Moldova is a landlocked country in Eastern Europe, located between Romania and Ukraine. Formerly part of the Soviet Union, Moldova declared itself independent when the Soviet Union dissolved in 1991. Moldova is one of the poorest countries in Europe, and its health care system lacks much of the modern equipment and facilities that other countries in Europe have. The fall of the Soviet Union exacerbated Moldova’s economic problems; its health care system crumbled, poverty rose, and the country became more vulnerable to the emerging TB crisis.
Many of these photographs depict Moldova’s prison population, where TB rates are much higher than in the rest of the country. The photographs focus on the emergence of multidrug-resistant TB (MDR-TB). This deadly strain of the disease can result from low-quality health care systems, poor-quality drugs, lack of access to treatment, or patients taking their medicine only intermittently or failing to complete their treatment. An estimated 34 percent of TB patients in Moldova are infected with MDR-TB, which has a very high mortality rate. The treatments that do work can last more than two years, involve chemotherapy, and cost tens of thousands of dollars. (Treatment for standard TB, in contrast, typically lasts six to eight months and can cost as little as 20 dollars.) The rise of MDR-TB in Moldova shows the damage and death that TB can cause if we do not devote sufficient resources to preventing and treating it. In addition to showing the current and future threat of MDR-TB, these photos depict prevention and treatment programs that can help eradicate TB.
A.O. was co-infected with HIV and disseminated TB. She was very weak and spent most of her time in bed. She tried to get admitted to the local TB hospital but was unable to do so.
TB and MDR-TB are serious problems in Moldova, whose TB infection rate is about 15 times higher than that of countries in Western Europe.* Of even greater concern are the high rates of MDR-TB, which is estimated at 43% of all TB cases in Moldova. MDR-TB is much more difficult and costly to treat than regular TB, a fact that is exacerbated by Moldova’s crumbling health care system.
Moldova’s highest TB rate can be found in the city of Balti (Bel’tsy on maps), where A.O. lived. Every day, Galina Zaporojan, a volunteer home health care worker for Speranta Terrei, a local non-governmental organization (NGO), brought A.O. her TB medicine to make sure that she was able to adhere to her treatment. Unfortunately, despite receiving treatment, A.O. died from the effects of her diseases.
Many people in Balti use public transportation, which, unfortunately, is a very efficient way to transmit TB.
When people with active TB (those who are sick and showing symptoms of the disease) cough, sneeze, spit, or even talk, they release tiny droplets of saliva containing TB bacilli (the bacteria that cause TB), which can infect anyone who breathes them in.* It does not take very many bacilli to cause an infection, so close contact with people who have active TB (which can happen on public transportation) can lead to new infections.
It’s estimated that a person with an untreated case of active TB can infect 10–15 new people a year.
* World Health Organization, Media Centre: Tuberculosis Fact Sheet
Moldova is one of the poorest countries in Europe, although its economy has been growing over the past decade. According to The CIA World Factbook, in 2009 about one-quarter of Moldovans lived below the poverty line.*
Poverty is linked to TB—poor countries are less able to provide health care to their citizens, and people living in poverty are less likely to have access to or be able to complete treatment for TB. The average incidence of TB in low-income countries is 20 times higher than in high-income countries.†
* CIA World Factbook, Moldova
† World Health Organization, Addressing Poverty in TB Control, 2005
Prisons in Moldova are a significant source of TB infections. Rates of TB infection in prisons are much higher than the national average.
Reasons for increased rates of TB in prison include overcrowding, poor sanitation, and poor nutrition. Although the prison system in Moldova has taken steps to reduce overcrowding and to reduce the spread of TB, the disease remains a serious problem among the prison population.*
* World Health Organization, Europe, Status Paper on Prisons and Tuberculosis, 2007
Prisoners with TB at a jail in Chisinau, the capital of Moldova, are housed together in order to isolate them from the general prison population. Because TB is easily spread from person to person in close quarters (such as prison cells), isolating the infected population is an important component of reducing the spread of the disease.
