of his friends and family deserted him. He was part of a now-defunct TB support group in Balti organized by the nonprofit Speranta Terrei.
And there's a stigma attached to the disease, says Snejana Negrescul, a 27-year-old mother from Balti, who finished treatment for MDR-TB last year.
Drug-resistant TB can now be found all over the planet, but some of the greatest concentrations of the disease are in the former Soviet Union.
The tiny country of Moldova, which sits right at the edge of Eastern Europe and Central Asia, has one of the highest rates of MDR-TB in the world outside of Africa. Roughly 18 percent of new TB cases in Moldova don't respond to conventional TB drugs, and 65 percent of patients who have previously been treated for TB now have MDR-TB, the World Health Organization reported a few years ago.
"This is really alarming, and it puts additional burdens on patients," says Andrei Moshneaga with the Center for Health Policies and Studies in Kishinau, Moldova.
MDR-TB can occur when TB drugs are prescribed or used incorrectly. Once established in a community, the bacteria can spread through a cough, or a sneeze, to anyone.
"Because these forms [of TB] are much more complicated, they require much longer and more complex treatment," he says. "Many patients default from treatment, they interrupt treatment." And this leads to the TB bacteria mutating further and causing even more drug resistance.
Nikolay Popa, 47, first caught TB while working in Ukraine. He abandoned the medications after two weeks because he felt better.
Now back in his home country of Moldova, Popa says he understands the need to stay on treatment. He's been in the hospital for eight months.
So why is MDR-TB so prevalent in Moldova?
The collapse of the Soviet Union and the communist health care system has caused part of the problem. There was a shortage of TB drugs throughout Eastern Europe in the 1990s, and that may have helped foster drug resistance.
TB has also been a huge problem in the prisons of Eastern Europe. Overcrowding and crumbling infrastructure turned penitentiaries into hotbeds of TB transmission.
Getting prisoners to stick with TB treatments is tough but crucial, says Svetlana Doltu, who is in charge of health care in Moldovan prisons.
But the main reason for the rise in drug-resistance in Moldova seems to be the country's poverty. TB gravitates toward the poor, the downtrodden, the immune-compromised and the dispossessed. In the United States the most recent large TB outbreak was on skid row in Los Angeles.
Moldova might not be exactly the skid row of Europe, but this small country of just 3.5 million people has the lowest per capita income on the continent. Moldova is the kind of place where TB flourishes.
After the fall of the Soviet Union, TB exploded as Moldova's economy collapsed.
The economy there remains stagnant. Roughly 30 percent of Moldovans regularly leave the country to find temporary work in Russia and the European Union.
Drug-resistant TB is placing huge burdens on the hospitals in Balti, the second-largest city in Moldova, says Veaceslav Batir, the head of the health department there.
Patients stay for extremely long periods of time at public hospitals. Other medical procedures have been moved out of the TB hospitals because even the doctors and nurses are afraid of getting infected.
Until this year, the Global Fund to Fight AIDS, TB and Malaria had been paying for all the TB drugs in Moldova. But that funding's being phased out.
The cost of treating a single case of MDR-TB in the U.S. runs up to hundreds of thousands of dollars, mainly because patients are isolated in medical facilities. In Moldova, the cost isn't anywhere near that high but is still significant — $5,000 for medicines alone to treat one case of MDR-TB, according to the Center for Health Policy and Studies in the Moldovan capital.
The Balti health minister, Batir, says this is money the government simply doesn't have.
"It's impossible. It's practically impossible for us to fight TB all by ourselves," Batir says.
And that brings up a bigger global concern: If drug-resistant TB gets worse in Moldova, it could easily spread through Europe and Russia as Moldovans are forced to look for work outside their own country.
All the photographs in this story were taken by Jason Beaubien for NPR.
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Around the world, new forms of potentially fatal tuberculosis are emerging that are costly and difficult to treat, at times impossible to treat. Drug resistant TB is becoming a major burden in China, India and Eastern Europe. The former Soviet Republic of Moldova has one of the world's highest rates of TB.
This week, we've been hearing about Moldova from NPR's Jason Beaubien. Today, he reports on why TB is so bad there and what challenges it creates.
JASON BEAUBIEN, BYLINE: First, while tuberculosis travels through the air and has the potential to jump indiscriminately from one person to another, TB doesn't really seem to work that way. Tuberculosis gravitates to the poor, the downtrodden, the dispossessed. In the United States, a recent outbreak of TB occurred on skid row in Los Angeles.
