TB in Belarus: 'We may be a small MSF project, but we are mighty'

"It’s coming to the end of week 3. I’m definitely starting to feel like my understanding of the project, the ins and outs, the need, and where to go from here are becoming clearer."

It’s coming to the end of week 3. I’m definitely starting to feel like my understanding of the project, the ins and outs, the need, and where to go from here are becoming clearer. Let me give you some context.

Belarus is among one of the highest burden countries with MDR-TB (multi-drug resistant TB). As I wrote in my last blog, MDR-TB is a communicable disease and, left untreated, becomes a public health nightmare. MDR-TB treatment is comprised of up to 2 years of drugs. And this isn’t just a pill daily. This is an injection daily for the first 9 months combined with up to 15 pills. Once you’ve managed to swallow that, you’re facing side effects ranging from nausea, vomiting, headaches, psychosis and hearing loss. Lastly, if you’re not adherent, you risk converting from MDR to Extremely Multi-Drug Resistant TB (XDR-TB), which has a much higher mortality rate due to it’s resistance to more treatment drugs.

While there are new, more effective drugs being developed to combat MDR/XDR TB, access to them is limited. According to MSF Access Campaign in March 2017, only 4800 people with MDR-TB were treated with the new meds, even though they have been available for the last 4 years. That’s fewer than 5% of those diagnosed!!! The rest have access to the old, toxic regimes. There’s over half a million people with MDR/XDR-TB.

So, if you have MDR-TB, AND you’re adherent to your meds, AND you’re living in a country that has treatment available, AND you can get through 2 years of awful, toxic drugs without infecting anyone close to you, you have a 50% chance of survival as it is. Not odds I would go for.

That’s the playing field we are starting on. MSF treats a significant amount of TB worldwide, simply because it fits the mandate – an under-served disease that frequently hits marginalized populations most.

Now, we come to Belarus and why I’m here. In 2014, Belarus placed first in a WHO study of alcohol consumption per capita, with 17.5L. Combine high rates of alcohol use, plus a complex, daily regime of medication and the rate of default creeps higher. Defaulting means spreading TB further in the population, and converting to XDR TB.

Luckily, the health authorities have recognized this, and there is a good system of alcohol treatment in the country. The problem is linking them – if you have TB and are infectious and are in hospital, how can you access rehab or detox? It’s a significant barrier and creating coordinated care is not something that’s done often here, and that is my challenge – support and develop an integrated care plan where TB patients can access both TB and alcohol supports simultaneously.

So what does this look like for a day to day? I wish I could describe the stereotypical MSF assignment – driving around in the ubiquitous MSF land cruiser down dirt roads, working with marginal populations in basic healthcare facilities, wearing the white MSF t-shirt, saving lives on the frontline, operating in a deployable tent. But it’s not. There’s a subway here.

I spend my time primarily working with the current alcohol supports in Minsk, and setting up coordination with TB providers. I don’t do frontline practice because, aside from the fact that I can’t speak Russian, this isn’t sustainable. If I do direct frontline practice, what happens when I leave in 3 months? It makes much more sense to support Belarussian staff here to do the frontline work. I provide clinical supervision and support to the Patient Support Department with a huge focus on setting up sustainable alcohol supports. I’m hoping this will include a spectrum of harm reduction to detox to rehab for patients in hospital unable to leave, coordinated access to a range of supports for out patients, and the development of an intensive case management team for the most complex patients. All in 3 months.

I haven’t done purely program development and management, policy development, training, and high level coordination in a long time. I miss the patient access and I do sometimes feel a bit lost when I can’t just “do it myself”. I also feel incredibly useless that I can’t answer my phone when somebody calls because my Russian is so bad. But I also really like the big picture stuff. This is a context that has 2 huge public health issues that aren’t going away. We may be a small MSF project, but we are mighty. I don’t buy the overused saying that this “isn’t real MSF” because when I look around, we seem to be meeting the mandate of working in areas “where there is no medical infrastructure or where the existing one cannot withstand the pressure to which it is subjected”.