Nurses walk down a staircase at the prison in Rezina, a small town in Moldova. This prison houses all the TB patients who have refused or abandoned their TB treatment, both to isolate them from the general population and to prevent the spread of deadly strains of MDR-TB.
Ruslam Carp has MDR-TB and is a prisoner in Rezina. Carp's form of TB is resistant to most of the available TB medicines. Patients who stop a course of TB treatment before it is completed are at risk of developing MDR-TB, which results from exposing the TB bacteria to anti-TB drugs without a full course of treatment. Bacteria that are exposed to but not eliminated by, antibiotics can evolve to resist the killing effects of the medicine. A person who develops MDR-TB can then spread it to others.
Igor Tcaci is a former prisoner who just finished treatment for MDR-TB. He has been struggling with TB off and on for 22 years. He adhered finally to the course of treatment for his particular strain of MDR-TB and was cured.
Igori Revenco has been in and out of prison and has MDR-TB. The prison system in Moldova has greatly reduced its TB incidence rate over the past 5 years, but it is still 8 times the national rate for Moldova.
Valentin Guivan is currently homeless and has TB. It is very difficult for homeless people and those living in dire poverty to adhere to their TB treatment. The treatment for TB involves taking a series of drugs every day for six months or more. Someone concerned about finding safe shelter or enough food to eat may not be able to journey to a clinic every day for that period of time. Stopping treatment or taking the drugs only intermittently increases the risk that patients will develop MDR-TB.
A doctor at the TB hospital in Balti visits a patient with MDR-TB. The symptoms of MDR-TB are similar to those of regular TB, and include coughing (which may produce blood), chest pain, and fatigue. Another symptom is weight loss, which can be seen in the patient in the photograph.
TB patients take their daily medication at the TB hospital in Balti. The most common medications used to treat regular TB are ethambutol, pyrazinamide, isoniazid, and rifampicin.* The cost of a course of drugs—as low as $20—is relatively affordable, especially considering how effective the drugs are at curing TB if the treatment is completed.
* Mayo Clinic, Tuberculosis: Treatments and Drugs, 2011
A man gets an x-ray at the TB hospital in Balti. A chest x-ray can be used as part of a TB diagnosis to show abnormalities, such as lesions in the lungs. Although chest x-rays can show that TB may be present, they cannot be used to make a final diagnosis.
A skin test can determine if a patient is infected with TB—however, it cannot distinguish between active TB and latent TB (a patient is infected but not ill from the disease).
The most effective diagnostic tests are done by looking at mucus from the lungs (sputum). There are two different tests. One is a smear test, in which sputum is smeared on a slide and examined for TB bacilli. The smear test is relatively quick to do, but it isn’t accurate enough to identify everyone with active TB—in fact, the test may miss more than 50 percent of TB cases.* A much more accurate test takes the sputum and grows live cultures from it in the lab. However, this test can take up to six weeks to complete. Both tests require lab equipment and trained staff.
* National Institutes of Health, New Test Detects TB in Less than 2 Hours, September 13, 2010
A doctor visits an emaciated patient with MDR-TB at the TB hospital in Balti.
In poor or developing countries, MDR-TB may only be diagnosed after a patient does not respond to standard TB treatment. Tests to detect MDR-TB (using the same sputum culturing procedure that can be used to accurately diagnose active TB) can take several weeks to complete. However, scientists have developed new diagnostic methods that are much faster at detecting both regular TB and MDR-TB, and organizations such as the WHO are working to provide funding and equipment so that these tests are available in the countries where they are most needed.
After the breakup of the Soviet Union in 1991, Balti’s former TB hospital was closed down because the city could no longer afford it. Doctors and nurses who worked in this hospital say that it was much nicer than the current one.
