VZCZCXRO6185
PP RUEHAST RUEHDBU RUEHHM RUEHLN RUEHMA RUEHPB RUEHPOD RUEHTM RUEHTRO
RUEHVK RUEHYG
DE RUEHMO #0809/01 0911017
ZNR UUUUU ZZH
P 011017Z APR 09
FM AMEMBASSY MOSCOW
TO RUEHC/SECSTATE WASHDC PRIORITY 2636
INFO RUEHXD/MOSCOW POLITICAL COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE AND TECHNOLOGY COLLECTIVE

UNCLAS SECTION 01 OF 02 MOSCOW 000809 
 
DEPARTMENT FOR PRM/ECA AND OES/IHB JEHAN JONES 
 
SENSITIVE 
SIPDIS 
 
E.O.  12958: N/A 
TAGS: PGOV PHUM EAID TBIO RS
SUBJECT: TUBERCULOSIS REMAINS UNDER-REPORTED PROBLEM IN NORTH 
CAUCASUS 
¶1. (SBU) Summary:  The International Medical Corps (IMC) Acting 
Russia Country Director warned of the continuing spread of 
tuberculosis (TB) in the Russian republics of Chechnya and 
Ingushetia at a meeting of post's Refugee Assistance 
 
Roundtable/Forum on March 24, World Tuberculosis Day.  While the 
disease has a high prevalence throughout Russia, IMC's efforts are 
focused in the North Caucasus.  There are serious impediments to 
stopping the disease's proliferation:  absence of TB specialists in 
the region, non-adherence to standard treatment protocols, low early 
detection and registration of the illness, prohibitive drug prices, 
and the social stigma of acknowledging infection.  IMC wants to 
tackle this major public health challenge and has been in 
discussions with the principle Russian recipient of the Global Fund 
to Fight AIDS, Tuberculosis and Malaria (GFATM) about obtaining 
funding for training of health care workers.  End Summary. 
 
ALARMING STATISTICS 
------------------- 
¶2. (U) Representatives of the Finnish Embassy, USAID, and French NGO 
Samusocial Moskva met at Refcoord's invitation March 24 to hear from 
Simon Rasin, MD MPH, International Medical Corps (IMC) Russia's 
Acting Country Director.  Rasin shared alarming World Health 
Organization tuberculosis statistics regarding the prevalence of the 
disease in the Russian Federation, which ranks 12th on the list of 
high-burden TB countries.  The proportion of cases cured and treated 
in Russia is among the lowest worldwide.  Rasin acknowledged that 
some countries, such as Tajikistan, may actually have higher rates 
than Russia of TB infection but do not have the public health 
capacity to provide full statistics. 
 
¶3. (U) In the Chechen Republic, 925 new TB cases were registered in 
¶2008.  Some 554, or 60 percent, of these cases were already in the 
last stages of TB, when death is imminent.  There is a total of 
4,100 active TB cases in Chechnya - or .34 percent of the 
population, compared to the Russian Federation average of .22 
percent.  In general, Rasin averred, the numbers are greatly 
underestimated, and health officials lack the means to track those 
who are ill.  Rasin reckoned that the actual number of TB cases is 
likely more than three times the number of officially registered 
cases. 
 
¶4. (U) The situation in Ingushetia, while similar to that in 
Chechnya, is all the more appalling to Rasin because there was no 
war there.  In 2008, there were 1,195 individuals registered in the 
Ingush Republic with an active form of TB.  Unfortunately, Rasin 
noted, many of these individuals are registered as chronic, which in 
actuality means they have developed a multidrug-resistant (MDR) 
tuberculosis.  Some 47 percent of all TB patients are women, while 
the average country rate is 30-35 percent.  TB progression from 
infection to disease is reportedly much faster for women of 
reproductive age than it is for men.  In 2001, only three people 
were documented as having tuberculosis and HIV; by 2008, there was 
an increase of 38 cases.  The tuberculosis problem in Ingushetia is 
exacerbated by inadequate health care facilities.  HIV-positive 
individuals are accommodated in the same hospital as those with MDR 
and extensively drug-resistant (XDR) TB, increasing the risk of 
infection for all. 
 
OBSTACLES TO TREATMENT 
---------------------- 
 
¶5. (SBU) One of the greatest barriers to proper TB care in the 
region, particularly in Chechnya, is the amount of official 
corruption, according to Rasin.  The republic has one regional TB 
center, located in Groznyy, with 140 beds. Rasin believes that this 
is only a fifth of the number needed.  Funds have been allocated 
five separate times by the federal government for the construction 
of a new TB center, but each time the money has "disappeared." 
Existing facilities have modern equipment but suffer from lack of 
connections to basic services, including sewage and water.  Staff 
shortages are common, particularly in rural areas, due to poor 
living conditions and compensation.  Rasin contended that the local 
physicians are intellectually able but need guidance and support "in 
terms of everything." 
 
