But bureaucratic intransigence wasn't the problem here. Local doctors were more than willing to buck the national establishment and adopt DOTS. But their pharmacies had run dry. "We even lacked first-line drugs," recalls Alexander Pushkarev, the physician in charge of the prison TB hospital.
That only began to change in the late 1990s when financier and philanthropist George Soros as well as international relief organizations—first Great Britain's Medical Emergency Relief International, or Merlin, and later the Boston-based Partners in Health (PIH)—began using this province as a testing ground for developing a comprehensive program to combat TB. Funders over the years have included Soros's Open Society Institute, the Bill and Melinda Gates Foundation, the Eli Lilly and Company Foundation and, since 2004, the Global Fund to Fight AIDS, TB and Malaria, which gave the local health authorities a five-year, $10.7-million grant.
The strategy at first focused on bringing DOTS to Russia. But, starting in September 2000, the groups began taking a riskier and more expensive approach that had been developed by PIH in Peru. They encouraged local doctors, first in the prison system and then throughout the region, to aggressively treat all cases of MDR-TB, which can take as long as two years with anywhere from six to eight drugs. Its architects dubbed it DOTS-Plus.
The strategy was facilitated by the creation in the late 1990s of a drug procurement consortium dubbed the Green Light Committee, organized by the WHO, the U.S. Centers for Disease Control, several NGOs and pharmaceutical firms like Eli Lilly that still manufactured the rarely-used antibiotics such as capreomycin and cycloserine needed to treat MDR-TB. Guaranteed purchase contracts and subsidies enabled countries like Russia to buy these second-line drugs at sharply reduced prices. "The cost went from $10,000 to $15,000 per patient to $3,000 to $4,000 per patient," says Peter Cegielski, the CDC's MDR-TB specialist, who joined the committee in 2000 and chaired it from 2004 to 2006.
Before taking a small group of foreign reporters and physicians on a tour of the 1000-bed prison hospital (currently only 60 percent filled with TB patients), director Pushkarev claimed the eight-year-old program had dramatically improved results. "In 1996 we had 60 patients die a year. But with the DOTS-Plus program, the death rate has gone way down. Since 2000, we've had zero deaths among new cases," he said.
The hospital infrastructure had to be almost entirely rebuilt. Global Fund money helped to build an airtight closet for collecting sputum. The lab for analyzing and culturing the samples got new equipment. Whereas prisoners with susceptible TB were sent to live in barracks, those found to have MDR-TB were sent to an isolation ward in the hospital, where they lived six to eight in the room.
Although those conditions are a marked improvement from a decade ago (at least the MDR-TB patients are isolated from other prisoners), the opportunity for reinfection is ever present under such crowded conditions. "Russia just doesn't get it with infectious disease," says Michael Rich, a physician with PIH who splits his time between Siberia and Rwanda. "They have great doctors and a motivated staff. But putting four to five people in a room in winter with the windows closed? Infection control is still an issue here."