But Western advisers believe the Tomsk model saves lives, and if implemented broadly, could dramatically reduce the spread of the disease, even under current economic conditions. "We have shown how it could be done," says Oksana Ponomarenko, director of the Moscow office of Partners in Health (PIH), a humanitarian nonprofit based in Boston.
The TB outreach program didn't begin in earnest until 2002 when authorities began implementing DOTS-Plus in the region. PIH, run by Paul Farmer and Jim Kim of Harvard Medical School, helped local health officials set up the financial control and medical record-keeping systems that allowed them to buy lower cost drugs (second-line drugs for MDR-TB can cost $3,000 to $4,000 per patient, unlike the $20 per patient for DOTS medicines) through a multilateral purchasing consortium known as the Green Light Committee.
The province then applied for and received a special grant from the Global Fund to Fight HIV, TB and Malaria. It became one of the few areas in the world to obtain funding without backing from the national government. "The Russian Academy of Sciences and the Ministry of Health did not support our application, but the governor and vice government supported us," says Sergey Mishustin, head TB physician for Tomsk Oblast. "The Global Fund grant gave us money for second-line drugs, for side-effect medicines, for food and hygiene packages and social support."
But interviews with patients helped by the program quickly reveal its thumb-in-the-dike qualities. In Tomsk, the provincial capital, PIH operates a satellite health care delivery program—dubbed Sputnik—in which a driver and trained nurse visit a dozen people every day to watch them take the proper drugs.
And the patients include alcoholics, ex-prisoners, drug addicts—it is a tough crowd living in a tough environment. Many dwell in Soviet-era apartment blocs, whose dank stairwells reeking of urine and airless apartments are reminiscent of the worst of America's public housing projects. They are ideal breeding grounds for airborne transmission of M. tuberculosis, which can live up to six hours in a droplet after being spewed into the external environment by an infected person.
That's how 23-year-old Marina Rubina believes she caught the disease. Three years ago, while a college student still living in her parents' cramped apartment, she caught MDR-TB from a neighbor. "He just got out of prison," she says.
Thin, shy, an orange teddy bear propped on her bed's pillow, she has spent the past three years at the region's civilian TB hospital, a 19th- century–style sanitarium deep in the Siberian woods. She couldn't stomach the drugs in the initial regimen, which made her continually nauseous and dizzy. So her doctors changed the regime. Her TB morphed into extremely drug resistant or XDR-TB. She eventually had part of one lung removed, and has a long scar down her back to show for it.
Perhaps if there had been better drugs, less toxic with shorter regimens, her case might have had a shorter, simpler solution. But those drugs don't exist, at least not yet. "Even in the U.S., MDR-TB has a 10 percent mortality rate," says Michael Rich, a physician with PIH advising the Tomsk programs. "There are very few MDR studies that compare regimens in blinded, well-controlled ways. There hasn't been that kind of discipline. It's all been based on expert opinion and intuitive thinking."