Moldova might not be exactly the skid row of Europe but it's the poorest nation on the continent. It has few natural resources and its greatest export is its youth. This is the kind of place where TB flourishes.
BORIS PUGA: (Through Translator) At the moment, the problem of tuberculosis is one of the leading problems in Moldova.
BEAUBIEN: Boris Puga is head of the X-ray department at the government TB hospital in Moldova's second largest city, Balti. Puga has worked in TB since 1977 when Moldova was still part of the Soviet Union. As far as TB is concerned, he says things were much better under the Soviets. TB treatment back then was compulsory but patients were also given stipends to support their families and treated in well-funded hospitals. They were fed six times a day.
Back then, Puga says TB could be treated in a matter of months. Now it takes at least 18 months and, at times years, to cure strains of TB that have grown drug resistant.
PUGA: (Through Translator) More and more, we have people resistant to all the medicines.
BEAUBIEN: After the fall of the Soviet Union, tuberculosis exploded throughout Eastern Europe. In the 1990s, rates of TB in the region nearly doubled. This was in part driven by the collapse of the communist health care system but also the ensuing social and economic turmoil. Moldova's economy still remains stagnant. Roughly 30 percent of Moldovans now work outside the country.
Puga says Moldova's economic woes contribute to the spread of TB.
PUGA: (Through Translator) A patient who is under daily stress, who is always worried, plus has poor nutrition, is at great risk of developing tuberculosis.
(SOUNDBITE OF BELLS)
BEAUBIEN: The winters in Moldova are long. The summers are hot. Even in spring, dirty snow banks line Moldova's beat up highways. Ornate Russian Orthodox churches with golden domes standout against the drab Soviet style architecture.
(SOUNDBITE OF BELLS)
BEAUBIEN: Since the fall of the USSR, the country can't seem to decide whether it wants to be aligned with the European Union or Moscow. In March, the government collapsed for the fourth time in four years. And amidst this political, economic and social turmoil, drug resistant tuberculosis has found a fertile breeding ground. Currently, 40 percent of TB cases in Moldova don't respond to conventional TB drugs.
ANDREI MOSHHNEAGA: So this is really alarming and puts additional burdens onto the patient
BEAUBIEN: Andrei Moshneaga is with the Center for Health Policy and Studies in the Moldovan capital of Kishinau.
MOSHHNEAGA: Because these forms are much more complicated, they require much longer and much more complex treatment.
BEAUBIEN: They cause devastating side effects including hearing loss, blindness, nausea, aches and severe depression. Moshneaga says a variety of factors have contributed to the growth of drug resistant TB in Moldova.
MOSHHNEAGA: So many reasons are quoted that we had shortage of TB drugs in the '90s, quite bad shortages of TB drugs. Many patients default from treatment, so they interrupt treatment.
BEAUBIEN: They default from treatment because many of them can't afford not to work for months or even years on end. After all, no one else is paying to support the patients' families.
Moshneaga adds that the old Soviet practice of treating patients in large TB hospitals may also contribute to the growth of drug resistance. Infection control in these aging hospitals is often poor, allowing a single patient with resistant TB to spread it to everyone else on the ward.
Veaceslav Batir, the head of the health department for the city of Balti is not just worried about drug resistant TB spreading on the streets of his city, he says it already is.
VEACESLAV BATIR: (Through Translator) This is type of infection already exists. That's why we have a national plan and a city plan to address it. And the mayor himself regularly monitors its progress.
BEAUBIEN: Batir says drug resistant TB is placing huge burdens on the municipal hospitals. Patients stay for extremely long periods of time. Other medical procedures have been moved out of the TB hospitals because even the doctors and nurses are afraid of getting infected.
Until this year, the Global Fund to Fight AIDS, TB and Malaria had been paying for all the TB treatment drugs in Moldova. But that's being phased out. The cost of medicines to treat just one case of drug resistant TB in Moldova starts at $5,000.
Batir says this is money the government simply doesn't have.
BATIR: (Through Translator) It's impossible. It's practically impossible to fight all by ourselves such a disease as tuberculosis.
BEAUBIEN: And the bigger global concern is that if drug resistant TB gets worse in Moldova, it could easily spread through Europe and Russia, as Moldovans are forced to look for work outside their own country.
Jason Beaubien, NPR News. Transcript provided by NPR, Copyright NPR.