¶6. (U) Ingushetia's system of addressing TB is also deficient. 
Poverty and poor living conditions, particularly among IDPs, 
insufficient early detection, and scant public awareness all pose 
challenges to Ingush public health officials.  In the Nazran TB 
treatment center, the sewage and water systems are in a constant 
state of disrepair.  In addition, the Ingush center is severely 
understaffed, Rasin estimates by up to 60 percent.  In the health 
care system at large, some nurses refuse to care for TB patients, 
for - not unrealistic, in this environment -- fear of themselves 
developing TB. Clinic staff turnover is high. 
 
¶7. (U) Beyond the systemic challenges to TB patient care are 
unhelpful underlying social norms in the region.  There is great 
social stigma associated with TB.  Cases of TB are often concealed 
 
MOSCOW 00000809  002 OF 002 
 
¶1. (SBU) Summary:  The International Medical Corps (IMC) Acting 
Russia Country Director warned of the continuing spread of 
tuberculosis (TB) in the Russian republics of Chechnya and 
Ingushetia at a meeting of post's Refugee Assistance 
Roundtable/Forum on March 24, World Tuberculosis Day.  While the 
disease has a high prevalence throughout Russia, IMC's efforts are 
focused in the North Caucasus.  There are serious impediments to 
stopping the disease's proliferation:  absence of TB specialists in 
the region, non-adherence to standard treatment protocols, low early 
detection and registration of the illness, prohibitive drug prices, 
and the social stigma of acknowledging infection.  IMC wants to 
tackle this major public health challenge and has been in 
discussions with the principle Russian recipient of the Global Fund 
to Fight AIDS, Tuberculosis and Malaria (GFATM) about obtaining 
funding for training of health care workers.  End Summary. 
 
due to the shame the condition can bring to a family.  The refusal 
of a family to acknowledge that a member may have the illness can 
lead to the spread of the disease.  For example, elders are held in 
high esteem in Caucasian culture.  Family members will still give 
babies to a grandparent to kiss, even if the elder has been showing 
signs of pulmonary infection; to do otherwise would be considered 
disrespectful. 
 
OVERCOMING OBSTACLES 
-------------------- 
 
¶8. (U) IMC is working to increase prevention and early detection of 
TB.  The organization is waging a public awareness campaign to 
combat stigmatization.  IMC currently has State/PRM-funded mobile 
medical teams comprised of physicians and nurses that travel to 
rural areas and IDP settlements in Chechnya and Ingushetia.  The 
teams work at outpatient centers and give public lectures to 
increase public awareness four days a week.  On the fifth day, the 
teams conduct trainings for local health care personnel and health 
classes in schools with IDP populations (note: the disease is more 
prevalent among IDPs and recent returnees living in dormitories; end 
note).  During these classes, the medical team uses games to 
demonstrate normal lung capacity and identify children who may be 
infected.  Rasin says that the IMC has seen positive results from 
these classes.  For example, a child who discovers he cannot blow 
out a candle from three feet away may later attend the 
organization's mobile clinic for follow-up diagnosis and treatment. 
The team also works with community volunteers to train and develop 
prevention messages.  It meets with religious leaders and community 
elders in order to develop a culture of awareness and to reduce the 
stigma associated with TB infection.  Rasin argued that these 
measures are important but not enough. 
 
¶9. (SBU) For the future, IMC hopes to conduct skin tests in Chechnya 
- none were performed there in 2008 due to a lack of tuberculin. 
There is also a need to train village health facility staff. Groznyy 
has benefited from a great deal of NGO-provided training, but 
villages have had far fewer opportunities.  IMC hopes to close the 
gap.  It would like to partner with the Global Fund to Fight AIDS, 
Tuberculosis and Malaria, but it is not a member of the Russian 
Country Coordinating Mechanism Against Aids, Tuberculosis and 
Malaria (CCM),which selects the GFATM grant recipients. (Note: USAID 
sources tell us that IMC only recently began to attend the CCM 
meetings as an observer, and did not submit an application to GFATM 
or participate in the working groups that developed proposals. If 
IMC hopes to receive money from the GFATM, it may only do so as a 
sub-recipient of the Russian Health Care Foundation (RHCF), which 
was selected as the principal national recipient.  End note.) 
Speaking to the roundtable, Rasin simply said that GFATM money would 
not be available until 2010. He affirmed that IMC is actively 
working to identify other donors to improve TB prevention and 
treatment in the intervening months. 
 
Comment 
------- 
 
¶10. (SBU) Although the quality of official TB epidemiological data 
in the North Caucasus is no worse - and in some instances better - 
than in other Russian regions, the real extent of infection is still 
not apparent.  Weak political commitment from local governments, 
graft, poor infrastructure, an unstable economic environment, and 
the prejudices of the local population all hamper TB control. 
Inadequate public health response by federal and local officials to 
the high TB infection rate in the North Caucasus is sadly emblematic 
of the sloppiness and corruption that render the Chechen and Ingush 
republics miniature failed states.  U.S. assistance programs should 
continue to target the health sector as part of a broader protection 
strategy for the society's most vulnerable, including its IDPs.