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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

Deadly tuberculosis a specter on Europe

Belarus, with highest rate ever recorded for MDR-TB, asks for help

to TB control.

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In the Estonian capital of Tallinn, Piret Viiklepp, the head of the Estonian Tuberculosis Registry at the National Institute for Health Department, said that the country has been able to cut its rate of TB in half since 1998 because of political support. That was especially important, she said, in the years following the breakup of the Soviet Union in 1991, when countries once in the Soviet orbit, such as Estonia, were left with shattered economies and health systems in disarray.

“We had political support and commitment at the highest levels of our government,” Viiklepp said. “We knew that controlling TB is cost-effective — you save when you stop the spread of cases.”

She agreed with the WHO report that MDR-TB posed a threat to the continent. “MDR-TB is not just a problem of one country, it’s a problem of all of Europe,” she said. “We have no borders, and TB can be passed easily from one country to the next.”

Estonia now has about 300 to 330 cases of TB a year, and roughly a quarter of them are drug-resistant strains of the disease. The country has enough hospital beds in isolation wards for TB patients, and most stay in hospitals until they no longer can transmit the disease to others. In many cases, this means patients can leave the hospital in three or four months, but for those who do not improve the stay can last several years.

Among Estonia’s TB control steps: Stopping the sale of TB drugs in pharmacies and distributing them only through the government for greater oversight in use of the drugs; working with the WHO to obtain the drugs for MDR-TB at a lower price; and starting a training program for all medical staff on the best ways to oversee TB treatment.

One major factor in Estonia’s success, according to Viiklepp and others, is that many patients are highly motivated to take the drugs every day for up to two years, even though the medication can make them sick, cause dizziness, headaches, and other maladies. Many patients say the treatment is worse than the disease.

Annika Negin, 22, is one. She was infected with TB as a young girl when her father, an alcoholic, contracted the disease. She said others in her family, including her grandfather and great-grandfather also had TB.

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“The drugs are just awful,” Negin said one day earlier this month in a restaurant on the outskirts of Tallinn, the capital. “For the first two months, I was a sick person from them. The pills also hurt my ability to remember things, and they made me not want to eat anything.”

But she said she forced herself to eat for her health, and after nine months of being on treatment she said she had no doubt she will take the drugs for as long as she needs to.

“I will do what is right for me,” she said. “I am a young person, just 22, and I look forward so much to getting back to a normal kind of life.”

Viiklepp said that patients such as Negin have become much more common in the last decade. But she said that Estonia still grapples with some patients who don’t want to stay healthy. Among the worst offenders, she said, were alcoholics and drug abusers, who account for nearly half of those with MDR-TB. Another issue is the rising incidence in Estonia of HIV, raising fears, as of yet unfounded, that HIV-TB co-infection could grow rapidly.

For WHO’s Raviglione, the cases of how Estonia and Latvia tackled MDR-TB are important for the rest of Europe and Central Asia. 

“Other countries should follow the path of these two nations,” he said. “They showed it is possible to reverse the trend.”

Today, Belarus’ TB infection rate is the same as Estonia’s rate more than a decade ago. It doesn’t yet have the new diagnostic machine called GeneXpert, which can identify drug-resistant TB in two hours, compared to older methods that took more than two months. There is no central purchasing system of the drugs to treat MDR-TB; now the seven oblasts buy the drugs separately.

But Belarus, he said, with outside support from the WHO and others, will attempt to address these shortcomings. “I’m very happy that Belarus wants to do something serious about this problem,” he said. “We need to attack it there and in many other countries.”

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