When Moldova gained its independence in 1991, it had a large number of health care facilities (developed by the Soviet Union) and staff, but not enough resources to support the system. As a result, facilities deteriorated—some didn’t even have basic medical equipment—and health services declined.*
In part because of these problems with the health care system, rates of TB infection grew steadily until recently; by 2002, the number of TB cases had doubled from 1990.† Dr. Valeriu Crudu, program director at the Center for Health Policies and Studies in Chisinau, estimates that between 1995 and 2000, the country only had enough resources for 20 to 30 percent of its TB patients.
Thanks to a concerted effort by the government and development organizations, there has been a slight decline in the TB case rate in recent years, but the percentage of patients with MDR-TB has risen.
* MacLehose, L. in McKee, M. (ed.) Health care systems in transition: Republic of Moldova. Copenhagen, European Observatory on Health Care Systems, 4(5) (2002)
† USAID, Infectious Diseases: Moldova
A doctor checks on a patient in the intensive care unit at the TB hospital in Balti. TB can cause severe weight loss and fatigue.
J.C. is co-infected with MDR-TB and HIV and is being treated at the TB hospital in Vorniceni. He is very weak and is unable to move or get out of bed.
HIV and TB are sometimes considered a “dual epidemic” because of the links between the diseases. Because HIV weakens the immune system, people with HIV are more likely to contract TB. And, according to the WHO, “people who are HIV-positive and infected with TB are up to 50 times more likely to develop active TB in a given year than people who are HIV-negative.” HIV can also make TB more deadly—left untreated, TB kills up to 90 percent of people with HIV within months of getting the disease.*
* World Health Organization, Frequently asked questions about TB and HIV
Patients and nurses walk outside the TB hospital in Balti. The hospital has capacity for about 200 people but regularly operates above capacity.
A nurse at the city morgue waits for the autopsy to begin of an ex-prisoner who died from MDR-TB. In Moldova, practically every death results in an autopsy; in the case of TB patients, the attending doctor is asked to inspect the infected organs and confirm the diagnosis and cause of death.
In Moldova in 2009, the number of people who died (i.e., the mortality rate) from TB was 18 per 100,000.* By contrast, in the United States in 2009, the mortality rate from TB was 0.16 per 100,000.†
* Europe's Environment Assessment of Assessments, The Second Millennium Development Goals Report: Republic of Moldova, 2010
† World Health Organization, Tuberculosis Profile: United States of America, 2009
D.S. was an ex-prisoner who died of MDR-TB. His mother stands over his body at a wake.
D.S., who was living with HIV, had spent time in prison for a drug offense. D.S.’s father, who was also in prison, is sure that his son was infected with TB while in jail.
D.S.’s life was filled with many of the risk factors that can make it much more likely for a person to develop active TB, as well as make treating the disease more complicated: He lived in poverty, used drugs, was co-infected with HIV, and spent time in prison. His life—and death—are not only examples of the human tragedies that TB causes, but also of the complex set of social situations that make TB an incredibly difficult disease to prevent and treat.
Ivan Sevcenco, a patient with TB, relies on a local NGO to bring him his daily medicine. For patients who are unable to travel to a clinic or hospital, the availability of health care workers to visit and administer treatment is vital.
A nurse organizes medicine for a patient with MDR-TB at the TB hospital in Balti. The hospital has a dispensary and is a DOTS (Directly Observed Treatment Short course) treatment center that requires health care workers to observe patients taking their medicine.
DOTS, a TB control strategy, focuses on five main points of action:
Ensuring government commitment to TB prevention
Conducting quality diagnoses based on sputum smear tests done on patients who present with TB symptoms
Observing patients to make sure that the right drugs are taken at the right time for the full duration of treatment
Having a regular supply of high-quality medicines
Regularly reporting and recording TB cases and treatment outcomes
A nurse from the TB hospital visits Ivan Coroliuc every day to give him his TB medicine and apply an IV for his diabetes. Coroliuc’s diabetes makes it difficult for him to travel to the hospital every day to retrieve his medicine.
Galina Zaporojan, a health care worker with Speranta Terrei, Balti’s local NGO, brings pills to Ivan Sevcenco, a TB patient. If Ivan continues to take his complete course of TB medicine, he can eventually make a full recovery from TB.