I am in the Uzbekistan capital, Tashkent, for less than 24 hours before I fly in an old Soviet twin propeller plane over cracked mud, wasteland steppe (akin to the moon’s surface) to Nukus, the main city of Karakalpakstan and my home for the next nine months. I am met by an air temperature of -21 degrees Centigrade and row upon row of grey, featureless, one-storey houses: a sprawling barren city with no discernable landmarks.
Compared to the some places I have been, it looks relatively developed and I say a little ‘thank you’ when I see the roads are in reasonable condition (something you truly learn to appreciate after travelling in Africa). Every front yard contains only parched, brown, dead-looking and unidentifiable foliage in dry, cracked mud. The streets are lined with dehydrated and leafless trees.
It is freezing cold but creepily, the sun is blazing above and there is no snow. I am told that it hardly ever rains or snows here, as there is very little water since the environmental disaster that was the Aral Sea drying up and receding, and what water there is has been poisoned with chemicals and pesticides. There are feral mange-infested dogs on every street. The people on the streets have gold teeth and weathered faces from years of a climate that fluctuates between bitter cold and sweltering heat. They wear huge overcoats and mink-fur hats and they look a cross between Iranian, Russian and Chinese.
I am taken directly from the airport to the MSF office, a hive of activity and friendly faces. A framed copy of the Nobel Peace Prize certificate that MSF was awarded in 1999 hangs proudly above reception. Everyone eagerly shakes my hand and in one go I am introduced to what feels like the majority of the Nukus 20 ex-patriot and 110 national staff. ‘This is Gul, Gulnaz, Gulshat, Gulbakhar, Gulsiyma, Gulyaim, Gulnara, and here we have Azizbek, Bekmukhammed, Berdibek, Adilbek and Khasanbek, then there is Alisher from HR and Alisher supply log…got that?’
I am timetabled to have over a week of briefings in the office, through which I fidget uncomfortably and as soon as I meet the doctor whom I’m to succeed, Johanna, I tell her lets stop messing around and start seeing patients. She smiles knowingly. Patience has never been a virtue of mine.
On the Friday evening after I arrive 25 of us from the office hit the Nukus night scene for dinner and dancing. I have always fancied my hometown of London as a remarkably cosmopolitan place and being in the employment of the UK National Health System means the pleasure of having co-workers from a whole range of backgrounds. But working for MSF…now this takes the biscuit!
I look around our happy circle dancing to traditional Karakalpakstan music. We are: a Swedish doctor, a Uzbek psycho-social councilor, a Columbian logistician, a German nurse, an Uzbek infection control nurse, an Ethiopian medical coordinator, a Ukrainian head of laboratory, a Somali medical team leader, a Californian training coordinator, a Syrian epidemiologist, an Iranian doctor, a Canadian logistician, a Pakistani logistician, an Uzbek receptionist, a Chinese-Canadian pharmacist, a Sri Lankan Project coordinator, a Dutch doctor and me, a British doctor. We are united by our determination to both tackle TB and to dance badly. It is bonkers but brilliant and London may well look downright boring after Nukus, the new centre of the social universe.
The following Monday, and I get what I asked for – I’m up to my neck in work in the field. Karakalpakstan is divided into 16 districts (‘rayons’) and each ex-pat doctor is given a rayon to manage, with the aim of sorting out the TB care in that rayon over two years, handing it over to the Ministry of Health (MoH) and then moving onto the next rayon. The ultimate goal is summed up in the name of our programme: ‘Comprehensive TB care for all’. Each of the rayons has a central TB clinic (where the patients are diagnosed, counseled and commenced on treatment) and then tens of satellite SVPs (rural medical points - where the TB drugs are administered and the patients are followed up).
The majority of my time in Karakalpakstan is to be spent bouncing between the TB clinic and SVPs, training the MoH national doctors how to appropriately treat TB, including drug-resistant TB, and supervise them doing so. I am only to intervene and manage the patient myself if I see that they are getting compromised care, in which case I am first and foremost a doctor with a duty to act. Through this method of training local staff and ‘capacity-building’ rather than just looking after patients ourselves as four ex-pat doctors, MSF can ensure thousands rather than hundreds of lives are saved. Since MSF arrived in Karakalpakstan nearly 4000 patients have been started on appropriate TB treatment. I am now responsible for the rayon of Xojeli, in which has had MSF present since April 2010. It is a real success story thanks to my two medical predecessors, Jan and Johanna, and all their supporting staff, and as a result it is my job to hand over Xojeli in March 2013 and then face the challenge of opening a new rayon.
Standard practice before MSF first arrived in Karakalpakstan was for TB to be diagnosed from X-ray changes alone and for patients to be commenced on too few TB drugs for too short a time, and for the patients to then take them sporadically. This resulted in a spiraling TB epidemic, patients requiring treatment for TB multiple times and rife levels of drug-resistance. By way of comparison, in the UK, where TB care is carefully controlled, during my 6-year career as I doctor I have only ever seen three cases of multi-drug resistant TB, all of which were imported. 68% of the TB in Karakalpakstan is now drug-resistant. The situation has been likened to a train about to derail.
Now, since MSF have arrived in the area, the sputum samples of anyone suspected of having TB are processed rapidly by a state-of-the-art MSF laboratory. The lab then reports if TB is present, and which drugs it is resistant to. The patients are counseled carefully to tell them the importance of adhering to treatment right to the very end as this is their best hope of cure, not spreading their TB and the TB not coming back again, more drug-resistant than before. Sadly, given the levels of drug-resistance, in most cases treatment involves up to eight different fairly horrific, side-effect riddled drugs, for at least 20 months. Patients must visit their local clinic everyday to receive their medicines, which the nurse watches them take (Direct Observed Therapy, or DOTS). It ain’t easy or pretty. In fact, it’s bloody awful. But at the moment it’s the best system available to treat a wretched disease that was until recently, literally out-of-control.
On a superficial level, the situation here may not look like an emergency. This is not a war zone or a famine or an earthquake. Nukus will not be making the BBC ten o’clock news. Furthermore, the predicament in which MSF finds itself in Uzbekistan is not typical for the organisation. MSF’s bread and butter is deploying where there is little or no existing health infrastructure, where it can operate fairly unilaterally and therefore is able to control the agenda, self-regulate and hold its staff accountable. Here, MSF finds itself the unlikely bed-companion of the national MoH. But be in no doubt – the drug resistant TB epidemic in Karakalpakstan is a humanitarian crisis and MSF is making a huge difference for the better.