This weeks featured project : Médecins Sans Frontières Australia

June 2005

A complex challenge to treating Tuberculosis in a forgotten land

Prolonged political instability and exhaustion from a variety of violent internal divisions have left Georgia's health care system unable to cope with the demands placed upon it.
As a result, thousands of the country's civilians lack the most basic care and medicines. Médecins Sans Frontières (MSF) focuses on getting desperately needed help to groups lacking assistance including the disabled and the elderly. Robin Briant, a medical doctor from Auckland, is working in the separatist republic of Abkhazia – the focus for MSF’s tuberculosis (TB) work.

This patient had undergone an incomplete TB treatment
Photo © Serge Sibert/Cosmos

Poor diet, extreme poverty and a precarious existence create ideal conditions for tuberculosis. (Abkhazia) Linda has no income and lives with her three children in a house with unglazed windows. Her husband is in prison; she visits him once a month. She has a cough and has lost a lot of weight. The MSF social worker suggests that she go to Guliripchi TB hospital for a test. Linda recoils: she has neither time nor room for the disease in her life s daily struggles. But her face lights up when she learns that her family is on the list of Red Cross food-aid recipients.

This patient had undergone an incomplete TB treatment
Photo © Serge Sibert/Cosmos

Givi, 37, was almost dying when he was transferred to the anti-tuberculosis hospital. He will go back to prison after his treatment. .

Givi's one obsession is not to infect his 13-year-old daughter Lama.

He weighed thirty kilos when he was transferred from prison to Guliripchi. Alisa, one of the TB specialists at the hospital who visits patients in prison, found him in agony, vomiting blood on his straw mattress.

A few months earlier, Givi had gone to the prison infirmary: From the expressions of the doctor and nurse, it was clear to me that I had something serious. But they didn t tell me it was TB. They sent me back to my cell with a few medicines.

There were nine of us squashed into a few square metres, fed on gruel like animals. Alone in his hospital room, Givi changes beds every day as if he wants to make the most of the luxury of space. In here, the air is pure that s treatment enough, he says, as he watches clouds drifting past outside the window.

I am in a place that three months ago I did not know existed! Sokhumi is on the Black Sea, the main town of the quasi-Independent Republic of Abkhazia, a disputed territory. Independent in the distant past, Abkhazia became part of the Soviet Union, then after 1989 it became a reluctant part of Georgia. In 1992-3 there was a bitter – but little-known – war of secession, resulting in heavy loss of life, and thousands of people (Georgian settlers) displaced across the border into Georgia. They remain there in very dire circumstances. The population of Abkhazia is now only about 200,000, down from half a million before the war, the majority of them elderly and alone. Abkhazia is not recognised by any country; indeed it is embargoed in the region, has no international assistance and basically is broke.

The MSF project here has two parts – Health Access and Tuberculosis treatment. Health Access brings medical assistance to many thousands of vulnerable, elderly, poor or disabled people. It uses local doctors in regional clinics and provides a mobile team for home visits.

I am managing the TB project. Tuberculosis, a disease of poverty and poor living conditions, is a very big problem in all the ex-Soviet Union countries, where societal values and standards have collapsed, and so has the health service. A major aspect of the disease is the length of treatment (minimum six months for the simplest cases), and many people do not complete the course – either they cannot afford the drugs, or the doctors have the wrong approach and treat only until the symptoms disappear. Incomplete treatment leads to drug resistance, and for these patients treatment is unavailable in most countries. MSF France started the TB programme here (in close association with the local health authority) in 1998 and began treating multi-drug resistant TB in 2001. For this group the treatment takes at least two years with very expensive drugs. All TB patients in Abkhazia have free access to our programme, but bad care continues in surrounding countries and many of our patients have had their first treatment across the borders and many have very resistant TB.

So far 1300 patients with regular TB and 80 with resistant TB have been included in the programme; currently in the two groups there are 120 and 50 patients being treated, either in the TB hospital or in the community. There are eight Ambulatory Points where DOTS (Directly Observed Treatment, the World Health Organisation [WHO] standard) is dispensed and supervised. Many people live in remote villages in the mountains, the roads barely passable in the best of weather. So although the country is quite small, the logistical effort to deliver this sort of treatment is huge.

As well as the geographic hurdles there are cultural, bureaucratic, political and financial ones to making such a complex programme work, and we have to try to prepare the authorities to take on the responsibility. The old Soviet system discouraged initiative; people here are paid very little for their work (the hospital cook takes home 500 Roubles per month, 20 US dollars), so change is a way off yet.

Treating tuberculosis patients and the excluded
Prolonged political instability and exhaustion from a variety of violent internal divisions have left Georgia's health care system unable to cope with the demands placed upon it.» More

COUNTRY PROFILE Georgia
Expatriate staff: 14 | National staff: 65
MSF worked in Georgia from 1993

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